Raised Serum Creatinine Research Articles

131 ACUTE KIDNEY INJURY IN THE ELDERLY IN HOSPITAL SELAYANG: EPIDEMIOLOGY AND RISK FACTORS

Category: Epidemiology and Outcomes from AKI Presenter: Dr VUI ENG PHUI Keywords: Acute kidney injury; Elderly The aging kidney undergoes important anatomic and physiologic changes that increase the risk of acute kidney injury (AKI) in the elderly. Improvements in life expectancy resulted in aging population in Malaysia. Multiple studies have demonstrated that the elderly are more susceptible to developing AKI but data on elderly Malaysians is lacking. To determine the incidence and risk factors of developing AKI in elderly patients. This single-centre, prospective, observational study was performed on all patients who were admitted from 1st till 31st March 2017. Elderly was defined as individual aged 65 year or more at time of admission while AKI was defined as a raised serum creatinine (SCr) of at least 26.5 umol/L within 48 hours or 1.5 times increment from baseline within 7 days. Laboratory SCr results of all adult patients admitted during the study period were retrieved from the hospital Laboratory Information System (LIS). Demographic, patient characteristics and clinical data were collected for all adult patients. Results were analyzed using SPSS Version 23. Of a total of 4845 adult admissions during the study period, 874 (18.0%) admission involved the elderly. A total of 283 adults had AKI where 126 cases involved the elderly. The incidence rate of AKI among the hospitalized elderly was 14.4% compared to 3.9% in hospitalized adults aged less than 65 (p<0.001). The mean age of elderly AKI was 74.8±6.5 years with a male preponderance [81(64.3%)]. Malay accounted for 55 (43.7%) cases, followed by Chinese 53 (42.1%) and Indian 17 (13.5%). Comorbidities were common with 74(58.7%) having both diabetes mellitus (DM) and hypertension and 35 (27.8%) had chronic kidney diseases (CKD). The mean baseline SCr was 145.6+95.5 ìmol/L. The two most causes of AKI in the elderly were infection (39.7%) and hypovolemia (33.3%) and this is followed by obstructive uropathy (11.1%), cardiac (7.9%) and others (8%). Compared to elderly without AKI, elderly with AKI were older (74.7yrs vs 72.8yrs, p<0.001) and had a longer duration of hospitalization (10.1 days vs 4.5 days; p<0.001) The incidence of AKI in the hospitalized elderly patients was 3.7 times higher than those aged less 65years. More than half of the elderly AKI had both DM and hypertension and a quarter had CKD. Infections and hypovolemia resulted in AKI in 73% of cases. Older age and longer duration of hospitalization appeared to be associated with AKI in the elderly.

MICROALBUMINURIA;

Objectives: To determine the frequency of microalbuminuria in patientswith acute ischemic stroke. Study Design: Cross-sectional study. Setting: Medical floor,Independent University Hospital, Marzipura, Faisalabad. Study Duration: Two years, from 1stOctober 2013 to 30th September 2015. Materials and Methods: 95 patients of ischemic stroke,with or without diabetes mellitus and hypertension were tested for early morning urine albuminto creatinine ratio, after excluding patients with raised serum creatinine, urinary tract infection,congestive heart failure and menstruation. A urinary albumin to creatinine ratio of 30 to300 μg/mg was considered as MA. Results: Out of a total of 95 patients, MA was present in 46(48.4%)and absent in 49(51.6%) patients. Out of 33 diabetic patients, MA was present in 18(54.5%)patients while out of 62 non-diabetics 28(45.2%) had MA. Out of 55 hypertensive patients,MA was present in 27(49.1%) while out of 40 non-hypertensives 18(45.0%) had MA. Among14 patients having both diabetes mellitus and hypertension, 8(57.1%) were having MA. Outof 20 patients without both diabetes and hypertension, 8(40.0%) had MA. Conclusion: Giventhe high frequency of microalbuminuria in patients with ischemic stroke, microalbuminuria is auseful modifiable factor in addition to conventional risk factors in identifying those at increasedrisk of ischemic stroke.

