A unique case of Salmonella typhi peritonitis in a CAPD patient.

Peritonitis is the Achilles heel of continuous ambulatory peritoneal dialysis (CAPD) leading to significant morbidity and mortality. We report a 57 year old lady with coronary artery disease, pulmonary hypertension and diabetic kidney disease on CAPD for four years, who presented with Salmonella typhi peritonitis. As response to intraperitoneal antibiotics was unsatisfactory, the peritoneal dialysis catheter was removed after five days and shifted to maintenance hemodialysis. Following resolution of infection after a prolonged course of intravenous antibiotics, a swan neck catheter was re-implanted after eight weeks. There was peritoneal membrane failure and hence she continued on hemodialysis but she succumbed.

Correlation of AKI with Risk Factors, Ventilatory Support, Renal Replacement Therapy in a Cohort of COVID-19 Patients.

Introduction: There is a scarcity of information on the incidence and outcomes of acute kidney injury (AKI) in COVID-19 patients in India. Therefore, we analyzed the correlation of AKI risk factors, ventilatory support, and renal replacement therapy and compared the outcomes of first and second COVID-19 waves in this tertiary care center. Methods: We retrospectively analyzed the patients' medical records with a positive RT-PCR for COVID-19 between July 2020 and May 2021. We looked at the clinical outcomes of the first and second COVID-19 waves and documented the frequency, risk factors for AKI, and the relationship between AKI and in-hospital mortality. Univariate and multivariate binomial logistic regression yielded odds ratios for the risk variables of AKI. Risk differences and age-adjusted odds ratios, as well as 99.5% confidence intervals, were used to compare COVID-19 outcomes between the first and second waves. Results: Of the 1260 hospitalized patients with COVID-19, 86 (6.8%) presented with AKI and 8 (0.7%) patients required dialysis. The most common comorbidity was diabetes mellitus (55.2%), hypertension (42.1%), hypothyroidism (11.3%), and coronary artery disease (8.1%). A total of 229 (18.17%) patients were admitted to ICU, 574 (45.5%) received ventilation, and 26 (2.0%) required mechanical ventilation.The incidence of in-hospital death in the patients with AKI as per the stage from 1 to 3 was 9 (15.8%), 7 (35%), and 5 (55.6%), respectively.Compared to the first wave, the second wave cohort had a lower risk of AKI (adj OR: 0.426; CI: 0.232-0.782) and mortality (adj OR: 0.252; CI: 0.090-0.707). Conclusions: In our study, AKI prevalence was 6.8%, the need for ventilation was 45.5%, ECMO 0.2%, and the mortality rate 2.9%. Second wave of COVID-19 exhibits improved clinical outcomes compared to the first wave.

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.

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.

Pathology of Uddanam Endemic Nephropathy.

In the last decade, pockets of endemic nephropathy have been recognized worldwide, in regions of Central America, Sri Lanka, and India. In India, the nephropathy has been recognized in the Uddanam area of north Andhra Pradesh and has been termed the Uddanam endemic nephropathy (UEN). The disease is distinctive in that besides the geographic distribution, it affects rural populations engaged in farm labor and agriculture, often silent in the initial phase with most patients presenting with advanced renal failure. The renal biopsy findings in all geographic areas including UEN have been one of a chronic tubulointerstitial nephritis with varying degrees of tubular injury, interstitial inflammation, tubular atrophy, and interstitial fibrosis with nonspecific glomerular obsolescence and lack of immune deposits. More recently, the demonstration of dysmorphic lysosomes in renal biopsies has favored a toxic etiology. There are thus many gaps in the understanding of this serious disease prevalent among poorer populations.

Dietary Management in Slowing Down the Progression of CKDu.

