Direct Oral Anticoagulants in Nephrotic Syndrome: Our Experience and Literature Review.

Nephrotic syndrome (NS) is one of the common presentations of kidney diseases both in children and adults. NS patients, particularly those with membranous nephropathy, have increased risk of thromboembolic events. Heparin and vitamin K antagonists (VKAs) continue to be commonly used as prophylactic and therapeutic agents, given the experience of use of these agents in NS and nonrenal indications of anticoagulation. The use of direct oral anticoagulants (DOACs) in NS is reported in some case series, conference abstracts, and a few small studies. We report our experience of using DOACs in 11 patients of NS with severe hypoalbuminemia. Out of 11, one patient required change of anticoagulation from DOACs to VKA and the rest of them did well with DOACs. There were no bleeding episodes in our study. We suggest larger studies to be carried out to better understand the use of these agents in NS.

Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis with COVID-19: A Single Center Experience.

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients particularly presenting as rapidly progressive glomerulonephritis (RPGN) are at extremely high risk of progressing to end-stage kidney disease (ESKD); therefore, timely intervention is important. We describe our experience of managing six AAV patients who were on treatment (induction phase) and developed COVID-19. Cyclophosphamide was stopped till RT-PCR for SARS-CoV-2 was reported negative and patient had improved symptomatically. Out of our six patients, one died. Subsequently, cyclophosphamide was successfully resumed in all the surviving patients. In patients of AAV with COVID-19, close monitoring and withholding of cytotoxic medication and continuing steroids till active infection subsides is an effective treatment strategy until more and more data from well-conducted largescale studies become available for guidance.

Impact of Fasting during Ramadan on Renal Functions in Patients with Chronic Kidney Disease.

Introduction: The impact of Ramadan fasting in patients with chronic kidney disease (CKD) remains less studied and with inconsistent results. In this study, we tried to look at the impact of Ramadan fasting on renal function in patients with CKD. Materials and Methods: In this prospective observational study, we included 28 adult CKD patients. All relevant biochemical parameters including renal function tests were done in the month before Ramadan fasting and within 3 months after Ramadan. Urine output, body weight, and blood pressure were also monitored during Ramadan and after the end of Ramadan for at least 10 days. Results: All the 28 patients (mean age: 46 ± 12 years) included in the study managed to fast for the whole month, and none displayed any new clinical symptoms or signs. The renal function worsened in four (14.28%), and it was significant in those with CKD Stages 4 and 5 (P < 0.003). Conclusion: Stable CKD patients can fast with careful monitoring; however, there is a risk of renal function deterioration in advanced CKD.

Paint-thinner-induced Acute Kidney Injury: A Case Series and Review.

Occupational health hazards contribute significantly to the morbidity and mortality of workers in factories. Toluene has become a widely abused inhaled volatile drug. The spectrum of toluene-induced renal injury includes rhabdomyolysis, myoglobinemia, distal renal tubular acidosis (RTA), acute tubular necrosis, glomerulonephritis, and interstitial nephritis. We describe two patients with paint-thinner-induced kidney injury who were affected through different routes of exposure and recovered well, with one requiring dialysis support; the second patient, who had developed Type 1 distal RTA and mild kidney injury, was managed with conservative measures. Toluene can cause acute neurological symptoms, accompanied by severe metabolic alterations, as well as organ injury and dysfunction. A common association of the development of hypokalemic paralysis and metabolic acidosis with toluene intoxication was observed. Liver injury and rhabdomyolysis are also common. Vomiting, dehydration, tubular injury, and rhabdomyolysis are all possible additional causes of acute renal failure in toluene intoxication. Type 1 distal RTA, which is characterized by an inability to lower urine pH despite acidemia, results in hyperchloremic metabolic acidosis with hypokalemia. The management of acute toluene toxicity is largely conservative, consisting of correcting the electrolytes and the acid-base balance, fluid alterations, and renal replacement therapy in severe acute kidney injury. A clinical suspicion of organ failure and prompt supportive care leads to encouraging results. Adequate protective steps for workplaces involved in the use of such substances in confined spaces include prior risk assessment, using low-toxicity chemical products, ensuring adequate ventilation, safety training, and using appropriate personal protective equipment.

Levothyroxine-Induced Pseudotumor Cereberi.

