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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
Evaluation of Diameter of Main Hilar Renal Artery to Predict the Presence of Supplementary Renal Artery by Contrast-enhanced MDCT: A Retrospective Study in Northern India
Correspondence Address :
Dr. Manu Gupta,
PhD Scholar, Department of Anatomy, Santosh Medical College,
Hapur, Uttar Pradesh, India.
E-mail: manug0409@gmail.com
Introduction: Accessory renal arteries are non anastomotic end arteries that correspond to a single renal artery’s segmental branch. It is the most common anatomic variation of renal artery, with an incidence ranging from 8.7-75.7%.
Aim: To determine the normal reference range of diameter of the main hilar renal artery in presence or absence of supplementary renal arteries and using contrast-enhanced Multidetector Computerised Tomography (MDCT) in North Indian population.
Materials and Methods: This retrospective study was conducted in the Department of Anatomy in collaboration with the Department of Radiodiagnosis at Santosh Medical College and Hospital, Ghaziabad and Dr. O.P Gupta Imaging Centre, Meerut, Uttar Pradesh, India, from April 2019 to October 2021. Data analysis was done from November 2021 to December 2021. Contrast-enhanced MDCT scan images were reviewed for measurement of the diameter of main hilar and supplementary renal artery. A total of 108 patients were recruited through consecutive sampling.
The diameter of the main hilar and supplementary renal artery on each side was measured at the site of origin from the abdominal aorta with the help of an electronic calliper in axial view of MDCT images. The mean differences among the groups with and without supplementary renal artery were evaluated using the student’s t-test.
Results: The mean diameter of the main hilar renal artery in the absence of the supplementary renal arteries on the right and left side were 5.99±1.13 mm and 6.07±1.25 mm, respectively. The mean diameter of the main hilar renal artery with supplementary renal arteries on the right side was 5.11±1.096 mm and on the left was 5.18±1.08. The mean diameter of the main hilar renal artery was smaller in kidneys with a supplementary renal artery than in those without a supplementary renal artery, statistically significant difference was evaluated (p-value <0.001 on the right and left side).
Conclusion: The diameter of the main hilar renal artery can indicate whether supplemental renal arteries exist or not.
Contrast-enhanced multidetector computed tomographic, Hilar supplementary artery, Renal transplant
Each kidney is supplied by the single renal artery on each side, which arises from the Abdominal Aorta (AA), corresponding to the disc between the L1 and L2 vertebrae (1). In addition, accessory renal arteries are also present, which seems to be the most common anatomic variation, with an incidence ranging from 8.7-75.7% (2).
According to Stephens FD, accessory renal arteries are non anastomotic end arteries that correspond to a single renal artery’s segmental branch. Clinically, the presence of these accessory renal arteries increases the operative time and complexity of the surgeries for both donor and recipient, with a resultant risk of arterial thrombosis (3). During renal transplant surgery, a luminal diameter of atleast 3 mm is necessary to create a safe anastomotic site for both the main and accessory renal arteries. So, awareness of the normal reference range for the diameter of the renal artery and its anatomical variants is very essential (4).
Renal artery variations show social, ethnic and racial differences (5). The racial distribution of renal artery variation is as follows: Africans (37%), Caucasians (35%), Hindus (17%), Chinese (14.5%), Caribbean (36.5%), Columbian (33.3%) and Greek population (11.2%) (5),(6). Various terminologies have been given to the variable number of renal arteries, such as: aberrant, supplementary, multiple, extra, accessory, and supernumerary (6),(7).
Bordei P et al., introduced three new terms (8):
1. The main hilar renal artery is the largest hilar artery.
2. The hilar supplementary artery is the smaller one.
3. The superior and inferior polar arteries supply blood to the renal poles.
In the current time period, due to a variety of factors, the prevalence of End-Stage Renal Disease (ESRD) is steadily rising. For ESRD, renal transplantation is considered the ideal choice of treatment modality (9). A complete renal vasculature assessment of donor is mandatory before transplant surgery (10).
To achieve success in renal transplant surgery, it is very important to remember the anatomy of the renal artery and its anatomical variants. An awareness of the anatomical morphometric data on the diameter of the main renal artery is beneficial:
a) In selecting donors for renal transplants.
b) Guiding the radiologist during arterial catheterisation.
c) Designing an artery stent graft as well as for the surgeon who places such a stent.
d) In robotic surgery, where surgeons cannot identify the arteries by palpation.
e) During urologic procedures involving endovascular and laparoscopic techniques (11).
The aim of the study was to determine the normal reference range of diameter of the main hilar renal artery in the presence or absence of supplementary renal arteries and to predict the presence of supplementary renal artery using contrast-enhanced Multidetector Computerised Tomography (MDCT) in the North Indian population.
