Prevalence and outcome of abdominal wall hernia in patients with end-stage renal disease on peritoneal dialysis.

INTRODUCTION: We aimed to study the prevalence, risk factors, management, and outcome of hernias in end-stage renal disease (ESRD) patients on peritoneal dialysis (PD) from India. METHODS: This was a retrospective study of ESRD-PD patients who developed hernias over 11 years. RESULTS: Of 470 PD patients, 21 developed hernias (4.2%). Mean age of patients was 49.9 ± 15.36 years; 15 (66.66%) were males; 18 (85.71%) patients had umbilical hernia, 3 (14.28%) had inguinal hernia. Continuous ambulatory PD (CAPD) versus automated PD (APD) (OR: 11.623, 95% CI: 2.060-65.581, p = 0.005) was the independent risk factor identified. Incarcerated umbilical/inguinal hernia was managed surgically (6 [28.57%]); uncomplicated umbilical hernia (15 [71.42%]) managed conservatively (shift to (APD) [33.33%]; switch to low-volume APD [20%], switch to low-volume CAPD [46.66%]). None had postoperative hernia recurrences; 4 (19%) had PD technique failure; median PD survival was 36 (IQR 17-55) months. CONCLUSION: Although complicated hernias in PD require surgical repair, uncomplicated umbilical hernias can be managed conservatively by switching to APD/low-volume CAPD, with good long-term PD technique survival.

Comprehensive Conservative Care in End-Stage Kidney Disease.

In patients with end-stage kidney disease (ESKD), when there maybe situations where dialysis does not offer benefits in terms of survival or health-related quality of life, dialysis should not be viewed as the default therapy. Such patients can be offered comprehensive conservative care as an alternative to dialysis. Conservative (nondialytic) management of ESKD includes careful attention to fluid balance, treatment of anemia, correction of acidosis and hyperkalemia, blood pressure, and calcium/phosphorus metabolism management and dietary modification. Individualized symptom management and supportive care are crucial to maximize the quality of life. We propose that model of comprehensive conservative care in ESKD should manage both diseases as well as provide supportive care. Facilitating implementation of comprehensive conservative care requires coordination between nephrology and palliative care at patient, professional, administrative, and social levels to maximize benefit with the motto to improve the overall quality of life.

Red Cell Distribution Width as a Severity Marker on the Outcome of Patients with Acute Kidney Injury on Renal Replacement Therapy.

BACKGROUND: Acute kidney injury (AKI) requiring dialysis is associated with high mortality and morbidity. Red blood cell distribution width (RDW) has been shown as a predictor of mortality in different subsets of patients admitted to intensive care unit (ICU). This study compares the predictive ability of RDW and other severity illness prognostic models on 30 days mortality in adult patients admitted to ICUs with AKI necessitating dialysis. MATERIALS AND METHODS: Thirty patients were evaluated using five different prognostic scoring models. Sequential organ failure assessment (SOFA) score, acute tubular necrosis-individual severity index (ATN-ISI), version II of acute physiology and chronic health evaluation (APACHE II), vasoactive-inotropic score (VIS), version II of simplified acute physiology score (SAPS II), and RDW as a marker were used to prognosticate the severity of illness. The scores were calculated using the values of clinical and laboratory parameters at the time of admission. RESULTS: The prognostic abilities of the scores were compared for their discriminatory power using receiver-operating characteristic (ROC) curves. The area under the ROC curve (AROC) of RDW was 0.904, SOFA score was 0.828, ATN-ISI was 0.743, SAPS was 0.857, and APACHE II score was 0.828. Vasoactive-inotropic score has the lowest discriminatory power with AROC of 0.487. Red blood cell distribution width has a strong and significant correlation with APACHE II and SOFA scores and a weak relation with ATN-ISI score and SAPS II. CONCLUSION: Red blood cell distribution width has a better predictive ability than other disease severity scoring systems to predict mortality in an adult AKI patient admitted to ICU with need for renal replacement therapy (RRT). HOW TO CITE THIS ARTICLE: Nanjarapalle S, Samantaray A, Vishnubhotla S. Red Cell Distribution Width as a Severity Marker on the Outcome of Patients with Acute Kidney Injury on Renal Replacement Therapy. Indian J Crit Care Med 2020;24(2):95-98.