Renal function in Ankylosing Spondylitis

Background: To study renal functions in patients with ankylosing spondylitis (AS) and compare with matched healthy controls and correlation between renal function parameters and disease activity markers. Methods: Renal functions of forty cases with AS and the same number of age- and sex-matched individuals were evaluated. Disease activity was assessed using Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index scores, C-reactive protein, and erythrocyte sedimentation rate. Results: Among AS cases, 31 AS cases (77.50%) had renal function abnormalities including hematuria (20%), proteinuria (30%), albuminuria (52.50%), increased 24 h urine protein (22%), raised serum creatinine (17%), and reduced glomerular filtration rate (GFR) (37%). Among healthy controls, 20/40 (50%) had renal function abnormalities including albuminuria (15%), raised serum creatinine (7.50%), and reduced GFR (20%). Abnormal renal functions were significantly more in AS cases (31/40, 77%) than healthy controls (20/40, 50%) (P Renal function abnormalities were more frequent among AS cases having elevated markers of disease activity. Renal abnormalities were more prevalent in cases taking nonsteroidal anti-inflammatory drugs (NSAIDs) for Conclusions: In this study with small number of participants abnormalities in the renal function were common in patients with AS. No significant correlation was found between renal functions and markers of disease activity.

Efficacy and Safety of Deferasirox in Pediatric Patients of Thalassemia at a Tertiary Care Teaching Hospital.

Objective:To evaluate efficacy, safety and utilization pattern of deferasirox in paediatric patients of transfusion dependant β Thalassemia Major at a tertiary care teaching hospital in Gujarat.Materials and Methods:This observational, prospective-retrospective, single centre, continuous study was conducted in a tertiary care teaching hospital among paediatric patients of transfusion dependent β Thalassemia Major. Patients treated with deferasirox for not more than 12 weeks were enrolled. Details of blood transfusions, relevant investigations performed every 3 weeks and 3 months and drugs used were recorded in a pretested case record form. Parents were provided with a diary to record the details of ADRs. Data were analyzed for demographic characteristics, number and mean volume of blood transfusions, changes in serum ferritin and iron levels, number and types of ADRs and progression, causality, severity and preventability of ADRs.Results:Of the 60 patients enrolled, one patient was lost to follow up and four withdrew their consent. Of the remaining 55 patients, 36 were boys and 19 were girls (mean age: 6 ± 3.14 years), including patients of 1-3 years (11), 4-6 years (24), 7-10 years (12) and 11-12 years (8). Thirty six patients were born of consanguineous marriages. Adherence to blood transfusion guidelines and deferasirox prescribing and administration guidelines was observed. A serial and significant decrease in mean serum ferritin and serum iron at 3 weeks and 3 months with deferasirox treatment was observed in all age groups except that of 11-12 years. A total of 117 ADRs were observed in 52 patients from 19498 doses, most common being diarrhea (24), raised serum creatinine (15), raised hepatic enzymes (14), abdominal pain (14) and rashes (14). A reduction in dose was required in 32 cases, while a temporary stoppage was indicated in 41 cases. Deferasirox was the possible and probable cause of 65 and 51 ADRs respectively as assessed by WHO-UMC scale. Majority of ADRs were definitely preventable and mild in nature.Conclusion:β Thalassemia Major is more common in males. A rational prescribing of deferasirox was observed. Deferasirox effectively reduced serum ferritin and serum iron levels in these patients.

Determinants and Outcome of Metabolic Acidosis in Diarrheal Children Under 5 Years of Age in an Urban Critical Care Ward in Bangladesh.

We evaluated the independent determinants and outcome of metabolic acidosis in diarrheal children. Children under 5 years of age admitted with diarrhea and severe respiratory distress in the critical care ward at Dhaka Hospital of icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh) from April 2010 to April 2014 who had their reports of arterial blood gas analyses were enrolled in the study. We compared clinical and laboratory characteristics between the study children with (cases = 74) and without metabolic acidosis (controls = 65). Metabolic acidosis was defined if pH < 7.35 and HCO3 < 22 mmol/L in ABG. Cases had higher mortality (53% vs 29%, P = .01) compared to controls. After adjustment of potential confounders, for instance, hypokalemia and dehydration, the cases were independently associated with severe sepsis and raised serum creatinine (for both P < .05). Thus, early identification of these features of metabolic acidosis in diarrheal children may help clinicians to have prompt management that may further help reduce mortality in such children especially in resource-limited settings.

