Day 2 :
University of Southern California, USA
Elaine M Kaptein completed her MD in 1973 from the University of Saskatchewan, and her Internship, Residency and Fellowship at McGill University in Montreal Quebec in 1977. She is a Full Professor of Medicine at the University of Southern California, Los Angeles, CA. She has published 65 peer-reviewed articles in reputed journals.
Wide ranges of sodium concentrations for different body fluid losses have been noted with
minimal substantiating data and variability among sources, leading to use of “cumulative fluid balance” regardless of composition in hospitalized patients. We defined sodium concentrations of body fluid losses by performing a systematic literature review in adult humans using PubMed database. Inclusion criteria were met for 107 full-text articles. Mean sodium concentrations were significantly lower for acidic (mean+SD:44+12 mEq/L) than for alkaline (55+13 mEq/L) gastric fluid, higher for bile (184+24 mEq/L) or pancreatic fluid (156+3 mEq/L) than all other body fluids, and similar between intact small bowel (119+14 mEq/L) and ileostomy outputs (116+25 mEq/L). Sodium concentrations were significantly greater for cholera-induced diarrhea (128+18 mEq/L) and lower for osmotic-induced cause (28+16 mEq/L) than all other causes of diarrhea. For osmotic diarrheas, sorbitol-induced diarrhea sodium concentration was higher (63+17 mEq/L) than for carbohydrate malabsorption (43+20 mEq/L), lactulose (26+19 mEq/L), Idolax (16+13 mEq/L) and polyethylene glycol (13+7 mEq/L). For pleural, peritoneal, and edema fluid, sodium concentrations (137+13 mEq/L) were similar to plasma. In summary, this is the first in-depth review of verifiable sodium concentrations of body fluids most commonly lost in hospitalized patients. Sodium concentrations are fluid-specific and consistent. Sodium concentrations of enteral and parenteral fluids have been summarized. (Clinical Nephrology 86 (10): 203-28, 2016. PMID: 27616761). We have used these data to develop a calculator to assess net volume and water inputs and losses, to facilitate prevention and treatment of free water and volume disorders in hospitalized patients. Case examples of this application are included.
Christian Medical College & Hospital, India
Keynote: Pediatric Kidney Transplantation
V. Tamilarasi is working as head of department nephrology as in Christian Medical College Vellore, India. She was a dean of Vellore Medical College. She has attended several national and international conferences.
Introduction: Renal transplantation is undoubtedly the treatment of choice for children with End Stage Renal Disease. Successful transplantation in children and adolescents not only ameliorates uremic symptoms but also allows for significant improvement, and often correction, of delayed skeletal growth, sexual maturation, cognitive performance, and psychosocial functioning. In addition, lack of awareness among parents and physicians alike, resource allocation and the perceived infective milieu makes pediatric renal transplantation in India a challenge.
Method: A retrospective analysis on 133 pediatric renal transplants (age at transplant <18yr) done in a tertiary care center in south India over a 25 year period (1991 to 2016) was done. Data was collected from renal transplant database and Clinical workstation network. Mortality and graft loss were primary outcome variables studied.
Results: The mean age of the recipients was 25 years (6 to18 years), [accounting for 6.1% of all the renal transplants done at our center (133/3455). 96% of patients received kidney from live related donors. The major causes of ESRD were glomerulonephritis (29%) and urological abnormalities (18%), while the aetology was unknown in 46.5%. Immunosuppression was based on a triple drug regimen in 99% of children. Amongst complications, any rejection episode (41.7%), UTI (29.7%) and CMV disease (16.8%) were predominated. The mean duration of follow up was 38.6 ± 33.5 months (4,159) Graft loss occurred in 10 children (10%) at a mean duration of 35 ± 22 month (6.70). Overall 1, 5 and 10 year graft survival was 97% 83%, and 75% respectively Overall 1.5 year and 10 year patient survival was 95%, 86% and 79%. The significant predictor of graft loss was CMV disease (p=0.039) while sepsis (p=0.01) was the most important contributor to patient loss.
Conclusion: Pediatric renal transplantation in India can be accomplished successfully. The graft and patient survival in our study, the largest from India, is comparable to those published from developed countries and is encouraging given the limited resources.
