Traditional medicines prescribed for prevention of COVID-19: Use with caution.

Acute interstitial nephritis can result due to exposure to any medication, toxins, infections or malignancy. In the midst of this Coronavirus (COVID-19) pandemic, there has been a race for finding remedies to prevent the spread of and control the complications due to Severe Acute Respiratory Syndrome Coronavirus 2. Certain Indian medicinal herb concoctions like kabasura kudineer and nilavembu kudineer are being widely publicized to boost immunity and reduce the risk of developing COVID-19. Little knowledge exists about the adverse effects of these herbal remedies. We report two patients who presented to us with vague complaints following the ingestion of kabasura kudineer and we diagnosed them with acute tubulointerstitial nephritis (ATIN). The temporal relationship of ingestion of these remedies to the development of ATIN calls for vigilance and caution with regular monitoring of renal functions especially in those with chronic kidney disease.

Risk Factors and Outcomes of Acute Cardio-renal Syndrome in a Tertiary Care Setting in South India.

AIMS AND OBJECTIVES: To study the incidence,risk factors and in hospital mortality of Type I Cardiorenal syndrome(CRS1). To study the incidence of hyperkalemia in patients receiving Acei, ARB's or MRA Materials and Methods: Prospective observational cohort study done between June and December 2015 in Madras Medical Mission, Chennai. Consecutive patients admitted with ACS/ADHF were studied and clinical, biochemical and laboratory data was collected. The development of CRS1 was determined by KDIGO criteria. Statistical analysis was done using IBM SPSS version 21. RESULTS: Among 460 patients studied, 153 (34%) developed CRS 1 according to KDIGO criteria. The number of diabetics and patients with pre-existing CKD was significantly higher in the CRS 1 group (p=0.00). Mortality was significantly higher in the CRS 1 group (20.2% vs. 7.8% p=0.00). The presence of CKD, Diabetes mellitus, inotropic requirement and eGFR, 60 ml/min/1.73 m2 were significant predictors of CRS 1. Among patients with CRS1, 55 patients (23.5%) needed renal replacement therapy (15.6 % acute peritoneal dialysis, 20.2% SLED). There was no significant difference in the incidence of hyperkalemia in patients who were on prior Acei, ARBs and MRA. CONCLUSION: There is a high incidence of CRS 1 in our setting and the mortality is significantly higher in this group of patients. Early nephrology referral and prompt stoppage of nephrotoxic agents can significantly reduce the incidence and risk of CRS1.

End of Life Care in End-Stage Kidney Disease.

There is a rise in burden of end-stage renal disease globally and in India. The symptom burden, prognosis, and mortality in chronic kidney disease closely mimics that of cancer. However, the palliative and end of life care needs of these patients are seldom addressed. A consensus opinion statement was developed outlining the provision of end of life care in end-stage kidney disease. Recognition of medical futility, consensus on medical futility, and cessation of potentially inappropriate therapies and medications are the initial steps in providing end of life care. Conducting a family meeting, communicating prognosis, discussing various treatment modalities, negotiating goals of care, shared decision-making, and discussion and documentation of life sustaining treatment are essential aspects of end of life care provision. The provision of end of life care entails assessment and the management of end-stage kidney disease symptoms and the care extends beyond the death of the patient to their families in the bereavement period.

A multicentre analysis of the outcome of arteriovenous fistula in maintenance haemodialysis.

