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|Year : 2017 | Volume
| Issue : 7 | Page : 1-17
|Date of Web Publication||8-Nov-2017|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Oral Presentations. Indian J Nephrol 2017;27, Suppl S1:1-17
| Oral Paper Presentations 15 December 2017 (10.20am to 11.40am) Hall A|| |
1. 5-HT2/5-HT2B Receptor Antagonism Attenuate Fibrotic Phenotype of Human Peritoneal Fibroblasts via Non-Canonical Signalling in Patients Receiving Continuous Ambulatory Peritoneal Dialysis
Saurabh Chaturvedi, Harshit Singh1, Vikas Agarwal, Akhilesh Jaiswal1, Ravi Mishra, Narayan Prasad1
Departments of Clinical Immunology and 1Nephrology; SGPGIMS; Lucknow; Uttar Pradesh; India
Background: Peritoneal fibrosis is a major cause of ultrafiltration failure in continuous ambulatory peritoneal dialysis (CAPD) patients. 5-hydroxytryptamine (5-HT;) induces extracellular matrix synthesis in interstitial fibroblasts in a Transforming growth factor beta 1 (TGF-β1) dependent manner. We evaluate anti-fibrotic role of 5-HT2 and 5-HT2B inhibitors; Terguride and SB204741; in human peritoneal fibroblasts (HPFB) isolated from omentum and parietal peritoneum of CAPD patients undergone catheter change.
Aim of the Study: To evaluate the effect Terguride and SB 204741 on fibroblasts derived from omentum and peritoneum of chronic renal failure patients receiving long term continuous ambulatory peritoneal dialysis.
Methods: Omentum biopsy (OB) of control patients (n=5) undergone elective abdominal surgery and of CAPD patients (n=2) was washed with sterile PBS and incubated in 0.125% trypsin/0.01% EDTA twice for 20 minutes followed by two times for 40 minutes at 37°C. Biopsy from parietal peritoneum (PB) from control patients undergone elective cholecystectomy and of CAPD patients was incubated overnight in dispase (2.4 U/mL)/37°C. Pellet obtained from OB and PB; incubated in cDMEM gave HPFB in 2 weeks. In 1st strategy; HPFB from OB and PB were incubated with 5-HT-1 μM for 1 hr and later with 5-HT-1 μM and (Terguride; SB 204741-1 μM; each) for 24 hr. In 2nd; HPFB from OB and PB were pretreated with (Terguride; SB 204741-1 μM; each) for 1 hr and later with 5-HT-1 μM for 24 hr. Real time PCR for pro-fibrotic (TGF-β1; Col1a1; Col1a2; ACTA2; CTGF and FN1) and anti-fibrotic genes (MMP2/TIMP1) expression was performed. Type I collagen and α-SMA; phosphorylation status of Smad-3 and ERK1/2 was examined by immunoblotting.
Results: In 5-HT stimulated HPFB; upregulated expression of Col1a1; Col1a2; ACTA2; CTGF and FN1 (p<0.05) mRNA at 24 hr was observed. Co-culture of HPFB with 5-HT2 and 5-HT2B receptor antagonists; Terguride and SB 204741; significantly reduced pro-fibrotic genes expression (p<0.05) in both the strategies. Effect on anti-fibrotic genes mRNA in both the strategies was not affected. Pre-treatment with Terguride and SB204741 decreased the production of type 1 collagen and α-SMA significantly (p<0.05). 5-HT dose-dependently increased the mRNA levels of TGF-β1. Terguride and SB 204741 did not influence Smad-3 phosphorylation (canonical pathway) rather they significantly reduced ERK1/2 phosphorylation (non-canonical pathway) (p<0.05).
Conclusions: 5-HT2 and 5-HT2B receptor antagonists reduce pro-fibrotic mRNA expression in 5-HTstimulated HPFB by suppressing TGF-β1 mediated non-canonical pathway.
2. To Study the Utility of M-Type Phospholipase A2 Receptor Antibody (PLA2R) in Membranous Nephropathy
Shingada Aakash Kirit, Gupta Ashwani, A K Bhalla, M Malik, Gupta Anurag, V Bhargava, Gaur Lovy, Gupta Pallav1, D S Rana
Departments of Nephrology and 1Pathology; Sir Ganga Ram Hospital; New Delhi; India
Background: Membranous Nephropathy is one of the common cause of nephrotic syndrome in adults. The M-type phospholipase A2 receptor (PLA2R) was recently identified as a major target antigen in adult iMN. Circulating antibodies against PLA2R were found in up to 70– 80% of patients with iMN but not in any other glomerular diseases or healthy people; and very rarely in secondary MN. Levels of circulating anti-PLA2R revealed a strong correlation with clinical disease activity.
Aim of the Study: This study aimed to assess the sensitivity of Antibody to PLA2R as a marker for Idiopathic MN. We also correlated the presence of Antibody to PLA2R to the degree of proteinuria.
Methods: All patients with suspected nephrotic syndrome were enrolled in the study after taking informed consent. Blood samples were collected and stored at the time of kidney biopsy and in patients with biopsy proven membranous nephropathy these samples were processed for antibody to PLA2R. Anti-PLA2R antibody detection was performed using transfected cell-based indirect immunofluorescence (IIFT) using the Euroimmune kit. PLA2R antigen deposits in tissue were detected by direct immunoflorescence using FITC conjugated anti rabbit secondary antibody ab6717 along with primary PLA2R ab80054 by Abcam. Proteinuria was quantified by Urine spot samples for Protein: Creatinine ratio. Serum Albumin and Creatinine were measured. Detailed history; examination and investigations (including tumour markers; HbsAG; autoimmune markers and imaging where necessary) were performed to rule out a secondary cause of MN. Statistical analysis were performed using SPSS software.
Results: 29 MN patients were included. Mean age of patients was 45.17 +/- 11.85 yrs. 3/29 patients had a secondary cause of MN. PLA2R (either serum or tissue) was positive in 18/29 (62.1%) patients; 17/26 (65.38%) in iMN and 1/3 (33%) in secondary MN. 14/26 (53.8%) patients with iMN had positive Serum PLA2R ab; 14 (53.8%) had PLA2R deposits in glomerulus. 10 patients with positive Serum PLA2R ab also had PLA2R in glomerular deposits. 4 patients with positive Serum PLA2R did not stain for PLA2R in tissue; while 4 patients with tissue PLA2R did not have circulating PLA2R. Thus; 8 (27.5%) patients had discordance in positivity to PLA2R in serum and tissue; suggestive of epitope spread. PLA2R was associated with heavier proteinuria and hypoalbuminemia with proteinuria of 11.53 +/- 6.18 gm in patients with PLA2R versus 4.43 +/- 2.64 gm in patients negative for PLA2R (p<0.001) and serum albumin 1.87 g/dl +/- 0.62 g/dl in PLA2R positive patients versus 2.86 +/- 0.24 g/dl in patients negative for PLA2R (p<0.001).
Conclusions: PLA2R is an important diagnostic tool in patients with Membranous nephropathy; though it cannot replace biopsy in view of moderate sensitivity. PLA2R is associated with heavy proteinuria and hypoalbuminemia and pattern of PLA2R positivity and epitope spread may help identify difficult to treat cases.
3. Effectiveness of an Intervention Package on Internal Jugular Vein Catheter Related Infection Among the Patients Undergoing Hemodialysis: A Randomised Control Trial
Geetanjali Loomba, Manju Dhandapani, Chandigarh Sukhpal Kaur, Manisha Biswal, Sandhya Ghai, Raja Ramachandran
Postgraduate Institution of Medical Education and Research; Chandigarh; India
Background: Temporary vascular access continues to be the initial choice of vascular access in the developing and underdeveloped world for patients on hemodialysis. Infection of the internal jugular vein (IJV) catheter continues to be a common cause of death in patients with end-stage renal disease (ESRD) undergoing hemodialysis.
Aim of the Study: The present study aimed to evaluate the effectiveness of an intervention package on the incidence of IJV catheter-related blood stream infection (CRBSI).
Methods: A randomised; controlled; parallel; and non-inferiority trial was conducted on patients with ESRD undergoing hemodialysis via right IJV catheter. Patients were randomly allocated to control and experimental group via computer generated random table. Ethical approval was taken for study. Recruitment of participants was done from July 2016 to October 2016. Intervention package for the experimental group included hand washing; feet washing and axillary shave. Patients were provided with a pamphlet and reinforced to continue package till IJV catheter is in situ. Patients were followed up twice a week for one month from date of catheter insertion for incidence of CRBSI; which was diagnosed based on Kidney Disease Outcome Quality Initiative 2006 criteria. Participants and microbiologists assessing the swab cultures and blood cultures were masked to group assignment. The primary outcome of the study was a percentage of patients free from CRBSI.
Results: Mean age was 44.26±14.43 years in control and 41.6±12.8 years in experimental group. Sixty-six percent of the patients in both the study groups were males. There were nodifferences in baseline parameters in both the control and experimental group. Similar organisms were found in pre-procedure swab cultures of both the groups. Staphylococcus epidermidis the most common bacteriaisolated at all sites (nasal; axilla; throat and catheter insertion site) except toe webs where staphylococcus hemolyticus was most common. On the intention-to-treat analysis; the percentage of patients without CRBSI was 53.7% and 29.3% of patients in the experimental and control arm; respectively (p=04; 25.12% (1.43-45.28%). Blood culture positives were higher in control (73.3%) as compared to the experimental group (28.6%).
Conclusions: Non-pharmacological interventions are an effective method to reduce the incidence of CRBSIs among population undergoing maintenance hemodialysis via temporary IJV catheter.
4. Mortality Rate and its Determinants in End Stage Renal Disease Patients
Neha Jain, Sanjiv Saxena
PSRI Sheikh Sarai Phase II; New Delhi; India
Background: An Indian population-based study determined the crude and age-adjusted end-stage renal disease (ESRD) incidence rates 151 and 232/million populations; respectively. Mortality rate in ESRD patients remains high; ~ 20% reported in 2 yr follow up study. We performed this study to assess the mortality rate and to assess various factors promoting mortality in ESRD population.
Aim of the Study: To assess the mortality rate in ESRD population in India at the end of 1 yr. To evaluate various factors predisposing to mortality.
Methods: We included 167 patients on hemodialysis and after taking history of primary cause of renal failure (diabetes; chronic glomerulonephritis; chronic interstitial nephritis or others); residual renal function by total urine output in 24 hrs; dialysis access (Arteriovenous fistula; temporary jugular/femoral catheters; perm-cath or arteriovenous grafts); dialysis vintage (duration on dialysis); weight; BMI; we followed them every 3 months and haemoglobin; pre and post dialysis BUN; calcium; phosphate and albumin were checked. PTH and 25 hydroxy D were also done. ADLs-activities of daily living (maximum score 5) and IADL-instrumental activities of daily living (maximum score 8 for women and 5 for male) which suggest an individual's ability to perform daily routine and to carry out work; respectively were done to assess functional status of patients.
