Acute renal failure in an intensive care unit in India--prognostic factors and outcome.

We prospectively analyzed 70 consecutive patients who developed acute renal failure (ARF) in the intensive care unit (ICU) during a six year period to define prognostic factors and outcome. Age, sex, preexisting chronic diseases, systemic infections, number of organs failing during the disease course, need and mode of renal replacement therapy (RRT), and length of stay in ICU were recorded. Analysis of factors in survivors (n=7, Gp A) and nonsurvivors (n=63, Gp B) was done by univariate and multivariate analysis. The mean age of patients was 28.6 years. Forty nine (70%) patients developed ARF following surgery, whereas 21 (30%) developed ARF in a medical setting. Cardiovascular surgery (39) and pancreatic surgery (7) were important causes in the surgical group, whereas in the medical group acute pancreatitis (11) was the main causative factor. One patient had ARF only, while in the rest, other organs were also involved. In more than 80% of these patients, organ failure and sepsis were present before the onset of ARF. Fifty two (74.3%) patients required dialytic support. The overall mortality was 90%. Number of organs failing, (1.5 +/-9 in Gp A vs 3.6 +/- 8 in Gp B), presence of systemic infection (1 in Gp A vs 55 in Gp B), prolonged stay in ICU (3.7 +/- 1.1 days in Gp A vs 8.0 +/- 5.4 in Gp B) and need for RRT (2 in Gp A vs 50 in Gp B) correlated with the mortality. Using multiple logistic regression analysis, only multiple organ failure (3 or more) correlated with the mortality. We conclude that multiple organ failure is a poor prognostic factor in patients with ARF in the setting of the ICU.

Does serum albumin at start of continuous ambulatory peritoneal dialysis (CAPD) or its drop during CAPD determine patient outcome?

The impact of serum albumin at start of continuous ambulatory peritoneal dialysis (SA1), serum albumin before death (SA2), and change in serum albumin during continuous ambulatory peritoneal dialysis (delta SA) were prospectively studied in 41 continuous ambulatory peritoneal dialysis (CAPD) patients with a follow-up of 19 +/- 11.6 months. For analysis, patients were divided into two groups at each measurement point: SA1 or SA2 > 3.0 g/dL or delta SA < 1.0 g/dL (group I), and SA1 or SA2 < 3.0 g/dL or delta SA > 1.0 g/dL (group II). On log rank test, the mortality rate was significantly higher in group II patients in relation to SA1 (p < or = 0.0001), SA2 (p = 0.0002), and delta SA (p = 0.001). On univariate Cox proportional hazard regression analysis, SA1 (p = 0.0001), SA2 (p = 0.0001), delta SA (p = 0.002), and episodes of peritonitis (p = 0.0001) were significant. On multivariate analysis, SA2 (p = 0.003) was significantly related to patient mortality. SA2 (r = 0.8; p = 0.0001), but not delta SA, was related to SA1. We conclude that SA2 is the best predictor of patient mortality on CAPD. SA2 is strongly related to SA1. Thus protein restriction in the pre-dialysis stage should be advised cautiously to avoid consequent hypoalbuminemia.

A case report: adrenal ganglioneuroblastoma in a 59-year old man.

Ganglioneuroblastoma is a common type of tumor in children, but is rarely seen in adults. We present here a case of adrenal ganglioneuroblastoma in a 59-year old man.

The relation of mutant p53 accumulation in transitional cell carcinoma of bladder with pathological stage, grade, recurrence and survival.

In this study prognostic significance and clinical value of mutant p53 gene in bladder transitional cell tumors is investigated. In our clinic, between 1997-2000, transurethral resection was performed in 48 cases, 3 females (6%) and 45 males (94%) with the diagnosis of primary bladder tumor, age ranges between 30-81 years old (average 58.9 +/- 9.9). The patients whose pathology results were transitional cell carcinoma were gathered into two groups as p53 positive and p53 negative by immunohistochemical study. These cases who were followed 1-36 months were compared to each other for pathologic state, tumor grade, recurrence and survival. It's found out that mutant p53 accumulation is related to high grade and pathologic stage tumors. But it's concluded that p53 positivity doesn't effect recurrence and survival rates.