Rise in intracranial tension (ICT) has varied clinical presentation which can range from subtle disturbances like headache to frank neurologic impairment. An important aspect is rapidity of rise of ICT. Pseudotumor cerebri is associated with many syndromes, toxication, and drugs. Our case is a unique one given the rarity of eltroxin, which is otherwise relatively safe drug and commonly used in this part of the world, induced Pseudotumor cerebri. Our patient had dramatic response to discontinuation of levothyroxine.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) in Kidney transplant patients: A case series and literature review.

COVID-19 is a novel highly contagious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Immunosuppressed people are at a higher risk for unfavourable outcomes if infected with SARS-CoV-2, as cellular immunity plays a key role in determining the course and outcome in COVID-19. Kidney transplant recipients (KTRs) are thus a distinct subset of the population. We describe our early experience with 2 KTRs requiring hospital admission due to COVID-19 and who recovered well. We conclude that timely intervention in the form of modifying immunosuppression and close monitoring and institution of further measures based on clinical severity is needed in KTRs with COVID-19.

Incidence and Risk Factors of Acute Kidney Injury in Patients Hospitalized with Pneumonia: A Prospective Observational Study.

Background: Acute kidney injury (AKI) is frequent in hospitalized patients with critical illness and presents in up to one-quarter of patients with non-severe community-acquired pneumonia (CAP), resulting in increased short and long-term mortality. There is a paucity of literature from resource-limited settings regarding the incidence and risk factors for AKI in patients with CAP. In this study, we looked at the incidence and risk factors for AKI in patients hospitalized with CAP in a resource-limited setting Methods: This prospective observational study conducted over 1 year period included patients ≥ 18 years of age diagnosed with CAP admitted to a tertiary care center. The differences in baseline characteristics between hospitalized CAP patients with and without AKI; and risk factors for AKI and the need for renal replacement therapy (RRT) were analyzed using Chi-square test, t-test, Mann-Whitney U test, and logistic regression with p-value <0.05 considered statistically significant. Results: We observed 27.6 % (58/210) of patients had AKI in our study. Patients with AKI had significantly higher baseline comorbidities of chronic kidney disease (p=0.005) and coronary artery disease (p=0.032), and significantly higher uric acid (p=0.002), lower albumin (p=0.005), lower total protein (p=0.015), higher bilirubin (p=0.001), higher LDH (p=0.041), and higher CURB-65 score (p<0.001) in addition to elevated creatinine, BUN (p<0.001) compared to the no-AKI group. The patient group requiring RRT had significantly more males (p=0.019), with significantly higher phosphorus (p=0.038), lower ALT (p=0.022), and expectedly higher creatinine (p<0.001) and blood urea nitrogen (p=0.016). The adjusted logistic regression analysis revealed that patients with higher CURB-65 scores were at increased odds of undergoing RRT (OR 8.74, 95% CI 5.27 to 12.21, p=0.039). Conclusion: There is a high incidence of AKI in patients hospitalized for CAP in developing countries. Clinicians should be alert for the prevention and early detection of AKI in CAP patients.

Uncommon Adverse Effects of Commonly Used Chemotherapeutic Agents in Medical Oncology Practice: A Series of Two Cases of Hand-Foot Syndrome.

Chemotherapy has an increasing potential for cure and palliation of most forms of cancer in different stages. However, its use is associated with a multitude of side effects some very common and few very rare. We present two patients of metastatic nonsmall lung cancer who had severe forms of hand-foot syndrome with two different classes of antineoplastic drugs and have to discontinue chemotherapy.

Aluminium phosphide poisoning with severe cardiac dysfunction and the role of digoxin.

Aluminium phosphide (ALP) is a common cause of suicidal poisoning in India where it is easily available and commonly known as 'rice tablet'. In rural areas of India, it is still used to protect rice and stored grains from rodents and pests. 1 There is no specific antidote for phosphide poisoning and treatment involves meticulous supportive care. Ingestion can lead to severe cardiac suppression and cardiogenic shock. For patients poisoned with ALP who continue to have refractory shock with persistent myocardial suppression despite the use of adrenergic inotropic agents, the addition of digoxin may be beneficial. We present a case where digoxin was utilised with beneficial patient outcomes.

Early onset symptomatic neuropathy in a child with Type 1 Diabetes mellitus.

