Pain Killers and Kidney

Pain Killers and Kidney

Analgesics (pain killers) are one of the most important causes of permanent kidney damage. These drugs are grouped as NSAIDs or Non-steroidal anti-inflammatory drugs.

In European countries these form one of the commonest cause of CKD in countries like Belgium, Sweden, Australia and US. With greater awareness of this problem, the incidence is decreasing in the western world while more and more cases are being diagnosed in India.

The vultures, hawks, and raptors, crows and similar birds are on the verge of extinction. A theory postulating the cause of this decline in their numbers is consumption of carcass of dead animals fed analgesics for fattening and milk productions. The analgesics remaining in the dead tissue causes kidney failure in these birds resulting in their premature death.

The commonest drug implicated is phenacetin in combination with aspirin and codeine. Combination drugs are more likely to cause kidney damage. Ingestion of 1000 to 5000 tab is sufficient to cause permanent renal damage.

Most countries have banned phenacetin while in many analgesics are not sold without a prescription.

The disease is more common in a woman suffering from a headache, arthritis or a backache. Psychological dependence and abuse of analgesics is a common problem. This causes further abuse of the drugs and often denial of the same. Underestimation of analgesic abuse is common.

These drugs may also cause edema of feet, high blood pressure, atherosclerosis of blood vessels and damage to the stomach and intestines. These have also caused urinary bladder tumours of malignant variety.

The kidney damage starts in the tip of filtering system called papilla. These are may become thick, calcified and may break off (papillary necrosis). This is a result of less blood supply to this area of the kidney.

Additionally, NSAIDs may also cause AKI (acute kidney injury) by a mechanism akin to allergy.

These diseases can be prevented by limiting analgesic usage to only situations where medically needed while keeping a watch on dosage and regular monitoring of kidney function.


Malaria :

Signs and Symptoms

After a mosquito bite, the parasite goes to the liver where it multiplies and matures through different forms.

After 10 to 35 days, the parasites get released in blood in waves and cause fever. Falciparum incubation period is 10 to 14 days.

Fever may be > 40 0 . It comes on alternate days in P vivax and falciparum and every 3rd day in P ovale. However, if many mosquitoes have bitten laden with parasites, fever may come daily and sometimes many times in a day.

There are typically 3 stages. Stage of chills and shivering, the bed might shake if it is pronounced, stage of warmth and finally sweating before temperature settles down. The patient may feel well in between the fever episodes.

Red blood cells release hemoglobin and anemia ensues. The spleen enlarges in most cases. Untreated fever may continue for weeks and then subside as the body develops immunity or recur again and again over months and at times years.

Malaria can be complicated, often in falciparum variety but sometimes in vivax as well. Complications can involve liver, kidney, brain, heart, lungs, intestines etc. There may be bleeding from various sites, glucose in blood may decline and patients without treatment often die of these complications.

It can cause Coma or unconsciousness, fits, jaundice, kidney failure, bleeding from various sites (DIC), loose motions with low BP and shock (algid malaria). Abortions may occur if patient is pregnant.


Diagnosis is made by peripheral smear examination. A drop of blood is spread (smeared ) on a slide and seen under a microscope after staining. Parasites may be seen and their no can inform us about the severity of infections. Trained and sincere laboratory technicians are required for this test.

Easier tests include looking for malarial parasite antigen and antibodies. These nowadays are quite accurate.

Blood and urine tests are also done for associated complications if any.

Next Prevention and treatment

Drugs after Renal Transplant: II

Drugs after Renal Transplant: II

There are a number of other drugs used in transplant recipients after they are discharged from the hospital.

In the initial period these include:

Antibiotics to prevent urinary tract infections. These may need to be continued for 6 months. These (Trimethoprim + Sulfas) may prevent pneumocystis infection of the lungs as well.

A common infection in transplant recipients is due to cytomegalovirus. This can be prevented by a drug called Valgancyclovir. It is usually given for 90 – 100 days. It is a costly drug and the total treatment may cost about 25000 to 45000 ₹ depending on the dose and duration of CMV prophylaxis.

