Osmania General Hospital

BACKGROUND: Hypothyroidism is believed to be a common health issue in India, as it is worldwide. However, there is a paucity of data on the prevalence of hypothyroidism in adult population of India. MATERIALS AND METHODS: A cross-sectional, multi-centre, epidemiological study was conducted in eight major cities (Bangalore, Chennai, Delhi, Goa, Mumbai, Hyderabad, Ahmedabad and Kolkata) of India to study the prevalence of hypothyroidism among adult population. Thyroid abnormalities were diagnosed on the basis of laboratory results (serum FT3, FT4 and Thyroid Stimulating Hormone [TSH]). Patients with history of hypothyroidism and receiving levothyroxine therapy or those with serum free T4 <0.89 ng/dl and TSH >5.50 μU/ml, were categorized as hypothyroid. The prevalence of self reported and undetected hypothyroidism, and anti-thyroid peroxidase (anti-TPO) antibody positivity was assessed. RESULTS: A total of 5376 adult male or non-pregnant female participants ≥18 years of age were enrolled, of which 5360 (mean age: 46 ± 14.68 years; 53.70% females) were evaluated. The overall prevalence of hypothyroidism was 10.95% (n = 587, 95% CI, 10.11-11.78) of which 7.48% (n = 401) patients self reported the condition, whereas 3.47% (n = 186) were previously undetected. Inland cities showed a higher prevalence of hypothyroidism as compared to coastal cities. A significantly higher (P < 0.05) proportion of females vs. males (15.86% vs 5.02%) and older vs. younger (13.11% vs 7.53%), adults were diagnosed with hypothyroidism. Additionally, 8.02% (n = 430) patients were diagnosed to have subclinical hypothyroidism (normal serum free T4 and TSH >5.50 μIU/ml). Anti - TPO antibodies suggesting autoimmunity were detected in 21.85% (n = 1171) patients. CONCLUSION: The prevalence of hypothyroidism was high, affecting approximately one in 10 adults in the study population. Female gender and older age were found to have significant association with hypothyroidism. Subclinical hypothyroidism and anti-TPO antibody positivity were the other common observations.

Habibullah, C Mohammed; Syed, I Hassan; Qamar, Ayesha; Taher-Uz, Zaman Author Information

BACKGROUND: The role of crystalloid preloading to prevent hypotension associated with spinal anesthesia in parturients during cesarean section has been challenged. Direct measurement of blood volume should provide insight regarding the volume-expanding effects. The aim of the current study was to clarify the effects of volume preload with either crystalloid or colloid solution on the changes in blood volume of parturients undergoing spinal anesthesia for cesarean section. METHODS: Thirty-six healthy parturients scheduled for elective cesarean section during spinal anesthesia were allocated randomly to one of three groups receiving 1.5 l lactated Ringer's solution (LR; n = 12), 0.5 l hydroxyethylstarch solution, 6% (0.5 l HES; n = 12), and 1.0 l hydroxyethylstarch solution, 6% (1.0 l HES; n = 12), respectively. Blood volume and cardiac output were measured before and after volume preloading with indocyanine green (ICG), and the indocyanine green blood concentrations were monitored by noninvasive pulse spectrophotometry. RESULTS: After volume preload, the blood volume significantly increased in all three groups (P < 0.01). The volume of infused solution remaining in the vascular space in the LR, 0.5-l HES, and 1.0-l HES groups were 0.43+/-0.20 l, 0.54+/-0.14 l, and 1.03+/-0.21 l, respectively, corresponding to 28% of lactated Ringer's solution and 100% of hydroxyethylstarch solution infused. Significant increases in cardiac output were observed in the 0.5-l and 1.0-l HES groups (P < 0.01). A significant correlation between the percentage increase in blood volume and that of cardiac output was observed by volume preloading (r2 = 0.838; P < 0.001). The incidence of hypotension was 75% for the LR group, 58% for the 0.5-l HES group, and 17% for the 1.0-l HES group, respectively. CONCLUSIONS: The incidence of hypotension developed in the 1.0-l HES group was significantly lower than that in the LR and 0.5-l HES groups, showing that greater volume expansion results in less hypotension. This result indicates that the augmentation of blood volume with preloading, regardless of the fluid used, must be large enough to result in a significant increase in cardiac output for effective prevention of hypotension.

Abstract The hypoglycaemic activity of fenugreek seeds ( Trigonella foenum graecum ) in experimental animals and humans has been well documented. Fenugreek has been shown to reduce fasting and postprandial blood glucose levels in diabetic patients. However, it is not clear whether the improvement in glucose tolerance is due to the effect of fenugreek on the absorption or metabolism of glucose. A metabolic study was carried out, and diets with or without 25 g fenugreek were given randomly to 10 non‐insulin dependent diabetics, each for 15 days, in a crossover design. An intravenous glucose tolerance test (GTT) at the end of each study period indicated that fenugreek in the diet significantly reduced the area under the plasma glucose curve (AUC), half‐life, and increased the metabolic clearance rate. In addition, it increased erythrocyte insulin receptors. These results suggest that fenugreek can improve peripheral glucose utilization which contributes to an improvement in glucose tolerance. Thus, fenugreek may exert its hypoglycaemic effect by acting at the insulin receptor as well as at the gastrointestinal level.

