Impact of immunosuppressive medication on the risk of renal allograft failure due to recurrent glomerulonephritis.

Recurrent glomerulonephritis is a major problem in kidney transplantation but the role of immunosuppression in preventing this complication is not known. We used data from the United States Renal Data System to examine the effect of immunosuppressive medication on allograft failure due to recurrent glomerulonephritis for 41,272 patients undergoing kidney transplantation from 1990 to 2003. Ten-year incidence of graft loss due to recurrent glomerulonephritis was 2.6% (95% confidence interval [CI]: 2.3-2.8%). After adjusting for important covariates, the use of cyclosporine, tacrolimus, azathioprine, mycophenolate mofetil, sirolimus or prednisone was not associated with graft failure due to recurrent glomerulonephritis. There was no difference between cyclosporine and tacrolimus or between azathioprine and mycophenolate mofetil in the risk of graft failure due to recurrent glomerulonephritis. However, any change in immunosuppression during follow-up was independently associated with graft loss due to recurrence (adjusted hazard ratio 1.30, 95% CI: 1.06-1.58, p = 0.01). In patients with a pretransplant diagnosis of glomerulonephritis, the risk of graft loss due to recurrence was not associated with any specific immunosuppressive medication. The selection of immunosuppression for kidney transplant recipients should not be made with the goal of reducing graft failure due to recurrent glomerulonephritis.

Comparison of serum creatinine-based estimating equations with gates protocol for predicting glomerular filtration rate in indian population.

In clinical practice, serum creatinine-based predicting equations and Gates protocol based on gamma camera imaging of kidneys after injection of Tc99m-diethylenetriaminepentaacetic acid (DTPA) are commonly used to assess glomerular filtration rate (GFR). Comparison of these methods, especially the chronic kidney disease-epidemiology collaboration (CKD-EPI) equation with gold standard method of assessment of GFR by plasma clearance of Tc-99mDTPA is not well-studied in Indian population. We conducted this study to compare GFR estimation by gamma camera-based Gates protocol and serum creatinine-based predicting equations with GFR measured by plasma clearance of Tc-99mDTPA. One hundred and five patients (65 male and 40 female) underwent Tc-99m DTPA renal scan followed by withdrawal of venous blood samples at 2, 3, and 4 h as per predefined protocol. Gates method GFR (GFRs) was assessed using standard protocol. GFR by plasma sampling (GFRp) was calculated by slope-intercept method with provision for corrections. Estimated GFR was calculated by Cockroft-Gault formula, four variable modification of diet in renal disease (MDRD) equation, and CKD-EPI equation (GFRCG, GFRMDRD, GFRCKD-EPI, respectively). GFR measured by gold standard method (GFRp) was compared with that estimated by other methods by calculating correlation coefficient, bias, precision, and accuracy. GFR estimated by all three estimating equations correlated better than GFRs with GFRp. For estimating GFRp, GFRCKD-EPI had highest correlation with GFRp with least bias and highest precision. Gamma camera-based Gates protocol was the least precise and least accurate method for estimating GFRp. To conclude, all three estimating equations based on serum creatinine are superior to Tc-99m DTPA scintigraphy for estimating GFR; CKD-EPI equation being the most accurate and precise.

The Relationship between Metabolic Acidosis and Nutritional Parameters in Patients on Hemodialysis.

The progressive loss of kidney function is accompanied by metabolic acidosis. The relationship between metabolic acidosis, nutritional status, and oral bicarbonate supplementation has not been assessed in the Indian chronic kidney disease (CKD) population who are on maintenance hemodialysis (MHD). This is a single-center prospective study conducted in the Western part of India. Thirty-five patients, who were receiving MHD were assessed for metabolic acidosis along with various nutritional parameters at the baseline and at the follow-up after 3 months, postcorrection of acidosis with oral sodium bicarbonate supplements. The relationship between the correction of metabolic acidosis with oral bicarbonate supplements and changes in dietary and various nutritional parameters were evaluated. Metabolic acidosis at the baseline evaluation was found in 62.86% cases of the cohort with a mean serum bicarbonate value of 20.18 ± 4.93 mmol/L. The correction of acidosis with increment in the mean dosage of oral sodium bicarbonate supplements from 0.69 ± 0.410 mmol/kg/day at baseline to 1.04 ± 0.612 mmol/kg/day, significantly reduced the prevalence of metabolic acidosis to 23.33% cases at the follow-up. Improvement in serum bicarbonate level showed significant dietary, anthropometric, and nutritional improvements in these patients. Hence, we conclude that correction of metabolic acidosis with optimal oral bicarbonate supplementation plays a pivotal role in the treatment of malnourished CKD patients on MHD.