Anti Hypertensive drugs, sugar lowering drugs may be required in cases of Hypertensives and diabetics.


Malaria Introduction

It is a disease caused by a protozoan parasite named Plasmodium. The various species are

P falciparum, P vivax, P malariae, P ovale and P knowlesi.

First 2 are common in India. P ovale is found only in Africa. P malariae is also rare while it is not certain whether P knowlesi transmission occurs through monkeys.

The disease is spread from one human being to another by the bite of female Anopheles mosquito. This bites during the night (after sunset) till day break.

Transmission is influenced by no of mosquitoes, no of bites, the no of parasites in the blood which is ingested by mosquitoes and the no of parasites in the saliva of mosquitoes injected in man.

Falciparum is usually more dangerous than vivax. However, more and more cases of complicated vivax malaria are being seen now.

After a bite of infected man by mosquitoes, it takes 8 to 30 days before the mosquito can transmit malaria.

Coming up Clinical manifestations and diagnosis.


Hypertension in Dialysis Patients

Hypertension in Dialysis Patients I

About ½ of dialysis patients have high BP while on regular dialysis. A pre-dialysis BP > 140/90 mm Hg is required for the diagnosis of hypertension in this group.

Mortality, cardiovascular events including heart attacks, congestive heart failure, strokes are more common in hypertensive dialysis patients.

Systolic BP < 110 mm Hg Or >160 mm Hg is also associated with poor outcome in dialysis patients. Hence the BP has to be optimised and kept somewhere between these two limits.

Causes of high BP in dialysis population:

Expansion of body water and blood volume

Reduced blood supply to kidneys

Salt accumulation

High Calcium level

Thickened arteries

Preexisting essential hypertension

Increased sympathetic nervous activity

Poor water compliance

Poor drug compliance.

BP is measured before and after dialysis. For better overall BP, 24-hour ambulatory recordings are made.

Coming up Treatment of hypertension in the dialysis population.



Overweight is the term used when a person weighs more than the set limits for him or her. Obesity on the other hand is an excess of body fat.

Appropriateness of weight is measured by BMI (body mass index).

The formula for this is:-

Weight in Kilograms ÷ (Height in meters) 2

eg if a person weighs 80 kgs and his height is 1.6 meters than his BMI is

80/ 1.6 X 1.6 =80/2.56 =31.3.

A person with BMI > 25 but < 30 is considered overweight and > 30 obese. If BMI is > 35 a person is considered to have a severe problem.

Causes of overweight in children :

Being overweight or obese is always due to the accumulation of fat as the calories consumed are more than calories burnt by the body.

In children, obesity is often due to over indulgence in sweets, sugar in ice creams and beverages or cold drinks, lack of exercise, more fats in the diet.

Food habits in the family, genetics and overweight family members play a significant role.

Other factors are video games, TV, android phones, excess sleep etc. In some cases hormonal disorders or brain disorders may alter hunger and satiety and thus may cause obesity. These conditions are rare.

Childhood obesity persists into adulthood if the obesity is severe, if parents or other family members are obese and if no action is taken to correct the cause.

CKD (Chronic Kidney Disease)

CKD ( Chronic kidney disease)


The  common causes of CKD are

  • Long standing Diabetes mellitus

  • Hypertension

  • Chronic glomerular diseases ( usually underlying cause is obscure)

  • Chronic interstitial diseases.

  • Stone disease or other obstructive diseases like enlarged prostate, narrowing of urethra, cancer of cervix in woman or prostate in man,

  • Genetic diseases Polycystic kidneys, vesicoureteric reflux

  • Acute kidney injury that does not recover, Analgesic abuse,

  • HIV related kidney disease etc.

Japanese Encephalitis (JE)

Japanese Encephalitis( JE)

It is caused by a virus called JE Virus or JEV. It is now endemic in Asia. Most cases occur in the beginning of rainy season.

