Continuous Ambulatory Peritoneal Dialysis Peritonitis Guidelines - Consensus Statement of Peritoneal Dialysis Society of India - 2020.

Continuous ambulatory peritoneal dialysis (CAPD) related peritonitis is a major cause of technique failure, morbidity, and mortality in patients on CAPD. Its prevention and management is key to success of CAPD program. Due to variability in practice, microbiological trends and sensitivity towards antibiotics, there is a need for customized guidelines for management of CAPD related peritonitis (CAPDRP) in India. With this need, Peritoneal Dialysis Society of India (PDSI) organized a structured meeting to discuss various aspects of management of CAPDRP and formulated a consensus agreement which will help in management of patients with CAPDRP.

Is it Safe to Be Transplanted From Living Donors Who Recovered From COVID-19? Experience of 31 Kidney Transplants in a Multicenter Cohort Study From India.

BACKGROUND: There is lack of data on feasibility and safety of kidney transplants from living donors who recovered from COVID-19. METHODS: Here, we present a retrospective cohort study of 31 kidney transplant recipients (KTR) from living donors who recovered from polymerase chain reaction confirmed COVID-19 across 19 transplant centers in India from July 3, 2020, to December 5, 2020. We detailed demographics, clinical manifestations, immunosuppression regimen, treatment, and outcomes. Donors with a previous diagnosis of COVID-19 were accepted after documenting 2 negative polymerase chain reaction tests with complete symptom resolution for at least 28 days and significant social distancing for 14 days before surgery. RESULTS: COVID-19 clinical severity in donors ranged from completely asymptomatic (71%, n = 22) to mild infection (29%, n = 9). None progressed to moderate or severe stages of the disease in the entire clinical course of home treatment. Patient and graft survival was 100%, respectively, with acute cellular rejection being reported in 6.4% (n = 2) recipient. All recipients and donors were asymptomatic with normal creatinine at median follow-up of 44 days after surgery without any complications relating to surgery and COVID-19. CONCLUSIONS: Our data support safety of proceeding with living donation for asymptomatic individuals with comprehensive donor, recipients screening before surgery, using a combination of clinical, radiologic, and laboratory criteria. It could provide new insights into the management of KTR from living donors who have recovered from COVID-19 in India. To the best of our knowledge, this remains the largest cohort of KTR from living donors who recovered from COVID-19.

Improved Glioma Grading Using Deep Convolutional Neural Networks.

BACKGROUND AND PURPOSE: Accurate determination of glioma grade leads to improved treatment planning. The criterion standard for glioma grading is invasive tissue sampling. Recently, radiomic features have shown excellent potential in glioma-grade prediction. These features may not fully exploit the underlying information in MR images. The objective of this study was to investigate the performance of features learned by a convolutional neural network compared with standard radiomic features for grade prediction. MATERIALS AND METHODS: A total of 237 patients with gliomas were included in this study. All images were resampled, registered, skull-stripped, and segmented to extract the tumors. The learned features from the trained convolutional neural network were used for grade prediction. The performance of the proposed method was compared with standard machine learning approaches, support vector machine, random forests, and gradient boosting trained with radiomic features. RESULTS: The experimental results demonstrate that using learned features extracted from the convolutional neural network achieves an average accuracy of 87%, outperforming the methods considering radiomic features alone. The top-performing machine learning model is gradient boosting with an average accuracy of 64%. Thus, there is a 23% improvement in accuracy, and it is an efficient technique for grade prediction. CONCLUSIONS: Convolutional neural networks are able to learn discriminating features automatically, and these features provide added value for grading gliomas. The proposed framework may provide substantial improvement in glioma-grade prediction; however, further validation is needed.

Peritoneal Dialysis Patients During COVID 19 Pandemic.

COVID pandemic poses challenges to peritoneal dialysis patients, caretaker, and service provider to the PD patients as well. The chronic peritoneal dialysis (PD) patients are trained to do the PD procedure at home, therefore can avoid in-center hospital visit unlike patients on hemodialysis. Thus, PD patients can avoid undue exposure to the novel coronavirus. The PD can be offered in COVID induced AKI patients, even in remote places where hemodialysis cannot be offered. The paper is aimed to provide guidelines about the safe use of PD and treatment of complications during the COVID pandemic.

What Is the Best Dialysis Therapy for South Asia: HD or PD?

