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ABSTRACT
Year : 2021  |  Volume : 31  |  Issue : 7  |  Page : 1-77
 

Abstract submitted for 51st annual conference of Indian society of nephrology, 2021 at Chennai



Date of Web Publication6-Dec-2021

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-4065.331808

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How to cite this article:
. Abstract submitted for 51st annual conference of Indian society of nephrology, 2021 at Chennai. Indian J Nephrol 2021;31, Suppl S1:1-77

How to cite this URL:
. Abstract submitted for 51st annual conference of Indian society of nephrology, 2021 at Chennai. Indian J Nephrol [serial online] 2021 [cited 2022 Aug 9];31, Suppl S1:1-77. Available from: https://www.indianjnephrol.org/text.asp?2021/31/7/1/331808





  Three-Year Clinical Outcomes of the First South-Asian Prospective Longitudinal Observational IGA Nephropathy Cohort (Grace-IGANI) Top


Suceena Alexander, Santosh Varughese, Rajanbabu Franklin, Sanjeet Roy, Vinoi George David, Anna T Valson, Elenjickal Elias John, Jeethu Joseph Eapen, Athul Thomas, Sabina Yusuf, John Feehally, Mohamed R Daha, Jonathan Barratt, George T John

Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India; 1Department of General Pathology; University of Leicester; Leicester; UK; 2UMCG; Groningen; The Netherlands

E-mail: [email protected]

BACKGROUND: Glomerular Research And Clinical Experiments-IgA Nephropathy in Indians (GRACE-IgANI) is the first prospective South-Asian IgAN cohort with prespecified objectives and protocolized longitudinal follow-up.

AIM OF THE STUDY: The aim of the study is to report the 3-year clinical outcome in the GRACE-IgANI cohort.

METHODS: Out of 201 incident adults with kidney biopsy-proven primary IgAN recruited into GRACE-IgANI, 195 patients (97%) had completed 3-year longitudinal follow-up in September 2020. Rapid progressors (RPs) were defined as average annual fall in eGFR <5 ml/min/1.73 m2. Composite outcome (CO) was defined as <50% fall in eGFR (CKD EPI) from baseline and/or eGFR (CKD EPI) <15 ml/min/1.73 m2 or RRT/death.

RESULTS: The use of RASB was consistent (66%–75%) throughout and a short course IS was given to patients with proteinuria >1 g/day and/or renal impairment (73%). 76 patients (39%) were RP and 72 patients (37%) had CO at 3 years. At each scheduled follow-up proteinuria <1 g/day significantly increased time to CO. The ROC curve of average annual decline in eGFR <5 ml/min/1.73 m2 had 82% sensitivity and 89% specificity for CO and a good discrimination from 1 year (AUC 0.81) onward. The significant predictors for CO were MEST-C T2 score (hazard ratio [HR] 4; 95% confidence interval [C.I.] 2–9; P < 0.001) at baseline; hemoglobin >12 g/dl (HR 2; 95% C.I. 1–5; P = 0.02) at 6 months; 24-h urine protein <1 g/day at 6 months combined with serum albumin >4 g/dl (HR 2; 95% C.I. 1–5; P = 0.02) at 1year; and fall in eGFR <5 ml/min/1.73 m2 at 1 year (HR 4; 95% C.I. 2–8; P < 0.001). Mortality was 6% in the cohort.

CONCLUSIONS: The South-Asian IgAN had CO in 37% of patients at 3-year and longitudinal clinical variables along with baseline MEST-C T2 score predicted poor renal outcome.


  Chronic Antibody-Mediated Rejection in Patients Transplanted with Renal Allografts Activates an Inflammatory Amplifying Loop (IL-6+IL-17) when prolonged IL-6 Secretion Occurs Top


Mantabya K Singh, Mohit Rai1, Vikas Agarwal1, Durga P Misra1, Narayan Prasad

Departments of Nephrology and 1Clinical Immunology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Recently; nonimmune cells such as fibroblast have been postulated to mediate allograft rejection via activation of the IL-6 amplifier loop (IL-6+IL-17). We evaluated IL-6 amplifier loop activation by IL-6 and Il-17 in chronic antibody-mediated rejection (CABMR).

AIM OF THE STUDY: To study the effects of IL-6+IL-17 on IL-6 secretion in culture supernatants of fibroblasts derived from a renal biopsy of CABMR patients.

METHODS: Fibroblasts from grafted kidneys from CABMR patients (n = 6) were cultured and stimulated with IL-6 (20 ng/μl), IL-17 (50 ng/μl), and IL-6 plus IL-17 for 24 h. Levels of IL-6, MCP-1, and CCL20 were estimated in culture supernatants by ELISA as markers of IL-6 amplifier loop activation. mRNA expression of IL-6, MCP1, CCL20, and SOCS3 genes were measured in the stimulated fibroblasts. In addition, IL-6, MCP1, and CCL20 levels were measured in healthy control (n = 10), CABMR (n = 20), and non-CABMR (n = 30) patients.

RESULTS: IL-6 and IL-17 synergistically induced more IL-6, CCL-20, and MCP-1 production from fibroblasts. Gene expression analysis of IL-6, MCP1, and CCL20 was significantly higher with synergistic activation of IL-6 and IL-17 as compared to either IL-6 or IL-17 alone, while SOCS3 gene expression was downregulated. In addition, concentrations of IL-6, CCL-20, and MCP-1 in the sera were significantly higher in CABMR patients compared to nonrejection patients (P < 0.001). There was a significant reduction in IL-6 concentration in culture supernatant with IL-6 and IL-17 inhibitor together and mRNA expression of IL-6 and MCP-1 was significantly reduced.

CONCLUSIONS: CABMR is perpetuated by inflammation amplifier loop or synergistic induction of IL-6 and IL-17. Inhibition of IL-6 with anti-IL-6 (tocilizumab) and IL-17 with anti-IL-17 together reduces the tissue injury marker (IL-6, MCP1, CCL20) and allograft rejection.


  Serum And Glomerular Complement Components As Biomarkers In The First South Asian Prospective Longitudinal Observational IGA Nephropathy Cohort (Grace-IGANI) Top


Suceena Alexander, Anita Meter, Santosh Varughese, Athul Thomas, Jeethu J Eapen, Elenjickal E John, Anna T Valson, Vinoi G David, John Feehally, Jonathan Barratt, George John, Marc M Seelen, Mohamed R Daha

Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India; 1University of Leicester; Leicester; UK; 2UMCG; Groningen; The Netherlands

E-mail: [email protected]

BACKGROUND: The Glomerular Research And Clinical Experiments-IgA Nephropathy in Indians is a prospective longitudinal cohort. The study protocol has been published and is registered with WHO trial id: ISRCTN36834159. The role of serum and glomerular complement components in South Asian IgAN is unknown.

AIM OF THE STUDY: To study the relevance of serum and glomerular complement components on composite outcome at 3 years.

METHODS: A total of 201 consenting adult IgAN patients were consecutively recruited postkidney biopsy. 192 (97%) patients completed 3 years. Serum complement C3 and C4 levels and glomerular C3d, C4d, and C5b-9 by IHC were quantified at baseline in IgAN patients. Composite outcome (CO) was defined as <50% fall in eGFR from baseline and/or eGFR <15 ml/min/1.73 m2 or RRT/death.

RESULTS: A total of 195 patients (97%) completed 3-year longitudinal follow-up. Lower serum C3 was significantly associated with S1, T1/T2 according to the Oxford MEST grading and with global glomerulosclerosis (GS >33%), whereas higher C4 levels were associated S1 scores. Increased mesangial C3d deposition correlated with increased mean arterial pressure, proteinuria, decreased serum albumin, decreased eGFR, and GS >33%. Similar to C3d, increased mesangial C4d correlated with increased systolic blood pressure, decreased serum protein, and decreased eGFR and with GS >33%. Mesangial deposition of C5b-9 did not have any clinical associations. Lower serum C3, higher serum C4, and increased mesangial C3d were significantly associated with CO over 3 years.

CONCLUSIONS: Serum and tissue complements could be potential biomarkers for severity and progression in the GRACE-IgANI cohort. This requires furhter validation.


  Relevance Of Serum Galactose-Deficient IGA1 Levels in South Asian IGAN Top


Suceena Alexander, Rajanbabu Franklin, Santosh Varughese, Sanjeet Roy, Vinoi George David, Anna T Valson, Elenjickal Elias John, Jeethu Joseph Eapen, Athul Thomas, Sabina Yusuf, John Feehally, Mohamed R Daha, Jonathan Barratt, George T John

Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India; 1Department of General Pathology; University of Leicester; Leicester; UK; 2UMCG; Groningen; The Netherlands

E-mail: [email protected]

BACKGROUND: The role of serum galactose-deficient IgA1 (s. Gd-IgA1) in a prospective longitudinal South Asian IgAN cohort (GRACE-IgANI) and the impact of immunosuppression are not known.

AIM OF THE STUDY: To study the clinical relevance of s. Gd-IgA1 as a diagnostic and prognostic biomarker and the impact of oral steroids on longitudinal measurements of S. APRIL should be serum a proliferation-inducing ligand at 1 year and 2 years.

METHODS: s. Gd-IgA1 levels were measured in baseline and longitudinal sera (1 year and 2 years) in IgAN patients and at baseline in disease controls and healthy controls using KM55 ELISA (IBL International GmBH; Germany). Serum immunoglobulins were measured in a fully automated immunoturbidometric assay (Cobas 8000) (Roche Diagnostics GmbH Mannheim, Germany). Serum immune complex and serum secretory IgA were measured by in-house sandwich ELISAs.

RESULTS: s. Gd-IgA1 levels were not diagnostic of IgAN in our cohort. Baseline s. Gd-IgA1 levels had strong positive correlation serum IgA. Baseline s. Gd-IgA1 levels were significantly elevated in MEST-C S1 and T1/T2 scores. There was a significant decrease in Gd-IgA1 levels in treatment group II at 1-year post IS. The longitudinal change in Gd-IgA1 levels paralleled the change in s. IgA levels for the same period. Baseline elevated s. Gd-IgA1/s. IgA levels had significant association with composite outcome at 3 years in the treatment group II (high-risk group with IS) in unadjusted Cox regression analysis. Prediction model identified baseline elevated s. Gd-IgA1/s. IgA levels as a significant prognostic marker along with 24 Hrs urinary protein, rate of decline in renal function, serum albumin, and MEST-T2 score.

CONCLUSIONS: Elevated s. Gd-IgA1/s. IgA levels were a significant prognostic marker in the GRACE-IgANI cohort. External validation is awaited.


  Serum a Proliferation-Inducing Ligand as a Biomarker in South Asian Prospective Longitudinal Observational IGA Nephropathy Cohort (Grace-IGANI) Top


Suceena Alexander, Rajanbabu Franklin, Santosh Varughese, Sanjeet Roy, Vinoi George David, Anna T Valson, Elenjickal Elias John, Jeethu Joseph Eapen, Athul Thomas, Sabina Yusuf, John Feehally, Mohamed R Daha, Jonathan Barratt, George T John

Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India; 1Department of General Pathology; University of Leicester; Leicester; UK; 2UMCG; Groningen; The Netherlands

E-mail: [email protected]

BACKGROUND: A proliferation-inducing ligand (APRIL) is believed to play a role in the production of pathogenic IgA1 in IgAN. In this study, we measured serum APRIL (s. APRIL) levels in a prospective longitudinal South Asian IgAN cohort (GRACE-IgANI).

AIM OF THE STUDY: To study the clinical relevance of s. APRIL as a diagnostic and prognostic biomarker and the impact of oral steroids on longitudinal measurements of s. APRIL at 1, 2, and 3 years.

METHODS: s. APRIL levels were measured in baseline and longitudinal sera (1, 2, and 3 years) in IgAN patients and in disease controls and healthy subjects by ELISA (R&D Systems; Catalog No: DY884B). All patients with proteinuria >1 g/day and/or renal impairment (73%) at inclusion were treated with immunosuppression (IS). Composite outcome (CO) was defined as >50% fall in eGFR (CKD EPI) from baseline and/or eGFR <15 mL/min/1.73 m2 or RRT/death.

RESULTS: S. APRIL is not a diagnostic biomarker in the GRACE-IgANI cohort. There were no significant baseline clinical correlations with s. APRIL levels. Lower median s. APRIL levels (<944 pg/mL) were significantly associated with time to CO at 3 years. No significant baseline biomarker correlations with s. APRIL levels. No significant change in longitudinally measured s. APRIL levels with IS. Lower median s. APRIL levels showed significant association with time to composite outcome in unadjusted Cox regression. Prediction model using baseline variables identified s. APRIL and serum galactose-deficient IgA1 (s. Gd-IgA1)/s. IgA ratio as significant prognostic biomarkers along with MEST T2 score, serum albumin, and serum bicarbonate for time to CO. Prediction model using longitudinal clinical variables identified s. APRIL and S. Gd-IgA1/s. IgA ratio as significant prognostic biomarkers along with MEST T2 score, rate of eGFR decline, albumin, and 24-h urine protein measured at 6 months for time to CO.

CONCLUSIONS: Lower median s. APRIL level is a significant prognostic biomarker in IgAN cohort treated with short course immunosuppression. External validation is awaited.


  Urinary Soluble CD163 and CD163+ M2 Macrophage Tissue Infiltration in IGAN Top


Snigdha Singh, Shubhi Kamthan, Niharika Bharti, Narayan Prasad1, Vikas Agarwal2, Vinita Agrawal

Departments of Pathology; 1Nephrology and 2Clinical Immunology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Macrophages contribute to kidney injury by a variety of mechanisms. CD163, a M2-macrophage marker, has been shown to be associated with glomerular inflammation and renal fibrosis. Increased infiltration of macrophages in the kidney may have altered levels of sCD163 in urine.

AIM OF THE STUDY: We performed this study to evaluate the degree of CD163+ macrophage infiltration and urinary sCD163 levels in IgAN and correlated it with clinicohistological features.

METHODS: Twenty renal biopsy-proven IgAN patients were included from October 2019 to August 2021 and were classified according to Oxford Classification by MEST-C scoring. Age- and sex-matched healthy controls were included as negative control while lupus nephritis patients were taken as disease controls. Immunohistochemistry with M2 macrophage marker CD163 (clone-EP324) was performed on renal biopsies. Quantitative estimation of macrophage infiltration in glomeruli and the tubulointerstitial compartments was performed using ×40 objective. Urinary sCD163 level was estimated by ELISA as per the manufacturer's protocol.

RESULTS: The mean age of IgAN was 34.4 ± 10 years and 13 were males. IgAN group had 4.5 ± 5.2 CD163+ cells/glomeruli ranging from 20 to 0. The number of CD163+ cells in the glomerulus was associated significantly with endocapillary hypercellularity (E1) and crescents (C2) on histology. CD163+ cells/5 hpf of tubulointerstitium were 112.7 ± 60 and correlated significantly with the level of 24-h proteinuria. Mean levels of urinary sCD163 in IgAN, LN, and healthy control group were 11.8 ng/ml, 27.1 ng/ml, and 0.18 ng/ml, respectively. sCD163 levels correlated significantly with the number of CD163+ cells in the glomeruli.

CONCLUSIONS: CD163+ M2 macrophage infiltration in IgAN correlates with severity of glomerular injury. Urinary sCD163 correlate with CD163+ macrophages in the glomeruli and may act as noninvasive biomarkers for the severity of glomerular injury.


  Comparing the Clinical Characteristics and Outcome of COVID-19 Among Hemodialysis Requiring Patients During the Two Waves of the Pandemic Top


Dolphin Solomon, Goutham Kamalakannan, sajmi Shaji, vathsalyan Paulpandian, Krishna Ravindran, Badri Srinivasan Kannan, Changanidi Aruyerchelvant, Anuj Moses Lamech, sheik Sulthan Alavudeen, Dinesh Kumar Thanigachalam, Rajendran Padmaraj, Natarajan Gopalakrishnan

Department of Nephrology; Madras Medical College; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Patients with chronic kidney disease (CKD), particularly those on dialysis, are highly vulnerable for contracting COVID-19 infection and developing severe disease due to their immunocompromised state.

AIM OF THE STUDY: This study aimed at comparing the clinical course and outcome of COVID-19 infection between the two waves in hemodialysis patients.

METHODS: This is a single-center prospective observational study of patients with COVID-19 infection who were on maintenance hemodialysis or who had an acute worsening of CKD warranting dialysis initiation. Two time periods were studied – April 2020 to January 2021 (first wave) and April 2021 to July 2021 (second wave). Demographic and clinical data were collected and outcomes of hospitalization were recorded. Patients were dialyzed in a dedicated COVID-19 dialysis unit for the duration of their hospital stay. The two time periods were compared in terms of severity of infection and mortality, and appropriate statistical tests of significance were applied.

RESULTS: A total of 939 patients were studied. Of them; 755 patients (80.4%) were on chronic hemodialysis and 184 patients (19.6%) had worsening of CKD warranting initiation of dialysis. Overall mortality was 20%. There were 705 patients (75%) during the first wave and 234 patients (25%) during the second wave. In the first wave, the mean age was 52.4 years and gender ratio was 2.5. 308 (43.7%) were diabetic; 559 (79.3%) were hypertensive and 126 (17.8%) patients had acute worsening of renal function. 500 (70.7%) were symptomatic at presentation; 323 (45.7%) required oxygen; 164 (23.2%) had more than 50% lung involvement; and 123 (17.4%) died. In the second wave, the mean age was 51.6 years and gender ratio was 2.4. 106 (45.3%) were diabetic; 186 (79.5%) were hypertensive; and 58 (24.8%) patients had acute worsening of renal function. 211 (90.2%) had symptomatic illness; 127 (54.3%) required oxygen; 54 (23.1%) had severe lung involvement; and 54 (23.1%) patients died.

CONCLUSIONS: The presence of symptomatic illness at presentation, requirement of oxygen during hospital stay, acute deterioration of kidney function, and mortality were significantly higher among hemodialysis patients in the second wave when compared to the first wave.


  Longitudinal Assessment of Health-Related Quality of Life in Three Different Hyperphosphatemia Management Groups of Stage 3 And 4 Chronic Kidney Disease Patients Top


Navjot Kaur, Himansu Mahapatra

Department of Nephrology; ABVIMS Dr. R. M. L Hospital; New Delhi; India

E-mail: [email protected]

BACKGROUND: Health-related quality of life (HRQoL) has emerged as an important outcome measure in patients with chronic kidney disease (CKD). The lack of prospective studies on HRQoL and relation with hyperphosphatemia control measures among the predialysis patients necessitated the need for this study.

AIM OF THE STUDY: Assessment of HRQoL in three different hyperphosphatemia management groups of stage 3 and 4 CKD patients.

METHODS: This 1-year, prospective, randomized controlled, open-labeled study conducted among 120 CKD stages 3 and 4 patients, divided into three groups: Group 1 – Dietary phosphorus modification n = 40; Group 2 – Calcium-based phosphate binders n = 40; and Group 3 – Noncalcium-based phosphate binders n = 40. They were assessed for HRQoL through short form 36-item, FGF 23, intact PTH (iPTH), phosphorus, and nutrition along with dietary phosphorus control strategies. Out of total score of 3500, the maximum physical component score (PCS) and mental component score (MCS) were 2500 and 1000, respectively. Quantitative data of HRQoL between three groups were assessed by mean, ANNOVA, or Kruskal–Wallis H test at baseline and at 12th month. The correlation of HRQoL with calcium, phosphorus, iPTH, and FGF 23 was studied at baseline.

RESULTS: At baseline, PCS and MCS were equally distributed among three groups. PCS of HRQoL improved significantly (P < 0.00) from baseline to 1 year, viz., in Group 1, PCS was 1621.38 ± 431.11–1857.25 ± 297.20; in Group 2, the PCS was 1745 ± 319.27–1929.50 ± 187.49; and in Group 3, PCS was 1666.13 ± 332.92–1844.13 ± 231.65. However; MCS did not change significantly. FGF 23 has correlated significantly with general health and mental health but not serum calcium and phosphorus.

CONCLUSIONS: All forms of hyperphosphatemia management strategies in early stage of CKD had significant improvement in PCS over a period of 12 months. Further; FGF 23 as an early marker of CKD-MBD has shown significant association with general health and mental health but not with serum calcium and phosphorus.


  Follow-Up Study of Kidney-Transplant Recipients Infected with SARS-CoV2 - A Single-Center Experience Top


Sajmi Shaji, Krishna Ravindran, Goutham Kamalakannan, Natarajan Gopalakrishnan, Paulpandian Vathsalyan, Badri Srinivasan Kannan, Dolphin Solomon, Venkatesh Arumugam, Sakthirajan Ramanathan, Dineshkumar Thanigachalam

Institute of Nephrology; Madras Medical College and RGGGH; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Previous studies on kidney-transplant recipients (KTRs) infected with SARS-CoV2 have shown increased mortality compared to general population. However, data on the long-term follow-up of these patients remain limited.

