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.

Acute kidney injury in pregnancy.

PURPOSE OF REVIEW: Pregnancy-related acute kidney injury (Pr-AKI) is associated with increased maternal and fetal morbidity and mortality and remains a large public health problem. RECENT FINDINGS: Pr-AKI incidence has globally decreased over time for the most part. However, the cause presents a disparity between developing and developed countries, reflecting differences in socioeconomic factors and healthcare infrastructure - with the noteworthy outlier of increased incidence in the United States and Canada. Although Pr-AKI can be secondary to conditions affecting the general population, in most cases it is pregnancy specific. Septic abortion, hyperemesis gravidarum, and hemorrhage have become less prevalent with access to healthcare but are being displaced by thrombotic microangiopathies, such as preeclampsia, hemolysis, elevated liver enzymes, low platelets syndrome, thrombotic thrombocytopenic purpura, and pregnancy-associated hemolytic-uremic syndromes, as well as acute fatty liver of pregnancy. Understanding these conditions plays a pivotal role in the timely diagnosis and enhancement of therapeutic approaches. SUMMARY: In this review, we focus on the renal physiology of the pregnancy, epidemiology, and specific conditions known to cause Pr-AKI, summarizing diagnostic definition, insights in pathophysiology, clinical considerations, and novel treatment approaches, thus providing the reader a framework of clinically relevant information for interdisciplinary management.

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.

Pregnancy and the kidney transplant recipient.

PURPOSE OF REVIEW: The current article reviews the available literature on the incidence, complications, outcomes, and management of pregnancies in kidney transplant recipients. RECENT FINDINGS: Pregnancy can be a reasonable option for women with a kidney transplant. More than 4700 successful pregnancies have been reported after kidney transplantation. New data have emerged regarding the risk of allograft dysfunction following pregnancy. There is a lack of consensus on the optimal time for conception, immunosuppressive targets, the safety of allograft biopsy, and infection surveillance. Successful pregnancies have recently been reported in ABO-incompatible transplant recipients and recipients of combined heart-kidney transplants. SUMMARY: The ideal contraceptive method, timing of conception, immunosuppressant protocol, infection surveillance, and the method of delivery should be individualized depending on the patient's age and medical conditions.

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.

Recreational use of marijuana: Current experience and information for nephrologists.

Support for legalizing the recre- ational use of marijuana has been steadily climbing. While there has been a decline in marijuana-related convictions and increase in state rev- enues, the .impact on public health and safety is not clear. The nephrology community must be aware of the complications of chronic marijuana use, such as recurrent acute kidney injury secondary to hyperemesis.

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.

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.

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 Amplifiers for Vascular Disease and CKD in South Asians: When Intrinsic ß-Cell Dysfunction Meets a High-Carbohydrate Diet.

South Asians, comprising almost one fourth of the world population, are at higher risk of type 2 diabetes mellitus, hypertension, cardiovascular disease, and CKD compared with other ethnic groups. This has major public health implications in South Asia and in other parts of the world to where South Asians have immigrated. The interplay of various modifiable and nonmodifiable risk factors confers this risk. Traditional models of cardiometabolic disease progression and CKD evaluation may not be applicable in this population with a unique genetic predisposition and phenotype. A wider understanding of dietary and lifestyle influences, genetic and metabolic risk factors, and the pitfalls of conventional equations estimating kidney function in this population are required in providing care for kidney diseases. Targeted screening of this population for metabolic and vascular risk factors and individualized management plan for disease management may be necessary. Addressing unhealthy dietary patterns, promoting physical activity, and medication management that adheres to cultural factors are crucial steps to mitigate the risk of cardiovascular disease and CKD in this population. In South Asian countries, a large rural and urban community-based multipronged approach using polypills and community health workers to decrease the incidence of these diseases may be cost-effective.

Complement-Mediated Disorders in Pregnancy.

Complement-mediated disorders in pregnancy span a large spectrum and have been implicated in all three complement pathways: classical, lectin, and alternative. Our understanding of these disorders in recent years has advanced due to a better understanding of complement regulatory proteins, such as complement factor H, complement factor I, membrane cofactor protein, and thrombomodulin that particularly affect the alternative complement pathway. Enthusiasm in genotyping for mutations that encode these proteins has allowed us to study the presence of genetic variants which may predispose women to develop conditions such as pregnancy-associated hemolytic uremic syndrome (P-aHUS), thrombotic thrombocytopenic purpura, preeclampsia/hemolysis, elevated liver enzymes, low platelets (HELLP), systemic lupus erythematosus/antiphospholipid syndrome, and peripartum cardiomyopathy. The advent of the anti-C5-antibody eculizumab to quench the complement cascade has already proven in small case series to improve maternal kidney outcomes in complement-mediated obstetric catastrophes such as P-aHUS and HELLP. In this review, we will detail the pathogenesis behind these complement-mediated pregnancy disorders, the role of complement variants in disease phenotype, and the most up-to-date experience with eculizumab in this population.

