Renal replacement therapy in Nepal fulfills only a small part of the current needs, with 97 hemodialysis machines available for the general population of 29 million. Transportation difficulties to dialysis centers preclude many of the patients from end-stage renal disease care, due to the rural nature of the population. Peritoneal dialysis (PD) organized into rural sub segments, considering the Mexican model of PD and government funding appear to offer some solution to provision of care for this mountainous rural country. We review the current statistics of dialysis patients, hemodialysis numbers, and renal transplantations within Nepal and offer suggestions regarding possibilities for increasing renal care within the country.

Background: Vitamin D (25-hydroxyvitamin D; 25[OH]D) deficiency (VDD) is highly prevalent in chronic kidney disease. The aim of this study was to evaluate the effect of oral ergocalciferol supplementation on requirement of erythropoietin (EPO) and active vitamin D analogues, and hospitalization rate in maintenance hemodialysis (HD) patients.Methods: This retrospective cohort study included 186 patients who were on HD for 3 months and had 25(OH)D levels < 30 ng/ml. Over 1-year period, 107 patients were supplemented with protocol-based ergocalciferol (D 2 group) and 79 were not (control). Parameters of erythropoiesis and bone-mineral metabolism, and monthly doses of EPO and paricalcitol were assessed at 6-and 12-months of ergocalciferol supplementation. Total hospitalizations were recorded for the same year. Results: Baseline characteristics were similar across two arms except higher serum ferritin, transferrin saturation and prevalence of stroke in D2 and higher coronary artery disease in control group with overall mean ± SD 25(OH)D level of 16.8 ± 7 ng/ml. At 12 months, 25(OH)D levels increased significantly in D 2 group compared to control (30.5 ± 11.7 vs. 14.2 ± 9.3 ng/ml; p < 0.001). The EPO dose remained same with no difference in hemoglobin values between the two groups during the intervention period. On multivariate regression which included above variables there was no effect of ergocalciferol treatment on EPO dose (p = ns). Hospitalization rate was similar in two arms; however, ergocalciferol treatment inversely associated with paricalcitol dose (β ± SE = −10. 4 ± 2.8; p < 0.001). Conclusions: One-year of ergocalciferol supplementation was not associated with reduction in EPO requirement or hospitalization rate in HD patients with VDD. Further studies are warranted to determine definitive role of nutritional vitamin D in these patients.

In contrast to epidemiological data from the general population, maintenance hemodialysis (MHD) patients with a naturally small body size experience an increased mortality rate compared to their larger fellow patients. Since body mass index is a poor surrogate of body composition, attempts were made to delineate muscle, fat and visceral organ mass in MHD patients. Several lines of evidence indicate that (a) increased fat and muscle mass exerts protective effects, (b) some markers of inflammation may be increased with fat mass, and (c) a high visceral mass per body weight is associated with a reduced survival time. The reasons for the positive effects of fat and muscle mass on survival are not clear. A novel hypothesis predicts lower uremic toxin concentrations in larger subjects. This is based on the observation that both in healthy subjects and in dialysis patients, visceral organ mass is inversely related to body mass. Since visceral organs are the most prominent source of uremic toxins, large patients may have a lower toxin production rate per unit of body mass. Moreover, large patients have a greater volume of distribution (total body water, fat mass) resulting in lower toxin concentrations. Future studies should aim to tackle the Janus-like duality of obesity by a system biology approach.

In a relatively small cohort of clinically stable MHD patients, the veterans showed equivalent nutrition status and dietary intake and less inflammation than the nonveterans, thus not supporting the possibility that veteran MHD patients may have worse nutrition than the nonveteran counterpart.

Cocaine abuse is commonly associated with myocardial ischemia, mesenteric ischemia, and cerebrovascular accidents. Renal infarction is an uncommon complication of cocaine abuse. Various mechanisms have been postulated for this cocaine-related injury. There are only 15 cases reported on cocaine-induced renal infarction. Among the cases with available data, very few cases had left kidney involvement. We report a case of a 65-year-old African American man with history of cocaine abuse who presented with left flank pain and had left renal infarction.