AIM OF THE STUDY: To study the long-term effects of SARS-CoV2 infection on KTRs who survived initial hospitalization.

METHODS: This is a prospective observational study conducted at the Madras Medical College between March 2021 and August 2021. All KTRs who were discharged from the hospital after successful treatment of RT-PCR-confirmed COVID-19 were followed up until August 2021, and their clinical course was studied.

RESULTS: Of a total of 141 KTRs admitted for acute COVID-19 during the study period, 113 patients were discharged and 80 (70.7.%) were followed up. This included 51 patients from the first wave (March 2020–February 2021) and 29 patients from the second wave (March 2021–July 2021) The median duration of follow-up was 34 weeks (interquartile range: 3–51). Of the 80 patients who were studied after discharge, seven (9%) patients died on follow-up. One patient continued to be oxygen dependent as a result of post-COVID pulmonary fibrosis, 1 year after discharge. Complete renal recovery with a return to baseline GFR was seen in 46 patients (57.5%). Incomplete renal recovery with chronic graft dysfunction was noted in 22 patients (27.5%), and graft loss occurred in 5 patients (6%) .Allograft biopsies were performed in 8 patients (10%), which showed acute cellular rejection (3 patients), antibody-mediated rejection (2 patients), and graft pyelonephritis (3 patients).

CONCLUSIONS: Persistent graft dysfunction was seen in 27.5% KTR infected with SARS-CoV2 infection during follow-up. Renal allograft biopsies for graft dysfunction revealed cellular and antibody-mediated rejection along with three cases of graft pyelonephritis. Postdischarge mortality during follow-up was 9%.


  Bioprospecting of Chronic Kidney Disease Genes Through Bioinformatics Approach and its In Vivo Validation in Obstructive Nephropathy Rat Model Top


Shruti Tomar, Sanjeev Puri1, Veena Puri2, Seemha Rai

Centre for Stem Cell and Tissue Engineering; Panjab University; 1Biotechnology Branch; University Institute of Engineering and Technology; Panjab University; 2Centre for Systems Biology and Bioinformatics; Panjab University; Chandigarh; India

E-mail: [email protected]

BACKGROUND: Chronic kidney injury leads to nephritis, apoptosis, and fibrosis, irrespective of the underlying root cause, eventuating in expensive treatments. Identifying the peril of disease at an early stage is important in providing suitable and timely intervention for impeding the advancement of the disease. Bioinformatics has become a much-vaunted choice in attaining a full insight of biological information and scrutinizing potential therapeutic targets by penetrating into its molecular mechanism.

AIM OF THE STUDY: The aim of the study is to find the participation of the key genes involved in chronic kidney injury and to uncover other genes that are in close alliance during the progression of the disease.

METHODS: List of genes related to chronic kidney disease (CKD) for rat kidney were downloaded from NCBI with keywords “;chronic kidney genes,” “;inflammatory genes for CKD,” “;apoptotic genes for CKD,” and “;fibrotic genes in CKD.” To construct the Protein Interaction Network of the genes retrieved from NCBI, Search Tool for the Retrieval of Interacting Genes (STRING) database was employed to find interactions between the genes. The network retrieved from STRING was then imported to CYTOSCAPE which analyzed the network by computing various topological parameters. The top three genes so obtained were validated in vivo by creating a rat model of CKD by unilateral ureter obstruction method. It was performed by surgically ligating the left ureter at two points. Blood samples were collected for BUN-creatinine tests and kidney samples were harvested for histology; at 14 and 18 days of control and operated rats. Expression analysis of these three genes was performed by real-time PCR and immunohistochemistry.

RESULTS: Using NCBI database, a total of 134 genes related to “;chronic kidney genes” were retrieved. The redundant genes were eliminated confining the list to 37 genes. The network was then exported to Cytoscape. Using the Molecular Complex Detection clustering algorithm; cluster analysis of the protein network was performed which generated two modules. Module 1 with the highest score was selected constituted by 13 genes. These were further analyzed for topological characteristics by Cytoscape plugin Cytohubba. This reduced the list to 9 hub genes out of which STAT3, TNF-α ± and TGF-β were selected as the top three hub genes. The expression of these hub genes was found to be elevated in unilateral ureter obstruction model of CKD. The expression level also increased with the duration of injury with greater level at 18 days and then at 14 days. The expression level of the hub genes correlated well with the immunohistochemistry analysis in the tissue as well.

CONCLUSIONS: The observations provide the bioinformatics approach to decode the biomarkers for CKD that can be used for the prognosis of disease progression and eventually can be harnessed for potential therapeutic targets.


  Prevalence of Genetic Mutations Associated with Kidney Disorders in a Renal-Transplant Recipients - Single-Center Experience Top


Ankur Mittal, Abhijit Konnur, Sishir Gang, M M Rajapurkar, Umapati Hegde, Hardik Patel, Sachidanand Panday

Departments of Nephrology and 1Molecular Biology; Muljibhai Patel Society for Research in Nephro-Urology; Nadiad; Gujarat; India

E-mail: [email protected]

BACKGROUND: Genetic analysis often reveals the cause of kidney failure in patients with unknown kidney disease. For patients awaiting renal transplantation, genetic testing before kidney transplant may help to understand the outcome in these patients.

AIM OF THE STUDY: To study the role of pretransplant genetic analysis in a patient of ESRD and to study the prevalence of complement regulatory gene mutations in patients with ESRD undergoing renal transplant

METHODS: Between October 2019 and July 2021, 123 renal-transplant (RTx) recipients were analyzed using Multiplex Ligation-dependent Probe Amplification and clinical exoms sequencing for mutations related to kidney disease.

RESULTS: Mean age was 36 ± 12 years; 96 (78%) were males. 88 (71.5%) were undetermined and 35 (28.4%) had established cause of chronic kidney disease (CKD); renal biopsy in 12 patients; 8 had structural or hereditary kidney disease; and 27 were nonhereditary including DKD, glomerulopathy, obstructive uropathy, and CTID. 17/88 (19.3%) patients with undetermined CKD on renal biopsy showed glomerulosclerosis (6); CGN (8), and TMA (2); 1 had advance renal damage. 29/88 (32.9%) patients had genetic mutations related to kidney disease. 20 were structural congenital or hereditary kidney disease and 9 had a mutation for glomerulopathies. Mutations related to complement regulatory genes were found in 83/123 (68.3%). Six patients had congenital or hereditary kidney disease; 12 were DKD; 5 glomerulopathy; 2 obstructive kidney disease; and 1 had CTID. Homozygosity and heterozygosity were seen in 14 (16.8%) and 10 (12%) patients, respectively. 67/88 (80.7%) also showed CFHR1/CFHR3 gene complex duplication, reported as variant of uncertain significance.

CONCLUSIONS: This study demonstrates 83.7% (103/123) prevalence of genetic mutation in RTx recipients. Genetic analysis provides the etiology in 35 patients of undetermined kidney disease. Significance of complementary regulatory gene-related mutation remained uncertain.


  Angiotensin Receptor Blocker Combined With Neprilysin Inhibitor in Heart Failure with Reduced Ejection Fraction in Advanced Chronic Kidney Disease Top


Anjana Gopal, Jacob George, Noble Gracious, Sajeev Kumar

Department of Nephrology; Government Medical College; Thiruvananthapuram; Kerala; India

E-mail: [email protected]

BACKGROUND: Though the combination of an angiotensin receptor blocker (ARB) and a neprilysin inhibitor (ARNI) has been shown to be useful in heart failure with reduced ejection fraction (HFrEF), its use has mostly been restricted to chronic kidney disease (CKD) patients with an estimated glomerular filtration rate (eGFR) >30 ml/min/1.73 m2. However; HFrEF is a common cause of morbidity and contributes to mortality more so in advanced CKD.

AIM OF THE STUDY: The primary objectives were to study the effect of ARNI on hospitalization, symptoms, and the change in concentration of NT-proBNP level.

METHODS: Patients with HFrEF and advanced CKD with an eGFR <30 ml/min/1.73 m2 were given ARNI (sacubutril with valsartan) and prospectively studied for changes in hospitalization rate for heart failure, clinical symptoms (NYHA stage and Kansas City Cardiomyopathy Questionnaire (KCCQ) score), levels of NT-pro BNP, eGFR, proteinuria, and hyperkalemia. All were on potassium-restricted diet. ARNI was withdrawn in case of hyperkalemia or decrease in eGFR >30%.

RESULTS: Twenty-six patients with a mean age of 55.04 + 12.51 including 17 with diabetes mellitus and 23 with underlying coronary artery disease were studied. Eight patients had stage 4 CKD and 18 were in Stage 5 and eight required hemodialysis. Following ARNI, there was a significant decrease in need for hospitalization for breathlessness (2.04 ± 1.03–0.23 ± 0.51; P < 0.05); NYHA and KCCQ scores (3.77 ± 0.43–2.19 ± 0.56 and 28.58 ± 9.04–64.81 ± 14.3, respectively; P < 0.001); NT pro-BNP levels (24,761 ± 12157.51–20,149.92 ± 13,555.269; P < 0.05), and proteinuria (1.36 ± 1.08–0.99 ± 0.95; P < 0.05) without significant change in eGFR after 6 months. Discontinuation of ARNI was required in seven patients due to >30% decrease in eGFR and one due to hyperkalemia. There was no significant differences in the need for hospitalization, changes in NT pro BNP levels, and eGFR between the stages 4 and 5.

CONCLUSIONS: ARNI is effective and can be used with care even in patients with CKD Stages 4 and 5 having HFrEF.


  Clinical Outcomes of Low-Dose Therapeutic Plasma Exchange in Yellow Phosphorus Poisoning - A Prospective Study Top


Archana Chiniwalar, Edwin Fernando1, Srinivasa Prasad1, S Sujit1, K Thirumalvalavan1, A Poongudi1

Department of Nephrology; Government Stanley Medical College; 1Department of Nephrology; Government Stanley Medical College and Hospital; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Consumption of yellow phosphorus is a common mode of poisoning in developing countries. It has no specific antidote. Data on low-dose therapeutic plasma exchange (TPE) for hepatic dysfunction in yellow phosphorus poisoning (YPP) are limited. Hence, we conducted a prospective study to demonstrate the same.

AIM OF THE STUDY: We aimed to determine the clinical outcomes of low-dose TPE in YPP and assess the complication profile in the same cohort.

METHODS: We enrolled around 60 patients with history of YPP and hepatic dysfunction between July 2020 and January 2021. Three to five sessions of low-dose TPE were performed for all the patients satisfying criteria for acute liver injury (ALI) or acute liver failure (ALF). Demographic data and biochemical parameters were measured before and after TPE. Overall survival and transplant-free survival were statistically analyzed.

RESULTS: Sixty patients underwent TPE for ALF due to YPP. Most of them were young females (60%). Mean age was 27 ± 9.1 years. Low-dose TPE showed significant improvement in alanine aminotransferase, aspartate aminotransferase, and international normalized ratio (INR) (P < 0.05). Overall survival and transplant-free survival was seen in 47 patients (78%). Acute kidney injury (AKI) was seen in 60%; most of them were managed conservatively. Adverse events such as hypotension and perioral paresthesia (16%) and allergic reaction (4.5%) were managed conservatively.

CONCLUSIONS: TPE in YPP with hepatotoxicity of early stages was found to be safe and effective procedure, showed survival benefits, and can be used as bridging therapy before liver transplantation. Large-scale prospective studies are required to assess its efficacy in severe ALF.


  Comparative Study Between Single-Dose Rituximab Therapy Versus Multiple Dose Regimen in Idiopathic Membranous Nephropathy and its Correlation with Peripheral Blood CD19 Count Top


Arindam Kargupta, Pinaki Mukhopadhyay

Department of Nephrology, NRS Medical College and Hospital, Kolkata, West Bengal, India

E-mail: [email protected]

BACKGROUND: This study is conducted to look for the role of single-dose rituximab in idiopathic membranous nephropathy (MN) and to compare it with multiple dose regimen. We will also try to correlate B cell suppression by rituximab by CD19 count with therapeutic response.

AIM OF THE STUDY: To compare the therapeutic response to single-dose rituximab against multiple dose regimen and to correlate the degree of B cell suppression by peripheral blood CD19 count with the therapeutic response.

METHODS: Single-center, prospective, open-label, parallel group interventional study where after recruiting patients with IMN will be followed up and when immunosuppressive indicated will be divided in two arms where one arm will receive single dose of rituximab 375 mg/m2 and the other group will receive two doses at an interval of 7 days. All will be followed up for 6 months along with periodic CD19 count monitoring to look for B cell suppression.

RESULTS: A total of 28 patients underwent randomization in the study; 13 into single-dose arm and 15 patients in the multiple dose arm. After rituximab administration, 12 patients in the single-dose arm and 13 patients in the multiple dose arm completed 6-month follow-up period. Regarding the primary outcome of the study, at the end of 6-month follow-up period, a total of 7 patients out of 13 in the single-dose arm (53.87%) and 8 patients out of 15 patients in the multiple dose arm (53.33%) achieved either complete or partial remission, and regarding secondary outcomes, both groups performed equally well without any statistically significant differences.

CONCLUSIONS: Rituximab is very effective and safe in primary MN. Rituximab induced proteinuria reduction occurs slowly and may take up to 6 months. There is no statistically significant difference regarding remission rate and adverse effects in between single-dose rituximab and multiple dose regimen


  Effect of Ultrasonic Waves in Increasing the Clearance of Uremic Toxins Top


Nikhil Das

Medical Device Development; Sedign Solutions Pvt. Ltd. Incubated at CCAMP; NCBS; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: During hemodialysis, particles such as uremic toxins and proteins get deposited on the surface of the dialyzer membrane, causing its clogging, known as concentration polarization. It reduces the effective membrane surface area available for diffusion of toxins. Concentration polarization may result in dialysis inadequacy, poor dialyzer reusability, longer treatment duration, and poor quality of life of patients.

AIM OF THE STUDY: The study investigates the role of ultrasonic waves in reducing concentration polarization to increase the efficiency of hemodialysis.

METHODS: Human blood from blood bags was circulated through a dialysis machine to simulate dialysis. Urea was added to make the blood uremic. The investigational device was attached to the dialyzer externally to send ultrasonic waves into it during dialysis. Samples were drawn at regular intervals from the arterial and venous ports. The urea concentration values of the samples were used to measure dialyzer clearance. Complete blood pictures of the samples were used to check if ultrasonic waves were causing any damage to the cells. The blood leak detector of the dialysis machine checked for any rupture of the membranes due to exposure to the ultrasonic waves. After exposing the dialyzers to ultrasonic waves, they were subjected to a pressure test using a dialyzer reprocessing machine to detect any damage to the membranes.

RESULTS: It was observed that the clearance of urea increased by at least 10% when ultrasonic waves were transmitted into the dialyzer using the investigational device. The blood cell counts and the red cell indices did not reduce upon the exposure to ultrasonic waves. The peripheral smear of the samples did not show any damage to the cells due to the exposure to ultrasonic waves. The dialysis machine did not detect any blood leak or change in the transmembrane pressure after the use of the investigational device. The dialyzers exposed to ultrasonic waves passed the pressure test on the dialyzer-reprocessing machine.

CONCLUSIONS: The study proves that ultrasonic waves from the investigational device indeed improve the clearance of urea and are safe for medical use. It paves way for more studies investigating the impact of ultrasonic waves in increasing dialysis adequacy and better removal of middle molecules.


  Vascular Endothelial Growth Factor Gene Polymorphism Association with Acute Allograft Rejection in Live-Related Renal-Transplant Recipients Top


Narayan Prasad, Vinita Agarwal1, Manas Ranjan Patel, Brijesh Yadav

Departments of Nephrology and 1Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

E-mail: [email protected]

BACKGROUND: Renal allograft rejection risk associated with donor's vascular endothelial growth factor (VEGF) gene polymorphism remains unelucidated till now. Although studies have shown an association of recipient's VEGF polymorphism with the end-stage renal disease and early acute rejection, VEGF has pleiotropic function which regulates vasculogenesis and endothelial cell survival signaling.

AIM OF THE STUDY: To investigate the VEGF-634C>G; −1154G>A; −1190G>A; −1455T>C; −1499C>T; −2578C>A; −254918bp insertion/deletion +405C>G; +936C>T SNPs, VEGF mRNA, and protein expression among donors and recipients.

METHODS: Genotyping of VEGF SNPs among 320 recipients and 160 donors was done through PCR-RFLP technique; the recipient group was divided into nonrejecters (160) and rejecters (160) and analyzed further. VEGF serum level and intragraft mRNA; protein expression was analyzed by ELISA; RT-PCR and immunohistochemistry.

RESULTS: On comparison between donors and recipients genotypes of VEGF+936C>T (CT [odds ratio (OR) = 7.16; 95% confidence interval (CI) = 4.33–11.84; P = 0.00] and TT [OR = 49.30; 95% CI = 11.84–205.29; P = 0.00]), −1154G>A (AG [OR = 2.22; 95% CI = 1.40–3.50; P = 0.00]); −1190G>A (GG [OR = 2.21; 95% CI = 1.22–4.01; P = 0.00]); −634C>G (GG [OR = 2.34; 95% CI = 1.34–4.10; P = 0.00]); and −2549 18 bp insertion/deletion (ID [OR = 1.58; 95% CI = 1.01–2.46; P = 0.04]) were significantly associated with risk of rejection, whereas mutant genotypes of −2578 C>A (CA [OR = 0.45; 95% CI = 0.26–0.79; P = 0.005] and CC [OR = 0.23; 95% CI = 0.11–0.46; P = 0.000]) and +405C>G (GG [OR = 0.43; 95% CI = 0.20–0.91; P = 0.02]) have shown protective association with rejection. The VEGF mRNA, protein expression, and serum VEGF level were significantly higher in intragraft and in serum of allograft recipients compared to healthy donor, which was further higher in rejecters compared to nonrejecters.

CONCLUSIONS: Mutant genotypes of VEGF+936C>T, −1190G>A, −2549 18 bp insertion/deletion, and −1455T>C SNPs were associated with increased risk for renal allograft rejection and −2578C>A and CC and +405C>G have shown protective association.


  Remnant Cortical and Whole Kidney Volume and PR-Nephrectomy Estimated GFR as Predictors of 5-Year Postnephrectomy Egfr in South Asian Living Kidney Donors Top


Anna T Valson, Reettika Chanda, Shweta Singh, Anu Eapen, Vinoi George David, B Antonisamy, Rajiv Paul Mukha, M Rajadoss, Jeethu Joseph Eapen, Athul Thomas, Elenjickal Elias John, Sabina Yusuf, Suceena Alexander, Santosh Varughese

Departments of Nephrology; 1Radiodiagnosis; 2Urology and 3Biostatistics; Christian Medical College; Vellore; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: The predictive value of remnant cortical kidney volume (rCKV) and whole kidney volume (rWKV) for postnephrectomy eGFR in living kidney donors (LKDs) from a population with a significant prevalence of low birth weight and likely low nephron endowment is unknown. In addition, there are no data from the Indian subcontinent on the long-term outcome of LKDs or the factors that predict it – information that is crucial for donor selection and prognostication.

AIM OF THE STUDY: To determine the correlation between body surface area (BSA) adjusted rCKV, rWKV, and 5-year postnephrectomy CKD EPI creatinine eGFR (5yeGFR) in LKDs and predict 5yeGFR from prenephrectomy variables.

METHODS: This retrospective cohort study included all LKDs who underwent donor nephrectomy between January 1, 2006, and December 31, 2015, at our center; had prenephrectomy height, weight, and CT angiography with arterial and nephrographic phase documented; and for whom 5-year postnephrectomy creatinine values were available. Total and rWKV and rCKV were measured by two radiologists and standardized for BSA (rWKV/BSA; rCKV/BSA). Data on prenephrectomy demographic variables (age, gender, relation, country of origin); clinical variables (height, weight, smoking status,; hypertension, prenephrectomy CKD EPI creatinine/creatinine-cystatin/cystatin eGFR, dysglycemia, 24-h urine protein); and postnephrectomy variables (1-month, 1-year, and 5-year CKD EPI creatinine eGFR and 24-h urine protein; postnephrectomy dysglycemia; hypertension; and weight gain) were obtained from transplant records and the hospital information system.

RESULTS: A total of 196 LKDs (74% female; mean age 41.7 ± 11.0 years) were included in the study. rWKV/BSA and rCKV/BSA were not different between male and female LKDs; but 1-month and 1-year postnephrectomy CKD EPI creatinine eGFR and 5yeGFR were higher in the latter (5yeGFR 79 vs. 71 ml/min/1.73 m2; P = 0.017). The percentage of prenephrectomy eGFR achieved 5-year postnephrectomy was 10% higher, and the calculated percentage hyperfiltration of the remnant kidney 25% higher; for female LKDs compared to their male counterparts. Correlation between rWKV/BSA, rCKV/BSA, and 5yeGFR was 0.428 and 0.387, respectively (P < 0.001 for both). A linear regression model incorporating age, gender, predonation creatinine eGFR, and rWKV/BSA had a higher R2 compared to one incorporating rCKV/BSA (0.464 and 0.457, respectively); and a model incorporating age, gender, rWKV/BSA, and creatinine-cystatin eGFR had a higher R2 than that incorporating creatinine eGFR (0.479 and 0.464, respectively).