INTRODUCTION: Arteriovenous fistulas (AVF) are the preferred choice for vascular access in hemodialysis. We aim to identify factors that may contribute to AVF failure. METHODS: Data regarding AVF survival were collected from 441 patients. All AVFs were either radial or brachial, of the end-to-side variety. Parameters studied were age, gender, diabetes mellitus, hypertension prior to end-stage kidney disease (ESKD), site of fistula, blood flow rate, venous pressure, dialysis vintage and frequency, needle gauge used during dialysis, year of fistula creation, and details of fistula failure. FINDINGS: The 6-month, 1-year and 2-year AVF survival rates were 98.41%, 95.01%, and 89.57%. Failure rates were 17.2%, 5.5%, 26.8%, and 14.4% for dominant radial, non-dominant radial, dominant brachial and non-dominant brachial respectively (P < 0.001). Using a larger needle size had better AVF survival rate (P < 0.05). All other factors had no significant correlation with AVF failure. CONCLUSION: There were no statistically significant differences in AVF patency with respect to gender, age, blood flow rate, presence of diabetes mellitus or systemic hypertension. A distally placed AVF in the nondominant arm had the best survival rate. Using a larger needle size, specifically 15G during dialysis, was associated with lowest AVF failure.

Increasing access to integrated ESKD care as part of universal health coverage.

The global nephrology community recognizes the need for a cohesive strategy to address the growing problem of end-stage kidney disease (ESKD). In March 2018, the International Society of Nephrology hosted a summit on integrated ESKD care, including 92 individuals from around the globe with diverse expertise and professional backgrounds. The attendees were from 41 countries, including 16 participants from 11 low- and lower-middle-income countries. The purpose was to develop a strategic plan to improve worldwide access to integrated ESKD care, by identifying and prioritizing key activities across 8 themes: (i) estimates of ESKD burden and treatment coverage, (ii) advocacy, (iii) education and training/workforce, (iv) financing/funding models, (v) ethics, (vi) dialysis, (vii) transplantation, and (viii) conservative care. Action plans with prioritized lists of goals, activities, and key deliverables, and an overarching performance framework were developed for each theme. Examples of these key deliverables include improved data availability, integration of core registry measures and analysis to inform development of health care policy; a framework for advocacy; improved and continued stakeholder engagement; improved workforce training; equitable, efficient, and cost-effective funding models; greater understanding and greater application of ethical principles in practice and policy; definition and application of standards for safe and sustainable dialysis treatment and a set of measurable quality parameters; and integration of dialysis, transplantation, and comprehensive conservative care as ESKD treatment options within the context of overall health priorities. Intended users of the action plans include clinicians, patients and their families, scientists, industry partners, government decision makers, and advocacy organizations. Implementation of this integrated and comprehensive plan is intended to improve quality and access to care and thereby reduce serious health-related suffering of adults and children affected by ESKD worldwide.

CTX-M type extended-spectrum ß-lactamase in Escherichia coli isolated from extra-intestinal infections in a tertiary care hospital in south India.

Background & objectives: Infections caused by extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli carrying blaCTX-M genes have been spreading globally, but there are geographical variations in the type of blaCTX-Mgenes prevalent and there are scanty data from India. This study was conducted to determine the CTX-M type ESBLs in E. coli isolates obtained from clinical specimens from patients with extra-intestinal infections attending a tertiary care hospital in south India. Methods: ESBL-producing E. coli isolated from patients with extra-intestinal infections were subjected to PCR using CTX-M group-specific primers. From a representative isolate, full-length CTX-M-15 gene was amplified and sequenced. An internal fragment of this gene was sequenced in 10 representative isolates. Results: Of the 300 isolates of E. coli tested, 88 per cent carried CTX-M genes and blaCTX-M-15was the most dominant gene present in 90 per cent of the positive isolates. Most (91%) of the isolates positive for blaCTX-M were sensitive to meropenem. Interpretation & conclusions: Our findings showed blaCTX-M-15 to be the dominant gene. Based on the data on antimicrobial susceptibility, cefoperazone-sulbactum could be an antimicrobial of choice.

Renal outcomes among snake-envenomed patients with acute kidney injury in southern India.