Hyponatremia is an important and common clinical problem. The etiology is multifactorial. Hyponatremia may be euvolemic, hypovolemic or hypervolemic. Proper interpretation of the various laboratory tests helps to differentiate the various types of hyponatremia. Treatment varies with the nature of onset -acute or chronic, severity and symptoms. Normal saline forms the mainstay of treatment for hypovolemic hyponatremia while 3% NaCl and fluid restriction are important for euvolemic hyponatremia. Hypervolemic hyponatremia responds well to fluid restriction and diuretics. There have been several recent advances in the last year with revision in the guidelines for treatment and availability of vaptans. Judicious use of vaptans may help in treatment of hyponatremia.

A proliferation-inducing ligand (APRIL) is implicated in the pathogenesis of IgA nephropathy. Sibeprenlimab is a humanized IgG2 monoclonal antibody that binds to and neutralizes APRIL. Download a PDF of the Research Summary. In this phase 2, multicenter, double-blind, randomized, placebo-controlled, parallel-group trial, we randomly assigned adults with biopsy-confirmed IgA nephropathy who were at high risk for disease progression, despite having received standard-care treatment, in a 1:1:1:1 ratio to receive intravenous sibeprenlimab at a dose of 2, 4, or 8 mg per kilogram of body weight or placebo once monthly for 12 months. The primary end point was the change from baseline in the log-transformed 24-hour urinary protein-to-creatinine ratio at month 12. Secondary end points included the change from baseline in the estimated glomerular filtration rate (eGFR) at month 12. Safety was also assessed. Among 155 patients who underwent randomization, 38 received sibeprenlimab at a dose of 2 mg per kilogram, 41 received sibeprenlimab at a dose of 4 mg per kilogram, 38 received sibeprenlimab at a dose of 8 mg per kilogram, and 38 received placebo. At 12 months, the geometric mean ratio reduction (±SE) from baseline in the 24-hour urinary protein-to-creatinine ratio was 47.2±8.2%, 58.8±6.1%, 62.0±5.7%, and 20.0±12.6% in the sibeprenlimab 2-mg, 4-mg, and 8-mg groups and the placebo group, respectively. At 12 months, the least-squares mean (±SE) change from baseline in eGFR was −2.7±1.8, 0.2±1.7, −1.5±1.8, and −7.4±1.8 ml per minute per 1.73 m2 in the sibeprenlimab 2-mg, 4-mg, and 8-mg groups and the placebo group, respectively. The incidence of adverse events that occurred after the start of administration of sibeprenlimab or placebo was 78.6% in the pooled sibeprenlimab groups and 71.1% in the placebo group. In patients with IgA nephropathy, 12 months of treatment with sibeprenlimab resulted in a significantly greater decrease in proteinuria than placebo. (Funded by Visterra; ENVISION ClinicalTrials.gov number, NCT04287985; EudraCT number, 2019-002531-29.) QUICK TAKE VIDEO SUMMARYSibeprenlimab for IgA Nephropathy 02:07

Rickets is an important problem even in countries with adequate sun exposure. The causes of rickets/osteomalacia are varied and include nutritional deficiency, especially poor dietary intake of vitamin D and calcium. Non-nutritional causes include hypophosphatemic rickets primarily due to renal phosphate losses and rickets due to renal tubular acidosis. In addition, some varieties are due to inherited defects in vitamin D metabolism and are called vitamin D dependent rickets. This chapter highlights rickets/osteomalacia related to vitamin D deficiency or to inherited defects in vitamin D metabolism. Hypophosphatemic rickets and rickets due to renal tubular acidosis are discussed in other sections of the journal.

There is a paucity of health policy relevant data for chronic liver disease from India, impeding formulation of an interventional strategy to address the issue. A prospective, multicentric study to delineate the etiology and clinical profile of chronic liver disease in India is reported here. A centrally coordinated and monitored web-based data repository was developed (Feb, 2010 to Jan, 2013) and analyzed. Eleven hospitals from different parts of India participated. Data were uploaded into a web based proforma and monitored by a single centre according to a standardized protocol. 1.28% (n = 266621) of all patients (n = 20701383) attending the eleven participating hospitals of India had liver disease. 65807 (24·68%) were diagnosed for the first time (new cases). Of these, 13014 (19·77%, median age 43 years, 73% males) cases of chronic liver disease were finally analyzed. 33.9% presented with decompensated cirrhosis. Alcoholism (34·3% of 4413) was the commonest cause of cirrhosis while Hepatitis B (33·3%) was predominant cause of chronic liver disease in general and non-cirrhotic chronic liver disease (40·8% out of 8163). There was significant interregional differences (hepatitis C in North, hepatitis B in East and South, alcohol in North-east, Non-alcoholic Fatty Liver Disease in West) in the predominant cause of chronic liver disease. Hepatitis B (46·8% of 438 cases) was the commonest cause of hepatocellular Cancer.11·7% had diabetes. Observations of our study will help guide a contextually relevant liver care policy for India and could serve as a framework for similar endeavor in other developing countries as well.

We studied epidemics of viral hepatitis occurring at three different places in India. One was a combined epidemic due to hepatitis E virus (HEV) and hepatitis A virus (HAV) infections. In this epidemic, HAV affected children below 10 years of age, whereas HEV infected the young adult population. HEV was transmitted to rhesus monkeys (Macaca mulata) and confirmed by the polymerase chain reaction (PCR) on bile from the animals. Fecal material from acutely infected patients in one of the epidemics was also found positive for HEV RNA by PCR. This may help in confirming the nature of future epidemics. The bile and liver from experimental animals can be used as a source of material for further virological and molecular biological studies of HEV.