CONCLUSIONS: Prenephrectomy rWKV and rCKV predict 5yeGFR in South Asian LKDs; however, rWKV/BSA and creatinine-cystatin eGFR may be marginally superior to rCKV/BSA and creatinine eGFR for predicting 5yeGFR. Female LKDs show greater adaptive hyperfiltration postnephrectomy despite similar BSA adjusted rWKV and rCKV


  Outcome of COVID-19 in Kidney-Transplant Patients from Eastern India: A Single-Center Study Top


Prit Pal Singh, Amresh Krishna, Prem Shankar Patel, Abhishek Kumar, Om Kumar

Department of Nephrology; Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India

E-mail: [email protected]

BACKGROUND: India is among the countries worst hit by COVID-19. Infections are more common and have poorer outcome in kidney-transplant recipients (KTRs). Standard management of COVID-19 in KTR is still not clear and is evolving. Outcome of KTR affected with COVID-19 varies in different geographic areas and populations.

AIM OF THE STUDY: To estimate the outcome, demographic characteristics, clinical manifestations, laboratory parameters, and overall management of COVID-19 in KTR.

METHODS: This is a retrospective observational single-center study. We included all KTR aged >18 years and <65 years who had COVID-19 diagnosed by RTPCR test between June 1, 2020, and May 30, 2021. Severity of COVID-19 was determined as per the guidelines given by Ministry of Health and Family Welfare, Government of India. Acute kidney injury was defined as increase in serum creatinine >0.3 mg/dl within 24 h or >1.5 times the baseline. Statistical analysis was done by SPSS®; IBM®.

RESULTS: Out of 34 patients; 29 were male. Median age of the patients was 39.9 years and median time since transplantation was 34 months. Presenting symptoms were fever (100%); cough (n = 27; 79.4%); gastrointestinal symptoms (23.5%); and dysgeusia/anosmia in 23.5% cases. COVID-19 disease was severe in six (17.6%) patients and had moderately severe in 11 (32.4%) and mild in 17 (50%) patients. Duration of symptoms, hospital stay, and inflammatory markers such as LDH, CRP, ferritin, and d-dimer were significantly associated with severity of the disease (P < 0.05). Steroids were increased in 35%; antiproliferative agents stopped in 97%; and CNIs stopped in nine patients. Three patients received remdesivir and one received favipiravir. Overall, 24 (70.6%) patients were managed in home isolation.

Acute kidney injury occurred in 58.8% of cases. 75% of the recovered patients had attained pre-COVID serum creatinine by 28 days after discharge. 33 patients recovered and one patient died of sepsis and multiorgan failure.

CONCLUSIONS: Outcome of COVID-19 in KTRs in eastern parts of India is better than the outcome seen in other parts of India and rest of the world. Cure rate and death rate were comparable to that of general population in this region. Almost 60% of patients developed acute kidney injury.


  Study on Prediction of Arteriovenous Fistula Maturation by Flow-Mediated Dilatation and Arteriovenous Fistula Blood Flow Top


Mansi Singh, Himansu Sekhar Mahapatra

Department of Nephrology; ABVIMS; Dr. R. M. L. Hospital; New Delhi; India

E-mail: [email protected]

BACKGROUND: The physiology and pathology of arteriovenous fistula (AVF) maturation depend on the vessels characteristics and its ability to remodel.

AIM OF THE STUDY: To study the outcome of AVF using flow-mediated dialation (FMD) and AVF blood flow and diameter.

METHODS: The present observational study included single-stage AVF (both radiocephalic and brachiocephalic) in consecutive chronic kidney disease five patients (n = 158) prospectively over 1 year. Demographic and Doppler ultrasound parameters of upper limb (for vessel diameter and FMD) at baseline were recorded. Blood flow, diameter, and depth of AVF were studied at 2, 6, and 12 weeks and their association with clinical maturation (usage of fistula with two needles for 75% of dialysis sessions during 15-day period) was studied (n = 129); after excluding lost to follow-up and expired patients, accordingly, cohort was divided in matured (M) or nonmatured (NM) groups. Clinical and radiological parameters between both groups were compared; receiver operator curve (ROC) and correlation of Doppler parameters were analyzed.

RESULTS: Of 129 AVF, 67.4% were matured and 32.5% were nonmatured. Mean age was 40 years with male predominance (75%) in both the groups. The mean arterial diameter for distal (NM = 1.96 ± 0.58 and M = 2.02 ± 0.41) and proximal AVF (NM = 3.37 ± 0.82and M = 3.36 ± 0.75) was not statistically different in both the groups. The matured fistula group had a mean FMD of 11.67 ± 4.09 as against FMD value of 9.365 ± 3.55 in the failed fistula group (P = 0.01). For maturation prediction, sensitivity and specificity of blood flow at 2 weeks were 86.2% and 59.5% and at 6 weeks were 96.6% and 64.3%, respectively.

In multivariate analysis, predictors for AVF maturation were FMD (adjusted odds ratio [AOR] =1.15) and blood flow (AOR = 1.67).

CONCLUSIONS: Second and sixth week AVF blood flow was found to be predicting AVF maturation. Higher baseline FMD correlated with the AVF maturation, but not with vessel diameter.


  Cystinosis: A 12-Year Follow-Up Study Top


P Lakshmi Aishwarya, Ram, V Siva Kumar, M Murali, N Prasanna, Mathini, B Alekhya, Maria

Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India

E-mail: [email protected]

BACKGROUND: Cystinosis is an autosomal recessive disorder, in which free cystine accumulates continuously in lysosomes, eventually resulting in intracellular crystal formation throughout the body. It leads to cellular dysfunction of many organs, the most serious being renal involvement.

AIM OF THE STUDY: To study clinical presentation, progression of disease, and outcome in cystinosis patients.

METHODS: From 2009 to till date, we identified eight patients of cystinosis and were followed till May 2021. We provisionally diagnosed cystinosis when patients presented with proximal renal tubular acidosis (RTA), with or without Fanconi syndrome. We confirmed it with slit lamp examination which revealed corneal cystine crystals.

RESULTS: From 2009 to till date, we identified eight patients of cystinosis and were followed till May 2021. All eight patients had Fanconi syndrome, proximal RTA, and corneal cystine crystals. Chronic kidney disease stage 5D evolved in five of the six patients who had raised serum creatinine.

CONCLUSIONS: We should seize the early wake-up calls to the diagnosis of cystinosis. An early diagnosis in infancy and the higher number of patients would ease the availability and scale down the price of cysteamine.


  Clinical Utility of Genetic Testing in Children from Western India with Kidney Diseases Top


Anshuman Saha, Shahenaz Kapadia1, Kinnari B Vala1, Himanshu V Patel1

Department of Nephrology; IKDRC-ITS; 1Division of Pediatric Nephrology; Department of Pediatric Nephrology; Institute of Kidney Diseases and Research Centre; Gujarat University of Transplantation Sciences; Ahmedabad; Gujarat; India

E-mail: [email protected]

BACKGROUND: Almost one-third of children with kidney diseases have a genetic etiology with a varying overlapping spectrum of manifestations.

AIM OF THE STUDY: This retrospective study aimed to evaluate the clinical utility of genetic testing in the diagnosis and management of children with suspected genetic kidney disease.

METHODS: Children below 18 years in whom a genetic test was ordered from September 2016 to January 2021 were included. Clinical indication for genetic testing was categorized as glomerular diseases, tubular disorders, nephrolithiasis and/or nephrocalcinosis, cystic kidney diseases, congenital abnormality of kidney and urinary tract (CAKUT), chronic kidney disease of unknown etiology, and others. The genetic test of choice was clinical exome sequencing. Other genetic tests ordered were gene panel, Sanger sequencing, multiplex ligation-dependent probe amplification, and karyotyping. The pathogenicity of the genetic variant was interpreted as per the American College of Medical Genetics classification.

RESULTS: A total of 89 samples were sent for genetic testing from 76 children, 8 parents, and 2 fetuses. A total of 73 variants were reported in 47 genes. Out of 73 variants, 43 were missense, 8 were nonsense, 13 were frameshifts, 1 was indel, 4 variants affected the splicing regions, and 4 were copy number variants. Thirty-three children had pathogenic and 6 had likely pathogenic variants. Twenty children (26.3%) had variants of uncertain significance. No variants were reported in 17 children (22.3%). A genetic diagnosis was made in 39 children with an overall yield of 51.3%. The solve rate was 32.4% for glomerular diseases; 61.5% for tubular disorders, 100% for nephrolithiasis and/or nephrocalcinosis, 60% for cystic kidney diseases, and 50% for chronic kidney disease of unknown etiology. Genetic testing made a new diagnosis or changed the diagnosis in 15 children (19.7%).

CONCLUSIONS: Almost half of the children suspected and tested for a genetic disease had a genetic disease. Genetic testing confirmed the clinical diagnoses, made new diagnoses, or changed the clinical diagnoses which helped in appropriate management.


  Effect of Cholecalciferol on Vascular and Immune Function in Chronic Kidney Disease Top


Kajal Kamboj, P Aruna, Manphool Singhal, Vivek Kumar, Ashok Kumar Yadav

Departments of Nephrology; 1Experimental Medicine and 2Biotechnology and Radiodiagnosis; PGIMER; Chandigarh; India

E-mail: [email protected]

BACKGROUND: Vitamin D deficiency is common in chronic kidney disease (CKD), and evidence from several observational studies suggests an association between Vitamin D deficiency and mortality both in predialysis CKD patients and in patients on dialysis. Short-term studies have shown beneficial effects of vitamin D supplementation on vascular function in CKD. However, none of these have studied the immunological axis in connection with Vitamin D supplementation and changes in vascular function.

AIM OF THE STUDY: In this study, we investigated the effect of cholecalciferol supplementation on vascular and immune function in nondiabetic early-stage CKD subjects.

METHODS: The study is a single-center, prospective, nonrandomized, pre–post study that is enrolling participants at Postgraduate Institute of Medical Education and Research, Chandigarh, India (CTRI/2019/10/021494). Nondiabetic CKD subjects with eGFR 15–60 ml/min/1.73 m2 and serum 25(OH)D levels <20 ng/ml are eligible. Clinical and laboratory assessments are done at baseline and 8 and 16 weeks. The primary objective is change in circulating T cell subsets (Th1, Th2, Th17, and Treg) at 16 weeks after cholecalciferol treatment. The secondary objectives are change in flow-mediated dilatation (FMD), NMD, and pulse wave velocity (PWV); Vitamin D–responsive genes (cathelicidin and IL-10); and association of change in FMD, NMD, and PWV with change in circulatory T cells subsets at 16 weeks. Participants receive 300,000 IU of cholecalciferol after baseline assessment and at 8 weeks.

RESULTS: 23 CKD subjects have been enrolled till date, out of which 14 subjects have completed follow-up at 16 weeks and included in the current analysis. Mean age was 46.21 ± 12.78 years with majorly (60%) males. Baseline 25(OH)D levels were 12.60 (8.25, 16.05) ng/ml which increased to 42.10 (36.33, 54.50) ng/ml at 16 weeks. Immune function analysis shows that treatment with cholecalciferol favors the Th2 cell phenotype; CD3+CD4+IL4+ T cells (7.82% ± 11.03% at baseline and 24.25% ± 24.03% at 16 weeks; P = 0.013). However; no significant difference was noted for Th1 cell/Th17/Treg cell phenotype. A trend was seen for improvement of vascular function with cholecalciferol supplementation as FMD (9.22% ± 8.07% at baseline to 13.36% ± 7.72% at 16 weeks; P = 0.155) and PMV (8.56 ± 3.12 m/s at baseline to 10.07 ± 2.69 m/s at 16 weeks; P = 0.260). Further, Vitamin D–responsive genes expression was increased fivefold for CAMP and 12fold for IL-10 at 16 weeks of follow-up.

CONCLUSIONS: Cholecalciferol supplementation favors Th2 cell phenotype, increased expression of Vitamin D-responsive genes, and shows a trend in improved vascular function.


  Assessment of Oral Health in Patients of Chronic Kidney Disease Top


Sahil Gupta, Gurvanit Kaur Lehl1, Sanjay D'Cruz

Departments of General Medicine and 1Oral Health Sciences; Government Medical College and Hospital; Chandigarh; India

E-mail: [email protected]

BACKGROUND: The prevalence of chronic kidney disease (CKD) is constantly increasing not only in industrialized countries but also throughout the world. Incidence of CKD in Indian population is estimated to be 17%. CKD, like many other systemic diseases, is associated with oral problems due to the disease process itself or the effects of therapy or both and can result in a wide spectrum of oral manifestations. Patients with CKD have increased prevalence of oral health problems in comparison to general population.

AIM OF THE STUDY: This study is to find out oral health status of patients of CKD and to compare with age- and sex-matched controls.

METHODS: This was a prospective, observational study spanning 18 months. Sample size of 125 was estimated using appropriate statistical tool. Inclusion: Adults diagnosed with CKD. Exclusion: Patients on hemodialysis. Demographic data, history, physical examination, and laboratory investigations were carried out. The selected patients were administered questionnaire and were also subjected to oral health examination by a qualified dental surgeon using following tools: (1) WHO oral health questionnaire which included questions regarding number of natural teeth, dentures, pain/discomfort in teeth, patients' assessment of their oral health, frequency of cleaning teeth, type of toothpaste, visits to dentist, difficulty in biting and chewing food, embarrassment due to appearance of teeth, dietary habit, dryness of mouth, tobacco use, and alcohol use. (2) WHO oral health assessment form to look at various aspects of oral health such as dentition status, periodontal status, loss of attachment, dental erosion, and oral mucosal lesions.

RESULTS: Of 125 CKD patients, 75 were males and 50 females. 25 were non-CKD age- and sex-matched controls; 15 were males and 10 were females. CKD Stage I, II, III, IV, and V were present in 29, 2, 18, 28, and 48, respectively. Only 17.6% of CKD patients had complete and sound dentition compared to 48% in controls. (ii) Due to periodontal disease was seen in 34.4% of CKD patients as compared to none in controls. Total > 4 > 8 > 16 edentulous CKD 34.4% 22.4% 16.8% 10.4% 8% Controls None None None None None. 71.2% of CKD patients had gingival bleeding compared to 48% in controls. 33.6% of CKD cohort had pockets with 2.4% having deep pockets (>6 mm) compared to 16% of controls having pockets with nil having deep pockets.

CONCLUSIONS: 82% of CKD patients had oral health issues, followed by gingival bleeding (71.2%), missing teeth due to caries (45.6%), and carious teeth in 42.4%. Findings were more prevalent in CKD patients compared to controls. Poor oral health in CKD represents an important, overlooked, problem which leads to malnutrition.


  Knowledge and Attitudes Of Medical and Allied Healthcare Students Toward Organ Donation - Survey From a Single Medical College in Southern India Top


Ankita Gharge, Shobhana Nayak Rao1, M Pradeep Shenoy1

Departments of Internal Medicine and 1Nephrology; K. S Hedge Medical Academy University Enclave; Derlakatte; Mangalore; Karnataka, India

E-mail: [email protected]

BACKGROUND: Transplantation is the best and frequently the only lifesaving treatment for end-stage organ failure. The annual number of organ transplants represents <10% of the prevailing global need. Healthcare professionals, especially doctors, and those in the allied heath sectors including nurses, technicians, and physiotherapists have a key role in the disseminating correct knowledge and eliminating the various barriers regarding organ donation among the public.

AIM OF THE STUDY: The study aimed to assess knowledge, information, and attitudes about organ donation among medical and paramedical students of the K. S Hegde Medical Academy and Allied Institutions.

METHODS: Data were collected using a structured questionnaire which was divided into three sections. The first section comprised demographic details; second section was to understand the knowledge of the respondents toward organ donation; and the third section assessed the attitudes and perception of the participants for organ donation and also exploring the reasons for the same.

RESULTS: About 1000 questionnaires were distributed including 618 medical students and 382 paramedical students. The mean age of the medical students was 22.4 years ranging from 17 to 32 years, while the mean age of the paramedical students was 23.8 years with age ranging from 18 to 32 years. About 60%–70% of the respondents were female and more than 70% were single and came from an urban background. Regarding the knowledge about brain death and the laws that govern human organ transplants within the country, 96% and 52.7% of medical students and 64.4% and 63.3% of paramedical students, respectively, had information on the topic. There were no statistical differences between groups. However, about 87.5% of medical students and 77.7% of the paramedical students felt that a more effective and clear law was needed to prevent misuse and simplify matters related to organ transplantation.

CONCLUSIONS: Students showed adequate knowledge with regard to aspects of organ donation and the legal framework; their attitudes needed some motivation and positive support. It is important to develop a satisfactory program to incorporate aspects of deceased donor transplantation in the medical curriculum.


  A Propensity Score Matched Case–CONTROL Study on Patients with Biopsy-Proven Acute Rejection Between ABO-Incompatible and ABO-Compatible Renal Transplantation Top


S Sabarinath, Manas Patel, Narayan Prasad, A Kaul, D S Bhadauria, Ravi, M R Behera, M Yachha

Department of Nephrology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: ABO-incompatible kidney transplants (ABOi KTx) increased the pool of living donations. Although available outcome data in ABOi KTx are equivocal for its noninferiority when compared to ABO-compatible–transplant recipients (ABOc KTx), the data on graft survival after a biopsy-proven acute rejection (BPAR) episode are scarce in ABOi KTx.

AIM OF THE STUDY: To study postrejection graft survival in patients with BPAR in ABO-incompatible (case) transplants and compare it with ABO-compatible (propensity-matched cohort) transplants.

METHODS: This was a single-center; case–control, retrospective study; end-stage renal disease patients (ESRD) transplanted between 2014 and 2019 were included. Among 100 ABOi KTx, 37 had BPAR and were analyzed. A matched cohort of 37 ABOc KTx with BPAR was identified as controls from 680 ABOc KTx by propensity score matching (nearest neighbor matching) using recipient age and sex, donor age and sex, donor GFR, HLA match, and induction agent used as matching covariates. Rejection rates, BANFF score, response to antirejection treatment, overall graft survival, and postrejection graft survival were compared between two groups. Patient characteristics were compared using the Pearson Chi-square test or Fisher's exact test for categorical variables and the Student's t-test for continuous variables We estimated Kaplan–Meier survival in the matched-pair cohort and compared them using the log-rank test. Statistical analysis was carried out by using SPSS v25 and GraphPad v7.

RESULTS: Overall graft survival in patients with BPAR at 1, 3, and 5 years was 86%, 72%, and 50% in ABOi KTx and 97%, 91%, and 79% in ABOc KTx, respectively. The post-BPAR graft survival at 1 and 3 years was 80% and 63% in ABOi KTx and 92% in both 1 and 3 years in ABOc KTx (P = 0.017). ABMR was more common in the early period (<6 months) in ABOi KTx; ACR was predominant in the late period (>6 months) in ABOc KTx. No significant difference in the BANFF scoring between the two groups was noted. The response to anti-rejection therapy was similar between the two groups (P = 0.948); However; patients with no response (NP) in the ABOi KTx had the poorest graft outcome; and those with complete response (CR) in the ABOc KTx had the better graft survival. Among patients with CR, partial response (PR), and NR, no histopathological parameters were found significant in ABOi KTx, whereas in ABOc KTx, TI scores were higher in patients with PR when compared to those with CR.

CONCLUSIONS: The overall graft survival in patients with acute rejection and the postrejection graft survival were inferior in ABO-incompatible renal-transplant recipients when compared to a matched cohort of ABO-compatible recipients.


  Assessment of Knowledge, Attitudes, and Practices Regarding Chronic Kidney Disease in At-Risk Individuals: A Hospital-Based Cross-Sectional Study Top


Gaurav Shekhar Sharma, Hemlata1, Ranjeeta Kumari2, Sharon Kandari3, Ravi Kant4

Departments of Nephrology; 2Community and Family Medicine; 3Nephrology and 4Medicine; All India Institute of Medical Sciences; 1College of Nursing; All India Institute of Medical Sciences; Rishikesh; Dehradun; Uttarakhand; India

E-mail: [email protected]

BACKGROUND: Chronic kidney disease (CKD) is a global health problem, with prevalence ranging from 10% to 17% in India. The risk factors of CKD include diabetes, hypertension, coronary artery disease, male sex, and advancing age. There is a paucity of literature on assessment of knowledge, attitudes, and practices regarding CKD in at-risk individuals. There is a need for such study in the Indian scenario to guide future interventions for reduction of CKD burden in the population.

AIM OF THE STUDY: To assess knowledge, attitudes, and practices of individuals at risk for developing CKD using CKD Screening Index, a validated assessment tool.