University of Florida, USA
Title: Use of C4d biomarker as a diagnostic tool to classify membranoproliferative glomerulonephritis
Time : 11:10-11:40
Nirupama Gupta has completed her MD degree from the University of South Florida in 2009, Pediatrics Residency at Yale-New Haven Hospital in 2012 and Pediatric Nephrology Fellowship at University of Florida in 2015. Her clinical research interests include glomerulopathies, childhood hypertension and BK virus infection. As a Junior Faculty, she started the Pediatric Hypertension Clinic at University of Florida in 2015. She has given a CME talk on Pediatric Hypertension to community pediatricians and has lectured to medical students and residents on various nephrology topics.
Background: Membranoproliferative glomerulonephritis (MPGN type I, II, III) was reclassified in 2013 as MPGN and C3 glomerulopathy (C3G) based on classical or alternative pathway complement activation.
Objectives: To evaluate whether C4d, a component of the classical pathway could be a diagnostic tool in differentiating between MPGN and C3G.
Methods: We conducted a retrospective study of 15 MPGN type I, II, III and 13 minimal change disease (MCD) patients from 2000 to 2012. Formalin-fixed paraffin-embedded kidney tissues were stained for C4d using an immunoperoxidase method.
Results: Using the 2013 C3G consensus classification, the 15 MPGN types I, II, III biopsies were re-classified as MPGN (8) and C3G (7). Based on C4d immunohistochemical staining, of the 8 biopsies diagnosed as MPGN, 4 had classical pathway involvement [C1q (+), C3 (+), C4d (+)]; two had lectin pathway involvement [C1q (-), C3 (+), C4d (+)]; and, two were reclassified as C3G because the absence of C4d and C1q suggested the presence of the alternative pathway [C1q (-), C3 (+), C4d (-)]. Three of seven C3G biopsies presented classical pathway and were reclassified as MPGN. The alternative pathway was present in one of the other 4 considered to be C3G; the other two C3G biopsies likely involved the lectin pathway. The one case of dense deposit disease had lectin pathway involvement.
Conclusions: This study reports that C4d staining may help to differentiate between MPGN and C3G. In addition, the lectin pathway seems to play a role in the pathogenesis of these glomerulopathies.
Singapore General Hospital, Singapore
Objective: Prevention of exit site infection (ESI) is of paramount importance to peritoneal dialysis (PD) patients. The aim of this study was to evaluate the effectiveness of chlorhexidine in the prevention of ESI in incident PD patients compared with mupirocin.
Methods: This retrospective, pre-test/post-test observational study included all incident PD patients at Singapore General Hospital from 2012 to 2015. Patients received daily topical exit-site application of either mupirocin (2012-2013) or chlorhexidine (2014-2015) in addition to routine exit-site cleaning with 10% povidone-iodine. The primary outcome was ESI rate during the 2 time periods. Secondary outcomes were peritonitis rate, times to first ESI and peritonitis, hospitalization rate and infection-related catheter removal. Event rates were analyzed using Poisson regression and infection-free survival was estimated using Kaplan-Meier and Cox regression survival analyses.
Results: The study included 162 patients in the mupirocin period (follow-up 141.5 patient-years) and 175 patients in the chlorhexidine period (follow-up 136.9 patient-years). Compared with mupirocin-treated patients, chlorhexidine-treated patients experienced more frequent ESIs (0.22 vs 0.12 episodes/patient-year, p=0.048), although this was no longer statistically significant following multivariable analysis (incidence rate ratio [IRR] 1.78, 95% confidence interval [CI] 0.98-3.26, p=0.06). No significant differences were observed between the 2 groups with respect to time to first ESI (p=0.10), peritonitis rate (p=0.95), time to first peritonitis (p=0.60), hospitalization rate (p=0.21) or catheter removal rate (0.03 vs. 0.04/patient-year, p=0.56).
Conclusions: Topical exit-site application of chlorhexidine cream was associated with a borderline significant, higher rate of ESI in incident PD patients compared with mupirocin cream.
Htay Htay is a Nephrologist at Department of Renal Medicine, Singapore General Hospital. She was graduated from University of Medicine, Myanmar and received Master of Medicine (Internal Medicine) from the National University of Singapore. She has completed her basic specialist training in Internal Medicine and advanced specialist training in Nephrology at Singapore General Hospital. She has also completed her Fellowship training at Nephrology Department, Princess Alexandra Hospital, Brisbane, Australia. She is a Member of Royal College of Physician, International Society of Peritoneal Dialysis and Singapore Society of Nephrology.
