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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Renal Challenges in Pregnancy: Investigating Acute Kidney Failure and Perinatal Well-being- A Prospective Descriptive Study
Correspondence Address :
Dr. Rose Mary Penumaka,
Flat 202, Celesta, G-14-1, Aarthika CBn1 Compound, NP Road, Visakhapatnam-530003, Andhra Pradesh, India.
E-mail: dr.rosemarypenumaka@gmail.com
Introduction: Acute Kidney Injury (AKI) poses life-threatening risks in pregnancy, leading to adverse perinatal and maternal outcomes.
Aim: To estimate the incidence of Pregnancy-Related Acute Kidney Injury (PRAKI) and describe maternal and foetal outcomes in cases of Acute Renal Failure (ARF) at a tertiary care institute.
Materials and Methods: A prospective descriptive study was conducted on 104 antenatal women with ARF attending King George Hospital, Visakhapatnam, Andhra Pradesh, India, from January to December 2020. A total of 7,409 deliveries occurred during the study period, and antenatal women with evidence of pre-existing renal disease were excluded. A detailed history was obtained, and evaluation included renal function tests and a total abdominal scan. Mode of delivery, foetal deaths, stillbirths, maternal deaths, and APGAR scores were analysed. Laboratory findings were also reported. Data analysis was performed using coGuide statistical software, and results were expressed in terms of frequency and percentages.
Results: The incidence of PRAKI was 14 per 1,000 deliveries (1.4%). The mean age of the participants was 24.05±4.11 years. The majority (78 out of 104, 75%) were in the third trimester. Out of the 104 cases of PRAKI, 77 (74%) were due to hypertension. There were 16 (15.4%) maternal deaths and 19 (21.8%) perinatal deaths.
Conclusion: Pregnant women with ARF experienced increased morbidity and mortality. Urgent improvements in antenatal care, early detection of complications, effective management, and timely referrals to tertiary centres are crucial.
Foetus, Maternal death, Mothers, Outcome, Renal injury
AKI, also known as ARF, is a life-threatening complication in pregnancy, with an increased risk of adverse perinatal and maternal outcomes (1). PRAKI can occur during the antenatal, intrapartum, and postpartum periods (2). AKI can be caused by obstetric complications such as preeclampsia, eclampsia, HELLP syndrome (Haemolysis, Elevated Liver Enzymes, Low Platelets), septic abortion, placental abruption, hyperemesis gravidarum, sepsis, etc., even in pregnant women without a history of renal dysfunction (3). Maternal and neonatal mortality from traditional causes has been decreasing, with a 34% improvement in maternal care from 2000 to 2020, according to UNICEF (4). However, conditions like PRAKI are emerging as significant contributors to maternal and foetal mortality and morbidity, reflecting changing trends (5),(6). A Systematic Review and Meta-Analysis (SRMA) reported that women with PRAKI had a 1.49 times higher likelihood of caesarean delivery, 1.26 times higher risk of haemorrhage, 1.86 times higher risk of HELLP syndrome, 3.13 times higher risk of placental abruption, 3.41 times higher risk of Disseminated Intravascular Coagulation (DIC), and 4.5 times higher risk of maternal death compared to women without PRAKI, but had a lower risk of eclampsia. The rate of end-stage renal disease requiring dialysis was 2.4% in PRAKI cases (6).
The incidence of PRAKI has been declining in developing countries but remains a significant contributor to foetal and maternal mortality (7). The projected incidence of PRAKI in developed countries is one in 20,000 deliveries (8). ARF complicated 1.78% of total deliveries in the third trimester of pregnancy (9). The incidence of ARF is relatively low in developing countries compared to developed countries, but the overall mortality rate is reported to be high at 20% (9). Despite the declining incidence rates, higher maternal and perinatal morbidity and mortality continue to be a concern in developing countries. There is also a lack of literature in the present study area, Visakhapatnam, to guide policy decisions and actions regarding AKI in pregnancy. Hence, the present study aims to estimate the incidence of PRAKI and describe maternal and foetal outcomes in cases of ARF at a tertiary care institute.
A prospective descriptive study was conducted on antenatal women attending King George Hospital, Visakhapatnam, Andhra Pradesh, India, from January to December 2020. Ethical approval was obtained from the institutional review board (Ref: 136/IEC/KGH/Sep/2019) of the concerned centre. Informed written consent was obtained from the participants or their legal representatives before the study started, and confidentiality was maintained throughout.
