Comparison between Urine Sodium and Clinical Evaluation to Assess Saline Responsiveness in Severe Hyponatremia - A Prospective Study.

INTRODUCTION AND BACKGROUND: Hyponatremia is a commonly encountered electrolyte disturbance seen in diverse clinical settings. The recently published European guidelines comprehensively summarize the present status of evaluation for hyponatremia. The guidelines emphasize the poor predictability of clinical criteria and instead suggest that the urine sodium (UNa) may be a better way to initially evaluate the cause of hyponatremia. AIMS AND OBJECTIVES: Aim of the study is to comparison between urine sodium and clinical evaluation to assess saline responsiveness in severe hyponatremia. MATERIALS AND METHODS: Prospective Cross sectional study carried out in Departments of Nephrology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala. Study Period between October 2014 to October 2016 (2 years), Patients diagnosed as Severe hyponatremia S.Sodium < 125mEq/L based on clinical and laboratory evaluations. INCLUSION CRITERIA: All clinically and lab confirmed cases of severe hyponatremia, Age >18 years. Outpatients, Inpatients admitted to medical wards and ICU, who give informed consent and serum sodium of less than 125mEq/L constitute the study population. These patients meeting the following criteria: blood glucose level less than 200mg/dl would be included. EXCLUSION CRITERIA: Patients with overt hypervolemia due to cardiac, hepatic, and renal disease with gross edema were excluded. RESULTS: Among 50 patients in the study 70% were found at age group > 60 yrs. 30% patients were < 60 years age group. Youngest patient was 14 yrs old and oldest patient was 83 yrs old. 21 (42%) were Females and Males were 29 (58%). Majority of the cases were symptomatic at time of presentation n=38 (76%). All were having hypotonic hyponatremia among them 14 patients (28%) were euvolemic, 3 patients (6%) were hypervolemic and 33 patients (66%) were hypovolemic. 31 patients (62%) had serum Sodium levels between 115-125mEq/L and 19 patients (38%) had serum Sodium levels between 100-114mEq/L. Among the 33 patients (66%) Hyponatremia due to volume depletion by clinical assessment by the Nephrologist and who were given saline 26 (78%) were saline responsive and 7 patients (22%) were saline non responsive. Among the 7 patients who are saline non responders 6 patients (85.7%) had UNa > 20 and 1 patient (14.3%) had UNa < 20, which is statistically not significant (p=0.840). Among the 44 patients who are saline responders 18 patients are saline responsive. Among the 44 patients 20 (76.9%) had UNa > 20 and 6 (23.1%) had UNa < 20, statistically not significant (p=0.604). Duration for normalizing sodium was noted during the study 17 cases, 1-3 days were needed, 22 cases needed 4-7 days. CONCLUSION: Volume status of patients with hyponatremia can be assessed clinically with a high degree of reliability if the hyponatremia is severe. Thus we re-emphasize the importance of measuring volume status in patients with hyponatremia and classify patients on basis of volume status prior to triaging management. The measurement of UNa had a poor correlation with saline responsiveness and this shows that the laboratory measure is subject to errors due to prior treatments given to the patient and has to be interpreted with the prior clinical scenario in mind.

Prevalence of depression and past suicide attempt in primary care.

BACKGROUND: It is known that persons who die by suicide commonly visit a primary care physician (PCP) shortly before the fatal act.There is little information on history of suicide attempt in depressed patients who consult PCPs for non-mental health indications.This information is important because past history of suicide attempt is a known predictor of future suicide risk. OBJECTIVE: To estimate the prevalence of depression among outpatients in primary care and to determine the prevalence and determinants of past suicide attempt among them. METHOD: This cross-sectional study was conducted in six primary care settings, both public and private, in Kerala, India. A psychiatrist evaluated adult outpatients (n=827), diagnosed depression using ICD-10 Diagnostic Criteria for Research, and elicited history of suicide attempt. RESULTS: Overall depression prevalence was 27.2% and was higher in women. Past suicide attempt was identified in 6.9% (95% CI, 5.17-8.63%) of all outpatients; higher in women (9.2%) than men (3.6%). Among the depressed, 21.3% had previously attempted suicide; while this figure was 1.5% in the non-depressed. The prevalence of current depression was 81% (severe depression, 61%) in patients reporting past suicide attempts. In univariate analyses, female gender, perceived financial stress, and being depressed were significantly associated with past suicide attempts. In multivariate analysis, current depression was the largest predictor of past suicide attempt (adjusted odds ratio, 14.3; 95% CI, 6.60-31.07). CONCLUSION: Depression and suicide attempt are both common in primary care. Depression is the single most important predictor of suicide attempt.

Primary care Screening Questionnaire for Depression: reliability and validity of a new four-item tool.

