It is well known that chronic kidney disease (CKD) is associated with significant morbidity and mortality, predominantly due to cardiovascular complications. Recent literature report pulmonary hypertension (PH) as a common accompaniment of CKD and in majority of these cases, secondary causes of PH are not evident. In this study, we looked at the prevalence and possible risk factors of PH in stage 5 CKD patients with a special focus on unexplained PH. In this cross-sectional study, 100 stage 5 CKD patients [50 each on maintenance hemodialysis (HD) and conservative management] were included. After baseline investigations participants underwent two-dimensional transthoracic echocardiogram. The routine method of PH diagnosis based on modified Bernoulli’s formula was complemented with an alternate method based on pulmonary artery acceleration time (PAAT). Detailed workup for secondary causes was carried out in patients with PH. The prevalence of PH in the study population was 89% (56% mild, 35% moderate, and 9% severe). Asymptomatic left ventricular diastolic and systolic dysfunction were noted in 54% and 20%, respectively. Significant association with PH was found with the duration of CKD, systolic and diastolic Blood pressure, hemoglobin, transferrin saturation, maintenance HD, and dialysis vintage. In sharp contrast to the existing data this study showed a very high prevalence of PH though severe PH was present only in 9%. The inclusion of PAAT-based method enabled the detection of more cases of PH. Further evaluation carried out for common secondary causes did not show significant abnormalities except for a sizeable proportion with asymptomatic left ventricular dysfunction.
pressure 138AE22 mm Hg, diastolic blood pressure 87AE12 mm Hg, serum creatinine 2.23AE1.85 mg/dl, serum albumin 3.7AE0.7 gm/dl and proteinuria 3.74AE2.92 gm/day. Twenty-nine (49%) received reninangiotensin-aldosterone system (RAAS) blocking agent at baseline which increased to 47 (89%) at last follow up. Forty-six (87%) received intensive immunosuppression (steroid and cyclophosphamide: 42, steroid and Mycophenolic acid: 3, steroid and azathioprine:1), 7 (13%%) received only steroid. The duration of follow up was 45.2AE33.7 months. Four (7.5%) reached the primary endpoint of doubling of serum creatinine or initiation of dialysis. The Δ systolic BP was-4.7AE26.4 mm Hg, Δ diastolic BP was-2.64AE15.1 mm Hg, ΔUP was-2.44AE2.9 gm/day, ΔSCr was-0.28AE1.97 and ΔSAlb was+0.34AE0.6 gm/ dl. Most patients tolerated immunosuppression well and there were no serious side effects when monitored closely. Conclusions: Intense immunosuppression with steroid and additional cytotoxic agent resulted in stabilization of renal function and decrease in proteinuria in most cases and progression of IgA nephropathy was seen in only 7.5% at a mean follow up period of 45 months. Our results indicate that intense immunosuppression monitored carefully may have substantial benefit in terms of retarding progression of IgA nephropathy. Strengths: Ours is one of the few studies that has analysed the effect of intense immunosuppression on the progression of IgA Nephropathy for a longer period. Limitations: Small sample size and lack of control group who did not receive immunosuppression for comparison.
Symmetrical peripheral gangrene (SPG) is a rare but well-described condition characterized by ischemic changes in the distal limbs with preserved flow in the major vessels. It results from thrombosis of the microcirculation resulting from a complex interplay of infectious and non-infectious factors. Often described as a complication of disseminated intravascular coagulation (DIC), it has got multiple aggravating factors. Timely recognition and management is important as significant residual disability is noted in surviving patients. Here, we describe a patient with chronic kidney disease on maintenance hemodialysis presenting with SPG associated with spontaneous bacterial peritonitis and DIC. She had multiple aggravating factors such as hypotension, use of inotropes, and renal failure. As there were no evidence-based guidelines and since the general condition of the patient was poor, she was managed with supportive care.
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