45th Indian Society of Nephrology Conference, Kolkata, 18th to 21st December 2014
An Interview with: Prof. Dr DK Agarwal, New Delhi
Q.1 What is the KDIGO Guidelines recommendation relating to pharmacological cholesterol-lowering treatment in adults?
Ans: Following are the recommendations: 1. In adults aged =50 years with eGFR <60 mL/min/1.73 m2 but not treated with chronic dialysis or kidney transplantation (GFR categories G3A-G5) , treatment with a statin or statin/ezetimibe combination is recommended. 2. In adults aged =50 years with CKD and eGFR =60 mL/min/1.73 m2 (GFR categories G1-G2), treatment with a statin is recommended. 3. In adults aged 18-49 years with CKD, but not treated with chronic dialysis or kidney transplantation. Statin treatment in people with one or more of the following conditions is recommended: • Known coronary disease (myocardial infarction or coronary revascularization) • Diabetes mellitus • Prior ischemic stroke • Estimated 10-year incidence of coronary death or nonfatal myocardial infarction >10%. 4. In adults with dialysis-dependent CKD, it is suggested that statin or statin/ezetimibe combination is not to be initiated. 5. In patients already receiving statin or statin/ezetimibe combination at the time of dialysis initiation, it is suggested that these agents to be continued. 6. In adult kidney transplant recipients treatment with a statin is recommended.
Q.2 Why should we obtain a full lipid profile in all CKD patients at first presentation?
Ans: Initial evaluation of the lipid profile mainly serves to establish the diagnosis of severe hypercholesterolemia and/or hypertriglyceridemia and potentially rule out a remediable secondary cause if present.
Q.3. What is the rationale for not taking frequent follow-up measurements of serum lipids?
Ans: Since higher cardiovascular risk and not elevated LDL-C is now the primary indication to initiate or adjust lipid-lowering treatment in CKD patients, follow-up monitoring of serum lipids is not useful.
Q.4 The SHARP study had a large impact on a strong recommendation in GFR categories G3A-G5. Could you please highlight the same?
Ans: In SHARP study statin plus ezetimibe therapy was associated with a significant 17% RR reduction of the primary outcome of major atherosclerotic events like coronary death, MI, nonhemorrhagic stroke or any revascularization, compared with placebo. SHARP indicated death risk for the primary outcome of major atherosclerotic events other than death was reduced by simvastatin/ezetimibe among a wide range of patients with CKD.
An Interview with: Dr DK Pahari, Kolkatta
Q: 1. What are the major concerns pertaining to quality-of-life in your ND-CKD patients report?
Ans: 1. Patients with ND-CKD report fatigue, cognitive impairment, sleep disturbance, pain, impaired mobility, anxiety and depression and with predialysis ND-CKD (Stages 4 and 5) report health utility scores within the same range as those with stroke and severe peripheral vascular disease. Because iron is a key functional component of hemoglobin (Hb), myoglobin and a large number of enzymes involved in cellular energetics, immune mechanisms and the synthesis and degradation of complex molecules such as DNA, deficiency of iron is a cause of great concern.
Q: 2. What is the recommendation to treat iron deficient ND-CKD patients with comorbid condition like CHF?
Ans: 2. CHF is highly prevalent in CKD patients. According to available data report, overall prevalence of CHF in CKD is 31.2%. Although, the prevalence may depend on age and stage of renal failure, ranging from 18.8% (CKD stages 1-2,) to 47.3% (CKD stages 4-5).
Nephrology guidelines recommend that ID should be addressed with iron therapy before initiating erythropoiesis-stimulating agent (ESA) for anemia treatment. Routine testing for TSAT and ferritin should be used to identify ID in patients with ND-CKD (especially those with comorbid CHF) who present symptoms such as fatigue or decreased physical function. Evidence from FAIR HF showed that treatment with intravenous iron (Ferinject) helps to correct ID and may alleviate symptoms that were previously attributed to anemia or an underlying chronic condition such as CKD and/or CHF.
Q: 3. What hemoglobin level do you try to achieve in CKD patients?
