Rare occurrence of fatal Candida haemulonii peritonitis in a diabetic CAPD patient.

A 68-year-old diabetic chronic kidney disease patient on continuous ambulatory peritoneal dialysis for two years developed Candida haemulonii peritonitis without any predisposing factors. There is no effective treatment for this fungus. A peritoneal biopsy showed morphological changes of acute inflammation and chronicity.

Nutritional status in stage V dialyzed patient versus CKD patient on conservative therapy across different economic status.

BACKGROUND: This aim of this multi-centric cross-sectional study was to assess the nutritional status in Indian chronic kidney disease (CKD) patients and to compare the nutritional indicators between stage 5 dialyzed (CKD-D) patients below the poverty line (BPL), and stage 3-4 non-dialyzed (CKD-ND) patients above (APL) and below the poverty line. METHODS: Patients were selected from a government medical college hospital, a charity-based outpatient dialysis unit, and a non-profit tertiary care center. The study groups included BPL CKD-ND (n = 100), BPL CKD-D (n = 98), and APL CKD-ND (n = 92) patients, based on a cut-off of per capita income US $1.25 a day. Patients were enquired by a qualified renal dietitian about their pattern of diet, and daily energy and protein intake by 24 h recall method. Anthropometric measurements and biochemical investigations were made and compared. RESULTS: Nutritional indicators were low in all three groups compared to those prescribed by European Best Practice Guidelines (EBPG). BPL CKD-D patients had low serum albumin levels (32.44444 ± 6.279961 g/L; p = 0.017) and 41.83% of them were underweight. The APL CKD-ND group registered the lowest mean daily energy (22.576 ± 6.289 kcal/kg/day) and protein intake (0.71 ± 0.06 g/kg/day), due to dietary restrictions imposed on them by themselves and unqualified renal dietitians. The APL group had better indicators of nutritional status in terms of mid-upper arm circumference (p = 0.001), triceps skin fold thickness (p < 0.001), and serum hemoglobin (p < 0.001). CONCLUSION: Several nutritional parameters were below the recommended international guidelines for all the three groups, though the high income group had better parameters from several indicators. There is an urgent need for nutritional counseling for CKD-D and CKD-ND patients.

A maintenance hemodialysis diabetic patient with unexplained pulmonary and gastrointestinal involvement.

A 50-year-old man with diabetes mellitus with diabetic retinopathy, peripheral neuropathy, hypertension, and end-stage renal disease on maintenance hemodialysis, presented with persistent cough and hiccups, continued to be unwell with weight loss, poor appetite, and recurrent respiratory symptoms such as wheezing and cough. Whole body positron emission tomography-computed tomography scan showed metabolically active lesions in liver, stomach/lesser sac, pancreas, and left sixth rib. As he had repeated bilateral transudative pleural effusion, left mini thoracotomy with pleural biopsy showed no evidence of granuloma or malignancy. Upper gastroscopy showed tiny gastric polyp; biopsy revealed benign lesion. Left posterior rib biopsy from the lesion and iliac crest biopsy showed no evidence of malignancy or granuloma. Further evaluation showed plasma chromogranin A -5737 µg/L (<100 µg/L) with a repeat value of 6950 µg/L (<100 µg/L). He was initiated on oral sunitinib 25 mg once a day and injection octreotide 20 mg subcutaneously once a month. The plasma chromogranin A level and his symptoms, however, showed an initial improvement, but gradually worsened after 4 months despite being on treatment. After 6 months, the patient developed a gangrenous lesion of his glans penis with necrosis. Due to severe pain on conservative measures, penectomy with perineal urethrostomy was performed. Biopsy of the lesion showed blood vessels with intimal calcifications and thrombosis suggesting penile necrosis.

Effect of high-protein supplemental therapy on subjective global assessment of CKD-5D patients.

