Acute renal failure (ARF) occurs in wide range of conditions, making the evaluation of its prognosis a difficult task. Data regarding prognostic factors in ARF in a general population in developing countries are scarce. The objective of the study was to describe predictors of mortality in ARF that are relevant in the developing world. This prospective study was carried out over a one-year period; all hospitalized adults with ARF were included in the study. Predictors of mortality studied included causes of ARF, pre-existing diseases, and severity as well as complications of ARF. Of 33,301 patients admitted during the study period, 294 (0.88%) were either admitted with or developed ARF after hospitalization. Mean age was 43.9 ± 16.9 (18-86 yrs). Sepsis was the most common cause (63.26%). Pre-existing diseases like cardiovascular disease (CVSD), respiratory system disease (RSD), central nervous system disease (CNSD), hypertension, diabetet mellitus (DM), and malignancy were significantly higher in elderly as compared to younger patients. On univariate analysis sepsis, hypoperfusion as a cause of ARF and hospital-acquired ARF were associated with higher mortality. Pre-existing diseases viz. RSD, CVSD, CNSD, and DM had higher mortality. Among the severity and complications of ARF, oliguria, bleeding and infection during the course of ARF and critical illness were predictors of poor outcome. Age >60 yrs was associated with significantly higher mortality. However, on multivariate analysis, only critical illness (odds ratio 37.3), age > 60 years (odds ratio of 5.6), and sepsis as cause of ARF (odds ratio of 2.6) were found to be independent predictors of mortality.

Kidney biopsy plays an important role in the diagnosis and management of several renal diseases. There is a general reluctance to perform kidney biopsy in elderly due to fear of complications. There is no prospective head to head trial comparing complications of percutaneous kidney biopsy in elderly versus young. This prospective study was undertaken to know the frequency and type of biopsy related complications in elderly. Biopsy was performed using a spring loaded automatic 16 G biopsy gun. Post-biopsy, patients were confined to bed rest for 24 h. A record of intraprocedural problems and post-procedural complications was kept. A total of 210 native kidney biopsies were done of which 26 were performed in elderly patients (61-78 years). Co-morbid conditions were present in 17 patients, some having more than one, hypertension (11), diabetes mellitus (5), chronic obstructive airway disease (6), interstitial lung disease (2) and coronary artery disease (2). Mean serum creatinine was 5.6 mg/dl (range 0.8-14.1 mg/dl). Pre-biopsy dialysis was given to 10 patients. Adequate tissue for histopathological diagnosis was seen in 24 out of 26 biopsies. In two elderly patients biopsy had to be abandoned though indicated due to inability to hold the breath because of underlying lung and cardiac disease. Clinico-pathologic discorrelation was seen in eight patients. Incidence of gross hematuria was more in elderly than in young (4/26 vs. 7/184 P<0.01). Hematuria subsided within 1-2 days in three, one had persistent hematuria for 1 week. Other complications viz. gross hematuria with need of blood transfusions or hemodynamic compromise (0/26 vs. 4/184), perinephric hematoma (0/26 vs. 1/184) and need of intervention (0/26 vs. 1/184) were not higher in the elderly. We conclude that the standard precautions kidney biopsy in elderly is a safe procedure.

Evaluation of body composition provides clinically useful information in several diseases including chronic kidney disease. Bioimpedance analysis (BIA) is a simple, cheap, and noninvasive tool for monitoring body composition. We performed BIA in 451 healthy adults and 162 end-stage renal disease (ESRD) patients. Resistance (R) and reactance (Xc) values were obtained at 50-kHz frequency using a tetrapolar impedance meter. Body compartments were derived using population-specific regression equations. Phase angles (arctan Xc/R) were calculated and impedance vector distribution was determined using the RXc graph method. Compared to healthy population, ESRD patients had similar post-dialysis resistance with lower reactance and phase angle, indicating decreased soft tissue mass and inadequate ultrafiltration. BIA equations estimated decreased fat mass index and intracellular water, whereas the total body and extracellular water percentages were increased. Sex-specific reference RXc plots with 95, 75, and 50% tolerance ellipses were drawn for the healthy population. A significant difference was noted in the vector positions and 95% confidence ellipses of the two sexes and body mass indices of 25. In conclusion, we present the reference BIA parameters for Indian population. ESRD patients show significant body compartment alterations. The RXc score graph can differentiate ESRD patient from normal controls and can be used to monitor nutrition and hydration status.

Uremia is a state of heightened inflammatory activation. This might have an impact on several parameters including anemia management. Inflammation interferes with iron utilization in chronic kidney disease through hepcidin. We studied the body iron stores, degree of inflammatory activation, and pro-hepcidin levels in newly diagnosed patients with end-stage renal disease (ESRD), and compared them with normal population. In addition to clinical examination and anthropometry, the levels of iron, ferritin, C-reactive protein, tumor necrosis factor alfa, interleukin-6, and prohepcidin were estimated. A total of 74 ESRD patients and 52 healthy controls were studied. The ESRD patients had a significantly lower estimated body fat percentage, muscle mass, and albumin; and higher transferrin saturation (TSAT) and raised serum ferritin. Inflammatory activation was evident in the ESRD group as shown by the significantly higher CRP, IL-6, and TNF-α levels. The pro-hepcidin levels were also increased in this group. Half of the ESRD patients had received parenteral iron before referral. Patients who had received intravenous iron showed higher iron, ferritin, and TSAT levels. These patients also showed more marked inflammatory activation, as shown by the significantly higher CRP, TNF-α, and IL-6 levels. We conclude that our ESRD patients showed marked inflammatory activation, which was more pronounced in patients who had received IV iron. High hepcidin levels could explain the functional iron deficiency. The cause of the relatively greater degree of inflammatory activation as well as the relationship with IV iron administration needs further studies.

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