Factors affecting the outcome of acute renal failure among the elderly population in India: a hospital based study.

The spectrum of acute renal failure (ARF) in the elderly population and the factors predicting poor outcome in these patients are not well defined in literature. Identification of risk factors and poor prognostic markers in these patients can help in planning strategies to prevent ARF and to prioritise the utilization of sparse and expensive therapeutic modalities, especially in a developing country like ours. We retrospectively analyzed data of 454 elderly patients (age >or=60 years), detected having ARF in a tertiary care super-speciality hospital in North India, from April 2000 to March 2004. The mean age of this population was 66.4 years with 70.5% being male. 64% patients had more than one precipitating factors for ARF, with volume depletion being the most common precipitating factor (33% cases). Infection/sepsis (21.6%) and drugs (11.5%) were other important precipitating factors. 31.8% were recorded as having oliguric ARF (urine output <400 ml/day) and 33.5% required renal replacement therapy (RRT). Acute peritoneal dialysis was the most frequent form of RRT given (62.5%). Mortality was 41.2% (187 cases), of whom 56 (29.8%) died inspite of recovery from ARF. Among the survivors, 103 patients (22.7%) had complete renal recovery, 141 (31.1%) had partial renal recovery, while 23 (8.6%), remained dialysis dependent. The factors which were found to be associated with increased mortality were; age >or=70 years, presence of previous chronic illness, ARF precipitated by cardiac failure and infection, need for RRT, oliguria and increasing numbers of failed organs. To conclude, ARF among elderly is a common problem in nephrology practice at our institute and is responsible for 48.9% of nephrology admissions/consultations among elderly patients. Majority of these patients are prone to multiple renal insults. Underlying chronic illness, presence of cardiac failure and sepsis, oliguria, need for RRT and increasing number of organ failure is associated with poor outcome.

Effects of correction of metabolic acidosis on blood urea and bone metabolism in patients with mild to moderate chronic kidney disease: a prospective randomized single blind controlled trial.

BACKGROUND: There are no controlled trials on the efficacy of oral bicarbonate therapy in patients with mild to moderate chronic kidney disease (CKD). This prospective randomized controlled study was done to evaluate the effects of correction of metabolic acidosis on renal functions and bone metabolism in this group of patients. PATIENTS AND METHODS: Forty patients were randomized to treatment with oral bicarbonate or placebo for a period of 3 months. Investigations at baseline included venous pH, bicarbonate, renal functions, serum iPTH, and bone radiology. The treatment group (Group B) received daily oral sodium bicarbonate therapy at a dose of 1.2 mEq/kg of body weight. Their venous blood pH and bicarbonate levels were estimated weekly to keep blood pH near 7.36 and bicarbonate at 22-26 mEq/L by adjusting the dose of sodium bicarbonate. At the end of 3 months, all the tests were repeated in both groups. RESULTS: After oral bicarbonate therapy (OBT), there was a significant decline in the rise of blood urea level in Group B associated with a sense of well-being in 50% patients. The rise in parathormone (PTH) was six times the baseline value in Group A and only 1.5 times baseline value in Group B, although not statistically significant. There was no significant change in total calcium, phosphorus, alkaline phosphatase, creatinine, total protein, or albumin levels. CONCLUSION: Correction of metabolic acidosis in patients with moderate CKD attenuates the rise in blood urea and PTH, which might prevent the deleterious long-term consequences of secondary hyperparathyroidism.

Effect of local mupirocin application on exit-site infection and peritonitis in an Indian peritoneal dialysis population.

