Clinico-biochemical Profile of Biopsy-proven Minimal Change Disease in Adults from a Tertiary Care Center in South India.

Minimal change disease (MCD) is the most common cause of nephrotic syndrome (NS) in children, and in adults, it contributes to 10%-25% of NS. MCD in adults follows a slightly different course associated with increased incidence of steroid resistance, hematuria, and HTN. This is a prospective-record analysis study aimed to analyze the profile of MCD in adults, response to treatment, and relapse rates. A retrospective observational study was carried out and data were collected retrospectively from all biopsy-proven MCD patients between 2012 and 2018. A total of 86 adults were diagnosed to have biopsy-proven MCD. Of these, 32 were excluded due to insufficient data/lost for follow-up. The IBM SPSS Statistics version 22.0 was used for the statistical analysis. Descriptive analysis includes expression of all the explanatory and outcome variables in terms of frequency and proportions for categorical variables whereas in terms of mean ± standard deviation for continuous variables. Chi-square test was used to compare the age, gender, remission, renal failure and response of different drugs, treatment durations, comorbidity conditions, relapse episodes, and different types of infections based on the degree of proteinuria among study patients. A total of 54 biopsy-proven adult MCD patients were analyzed. The mean age of the patients studied was 36.67 years, with the oldest patient being 76 years. In the study group, 37 (68.5%) patients were male and 14 (31.5%) were female. In the study population, 20 (37%) were hypertensive, 3 (5.6%) were diabetic, and 10 (18.5%) had renal failure at presentation. On treatment, 52 out of 54 patients received steroids, of which 41 (75.9%) were steroid responsive, 6 (11.1%) steroid dependent, and 7 (13%) steroid resistant. The mean time for remission in steroidsensitive patients was 8.8 weeks. Among the steroid-dependent and steroid-resistant patients, 11 patients received calcineurin inhibitors (CNIs), of which 3 were CNI resistant. In the study Group 1 patient received cyclophosphamide and two received rituximab. In the study population, two patients failed to achieve remission and one patient was initiated on hemodialysis and later lost for follow-up. Minimal change NS is a type of NS which is highly responsive to steroids with good prognosis in children. Adult MCD patients require a higher and prolonged course of steroid when compared to children. CNIs and rituximab form a promising second-line drug in patients who are steroid resistant/dependent. However, CNI dependency or relapse after stopping steroids is a concern.

Unusual presentation of systemic lupus erythematosus.

Bullous systemic lupus erythematosus is a rare distinctive subepidermal blistering disorder that can occur in patients with systemic lupus erythematosus (SLE). It is histologically characterized by a neutrophil-predominant infiltrate in the subepidermal region with deposition of immunoglobulins (IgG, IgA, IgM), C3, and auto-antibodies against collagen VII. Herein, we report a case of a 13-year-old girl who presented with bullous SLE and Class III lupus nephritis, which is extremely rare at this age.

Pregnancy-related acute kidney injury: An analysis of 165 cases.

Pregnancy-related acute kidney injury (PRAKI) contributes to 3-7% of overall acute kidney injury (AKI) cases in Indian subcontinent. The aim of this study was to determine the outcomes of PRAKI and risk factors associated with renal injury and maternal mortality. One hundred and sixty-five patients with PRAKI, seen at M. S. Ramaiah Medical College between 2005 and 2014, were included in this, observational study. AKI was analyzed in terms of maximal stage of renal injury attained as per Risk, Injury, Failure, Loss of function, and End-stage renal disease (RIFLE) criteria. Outcomes included requirement for renal replacement therapy (RRT), maternal, and fetal mortality. Incidence of PRAKI was 1.56%, and the mean age of the study population was 25 years. Fifty percent of the patients were diagnosed with PRAKI during their first pregnancy. PRAKI was observed most commonly in the postpartum period (60%), followed by third trimester (32%); as per RIFLE criteria, failure was seen in 36% and injury in 34%. Thirty percent of cases required RRT. Sepsis (59%), pre-eclampsia, and eclampsia (56%) were the leading causes of PRAKI, while sepsis was the leading cause of maternal mortality. Maternal and fetal mortality were 20% and 22%, respectively. In univariate analysis, shock, hemorrhage requiring transfusion of >5 units packed red blood cells, oliguria, and "Loss" category of RIFLE were significantly associated with mortality. Majority of the patients (57%) required Intensive Care Unit care with a mean duration of admission at 7.3 days, and 75% was diagnosed with AKI at the time of admission. We report the lowest incidence of PRAKI in contemporary Indian literature. PRAKI was associated with high maternal and fetal mortality, with sepsis being the leading cause. No association was noted between mortality and initial stages of RIFLE criteria.