Results: We found that mortality rate was 11% in our study (18 patients out of 167) over span of 1 year. Mean age of 149 survival group patients was 50.5 years compared to mean age of mortality group patients 60.5 years which was statistically significant with a p value of 0.002.154 (92%) patients had good LVEF (>50%) and mortality rate in this group was no different than in patients having LVEF <50%; suggesting that having good left ventricular ejection fraction alone is not protective against cardiovascular mortality. Low score of instrumental activities of daily living <5 for male and <8 for female; was associated with increased mortality compared to the patients with normal IADL scores with a significant p value 0.036. Four patients out of 9 who had mean PTH level <300 pg/ml expired while none of the patients with PTH value >300 pg/ml had mortality (p value <0.05). The mean value of PTH in mortality group patients was 47.5 pg/ml.
Conclusions: We conclude that age and instrumental activities of daily living are significant determinant of mortality. Cardiovascular mortality occurs even in patients with less apparent cardiac disease. Hypoparathroidism was associated with significantly higher mortality in ESRD patients.
5. Cholecalciferol Supplementation is Effective for Suppressing Secondary Hyperparathyroidism in Chronic Kidney Disease Patients with Vitamin D Deficiency
Ashok Kumar Yadav1, Vivek Kumar1, Vinod Kumar1, Krishan Lal Gupta1, Vivekanand Jha1,2,3
1Department of Nephrology; Postgraduate Institute of Medical Education and Research; Chandigarh; 2The George Institute for Global Health; New Delhi, India; 3University of Oxford; Oxford; England; United Kingdom
Background: Chronic Kidney Disease (CKD) is considered a state of functional resistance to native forms of vitamin D. Use of active forms of vitamin D is advocated in CKD patients for treatment of mineral bone disease because of the presumption that native forms of vitamin D would not undergo significant activation to calcitriol; the most active biological form of vitamin D.
Aim of the Study: To evaluate the effect of cholecalciferol versus placebo on bone and mineral metabolism markers.
Methods: This was a randomized; double blind; placebo controlled trial to evaluate the effect of cholecalciferol supplementation on improvement in endothelium dependent flow mediated dilatation in adults with non-diabetic CKD stage G3–4 and vitamin D deficiency [serum 25(OH)D ≤20 ng/ml]. Patients were randomized (1:1) to receive either two directly observed oral doses of 300; 000 IU of cholecalciferol or matching placebo at baseline and 8 weeks [Clinical Trials Registry of India number: CTRI/2013/05/003648]. We present a secondary analysis of this clinical trial data looking at effect of cholecalciferol versus placebo on bone and mineral metabolism markers.
Results: Out of 423 screened subjects; 120 were enrolled; and 58 in the cholecalciferol group and 59 in the placebo group completed the study. At 16 weeks; the serum 25(OH)D levels increased in the cholecalciferol group but not in the placebo group [between-group difference in mean change: 23.40 ng/ml; p<0.001]. Serum calcium and serum 1; 25(OH)2D levels increased in the cholecalciferol group [between-group difference in mean change: 0.69 mg/dl (p=0.001) and 14.98 pg/ml (p=0.007) respectively]. Serum alkaline phosphatase and (iPTH) levels decreased in the cholecalciferol group [between-group difference in mean change: -20.25 U/L (p=0.008) and -100.73 pg/ml (p<0.001) respectively]. Correlation analysis of change (Δ) in serum 25(OH)D levels at 16 weeks showed that there was significant correlation of Δ 25(OH)D with Δ iPTH (r=-0.384; p<0.0001); Δ 1; 25(OH)2D (r=0.296; p=0.001); Δ inorganic phosphorus (r=0.225; p=0.019); Δ Calcium (r=0.195; p=0.05) and Δ SAP (r=-0.298; p=0.002).
Conclusions: Cholecalciferol supplementation corrects vitamin D deficiency and is effective in lowering serum intact parathyroid hormone and alkaline phosphatase in early stages of CKD.
6. A Study on the Assessment of Nutritional Status in CAPD Patients at Tertiary Care Hospital
Amaravadi Ayyappa, Manisha Sahay, Kiran Mai, Sharmas Vali Osmania
Medical College; Hyderabad; Telangana; India
Background: Malnutrition is a common finding in patients with ESRD. Appearance and progressive development of malnutrition significantly influence the efficacy and treatment outcome in chronic renal failure (CRF) patients receiving continuous ambulatory peritoneal dialysis (CAPD) therapy. Malnutrition is associated with an increased risk of morbidity and mortality. Therefore; periodic assessment of nutritional status and taking appropriate measures is important in improving the outcome.
Aim of the Study: To assess the nutritional status and to estimate the incidence and risk factors of the malnutrition development in CRF patients treated with continuous ambulatory peritoneal dialysis (CAPD).
Methods: Is a Cross sectional observational study to evaluate nutritional status of 55 CKD patients who are on CAPD (continuous ambulatory peritoneal dialysis) at Osmania general hospital. To evaluate Nutritional status - Anthrometric measurments including mid arm circumference (MAC); triceps skin fold thickness; calculated mid – arm muscle circumference (MAMC); body mass index (BMI); laboratory parameters including serum albumin; normalized protein nitrogen appearance rate (nPNA) and subjective global assessment score were used. Statistical analysis was performed using SPSS software. continuous variables were expressed as the means and standard deviation. The results from standard methods were correlated with SGA scores.
Results: 78.2% were males; 21.8% were females. Mean level of Hb was 9.1 g/dl ± 1.95. Mean level of Scr was 6.45 mg/dl +/- 2.33. Mean level of weekly Kt/V was 2.11 ± 1.87; with weekly Kt/V below the desired range in 38.2% patients. Mean level of CrCL was 56.66 L/week +/-18.72; with CrCl below the target in 47.27% patients. Mean BMI was 18.65 +/- 4.30. Normal BMI seen in 41.8% and high BMI seen in 9.1% patients; decreased BMI was seen in 49% patients with mild in 9.1%; moderate in 12.7% and severe malnutrition in 27.2% patients. Overall mean SALB was 3.11 g/dl +/- 0.66 g/dl; with 41% patients with low serum albumin. Mean level of PCR was 1.16 +/- 0.30; 47.27% patients on low level PCR. Mean triceps skin fold thickness was 11.52 mm +/-4.89. Mean mid arm circumference was 28.94 cm +/- 3.07 cm. Mean mid arm muscle circumference was 25.13 cm +/-2.93 cm. 51% patients had a SGA score in malnutrition range and 49% patients had normal score. Mortality seen in 20% patients.
Conclusions: Malnutrition is quite common and plays an important role in mortality in CAPD patients independent of dialysis efficacy and prevention or treatment of malnutrition by suitable means is necessary to improve clinical outcomes in CAPD patients.
7. Clinical Outcome of Twice Weekly and Thrice Weekly Hemodialsysis
Arun Kumar Ponna, P S Vali, Kiranmai, Manisha Sahay
Osmania Medical College; Hyderabad; Telangana; India
Background: Twice weekly renal replacement therapy is rapidly expanding in India; but survival advantage on these practice pattern are limited. Residual renal function (RRF) has consistently been a predictor of good survival in maintenance hemodialysis (MHD) patients.
Aim of the Study: In this study; we compared the clinical outcomes of twice and thrice weekly maintenance hemodialysis in ESRD patients and the impact of residual renal function.
Methods: 100 Patients in age group 18-70 years who presented to Osmania general hospital were assigned to twice and thrice weekly groups based on their clinical status. 68 patients were male and 32 were female. 42 patients were initiated on Twice weekly Maintenance Hemodialysis and 58 patients were maintained on thrice weekly maintenance hemodialysis. All the patients were on a standard 4 hour dialysis sessions.
Results: There were no significant differences between the two groups in gender; age; blood pressure and primary cause of ESRD (p > 0.05). Hemoglobin; albumin; total cholesterol; BMI; nPNA; CRP; showed no difference between the two groups (p > 0.05). A slightly lower serum phosphorus and low PTH was observed in twice weekly MHD group (p>0.05). The weekly Kt/V as well as URR were not significantly different between the two groups (p>0.05); suggesting that twice-weekly treatment can achieve the comparable HD adequacy in selected patients. The average ultrafiltration rate per HD session was higher in twice weekly MHD group (0.91 vs 0.82 L per hr). The prevalence of CVD was higher (76% vs 59%) in thrice weekly MHD group of patients than in twice weekly MHD group; and also seen higher in patients without RRF. Our data showed overall mortality higher in thrice weekly MHD group than in twice weekly group due to selection bias; high prevelance of CVD; DM in thrice weekly group.
Conclusions: Our data suggests that ESRD patients with good urine output; non CVD; non Diabetic patients may undergo twice-weekly HD without suffering from dialysis inadequacy.
8. Incidence and Risk Factors of Diarrhoea Among Renal Transplant Recipients and its Influence on Graft Outcome
Jeethu Joseph Eapen, Suceena Alexander, Vinoi G David, Shibu Jacob, Shailesh K Tulsidas, Anna Valson, Anjali Mohapatra, Santosh Varughese
Christian Medical College and Hospital; Vellore; Tamil Nadu; India
Background: Diarrhoea in the post renal transplant setting contributes to significant morbidity. There is sparse literature regarding causes of post renal transplant diarrhoea in the Indian setting. This study was conducted to identify the etiological agents and risk factors for diarrhoea among renal transplant recipients in the Indian setting.
Aim of the Study: (1) To study the incidence and risk factors for diarrhoea in a cohort of renal transplant recipients. (2) To assess the effect of diarrhoeal illnesses on graft outcome.
Methods: A retrospective chart review was conducted to identify all causes of diarrheal illnesses among renal transplant recipients. Causes of diarrhoea were classified as (1) Infective - bacterial; viral; parasitic; (2) Non-infective –drug induced or other non-infective causes or (3) No causative aetiology identified. A multivariate regression analysis was done to identify risk factors associated with diarrhoea.
Results: A total of 828 patients who underwent renal transplant between January 2007 and December 2016 at CMC Vellore were followed up. A total of 103 diarrheal episodes were recorded among this cohort; affecting 12.5% of the entire population. MPA related diarrhoea was the most common etiological agent; causing 40% of all cases of diarrhoea. Parasitic infections were the cause for 13% of all diarrheal illnesses; CMV infections caused 6% of all diarrheal diseases. No particular etiological agent was identified in over 30% of all cases. Using multivariate Cox proportionate hazard analysis; female sex; HLA mismatch; use of ATG as induction therpy and mycophenolate containing regimens were associated with an increased risk for diarrhoea.