Diabetic neuropathy (DN) is a major complication of Type 1 Diabetes Mellitus (T1DM). It is usually subclinical in childhood, but can cause significant impairment with its progression through to adulthood. Current guidelines vary in their recommendation regarding screening for DN in children with T1DM, with some advocating starting screening 5 years after the diagnosis of T1DM. Clinical assessment comprising of history and neurological examination is the most commonly used method for screening, though Nerve Conduction Studies (NCS) provide better sensitivity in picking up early subclinical diabetic neuropathy. We describe an adolescent female with poorly controlled T1DM, presenting with symptomatic diabetic neuropathy within 2 years of disease onset and as the initial long term complication. Thus, guidelines regarding screening for DN may need revision, to start screening earlier than presently recommended, and NCS could play a prominent role in screening children with significant risk factors for developing DN.

Novel risk factors and early detection of anti tubercular treatment induced liver injury-Looking beyond American Thoracic Society Guidelines.

INTRODUCTION: ATT remains the standard treatment for tuberculosis. Drug-induced liver injury (DILI) has been a long-standing concern in the treatment of tuberculosis (TB) infection. AIMS AND OBJECTIVES: To study the occurrence and risk factors of DILI in patients on ATT by regular clinical and biochemical monitoring. MATERIALS AND METHODS: 200 patients, in whom ATT was started, were enrolled in the study. None of the patients with established risk factor for DILI as recognized by ATS guidelines was included in our study population. Regular clinical and liver function test monitoring was done at the commencement of ATT and then at 2, 4, and 8 weeks in the intensive phase subsequently at 4 and 6 months. RESULTS: DILI developed in 16 patients. Among those, 10 patients (62.5%) developed early DILI and 6 patients (37.5%) developed late DILI. Female gender and extrapulmonary tuberculosis were found to be associated with increased risk of ATT-induced DILI, whereas age, BMI, and serum albumin were not found to significantly increase DILI risk. CONCLUSION: DILI is a common problem among patients on ATT in our population. Early detection not only reduces the risk of developing Hepatic Failure but also prevents mortality.

Nonalcoholic fatty liver disease as an independent risk factor for carotid atherosclerosis.

PURPOSE: Nonalcoholic fatty liver disease (NAFLD) is a frequently encountered clinical condition in clinical practice, particularly in obese and diabetic patients. Carotid atherosclerosis is regarded as surrogate marker of coronary atherosclerosis. We aimed to know whether evaluation for carotid atherosclerosis should be done in all patients of NAFLD. MATERIALS AND METHODS: A total of 200 NAFLD patients and 100 age- and sex-matched controls were enrolled into the study. Ultrasound was done to document fatty liver and carotid intimal thickness, and relation between these two was observed. RESULTS: Grade 1 fatty liver was seen in 36% patients while Grade 2 fatty liver was found in 39% and Grade 3 fatty liver in 25%. Patients with Grade 1 fatty liver had left intima-media thickness (IMT) in the range of 0.4-0.6 mm (mean IMT - 0.69 mm) and had right IMT in the range of 0.5-0.8 mm (mean IMT - 0.71 mm). In patients with Grade 2 fatty liver, left IMT was in the range of 0.6-1.0 mm (mean IMT - 0.80 mm) and right IMT in the range of 0.7-1.0 mm (mean IMT - 0.84 mm), while in patients with Grade 3 fatty liver, left IMT was in the range of 0.8-1.2 mm (mean IMT - 0.93 mm) and right IMT in the range of 0.9-1.4 mm (mean IMT - 0.99 mm). Among controls, the mean left IMT was 0.579 mm and mean right IMT was 0.575 mm. CONCLUSION: The level of carotid intimomedial thickness was more in cases than in controls and progressively increased with the grade of fatty liver which was statistically significant.

Differentiating secondary from primary dengue using IgG to IgM ratio in early dengue: an observational hospital based clinico-serological study from North India.