English

Objectives: To determine the frequency of microalbuminuria in patientswith acute ischemic stroke. Study Design: Cross-sectional study. Setting: Medical floor,Independent University Hospital, Marzipura, Faisalabad. Study Duration: Two years, from 1stOctober 2013 to 30th September 2015. Materials and Methods: 95 patients of ischemic stroke,with or without diabetes mellitus and hypertension were tested for early morning urine albuminto creatinine ratio, after excluding patients with raised serum creatinine, urinary tract infection,congestive heart failure and menstruation. A urinary albumin to creatinine ratio of 30 to300 μg/mg was considered as MA. Results: Out of a total of 95 patients, MA was present in 46(48.4%)and absent in 49(51.6%) patients. Out of 33 diabetic patients, MA was present in 18(54.5%)patients while out of 62 non-diabetics 28(45.2%) had MA. Out of 55 hypertensive patients,MA was present in 27(49.1%) while out of 40 non-hypertensives 18(45.0%) had MA. Among14 patients having both diabetes mellitus and hypertension, 8(57.1%) were having MA. Outof 20 patients without both diabetes and hypertension, 8(40.0%) had MA. Conclusion: Giventhe high frequency of microalbuminuria in patients with ischemic stroke, microalbuminuria is auseful modifiable factor in addition to conventional risk factors in identifying those at increasedrisk of ischemic stroke.

Autosomal dominant polycystic kidney disease: Study of clinical characteristics in an Indian population.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary form of kidney disease. Clinical data on this multisystem disorder are scarce from developing countries. We conducted a prospective observational study of the clinical profile of ADPKD patients at a single center over a period of six years. A total of 208 patients were studied. Majority were male (60.6%) and the mean age was 45.8 ± 14.5 years. About 61.5% had early stage (Stages 1-3) of chronic kidney disease (CKD) and 38.5% had advanced CKD (Stages 4 and 5). Clinical features observed included pain abdomen (46.2%), nocturia (65.9%), hematuria (21.6%), nephrolithiasis (38.9%), urinary tract infection (UTI) (38.9%), hypertension (69.5%), and raised serum creatinine (54.3%). The prevalence of nocturia, hypertension, and renal dysfunction showed a significant increase with age (P = 0.001). Extrarenal manifestations were polycystic liver disease in 77 patients (37%), cysts in pancreas in two (1%), and stroke in three (1.5%) (hemorrhage in 2 and infarct in 1). There was significantly higher prevalence of hypertension (P = 0.027) and nephrolithiasis (P = 0.044) in males compared to females. Ninety-two patients (44.2%) had a positive family history for ADPKD. Fifteen (7.2%) had kidney failure at the diagnosis of ADPKD, were hospitalized, and underwent emergency dialysis. A total of 20 patients (9.6%) developed end-stage kidney disease during the study period. The age at diagnosis was higher, and there was a high prevalence of hypertension, nocturia, abdominal pain, nephrolithiasis, UTI, and renal dysfunction in Indian ADPKD patients.

Nephrotic syndrome and Obstetric anesthesia

Renal disorders in pregnancy can be both difficult to diagnose and manage. They are associated with poor maternal and/or fetal outcomes. In pregnancy, proteinuria is common and can range from mild urinary protein elevations to nephrotic levels. The diagnosis of nephrotic syndrome (NS) can be challenging, especially in pregnancy as it can be confused with preeclampsia. NS has an incidence of 0.012%–0.025% in pregnant women. It is diagnosed by the presence of more than 3 g/day of proteins in urine, serum albumin <30 g/dL, generalized edema, hypercholesterolemia, and lipiduria. Proteinuria with hypertension is characterized by the presence of hematuria, red cell casts, raised serum creatinine, and features suggestive of systemic disease. Other causes of proteinuria include preeclampsia, diabetes mellitus (Type 1 and Type 2), Immunoglobulin A nephropathy (Ig A glomerulonephritis), focal and segmental glomerulosclerosis, and lupus nephritis. The maternal risks of NS include acute kidney insult, chronic renal failure, gestational hypertension, preeclampsia, and complications due to hypoalbuminemia. Fetal considerations in NS include fetal growth retardation, prematurity, stillbirth, fetal anasarca, and polyhydramnios. Preconception counseling and immunosuppressive drug therapy can improve overall fetomaternal outcome. We hereby present a unique case of successful anesthetic management of NS in a parturient along with concurrent hypothyroidism and hypertension, for elective cesarean section.