METHODS: This is an observational (cross-sectional) study. A total of 136 patients were enrolled. Patients aged >18 years, at risk of developing CKD, and presenting to outpatient/inpatient department blocks of departments of nephrology, medicine, and surgery in a tertiary care hospital were included in this study. Those younger than 18 years of age and those who were known cases of CKD were excluded. The patient enrolment was done from the day of getting approval by the IEC. Participants filled up CKD Screening Index Questionnaire and scoring was done for all three components – knowledge; attitudes, and practices.

Patients were categorized as low/average/high scorers based on the cutoff scores of <50%, 50%–75%, and >75%, respectively, of total score. All the data were entered in MS excel and were analyzed using SPSS version 23.0. The outcome was assessed in the form of factors significantly associated with higher levels of knowledge, attitudes, and practices.

RESULTS: A total of 136 patients participated in the study. The mean age of the participants was 49.21 ± 13.9 years. Male:female ratio of the study participants was 1:1. Majority of patients were known diabetic (79%) while 16.9% patients were known hypertensives. Majority of respondents scored “;low” on knowledge, scored “;average” on attitude, and scored “;average” on practice scales (49%: n = 66; 75%: n = 101; 58%: n = 79; respectively). There is a positive correlation between knowledge and attitude score of patients (r = 0.266; P = 0.002). Furthermore, a positive correlation is seen among attitude and practice score (r = 0.285; P = 0.001) of the patients. Statistically significant association was observed between attitude and patients who were known diabetic (P = 0.01); known smokers (P = 0.033); and those having a known family history of CKD (P = 0.008).

CONCLUSIONS: The knowledge on risk of getting CKD was found to be poor among hospitalized adults, which implies a need for improving public awareness in this field. As all three assessment domains have been found to be interlinked to each other, improving knowledge would help in improving other two domains.


  Rabbit Antithymocyte Globulin as Induction Therapy in Indian Patients Undergoing Renal Transplantation: Clinical Experience from Rise Registry Top


Deepak Shankar Ray, Sishir Gang1, Aniket Mandrekar2

Renal Transplant Programme; RNTIICS; Kolkata; West Bengal; 1Department of Nephrology; Muljibhai Patel Urological Hospital; Nadiad; Gujarat; 2Medical Affairs; Sanofi; Mumbai; Maharashtra, India

E-mail: [email protected]

BACKGROUND: Induction immunosuppression therapy plays an important role in prevention of acute rejection in renal transplantation.

AIM OF THE STUDY: To evaluate safety and effectiveness of induction immunosuppression using rabbit antithymocyte globulin (rATG) in patients undergoing renal transplantation in India.

METHODS: This multicenter, prospective, observational cohort study (CTRI/2017/09/009/009700) included adult patients (>18 years) who were undergoing renal transplant and physician decides to use rATG as induction therapy. Acute rejection, graft survival, renal function, and safety were evaluated over 12 months.

RESULTS: Of the 325 patients enrolled, 313 received at least one dose of rATG (safety population), and of these, 299 were evaluable (no critical protocol deviation). The mean (standard deviation [SD]) age was 42.8 (11.7) years and 76.3% patients were men. The cumulative mean (SD) rATG dose was 2.6 (1.5) mg/kg. Twenty-three (7.7%) patients experienced graft rejection. Cellular rejection was the predominant pathology (n = 17; 77.3%). The graft survival was 93.3% (n = 279) at 6 months and 92.3% (n = 276) at 12 months. The mean (SD) glomerular filtration rate was 64.59 (19.57) and 64.93 (20.26) mL/min/1.73 m2 at 6 and 12 months, respectively. Fifty-three patients (17.7%) reported 74 infections, the most common being bacterial (n = 37). A total of 342 adverse events were reported in 154 (49.2%) patients and 111 serious adverse events were reported in 56 patients. Seven deaths were reported, of them three were due to sepsis, two were due to cardiovascular disease, and in remaining two, the reason was undetermined.

CONCLUSIONS: Results demonstrated low rejection rate, better good survival and function at 6 months and 1 year, and an acceptable safety profile of rATG with overall infection incidence less than 18%.

FUNDING: Sanofi.

NOTE: This abstract was first presented at ERA-EDTA 2021 as mini-oral.


  Comparison of Concurrent Versus Countercurrent Dialysate Flow in Dialysis Requiring Hyponatremic Patients Top


Amandeep Singh, Lalit Pursnani, B Muthukumar, Himansu Sekhar Mahapatra, Manoj Prabhakran, Sanket Patil, Abhishek Gautam

Department of Nephrology; ABVIMS and Dr. RML Hospital; New Delhi; India

E-mail: [email protected]

BACKGROUND: Rapid correction of hyponatremia during standard hemodialysis (HD) can result in osmotic demyelination; thereby, it is prudent to correct severe chronic hyponatremia at gradual rate. Dialysis with co-current dialysate flow is one of the methods. This study compared the rate of sodium correction in concurrent versus countercurrent dialysate flow.

AIM OF THE STUDY: To compare the rate of change of sodium correction in countercurrent versus concurrent dialysate flow in hyponatremic patients requiring HD.

METHODS: This study was prospective randomized controlled trial done from period of January 2020 to May 2021. Patients with sodium level <125 and dialysis requiring renal dysfunction were included. Patients were randomized to concurrent or countercurrent blood-dialysate flow group. HD duration was kept at 2 h and sodium was tested at baseline and at consecutive hours. Rate of change of sodium level was compared and outcome was analyzed in the form of morbidity and mortality.

RESULTS: A total of 44 patients were included. 23 (52.2%) patients underwent dialysis via concurrent dialysate flow and 21 (47.7%) patients underwent HD via countercurrent dialysate flow. Rapid rate of correction was seen in 8 (18.1%) patients; 3 having underwent co-current dialysis and 5 having underwent countercurrent dialysis (P = 0.44). Neurological deterioration and mortality were seen in 6 patients who had undergone concurrent dialysis and 7 patients who had undergone countercurrent dialysis (P = 0.59).

CONCLUSIONS: In this pilot study, we have seen that though we can avoid rapid rate of correction with use of co current dialysis, its mortality benefit cannot be proven and needs further large studies.


  Seroprevalance of COVID Antibodies in Patients on Maintenance Hemodialysis: Single-Center Study Top


Mahesh Desai, Abhijit Konnur, Sishir Gang, M Rajapurkar, Umapati Hegde, Hardik Patel, Sachidanand Pandey

Department of Nephrology, MPUH, Nadiad, Gujarat, India

E-mail: [email protected]

BACKGROUND: Hemodialysis (HD) patients have been found to be more susceptible to COVID-19 infection and have higher morbidity and mortality than general population. Various measures are being implemented globally to limit acquisition and transmission of COVID-19 infection in patients with CKD on maintenance HD. Despite all the strategies taken, COVID-19 infection rates confirmed by RT-PCR testing have been high.

AIM OF THE STUDY: (1) To determine the seroprevalence of IgG anti-spike COVID-19 antibodies in ESRD patients. (2) To determine the COVID-19 infection rate in ESRD patients.

METHODS: It is a single observational study in ESRD patients at the Muljibhai Patel Urological Hospital Dialysis Unit. Ninety-two patients who were undergoing HD at our center were studied. Plain blood sample was collected for anti-COVID 19-IgG level against spike protein determined by Solid Phase Sandwich ELISA Method (Kit name-HU SARS-COV2 S TRIMER ELISA BMS2323 ThermoFisher) from all patients in January 2021 before the second peak of COVID.

RESULTS: Mean age was 50.08 years and mean dialysis vintage was 30.3 months. In 92 patients; 77.1% (71) were males; and 23.9% (22) were females. 25% (23) were diabetics. 33.6% (31) were above 60 years of age. 94.5% (87) patients were found to have positive for SARS CoV-2 Ig antibodies in serum. Four patients had history of COVID infection in the past, and two patients were vaccinated before the study. When all the subjects were followed up at 6 months; 17 (19.5%) patients developed symptomatic COVID despite having IgG antibodies. Twenty (21.5%) patients underwent renal transplants. The all-cause mortality rate was 7.5% (7 patients); and the case-fatality rate for COVID infection was 28.5% (2 patients; in that one patient had no IgG antibodies against COVID spike protein). Among 87 patients, 19.5% (17) patients developed symptomatic COVID despite having IgG antibodies.

CONCLUSIONS: In our study, the seroprevalence rate was 94.5%. It was seen that 19.5% of patients still developed symptomatic COVID despite having antibodies.


  Serum and Urinary Von Willebrand Factor in Antibody-Mediated Renal-Allograft Rejection Top


Shubhi Kamthan, Snigdha, Niharika Bharti, Narayan Prasad1, Vikas Agarwal2, Vinita Agrawal

Departments of Pathology; 1Nephrology and 2Clinical Immunology; Sanjay Gandhi Post Graduate Institute of Medical Science; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Antibody-mediated rejection (ABMR) is associated with endothelial activation and injury in renal allografts. This may result in release of various cytokines. We performed this study to evaluate serum and urinary Von Willebrand factor (vWF) levels, a marker of endothelial injury, in ABMR and correlated it with clinical and histological parameters.

AIM OF THE STUDY: To evaluate serum and urinary vWF levels, a marker of endothelial injury, in ABMR and correlate it with clinical and histological parameters.

METHODS: Patients with renal-allograft dysfunction diagnosed on renal-allograft biopsies as ABMR (n = 10) and no evidence of rejection (NER) (n = 10) were included from January 2021 to June 2021. Ten age- and sex-matched healthy controls were also included. ELISA (R&D) for vWF was done in serum and urine samples in duplicates as per manufacturer's protocol and OD was taken at 450 nm.

RESULTS: All patients with ABMR were males with a mean age of 37.6 ± 6.36 years. ABMR had significant elevated levels of serum and urine vWF with a mean of 51.66 ± 40.26 ng/ml and 0.25 ng/ml ± 0.45 ng/ml, respectively, as compared to NER (serum vWF: 23.1 ± 14.62 ng/ml; urine vWF: 0.22 ± 0.58 ng/ml) and healthy controls (serum vWF 8.50 ± 1.06 ng/ml; undetectable levels in urine). In ABMR, the serum vWF significantly correlated with high serum creatinine (r = 0.459; P = 0.045) and urine vWF significantly correlated with the degree of peritubular capillaritis on histology (r = 0.738; P = 0.036).

CONCLUSIONS: Urine vWF can be a noninvasive biomarker for detection of endothelial injury and can predict the degree of peritubular capillaritis in ABMR of renal allografts.


  AVF Creation and Estimated GFR Decline in Predialysis Patients: A Matched Cohort Study With Non-AVF CKD Patients Top


Venkataramanan Krishnamoorthy, Prabhu Kanchi

Department of Nephrology; K V R Kidney and Diabetic Centre; Vellore; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: AVF creation and estimated GFR decline in predialysis patients: A matched cohort study with non-AVF CKD patients.

AIM OF THE STUDY: This study aimed to compare eGFR decline in predialysis patients with an AVF creation, matched to patients without AVF.

METHODS: CKD stage V patients with and without AVF creation were retrospectively matched with propensity score from January 2014 to June 2020 in a single center in South India. Time zero was defined as the “;AVF creation date” for the AVF group and the “;date when eGFR was closest to the matched patients” for non-AVF group. eGFR decline in AVF and non-AVF groups was compared after time zero using mixed-effect linear regressions.

RESULTS: In total, 151 preemptive fistulae were created during the period with the median age of 51.5 ± 13.3 years and a median eGFR at the time of AVF creation of 12.3 ± 1.6 mL/min/1.73 m2. Among them, 109 fistulas were matched with predialysis patients without AVF. Ten AVF-created patients were on conservation management more than 24 months before going for dialysis. The eGFR decline after AVF creation/time zero was −2.1 ml/min per m2 per year in the AVF group versus −5.6 ml/min per m2 per year in the non-AVF group (P < 0.05) which is statistically significant.

CONCLUSIONS: In this prospective study, preemptive AVF creation in predialysis patients was associated with less decline in kidney function compared with non-AVF CKD group. It may be a new target to slow the progression of CKD.


  Role of Polymerase Chain Reaction in Peritoneal Dialysis Patients with Nonbacterial Peritonitis Top


Atul Kumar Srivastava, Indranil Ghosh1, Sudheer Dubey2

Departments of Nephrology and 2Lab Medicine; Base Hospital; Delhi Cantt; 1Department of Nephrology; Command Hospital; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Peritonitis in peritoneal dialysis (PD) patients is an important cause of technique failure. Majority of PD-related peritonitis is of bacterial origin, and in very few cases, Mycobacterium tuberculosis (MTB) complex and fungal pathogens are isolated. Due to use of conventional culture media, the isolation of microorganism is less and culture-negative rates are high. Polymerase chain reaction (PCR) technique can be used for isolation of fungal and mycobacterial pathogen in these patients.

AIM OF THE STUDY: To assess the role of PCR in diagnosis of fungal and MTB infection in patients with PD-related peritonitis.

METHODS: This was a single-center prospective study conducted in the department of nephrology at our institute. The study included patients who had PD-related peritonitis between July 2018 and December 2019. Patients less than 18 years were excluded from the study. All patients underwent detailed clinical history and examination at presentation. All patients underwent following tests on admission: CBC, kidney function test, total protein, and albumin. CAPD effluent tests included TLC, DLC, Gram Stain, ZN stain, and bacterial and fungal culture. Panfungal PCR and MTB PCR of CAPD fluid were done using Genosens Real-Time PCR kit on day 1 of admission. TLC of CAPD fluid was repeated on day 3 and day 5. All patients were managed with standard antibiotics regimens. All patients who had positive Pan Fungal and MTB PCR of CAPD underwent CAPD catheter removal. The outcome was measured in terms of patient survival.

RESULTS: During the study period, 200 patients of end-stage renal disease received CAPD. 85 patients had CAPD-associated peritonitis and the peritonitis rate was 1 episode per 16 patient-month Out of 85 patients, bacterial culture was positive in 6 (7.0%) cases. The organisms isolated were Escherichia coli 2 (2.4%); Staphylococcus aureus 1 (1.2%); Klebsiella 1 (1.2%) and Acinetobacter 2 (2.4%). Fungal organisms were isolated in 10 (11.7%) cases. One of the major causes of poor culture-positive rate in this study was use of intraperitoneal/intravenous antibiotics by patients (32.9%) before admission. The fungal organisms isolated were Candida 7 (8.2%) and Aspergillus 3 (3.5%). 55 (64.7%) cases had culture-negative peritonitis. MTC PCR of CAPD fluid was positive in 2 (2.4%) cases and Panfungal PCR was positive in 22 (25.8%), out of which 12 (14.1%) cases had no growth on fungal culture. 6 (7.0%) patients died during the study period. Out of these, 1 (1.1%) had bacterial peritonitis, 2 (2.4%) had fungal peritonitis, and 2 (2.4%) had tubercular peritonitis.

CONCLUSIONS: Culture-positive CAPD peritonitis is limited by availability of appropriate culture media. This leads to loss of precious time to preserve the peritoneum and exposes the patient to life-threatening complications. Use of PCR will help in early diagnosis and prompt treatment in these patients.


  role of NORO Virus Infection in Renal-Transplant Patients Presenting with Persistent Diarrhea Top


Abhishek Y Kadam, Sishir Gang, Abhijit Konnur, Umapati Hedge, Mohan Rajapurkar, Hardik Patel, Sachchidanand Pandey

Department of Nephrology; Muljibhai Patel Urological Hospital; Nadiad; Gujarat; India

E-mail: [email protected]

BACKGROUND: Diarrhea is common gastrointestinal problem in kidney-transplant recipients. Numerous cases of posttransplant diarrhea in the past have been ascribed solely to the toxicity of immunosuppressive drugs, leading to diagnostic misconceptions. Noro virus, one of the common causes of acute diarrhea in adults, is emerging as important cause of persistent diarrhea in solid organ-transplant recipients. Here, we present our experience with chronic Noro virus infection in renal-transplant recipients.

AIM OF THE STUDY: To determine the clinical significance of Noro virus infection in renal-transplant recipients with persistent diarrhea.

METHODS: Between December 2019 and November 2020; renal-transplant recipients presenting with persistent diarrhea (>3 stools/day for >14 consecutive days) were evaluated in a step-wise manner including stool Noro virus RTPCR and were followed for 12 months. Stool specimen were collected in container (Cary-Blair Transport Media) and stored or at −94°F (−70°C).This tests were performed using TaqMan real-time reverse transcription-PCR assay (Fast-track diagnostic). The detection and typing of Norovirus by conserved nucleotide sequences of the ORF1-ORF2 junction region of the Norovirus genome. Patients were followed up clinically. Repeat RTPCR Noro virus in stool was evaluated on follow-up at 3, 6, 9, and 12 months. Because of COVID-19 pandemic, we were not able to collect repeat stool RTPCR samples for Noro virus on follow-up in all patients. Telephonic follow-up was obtained in patients who had not come for follow-up during study period.

RESULTS: 29 out of 39 patients were positive for Noro virus RTPCR. Median time of presentation following transplant was 59 months (range 12–143 months). Median duration of diarrhea was 69 days (range 14–365 days). Median weight loss on presentation was 6.4 kg (range 1.7–17.3 kg). Out of 20 patients who were on Tac/MMF/prednisolone at presentation, MMF was withheld in 11, switched to azathioprine in 3, switched to everolimus in 3 and 3 were continued on the same medications. Out of 7 patients receiving Tac/azathioprine/prednisolone, azathiporine dose reduced in all; 3 were switched to cyclosporine from tacrolimus. Two patients receiving tacrolimus and prednisolone only were switched to cyclosporine. Diarrhea responded in all. Out of 13 patients presenting with renal dysfunction, 6 had worsening of renal function whereas 8 had steady or better renal function at 6 months. 15 patients gained weight at 6 months; 8 had persistent weight loss.

CONCLUSIONS: Noro virus infection is important cause of persistent diarrhea in renal-transplant recipients. It is associated with significant weight loss, renal dysfunction, and prolonged asymptomatic viral shedding. We should look for etiologies other than immunosuppression drugs as cause of persistent diarrhea.


  A Therapeutic Approach Toward Russell'S Viper Venom-Induced Acute Kidney Injury Using Melanin Isolated From Thea Sinensis Top


Sudeshna Kundu, Pinaki Mukhopadhyay, Raghwendra Mishra, Roshnara Mishra

Department of Physiology; University of Calcutta; Kolkata; West Bengal; India

E-mail: [email protected]

BACKGROUND: Acute kidney injury (AKI) secondary to Russell's viper envenomation is of great clinical relevance affecting about 12%–45% victims despite anti-snake venom serum treatment and is associated with high mortality (≈30%). Therefore, search for complementary therapies to treat snakebite is relevant. Thea sinensis, commonly used as black tea, contains the bioactive compound melanin, which has potential beneficial roles such as antioxidant, immunomodulatory, and hepato and nephroprotective activity.

AIM OF THE STUDY: To check the potential of oral administration of T. sinensis melanin for protecting viper venom-induced AKI in experimental murine model.

METHODS: To find out the efficacy of melanin against Russell's viper venom-induced nephrotoxicity; first melanin was isolated from black tea and characterized using synthetic melanin as a standard. AKI model was developed using intramuscular injection of snake venom at a dose of 30ug/100 g body weight in adult male Swiss albino mice. In treatment group, venom injection was followed by oral application of melanin. After 60 h, renal functional alterations were checked by assessing plasma creatinine, blood urea nitrogen (BUN), urinary creatinine, and microprotein among the studied groups. Histopathological alterations were examined in H and E-stained kidney sections. Inflammatory and oxidative stress parameters such as nitric oxide (NO), thiobarbituric acid reactive substances (TBARS), and oxidative stress index (OSI) were also measured in plasma and renal tissue homogenate. Data were represented as mean ± standard error of mean and P < 0.05 was considered as statistically significant.

RESULTS: The isolated melanin from T. sinensis showed similar characterization profile as synthetic melanin. AKI in venom-injected group was confirmed from oliguria, elevated plasma creatinine and BUN, as well as increased urinary microprotein and decreased urinary creatinine and creatinine clearance. Renal damage was reaffirmed by signs of tubular injury and glomerular damage with mesangial proliferation. Significant elevation in NO, TBARS, and OSI levels in venom group favors a state of acute inflammation and oxidative stress both in the plasma and renal tissue homogenate. Surprisingly, oral application of melanin was found to ameliorate all the venom-induced pathological changes significantly.

CONCLUSIONS: The present study concluded that oral administration of melanin isolated from T. sinensis can improve snake venom-induced acute kidney injury and associated inflammatory and redox changes and therefore can be considered for the therapeutic purpose.