Chronic Kidney Disease of Unknown Etiology: Hotspots in India and Other Asian Countries.

There has been increased reporting of chronic kidney disease of unknown etiology (CKDu) in certain agricultural communities in the world. In India, an increased prevalence of CKDu has been observed in the states of Andhra Pradesh, Odisha, Goa, and Maharashtra. Although no single causative factor has been proved, several have been proposed: water-borne agrochemicals, silica, chemical flavors in betel nuts, and pesticides. The renal biopsy findings have been similar to those seen in Sri Lanka and Mesoamerican nephropathy in that the predominant findings have been tubular atrophy and interstitial fibrosis with little or no involvement of the glomerular and vascular compartments. Because most of the affected communities belong to the lower socioeconomic group including farmers, a multipronged approach is required for addressing this CKDu epidemic with an emphasis on awareness, prevention, screening, surveillance, provision of renal replacement therapy, increased government spending on health care, and systematic research.

Twenty-one episodes of peritonitis in a continuous ambulatory peritoneal dialysis patient: What is the root cause?

A 51-year-old female, with non-alcoholic liver cirrhosis, portal hypertension, type 2 diabetes mellitus, autosomal dominant polycystic kidney disease with a clipped cerebral aneurysm and chronic kidney disease stage 5 was on continuous ambulatory peritoneal dialysis (CAPD) for 6.5 years elsewhere. She came for opinion on continuation of CAPD as she had 21 episodes of peritonitis in 76 months. Her blood pressure was 80/50 mmHg. She was on haemodialysis with a temporary central access for 2 weeks. She had no abdominal tenderness, and exit site looked normal. Fluid was negative for Mycobacterium tuberculosis. Laparoscopically, we replaced the catheter with a new swan-neck Tenckhoff double-cuff catheter through a different exit site in the same sitting. Catheter-tip biofilm culture isolated Enterococcus casseliflavus. Peritoneal sampling biopsy showed evidence of fibrosis. She has adequate ultrafiltration and is currently on automated peritoneal dialysis for 5 months.

Effect of high-protein supplemental therapy on subjective global assessment of CKD-5D patients.

Adequate nutrition in patients on hemodialysis is an important step for improving the quality of life. This prospective study was undertaken to monitor the nutritional status of patients who were given high-protein supplements on malnutrition inflammation score (MIS) and to correlate with biochemical parameters in maintenance hemodialysis (MHD) patients. This prospective study was conducted on 55 chronic kidney disease patients on MHD (37 women, 18 men), aged between 21 and 67 years. Of the 55 patients, 26 patients received high-protein commercial nutritional supplements, whereas 29 patients received high-protein kitchen feeding. Every patient had their MIS, 24-hour dietary recall, hand grip, mid arm circumference, triceps skin-fold thickness at 0, 3, and 6 months. Each of the above parameters was compared between the high-protein commercial nutritional supplement cohort and high-protein kitchen feeding cohort, and the data were analyzed. Of the 55 patients, 82.61% of patients on high-protein kitchen feeding group and 66.67% in high-protein commercial nutritional supplement group were nonvegetarian (P = 0.021). According to the MIS, improvement was observed in malnutrition status from 3- to 6-month period in 38.1% of patients in high-protein commercial supplement group, whereas only in 8.7% in high-protein kitchen feeding group (P = 0.04). Assessment showed improvement in malnutrition status with high-protein commercial nutritional supplement, which was marked in patients with age group >65 years (P = 0.03) and in those in whom serum albumin is <35 g/L (P = 0.02). Both high-protein kitchen feeding and high-protein commercial nutritional supplement cohorts were observed to have improvement in overall nutritional status. Older patients >65 years with lower serum albumin levels (<3.5 g/dL) were observed to have significant improvement in nutritional status with high-protein commercial nutritional supplements.

Diabetic kidney disease patients on hemodialysis: a retrospective survival analysis across different socioeconomic groups.