A surprising case of bilateral ureteric stones causing acute renal failure and anuria

Introduction: We present a case of bilateral ureteric colic that causes anuric acute renal failure. Bilateral ureteric colic causing acute renal failure is not a new presentation. However, the patient had only 3 mm calculi, making our case unique. Background: Bilateral renal calculi are an uncommon cause of acute kidney injury (AKI). Obstructing ureteroliths rarely lead to AKI without any underlying renal disease or anatomic abnormalities, such as a solitary kidney or horseshoe kidney. The literature has reported the incidence of a unilateral ureterovesicular junction obstruction secondary to a stone as 20%. However, there are a very few case reports in the literature of urology, nephrology or emergency medicine regarding the incidence of bilateral ureteric calculi. Cases of bilateral ureteric calculi are rare, and cases with AKI and anuria are very rare. Case presentation: A 30-year-old male presented with bilateral colicky flank pain for 4 days and started to develop macroscopic haematuria. After proper pain management in the Emergency Department, the patient was found to have a raised serum creatinine level (152 μmol/L). A CT scan was performed showing two 3 mm calculi in the left and right proximal ureters. Ultrasound showed moderate left and mild right hydroureteronephrosis. Due to the relatively small size of the stones, and the clinical image of the patient, he was planned for medical expulsive therapy. Surprisingly, the patient developed complete anuria for 2 days and presented to the ED with a serum creatinine level of 843 μmol/L. Bilateral double J stents were placed and urgent ureteroscopy was done. Following treatment, the patient's condition significantly improved and his renal function returned to normal within 4 days. Conclusion: Even small bilateral stones can result in acute kidney injury.

Curvilinear bodies are associated with adverse effects on muscle function but not with hydroxychloroquine dosing.

The clinical significance of curvilinear bodies (CB) seen in association with hydroxychloroquine (HCQ) therapy is uncertain. Patients with CB on muscle biopsy performed between 2006 and the present were identified, and their clinical features including body mass index and cumulative HCQ dose were recorded. A control group of 16 patients with idiopathic inflammatory myositis (IIM) on HCQ at time of biopsy but without evidence of CB was identified. Nineteen patients with CB were identified; details were available for 18. Among patients with CB, 7/18 also had IIM. Seven out of ten patients with CB who did not have IIM or MHCI/II expression had proximal weakness; 7/11 had raised serum creatinine kinase (CK) levels. There was no difference in body weight (p=0.47), body mass index (p=0.93), cumulative HCQ dose (p=0.52) or cumulative dose adjusted for body weight (p=0.39) or body mass index (p=0.32) between patients with CB and controls. Patients with CB had lower median CK levels than controls (p=0.034). Weakness was present in 12/17 patients and 12/16 controls (p=1.0). Concurrent proton-pump inhibitors were co-prescribed in 12/18 (67%) patients with CB and in 6/16 (38%) controls (p=0.17). Development of CB does not appear to be related to cumulative HCQ dose or body weight. Patients with CB frequently have muscle weakness in the absence of MHC1 expression suggesting a role for non-immune mechanisms of muscle injury. A high proportion of patients with CB are co-prescribed proton-pump inhibitors raising the possibility that co-prescription of both agents may disrupt lysosomal function and adversely affect muscle function.

Prevalence of Low Glomerular Filtration Rate (Low eGFR), Proteinuria and Associated Risk Factors in a Rural Area of Bangladesh using Cockcroft-Gault and Modification of Diet in Renal Disease Equation: An Observational, Cross-sectional Study