Idiopathic erythrocytosis in IgA nephropathy.

We report a case of idiopathic erythrocytosis in a 31-year-old male who was incidentally detected to have hypertension during his preemployment checkup. Urine routine showed proteinuria and hematuria. Biochemical parameters revealed raised serum creatinine, and histological findings of the renal biopsy showed IgAN.

Bacteriological Quality of Treated Water and Dialysate in Haemodialysis Unit of A Tertiary Care Hospital.

INTRODUCTION: Haemodialysis is one of the treatment modalities for patients suffering from end stage renal disease (ESRD). Dialysis patients are exposed to large volumes of water for production of dialysis fluids. Treated water and dialysate come in direct contact with the patient's bloodstream. Such patients suffer from abnormalities of the immune system, making them more susceptible to infections. Microbial contamination of the treated water and dialysate can lead to biofilm formation and release of endotoxins in Haemodialysis system. These can give rise to pyrogenic reactions in the short term and ß2 amyloidosis, atherosclerosis, and increased mortality in the long term. AIM: To assess the bacteriological quality of treated water and dialysate used in the Haemodialysis unit of a tertiary care hospital. MATERIALS AND METHODS: A retrospective review of records of treated water and dialysate samples sent to the Microbiology laboratory for analysis of bacteriological contamination of the water used in haemodialysis treatment from January 2013 to June 2014 was conducted. The acceptable limits for treated water and dialysate were taken as <200 CFU/ml and < 2000 CFU/ml respectively as per Government of India Guidelines for Maintenance Haemodialysis. RESULTS: Thirty six samples of treated water and 394 samples of dialysate were analysed for bacteriological contamination. 4 out of 36 (11.1%) samples of treated water and 44 out of 394 dialysate samples (11.2%) showed unacceptable bacteriological growth. CONCLUSION: Regular and continual monitoring of the disinfection protocol of the water distribution system in haemodialysis unit is necessary to get good microbiological quality of treated water and dialysate fluid.

Unusual fungal infections in renal transplant recipients.

Fungal infections are an important cause of morbidity and mortality in renal transplant recipients. The causative agent and the risk factors differ depending on the period after the kidney transplant. Also the incidence varies according to the geographical area. We are reporting three cases of fungal infections in renal transplant recipients. Two of them have etiological agents which are common among immunosuppressed patients, but with an atypical clinical presentation, while one of them is a subcutaneous infection caused by a less frequent dematiaceous fungus, Aureobasidium pullulans. These cases highlight how a high index of clinical suspicion and prompt diagnosis is very much essential for better outcome. The emerging fungal infections and paucity of data regarding their management pose a challenge to the transplant physicians.

Prevalence of medication-related problems among patients with renal compromise in an Indian hospital.

WHAT IS KNOWN AND OBJECTIVE: Patients suffering from renal dysfunction often have multiple medical conditions either as a cause or as a consequence of their renal disease. These patients receive an average of 10-12 medications daily leading to complex dosing schedules and are more likely to develop medication-related problems (MRPs). The objectives of this study were to determine the nature and extent of MRPs in renally compromised patients and to explore the potential clinical significance of the MRPs. The potential for a clinical pharmacist to contribute towards resolving or preventing some of these MRPs was also explored. METHODS: A prospective study was conducted for a period of 9 months in the renal unit of Jagadguru Shri Shivaratheeshwara (JSS) Medical College Hospital, Mysore, India. Patients undergoing dialysis on outpatient basis and patients who were admitted under the care of or referred to the nephrologists for renal dysfunction from other specialties were reviewed. Patterns of the MRPs were identified using an adapted Hepler and Strand criteria. The potential clinical significance of the MRPs and the contribution of the clinical pharmacist in resolving or minimizing some of the MRPs were also explored. RESULTS AND DISCUSSION: Three hundred and twenty-seven MRPs were identified with 308 patients reviewed. The incidence of MRPs was found to be 1·06 ± 0·85 per patient reviewed. The most common MRP identified in our study was overdose (19·3%) followed by adverse drug reactions (19·0%). Cardiovascular agents (33·6%) followed by anti-infective agents (26·3%) were the most common therapeutic classes of medication implicated in causing MRPs. Twenty-six per cent of the MRPs identified were explored to be potentially moderate or major in clinical significance. The clinical pharmacists' recommendations were accepted in 97% of the cases, which resulted in a change in therapy in 83% of the cases. WHAT IS NEW AND CONCLUSION: Medication-related problems are frequent in renally compromised patients in our patient population. The high level of acceptance of clinical pharmacist's recommendations by the nephrologists demonstrates that clinical pharmacists may help improve overall patient care in this setting.

