An Improvised Cost-Effective Repair Technique for Management of Broken Luer Connections of Tunneled Dialysis Catheter and Salvage Existing Catheter.

Mechanical problems like break or crack in Luer connectors or hubs, clamps, and tubings are common non-infectious complications of tunneled dialysis catheters (TDC), which may lead to other TDC complications and the need to insert a new catheter. These can be tackled using TDC repair kits or spare parts, which are often not available, resulting in the insertion of a new TDC that increases morbidity, TDC-related procedures, and healthcare costs. We discuss two cases of broken Luer connections of TDC, which were managed by exchanging the broken Luer connector of TDC with the similar Luer connector of a temporary dialysis catheter. Both the repaired TDCs are thereafter functioning well. This improvised technique provides an easy, effective, long-lasting option that salvages the existing TDC and reduces the cost factor.

Clinico-laboratory Profile and Outcomes of Megaloblastic Anemia presenting as Severe Pyrexial Illness mimicking Tropical Infection.

BACKGROUND: Anemia-causing fever has been described in patients with megaloblastic anemia. Although the exact mechanism of this is unknown, high-grade fever is relatively less reported. MATERIALS AND METHODS: This prospective observational study included all new cases of megaloblastic anemia presenting with febrile illness (>101°F) during a 3-year period. Patients with existing anemia, comorbidities, and other causes of macrocytosis were excluded. A detailed evaluation for megaloblastic anemia and workup for excluding tropical infections was done. The patients were treated with parenteral vitamin B12, folic acid, and other hematinics. RESULTS: Around 24 cases of megaloblastic anemia presenting with high-grade fever were included, with 14 (58.3%) males, mean duration of fever 7.7 days (4-18 days), and 09 (37.5%) having temperature >103°F. The mean hemoglobin (Hb) was 8.15 g/dL (3.7-11.1 g/dL), the mean corpuscular volume (MCV) was 111 ± 7.8 fL, 18 (75%) had unconjugated hyperbilirubinemia, the mean lactate dehydrogenase (LDH) was 814 ± 24 IU/L, and 21 (87.5%) had low B12 or folate levels. Most showed good therapeutic response to B12 or folic acid with defervescence in 1-5 days (mean 2.6 days) and improvement in lab parameters in 1 week. The study population was divided into those with temperature ≥103°F, and temperature <103°F it was seen that there was a significant association (p < 0.05) with leucocyte count of ≤3000/cumm, and MCV ≥110 fL, in patients with temperature ≥103°F Conclusion: Megaloblastic anemia should be considered in the differentials of a patient presenting with a febrile illness with no clinical localization and a negative initial fever workup. Early identification and prompt therapy of this easily treatable disorder are very essential.

Kidney transplantation: The journey across a century.

The Journey of kidney transplantation began a century ago with animal experiments and xenotransplants. The initial attempts of human to human kidney transplant were made by Yuri Voronoy, Jean Hamburger and several others between 1930 and 40s, but most of these were unsuccessful. The first successful live related kidney transplant between identical twins was performed at the Brigham Hospital in Boston in December 1953, by Joseph Murray and John P. Merrill, which paved the way for future live transplants. With the gradual improvement in the understanding of immunity and tolerance, the use of immunosuppression was attempted using irradiation and steroids, which gradually evolved over the decades to include azathioprine and cyclosporine. Discoveries of human leukocyte antigen by Dausset, complement dependent cross match by Paul Terasaki, and other developments in transplant immunology improved outcomes of kidney transplant. This journey was marked by new discoveries and improvements in surgical techniques including laparoscopic and robotic transplant surgery, better and safer immunosuppression, advances in transplant immunology, advent of the concept of brain death and deceased donor transplant program, and complicated transplants like transplants in highly sensitised recipients and ABO incompatible transplants. India was not far behind the rest of the world, and after a few unsuccessful attempts, the first successful transplant was done in CMC Vellore in 1971, which was followed by advancements in kidney transplants keeping in pace with the rest of the world.

Plasma Renin-guided Therapy in Patients of Primary Hypertension on Antihypertensives: A Prospective Cohort Study.