Manipal hospital, India
Ravi shankar B has completed MBBS from Andhra Medical College, Vishakapatnam, Andhra Pradesh, India. He did his MD in Internal Medicine from PGIMER, Chandigarh, India. He has done DM (Nephrology) training at Osmania General Hospital, Hyderbad, India. He also had a short stint at Toronto General Hospital, Toronto, Canada in 2007. Currently he is a Senior Consultant at Manipal Group of Hospitals, Bangalore, India. He has 20 years of experiene in Nephrology and has been a Teacher for Nephrology Trainining Programme in India and he has publications in national and international journals
Nutritional status assesment in dialysis patients is very important since malnutrtion in dialysis is common and increases morbidity and mortality.The commonly used mehtods such as; BMI, anthropometry are not accurate for assessing the nutritional status in dialysis patients because of their altered fluid status. However, adding subjective global assessment (SGA) or malnutrition inflammatory score (MIS) to anthropmetry may provide better information. The fat mass, fat free mass (lean body mass) are the two most important parameters of nutrition and can be abnormal even with normal body weight in dialysis patients. DEXA scan, CT, MRI which are relatively simple methods to perform but involve expertise to analyze the data are a bit more expensive and expose patients to ionizing radiation. More accurate methods such as dueterium oxide and total body potassium estimation are complex, and used as advanced tools. Bioimpedance analysis (BIA), a relatively simpler, cheaper, bedside and user freindly tool has become more popular in the recent past in assesing the nutritional status in dialysis patients. In our expereince, bioimpedance analysis yielded body composition parameters which correlated well with BMI and anthropometric parameters in a subset of our dialysis patients. In addition, we found that subjective global assesment is also a less expensive method and provided nutritional as well as functional status in our dialysis patients. We conclude that, in our experience, bioimpedance analysis and subjective global assessment are simple tools and are complimenary to anthropometry for nutritional assesment in dialysis patients.
ASST Valle Olona UO Nefrologia e Dialisi, Italy
Title: Nonconvulsive status epilepticus due to fentanyl intoxication in hemodialysed patients: two case reports and review of the literature
Time : 12:40-13:10
Daniela Pogliani has completed her MD from Università Milano-Bicocca, Milan and Postdoctoral studies from the same university. She is specialized in Nephrology. She currently works in a Nephrology and Dialysis Unit in a Public Hospital, Gallarate, Italy. She has been co-author of up to 11 papers in reputed journals and is a Member of the Editorial Board of the Giornale Italiano di Nefrologia.
The management of the pain therapy (ischemic pain, neoplastic pain) in hemodialysis patients has become a frequent challenge in the last years. These patients often require the prescription of major analgesic drugs such as opioids like Fentanyl, in order to control the pain. It is necessary to pay attention to the correct dosage and to the half-life of these drugs that results prolonged in the chronic renal insufficiency. The main side effect of opioids is respiratory depression and is well known, but to date in the literature reports about other less frequent side effects, like epilepsy or status epilepticus are lacking. We report two cases of chronic hemodialysed patients who developed a generalized non-convulsive status epilepticus secondary to fentanyl intoxication administered for the pain therapy. These cases required a synergic team management implicating the nephrologists, the neurologist and the intensivist. The generalized non-convulsive status epilepticus could be an important and serious side effect of fentanyl in hemodialysis patients and it is therefore necessary a sharp monitoring of the pain therapy in these subjects.
Uwajima City Hospital, Japan
Koji Nagatani was graduated from Hamamatsu University, School of Medicine, Shizuoka, Japan in 1998 and belonged to Ehime University Graduate School of Medicine, Department of Pediatrics. He is a Member of The Japanese Society for Pediatric Nephrology, Japanese Society of Nephrology, International Pediatric Nephrology Association and International Society of Nephrology. He is the Director of Department of Pediatrics, Uwajima City Hospital, Japan.
