A rare case of dialysis associated reaction presenting with urticarial vasculitis and haemoglobinuria.

Dialysis associated reactions presenting with urticarial vasculitis is rarely reported in medical literature. We report a 61-year-old gentleman who developed sudden onset dyspnea with diffuse erythema within 20 min of haemodialysis. Patient was started on Azilsartan 3 days prior to this clinical event. Labs revealed features of hemolysis and urine was positive for hemoglobinuria. All dialysis related factors responsible for this reaction were ruled out. Due to non-resolution of skin rash, skin biopsy was attempted which revealed fibrinoid necrosis of occasional vessels with predominant lymphocytic infiltration suggestive of drug induced urticarial vasculitis. Complement levels were normal. He was managed with steroids, anti-histaminic, discontinuation of azilsartan and change of dialyzer membrane. This case highlights a rare dermatological presentation of Type A dialysis associated reaction involving azilsartan with differential diagnosis and treatment strategies.

Correlation of Beta Trace Protein Levels with Serum Creatinine-Based Estimated Glomerular Filtration Rate Equations in Chronic Kidney Disease.

Background. Estimated GFR (eGFR) is calculated using serum creatinine (SCr) based equations which have their own limitations. Novel biomarkers like beta trace protein (BTP) are studied for eGFR estimation. The aim of this study is to determine the serum levels of BTP in healthy controls and chronic kidney disease (CKD) cases and to find out the correlation of BTP levels with that of SCr and SCr-based eGFR formulas. Methods. The control group comprised of 20 healthy adults. The cases comprised of 20 patients each in CKD stages 3, 4, and 5, categorized based on eGFR calculated using MDRD formula. Baseline characteristics of the study population were recorded. BTP was measured by ELISA (Enzyme Linked Immunosorbent Assay) method and SCr by modified Jaffe's method. The statistical analyses were performed with the SPSS for Windows, version 16.0. Results. The median value of blood urea nitrogen (BUN) in the cases was 26.50 mg/dL (IQR 19.25-37) and for control it was 9.5 mg/dL (IQR 8-12). The median value of SCr in the cases was 2.75 mg/dL (IQR 1.725-4.45) and in the controls, it was 0.7mg/dL (IQR 0.6 -0.8). The median value of BTP in cases was 6389.25 ng/ml (IQR 5610.875-10713.75) and in controls, it was 1089.5 ng/ml (IQR 900.5-1309.75). Conclusion. Serum BTP levels correlated with SCr levels and renal function. We could establish the relationship between the two biomarkers, SCr and BTP, and derive a regression equation.

Influenza A (H1N1) Virus Infection Associated Acute Kidney Injury - A Study from a Tertiary Care Center in South India.

Influenza A (H1N1) infection in 2009 spread rapidly all over the world. Mortality was high in patients with H1N1-associated acute kidney injury (AKI). We estimated the incidence, risk factors of AKI and mortality associated with H1N1 infection. This is a prospective observational study, including 158 adult patients with H1N1 infection confirmed with real-time reverse transcriptase-polymerase chain reaction conducted between August 2016 and September 2017. AKIN criteria were used to define AKI. Of 158 patients in this study, 112 were male and the mean age was 46.4. Fifteen patients (9.5%) were found to have AKI. The mean age was higher (56.13 ± 10.02) in the AKI group compared to non-AKI (45.48 ± 16.26) (P = 0.007). Presence of shock, multiple organ dysfunction syndrome (MODS), ventilatory support were observed more in the AKI group (P = 0.000). Among AKI patients, the requirement of dialysis was more than 50% (n = 8/15, 53.3%). Eighteen patients died following H1N1 infection (11.4%).Shock (n = 8/18, 44.4%, P = 0.000), MODS (n = 13/18, 72.2%, P = 0.000), intensive care unit (ICU) care (n = 17/18, 94.4%, P = 0.000), ventilatory support (n = 18/18, 100% P = 0.000), AKI (n = 11/18, 61.1%, P = 0.000), and requiring dialysis (n = 7/18, 38.9%, P = 0.000) were significantly associated with mortality compared to patients who survived. The incidence of H1N1 AKI was 9.5%, with > 50% requiring dialysis. Risk factors for AKI included older age, underlying chronic kidney disease, presentation with sepsis, shock, MODS, ICU care, and mechanical ventilation. Mortality was high in patients with AKI compared to non-AKI patients.

Pulmonary hypertension - prevalence, risk factors, and its association with vascular calcification in chronic kidney disease and hemodialysis patients.

Pulmonary hypertension (PHTN) is a recently recognized complication in dialysis and it is associated with a poor outcome. We estimated the prevalence of PHTN and its association with vascular calcification in chronic kidney disease (CKD) and hemodialysis (HD) patients. One hundred and thirteen adult CKD patients were included in this study, of which 56 (49.6%) were on conservative treatment (nondialysis group) and 57 (50.4%) were on maintenance HD (dialysis group). Demographic, clinical, and biochemical parameters were collected and compared between the groups. Thirty-nine (69.6%) and 33 (57.8%) males were included in nondialysis and dialysis group, respectively. Mean age was 47.5 ± 13.7 in nondialysis group and 52.8 ± 13.9 in the dialysis group. PHTN was estimated using Doppler echocardiography and peripheral vascular calcification by lateral lumbar X-ray with aortic calcification scoring. Patients with and without PHTN and vascular calcification in dialysis and nondialysis group were compared. PHTN was found in 55 patients (48.7%) and it was high in patients on dialysis compared to nondialysis(59.6% vs. 37.5%, P <0.019). Abdominal aortic calcification was present in 35 patients (30.9%), dialysis versus nondialysis group was 22.8% and 39.3%. Increased left atrial diameter was significantly associated with PHTN (P <0.003), whereas peripheral artery calcification was not related to PHT (P = 0.248). The prevalence of PHTN in CKD was 48.7% which was higher in dialysis group than non dialysis group. Increased left atrial (LA) diameter was associated with PHTN but not peripheral arterial calcification.

Low Concentration Trisodium Citrate as a Non-inferior Locking Agent for Non-tunneled Dialysis Catheters in the Asian Setting.

INTRODUCTION: Unfractionated heparin is the commonly used catheter lock solution in patients with temporary dialysis catheters as hemodialysis access. The effectiveness of trisodium citrate as an alternate catheter lock agent has not been studied in Asian population. METHODS: In this prospective quasi-experimental study, which included 180 patients with central venous dialysis catheter, patients were randomly allotted to citrate 4.67% and heparin 5000 units/ml arms in the ratio of 2:1. Baseline demographic and dialysis related data, incidence of catheter-related bloodstream infections, and mean catheter days in both the study cohorts were collected and compared. Formal cost analysis for citrate 4.67% use as catheter lock was done. RESULTS: The mean age of the total study population was 50.49 ± 14.87 years. Sixty-six females (36.7%) and 80 (44.4%) diabetic patients were included in the study. The overall incidence of catheter-related bloodstream infection (CRBSI) was 11.11%. The majority had nontunneled dialysis catheters (95%; n = 114). On analyzing the data of patients with nontunneled catheters, it was found that the total number of catheter days for the citrate and heparin groups were 4,795 and 2,419 days, respectively. The number of CRBSI episodes per 1,000 catheter days for the citrate and heparin groups were 2.711 and 2.89, respectively. Citrate catheter lock cost only 6% of that of heparin lock. CONCLUSIONS: The incidence of catheter related bloodstream infections was comparable between the heparin and citrate 4.67% lock cohorts. The use of low concentration citrate as catheter lock was cost-effective when compared with heparin.