Infectious complications in children with nephrotic syndrome: Can they be prevented?

Background: Sixty percent of children with nephrotic syndrome have frequently relapsing or steroid-dependent course. Serious infections like peritonitis, cellulitis, pneumonia etc. and anasarca with reduced urine output and complications there of including acute kidney injury and thromboembolism contribute significantly to morbidity and mortality in these children. Methods: Questionnaire-based module to study infectious complications in children with nephrotic syndrome was circulated through survey monkey portal to paediatric nephrologists in our country. Twenty-two responded. Forty percent said that they saw patients with severe infections once a month. Fish bone analysis conducted on such patients reporting to our centre over next 3 months revealed that only 22% regularly monitored urine protein by dipstick. We proposed that reduction in time to report relapse by regularly monitoring urine protein could reduce complications in these children. Six urine protein dipsticks were handed over to patients who presented >7 days since relapse or with severe infection or anasarca in the last 1 year. These children were followed up for the next 1 year and given six more urine dipsticks every 3 months. Results: Twenty-three patients were given urine protein dipsticks. Nine of them had 12 severe complications in the previous 6 months. None had any serious infections/anasarca on follow-up. Sixteen new patients had 14 serious complications in this time. Conclusions: Early detection of relapse by home monitoring of urine protein by dipsticks was effective in significantly reducing the number of patients with severe infections and anasarca with reduced urine output.

Primary Sjogren's syndrome manifesting with distal renal tubular acidosis and severe metabolic bone disease.

Sjogren's syndrome (SS) is a chronic, autoimmune, inflammatory disorder affecting primarily the salivary and lacrimal glands with potential for systemic involvement. The disease predominantly occurs in women in the age group of 35-45 years and is relatively rare in children. It mainly affects salivary and lacrimal glands with potential for systemic involvement. Children presenting with the severe metabolic bone disease at the very outset has not been reported in the paediatric literature. We report a 13-year-old girl who presented with pain in multiple large joints with predominant involvement of hip joints leading to difficulty in walking for the past 6 months and unintentional weight loss of the same duration. Investigations revealed distal renal tubular acidosis with severe metabolic bone disease as an extra-glandular manifestation of primary SS.

Preoperative Predictors of Level of Difficulty of Laparoscopic Cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic gallbladder stone disease. This is due to its safety, reliability, cost-effectiveness, negligible mortality, shorter duration of hospitalization (early return to work), better cosmesis, minimal wound complications, and temporary paralytic ileus. In spite of these, conversion to open cholecystectomy which is sometimes required in difficult cases could be challenging. AIMS AND OBJECTIVES: The aim of the present study is to aid the prediction of difficult cases undergoing LC, thereby better selection of patients with the least conversion rates. MATERIALS AND METHODS: This prospective study was conducted on 100 consecutive patients with cholecystitis, over a 2-year period from January 1, 2017, to December 31, 2018, having undergone LC. Various preoperative parameters, including age, sex, previous attacks of cholecystitis, deranged liver functions, and ultrasonographic findings, were analyzed for their effects for predicting the level of difficulty during LC. RESULTS: Twenty-five percent of the cases were correctly predicted as difficult in the age group of >65 years. Cholecystitis was more common (79%) in females, but difficulties were encountered more frequently while performing LC in males. Abnormal serum hepatic and pancreatic enzyme profiles were associated with difficulties during surgery as about 83.3% of the patients predicted as moderately difficult peroperatively had deranged liver functions. The preoperative ultrasonography findings were helpful for predicting the degree of difficulty involved in the procedure. About 33.3% of the patients that had pericholecystic fluid on ultrasound preoperatively were correctly predicted to have moderately difficult surgeries. The Chi-square test and P value were used to determine statistical significance. CONCLUSIONS: Females, the absence of previous repeated attacks of cholecystitis and hospitalizations, no upper abdominal surgery in the past, normal liver function tests, normal amylase levels, nondistended and uncontracted gallbladder, absence of pericholecystic collection, afebrile, and single stone are positive preoperative predictors of safe LC in symptomatic gallbladder stone disease.

Monitoring oxidative stress across worsening Child Pugh class of cirrhosis.

CONTEXT: Oxidative stress has been increasingly implicated in the pathogenesis and progression of cirrhosis. AIMS: We studied oxidative stress in patients with cirrhosis by measuring markers reflecting pro-oxidant (serum malondialdehyde-MDA) and antioxidant factors (RBC catalase-CAT, superoxide dismutase-SOD and blood reduced glutathione-GSH) factors. The level of oxidative stress was also assessed with respect to functional compromise of liver, as determined by Child Turcotte Pugh (CTP) scoring. DESIGN: Case-controlled retrospective study. MATERIALS AND METHODS: Twenty-three patients of cirrhosis along with 23 age and sex matched healthy controls were studied. Exclusion criteria were concurrent use of anti-oxidant drugs; co-existing diseases like DM, CKD; alcohol use, gastrointestinal bleed or blood transfusion within previous 2 weeks. Besides routine investigations, MDA, CAT, SOD and GSH levels were measured and compared with controls. STATISTICAL ANALYSIS: Continuous variables were recorded as mean +/- SD; ANOVA-f test, followed by Tukey's test, was used to evaluate the significance of difference (P < 0.05) among groups. RESULTS: Mean age of patients was 41.04 +/- 12.3 yrs. Patients showed a significant increase in MDA {control 3.31 +/- 0.25 (95% CI 3.21-3.41), Child B 6.30 +/- 0.4 (95% CI 6.03-6.53), Child C 8.05 +/- 0.66 (95% CI 7.29-8.81) nmol/l} and a significant decrease in levels of SOD {control 845.13 +/- 36.44 (95% CI 829.92-860.34), Child B 582.91 +/- 42.12 (95% CI 557.45-608.32), Child C 489.5 +/- 17.66 (95% CI 479.3-499.7) U/gm Hb}, CAT {controls 2.54 +/- 0.22 (95% CI 2.45-2.63), Child B 1.93 +/- 0.23 (95% CI 1.72-2.14), Child C 1.46 +/- 0.10 (95% CI 1.40-1.52) U/ gm Hb} and GSH {controls 6.52 +/- 0.25 (95% CI 6.42-6.52), Child B 3.85 +/- 0.18 (95%CI 3.74-3.96), Child C 2.99 +/- 0.30 (95% CI 2.82-3.16) mmol/ gm Hb}. CONCLUSIONS: Oxidative stress is associated with the development and progression of cirrhosis.