Ans: 3. Recently, many reviews and meta-analyses exploring the optimal Hb targets for CKD patients with anemia have been published. Now-a-days, many nephrologists propose that partial correction of anemia to maintain Hb levels in the target range of 10-12 g/dL was a safe strategy. Nonetheless, recently released modified recommendations for usage of ESAs in patients with CKD suggest lowering the ESAs dose, while Hb levels is more than 10 g/dL and 11 g/dL, respectively, in predialysis and dialysis patients. And the previously recommended Hb targets around 10-12 g/dL have been removed from its label.
Q: 4. Optimal treatment algorithms for ESA and iron therapy in anemic CKD patients are lacking. How do you maintain a balance between these two agents in your clinical practice?
Ans: 4. The clinical management approaches for anemia in CKD patients have changed markedly over the past 10 years. Following changes to ESA drug labels, clinicians are prescribing fewer ESAs and more intravenous iron.
Although, ESAs have become the mainstay of anemia therapy in CKD patients, iron deficiency and/or insufficient iron bioavailability emerges as a major limiting factor in the effectiveness of these treatments. Providing sufficient levels of iron via intravenous iron administration is a prerequisite in many patients with CKD to ensure optimal ESA responses.
The newer generation of intravenous iron maximizes clinical benefits and minimizes adverse outcomes in anemic CKD patients treated with ESA and iron supplements.
Q: 5. What are the current practices of administering iron in CKD patients in India?
Ans: 5. The use of oral versus intravenous iron as the first-line management in this condition varies, partly because of the individual nephrologist's beliefs and also partly due to a paucity of scientific evidence in this clinical setting, but is also influenced by the accessibility to a service that is readily able to provide intravenous iron supplementation. Thus, in primary care, general practitioners are likely to start with oral iron, whereas the renal units that support an intravenous iron clinic (usually nurse-led) are more likely to start with intravenous iron.
Q: 6. What are the guidelines recommendations for intravenous iron in CKD patients?
Ans: 6. Once a diagnosis of iron deficiency anemia is made, it has been recommended that iron replacement therapy be administered in patients with CKD on HD to achieve serum ferritin >200 ng/mL (and up to 500 ng/mL), TSAT >20% (or CHr (reticulocyte Hb content) >29 pg/cell); and in patients with CKD on peritoneal dialysis or those not on dialysis, to a target of serum ferritin >100 ng/mL (up to 500 ng/mL) and TSAT >20%.
More specifically, recent KDIGO 2012 treatment guidelines suggest that a trial of intravenous iron should be given to patients with anemia and CKD not on iron or an ESA to increase Hb without starting ESA, and if the patients are on ESA, the objective should be to decrease the dose of ESA.
News Around The Globe
The US Food and Drug Administration (FDA) has approved the fluoroquinolone antimicrobial, finafloxacin otic suspension, to treat acute otitis externa, commonly known as swimmer's ear, caused by Pseudomonas aeruginosa and Staphylococcus aureus.
MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) shows a benefit on functional outcomes of an intra-arterial interventional approach for treating stroke vs the current standard of care. The findings are published online December 17 in the New England Journal of Medicine.
Weekly azithromycin pulse therapy appears to be a quick and effective means of treating orofacial granulomatosis, suggested a case series from India published online in JAMA Dermatology.
Maintenance nilotinib plus relatively mild combination chemotherapy produced an 87% complete remission rate and a 70% rate of survival at 2 years in older patients with acute lymphoblastic leukemia (ALL), reported new research presented at the American Society of Hematology 56th Annual Meeting.
Users of methamphetamine are at three times more risk for getting Parkinson's disease than people who do not use illegal drugs, suggests new research published in the journal Drug and Alcohol Dependence.
Dr KK Spiritual Blog
Ganesha, The Stress Management Guru
If Lord Krishna was the first counselor who taught the principles of counseling, Lord Ganesha taught us the principles of stress management.
We should worship Lord Ganesha and become like him whenever we face any difficulty or are stressed out.