Background: . Acute kidney injury (AKI) is a common complication of snake envenomation. However, the long-term renal outcomes of such patients are not well defined. We aimed to determine the proportion of patients who developed AKI, characterize the presenting syndromes and ascertain the long-term resolution of AKI. Methods: . We did a cohort study with prospective follow- up from two centres in southern India. All admitted patients >15 years of age with snake envenomation and serum creatinine ≥1.5 mg/dl over the past 10 years were identified through their discharge summaries. These patients were prospectively contacted, interviewed telephonically and requested to come for a hospital review. Results: . Of the 866 patients screened, 1 84 developed AKI (21.2%). Among these, 53% had combined renal, haematological and neurological manifestations; 33.6% required admission to the intensive care unit and 38% were dialysed. On follow-up of hospital records the creatinine of 49% of patients had normalized. Of those admitted, 36% were contacted and none had a known renal disease or were on dialysis. Among these, 16 patients came to the hospital for review and only 2 had an elevated creatinine. The total mortality was 1 4. Conclusion: . AKI is an important cause of morbidity with snake envenomation and a proportion will require dialysis. The mortality in our study was low and long-term renal outcomes were relatively good.

Quantification of Subcutaneous and Visceral Fat in Abdominal CT and the Correlation with Metabolic Parameters.

The objective of this study was to determine the association of Computed tomography quantified visceral (VAT) and subcutaneous adipose tissue (SAT) with estimated glomerular filtration rate (eGFR) using CKD-EPI formula, diabetes mellitus, body mass index (BMI), proteinuria, lipid profile, and hypertension. Increased adipose tissue is the primary phenotypic characteristic of obesity. The amount and distribution of adipose tissue is associated with many adverse consequences, as hypertension, type 2 diabetes, cardiovascular disease etc. Abdominal CT with semi-automated software can quantify adipose tissue and predict the risk for metabolic diseases. This cross-sectional study was carried out of 101 individuals (71 Males and 30 Females) with the mean age of 59.4 ± 5.2 years. Axial sections of non-contrast CT abdomen between L4-5 intervertebral disc (10 mm) were selected to quantify VAT and SAT utilizing GE advanced workstation software. We took 18.5-22.9 kg/ m2 as the normal BMI for Indian population is. Hypertension was defined as per JNC 8 guidelines. The mean eGFR among hypertensives (no of ppl) was 78.1 ± 38.1, compared to 106 ± 29.8 in normotensives (p<0.001). A trend was observed towards lower eGFR with higher VAT (r=-0.194, p= 0.052). The mean eGFR among diabetics (82.1 ± 38 ml/min) was lower compared with non-diabetics (104.7 ±31.9ml/min, p= 0.002). There is a significant increase in VAT with increasing age (p=0.003). In a sample of 72 individuals' with high TGL and low HDL, showed trend towards increased adipose tissue in subcutaneous and visceral compartment. BMI showed positive association with VAT (p<0.001) and SAT(p<0.001). CT quantification of adipose tissue can be used as a predictive tool to assess risk for metabolic diseases and decline in renal function. Further, it helps in early implementation of pharmacological or life-style based modification for better survival.

Could metformin be used in patients with diabetes and advanced chronic kidney disease?

Diabetes is an important cause of end stage renal failure worldwide. As renal impairment progresses, managing hyperglycaemia can prove increasingly challenging, as many medications are contra-indicated in moderate to severe renal impairment. Whilst evidence for tight glycaemic control reducing progression to renal failure in patients with established renal disease is limited, poor glycaemic control is not desirable, and is likely to lead to progressive complications. Metformin is a first-line therapy in patients with Type 2 diabetes, as it appears to be effective in reducing diabetes related end points and mortality in overweight patients. Cessation of metformin in patients with progressive renal disease may not only lead to deterioration in glucose control, but also to loss of protection from cardiovascular disease in a cohort of patients at particularly high risk. We advocate the need for further study to determine the role of metformin in patients with severe renal disease (chronic kidney disease stage 4-5), as well as patients on dialysis, or pre-/peri-renal transplantation. We explore possible roles of metformin in these circumstances, and suggest potential key areas for further study.

Typical Hemodialysis in India: A Case Report.