Conclusions: Mycophenolate use was the most common risk factor associated with diarrheal illnesses in the post renal transplant setting; although in one third of cases no etiological agent could be identified. Diarrheal illnesses are associated with worse graft outcomes.
| Oral Paper Presentations 15 December 2017 (10.20am to 11.40am) Hall B|| |
9. Clinico-Pathologic Correlation in Response to Therapy in Proliferative Lupus Nephritis at Six Months
S R Patil, L Umesha
Department of Nephrology; Institute of Nephro Urology; Victoria Hospital Campus; Bengaluru; Karnataka; India
Background: Presently; the response of lupus nephritis (LN) to treatment is assessed according to specific clinical metrics. Although there are several definitions of complete and partial renal remission in current use; all rely mainly on an improvement in proteinuria; an improvement; stabilization or limited worsening of kidney function; and variably on the resolution of hematuria. Renal response definitions do not routinely include a kidney histology component.
Aim of the Study: To study clinico-pathologic correlation in respnse to treatment in proliferative lupus nephritis patients at six months.
Methods: This study is a ongoing prospective observational clinical study between February 2016 to February 2018. Patients with clinical features of lupus nephritis satisfying at least four of the ARA criteria for SLE and newly diagnosed at the time of renal biopsy were included. Descriptive statistics; One way ANOVA and Chi square test was applied during analysis.
Results: We studied 35 patients with LN with renal biopsies performed at baseline and after six months of therapy. The baseline and protocol biopsies were compared with respect to histological class transformation; crescents; tubular atrophy; interstitial fibrosis and glomerulosclerosis. We also compared serum creatinine; hemoglobin; systemic lupus erythematosus disease activity index (SLEDAI) scores; 24-h urine protein excretion and C3 levels as well as AI and CI at baseline and at six months. Histological class transformation was seen in 05 patients (14%). Intra-class progression to greater chronicity was seen in 10 other patients (28.5%). There was an increase in glomerulosclerosis; tubular atrophy; interstitial fibrosis and a reduction in cellularity; crescent formation and wire loop lesions in the protocol biopsy. A decline in AI (6.05 vs. 2.50; P <0.001) and SLEDAI scores (8.1 vs. 3.7; P <0.001) and an increase in CI (0.68 vs. 2.52; P <0.001) was observed at the time of protocol biopsy.
Conclusions: In conclusion; protocol renal biopsies performed at six months showed an increase in chronicity; especially within the same histological class. Histological class transformation was not frequently observed in our study.
10. Histone Deacetylases 2: An Epigenetic Player in Steroid Resistant Childhood Nephrotic Syndrome
Akhilesh Jaiswal, Harshit Singh, Saurabh Chaturvedi1, Vikas Agarwal1, Vinita Agarwal2, Niharika Bharti2, Ravi Mishra1, Narayan Prasad
Departments of Nephrology and 1Clinical Immunology; SGPGIMS; Lucknow; Uttar Pradesh; India.
Background: Glucocorticoids (GCs) are one of the most common and reliable therapy for inflammatory; autoimmune and proliferative diseases. Moreover; some patients show a poor or absent response. The activated glucocorticoid receptors (GR) interact with co-repressor molecules to impair NFκB-associated coactivator activity; which reduces histone acetylation. Reduction in histone acetylation occurs via recruitment of histone deacetylase (HDAC) 2 to the activated inflammatory gene complex by activated GR.
Aim of the Study: To evaluate HDAC-2 expression via immunohistochemistry and assess the HDAC2 mRNA expression in SR INS.
Methods: The immunohistochemical HDAC-2 expression was analyzed on renal biopsy samples in SR patients (n=15; M=9; mean age 8.4±2.59); and healthy control (HC) (n=6; M=3; mean age 20.47± 7.26). Healthy control samples were taken from Nephrectomy specimen; which were biopsy proven. Patients in sustained remission (SS) (n=25; M=5; mean age 9.85±7.08) for at least 6 months without steroid were recruited. All definitions are as per the criteria of ISKDC. Immunohistochemistry was performed with formalin fixed; paraffin embedded tissue section following heat induced antigen retrieval in Tris EDTA buffer (pH 8.6). Peripheral blood mononuclear cells (PBMCs) were isolated from heparinized blood. Total RNA was isolated using trizol method. Real time quantitative PCR was performed using light cycler LC480 using SYBR green PCR technology with SYBR premix Relative gene expression levels were calculated and normalized to the corresponding levels of the housekeeping gene (GAPDH).
Results: Biochemical difference were found significant in S. Albumin (SSNS=2.87±.98; SRNS=2.27±.79; p=0.012) and proteinuria (SSNS=13.18±3.09; SRNS=284±193.45; p<0.001). HDAC2 nuclear expression in healthy control and steroid dependent samples was significantly higher as compared to the nuclear expression of HDAC2 of SR patients (86.67%); (p=0.002). HDAC2 mRNA expression remained similar in PBMCs of SS patients (p=0.730) as compared to that of HC whereas in SR patients was significantly decreased (p=0.023).
Conclusions: Lower HDAC2 nuclear and gene expression in SR patients suggests use of inducers; which might lead to restoration of glucocorticoid response and better management of patients.
11. Profile of Pulmonary Infections in Renal Transplant Recipients in a Tertiary Care Centre
Shreepriya Mangalgi, Soumita Bagchi, Karan Madan, Chandan J Das, Gagandeep Singh, R K Yadav, Immaculata Xess, Sarman Singh, S K Agarwal
All India Institute of Medical Sciences; New Delhi; India
Background: Pulmonary infections are the commonest cause of infection related morbidity and mortality in renal transplant recipients. There is a paucity of data about the pattern and outcome of pulmonary infections after renal transplantation in India.
Aim of the Study: To characterize the clinical; radiological and microbiological profile and outcome of pulmonary infections in renal transplant recipients in Indian context.
Methods: In this ongoing prospective observational cohort study; renal transplant recipients following up in the nephrology department; AIIMS who were diagnosed with pulmonary infections between November 2015 and June 2017 were included. Details of immunosuppression including induction; maintenance regimens and previous rejection episodes were noted. All patients underwent detailed investigations including chest X-ray; CT scan; sputum analysis; bronchoalveolar lavage (BAL); endobronchial ultrasound with transbronchial node aspiration (EBUS-TBNA) and lung biopsy as and when required. The spectrum of radiological findings; causative organisms; treatment; patient and graft outcomes were studied. Patients were followed up till hospital discharge or death.
Results: There were 87 pulmonary infection episodes in 73 patients. 39/73 (53.4%) received induction and 65 (89.0%) were on triple drug immunosuppression. All patients received steroids; 71 (97.3%) were on calcineurin inhibitors (CNIs) and 66 (90.4%) received an antiproliferative agent. 31 episodes (35.6%) occurred in the first year. BAL was done in 64 (73.6%); lung biopsy in 13 (14.9%) and EBUS-TBNA in 4 (4.6%). At least one causative organism was found in 47 (54.0%) episodes. Multiple etiologies were confirmed in 14 (29.8%) episodes. 17 (19.5%) were hospital acquired infections. Microbiologically confirmed bacterial infections were seen in 18 (38.3%); fungal in 13 (27.7%); Tuberculosis (TB) in 19 (40.4%; 3 were drug resistant); Nocardia in 7 (14.9%) and Pneumocystis jiroveci in 6 (12.7%). 14 (16.1%) had CMV co-infection of which BAL CMV was positive in 2 cases. 17/73 patients (23.2%) died; all due to the pulmonary infection.
Conclusions: Bacterial pneumonia and TB are the commonest causes of pulmonary infections in renal transplant recipients in Indian context. There is emergence of drug resistant TB. Despite aggressive diagnostic testing; determining causative etiology is difficult. Mortality due to pulmonary infections is high.
12. Intra-Ocular Pressure Changes During Hemodialysis – An Observational Study
Jayanivash Jayam, G Nithya, S Sujit, S Thirumavalavan, K Thirumalvalavan, N D Srinivasaprasad, Noor Mohamed, M Edwin Fernando
Stanley Medical College, Chennai; Tamil Nadu; India
Background: The hemodynamic alterations during Hemodialysis in CKD –stage V patients have been associated with fluctuations in Intra ocular pressure and Ocular Perfusion Pressure which in turn has been associated with development of Glaucomatous field defects.
Aim of the Study: To assess the correlation of intraocular pressure (IOP) and ocular perfusion pressure (OPP) changes during HemodialysisTo assess their efficacy in identifying individuals at risk for glaucoma.
Methods: The study was done on 100 CKD stages –V patients undergoing hemodialysis for a period of more than one month in our dialysis unit at Stanley Medical College. Medical and Ocular history was obtained from those who were eligible for the study and they underwent relevant medical examinations including intraocular pressure measurement using Schiotz tonometry. The blood pressure was measured using a sphygmomanometer on the upper arm over the brachial artery thrice - 15 minutes prior to HD initiation (T1); 2 hours after initiation of HD (T2); 15 minutes after HD session (T3). From the above data; Mean Arterial Pressure (MAP); OPP; Systolic; Diastolic and Mean OPP were derived using standardized formulas. The high risk patients were followed up for a period of 2 years.
Results: 46% of patients were between 40-50 years of age and 59% of them were male. Type II Diabetes was the major cause of CKD (40%) followed by Hypertension. The mean systolic; diastolic and mean arterial pressure was found to be decreased by 11.1; 8.5 and 10.13 mm Hg respectively from T1 to T3 (from initiation to end of HD). The mean intraocular pressure was found to rise by 2.7 mm Hg in both eyes from T1-T3. The ocular perfusion pressures from T1-T3 were found to be decreased by 12.8 mm Hg in both eyes. The SOPP; DOPP; MOPP was found to be decreased by 13.9; 12.0 and 8.5 mm Hg in both the eyes from T1-T3. On applying the thresholds used in Barbados eye studies 58% had SOPP and DOPP less than normal.6 out of the 58 patients followed up for the 2 years had elevated intraocular pressures and early glaucomatous visual field defects.
Conclusions: Our series reveals significant fluctuations in intraocular pressure and Ocular perfusion pressures during HD and high risk individuals were predisposed to develop glaucomatous field defects. The routine screening of patient IOP will be beneficial tool.