The elephant head of Lord Ganesha represents that when in difficulty, use your wisdom, intelligence and think differently. It can be equated to the Third Eye of Lord Shiva. Elephant is supposed to be the most intelligent animal in the kingdom. Hear wisdom implies to think before speaking. Lord Budha later also has said that don’t speak unless it is necessary and is truthful and kind.
The big elephant ears of Lord Ganesha signify listening to everybody when in difficulty. Elephant ears are known to hear long distances. Elephant eye see a long distance and in terms of mythology, it represents acquiring the quality of foreseeing when in difficulty. The mouth of Lord Ganesha represents speaking less and hearing and listening more.
The big tummy of Lord Ganesha represents digesting any information gathered by hearing to people in difficulty. The trunk represents to use your power of discrimination to decide rom the retained information. It also indicates to do both smaller and bigger things by yourself. Elephant trunk can pick up needle as well as a tree.
The broken and unbroken teeth of Lord Ganesha represent being in balance in loss and gain. It indicates that one should not get upset if the task is not accomplished and also not get excited if the task is accomplished. In times of difficulty, Ganesha also teaches us not to lose strength and control one’s attachments, desires and greed.
The four arms of Lord Ganesha represent strength. Ropes in two hands indicate attachment, Laddu or Sweet in one hand represent desires and mouse represents greed. Riding over the mouse indicates controlling one’s greed.
Lord Ganesha is worshiped either when one’s task is not getting accomplished or when a new work is initiated. In these two situations, these principles of Lord Ganesha need to be inculcated in one’s habits.
The Choice - I
My dad was everything to me, I idolized him. There was no one that could be higher on the pedestal than he. Time and again, he'd pitch a ball to me and then retrieve it when I managed to hit it. I helped him wash his car nearly every weekend. I was his shadow and he the image that as I looked up, blocked everything else out. Nothing bad could happen when my daddy was around.
My dad owned a store in our basement. He didn't mind when I ran downstairs and bothered him when he had customers. Actually, he never hesitated to put me to work bagging up their purchases. When the day was done, I would sit on his lap and count the money earned that day. I loved helping him.
My dad also had a problem. He was an alcoholic. Before I was five, I never knew that it affected our family. I didn't hear my parents fighting. I never saw him stagger around. When he was gone throughout the night, I never realized where he might have gone. I know I didn't understand much of what my parents and older sisters were facing. I was the untouched child thus far.
My sisters were eight and nine years older than I was. I had no idea that their play time with me was really them protecting me from the one that I looked up to. I was just excited that for once that day they were paying attention to me instead of pushing me away. I was five. Who at that age would have guessed what that play time was hiding?
One day while watching cartoons, with my chin in my hands I was randomly kicking my feet through the air. Everything seemed to disappear when Daffy Duck was on the television. Every few moments or so, I would twist my hair in my fingers, then go back to holding up my chin. I heard the back door open and slam closed. My senses heightened when I realized it was the middle of the day. No one but my sisters should be home when Daffy was on. In came my dad. He was falling, catching himself on the walls and mumbling quite loudly. I was scared because this wasn't like my Daddy. I ran to him yelling "Daddy, Daddy, Daddy." At the same time as I was reaching him, my sisters came bounding down the stairs intercepting me with their arms. Why were they holding me back from my dad?
"Let me go to my Daddy, he needs me!" I yelled. By this time, tears were pooling in my eyes as I struggled to get free. I also noticed that my dad was saying some horrible expletives.
"No Cindy, he'll hurt you. You need to stay back," Amy, the older, self-acclaimed wiser sister cautioned me. She was always trying to be bossy. I wasn't going to let her get away with it this time.
Inching closer to my parents' bedroom to where my dad had escaped, I peered in while saying to her, "You let me go! He's my Daddy and he won't hurt me!" I then noticed that my dad had a suitcase out on the bed and was haphazardly throwing items into it.