We report here a typical case of a patient on hemodialysis (HD) for end-stage renal disease (ESRD) in India that highlights some of the management issues encountered in a country with an enormous burden of ESRD and major challenges of underdialysis and management of comorbidities. The patient, a 42-year-old multiparous woman with chronic kidney disease (CKD) stage V, type 2 diabetes mellitus, and hypertension is a homemaker from a middle-class family, living in a large city, with no family history of CKD. From May 2013 to December 2016, she has been receiving twice-weekly maintenance HD for 4 h (intermittent HD); access was via an internal jugular line initially and then via a left brachiocephalic arteriovenous fistula (AVF) from late June 2013. Medical problems in this patient included poor medication and dietary compliance, underdialysis, anemia, volume overload, congestive cardiac failure with recurrent pulmonary edema, and hypertensive crisis. In December 2016, she complained of pain in the fistula arm during dialysis, and in January 2017, she developed edema of the arm. Specific endovascular intervention with balloon angioplasty resulted in a resolution of the stenosis of the venous side of the AVF and the edema. Counselling for dietary compliance and drug adherence resulted in good blood pressure control. Unlike in most other dialysis units, we have been able to increase her HD to thrice weekly and institute several ancillary services, including skilled dietary counselling, cardiac care, and regular bioimpedance analysis with favorable outcomes. Thus, a multidisciplinary team approach offering such ancillary services would allow for better management and improved outcomes in patients with ESRD in resource-poor settings.

Role and Relevance of Blood Pressure Variability in Hypertension Related Co-morbidities.

Despite maintaining mean blood pressure at optimal levels, cardiovascular complications still occur in hypertensive patients. Blood pressure variability (BPV) has been implicated as a prominent factor responsible for incurring this additional risk. In this review we attempted to generate a consensus on the importance of BPV in the hypertension management and to evaluate different therapeutic options available to reduce BPV. Panel comprising of 11 leading experts from India in different areas of clinical practice (including nephrology, diabetes and endocrinology, cardiology, and critical care medicine) was convened. The board reviewed up to date literature on BPV, shared personal experiences from their clinical practice, and debated their opinions on the significance of BPV in hypertension management and also on various therapeutic options available to control it. The reviewers agreed that BPV is frequently observed in hypertensive individuals and it is a critical factor in hypertension management. Blood pressure variability can be measured by ambulatory blood pressure monitoring, home blood pressure monitoring, and office blood pressure monitoring. Members concurred that variations in blood pressure that are 10 standard deviations above the mean blood pressure should be considered as pathologically significant and such variations should be reduced using pharmacological therapies. The board opined that Angiotensin II Receptor Blockers,Calcium Channel Blockers etc such as Olmesartan, Nifedipine can be used to reduce BPV. As a way forward, the panel recommends to bridge the evidence gap that establishes a possible direct relationship between BPV and cardiovascular complications. Blood pressure variability has paramount role in the current hypertension management scenario. To reduce disease burden and increase quality of life of hypertensive individuals, physicians should consider lowering BPV along with physiological BP levels.

The impact of kidney foundations in alleviating the burden of CKD in India - an example, Tamilnad Kidney Research Foundation.

Chronic kidney disease (CKD) is a major public health problem in India. The CKD registry of India has been formed to understand the epidemiology of CKD in India. Due to health economics in India, the majority of CKD-affected patients cannot afford renal replacement therapy (RRT) services. There is an unmet need to improve the awareness of kidney disease in India, and the focus should be on prevention and early detection of CKD by screening high risk populations. The Tamilnad Kidney Research (TANKER) Foundation is a charitable trust established in 1993 with the aim to improve awareness and provide quality affordable treatment to underprivileged patients. TANKER is supported by contributions from well-wishers. It has three arms: i) treatment arm, ii) research arm, and iii) awareness and screening arm. TANKER Foundation offers free and subsidized dialysis twice weekly to 227 underprivileged patients. TANKER dialysis has been supported by state government funding schemes. TANKER actively supports and conducts research in nephrology. More than 100,000 people have benefitted from TANKER's kidney awareness programs. The screening programs have provided for early detection of CKD in both urban and rural areas. TANKER award functions are held annually to recognize research and exemplary service to society. The TANKER Foundation can be used as a model for developing countries to address the unmet needs in CKD management.