Chronic kidney disease of unknown etiology (CKDu) is an emerging entity in the South Asian region. This predominately affects the farming community belonging to the lower socioeconomic status. CKDu being a progressive condition often leads to end-stage renal failurerequiring renal replacement therapy (RRT). Due to the high cost and limited availability of RRT in many areas of geographical locations in India and worldwide, there is an unmet need to slow down the progression of CKDu. The intestinal microbiota is different in patients with CKD, with low levels of beneficial bacteria such as Lactobacillus and Bifidobacteria. Prebiotics and probiotics modify the intestinal microbiota and thereby slow down the progression. Soda bicarbonate therapy is cheap and cost-effective in slowing down the progression of CKDu in a subset of patients. There is also evidence of the beneficial effect of N-acetyl cysteine in early stages of CKD and it should benefit CKDu also. Dietary interventions to prevent dehydration, by providing uncontaminated drinking water, sufficient protein containing diet with adequate calories, and tailored salt intake to prevent hypotension, are necessary compared to other causes of CKD. The objective is to prevent malnutrition, and uremic symptoms. Early diagnosis and prompt intervention may delay the progression of CKDu in the early stages.

Novel Homozygous FAN1 Mutation in a Familial Case of Karyomegalic Interstitial Nephritis.

Karyomegalic interstitial nephritis (KIN) is a rare genetic kidney disease associated with a mutation in FAN1 gene and is often underdiagnosed. The histomorphology demonstrates chronic interstitial nephritis with tubular epithelial cells showing bizarre enlarged nuclei. We present a case report of a 47-year-old multiparous South-Indian woman presenting with bilateral pitting pedal oedema and mild hypertension. At the time of presentation, her serum creatinine was 1.52 mg/dL and urine analysis showed mild proteinuria. Kidney biopsy showed features of tubular injury with bizarre enlarged nuclei and focal mild chronic tubulointerstitial nephritis. Immunohistochemistry was negative for cytomegalovirus (CMV) Ag and SV40 Ag. Real-time polymerase chain reaction (PCR) done for CMV and BK virus genomes was negative. Relevant family history was that her older brother was also diagnosed with kidney failure and is on renal replacement therapy. Genetic analysis for FAN1 gene of the proband and her sibling showed two rare mutations of the FAN1 gene in the exon 4, of which, one is non-synonymous mutation and the other is a stop-gain mutation in the proband. This case illustrates a rare presentation of karyomegalic interstitial nephritis in siblings with previous unknown FAN1 gene mutations.

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.

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.

A rare association of Mycobacterium tuberculosis infection of kidney and urinary tract with immunoglobulin A nephropathy.

Mycobacterium tuberculosis(MTB)-related secondary immunoglobulin A (IgA) nephropathy is reported in a 72-year-old male patient. The patient was diagnosed to have MTB infection of the kidney and genitourinary tract which was diagnosed by the demonstration of the organism by GeneXpert Ultra and culture. Concurrent kidney biopsy showed IgA nephropathy. The patient responded to urethral double-J stenting and four-drug antituberculous therapy with improvement of kidney function and resolution of MTB. IgA nephropathy can present as primary glomerulonephritis or secondary to MTB infection.

A rare fatal complication of bleeding immediately following polytetrafluoroethylene arteriovenous grafting in a lady with Goodpasture syndrome.

We report a 28-year-old female with no history of allergies and recent onset of Goodpasture syndrome who developed life-threatening bleeding immediately after placement of a polytetrafluoroethylene (PTFE) graft as an access for hemodialysis in the left upper limb by an experienced vascular surgeon. In spite of transfusing fresh frozen plasma, packed cells and cryoprecipitate, her prothrombin time (PT), activated partial thromboplastin time and international normalized ratio became progressively worse which were normal at the beginning of the surgery. She had profound hypotension and succumbed within 8 hours. We suspect a rare phenomenon of the interaction of her blood with the PTFE graft causing activation of bleeding and coagulation factors leading to disseminated intravascular coagulation (DIC).

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.

An unusual case of unresolving tunnel infection in a patient on continuous ambulatory peritoneal dialysis.

Atypical mycobacteria remain a rare cause of peritoneal dialysis catheter-related tunnel infection (TI) and poses serious risk because of the resistant nature to most antibiotic therapy. Non-tubercular mycobacterial infections lead to chronicity requiring peritoneal dialysis catheter removal. We report an 82-year-old male, with diabetic nephropathy who had a coinfection with Staphylococcus hominis and Mycobacterium abscessus who presented with pus discharge at exit site and TI. He was treated with relocation of the extraperitoneal part of the catheter with a new exit site without catheter removal and multidrug mycobacterial therapy.

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.

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.