BACKGROUND: Unidentified depression in primary care is a public health concern, globally. There is a need for brief, valid and easily administered tools in primary care. AIMS: To estimate reliability and validity of the newly developed Primary care Screening Questionnaire for Depression (PSQ4D), a four-item tool, with 'yes' or 'no' options. METHOD: PSQ4D was administered verbally (time required, <1 min) by primary care physicians to adult outpatients (n=827) in six primary care settings in Kerala, India. A psychiatrist evaluated each patient on the same day, using ICD-10 Diagnostic Criteria for Research, based on unstructured clinical interview. RESULTS: The Cronbach's alpha for internal consistency reliability was 0.80; kappa coefficient for test-retest reliability was 0.9 and that for interrater reliability was 0.72. At a score ≥2, sensitivity was 0.96, specificity was 0.87, positive predictive value was 0.74, negative predictive value was 0.98, positive likelihood ratio was 7.4 and negative likelihood ratio was 0.05. CONCLUSIONS: When physician administered, PSQ4D has good reliability. At a cut-off score of ≥2, it has high sensitivity and specificity to identify depressive disorder in primary care. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

What do we know about chronic kidney disease in India: first report of the Indian CKD registry.

BACKGROUND: There are no national data on the magnitude and pattern of chronic kidney disease (CKD) in India. The Indian CKD Registry documents the demographics, etiological spectrum, practice patterns, variations and special characteristics. METHODS: Data was collected for this cross-sectional study in a standardized format according to predetermined criteria. Of the 52,273 adult patients, 35.5%, 27.9%, 25.6% and 11% patients came from South, North, West and East zones respectively. RESULTS: The mean age was 50.1 ± 14.6 years, with M:F ratio of 70:30. Patients from North Zone were younger and those from the East Zone older. Diabetic nephropathy was the commonest cause (31%), followed by CKD of undetermined etiology (16%), chronic glomerulonephritis (14%) and hypertensive nephrosclerosis (13%). About 48% cases presented in Stage V; they were younger than those in Stages III-IV. Diabetic nephropathy patients were older, more likely to present in earlier stages of CKD and had a higher frequency of males; whereas those with CKD of unexplained etiology were younger, had more females and more frequently presented in Stage V. Patients in lower income groups had more advanced CKD at presentation. Patients presenting to public sector hospitals were poorer, younger, and more frequently had CKD of unknown etiology. CONCLUSIONS: This report confirms the emergence of diabetic nephropathy as the pre-eminent cause in India. Patients with CKD of unknown etiology are younger, poorer and more likely to present with advanced CKD. There were some geographic variations.

Comparing continuous venovenous hemodiafiltration and peritoneal dialysis in critically ill patients with acute kidney injury: a pilot study.

BACKGROUND: There are few reports on the role of peritoneal dialysis in critically ill patients requiring continuous renal replacement therapies. METHODS: Patients with acute kidney injury and multi-organ involvement were randomly allotted to continuous venovenous hemodiafiltration(CVVHDF, group A) or to continuous peritoneal dialysis (CPD, group B). Cause and severity of renal failure were assessed at the time of initiating dialysis. Primary outcome was the composite correction of uremia, acidosis, fluid overload, and hyperkalemia. Secondary outcomes were improvement of sensorium and hemodynamic instability, survival, and cost. RESULTS: Groups A and B comprised 25 patients each with mean ages of 45.32 ± 17.53 and 48.44 ± 17.64 respectively. They received 21.68 ± 13.46 hours and 66.02 ± 69.77 hours of dialysis respectively (p = 0.01). Composite correction was achieved in 12 patients of group A (48%) and in 14 patients of group B (56%). Urea and creatinine clearances were significantly higher in group A (21.72 ± 10.41 mL/min and 9.36 ± 4.93 mL/min respectively vs. 22.13 ± 9.61 mL/min and 10.5 ± 6.07 mL/min, p < 0.001). Acidosis was present in 21 patients of group A (84%) and in 16 of group B (64%); correction was better in group B (p < 0.001). Correction of fluid overload was faster and the amount of ultrafiltrate was significantly higher in group A (20.31 ± 21.86 L vs. 5.31 ± 5.75 L, p<0.001). No significant differences were seen in correction of hyperkalemia, altered sensorium, or hemodynamic disturbance. Mortality was 84% in group A and 72% in group B. Factors that influenced outcome were the APACHE (Acute Physiology and Chronic Health Evaluation) II score (p=0.02) and need for ventilatory support (p < 0.01). Cost of disposables was higher in group A than in group B [INR 7184 ± 1436 vs. INR 3009 ± 1643, p < 0.001 (US$1=INR 47)]. CONCLUSIONS: Based on this pilot study, CPD may be a cost-conscious alternative to CVVHDF; differences in metabolic and clinical outcomes are minimal.

Decoy cells in the urine cytology of a renal transplant recipient: an immunohistochemical study.

