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COMMENTARY |
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An insight into the sites of noncuffed hemodialysis catheters |
p. 261 |
H Mehta DOI:10.4103/0971-4065.152729 PMID:26628788 |
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Urinary liver-type fatty acid binding protein and chronic kidney disease |
p. 263 |
A Kamijo-Ikemori, K Kimura DOI:10.4103/0971-4065.150726 PMID:26628789 |
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ORIGINAL ARTICLES |
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A comparative study of central versus posterior approach for internal jugular hemodialysis catheter insertion |
p. 265 |
M Mathur, A. V. L D'Souza, D Prasad, R Garsa, N Bansal, R Jhorawat, S Sharma, P Beniwal, D Agrawal, V Malhotra DOI:10.4103/0971-4065.151356 PMID:26628790Internal jugular (IJ) catheter insertion for hemodialysis (HD) is an indispensable procedure in the management of patients with renal failure. The central approach is favored over posterior approach to insert IJ catheters. There are no studies comparing the outcomes between the two approaches. The aim of this study was to compare central approach with posterior approach for IJ HD catheter insertion and to analyze various outcomes like procedure-related complication rates, catheter insertion failure rates, interruptions during dialysis due to blood flow obstruction and catheter infection rates between the two methods among patients receiving HD. All patients requiring IJ HD catheter insertion during a 1-month period were randomly assigned to undergo catheter insertion via either conventional central approach or posterior approach. Patients were followed-up till the removal of the catheter. Among 104 patients included in the study, 54 were assigned to the central approach group and 50 to the posterior approach group. The central approach group had higher rate of procedure-related complications (14.81% vs. 6%, P = 0.04). Catheter insertion failure rates were marginally higher in posterior approach group (20% vs. 12.96%, P = 0.07). One or more instance of interruption during HD due to obstruction in blood flow was more common in posterior approach (46% vs. 9.25%, P < 0.01). Catheter infection rates were similar between the two groups; 16.66% ( n = 9) in central group vs. 14% ( n = 7) in posterior group. Posterior approach is a reasonable alternative to conventional central approach in IJ cannulation for HD catheter. It is, however, associated with a significantly high rate of interruption in HD blood flow and catheter insertion failure rates. The posterior approach can be used in patients with local exit site infection or in failed attempts to cannulate IJ vein via the conventional central approach. |
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Clinical significance of urinary liver-type fatty acid binding protein at various stages of nephropathy |
p. 269 |
V Viswanathan, S Sivakumar, V Sekar, D Umapathy, S Kumpatla DOI:10.4103/0971-4065.145097 PMID:26628791This cross-sectional study was to evaluate the levels of urinary liver-type fatty acid binding protein (u-LFABP pg/mg urine creatinine ratio) at different stages of diabetic nephropathy and to see its correlation with other clinical parameters in South Indian patients with type 2 diabetes mellitus (T2DM). A total of 65 (M: F; 42:23) T2DM subjects were divided into three groups, and were compared with 13 (M: F; 3:10) nondiabetic controls. The study groups were as follows: normoalbuminuric (n = 22), microalbuminuric (n = 22) and macroalbuminuric (n = 21). Estimated glomerular filtration rate (eGFR) was calculated using Cockcroft and Gault formula. u-LFABP levels in spot urine samples were measured with a solid phase enzyme linked immunosorbent assay. This study showed that u-LFABP levels were undetectable in healthy controls and was very low in the normoalbuminuric subjects. Elevated levels of u-LFABP are evident from the microalbuminuric stage indicating tubular damage. The levels of u-LFABP increased gradually with declining renal function. Geometric mean (95% confidence interval) for normoalbuminuria was 0.65 (0.47-0.97), microalbuminuria was 0.99 (0.55-1.97) and macroalbuminuria was 5.16 (1.8-14.5), (P = 0.005). In conclusion, u-LFABP levels were elevated in patients with reduced eGFR and showed a positive correlation with systolic blood pressure and protein to creatinine ratio in the total study subjects. |