Chronic kidney disease (CKD) has become a global public health concern. The adverse outcomes of CKD are enormous in developing countries due to paucity of facilities for renal replacement therapy and high cost of services for management of ESRD. Chronic kidney disease and its risk factors are common in Bangladesh, however community-based data on the subject is lacking. The purpose of this study to estimate and compare the prevalence of low GFR, proteinuria and associated risk factors using Cockcroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) equation based on serum creatinine (SCr) in a rural area of Bangladesh. An observational cross-sectional study performed on patients aged 18 years or older living in the rural area of Mymensingh were randomly selected from the database of the health care system and who gave informed consent to participate in the study. Subjects with nonresidents, pregnant, cognitive dysfunction that interfered with understanding and answering the study questionnaire were excluded from the study. The sample size was calculated with a formula for cross-sectional study and to meet the following criteria: a confidence level of 95%, acceptable error 15% and expected prevalence of CKD 15.7%. Therefore a sample size of 920 was considered appropriate for the study. The study was carried out for a period of 16 months between March 2014 and June 2015. Renal impairment was defined as eGFR less than 60 ml/min/1.73 m2. Thus stage 3, 4 and 5 of KDOQI were grouped as renal impairment. Renal function was estimated from serum creatinine using Cockcroft-Gault and MDRD (modification of diet in renal disease) equations. Data are presented as frequencies, percentages or mean ± standard deviation as appropriate. The Chi-square test was used for categorical variables and multivariate analyses was performed by binary logistic regression to identify the risk factors of CKD. All statistical tests were 2-sided. A p value lower than 0.05 was considered to be significant. All statistical analyses were done with SPSS Version 11.5 for Windows. Over half (51.7%) of the patients were male and rest 48.3% female with mean age 42.3 ± 13.2 years. Most (67.3%) of the patients were illiterate and only 22.8% engaged in salaried job. Over two-third (67.4%) of the patients were overweight and obese, 31.2% normal and very few (1.4%) underweight. The prevalence of low eGFR was 15.3% by Cockcroft-Gault and 15.9% by MDRD equation. The survey population had a 17% prevalence of proteinuria. Sex, illiterate, overweight &amp; obese, obese by WC, hypertension, proteinuria, raised serum creatinine, diabetes mellitus, anaemia, family H/O CKD, low HDL cholesterol and raised total cholesterol were found to be the independent predictors of CKD. The prevalence of low eGFR in this rural population is common and an increase prevalence of proteinuria. The association between CKD and risk factors was also highly significant. There is an urgent need for more detailed measurement for these risk factors through a comprehensive survey to evaluate individuals with risk factors, to enable earlier detection and risk factor reduction through rising of awareness.&#x0D; CBMJ 2016 July: Vol. 05 No. 02 P: 04-13

Analysis of factors affecting mortality outcome in ischemic bowel disease- a study of 50 cases

Introduction: Ischemic bowel disease is the outcome of inadequate supply of oxygen to the intestine leading to ischemia having a plethora of symptoms and signs which are often inconspicuous leading to delayed diagnosis exacerbating already poor patient outcomes. There is a definite need to classify patients into high and low risk categories, so that intensive monitoring and care can be delivered to improve mortality outcome. Methods: We have done a prospective study of 50 adult cases of ischemic bowel disease confirmed on radiology, intra-operative findings and histopathology and compared the mortality and severity of disease with various patient parameters and analyzed significant correlations if any. Results: Majority of patients were adult males above age of 50 years with acute presentation. Hypertension and diabetes were commonly seen. Clinically, tenderness and tachycardia were common. ECG was abnormal in 72% patients. On imaging, thrombotic SMA involvement was present in majority of patients. Therapeutically, 90% patients were explored with a high mortality rate (71%) commonly the cause being sepsis (47%). Overall mortality was 64%. Small bowel was commonly affected. Majority of patients suffered from sepsis requiring ionotropic and ventilatory support. All patients with SMV thrombosis survived. Raised serum creatinine and altered pH were strongly associated with mortality. Also patients with ischemic bowel segment more than 80cm were at a high risk of death. Conclusion: The need for a scoring system based on parameters discussed has to be addressed, to stratify patients who will require critical and specialized intensive care and improve mortality outcomes.

A Prospective Study on Prevalence and Causes of Anaemia in Patients with Acute Coronary Syndrome.