  Comparison of Risk Factors, Clinical Characteristics, and Short-Term Clinical Outcome Of Urinary Tract Infections In Children Caused by Nonextended-Spectrum B-Lactamase- and Extended-Spectrum B-Lactamase-Producing Bacteria Top


Elayarani Elavarasan, Sukanya Govindan, Sudha Ekambaram, Kalaivani Ganesan, Shiji Ravi, B R Nammalwar

Department of Pediatrics and Pediatric Nephrology; Mehta Multispeciality Hospital Pvt. Ltd.; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Urinary tract infections (UTIs) are common infections in childhood. Majority of pediatric UTIs are caused by Enterobacteriaceae family. There is recent rise in community-acquired UTIs due to extended-spectrum b-lactamase (ESBL)-producing bacteria. Although difficult to treat, whether these infections are clinically more severe compared to non-ESBL UTIs is not clear. Hence, in this study, we compared the clinical characteristics, risk factors, and outcomes of UTIs caused by ESBL and non-ESBL bacteria.

AIM OF THE STUDY: To compare the risk factors, clinical characteristics, and short-term clinical outcome of UTIs caused by ESBL-producing bacteria and non-ESBL bacteria.

METHODS: We did a retrospective case–control study of children with ESBL and non-ESBL UTI who were hospitalized between January 2019 and December 2020. Children aged 1 month to 18 years hospitalized with symptomatic UTI and positive urine cultures were included in the study. Data on presenting symptoms, signs, risk factors such as previous UTI, abnormal kidney anatomy, antibiotic prescription in the last 30 days, urine culture growth and antibiotic sensitivity, sepsis markers such as leukocyte counts, C-reactive protein, antibiotics, and intravenous (IV) fluids received were recorded from case files. We compared outcomes such as duration of hospital stay, duration of intravenous (IV) antibiotics, response to empiric therapy, and number of antibiotics received between ESBL UTI and non-ESBL UTI group. Comparison of categorical variables and categorical variables were done by Chi-square test and unpaired t-test, respectively. Odds ratio was used for comparison of outcome variables wherever necessary.

RESULTS: We included 157 UTI episodes (ESBL UTI: 68 [43.3%]; non-ESBL UTI: 89 [56.7%]). Mean age of our patients was 37 months and 53% were female. The most common presenting symptom was fever (89.2%). Of the 157 episodes, 114 (72.6%) were first episode UTIs. Children with history of prior UTI were more likely to have non-ESBL UTI (P < 0.05). Risk factors such as exposure to antibiotics and renal anomalies were not different between two groups. There was no difference in length of hospital stay, duration of IV antibiotics, and response to empiric therapy between the two groups. Although ESBL isolates showed high resistance to cephalosporins (cefuroxime [98.5%]; cefixime [80.9%]; ceftriaxone [75.0%]); 75% of patients with ESBL UTI had defervescence within 72 h when ceftriaxone was used as empiric therapy. Antibiotics with good in vitro sensitivity to ESBL isolates were nitrofurantoin (94.1%); cefoperazone sulbactam and piperacillin tazobactam (both 73.5%); and carbapenams (60.3%).

CONCLUSIONS: ESBL prevalence among pediatric UTIs is increasing. In our study, we were unable to find any risk factors or adverse clinical outcomes in ESBL UTI compared to non-ESBL UTI. Despite in vitro resistance; ESBL UTI shows good clinical response to third-generation cephalosporins, especially ceftriaxone.


  Use of High Cutoff Hemodialysis with Hemofeel™ in COVID-19 Patients Requiring Renal Replacement Therapy Top


Rakesh S Patil, Vipul Chakurkar, Sagar Kulkarni, Valentine Lobo

Renal Unit; KEM Hospital; Pune; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Cytokine storm is thought to be responsible for various manifestations of severe coronavirus disease (COVID-19). Various therapies have been tried to act against this cytokine storm. Extracorporeal therapies to reduce cytokine levels are being explored in COVID-19. HEMOFEELâ„¢ is a polymethylmetacrylate dialyzer with cytokine-adsorbing properties. We present our experience with use of HEMOFEEL in COVID-19.

AIM OF THE STUDY: To determine the effect of HEMOFEELâ„¢ on 30-day mortality in severe COVID-19 patients requiring renal-replacement therapy (RRT).

METHODS: Twelve patients with RT PCR positive for COVID-19 requiring RRT for various reasons were included in the study. HEMOFEELâ„¢ (CH-1.8W) was the filter used during RRT in the study. Pre- and post-samples of interleukin-6 (IL-6) and C-reactive protein (CRP) were collected and measured. Standard of care treatment was continued. Improvement in clinical status and oxygen therapy was noted.

RESULTS: Of 12 patients (M = 9), seven had diabetes mellitus and two were organ-transplant recipient patients. Five of them had acute kidney injury (AKI) while three had acute-on chronic kidney disease (CKD) and four were CKD on maintenance hemodialysis. Four patients required oxygen by reservoir bag, five were mechanically ventilated, and three patients required noninvasive ventilation/high-flow nasal cannula. Patients underwent an average of 2.5 ± 0.3 sessions of hemodialysis or hemodiafiltration with the HEMOFEELâ„¢ filter on a 4008S hemodialysis machine. There was a significant reduction in CRP (pre-CRP = 128.02 ± 22.61 vs. post-CRP = 24.57 ± 1.37; P ≤ 0.0001); also IL-6 levels decreased significantly postsessions (pre-IL-6 = 814.33 ± 335.4 vs. post-IL-6 = 145.14 ± 96.17; P ≤ 0.004). Thirty-day mortality was 42% (5/12); 3- and 7-day overall improvement in oxygenation was seen in 5/12.

CONCLUSIONS: In this study, we demonstrated that there was significant reduction in cytokine levels and clinical improvement with the use of HEMOFEELâ„¢ filter in COVID-19 patients requiring RRT. Larger studies are required for confirmation.


  A Surge in Cases of Fungal Pyelonephritis Post-COVID-19 infection: Case Series Top


Sandeep Singhal, Mohan Rajapurkar, Sishir Gang, Umapati Hegde, Abhijit Konnur, Hardik Patel

Department of Nephrology; Muljibhai Patel Urological Hospital; Nadiad; Gujarat, India

E-mail: [email protected]

BACKGROUND: Association of fungal pyelonephritis with COVID-19 disease is emerging as a matter of concern. There are multiple reports of tissue invasive fungal infection having rhino-cerebral-orbital and pulmonary involvement. Fungal pyelonephritis is rare among immunocompetent young males without any risk factors. Awareness of the possibility of fungal co-infection is essential to reduce delays in diagnosis and treatment to help prevent severe illness and death from these infections

AIM OF THE STUDY: To report a rare case series of primary fungal pyelonephritis in patients following recovery from COVID-19 infection and its outcome.

METHODS: We report a case series of six patients developed fungal pyelonephritis following recovery from COVID-19. We enrolled the patients who had developed fungal pyelonephritis in post-COVID-19 recovery period. The diagnosis of COVID 19 illness was made on the basis of RT PCR test and COVID antibody titer in whom RT PCR test was negative during COVID-like illness and has not received even single dose of COVID vaccination. The diagnosis of fungal pyelonephritis was based on urine and tissue culture for fungus and other supporting investigations - USG KUB, renal Doppler, CT KUB with contrast or CT renal angiography for vascular involvement, and renal biopsy in one patient who did not have any vascular involvement. All patients were started on antifungals – injection amphotericin and tablet posaconzole or voriconazole – and underwent simple open nephrectomy in case of vascular involvement or if patient's condition was deteriorating.

RESULTS: The mean age at presentation was 39.99 years (20–59 years), and among them, 5 patients were males and 1 patient was female. 50% of patients (3/6) did not have any known risk factors for fungal pyelonephritis and also were younger as compared to other 3 patients. The mean duration between COVID-19 infection and development of fungal pyelonephritis is 50 days. In our study, 4 patients were diagnosed to have COVID-19 infection on the basis of RT PCR test, and 2 patients were diagnosed to have COVID-19 infection on the basis of raised COVID antibody levels and has not received even single dose of COVID vaccination. Only two patients required hospitalization during COVID illness and had received injection remedesivir, steroid, and O2 therapy during COVID illness and rest were managed symptomatically at home. The most common presentation during admission was fever, flank pain, and sepsis. In our case series, three patients had vascular involvement and four patients underwent nephrectomy and 3/6 patients succumbed to this infection.

CONCLUSIONS: The aggressive nature of disease necessitates a high index of suspicion even in immunocompetent individuals and that prompt treatment should be initiated in initial period of illness. Early nephrectomy in patients presenting with sepsis and vascular involvement is vital for successful outcome.


  Assessment of Hypertension Using Ambulatory Blood Pressure Monitoring in Children with Kidney Failure on Maintenance Dialysis Top


Seher Kamal, Steevan Sebastian, Priya Pais

Department of Pediatric Nephrology; St. John's Medical College; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: In adults on dialysis, cardiovascular disease is the most common cause of death. Prevalence of hypertension (HTN) in pediatric chronic kidney disease (CKD) is high (50%–70%) and associated with cardiovascular morbidity markers such as left ventricular hypertrophy (LVH). Pediatric ambulatory blood pressure monitoring (ABPM) is superior to clinic blood pressure (BP) in diagnosing masked HTN and predicting HTN end-organ damage. There are limited data on HTN in children with kidney failure on dialysis. In this study, clinic BP measurements were compared with ABPM to assess HTN control.

AIM OF THE STUDY: (1) Compare prevalence of uncontrolled HTN by clinic BP and ABPM. (2) Compare severity of daytime versus night time ambulatory HTN. (3) Determine factors associated with ambulatory BP severity.

METHODS: Patients: Children (<18 years) on maintenance HD or PD who underwent 24 h ABPM. Data regarding native kidney disease, anti-HTN medications, residual kidney function (RKF), and interdialytic weight gain (IDWG) were noted. “;Clinic BP index” = systolic BP/diastolic BP (SBP/DBP) manual BP ÷95th percentile of normative data. Clinic HTN + if SBP ± DBP index >1. “;Ambulatory BP index” = Daytime/night mean BP à normative ABPM 95th centile. Ambulatory HTN + if daytime/night SBP ± DBP index >1. HTN classification: New diagnosis HTN (no HTN diagnosis; no clinic HTN; ABPM HTN+), Controlled HTN (no clinic or ambulatory HTN), uncontrolled HTN (clinic HTN + and ABPM HTN+), hidden uncontrolled HTN (no clinic HTN, ABPM HTN+), isolated nocturnal HTN (no daytime ABPM HTN; night ABPM HTN+), nocturnal dip blunted if <10%. BP load = % of ABPM values >95th centile. Wilcoxon signed-rank test and paired t-test were used to study between group differences. Agreement between clinic and ABPM HTN diagnosis was measured with Kappa value.

RESULTS: Of 27 patients, 52% were male; 67% were on CAPD; median age was 11 years; 67% with nonglomerular etiology; 96% had clinical diagnosis of HTN on median of 3 antihypertensives. RKF >150 ml/day present in 72%; concentric LVH was present in 71.1%. BP control assessment: Clinic HTN was present in 17(62%) but ABPM HTN present in 22 (81%) of whom 1 had new diagnosis HTN; 17 (72%) had uncontrolled HTN; 4 (18%) had hidden uncontrolled HTN and 5 (18.5%) had controlled HTN. Of 10 patients with normal clinic BPs, 50% had HTN only by ABPM. Level of agreement between clinic BP and ABPM was only moderate (kappa = 0.5). Day versus night ambulatory BP: Isolated nocturnal HTN present in 7 (31%). Mean night DBP indices > daytime indices (1.19 vs. 0.98; P < 0.001) and > clinic DBP indices (1.19 vs. 0.96; P < 0.001). Night SBP loads > daytime SBP loads (52% vs. 42%; P = 0.012). Night DBP loads > awake DBP loads (89% vs. 58%; P = 0.0005). Blunting of nocturnal dip in 25 (92%) with reversal in 5 (20%). Severity of ABPM HTN did not differ by mode of dialysis, IDWG, or RKF (P > 0.05).

CONCLUSIONS: ABPM was superior to clinic BP at diagnosing uncontrolled HTN. This is due to the greater severity of HTN at night regardless of dialysis modality, IDWG, or presence of residual renal function. Better management of nocturnal HTN needs to be implemented to reduce cardiovascular risk.


  Assessment of Daily Salt Intake Using 24 H and Spot Urine Sodium Excretion Among North Indians Top


Prabhjot Kaur, Ashok Kumar Yadav, Vivek Kumar, Arnab Pal, Ravjit Singh Jassal, Nusrat Shafiq, Kajal Kamboj, Vivekananad Jha

Departments of Nephrology; 1Experimental Medicine and Biotechnology; 2Biochemistry and 3Pharmacology; Postgraduate Institute of Medical Education and Research; Chandigarh; 4George Institute for Global Health; New Delhi; India

E-mail: [email protected]

BACKGROUND: Accurate monitoring of daily salt intake is essential to reinforce strategies to reduce sodium/salt intake in a population. 24-h urinary sodium excretion method is the gold standard for estimating population salt intake. Several formulae to evaluate sodium intake have been derived in different populations. However, data on performance of estimating formulae based on spot urine against 24-h urinary sodium excretion method are sparse in India.

AIM OF THE STUDY: The study aimed to measure daily salt intake using 24-h urinary sodium in North Indians and to assess performance of spot urine-based estimating equations against measured using 24-h urine.

METHODS: The study was conducted at Postgraduate Institute of Medical Education and Research, Chandigarh, India, from 2016 to 2020. The study included clinically stable adults with chronic kidney disease (CKD) and healthy individuals. 24-h urine was collected for the whole day and night including the first void of the following day. Subjects were asked to collect second morning spot urine sample in 50 ml container. 24-h urine collection compliance was confirmed. Demographic details, weight, height, waist and hip circumferences, and blood pressure were also recorded. 24-h urine samples as well as spot samples were analyzed for sodium, creatinine, and protein. Dietary salt intake was measured using 24-h urine sodium excreted. Salt intake from spot urine samples were estimated using existing estimating equations for 24-h urinary sodium excretion such as Kawasaki, Tanaka, Toft, and INTERSALT with and without potassium and Whitton and Mage.

RESULTS: The study constituted 404 subjects; 182 healthy individuals and 222 CKD patients. Mean age was 47.0 ± 11.5 years with equal distribution of both sexes. 24-h urinary sodium and salt intake were 2.9 ± 1.6 and 7.4 ± 4.2 g/day, respectively. Measured salt intake was higher among males compared to females (8.3 ± 4.4 vs. 6.5 ± 3.8 g/day; P < 0.001) and similar findings in CKD and healthy subjects (7.7 ± 4.4 vs. 7.1 ± 4.0 g/day). Blood pressure was seen increasing among subjects grouped by salt intake groups (<5, 5–10, >10–15, and >15 g/day) (systolic blood pressure: P = 0.002 and diastolic blood pressure: P = 0.003). Measured salt intake was overestimated by Kawasaki (−2.8 ± 4.6; 95% confidence interval [CI] −3.2 to −2.3; P < 0.001); Toft (−1.4 ± 3.9; 95% CI −1.8 to −1.0; P < 0.001); and Tanaka (−0.5 ± 4.0; 95% CI −0.9 to −0.1; P = 0.048) and underestimated by Whitton (2.5 ± 4.2; 95% CI 2.1–2.9; P < 0.001) and Mage (0.9 ± 5.9; 95% CI 0.3–1.5; P = 0.015). INTERSALT1 (0.1 ± 3.9; 95% CI −0.2–0.5; P = 0.564) and INTERSALT2 (0.1 ± 3.9; 95% CI −0.3–0.4; P = 0.784) were not significantly different.

CONCLUSIONS: More than 60% of subjects were consuming salt more than WHO recommendation of μg/day. The INTERSALT2 and INTERSALT1 formulae performed well; and the Kawasaki formula exhibited the highest bias when compared with measured salt intake in Indians


  Clinico-Histopathologic Profile and Prognostication of Infection-Related Glomerulonephritis in Diabetes Mellitus Top


T S Arjunlal, A Poongodi, N D Srinivasa Prasad, S Sujit, K Thirumalvalavan, K Anila Abraham, M Edwin Fernando

Department of Nephrology, Stanley Medical College, Chennai, Tamil Nadu, India

E-mail: [email protected]

BACKGROUND: Diabetics are prone to infection and is often associated with immune mediated acute renal dysfunction set off by the infective antigen, termed as infection-related glomerulonephritis (IRGN). IRGN in diabetics has been associated with worse prognosis and many patients move into dialysis-dependent renal failure. Despite being a common entity, Indian data are very scarce. This study attempts to correlate various clinicopathological factors related with IRGN and its management among the diabetics

AIM OF THE STUDY: (1) To determine the clinical profile and histopathological patterns of patients presenting with IRGN in diabetics. (2) To assess/identify the risks factors for progression to CKD/ESRD.

METHODS: Retrospective analysis and follow-up of all diabetic patients consistent with a diagnosis of IRGN between the period of January 2017 and August 2021 were done. Clinical characteristics, laboratory data, renal biopsy reports, and follow-up data were obtained. Factors affecting outcomes were studied and the rate of progression to CKD, ESRD, and mortality were determined. Data were presented as mean with standard deviation. Multivariate regression analysis was performed to identify independent risk factors that predicted type of presentation and adverse outcomes

RESULTS: 40 patients of diabetic IRGN was included in study, consisting predominantly of males (60%). The mean age was 53.08 ± 10 years and the duration of diabetes was 6.86 ± 4 years. Volume overload (92%) dominated in presentation with 22 (55%) requiring dialysis. Diabetic foot (35%) was the most common trigger; while no foci could be found in 37.5%. The mean C3 and C4 levels were 53.5 ± 19.2 mg/dl and 19.1 ± 2.4 mg/dl; while normo-complementemia was found in 10%. Complete renal recovery ensued in 15 patients (37.5%); while 12 patients (30%) progressed to ESRD. Crescentic glomerulonephritis was noted in 17 patients (42%). IF showed predominant C3 deposition in 80%. Anuria, diabetic retinopathy and diabetic nephropathy (DR and DN), interstitial edema, arterial hyalinosis, coexisting IgG deposition, glomerulosclerosis (GS) >35%, and IFTA >30% had correlation with progression ESRD. No relation was noted between creatinine, ATI, endocapillary proliferation, intensity of immunoglobulin deposits, type crescents, and complement levels with final outcome

CONCLUSIONS: IRGN in diabetics can have poor renal prognosis. Anuria and DR were clinical predictors of poor renal outcome. Histopathological evidence, DN, interstitial edema, GS >35%, and IFTA >30% were predictive of poor renal recovery. Crescents and complement levels showed no relation to renal outcome.


  Arteriovenous Fistulas Creation by Trained Nephrologist is it Really Advantageous? – Single-Center Study Top


K Venkataramanan, Prabhu Kanchi

Department of Nephrology, K V R Kidney and Diabetic Centre, Vellore, Tamil Nadu, India

E-mail: [email protected]

BACKGROUND: Functional arteriovenous fistula (AVF) is the life line for patients on maintenance hemodialysis (MHD). In India, there is a huge number of end-stage renal disease (ESRD) patients waiting for MHD and renal transplant.

AIM OF THE STUDY: By involving trained nephrologists for successful creation of AVF leads to decrease the demand and other added advantages.

METHODS: This a retrospective study done to analyze the outcome and merits of AVFs created by trained nephrologist from a single center from South India. This study included all AVFs created by single nephrologist from January 2014 to June 2021. Data were collected with relation to age, sex, site of the fistula, time of avf creation, waiting time, basic kidney disease, Hb, and mineral bone disease. The causes for primary and secondary failure and the predictors for primary and secondary patency rates were analyzed.

RESULTS: Eight hundred and fifty-five AVFs were created during the study period; including 141 (16.6%) preemptive AVFs. Mean age of the patients were 51.5 ± 13.3 years. Among them, 640 (75.7%) were males and 405 (47.95%) were diabetic. Most commonly left radiocephalic 455 (53.8%) followed by right radiocephalic 245 (28.9%); left brachiocephalic 90 (10.6%); and right brachiocephalic 50 (5.9%) were created. In the study, 63 patients (7.4%) had primary failure and 44 (5.2%) patients had secondary failure. Female sex and small radial artery are associated with primary failure. Thrombosis secondary to hypotension is associated with secondary failure. The primary patency rates at 1, 3, 6, and 12 months were 89%, 86%, 83%, and 79%, respectively. Diabetes was associated with poor primary and secondary patency rates.

CONCLUSIONS: The functional outcome of AVFs created by a trained nephrologist is as par with the surgeon outcomes with advantage of more number of preemptive AVF creations and less waiting time.


  Metabolic Characterization of Chronic Antibody-Mediated Rejection Using NMR-Based Serum Metabolomics Top


Akhilesh Jaiswal, Mantabya Singh, Narayan Prasad, Vikas Agarwal1, Durgesh Dubey1, Dinesh Kumar2

Departments of Nephrology and 1Clinical Immunology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; 2Centre for Biomedical Research; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: A common complication after renal transplantation is allograft rejection, which often leads to chronic rejection and eventual graft loss, while renal allograft biopsy continues to be considered the gold standard in the diagnosis of chronic rejection.