13. Clinical Applicability of Tacrolimus Genotyping in Kidney Transplant Patients Using Tacrolimus
Shweta S Shah, T Ashavaid, D Kirpalani, H Shah, A Kirpalani
Bombay Hospital Institute of Medical Sciences & Hinduja National Hospital; Mumbai; Maharashtra; India
Background: The large inter-patient variability of Tac levels observed in KTx patients is due to different genetic profiles of the enzymes handling Tacrolimus metabolism i.e. CYP3A4; CYP3A5 and MDR- 1 genes. The CYP3A5 *3 allele is associated with decreased CYP3A5 activity. In the Indian population; known genotypes are *1/*1 (extensive metabolizers); *1/*3 (intermediate metabolizers) and *3/*3 (poor metabolizers.
Aim of the Study: To study whether; CYP3A5 genotyping helps in predicting the behavior of Tac levels in KTx patients.
Methods: 24 Tx recipients underwent genotyping for CYP3A5 gene polymorphism. Detailed Tac levels (S) were available for 17 patients. 14/17 patients had S values available only after 3 months post KTx; 1 had S values within 3 months of transplant and 3 were prospective recipients. Steroids were universal confoundersin all patients; however after 3 months of Ktx; the dose of steroids was stable. Levels in the first 3 months as well as levels done when the patients were on other confounding drugs were discarded. The Tac levels per weight-adjusted Tac dose (L/D) (i.e. ngm/ml per mcg/kg) in each group were compared.
Results: The most common genotype was CYP3A5 *3/*3 detected in 13/24. The CYP3A5 *1/*1 genotype was detected in 1/24; and CYP3A5 *1/*3 in 10. Poor metabolizers had a higher L/D in comparison to intermediate metabolizers (p<0.05). The MEAN +/- SD of weight adjusted tac levels (ng/ml per mcg/kg) were found to be 0.05 +/- 0.02 (extensive metabolisers n=1; s=19); 0.21 +/-0.2 (intermediate metabolisers n=7; s=50) and 0.29 +/-0.26 (poor metaboliser n=7; s=60) n=no. of patients; s=sample.
Conclusions: Three genotypes were identified *3/*3 having the highest levels; 1*/3 with intermediate and 1*/1* having the lowest. Knowing the CYP3A5 genotype may help to “fine tune” the optimal dose of tacrolimus and avoid acute rejection/Tac toxicity.
14. The Temporal Profile; Risk Factors and Outcome of Catheter Associated Blood Stream Infection (CABSI) with Temporary Uncuffed Catheters (TUCS) in Adult Incident Haemodialysis Patients
Varun Agrawal, Anna T Valson, Shailesh Kakde, Anjali Mohapatra, Vinoi George David, Suceena Alexander, Shibu Jacob, Yamuna Devi1, John A Jude Prakash1, Balaji Veeraraghavan1, Santosh Varughese, Veerasamy Tamilarasi
Departments of Nephrology and 1Microbiology; Christian Medical College; Vellore; Tamil Nadu; India
Background: Temporary uncuffed catheters (TUCs) are the HD vascular access of choice in low resource settings. Although TUCs should be converted to a permanent vascular access within 21 days; this is rarely possible due to various socioeconomic and logistical constraints; leading to a high incidence rate of catheter associated blood stream infection (CABSI) in this group.
Aim of the Study: We set out to study the temporal profile; risk factors and outcome of CABSIs in incident HD patients with TUCs at a large; tertiary care hospital in Southern India.
Methods: All adult (≥18 years) patients who underwent TUC insertion for HD for various indications at our centre between 1st January 2016 to 30th June 2017; had no history of temporary vascular access insertion or HD prior to the index insertion and who had at least 14 days follow up after catheter insertion at our centre; were included in the study. Clinical and laboratory parameters were retrieved from the hospital information system.
Results: Out of 897 TUCs inserted for HD; 169 patients were included in the study and contributed 7334 patient days (median 39 days). Mean age was 47.19±14.18 years; 64.5% were male; 40.8% were diabetic; median Charlson's comorbidity score was 4. CABSI incidence rate was 7.22 episodes per 1000 patient days occurring a median 28 days after TUC insertion. 88.6% presented with chills and fever and 5.6% with septic shock. The most common organisms causing CABSI were CoNS (32%); NFGNB (30.1%); and S. aureus (13.2%). Drug resistant pathogens constituted 46.5% of total CABSIs. Compared to CoNS; Gram negative and Gram positive infections had higher procalcitonin and were more likely to show left shift. Hospitalizations (11.3%); mortality (3.7%) and metastatic complications (3.7%) were exclusively seen with Gram negative organisms. No demographic; clinical or laboratory risk factors for CABSI could be identified; including duration of catheter use.
Conclusions: CABSIs occur a median of 28 days after TUC insertion; however it is likely that risk factors for CABSI are centre rather than patient related. The high incidence of gram negative and drug resistant CABSIs is a cause for concern.
15. ABO-Incompatible Kidney Transplant
Bharat Shah, Prashant Rajput, Zaheer Virani, Pawan Deore
Global Hospital; Mumbai; Maharashtra; India
Background: Kidney transplantation is the best form of renal replacement therapy (RRT) for end-stage renal disease (ESRD) patients. Yet; less than 5% of ESRD patients undergo kidney transplant in our country which has predominantly living related donor program. Accepting ABO incompatible (ABOi) donors can increase the living donor pool by 35%. There are only 2 reports with small number of patients from our country.
Aim of the Study: To determine the outcome of ABO incompatible transplant and compare with that of ABO compatible (ABOc) transplants.
Methods: This is a retrospective analysis of 42 ABOi transplants performed from March 1; 2014 to July 31; 2017. All combinations of ABO-incompatibilities were accepted including a two-blood group antigen mismatch; that is; with donor AB and recipient O. The Anti-A & Anti-B antibody titres (IgG & IgM) were estimated by column agglutination technology (CAT) using automated Ortho BioVue System. For desensitization; pre-transplant plasmapheresis (PP) and or immunoadsorbtion; rituximab (200 mg; 2 doses) and bortezomib (2 mg; 2 doses) were used. Transplant was performed when anti blood group antibody titre (IgG) dropped to ≤ 1:16. Induction and maintenance immunosuppression used was same as that used for ABOc transplant patients.
Results: Out of 208 patients; 42 (20%) were ABOi transplants and 166 (80%) were ABOc transplants. The characteristics of patients in 2 group were comparable. One and 3 years patient survival was 88% and 84% while death censored graft survival was 86% and 86% in ABOi kidney transplants. One and 3 years patient survival was 96% and 94% while death censored graft survival was 97% and 95% in ABOc kidney transplants. All patients who died after ABOi kidney transplant were elderly and diabetic. There were similar number of acute rejection episodes and infections in the 2 groups.
Conclusions: Our study shows that results (1 and 3 years survival) of ABOi kidney transplants are not significantly inferior to that of ABOc kidney transplants.
16. Preemptive Kidney Transplant
Pawan Deore, Prashant Rajput, Zaheer Virani, Bharat Shah
Global Hospital; Mumbai; Maharashtra; India
Background: Kidney transplant is the best renal replacement therapy for ESRD. Pre-emptive kidney transplantation (PKT) refers to transplantation before the initiation of chronic maintenance dialysis. It also means substantial cost saving by avoiding cost involved in creating vascular access; regular dialysis treatment and its complications. This is significant in economically deprived country like ours. But how do patients with PKT perform? There is no data from our country.
Aim of the Study: To assess the outcome of PKT and compare with that of non pre-emptive kidney transplants (NPKT).
Methods: We retrospectively studied 223 patients who underwent living related donor kidney transplant between August 1; 2013 and June 30; 2017. These patients were divided into two groups; PKT (defined as no or less than 1 week of dialysis) group and NPKT group. In all patients (except HLA full match patients); induction immunosuppression used was single dose thymoglobulin (1 mg/kg) or 2 doses of basiliximab (20 mg). Maintenance immunosuppression included tapering doses of steroids; tacrolimus and mycophenolate sodium salt or azathioprine. Patient survival; graft survival (death censored) and incidence of acute rejection was determined in both groups. Acute rejection was suspected when there was ≥20% rise in serum creatinine from the baseline which responded to empiric steroid pulse or was confirmed on kidney biopsy.
Results: Out of 223 patients; 68 (30.5%) underwent PKT and 155 patients underwent NPKT. Patients in both groups were comparable in terms of age; sex and etiology of CKD). The 1 year and 3 year patient survival was 98% and 96% in PKT group and 94% and 88% in NPKT group. The 1 year and 3 year death censored graft survival was 100% and 100% in PKT group and 95% and 94% in NPKT group. Fourteen patients (20%) had acute rejection in PKT group and 42 patients (27%) in NPKT group.
Conclusions: The patient and graft survival was better in PKT group. Also the incidence of acute rejection was lower in PKT group. Most importantly; there was significant cost saving by avoiding dialysis. Efforts should be made to perform PKT.
| Oral Paper Presentations 16 December 2017 (11.20am to 12.35pm) Hall A|| |
Rekha-1 Non Invasive Method of Differentiating Diabetic Nephropathy and Nondiabetic Renal Disease Using Serum BMP-7 and TGF-BETA 1 Levels
K J Priyadarshini
Gandhi Medical College/Hospital; Secunderabad; Telangana; India
Aims and Objectives: (1) To determine the usefulness of serum BMP 7 and TGF beta 1 levels as screening markers to distinguish Diabetic nephropathy and Non diabetic renal disease in patients of type 2 Diabetes mellitus. (2) To assess the correlation between circulating levels of serumBMP 7 and TGF β1 with interstitial fibrosis and tubular atrophy on renal biopsy. (3) To assess various factors affecting serum BMP 7 and TGF β1 levels.
Patients and Methods: This is a prospective observational study done from December 2014 to December 2016 in Department of Nephrology, Gandhi hospital, Hyderabad in 100 patients of type 2 Diabetes mellitus patients presenting with symptoms and signs of renal disease.
Inclusion Criteria: Patients with Type 2 Diabetes mellitus presenting with clinical features of renal disease in the form of urinary abnormalities with or without rise in serum creatinine.
Exclusion Criteria: Diabetes mellitus with acute kidney injury. (1) DM with pregnancy. (2) Type 1 diabetes mellitus. (3) Type 2 diabetes mellitus without renal insufficiency and proteinuria. Patients were diagnosed to have presumed diabetic nephropathy based on presence of 24 hour urinary protein of >300 mg along with presence of diabetic retinopathy. Those patients who did not have diabetic retinopathy but had significant urinary abnormalities were subjected for renal biopsy.