BACKGROUND: Staphylococcus aureus-associated peritonitis and catheter exit-site infections (ESIs) are important causes of hospitalization and catheter loss in patients undergoing chronic peritoneal dialysis. Intranasal and topical use of mupirocin has been found to be an effective strategy in decreasing S. aureus-related infectious complications in persons who are carriers of S. aureus; however, there is no consensus regarding the prophylactic use of mupirocin irrespective of carrier status. We aimed to determine the potential effectiveness of application of mupirocin cream at the catheter exit site in preventing ESI and peritonitis irrespective of carrier status in a tropical country such as India. METHODS: This prospective historically controlled study was done in a total of 40 patients. From August 2003, all patients, incident and prevalent, were instructed to apply 2% mupirocin cream daily to the exit site instead of the older practice of povidone-iodine and gauze dressing. Patients were not screened to determine whether they were S. aureus carriers. The infection-related data for 1 year, until July 2004, were compared with the historical control, which was infection-related data for the year preceding the year of mupirocin application. RESULTS: Mean age of the study population was 62 years, with 61.8% being male and 64.3% being diabetic. Local application of mupirocin led to a significant reduction in the incidence density per patient-month of both ESI and peritonitis compared to controls (0.15 vs 0.37 and 0.37 vs 0.67, p = 0.01 for both). This amounted to a relative reduction of 60.5% and 55% respectively. ESI and peritonitis due to S. aureus were also significantly lower in the study group compared to controls (incidence density per patient-month 0.05 vs 0.13 and zero vs 0.17 respectively, p < 0.01 for both). There occurred no catheter removal due to infection-related complications during the study period compared to two during the control period. None of the patients reported a mupirocin-related adverse effect. CONCLUSIONS: Daily application of mupirocin at the exit site is a well-tolerated and effective strategy in reducing the incidence of ESI and peritonitis in a tropical country such as India. It can thus significantly reduce morbidity, catheter loss, and transfer to hemodialysis in peritoneal dialysis patients.

Assessing suitability for renal donation: can equations predicting glomerular filtration rate substitute for a reference method in the Indian population?

BACKGROUND: Accurate measurement of donor renal function has important long-term implications for both the donor and recipient. As the use of recommended filtration markers is limited by cumbersome and costly techniques, renal function is typically estimated using 24-hour urinary creatinine clearance (urine-CrCl). Prediction equations used for rapid bedside estimation of glomerular filtration rate (GFR) are simple and overcome the inaccuracies of urinary collection and, if validated, can expedite the donor workup besides reducing the cost. We assessed the suitability of urine-CrCl and prediction equations for evaluating potential Indian renal donors. METHODS: 173 consecutive renal donors were enrolled. The predictive capabilities of the Cockcroft and Gault equation for creatinine clearance (CrCl) corrected for body surface area (CG-CrCl), CG-CrCl corrected for GFR (CG-GFR), MDRD-1, MDRD-2 and urine-CrCl were evaluated with 99mTc-diethylenetriaminepentaacetic acid (DTPA)-GFR as reference GFR. RESULTS: The study population had a mean age of 44.1 years with 74% being females. Mean DTPA-GFR was 83.85 ml/min/1.73 m2. The median percent absolute difference was most with urine-CrCl and least with CG-GFR (21.84 and 13.82). The Pearson's correlation varied from 0.08 to 0.26 (urine-CrCl and MDRD-1). The precision was most with MDRD-1 and least with urine-CrCl (0.07 and 0.01). The bias was least with CG-GFR and most with MDRD-2 (1.34 and 17.16). The number of subjects with predicted GFR values within 30% of DTPA was most with MDRD-1 (86%) and least with urine-CrCl (69%). The sensitivity for selecting a donor with a GFR of > or = 80/ml/min/1.73 m2 was the most with CG-GFR (65.7%), while specificity was maximum with MDRD-2 (90.1%). CONCLUSION: Our results in potential Indian renal donors show that of all the prediction equations MDRD-1 is the most precise and accurate, while CG-GFR is the least biased. However, the poor correlation and level of error exhibited by these equations makes them suboptimal for donor evaluation.

Assessing glomerular filtration rate in healthy Indian adults: a comparison of various prediction equations.