Analysis of adductors angle measurement in Hammersmith infant neurological examinations using mean shift segmentation and feature point based object tracking.

This paper presents image and video analysis based schemes to automate the process of adductors angle measurement which is carried out on infants as a part of Hammersmith Infant Neurological Examination (HINE). Image segmentation, thinning and feature point based object tracking are used for automating the analysis. Segmentation outputs are processed with a novel region merging algorithm. It is found that the refined segmentation outputs can successfully be used to extract features in the context of the application under consideration. Next, a heuristic based filtering algorithm is applied on the thinned structures for locating necessary points to measure adductors angle. A semi-automatic scheme based on the object tracking of a video has been proposed to minimize errors of the image based analysis. It is observed that the video-based analysis outperforms the image-based method. A fully automatic method has also been proposed and compared with the semi-automatic algorithm. The proposed methods have been tested with several videos recorded from hospitals and the results have been found to be satisfactory in the present context.

Functional restoration after early tendon transfer in high radial nerve paralysis.

We assessed the effect of an early transfer of pronator teres to extensor carpi radialis brevis on hand function in patients with high radial nerve paralysis. Power grip and precision grip were measured preoperatively and postoperatively using a dynamometer. Fifteen patients were operated on, of which ten could be assessed at the end of 6 months. At 6 months after surgery, there was a median increase of 48% in power grip, 162% in tip pinch, 90% in key pinch and 98% in palmar pinch. Decreased palmar flexion was seen in four patients. Fraying of the periosteal extension and rupture of sutures at the junction site were each seen in one patient, leading to unsatisfactory results. Early tendon transfer quickly restored efficient grip while awaiting reinnervation of wrist extensors, avoiding the need for prolonged external splintage.

Spectrum of adolescent-onset nephrotic syndrome in Indian children.

There are few data regarding adolescent-onset nephrotic syndrome (NS) and no guidelines for biopsy criteria and treatment protocol. This study was conducted to analyze the clinical spectrum of adolescent-onset NS and evaluate possible biopsy criteria in these children. A prospective analysis was carried out on all patients with idiopathic NS (fulfilling the ISKDC criteria) with onset between 1 and 18 years of age. They were evaluated clinically, followed by biochemical investigations and kidney biopsy. These characteristics of patients with onset between 1 and 12 years (group A) were compared with the same parameters in patients with onset between 12 and 18 years of age (group B) referred to our hospital over the same period. Among all clinical parameters, microhematuria was significantly more prevalent in adolescents (P<0.001). Kidney biopsy was performed in 88% of adolescent patients. Focal segmental glomerulosclerosis (FSGS) was the most-common histopathology in group B (46.3%) compared with minimal change disease (MCD) in group A (42.9%). Group B had a significantly higher frequency of membranoproliferative glomerulonephritis (MPGN) (P<0.005) and a significantly lower frequency of MCD (P<0.001). The biochemical parameters at the onset were similar. On comparing microhematuria, hypertension, and renal insufficiency at presentation, we observed that two or more of these features were present in all patients with MPGN and only in 19.6% of adolescents with MCD, mesangioproliferative glomerulonephritis, and FSGS. The frequency of steroid resistance was significantly higher in group B (P<0.001). In conclusion, adolescent-onset NS differs from the childhood variety in having a significantly higher frequency of hematuria, steroid resistance, and evidence of non-MCD, especially MPGN, on histopathology. Kidney biopsy can be restricted to those adolescents who have at least two abnormal clinical/biochemical features or are steroid non-responders.

Acute renal failure associated with liver disease in India: etiology and outcome.

