Influenza A (H1N1) Virus Infection Associated Acute Kidney Injury - A Study from a Tertiary Care Center in South India.

Influenza A (H1N1) infection in 2009 spread rapidly all over the world. Mortality was high in patients with H1N1-associated acute kidney injury (AKI). We estimated the incidence, risk factors of AKI and mortality associated with H1N1 infection. This is a prospective observational study, including 158 adult patients with H1N1 infection confirmed with real-time reverse transcriptase-polymerase chain reaction conducted between August 2016 and September 2017. AKIN criteria were used to define AKI. Of 158 patients in this study, 112 were male and the mean age was 46.4. Fifteen patients (9.5%) were found to have AKI. The mean age was higher (56.13 ± 10.02) in the AKI group compared to non-AKI (45.48 ± 16.26) (P = 0.007). Presence of shock, multiple organ dysfunction syndrome (MODS), ventilatory support were observed more in the AKI group (P = 0.000). Among AKI patients, the requirement of dialysis was more than 50% (n = 8/15, 53.3%). Eighteen patients died following H1N1 infection (11.4%).Shock (n = 8/18, 44.4%, P = 0.000), MODS (n = 13/18, 72.2%, P = 0.000), intensive care unit (ICU) care (n = 17/18, 94.4%, P = 0.000), ventilatory support (n = 18/18, 100% P = 0.000), AKI (n = 11/18, 61.1%, P = 0.000), and requiring dialysis (n = 7/18, 38.9%, P = 0.000) were significantly associated with mortality compared to patients who survived. The incidence of H1N1 AKI was 9.5%, with > 50% requiring dialysis. Risk factors for AKI included older age, underlying chronic kidney disease, presentation with sepsis, shock, MODS, ICU care, and mechanical ventilation. Mortality was high in patients with AKI compared to non-AKI patients.

Pulmonary hypertension - prevalence, risk factors, and its association with vascular calcification in chronic kidney disease and hemodialysis patients.

Pulmonary hypertension (PHTN) is a recently recognized complication in dialysis and it is associated with a poor outcome. We estimated the prevalence of PHTN and its association with vascular calcification in chronic kidney disease (CKD) and hemodialysis (HD) patients. One hundred and thirteen adult CKD patients were included in this study, of which 56 (49.6%) were on conservative treatment (nondialysis group) and 57 (50.4%) were on maintenance HD (dialysis group). Demographic, clinical, and biochemical parameters were collected and compared between the groups. Thirty-nine (69.6%) and 33 (57.8%) males were included in nondialysis and dialysis group, respectively. Mean age was 47.5 ± 13.7 in nondialysis group and 52.8 ± 13.9 in the dialysis group. PHTN was estimated using Doppler echocardiography and peripheral vascular calcification by lateral lumbar X-ray with aortic calcification scoring. Patients with and without PHTN and vascular calcification in dialysis and nondialysis group were compared. PHTN was found in 55 patients (48.7%) and it was high in patients on dialysis compared to nondialysis(59.6% vs. 37.5%, P <0.019). Abdominal aortic calcification was present in 35 patients (30.9%), dialysis versus nondialysis group was 22.8% and 39.3%. Increased left atrial diameter was significantly associated with PHTN (P <0.003), whereas peripheral artery calcification was not related to PHT (P = 0.248). The prevalence of PHTN in CKD was 48.7% which was higher in dialysis group than non dialysis group. Increased left atrial (LA) diameter was associated with PHTN but not peripheral arterial calcification.

Low Concentration Trisodium Citrate as a Non-inferior Locking Agent for Non-tunneled Dialysis Catheters in the Asian Setting.

INTRODUCTION: Unfractionated heparin is the commonly used catheter lock solution in patients with temporary dialysis catheters as hemodialysis access. The effectiveness of trisodium citrate as an alternate catheter lock agent has not been studied in Asian population. METHODS: In this prospective quasi-experimental study, which included 180 patients with central venous dialysis catheter, patients were randomly allotted to citrate 4.67% and heparin 5000 units/ml arms in the ratio of 2:1. Baseline demographic and dialysis related data, incidence of catheter-related bloodstream infections, and mean catheter days in both the study cohorts were collected and compared. Formal cost analysis for citrate 4.67% use as catheter lock was done. RESULTS: The mean age of the total study population was 50.49 ± 14.87 years. Sixty-six females (36.7%) and 80 (44.4%) diabetic patients were included in the study. The overall incidence of catheter-related bloodstream infection (CRBSI) was 11.11%. The majority had nontunneled dialysis catheters (95%; n = 114). On analyzing the data of patients with nontunneled catheters, it was found that the total number of catheter days for the citrate and heparin groups were 4,795 and 2,419 days, respectively. The number of CRBSI episodes per 1,000 catheter days for the citrate and heparin groups were 2.711 and 2.89, respectively. Citrate catheter lock cost only 6% of that of heparin lock. CONCLUSIONS: The incidence of catheter related bloodstream infections was comparable between the heparin and citrate 4.67% lock cohorts. The use of low concentration citrate as catheter lock was cost-effective when compared with heparin.

