Bartter syndrome-like phenotype in a patient with type 2 diabetes mellitus.

Bartter syndrome (BS) is a rare genetic tubulopathy affecting the loop of Henle leading to salt wasting. It is commonly seen in utero or in the early neonatal period. Rare cases of acquired BS are reported in association with infections like tuberculosis, granulomatous conditions like sarcoidosis, autoimmune diseases and drugs. The mainstay of management includes potassium, calcium and magnesium supplementation. We report the case of a woman in her 50s with a history of type 2 diabetes mellitus for the last 10 years, who presented with diabetic foot ulcers and generalised weakness with ECG changes suggestive of hypokalaemia. She had severe hypokalaemia with high urine potassium excretion and hypochloraemic metabolic alkalosis. She poorly responded to intravenously administered potassium supplements and had persistent hypokalaemia. On further evaluation of the persistent hypokalaemia, a diagnosis of idiopathic Bartter-like phenotype was made. She responded well to tablet indomethacin and is presently asymptomatic and is being maintained on tablet indomethacin after 6 months of follow-up.

Pneumoperitoneum needle vs. introducer needle: Comparison of complications and short-term outcomes in percutaneously inserted peritoneal dialysis catheters in naïve abdomens.

Percutaneous peritoneal dialysis catheter (PDC) insertion for continuous ambulatory peritoneal dialysis (CAPD) entails a higher risk of complications such as bowel injury, vascular injury, and catheter migration compared to the surgical insertions. We conducted a comparative analysis of two techniques of peritoneal entry for PDC insertion by Seldinger technique. We performed a retrospective review of 426 percutaneously inserted PDCs in nonobese naïve abdomens for CAPD at two tertiary care teaching hospitals in India over 6 years. Comparison of various mechanical complications, and short-term catheter survival was done between use of introducer needle (Group "I") and spring-loaded pneumoperitoneum (Veress) needle (Group "V"). Group "I" to "V" patient ratio was 277:149. Group "I" had heavier patients (p = 0.03) whereas "V" group had a dominance of diabetes (p = 0.009) and prior hemodialysis patients (p = 0.03). At 3 months, the odds of mechanical complications (OR = 0.27, p = 0.004), PDC migration (OR = 0.18, p = 0.02), and omental wrapping (OR = 0.13, p = 0.04) were less in "V" group. No bowel injury occurred with Veress needle use. At 6 months, "V" group had higher odds of event-free sustained PDC tip position (OR = 0.39, p = 0.003), and catheter survival (p = 0.03), and the cumulative events were lesser too (p = 0.002). Refractory peritonitis and deaths with functioning catheter were comparable between both the groups. In this first-of-its-kind study, spring-loaded Veress pneumoperitoneum needle use was safer, entrusted sustained PDC tip position in pelvis, and had a better catheter survival compared to use of introducer needle for peritoneal entry in percutaneously inserted PDCs. These findings should be confirmed by a randomized controlled study.

Peritoneal Dialysis Catheter Insertion by Nephrologist Using Minilaparotomy: Do Survival and Complications Vary in Obese?

INTRODUCTION: Peritoneal dialysis catheter (PDC) placement for chronic kidney disease (CKD) amongst overweight and obese patients is difficult owing to deeper operating field. Literature being discordant on survival and complications in this patient subset, we attempted to analyse this research question in Indian population. MATERIALS AND METHODS: We retrospectively analysed PDC inserted by nephrologist using surgical minilaparotomy for survivals and complications amongst 'overweight and obese' cohort ('O') at two tertiary care government hospitals in India, and compared results with normo-weight cohort ('N'), with 12-36 months follow-up. RESULTS: 245 PDCs were inserted by surgical minilaparotomy and 'N' to 'O' ratio was 169:76. 'O' group were more rural residing (P = 0.003) and post-abdominal surgery (P = 0.008) patients. The 1, 2, and 3-year death censored catheter survival rate was 98.6%, 95.8%, and 88.2% respectively in 'O' group, and 97.6%, 94.5% and 91.8% in 'N' group respectively (P = 0.52). Patient survival (P = 0.63), mechanical complications (P = 0.09) and infective complications (P = 0.93) were comparable despite technically challenging surgery in 'O' group. Refractory peritonitis related PDC removal was comparable (P = 0.54). Prior haemodialysis or catheter related blood stream infections or diabetes were non-contributory to results. CONCLUSIONS: Catheter survival and patient survival amongst obese and overweight CAPD patients was non-inferior to normal weight patients. Mechanical, and infective complications were comparable despite technically challenging abdominal terrain in 'O' group. The overall CAPD performance was good amongst obese and overweight.