Acute renal failure (ARF) associated with liver disease is a commonly encountered clinical problem of varied etiology and high mortality. We have prospectively analyzed patients with liver disease and ARF to determine the etiology, clinical spectrum, prognosis and factors affecting the outcome. Other than hepatorenal syndrome patients, out of 221 cases, 66 developed ARF secondary to various liver disease like cirrhosis (n = 29, mortality 8, risk factors-older age p < 0.01, grade III/IV encephalopathy p < 0.05), fulminant hepatic failure (n = 25, mortality 15, risk factor-prolonged prothrombin time p < 0.01), and obstructive jaundice (n = 12, mortality 7, risk factor-sepsis p < 0.01). In these three groups the factors leading to ARF were volume depletion (24), gastrointestinal bleed (28), sepsis (34), drugs (27) [aminoglycosides (9) and NSAID (18)] along with hyperbilirubinemia. Various types of ARF with contemporaneous liver injury were malaria (n = 37, mortality 15, risk factors-higher bilirubin p < 0.001, higher creatinine p < 0.05, anuria p < 0.05 and dialysis dependency p < 0.05), sepsis (n = 36, mortality 22, risk factors-age p < 0.001, higher bilirubin p < 0.01, oliguria p < 0.05), hypovolemia with ischemic hepatic injury (n = 14, mortality 5, risk factors-higher creatinine p < 0.05 and SGPT p < 0.01), acute pancreatitis (n = 12, mortality 4, risk factors-higher bilirubin p < 0.001, higher SGPT p < 0.01, dialysis dependency p < 0.05), rifampicin toxicity (n = 10, no mortality), paroxysmal nocturnal hemoglobinuria (n = 3, no mortality), CuSO4 poisoning (n = 3 mortality 2), post abortal (n = 11, mortality 6, risk factors higher creatinine p < 0.05 and SGPT p < 0.01), ARF following delivery including HELLP syndrome (n = 12, mortality 4, risk factors-higher bilirubin p < 0.01 and SGPT p < 0.01), and of uncertain etiology (n= 14 mortality 4). 133 patients (60.2%), required hemodialysis hemodialfiltration or peritoneal dialysis. ARF associated with liver disease is having high mortality (42.5%). Avoidance of dehydration, hypotension, nephrotoxic drugs and sepsis, with promote dialytic support are necessary to reduce mortality and morbidity.

Etiology, prognosis, and outcome of post-operative acute renal failure.

A Multivariate analysis was done in all patients who developed post operative ARF, during the period 1990-1995 to determine the etiological spectrum and to identify various variables affecting the outcome. Of 140 patients (110 operated at SGPGI and 30 operated outside) 116 underwent elective surgery. The different types of surgery leading to ARF were urosurgery (3.5%), open heart surgery (32.9%), gastrosurgery (16.4%), pancreatic surgery (9.3%), obstetrical surgery (3.6%) and others (2.8%). The incidence of ARF in SGPGI patients was highest in pancreatic surgery group (8.2%) followed by open heart surgery (3%). The different etiological factors responsible for ARF were perioperative hypotension (67.1%), sepsis (63.6%) and exposure to nephrotoxic drugs (29.3%). Sixty-four patients (45.7%) required dialysis. The overall mortality was 45%. The mortality was highest in patients who underwent open heart surgery (89.1%) followed by pancreatic surgery (84.6%). The factors associated with high mortality, other than the type of surgery, were preoperative hypotension (p < 0.05), oliguria (p < 0.01), need for dialysis (p < 0.05) and multiorgan failure (p < 0.001). AM following emergency surgery had poor outcome, though not statistically significant. Perioperative sepsis (p < 0.05) and preoperative use of aminoglycoside (p < 0.05) were significantly higher in patients operated outside SGPGI. This was associated with higher incidence of ARF. Thus we conclude that presence of multiorgan failure, oligoanuria, preoperative hypotension and need far dialysis are poor prognostic markers in ARF following surgery.