Lactic acidosis due to metformin in type 2 diabetes mellitus and chronic kidney disease stage 3-5: is it significant?

PURPOSE: To study the incidence of lactic acidosis due to metformin in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) stage 3-5. METHODS: We estimated plasma lactate in patients of CKD stage 3 and worse who were continuing metformin on their own prior to stopping the drug. RESULT: Of 40 patients included, median duration of T2DM was 60 months (interquartile range IQR 24-120). The mean serum creatinine was 309.4 ± 159.1 µmol/L and mean eGFR was 27.82 ± 12.93 mL/min/1.73 m2 with 3 (7.5%), 16 (40%), 11 (27.5%) and 10 (25%) in CKD stages 3a, 3b, 4 and 5, respectively. They were receiving metformin for a median duration of 24 months (IQR 12.5-60), an average dose of 896 ± 350 mg per day. The median of plasma lactate was 1.36 mmol/L (IQR 1.11-1.75 mmol/L) with three (7.5%) having levels above normal, two (20%) in CKD stage 5 and one (9.1%) in stage 4. CONCLUSION: Metformin can be safely used in CKD stage 3 and with regular measurement of plasma lactate in later stages.

Impact of body mass index on progression of primary immunoglobulin a nephropathy.

The role of obesity in the progression of primary glomerular diseases is controversial. A few studies report overweight/obesity as a risk factor for disease progression in immunoglobulin A nephropathy (IgAN), and the real impact of it still remains unclear. The aim of this study was to elucidate the effect of body mass index (BMI) on disease progression and proteinuria in patients with IgAN in Indian population. A cohort of biopsy-proven primary IgAN patients diagnosed between March 2010 and February 2015 who had a follow-up for a minimum of 12 months were included in the study. We defined two groups of patients according to the BMI value at diagnosis: non-obese group (Group N) with BMI <23 Kg/m2 and the overweight/obese group (Group O) with BMI >23 Kg/m2 as per Asia-Pacific task force criteria. Baseline characteristics were compared between the groups. The estimated glomerular filtration rate (eGFR) and urine protein-creatinine ratio (UPCR) were followed up at entry time, 6 months, 12 months, and at the end of follow-up. Outcomes studied were change in eGFR, proteinuria, and progression to end-stage renal disease. Statistical analysis was done using the Statistical Package for the Social Sciences version 15.0. Of 51 patients, 25 (49%) had BMI <23 kg/m2 (Group N) and 26 (51%) had BMI >23 kg/m2 (Group O) (P = 0.01). The baseline clinical, histopathological, and treatment characteristics of both the groups were comparable. The BMI at the time of diagnosis did not have any significant effect on eGFR (P = 0.41) or proteinuria (P = 0.99) at presentation. At the end of follow-up, both the groups had a similar reduction of proteinuria (UPCR) (P = 0.46) and eGFR (P = 0.20). Two patients in each group have reached chronic kidney disease Stage 5. In the present study, BMI at presentation did not have any impact on eGFR or proteinuria, either at diagnosis or at follow-up. It needs further large multicenter randomized control studies to see the effect of BMI on progression of IgAN.

Immune mediated crescentic MPGN secondary to HBV infection: A rare presentation for a common infection.

Hepatitis B virus (HBV) infection presenting as crescentic glomerulonephritis in the absence of cryoglobulinemia is an extremely rare phenomenon. We report a case of a 44-year-old male with HBV infection, who underwent kidney biopsy for rapidly progressive renal failure and nephrotic range proteinuria. Histopathological evaluation of the kidney biopsy was consistent with immune complex mediated crescentic membranoproliferative glomerulonephritis (MPGN). The patient achieved complete renal and virological remission with steroids, plasmapheresis and antiviral therapy. This case report summarises the importance of early initiation of immunosuppression and plasmapheresis under antiviral coverage for improved clinical outcomes.

Pharmacoeconomic evaluation of hospitalised pre-dialysis and dialysis patients: A comparative study.

BACKGROUND: The progression of chronic kidney disease (CKD) can be attributed to various factors, including lack of medical services, delayed referral, lack of awareness about the disease, drugs, and financial support. AIMS: To compare the pharmacoeconomic-related direct medical and non-medical costs among hospitalised pre-dialysis and dialysis patients. METHODS: A prospective observational study was conducted on the inpatients admitted to the Department of Nephrology. Patients undergoing maintenance dialysis or initiated on renal replacement therapy were included in the dialysis patients group and other CKD patients in the pre-dialysis group. The data pertaining to the pharmacoeconomic-related direct medical and non-medical costs were collected from the patient records, medical bills, and other relevant sources. RESULTS: Out of 100 patients, 43 were in the pre-dialysis group and 57 were in the dialysis group. The median direct medical costs (INR 4,731.62, USD $76.47) for dialysis group patients were significantly higher than for the pre-dialysis group (INR 1,820.95, USD $29.43). The median direct non-medical costs (INR 550, USD $8.88) for pre-dialysis group patients were not significantly higher than for the dialysis group (INR 480, USD $7.75). CONCLUSION: There was a significant difference in the median direct total costs between pre-dialysis and dialysis patients. The number of medications per prescription and length of hospital stay are the factors that influence the median direct total costs.