Patients were categorized in to 3 groups: Groups – (1) GROUP I (Presumed DN). (2) GROUP II (NDRD). (3) GROUP III (Biopsy Proven DN)
After obtaining the Institutional ethics committee approval, patients were enrolled in the study. Informed consent is taken from the patient at the time of renal biopsy. Lithium heparin anticoagulated blood samples were collected for estimation of serum BMP 7 and TGF β 1 levels. Serum BMP 7 and TGF β1 levels are correlated with the amount of IFTA on renal biopsy. Factors influencing serum BMP 7 and TGF β1 are analyzed.
Data Analysis: Statistical analysis was performed by utilizing SPSS software version 18. Initially frequency tables are made to estimate the frequency and percentage of each parameter analyzed. Descriptive statistics are expressed in terms of mean and standard deviation. The probability of association between two discrete attributes was made by chi square test. Means of the various parameters are compared by using student t- test (for 2 groups) and by analysis of variance - ANOVA (for more than 2 groups). P< 0.05 was considered significant. Spearman correlation coefficient “r” is calculated to see the correlation between BMP 7, TGF β1 levels with amount of IFTA and proteinuria. Scatter plot graphs are drawn to estimate the correlation between serum BMP 7, TGFβ 1 levels with amount of IFTA and the degree of proteinuria. Box plot graphs are drawn using ANOVA between SerumBMP 7, TGF β1 levels and amount of IFTA on renal biopsy. Sensitivity, Specificity, Positive predictive value, Negative predictive value, accuracy are calculated for BMP 7 and TGF β1.
Results: Of the 100 patients enrolled in the study, 45 patients were presumed to have diabetic nephropathy (Group 1) based on presence of proteinuria>300 mg and diabetic retinopathy. 30 patients had biopsy proven non diabetic renal disease (Group 2) and 25 patients biopsy proven diabetic nephropathy (Group 3). Number of men,,duration of diabetes,degree of proteinuria, presence of hypertension, diabetic retinopathy, mean GFR, presence of macrovascular disease, hepatitis c seropositivity were found to have statistically significant association amongst the 3 groups. Duration of diabetes, mean degree of proteinuria, mean GFR, mean level of hemoglobin were higher in Group 2 compared to Group 1 and Group 3. Degree of hypertension, associated macrovascular disease, presence of diabetic retinopathy were associated with a statistically significant difference in Group 1. Degree of hyperglycemia, number of patients with hepatitis C seropositivity were higher in Group 3. Of the lab parameters, severe hypoalbuminemia and severe hypocalcemia were noted in Group 3. Factors affecting low BMP 7 and high TGF beta 1 levels are presence of hypertension,degree of proteinuria,eGFR presence of macrovascular disease,diabetic retinopathy, presence of anemia, hypoalbuminemia, hypocalcemia. Mean age of the study population was 50.99 ± 9.21 yrs. Mean serum BMP 7 levels was 248±219 ng/ml and mean serum TGF beta 1 levels was 710±210 pg/ml among the study population and the values did not vary with age. Males constituited 67% and females 37%. Mean BMP 7 levels in males was 247.38 ± 220 ng/ml, in females was 211.5 ± 231.8 ng/ml. Serum BMP 7 levels did not vary with gender (P = 0.45). Mean TGF β1 levels in males was 728 ± 223 pg/ml, in females was 711 ± 290 pg/ml. Serum TGF β1 levels did not vary with gender (P = 0.88).
Mean BMP 7 levels in histopathological class DN II was 28 ng/ml, DN III was 18±7.13 ng/ml, DN IV was 15.15±9 ng/ml. Over all Serum BMP 7 levels are lower in DN and the levels progressively decreased with increasing histopathological class of DN (P = 0.47). Mean TGF β1 levels in DN II was 900 pg/ml, in DN III was 912±173 pg/ml, in DN IV was 1072±170 pg/ml. Over all serum TGF β1 levels are higher in patients with DN and the values progressively increased with increasing histopathological class of DN (P = 0.07). Mean BMP 7 levels in patients with IFTA < 25% in NDRD was 474.89 ± 58 ng/ml, in biopsy proven DN was 12 ± 5.8 ng/ml, and the difference is statistically significant (P< 0.0001). Mean BMP 7 levels in patients with IFTA 25% to 50% in NDRD was 460 ng/ml, in biopsy proven DN was 21.7 ± 12.8 ng/ml and the difference is statistically significant (P = 0.02). Three patients had IFTA > 50% and all of them had DN with mean BMP 7 values of 8 ± 1.73 ng/ml. There is a strong negative correlation between serum BMP 7 levels and amount of IFTA on renal biopsy as estimated by Spearman correlation coefficient (r=-0.83). Mean TGF β1 levels in patients with IFTA < 25% in NDRD was 45.44 ± 20 pg/ml, in biopsy proven DN is 885 ± 120 pg/ml (P < 0.0001). Mean TGF β1 levels in patients with IFTA 25% to 50% in NDRD was 69 pg/ml, in biopsy proven DN was 1055 ± 104 pg/ml (P < 0.0001). 3 patients had IFTA>50% and all of them had DN with mean TGF β1 levels of 1100 ± 256 pg/ml. There is a strong positive correlation between amount of IFTA and TGF β1 levels as estimated by Spearman correlation coefficient (r=0.86).
Conclusions: (1) Low serum BMP 7 and high TGF beta 1 levels may be used as screening markers to differentiate diabetic nephropathy and non diabetic renal disease, instead of subjecting the patients to an invasive procedure like renal biopsy. (2) Low serum BMP 7 and high TGF beta 1 levels have a strong correlation with increasing severity of histopathological class of diabetic nephropathy.
Rekha-2 Individualised Dialysate Sodium Prescription in Hemodialysis – Results from a Prospective Interventional Trial
Radhika C Radhakrishnan, Santosh Varughese, Abitha Chandran, Vinoi G David, Suceena Alexander, Anjali Mahopatra, Anna T Valson, Shibu Jacob, Basu Gopal, Shailesh Kakde, C Palani, Arun Jose1, B Antonisamy2, V Tamilarasi
Departments of Nephrology; 1Biochemistry and 2Biostatistics; Christian Medical College; Vellore; Tamil Nadu; India
Background: Individualised dialysate sodium prescription in hemodialysis (HD) has the potential to address the problem of fluid overload and hypertension in HD patients. DISO (Dialysate Individualised Sodium) trial was designed to address this core issue in hemodialysis.
Aim: To study the effect of individualised sodium profiling on weight gain, blood pressure and intradialytic complications.
Materials and Methods: 40 patients on thrice-weekly maintenance hemodialysis for at least 6 weeks were enrolled. The study was performed in two different phases, with each subject used as his/her own control. In the first phase, patients were submitted to 12 consecutive HD sessions with a standard dialysate sodium concentration fixed at 140 mEq/L (standard concentration used in our dialysis facility). The pre and post-HD plasma sodium concentration were determined for each patient in three different midweek dialysis sessions. In the second phase of the study, patients were subjected again to 12 consecutive HD sessions with dialysate Na+ concentration set to individualized value (mean of pre-HD Na+ concentration multiplied by Donnan coefficient of 0.95). Differences in pre and post-HD sodium values, interdialytic weight gain (IDWG), Pre- and post-HD BP, thirst scores, intradialytic adverse events (headache, cramps, nausea, vomiting, hypotension/hypertension, requirement of nursing interventions) during both phases were assessed.
Results: The mean age was 45.65 years (24 males, 16 females). The mean serum pre-HD sodium level in the standard phase was 138.7 meq/L (range: 136-142 meq/L). Average sodium level set during individualised sodium HD sessions was 132 meq/L (range–130-136 meq/L). In standard phase, mean IDWG was 2.63±0.99 kg and in individualised phase 2.52±1.53 kg (p =0.422). Mean predialysis systolic BP was 138 ± 18 mm of Hg and 134 ± 17 mm of Hg in standard and individualised phases (p =. 0.008). Mean post-HD systolic BP was 135 ± 19 and 131 ± 19 mm of Hg respectively in the 2 phases (p =. 0.065). There were a mean of 4.2 HD adverse events in standard phase and 2.9 in individualised phase (p<0.001) and mean symptomatic episodes were 0.6 and 0.5 respectively (p=0.580). Mean episodes requiring intervention were 1.2 and 1.4 in standard and individualised phases (p=0.481). Mean of hypotensive episodes was 2 in both phases (p=0.933). Mean Hypertension episodes were 2.2 and 1.2 in standard and individualised phases respectively (p=0.006).
Discussion: There was significantly lower pre and postHD systolic BP and intradialytic hypertension episodes in individualised sodium phase but no difference in IDWG. DISO trial shows that using lower sodium dialysate is safe and may be beneficial in HD, especially in patients with intradialytic hypertension.
| Oral Paper Presentations 16 December 2017 (11.20am to 12.35pm) Hall A|| |
17. The Effect of Carnosine on Venom Induced Acute Kidney Injury in Experimental Rat Model
Pinaki Mukhopadhyay, Debarati Mukherjee1, Raghwendra Mishra1,2, Roshnara Mishra1
Department of Nephrology; NRS Medical College & Hospital; 1Department of Physiology; University of Calcutta; 2Department of Physiology; Ananda Mohan College; Kolkata; West Bengal; India
Background: Snakebite is a common occupational hazard with lot of morbidity and mortality. Snake bite mediated AKI is multi factorial and role of Carnosine as renoprotective is not well studied.
Aim of the Study: This study has objective to evaluate the potential of carnosine; a renoprotective dipeptide; in preventing Russell's viper venom (RVV) induced acute kidney injury (AKI) in wistar rat.
Methods: Male wistar rats were injected with RVV (0.3 mg/kg; i.m.) and renal function was evaluated in a kinetic model to find appropriate time point of AKI development. AKI was confirmed by altered creatinine clearance; serum creatinine; urinary microprotein and microscopic evaluation of urine slides. Animals were divided into: control group; venom injected group and carnosine treated venom injected group. In addition to above parameters; plasma methylglyoxal (MG); protein modification markers including advanced oxidation protein products (AOPP) were also assessed. Histopathological alteration of renal tissue were also studied. Control and venom injected group received normal saline whereas carnosine treated group received carnosine (1 mg/100 μl; 4 times daily) per orally.
Results: Venom inflicted AKI model was established which was manifested by reduced urinary function and shows signs of proteinuria; hematuria/hemoglobinuria; and urinary crystals. Elevation of plasma creatinine; MG; AOPP and other associated markers were observed in venom injected group of rats as compared to sham control. Histopathological alterations including glomerular injury; increased Bowman's space; tubular necrosis; etc. were also ovserved in venom injected group of rats. Per oral treatment of carnosine showed to prevent all the above signs of renal inefficiencies and damage significantly (p<0.05).
Conclusions: These findings suggests that carnosine have renoprotective potential against venom induced AKI. More studies are needed to establish underlying mechanism.