AIM OF THE STUDY: To the development of noninvasive methods for the accurate detection of chronic rejection of renal allografts.

METHODS: NMR-based serum metabolomics was employed for the analysis of serum metabolites in 18 renal allograft recipients with chronic rejection and 28 with nonchronic rejection. Samples were analyzed by 800 MHZ NMR spectrometer. The metabolic profiles and differential metabolites of sera were analyzed by multivariate statistical analysis (MSA), including orthogonal partial least squares discriminant analysis (OPLS-DA) methods

RESULTS: The orthogonal projection to latent structures discriminant analysis (OPLS-DA) model resulted in a R2 (Cum) of 0.9 and a Q2 (Cum) of 0.5 for CABMR and NCAMR subjects, respectively. Among the differential unregulated metabolites identified in CABMR, citrate, acetyl-carnitine, carnitine, proline, and tyrosine were upregulated from MSA. Citrate had the highest discriminatory potential (AUC 0.8; P = 0.0006) followed by carnitine (AUC 0.7; P = 0.02) and proline (AUC 0.7; P = 0.01). The results demonstrated that CABMR possesses an active phenylalanine, tyrosine, and tryptophan synthesis pathway.

CONCLUSIONS: Despite being in its early stages, metabolomics monitoring in kidney transplantation can provide reliable indicators of chronic kidney injuries and allograft rejection


  Incidence of Acute Kidney Injury in Patients Receiving Cisplatin And Carboplatin And To Evaluate Associated Risk Factors For Acute Kidney Injury Top


Nikita Hapani, Kislay Dimri1, Sanjay D'Cruz

Departments of General Medicine and 1Radiation Oncology; Government Medical College and Hospital; Chandigarh; India

E-mail: [email protected]

BACKGROUND: Nephrotoxicity of anticancer drug is increased in the presence of pre-existing CKD and presence of concomitant comorbidities. Proposed mechanisms of platin toxicity include apoptosis, mitochondrial dysfunction, autophagy, and DNA damage. The most common side effect of platins is nephrotoxicity. Carboplatin is more chemically stable and causes less nephrotoxicity than cisplatin; however, low plasma protein binding and considerable renal elimination may produce undue toxicity in patients with decreased renal function.

AIM OF THE STUDY: (1) To evaluate incidence of AKI in patients receiving cisplatin and carboplatin. (2) To evaluate risk factors associated with platin-induced AKI.

METHODS: This was a prospective observational study in the patients of cancer undergoing chemotherapy at a tertiary care center in North India. 100 patients – 50 patients each in cisplatin and carboplatin groups were studied. Detailed history, examination, and relevant baseline investigations were carried out in each patient. All the comorbidities were recorded. eGFR was calculated according to Cockroft and Gault formula. AKI staging was done according to the KDIGO guidelines. The study drugs were administered as per the department chemotherapy protocol. Inclusion criteria: All treatment naive patients of either sex receiving cisplatin and carboplatin at GMCH Sector 32. Exclusion criteria: (1) Baseline creatinine clearance less than 50 ml/min; (2) patients or caregivers who did not give consent; (3) patients who lost to follow-up; (4) patients who had received platins in the past and (5) patients with AKI attributable to other cause.

RESULTS: Mean age was 54.8 ± 10.3 years and 57.1 ± 8.9 years in cisplatin and carboplatin group, respectively. M:F = 47:53. Mean height, mean weight, mean body mass index, and mean body surface area were comparable in two groups. Mean baseline eGFR was 91 and 86 ml/min in cisplatin group and carboplatin group, respectively. 31 patients developed AKI; 19 in cisplatin (38%) and 12 (24%) in carboplatin group (P = 0.056). 18/31 patients regained renal function at 1 month. 11/19 and 7/12 patients in cisplatin and carboplatin recovered from AKI 1 month following the last dose. Recovery rate was similar among the two groups (P = 0.29). The incidence of AKI increased with age (P = 0.07). As the eGFR decreased, the incidence of AKI increased (P = 0.01). Low serum albumin was associated with increased incidence of AKI (P = 0.00). Diabetes (P = 0.025), CKD (P = 0.03), Ca cervix (P = 0.040), and HDUN (P = 0.029) were significantly associated with new-onset AKI. Carcinoma cervix patients had more incidence of AKI than other cancers may be because of HDUN in these patients.

CONCLUSIONS: (1) 38% in cisplatin group and 24% in carboplatin developed AKI (P = 0.06). (2) 58% recovered their renal function at 1-month postlast chemotherapy. Recovery rate was similar in two groups (P = 0.29). (3) Low eGFR, low albumin, diabetes, CKD, HDUN, and Ca cervix were associated significantly with AKI.


  Advanced Reliable Markers for the Detection of Snake Venom-Induced Acute Kidney Injury Top


Rajdeb Banerjee, Raghwendra Mishra, Roshnara Mishra, Pinaki Mukhopadhyay

Department of Nephrology; Nil Ratan Sircar Medical College and Hospital; 1Department of Physiology; University of Calcutta; 2Department of Physiology; Ananda Mohan College; Kolkata; West Bengal; India

E-mail: [email protected]

BACKGROUND: Snake envenomations are a major health concern worldwide. According to WHO, almost half of the annual deaths due to snakebite occurs in India, and in most of the cases, victims are Russell's viper bitten. It is responsible for causing acute kidney injury (AKI) at a rate ranging from 5% to 29%. However; the finding of reliable biomarker(s) for early detection of snake venom-induced acute kidney injury (SAKI) is not studied well.

AIM OF THE STUDY: To investigate the new renal injury and functional markers in snakebite patients to assess the early detection of AKI.

METHODS: A prospective study on patients admitted to the NRS Medical College and Hospital during July 2018 to January 2020 was done. Clinical history was checked; blood and urine samples were collected from the patients with proper consent. Renal injury and functional markers such as plasma and urinary NGAL, KIM-1, and plasma cystatin C were analyzed. Data were represented as mean ± standard error of the mean. T-test and ANOVA were performed to check any statistical difference between the parameters of the studied groups. The diagnostic performance of each biomarker for snakebite-associated AKI was assessed by area under the receiver operator characteristic curve (AUC-ROC). All calculations were carried out by statistical program package SPSS version 26.

RESULTS: Clinical features of renal involvement such as hematuria, proteinuria, and anuria were present in the SAKI group. The gold standard marker plasma creatinine was significantly increased in the SAKI group compared to the control and without kidney injury group (NSAKI). eGFR was also significantly altered between the studied groups. The renal functional and injury makers such as plasma and urinary NGAL, KIM-1, and plasma cystatin C were also significantly elevated in the SAKI group compared to control and NSAKI before the renal involvement. Both urinary and plasma NGAL was found to be elevated but urine to plasma NGAL ratio was better for prediction. After renal involvement, urinary NGAL was declined. Urinary KIM-1 was significantly elevated in the early stage of AKI. AUC-ROC analysis showed a modest diagnostic performance for all the markers.

CONCLUSIONS: It can be concluded that all of the studied markers can be used for better prediction of SAKI.


  Urinary MT-DNA A New Noninvasive Biomarkers of Acute Kidney Injury in Renal-Allograft Recipient After COVID Recovery Top


Narayan Prasad, Brijesh Yadav, Ankita Singh, Deependra Yadav, Sonam Gautam

Department of Nephrology and Renal Transplantation; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: SARS-CoV2 affected multiple organs such as lung, gastrointestinal system, kidney, liver, and heart. To prevent severe acute respiratory coronavirus 2 (SARS-CoV2) multiplication and spread, infected cell undergoes cellular necrosis; results release of death-associated molecular pattern (DMAPs) ligands like mt-DNA, which binds to TLR9 and triggers innate immunity leading allograft injury.

AIM OF THE STUDY: To determine the specificity and sensitivity of urinary mt-DNA as a noninvasive biomarker of acute kidney injury (AKI) in COVID-19–recovered renal-allograft recipient patients.

METHODS: Sixty-six (n = 66) live-related renal-allograft recipient patients with previous history of SARS-CoV2 infection were categorized as non-AKI (n = 47) and AKI (n = 19) as per the KDIGO guideline of AKI diagnosis (rise in serum creatinine >1.5 times of baseline creatinine) were included in the study. Blood and urine samples were collected. Urinary mt-DNA and neutrophil gelatinase-associated lipocalin were determined by the RT-PCR and ELISA methods. Anti-SARS-CoV2 spike protein antibody titer was determined by CMIA methods in serum.

RESULTS: Both the urinary mitochondrial gene NADH dehydrogenase-1 (ND-1) and urinary N-GAL (uNGAL) level were significantly higher in AKI patients compared to non-AKI. The mean ND-1 Ct in AKI group was (19.44 ± 2.58 a.u.) compared to non-AKI (21.77 ± 3.60; P = 0.013). The normalized ND-1 Ct in AKI was (0.79 ±0.11 a.u.) compared to non-AKI (0.89 ± 0.14; P = 0.007). The median uNGAL level in AKI group was 453.53 (range; 320.22–725.02; 95% CI) ng/ml compared to non-AKI 212.78 (range; 219.80–383.06; 95% CI; P = 0.015). The area under curve of ND-1 Ct was 0.725, normalized ND-1 Ct was 0.713, and uNGAL was 0.663 for detecting AKI in patients.

CONCLUSIONS: SARS-CoV2 infection may lead to AKI in renal-allograft recipient patients. Urinary mt-DNA quantification can detect the post-COVID AKI with higher sensitivity compared to uNGAL.


  Patterns of Renal Graft Versus Host Disease Posthematopoietic Stem Cell Transplant (Ghost Study) Top


Elenjickal Elias John, Sanjeet Roy, Anup Devasia, Reka Karuppusami, Sabina Yusuf, Vikram Raj Gopinath, Vikram Mathews, Biju George, Santosh Varughese, Suceena Alexander

Departments of Nephrology; 1Pathology; 2Hematology and 3Biostatics; Christian Medical College; Vellore; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: There is a paucity of data on the incidence and outcomes of renal graft versus host disease (GVHD).

AIM OF THE STUDY: In this study, we describe the two patterns of renal GVHD, i.e., thrombotic microangiopathy (TMA) and nephrotic syndrome (NS).

METHODS: A total of 2930 patients underwent hematopoietic stem cell transplant (HSCT) between 2005 and 2020 at our tertiary care hospital of which 2092 (70%) were allogenic stem cell transplant. 24 patients underwent renal biopsy in the same time period, with biopsy incidence of renal GVHD being 0.9%.

RESULTS: Mean age of the cohort was 35.8 ± 16.7 years with one-third being males. Two-thirds of cases developed extra-renal GVHD of which skin (77.8%) and mucosa (55.5%) were the most common sites. Median time to extrarenal and renal GVHD from HSCT was 5 (3–5) and 13 (9–17) months, respectively. eGFR at presentation was lower in TMA pattern (29.8 vs. 118.3 ml/min/1.73 m2; P = 0.007); whereas NS pattern had more proteinuria and lower serum albumin at presentation. C4d staining was positive only in patients with TMA pattern. Over a median period of follow-up of 18 (5–162) months, 7 (33.3%) progressed to kidney failure. By Cox regression model, predictors of kidney failure were advanced age, diabetes mellitus, autologous transplant, lower eGFR at presentation, global glomerulosclerosis, IFTA, arteriosclerosis, and tubulitis, of which the only significant predictor in multivariate analysis was arteriosclerosis (hazard ratio 5.2 [1.1–26]; P = 0.042).

CONCLUSIONS: This is largest case series of renal GVHD described in the literature up to date. Renal GVHD presenting as TMA or NS post-HSCT is associated with poor prognosis.


  Comparison of Outcomes of H1N1 AKI and COVID-19 AKI in a Tertiary Care Hospital Top


Kudithi Soundarya, Manjusha Yadla

Department of Nephrology; Gandhi Hospital; Secunderabad; Telangana; India

E-mail: [email protected]

BACKGROUND: Influenza viruses cause problems globally in humans and their livestock, representing a continuous pandemic threat. Clinical spectrum caused by pandemic H1N1 ranges from flu symptoms to multiorgan failure. COVID-19 caused by SARS CoV-2 is an ongoing pandemic with high morbidity and mortality rates. COVID-19 infection often compared with H1N1 influenza and the two diseases have similarities, including the risk of systemic manifestations such as AKI.

AIM OF THE STUDY: To evaluate the outcomes of AKI in patients with H1N1 infection and COVID-19 infection

METHODS: The study design is retrospective. Patients admitted with respiratory symptoms whose throat swab was H1N1 positive and who were admitted in Gandhi Hospital, Secunderabad, from May 2018 to November 2019 were analyzed. Patients admitted with respiratory symptoms whose nasal swab was COVID-19 positive admitted during April 2020 to November 2020 were analyzed. Outcomes assessed were clinico-demographic profile, occurrence of AKI according to AKIN criteria, need for RRT, and in-hospital mortality. Data were analyzed using appropriate statistical tools such as SPSS version 17 and the results were noted.

RESULTS: Patients of H1N1 AKI group (41) were compared with patients of COVID-19 AKI group (81). Flu symptoms were common in both groups, whereas presentation with breathlessness was more common with COVID-19 AKI group (90%) than with H1N1 AKI group (65%). Oliguria is more common with H1N1 AKI group (63%) than with COVID-19 AKI group (29%). Mean serum creatinine in H1N1 AKI group was 3.3 ± 2.1 and COVID-19 AKI group was 5.8 ± 3.4. Mean total leukocyte counts (TLC) were lower with H1N1 AKI group (8139 ± 4390) compared with COVID-19 AKI group (12803 ± 6072). AKIN stage 1 was seen in 7 patients (16%) versus 1 patient (1.5%); AKIN stage 2 was seen in 10 patients (23%) versus 12 patients (14.8%); AKIN stage 3 was seen in 22 patients (53.7%) versus 68 patients (83.9%) in H1N1 AKI group and COVID-19 AKI group, respectively. The need for RRT was seen in 13 patients (31.7%) in H1N1 AKI versus 60 patients (74.1%) in COVID-19 AKI. Mortality was more in patients of COVID-19 AKI (55%) than with patients of H1N1 AKI (24%).

CONCLUSIONS: Renal involvement was more severe with COVID-19 and need for RRT was also more in COVID AKI group compared with H1N1 group. Mortality was more in patients of COVID-19 AKI compared to H1N1 AKI group.


  Evaluation of Pregnancy-Induced Acute Kidney Injury And its Outcome in a Tertiary Care Hospital Top


Aniruddha Rudra, Manik Kataruka, Pinaki Mukhopadhyay

Department of Nephrology; Nil Ratan Sircar Medical College and Hospital; Kolkata; West Bengal; India

E-mail: rudra. [email protected]

BACKGROUND: In recent years, the incidence of pregnancy-related acute kidney injury (PRAKI) has decreased in developed countries to 1%–2.8%. In developing countries, the incidence is around 4.2–15%. PRAKI is usually caused by septic abortion in early pregnancy, by hypertensive disorder of pregnancy, hemorrhages during pregnancy, and ATN in the late pregnancy. The aim of this study is to investigate the characteristics of PRAKI and determine the factors associated with unfavorable outcome

AIM OF THE STUDY: To evaluate frequency, etiologies, maternal outcome, and progression to CKD of pregnancy-induced AKI.

METHODS: A hospital-based, prospective, observational study was conducted from October 2019 to January 2021 at Nil Ratan Sircar Medical College Hospital, Kolkata. Patients who satisfied the criteria of AKI by KDIGO were recruited. Exclusion criteria were evidence of renal disease before pregnancy. The need for renal replacement therapy was based on patients' symptoms and clinical status. Renal biopsy was done in case of nonrecovering of renal function at the end of 3 weeks or in anuric patients as earliest.

Outcomes recorded were maternal death due to any cause, fetal death, and renal outcomes defined as complete recovery or nonrecovery if eGFR was <60 persisting for 3 months. All patients were followed up at 4-week interval till 6 months after discharge. For statistical analysis, Chi-square test and analysis of variance were performed; multivariate analysis was applied to compare the risk of nonrecovery of renal function in different etiologies.

RESULTS: During the study period, 72 patients were admitted with PRAKI, of whom 58 (80%) received hemodialysis. A total of 476 patients including all cases of AKI underwent hemodialysis during study period. The incidence of dialysis requiring PRAKI was 58 out of the 476 patients (12%). Sepsis was the most common cause of PRAKI (41.7%) followed by pregnancy hemorrhages (34.7) and hypertensive disorder of pregnancy (16.7%). Three patients had thrombotic microangiopathy (TMA), one had acute fatty liver of pregnancy, and one had rectus sheath hematoma. Eighteen (25%) patients underwent renal biopsy and histopathological pattern showed that 39% had acute tubular necrosis; 33% had acute cortical necrosis; 17% had TMA; and 11% had diffuse glomerulosclerosis. The maternal mortality (20.8%) and fetal mortality (13.8%) were high. Complete recovery of renal function was seen in 56%, while 28% had nonrecovery of renal function. At 6 months, 9% had dialysis-dependent renal failure.

CONCLUSIONS: This study revealed that PRAKI remains a critical situation in developing countries and results significantly to the total burden of AKI cases admitted in a tertiary care hospital, due to a mostly preventable etiology, sepsis, with poor renal survival, and grave fetomaternal outcome.


  The Outcomes of Renal-Transplant Recipients with Coexisting Acute Rejection and BK Virus Nephropathy Top


S Sabarinath, D S Bhadauria, N Prasad, A Kaul, M R Patel, R Kushwaha, M R Behera, Monika

Department of Nephrology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Polyomavirus nephropathy (PyAN) is one of the major causes of graft loss with the advent of potent immunosuppressive drugs. The coexistence of acute rejection and BKV nephropathy is a rare phenomenon. The literature on the management and outcome of concurrent PyAN and acute rejection is scarce.

AIM OF THE STUDY: To study the clinical presentation, diagnosis, management, and outcomes of coexistent acute rejection with BKV nephropathy.

METHODS: This retrospective analysis was carried out in a major transplant center in Northern India. We reviewed the allograft biopsies of patients transplanted between 2011 and 2021 from our hospital information system. The allograft biopsies that showed evidence of coexistent acute rejection and BKV nephropathy were included in the study. The kidney biopsies were reexamined by a nephropathologist and biopsy findings were scored as per the recent BANFF 2019. The demographic profiles, clinical presentation, treatment details, response to therapy, and outcomes of the cases were analyzed.

RESULTS: Out of 1182 transplants, 6 cases were found. Mean age was 43 years. Predominant presentation was creeping rise in serum creatinine. Mean duration to diagnosis from transplant was 11 months. All had significant viremia at presentation. All biopsies showed type 1 inclusion bodies with SV40 positivity on immunohistochemistry (1 patient had Class I PyAN; 2 had Class III PyAN; 3 had Class II PyAN). Coexistent T-cell rejection was found in 4; acute ABMR in 2. 2 received pulse IV MPS; 5 out of 6 received 2 gm/kg IVIG; and 2 received PLEX. Maintenance immunosuppression reduction was done in all. Mycophenolic acid stopped in 2, dose reduced in 2, and switched to azathioprine and everolimus in 2 cases. Quinolone therapy was given to all, and leflunomide in 2 cases. Viremia clearance noted in all at a mean duration of 3.5 months. The mean duration of follow-up was 43 months. Graft loss noted in 2; 4 patients had stable graft function till the last follow-up with a mean serum creatinine of 1.54 mg/dl.

CONCLUSIONS: Transient increase in immunosuppression to treat acute rejection followed by reduction in maintenance immunosuppression to control viral proliferation, along with IVIG and antiviral therapies, showed good long-term graft survival in patients with coexistent BKV nephropathy and acute rejection.


  Predictors of Mortality Among Hemodialysis Patients Dialyzed in Centers Under Public–Private Partnership: A Case–Control Study of a Large Dialysis Network Top


Suresh Sankarasubbaiyan, Venkatraman Ganapathi Subramanian, Kaparaboina K Kumar, S Guruvulu, Vikram A Sonawane, Devender Pandey, Sataynarayana R Puvvada, Kamal D Shah

Department of Quality; Nephroplus; Hyderabad; Telangana; India

E-mail: [email protected]

BACKGROUND: Hemodialysis (HD) is the dominant RRT modality in India. Access to HD has increased exponentially due to implementation of public insurance. Delivery of HD is also shifting to a new model of public–private partnership (PPP) centers. Yet significant challenges to quality of care and outcome in this population are observed. Understanding factors influencing mortality in this population may enable system interventions to improve care.

AIM OF THE STUDY: (1) To study characteristics of mortality among patients dialyzed in facilities under PPP; (2) to analyze predictors of mortality among patients under PPP.

METHODS: All deaths in a large dialysis network from January 1 to March 3, 2021, were reviewed. Nonsurvivors and survivors dialyzed in centers under PPP were identified. Demographic characteristics, educational status, BMI, dialysis factors including frequency per week, duration on HD, Hb, HD adequacy, serum albumin; dialysis access; history of diabetes and hypertension; and history of heart failure were noted. An age-matched control population was selected. The proportion of variables were compared among cases and controls using Chi-square method (P < 0.05 was significant).

