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.

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.

Urinary tract infections in the era of newer immunosuppressant agents: a tertiary care center study.

We studied the incidence and the risk factors predisposing to post transplantation urinary tract infection (UTI) and the association with use of different immunosuppressive regimens. We performed a retrospective analysis of 152 recipients of renal transplantation over a period of two years. Seventy one (46.71%) patients had culture positive UTI, Escherichia coli (45.1%) being the commonest. Thirty four (22.39%) patients had acute rejection and 14.4% of those had suffered UTI in the early post transplant period. Immunosuppression included induction with various antibodies and maintenance on antirejection medications. Trimethoprim-sulphamethoxazole was given as prophylaxis throughout the period. The UTI was treated according to microbiological sensitivity. 2.8% died due to urosepsis. In our retrospective analysis renal transplant recipients under the age of 45, female gender and diabetics suffered more UTI. Combination therapy with micro-emulsion form of cyclosporine A, prednisolone and azathioprine developed more UTI (P= 0.0418).

Resource settings have a major influence on the outcome of maintenance hemodialysis patients in South India.

Chronic kidney disease is reaching epidemic proportions and the number of patients on renal replacement therapy (RRT) is increasing worldwide and also in developing countries. To meet the challenge of providing RRT, a few charity organizations provide hemodialysis units for underprivileged patients, as the private hospitals are unaffordable for the majority. There is a paucity of information on the outcome of dialysis in these patients. Here, we describe the outcome of hemodialysis patients comparing the middle- and upper-class income group with the lower class income group. A retrospective analysis was carried out in 558 CKD patients initiated on maintenance hemodialysis in two different dialysis facilities. Group A (n=247) included those who belonged to the lowermost socioeconomic status and were undergoing dialysis in two nonprofit, charity (TANKER)-run dialysis units, and Group B (n=311) was undergoing dialysis in a nonprofit hospital setting where no subsidy was given. Those patients of a low socioeconomic status, especially those who are diabetics, have a higher death rate (Group A-38.1%, Group B-4.2%) and loss to follow-up (Group A-25.9%, Group B-0.3%) compared with those who are in the middle- and high-income group. Higher EPO use and hence higher hemoglobin levels (Group A-6.4+/-1.2, Group B-8.9+/-1.5 P<0.001) were observed in those who were in the middle and the higher income group. Lower serum phosphorus level was observed in the low-socioeconomic group (Group A-4.7+/-1.5, Group B-5.5+/-1.9, P<0.001). Patients belonging to the middle and higher socioeconomic group undergo more transplantations compared with the lower socioeconomic group (Group A-2.4%, Group B-65.6%).

Predictors of long-term survival on peritoneal dialysis in South India: a multicenter study.

BACKGROUND: Little is known about survival on peritoneal dialysis (PD) in Indian patients since the initiation of continuous ambulatory PD (CAPD) in India in 1991. Survival data from single centers with small numbers have been published. OBJECTIVE: A retrospective 4-center analysis for predictors of survival >3 years in south Indian chronic PD patients. METHODS: A total of 309 patients were trained during the observation period (from 1999 to 2004) and were analyzed in a multicenter study (4 centers), including 150 patients (male:female 109:41) that survived > or = 3 years and 59 patients that did not survive > or = 3 years (nonsurvivors; male: female 43:16) that were taken as controls. The patients were on chronic PD, predominantly CAPD, using double-bag disconnect systems. They were supervised by 4 nephrologists. Mean age in the nonsurvival group was 56.6 +/- 10.6 years. In the survival group, mean age was 50.9 +/- 14.9 years; there were 92 (62%) nondiabetics and 58 (38%) diabetics; the majority were nonvegetarians; 148 patients were doing 6 - 8 L exchanges and 2 were doing >8 L exchanges daily; 93 of 102 patients were average transporters based on peritoneal equilibration testing. At the beginning, mean combined Kt/V was 2.31 and weekly creatinine clearance was 73 L. Patients making one lifetime payment were 46% and 21% belonged to the full reimbursement group. RESULTS: Body mass index (BMI) was normal in 114 patients (76%). Ultrafiltration volume was 1377 +/- 452 at the start and 1400 +/- 461 mL/day after 3 years. Anuric patients at the start were 12% and after 3 years 44%; urine output decreased from 527 +/- 26 to 253 +/- 14 mL/day from the start to after 3 years. Peritonitis rate was 1 episode/75 patient-months at the beginning and after 3 years it was 1 episode/30 patient-months. Exit-site care was done daily by 88% and 3 times weekly by 12%. Nonsmokers were 92% and smokers were 8%. Those that lived in the city were 62% and rural areas were 38%. Mean blood pressure was 143 +/- 16/88 +/- 10 and 136 +/- 18/85 +/- 9 mmHg, calcium x phosphorus product 44.6 +/- 15.6 and 45.9 +/- 15.7 mg(2)/dL(2), albumin 3.33 +/- 0.5 and 3.25 +/- 0.4 g/dL, hemoglobin 9.18 +/- 2 and 9.48 +/- 1.8 g/dL at the beginning and after 3 years, respectively. Statistical analysis showed a significant fall in both systolic (p < or = 0.001) and diastolic blood pressure (p < or = 0.05), an increase in BMI (p < or = 0.01), and a decrease in blood urea (p < or = 0.001) in the survival group. Those with Hb > or = 11 g/dL survived longer (p < or= 0.001), those with serum albumin > or = 3 g/dL had better survival (p = 0.001), and anuric patients survived longer (p = 0.001). CONCLUSION: This multicenter cohort study of prevalent continuous PD patients in south India showed nondiabetics, average transporters, nonsmokers with reasonable nutritional status, with Hb 11 g/dL, with low peritonitis rate, with over 1 L ultrafiltration volume per day, the great majority that joined the once per lifetime payment scheme, and the reimbursement group survived for 3 years or longer.