This retrospective study was conducted in the Department of Anatomy in collaboration with the Department of Radiodiagnosis, Santosh Medical College and Hospital, Ghaziabad and Dr. O.P Gupta Imaging Centre, Meerut, Uttar Pradesh, India, who were referred for contrast-enhanced MDCT examination for evaluation of various suspected abdominal complaints/conditions/pathologies from April 2019 to October 2021. Data analysis was done from November 2021 to December 2021. A proper ethical clearance was obtained from Ethical committee of Santosh Medical College, Ghaziabad (F. No.SU/2021/092/25). Informed consent was obtained from all the patients who participated in the study.
Contrast-enhanced MDCT scan images were reviewed for measurement of the diameter of main hilar and supplementary renal artery. The sample population and study period of this study is same as that of study conducted by Gupta M et al., (12). A total of 108 patients were recruited through consecutive sampling.
Inclusion criteria
• Patients (male or female) between 18-70 years of age.
• The kidney function test revealed that the patients’ kidneys are in normal functioning order.
• Two normal kidneys with good quality of reformatted contrast-enhanced MDCT images of the renal vasculature.
• Absence of morphological features of renal artery diseases.
• No history of renovascular diseases and hypertension.
Exclusion criteria
• Allergy to contrast
• Contraindication to radiation exposure (like pregnancy)
• Contrast-enhanced MDCT images with artifacts, suboptimal postcontrast arterial opacification.
• Contrast-enhanced MDCT images of patients with abnormalities that could interfere with optimum evaluation of the renal artery, aortic or renal vascular pathologies, renal masses, prior nephrectomy and other retroperitoneal lesions.
Preprocedural precaution
• The patient was enquired about some queries to rule out any drug allergy.
• The patient has been asked to come empty stomach (overnight fasting).
• Just before the procedure, the patient was recommended to drink only water.
• Blood urea and Creatinine levels were evaluated before the procedure.
• Females were asked about confirmed pregnancy or last menstrual period.
Computer Tomography Procedure
Ensured that the patient was properly prepared and positioned. The patients were placed in the supine position for contrast-enhanced computerised tomographic scans of abdomen, with the feet entering the gantry first. An 18-gauge venous line was placed in an antecubital vein. Pre contrast computerised tomographic scans covering both kidneys from the diaphragmatic dome to the iliac crest were obtained. Based on the pre-contrast scan, a region of interest with an area of 1 mm2 was established in the lumen of the aorta at the level of the Superior mesenteric artery and a series of thin cuts were obtained. Following that, an automated power injector was used to inject 100-140 mL of non ionic iodinated contrast agent (iodixanol, visipaque 320 mgI/mL) at a flow rate of 4 mL/s through a cannula positioned in the antecubital vein. All contrast-enhanced computerised tomographic scans were started with the bolus tracking technique, which utilised automatic scan triggering software. At 25 and 55 seconds after the start of an intra venous infusion of contrast material, volumetric data sets for the arterial and venous phases were collected.
Image Analysis
After the raw images were obtained, post-processing was the next step, images were sent to a separate workstation after which they were analysed and interpreted. Individual volume data were loaded into the 3D program and the data were reformatted into routine 3D images. The 3D images were manipulated by rotating them to achieve the correct planes and removing unnecessary anatomical details to separate the renal artery from the overlying structures. The diameter of the main hilar and supplementary renal artery on each side was measured at the site of origin from the abdominal aorta with the help of an electronic calliper in axial view of MDCT images shown in (Table/Fig 1). When more than one renal artery supplies to the kidney, the artery with greatest diameter was considered as the main hilar renal artery.
Statistical Analysis
The collected data was entered into a Microsoft Excel sheet and analysed by using IBM Statistical Package for Social Sciences (SPSS) version 25.0 software. The result was expressed as the mean, Standard Deviation (SD), minimum, maximum, range. The mean differences among the groups with and without supplementary renal artery were evaluated using the student’s t-test. A binary logistic regression analysis was used to predict the presence of supplementary renal arteries.
The mean diameter of the main hilar renal artery on the right side in the absence of the supplementary renal arteries was 5.99±1.13 mm and in the presence of one/two Supplementary Renal Arteries (SRA), it was 5.20±1.13 mm and 4.62±0.75 mm respectively (Table/Fig 2).
The mean diameter of the main hilar renal artery on the left side in the absence of the supplementary renal arteries was 6.07±1.25 mm and in the presence of one/two/three supplementary renal arteries, it was 5.39±1.01 mm, 4.45±0.94 mm and 3.95±1.20 mm (Table/Fig 3).
The mean diameter of the main hilar renal artery on the right side was 5.11±1.096 mm in kidneys with supplementary renal arteries. The mean diameter of the main hilar renal artery on the left was 5.18±1.08 mm in the kidneys with supplementary renal artery. The main hilar renal artery diameter was smaller in kidneys with a supplementary renal artery than in those without supplementary renal arteries, statistically significant difference was evaluated (p-value <0.001 on the right and left side) (Table/Fig 4).
