Is Ambulatory Blood Pressure Monitoring Required for Elderly Hemodialysis Patients during the Interdialytic Period? - Experience of a Tertiary Care Center in South India.

Introduction: Hypertension (HT) is a common and challenging problem in patients on dialysis. Routine peri-dialytic blood pressure (BP) recordings are unable to diagnose HT accurately and stratify cardiovascular risk. We report here an analysis of 2 years, single-center experience on 24-hour ambulatory blood pressure monitoring (ABPM) in elderly hemodialysis patients in the interdialytic period. Materials and Methods: Data of all the patients above 65 years of age undergoing hemodialysis between November 2017 and December 2019 in our hemodialysis unit and for whom 24-hour ABPM was done were collected. Demographics, clinical profile, pre- and post-dialysis BP recordings, 24-hour ABPM characteristics, and the outcome status were analyzed. Results: Of the 37 patients, 28 (75.7%) were males with a mean age of 67.73 years; 67.6% were diabetic. HT was found in all patients (100%), and uncontrolled HT was noted in 30 (81%) patients by ABPM. Patients with uncontrolled HT were also nondippers of BP (100%). A significant association was observed between nondippers and coronary artery disease (n = 27, 90%, P = 0.004). Masked HT was found in 9 (24.3%) patients with normal peridialytic BP (n = 9, 24.3%, P = 0.000). No significant difference was noted between diabetic and nondiabetic patients regarding dipping status or mortality. Among 37 patients, 9 (24.3%) died during follow-up with uncontrolled HT as a significant risk factor (P = 0.05). Conclusion: The prevalence of uncontrolled HT with blunted circadian rhythm was high as detected by ABPM in the interdialytic period among elderly hemodialysis patients and had a significant impact on mortality. Masked uncontrolled HT as measured by ABPM was not uncommon in patients with normal peridialytic BP.

Scrub typhus-associated acute kidney injury: A study from a South Indian Tertiary Care Hospital.

Infections including scrub typhus contribute to a significant proportion of community-acquired acute kidney injury (AKI) in the tropics. Scrub typhus infection now requires global attention since disease outbreaks are being reported across continents. We intended to study the clinical profile, renal involvement, and parameters predicting renal involvement in scrub typhus infection. This is a retrospective study. The medical records of all patients who were admitted and treated for scrub typhus infection for a study period of two years (from September 2015 to August 2017) were analyzed, and salient clinical features and laboratory results were collected from the hospital data. Statistical analysis was done from the collected data. Our study had 272 patients including 81 children. Adults constituted 70.96% (n = 193) and the remaining 29.04% (n = 81) were pediatric population. Among adults, females constituted 62.7% (n = 121) and males 37.3% (n = 72). The mean age of the adult population was 45.7 ± 15 years and that of pediatric patients was 8.56 ±5.1 years. 18.7% of adult cases and 3.70% of pediatric cases had AKI. Renal replacement therapy was required in 3.67% of adult cases. Mortality was 4.14% in adults and 1.23% in children. Hypotension, pulmonary involvement, central nervous system involvement, multiorgan dysfunction syndrome, increased total counts, elevated aspartate transaminase levels, and hypoalbuminemia predicted AKI in our adult population. Scrub typhus should be considered as a differential in cases presenting with fever and AKI. Outcomes of scrub typhus infection in terms of mortality seem to be improving in this region.

Inflammation and nutritional status assessment by malnutrition inflammation score and its outcome in pre-dialysis chronic kidney disease patients.