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Endemic chronic kidney disease of unknown etiology in Sri Lanka: Correlation of pathology with clinical stages |
p. 274 |
S Wijetunge, N. V. I. Ratnatunga, T. D. J. Abeysekera, A. W. M. Wazil, M Selvarajah DOI:10.4103/0971-4065.145095 PMID:26628792Chronic kidney disease of unknown etiology (CKDU) is endemic among the rural farming communities in several localities in and around the North Central region of Sri Lanka. This is an interstitial type renal disease and typically has an insidious onset and slow progression. This study was conducted to identify the pathological features in the different clinical stages of CKDU. This is a retrospective study of 251 renal biopsies identified to have a primary interstitial disease from regions endemic for CKDU. Pathological features were assessed and graded in relation to the clinical stage. The mean age of those affected by endemic CKDU was 37.3 ± 12.5 years and the male to female ratio was 3.3:1. The predominant feature of stage I disease was mild and moderate interstitial fibrosis; most did not have interstitial inflammation. The typical stage II disease had moderate interstitial fibrosis with or without mild interstitial inflammation. Stage III disease had moderate and severe interstitial fibrosis, moderate interstitial inflammation, tubular atrophy and some glomerulosclerosis. Stage IV disease typically had severe interstitial fibrosis and inflammation, tubular atrophy and glomerulosclerosis. The mean age of patients with stage I disease (27 ± 10.8 years) was significantly lower than those of the other stages. About 79.2%, 55%, 49.1% and 50% in stage I, II, III and IV disease respectively were asymptomatic at the time of biopsy. |
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Drug-induced acute interstitial nephritis: A clinicopathological study and comparative trial of steroid regimens
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p. 281 |
R Ramachandran, K Kumar, R Nada, V Jha, KL Gupta, HS Kohli DOI:10.4103/0971-4065.147766 PMID:26628793Steroids are used in the management of drug-induced acute interstitial nephritis (AIN). The present study was undertaken to compare the efficacy of pulse methyl prednisolone with oral prednisolone in the treatment of drug-induced AIN. Patients with biopsy-proven AIN with a history of drug intake were randomized to oral prednisolone (Group 1) 1 mg/kg for 3 weeks or a pulse methyl prednisolone (Group II) 30 mg/kg for 3 days followed by oral prednisolone 1 mg/kg for 2 weeks, tapered over 3 weeks. Kidney biopsy scoring was done for interstitial edema, infiltration and tubular damage. The response was reported as complete remission (CR) (improvement in estimated glomerular filtration rate [eGFR] to ≥60 ml/min/1.73 m 2 ), partial remission (PR) (improvement but eGFR <60 ml/min/1.73 m 2 ) or resistance (no CR/PR). A total of 29 patients, Group I: 16 and Group II: 13 were studied. Offending drugs included nonsteroidal anti-inflammatory drugs, herbal drugs, antibiotics, diuretic, rifampicin and omeprazole. There was no difference in the baseline parameters between the two groups. The biopsy score in Groups I and II was 5.9 1.1 and 5.1 1.2, respectively. At 3 months in Group I, eight patients each (50%) achieved CR and PR. In Group II, 8 (61%) achieved CR and 5 (39%) PR. This was not significantly different. Percentage fall in serum creatinine at 1 week (56%) was higher in CR as compared to (42%) those with PR. ( P = 0.14). Patients with neutrophil infiltration had higher CR compared to patients with no neutrophil infiltration ( P = 0.01). Early steroid therapy, both oral and pulse steroid, is equally effective in achieving remission in drug-induced AIN. |
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Nitric oxide status in patients with chronic kidney disease |
p. 287 |
