Journal of Renal and Hepatic Disorders

A Prospective Non-Randomised Interventional Study of Goal-Directed Ultrafiltration Compared With Clinical Dry-Weight Assessment in Achieving Euvolemic Status of Patients on Maintenance Hemodialysis

2023-04-06T18:44:19+00:00

An accurate assessment of intravascular volume status in hemodialysis (HD) patients presents a significant challenge. Current clinical practices to determine dry weight is flawed due to interobserver variability and nonreproducibility. This miscalculation results in either chronic hypervolemia or hypovolemia with intra or interdialytic hypotension. The quest for noninvasive volume assessment tools to aid in the estimation of dry weight still continues. This study aims at goal-directed ultrafiltration removal compared with clinical dry-weight assessment in achieving euvolemic status of patients on chronic HD. It is a prospective, single-centered, nonrandomized, noninvasive interventional study on HD patients, for 12 months. Fifty two patients participated out of which 46 completed the study. Ultrasound-guided inferior vena cava collapsing index (IVCCI) and B lines were measured at intervals along with cardiac parameters. Dry weight was first estimated clinically by trial and error method. New dry weight target was set when B-lines were less than four in the eight site lung ultrasound and IVCCI between 50 and 75%, after 30 min post dialysis. Approximately 23.9% of the patients did not require dry-weight modification throughout the study. About 19% patients did not achieve dry weight in spite of all interventions. Overall, 56.5% of the patients achieved dry weight during the study period. A total of 46.3% of patients with NYHA Grade 3 dyspnoea observed at the start of study was reduced to 2.2%, showing statistical significance. Clinical assessment when bundled with noninvasive technology of assessment of dry weight showed encouraging results. B-lines and IVCCI estimation could be additional tools to achieve target weight goals, reducing complications and increasing compliance.

Pulmonary Hypertension in Patients of Chronic Kidney Disease on Maintenance Hemodialysis: Study from a Tertiary Care Center in Central India

2023-08-03T15:34:12+00:00

To study the incidence of pulmonary hypertension (PH) in chronic kidney disease (CKD) stage V patients on maintenance hemodialysis (HD) at our center. To compare clinical and metabolic variables among CKD patients with and without PH to search for possible etiologic factors. Comparison of PH in CKD patients at baseline and after 3 months of sildenafil therapy. The study was conducted in the Department of Nephrology, Sri Aurob-indo Institute of Medical Sciences, Indore, for a period of 1 year from December 2021 to November 2022. All CKD patients on maintenance HD at our center were included in the study. A pre-structured proforma was used to record patient data. Detailed clinical examination, 2DECHO, and Biochemical tests were done. All patients with mean pulmonary artery pressure (mPAP) > 25 mmHg on 2D echocardiography were considered to have PH and were started on sildenafil therapy 20 mg three times a day for 3 months. PH was classified as mild PH (mPAP > 25 up to 40 mmHg), moderate PH (mPAP > 40 mmHg to 60 mmHg), and severe PH (mPAP > 60 mmHg). Patients were then followed for 3 months to look for episodes of dyspnea and emergency admissions and reassessed after 3 months by repeat 2D echocardiography to find improvement in PH. A total of 102 patients were analyzed during the study period; among them, 40 patients (39.2%) had PH. Out of them, 18 patients (45%) had mild PH, 14 patients (35%) had moderate PH, and 8 patients (20%) patients had severe PH. Average age of our patients was 48.8 ± 9.4 years, the majority being men. On comparing the clinical features between patients with and without PH, none of the clinical parameters had any statistically significant impact on PH. Also, none of the laboratory parameters had statistical significance among PH and non-PH groups. Among the patients with PH, 25 patients (62.5%) had Arteriovenous (AV) fistula, 10 patients (25%) had temporary dialysis catheters. Eight patients (20%) had jugular catheters, two patients (5%) had femoral catheters, and 5 (12.5%) patients had tunneled jugular catheters. Initially, 102 patients were enrolled in the study. Of these, 40 (39.2%) had PH and 62 (60.7%) did not. Patients who had PH started sildenafil 20 mg three times a day. Of these 40 patients, at 3 months, eight patients were lost to follow-up, and 32 patients with PH remained in the study. Emergency admissions in each group of PH declined after 3 months, and the result was statistically significant. Echocardiographic findings were compared in patients with PH and without PH, but the difference in patients on HD with PH and without PH was not statistically significant. PH is a significant problem in CKD patients on HD. This issue needs to be evaluated in a timely manner to avoid the risk of morbidity and mortality. It is vital to treat them at the earliest to prevent life-threatening complications.