BACKGROUND: Achievement of diabetes care goals is suboptimal globally. Diabetes-focused quality improvement (QI) is effective but remains untested in South Asia. OBJECTIVE: To compare the effect of a multicomponent QI strategy versus usual care on cardiometabolic profiles in patients with poorly controlled diabetes. DESIGN: Parallel, open-label, pragmatic randomized, controlled trial. (ClinicalTrials.gov: NCT01212328). SETTING: Diabetes clinics in India and Pakistan. PATIENTS: 1146 patients (575 in the intervention group and 571 in the usual care group) with type 2 diabetes and poor cardiometabolic profiles (glycated hemoglobin [HbA1c] level ≥8% plus systolic blood pressure [BP] ≥140 mm Hg and/or low-density lipoprotein cholesterol [LDLc] level ≥130 mg/dL). INTERVENTION: Multicomponent QI strategy comprising nonphysician care coordinators and decision-support electronic health records. MEASUREMENTS: Proportions achieving HbA1c level less than 7% plus BP less than 130/80 mm Hg and/or LDLc level less than 100 mg/dL (primary outcome); mean risk factor reductions, health-related quality of life (HRQL), and treatment satisfaction (secondary outcomes). RESULTS: Baseline characteristics were similar between groups. Median diabetes duration was 7.0 years; 6.8% and 39.4% of participants had preexisting cardiovascular and microvascular disease, respectively; mean HbA1c level was 9.9%; mean BP was 143.3/81.7 mm Hg; and mean LDLc level was 122.4 mg/dL. Over a median of 28 months, a greater percentage of intervention participants achieved the primary outcome (18.2% vs. 8.1%; relative risk, 2.24 [95% CI, 1.71 to 2.92]). Compared with usual care, intervention participants achieved larger reductions in HbA1c level (-0.50% [CI, -0.69% to -0.32%]), systolic BP (-4.04 mm Hg [CI, -5.85 to -2.22 mm Hg]), diastolic BP (-2.03 mm Hg [CI, -3.00 to -1.05 mm Hg]), and LDLc level (-7.86 mg/dL [CI, -10.90 to -4.81 mg/dL]) and reported higher HRQL and treatment satisfaction. LIMITATION: Findings were confined to urban specialist diabetes clinics. CONCLUSION: Multicomponent QI improves achievement of diabetes care goals, even in resource-challenged clinics. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute and UnitedHealth Group.

ABSTRACT Background Chronic kidney disease (CKD) is an important cause of morbidity and mortality worldwide. There is a lack of information on epidemiology and progression of CKD in low–middle income countries. The Indian Chronic Kidney Disease (ICKD) study aims to identify factors that associate with CKD progression, and development of kidney failure and cardiovascular disease (CVD) in Indian patients with CKD. Methods ICKD study is prospective, multicentric cohort study enrolling patients with estimated glomerular filtration rate (eGFR) 15–60 mL/min/1.73 m2, or &amp;gt;60 mL/min/1.73 m2 with proteinuria. Clinical details and biological samples are collected at annual visits. We analysed the baseline characteristics including socio-demographic details, risk factors, disease characteristics and laboratory measurements. In addition, we compared characteristics between urban and rural participants. Results A total of 4056 patients have been enrolled up to 31 March 2020. The mean ± SD age was 50.3 ± 11.8 years, 67.2% were males, two-thirds of patients lived in rural areas and the median eGFR was 40 mL/min/1.73 m2. About 87% were hypertensive, 37% had diabetes, 22% had CVD, 6.7% had past history of acute kidney injury and 23% reported prior use of alternative drugs. Diabetic kidney disease, chronic interstitial nephritis (CIN) and CKD-cause unknown (CKDu) were the leading causes. Rural participants had more occupational exposure and tobacco use but lower educational status and income. CIN and unknown categories were leading causes in rural participants. Conclusions The ICKD study is the only large cohort study of patients with mild-to-moderate CKD in a lower middle income country. Baseline characteristics of study population reveal differences as compared with other cohorts from high-income countries.

Pregnancy is a period that places great physiological stress on both the mother and the fetus. When pregnancy is compounded by endocrine disorders such as hypothyroidism, the potential for maternal and fetal adverse outcomes can be immense. While a lot of attention has been focused on the adverse fetal outcomes consequent to hypothyroidism, attention is also being gradually directed towards the adverse maternal outcomes of this disorder. Role of antibody positivity in influencing outcomes in a euthyroid woman, also needs further clarification. Prompt diagnosis and treatment of hypothyroidism in pregnancy is very essential. Subclinical hypothyroidism also needs to be detected and treated to prevent adverse outcomes, especially maternal. Since women with hypothyroidism during pregnancy, especially of the autoimmune variety might have a flare up of the disorder post-partum, or might continue to require thyroxine replacement post-partum, adequate follow-up is mandatory. While targeted case finding is generally practised, recent evidence seems to indicate that universal screening might be a better option. In conclusion, routine screening, early confirmation of diagnosis and prompt treatment. Allied with regular post-partum follow up, is required to ensure favourable maternal and fetal outcomes.

