Incidence of end stage renal disease on renal replacement therapy in Nepal.

BACKGROUND: End stage renal disease patients are treated with dialysis in Nepal. But there is no renal registry to indicate the burden of disease in the country. OBJECTIVES: The objective of this study is to find out the incidence of ESRD on renal replacement therapy and their out come. MATERIALS AND METHODS: It is a retrospective analysis (audit) of all ESRD patients who had received dialysis inside Nepal and had under gone transplantation from 1990 to 1999. The haemodialysis (HD) registry, HD patients file, intermittent peritoneal dialysis (IPD) registry of Bir Hospital, Shree Birendra Hospital, Tribhuwan University Teaching hospital and National Kidney Center were reviewed. Acute renal failure and acute on chronic renal failure were excluded and the demographic profile, dialysis session, dialysis duration and outcome of all ESRD patients were computed. One patient was counted only once in spite of attending more than one center for dialysis. SPSS package was used for analysis. RESULTS: Total number of 1393 ESRD patients received renal replacement therapy (RRT) in the decade. Mean age of patients were 46.7 +/- 16.7 with 70% of ESRD were between 20-60 years age with male: female ratio of 1.8:1. Initial mode of RRT was IPD in 58.2%, HD in 41.7% and pre-emptive transplantation in 0.1% patients. Records of 189 patients could not be found and out of remaining 1208 patients, 85.8% received dialysis for < 3 months, 6% received dialysis for more than a year and 9.5% had undergone kidney transplantation. The incidence of ESRD had increased gradually with 3.4 per million populations (pmp) in 1990 to 11.89 pmp in 1999 with an average annual incidence of 6 pmp and only 0.31% of expected ESRD patients received RRT. CONCLUSION: The incidence of ESRD is increasing but majority discontinue or die within 3 months. Dialysis centers needs to be expanded to different parts of country and prospective studies have to be carried out to fi nd out of cause of ESRD and to institute preventive measures.

Thyroid hormone profile in patients with chronic kidney disease: a single centre study.

BACKGROUND: Chronic kidney disease (CKD) is a global burden and now recognized as a major public health problem worldwide. Patients with CKD have alteration in thyroid hormone metabolism. This study aims to evaluate the status of thyroid hormone profile in different stages of CKD. METHODS: The cross-sectional study included 103 CKD patients attending Nephrology and Dialysis unit of KIST Medical College Teaching Hospital, Lalitpur, Nepal. Serum creatinine, free triiodothyronine (fT3), free thyroxine (fT4), and thyroid stimulating hormone (TSH) were measured. Risk factors, duration of illness and physical examination of patients were recorded along with their written informed consent. Patients with history of any thyroid function abnormalities, on medication for hypothyroidism and pregnancy were excluded. RESULTS: Out of 103 CKD patients, 59 (57.28%) were males and 44 (42.71%) were females. Thirty five (33.98%) CKD patients had low fT3 and 19 (18.44%) had low fT4 with normal TSH. Six (5.82%) CKD patients had increased TSH concentrations with normal fT3 and fT4. The median value of creatinine, fT3 and fT4 were significantly altered at different stages of CKD. Among the risk factors for CKD, diabetic nephropathy (44.66%) was found to be the lead primary cause followed by chronic glomerulonephritis (26.21%) and hypertension (23.30%). CONCLUSIONS: In our study thyroid hormone profile was altered in CKD patients, mainly in the stage 5 CKD. Most common thyroid dysfunction was low fT3 and low fT4 with normal TSH levels.

Pattern of glomerular disease in Nepal: A single-center experience.

Glomerulonephritis (GN) is the most common cause of end-stage renal disease in Nepal. The aim of the present study is to determine the clinical presentation and histological pattern of GN with and without immunofluorescence (IF). It is a retrospective analysis of all GN patients with kidney biopsy at the Bir Hospital from January 2000 to April 2009. The clinical presentation, blood pressure, urine analysis, 24-h urinary protein, biochemistry, hemoglobin, antinuclear antibody, anti-ds DNA, light microscopy (LM) and IF findings of kidney biopsies were computed from hospital records. SPSS package was used for analysis. A total of 398 patients [LM 204 (51%) and LM plus IF 194 (49%] were analyzed. The mean age of the study patients was 28 ± 13.6 years (range 7-74); males comprised 52.8% and females 47.2% of the patients; 51% were between 16 and 30 years of age. The common clinical presentations included nephrotic syndrome (NS), seen in 69% of the patients, followed by acute nephritic syndrome, seen in 14.4% of the patients. Kidney biopsy without IF showed mesangial proliferative GN (MesPGN) in 21.1%, membranoproliferative GN (MPGN) in 18.6%, membranous nephropathy (MN) in 14.2%, minimal change disease (MCD) in 12.3% and focal and segmental glomerulosclerosis (FSGS) in 9.8% of the cases. With IF, MCD was seen in 23.2%, FSGS in 18%, MN in 11.9%, IgA nephropathy in 9.8%, MesPGN in 8.2%, MPGN in 4.1% and crescentic GN in 3.1% of the cases. Lupus nephritis in the cases GN was most common in young adults, with the majority presenting with NS. MCD and FSGS were the most common glomerular lesions; over-diagnosis of MesPGN and MPGN by LM could be due to exclusion of IgA nephropathy.