Can serial eGFR, body mass index and smoking predict renal allograft survival in south Asian patients.

Limited data exist regarding long-term allograft survival in South Asian patients in the era of modern immunosuppressive therapy. This retrospective cohort study was undertaken to see the graft survival based on serial eGFR, immunosuppressive therapy, BMI and other confounding factors including smoking in patients who have undergone renal transplantation in a tertiary care center in south India. Three hundred and three kidney transplant recipients including live and cadaveric transplantation performed between 2001 and 2006 were included in this study. The mean graft survival after transplantation was 6.38 +/- 0.11 years, graft survival at one, two, three and five years were 95.7%, 92.72%, 91.72% and 89.21%, respectively. The mean serum creatinine and eGFR in the biopsy proven acute rejection (BPAR) group were 1.74 +/- 0.94 mg/dL and 43.73 +/- 13.65 mL/min com-pared with 1.24 +/- 0.59 mg/ dL and 61.50 +/- 17.40 mL/min in the non-BPAR group (P < 0.001 and P= 0.0159) respectively. The mean BMI in the BPAR group at one year was 26.59 +/- 3.18 kg/m 2 compared with 21.63 +/- 2.29 kg/m 2 in the non-BPAR group (P < 0.05). The mean graft survival in patients who were smokers at the time of pretransplant evaluation was 89.3% compared with 92.5% in the non-smokers (P=0.347). This retrospective cohort study found that serial eGFR, body mass index and smoking were significant predictors of graft survival following renal transplantation in South Asian patients.

Correlation of CD4 counts with renal disease in HIV positive patients.

To correlate CD 4 counts with albuminuria and glomerular lesions in patients infected with human immunodeficiency virus (HIV), we studied 104 HIV positive patients (68 males, 36 females) of whom 100 patients were infected by heterosexual contact, 3 by transfusion, and 1 by i.v. drug abuse. We screened over nine months for albuminuria by urine dip stick method, and performed renal biopsy on patients with albuminuria 2+ or more. Histological examination was accomplished by light microscopy in all and by electron microscopy when it was feasible. Albuminuria was observed in 29 (27%) patients, and it revealed a significant negative correlation with CD4 count (p<0.01). Patients with CD4 cells <350 cells/mm(3) disclosed a 3.5 fold increased risk of albuminuria as compared with patients with CD4 >350 cells/mm(3). There was no significant correlation between proteinuria and the duration of infection from the time of diagnosis. Albuminuria also demonstrated a significant negative correlation with the levels of hemoglobin (p<0.05). In addition, low numbers of CD4 cells were associated with lower levels of hemoglobin (p<0.001). Only 10 patients received renal biopsies, and the results revealed HIV-associated nephropathy (HIVAN) in 7 (70%) patients, chronic tubulointerstitial nephritis in 1, membranous glomerulopathy in 1, and diffuse proliferative glomerulonephritis in 1. Acute renal failure was present in 5 patients, of whom four had a pre renal component and one had multiorgan dysfunction syndrome. We conclude that our study demonstrates that both proteinuria and HIVAN are common in HIV infected patients. Proteinuria has a negative correlation with the CD4 counts and hemoglobin levels.

Nutritional status in renal transplant recipients.