Wilms’ tumor suppressor gene 1 (WT1) mutations are found in Denys-Drash syndrome, Frasier syndrome and isolated diffuse mesangial sclerosis; these mutations lead to the occurrence of diffuse mesangial sclerosis (DMS) and focal segmental glomerulosclerosis. Nephrotic syndrome (NS) caused due to DMS is unresponsive to drug therapy and is characterized by rapid progression to end-stage renal disease. Here, we report a case of a 3 years and 5 months old girl with NS caused due to DMS who responded favorably to cyclosporin A (CsA) and angiotensin-I converting enzyme inhibitor (ACE-I). The light microscopic findings of the renal biopsy before CsA therapy revealed the early stage of DMS, which showed small glomerulus with diffuse mesangial matrix increase and mesangial hypercellularity and hyperplastic podocytes. However, prominent epithelial proliferation was not found in the specimen. CsA therapy induced a dose-dependent decrease in her urinary protein/creatinine ratio and resulted in partial remission of NS and maintenance of normal renal function for over 3 years. The second biopsy at 3 years old revealed the improvement on the light microscopic findings. CsA may be effective for DMS with WT1 mutations, if therapy is started before creatinine levels increase and in the early stage of DMS. In children with WT1 mutation, CsA therapy may prevent prompt progression to end-stage renal disease.
Kidney Care Hospital & Research Centre Udaipur, India
Sonia Gupta has completed her medical education along with the specialization in nephrology from Institute of Kidney Diseases in Ahmedabad, India. At present she runs her own kidney hospital kidney care hospital & research center Udaipur. She has more than 15 publications to her credit and tries to focus on delivering affordable quality nephrology care to her patients.
Background: In critically ill patients with AKI, unacceptably high mortality rates reaching up to 50-80% in all dialyzed ICU patients are seen despite the availability of intensive renal support. At present there is no specific or targeted therapy for AKI. The exact molecular pathophysiology of AKI is complex and also multifactorial. Ulinastatin is a multifunctional Kunitz type serine protease inhibitor; it has been shown to exhibit significant renoprotective effects in various models of mechanical and chemical injury.Our premise regarding the use of molecule in AKI was based on the fact that this molecule acts at multiple levels in the sepsis conundrum and can act to stop the cascade and thereby halt the “storm”.
Aim: The aim of our study, done in a semi urban nephrology set up, was to find out if using ulinastatin in patients with AKI has any beneficial result on the outcomes in patients with AKI. Ours is a retrospective comparative study done in patients with AKI who were critically ill.
Method: We studied a total of 280 patients with AKI who needed ICU care in our hospital in the period between May 2012- Dec 2015. Out of these, 140 patients received Injection ulinastatin 3 doses a day for 5 days, against a similar number of control patients. We included those patients with AKI who had SOFA scores more than 8. We recorded the age and the etiologies of the patients. We recorded the length of stay, need and duration of renal replacement therapy, time to stoppage of renal replacement therapy, need for mechanical ventilation, mortality and post AKI recovery and progression to CKD.
Results: The patients who received ulinastatin had a shorter stay in the ICU (p <0.01 vs control group); also the time to stoppage of renal replacement therapy was shorter (p < 0.05). The recovery to renal function was seen in 84% (n=118). The progression to CKD was seen in 11% (n=10; 20 in control group), of patients .The average number of sittings of dialysis needed were 11 (range3-20), less number of dialysis were needed in the ulinastatin group .The overall mortality was 26 %( n=72, 39 in the control group).
Yokohama City University Medical Center, Japan
Shinnosuke Kuroda was graduated from Yokohama City University School of Medicine. He has worked at Ohguchi Higashi General Hospital in Japan from 2014 to 2015. He has published more than 10 papers about male infertility and urolithiasis.
Objectives: To compare outcomes of retrograde intrarenal surgery for urolithiasis between patients with solitary kidneys and patients who have single-side urolithiasis with bilateral kidneys.
Methods: We retrospectively analyzed outcomes of retrograde intrarenal surgery in solitary kidney patients (group A) carried out during 2007-2014 and in patients with bilateral kidneys with comparable stone burdens (group B). Stone-free status was defined as no residual fragment on computed tomography 1 month later.