Patients with decompensated cirrhosis owing to chronic hepatitis B viral (HBV) infection have a high morbidity/mortality rate, and the treatment remains a challenge. We studied the safety and efficacy of telbivudine and lamivudine in such patients. This noninferiority, double-blind trial randomized 232 treatment-naive patients with decompensated HBV (1:1) in 80 academic hospitals to receive once-daily telbivudine 600 mg or lamivudine 100 mg for 104 weeks. Primary composite endpoint was proportion of patients with HBV DNA <10 000 copies/mL, normal alanine aminotransferase (ALT) and Child-Turcotte-Pugh score improvement/stabilization at week 52. Response rates using a post hoc modified endpoint (HBV DNA <300 copies/mL [57 IU/mL] and ALT normalization) in intent-to-treat analysis (missing = failure) were 56.3%vs 38.0% after 76 weeks (P = 0.018) and 45.6%vs 32.9% after 104 weeks (P = 0.093) for telbivudine vs lamivudine. Telbivudine treatment was an independent predictive factor for HBV DNA <300 copies/mL and ALT normalization (P = 0.037). Response rates with protocol-defined composite endpoint in intent-to-treat analysis (M = F) were 56.2 vs 54.0% (noninferiority not achieved) and 39.1%vs 36.4% (noninferiority achieved) in telbivudine and lamivudine groups at 52 and 104 weeks. Telbivudine treatment was associated with a significant improvement in glomerular filtration rate compared to lamivudine treatment and was also associated with a trend for improvement in survival (87%vs 79%). No cases of lactic acidosis were reported. Telbivudine compared to lamivudine was associated with a higher rate of patients with both viral suppression and ALT normalization, a trend towards a higher rate of survival and significant improvement in glomerular filtration.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has affected the care of patients with noncommunicable diseases, including those suffering from kidney-related ailments. Many parts of the world, including India, adopted lockdown to curb community transmission of disease. The lockdown affected transportation, access to health care facilities, and availability of medicines and consumables as well as outpatient and inpatient services. We aimed to analyze the effect of lockdown imposed due to the COVID-19 pandemic on the care of patients with kidney diseases in India. METHODS: We surveyed 19 major hospitals (8 in the public and 11 in the private sector) to determine the effect of lockdown on the care of patients with kidney disease, including those on dialysis after the first 3 weeks of lockdown. RESULTS: The total number of dialysis patients in these centers came down from 2517 to 2404. Approximately 710 (28.2%) patients missed 1 or more dialysis sessions, 69 (2.74%) required emergency dialysis sessions, 104 (4.13%) stopped reporting for dialysis, and 9 (0.36%) were confirmed to have died. Outpatient attendance in the surveyed hospital came down by 92.3%, and inpatient service reduced by 61%. Tele-consultation was started but was accessed by only a small number of patients. CONCLUSION: Lack of preparedness before lockdown resulted in an interruption in health care services and posed an immediate adverse effect on the outcome of dialysis patients and patients with kidney disease in India. The long-term impact on the health of patients with less severe forms of kidney disease remains unknown.

Human immunodeficiency virus type 1 (HIV-1) subtype C viruses are associated with nearly half of worldwide HIV-1 infections and are most predominant in India and the southern and eastern parts of Africa. Earlier reports from India identified the preponderance of subtype C and a small proportion of subtype A viruses. Subsequent reports identifying multiple subtypes suggest new introductions and/or their detection due to extended screening. The southern parts of India constitute emerging areas of the epidemic, but it is not known whether HIV-1 infection in these areas is associated with subtype C viruses or is due to the potential new introduction of non-subtype C viruses. Here, we describe the development of a specific and sensitive PCR-based strategy to identify subtype C-viruses (C-PCR). The strategy is based on amplifying a region encompassing a long terminal repeat and gag in the first round, followed by two sets of nested primers; one amplifies multiple subtypes, while the other is specific to subtype C. The common HIV and subtype C-specific fragments are distinguishable by length differences in agarose gels and by the difference in the numbers of NF-kappaB sites encoded in the subtype C-specific fragment. We implemented this method to screen 256 HIV-1-infected individuals from 35 towns and cities in four states in the south and a city in the east. With the exception of single samples of subtypes A and B and a B/C recombinant, we found all to be infected with subtype C viruses, and the subtype assignments were confirmed in a subset by using heteroduplex mobility assays and phylogenetic analysis of sequences. We propose the use of C-PCR to facilitate rapid molecular epidemiologic characterization to aid vaccine and therapeutic strategies.

As injectable therapies such as human insulin, insulin analogs, and glucagon-like peptide-1 receptor agonists are used to manage diabetes, correct injection technique is vital for the achievement of glycemic control. The forum for injection technique India acknowledged this need for the first time in India and worked to develop evidence-based recommendations on insulin injection technique, to assist healthcare practitioners in their clinical practice.