BACKGROUND: South Asian countries have a population of 1.7 billion and are classified as low-middle to poor income nations. Their health care systems cannot presently meet the growing need for renal replacement therapy (RRT), provided as haemodialysis or peritoneal dialysis (PD). Most patients cannot afford the treatment and quickly default. Furthermore, most of the population is located in rural areas, where there are few treatment centres; therefore, there is a huge gap between those treated and those in need. SUMMARY: PD can bridge this gap and can serve as a first line of therapy if it becomes more affordable. Government reimbursement schemes, the Once-in-a-Lifetime Payment Scheme, and PD insurance all provide strong impetus to dialysis programmes. Local manufacturing of PD fluid has also reduced the cost of therapy to some extent. PD may be preferable for patients with cardiovascular morbidity and it also obviates the risk of transmission of blood-borne diseases such as HIV, hepatitis B, and hepatitis C. In our own centre, automated PD is being used as initial RRT for acute kidney injury with good results. In prospective transplant recipients, PD has been found to decrease the risk of posttransplant graft dysfunction. Key Messages: Remote PD and home visits by PD clinical coordinators have brought faraway patients and their nephrologists closer with the use of technology. For these reasons, the current pressing need is to bring PD to the forefront of RRT in resource-poor countries in South Asia to enable universal treatment of patients with renal disease.

Model-based stability assessment of ventilatory control in overweight adolescents with obstructive sleep apnea during NREM sleep.

Obstructive sleep apnea (OSA) involves the interplay of several different factors such as an unfavorable upper airway anatomy, deficiencies in pharyngeal muscle responsiveness, a low arousal threshold, and ventilatory control instability. Although the stability of ventilatory control has been extensively studied in adults, little is known about its characteristics in the pediatric population. In this study, we developed a novel experimental setup that allowed us to perturb the respiratory system during natural non-rapid eye movement (NREM) sleep conditions by manipulating the inspiratory pressure, provided by a bilevel pressure ventilator, to induce sighs after upper airway stabilization. Furthermore, we present a modeling framework that utilizes the noninvasively measured ventilatory responses to the induced sighs and spontaneous breathing data to obtain representations of the processes involved in the chemical regulation of respiration and extract their stability characteristics. After validation with simulated data, the modeling technique was applied to data collected experimentally from 11 OSA and 15 non-OSA overweight adolescents. Statistical analysis of the model-derived stability parameters revealed a significantly higher plant gain and lower controller gain in the OSA group (P = 0.046 and P = 0.007, respectively); however, no differences were found in loop gain (LG) and circulatory time delay between the groups. OSA severity and LG, within the 0.03-0.04-Hz frequency band, were significantly negatively associated (r = -0.434, P = 0.026). Contrary to what has been found in adults, our results suggest that in overweight adolescents, OSA is unlikely to be initiated through ventilatory instability resulting from elevated chemical loop gain.

The use of a tablet computer platform to optimize the care of patients receiving peritoneal dialysis: a pilot study.

BACKGROUND: Peritoneal dialysis (PD) affords patients increased independence and improved quality of life. However, the lack of more frequent monitoring may compromise outcomes and decrease wider uptake of this modality. This study uses a novel tablet computer-based interface to allow real-time monitoring and two-way communication to better link PD patients with a dialysis center and care providers. METHODS: A tablet computer with an application that allows enhanced monitoring of all aspects of PD was given to patients to assess their usage in a pilot trial. The interface allows patients to review sterility techniques, enter vital signs and exchange data, upload media such as photos and video clips, synchronize data to be viewed by medical staff, and allow real-time adjustments to the PD prescription. Satisfaction with the interface and comments for enhancement were analyzed using a simple self-administered questionnaire. RESULTS: Six continuous ambulatory PD patients were enrolled in this pilot study. A total number of 1,172 exchanges were recorded over a period of 251 days. Compliance with the applications ranged from 51 to 92%. No major adverse events were recorded. The overall impression of the interface was 5.2 out of 10. The major criticism was that the application needs to be adjusted depending upon the experience level of the patient and that data entry needs to be simplified and automated. CONCLUSION: A tablet computer platform is a feasible concept for continuous ambulatory PD. The major components include flexibility, advanced infrastructure, two-way communication, and real-time interaction. This may encourage more patients to take up PD as their preferred modality of therapy for end-stage renal disease. Modifications to enhance use will be incorporated in subsequent versions.

Noninvasive identification and assessment of functional brown adipose tissue in rodents using hyperpolarized ¹³C imaging.