Adequate nutrition in patients on hemodialysis is an important step for improving the quality of life. This prospective study was undertaken to monitor the nutritional status of patients who were given high-protein supplements on malnutrition inflammation score (MIS) and to correlate with biochemical parameters in maintenance hemodialysis (MHD) patients. This prospective study was conducted on 55 chronic kidney disease patients on MHD (37 women, 18 men), aged between 21 and 67 years. Of the 55 patients, 26 patients received high-protein commercial nutritional supplements, whereas 29 patients received high-protein kitchen feeding. Every patient had their MIS, 24-hour dietary recall, hand grip, mid arm circumference, triceps skin-fold thickness at 0, 3, and 6 months. Each of the above parameters was compared between the high-protein commercial nutritional supplement cohort and high-protein kitchen feeding cohort, and the data were analyzed. Of the 55 patients, 82.61% of patients on high-protein kitchen feeding group and 66.67% in high-protein commercial nutritional supplement group were nonvegetarian (P = 0.021). According to the MIS, improvement was observed in malnutrition status from 3- to 6-month period in 38.1% of patients in high-protein commercial supplement group, whereas only in 8.7% in high-protein kitchen feeding group (P = 0.04). Assessment showed improvement in malnutrition status with high-protein commercial nutritional supplement, which was marked in patients with age group >65 years (P = 0.03) and in those in whom serum albumin is <35 g/L (P = 0.02). Both high-protein kitchen feeding and high-protein commercial nutritional supplement cohorts were observed to have improvement in overall nutritional status. Older patients >65 years with lower serum albumin levels (<3.5 g/dL) were observed to have significant improvement in nutritional status with high-protein commercial nutritional supplements.

State of deceased donor transplantation in India: A model for developing countries around the world.

Renal replacement therapy (RRT) resources are scarce in India, with wide urban-rural and interstate disparities. The burden of end-stage renal disease is expected to increase further due to increasing prevalence of risk factors like diabetes mellitus. Renal transplantation, the best RRT modality, is increasing in popularity, due to improvements made in public education, the deceased donor transplantation (DDT) programme and the availability of free and affordable transplant services in government hospitals and certain non-governmental philanthropic organizations. There are about 120000 haemodialysis patients and 10000 chronic peritoneal dialysis patients in India, the majority of them waiting for a donor kidney. Shortage of organs, lack of transplant facilities and high cost of transplant in private facilities are major barriers for renal transplantation in India. The DDT rate in India is now 0.34 per million population, among the lowest in the world. Infrastructural development in its infancy and road traffic rules not being strictly implemented by the authorities, have led to road traffic accidents being very common in urban and rural India. Many patients are declared brain dead on arrival and can serve as potential organ donors. The DDT programme in the state of Tamil Nadu has met with considerable success and has brought down the incidence of organ trade. Government hospitals in Tamil Nadu, with a population of 72 million, provide free transplantation facilities for the underprivileged. Public private partnership has played an important role in improving organ procurement rates, with the help of trained transplant coordinators in government hospitals. The DDT programmes in the southern states of India (Tamil Nadu, Kerala, Pondicherry) are advancing rapidly with mutual sharing due to public private partnership providing vital organs to needy patients. Various health insurance programmes rolled out by the governments in the southern states are effective in alleviating financial burden for the transplantation. Post-transplant immunological and pathological surveillance of recipients remains a challenge due to the scarcity of infrastructure and other facilities.

Occurrence of double primary malignancies in an African renal transplant recipient.

A 63-year-old African male with end stage renal disease who received a renal transplantation from his daughter after successful treatment of hepatitis C virus, type 1 genotype developed metastatic Kaposi's sarcoma and subsequently adenocarcinoma of the prostate. He was successfully treated with chemotherapy and reduction of immunosuppression and switch over to rapamycin.

Case Report: Rare occurrence of Pseudomonas aeruginosa osteomyelitis of the right clavicle in a patient with IgA nephropathy.

We describe the case of a 47 year old patient with proven primary IgA nephropathy who presented with osteomyelitis of the medial end of the right clavicle. The patient was not on immunosuppressive medications. He underwent aspiration curettage and CT scan of the clavicle which yielded pus that grew Pseudomonas aeruginosa. Following treatment with appropriate antibiotic therapy the patient presented a complete recovery of the lesion with no loss of renal function. This case highlights the importance of positive cultures in the choice of the appropriate therapy in an extremely rare case of an immunocompetent patient with osteomyelitis of the clavicle.