Results: There were 19 patients in group A (mean age 62.5±18.4 years, range 14-76 years). The mean stone diameter and burden were 6.0 mm (range 3-24 mm) and 10.42±6.92 mm, respectively. The stone-free rate was 94.7% and no repeat procedure was required. The glomerular filtration rate tended to rise post-surgery (postoperative day-1: 48.67±15.92 mL/min, 100.2%, P=0.940; postoperative month-1: 51.32±16.90 mL/min, 105.7%, P=0.101) compared with preoperative rates. The stone-free rate and surgery time were not significantly different between the two groups, although post-surgical hospitalization time was longer for group A (4.05 vs. 3.08 days, P=0.037). The change in glomerular filtration rate was not significantly different between groups A and B (postoperative day-1: +0.101 vs. +0.547 mL/min, respectively, P=0.857; postoperative month-1: +2.749 vs. 3.161 mL/min, respectively, P=0.882). No significant difference was found in terms of complication rate.
Conclusions: Retrograde intrarenal surgery in solitary kidney patients is as safe and effective as in bilateral kidney patients.
Haute Ecole de Santé Vaud, Switzerland
Title: The impact of a multidisciplinary self-care management program on quality of life, self-care, adherence to anti-hypertensive therapy, glycemic control and renal function in diabetic kidney disease: A cross-over study
Time : 15:40-16:10
Nancy Helou is an Associate Professor in Nursing Sciences at University of Health Sciences, University of Applied Sciences and Arts of Western Switzerland (HES-SO). She has completed her PhD in Nursing Sciences from the University of Lausanne, Switzerland. She holds a Master of Science degree in Nutrition and Dietetics from the American University of Beirut. She has started her academic career in 2004 as a Research Assistant and became an Associate Professor in 2016. She has also build a clinical career as a Cardiac Intensive Care Nurse for four years before becoming a Quality Nurse Manager ensuring Joint Commission Accreditation and Magnet Designation. She is currently interested in clinical research areas and interdisciplinary work. Her research emphasizes on chronic diseases prevention and management and patient self-management.
Diabetic Kidney Disease (DKD) is a global health concern that is associated with high morbidity and mortality. Patients with DKD are expected to manage their daily self-care activities. Patients’ non-adherence to treatment regimen is thought to be the major cause for the poor control and the occurrence of complications. Previous research has shown that multidisciplinary management of DKD can improve patient outcomes. The effect of nurse-led multidisciplinary self-care management on Quality of Life (QoL), self-care, adherence to antihypertensive therapy, glycemic control and renal function of patients with DKD is not yet well established. The aim of this study was to investigate the effect of a nurse-led Multidisciplinary Self-care Management Program (MSMP) on QoL, self-care behavior, adherence to anti-hypertensive therapy, glycemic control and renal function of adults with DKD. A uniform balanced cross-over design was used with 32 participants randomized into four study arms. Cross-over designs allow efficient comparison of treatments when recruiting fewer participants and attaining the same level of statistical power as randomized controlled trials. It is for use more importantly in chronic diseases for comparison of participants’ responses to different treatments. Each participant receives treatment and serve of own control thus, overcoming the mixed effects related to heterogeneity of co-morbidities when comparing two different groups. The uniform strongly balanced design represents the ideal cross-over because it overcomes the statistical bias of carry-over effect. Each participant received twice, at different time intervals and over 12 months, three months of Usual Care (UC) alternating with three months of MSMP. QoL was evaluated using the Audit of Diabetes-Dependent QoL scale, patient self-care behavior was measured using the Revised Summary of Diabetes Self-Care Activities and adherence to anti-hypertensive therapy was assessed using the Medication Events Monitoring System (MEMS). Blood glucose control was measured by glycated hemoglobin (HbA1c) levels and renal function by serum creatinine, estimated glomerular filtration rate and urinary albumin/creatinine ratio. The present QoL was improved by MSMP with a higher mean rank (55.95) as compared to UC (42.19) (p<0.05, Confidence Interval (CI) of 95%). MSMP also improved the general diet habits, diabetes specific diet habits and blood sugar testing frequency demonstrating overall higher mean ranks as compared to UC (p<0.01, 95% CI, respectively 59.56 vs. 39.44, 59.98 vs. 37.02 and 57.75 vs. 40.43). Results of glycemic control and renal function did not show a significant difference between MSMP and UC. MEMS adherence overall percentage mean (n=21) over the 12 months, for UC and MSMP confounded was high (95.38%, Minimum=69%, Maximum=100%). The implementation of a nurse-led multidisciplinary self-care management program with a theory-based nursing practice improved general QoL and self-care activities of DKD patients.