Anaemia is a contributor for adverse prognosis in Acute Coronary Syndrome (ACS), but the epidemiology and causes of anaemia in such patients is not defined. To study the prevalence and aetiology of anaemia in hospitalized patients with ACS. All consecutive patients admitted with ACS from January to March, 2010 were included. Their clinical information was recorded. Of 130 (87 males) consecutive admissions for ACS, 47.7% had unstable angina, 10% had Non ST-Elevation Myocardial Infarction (NSTEMI) and 42.3% had ST-Elevation Myocardial Infarction (STEMI). Overall prevalence of anaemia (haemoglobin <130 g/l in men and <120 g/l in women) was 51.5% (n=67) and was more prevalent in women (n=30, 69.8%) than men (n=37, 42.5%). Moderate to severe anaemia was more in women (34.9%) compared to men (20.8%). Anaemia was more common in unstable angina patients (58.2%) than in NSTEMI (11.9%) or STEMI (29.9%) patients (p=0.013). Aspirin (p<0.01) and/or clopidogrel intake (p<0.01) and raised serum creatinine (p<0.01) were more often in anaemic patients. Heart failure (p<0.01) and triple vessel disease (p<0.05) were associated with anaemia. Multivariate predictors of duration of hospital stay were haemoglobin (p<0.05) at admission and revascularisation procedure (p=0.01) during hospital stay. The most common cause of anaemia was iron deficiency (29.9%). Anaemia was common in our patients admitted with ACS. Female gender, antiplatelet drug intake and raised creatinine were associated with anaemia, which in turn was associated with adverse in-hospital outcomes. The impact of correcting anaemia on outcomes in ACS needs long term prospective study.

Study of patients with nephrotic syndrome in Sohag University Hospital

Background Nephrotic syndrome is not a disease; it is the manifestation of a wide variety of underlying disease processes. Objectives The aim of the present study was to investigate different clinic-laboratory and histological patterns of nephrotic syndrome and the relationship between its clinical character and prognosis. Methods From January 2010 to December 2011 the authors of the present study retrospectively and prospectively studied 139 patients with nephrotic syndrome, diagnosed on the basis of heavy proteinuria greater than 3 g/day, hypoalbuminemia, evidence of fluid retention or edema, and hyperlipidemia. Results A total of 139 patients (M : F = 79 : 60) were included in the present study; their mean age was 33.9 ± 13.47 years (primary : secondary nephrotic syndrome = 80 : 59). Systemic lupus erythematosus was the most common underlying cause of secondary nephrotic syndrome [24 cases (40.7%)], followed by DM [13 cases (23.7%)]. Renal biopsy revealed 18 patients (30.5%) with membranoproliferative glomerulonephritis, 15 (25.43%) with membranous nephropathy, seven (11.86%) with mesangial proliferative glomerulonephritis, six (10.16%) with amyloidosis, five (8.47%) with focal segmental glomerulosclerosis, three (5.08%) with diffuse proliferative glomerulonephritis, one (1.69%) with focal proliferative, minimal mesangial, sclerosing glomerulonephritides, one patient (1.69%) with crescent glomerulonephritis, and another one (1.69%) with IgA nephropathy. A raised serum creatinine level was found in 49 (35%) patients, and 35 (74.4%) of them had normal renal function at the last follow-up. Complete remission of proteinuria occurred in 69 (49.6%) patients, partial remission in 53 (38.1%), and resistant proteinuria in 17 (12.2%). Conclusion Clinical features and biochemical values do not give many clues about the underlying histological types of glomerulonephritis. Therefore, renal biopsy should be carried out in all patients with adult nephrotic syndrome, as results permit us to establish a specific diagnosis, which helps in counseling the patients about the likely prognosis of their disease and to select a specific therapeutic regimen.

Outcome of lupus nephritis in childhood onset SLE in North and Central India: single-centre experience over 25 years.

Childhood SLE (cSLE) has a higher prevalence of lupus nephritis (LN), and there are ethnic variations in response to treatment as well as outcome of LN. There are limited data on long-term outcome of LN in cSLE from the Indian subcontinent. Retrospective analysis of case records of patients with cSLE (satisfying revised American College of Rheumatology (ACR) 1997 criteria for diagnosis) and age of onset <18 years was conducted from 1989 to 2013. Data on clinical features, renal involvement and biopsy findings, treatment, renal outcome, damage accrual and mortality were collected. End-stage renal disease (ESRD) was defined as the need for renal replacement therapy. Actuarial ESRD-free survival was studied as the primary outcome measure using Kaplan-Meier analysis. Among 205 children with cSLE, 134 (121 girls) had evidence of LN. The mean age at disease onset was 13.7 ± 3.5 years and the mean disease duration at presentation was 1.9 ± 2.5 years. Kidney biopsy was available for 92 patients, and histology included: 13 (14.2%) Class II, 24 (26%) Class III, 43 (46.7%) Class IV and 12 (13.1%) Class V LN. The mean follow-up period was 6.75 ± 5.7 years. At last visit, 81 (60.4%) children were in complete remission, 28 (20.9%) were in partial remission, 15 (11.2%) still had active nephritis and 10 (7.4%) had progressed to ESRD. Almost two-thirds (62.9%) of patients experienced lupus flares, and mean flare rate was 0.09 flares/patient follow-up year. Fifty-six (43.8%) children accrued damage and the mean Systemic Lupus International Collaborating Clinics (SLICC)/ACR damage score was 0.79 ± 1.13. Actuarial ESRD-free survival at five, 10 and 15 years was 91.1%, 79% and 76.2%, and five-, 10- and 15-year renal survival was 93.8%, 87.1% and 84%, respectively. Although multiple factors individually predicted poor outcome (death/ESRD), only raised serum creatinine at onset (R square = 0.65, p ≤ 0.0001) and damage accrual (R square = 0.62, p ≤ 0.0001) remained significant on multivariate analysis. Eleven (8.2%) children died during the follow-up period, and infections were the leading cause of mortality. Long-term outcome of LN in cSLE in our cohort was better than previous reports from India. However, a high rate of major infection still remains the leading cause of mortality.

