Chronic Kidney Disease and COVID-19: Outcomes of hospitalised adults from a tertiary care centre in North India.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel disease caused by the SARS-CoV-2 virus and has emerged as a deadly pandemic affecting countries all over the world. Here we share our experience of managing adults with chronic kidney disease (CKD) and concomitant COVID-19 infection jointly managed by pediatric and adult nephrology teams. METHODS: This retrospective study was done on patient admissions (>18 years) between 20th June- 30th October 2020 with previously diagnosed CKD and hospitalised with COVID-19 infection. The demographic details, underlying comorbidities, clinical presentation, medications, laboratory, radiological profile and outcomes were studied. RESULTS: A total of 213 adults (62% males) with CKD were admitted during this period with a median (IQR) age of 52 (42, 60) years; 75 (35.2%) had associated diabetes mellitus, 83.1% hypertension, 5.2% hypothyroidism and 7% coronary artery disease. 165 (77.5%) were on maintenance haemodialysis (MHD), and 72.8% had arteriovenous fistula as vascular access at presentation. Most (84.5%) patients were symptomatic for COVID-19, and about 2/3 diarrhoea had moderate to severe disease. Oxygen therapy was needed in 62.9%, and medications used were hydroxychloroquine in 84.5%, azithromycin in 21.6%, ivermectin in 82.6%, steroids in 63.8% and Low molecular weight heparin in 59.2%. A further comparison of patients with CKD5D and CKDND revealed similar parameters except for a higher incidence of diarrhoea, acute kidney injury (AKI) and a shorter period to RTPCR negativity (12.5 vs 15 days; P = 0.038) in CKDND. The overall mortality was 24.4%, with similar mortality rates in both groups (P = 0.709) and 20.7% needed ICU transfer. CONCLUSIONS: Adults with CKD especially on haemodialysis, are prone to more severe COVID-19 infection and take a longer time for viral clearance (>2 weeks); the mortality too is higher in these patients.

Potential of organ donation from deceased donors: study from a public sector hospital in India.

Deceased donor organ programme is still in infancy in India. Assessing deceased donation potential and identifying barriers to its utilization are required to meet needs of patients with organ failure. Over a 6-month period, we identified and followed all presumed brainstem dead patients secondary to brain damage. All patients requiring mechanical ventilation with no signs of respiratory activity and dilated, fixed and nonreacting pupils were presumed to be brainstem dead. All events from suspicion of brainstem death (BSD) to declaration of BSD, approach for organ donation, recovery and transplants were recorded. Subjects were classified as possible, potential and effective donors, and barriers to donation were identified at each step. We identified 80 presumed brainstem dead patients over the study period. The mean age of this population was 35.9 years, and 67.5% were males. When formally asked for consent for organ donation (n = 49), 41 patients' relatives refused. The conversion rate was only 8.2%. The number of possible, potential and effective donors per million population per year were 127, 115.7 and 9.5, respectively. The poor conversion rate of 8.2% suggests a huge potential for improvement. Family refusal in majority of cases reflects poor knowledge and thus warrants interventions at community level.

Attitude and knowledge of healthcare workers in critical areas towards deceased organ donation in a public sector hospital in India.

BACKGROUND: The attitude of healthcare workers towards organ donation can either facilitate or hinder the process of organ donation. We assessed the attitude of healthcare workers employed in intensive or emergency care units of our hospital towards organ donation, and the influence of various factors on willingness for self-organ donation after death. METHODS: All doctors, paramedical workers, nursing staff and other staff members working in six distinct intensive or emergency care units in the hospital were requested to fill a completely anonymous, voluntary and self-administered questionnaire. Younger individuals, women and nurses constituted a majority of the study population. RESULTS: The questionnaire completion rate was 99%. About 55% of the study population were agreeable to donating organs after death and 27% were undecided. The factors that positively influenced their willingness to donate organs after death were favourable attitude of the spouse, religious beliefs supporting organ donation, knowledge of hospital's organ transplant programme, personal experience of the organ donation scenario, having ever donated blood or involvement in social activities, willingness to become an eye donor and willingness to become a living kidney donor. CONCLUSION: A largely favourable attitude towards organ donation was seen in our study population. However, the study reflects incomplete knowledge leading to confusion and thus, desire to know more among participants with respect to various aspects regarding organ donation. The factors identify that positively influence decisions regarding organ donation can be used as direct interventions.

Pneumocystis jirovecii infection of bilateral adrenal glands in an immunocompetent adult: a case report.

Pneumocystis jirovecii (PJ) infection is one of the most common opportunistic infections occurring in patients with HIV/AIDS and other immunocompromised states. It is not known to cause clinically significant illness in immunocompetent hosts. We report a 48-year-old HIV-negative, diabetic male who presented with fever and adrenal insufficiency. Abdominal sonography and PET-CT revealed bilateral enlarged adrenal glands with peripheral enhancement and central necrosis. An endoscopic ultrasound-guided fine-needle aspiration cytology of the left adrenal gland demonstrated well-defined, round cysts of PJ. There was no evidence of pulmonary involvement. The response to first-line treatment was poor and the patient responded to second-line treatment for Pneumocystis infection.

Association of 18bp insertion/deletion polymorphism, at -2549 position of VEGF gene, with diabetic nephropathy in type 2 diabetes mellitus patients of North Indian population.