OBJECTIVE: The recent identification of functional depots of brown adipose tissue (BAT) in adult humans has potential implications for the treatment of obesity. In order to evaluate new therapies aimed at inducing the production of more BAT or activating BAT in humans, it will be important to develop noninvasive methods to assess the functional state of the tissue in vivo. In this study, we investigate the feasibility of using hyperpolarized (13)C imaging to noninvasively identify functional, activated BAT in an in vivo rodent model, in less than 1 min, following an infusion of pre-polarized [1-(13)C] pyruvate. DESIGN: Hyperpolarized (13)C imaging was used to monitor BAT metabolic conversion of pre-polarized [1-(13)C] pyruvate in rats during baseline and norepinephrine (NE)-stimulated conditions. RESULTS: Activated BAT, stimulated by NE injection, can be detected in rats by increased conversion of pre-polarized [1-(13)C] pyruvate into its downstream products (13)C bicarbonate and [1-(13)C] lactate. The colocalization of the (13)C signal to interscapular BAT was validated using hematoxylin-eosin histological staining. CONCLUSION: The radiation-free nature and recent translation into the clinic of the hyperpolarized (13)C-imaging test may potentially facilitate trials of therapeutics targeting BAT activation in humans.

Remote monitoring of peritoneal dialysis in special locations.

Peritoneal dialysis (PD) as a therapy with all its advantages has not grown as would have been expected except in certain pockets, notably in Asia. In our opinion, from patient and their family interviews, a perception among prospective PD patients of inaccessibility to the referral PD Unit (RPU), usually for patients from rural areas in far flung places, inaccessible due to difficult terrain or long distances, play a strong role against the choice of PD as their modality choice for end-stage renal disease. We decided to address this issue by adopting novel initiatives such as easy access to the RPU through usage of internet and mobile phones from the patient homes especially in addressing the more clinically relevant infectious complications such as peritonitis and exit site infections with immediate treatment management responses from the RPU. In addition, we found that inherently the rural PD patients had several advantages over their urban counterparts and also over their hemodialysis (HD) counterparts in many socioeconomic, emotional support and nutritional parameters. We enhanced these advantages with an intensive home visit program. This two pronged approach has paid dividends in that our rural PD patients do as well, if not better than the urban PD and the HD patients, contrary to prevailing international experience.

Maximizing the erythropoietin response: iron strategies.

Anemia is a significant cause of morbidity and lowers the quality of life of patients suffering from chronic kidney disease (CKD). Iron deficiency is the most important cause of erythropoietin (EPO) hyporesponsiveness in CKD. EPO administration significantly increases the costs of CKD management. It follows that paramount importance must be given to enhancing responsiveness to EPO thereby ensuring that the patient derives maximum benefit. Intravenous iron (IVI) administration has been used for decades to replenish body iron stores. Multiple preparations of Iron are available in the market. However, IVI administration is fraught with dangers like adverse drug reactions, susceptibility to infection, and, as recently postulated, direct cellular toxicity. Traditional approaches to IVI administration have focused on multiple administrations of lower doses for fear of adverse reactions. However, recent studies have demonstrated that higher doses can be safely administered in a single infusion, thereby reducing hospitalization costs and patient inconvenience. Newer preparations of IVI are relatively safer, easier to administer and efficacious. Preparations like Iron sucrose, ferumoxytol, ferric carboxymaltose and iron isomaltoside do not require test doses and allow higher doses to be administered at a time with cost and effect benefits.

Assessment of abdominal adipose tissue and organ fat content by magnetic resonance imaging.

As the prevalence of obesity continues to rise, rapid and accurate tools for assessing abdominal body and organ fat quantity and distribution are critically needed to assist researchers investigating therapeutic and preventive measures against obesity and its comorbidities. Magnetic resonance imaging (MRI) is the most promising modality to address such need. It is non-invasive, utilizes no ionizing radiation, provides unmatched 3-D visualization, is repeatable, and is applicable to subject cohorts of all ages. This article is aimed to provide the reader with an overview of current and state-of-the-art techniques in MRI and associated image analysis methods for fat quantification. The principles underlying traditional approaches such as T(1) -weighted imaging and magnetic resonance spectroscopy as well as more modern chemical-shift imaging techniques are discussed and compared. The benefits of contiguous 3-D acquisitions over 2-D multislice approaches are highlighted. Typical post-processing procedures for extracting adipose tissue depot volumes and percent organ fat content from abdominal MRI data sets are explained. Furthermore, the advantages and disadvantages of each MRI approach with respect to imaging parameters, spatial resolution, subject motion, scan time and appropriate fat quantitative endpoints are also provided. Practical considerations in implementing these methods are also presented.

Outcome of patients with end stage renal disease admitted to an intensive care unit in India.

