In the past vascular surgeons were called in to place tunneled central venous catheter (TVC) for hemodialysis patients. Advent of percutaneous technique has resulted in an increasing number of interventional nephrologists inserting it. A single centre three year audit of 100 TVCs with a cumulative follow up of 492 patient months is presented here. From 2007 to 2010, 100 TVCs were placed by nephrologists in a percutaneous fashion in the operative room or the interventional nephrology suite. Those who completed minimum of three months on the catheter were included in analysis. There were 69 males and 31 females with a mean age of 52.3±13.6 years.(range: 25-76). Chronic glomerulonephritis was the commonest cause of CKD (45%) followed by diabetes (39%).Right internal jugular vein was the preferred site (94%). TVC was utilized as the primary access to initiate dialysis in 25% of patients in whom a live donor was available for renal transplant. The blood flow was 250-270 ml/min. The Kaplan-Meier analysis showed that 3 months and 6 months catheter survival rates were 80% and 55%, respectively. The main complications were exit site blood ooze, catheter block and kink. Catheter related bacteremia rate was low at 0.4/1000 patient days. Primary cause of drop out was patient death unrelated to the TVCs. Those under the age of 40 years showed better survival, but there was no bearing of gender, catheter site, and etiology of CKD on survival. Tunneled central venous catheters could find a niche as the primary access of choice for pretransplant live donor renal transplants in view of its immediate usage, high blood flows, low infection rates and adequate patency rates for 3-6 months.

No abstract

Systemic vasculitides (SV) are a group of diseases with multi system involvement and varied clinical presentation. Anti-neutrophil cytoplasmic antibody (ANCA) testing has high sensitivity and specificity for SV. We describe the clinical course of four patients who had pauci-immune glomerulonephritis with systemic involvement without serological ANCA positivity; they were followed up for a cumulative 55 patient months. The mean Birmingham vasculitis score score was 23. All four had systemic symptoms with arthralgias and fever (100%). Neurological manifestations were seen in two patients (66%). Accelerated hypertension was seen in one. One patient had pulmonary renal syndrome. Renal manifestation was characterized by nephrotic range of proteinuria with glomerular hematuria in all (100%) and severe renal failure requiring dialysis in three (66%). At admission the mean blood urea was 146 ± 19 mg% and mean serum creatinine was 5.6 ± 1.9 mg%. Renal biopsy revealed focal proliferative glomerulonephritis with crescents only in 20-30% of glomeruli. There was significant chronic interstitial involvement in two patients (66%). Therapy with pulse steroids, cyclophosphamide, and mycophenolate mofetil (MMF) was effective in three patients while one died with lung hemorrhage. In conclusion, majority of patients with ANCA negative pauci-immune glomerulonephritis have multi-system involvement at admission. Renal biopsy is characterized by focal proliferative lesions with crescents and significant chronic interstitial fibrosis. Immunosuppressive drugs in the form of corticosteroids, MMF and cyclophosphamide bring about marked renal recovery in most patients.

A variety of skin infections are encountered in postrenal transplant setting. Though bacterial and fungal infections are more common, surprises are in store for us sometimes. We describe a patient who underwent renal transplant two years ago, presenting with a painless, mildly pruritic expanding skin rash over abdomen. Histological examination of the skin biopsy showed that stratum corneum had multiple burrows containing larvae and eggs of Sarcoptes scabiei. The patient was treated with ivermectin 12 mg weekly once for 2 doses along with topical 5% permethrin and permethrin soap bath. There was remarkable improvement in the skin lesions with complete resolution in two weeks. Norwegian or crusted scabies is caused by massive infestation with Sarcoptes scabiei var. hominis. It can be rarely encountered in the post-transplant setting, which underscores the importance of early diagnosis and treatment before secondary bacterial infection sets in.

The incidence of acute kidney injury (AKI) after cardiac surgery remains high. The nonspecific adenosine receptor antagonist aminophylline has been shown to confer benefit in experimental and clinical acute renal failure (ARF) due to ischemia, contrast media, and various nephrotoxic agents. We conducted a prospective open label trial to assess the effectiveness of aminophylline for prevention of renal impairment after cardiac surgery. One hundred and thirty-eight patients undergoing cardiac surgery were risk stratified as per Cleveland score to assess for prediction of AKI. Sixty-three patients received a bolus aminophylline of 5 mg/kg and a subsequent continuous infusion of 0.25 mg/kg/h for up to 72 h, while 75 patients received usual postoperative care. Serum creatinine concentrations were measured preoperatively and daily until day 5 after surgery and the glomerular filtration rate estimated using Cockcroft and Gault formula. Hourly urine output was recorded and patients assigned to respective RIFLE stage of AKI. Cleveland score ≥6 was associated with higher incidence of AKI: I and F (P<0.005). Number needed to treat, an insight into the clinical relevance of a specific treatment, is 8. These results suggest that the perioperative use of aminophylline infusion is associated with lower incidence of deterioration in renal function following cardiac surgery in high-risk patients.