Chronic kidney disease (CKD) not associated with known risk factors has been reported from parts of India and is presumed to be similar to CKD of unknown etiology (CKDu) that has been described from Central America. The reports from India have been fragmented without clear description of the disease phenotype or its determinants. This paper summarizes the current state of knowledge around CKDu in India based on a review of literature, multi-stakeholder consultation, and a survey of Indian nephrologists. We also contacted individual research groups to solicit data. Our findings suggest that that CKDu is reported from most regions in India; however, it is interpreted differently from the phenotype described from Central America and Sri Lanka. The differences include lack of a clear demographic or occupation group, older age of affected participants, and presence of mild hypertension and low-grade proteinuria. Well-designed prospective field studies with appropriate diagnostic workup are needed to establish the disease burden and identify etiologies, along with socioeconomic and health consequences, the intersection with the environment, and the public health response. Community-based research should phenotype the entire CKD population rather than be restricted to cases with presumed CKDu based on predefined criteria. Guidelines are needed for clinical evaluation, referral, management, and harmonization of clinical documentation and health records. More data are needed to support the existence of a unique CKDu phenotype in India. Chronic kidney disease (CKD) not associated with known risk factors has been reported from parts of India and is presumed to be similar to CKD of unknown etiology (CKDu) that has been described from Central America. The reports from India have been fragmented without clear description of the disease phenotype or its determinants. This paper summarizes the current state of knowledge around CKDu in India based on a review of literature, multi-stakeholder consultation, and a survey of Indian nephrologists. We also contacted individual research groups to solicit data. Our findings suggest that that CKDu is reported from most regions in India; however, it is interpreted differently from the phenotype described from Central America and Sri Lanka. The differences include lack of a clear demographic or occupation group, older age of affected participants, and presence of mild hypertension and low-grade proteinuria. Well-designed prospective field studies with appropriate diagnostic workup are needed to establish the disease burden and identify etiologies, along with socioeconomic and health consequences, the intersection with the environment, and the public health response. Community-based research should phenotype the entire CKD population rather than be restricted to cases with presumed CKDu based on predefined criteria. Guidelines are needed for clinical evaluation, referral, management, and harmonization of clinical documentation and health records. More data are needed to support the existence of a unique CKDu phenotype in India. In the past 2 decades, a form of CKD has been described in people without any known risk factors such as diabetes, hypertension, glomerulonephritis, or genetic kidney disease from several geographically distinct, predominantly rural locations in diverse regions across the world.1Gifford F.J. Gifford R.M. Eddleston M. et al.Endemic nephropathy around the world.Kidney Int Rep. 2017; 2: 282-292Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Initially reported from Central America2Trabanino R. Aguilar R. Silva C. et al.End-stage renal disease among patients in a referral hospital in El Salvador [In Spanish].Rev Panam Salud Publica. 2002; 12: 202-206Crossref PubMed Scopus (110) Google Scholar and Sri Lanka,3Lanerolle R. Nanayakkara S. Sheriffdeen A. et al.Demographic characteristics of end stage renal disease in Sri Lanka.J Ceylon Coll Phys. 2000; 33: 3Google Scholar this entity has now been documented or suspected in Nicaragua, El Salvador, Costa Rica, Guatemala, Mexico, Panama, Sri Lanka, India, Egypt, Tunisia, Cameroon, Egypt, South Africa, the Philippines, Taiwan, Indonesia, Thailand, the United States, and the United Kingdom.4Gunasekara T. De Silva P.M. Herath C. et al.The utility of novel renal biomarkers in assessment of chronic kidney disease of unknown etiology (CKDu): a review.Int J Environ Res Public Health. 2020; 17: 9522Crossref Scopus (14) Google Scholar There is no agreement on whether the CKD in all these clusters represents a single disease or a group of different diseases. The clinical features indicate the presentation to be consistent with the predominant tubulointerstitial pattern of injury. As the cause of these nephropathies is not clear, the term chronic kidney disease of unknown etiology (CKDu) has been used. Other names include CKD of nontraditional origin, Mesoamerican nephropathy, and chronic interstitial nephritis in agricultural communities.5Jayasumana C. Chronic Interstitial Nephritis in Agricultural Communities (CINAC) in Sri Lanka.Semin Nephrol. 2019; 39: 278-283Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar This diagnosis is primarily one of exclusion, but based on the initial reports from Central America, certain criteria have been proposed — including young age, lack of known CKD risk, and presentation with reduced glomerular filtration rate, minimal proteinuria, and no or slight increase in blood pressure.6Johnson R.J. Wesseling C. Newman L.S. Chronic kidney disease of unknown cause in agricultural communities.N Engl J Med. 2019; 380: 1843-1852Crossref PubMed Scopus (110) Google Scholar The first description resembling what would later become known as CKDu can be found in a 1993 report by Mani.7Mani M. Chronic renal failure in India.Nephrol Dial Transplant. 1993; 8: 684-689Crossref PubMed Scopus (59) Google Scholar He described chronic interstitial nephritis as the leading cause of chronic renal failure in patients presenting to a single hospital in Chennai. The overall prevalence of chronic interstitial nephritis in this report was 28%, increasing to 38% among lower-income patients. Approximately 70% presented with advanced kidney failure.7Mani M. Chronic renal failure in India.Nephrol Dial Transplant. 1993; 8: 684-689Crossref PubMed Scopus (59) Google Scholar Around the same time, cases of unexplained kidney failure were rising in a region known as Uddanam in the coastal district of Srikakulam in Andhra Pradesh, as reported by the local press.8Ganguli A. Uddanam nephropathy/regional nephropathy in India: preliminary findings and a plea for further research.Am J Kidney Dis. 2016; 68: 344-348Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar By 2015, an estimated 34,000 people had been diagnosed with CKD with about 4500 reported deaths.9Staff ReporterNo end to agony of kidney patients in Uddanam region.The Hindu. 2015; (Available at:)https://www.thehindu.com/news/national/andhra-pradesh/no-end-to-agony-of-kidney-patients-in-uddanam-region/article6992310.eceDate accessed: August 18, 2021Google Scholar This condition attracted national and international attention and received the eponym Uddanam nephropathy. Soon after, nephrologists in other parts of the country started reporting similar presentations.8Ganguli A. Uddanam nephropathy/regional nephropathy in India: preliminary findings and a plea for further research.Am J Kidney Dis. 2016; 68: 344-348Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Unfortunately, no studies were performed, and there remained a degree of confusion on what constitutes CKDu in India because it is common for patients with kidney disease due to other conditions such as diabetes, glomerulonephritis, and vascular disease to remain undiagnosed and present late. In 2005, the CKD Registry of India Working Group suggested a diagnostic category of “CKD — cause undetermined.” This was deemed to be a diagnosis of exclusion, and no definition was provided. In the Registry report containing data on 52,273 patients, this category emerged as the second most common cause of CKD (16%) after diabetic nephropathy (31%). An additional 7% were labelled as chronic interstitial nephritis.10Rajapurkar M.M. John G.T. Kirpalani A.L. et al.What do we know about chronic kidney disease in India: first report of the Indian CKD registry.BMC Nephrol. 2012; 13: 1-8Crossref PubMed Scopus (230) Google Scholar In 2019, O’Callaghan Gordo et al.11O’Callaghan-Gordo C. Shivashankar R. Anand S. et al.Prevalence of and risk factors for chronic kidney disease of unknown aetiology in India: secondary data analysis of three population-based cross-sectional studies.BMJ Open. 2019; 9e023353PubMed Google Scholar published the results of secondary data analysis of three population-based studies. They found a higher prevalence of CKD without diabetes, hypertension, or heavy proteinuria among rural populations in southern India. In the meantime, several research groups visited Uddanam, surveyed the local population, and tested the water for contaminants, but the findings were inconclusive and not published. This paper outlines the current landscape of CKDu in India, its socioeconomic and health consequences, possible intersection with the environment, the public health response, and suggested a research agenda. The analysis presented in this paper is based on1)Literature review: using standardized methods, we identified peer-reviewed papers and public reports that examined the burden, risk factors outcomes, and policy aspects of CKD of undetermined cause in India.2)We supplemented the literature review witha)A search of the grey literature and interviews with nephrologists and other experts to gain understanding around perceptions of the burden, determinants, cause and outcome of CKD where the cause is not identifiable. We also sought their opinion on the landscape around research, policy and operational aspects of CKD care.b)An online survey to the membership of the Indian Society of Nephrology. A total of 110 of 1687 members returned the survey. The results of the survey are tabulated in Table 1.3)Two national stakeholder consultations — the first one on the side lines of the Annual Congress of the Indian Society of Nephrology at Chandigarh in November 2019, and an online meeting in May 2021. A total of 26 experts in CKDu research and policy response participated in two roundtable discussions. On the basis of this review, we were unable to frame CKDu in India in the same way that it has been done in Central America — in particular, the strong anchoring to certain professions, younger age, male preponderance, and the almost complete absence of proteinuria and hypertension. Further, the diagnostic label has been used loosely for all cases where an etiologic diagnosis was not apparent. Therefore, we present the analysis of CKDu as it is understood in India, because it has a bearing on future research and priority-setting.Table 1Survey results on CKDu clinical and research practices in IndiaParameterReponses (n = 110)How many new cases with CKD do you see in your practice in a month?25 ± 45In how many do you make a presumed diagnosis of CKDu?4 ± 6.5What is the age of patients with CKDu?35 ± 10Have you noticed any geographic clustering of patients with CKDu? Yes38 No45 Not sure24Do you maintain a record/registry of patients with CKD? Yes34 No76Are you aware on local programs to address the burden of CKD? Yes31 No79Are you interested in participating in research on CKDu? Yes88 No2 Maybe20CKD, chronic kidney disease; CKDu, chronic kidney disease of unknown etiology. Open table in a new tab CKD, chronic kidney disease; CKDu, chronic kidney disease of unknown etiology. Despite the long-standing interest,12Ramesh K. Sasibhushan K. et al.The renal failure in Uddanam of Srikakulam Andhra identified for further J Scholar findings from population-based that examined the prevalence of CKD in Uddanam were published In a of participants, et S. et prevalence of CKD of unknown etiology in Uddanam, Int Rep. Full Text Full Text PDF PubMed Scopus Google Scholar found the prevalence of CKD at with meeting the definition of This was by a single of the kidney and the of The to and for CKD of from in the A. et to and for CKD of undetermined etiology in Andhra Pradesh, Int Rep. 2019; Full Text Full Text PDF PubMed Scopus Google Scholar and found the CKD prevalence to be and among and This used a including all by with estimated glomerular filtration were to be and had hypertension, disease and of of these studies found the population age to be and increasing CKD risk with The also found a prevalence of hypertension and proteinuria in 7% and in John A. et of the prevalence and risk factors of CKD in Uddanam, Int Rep. 2020; Full Text Full Text PDF PubMed Scopus Google Scholar with CKD burden have also been reported from other in Andhra Pradesh, in particular, and this is than K. et risk factors for chronic kidney disease in Andhra 2020; PubMed Scopus Google renal in Hindu. 