Incidence and causes of early hospital readmissions after living donor renal transplant - A single centre study.

Background: Kidney transplantation in spite of being the best modality for the treatment of ESRD remains a complex therapeutic option as it has its own set of problems due to associated morbidity especially in the first month after transplantation. Aim: The primary aim of this study was to find the incidence, causes, and factors responsible for early hospital readmissions (EHRs) and secondary aim was to find the effect of EHR on morbidity, mortality, and graft loss. Patients and Methods: A retrospective analysis of the records of the chronic kidney disease (CKD) patients who underwent living donor renal transplantation. 202 patients were included in the study. Inpatient records and charts were assessed for the medical status of the patients, cause of CKD, comorbidities, admissions 3 months prior to transplant, vintage dialysis, and modality of dialysis. Results: Sixty-one (30.2%) patients were readmitted to the hospital once or more within 30 days of discharge after renal transplantation. Thirty-four (55.7%) patients in the EHR group were admitted once or more in the 90 days prior to transplant as compared to 48 (34%) patients in the no readmission group. Thirty-four (55.7%) patients in the EHR group were hospitalised again within 1 year of EHR and 50 (35.5%) in the no EHR group got admitted within 1 year of discharge. Conclusions: Renal transplant recipients with hospital admissions 90 days before transplant and readmissions within 30 days of discharge after transplantation are at high risk of morbidity and should be treated as high-risk category and should have more stringent follow-up protocols.

Incidence, Risk Factors, and Outcomes of Transition of Acute Kidney Injury to Chronic Kidney Disease in Cirrhosis: A Prospective Cohort Study.

Transition to chronic kidney disease (CKD) after an episode of acute kidney injury (AKI) is known in patients without cirrhosis. We studied the incidence and risk factors for development of CKD in patients with cirrhosis. Competing risk analysis was performed to identify risk factors for CKD development. Of 818 patients with cirrhosis (age, 50.4 ± 11.8 years; 84% males; Model for End-Stage Liver Disease [MELD], 19.9 ± 9.9), 36% had AKI at enrollment, 27% had previous AKI, and 61% developed new episodes of AKI during the follow-up period. CKD developed in 269 (33%) patients. Serum cystatin C (CysC; subdistribution hazard ratio [SHR], 1.58; 1.07-2.33), episodes of previous AKI (SHR, 1.26; 1.02-1.56), and AKI stage at enrollment (no AKI [SHR, 1] vs. stage 1 [SHR, 3.28; 1.30-8.25] vs. stage 2 [SHR, 4.33; 1.76-10.66] vs. stage 3 [SHR, 4.5; 1.59-12.73]) were identified as baseline risk factors for CKD development. On time-varying competing risk analysis, MELD (SHR, 1.01; 1.00-1.03), number of AKI episodes (SHR, 1.25; 1.15-1.37), and CysC (SHR, 1.38; 1.01-1.89) predicted CKD development. Development of CKD was associated with higher risk of death. Reduction in glomerular filtration rate (GFR) not meeting CKD criteria was observed in 66% of patients with cirrhosis, more so in those with previous AKI episodes and a high CysC level and MELD score. Renal histology, available in 55 patients, showed tubulointerstitial injury in 86%, cholemic nephrosis in 29%, and glomerular changes in 38%. Conclusion: Almost two-thirds of patients with cirrhosis develop episodes of AKI and reduction in GFR; one-third progress to CKD, resulting in adverse outcomes. Higher MELD and CysC levels and number of AKI episodes predict development of CKD in patients with cirrhosis.

Role of Alpha Blockers in Hypertension with Benign Prostatic Hyperplasia.

Hypertension and benign prostatic hyperplasia (BPH) are common disorders of aging men. As the world population is aging these two diseases are becoming a significant public health problem worldwide. Approximately 30% of men treated for BPH have coexisting hypertension. The α-Adrenergic Blockers: Prazosin, Terazosin and Doxazosin are established agents in the therapy of hypertension, and are also effective drugs in the treatment of BPH. It is reasonable to use α-Adrenergic Blockers as the treatment of choice for men with hypertension and BPH.

APASL clinical practice guidelines on the management of acute kidney injury in acute-on-chronic liver failure.