Hemodialysis: a therapeutic option for severe attacks of acute intermittent porphyria in developing countries.

Acute intermittent prophyria (AIP) is an autosomal dominant disease that results from a defect in the enzyme porphobilinogen deaminase. Acute intermittent porphyria is the most common of hepatic porphyrias and can tax the therapeutic capabilities of the physician to the limit. Motor weakness is a major feature of an acute attack, and flaccid paralysis of all extremities can occur rapidly, within a matter of days. The acute attacks may be life threatening. Hematin (Heme Arginate) should be given early during an acute attack to prevent neurologic sequel. Hemodialysis and hemoperfusion have been tried in the treatment of acute attacks of AIP with success. As hematin is not available in India, a severe acute attack of AIP in a patient was managed with hemodialysis successfully. Later, hematin was imported and provided to the patient. An 18-year-old girl was admitted to our hospital with recurrent abdominal pain and 2 episodes of convulsions. She had undergone an appendectomy earlier at another hospital for abdominal pain. On evaluation, she had hyponatremia, episodic abnormal behavior, generalized muscle pain, hypertension, and sinus tachycardia. In view of the above clinical picture, a clinical diagnosis of acute intermittent porphyria was made. Her 24-hr urinary porphobilinogen was 90.8 mg/day (<2 mg-normal) and alpha amino levalunic acid was 108.8 mg/day (1-7 mg-normal), consistent with the diagnosis. Her hyponatremia was corrected. Arrangements were made to import hematin and she was managed with dextrose infusion. Meanwhile, she developed flaccid quardriparesis with urinary incontinence and bulbar palsy. Her brain MRI was normal. Her nerve conduction study was suggestive of motor radiculoneuropathy. Specific treatment for severe porphyric crisis was planned. She failed to improve with dextrose infusion alone. As hematin was not readily available in the country, other therapeutic options were considered. As few case reports of AIP being successfully treated with hemodialysis were available, the option of dialytic support was explained to the family. After procuring informed consent, she was subjected to hemodialysis for 4 hr in the first day, increasing to 6 hr a day for the next 6 days. Her abdominal pain and myalgia subsided on the third day of dialysis. Her lower limb muscle power improved and she became ambulant by the fourth day. Urinary retention improved within 4 days. Hematin was imported by then from the United States. Later, 2 doses of hematin (4 mg/kg-160 mg in 20% albumin) were given via a central vein. She was maintained on physiotherapy. Repeat nerve conduction study revealed recovery. She has been provided with a list of drugs that have to be avoided. Currently, she is on outpatient follow-up with occasional abdominal pain, which subsides with intravenous dextrose therapy.

Acute renal failure due to rifampicin: a study of 25 patients.

BACKGROUND: Acute renal failure (ARF) caused by rifampicin typically occurs on intermittent administration. There are isolated case reports and only one series reported in the literature. Systematic data, especially from countries endemic for tuberculosis and leprosy, are sparse. METHODS: We studied demographic, clinical, biochemical, and histopathologic features and prognosis of 25 consecutive patients with rifampicin-associated ARF admitted from July 1990 to June 2000. RESULTS: Rifampicin-associated ARF constituted 2.5% of all cases of ARF seen during the study period. The most common pattern of drug intake resulting in ARF (40%) was ingestion of a single dose preceded by a drug-free period (range, 10 days to 6 years) after a course of daily rifampicin (range, 8 days to 18 months). Onset was with gastrointestinal and flu-like symptoms 4 hours (median) after drug intake. All patients were oliguric. Anemia and thrombocytopenia each occurred in 60% of patients. Acute hepatitis was present in 32%. Among 12 patients who underwent kidney biopsy, 7 patients (58%) had acute interstitial nephritis (AIN). Crescentic glomerulonephritis was seen in 1 patient, and mesangial proliferation, in 3 patients. No single feature at presentation predicted the severity of renal failure. There were no deaths, and all patients recovered renal function. CONCLUSION: Patients with rifampicin-associated ARF were oliguric and presented with gastrointestinal and flu-like symptoms, typically after reintroduction of the drug after a drug-free period. Anemia and thrombocytopenia were common. AIN was the most common biopsy finding. No factor predicted severity, but the renal prognosis was good.