Pill burden does not influence compliance with oral medication in recipients of renal transplant.

OBJECTIVES: Insights about the predictors of noncompliance are key to develop compliance enhancing strategy in a given therapeutic situation. Renal transplantation is a critical surgical procedure that imposes a large medication burden on patients. There is a suspicion that the large pill burden may lead to noncompliance. Our objective was to ascertain the influence of pill burden on medication compliance in renal transplant patients in the Indian sociocultural context. METHODS: A longitudinal observational study was conducted in two Tertiary Care Hospitals in Kolkata running renal transplant program - one each from the government and private sectors. Totally 120 literate adult transplant recipients were recruited through purposive sampling and followed up at 3 months intervals for 1 year. Data were collected through interview and review of prescriptions and medical records. RESULTS: Data of 110 subjects were analyzed. The pill burden was high - ranging from 10-21 (median 14) at first visit shortly after discharge to 7-22 (median 11) at last visit at 12 months in the government sector; corresponding figures in the private sector were 14-32 (median 21) and 10-28 (median 17). Pill burden increased with age. Only 60.91% of the patients were fully compliant until 1 year after transplantation. The rate of immunosuppressant noncompliance was 27.78% in government sector and 25.00% in private sector. There was no significant association between median pill burden and medication compliance. Satisfaction with caregiver support was associated with better immunosuppressant compliance. CONCLUSIONS: Noncompliance in renal transplant recipients is likely to be multifactorial. Contrary to popular belief, pill burden was not a major determinant of noncompliant behavior.

Successful use of sustained low efficiency dialysis in a case of severe phenobarbital poisoning.

A 30-year-old female presented with coma and subsequent cardiac arrest caused by phenobarbital overdosage, requiring ventilatory and vasopressor support. She had also developed severe hypoxia following gastric aspiration. Initial therapy, including activated charcoal and forced alkaline diuresis, failed to significantly lower her drug levels and there was minimal neurological improvement. As she was hemodynamically unstable, and unsuitable for conventional dialysis, she was put on sustained low efficiency dialysis (SLED) to facilitate drug removal. SLED resulted in marked reduction in plasma level of phenobarbital, which eventually led to early extubation, improved cognition and aided full recovery. Thus, we concluded that SLED can be an effective alternative in cases of severe phenobarbital poisoning, where conventional hemodialysis or hemoperfusion cannot be initiated, to hasten drug elimination and facilitate early recovery.

Nephrogenic systemic fibrosis: a brief review.

Nephrogenic systemic fibrosis is a fibrosing disorder of the skin that develops in patients with advanced renal failure. It mostly presents with progressive hardening or induration of the skin of the extremities. Systemic involvement is also known to occur in this entity. Exposure to gadolinium contrast for radiological evaluation has been identified as the offending agent. The condition is progressive and can be seriously disabling. Therapeutic options are limited and not rewarding in majority of the cases. Awareness of this entity is important so that proper precautionary measures can be taken at the earliest to ameliorate the condition.

Pregnancy-related acute renal failure in eastern India.

OBJECTIVE: To study the causes, burden, and impact of pregnancy-related acute renal failure (PRARF) in a low-resource setting. METHODS: A prospective observational study of consecutive women admitted to the Seth Sukhlal Karnani Memorial Hospital, Kolkata, India, with PRARF between February 1, 2007, and May 31, 2009, was conducted. The information collected included causes and predisposing conditions leading to PRARF, clinical presentations, medical and obstetric management-including need for dialysis-and maternal outcome. RESULTS: The leading causes of PRARF among the 57 participants were sepsis 19 (33.3%), hemorrhage 16 (28.1%), and hypertensive disorders 15 (26.3%). The condition occurred in 11 (19.3%) cases before 20 weeks of gestation, 6 (10.5%) cases after 20 weeks of gestation, and 40 (70.2%) cases during puerperium. Most women were from rural areas and received inadequate prenatal care. Although 40 women had PRARF during puerperium, the precipitating event mostly started during the process of labor/delivery. Despite multidisciplinary care, mortality was high (28.1%); cause-specific fatality was highest with sepsis (36.8%) and hemorrhage (25.0%). Many women who survived experienced prolonged morbidity. CONCLUSIONS: Pregnancy-related acute renal failure is potentially fatal but largely preventable. Universal prenatal care and greater access to emergency obstetric services, especially in rural India, could avert PRARF and its consequences.

Ten-year follow-up of children after acute renal failure from a developing country.

OBJECTIVE: The acute-stage mortality and morbidity of acute renal failure (ARF) is well documented, but there are few long-term follow-up studies in children with ARF, particularly from developing countries. The aim of this study was to look at the spectrum of ARF on presentation at a tertiary centre in Kolkata, India, with subsequent 10 years of follow-up. SUBJECTS AND METHODS: All cases of ARF between the ages of 1 month and 10 years presenting between April and September 1996 were included. We did exclude children with any known renal abnormality. The study group was subsequently monitored for renal survival and mortality until 10 years post-ARF episode. RESULTS: A total of 37 (n = 37) cases were enrolled. Glomerulonephritis and snakebite were the two most common aetiologies (n = 17 and n = 9). The acute mortality was 35% (n = 13), and it was significantly associated with peak creatinine and presence of multiple organ failure (P < 0.05). The outcome at 6 months could be assessed for 92% (n = 22) of acute survivors and at 10 years for 67% (n = 16). The children that were traced showed in 32% (n = 7) at 6 months and 38% (n = 6) at 10 years, respectively, at least one of the four (abnormal creatinine, hypertension, haematuria and proteinuria) abnormal renal parameters. Snakebite, acute-stage peak creatinine and duration of oliguria were significantly associated with adverse long-term outcome (P < 0.05). CONCLUSION: We found that nearly 25% (n = 6) of the survivors of an acute episode of renal failure had renal morbidity after 10 years, a percentage significant enough for these children to need long-term follow-up.