BACKGROUND: Accurate measurement of renal function is important for the diagnosis, stratification and management of kidney disease. As the use of recommended filtration markers is limited by cumbersome and costly techniques, renal function is typically estimated by using various specifically derived prediction equations. Most of these equations have been derived from Caucasian patients suffering from varying degrees of chronic kidney disease. This study considers the validity of these equations in an Indian population without known kidney disease. METHODS: One hundred and twenty-two consecutive renal donors who had undergone 99mTc-diethylenetriaminepentaaceticacid (DTPA) glomerular filtration rate (GFR) estimation were enrolled. The predictive capabilities of the Cockcroft and Gault equation for creatinine clearance corrected for body surface area (CG-CrCl), CG-CrCl corrected for GFR (CG-GFR), modification of diet in renal disease (MDRD) 1, MDRD 2 and 24-hr urinary creatinine clearance (urine-CrCl) were evaluated with DTPA GFR as measured GFR. RESULTS: The mean age of the study population was 44.7 yrs with 72.2% being female). The mean measured DTPA GFR was 83.42 ml/min with a range of 61-130 ml/min. The median % absolute difference between the calculated and measured GFR was 19.7, 15.4, 19.3, 20.8 and 25.5, respectively, for CG-CrCl, CG-GFR, MDRD 1, MDRD 2 and urine-CrCl. Pearson's correlation between the measured and estimated GFR varied from 0.09-0.27. The precision as reflected by R2 value was 0.05 for CG-CrCl and CG-GFR, 0.06 for MDRD 1 and MDRD 2 and 0.01 for urine-CrCl. The bias was -14.14, 1.46, 11.89, 17.70 and -2.80 for CG-CrCl, CG-GFR, MDRD 1, MDRD 2 and urine-CrCl, respectively. The accuracy within 30% was 71.3, 85, 86, 76 and 69% for CG-CrCl, CG-GFR, MDRD 1, MDRD 2 and urine-CrCl, respectively. CONCLUSIONS: Our results from a healthy Indian population suggest that of all the predictive equations, MDRD 1 and MDRD 2 were the most precise, MDRD 1 the most accurate and CG-GFR the least biased. However, the poor correlation and error level exhibited by these equations makes them sub-optimal for clinical use.

Low prevalence of restless legs syndrome in patients with advanced chronic renal failure in the Indian population: a case controlled study.

BACKGROUND: Restless legs syndrome (RLS) is reported to occur in 20-70% of uremic patients. There is no study from India regarding the prevalence of RLS in chronic renal failure (CRF) patients. Studies from other Asian countries have shown a much lower prevalence compared to the West. This study investigated the prevalence of RLS in patients with advanced CRF in the Indian population. PATIENTS AND METHODS: Sixty-five CRF patients and 99 controls were evaluated using a predesigned standard questionnaire. The control group consisted of prospective renal donors. RESULTS: The mean age of our patients was 42.4 +/- 14.9 years as compared to 43.7 +/- 11.2 years (p = NS). The distribution of cause of CRF was as follows: diabetes 38.5%, hypertension 13.9%, chronic interstitial nephritis 29.2% and chronic glomerulonephritis 18.4%. RLS was present in 1 patient (1.5%) and none of the controls. CONCLUSION: The prevalence of RLS in CRF patients in India is very low as compared to the Western population.

Restless legs syndrome in hemodialysis patients in India: a case controlled study.

OBJECTIVE: To assess the prevalence of restless legs syndrome (RLS) in Indian patients on hemodialysis as compared to controls. METHODS: One hundred and twenty-one consecutive hemodialysis patients and 99 controls were evaluated using a standard predesigned questionnaire. The control group comprised completely normal healthy adults who were being evaluated as renal donors. Nerve conduction studies were done in those patients diagnosed with RLS. RESULTS: RLS was present in eight hemodialysis patients (6.6%) and none of the controls. Patients (87.5%) with RLS had delayed sleep onset. Nerve conduction showed evidence of sensori-motor neuropathy in five patients and a normal study in one patient. When we compared the patients with RLS to those without RLS, there was no significant difference in their age, duration of hemodialysis, hemoglobin, blood urea, creatinine, serum ferritin or use of erythropoeitin. CONCLUSIONS: The prevalence of RLS was 6.6% in patients on hemodialysis; and 0% in controls, which is much lower than that reported from the West.

Multiple myeloma presenting as collapsing glomerulopathy.

A 54 year old male patient was admitted with advanced renal failure of recent onset. Serology was noncontributory. Renal biopsy showed collapsing glomerulopathy with interstitial fibrosis. Bone marrow examination confirmed the diagnosis of multiple myeloma. With chemotherapy multiple myeloma went into remission. However he continued to remain dialysis dependent and a repeat kidney biopsy showed progression to endstage renal disease.