BACKGROUND: Malnutrition-inflammation complex syndrome (MICS), hyperhomocysteinemia, calcium and phosphate levels derangement have been predicted as important contributing factors for the progression of cardiovascular burden. Among patients with earlier stage of CKD, hypoalbuminaemia and inflammation deliberated as non-traditional cardiovascular risk factors, which add more burden to circulatory disease, mortality and rapid advancement to CKD stage 5. AIM: The aim of the study is to evaluate inflammation and nutritional status of CKD patients not on dialysis using Malnutrition inflammation score (MIS) and to verify the association with mortality in the follow-up period. METHODS AND MATERIAL: In this prospective cohort study 129 (66 males, 63 females) pre-dialysis CKD patients enrolled between June 2013 to August 2014 and censored until March 2017. Malnutrition and Inflammation assessed using Malnutrition inflammation score. Blood urea nitrogen, serum creatinine, albumin, Interleukin - 6, highly sensitive C reactive protein (hsCRP), total cholesterol and anthropometric data were analyzed. RESULTS: The Malnutrition inflammation score in pre-dialysis CKD patients ranged from 0 to 18 with the median score of two. During 36 or more months of follow-up, there were 30 (23.2%) deaths, 35 (27%) patients initiated on hemodialysis, one (0.7%) patient was initiated on peritoneal dialysis, two (1.4%) patients underwent renal transplantation and two (1.4%) patients were lost for follow-up. In this study, 33% had varying degree of malnutrition and inflammation. Patients who had MIS ≥7 had significant increase in IL-6 (p = 0.003) and HsCRP levels (p < 0.001) when compared with other tertiles of MIS. ROC curve analysis of MIS showed 56.5% sensitivity and 81% specificity in predicting death rate (AUC 0.709; 95% CI 0.604-0.815, p < 0.001). Kaplan-Meier survival analysis showed MIS ≥7 had a strong association (log rank test, p < 0.001) with mortality during 36 and more months of follow-up time. In unadjusted analyses, MIS (HR 1.140; 95% CI 1.054-1.233; p < 0.05) and HsCRP (HR 2.369; 95% CI 1.779-3.154; p < 0.001) found to be predictors of mortality. MIS and HsCRP remained predictors of mortality even after adjustments. CONCLUSIONS: This study shows MIS is an important factor that determines mortality in pre-dialysis CKD patients during 36 and more months of follow-up time. Patients with MIS ≥7 have high risk for mortality and needs close monitoring. In clinical setting application of MIS has a greater utilization in pre-dialysis CKD patients. Further research with longitudinal assessment of MIS and its association with outcomes are warranted. Pre-dialysis CKD patients should be assessed for their nutritional status and inflammation using MIS regularly to prevent malnutrition and its associated complications through appropriate medical and nutritional intervention.

The risk factors and outcome of fungal peritonitis in continuous ambulatory peritoneal dialysis patients.

AIM: To determine the risk factors and outcome of fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients over a 7-year period. PATIENTS AND METHODS: This retrospective study was conducted on 30 cases of fungal peritonitis in CAPD patients during a 7-year period (2000-2007). The diagnosis was based on elevated CAPD effluent count and isolation of fungi. Patients were evaluated for previous episode of bacterial peritonitis. RESULTS: The incidence of fungal peritonitis was 16.2%. Age varied between 8 and 75 years, with a mean age of 57 years. Twenty-three were males (76.7%) and seven were females (23.3%). Seventeen patients (56.6%) had previous episodes of bacterial peritonitis that was treated with multiple antibiotics. The common fungus was Candida species (50%). CAPD catheter removal and initiation of antifungal therapy was done for all patients. Reinsertion was done for three (10%) patients. Mortality rate was 20%. CONCLUSION: Patients with previous bacterial peritonitis and antibiotic usage are at greater risk of developing fungal peritonitis.

Peritoneal dialysis in a patient with neurogenic bladder and chronic kidney disease with ventriculoperitoneal shunt.

Long-term dialysis in children with multiple handicaps has become easier with the advent of continuous ambulatory peritoneal dialysis (PD). Due to the widespread use of PD and the long survival of patients with spina bifida, an increasing number of patients with spina bifida are on PD. The viability and safety of PD in spina bifida patients with a ventriculoperitoneal shunt (VPS) have been a matter of concern. Some authors consider the presence of a VPS a relative contraindication for PD, but more recent reports suggest that PD under close monitoring is not contraindicated. We report a 17-year-old girl born with meningomyelocele, hydrocephalus and neurogenic bladder who was maintained on VPS. She reached end-stage renal failure 17 years later and was put on PD based on family and patient preference. She had an uneventful course in the initial 9 months, but later developed fungal peritonitis which was successfully managed with catheter withdrawal and an intravenous antifungal agent (amphotercin 0.75 mg/kg). Simultaneous ventricle-aspirated cerebrospinal fluid was sterile. To our knowledge, this is the first report of fungal infection in such a patient. Although we share the view that PD is not an absolute contraindication in patients with a functioning VPS, its likely complications, especially infectious complications in developing countries, should be kept in mind before initiating PD in such patients.