18. P-Glycoprotein and Multidrug Resistance-Associated Protein-1 on Different T-Cell Subsets in Idiopathic Nephrotic Syndrome in Children
Harshit Singh, Saurabh Chaturvedi1, Akhilesh Jaiswal, Ravi Mishra1, Vikas Agarwal1, Narayan Prasad
Departments of Nephrology and 1Clinical Immunology; SGPGIMS; Lucknow; Uttar Pradesh; India
Background: Idiopathic nephrotic syndrome (INS) represents one of the most common types of primary glomerular disease in children. INS has been considered a T-cell disorder; Glucocorticoids remain the mainstay of therapy. However; 60-80% of patients become resistant to steroid. Overexpression of P-glycoprotein (P-gp) and Multidrug resistance associated protein 1 (MRP-1) might be responsible for steroid resistance due to their ability to mswodulate the pharmacokinetics of steroids.
Aim of the Study: To evaluate the differential alteration of P-gp and MRP-1 on CD4+ and CD8+ T-cell subsets in steroid resistant as well as steroid sensitive patients.
Methods: AAfter ethical approval; all paediatric patients who matched the inclusion criteria were recruited. P-gp andMRP-1 (PE-conjugated human anti-P-gp and anti-MRP-1 mAb) expression were evaluated on whole blood and functional activity on peripheral blood mononuclear cells (PBMCs) in steroid sensitive nephrotic syndrome (SSNS) (n=80; male 33; mean age=8.54±4.3) and steroid resistant nephrotic syndrome (SRNS) (n=50; male 29; mean age=7.43±4.6) patients. SSNS patients were in sustained remission for at least 6 months without steroids. All definitions are as per the criteria of ISKDC.P-gp andMRP-1 expression were analyzed by Flow Cytometery. The absolute values were calculated using formula (% of positive cells × Relative Fluorescent Intensity (RFI)); Multi resistance activity factor (MAF) for each transporter; was calculated using formula (MAFMDR1=100× (FMDR1-F0)/FMDR1). All data are expressed as mean±s.d.
Results: Among 130 patients; demographic significant difference were in S. Albumin (SSNS=2.87±.98; SRNS=2.27±.79; p=0.012) and proteinuria (SSNS=13.18±3.09; SRNS=284±193.45; p<0.001). The% of P-gp and MRP-1 positive cells were significantly higher in SRNSas compared toSSNS (11.07±5.23 v/s 5.70±2.97; p<0.001); (17.12±7.10 v/s 7.15±3.83; p<0.001). Absolute P-gp and MRP-1 expression were significantly high in SRNS (63.01±21.01 v/s 33.51±20.30; p<0.005); (67.04±22.40 v/s 40.19±19.17; p<0.005) respectively. P-gp expression on CD4+ and CD8+cells were significantly high in SRNS (6.18±2.34 v/s 3.21±1.06; p=0.008); (6.42±1.09 v/s 1.96±0.91; p<0.001) respectively. MRP-1 expression on CD4+ and CD8+cells were significantly higher in SRNS (11.14±5.33 v/s 3.16±1.31; p=0.043); (5.06±0.89 v/s 1.40±0.93; p<0.001) respectively. Functional activity of P-gp and MRP-1 was significantly increased in SRNS as compared to SSNS (48.10±20.10 v/s 91.94±34.07; p<0.001); (86.19±31.72 v/s 51.10±32.83; p<0.001) respectively.
Conclusions: We conclude that overexpression of P-gp and MRP-1 on CD4+ and CD8+ cells may contribute to resistance to corticosteroids in idiopathic nephrotic syndrome in children.
19. Role of P-Gp in Pathogenic Conversion of Th17 Cells in Lupus Nephritis Leading to Glucocorticoid Resistance
Mohit Kumar Rai, Akhilesh Jaiswal, Mantabya Singh, Narayan Prasad1, Vikas Agarwal
Department of Clinical Immunoloy; SGPGIMS; Lucknow; Uttar Pradesh; India;
Background: Th17 cells and cytokine IL-17 are mainly involved in autoimmunity. Recently IL-17/IFN-g double-positive Th17 cell were found to be allied with inflammatory diseases. P-glycoprotein (P-gp) +ve Th17 cells are refractory to steroid. P-gp on lymphocyte effluxes out steroid and prevents its action. We conducted this study with hypothesis that P-gp positive IL-17/IFN-g double+ve Th17 are one of key pharmacokinetic and pharmacodynamic modulator liable for steroid resistance in lupus nephritis (LN).
Aim of the Study: We planned to study the frequency of P-gp expressing pathogenic Th17 cells in steroid responsive and non-responsive steroid patients.
Methods: We analysed the frequency of pathogenic IL-17/IFN-g double-positive Th17 lymphocytes and P-gp expression on their surface by flowcytometry in responsive (n=52; mean age 34.06±10.84) and non-responsive (n=25; mean age 37.29±13.73) patients. We also included 10 age and sex matched healthy controls. All patients were biopsy proven LN.
Results: We found a significant increase in the frequency of Th1 (p=0.001); Th17 (p=0.006) and IL-17/IFN-g double-positive Th17 (p<0.001) cells in non-responsive as compared to responsive patients and healthy controls (p<0.001). Of the total Th1; Th17 and pathogenic Th17; 78.45%; 72.37% and 95.8% cells expressed P-gp on their surface in non-responsive;45.0%; 30.27% and 30.1% cells expressed P-gp in responsive group; and 30.91%; 15.51% and 15.62% in healthy control respectively.
Conclusions: Higher frequency of IL-17/IFN-g double-positive Th17 cell with P-gp expression may be associated immunological and pharmacological factor for steroid resistance in LN.
20. Outcome of Omentectomy in Omental Wrapping in Continuous Ambulatory Peritoneal Dialysis Catheter Peritoneal Dialysis: A Single Centre Experience
G Pramod, S Renuka, M Limesh
St. Johns Medical College; Bengaluru; Karnataka; India
Background: Omental wrap is a common cause of catheter obstruction. Techniques for correcting obstruction include omentopexy and/or omentectomy.
Aim of the Study: To evaluate the incidence of omental wrapping and outcome of revision of obstructed peritoneal dialysis (PD) catheters omentectomy on PD survival.
Methods: This is a retrospective analysis of hospital records of all patients who underwent CAPD catheter placement at St. Johns Medical college and hospital; bengaluru from July 2013 to June 2017 were analyzed. The incidence; time of wrapping; outcome and treatment: catheter survival and Long term outcome were studied.
Results: Of the 190 patients who underwent CAPD catheter placement; 143 (75%) were males and 47 (25%) were females. 27 patients developed PD outflow obstruction; of which 18 patients had catheter kink and catheter migration. 9 (17%) patients had omental wrapping. The mean age was 51 years (ranged from 15 to 76 years). The average time of development of omental wrap was 25+/-20 days. 3 patients had PD catheter removed and converted to hemodialysis. 6 patients underwent omentectomy and required PD catheter re-insertion. All patients were followed upto 1 year and no patients lost PD catheter.
Conclusions: Our results demonstrate that omental wrap is a common complication of PD catheter insertion and does not significantly alter catheter and patient survival.
21. Study of Non Diabetic Kidney Disease in Type2 Diabetic Patients with Renal Involvement
K A Arun, S Gomathy, Usha Samuel, B Pradeep, K H Deepa, T K Suma
Government TD Medical College; Alappuzha; Kerala; India
Background: Diabetes mellitus is the most common cause of CKD worldwide. 20-40% patients with diabetes develop renal disease of which Diabetic Nephropathy is the most common. Other forms of diabetic kidney disease; known as Non Diabetic Renal Disease (NDRD) occur as either isolated or superimposed on DN which is common in Ty2DM. The precise diagnosis of NDRD requires renal biopsy. Diabetic nephropathy is irreversible; but certain NDRD are treatable. So the diagnosis of NDRD is very important.
Aim of the Study: (1) To estimate the prevalence of Non Diabetic Renal Disease in Type 2 diabetic patients (2) To study the spectrum and predictive factors of Non Diabetic Renal Disease in Type 2 diabetic patients.
Methods: The study was done in the Dept of Nephrology; Govt. T D Medical College; Alappuzha; Kerala. All Ty2 DM patients of age 13 to 60 yrs with proteinuria; microscopic or macroscopic hematuria; features of renal failure were enrolled during the study period (Sept 2014 to Aug 2015). It was a cross sectional study. patients with cystic kidney disease; Ischemic nephropathy; POVD; USG showing medical renal disease of Grade 2 or 3; Renal artery stenosis were excluded. Basic clinical details; blood; urine investigation and USG abdomen was done. Based on these data the need for renal biopsy was assessed. Renal biopsy was analyzed by LM (H&E; PAS; Acid Fuschin Orange G stains) and IF. In selected cases Methyl violet and Congo red staining also done. Optic fundae examination done in the Dept of Ophthalmology. Based on biopsy patients were grouped into three (i) Isolated NDRD (ii) NDRD with underlying DN and (iii) Isolated DN. Statistical analysis was done with SPSS vesion 16.
Results: 684 patients were enrolled with 369 males & 315 females. 75% were > 50 yrs. Renal biopsy done in 20 patients. 55% had duration of DM < 5 yrs. Majority had proteinuria 300-3500 mg/d with 1 case >3500 mg/d. 65% had microscopic hematuria and 30% had macroscopic hematuria. Low C3 noted in 60%. Active urine sediment (>5 cells/HPF or cellular casts) seen in 85%. Diabetic retinopathy was seen in 70%. Based on biopsy patients were grouped into 3 (NDRD-40%; DN-30%; NDRD+DN-30%). Microhematuria seen in 53.8% patients with isolated NDRD. Overlap of NDRD & DN reported in 30.8% of cases with microhematuria. Nephrotic range proteinuria more common in DN. NDRD was more common (54.5%) than DN (27.3%) when the duration of DM was <5 yrs. No NDRD was seen when the duration of DM > 10 yrs. Diabetic retinopathy (DR) was present 83% with DN whereas no NDRD patients had DR. In the absence of DR 92.8% had evidence of NDRD (isolated NDRD 57.1%; combined disease 35.7% and 7.1% had evidence of DN.
Conclusions: 70% patients with atypical presentation had NDRD. Females are more common in NDRD. Long duration (>10 yrs) predicts DN. IgA nephropathy-most common in isolated NDRD & diffuse proliferative GN in combined disease. Short duration; absence of DR; hematuria; low C3 and active sediments- pointers of NDRD.