BACKGROUND: Most guidelines for hypertension overlook the underlying pathophysiologic basis in deciding antihypertensives. Based on renin levels, hypertension may be classified as high-renin hypertension (HRH), low-renin hypertension (LRH), and normal-renin hypertension (NRH). The study examined the renin levels in a hypertensive population and assessed the effect of renin-guided antihypertensive management on blood pressure (BP) control. MATERIALS AND METHODS: This study was a single-center prospective cohort study. Subjects with primary hypertension (aged 20-60 years) on antihypertensives were included in the study. Initial BP was recorded and subsequently, all antihypertensives were discontinued. After 2 weeks, second BP was recorded and plasma renin assay (PRA) sample was collected. All patients were restarted on the previous antihypertensives and further modification of medication was performed based on their PRA. Anti V drugs, such as diuretics and calcium channel blockers (CCBs) were used in LRH while beta-blockers and antirenin drugs (Anti R drugs) were used in HRH. RESULTS: The study included 918 patients with hypertension and 896 cases were finally analyzed. Of these patients, 287 (32.03%) had LRH (<0.51 ng/mL/hr), 412 (45.98%) had HRH (>2.64 ng/mL/hr), while 197 (21.99%) had NRH (0.51-2.64 ng/mL/hr). Renin-guided management caused significant BP reduction. In controlled BP group, the systolic BP (SBP)/diastolic BP (DBP) before and after modification were 133.83 ± 3.36/84.77 ± 3.12 and 123.87 ± 10.59/84.05 ± 1.84, respectively (p-value < 0.05). In uncontrolled BP group, the corresponding SBP/DBP were 152.17 ± 2.95/90.36 ± 5.02 and 138 ± 1.23/87.78 ± 0.84, respectively (p-value < 0.05). The number of hypertensives used in patients also reduced with reduction in patients on two, three, or four drugs. CONCLUSIONS: Renin-guided therapy is useful for improving BP control in both controlled and uncontrolled hypertensive patients and in reducing the number of antihypertensive drugs.

An analysis of mortality and survival of COVID 19 patients admitted to a tertiary care hospital in Maharashtra, India.

BACKGROUND: After nine months of responding to the coronavirus disease-19 (COVID-19) pandemic, the scientific fraternity is yet to unravel the mystery of those who are at most risk from mortality. Despite resistance to wear masks, the global public health response has beaten the grimmer projections of millions of deaths. The present study seeks to analyze the survival of COVID-19 patients at a tertiary care hospital and identify the risk factors of mortality. METHODS: Medical records of 1233 RT PCR confirmed COVID-19 patients admitted in a tertiary care hospital between 01 April and 30 September 2020 were retrospectively analyzed for calculating overall survival and to investigate the independent predictors of survival of COVID-19 patients. RESULTS: There were 72 (5.8%) deaths; which occurred in 24.9% of the elderly (age > 60yrs) people (P < 0.001), 76.0% in people with multiple comorbidities (having more than one comorbidity) (P < 0.001), 75.6% in people with diabetes (P < 0.001), and 75.5% in people with hypertension (P < 0.001). A significantly higher risk of mortality was observed in elderly patients, patients with comorbidities, and patients requiring oxygen while admitted in the hospital. CONCLUSION: Survival reflects the cure rates and is used by health professionals and policymakers to plan and implement disease control measures. The insights provided by the study would help facilitate the identification of patients at risk and timely provision of specialized care for the prevention of adverse outcomes in the hospital setting.

Use of fetal echocardiography for characterization of fetal cardiac structure in women with normal pregnancies and gestational diabetes mellitus.