An assessment of the quality of life in hemodialysis patients using the WHOQOL-BREF questionnaire.

A cross-sectional study was conducted to evaluate the quality of life (QOL) of hemodialysis patients. An attempt was made to compare the QOL of hemodialysis patients with the QOL of the general population, renal transplant patients, and patients with a chronic disease, in this case, asthma. The WHOQOL-BREF questionnaire was used to assess the quality of life. Hemodialysis patients who had completed three months of maintenance hemodialysis (n = 75) were enrolled into the study. The quality of life of hemodialysis patients was found to be significantly impaired (P < 0.05) in comparison to healthy individuals of the general population, particularly with respect to the physical, psychological, and social relationship domains. In comparison to the quality of life of renal transplant patients, the quality of life of hemodialysis patients was significantly (P < 0.05) lower in all the four WHOQOL-BREF domains. Only in the environmental dimension was the quality of life of hemodialysis patients found to be significantly lower than that of the asthma patients. Female hemodialysis patients showed significantly (P < 0.05) lower quality of life than did male patients in the psychological and environmental dimensions of WHOQOL-BREF. A positive association was seen between higher education and the psychological functioning and the environmental dimensions of WHOQOL-BREF. Thus, the quality of life of hemodialysis patients was found to be considerably impaired when compared to that of healthy individuals of the general population as well as of renal transplant patients.

Subclavian vein catheters for haemodialysis with and without a subcutaneous tunnel.

We have retrospectively analysed the usefulness of a subcutaneous tunnel in patients undergoing haemodialysis through a double lumen subclavian catheter; 194 catheters were used in 145 patients. In 105 patients a subcutaneous tunnel was created. Entry site infection was significantly higher in the no tunnel group (30%; P < 0.02). There was no statistically significant difference in the incidence of septicaemia in the two groups. Eighty five percent of episodes of septicaemia and 67% of entry site infections were due to Staphylococcus aureus. All responded to removal of the catheter and to antibiotics. The average duration the catheter was in place was 20.39 and 21.94 days in the groups with and without tunnel respectively. The average number of dialyses was 9.13 and 9.33 per catheter in the tunnel and no tunnel groups respectively. Three patients had pneumothorax. Subclavian vein thrombosis was suspected clinically in 3 cases. There was no catheter related mortality. We concluded that while entry site infection occurred more frequently in the no tunnel group, the overall incidence of septicaemia was not different in the two groups. Creation of a subcutaneous tunnel has no added advantage.

Short term study on relative merits of acetate and bicarbonate dialysis.

We did a double blind, crossover, prospective study comparing bicarbonate and acetate containing solutions in haemodialysis. Thirty stable patients with end stage renal disease on maintenance haemodialysis while awaiting a renal transplant were each studied on three dialysis with acetate and three with bicarbonate. Nine patients developed symptoms like headache, nausea, vomiting, giddiness, and malaise and developed hypotension during acetate dialysis and three patients during bicarbonate dialysis. There were symptoms during 16.66% of acetate dialysis sessions and 5.55% of bicarbonate dialysis sessions. (P less than 0.05). There was a statistically significant decrease in PaO2 and PaCO2 on acetate dialysis at 30 minutes after initiation of dialysis. There was no significant difference in weight loss on dialysis, or in blood pressure and correction of acidosis. We conclude that bicarbonate dialysis is better tolerated, but acetate intolerance is not a major problem since we use small surface area dialysers (0.8 M2).