When the main hilar renal artery on the right side has a diameter of <5.11 mm, the presence of supplementary renal arteries is very likely. However, if the diameter of the main hilar renal artery on the right side is >5.99 mm, the presence of supplementary renal arteries is less likely. Similarly, if the diameter of the main hilar renal arteries on the left side is <5.18 mm, the presence of a supplementary renal artery is more likely, and if it is >6.07 mm, the presence of a supplementary renal artery is less likely.
The absence or presence of a supplementary renal artery was predicted by applying a binary regression analysis (Table/Fig 5). After including the parameters of side and diameter of the Main Hilar Renal Artery (MHRA) in the binary logistic regression analysis to predict the absence or presence of a supplementary renal artery, the regression equation of prediction was found to be:
Pr=2.778-0.78×side-0.647×MHRA.
In the given equation side=1 if there is right side else side=0.
MHRA denotes the diameter of main hilar renal artery
The presence of supplementary renal artery predicted if Pr >0.5.
The above model has predictive accuracy of 72.69%.
Supplementary renal arteries are of critical clinical importance because omitting them during pre-operative preparation of patients for surgical procedures, particularly those requiring a small field of view, such as laparoscopic and retroperitoneoscopic nephrectomy, can result in fatal consequences. A proper decision regarding the planning of the nephron-sparing surgery and prevention of possible perioperative surprises can be achieved by knowing the variable number of renal arteries (13),(14),(15).
Previous studies concluded that the presence of an accessory renal artery is inversely proportional to the diameter of the main renal artery. Similarly, the statistically significant difference in the diameter of the main renal artery in kidneys without accessory renal arteries and in kidneys with accessory renal arteries shows that the renal artery diameter is a factor that should be considered preoperatively for predicting the presence of additional renal arteries (13),(16),(17),(18),(19) (Table/Fig 6).
Ramadan SU et al., evaluated the mean diameter of the renal artery in absence of accessory renal artery 5.71±0.83 mm and with the presence of one and two accessory renal arteries were 4.88±1.07 mm, 4.46±0.97 mm respectively. Likewise, in the current study, we concluded that the mean diameter of the main hilar renal artery decreased in the presence of number of supplementary renal arteries (18).
Knowledge about the presence of supplementary renal arteries are very essential for the renal transplant surgeons. Bleeding from a damage to a supplementary renal artery during a laparoscopic Living Donor Nephrectomy (LDN) can result in an open laparotomy (20). A missing case of supplementary renal artery can result in a transplanted kidney infarction and accompanying hypertension in the recipients. It may have an impact on the kidney donation decision, post-transplantation period, and can complicate donor and recipient operations, that may increase the risk of arterial thrombosis (21),(22). Supplementary arteries, if present, need multiple anastomoses and longer ischaemia time in the recipient, thus increasing the risk of renal failure, graft reduction, and graft function reduced (12).
The present study, the dimensions of main hilar renal artery diameter in the adult North Indian population, will add more information into the body of literature and help to transmit this knowledge to enlighten the surgeons during the renal surgery practice in the same region and beyond.
Limitation(s)
Present study database is limited to only limited patient’s group who came to the Department of Radiology in the SMC Ghaziabad and Dr. O.P Gupta Imaging Centre. This need to be included different patient’s group in the North Indian population to validate the result in the same population.
The presence or absence of supplementary renal arteries can be determined by measuring the diameter of the main hilar renal artery and it can be used to detect the presence of supplementary renal arteries. This finding decreases the assessment duration and facilitates radiologist decisions concerning the requirement for advanced investigations.
Authors would like to express the sincere gratitude to thesis committee of Santosh Medical College for their insightful comments and encouragement, but also for the hard question which incented me to widen my research from various perspectives. Authors are grateful to technical staff from department of anatomy and radiology of Santosh Medical College. Authors would like to give special thanks to Dr. O.P. Gupta, who allowed us to do research in his centre.
Declaration: Present manuscript belongs to my PhD Thesis topic “A morphometric study on the renal vasculature and its anatomical variants in north india population by multidetector computerised tomography”. One article of this research titled “A Contrast-Enhanced MDCT Study on the Morphology of Renal Vessels, Their Variations and Clinical Implications. published in the International Journal of Anatomy and Research. ISSN 2321-4287. Int J Anat Res. 2022;10(1):75-82 (12).
DOI: 10.7860/JCDR/2022/56008.16387
Date of Submission: Mar 02, 2022
Date of Peer Review: Mar 26, 2022
Date of Acceptance: Apr 26, 2022
Date of Publishing: May 01, 2022
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
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