The disease is spread by mosquitoes. The virus multiplies in pigs and aquatic birds. When a mosquito bites human beings after biting pigs the virus is transmitted to man. Pigs are the most important hosts due to very high levels of virus in their blood.

In man the virus multiplies but does not reach levels where a mosquito after biting one human being can transmit it to others. The name of mosquito spreading it most often is Culex Vishnui. However, it is found in other species of mosquitoes as well.

After a gap of 5 to 15 days (called incubation period), signs and symptoms of the disease appear.

Most of the cases where the bite transmits the virus are subclinical or mild. Only about 1% of the cases are severe and brain inflammation or encephalitis is seen.

In the beginning, there is fever and sometimes loose motions and body aches. Chills and rigors, headache and vomiting may occur. A few days later involvement of the brain is seen with the occurrence of fits, drowsiness, and patients may become unconscious.

Diagnosis is achieved by finding antibodies against this virus in the blood (ELISA Test) and rarely by finding viral particles (NAAT )

They may remain bedridden for weeks.

20 to 30 % of the patients who are hospitalised with JE die due to the illness. Of the survivors, 40 to 50 % may have permanent neurological damage.

Prevention is accomplished by preventing mosquito bites.

A vaccine grown in vera cell line given in doses of .5 ml on day 0 and 28 is available for adults. A live attenuated vaccine and other vaccines have also been manufactured. These vaccines may have side effects.

The efficacy of the vaccine is not yet clear.

Immunosuppression after Kidney Transplant

Immunosuppression after Kidney Transplant

The drugs are always taken on the advice of a physician experienced in dealing with transplants. Patients should never change doses on their own. Stopping of drugs may result in acute rejection and damage to or loss of the kidney. Usually three drugs are given. These are required to be taken lifelong.

The medicines may be Tacrolimus/ cyclosporine.

Older patients of functioning transplants may be on cyclosporine. These drugs are similar and called Calcineurin inhibitors. These drugs have a no of interactions with other drugs. Simultaneous intake of other drugs may increase or decrease the levels of these drugs.

Some common side efftects of CNI inhibitors are tremors, high BP, increase in urea and creatinine( due to kidney dysfunction) , swelling of the feet and high blood sugars. These also increase chances of infections.

Cyclosporine can also increase body hair, facial hair, or hair from the ears. This is called hirsutism and may be very unpleasant side effect in ladies. The dosage of these drugs are based on their blood levels which need to be checked periodically.

Azathioprine or mycophenolate.

These drugs are the other commonly used immunosuppressives. They may decrease blood cell formation (WBCs or RBCs or platelets or all three togather. They can also increase infections in the transplant recipient. Mycophenolate may cause abdominal cramps, diarrhoea or constipation.

These are expensive drugs and the blood levels are not easily available.

The interactions are fewer with other drugs.


This is an important component of the immunosuppressive regime.

These drugs are started at very high levels in the 1st few days and rapidly reduced.

Though very effective in its action, these drugs are full of side effects. These drugs may cause weight gain, high sugars, high BP, dyslipidemias, behavioral disorders, hirsutism, rounding of the face, muscle weakness and sleeplessness. They can also cause bone weakness and increase chances of infections as do the other transplant medicines.

The drugs are always taken under medical supervision and sudden changes or stoppage of the drug may be catastrophic.

Obesity III Treatment of Obesity

Obesity III Treatment of Obesity

Obesity treatment or weight loss is important as weight loss reduces the complications of obesity. It decreases chances of heart disease, diabetes, high blood pressure, stroke or hyperlipidemias. After weight loss, the metabolism of the body slows down and fewer calories are consumed. Hence weight loss is never easy. Lost weight may be regained (Recidivism). A person has to watch his weight regularly, exercise regularly and continue diet precautions usually lifelong.

Some times losing weight rapidly by consuming a very low fat diet may result in iformation of gall bladder stones. In them increasing fat in diet may reduce the risk of gall stones.