2017; (Available accessed: August 18, 2021Google A.L. et of water with and in chronic kidney an in an Indian J Health. 2015; Scholar The are their to the of CKD as as the and risk factors of disease of additional studies are with to kidney and water John and for the burden of Chronic Kidney of etiology in Andhra CKDu accessed: August 18, 2021Google Scholar et S. M. of Uddanam J Nephrol. 2020; Google Scholar patients with from to The findings were by interstitial and of and glomerular in in and have a increase in the of patients presenting to the renal with a advanced kidney no of hypertension or proteinuria, and The affected population is predominantly rural and of male agricultural and in et group of patients has a of returned from the region where had been in had received a of health at the of but were later to have CKD and A report from a referral at reported on CKD patients — a of from the of and in Approximately were as A CKD in a CKD prevalence of S. et region of CKD of undetermined etiology (CKDu) in South India — Int Rep. 2020; Full Text Full Text PDF PubMed Scopus Google Scholar In reports in the have CKDu in the and A total of people have of CKD without in one with a population of has kidney disease in one the (Available accessed: August 18, 2021Google Scholar A paper described a of cases in referral patients from agricultural and the clinical presentation was to be consistent with the CKDu Kidney in two cases interstitial chronic and patients used and containing heavy or other and A identified of in and in K. et of unknown in Int Rep. Full Text Full Text PDF PubMed Scopus Google Scholar and has been aware of the existence of a prevalence of kidney disease without known risk factors in the In a in of had reduced and were in R. T. M. et al.Prevalence of renal among the of in India: analysis of the data from a J Google Scholar data were on risk An and in the disease to in and and in for for accessed: 2021Google Scholar An reported of in blood and practice of S. S. A. of — and in the of chronic kidney 2017; PubMed Scopus Google Scholar in the region of has been reporting a burden of There have been no et A. et of chronic kidney disease of unknown in patients of Scholar described patients from with a age was ± or in have been about the of and of water from with S. M. of Uddanam J Nephrol. 2020; Google Scholar A burden of CKD has been reported from several — and and in the district are by the local as In a cross-sectional in from of the people and were diagnosed with CKD, of not have or hypertension. More than 70% to socioeconomic and were in agricultural The prevalence of CKD was in the two The prevalence was or in of the geographic S. et al.Prevalence of chronic kidney disease in district of J Res Public Health. 2020; 17: Scopus Google Scholar This an or genetic basis to the with for higher to or of how are or genetic in An analysis of a of from the population, had participated in the to survey for an reduced The population was by a prevalence of hypertension. This not report on or other CKD risk et of chronic kidney disease prevalence and risk factors among in the India and the Open. 2020; PubMed Scopus Google Scholar There was a of the and health in diagnosed with CKD in rural In the affected people a diagnosis of kidney disease because it exclusion, and of and a of and kidney disease to be an to November 18, There is and a The on and to a of health a of and patients are to any leading to of including from of that be There is a lack of in public because of a lack of and patients in the is There has been but published research on risk factors of CKD in India. have been such as of and other heavy in and John and for the burden of Chronic Kidney of etiology in Andhra CKDu accessed: August 18, 2021Google J Environ Med. Google Scholar many of these have and from other of the to a is of water is the most and research groups have tested the on heavy but have not found any consistent in the water in the Uddanam J Environ Med. Google Scholar The data in that the is in Uddanam to other A. Chronic kidney disease in two coastal of Andhra Pradesh, India: of Health. PubMed Scopus Google Scholar et A.L. et of water with and in chronic kidney an in an Indian J Health. 2015; Scholar found of and in the water in the district of Andhra of however, have been to be with kidney data have of total in water from Uddanam that indicate from and the prevalence of hypertension K. M. et of of CKDu affected region in Srikakulam district and across Andhra Pradesh, 2020; Scopus Google Scholar et S. et prevalence of CKD of unknown etiology in Uddanam, Int Rep. Full Text Full Text PDF PubMed Scopus Google Scholar were unable to establish any and CKDu in They not or of and were on is to On the et R. M. et in patients with chronic kidney disease of unknown etiology and its with renal Med. 2017; 1-8Crossref PubMed Scopus Google Scholar found a in the blood and the in the population of diagnosed with used in India and have been with CKD, with studies due to the to and the risk factors of with and et and the of CKD from in rural the for J Nephrol. 2016; PubMed Scopus Google Scholar leading to of kidney S. T. et kidney and in a of agricultural J Med. 2020; PubMed Scopus Google L.S. et kidney and chronic kidney disease as Engl J Med. PubMed Scopus Google Scholar to CKD is as the leading cause for CKDu in Central R.J. Chronic kidney disease of unknown a disease to PubMed Google of chronic kidney disease of unknown etiology (CKDu): a Nephrol. 2015; 1-8Crossref Scopus Google Scholar in most from where CKD burden is reported in India are in in and An is the and kidney disease in John and for the burden of Chronic Kidney of etiology in Andhra CKDu accessed: August 18, 2021Google Scholar An and CKD has been in and the United et and risk of chronic kidney disease and renal a population-based 2020; PubMed Scopus Google T. et and the risk of CKD and to Nephrol. PubMed Scopus Google Scholar India has of most in the The In India: India accessed: August 18, 2021Google Scholar of and to in rural and on are common in rural Indian has not received as a to CKD in India. In data from have the of the of past with in the of renal of chronic kidney disease unknown PubMed Scopus Google Scholar in and about has a in its in the of CKD in India the of genetic factors has not been In the of kidney disease was an of In a cases from labelled as CKDu and et S. analysis to genetic and associated with chronic kidney disease of unknown at Int Rep. 2019; Full Text Full Text PDF Google Scholar found a of CKDu with single to and S. analysis to genetic and associated with chronic kidney disease of unknown at Int Rep. 2019; Full Text Full Text PDF Google Scholar and health lack of research, and were identified as the to a understanding of CKDu in India. that CKD where the cause is is the clusters described The to and of CKD has been a the Andhra state in than in but of proteinuria or of data on CKD risk or were not of geographic clustering of CKDu chronic kidney disease of unknown etiology. Open table in a new tab CKDu, chronic kidney disease of unknown etiology. workup of cases has CKDu and with CKD due to undiagnosed glomerular disease and CKD and kidney diseases. The published of CKDu for are used by to a label and to et John A. et of the prevalence and risk factors of CKD in Uddanam, Int Rep. 2020; Full Text Full Text PDF PubMed Scopus Google Scholar found diagnostic and with most patients not the diagnostic workup — of cases had renal There are no published kidney studies on CKDu from India. The of India the for and of and in of of for of accessed: 2021Google Scholar the do not include proteinuria The increasing reports of CKD without risk factors present a for for CKD in burden such should be or to studies in the suspected We the for clinical and research in CKD in of a CKD to the national CKD research and response — a group should of health health and of for clinical and diagnostic evaluation, criteria for referral and of CKD at all of health including health and district and of these and The by the of should be of of and of India. of India. August 18, Scholar for and proteinuria using should be of clinical documentation and definition of a for of and future research, including and including including of and and health and studies are Well-designed prospective field studies establish the disease burden and complete diagnostic They also present for using a Anand S. et al.The Society of of on Chronic Kidney of report of the group on to and for a 2019; Full Text Full Text PDF PubMed Scopus Google Scholar The and have proposed for such studies. We that there is no on the for CKDu, and S. et of unknown etiology (CKDu) in Sri a clinical definition for and Int Rep. 2019; Full Text Full Text PDF PubMed Scopus Google Scholar are to be as new from studies. Therefore, a is to that in the research studies or cross-sectional in locations should be done using a to the disease and that include and proteinuria should be as of the for and of and in studies should include to definition of this there is to a unique CKDu phenotype in CKDu definition by groups in other parts of the should not be used to the diagnostic workup or clinical kidney should be done and reported using research should phenotype the entire CKD population rather than to cases with presumed CKDu based on predefined criteria. should not be on the basis of predefined proteinuria an interstitial disease can also in with other conditions such as and hypertension have a population prevalence in in the these cases should also be in such should report all cases with CKD and their to and proteinuria There is a to for etiologic and should with the where such studies are should be with local health identified to have a health as of the research should have to appropriate should the individual and include for of results to and and risk should be and in all CKD of prevalence and in regions with the or suspected disease of prevalence locations for geographic health and should be after a assessment of local risk factors and include of water and to and using as of and research should to possible risk of a national is with for and data for future of a that common health conditions including CKD using a of with appropriate and referral is In CKD is a health in India, with increasing that kidney disease in do not have risk there has been attention a to understanding and this diagnosis and on the of advanced kidney disease have to the of of The factors and CKD be studies understanding of risk factors for disease and policy on and to the burden of CKDu the to the health that on water and and that to has research from and reports and from and the published were to has research from India, and with and India. that in this paper were in by a from the of South and of to J The is by a from the of Andhra The all the and survey for their data and