22. Pulmonary Hypertension in Various Stages of Chronic Kidney Disease in Indian Patients
Kalpana Mehta, Abhishek Shirkande, Sandip Bhurke, Atim Pajai, Rudramani Swami, Swapnil Jadhav
Department of Nephrology; T.N. Medical College & B.Y.L. Nair Ch Hospital; Municipal Corporation of Greater Mumbai; Mumbai; Maharashtra; India
Background: The majority of CKD patients have hypertension with diastolic dysfunction; arterio-venous fistulas (AVF); anemia; uremic lung; volume overload with interstitial pulmonary edema; and a high cardiac output state; all of which can lead to increased pulmonary vascular pressures. There is a paucity of data on the incidence and prevalence of pulmonary hypertension (PH) in CKD in Indian patients.
Aim of the Study: (1) prevalence of PH in CKD & various CKD stages; (2) association of PH with CKD etiology; (3) correlation between the severity of PH with CKD duration; various related biochemical parameters.
Methods: This is a prospective and cross sectional study. CKD stage 2 and above [as per K-DOQI guidelines] with normal pulmonary function tests (by spirometry) were included. Medical history included age; sex; associated co morbidity particularly diabetes and hypertension; CKD etiology; duration; duration of dialysis and presence or absence of AVF. Laboratory investigations included hemoglobin: BUN; serum creatinine; serum albumin; calcium phosphorus product and urinary albumin. Transthoracic Doppler echocardiography; 4 hours post hemodialysis; for measurement of Pulmonary Artery Systolic Pressure (PASP); based on the tricuspid regurgitation jet was performed in all. PH was defined as present with mean PASP exceeded 30 mm Hg. Pulmonary hypertension was further categorized as mild [< 35 mmHg]; moderate [35 to 50 mm of Hg] & severe [> 50 mm of Hg]. Statistical analysis was done.
Results: The study included a total of 200 CKD patients. Prevalence of PH in CKD was 60.5%; with mean PASP: 38.52±7.32 mmHg. The mean age of those with PH was 47.85±13.09 years. The prevalence of PH increased as CKD stage advanced (p<0.001). Diabetes and hypertension had strong association with PH. The prevalence (p=0.003) and severity (p=0.011) of PH increased with increase in CKD duration. Prevalence (p<0.001) and severity (p=0.022) of PH was significant in HD pts as compared to those on conservative treatment. The prevalence (p<0.001) and severity (p<0.001) of PH significantly increased as duration of HD increased. The prevalence of PH was significantly higher in patients with arterio-venous fistula (p=0.002). S. creatinine (p=0.02) and serum calcium-phosphorus product (p<0.001) were significantly higher in patients with PH than those without PH. There was positive correlation between PH and duration of CKD; duration of HD; BUN; s. creatinine and serum calcium-phosphorus product.
Conclusions: The prevalence of PH in CKD is 60.5%. It rises with stages & duration of CKD; & in those on HD and with AVF. The severity of PH is proportional to duration of CKD and HD. Serum creatinine and calcium phosphorus product were significantly higher in CKD patients with PH.
| Oral Paper Presentations 16 December 2017 (11.20am to 12.35pm) Hall B|| |
23. Nutritional Assessment in Haemodialysis Patients to Identify Factors Predicting Poor Outcomes
Walter Anthony, Lloyd Vincent
Naraya Hrudayalaya Hospital; Bengaluru; Karnataka; India
Background: Malnutrition is a significant problem in hemodialysis patients which is also an important factor determining poor outcomes. Identifying malnutrition and timely intervention may improve haemodialysis outcomes.
Aim of the Study: To estimate the prevalence of malnutrition in hemodialysis patients. To identify nutritional factors which can predict poor outcomes in hemodialysis patients.
Methods: This was a prospective; observational cohort study in which 54 stable patients attending out-patient haemodialysis unit for a minimum of 3 months were recruited. Patients were interviewed and subjected to nutritional status assessment by 3-point Subjective global assessment; laboratory investigations (Hemoglobin; serum albumin; serum creatinine; serum bicarbonate; serum calcium; serum phosphorus and blood urea nitrogen) and anthropometrical measurements (Height; weight; BMI; mid-arm circumference; mid-arm muscle circumference; triceps skinfold thickness). Patients were divided into well nourished and malnourished group based on SGA score and were followed up over 11 months for emergency department visists for haemodialysis; hospitalisations and death.
Results: The prevalence of malnutrition as assessed by SGA was 29.1% among the hemodialysis patients. Only one patient (1.8%) expired during the follow –up period. Malnourished patients did not have more hospitalisations compared to well nourished (29.6% vs. 70.4%). Nutritional status assessed by SGA had significant correlation with BMI; MAC and TSF (P= 0.039; P=0.047 and P= 0.037 respectively). Among the biochemical parameters assessed; only hemoglobin and BUN had significant correlation with SGA (P= 0.039; P=0.048). Though the mean height; weight and BMI were higher in the non-hospitalised patients; they were not strong predictors of risk of hospitalisation. None of the biochemical parameters had predictive value for prospective hospitalisation.
Conclusions: SGA is a simple nutritional assessment tool even in hemodialysis patients. BMI; MAC; TSF; hemoglobin and BUN can be used as reliable markers of malnutrition. Anthropometric measurements and the biochemical parameters does not have strong predict hospitalisation risk in hemodialysis patients.
24. ABO Incompatible Transplantation without Induction Agent - Our Experience
Feroz Aziz1&2, N A Ismail1; Sajith Narayanan1, Benil Hafeeque1&2, Jyotish Chalil Gopinathan2, Julie Jose2
1Department of Nephrology; Aster MIMS; 2Iqraa International Hospital and Research Center; Kozhikode; Kerala; India
Background: Transplantation across ABO blood-group (ABOi-Tx) has facilitated more living-donor kidney-transplantation by increasing donor pool. Augmented Immunosuppression (IS); financial overburden; lack of awareness and need of multidisciplinary team has made ABOI-Tx impractical to many centers.
Aim of the Study: Induction agents like IL2RB and Thymoglobulin adds to infectious risk and financial burden to majority of patients. We aim to analyze the outcome of 19 consecutive ABOi-Tx recipients without induction.
Methods: Retrospective analysis of ABOi transplants in two tertiary-care hospitals in Calicut with same protocol. Only recipients with Anti-A/anti-B titers ≤ 1:512 by Gel-method (Biorad) were accepted. Patients underwent CDC/Flow-crossmatch and anti-HLA-antibody-screen (Luminex). Desensitization regimen: Day (-21): Rituximab 200 mg; Day (-14): Triple IS; Prednisolone 10 mg; MMF 1000 mg and Tacrolimus 0.05 mg/bodywt; Day: (-7) Plasma-exchange (PLEX) 3-4 sessions to attain titer of 1:8. Transplantation was done without induction IS.
Results: Nineteen patients (Male:Female-16:3) underwent ABOi-Tx. Recipients' age was 34±10 yrs. Follow-up duration-417±280 days. Donors'age was 42.3 ± 10.1 years; Spouse/Unrelated-10; Parents-7 and siblings-2. Sixteen patients have normal functioning transplant with creatinine 1.34± 0.3 mg/dL. Two patients were lost; one on post-op day (POD) 3 due to ACS and second on POD-22 due to fungal sepsis. One graft loss occurred due to post-transplant HUS with no evidence of rejection. Of the functioning 16 allograft-recipients none had cellular rejection; one developed HUS due to CNI which recovered with PLEX and switch to non-CNI based IS. One patient developed AMR on POD-4 which was completely reversed with PLEX and augmentation of IS. Opportunistic infections included CMV viremia in 3; BKV viremia-1 and Fungal sepsis-1. None of the patients received Thymoglobulin or IL2RB.
Conclusions: ABOi-Tx can be done successfully without agents like Thymoglobulin/IL2RB with good outcome and minimizing the risk of infectious complications and financial overburden.
25. The Effect of Arterio-Venous Fistula Creation for Haemodialysis Access on Blood Pressure Control in Advanced Chronic Kidney Disease
Ajith Abraham Kurien, Awais Hameed, Teun Wilmink, Indranil Dasgupta
Heartlands Hospital; Birmingham; UK
Background: Hypertension and Chronic Kidney Disease have an inverse relationship; with Resistant hypertension posing an ever increasing problem for nephrologists. A novel technique of creating a Central arterio-venous anastomosis (ROX Coupler) has been shown to help blood pressure (BP) control in such cases.
Aim of the Study: To assess if creation of arterio-venous fistula (AVF) for haemodialysis (HD) access improves BP control in severe chronic kidney disease (CKD).
Methods: The study group consisted of patients with eGFR ≤25 ml/min/1.73 m2; who had successful AVFs over 2002-2015 in our centre. A “successful fistula” was defined as one that was successfully used for haemodialysis on 6 consecutive occasions over 2 weeks. Pre and post AVF BP readings over 1 year and the number of antihypertensive medication were compared with a control group; who had unsuccessful AVF operations. The data were censored for death; dialysis and transplantation.
Results: There were 380 patients in the study group and 107 in the control group. Significant reductions in diastolic BP (-3.76 mmHg; p<0.001); 1 year average diastolic BP (-3.77 mmHg; p<0.001) and average MAP (-2.94 mmHg; p<0.001) were observed between pre and post AVF in the study group. In comparison; there was a smaller reduction in the average diastolic BP (-2.8 mmHg; p=0.03) in the control group over the same time duration. There were no differences seen in systolic BP or medication use between pre and post AVF periods.
Conclusions: Our preliminary analysis suggests that a successful AVF creation for HD access in patients with advanced CKD is associated with lowering of BP. A further multivariate analysis of the data and a future prospective trial with a larger cohort of patients will help to confirm these findings.
26. Assessing Dry Weight on Hemodialysis: Are we Wide off the Mark?
Abhishek Dixit, Deepa Usulumarty, Ganesh Sanap, Jatin Kothari, Rajesh Kumar, Shrirang Bichu, Parag Tilve, Viswanath Billa
Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India
Background: Volume excess inpatients on regular hemodialysis are conventionally assessed using clinical signs and symptoms including; dyspnea; presence of peripheral edema; basal crackles and raised JVP. However this is not sensitive enough approach. Since achieving ideal dry weight is critical to maintain BP; and reduce cardiovascular complications in long term dialysis patients; we need a more sensitive test to identify volume excess states.
Aim of the Study: To identify pulmonary congestion in clinically euvolemic patients on HD by using Ultrasound lung comets & to establish its superiority over clinical criteria; Body Composition Monitor & IVC diameter.
Methods: Fifteen patients on regular maintenance hemodialysis who were found to be euvolemic by clinical criteria were selected for the purpose of study. At baseline; their lung ultrasound to identify pulmonary congestion by a quantitative comet score (ULCs); IVC diameter and BCM were done to assess the volume status. If lung congestion was detected by a higher ULCscore (>5); then the dry weight of the patient was reduced. A week later; same 3 tests were repeated to document the change alongside the decrease in dry weight.