RESULTS: 426 deaths occurred during the study period among patients dialyzed in PPP centers. Men: 76.7%; age: <40 years: 20%; 41–60 years: 53.5%; 61–80 years: 26.2%. DM: 29.8%. Educational status: 58.5% illiterate; 25.5% school education. BMI: <18.5: 18.5%; 18.5–22.9: 39.4%; >23: 42%. HD duration: <1 month: 22.1%; 1 month–1 year: 37.3%; 1–2 years: 17.6%; >2 years: 23%. HD frequency: 1 week: 2.1%; 2/week: 45.4%; 3/week: 52.1%. Hb: 8–10 g%: 51.6%; <8 g%: 35.6%; Kt/V ≥1.2: 88%; HD catheter: 31.4%; serum albumin <3.5 G%: 121/216: 56%. Hospitalizations in previous 3 months: 23.7% Diabetic status, history of hypertension, shorter duration of HD, temporary HD catheter, severe anemia, and lower albumin level were more likely among nonsurvivors than survivors (P < 0.05). Gender; educational status, BMI, HD frequency, dialysis adequacy, and history of heart failure were not significantly different between survivors and nonsurvivors (P > 0.05)

CONCLUSIONS: Diabetics, dialysis with a catheter, anemia, lower albumin level, duration of dialysis of less than 1 year, and history of hospitalization <3 months predict mortality in patients dialyzed in centers under PPP model. Limitations are the cross-sectional design and small sample size.


  Spectrum Of Nondiabetic Kidney Disease in Patients with Type 2 Diabetes and its Clinicopathological Correlation Top


S V Gigin, Geeta, Rakesh Gupta, Megha Agarwal, Vinay Malhotra, Dhananjai Agrawal, Tushar Gupta, Shubham Agrawal

Department of Nephrology; Sawai Man Singh Medical College and Hospital; Jaipur; Rajasthan; India

E-mail: [email protected]

BACKGROUND: Diabetes mellitus (DM) is the leading cause of chronic kidney disease worldwide chiefly attributable to diabetic nephropathy (DN). In these patients, nondiabetic kidney disease (NDKD) can also occur either alone or superimposed on DN. This study aimed to identify the prevalence and the etiology of NDKD in our center and also the clinical and laboratory parameters to help distinguish these two entities.

AIM OF THE STUDY: This study aimed to identify the prevalence and the etiology of NDKD in our center and also the clinical and laboratory parameters to help distinguish these two entities.

METHODS: This was a cross-sectional observational study conducted in the Nephrology Department of the SMS Hospital. A total of 47 patients were enrolled in the study during the study period. In all the patients, kidney biopsy was done because of atypical presentations and was examined by light and immunofluorescence microscopy. The clinical and laboratory parameters and the biopsy findings were recorded in a standardpro forma.

RESULTS: A total of 47 patients (male/female: 34/13 and mean age 52.11 ± 9.36) were included in the study. The chief comorbidity was hypertension which was present in 61.7% of patients. The most common indication of biopsy was nephrotic presentation (38.3%) followed by nephritic illness (25.5%). The prevalence of NDKD in our study cohort was 85.1%, of which isolated NDKD was 57.4% and NDKD + DN was 27.7%. The most common histological lesion was membranous glomerulopathy and focal segmental glomerulosclerosis (FSGS) each with a frequency of 15% followed by chronic tubulointerstitial nephritis (CTIN), IgA nephropathy, and others. There was significant difference in the median duration of diabetes in these groups and it was around 5 years less in the NDKD group. There was no difference among three groups in terms of eGFR, HbA1C, and proteinuria.

CONCLUSIONS: The duration of diabetes was the strongest predictor of NDKD. Kidney biopsy should be undertaken liberally whenever there is strong clinical suspicion, especially in the presence of atypical features. The exact histological diagnosis can clarify the further treatment planning.


  Antibody Immune Response of SARS-COV-2 Infection and ANTI-SARS-COV-2 Vaccination in Renal-Transplant Recipient Patients Top


Brijesh Yadav, Narayan Prasad, Deependra Yadav, Sonam Gautam, Mantabya Singh, Manas Ranjan Patel, Ravi Shankar Kushwaha

Department of Nephrology and Renal Transplantation; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Adequate induction of SARS-CoV2 neutralizing antibodies and its long-term persistent is required for the Herd immunity development. For it, vaccination remained a mainstay modality across the world. However; the efficacy of vaccination in antibody development and its persistent remain a challenge for the successful vaccination drive. Immunocompromised, solid organ-transplant recipient patients further respond poorly to vaccine.

AIM OF THE STUDY: To evaluate the anti-SARS-CoV2 spike protein seroconversion rate in renal-transplant recipient patients after COVAXIN and COVISHILED vaccination.

METHODS: In this cross-sectional study, we recruited 222 live-related renal-allograft recipient patients irrespective of their vaccination and infection history and analyzed the serum titer of anti-SARS-CoV2 spike protein antibody by chemiluminescent magnetic microparticle immunoassay in patients with no vaccination and no SARS-CoV2 infection (n = 86), patients with no vaccination and having SARS-CoV2 infection (n = 75); patients with with vaccination and no SARS-CoV2 infection (n = 41), and patients with vaccination and having SARS-CoV2 infection (n = 20).

RESULTS: Overall seroconversion rate was 193/222 (86.9%) with median titer (1095.20 AU/ml; interquartile range [IQR]: 384.85–2823.15). The median IgG titer value in patients with no vaccination and no SARS-CoV2 infection was 563.40 AU/ml (IQR: 141.62–1537.72); in patients with no vaccination and having SARS-CoV2 infection was 680.0 AU/ml (IQR: 341.0–2364.90); in patients with vaccination and no SARS-CoV2 infection was 1409.0 AU/ml (IQR: 14.50–3882.55), and in patients with vaccination and having SARS-CoV2 infection was 1831.30 AU/ml (IQR: 565.25–7644.65). COVAXIN-associated seroconversion was in 16/19 (84.21%), median titer 1373.90 (IQR: 507.80–3765.10) AU/ml compared COVISHIELD 32/42 (76.19%), median titer 1831.10 (81.26–7522.56) AU/ml.

CONCLUSIONS: In renal-transplant patients, the seroconversion rate was (86.9%) and both COVAXIN and COVISHILED vaccines are effective for inducing robust anti-SARS-CoV2 spike protein humoral immune response.


  Tocilizumab - A Rescue in Secondary Amyloidosis with Undetermined Etiology Top


Jayaprakash Thangavel, Athul Thomas, Sanjeet Roy1, Sabina Yusuf, Elenjickal Elias John, Jeethu Joseph Eapen, Anna T Valson, Vinoi George David, Santosh Varughese, Suceena Alexander

Departments of Nephrology and 1General Pathology; Christian Medical College; Vellore; Tamil Nadu; India

E-mail: dr. [email protected]

BACKGROUND: AA (secondary) amyloidosis is a disorder characterized by the extracellular tissue deposition of fibrils composed of fragments of serum amyloid protein (SAA). It may occur as a complication of variety of chronic inflammatory disorders, chronic infections, and certain neoplasms, and in a proportion of cases, the underlying cause remains unknown. No definite protocol is available for the treatment of secondary amyloidosis with undetermined etiology.

AIM OF THE STUDY: Here, we describe the presentation, evaluation, treatment, and clinical outcome of an adolescent girl with systemic AA amyloidosis.

METHODS: A 17-year-old girl presented with severe anemia requiring multiple transfusions, hypertension, and hematochezia. At presentation, her hemoglobin was 4.3 g/dL; serum (Sr.) creatinine was 2.3 mg/dL; 24-h urine protein was 5.1 g/day, and Sr. albumin was 1.6 g/dL. Abdominal imaging revealed massive hepatosplenomegaly with renomegaly. ANA, dsDNA, RF, and complements were normal. She had significant elevation of inflammatory markers (CRP at 33.6 mg/L and ESR at 132 ml in 1 h). Colonoscopy with biopsy was normal. Renal biopsy showed glomerular and interstitial amyloid deposits showing positivity for Sr. amyloid A (SAA) protein by immunohistochemistry. Thorough etiological workup for secondary amyloidosis was negative. Within the next 2 weeks, she developed malignant hypertension with PRES and a fresh bout of hematemesis due to gastric ulcer which was managed conservatively. She also developed oliguric renal failure and fluid overload and was started on hemodialysis. She was maintained on thrice weekly hemodialysis.

RESULTS: She was treated with intravenous (IV) followed by oral methylprednisolone, oral colchicine, and IV cyclophosphamide elsewhere. Since there was no improvement in renal functions after 1 month of treatment, steroids were tapered and stopped along with colchicine and cyclophosphamide. In our center, she was started on IV infusion of tocilizumab (8 mg/kg). She was monitored with serum CRP, IL6, and renal functions. Serum SAA level was not available in our center. There was steady and continuous improvement starting after the first dose of tocilizumab and became non oliguric and dialysis independent. Serum CRP became undetectable after second dose. Her initial IL6 level was 20.21 which increased to 508.8 after 1st dose of tocilizumab showing good receptor blockade with the drug. After 2 monthly infusions, her serum creatinine reached a nadir of 1.7 mg/dl over the next 3 months. The infusions are being planned on quarterly basis based on her Sr. creatinine, Sr. CRP, and Sr. IL6 levels.

CONCLUSIONS: This is the first such case report of dialysis independence achieved with tocilizumab and improvement of AA amyloidosis of undetermined etiology. It also shows the usefulness of monitoring treatment with Sr. CRP and IL6 in the absence of Sr. SAA for decisions on dosage and frequency of Tocilizumab.


  Assessment Of Endothelial Function Measured by Flow-Mediated Vasodilatation in Patients of Chronic Kidney Disease Top


Tagru Raju, Anita Malhotra1, Ravinder Kaur2, Mandeep Singla, Sanjay D'Cruz

Departments of Medicine; 1Physiology and 2Radiodiagnosis; Government Medical College and Hospital; Chandigarh; India

E-mail: [email protected]

BACKGROUND: Chronic kidney disease (CKD) is associated with cardiovascular (CV) risk which is not fully attributable to the traditional risk factors. Endothelial dysfunction seen in CKD is mostly observed in patients on chronic hemodialysis. We have measured the endothelial dysfunction and carotid intimal medial thickness (CIMT) in patients of CKD not on hemodialysis and their correlation with the control population

AIM OF THE STUDY: (1) Assess the endothelial function in patients of CKD. (2) Correlation between degree of endothelial dysfunction and severity of CKD. (3) Correlation between endothelial dysfunction and CIMT in CKD.

METHODS: This was a cross-sectional study conducted at a single North Indian tertiary care center. The CKD-EPI creatinine 2009 equation was used to calculate the estimated glomerular filtration rate. Flow-mediated vasodilatation (FMD) was measured by using ultrasonography. Longitudinal section of the brachial artery was analyzed. FMD, which reflects endothelium-dependent vasodilatation, was calculated as percentage increase in diameter from baseline (d1) to maximum value (d2) obtained after cuff deflation using the formula [d2 − d1]/d1. CIMT was measured bilaterally by a senior sonologist. CIMT was defined as a hypoechogenic space between two echogenic lines containing intima media interface and media–adventitia interface on the posterior wall of the internal carotid artery. Inclusion criteria: Adult CKD patients who consented for study. Exclusion criteria: Any systemic illness, smokers, dyslipidemia, anemia (Hb <7 g/dl), those who received intravenous iron, peripheral vascular disease, and neuropathy.

RESULTS: 74 patients and 51 controls were enrolled. 39 (53%) were male; 36 (47%) were female. Mean age of the study population and control was 51.8 ± 16.7 and 47.0 ± 12.0 years. The FMD in patients of CKD-ND was 7.46 ± 6.08 compared to 8.26 ± 5.7 in control group. This difference was not statistically significant (P = 0.5). FMD in stages 1, 2, 3, 4, and 5 CKD were 7.04% ± 6.39%, 8.39% ± 6.09%, 7.23% ± 1.37%, 6.08% ± 4.25%, and 7.68% ± 7.2%, respectively. FMD was lesser in CKD 4/5 compared to CKD 1/2/3. The CIMT of patients in various stages of CKD was 0.44 ± 0.05 mm, 0.46 ± 0.03 mm, 0.42 ± 0.18 mm, 0.53 ± 0.13 mm, and 0.52 ± 0.12 mm. CIMT was found to be more in stages 4 and 5 as compared with stages 1, 2, and 3. The carotid intimal thickness increased as the CKD stage progressed, indicating increase in the arterial thickening in advanced CKD. The mean value of CIMT was 0.479 ± 0.126 and FMD was 7.46% ± 6.08%) in CKD. On Pearson correlation, the value of R was 0.1537 and P = 0.20; though a positive correlation; the relationship was weak.

CONCLUSIONS: Endothelial dysfunction and increase in CIMT were seen in early stages of CKD which progressed as the renal failure advanced, which increases the CV risk in patients with CKD. Patients with advanced CKD are more prone to increased morbidity and mortality due to increased risk of CV events.


  Development And Characterization of a Murine Model of Russell's Viper Venom-Induced Acute Kidney Injury Top


Raghwendra Mishra1, Sreyasi Das1,2,3, Farhat Nasim2, Pinaki Mukhopadhyay3, Roshnara Mishra2

1Department of Physiology; Ananda Mohan College; 2Department of Physiology; University of Calcutta; 3Department of Nephrology; NRS Medical College and Hospital; Kolkata; West Bengal; India

E-mail: [email protected]

BACKGROUND: Snake envenomation-induced acute kidney injury (SAKI); is a significant contributor of tropical nephropathy. Despite ASVS administration, the standard treatment for snake envenomation, an appreciable number of bite victims develop AKI suggesting involvement of other contributing factor(s) in its pathogenesis. Due to a dearth of reproducible experimental models of SAKI, there is a lack of understanding of underlying pathophysiological mechanism and evaluation of alternate management of SAKI.

AIM OF THE STUDY: In the present study; we aim to develop a reproducible murine model of snake venom-induced acute kidney injury and the characterization of the associated kinetic biochemical and histological changes.

METHODS: 6–8-week-old adult male Swiss albino mice (body weight ~22–24 g) were selected, housed underregulated ambiance, and maintained on balanced diet and water ad libitum. Russell's viper venom (RVV) was collected from snakes rescued from the local area adjacent to Kolkata after permission from the competent authorities. The study procedure was approved by the institutional animal ethical committee. The intramuscular (i.m.) median lethal dose (LD50) of RVV in a dose range of 10–150 μg per 100 g body weight of mice was assessed by following the status of animal over the next 24 h. To ensure renal involvement in mice after i.m. injection of sublethal dose of RVV, time kinetic study was performed over a period of 0–168 h. The kidney injury at different time point was assessed using a battery of urinary and plasma biochemical renal function markers and associated histological changes in the kidney using H and E, PAS, and Picro Sirius Red (PSR) staining.

RESULTS: During 24 h follow-up of the RVV-injected mice; the i.m. LD50 dose of RVV was found to be 90 μg/100 g body weight of mice. Based on the above finding, three sublethal doses – 15 μg, 30 μg, and 60 μg RVV/100 g body weight of mice – were selected for the time–kinetic study. All the selected venom doses show renal injury in the following order of 15 μg,<30 μg, and<60 μg both in terms of urinary and plasma biomarkers, viz., urine volume, creatinine, microprotein, creatinine clearance (P < 0.05), and histological changes. The H and E; PAS, and PSR staining confirm dose- and time-dependent alteration in the renal histoarchitecture as characterized by glomerular and tubular injury. The injury phase was set in within 12–24 h and the peak of AKI phase was noticed during 48–72 h postvenom injection. At the end of 168 h, the renal injury was nearly reversed in 15 μg and 30 μg groups, whereas in the 60 μg group, persistent signs of injury associated with insufficient recovery were noticed.

CONCLUSIONS: The finding of the present study suggests that the dose of 30 μg RVV mimics the events of SAKI in human victims and thus can be used as a reproducible model of SAKI for the better understanding of the underlying pathophysiological mechanism of renal injury in snake-bite victims.


  Incidence and Outcomes of Glomerulonephritis After Renal Transplantation Top


Sabina Yusuf, E E John, S Roy, G Rebecca, A Thomas, J J Eapen, A T Valson, V G David, S Varughese, S Alexander

Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Risk of glomerulonephritis (GN) after renal transplantation and its impact on graft outcomes is an area of active research in the field of renal transplantation. Strategies to predict the risk of GN after renal transplantation and appropriate interventions for its prevention and treatment are current areas of focus.

AIM OF THE STUDY: To examine the incidence, types, and timelines of GN after renal transplantation and impact on graft and patient survival.

METHODS: Data were collected from hospital records of all renal-allograft recipients who underwent renal transplantation in our hospital from 1971 till 2018. Patients who developed biopsy-proven GN after renal transplantation were included in the study.

RESULTS: Between 1971 and 2018, 3630 patients underwent renal transplantation of which 4.8% developed GN. The most common types of GN after transplantation were IgAN (n = 93; 52.5%), followed by FSGS (n = 37; 21%). GN was the most common cause of graft loss accounting for 50% of cases (varying from 30% in IgAN to 80% in FSGS) followed by chronic rejection. Cox proportional hazards analysis was done to determine risk factors for death and graft loss. On univariate analysis; S. Cr. at 1-year posttransplant, time of detection of GN posttransplant, and CMV infection were significant risk factors for death. On multivariable analyses; only S. Cr >2 mg/dl at 1-year posttransplant was significant. For death-censored graft loss, significant risk factors on univariate analysis were S. Cr. at 1 year; time to detection of GN posttransplant, and CMV infection, whereas new-onset diabetes after transplant was protective. On multivariable analyses, S. Cr. >2 mg/dl at 1-year posttransplant and CMV infection were significant risk factors.

CONCLUSIONS: GN after renal transplant is an important cause of graft loss. The risks of cumulative immunosuppression burden from the pretransplant period needs to be balanced with risks of recurrence, leading to inferior graft outcomes in the posttransplant period.


  A Study on Comparison of Pre- and Post-Echo Cardiographic Evaluation of Systolic and Diastolic Dysfunction and its Clinical Correlation on Patients Undergoing Maintenance Hemodialysis Top


Anagha Auradkar, E Ramprasad, M Jayakumar

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: In patients without overt cardiac disease, the degree of left ventricular hypertrophy (LVH) gets worse following hemodialysis (HD) initiation; however; in patients with both advanced chronic kidney disease (CKD) and symptomatic heart failure (HF) with reduced ejection fraction (EF), the short-term effect of HD on LVH and LV geometry has not been examined. We hypothesized that left ventricular mass index (LVMI) would decrease; further, the diastolic functional improvement following HD initiation.

AIM OF THE STUDY: The aim of this study is to assess pre- and post-echocardiographic abnormality changes on patients undergoing HD.

METHODS: This was cross-sectional study on consecutive patients on maintenance HD at Sri Ramachandra Medical College and Hospital from June 2019 to August 2020 who were enrolled and followed up. Changes in LVMI, LV geometry, and LV fractional shortening (LVFS), and diastolic function were assessed by 2D thransthoracic ECHO(TTE) in 43 patients with HF on maintanence HD. HF was defined by LVEF >45% or dyspnea plus two of the following: raised jugular venous pressure, bibasilar crackles, pulmonary venous hypertension, interstitial edema on chest X-ray, or both. TTE was performed within 3 months before first HD and repeated 3 months after start of HD. TTE recordings were obtained from storage and analyzed by a cardiologist blinded to patient clinical characteristics.

RESULTS: Before initiation of HD, LVMI in 39 patients was 169.2 g/m2 and it decreased by −22.7 g/m2 by follow-up; P < 0.001. 26% of patients with concentric LVH at baseline had concentric remodeling or eccentric LVH at follow-up. LVFS did not significantly change over time in all 43 patients with HF (P = 0.66). However; diastolic function showed significant improvement in patients with HF following HD initiation (37% > 47.2%, P < 0.001).

CONCLUSIONS: LVMI decreases following HD initiation in CKD patients with symptomatic HF and reduced LVEF, possibly due to relief of venous congestion. Further, the diastolic function showed significant improvement post-HD initiation. Increase in LVFS following HD initiation predicts improved cardiac outcome.


  Renal Functional Reserve in Prospective Kidney Donors Top


Vipul Chakurkar, Shefali Gokhale1, Sagar Kulkarni, Valentine Lobo

Renal Unit; KEM Hospital; 1Department of Nuclear Medicine; Inlaks and Budhrani Hospital; Pune; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Renal functional reserve (RFR) is the acute increase in the “;resting” glomerular function rate (GFR) after a variety of physiological or pathological stimuli, such as amino acid infusion. RFR is decreased in chronic kidney disease and with age. However, the normal values in healthy individuals are not defined as the studies in healthy persons are limited.