We performed this study to observe the nutritional status in our renal transplant recipients using serum parameters, body mass index (BMI), and dual energy x-ray absorptiometry (DEXA) that measured the fat distribution. We studied 109 patients who had chronic kidney disease due to different etiologies, and received mean hemodialysis before they underwent successful renal transplantation. The body mass index and the prevalence of type 2 diabetes mellitus revealed a significantly positive correlation with older age (p< 0.05). The mean values of serum sodium, chloride, potassium, calcium, and phosphorous were found to be within the normal range. There were no significant differences in these parameters according to age distribution. However, the mean serum creatinine was elevated, 154 +/- 18 micromol/L, which was compatible with a significant but stable renal dysfunction. iPTH levels in most of our patients were within two times the normal values (101+/- 81 pg/ml). The mean hemoglobin levels were low in all our patients (91.6 +/- 19.4 g/L). The mean bicarbonate levels were within normal limits (23 +/- 3.5 mmol/L), however there were some patients below normal. The plasma proteins and albumin were lower than normal; 62.2 +/- 8.6 g/L, and 36.1 +/- 5.1 g/L, respectively. We conclude that the BMI, fat distribution and percentage as measured by DEXA scan, as well as the prevalence of type 2 diabetes mellitus in our transplant population revealed a significantly positive correlation with older age. The elevated mean plasma iPTH levels, decreased mean serum bicarbonate, albumin, and hemoglobin levels are most likely related to renal allograft dysfunction which is usually inherent with the grafts and may eventually affect the nutritional status of the patients. Subsequently, the initial weight gain may be hampered by the graft dysfunction. Prospective long-term studies are required to confirm our findings on larger transplant populations.

Predictors of prolonged mechanical ventilation after on-pump coronary artery bypass grafting.

The predictors of prolonged mechanical ventilation and subsequent morbidity after cardiac surgery are ill defined. Our aim was to evaluate them. Four hundred and seventy consecutive patients undergoing coronary artery bypass grafting on cardiopulmonary bypass (CPB) between January and June 2002 were retrospectively analysed for preoperative predictors of prolonged ventilation, which included age, gender, ejection fraction (EF), renal function, diabetes, angina status, severity of the disease (New York Heart Association class), number of vessels diseased and chronic lung disease. Intraoperative variables such as prolonged CPB, aortic cross clamp time, intra-aortic balloon pump (IABP) usage, inotropes and postoperative variables like temperature on arrival at intensive care unit(ICU), IABP usage, organ dysfunction, inotropes and reintervention (reintubation and re-exploration) were also analysed. Prolonged ventilation was defined as > or = 24 hours and these patients were included in group I (n=22). Patients requiring less than 24 hours ventilation (n=448) were included in group II. Stepwise logistic regression analysis was performed. The average age of patients was 56.9 +/- 8.8 years with male predominance (88.4%). The overall perioperative mortality was 2.1% (10 patients) with Group I showing mortality rate of 36.3% (8 patients). In multivariate analysis, predictors of prolonged ventilation were found to be EF <40% (odds ratio, (OR) 13.38), preoperative renal dysfunction [OR 4.06 (serum creatinine > 1.2 mg%)], prolonged CPB, > 120 min (OR 9.6) and reintervention in the form of re-exploration or reintubation in the ICU (OR 13.8). Identification of perioperative variables, which may lead to prolonged ventilation may allow the development of strategies to optimize the patient's condition and ICU management.

Homograft valve bank: our experience in valve banking.

BACKGROUND: A cardiac homograft valve bank with cryopreservation facility was established at the Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai in July 1995. METHODS AND RESULTS: During the last 7 1/2 years of its existence, from July 1995 to March 2003, 588 hearts were processed. The valves harvested were 390 aortic, 400 pulmonary and 39 others including mitral valve, aortic conduits, pericardium etc.; 176 (29.9%) hearts were discarded for various reasons which included failure to sterilize, HBV, HIV, HCV, treponema pallidum hemagglutination test positivity, atheromatous/fatty streaks, incompetent valves, and dissection mistakes. The valves were sterilized using an antibiotic cocktail of vancomycin, amikacin, streptomycin, cefotaxime and amphotericin B in Hank's balanced salt solution. Of the 585 valves issued for clinical use, 247 were aortic, 323 pulmonary and 15 others (mitral valve, pericardium, conduits). Gram negative bacilli were the predominant contaminants from the hearts during the first half (July 1995 to February 1999) and gram positive organisms were the predominant contaminants during the later half (March 1999 to March 2003) of the study period. A variety of fungal contaminants like candida, aspergillus, penicillium and other fungi were also isolated from the homograft hearts at procurement. The valves were used most commonly for Rastelli procedure/right ventricular-pulmonary artery conduit (48.71%) followed by Ross procedure (23.41%). The other procedures were aortic valve replacement (6.15%), truncus repair (5.81%), unifocalization with conduit repair (6.49%), aortoplasty (0.512%), left ventricular-pulmonary artery conduit (0.512%), pulmonary valve replacement (0.512%), aneurysm repair (0.34%), Norwood repair (0.34%), mitral valve replacement (0.17%) and other procedures (7%). CONCLUSIONS: We have established a viable and functioning cardiac homograft valve bank to suit Indian conditions and till date, have issued 585 homograft valves for clinical use.