Study of contrast-induced oxidative stress in nondiabetic patients undergoing coronary angiography.

Administration of iodinated contrast media is associated with serious complications such as acute kidney injury (AKI). Oxidative stress is implicated as a major mechanism underlying the production of contrast-induced AKI (CI-AKI). There are very few human studies on oxidative stress occurring after contrast administration. Twenty-seven patients scheduled for coronary angiography were recruited. An average of 22.2 mL low-osmolal nonionic contrast was administered. Plasma conjugated dienes (CD), lipid hydroperoxides (LOOH), malondialdehyde (MDA), protein carbonyl (PC), protein thiols (PTs), ferric reducing ability of plasma (FRAP), erythrocyte super oxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), and glutathione reductase were estimated before, 30 min, 2 and 4 h after contrast administration. CD, LOOH, MDA, and PC increased (P <0.001), whereas PTs, FRAP, SOD, CAT (P <0.001), and GPx (P = 0.013) decreased in the first 4 h. Estimated glomerular filtration rate (eGFR) showed inverse association with MDA and positive association with GPx. The study provides evidence for oxidative stress following contrast administration even in the absence of predisposing factors. Association of eGFR with MDA and GPx indicate kidney as the source of oxidative stress. Hence, antioxidant therapy before contrast administration helps to prevent the development of oxidative stress, thereby reducing the risk of CI-AKI.

Adipokines and their Relation to Endothelial Dysfunction in Patients with Chronic Kidney Disease.

INTRODUCTION: Chronic Kidney Disease (CKD) patients are at high risk of cardiovascular diseases (CVDs). Reduced nitric oxide (NO) bioavailability is a key element in connecting kidney disease to endothelial dysfunction (ED) and cardiovascular (CV) complications. Further, inflammation is implicated in ED in CKD. Besides these, adipose tissue factors were thought to have a role in inflammation and ED in CKD. AIM: It is proposed to evaluate the concentration changes of adipokines, inflammatory and ED markers in CKD patients compared to healthy controls. Further, to assess the associations between adipokines, inflammation and ED in CKD patients. MATERIALS AND METHODS: A total of 120 CKD patients were included and classified into 3 groups based on Glomerular filtration rate (GFR). Group I (n=40) patients had a GFR between 60-119 ml/min/1.73m(2) (stage I, II), group II (n=40) had 15-59 ml/min/1.73m(2) (stage III, IV) and group III (n=40) had <15 ml/min/1.73m(2) (stage V). Forty healthy subjects served as controls. Adiponectin, Leptin, Interleukin-10 (IL-10), Interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α) were estimated by ELISA. High sensitivity C-reactive protein (hsCRP) was estimated by immunoturbidimetry and NO by Griess method. STATISTICAL ANALYSIS: Mann-Whitney U test was used to compare the difference in variables between controls and CKD patients. One-way ANOVA Kruskalwallis test was used for comparison of variables between groups in CKD patients. Spearman's rank correlation was used to explore the associations between variables. Simple univariate linear regression analysis was used to predict the value of variable from another variable. RESULTS: A significant increase in leptin, IL-6, TNF-α, IL-6/IL-10 ratio, hsCRP and decrease in adiponectin, IL-10, NO was observed in CKD patients compared to controls (p<0.05). In CKD patients, adiponectin, leptin, IL-6, IL-6/IL-10 ratio, TNF-α were significantly increased and IL-10 levels were decreased from group I to group III (p<0.05). In group III CKD patients IL-6 showed a significant negative correlation with NO (r=-0.557; p=0.005). In linear regression analysis also, IL-6 showed a significant negative association with NO (B±SE=-0.038±0.11; p=0.002) in CKD patients. CONCLUSION: The present study demonstrates that adipokine levels are altered from initial to final stages of CKD due to renal dysfunction which in association with an exaggerated inflammation may contribute to the ED and CV events.