BACKGROUND: Diabetic kidney disease is the leading cause of stage 5 chronic kidney disease (CKD) in India. Renal replacement therapy (RRT) is accessible to very few patients because of socioeconomic deprivation. We studied the effect of diabetes and socioeconomic status on the outcome of patients on maintenance hemodialysis (MHD). METHODS: We retrospectively analyzed the outcome of 897 patients (629 males/268 females; mean age ± standard deviation 48.69 ± 14.27 years) initiated on MHD from 2003 to 2009 at five dialysis centers in south India. There were 335 type 2 diabetic patients and 562 non-diabetic patients. Group 1 comprised the self-paying patients (518 patients) and Group 2 included the TANKER Foundation charity dialysis patients (379 patients). We compared the 5-year survival rates of Group 1 versus Group 2 and also those of diabetic versus non-diabetic patients, using the Kaplan-Meier survival estimator. RESULTS: Of the 897 patients, 166 patients survived, 350 died, 234 were lost to follow-up, 137 had renal transplantation and 10 patients were transferred to peritoneal dialysis. The 5-year survival rates after censoring were 20.7 and 38.2% for diabetic and non-diabetic patients, respectively (P < 0.001). The survival rate of diabetic patients was significantly lower, compared with non-diabetic patients, in Group 2 (P < 0.001), but not significantly lower in Group 1 (P = 0.226). CONCLUSIONS: Diabetic patients have poor survival rates on MHD, especially those from poor socioeconomic groups. Due to scarce RRT facilities and poor survival rates of diabetic patients, prevention, early detection and management of diabetic CKD patients should be the way to go forward.

State of deceased donor transplantation in India: A model for developing countries around the world.

Renal replacement therapy (RRT) resources are scarce in India, with wide urban-rural and interstate disparities. The burden of end-stage renal disease is expected to increase further due to increasing prevalence of risk factors like diabetes mellitus. Renal transplantation, the best RRT modality, is increasing in popularity, due to improvements made in public education, the deceased donor transplantation (DDT) programme and the availability of free and affordable transplant services in government hospitals and certain non-governmental philanthropic organizations. There are about 120000 haemodialysis patients and 10000 chronic peritoneal dialysis patients in India, the majority of them waiting for a donor kidney. Shortage of organs, lack of transplant facilities and high cost of transplant in private facilities are major barriers for renal transplantation in India. The DDT rate in India is now 0.34 per million population, among the lowest in the world. Infrastructural development in its infancy and road traffic rules not being strictly implemented by the authorities, have led to road traffic accidents being very common in urban and rural India. Many patients are declared brain dead on arrival and can serve as potential organ donors. The DDT programme in the state of Tamil Nadu has met with considerable success and has brought down the incidence of organ trade. Government hospitals in Tamil Nadu, with a population of 72 million, provide free transplantation facilities for the underprivileged. Public private partnership has played an important role in improving organ procurement rates, with the help of trained transplant coordinators in government hospitals. The DDT programmes in the southern states of India (Tamil Nadu, Kerala, Pondicherry) are advancing rapidly with mutual sharing due to public private partnership providing vital organs to needy patients. Various health insurance programmes rolled out by the governments in the southern states are effective in alleviating financial burden for the transplantation. Post-transplant immunological and pathological surveillance of recipients remains a challenge due to the scarcity of infrastructure and other facilities.

A review of acute and chronic peritoneal dialysis in developing countries.

Various modalities of renal replacement therapy (RRT) are available for the management of acute kidney injury (AKI) and end-stage renal disease (ESRD). While developed countries mainly use hemodialysis as a form of RRT, peritoneal dialysis (PD) has been increasingly utilized in developing countries. Chronic PD offers various benefits including lower cost, home-based therapy, single access, less requirement of highly trained personnel and major infrastructure, higher number of patients under a single nephrologist with probably improved quality of life and freedom of activities. PD has been found to be lifesaving in the management of AKI in patients in developing countries where facilities for other forms of RRT are not readily available. The International Society of Peritoneal Dialysis has published guidelines regarding the use of PD in AKI, which has helped in ensuring uniformity. PD has also been successfully used in certain special situations of AKI due to snake bite, malaria, febrile illness, following cardiac surgery and in poisoning. Hemodialysis is the most common form of RRT used in ESRD worldwide, but some countries have begun to adopt a 'PD first' policy to reduce healthcare costs of RRT and ensure that it reaches the underserved population.