OBJECTIVES: To assess fetal cardiac structure and function and to evaluate the efficacy of routine fetal echocardiography for detection of fetal cardiac abnormalities in women with normal pregnancies and those with gestational diabetes mellitus. METHODS: In this prospective study, we studied fetal cardiac structure and function in 294 uncomplicated singleton pregnancies and 302 pregnancies complicated by gestational diabetes. Fetal echocardiography (2-dimensional sonography and pulsed wave Doppler imaging) was used to assess functional parameters and to detect any cardiac structural abnormality. Data from clinical and echocardiographic evaluations of neonates at birth and 3 months were obtained to confirm the antenatal findings. RESULTS: The mean maternal age ± SD was 28.9 ± 5.0 years in the diabetes group and was comparable to that of women with normal pregnancies. The mean hemoglobin A1c value was 6.3%, and the mean body mass index was 28.0 kg/m(2). The systolic function as assessed by the ejection fraction increased significantly in the diabetes group compared to the normal pregnancy group independent of glycemic control (P < .001). The pulsed wave parameters (early diastolic peak flow velocity and early-to-late diastolic peak flow velocity ratio) were significantly different between the groups (P < .001). The interventricular septum and fetal ventricular wall thicknesses were significantly increased in the presence of gestational diabetes (P < .001). No major fetal cardiac structural anomaly was detected in either group. On follow-up after delivery, all neonates were assessed clinically and by transthoracic echocardiography to rule out congenital defects. CONCLUSIONS: In our study, significant increases in the interventricular septum and ventricular wall thicknesses were detected in the presence of gestational diabetes mellitus. Interestingly, none of the neonates of pregnant women with gestational diabetes were found to have echocardiographic evidence of congenital heart disease.

Osmotic demyelination syndrome in a normonatremic patient of chronic kidney disease.

Osmotic Demyelination Syndrome (ODS) is associated with rapid correction of hyponatremia or fluid shifts, and is characterized by neurological involvement related to pons, brainstem or other areas of the brain. All possible measures should be taken to prevent this serious disorder. Diagnosing this condition early is very important and requires a high index of suspicion. The treatment is purely supportive and most patients may show dramatic recovery. ODS occurring in normonatremic and hypernatremic patients is very rare. We report a case of an 18-year-old boy of end-stage renal disease who presented with an episode of acute gastroenteritis. He was managed with aggressive intravenous fluids, hemodialysis and other supportive therapy. But, he developed altered sensorium and seizures that progressed to features of spastic quadriparesis and lower cranial nerve palsy. Neuroimaging showed hyperintensities in pons and midbrain suggestive of ODS. The patient had normal sodium levels at all times and had no evidence of hyponatremia. The patient was managed with hemodialysis, physiotherapy and other conservative measures and had a gradual clinical and radiological recovery.

Successful Renal Transplant in End-Stage Renal Disease with Chronic Immune Thrombocytopenia using Thrombopoietin Receptor Agonists and Intravenous Immunoglobulin.

Chronic kidney disease in immune thrombocytopenia (ITP) is uncommon, and renal transplant in this setting is rare. We discuss the successful renal transplant of a 29-year-old male with chronic ITP. During transplant, he was managed with thrombopoietin receptor agonist eltrombopag, intravenous methylprednisone, and intravenous immunoglobulin to maintain adequate platelet level. He recovered well with no major complications and good graft function and has been stable during the follow-up period. The case report highlights that renal transplantation is a feasible option in patients with ITP, even in the presence of low platelet counts.

Pyonephrosis among Patients with Pyelonephritis Admitted in Department of Nephrology and Urology of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Pyonephrosis is a severe complication of pyelonephritis leading to rapid progression to sepsis and loss of renal function resulting in nephrectomy. Early identification of pyonephrosis based on clinical or radiological characteristics amongst pyelonephritis is paramount. This study aimed to determine the prevalence of pyonephrosis among patients with pyelonephritis admitted to the Department of Nephrology and Urology of a tertiary care centre. Methods: This descriptive cross-sectional study was done in a tertiary care centre among patients with pyelonephritis from 1 July 2016 to 31 Jan 2021. Ethical approval was obtained from Institution Ethics Committee (Reference number: IEC/56/21). The available clinical, demographic and laboratory parameters were recorded from the hospital records in a predesigned proforma. A convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 550 pyelonephritis patients, the prevalence of pyonephrosis was 60 (10.9%) (8.3-13.5, 95% Confidence Interval). The mean age was 54.62±12.14 years, and 41 (68.33%) were males. The most common clinical symptom was flank pain with or without fever in 46 (76.66%) patients. Escherichia coli was the most common offending organism in 20 (33.33%). Ultrasonography showed classical echogenic debris with floaters and internal echoes in 44 (73.33%) patients. Double J stenting was successfully done in 44 (73.33%) patients. Percutaneous nephrostomy was done in the remaining 16 (26.66%) patients. Conclusions: The prevalence of pyonephrosis in pyelonephritis is similar to previous studies done in similar settings. Keywords: pyelonephritis; pyonephrosis; kidneys.