Peritoneal Dialysis Catheter Insertion by Nephrologist Using Minilaparotomy: Do Survival and Complications Vary in Obese?

INTRODUCTION: Peritoneal dialysis catheter (PDC) placement for chronic kidney disease (CKD) amongst overweight and obese patients is difficult owing to deeper operating field. Literature being discordant on survival and complications in this patient subset, we attempted to analyse this research question in Indian population. MATERIALS AND METHODS: We retrospectively analysed PDC inserted by nephrologist using surgical minilaparotomy for survivals and complications amongst 'overweight and obese' cohort ('O') at two tertiary care government hospitals in India, and compared results with normo-weight cohort ('N'), with 12-36 months follow-up. RESULTS: 245 PDCs were inserted by surgical minilaparotomy and 'N' to 'O' ratio was 169:76. 'O' group were more rural residing (P = 0.003) and post-abdominal surgery (P = 0.008) patients. The 1, 2, and 3-year death censored catheter survival rate was 98.6%, 95.8%, and 88.2% respectively in 'O' group, and 97.6%, 94.5% and 91.8% in 'N' group respectively (P = 0.52). Patient survival (P = 0.63), mechanical complications (P = 0.09) and infective complications (P = 0.93) were comparable despite technically challenging surgery in 'O' group. Refractory peritonitis related PDC removal was comparable (P = 0.54). Prior haemodialysis or catheter related blood stream infections or diabetes were non-contributory to results. CONCLUSIONS: Catheter survival and patient survival amongst obese and overweight CAPD patients was non-inferior to normal weight patients. Mechanical, and infective complications were comparable despite technically challenging abdominal terrain in 'O' group. The overall CAPD performance was good amongst obese and overweight.

Demographic Characteristics, Outcome and Complications of Renal Transplantations at a Tertiary Care Center in South India.

BACKGROUND: Renal transplantation is the treatment of choice for selected patients with end-stage renal disease. In this study, we present our experience and follow up data of renal transplantations done at this center with special emphasis on demographic characteristics, outcome and its complications. MATERIALS AND METHODS: All those patients who underwent renal transplantations and had been followed up at this center were studied and their details were recorded. For living donor transplantation, donor and recipient were evaluated in detail. Graft loss was defined as the patient became dialysis-dependent or underwent second renal transplantation. RESULTS: A total of 250 renal transplantations were done during the study period. 16.4% of total transplantations were cadaveric transplants. Recipients mean age was 38.5±11.64 yrs and donor mean age was 42.25 ±10.79 yrs. The majority of the recipients were male (72.4%) while female donors were predominant among living donors(59.3%). Mean graft survival time was 98.2 months (95% confidence interval [CI]:72.2-114.4). Mean patient survival time was 104.5 months (95% confidence interval [CI]:82.4-126.2). CONCLUSION: There is increasing no. of cadaveric renal transplants due to well established deceased donation programs in the state. Our patient and graft survival are comparable. Most of the immediate graft loss was due to acute rejection and late graft loss was due to chronic antibody-mediated rejection.

The therapeutic dilemma in pre-transplant asymptomatic aspergilloma: A case report and review of literature.

Aspergillus species are ubiquitous, and inhalation of infectious conidia is not so uncommon. With immunosuppression, it can invade adjacent structures and lead to widespread invasive disease. There is no randomized, prospective trial for optimized treatment including the antifungal and surgical approach for aspergilloma. The available literature related to the management of asymptomatic aspergilloma in pre-renal transplant setting is scarce and debatable. Opinion favoring surgery is that it is necessary to eliminate the fungus reservoir before transplantation because of the inadequacy of pharmacological fungus control measures in immunocompromised patients. We present a case of end-stage renal disease that was planned for renal transplantation and during the workup, was detected to have asymptomatic right upper lobe aspergilloma. He underwent surgical resection of the aspergilloma before undergoing successful renal transplantation. In this case report, we will discuss this case and controversies related to its management before undergoing successful renal transplantation.

Clinical Profile, Histopathological Features and Outcome of IgA Nephropathy in a Tertiary Care Hospital in India.

IgA nephropathy (IgAN) is reported to be more common in Asians and is considered to be a very progressive disease with worse outcome. The present study encompasses a cohort of biopsy-proven IgAN in a tertiary care hospital to characterize the initial clinical presentation, Oxford classification profile and one year follow up of patients with clinical and biochemical investigations. All renal biopsies with a diagnosis of primary IgAN were included. In all biopsies with ≥8 viable glomeruli, the MEST-C scores were analyzed, according to the Oxford criteria. Demographic and clinical data included age, gender, presence of hypertension, presence of hematuria and edema. Baseline investigations include urine protein semiquantitative, spot urine protein creatinine ratio, 24-h urinary protein, serum creatinine, and serum albumin. All the details of the use of antiproteinuric drugs and immunosuppressive drugs were recorded. Total 48 renal biopsies (21.62%) were diagnosed as primary IgAN. Thirty-seven (77.08%) had renal dysfunction on initial presentation out of which 31 (64.5%) patients had subnephrotic range proteinuria (SNRP). MEST-C lesions distribution were interpreted in 39 patients. 42.85% of patients with nephrotic range proteinuria (NRP) and 55.55% of patients with SNRP had renal deterioration during follow up period while 28.57% patients with NRP and 41.66% patients with SNRP had reached end-stage renal disease (ESRD). Our study population of IgAN has a unique clinical profile with hypertension, microscopic hematuria and subnephrotic proteinuria as the predominant clinical presentation. In spite of low MEST-C score in our study cohort, the disease has an aggressive course with 47.91% of patients with renal function deterioration and about one third follow up patients approaching ESRD during the study period.

Osmotic demyelination syndrome in a normonatremic patient of chronic kidney disease.

Osmotic Demyelination Syndrome (ODS) is associated with rapid correction of hyponatremia or fluid shifts, and is characterized by neurological involvement related to pons, brainstem or other areas of the brain. All possible measures should be taken to prevent this serious disorder. Diagnosing this condition early is very important and requires a high index of suspicion. The treatment is purely supportive and most patients may show dramatic recovery. ODS occurring in normonatremic and hypernatremic patients is very rare. We report a case of an 18-year-old boy of end-stage renal disease who presented with an episode of acute gastroenteritis. He was managed with aggressive intravenous fluids, hemodialysis and other supportive therapy. But, he developed altered sensorium and seizures that progressed to features of spastic quadriparesis and lower cranial nerve palsy. Neuroimaging showed hyperintensities in pons and midbrain suggestive of ODS. The patient had normal sodium levels at all times and had no evidence of hyponatremia. The patient was managed with hemodialysis, physiotherapy and other conservative measures and had a gradual clinical and radiological recovery.

Hypertensive emergency: A unique manifestation of a pituitary disorder.

Acromegaly a common pituitary disorder has significant adverse effects on well-being and survival. The slight increase in the prevalence of hypertension in acromegaly is well known and is proposed to be the direct effects of growth hormone. The hypertension for calculating the prevalence in most series was defined as diastolic more than 100 mmHg, but hypertensive emergency is rarely ever described in the literature. Growth hormone excess has been associated with renal manifestations such as hypercalciuria and nephrolithiasis, but never with renal failure. We present a case referred to a tertiary care nephrology center with malignant hypertension. This is the first case of a patient of acromegaly presenting with hypertensive emergency progressing to malignant nephrosclerosis and renal failure.