How to reduce your weight?

There are only 2 options: either burn more calories or reduce their intake in food.

The first option is more troublesome as very little calories are consumed in daily activities. A person who is hardly doing any physical work consumes only 1200 to 1500 calories a day.

Each gram of fat provides 9 cal while proteins and carbohydrates provide about 4 cal each.

About 20 – 25 cal/kg body weight will maintain a constant body weight. In order to reduce the weight about 500 cal less than this would be sufficient.

The initial goal may be to reduce weight by 5 to 7 %. Most of the obese patients report less intake of food than they actually consume.

Fats should form only < 30 % of the calories and should preferably be polyunsaturated. Proteins can form upto 45% and remaining provided by carbohydrates. Very low calories, mediterranean and other various diets have been found to be less useful but are more fashionable in various countries.

Life After Kidney Transplant

Life After Kidney Transplant

Kidney transplant is preferable to lifelong dialysis as it usually provides a better quality of life. After initial 14 days, the risk of death is less in transplant recipients compared to patients on dialysis.

The human body tries to throw out the transplanted kidney as it is perceived as a foreign body by the tissues.

To overcome this tendency of the body, drugs are required to be taken lifelong by transplant recipients. These drugs are called immunosuppressives.

These drugs also reduce body’s reaction in case an infectious agent gains access to the body. Hence infections can occur more often, with smaller doses of bacteria and viruses. These infections may be severe and life threatening. At times bacteria and viruses which do not cause infections in other healthy individuals may also cause infections in transplant recipients.

These infections have to be suspected more often, investigated more aggressively and treated vigorously with appropriate antibiotics by a physician. In India, most  deaths take place with a functioning graft due to infections. Hence the importance of preventing these.

How to prevent infections in transplant recipients:

Infections spread by food, water, contact and by inhalation of droplets containing pathogens( bacteria, virus, fungi etc). They can also be introduced during surgery, by IV lines, tubes placed in the body and during various medical procedures.

Infections from water are prevented by drinking filtered / RO and clean water only. Tubewells, river, ponds, most municipal water in cities and towns may be having infectious agents. Hence it is not safe to drink untreated water. In case of dire necessity, boiled water as in tea can be consumed.

Food should be fresh, made from clean ingredients in clean utensils and consumed early. Food kept in refrigerator (especially as power cuts are common place) can be contaminated and when consumed may cause infectious diarrhoea.

Close contact of persons with obvious respiratory infections eg common cold, influenza, pneumonia, chickenpox, measles, sore throat etc should be avoided. Good quality masks (as used for preventing the spread of swine flu) are used for prevention of respiratory infections. Vaccines against pneumonia are similarly useful to protect against pneumonia.

Hygiene should be immaculate. In hospitals etc ensure absolute asepsis to prevent any infections during sampling, IV infusions, injections or surgical procedures.

If adequate care is taken a person can lead an active life. He can live a normal long, productive and useful life.

Next coming up

Various drugs after a transplant.

Obesity II

Obesity II

Obesity is evaluated by screening for confirmation and assessment of risk factors. Once the BMI confirms obesity severity is divided into

Grade I BMI >30 but < 35 Grade II BMI >35 but < 40 Grade III BMI > 40 Waist circumference is measured at the highest level of the hip bone by a tape placing it horizontally.

In woman a waist circumference of > 88 cm or 35 inches and in Man >102 cm or 40 inches signifies central obesity.

Persons with central obesity are more at risk for heart disease, diabetes, Obstructive sleep apnoea and hyperlipidemia (excess lipids in blood). Coexistence of coronary artery disease, atherosclerosis elsewhere, Sleep apnoea, high BP, h/o premature heart attacks in other close relatives, smoking and lack of exercise : all these act togather to increase mortality.

Cadaver Transplantation

Cadaver Transplantation

Cadaver transplant refers to removal of organs for transplant after a person’s death. Death can be of two types : Cardiac death or cessation of cardiac activity permanently is the conventional concept of death.