Obstructive sleep apnea in non-dialysis chronic kidney disease patients.

There is an enormous increase in the burden of chronic kidney disease both in developing and developed countries. There is a paucity of data on obstructive sleep apnea (OSA) in chronic kidney disease (CKD) patients in India. We used a cross-sectional prospective observational study to determine the prevalence of OSA in non-dialysis CKD patients. Of the 647 CKD patients 302 patients were in stage II, III and IV. The study population was screened using the Berlin questionnaire and 87 patients were positive for OSA (28%). Among the 87, 37 patients were excluded based on the exclusion criteria. Fifty patients underwent a split night sleep study. Stage II, III CKD patients were clubbed as early CKD or group one and stage IV CKD patients were clubbed as late CKD or group two. The spilt night study revealed an 88% incidence of OSA of varying severity. A sub group analysis was done to assess the severity of OSA. A statistical significance (p<0.05) between early and late CKD group was observed with respect to AHI and ODI. An improvement in the late CKD is observed and the Z values for AHI and ODI are 4.273 and 2.307, respectively. The prevalence and incidence of OSA was found to be 28% and 88% in non-dialysis CKD patients, respectively and the risk and severity of OSA increased with the progression of CKD stages and thus necessitating the need for screening the non-dialysis CKD population.

Body composition monitoring and nutrition in maintenance hemodialysis and CAPD patients--a multicenter longitudinal study.

Hydration and nutritional status of end stage renal disease (ESRD) patients are linked to increased morbidity and mortality. Body composition monitoring (BCM) by multi-frequency bioimpedance spectroscopy (MFBS) is considered to be a superior modality of fluid assessment in chronic kidney disease (CKD) dialysis. We did a longitudinal prospective study in South India on maintenance hemodialysis (MHD) and continuous ambulatory peritoneal dialysis (CAPD) patients over 24 months and looked at impact of baseline nutritional parameters and body composition parameters on 24-month mortality. Ninety-nine patients stable on dialysis for at least 3 months were recruited (MHD 85, CAPD 14) at baseline and at 24 months, 41 were alive and 33 had expired, 12 had undergone renal transplant and 13 were lost to follow-up. BCM and nutritional assessment were done at baseline and at follow-up. Baseline overhydration (OH) differed significantly between surviving and dead patients (p < 0.05). Receiver operating characteristic (ROC) curve between OH and mortality showed that the best cut-off point to differentiate between survived and expired patients was 3.15 L. ROC curve for BMI showed lower than cut-off of 22.65 kg/m(2) to predict mortality with sensitivity 41.30% and specificity 81.81%. At follow-up, triceps skin fold thickness (TSF), biceps skin fold thickness (BSF) and mid arm circumference (MAC) increased significantly from baseline (p < 0.001, p = 0.001 and p < 0.001, respectively). Overhydration and BMI are important predictors of mortality in dialysis patients. Improvement in anthropometric markers TSF, BSF and MAC in MHD patients was associated with survival.

Rethinking the Postgraduate Teaching Program and Examinations in Today's India.

Postgraduate medical education has undergone drastic changes in the developed and developing countries on par with advancements in technology. The Indian examination system which we imbibed from the British requires a rethinking and restructuring to keep pace with the changing trends shown by the Federation of the Royal Colleges of UK. In this manuscript we look at the strengths and weaknesses of different examination systems. We suggest changes in the theory examination which should be objectively based rather than the outdated essay and short notes. We discuss positive and proactive changes to reform our clinical examination system to enable a just and fair assessment of the candidate in a strictly time bound fashion.

Rare occurrence of fatal Candida haemulonii peritonitis in a diabetic CAPD patient.

