Assessment of South Asian Pediatric Acute Kidney Injury: Epidemiology and Risk Factors (ASPIRE)-a prospective study on "severe dialysis dependent pediatric AKI".

BACKGROUND: Pediatric acute kidney injury (AKI) is a global health concern with an associated mortality risk disproportionately pronounced in resource-limited settings. There is a pertinent need to understand the epidemiology of pediatric AKI in vulnerable populations. Here, we proposed a prospective study to investigate the epidemiology and associated risk factors of "severe dialysis dependent AKI" in children among South Asian nations which would be the first and largest of its kind. METHODS: The ASPIRE study (part of PCRRT-ICONIC Foundation initiative) is a multi-center, prospective observational study conducted in South Asian countries. All children and adolescents ≤ 18 years of age who required dialysis for AKI in any of the collaborating medical centers were enrolled. Data collection was performed until one of the following endpoints was observed: (1) discharge, (2) death, and (3) discharge against medical advice. RESULTS: From 2019 to 2022, a total of 308 children with severe AKI were enrolled. The mean age was 6.17 years (63% males). Secondary AKI was more prevalent than primary AKI (67.2%), which predominantly occurred due to infections, dehydration, and nephrotoxins. Common causes of primary AKI were glomerulonephritis, hemolytic uremic syndrome, lupus nephritis, and obstructive uropathy. Shock, need for ventilation, and coagulopathy were commonly seen in children with severe AKI who needed dialysis. The foremost kidney replacement therapy used was peritoneal dialysis (60.7%). The mortality rate was 32.1%. CONCLUSIONS: Common causes of AKI in children in South Asia are preventable. Mortality is high among these children suffering from "severe dialysis dependent AKI." Targeted interventions to prevent and identify AKI early and initiate supportive care in less-resourced nations are needed.

Towards the assessment of sediment connectivity in a large Himalayan river basin.

Sediment connectivity, defined as the degree of linkage between the sediment sources to downstream areas, is one of the most important properties that control landscape evolution in river basins. The degree of linkages amongst different parts of a catchment depends mainly on the hinterland characteristics (e.g. catchment morphology, slope, shape, relief, and elevation), channel characteristics (e.g. slope, stream network density, valley confinement), and the combined effects of vegetation (e.g. land use changes and land abandonment). This paper evaluates the sediment connectivity of the upper Kosi basin covering an area of ~52,731 km2 including Tibet and Nepal at different spatial scales. We have computed the index of connectivity (IC) using the equations originally proposed by Borselli et al. (2008) and modified by Cavalli et al. (2013) to evaluate the potential connection of sediment source areas to the primary channel network as well to the catchment outlet. Our results highlight significant spatial variability in sediment connectivity across the basin and provide important insights on structural sediment dynamics in a complex geological and geomorphological setting. We compare our results with the observed sediment load data at certain outlets and demonstrate that sediment flux in different sub-basins is controlled by variable slope distribution and land use and land cover that are strongly related to the structural connectivity. We argue that IC model can be extremely beneficial to understand sediment dynamics at catchment scale in a large river basin (~103-104 km2 scale), where systematic field investigations for mapping hillslope-channel linkages are not feasible.

Modelling impacts of climate change and socio-economic change on the Ganga, Brahmaputra, Meghna, Hooghly and Mahanadi river systems in India and Bangladesh.

The Ganga-Brahmaputra-Meghna (GBM) River System, the associated Hooghly River and the Mahanadi River System represent the largest river basins in the world serving a population of over 780 million. The rivers are of vital concern to India and Bangladesh as they provide fresh water for people, agriculture, industry, conservation and support the Delta System in the Bay of Bengal. Future changes in both climate and socio-economics have been investigated to assess whether these will alter river flows and water quality. Climate datasets downscaled from three different Global Climate Models have been used to drive a daily process based flow and water quality model. The results suggest that due to climate change the flows will increase in the monsoon period and also be enhanced in the dry season. However, once socio-economic changes are also considered, increased population, irrigation, water use and industrial development reduce water availability in drought conditions, threatening water supplies and posing a threat to river and coastal ecosystems. This study, as part of the DECCMA (Deltas, vulnerability and Climate Change: Migration and Adaptation) project, also addresses water quality issues, particularly nutrients (N and P) and their transport along the rivers and discharge into the Delta System. Climate will alter flows, increasing flood flows and changing pollution dilution factors in the rivers, as well as other key processes controlling water quality. Socio-economic change will affect water quality, as water diversion strategies, increased population and industrial development alter the water balance and enhance fluxes of nutrients from agriculture, urban centers and atmospheric deposition.

Water quality assessment and catchment-scale nutrient flux modeling in the Ramganga River Basin in north India: An application of INCA model.

The present study analyzes the water quality characteristics of the Ramganga (a major tributary of the Ganga river) using long-term (1991-2009) monthly data and applies the Integrated Catchment Model of Nitrogen (INCA-N) and Phosphorus (INCA-P) to the catchment. The models were calibrated and validated using discharge (1993-2011), phosphate (1993-2010) and nitrate (2007-2010) concentrations. The model results were assessed based on Pearson's correlation, Nash-Sutcliffe and Percentage bias statistics along with a visual inspection of the outputs. The seasonal variation study shows high nutrient concentrations in the pre-monsoon season compared to the other seasons. High nutrient concentrations in the low flows period pose a serious threat to aquatic life of the river although the concentrations are lowered during high flows because of the dilution effect. The hydrological model is satisfactorily calibrated with R2 and NS values ranging between 0.6-0.8 and 0.4-0.8, respectively. INCA-N and INCA-P successfully capture the seasonal trend of nutrient concentrations with R2>0.5 and PBIAS within ±17% for the monthly averages. Although, high concentrations are detected in the low flows period, around 50% of the nutrient load is transported by the monsoonal high flows. The downstream catchments are characterized by high nutrient transport through high flows where additional nutrient supply from industries and agricultural practices also prevail. The seasonal nitrate (R2: 0.88-0.94) and phosphate (R2: 0.62-0.95) loads in the catchment are calculated using model results and ratio estimator load calculation technique. On average, around 548tonnes of phosphorus (as phosphate) and 77,051tonnes of nitrogen (as nitrate) are estimated to be exported annually from the Ramganga River to the Ganga. Overall, the model has been able to successfully reproduce the catchment dynamics in terms of seasonal variation and broad-scale spatial variability of nutrient fluxes in the Ramganga catchment.

Prolonged intermittent renal replacement therapy in children.

Wide ranges of age and weight in pediatric patients makes renal replacement therapy (RRT) in acute kidney injury (AKI) challenging, particularly in the pediatric intensive care unit (PICU), wherein children are often hemodynamically unstable. Standard hemodialysis (HD) is difficult in this group of children and continuous veno-venous hemofiltration/dialysis (CVVH/D) has been the accepted modality in the developed world. Unfortunately, due to cost constraints, CVVH/D is often not available and peritoneal dialysis (PD) remains the common mode of RRT in resource-poor facilities. Acute PD has its drawbacks, and intermittent HD (IHD) done slowly over a prolonged period has been explored as an alternative. Various modes of slow sustained IHD have been described in the literature with the recently introduced term prolonged intermittent RRT (PIRRT) serving as an umbrella terminology for all of these modes. PIRRT has been widely accepted in adults with studies showing it to be as effective as CVVH/D but with an added advantage of being more cost-effective. Pediatric data, though scanty, has been promising. In this current review, we elaborate on the practical aspects of undertaking PIRRT in children as well as summarize its current status.