BACKGROUND: Secondary dengue causes more severe disease than the primary. Early on, it is important to differentiate the two. We tried to find important clinical and laboratory differences between the two for the purpose of early differentiation. METHODS: One hundred fourteen patients confirmed on reverse transcriptase-polymerase chain reaction (RT PCR) were studied. On day 2 of illness IgM and IgG indices were studied for calculation of IgG/IgM ratio. A one-step immunochromatographic assay was used for classification of patients into primary and secondary dengue. Patient characteristics were also studied. RESULTS: Dengue serotype 1 was the most common found in 60.5% patients. 66.7% (76 patients) had secondary dengue. Secondary dengue cases had a higher mean temperature (101.56 ± 1.55 vs. 100.79 ± 1.25,°F, p 0.015), lower platelet counts (50.51 ± 38.91 vs. 100.45 ± 38.66, x 103/micl, p <0.0001) and a significantly higher percentage of Dengue hemorrhagic fever/Dengue shock syndrome (38.2% vs. 2.6%, p <0.0001). In early phase of dengue NS1 and PCR were found to be better tests for diagnosis and later IgM is better. The IgG/IgM ratio of ≥ 1.10 had a sensitivity of 100%, specificity of 97.4% and accuracy of 67.5% in differentiating secondary from primary dengue. CONCLUSION: Early on in the clinical course, IgG/ IgM ratio can play an important role to differentiate the two. We found the ratio of ≥ 1.10 to be the best cut off for the same.

Epidermal growth factor receptor mutation in adenocarcinoma lung in a North Indian population: Prevalence and relation with different clinical variables.

INTRODUCTION: Lung cancer is one of the most common causes of cancer deaths worldwide. Adenocarcinoma is taking over squamous cell lung cancer as the predominant histological subtype. Several cytotoxic drugs are available for the treatment of lung cancer, but side effects limit their use. Recently, targeted therapies for cancers have come into clinical practice. AIMS AND OBJECTIVES: To determine the prevalence of epidermal growth factor receptor (EGFR) mutation in adenocarcinoma lung in a North Indian population and its relation with different clinical variables. MATERIALS AND METHODS: A total of 57 patients who met inclusion criteria were recruited into the study. Relevant history, clinical examination and investigations were done. EGFR mutation was done in all patients. RESULTS: A total of twenty patients tested positive for EGFR mutation. EGFR was more frequently detected in female patients (53.8%), while as only 19.4% of the male patients expressed EGFR mutation, which was statistically very significant (P = 0.007). EGFR mutation was more frequently detected in nonsmokers (52%) as compared to smokers (21.9%) which also was statistically significant (P value of 0.018). EGFR mutation was more common in Stage III and IV adenocarcinomas (48%) as compared to Stage I and II (21.4%) which was statistically significant (P value 0.034). CONCLUSION: EGFR mutation should be routinely done in all patients of adenocarcinoma lung particularly non-smoker females with Stage III and IV disease.

Levetiracetam Induced Drug Reaction with Eosinophilia and Systemic Symptom Syndrome.

Drug reaction with eosinophilia and systemic symptom syndrome (DRESS) is a hypersensitivity drug reaction, most frequently associated with antiepileptic drugs, characterized by skin rash, fever, pharyngitis, lymphadenopathy, and visceral organ involvement, typically presenting within 8 weeks of initiation of therapy. Management involves prompt withdrawal of the offending drug and use of systemic corticosteroids. We here present a rare case of DRESS secondary to levetiracetam. Only few case reports of DRESS secondary to levetiracetam have been published so far.

Prevalence of dyslipidemia in school children of Kashmir valley.

AIM: Increased incidence of CVD has been observed in recent years in the Kashmir valley (North India). Since the risk factor development of the cardiovascular diseases (CVD) takes place during childhood, we undertook an epidemiological survey to assess the prevalence of dyslipidemia in the school children of Kashmir valley. MATERIALS AND METHODS: 1131 children of 5-19 years of age were selected and evaluated for BMI, cholesterol, TGs, LDL and HDL levels from different areas of Srinagar city (urban) region of the Kashmir valley from June 2011-June 2014. RESULTS: The frequency of dyslipidemia in Kashmiri children varied along the subjects. Hypertriglyceridemia was seen in 82.6% of the males and 47.6% of females in the age group of 5-9 years, 38.5% of males and 51.1% of females in the age group of 10-14 years and 24.7% of males and 35.9% of the females in the age group of 15-19 years. Low levels of HDL than normal were seen in 34.7% of males and 19% of females in the age group of 5-9 years. Similarly low HDL levels were seen in 17.9% of males and 15.5% of females in the age group of 10-14 years. The incidence of low HDL was also seen in 4.9% of males and 10.8% of females in the age group of 15-19 years. CONCLUSIONS: In the present study dyslipidemia was more common in centrally obese children and the most common component was high triglycerides and low HDL's. Female school children were at higher risk of developing CVD than males.