Etiological diagnosis of granulomatous tubulointerstitial nephritis in the tropics.

BackgroundGranulomatous tubulointerstitial nephritis (GIN) is common due to infections, drugs or sarcoidosis. However, the cause is often difficult to establish and the studies are limited. We studied the etiology of GIN and compared the clinical and histological features and outcome in different etiologies at a tertiary care center in North India.MethodsRenaö biopsies from GIN cases diagnosed from January 2004 to April 2014 were retrieved. Stain for acid fast bacilli was performed in all biopsies. Etiological diagnosis was based on clinical features, extra-renal manifestations, radiology, history of drug intake and demonstration of infective agent. Tissue PCR for tubercular DNA was performed in seven biopsies.ResultsSeventeen GIN patients [mean age 35 ± 15 years; males 11] were identified. Tuberculosis was the commonest etiology followed by idiopathic, sarcoidosis and fungal. Both tuberculosis and sarcoidosis patients presented with subnephrotic proteinuria and raised serum creatinine. Acid fast bacilli were demonstrated in 1/9 and necrosis was demonstrated in 3/9 granulomas in tuberculosis. Tissue PCR for tubercular DNA was positive in six TB patients and negative in one sarcoidosis patient. Patients responded well to appropriate therapy.ConclusionEtiological diagnosis of GIN is essential for timely and appropriate therapy. Tuberculosis is the commonest etiology (53%) in the tropics. Necrosis in granuloma, demonstration of acid fast bacilli, blood interferon gamma release assay and urine culture is not sensitive for the diagnosis of tuberculosis in GIN. Our findings suggest that tissue PCR for tuberculosis performed in an appropriate clinical setting is useful in the diagnostic evaluation of GIN.

Targeted spontaneous reporting of suspected renal toxicity in patients undergoing highly active anti-retroviral therapy in two public health facilities in Uganda.

BackgroundAlthough the national HIV control programme in Uganda has a well-established system for monitoring disease progression and treatment outcomes, monitoring of adverse drug reactions (ADRs) is inadequate. In order to address under-reporting of ADRs, the National Pharmacovigilance Centre, in collaboration with the HIV control programme, piloted a targeted spontaneous reporting (TSR) system as a complementary method to traditional spontaneous reporting.MethodsFrom April 2012 to March 2014, all cases of suspected renal toxicity in 10,225 patients on tenofovir-based regimens were monitored in the regional pharmacovigilance centres of Masaka and Mbale. The identification of renal toxicity was performed using serum creatinine, urinalysis, and other signs and symptoms of kidney injury.ResultsThere was one suspected renal toxicity reported for every 200 patients on a tenofovir-based regimen. Some of the serious reactions reported were death in two cases and bone demineralisation in five patients. Most of patients had been on treatment for 2 years. Those that had been on tenofovir for more than 4 years had raised serum creatinine levels, emphasising the importance of monitoring for the risk of renal damage for longer. We also found that the reporting rate of suspected ADRs for all medicines in the two sites increased almost fivefold during the implementation period.ConclusionAlthough the occurrence of suspected tenofovir renal toxicity of HIV patients is low, there is need to monitor those at risk so as to prevent irreversible kidney injury. TSR can complement spontaneous reporting for collecting safety data on particular drugs and increase ADR reporting rates.Electronic supplementary materialThe online version of this article (doi:10.1007/s40264-015-0277-9) contains supplementary material, which is available to authorized users.