Post-partum bilateral renal cortical necrosis in antiphospholipid syndrome and systemic lupus erythematosus.

In the presence of systemic lupus erythematosus or related autoimmune disorders, antiphospholipid syndrome (APS) is termed secondary APS. Pregnancy-related renal failure due to SAPS is rarely reported in the literature. We present the case of a young primgravida woman with bilateral renal cortical necrosis due to secondary APS in late pregnancy.

Acute bilateral non-obstructive bacterial pyelonephritis with acute kidney injury in the elderly: role of non-invasive studies in its diagnosis.

Nine elderly patients who presented with features suggestive of acute pyelonephritis were studied with the help of laboratory and imaging investigations. All patients had acute kidney injury of variable severity at presentation. Renal imaging helped us in revealing bilateral involvement and the findings are discussed. The infection was treated with appropriate antibiotics. Because of severe renal failure, five patients were supported with hemodialysis, of them, three became dialysis independent. The remaining two patients were dialysis dependent at discharge. However, none of them came to us for follow-up.

Effect of a single hemodialysis session on endothelial dysfunction.

BACKGROUND: The mechanisms of endothelial dysfunction induced by hemodialysis are unclear. To gain a mechanistic view we have evaluated some of the biochemical markers which directly or indirectly lead to endothelial dysfunction during a single dialysis session. METHODS: Time course changes in plasma nitrate levels, arginine (ARG), citrulline, asymmetric dimethylarginine (ADMA), homocysteine (Hcy), malondialdehyde (MDA) and lipoprotein-associated phospholipase A2 (LpPLA2) were evaluated in 27 patients with end-stage renal disease on maintenance hemodialysis. Statistical evaluation of changes was done using analysis of variance for repeated measures and linear regression using generalized estimating equations for repeated measures. RESULTS: Nitrate levels significantly increased as a result of dialysis (p<0.001). Hcy (p<0.05) and ADMA (p<0.001) levels were found to be significantly decreased. ARG/ADMA ratio showed an increase (p<0.001). Presence of oxidative stress (OS) was observed in the form of increased plasma MDA levels. Nitrate levels were negatively associated with Hcy, ADMA and LpPLA2 activity. CONCLUSION: Our results show an increased production of nitric oxide (NO) during dialysis, which however is affected by increased OS ultimately favoring endothelial dysfunction. Measures to reduce the OS during hemodialysis are needed to get the complete benefit of clearance of circulating inhibitors of NO synthase during dialysis.

Effect of a single hemodialysis session on inflammatory markers.

Inflammation is a common feature of end-stage renal disease. Although there is evidence for hemodialysis (HD)-induced inflammatory process, the effect of a dialysis session on changes in inflammatory markers is still unclear. Seventeen patients of end-stage renal disease on maintenance HD along with 20 age-matched and sex-matched healthy controls were recruited after informed consent. C-reactive protein (CRP) and lipoprotein-associated phospholipase A2 (LpPLA2) activity were measured in the study and control groups. Intradialytic in CRP and LpPLA2 were studied. Comparison of pre-HD vs. the control group and predialytic and postdialytic values was performed using the Mann-Whitney U test and Wilcoxon's test, respectively. Statistical evaluation of intradialytic changes in inflammatory markers was performed using Friedman's test. Hemodialysis patients had higher CRP levels compared with controls (P=0.001). Post-HD LpPLA2 activity (n=17) was higher (P=0.039) compared with the pre-HD activity. Intradialytic changes in inflammatory markers showed a significant increase (P=0.012) in LpPLA2 activity (n=7), while no change (P=0.133) was observed in CRP levels (n=17). Evidence on the pro-inflammatory state being initiated by dialysis is provided by increased LpPLA2 activity. This may add to the atherogenic mileu and cause endothelial dysfunction in this high-risk group. Drugs that inhibit the LpPLA2 pathway have been developed and may be effective in these patients.