YS Reddy, VS Kiranmayi, AR Bitla, GS Krishna, P. V. L. N Srinivasa Rao, V Sivakumar DOI:10.4103/0971-4065.147376 PMID:26628794Patients with chronic kidney disease (CKD) are at an increased risk of cardiovascular (CVD) morbidity and mortality, mainly due to atherosclerosis. Decreased production or reduced bioavailability of nitric oxide (NO) can result in endothelial dysfunction (ED). Multiple mechanisms are known to cause a state of NO deficiency in patients with CKD. Patients in various stages of CKD grouped as group-1 (CKD stage 1 and 2), group-2 (CKD stage 3 and 4), group-3 (CKD stage 5) and healthy controls were included in the study. Each group of patients and controls comprised 25 subjects. Plasma nitrites, L-arginine, asymmetric dimethyl arginine (ADMA) and citrulline were measured in all the subjects. Patients in all stages of CKD had lower NO and higher ADMA levels compared to controls. Further, group-2 and group-3 patients had lower levels of NO and higher levels of ADMA than group-1 patients. L-arginine levels showed no difference between patients and controls. However, group-3 patients had lower L-arginine levels compared to group-1 patients. Citrulline levels were decreased in group-3 patients. NO production was decreased in patients in all stages of CKD. The decrease could be due to decreased availability of the substrate, L-arginine or due to an increased ADMA, a potent inhibitor of endothelial NO synthase. Therapeutic interventions directed towards improvement of NO production in addition to management of other CVD risk factors may prevent development of ED and facilitate proper management of CKD patients who are at increased risk for CVD. |
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The role of neutrophil-gelatinase-associated lipocalin in early diagnosis of contrast nephropathy
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p. 292 |
MR Khatami, M. R. P Sabbagh, N Nikravan, Z Khazaeipour, MA Boroumand, S Sadeghian, B Davoudi DOI:10.4103/0971-4065.147370 PMID:26628795Neutrophil-gelatinase-associated lipocalin (NGAL) is a biomarker of acute kidney injury. The aim of this study was to define a cut-off for NGAL in the early diagnosis of contrast-induced nephropathy (CIN) in patients with normal kidney function. We enrolled 121 patients with normal serum creatinine who underwent coronary angiography. NGAL was measured in urine before the procedure and 12 and 24 h afterward. CIN was defined as a 0.3 mg/dl increase in serum creatinine within 48 h after the procedure. Seven of 121 patients had CIN (5.8%). The NGAL levels in the 12- and 24-h urine samples of these patients were 30 (5-45) and 20 (15-40) ng/ml, respectively, whereas those in patients without CIN were 15 (5-45) and 15 (10-51) ng/ml, respectively (P = 0.8). In patients with CIN, the sensitivity and specificity of NGAL with a cut-off of 22.5 ng/ml were 71.4% and 57.9% in 12-h urine samples, with the negative predictive values (NPV) and positive predictive values (PPV) of 97.1% and 9.4%, respectively. In conclusion, we suggest that urine NGAL with cut-off point of 22.5 ng/ml has acceptable sensitivity and specificity for early diagnosis of CIN in patients with normal serum creatinine, but regarding NPV and PPV the best performance of this value is to rule out the CIN in patients at risk who received contrast media. |
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CASE REPORTS |
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Pyoderma gangrenosum in a renal transplant recipient: A case report and review of literature |
p. 297 |
PK Jha, A Rana, S Kapoor, V Kher DOI:10.4103/0971-4065.156900 PMID:26628796Pyoderma gangrenosum (PG) is a rare disorder of unknown etiology characterized by multiple cutaneous ulcers with mucopurulent or hemorrhagic exudate. This sterile neutrophilic dermatosis is known to occur in association with malignancy, infection, autoimmune disorders and drugs. Occurrence of PG in a renal transplant recipient, who is already on immunosuppressants, is rare. We hereby report a renal transplant recipient who developed PG 1-month after transplant and responded well to treatment with escalated dose of oral steroid. |
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Bardet-Biedl syndrome presenting with steroid sensitive nephrotic syndrome |
p. 300 |