Inclusion criteria: Previously healthy pregnant women with serum creatinine levels >1.2 mg/dL, oliguria (24-hour urine output <400 mL), and anuria were included in the study.
Exclusion criteria: Antenatal women with a previous history of chronic hypertension, Diabetes Mellitus (DM), pre-existing renal disease, increased serum creatinine levels before pregnancy due to other causes, and ultrasound findings indicating chronic kidney disease such as renal scarring or shrunken kidneys were excluded from the study.
The study population consisted of a total of 7409 deliveries that occurred during the study period. Out of these, 104 antenatal women were identified to have ARF.
Procedure
Data was collected regarding socio-demographic variables and baseline characteristics including the patient’s age, trimester during the visit, and parity. Systemic and obstetric examinations were performed. Investigations such as complete blood count, peripheral smear, renal function tests including serum electrolytes, serum uric acid, urine analysis, 24-hour urine protein, and total abdominal scan were carried out. Cases progressing into labour were closely monitored, and a Lower Segment Caesarean Section (LSCS) was performed when indicated. In cases of severe renal failure with indications, pregnancy was terminated and haemodialysis was performed. Ventilatory support and/or blood transfusion were provided as necessary for specified cases with indications. Subjects were closely monitored by keeping them in the labour ward. Renal function tests were performed and haemodialysis was planned accordingly when needed. Mode of delivery, maternal deaths, cause of death, foetal deaths, stillbirths, perinatal deaths, and APGAR scores were recorded.
Statistical Analysis
Data entry and analysis were performed using “coGuide Statistics software, version 1.0” (10). Foetal and maternal variables were considered as outcome parameters, while age, parity, etc., were considered as other relevant variables. Continuous variables were expressed as mean and standard deviation, while categorical variables were expressed as proportion and frequency.
The majority of participants were in the age group of 21 to 25 years (47.1%) and were primigravida (46%) (Table/Fig 1).
Hypertension (74%) was the major aetiological factor, and 87.5% presented during the antenatal period (Table/Fig 2).
(Table/Fig 3) shows that the majority (58%) had a serum creatinine level of 1.3 to 2 mg/dL. Hyponatremia was seen in 13.46% of cases, and hyperkalemia in 11.53%. Abnormal liver function tests were observed in 33.7% of cases.
(Table/Fig 4) shows that there were 16 (15.4%) maternal deaths and 19 (21.8%) perinatal deaths. Of the total, 69 (75.8%) women had a vaginal delivery.
The incidence of PRAKI was 14 per 1000 deliveries (1.4%). Out of the 104 cases of PRAKI, 77 (74%) were attributed to hypertension. There were 16 (15.4%) maternal deaths and 19 (21.8%) perinatal deaths. AKI has been identified as one of the main independent factors associated with maternal deaths (11). PRAKI can also lead to long-standing cardiac, neurocognitive, and renal complications that extend beyond the postpartum period (12).
In this study, a total of 7409 deliveries were recorded during the study period. According to the present study, the incidence of AKI was 14 per 1000 deliveries. Other studies have also compared the proportion of pregnant women among subjects with ARF, and the incidence has ranged from 7-9% (13),(14). The incidence observed in the present study was higher compared to developed countries. This difference could be attributed to lower socio-economic status, decreased awareness about antenatal care, and delays in treatment in developing countries like India.
The mean age in this study was 24.05±4.11 years, as shown in (Table/Fig 1). This finding was consistent with the study conducted by Aggarwal RS et al., where the mean age was reported as 26 years (15). In the present study, the majority of cases (75%) occurred in the third trimester. Aggarwal RS et al., reported that 50% of cases occurred in the second trimester and 42% in the postpartum period (15). In the first trimester, conditions such as hyperemesis gravidarum and septic abortions can result in PRAKI (1). In the third trimester, PRAKI is mainly associated with conditions like preeclampsia, antepartum haemorrhage, and thrombotic thrombocytopenic purpura (7),(9). In the postpartum period, the main causes of PRAKI are puerperal 12sepsis, postpartum haemorrhage, acute fatty liver of pregnancy, and haemolytic uremic syndrome (1),(7).
