Correlation of glycosylated hemoglobin with microalbuminuria to predict renal damage in diabetic patients

Background: Regular screening of levels of glycosylated hemoglobin and microalbuminuria, diabetic nephropathy can be prevented. The aim was to assess and compare the levels of glycosylated hemoglobin, microalbuminuria and serum creatinine in type 2 diabetic patients divided in groups of those on default antidiabetic treatment compared with those on regular antidiabetic treatment and to assess its correlation in type 2 of diabetic nephropathy. Methods:Two hundred diabetic patients above 40 years of age and 200 age matched control subjects with levels of glycosylated hemoglobin < 6.5% and on regular antiglycemic therapy were selected. Fasting plasma sugar was estimated by the glucose oxidase (GOD) - glucose peroxidase (POD). Glycosylated hemoglobin and microalbuminuria level was measured by the immunoturbidimetric method and serum creatinine estimation was done by the Jaffe’s kinetic method. p value was drawn using the student’s paired t-test. Results: There is a strong correlation between the increase in the levels of glycosylated hemoglobin with the corresponding rise in the levels of microalbuminuria and serum creatinine. Conclusion: Periodic surveillance of the levels of microalbuminuria should be carried out in the type 2 diabetic patients to prevent further damage by early detection of diabetic nephropathy.

Urinary bladder paraganglioma: a clinical dilemma in diagnosis and management: our experience at a tertiary care center

Urinary bladder paraganglioma (UBP) are rare neuroendocrine tumors with variable biological behavior. High index of suspicion in the preoperative evaluation would enable the clinician to formulate appropriate management of the rare tumors. Clinical and pathological data of seven cases evaluated and treated as per a devised protocol for suspected bladder paraganglioma from 2008 to 2019 was retrospectively reviewed. Among the seven cases, UBP’s were predominantly seen in middle aged men. Most of these presented with storage symptoms (85.71%; n=7) and gross painless hematuria (42.85%; n=3). Three patients were hypertensives and post-micturition syncope was seen in two patients. Among the seven patients two patients had functionally active tumors confirmed by elevated urinary and serum markers for catecholamine excess. Functional tumors, nonfunctional tumors involving uretero-vesical junction or broad based polypoidal tumor were considered for partial cystectomy. Other small nonfunctional tumors underwent trans-urethral resection of bladder tumour (TURBT). Follow up protocol included repeat ultrasound, check cystoscopy and completion TURBT at one month and annually thereafter. Repeat urinary catecholamines at 1 month was done in functional UBP. Cystoscopic examination of a bladder lesion which are solid, sessile and predominantly intramural, a prior to a definitive planned surgery may differentiate UBP from urothelial cancer. Most of the non-functional UPB are diagnosed by histopathological examination.  In symptomatic cases, functional evaluation with biochemical estimation of catecholamine excess allow better treatment planning and avoiding intraoperative hemodynamic instability. Due to high recurrence rate life-long follow-up despite complete excision is strongly recommended

Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lymphocyte-monocyte ratio (LMR) in predicting systemic inflammatory response syndrome (SIRS) and sepsis after percutaneous nephrolithotomy (PNL)