Health-care professionals in India frequently manage injection or infusion therapies in persons with diabetes (PWD). Patients taking insulin should know the importance of proper needle size, correct injection process, complication avoidance, and all other aspects of injection technique from the first visit onward. To assist health-care practitioners in their clinical practice, Forum for Injection Technique and Therapy Expert Recommendations, India, has updated the practical advice and made it more comprehensive evidence-based best practice information. Adherence to these updated recommendations, learning, and translating them into clinical practice should lead to effective therapies, improved outcomes, and lower costs for PWD.

AIMS: Ginkgo biloba is available as an over-the-counter drug and reported to cause haemorrhage when coadministered with other antiplatelet agents. We set out to study the interactions of G. biloba with cilostazol and clopidogrel. METHODS: A randomized, open-label, crossover study of 10 healthy male volunteers. The dosage schedules were 120 mg G. biloba, 240 mg G. biloba, 100 mg cilostazol, 200 mg cilostazol, 75 mg clopidogrel, 150 mg clopidogrel, 120 mg G. biloba+ 100 mg cilostazol and 120 mg G. biloba+ 75 mg clopidogrel. Platelet aggregation, platelet count, bleeding time and clotting time were measured 0 and 6 h after drug administration. Platelet aggregation was performed using a dual channel aggregometer, by the turbimetric technique using adenosine diphosphate 5 micromol and 10 micromol, and collagen 1 microg ml(-1). RESULTS: Platelet inhibition with the combination of G. biloba and clopidogrel or cilostazol was not statistically significant compared with individual doses of drugs, with all the three aggregants. There was significant (P < 0.05) potentiation of prolongation of bleeding time with the combination of cilostazol and G. biloba compared with individual doses of both the drugs. There was no significant change in clotting time and platelet count. CONCLUSIONS: Coadministration of G. biloba either with cilostazol or clopidogrel did not enhance antiplatelet activity compared with individual agents. Ginkgo biloba potentiated the bleeding time prolongation effect of cilostazol. There was no significant correlation between prolongation of bleeding time and inhibition of platelet aggregation.