Acute-on-chronic liver failure (ACLF) is a syndrome that is characterized by the rapid development of organ failures predisposing these patients to a high risk of short-term early death. The main causes of organ failure in these patients are bacterial infections and systemic inflammation, both of which can be severe. For the majority of these patients, a prompt liver transplant is still the only effective course of treatment. Kidneys are one of the most frequent extrahepatic organs that are affected in patients with ACLF, since acute kidney injury (AKI) is reported in 22.8-34% of patients with ACLF. Approach and management of kidney injury could improve overall outcomes in these patients. Importantly, patients with ACLF more frequently have stage 3 AKI with a low rate of response to the current treatment modalities. The objective of the present position paper is to critically review and analyze the published data on AKI in ACLF, evolve a consensus, and provide recommendations for early diagnosis, pathophysiology, prevention, and management of AKI in patients with ACLF. In the absence of direct evidence, we propose expert opinions for guidance in managing AKI in this very challenging group of patients and focus on areas of future research. This consensus will be of major importance to all hepatologists, liver transplant surgeons, and intensivists across the globe.

Observational study to evaluate the safety and efficacy of saroglitazar in Indian diabetic dyslipidemia patients.

UNLABELLED: Saroglitazar is a dual PPAR α/γ agonist approved in India for the management of diabetic dyslipidemia. AIMS: The objective of this study was to evaluate the safety and efficacy of saroglitazar 4 mg once daily in clinical practice. METHODS: This was an observational, multicenter, single-arm study. Patients with type 2 diabetes (with on-going antidiabetic medication), age above 18 years, and triglycerides ≥200 mg/dL were included. RESULTS: A total 2804 patients with a mean duration of diabetes 6.29 yrs were included in this analysis. The baseline demographic profile was: mean age of 53 yrs, mean body weight 72.3 kg and mean BMI of 27 kg/m(2). 62.5% patients were male and 57.8% were reported to be on statin therapy at baseline. All 2804 patients were on antidiabetic medications with 15.4% patients on monotherapy and rest were on two or more than two antidiabetic medications at baseline. The baseline triglycerides and HbA1C values were 312.3 mg/dL and 8.3% respectively. At 3 months follow-up, use of saroglitazar 4 mg led to significant reduction in TG (35.8%), LDL-C (16.4%), total cholesterol (19%) and non-HDL-C (23.4%). Addition of saroglitazar to baseline antidiabetic medications showed a significant 0.9% absolute reduction in HbA1c with significant improvement in fasting and post prandial plasma glucose. No serious adverse events, alteration in liver or renal enzymes and edema or weight gain were reported. CONCLUSION: Saroglitazar is a potential therapeutic option in type 2 diabetic patients with high TG levels, not controlled by statins, for comprehensive control of lipid and glycemic parameters with acceptable safety profile.

AKI in patients with acute on chronic liver failure is different from acute decompensation of cirrhosis.

BACKGROUND AND AIMS: The current definitions of acute kidney injury (AKI) including HRS have been derived from patients with decompensated cirrhosis. No studies have carefully addressed AKI in patients with acute on chronic liver failure (ACLF). We evaluated the prevalence, spectrum, natural history and mortality of AKI at admission and new-onset AKI in hospitalized patients with ACLF and compared the results with patients with acute decompensation of cirrhosis (ADC). PATIENTS AND METHODS: Consecutive patients with ACLF (n = 382) and ADC (n = 451) were prospectively studied. Serial renal and liver functions were recorded and correlated with the disease course and outcome. RESULTS: AKI at admission and new onset AKI in the hospital were not different in patients with ACLF and ADC (p > 0.05). However, a significant difference in the spectrum of AKI was noted; functional volume-responsive AKI was more common (p < 0.05) in ADC, while patients with ACLF more frequently had the structural form of AKI (p < 0.05). Moreover, patients with ADC had significantly less AKI progression (p < 0.05) and prolonged duration (p < 0.05), a lower requirement of RRT (p < 0.05) and also less AKI resolution (p < 0.05) compared to ACLF patients. Patients with ACLF (versus ADC) had a significantly higher mortality on multivariate analysis. CONCLUSIONS: The kidneys are differentially affected in patients with cirrhosis with or without liver failure. Patients with ACLF with AKI have more structural AKI, greater potential for reversibility despite higher progression as well as higher mortality compared to patients with ADC. Prevention and early detection of AKI should be considered in patients with ACLF.

Orbital apex syndrome due to rhinoscleroma. A case report.

A case of Rhinoscleroma of the left maxilla and ethmoid with involvement of the orbital apex, in a female diabetic, is reported. The significance of the associated diabetes is discussed.

Comparative evaluation of cell proliferative indices and epidermal growth factor receptor expression in gastric carcinoma.