The objective of this prospective observational study was to assess the clinical significance of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lymphocyte-monocyte ratio (LMR) as potential biomarkers to identify post-PNL SIRS or sepsis. Demographic data and laboratory data including hemoglobin (Hb), total leucocyte count (TLC), serum creatinine, urine microscopy and culture were collected. The NLR, LMR and PLR were calculated by the mathematical division of their absolute values derived from routine complete blood counts from peripheral blood samples. Stone factors were assessed by non-contrast computerized tomography of kidneys, ureter and bladder (NCCT KUB) and included stone burden (Volume = L x W x D x pi x 0.167), location and Hounsfield value and laterality. Intraoperative factors assessed were puncture site, tract size, tract number, operative time, the need for blood transfusion and stone clearance. Of 517 patients evaluated, 56 (10.8%) developed SIRS and 8 (1.5%) developed sepsis. Patients developing SIRS had significantly higher TLC (10.4 +/- 3.5 vs 8.6 +/- 2.6, OR 1.19, 95% CI 1.09-1.3, p = 0.000002), higher NLR (3.6 +/- 2.4 vs 2.5 +/- 1.04, OR 1.3, 95% CI = 1.09-1.5, p = 0.0000001), higher PLR (129.3 +/- 53.8 vs 115.4 +/- 68.9, OR 1.005, 95% CI 1.001-1.008, p = 0.005) and lower LMR (2.5 +/- 1.7 vs 3.2 +/- 1.8, OR 1.18, 95% CI 1.04-1.34, p = 0.006). Staghorn stones (12.8 vs 3.24%, OR 4.361, 95% CI 1.605-11.846, p = 0.008) and long operative times (59.6 +/- 14.01 vs 55.2 +/- 16.02, OR 1.01, 95% CI 1.00-1.03, p = 0.05) had significant association with postoperative SIRS. In conclusion, NLR, PLR and LMR can be useful independent, easily accessible and cost-effective predictors for early identification of post-PNL SIRS/sepsis.Manipal Academy of Higher Education, Manipa

Multiple renal veins in donor nephrectomy-preoperative assessment of feasibility for safe and selective ligation

The aim of the study is to provide an objective preoperative assessment protocol by computerized tomography angiography by measuring the vein volume (πr2h) instead of the vein diameter for accurate size and blood flow assessment in case of multiple renal veins during donor nephrectomy. To reduce rewarm ischemia time, smaller renal veins were safely ligated without compromising drainage due to their robust intrarenal anastomotic communications. The selection of vein for safe ligation is crucial to avoid congestion and high intrarenal pressures in the allograft venous system and was made by calculating the vein volume. Application of this formula in 343 donors with multiple veins (2003–2021) has led to uneventful intra- and postoperative course. This method prevails over the existing subjective assessment techniques, thereby ensuring the best possible perfusion and drainage of the allograft

Acute Kidney Injury Post-Percutaneous Nephrolithotomy (PNL): Prospective Outcomes from a University Teaching Hospital

Acute Kidney Injury (AKI) after percutaneous nephrolithotomy (PNL) is a significant complication, but evidence on its incidence is bereft in the literature. The objective of this prospective observational study was to analyze the incidence of post-PNL AKI and the potential risk factors and outcomes. Demographic data collected included age, gender, body mass index (BMI), comorbidities (hypertension, diabetes mellitus), and drug history—particularly angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin II receptor blockers and beta blockers. Laboratory data included serial serum creatinine measured pre- and postoperation (12, 24, and 48 h), hemoglobin (Hb), total leucocyte count (TLC), Prothrombin time (PT), serum uric acid and urine culture. Stone factors were assessed by noncontrast computerized tomography of kidneys, ureter and bladder (NCCT KUB) and included stone burden, location and Hounsfield values. Intraoperative factors assessed were puncture site, tract size, tract number, operative time, the need for blood transfusion and stone clearance. Postoperative complications were documented using the modified Clavien–Dindo grading system and patients with postoperative AKI were followed up with serial creatinine measurements up to 1 year. Among the 509 patients analyzed, 47 (9.23%) developed postoperative AKI. Older patients, with associated hypertension and diabetes mellitus, those receiving ACE inhibitors and with lower preoperative hemoglobin and higher serum uric acid, had higher incidence of AKI. Higher stone volume and density, staghorn stones, multiple punctures and longer operative time were significantly associated with postoperative AKI. Patients with AKI had an increased length of hospital stay and 17% patients progressed to chronic kidney disease (CKD). Cut-off values for patient age (39.5 years), serum uric acid (4.05 mg/dL) and stone volume (673.06 mm3) were assessed by receiver operating characteristic (ROC) curve analysis. Highlighting the strong predictors of post-PNL AKI allows early identification, proper counseling and postoperative planning and management in an attempt to avoid further insult to the kidney