Brain dead donation (Heart beating donors)

In cases admitted to the ICUs of various hospitals, a person may have cessation of all functions of brain or brainstem due to lack of blood supply to the brain. In these cases heart, kidneys, lungs and other organs can continue to function for sometime.

In India a committee of doctors in the hospital, declare a person brain dead after testing for the same as per Human organ trasplant act and rules. The organs i.e. heart, lungs , kidneys, pancreas and other useful organs may be allocated by the authorities as per guidelines.

Prior permission of the deceased individual and his close family members is required before organ retrieval. Till the organs are removed the ventilator and other supportive measures to keep these organs in optimum state are continued. In case donation of these organs is not agreed by relatives, the organs can not be removed. (Full details are mentioned in THOA 2014 and its various amendments and state level committees.

For cadaver donation of kidneys state and transplant centers maintain a waiting list of suitable patients. Weightage in waiting list is given as per set guidelines.

Donation after Cardiac Death:

In some countries now in cases of persons who have terminal diseases and organ donation is planned, the removal of organ is planned in such a way that organ(s) are removed immediately the heart function ceases. The results of such transplants are encouraging.

Swine Flu

Swine Flu

It is also known as H1N1 viral influenza A or simply as H1N1 Influenza.

The last big pandemic was in 2009. Nowadays it occurs off and on in India and other countries mainly during flu season.

Fever usually more than 100o F is common. It is accompanied by a sore throat, running nose, cough, headache and muscle pains. Shivering may occur as do vomiting and loose motions.

Individuals both very young and very old as well as pregnant women are at high risk of complications. Similarly, those with other debilitating conditions: malignancy, asthma, smokers, HIV +ve patients and those who have low immunity due to various drugs and disease may develop severe complications.

About 10 % persons may have no symptoms. Fever may not occur in some cases.

The complications may occur in about 20 % cases. These are in the form of failure of gas exchange by lungs, low BP, altered level or lack of consciousness, fits, liver and kidney failure etc. 

The diagnosis is made by both nasopharynx and throat (combined) real time reverse transcriptase (rt RTPCR) which is nearly always positive. Chest X Rays can show pneumonia.

In some cases, superadded bacterial infections occur a few days later and complicate the illness.

Treatment and prevention

Treatment with antiviral drugs reduces complications. The drugs used are Oseltamivir and Zanamivir. The doses are different for children. These drugs are also used for prevention of infection after and before contact with swine flu patients.

The spread is by droplets (during coughing and sneezing ) and close contact. Patients should be diagnosed early to prevent the spread of the disease.



Chronic Kidney Disease

Chronic Kidney Disease


Disease of the kidney of long standing, ie > 3 months are called chronic disease. These can be diagnosed.

If the kidney function is lower, this is measured indirectly by Serum Creatinine. If the measured GFR is > 90 ml / min, it is normal. CKD is diagnosed if GFR is < 60 ml/min persistently for > 3 months. If the urine albumin is > 30 mg/day, red or white blood cells are present in urine.

If on ultrasound, X Rays or kidney biopsy, the kidneys are found to have abnormalities.

CKD in early cases is without symptoms. Symptoms gradually increase as the kidney function decreases over time.

Nearly all kidney diseases are progressive in nature and keep worsening with time. These will result in End-Stage renal disease in most cases. End-Stage is diagnosed when the kidney function is so low that life without external support is difficult and RRT or Renal Replacement Therapy in the form of Dialysis (either Hemo or Peritoneal dialysis) or Renal transplant is required.

In some case, the function deteriorates suddenly and rapidly. This then is called Acute superimposed on CKD (Ac on CKD). This sometimes is reversible and the patient may require dialysis till this improvement is achieved.

The aim of the treatment is to alter the course of the disease (slow its progression or halt the progression).

In some cases the progression is very rapid (over months) while in others it may take decades.