Non-diabetic renal disease in patients with type-2 diabetes mellitus

Diabetic nephropathy (DN) is the leading cause of end-stage renal disease in diabetics worldwide, yet most patients with type-2 diabetes mellitus are not formally evaluated with a renal biopsy. The diagnosis is almost always based on clinical grounds. A wide spectrum of non-diabetic renal disease (NDRD) is reported to occur in patients with type-2 diabetes. It has been estimated that up to one-third of all diabetic patients who present with proteinuria are suffering from NDRD. The aim of this analysis was to evaluate the prevalence and etiology of NDRD in patients with type-2 diabetes. We retrospectively reviewed the medical records of patients with type-2 diabetes who underwent kidney biopsy on clinical suspicion of NDRD (absence of diabetic retinopathy and/or neuropathy; short duration of diabetes, i.e. less than five years) from January 2003 through December 2007 at the Aga Khan University Hospital, Karachi. Based on the biopsy findings, patients were grouped as Group-I, isolated NDRD; Group-II, NDRD with underlying DN; and Group-III, isolated DN. Of 68 patients studied, 75% were males and the mean age was 56 years. The mean duration of diabetes was nine years. Group-I included 34 patients (52%), Group-II included 11 patients (17%) and Group-III included 23 patients (31%). Among the Group-I patients, the mean age was 56 years (41-77 years). The most common NDRDs were acute interstitial nephritis (32%), diffuse proliferative glomerulonephritis (17%); membranous nephropathy (12%) and crescentic glomerulonephritis (12%). Among Group-II, the mean age was 60 years (46-71 years), and the most common lesion was interstitial nephritis superimposed on underlying DN (63% cases). Among Group-III, the mean age was 53 years (42- 80 years). The mean proteinuria was 5, 6.3 and 7.3 g/24 h of urine collection in Groups I, II and III, respectively (P = NS). The mean duration of diabetes was 7.3, 11.7 and 10.7 years in Groups I, II and III, respectively. The duration of diabetes was significantly less in Group-I compared with Group-II and Group-III (P = 0.04). Our study suggests that the prevalence of NDRD (either isolated or superimposed on underlying DN) is high in appropriate clinical settings. Performing renal biopsy in diabetics with no extrarenal end organ damage other than nephropathy helps to diagnose and treat NDRD. This is the first report from Pakistan documenting the prevalence of NDRD in patients with type-2 diabetes

Space-filling, multi-fractal, localized thermal spikes in silicon, germanium and zinc oxide

The mechanism responsible for the emission of clusters from heavy ion irradiated solids is proposed to be thermal spikes. Collision cascade-based theories describe atomic sputtering but cannot explain the consistently observed experimental evidence for significant cluster emission. Statistical thermodynamic arguments for thermal spikes are employed here for qualitative and quantitative estimation of the thermal spike-induced cluster emission from silicon, germanium and zinc oxide. The evolving cascades and spikes in elemental and molecular semiconducting solids are shown to have fractal characteristics. Power law potential is used to calculate the fractal dimension.The fractal dimension is shown to be dependent upon the exponent of the power law interatomic potential. Each irradiating ion has the probability of initiating a space-filling, multi-fractal thermal spike that may sublime a localized region near the surface by emitting clusters in relative ratios that depend upon the energies of formation of respective surface vacancies.Comment: 16 pages, 6 figure

Spot urine protein: creatinine ratio versus 24 hour urine protein at various levels of GFR patients referred to a tertiary care hospital of Pakistan

OBJECTIVE: To determine the correlation of random single voided urine protein: creatinine ratio to twenty four hour urine protein at different levels of glomerular filtration rate (GFR) in Pakistani population. METHODS: A total of 107 patients were included in this cross section study. Patients were divided into five groups according to the GFR. Spot urine protein: creatinine ratio and 24 hour urine protein was measured by the standard methods. The correlation coefficient ( r) between the two was calculated in each group separately. RESULTS: The GFR in groups 1 to 5 was \u3e or =90, 60-89, 30-59, 15-29, and /minute/1.73 m2 respectively. In group one correlation coefficient r was 0.96, in group two r was 0.81, in group three r was 0.94, in group four r was 0.82 and in group five r was 0.80. CONCLUSION: Random single voided urine protein: creatinine ratio may be used as an alternative to 24 hour urine collection for protein at all levels of GFR in Pakistani population

General practitioners\u27 knowledge and approach to chronic kidney disease in Karachi, Pakistan