Isolated right subclavian artery, interrupted aortic arch, and ventricular septal defect.

Isolated subclavian artery is extremely rare. The clinical and hemodynamic manifestations depend on the state of ductus arteriosus, pulmonary vascular resistance, and associated intracardiac and extracardiac malformations. We discuss 2 such cases in association with an interrupted aortic arch and ventricular septal defect.

Two-stage repair of adult coarctation of the aorta with congenital valvular lesions.

BACKGROUND: Coarctation of the aorta associated with intracardiac pathologic conditions presenting in adult life poses some technical and management challenges. When deciding on the best surgical strategy, the surgeon must pay careful attention to the changes that will occur in the circulation. METHODS: In our small series of 3 patients, the intracardiac pathologic lesions were corrected first, and the coarctation was repaired as a second-stage procedure 2 to 3 months later. RESULTS: All patients had an uneventful recovery from both operations. The potential problems of renal impairment caused by inadequate perfusion during bypass and perioperative systemic hypertensive complications resulting from coarctation of the aorta were not observed. At the time of coarctation repair as a second-stage procedure, anticoagulation was easily controlled. All 3 patients had short intensive care unit and hospital stays. CONCLUSIONS: Staged surgical repair of this complex pathologic combination in adult patients is a safe option and is easy to manage perioperatively.

Prevention of internal thoracic artery spasm.

Perioperative spasm of the internal thoracic artery is a common experience in coronary artery bypass grafting. We describe a simple method of harvesting the internal thoracic artery with improved ease of dissection that helps to prevent the arterial spasm.

Renin angiotensin system blockade in kidney transplantation: a systematic review of the evidence.

ACE-inhibitors and angiotensin receptor blockers (ARB) slow the progression of renal disease in non-transplant patients. A systematic review of randomized trials (n = 21 trials with 1549 patients) was conducted to determine the effect of ACE-inhibitor or ARB use following kidney transplantation. With a median follow-up of 27 months, ACE-inhibitor or ARB use was associated with a significant decrease in glomerular filtration rate (-5.8 mL/min; 95% CI -10.6 to -0.99). ACE-inhibitor or ARB use resulted in a lower hematocrit (-3.5%; 95% CI -6.1 to -0.95), reduction in proteinuria (-0.47 gm/d; 95% CI -0.86 to -0.08) but no change in the serum potassium (0.18 mmol/L; 95% CI -0.03 to 0.40). ACE-inhibitor or ARB use results in clinically important reductions in proteinuria, hematocrit and glomerular filtration rate in renal transplant recipients, but there are insufficient data to determine the effect on patient or graft survival. Randomized trials of sufficient power and duration that examine these hard outcomes should be conducted. Until such trials are completed, this study provides quantitative estimates of the risks and benefits of ACE-inhibitor or ARB use that can be used by clinicians considering prescribing these medications to kidney transplant recipients or to researchers designing future trials.

Surgical management of tetralogy of Fallot with anomalous coronary artery.

Fifteen patients of tetralogy of Fallot with an anomalous left anterior descending coronary artery arising from the right coronary artery were operated during a period of 1982 and 1988. One patient died in the early post-operative period (6.6%). Two patients had a hemodynamically insignificant residual ventricular septal defect. Post-operative peak systolic pressure gradient between the right ventricle and pulmonary artery ranged from 10 mm Hg to 40 mm Hg (mean 24 mm Hg) in 4 patients. There was no incidence of inadvertent coronary artery division.