PIRO concept: staging of sepsis.

Introduction:Sepsis is common presenting illness to the emergency services and one of the leading causes of hospital mortality. Researchers and clinicians have realized that the systemic inflammatory response syndrome concept for defining sepsis is less useful and lacks specificity. The predisposition, infection (or insult), response and organ dysfunction (PIRO) staging of sepsis similar to malignant diseases (TNM staging) might give better information.Materials and Methods:A prospective observational study was conducted in emergency medical services attached to medicine department of a tertiary care hospital in Northern India. Patients with age 18 years or more with proven sepsis were included in the first 24 hours of the diagnosis. Two hundred patients were recruited. Multivariate logistic regression analysis was done to assess the factors that predicted in-hospital mortality.Results:Two hundred patients with proven sepsis, admitted to the emergency medical services were analysed. Male preponderance was noted (M: F ratio = 1.6:1). Mean age of study cohort was 50.50 ± 16.30 years. Out of 200 patients, 116 (58%) had in-hospital mortality. In multivariate logistic regression analysis, the factors independently associated with in-hospital mortality for predisposition component of PIRO staging were age >70 years, chronic obstructive pulmonary disease, chronic liver disease, cancer and presence of foley's catheter; for infection/insult were pneumonia, urinary tract infection and meningitis/encephalitis; for response variable were tachypnea (respiratory rate >20/minute) and bandemia (band >5%). Organ dysfunction variables associated with hospital mortality were systolic blood pressure <90mm Hg, prolonged activated partial thromboplastin time, raised serum creatinine, partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FiO2) ratio <300, decreased urine output in first two hours of emergency presentation and Glasgow coma scale ≤9. Each of the components of PIRO had good predictive capability for in-hospital mortality but the total score was more accurate than the individual score and increasing PIRO score was associated with higher in-hospital mortality. The area under receiver operating characteristic curve for cumulative PIRO staging system as a predictor of in-hospital mortality was 0.94.Conclusion:This study finds PIRO staging as an important tool to stratify and prognosticate hospitalised patients with sepsis at a tertiary care center. The simplicity of score makes it more practical to be used in busy emergencies as it is based on four easily assessable components.

The utilization of diagnostic ultrasound in the evaluation of the kidneys in HIV-associated nephropathy

Aim: To evaluate the renal sizes and echogenicity pattern in patients with human immunodeficiency virus (HIV)-associated nephropathy and to correlate renal echogenicity with serum creatinine levels and proteinuria. Materials and Methods: A cross-sectional study of 100 consecutively confirmed HIV- seropositive patients aged between 19 and 65 years (Mean ± SD: 35 ± 10.79) comprising 32 males and 68 females with clinical and laboratory features of HIV-associated nephropathy (HIVAN) was conducted at the Infectious Diseases Clinic of the University of Maiduguri Teaching Hospital, between April 2011 and September 2012. The subjects were evaluated with renal ultrasound scan and the observed abnormalities were recorded. Serum creatinine levels and CD4 + lymphocyte counts were also obtained for all the patients. Proteinuria was established by dipstick method. Results: Of the 100 cases studied, ultrasound showed enlarged kidneys in 28 patients (28%) and abnormal echogenicity was present in 192 kidneys (96%). 100 kidneys (50%) were globular, 160 kidneys (80%) had decreased corticomedullary definition, 90 kidneys (45%) had decreased renal sinus fat and 80 kidneys (40%) had heterogenous renal parenchymal patterns. A high serum creatinine level, increased degree of proteinuria, lower CD4 counts, reproductive age group and black race were associated with HIVAN. Conclusion: The severity of HIVAN as indicated by raised serum creatinine level and proteinuria correlated positively with the degree of renal echogenicity.

Ofatumumab Versus Rituximab Salvage Chemoimmunotherapy in Relapsed or Refractory Diffuse Large B-Cell Lymphoma: The Orcharrd Study (OMB110928)

Ofatumumab Versus Rituximab Salvage Chemoimmunotherapy in Relapsed or Refractory Diffuse Large B-Cell Lymphoma: The Orcharrd Study (OMB110928)