Due to lack of adequate number of formally trained nephrologists, many patients with chronic kidney disease (CKD) are seen by general practitioners (GPs). This study was designed to assess the knowledge of the GPs regarding identification of CKD and its risk factors, and evaluation and management of risk factors as well as complications of CKD. We conducted a cross-sectional survey of 232 randomly selected GPs from Karachi during 2011. Data were collected on a structured questionnaire based on the kidney disease outcomes and quality initiative recommendations on screening, diagnosis, and management of CKD. A total of 235 GPs were approached, and 232 consented to participate. Mean age was 38.5 ± 11.26 years; 56.5% were men. Most of the GPs knew the traditional risk factors for CKD, i.e., diabetes (88.4%) and hypertension (80%), but were less aware of other risk factors. Only 38% GPs were aware of estimated glomerular filtration rate in evaluation of patients with CKD. Only 61.6% GPs recognized CKD as a risk factor for cardiovascular disease. About 40% and 29% GPs knew the correct goal systolic and diastolic blood pressure, respectively. In all, 41% GPs did not know when to refer the patient to a nephrologist. Our survey identified specific gaps in knowledge and approach of GPs regarding diagnosis and management of CKD. Educational efforts are needed to increase awareness of clinical practice guidelines and recommendations for patients with CKD among GPs, which may improve management and clinical outcomes of this population

The role of the C

A model has been developed that illustrates C60’s emergence from the condensing carbon vapour. It is shown to depend upon (i) the decreasing heats of formation for larger cages; (ii) exponentially increasing number of isomers for fullerenes that are larger than C60; (iii) large cages’ buckling induced by the pentagon-related protrusions that initiate fragmentation; (iv) the structural instability-induced fragmentation that shrinks large cages via Cx → Cx−2 + C2; and (v) an evolving gas of C2 that is crucial to the whole process. The model describes a mechanism for the provision and presence of plenty of C2s during the formation and fragmentation processes. Fullerenes portrayed as 3D rotors have partition functions describing ensemble’s entropy as a function of the fragmentation sequence. The bottom-up formations of large cages followed by the top-down cage shrinkage are shown to be stable, dynamical processes that lead to the C60 dominated fullerene ensemble

A case of Gitelman syndrome with severe hyponatraemia and hypophosphataemia

Gitelman syndrome (GS) is a renal tubular disorder of the thiazide-sensitive sodium chloride cotransporter, which is located in the distal tubule of the loop of Henle. We present a rare case of GS complicated by severe hyponatraemia and hypophosphataemia. A 17-year-old boy was admitted to our institution with fever and lethargy. The workup revealed typical features of GS, i.e. hypokalaemia, hypomagnesaemia and metabolic alkalosis. In this report, we discuss the differential diagnoses and rationale for accepting GS as the most likely diagnosis. This case was complicated by severe hyponatraemia (115 mmol/L) and hypophosphataemia (0.32 mmol/L). We concluded that the syndrome of inappropriate secretion of antidiuretic hormones could not be ruled out and that respiratory alkalosis was the most likely aetiology of hypophosphataemia. This case report also generates an interesting discussion on water and electrolyte metabolism

A comparison of definitions (RIFLE, AKIN, AND KDIGO) of acute kidney injury for prediction of outcomes in adults after isolated coronary artery bypass graft (CABG) surgery

Introduction: Acute kidney injury (AKI) occurs in as many as 40% of patients after cardiac surgery and is associated with an increased risk of mortality and morbidity, predisposes patients to a longer hospitalization, requires additional treatments, and increases the hospital costs. At present, there are three widely accepted consensus definitions providing uniform criteria for the diagnosis of AKI; RIFLE, AKIN and KDIGO. Each of these definition systems have their own benefits and limitations for predicting the degree of AKI as well as adverse outcomes (need for RRT, morbidity and mortality) in patients undergoing cardiac surgery. Having a standard definition for diagnosing and classifying AKI would enhance our ability to improve the management of patients and their clinical outcomes.The aim of this study is to compare the three AKI criteria (RIFLE (eGFR), AKIN and KDIGO) for their ability to predict all-cause mortality and morbidity after isolated CABG surgery in adult patients.Methods: A single center retrospective review was conducted on adults who had undergone isolated CABG surgery during January 2013- January 2017 at Aga Khan University Hospital Karachi, Pakistan. Patients with known chronic kidney disease or a baseline Serum Creatinine of \u3e1.1 and 1.3 mg/dL respectively for female and males were excluded. AKI was assessed on three definitions and estimated glomerular filtration rate (eGFR) was computed using standardized CKD-EPI-PK equations. Comparative ROC curves were built and Area under the Curve with sensitivity and specificity of each definitions were computed on percent change and the outcomes.Results: A total of 1508 patients were analyzed. Mean age of participants was 59.43 (±1.12) years and 82.6% were males. Patient with AKI were older and more likely to be diabetic and hypertensive. Their perfusion and cross clamp time and morbidities were higher than their counterpart. Incidence of AKI was 33.7%, 34.4% and 57.5% on AKIN, KDIGO and RIFLE (based on change in eGFR) respectively. Area under the curve for 30 day mortality was AKIN: [0.786 (0.764 to 0.806)], KDIGO: [0.796 (0.775 to 0.816)], and RIFLE [0.844 (0.825 to 0.862)]. However discrimination power for morbidity was \u3c0.7 and was undesirable.Conclusions: AKIN and KDIGO are comparable to estimate AKI, while RIFLE (eGFR based) definition though overestimates the incidence of AKI, however has excellent discriminatory power to predict mortality compared to other definitions. Since eGFR provides age and gender adjusted estimates of AKI rather absolute change in renal function over the course of recovery phase, it should be integrated for a subset of population undergoing surgical intervention