Acute intradialytic complications in end stage renal disease on maintenance hemodialysis.

INTRODUCTION: Hemodialysis is the preferred method of treatment for Nepalese patients with end stage renal disease. Despite the technological advances and better understanding of physiology associated with hemodialysis, a number of complications are known to be associated with hemodialysis. This study was undertaken to study the frequency of acute intradialytic complications in patients undergoing hemodialysis. METHODS: A cross-sectional study was conducted at Nephrology unit of a tertiary care hospital from 15 June, 2007 to 15 December, 2007. A total of 28 patients were included in the study. Patients with acute renal failure and acute on chronic renal failure were excluded from the study. RESULTS: Total sessions of hemodialysis during the period were 1455. Hypotensive episode were 66 (4.5%) and was the commonest complication and followed by hypertensive episodes were 58 (3.8%). Other problems encountered were transfusion reactions were 23 episodes (1.5%), rigors not related to transfusions were 13 episodes (0.8%), nausea/vomiting were 20 episodes (1.4%), muscle cramps were 12 episodes (0.8%), hypoglycemia were 6 episodes 5(0.4%). CONCLUSIONS: The frequency of intradialytic complications is low and many of them are not life threatening.

Pattern of end stage renal disease in a tertiary care center.

INTRODUCTION: End Stage renal disease (ESRD) is a major public health problem across the world and it is rising. The incidence prevalence and causes of ESRD is not known in Nepal. With a population of 27 million people the estimated incidence of ESRD is around 2700/year if we take 100/million population at par with India and Pakistan. However majority of patients do not reach hospitals with dialysis facilities. The aim of the present study was to analyze the clinico-epidemiological profile of ESRD in the Nepalese context. METHODS: A retrospective, cross sectional study was conducted on newly diagnosed ESRD patients within five years in a tertiary care center. Their demographic profile, etiology and follow up were studied. RESULTS: The mean age of the patients was 42 years, male to female ratio being 1.7:1. Chronic glomerulonephritis (41%) was the leading cause of ESRD, followed by diabetic nephropathy (16.8%) and hypertensive nephrosclerosis (13.7%). Unexplained renal failure constituted 18% of our cases. Intermittent peritoneal dialysis (IPD) remained the initial mode of therapy due to easy accessibility. Most of the patients dropped out after having single session of IPD. Others went for repeat sessions of IPD or haemodialysis. Out of the 23.6% who went for haemodialysis only 13% could continue dialysis for more than three months and 3.8% could go to neighboring country for renal transplantation. CONCLUSIONS: CGN is the leading cause of ESRD followed by diabetic nephropathy and hypertension. It affected younger age group people. ESRD treatment is costly and unaffordable by most Nepalese people. Stress should be given to the health education and screening programme for prevention and early detection of CKD.

Acute renal failure in a tertiary care center in Nepal.

From July 1998 to July 1999, 45 cases of acute renal failure were treated at Bir Hospital, Kathmandu. Out of which 24 were male and 21 were female. Age ranged from 11 months to 84 years with mean age being 35 years and 9 cases were below 10 years. Four cases with pre-renal azotaemia and twenty five cases of acute tubular necrosis (ATN) accounted for 64% of all cases. These were due to gastroenteritis 10, sepsis 6, post surgical 1, trauma 1 and obstretical complications 5. Multiple hornet stings were responsible for acute renal failure in 3 cases, acute urate nephropathy in 1 case and miscellaneous causes in 2 cases. Glomerulonephritis / vasculitis accounted for 17.7%, acute interstitial nephritis 4.4%, haemotytic uraemic syndrome (HUS) 6.6%, and post renal azotaemia in 6.6% of all cases. Mean serum creatinine was 8 mg/dl, mean blood urea 190 mg/dl. Eight cases were treated only conservatively, eighteen received haemodialysis, fourteen received peritoneal dialysis, three received both and two refused for dialysis. Average duration of hospital stay was 13.6 days. Out of the forty-five cases twenty-nine recovered normal renal function, ten expired, two recovered partially, two progressed to chronic renal failure and two left against medical advice. Overall mortality was 22.2%. Common causes of acute renal failure in our setting were gastroenteritis (22%) and sepsis (20%). HUS was exclusively seen in children following bacillary dysentery. Multiple hornet stings is an important cause of acute renal failure in our country.