Paying for Hemodialysis in Kerala, India: A Description of Household Financial Hardship in the Context of Medical Subsidy.

INTRODUCTION: Many low- and middle-income countries are implementing strategies to increase dialysis availability as growing numbers of people reach end-stage renal disease. Despite efforts to subsidize care, the economic sustainability of chronic dialysis in these settings remains uncertain. We evaluated the association of medical subsidy with household financial hardship related to hemodialysis in Kerala, India, a state with high penetrance of procedure-based subsidies for patients on dialysis. METHODS: Patients on maintenance hemodialysis at 15 facilities in Kerala were administered a questionnaire that ascertained demographics, dialysis details, and household finances. We estimated direct and indirect costs of hemodialysis, and described the use of medical subsidy. We evaluated whether presence of subsidy (private, charity, or government-sponsored) was associated with lower catastrophic health expenditure (defined as ≥40% of nonsubsistence expenditure spent on dialysis) or distress financing. RESULTS: Of the 835 patients surveyed, 759 (91%) reported their households experienced catastrophic health expenditure, and 644 (77%) engaged in distress financing. Median dialysis-related expenditure was 80% (25th-75th percentile: 60%-90%) of household nonsubsistence expenditure. Government subsidies were used by 238 (29%) of households, 139 (58%) of which were in the lowest income category. Catastrophic health expenditure was present in 215 (90%) of households receiving government subsidy and 332 (93%) without subsidy. CONCLUSIONS: Provision of medical subsidy in Kerala, India was not associated with lower rates of household financial hardship related to long-term hemodialysis therapy. Transparent counseling on impending costs and innovative strategies to mitigate household financial distress are necessary for persons with end-stage renal disease in resource-limited settings

Malarial acute kidney injury

Malaria has emerged as one of the top killer among infectious diseases, in the World. It is a parasitic disease of epidemiological importance in tropical countries and Malaria associated Acute Kidney Injury (MAKI) is emerging as a big Nephrological issue. We conducted a retrospective descriptive study to determine the demographic profile, incidence, clinical feature and outcome of AKI due to Malaria in our institution from January 2010 to December 2014. Out of 138 Malaria positive cases the incidence of AKI was 15.7 %( 21). The main presenting features were fever (95.23%), Jaundice (23.8%), Vomiting (23.8%) and shortness of breath (14.28%) among MAKI cases. 9.5 %( 13) of cases MAKI required some form of Renal replacement therapy (RRT). Two patients were managed with Sustained low efficiency dialysis (SLED) and 11 with intermitted Haemodialysis (IHD). The prognosis of AKI in Malaria is favourable with high quality intensive care, early diagnosis and prompt initiation of RRTs along with antimalarial therapy and avoidance of nephrotoxic medications [Med-Science 2017; 6(2.000): 355-6

A prospective study of clinical presentation, need for hospitalisation, microbiology and outcome of urinary tract infections in diabetes mellitus

Background: Diabetics are more prone to infections than their non diabetic counterparts. The urinary tract is the most common site of infection in diabetes mellitus patients. Urinary tract infections (UTIs) most of the time in diabetic patients are relatively asymptomatic, which can lead to renal failure and severe kidney damage. A combination of local risk factors and host factors in diabetes mellitus lead to bacteriuria commonly compared to non diabetics. Objective: To evaluate clinical presentation, need for hospitalisation, microbiology and outcome of UTI in diabetes mellitus. Methods: This prospective, descriptive study was conducted at Kerala Institute of Medical Sciences, a tertiary level multispecialty hospital in South India to study the clinical profile of UTI (clinical presentation, need for hospitalisation, microbiological profile and outcome) in Diabetes mellitus; also to find out reasons for hospitalisation and for UTI in Diabetes mellitus. Results: Among study population, 24% patients were in age group of 30 to 50 years, 52% patients were in age group of 51 to 70 year, 13% were in 71 to 80 year group. 32% (32patients) had growth of E. coli in urine, 14% (14 patients) had growth of k. pneumonia, 10%(10 patients) had growth of proteus, 9% (9 patients) had growth of S. aureus, 5%(5 patients) had growth of C. perfringens, 5% (5 patients) had growth of candida, 4% (4 patients) had growth of pseudomonas and Enterococcus. 52% (52 patients) had sepsis as the reason for hospitalization, 32% (32 patients) had fever as the reason, and 14% (14 patients) had flank pain as the reason and 1 patient each had pelvic pain and vomiting as the reason for hospitalisation. 18% (18 patients) had renal dysfunction and 32% (32 patients) had proteinuria. Conclusion: UTI requiring hospitalization in Diabetes mellitus was more common after 50 years of age and equal in men and women. Diabetics are at risk of an increased susceptibility to infections of the urinary tract and occur with increased frequency and severity, and complications are more common

Recurrence of membranous nephropathy three weeks' postrenal transplant: A surprise in store

Membranous nephropathy (MN) may occur in the transplanted kidney, either as recurrent disease in patients who had MN as the cause of end-stage renal disease (ESRD) in the native kidney or de novo, in patients who had another cause of ESRD initially. The reported incidence of recurrent MN ranges between 10% and 45%. Clinical manifestations of recurrent MN are typically observed 13-15 months after transplantation, although they may be observed much earlier (within weeks). Our patient had a recurrence in three weeks. Recurrent disease can lead to loss of the allograft

Bile cast nephropathy causing acute kidney injury in a patient with nonfulminant acute hepatitis A

Hepatitis A is usually a benign self-limiting disease with few or no extrahepatic manifestations. Acute hepatitis A causing severe renal dysfunction is not very common, although described. Patients developing renal dysfunction post hepatitis A infection usually have prerenal acute kidney injury (AKI) or acute tubular necrosis due to vomiting, diarrhea, and poor fluid replacement. However, if renal dysfunction persists, other causes need to be evaluated. The term cholemic nephrosis or more specifically bile cast nephropathy has been described in the setting of cholestatic jaundice and decompensated liver failure where bilirubin levels reach above 20 mg/dL. Herein, we describe the clinical course of a patient who developed acute hepatitis A with severe liver dysfunction and subsequently AKI which persisted for six weeks. Renal biopsy showed the evidence of bile cast nephropathy. After six weeks of hemodialysis, urine output improved. He slowly recovered both hepatic and renal functions