Download Haemodialysis in India Acute renal failure from intoxication by

Nephrol Dial Transplant (1999) 14: 2779
Haemodialysis in India
Sir,
Management of end stage renal disease (ESRD) varies in
different parts of the world. The overriding factor is the
economic status of the community which is served by the
medical facility. Communities where state financing exists,
or insurance privileges are available, ESRD management is
often uniform: whereas in communities where there is nonexistent state support for the treatment of ESRD, the frequency
with which one modality is offered is often determined by
the individuals paying capacity. Hence, often a heterogenous
picture emerges from a country like India as is borne out by
our data, which is different from that of CMC Vellore [1].
Our centre has been routinely offering maintenance haemodialysis (MHD) since its inception (7 years ago) and we have
patients who have been on dialysis for more than 6 years.
We offer bicarbonate dialysis to all patients. Cellulose acetate
(approximately 65%) and polysulphone (approximately 35%)
membrane dialysers are used. A large percentage of our
patients (40.5%) are on erythoropoeitin. A larger number
(30% in 1998) of patients were on MHD as compared to
that of patients receiving an allograft (13.5% in 1998) in
our group.
To look into our MHD cohort, a medical audit was
performed for 61 incident and prevalent patients who were
on MHD for more than 3 months during the period between
1 April 1997 and 31 March 1998. Of the 61 patients 39 were
on twice weekly dialysis and 22 thrice weekly. The mean
(SD) age of this cohort was 54.6 (±12.2) years which is
higher that what is reported for Indian patients in the
literature [2]. The number of diabetics (29 out of 61) on
MHD was again higher than reported in earlier studies [1,3].
In fact the demographics of our data was similar to that
reported from western ESRD data systems [4]. Despite a
large number of patients on twice weekly dialysis, most of
the patients seem to do well with 47 out of the 61 patients
having a serum albumin more than 3.5 g/dl and also there
was no difference in the serum albumin of patients who were
dialysed twice (3.9±0.4 g/dl ) and those who were dialysed
thrice (3.9±0.6 g/dl ). KT/V (calculated by single pool variable volume as described by Daugirdas JT ) [5] was done for
37 patients and the mean (±SD) of this measurement was
1.0 (±0.3). A lower dialysis dose also was not correlated
with serum albumin in our study. This reflects a similar
observation made from another Indian study which contends
that Indians in general require less dialysis [6 ]. Eight patients
died during the study period (mortality of 12.9%) which is
considerably lower than what is reported from CMC Vellore
[1], but compares favourably with the USRDS, 1998 [4].
The patients who expired were in general as a cohort older
(61.6±10.2 years), had more comorbidity and had lower
serum albumin (3.2±0.5 g/dl ).
The approximate 1-yearly cost of treatment for MHD
works out to be $2512 (twice weekly) to $3628 (twice weekly).
Transplantation costs in our centre (which is one of the
lowest in the country) works out to approximately $7000
(inclusive of immunosuppressive medications of 1 year).
Despite the higher first year cost of transplantation, many
centres offer transplantation as the first choice of renal
replacement not only because of medical reasons but also
because of a large percentage of out of town referral which
utilize the services of these centres [1]. We, being situated
in a large metropolis have a large local referral and hence
it is easier for us to provide MHD facilities to ESRD
patients.
2779
Our data of MHD patients highlights the fact that MHD
is a viable modality of renal replacement in India in select
centres and should be offered to patients in whom transplantation is not a possible alternative.
Manipal Institute of Nephrology
and Urology
Bangalore
India
H. Sudarshan Ballal
Urmila Anandh
1. Rao M, Juneja R, Shirly RBM, Jacob CK. Hemodialysis for end
stage renal disease in Southern India—a perspective from a
tertiary referral care centre. Nephrol Dial Transplant 1998; 13:
2494–2500
2. Sakhuja V, Jha V, Ghosh AK, Ahmed S, Saha TK. Chronic
renal failure in India. Nephrol Dial Transplant 1994; 9: 871–872
3. Mani MK. Chronic renal failure in India. Nephrol Dial Transplant
1993; 8: 684–689
4. Incidence and prevalence of ESRD. United States Renal Data
System 1998—Annual data report. National Institute of Diabetes
and Digestive and Kidney Diseases, National Institute of Health,
Bethesda AJKD 1998; 32: 538
5. Daugirdas JT. Chronic haemodialysis prescription. In:
Daugirdas JT, Ing TS, eds. Handbook of Dialysis, 2nd edition,
Little Brown, Boston, MA: 1994; 92–120
6. Desai JD, Shah BV, Sirsat KA. Urea kinetics; a guide to dialysis
prescription. Indian J Nephrol 199; 1 (Abstract): 49
Acute renal failure from intoxication by Cortinarius
orellanus: recovery using anti-oxidant therapy and
steroids
Sir,
Little brown mushrooms of the Cortinarius genus of fungi
are known to cause acute renal failure between 2 and 20
days after ingestion [1–4]. Renal histology typically shows
interstitial nephritis [5], which has been attributed to the
nephrotoxin orellanine. The toxic effect is probably exerted
by production of reactive oxygen species [6 ]. We report a
case of suspected orellanine poisoning treated with corticosteroids and N-acetylcysteine with encouraging results.
Case. A 66-year-old Austrian lady presented in August 1997
giving a 5-day history of colicky lower abdominal pain,
diarrhoea for 3 days and vomiting for 1 day. Her urine
output had decreased over 3 days. There was no haematuria
or dysuria, although 2 weeks earlier she had a possible
urinary tract infection treated with an antibiotic. On admission she was taking ciprofloxacin and hyoscine butlybromide
which had been prescribed for presumed infectious diarrhoea.
She denied having taken any over-the-counter medications.
She had been on holiday in the Irish Republic for 2 weeks
before admission, and had picked some wild mushrooms,
which she and her daughter ate in a soup 10 days before
presentation. She had safely picked wild mushrooms for
most of her life, and she identified the recently picked ones
as a Cortinarius species, almost certainly Cortinarius orellanus
(Figure 1). Unfortunately she was not aware that the species
was toxic.
The only past medical history of note was that of left
sided hydronephrosis in childhood treated by surgery. There
was no family history of renal disease.
She was apyrexial with a blood pressure of 140/80 mmHg
and was clinically euvolaemic. Abdominal examination
revealed tenderness in the left iliac fossa but no peritonism