KK Singh, R Kumar, J Prakash, A Krishna DOI:10.4103/0971-4065.151765 PMID:26628797Bardet-Biedl syndrome (BBS) is a rare autosomal recessive disorder characterized by postaxial polydactyly, retinitis pigmentosa, central obesity, mental retardation, hypogonadism, and renal involvement. Renal involvement in various forms has been seen in BBS. Cases with nephrotic range proteinuria not responding to steroid have been described in this syndrome. Here we report a case of BBS who presented with nephrotic range proteinuria. The biopsy findings were suggestive of minimal change disease. The child responded well to steroid therapy and remains in remission. |
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Immunoglobulin G4 related tubulointerstitial nephritis |
p. 303 |
N Nithyashree, S Rajagopalan, RA Annigeri, R Mani DOI:10.4103/0971-4065.152725 PMID:26628798Tubulointerstitial nephritis is an uncommon manifestation of IgG4 related disease. A case of tubulointerstitial nephritis with special features including isolated renal involvement in this multisystem disorder and the absence of response to steroid therapy in a young male is reported here. There was no nephromegaly, eosinophilia or other organ involvement. The importance of early detection and treatment for preservation of kidney function is highlighted. |
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Drug induced pseudoporphyria in CKD: A case report
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p. 307 |
S Quaiser, R Khan, AS Khan DOI:10.4103/0971-4065.160335 PMID:26628799Pseudoporphyria (PP) is used to describe a photodistributed bullous disorder with clinical and histologic features of porphyria cutanea tarda (PCT) but without accompanying biochemical porphyrin abnormalities. Medications, excessive sun and ultraviolet radiation exposure, have all been reported to develop PP. We report a case of PP in a 49-year-old man with CKD stage 3a, caused due to torsemide intake. This is probably the first reported case of PP developing in a dialysis naive patient CKD due to torsemide intake from India. |
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Spontaneous nontraumatic subarachnoid hemorrhage without cerebrovascular malformations in a maintenance hemodialysis patient |
p. 310 |
R Jayasurya, N Murugesan, R Kumar, AK Dubey, PS Priyamvada, RP Swaminathan, S Parameswaran DOI:10.4103/0971-4065.156909 PMID:26628800Nontraumatic subarachnoid hemorrhage (SAH) in a dialysis patient is an uncommon occurrence and is often associated with high mortality. We report for the first time in India, a case of spontaneous nontraumatic, nonaneurysmal SAH without any cerebrovascular malformation in a maintenance hemodialysis patient, following a session of hemodialysis. The dialysis prescription needs to be modified in these patients, in order to prevent worsening of cerebral edema and progression of hemorrhage. Where available, continuous forms of renal replacement therapies, with regional anticoagulation seem to be the best option for such patients, till neurologic stabilization is achieved. |
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IMAGES IN NEPHROLOGY |
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Bouquet of flowers: Clue to medullary sponge kidneys |
p. 315 |
B Sureka, K Bansal, V Jain, A Arora DOI:10.4103/0971-4065.150079 PMID:26628801 |
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LETTERS TO EDITOR |
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Gitelman syndrome in an infant |
p. 316 |
M Nandi, G Pandey, S Sarkar DOI:10.4103/0971-4065.156904 PMID:26628802 |
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Gangrene and bacteremia due to Corynebacterium jeikeium in a patient on maintenance hemodialysis |
p. 317 |
CK Kishore, BS Lakshmi, V Chaitanya, U Kalawat, R Ram, VS Kumar DOI:10.4103/0971-4065.157804 PMID:26628803 |
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Hemodialysis catheter-related bacteremia caused by Stenotrophomonas maltophilia |
p. 318 |
A Kataria, S Lata, V Khillan DOI:10.4103/0971-4065.157425 PMID:26628804 |
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BOOK REVIEW |
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Textbook of Systemic Vasculitis |
p. 320 |
Harbir S Kohli DOI:10.4103/0971-4065.164231 |
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