Human polyoma virus causes renal dysfunction and graft loss as a result of tubulo-interstial nephritis in renal transplant recipients after reactivation of latent virus in renal epithelium. The infected cells in the urinary sediments are characterized by large homogenous inclusions, which may cause diagnostic error in urine cytology. The epithelial cells with polyoma viral inclusions in urine cytology specimens are termed Decoy cells to caution pathologists not to misdiagnose these cells as cancer cells. We present a case of polyoma viral changes detected the first time in our laboratory in the urine of a 46year old male who underwent renal transplantation six months back and followed by immunotherapy. Urine cytological examination showed decoy cells and subsequently revealed on histopathology. Immunoperoxidase staining for SV-40 LT antigen (LT ag), expression of proliferating cell nuclear antigen (PCNA), p53 and Rb genes were also studied in the tissue sections for further observation. The expression of SV40 LT ag was negative, while PCNA showed strong positivity; p53 and Rb were expressed moderately in the nuclei of cells in the tubules. The report of a case of decoy cells in the urine of a patient with renal transplantation focuses the importance of cytologic analysis of urine as a diagnostic tool for screening renal transplant recipients at risk of polyoma viral infection.

Effect of lanthanum carbonate and calcium acetate in the treatment of hyperphosphatemia in patients of chronic kidney disease.

OBJECTIVES: The tolerability and efficacy of lanthanum carbonate has not been studied in the Indian population. This study was, therefore, undertaken to compare the efficacy and tolerability of lanthanum carbonate with calcium acetate in patients with stage 4 chronic kidney disease. DESIGN: A randomized open label two group cross-over study. MATERIALS AND METHODS: Following Institutional Ethics Committee approval and valid consent, patients with stage 4 chronic kidney disease were randomized to receive either lanthanum carbonate 500mg thrice daily or calcium acetate 667 mg thrice daily for 4 weeks. After a 4-week washout period, the patients were crossed over for another 4 weeks. Serum phosphorous, serum calcium, serum alkaline phosphatase, and serum creatinine were estimated at fixed intervals. RESULTS: Twenty-six patients were enrolled in the study. The mean serum phosphorous concentrations showed a declining trend with lanthanum carbonate (from pre-drug levels of 7.88 +/- 1.52 mg/dL-7.14 +/- 1.51 mg/dL) and calcium acetate (from pre-drug levels of 7.54 +/- 1.39 mg/dL-6.51 +/- 1.38 mg/dL). A statistically significant difference was seen when comparing the change in serum calcium produced by these drugs (P < 0.05). Serum calcium levels increased with calcium acetate (from pre-drug levels of 7.01 +/- 1.07-7.46 +/- 0.74 mg dL), while it decreased with lanthanum carbonate (from pre-drug levels 7.43 +/- 0.77-7.14 +/- 0.72 mg/dL). The incidence of adverse effects was greater with lanthanum carbonate. CONCLUSION: Lanthanum carbonate and calcium acetate are equally effective phosphate binders with trends obvious in the first 4 weeks of therapy. The decrease in serum calcium levels with lanthanum carbonate when compared to the increase in serum calcium levels due to calcium acetate is statistically significant. The drawback of lanthanum carbonate is its high cost and relatively higher incidence of adverse events during treatment.

Random capillary blood sugar and coronary risk factors in a south Kerala population.

BACKGROUND: High prevalence of type 2 diabetes in one subdivision of a district in south India prompted us to look at the prevalence of other major coronary risk factors, and relate these to random blood sugar values. DESIGN: Cross-sectional survey of all adult residents of four wards (clusters of households) of a subdivision. Detailed investigation for diabetes and blood lipids in a selected subsample with random blood sugar (RBS) >109 mg/dl by glucometer. METHODS: From the selected wards, we conducted a standard oral glucose tolerance test and serum lipids in all those who had RBS above 109 mg/dl by glucometer. Risk factors such as smoking, obesity (body mass index > 29.9), high blood pressure (systolic pressure > 139; diastolic pressure > 89 mmHg) and sedentary habits were assessed in all irrespective of RBS. RESULTS: Prevalence of all risk factors increases with age. Mean RBS ranges from 92.9 +/- 15.7 to 108.8 +/- 35.7 mg/dl in males and 88.6 +/- 16.0 to 117.3 +/- 61.6 mg/dl in females, between the age groups 20-29 to > 69. Risk factor prevalence varied with area of residence, with urban population reporting highest prevalence for type 2 diabetes and obesity, and coastal population for hypertension. For increasing levels of fasting plasma glucose (FPG < 100, 100-124 and > 125 mg/dl), serum total cholesterol values were 5.21 +/- 1.08 mM/l, 5.38 +/- 0.86 mM/l and 5.63 +/- 1.37 mM/l for males. For females, corresponding values were 5.23 +/- 1.11 mM/l, 5.54 +/- 1.15 mM/l, and 5.49 +/- 1.10 mM/l respectively. CONCLUSIONS: Risk factor prevalence varies with area of residence within the study population. Mean plasma lipid levels are high among both sexes, tending to rise with increasing mean fasting plasma glucose levels.