A total of 62 patients of gastric carcinoma were studied to find a correlation between newer prognostic indicators like cell proliferative indices including Nucleolar Organizer regions (AgNORs), Ki 67 Labelling Index and Epidermal Growth Factor Receptor (EGFR) expression with the various, histopathological criteria and compared with 30 controls of non neoplastic gastric diseases. EGFR expression was positive in 48(77.4%) cases. The Ki 67 labelling indices ranged from 0 to 50% with a mean of 21.35 +/- 17.88% among the cases. AgNOR counts ranged from 1.64 to 4.49 with a mean of 3.41 +/- 0.81 among the cases. Positive EGFR expression correlated strongly with differentiation of the tumour, poorly differentiated tumours showing a higher positivity. EGFR positivity also showed good correlation with metastasis as well as with the invasiveness of the tumour. Ki 67 labelling indices correlated significantly with metastatic status, microscopic types and degree of differentiation of the tumour. A strong correlation was observed between AgNOR counts and metastasis as well as the microscopic type of the tumour. EGFR expression correlated strongly with Ki 67 scores and weakly with AgNOR counts among the patients of gastric carcinoma.

Management of acute kidney injury in cirrhosis.

Acute kidney injury (AKI) is a relatively frequent problem, occurring in approximately 20 % of hospitalized patients with cirrhosis. Although serum creatinine (S Cr) is the most commonly used method to determine AKI because of easy availability and low cost, practically it underestimates the extent of kidney injury in patients with chronic liver disease. AKI is defined as an abrupt rise in S Cr of 0.3 mg/dl or more (>26.4 mmol/l) or an increase of 150 % or more (1.5-fold) from baseline. The cause of AKI in cirrhosis is multifactorial and is unique in terms of pathogenesis. The most common causes of AKI in cirrhosis can be subdivided into either functional or structural. The functional group includes volume-responsive (prerenal azotemia) and volume-unresponsive states (hepatorenal syndrome). Volume responsive is the most common type of AKI due to frequent use of diuretics, large volume abdominal paracentesis and gastrointestinal bleeding in patients with liver disease. The structural causes include acute tubular necrosis, tubulointerstitial and glomerular diseases. Patients with decompensated cirrhosis are in a vasodilatory state leading to a decrease in effective arterial blood volume, predisposing to AKI. Therefore, management of AKI depends on the underlying cause, and therapy should be directed toward removal of the cause. The outcome in cirrhosis when patients are on dialysis is very dismal. Every effort should be made to prevent AKI.

Laboratory evaluation of anticoagulant-treated baits for control of the northern palm squirrel, Funambulus pennanti Wroughton.

Individually caged northern palm squirrels, Funambulus pennanti, were fed with bait containing 0.025% warfarin or fumarin, 0.0075% chlorophacinone or 0.005% brodifacoum for a fixed number of days varying from 1 to 14. Brodifacoum (WBA 8119) was found most toxic since 66% and 70% of the animals died after one and two days' feeding respectively. Chlorophacinone killed 70% of the squirrels after three days' feeding. Squirrels were relatively tolerant to warfarin and fumarin since the mortality after a period of 14 days' feeding was only 58% and 75% respectively.

Evaluation of brodifacoum against T. indica, M. hurrianae and R. rattus.

Brodifacoum was evaluated in the laboratory against the two gerbils, Tatera indica and Meriones hurrianae and the house rat, Rattus rattus. The acute oral LD50 for these rodents was found to be 0.10 mg/kg, 0.083 mg/kg and 0.77 mg/kg respectively. Feeding tests with 0.002% and 0.005% brodifacoum produced a 100% mortality after a 3-day feeding period in the gerbils and after a 4-day period in R. rattus. The anticoagulant is toxic at both the concentrations to all three species but is less palatable in comparison to plain baits. Results of this laboratory evaluation indicates that 0.002% brodifacoum-treated bait can be effectively used against T. indica, M. hurrianae and R. rattus.

Simultaneous determination of a mixture of organophosphorus and carbamate pesticides by high performance liquid chromatography.

A simple HPLC procedure has been developed for the simultaneous determination of a mixture of standard carbaryl, carbofuran, carbendazim, dimethoate, malathion and methyl parathion from a spiked agricultural soil sample. The pesticide mixture has been extracted using methanol-water. A concave gradient elution with acetonitrile-phosphate buffer for 15 min followed by linear elution for 5 min, using a wavelength of 224 nm for detection, has been found to resolve the mixture efficiently.