Double-positive Goodpasture\u27s syndrome with concomitant active pulmonary tuberculosis.

Anti-glomerular basement membrane (anti-GBM) disease usually presents as rapidly progressive glomerulonephritis, and, when accompanied with pulmonary hemorrhage, it is called Goodpasture\u27s syndrome. Anti-neutrophilic cytoplasmic antibodies (ANCA) may co-exist with anti-GBM antibodies. In most of these double positive cases, ANCA is specific for myeloperoxidase (p-ANCA). We report a rare case of a critically ill patient c-ANCA-associated double-positive Goodpasture\u27s syndrome with concomitant tuberculosis that was successfully treated with immunosuppression, plasmapheresis and anti-tuberculous therapy (ATT). A 32-year-old gentleman with a 15 pack-year smoking history presented with massive hemoptysis, respiratory failure and oliguria. Laboratory investigation revealed anemia, elevated creatinine and active urinary sediment. Chest X-ray revealed bilateral pulmonary infiltrates. Broad-spectrum antibiotics and intravenous corticosteroids were started. Bronchoscopy showed alveolar hemorrhage and smears from bronchial lavage from both lungs were positive for acid fast bacillus (AFB). Vasculitis work-up revealed high titers of c-ANCA and anti-GBM antibodies. Kidney biopsy revealed crescents in \u3e50% glomeruli on light microscopy. Immunofluorescence showed linear deposition of IgG and C3. The patient received pulse methylprednisone for three days followed by oral prednisone and ATT. In addition, he also underwent nine sessions of plasmapheresis. Oral Cyclophosphamide was added on Day 10. The patient showed remarkable recovery as his lung fields cleared and his kidney function got stabilized. Cyclophosphamide was continued for three months and then switched to azathioprine. At six months, the creatinine is 1.2 mg/dL, with minimal proteinuria and a normal chest X-ray. To the best of our knowledge, this is the only reported case of double-positive Goodpasture\u27s syndrome (c-ANCA and anti GBM) with active tuberculosis treated successfully

Charlson Comorbidity Index for Prediction of Outcome of Acute Kidney Injury in Critically Ill Patients

Introduction: This study aimed to determine predictors of outcomes in critically ill patients with acute kidney injury (AKI), and to study the impact of the Charlson Comorbidity Index (CCI) as a prognostic indicator. MATERIALS AND Methods: This retrospective study included critically ill patients who were admitted with AKI or developed AKI during their hospital stay. The impact of comorbidity was evaluated by the CCI, while severity of AKI was assessed by the RIFLE criteria. Results: The mean age of 786 patients with AKI was 59.0 ± 17.0 years (59% men). The most common cause was sepsis in 51% of the patients. In-hospital mortality rate was 42%. The need for mechanical ventilation (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.23 to 3.04), vasoactive drugs (OR, 9.67; 95% CI, 6.35 to 14.73), dialysis (OR, 1.78; 95% CI, 1.14 to 2.78), failure class of RIFLE criteria (OR, 2.02; 95% CI, 1.00 to 4.08), and a CCI greater than 6 (OR, 2.20; 95% CI, 1.38 to 3.52) were independently associated with mortality. At 90 days of follow-up, 6% of the patients were dialysis dependent, while 32% and 62% had partial and complete recovery, respectively. In multivariable analysis, a CCI greater than 6 (OR, 0.47; 95% CI, 0.26 to 0.83), need for dialysis in hospital (OR, 0.31; 95% CI, 0.17 to 0.54), and failure class (OR, 0.19; 95% CI, 0.07 to 0.55) were independent predictors of poor renal outcomes. CONCLUSIONS: The CCI independently predicts in-patient mortality and poor renal outcomes in patients with AKI