Results: Ten out of 15 (66%) clinically euvolemic patients had a high lung comet score. In this group only 53% had abnormal BCM. Similarly only 13% had abnormal IVC. In response to this score; their dry weight was reduced from 0.5-2 kg. For a mean reduction in dry weight from 65.3+16.07 to 64.46+15 (p<0.05) there was a significant reduction in ULCs from 11.53+12.17 to 7.3+10 (p <0.05). However the reduction in BCM from 0.52+3.9 to -0.74+1.6 and IVC diameter from 14.33+4.29 to 14.24+3.93 was not significant. ULCs correlated significantly with overhydration status as compared to BCM and IVC diameter (r=0.5 vs r=0.38 and 0.36).
Conclusions: Ultrasound lung comets score is a promising sensitive tool for assessment of the degree of volume overload in clinically euvolemic patients and should be used for optimising dry weight in ESRD patients on maintenance hemodialysis.
27. One Year follow up Study of Outcome in Cases of Acute Kidney Injury
S Gomathy, Haseena Aboobacker, Arpitha Chowksey, K A Arun, B Pradeep, Usha Samuel
Government T D Medical College; Alappuzha; Kerala; India
Background: Even though majority of AKI are reversible within weeks of occurrence; recent observational studies suggest an association between AKI and subsequent CKD. This is due to incomplete healing process. So AKI leads to new CKD; progression of existing CKD to ESRD in long run & excess mortality.
Aim of the Study: (1) To estimate the proportion of AKI patients progressing to CKD during the study period. (2) To study the factors associated with progression of AKI to CKD.
Methods: A prospective study was conducted among patients who were 13-60 yrs of age; admitted with acute kidney injury in Dept. of internal medicine; Govt. TDMC; Alappuzhaduring March 2013 to August 2014. And they were followed up for a period of 1 year. Patientswith history of CKD; Systemic hypertension; Diabetes mellitus; Cardiac failure and chronic liverdisease were excluded from the study.
Results: 88 cases of acute kidney injury were studied. 60% were males. Infections like Leptospirosis and Cellulitis were the most common etiology. 27 patients (31%) had e GFR<60 ml/min/1.73 m2 at 3 months of follow up and 21 patients (24%) had e GFR of<60 ml/min/1.73 m2 at 1 year follow up. Renal biopsy was done in 21 cases among those who had persistent low GFR at 3 months. 6 were not willing for renal biopsy. Ig A Nephropathy was the commonest pathology identified biopsy followed by tubular necrosis. High level of proteinuria (>300 mg/day) and presence of active urinary sediment at presentation were associated with more risk of development of CKD. Those in the age group of >40 years also had more risk of development of CKD. Initial S. Creatinine level; Urine output and requirement of hemodialysis at presentation were not associated with subsequent development of CKD.
Conclusions: From the study it is concluded that simple markers like level of proteinuria and presence of active urinary sediment at presentation may predict the risk of persistent renal damage and development of CKD. The limitation of the study was a small sample size.
28. Panel Reactive Antibody Screening using Luminex Platform to Detect Preformed Anti HLA Antibody and its Clinical Significance in Kidney Transplant Rejections
Prashant Rajput, Zaheer Virani, Hepal Vora, Ashwinee Hotkar, Sibi Mathew, Priya Dhurandhar, Bharat Shah
Institute of Renal Sciences; Global Hospital; Mumbai; Maharashtra; India
Background: Presence of antibodies against Human Leukocyte Antigen (HLA) molecules is a known risk factor for acute rejections and graft loss. A pre-transplant PRA estimation is done to indentify sensitized patients prior to solid organ transplant.
Aim of the Study: To study the prevalence of PRA in ESRD patients undergoing kidney transplantation; identify risk factors and its impact on allograft rejection.
Methods: It is a single center retrospective study of 141 patients with End stage kidney disease who presented to our Institute for Kidney Transplant between July 2014 to July 2017. PRA Screening was done in all patients using a Luminex platform (LIFECODES lifescan deluxe) which detects all IgG antibodies to Class 1 & Class II molecules. Patients with a suitable donor who had a negative CDC Lymphocyte crossmatch underwent a Kidney transplantation (N=99) and others (N=42) were listed for deceased donor transplant. All transplant Patients received triple drug immunosuppression with steroids; mycophenolate sodium and calcineurin inhibitor. Induction agent was decided based on the recipients immunological risk profile. The primary end point was risk of rejection.
Results: The mean age of the study population was 42±12 years and 82.2% were males. The etiology of chronic kidney disease was diabetes mellitus in 32%. In patients who underwent transplantation Class 1 was positive in 0.9%; Class II in 6.06%% and both (Class 1 & II) in 9% patients. In waitlisted patients there were none positive for only class 1; 14.6% were positive for class II and 12.1% had both class 1 and Class II. On multivariate analysis blood transfusions; previous transplantation and dialysis vintage was significantly associated with risk of a positive PRA. A positive class I or class II PRA was independently not associated with significant acute rejection episodes (p=0.56). Patients with both positive Class 1 & Class II PRA had more rejections (33.3%) as compared to with negative PRA (13.5%) and this was statistically significant (p=0.02).
Conclusions: PRA screening is useful test to predict anti HLA antibodies pre transplantation. Patients with both positive Class 1 & Class II Panel Reactive antibodies have a significant higher risk factor for developing acute rejection episode as compared to patients with a negative PRA.
29. Study of the Carotid Intimal Medial Thickness in Patients with Chronic Kidney Disease in Indian Population: Observational Study
Pradip Saruk, Kalpana Mehta, Sandip Bhurke, R Swami, Swapnil Jadhav, Gajanan Pilgulwar, Vikram Kokate, Nitin Pawani, Saurabh Lande
T.N. Medical College and B.Y.L Nair Charitable Hospital; Mumbai; Maharashtra; India
Background: Accelerated atherosclerosis and adverse cardiovascular events are associated with CKD. Carotid Intimal Medial Thickness (CIMT) is a measure of subclinical atherosclerosis and carotid artery stiffness. It is non invasive; easy to measure and is reproducible. In this study we evaluated CIMT in various stages of CKD and correlated it with eGFR and other risk factors.
Aim of the Study: (1) To evaluate CIMT in patients with CKD (2) To evaluate association of CIMT with various risk factors.
Methods: Cross sectional Observational study was conducted. All patients >18 years old with eGFR <60 ml/min for >3 months; and those who were willing to give consent were enrolled between October 2015 and July 2017. All were evaluated with detailed clinical assessment and laboratory investigations (including serum calcium; phosphate; Vit D3 level and iPTH). CIMT was measured with high resolution 7.5 MHz B- Mode ultrasonography. Other risk factors like age; BMI; history of diabetes; hypertension; lipid abnormality; and proteinuria were also noted.
Results: Total 405 patients were enrolled in study. M:F ratio was (1.6:1). Mean age was (49.12 ± 15.12 years) (range 18-85 years) out of 405; 39 were in CKD stage 3a; 75 (18.5%) in CKD stage 3b; 98 in CKD stage 4; 125 (30.86%) in CKD stage 5; and 68 (16.8%) were in CKD stage 5D. Mean CIMT was (0.68 mm) CIMT in stage 3; 4 and 5 was 0.48 mm; 0.65 mm and 0.81 mm respectively. Statistically significant association was found with increased CIMT and high calcium phosphate product (p < 0.001); duration of CKD (p < 0.001); vitamin D deficiency (p < 0.001); hyperparathyroidism (p < 0.018). Presence of hypertension (p < 0.001); diabetes (p < 0.02); and dyslipidemia (p < 0.010) were associated with high CIMT. No statistically significant association with Proteinuria.
Conclusions: Positive co-relation of CIMT is noted with worsening of CKD stages; CKD duration. Monitoring and controlling risk factors: serum calcium and phosphorus product; hyperparathyroidism; vitamin D deficiency; hypertension; diabetes; dyslipidemia in early stages of CKD is of paramount importance.
30. Epicardial Adipose Tissue Volume as a Marker of Atherosclerosis in Hemodialysis Population
R Vivek Praveen, B Suhasini, N D Srinivasaprasad, M Edwin Fernando
Stanley Medical College; Chennai; Tamil Nadu; India
Background: Epicardial adipose tissue (EAT) is a visceral fat deposit accumulated between the visceral pericardium and the myocardium. Increased epicardial adipose tissue volume is associated with development of coronary atherosclerosis. It has been reported previously that epicardial adipose tissue volume was higher in CKD patients on hemodialysis and peritoneal dialysis.
Aim of the Study: To measure epicardial adipose tissue volume using CT in CKD patients on hemodialysis and to assess the correlation with coronary artery calcification score and carotid intimal medial thickness.
Methods: Thirty CKD patients on hemodialysis for more than 3 months between ages 18 to 58 years were taken as subjects. Thirty prospective renal donors between ages 18 to 58 years were acted as controls. Patients with active infection; autoimmune disease; cardiac failure; diabetes mellitus; hypothyroidism and h/o chronic smoking were excluded. Serum urea; creatinine; glucose; haemoglobin; total cholesterol; triglycerides; calcium; phosphate; albumin were estimated. BMI; dialysis vintage were calculated. Doppler was used to measure carotid intimal medial thickness. Transthoracic echocardiography was used to measure left ventricular ejection fraction and epicardial adipose tissue thickness. CT was used to measure coronary artery calcification score; epicardial adipose tissue thickness and volume.
Results: E.A.T volume is increased in 20% (6 out of 30) of cases and 16.67% (5 out of 30) of controls. Mean E.A.T volume in cases was 97.83 cc (±26.11) and in controls were 97.87 cc (± 28.53). No statistically significant difference was noted in E.A.T volume between cases and controlsNo significant association was noted using Pearson correlation between CACS (r=0.11; p=0.56); CIMT (right) (r= -0.08; p=0.67); CIMT (left) (r=0.11; p=0.56) with EAT volume in CKD patients on hemodialysis. No correlation was noted between EAT volume in CKD patients on hemodialysis and other parameters such as age (r=0.15; p=0.44); BMI (r=0.14; p=0.48); Triglycerides (r= -0.003; p=0.99); dialysis vintage (r= -0.185; p=0.328). However there is significant positive correlation between E.A.T thickness measured using echocardiography versus CT (r=0.94; p<0.05).
Conclusions: E.A.T volume measured by CT is not increased in most of the CKD patients on HD. No significant correlation found between E.A.T volume with other parameters (Age; BMI; TGL; dialysis vintage; CACS; CIMT) in CKD patients on HD.