Out of the 104 cases of PRAKI, 77 cases were attributed to hypertension, as shown in (Table/Fig 2) in the present study. Among the hypertensive cases, 62.3% were due to preeclampsia, 15.6% were due to antepartum eclampsia, 9.1% were due to HELLP syndrome, and 13% were due to abruptio placenta. Aggarwal RS et al., reported the aetiology of AKI in pregnancy as follows: puerperal sepsis (40%), haemorrhage (30%), and preeclampsia, eclampsia, and HELLP syndrome (36%) (15). Their study also found that antepartum haemorrhage contributed to 20% of cases, while postpartum haemorrhage contributed to 10% of cases. This reflects a trend towards an increasing incidence of hypertension and a decreasing incidence of haemorrhage and sepsis, indicating an improvement in antenatal care.
The incidence of AKI caused by sepsis has reduced due to widespread antibiotic use in sepsis management and the legalisation of abortion. Currently, hypertensive disorders of pregnancy are the major contributors to PRAKI. In a study by Aggarwal RS et al., (15) the rate of LSCS was reported as 22%, compared to 17.3% in the present study.
In the present study, the mortality rate was 15.4%, which was comparable to the 12% reported by Aggarwal RS et al., (15). Najar MS et al., reported a maternal mortality rate of 18.57%, with sepsis accounting for 61.5% of the deaths in their study (16). Maternal mortality appears to be higher in developing countries due to factors such as poor antenatal care, late referral, and frequent sepsis. In the study by Tripathy SS et al., 11 maternal deaths were reported, accounting for 11% of their subjects, which was relatively lower than the 15.4% observed in the present study (17).
The incidence of PRAKI was reported as 0.66% or 6.6 per 1000 deliveries in the study by Arrayhani M et al., (18). This was comparable to the incidence of 14 per 1000 deliveries reported in the present study. Sachan R et al., (5) reported an incidence of 1.02% (or 10 per 1000 deliveries) of AKI during pregnancy and the puerperium, which was similar to present study. Poor prognosis has been associated with two factors, as highlighted by Arrayhani M et al., in their study: older age (above 38 years in their study) and advanced stage of AKI (18). In the present study, dialysis was required in 10.6% of cases, while in the study by Aggarwal RS et al., 30% required long-term dialysis (15). Arrayhani M et al., reported that 16.2% of cases required haemodialysis in their study (18). In the present study, the majority (58%) had serum creatinine levels at admission in the range of 1.3 to 2 mg/dL, and only 7% had serum creatinine levels >5 mg/dL.
In the present study, the perinatal mortality rate was 21.8%, as shown in (Table/Fig 4), which was lower than the study by Drakeley AJ et al., (19). In the present study, 82.35% of babies had a mean APGAR score in the range of 8 to 10, while 4.42% had an Apgar score in the range of 4 to 6, as shown in (Table/Fig 4). In the present study, 3.4% were stillborn and 18.4% of babies did not survive. Tripathy SS et al., observed that 5% of deliveries resulted in stillbirth in their study (17).
In the study by Sachan R et al., reported a stillbirth rate of 38.4%, and Drakeley AJ et al., the perinatal mortality rate was 38% in their study (5),(19). They found that stillbirth or intrauterine death was more common in cases with Stage-II AKI and Stage-III AKI compared to Stage-I AKI.
AKI is a life-threatening complication. It is a serious and common complication of pregnancy, regardless of improvements in healthcare systems and reforms. Out of the 104 cases of PRAKI, 77 (74%) were attributed to hypertension. There were 16 (15.4%) maternal deaths and 19 (21.8%) perinatal deaths.
AKI in pregnancy is associated with increased foetal and maternal morbidity and mortality. Early detection of PRAKI and subsequent early interventions improve maternal and perinatal outcomes. It is crucial to create awareness among mothers and healthcare providers, especially in rural areas. Improving antenatal care and ensuring quick referral in complex cases in limited settings is essential.
Limitation(s)
The present study was limited to a single centre, which may limit the generalisability of the findings. Hospital-based results may not fully represent the scenarios of PRAKI in the community.
Kidney failure after birth has serious outcomes and an increased risk of death. Patients in shock are at greater risk. Anuria in PRAKI indicates a challenging situation. There is a higher incidence of cases in first-time pregnant women and during the final trimester.
DOI: 10.7860/JCDR/2023/66474.18728
Date of Submission: Jul 14, 2023
Date of Peer Review: Aug 21, 2023
Date of Acceptance: Sep 29, 2023
Date of Publishing: Nov 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 15, 2023
• Manual Googling: Sep 02, 2023
• iThenticate Software: Sep 27, 2023 (13%)
ETYMOLOGY: Author Origin
EMENDATIONS: 6
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