A 68-year-old diabetic chronic kidney disease patient on continuous ambulatory peritoneal dialysis for two years developed Candida haemulonii peritonitis without any predisposing factors. There is no effective treatment for this fungus. A peritoneal biopsy showed morphological changes of acute inflammation and chronicity.

Nutritional status in stage V dialyzed patient versus CKD patient on conservative therapy across different economic status.

BACKGROUND: This aim of this multi-centric cross-sectional study was to assess the nutritional status in Indian chronic kidney disease (CKD) patients and to compare the nutritional indicators between stage 5 dialyzed (CKD-D) patients below the poverty line (BPL), and stage 3-4 non-dialyzed (CKD-ND) patients above (APL) and below the poverty line. METHODS: Patients were selected from a government medical college hospital, a charity-based outpatient dialysis unit, and a non-profit tertiary care center. The study groups included BPL CKD-ND (n = 100), BPL CKD-D (n = 98), and APL CKD-ND (n = 92) patients, based on a cut-off of per capita income US $1.25 a day. Patients were enquired by a qualified renal dietitian about their pattern of diet, and daily energy and protein intake by 24 h recall method. Anthropometric measurements and biochemical investigations were made and compared. RESULTS: Nutritional indicators were low in all three groups compared to those prescribed by European Best Practice Guidelines (EBPG). BPL CKD-D patients had low serum albumin levels (32.44444 ± 6.279961 g/L; p = 0.017) and 41.83% of them were underweight. The APL CKD-ND group registered the lowest mean daily energy (22.576 ± 6.289 kcal/kg/day) and protein intake (0.71 ± 0.06 g/kg/day), due to dietary restrictions imposed on them by themselves and unqualified renal dietitians. The APL group had better indicators of nutritional status in terms of mid-upper arm circumference (p = 0.001), triceps skin fold thickness (p < 0.001), and serum hemoglobin (p < 0.001). CONCLUSION: Several nutritional parameters were below the recommended international guidelines for all the three groups, though the high income group had better parameters from several indicators. There is an urgent need for nutritional counseling for CKD-D and CKD-ND patients.

Risk factors for hospital-acquired hypernatremia among critically ill medical patients in a setting utilizing a preventive free water protocol: Do we need to do more?

CONTEXT: Hospital-acquired hypernatremia (HAH) is a frequent concern in critical care, which carries high mortality. AIMS: To study the risk factors for HAH in settings that practice a preventive protocol. SETTINGS AND DESIGN: Two tertiary-care hospitals. Prospective observational study design. MATERIALS AND METHODS: Patients aged >18 years admitted for an acute medical illness with normal serum sodium and need for intensive care >48 h formed the study population. Details of the basic panel of investigations on admission, daily electrolytes and renal function test, sodium content of all intake, free water intake (oral, enteral and intravenous) and fluid balance every 24 h were recorded. Individuals with serum Na 140-142 meq/l received 500 ml of free water every 24 h, and those with 143-145 meq/l received 1000 ml free water every 24 h. STATISTICAL ANALYSIS USED: Risk factors associated with HAH was analysed by multiple logistic regression. RESULTS: Among 670 study participants, 64 (9.5%) developed HAH. The median duration of hypernatremia was 3 days. A total 60 of 64 participants with HAH had features of renal concentrating defect during hypernatremia. Age >60 years (P = 0.02), acute kidney injury (AKI) on admission (P = 0.01), mechanical ventilation (P = 0.01), need for ionotropes (P = 0.03), worsening Sequential Organ Failure Assessment (SOFA) score after admission (P < 0.001), enteral tube feeds (P = 0.002), negative fluid balance (P = 0.02) and mannitol use (P < 0.001) were the risk factors for HAH. Mortality rate was 34.3% among hypernatremic patients. CONCLUSIONS: The study suggests that administration of free water to prevent HAH should be more meticulously complied with in patients who are elderly, present with AKI, suffer multi-organ dysfunction, require mechanical ventilation, receive enteral feeds and drugs like mannitol or ionotropes.