I didn't understand what was happening, but as my mind tried to grasp it all my sisters pulled me back into the living room. That's when I began to cry openly. I continued yelling "Daddy, my Daddy." Yet, he never came out to talk to me. It wasn't long before my voice starting going hoarse and both my sisters had me fully wrapped in their arms. We were entangled together, heaped on the floor. I was crying out, even as Amy was continuing to tell me that she didn't want him to hurt me. My other sister just kept agreeing with her.
Huddled together expecting the worst, my dad came out carrying as much as he could. Without looking back, he walked out the door. Instead of screaming, "Daddy!" I now was crying. "He didn't even say good-bye, my daddy didn't tell me good-bye," I sobbed. This horrible sense of loneliness came over me as I watched my hero stumble and trip past us carrying what he could and not caring what he left behind.
I am my dad's only child. My sisters belong to my mom, but I am the only one that belongs to my dad. I've heard it said that alcohol can play a lot of games with one's mind. What I couldn't understand was how it could cause someone to walk out on their loved ones.
That was the only time I recall seeing my dad incapacitated and it was the first time I saw my hero fall. He came back a few weeks later, sober. He's not had a drink since.
He's not perfect and he's slid off that pedestal a few times since then, but I still look up to him. He raised my sisters as his own and now, into his 60's, he's raising Amy's youngest child, also as his own. I believe all things come full circle, since his own grandparents raised him.
Years after his last binge, when I had enough courage to ask my mom about it, I learned that he took all the money and the only car with him when he left. My mom was ingenious enough to "steal" back the car and make do while he was gone. Then she told me something I'll never forget.
"I found the hotel he was staying at, Cindy. I told him that he could have his drink, but not his daughter. Or he could have his daughter and not his drink." He chose me.
Health Check Up and CPR 10 Camp at GB S School, Khan Pur, New Delhi, on 27th November 2014
Exercise impact on the knee
Sameer Malik Heart Care Foundation Fund
The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number +91 9958771177 or by filling the online form.
Madan Singh, SM Heart Care Foundation Fund, Post CAG
Kishan, SM Heart Care Foundation Fund, Post CHD Repair
Deepak, SM Heart Care Foundation Fund, CHD TOF
Total CPR since 1st November 2012 – 101090 trained
The CPR 10 Mantra is – "within 10 minutes of death, earlier the better; at least for the next 10 minutes, longer the better; compress the centre of the chest of the dead person continuously and effectively with a speed of 10×10 i.e. 100 per minute."
CPR 10 Success Stories
Ms Geetanjali, SD Public School
Success story Ms Sudha Malik
BVN School girl Harshita
Elderly man saved by Anuja
CPR 10 Videos
VIP’s on CPR 10 Mantra Video
Hands–only CPR 10 English
Hands–only CPR 10 (Hindi)
IJCP Book of Medical Records
IJCP Book of Medical Records Is the First and the Only Credible Site with Indian Medical Records.
If you feel any time that you have created something which should be certified so that you can put it in your profile, you can submit your claim to us on :
Dr Good and Dr Bad
Situation: A pregnant lady died.
Dr Bad: Declare her dead.
Dr Good: Deliver the infant within 5 minutes.
Lesson: "Five minute rule", the best outcome with regards to neonatal neurological outcome is most likely when delivery occurs within five minutes of maternal cardiac arrest.
Situation: A rape victim became pregnant.
Reaction: Oh my God! Why was emergency contraceptive not given to her?
Lesson: Make sure that all victims of rape are given an emergency contraceptive.
A real–estate agent was driving around with a new trainee when she spotted a charming little farmhouse with a hand–lettered "For Sale" sign out front. After briskly introducing herself and her associate to the startled occupant, the agent cruised from room to room, opening closets and cupboards, testing faucets and pointing out where a "new light fixture here and a little paint there" would help. Pleased with her assertiveness, the woman was hopeful that the owner would offer her the listing. "Ma’am," the man said, "I appreciate the home–improvement tips and all, but I think you read my sign wrong. It says, "HORSE for sale."
Twitter of the Day
Dr KK Aggarwal: Blood Pressure: A silent killer
Dr Deepak Chopra: Rewire your brain for higher consciousness by paying attention to love, compassion, and joy.