BACKGROUND: Vascular endothelial growth factor (VEGF) is a potent multifunctional cytokine which plays a key role in the pathogenesis of diabetic micro-vascular complications. Human VEGF gene is said to be highly polymorphic. Insertion/deletion (I/D) polymorphism of the 18 bp fragment at -2549 position of the promoter region in VEGF gene is said to be of particular interest. The study was aimed to evaluate association of Insertion/deletion (I/D) polymorphism of the 18 bp fragment at -2549 position of the promoter region in VEGF gene, with diabetic nephropathy in type 2 diabetes mellitus. METHODS: This cross sectional study enrolled 40 subjects each of diabetic nephropathy (DN), diabetes mellitus without nephropathy (DM) and normal control subjects. DNA was isolated from peripheral blood leukocytes. Genotyping of the VEGF gene insertion/ deletion (I/D) polymorphism was done by the polymerase chain reaction (PCR) methods. The frequency of VEGF alleles and genotype distribution were compared in diabetic nephropathy, uncomplicated diabetic and control groups. RESULTS: DD genotype and D allele were found to be significantly associated with DN group (p = 0.009 and 0.02 respectively) in comparison to DM group. Also DD genotype conferred significant risk of diabetic nephropathy in DM group (OR = 4.2) (against combined frequency of ID and II genotype) so does D allele 2.09 (against I allele). CONCLUSION: DD genotype and D allele in I/D polymorphism at -2549 position of VEGF gene is associated with increased susceptibility to diabetic nephropathy in north Indian population.

Interleukin-6 and C-reactive protein in pathogenesis of diabetic nephropathy: new evidence linking inflammation, glycemic control, and microalbuminuria.

INTRODUCTION: Recent studies have shown that subclinical inflammation is a part of type 2 diabetes mellitus. This study was designed to explore the relationships between low-grade inflammation and renal microangiopathy in patients with type 2 diabetes mellitus. MATERIALS AND METHODS: Sixty patients with type 2 diabetes mellitus were included in the study and further divided into normoalbuminurics, microalbuminurics, and macroalbuminurics, of 20 patients each. We analyzed serum concentrations of high-sensitivity C-reactive protein (HS-CRP) and interleukin-6 (IL-6) and studied their correlation with proteinuria. The patients and a control group of 20 healthy individuals were followed-up for a period of 6 months and the markers measured again. RESULTS: A positive correlation was found between urinary albumin excretion and levels of HS-CRP (r = 0.781, P < .001) and IL-6 (r = 0.708, P < .001). The level of glcosylated hemoglobin (HbA1c) showed a significant positive correlation with urinary albumin excretion (r = 0.630, P < .001), CRP (r = 0.750, P < .001), and IL-6 (r = 0.680, P < .001). Levels of HbA1c, HS-CRP, and IL-6 significantly decreased in all three diabetic groups after 6 months of treatment. Also, the percentage of HbA1c decrement correlated well with the decrease percentage in HS-CRP (r = .277, P = .01). CONCLUSIONS: Inflammatory markers in early type 2 diabetic nephropathy are elevated and are independently associated with urinary albumin excretion. It is possible to hypothesize on the participation of locally released cytokines in the development of kidney damage.

Extended daily dialysis in acute renal failure: a new therapeutic approach.

INTRODUCTION: Although intermittent hemodialysis (IHD) is the standard therapy in patients with acute renal failure, it is associated with several drawbacks. Extended daily dialysis (EDD) has been described as a compromise between IHD and continuous therapies and could potentially overcome problems associated with IHD. MATERIALS AND METHODS: We compared EDD with IHD each administered in 15 patients with acute renal failure. The IHD was administered 4 hours per session thrice weekly, while EDD was given for 8 hours per session daily with the same machines at similar blood and dialysate flow rates. Treatment outcome, metabolic control, and hemodynamic stability were assessed in the patients of each group. RESULTS: A total of 140 EDD treatment sessions and 82 IHD sessions were administered. Patients in the EDD and the IHD groups received a mean of 74.67 +/- 29.70 hours and 21.73 +/- 5.99 hours of dialysis, respectively (P < .001). The median urea reduction ratio in the EDD group was significantly higher (83.82% versus 64.66%, P < .001). Patients on EDD showed faster normalization of deranged metabolic parameters. Hemodynamically, EDD was better tolerated compared to IHD. The median predialysis mean arterial pressure in the EDD and IHD patients were 103.3 mm Hg and 100 mm Hg, respectively, while the postdialysis values were 78.6 mm Hg and 73 mm Hg, respectively. CONCLUSIONS: Extended daily dialysis appears to be a promising technique for dialysis in moderately ill patients having up to 2 organ failures.

Extensive medium-vessel vasculitis with SLE: an unusual association.

Systemic lupus erythematosus (SLE) is a multisystem disease of autoimmune origin. Vasculitis is often seen with SLE, but is usually limited to small vessels alone. The primary pathology in SLE-related vasculitis is leukocytoclastic vasculitis. Medium- and large-vessel vasculitis in association with SLE is distinctly uncommon and is limited to occasional case reports only. In addition, reports of medium-vessel vasculitis with SLE generally describe involvement of a single vessel bed. We report a rare case of extensive vasculitis involving medium-sized vessels in a patient with SLE. Our patient presented with classic signs and symptoms of SLE and satisfied a majority of the American College of Rheumatology criteria for SLE. She also had toe gangrene at presentation and developed paraplegia during the hospital stay. Radiologic studies showed evidence of diffuse medium-sized vessel vasculitis. The patient was treated with monthly pulse cyclophosphamide and high-dose prednisolone. Follow-up showed no new features of vasculitis and improvement in the signs and symptoms of SLE. Her paraplegia showed no response to treatment. This case stresses that medium-sized vessel occlusion anywhere in the body can occasionally occur due to vasculitis in a patient with SLE.