Azathioprine Causing Cholestatic Jaundice In A Lupus Nephritis Patient: A Case Report And Review Of Literature

The systemic lupus erythematosus (SLE) is an autoimmune disease affecting predominantly females of reproductive age group. Pregnancy is advised only after a period of disease quiescence for at least six months. Azathioprine (AZA) and prednisolone are the immunosuppressants commonly used during pregnancy in lupus nephritis. Azathioprine causing cholestatic jaundice has been reported only a few times but none in a patient with lupus nephritis, pregnant or otherwise to the best of our knowledge. We present an interesting case of a young pregnant patient of lupus nephritis (LN) developing cholestatic jaundice in the third trimester, causing diagnostic dilemma between drug-induced jaundice and Intrahepatic cholestasis of pregnancy which resolved after withholding azathioprine. We should be aware of this uncommon adverse effect of this very commonly used drug in SLE patients.

Arteriovenous Fistula Creation by Nephrologist: A Single Centre Experience

Introduction: Arteriovenous Fistula (AVF) is the preferredvascular access with the least rate of complications andmorbidities. Across the globe except European countriesAVF is created predominantly by surgeons. There are veryfew experiences shared by Nephrologists from Indiansubcontinent in creating AV fistulas and their follow up. Theaim of this study was to assess preoperative factors affectingthe outcome of AVF creation and the follow up of successfullycreated fistulas.Material and Methods: A prospective observational studywas carried at our hospital over a period of six months from01 October 2018 to 31 March 2019. All patients undergoingAVF creation by nephrologist from 01 October 2018 to 15Feb 2019 were included in the study and each patient wasfollowed for six weeks. Besides baseline parameter, historyof Diabetes, hypertension and coronary and peripheralvascular disease were noted. All the perioperative findingslike vascular calcification and Blood pressure were noted. Allsuccessful AVF were followed for six weeks with serial USGand Doppler at postoperative day 1, 2 week and 6 weeks.Results: A total of 20 (77%) out of 26 AVF were successfullycreated, The average age was 54.6±15.4 years, Among baselineparameters gender had statistical significance (p=0.03).During surgery more arterial diameter and hypertension wereassociated with successful outcome. During follow-up, botharterial and venous diameter as well as blood flow in arteryand AVF had significant correlation between postoperative 1st,2nd and 6th week (p<0.01). More than 35% and 80% of patientsat 2 and 6 weeks respectively achieved criteria for successfulmaturation as per NKF- KDOQI criteria and it was > 90% and100% as per UAB criteria.Conclusion: Our experience suggest good outcome of AVFcreation by nephrologist, even with those with risk factors forfailure and non maturation. Also we suggest early cannulationof AVF at four weeks or earlier.

Sjogren’s Syndrome Presenting With Recurrent Hypokalemic Paralysis

Sjogren’s syndrome is an autoimmune disorder commonly affecting females and presents with the dryness of the mouth and eyes. Here, we present an interesting case of Sjogren’s syndrome, initial presentation with distal renal tubular acidosis (RTA) causing recurrent hypokalemic paralysis, and dyspnea requiring ventilator support. The patient improved dramatically with potassium and alkali supplementation. She has been on follow-up for the past 3 months and remains asymptomatic. Only a few case reports and series have been reported on such initial presentation of Sjogren’s syndrome. To conclude, one must be aware of distal RTAs associated with autoimmune disorder presenting with hypokalemic paralysis.