PURPOSE: To present our experience and discuss the various endourological approaches for treating forgotten encrusted ureteral stents associated with stone formation. MATERIALS AND METHODS: From July 2006 to December 2008, 14 patients (11 men and 3 women) with encrusted ureteral stents were analyzed. The average indwelling time of the stent was 4.9 years (range 1 to 12). Plain-film radiography was used to evaluate encrustation, stone burden, and fragmentation of the stents. Intravenous urogram and a Tc99m diethylene triamine penta acetic-acid renogram was used to assess renal function. RESULTS: In seven patients, the entire stent was encrusted, in three patients the encrustation was confined to the ureteral and lower coil part of the stent, two patients had encrustation of the lower coil, and minimal encrustation was observed in two patients. Percutaneous nephrolithotomy was performed in 5 cases and retrograde ureteroscopy with intra-corporeal lithotripsy in 9 patients. Cystolithotripsy was used to manage the distal coil of the encrusted stent in eight patients. Simple cystoscopic removal of the stents with minimal encrustation was carried-out in two cases. Looposcopy and removal of the stent was performed in one patient with an ileal conduit and retained stent. Only one patient required open surgical removal of the stent. Thirteen out of 14 patients were rendered stone and stent free in one session. All except two stents were removed intact and stone analysis of encrustation and calcification revealed calcium oxalate and calcium phosphate in the majority of the cases. CONCLUSION: Endourological management of forgotten encrusted stents is highly successful and often avoids the need for open surgical techniques.