Incidence, Histopathological Pattern, and Predictors of Non-Diabetic Renal Disease in Type 2 Diabetes Mellitus

2023-08-03T15:44:48+00:00

Patients with type 2 diabetes mellitus (T2DM) may have renal involvement because of isolated diabetic nephropathy (DN), isolated non-diabetic renal disease (NDRD), or mixed lesions (DN combined with NDRD). This study was conducted to find out incidence, histopathological pattern, and clinical predictors of NDRD in the Kashmiri population. This is a single-center prospective observational study conducted from August 2015 to July 2017. Patients with T2DM presenting with atypical clinical features of renal involvement underwent kidney biopsy. A total of 33 patients were included. Isolated NDRD was found in 16/33 (48.5%) patients, isolated DN was discovered in 10/33 (30.3%), and mixed lesions in 7/33 (21.2%) patients. NDRD with or without DN was present in 23/33 (69.7%) patients. Overall, the most common renal histopathological lesion in NDRD was immunoglobulin A (IgA) nephropathy present in 7/23 (30.4%) patients. In mixed lesions, FSGS and TMA were the most common renal lesions present in 2/7 (28.57%) patients. The mean duration of diabetes in NDRD and isolated DN groups was 4.4±3.6 and 7.0±2.9 years, respectively (P = 0.04). NDRD was present in 21/23 (91.3%) patients without diabetic retinopathy (P = 0.016). Our data demonstrated that more than half of the patients with T2DM with atypical features had NDRD upon renal biopsy. The absence of diabetic retinopathy and a shorter duration of diabetes were indicators of NDRD. IgA nephropathy was the most prevalent renal pathology. Clinicians must consider kidney biopsy liberally, especially in patients with unclear etiology of a kidney disease. Patients with type 2 diabetes mellitus (T2DM) may have renal involvement because of isolated diabetic nephropathy (DN), isolated non-diabetic renal disease (NDRD), or mixed lesions (DN combined with NDRD). This study was conducted to find out incidence, histopathological pattern, and clinical predictors of NDRD in the Kashmiri population. This is a single-center prospective observational study conducted from August 2015 to July 2017. Patients with T2DM presenting with atypical clinical features of renal involvement underwent kidney biopsy. A total of 33 patients were included. Isolated NDRD was found in 16/33 (48.5%) patients, isolated DN was discovered in 10/33 (30.3%), and mixed lesions in 7/33 (21.2%) patients. NDRD with or without DN was present in 23/33 (69.7%) patients. Overall, the most common renal histopathological lesion in NDRD was immunoglobulin A (IgA) nephropathy present in 7/23 (30.4%) patients. In mixed lesions, FSGS and TMA were the most common renal lesions present in 2/7 (28.57%) patients. The mean duration of diabetes in NDRD and isolated DN groups was 4.4±3.6 and 7.0±2.9 years, respectively (P = 0.04). NDRD was present in 21/23 (91.3%) patients without diabetic retinopathy (P = 0.016). Our data demonstrated that more than half of the patients with T2DM with atypical features had NDRD upon renal biopsy. The absence of diabetic retinopathy and a shorter duration of diabetes were indicators of NDRD. IgA nephropathy was the most prevalent renal pathology. Clinicians must consider kidney biopsy liberally, especially in patients with unclear etiology of a kidney disease.

IgA Nephropathy Associated with IgA Vasculitis Coexisting with Focal Segmental Glomerulosclerosis Tip Variant: A Case Report

2023-06-04T15:40:10+00:00

IgA vasculitis (IgAV), previously known as Henoch–Schönlein purpura, is a form of small vessel vasculitis that affects the skin, joints, intestines, and kidneys. The clinical presentation in adults is usually infrequent, more severe, with a worse prognosis and a higher recurrence rate. Due to limited scientific evidence, IgAV is viewed similarly to IgA nephropathy (IgAN), and the renal histopathological lesions are indistinguishable between the two. IgAN is the most prevalent glomerular diseases worldwide. The diagnosis of IgAN is confirmed through a renal biopsy. The most frequently found histopathological lesions are mesangial proliferation and concurrent IgA deposition confirmed by direct immunofluorescence. Focal segmental glomerulosclerosis (FSGS) appears as a glomerular pattern of injury in up to 40% of renal biopsies with IgAN, although there are few reported cases in the international literature where both diseases coexist as primary etiologies. We report a case of a female patient presenting with vasculitic lesions, abdominal pain, and nephrotic syndrome, whose cause is confirmed by a renal biopsy with a diagnosis of IgAN secondary to IgAV and coexistence of FSGS, an unusual presentation with few case reports.

Acute Hepatitis by Bartonella henselae Infection in an Adult Patient with Decompensated Liver Cirrhosis

2023-08-04T15:37:57+00:00

Hepatitis caused by Bartonella henselae in adults is a condition that is seldom reported in the literature, as well as its current incidence and prevalence. While there is a broad spectrum of well-defined and established clinical entities, hepatic involvement represents the third most frequent clinical manifestation of infection by this genus of bacteria. It may or may not be characterized by the presence of hepatosplenic granulomas. Diagnosis requires a high level of clinical suspicion, exclusion of additional etiologies, and a causal relationship with risk factors. Polymerase chain reaction is the diagnostic test with the highest diagnostic yield, and treatment varies depending on the clinical expression. We describe the case of an adult patient with hepatitis secondary to Bartonella henselae infection.