AIMS: We sought to determine outcome and evaluate performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores upon admission in predicting 30-day mortality of end-stage renal disease (ESRD) patients admitted in ICU. METHODS: This prospective observational cohort study examined 73 consecutive ESRD patients admitted in an ICU of a tertiary care institute over 15 months. Primary outcome measure was 30-day mortality. Data on patient characteristics, reason for ICU admission, cause of ESRD, mode of renal replacement, and use of mechanical ventilation (MV) or inotropes were recorded. The APACHE 2 and SOFA scores were calculated based on admission characteristics. RESULTS: First-day median APACHE II, SOFA, and APACHE II-predicted hospital mortality rates were 26 (14-49), 7 (4-17), and 56.9% (18.6-97.4%), respectively. Observed ICU and 30-day mortality rates were 27.4%, and 41.1%, respectively. During the ICU course, MV and inotropic support was required in 27 (37%) and 23 (35.1%) patients, respectively. Need for MV (p < 0.001) and inotropic support (p < 0.001) were predictors of 30-day mortality in univariate analysis. Area under receiver operating characteristic curve for APACHE II in predicting 30-day mortality was 0.86 (95% CI, 0.76-0.93) compared with 0.92 (95% CI, 0.83-0.97) for SOFA score (p = 0.16). CONCLUSIONS: Outcome of ESRD patients admitted to ICU is poor, especially if they require other organ support. APACHE II and SOFA scores perform well as predictors of 30-day mortality.

Peritoneal dialysis in developing countries.

Peritoneal dialysis (PD) is acknowledged worldwide as a well-accepted form of renal replacement therapy (RRT) for end-stage renal disease (ESRD). Ideally, PD should be the preferred modality of RRT for ESRD in developing countries due to its many inherent advantages. Some of these are cost savings (especially if PD fluids are manufactured locally or in a neighboring country), superior rehabilitation and quality of life (QOL), home-based therapy even in rural settings, avoidance of hospital based treatment and the need for expensive machinery, and freedom from serious infections (hepatitis B and C). However, this is not the ground reality, due to certain preconceived notions of the health care givers and governmental agencies in these countries. With an inexplicable stagnation or decline of PD numbers in the developed world, the future of PD will depend on its popularization in Latin America and in Asia especially countries such as China and India, with a combined population of 2.5 billion and the two fastest growing economies worldwide. A holistic approach to tackle the issues in the developing countries, which may vary from region to region, is critical in popularizing PD and establishing PD as the first-choice RRT for ESRD. At our center, we have been pursuing a 'PD first' policy and promoting PD as the therapy of choice for various situations in the management of renal failure. We use certain novel strategies, which we hope can help PD centers in other developing countries working under similar constraints. The success of a PD program depends on a multitude of factors that are interlinked and inseparable. Each program needs to identify its strengths, special circumstances, and deficiencies, and then to strategize accordingly. Ultimately, teamwork is the 'mantra' for a successful outcome, the patient being central to all endeavors. A belief and a passion for PD are the fountainhead and cornerstone on which to build a quality PD program.

Our experience of home visits in city and rural areas.

In a peritoneal dialysis (PD) program, an efficient and well-structured home visit schedule is imperative for ensuring patient compliance, adherence to proper exchange technique, nutrition status monitoring and intervention, and early detection of evolving medical comorbid problems so as to prevent further complications. Regular home-visit follow-up of the PD patient directly affects technique survival and quality of life. The clinical coordinator is ideally placed to be the direct link between the PD center and patients in their domiciliary surroundings. This professional plays a crucial role in the success of a PD program.

Key success factors for a quality peritoneal dialysis program.

The success of a peritoneal dialysis (PD) program depends on a multitude of factors that are interlinked and inseparable from one another. Each program needs to identify its special circumstances, deficiencies, and strong points, and then to strategize accordingly. Ultimately, "teamwork" is the mantra for a successful outcome, the patient being central to all endeavors. A belief and a passion for PD are the fountainhead and cornerstone on which to build a quality PD program.

Polyclonal antibodies in renal transplantation--a relook.

Polyclonal antibodies have been used in renal transplantation for the past four decades. Increasing knowledge regarding their varied mechanisms of action have confirmed their versatility in clinical practice. They can be used for induction, reversing acute rejections (especially those resistant to steroids), and possibly conferring an element of allotolerance, thereby reducing chronic allograft nephropathy. Their recent usage as IV bolus, single-dose, preoperative infusion as induction therapy in renal transplantation is an attractive and extremely cost-effective strategy, especially in a developing country such as India.