AIM OF THE STUDY: To determine the normal range for RFR in healthy Indian kidney donor.

METHODS: We prospectively studied potential kidney donors. Baseline GFR was measured using plasma sampling method with 99 mTc-DTPA. Augmented GFR was calculated using the same method on a separate day, after infusion of 200 mg/kg aminoven infant 10% solution. RFR was calculated as the percent increment in baseline GFR after augmentation by the infusion. The relationship between RFR, age body mass index (BMI), and baseline GFR was determined by Pearson's R and linear regression.

RESULTS: We enrolled 20 prospective donors, 6 males and 14 females, with median (interquartile range [IQR]) age of 45 (38, 53) years. Four donors were hypertensive and mean (standard deviation [SD]) proteinuria was 11.6 (8.3) mcg/mg creatinine. Mean (SD) serum creatinine was 0.75 (0.12) mg/dl with eGFR by CKD-EPI formula of 102 (10.5) ml/min/1.73 m2. Median (IQR) baseline GFR was 100 (91.75, 114.75) while the median (IQR) augmented GFR was 116.5 (108.5, 132.25) ml/min/1.73 m2. Median (IQR) RFR was 15.1 (3.93, 30.74). %. RFR was inversely correlated to BMI (R = −0.470; P = 0.036) and baseline GFR (r = −0.496; P = 0.026), while there was no statistical correlation between age and RFR.

CONCLUSIONS: We believe that RFR more accurately assesses the kidney donor eligibility. Definition of a normal range will require larger studies.


  Outcomes of Peritoneal Dialysis in COVID-19 Patients at Tertiary Care Center Top


Devidas Bantewad, M Yadla

Department of Nephrology; Gandhi Hospital; Secunderabad; Telangana; India

E-mail: [email protected]

BACKGROUND: The COVID-19 pandemic resulted in extraordinary increase in the number of patients requiring renal replacement therapy (RRT). The kidneys are not typically the main target of SARS-CoV-2; however, surprisingly, acute kidney injury (AKI) occurs in 4%–23% of cases. The global healthcare system has been severely impacted due to rapidly increasing number of patients and need of RRT. This creates opportunity to use peritoneal dialysis (PD) for renal dysfunction requiring need of RRT in pandemic situation.

AIM OF THE STUDY: To study the outcomes of PD in COVID patients. Inclusion criteria: All admitted COVID-positive patients who underwent acute PD. Exclusion criteria: (1) Patients who are not diagnosed as COVID and (2) patients who are on other modalities of RRT.

METHODS: The study included all the patients treated with acute PD at our tertiary care center from April 2020 to July 2021 were retrospectively analyzed. PD considered when patient receiving vasopressors or hemodynamically unstable, heart failure refractory to medical management, and in whom vascular access was problematic. Overall, 46 patients were receiving PD; all 34 patients underwent bedside placement of rigid PD catheter. All patients underwent investigations such as complete blood picture and serum creatinine automated Jaffey's method.

RESULTS: We observed total 34 patients who underwent acute PD with male being 27 (79.41%) and 7 (20.58%) female were there. Mean age of population was 52.84 ± 13.00 years. Comorbidities such as type 2 diabetes mellitus was present in 14 (41.17%) patients; HTN in 22 (64.70%) patients, while CAD was in 4 (11.76%) patients. AKI was present in 16 (47.05%) patients while 10 (29.41%) patients had acute deterioration of previously known CKD, and rest 8 (23.52%) patients had CKD 5D who were already on MHD. 11 (32.35%) patients were receiving O2 support and rest 23 (67.64%) patients were either on NIV or mechanical ventilation. 17 (50%) patients were receiving inotropes; qSOFA more than 1 was seen in 23 (67.64%) patients. 14 (41.17%) patients were receiving remdesivirwhile all patients were receiving steroids. Mean serum creatinine values were 7.09 ± 2.61 mg/dl.

CONCLUSION: Mortality in this study was 25 (73.52%). (1) 47.05% of patients had CKD 5D; 23.52% patients were having acute deterioration of CKD, while 29.41% patients were having acute kidney injury. (2) Serum creatinine values among survivors and nonsurvivors were 7.3 ± 2.3 versus 7.0 ± 2.7 mg/dl.


  Acute Kidney Injury in COVID 19-A Study of the Characteristics and Outcomes of Hospitalized Patients from a Tertiary Care Hospital in South India Top


Gokul Prasannan, S Sujit, N D Srinivasa Prasad, K Thirumalvalavan, A Poongodi, R Vairakkani, M Edwin Fernando

Department of Nephrology; Government Stanley Medical College; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Since COVID-19 disease emerged, it has infected more than 216 million and caused deaths of over 4.5 million worldwide. Acute kidney injury (AKI) is common in COVID-19 disease. It is thought that severity of AKI is a factor that leads to worse outcomes. We analyzed the clinical and laboratory profile of all AKI patients with COVID-19 and their outcomes.

AIMS OF THE STUDY: (1) To study the clinical profile and short-term outcomes of COVID patients who develop AKI. (2) To evaluate the impact of AKI on mortality in these patients.

METHODS: All COVID-19–positive patients who had AKI during the first COVID wave (March to November 2020) and second COVID wave (April to June 2021) were included in the study. Laboratory confirmation of COVID-19 infection was done by RT-PCR of throat swab. Blood examinations include complete blood count and renal function tests. Laboratory parameters were measured at admission and serially and at discharge or before death. The data of all patients including AKI and acute worsening on preexisting CKD and renal transplants were also included. Patients with ESRD requiring maintenance dialysis were excluded from the study.

RESULTS: The incidence of AKI in hospitalized COVID patients was 1.9%. Of the 674 patients, males (66.9%) were more affected and 53.1% had diabetes mellitus. Known CKD with acute worsening was found in 22.7%, whereas 21.4% were found to have an underlying CKD after admission. Prerenal AKI was present in 83.7% of patients. Sepsis (10.2%), ischemic ATI (3.9%), drugs (3.0%), and cardiorenal syndrome(1.5%) were the other causes. In 84.9%, renal failure was incidentally detected on screening. Patients having KDIGO Stage 1, 2, and 3 AKI were 47.8%, 27.4%, and 24.8%, respectively. RRT was warranted in 9.3% of patients. Severity of COVID was mild, moderate, and severe in 43.8%, 26.1%, and 30.1%. The mortality in the study population was 15.7% while in Stage 1, Stage 2, and Stage 3 AKI was 7.5%, 9.7%, and 38.3% (P = 0.00). AKI resolved in 51.0% while 46.3% had acute kidney disease. Higher peak serum creatinine was found to be associated with death (P = 0.00) while older age (P = 0.06) and diabetes (P = 0.31) were not.

CONCLUSIONS: Severe AKI is associated with mortality in COVID. Routine screening of renal parameters and hydration is mandatory in all hospitalized patients. Old age and diabetes were not associated with mortality in our study. The long-term outcomes of unresolved AKI at discharge needs to be followed up.


  Nephrology Referral Pattern and Short-Term Outcomes in COVID-19–Positive Patients Top


Gokul Prasannan, S Sujit, N D Srinivasa Prasad, K Thirumalvalavan, A Poongodi, R Vairakkani, M Edwin Fernando

Department of Nephrology; Government Stanley Medical College; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Coronavirus disease is considered a pandemic by the WHO. Not much studies have described the pattern and outcomes of kidney disease in COVID patients. Although diffuse alveolar damage and acute respiratory failure are the main features of COVID-19, the involvement of other organs need to be explored. Kidney disease could be a factor which could have a negative outcome in these patients. Thus, this study is aimed at assessing the patterns of kidney disease and outcomes in COVID patients

AIM OF THE STUDY: (1) To study the clinical symptoms, laboratory profile, and short-term outcomes of COVID patients who develop kidney disease. (2) To evaluate the impact of kidney disease on mortality in these patients.

METHODS: All COVID-19–positive patients who got nephrology referral during the first COVID wave (March to November 2020) and second COVID wave (April to June 2021) were included in the study. Laboratory confirmation of COVID 19 infection was done by RT-PCR of throat swab in patients who present with symptoms suggestive of COVID-19 or those detected during routine screening. Blood examinations include complete blood count and renal function tests. Laboratory parameters were measured at admission and serially and at discharge or before death. The data of all patients including acute kidney injury, chronic kidney disease (CKD), and postrenal-transplant patients were collected.

RESULTS: Among 885 patients, 38.3% (n = 339) were previously diagnosed cases of CKD of which 41.8% (n = 142) were having CKD 5D and 50 were postrenal-transplant patients (5.5%). Acute worsening of renal function was noted in 76.2%, with 9.3% warranting renal replacement therapy. COVID severity graded as mild, moderate, and severe was seen in 41.6%, 28.2%, and 30.2%, respectively. We noticed a significant difference (P = 0.002) in death rates between COVID wave 1 (16.1%) and wave 2 (25.4%) in our study population. Overall mortality in the hospitalized COVID patients was only 2.39% and 6.12% in both waves. The mortality rate in our study population was 18.5% while that among transplant population was 30.0% and 31.3% among ESRD patients. Hypotension at admission (P = 0.00) and requirement of mechanical ventilation (P = 0.00) were associated with higher mortality. Baseline CKD was detected for the first time during admission in 18.1% of patients (n = 159). Among AKI patients, 46.2% of cases had acute kidney disease at discharge.

CONCLUSIONS: Mortality in the patients with kidney disease (especially ESRD and posttransplant) was higher among the COVID patients. Second COVID wave had higher mortality compared to the first wave. The long-term outcomes of AKI are unknown as a significant number of cases had acute kidney disease at discharge.


  A Case Series of Membranous Nephropathy Over Past 5 Years Top


Ayan Kumar Dey, Kiran Bijapur, Alan Almeida, Rasika Sirsat, Jatin Kothari

Department of Nephrology; P. D. Hinduja Hospital and Medical Research Centre; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Membranous nephropathy (MN), one of the common causes of adult-onset nephrotic syndrome (AoNS), accounts for up to 30% of AoNS with a peak incidence between 3rd and 5th decade of life and male preponderance. It predominantly presents as a primary form but underlying secondary causes such as malignancies, autoimmune diseases, and infections must be explored. This case series analyzes the changing practice patterns and delves into various manifestations of the disease over the past 5 years.

AIM OF THE STUDY: The aim of this study was to describe a case series of MN encountered over the past 5 years and analyze the clinical pattern of the disease. Long-term follow-up data analysis was also performed.

METHODS: Medical records of adult-onset nephrotic syndrome patients over the past 5 years were scrutinized. Patients with biopsy-proven MN were included in this case series. Demographic data, clinical presentation, anti-PLA2R positivity, relapses, and follow-ups were collated from the medical records. The data were entered into MS excel sheets and analysis was performed. Results for quantitative variables were expressed as mean (±standard deviation [SD]) and median (range). Results for qualitative variables were expressed as frequency and percentages. For categorized variables, Pearson's Chi square test or Fisher's exact test was used. Software used was “;R software version 3.5.2.” Patients who were lost to follow-up were excluded in sub-analysis data.

RESULTS: 27 patients with biopsy-proven MN over the past 5 years were identified. Mean age of presentation was 47 years with 33.3% females. Mean 24-h proteinuria was 6.3 (SD 3.8) g/day. Pedal edema was the most common symptom (70.3%) followed by frothy urine (18.5%) and anasarca (14.8%). 22.2% of patients were lost to follow-up (follow-up 3.76 ± 1.12 years). No patient had significant eGFR loss. In the period under study, stable renal functions were noted with no progression to ESRD. One patient died after 4 years postsudden cardiac event (autopsy evidence of cardiac tamponade). 33.34% of the patients did not have the PLA2R test (unavailable pre-2017). Anti-PLA2R antibody was positive in 47.1% of those tested. Major shift in treatment was evident from steroids/CNI to rituximab during the analysis. Relapses were noted at 1 year in 30% of the patients. 66.67% of these patients were PLA2R positive. Rituximab use and relapse rates were not statistically significantly associated.

CONCLUSIONS: This case series highlights the changing practice from the traditional Ponticelli regimen and CNI/steroids to rituximab in MN care over the past 5 years. Increasing use of PLA2R for decision-making was also evident. Relapse rates at 1 year were not influenced with initial treatment choices.


  COVID-Positive Renal Transplant: A Comparative Study of in First and Second Wave Of COVID-19 from a Tertiary Care Referral Hospital, South India Top


Shivam Yadav, Y Manjusha

Department of Nephrology; Gandhi Medical College and Hospital; Secunderabad; Telangana; India

E-mail: [email protected]

BACKGROUND: The world had witnessed a major health crisis caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Specific risk groups were defined for increased risk of mortality and morbidity in COVID-19 and renal-transplant recipients (RTRs) are at a significantly increased risk regarding outcomes due to their immunosuppressed conditions.

AIM OF THE STUDY: To assess the clinical features and outcomes of COVID-positive RTRs in the first and second wave

METHODS: This is a prospective comparative study using data of kidney-transplant patients with COVID-19 infection admitted in Gandhi Hospital, Secunderabad, in the last 2 years. Analysis was done regarding demographic parameters, initial presentation, need for ventilator support, indication, duration and outcomes of RRT, duration of hospital stay, and outcomes.

RESULTS: 29 RTRs with COVID-19 infection were admitted. A total of 21 patients (M/F: 18/3) of renal transplant with COVID-19 were admitted in 2020 amid first wave. A total of 8 patients (M/F: 8/0) were admitted in the second wave. Mean age of the patients was 40.62 ± 9.83 years versus 35 ± 8.14 years (P = 1.63). Mean duration of symptoms was 6.52 ± 2.35 days versus 12.75 ± 11.76 days (P = 0.03). Mean creatinine was 4.11 ± 2.70 mg/dl versus 5.20 ± 3.11 mg/dl (P = 0.3). Mean sessions of HD given were 2.95 ± 3.47 versus 3.50 ± 2.33 (P = 0.68). Average duration of hospital stay was 8.76 ± 4.40 days versus 12.75 ± 11.76 days (P = 0.19). In the first wave, 9 (42.9%) died and 11 (52.4%) were discharged compared to second wave in which 6 (75%) died and 2 (25%) got discharged. One patient expired due to rhinoorbital mucormycosis. All patients were on MMF-TAC-PRED. MMF was stopped in all and prednisolone was shifted to injectable dexamethasone in equivalent doses.

CONCLUSIONS: In our study, duration of symptoms was statistically significant. The clinical presentation was more severe in the first wave. Total number of patients and mortality of RTR with COVID-19 infection was also more in the first wave. Study limitation was less number of patients.


  Outcome of Kidney Transplants from Expanded Criteria Donors Top


Ishan Parekh, Madhavi Dadwe, Virendra Chauhan, Vishwanath Patil, Prashant Rajput, Zaheer Virani, Hepal Vora, Shruti Tapiawala, Bharat Shah

Institute of Renal Sciences; Global Hospital; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: There is a wide gap between the need and availability of kidney donors. Many patients die while waiting for transplant. Transplantation from expanded criteria donors (ECD) can benefit a significant number of patients, improving their survival when compared to those who remain on dialysis.

AIM OF THE STUDY: The aim of this study is to describe the outcome of patients who have received transplants from expanded criteria donors,

METHODS: From April 1, 2017, to March 31; 2021, forty patients older than 18 years received transplant from deceased donors. Of these, 17 received graft from an ECD. The ECD was defined as a donor over the age of 60 or a donor over the age of 50 with at least two of the following criteria – a history of high blood pressure; a creatinine level >1.5; or death resulting from stroke. Induction immunosuppression was thymoglobulin or basiliximab and maintenance immunosuppression was tacrolimus, MMF, and steroids. Prophylaxis against opportunistic infection included cotrimoxazole and valganciclovir. Patient survival and graft survival were the primary outcomes.

RESULTS: Of the 17 patients who received transplant from ECD, 1 patient died intraoperatively of cardiac cause even before transplant could be completed. This patient has been excluded from analysis. Of the remaining 16 recipients, there were 11 males and 5 females. The mean age (standard deviation) of these patients was 48 (13) years; ranging 30-70 years. One- and 3-year patient and graft survival in these patients is 100%.

CONCLUSIONS: Patients who received transplants from expanded criteria donors have good patient and graft survival.


  COVID-19 and Infection-Related Glomerulonephritis: A Single-Center Experience Top


M Murali, Ram, Sivakumar Vishnubotla, Aishwarya Pavaluri, Prasanna, Mathini, Maria Bethsaida, Alekhya Bommu

Department of Nephrology; Sri Venkateshwara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India

E-mail: [email protected]

BACKGROUND: Infection-related glomerulonephritis (IRGN) is an immunologically mediated glomerular injury triggered due to current or recent infections. Hematuria and proteinuria were predominant renal manifestations in patients with nonsevere respiratory manifestations of COVID-19. Here, we present 13 patients with history COVID-19 infection within preceding 3 months whose biopsy was suggestive of IRGN.

AIM OF THE STUDY: To determine the possible correlation (if any) between COVID-19 infection and IRGN.

METHODS: Clinical and outcome data from patients in a tertiary health care center in South India include biopsy-proven IRGN who presented between January 2021 and September 2021 were collected retrospectively. A total of 90 biopsy-proven IRGN patients and patients with history of COVID-19 diagnosed by RT PCR in preceding 3 months were included in the study. All patients had normal renal functions previously or at the time of admission for COVID-19 and were managed conservatively with remdesivir and intravenous steroids.

RESULTS: A total of 13 patients with biopsy-proven IRGN were identified. Any patients with history suggestive of cutaneous infections, cultures suggestive of active extrarenal infections, and high serum procalcitonin levels were excluded from the study. Of 90 patients who were screened, 13 patients were proven to have IRGN. Mean age of presentation was 49 years. Hypocomplementemia was seen in 90% of patients. Nephritic range proteinuria was seen in was seen in 12 of 13 patients. Eight patients had renal failure at presentation; 4 patients required renal replacement therapy at presentation. Most common pathological presentation was endocapillary proliferative glomerulonephritis, mostly in subacute forms.

CONCLUSIONS: Glomerular injury with IRGN was seen in those with preceding COVID-19 infection. Further research is necessary to determine causality.


  Renal Allograft Cortical Necrosis - A Single-Center Experience in two Decades! Top


S Sabarinath, Narayan Prasad, Anupama Kaul, D S Bhadauria, M R Patel, Ravi Kushwaha, M R Behera, M Yachha

Department of Nephrology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Renal graft cortical necrosis (GCN) is a catastrophic cause of graft failure. The published literature on the causes, management, and outcomes of such cases is only limited to very few case reports.

AIM OF THE STUDY: To study the incidence, causes, management, and outcome of allograft cortical necrosis.

METHODS: This case series is a retrospective analysis of transplant patients who had biopsy-proven allograft cortical necrosis transplanted between 2000 and 2020. Demographic details, immunological workup, induction, and maintenance regimen; cause of cortical necrosis; and the outcome were analyzed. Data were analyzed using SPSS version 20. Continuous data were presented in mean ± standard deviation; for nonnormal data; the median (interquartile range) was used.

RESULTS: Among 1975 transplant recipients, 37 (1.87%) patients had GCN, of which 36 patients (2.87/100 transplant/year) were between 2000 and 2012 and 2 patients (0.086/100 live transplants/year) between 2013 and 2020. All had CDC CXM negative. None had flow cross-match (FXM) testing before 2012 whereas majority were tested with FXM after 2013. Mean days to GCN was 8. 28 had early rejection (19 had vascular rejection), 7 had graft vessel thrombosis, 1 had mucormycosis. 60% had diffuse; 40% had partial GCN. 60% received ATG, and 11% received combined plasmapheresis and ATG as antirejection therapy. 25 patients had no recovery, 9 had partial recovery, and 3 had complete recovery. 15 patients underwent nephrectomy within 24 days (median); 11 patients died of sepsis; median day to death from transplant was 56 days. Four underwent a second renal transplant.

CONCLUSIONS: The significant decline in the incidence of graft cortical necrosis after 2013 could be attributed to improved DSA detection and cross-matching techniques; screening for prothrombotic states in selected patients. To date, this is the single largest study on allograft cortical necrosis.


  Impact of Nationwide Lockdown to Combat COVID-19 Pandemic on The Lives of Renal-Transplant Recipients Top


Jeethu Joseph Eapen, Elenjickal Elias John, J Mercy Nahomi Deborah, Athul Thomas, Sabina Yusuf, Anna T Valson, Suceena Alexander, Vinoi G David, Santosh Varughese

Department of Nephrology; Christian Medical College and Hospital; Vellore; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: A series of nationwide lockdown was implemented across the country to combat the spread of COVID-19 pandemic. The impact of the same on ability of renal-transplant recipients to access medical care and immunosuppressive medications is not known. Nonaccess of immunosuppressive medications can have disastrous consequences for the graft and patient.

AIM OF THE STUDY: To study the difficulties faced by renal-transplant recipients in procuring medications and access healthcare due to nationwide lockdown.

METHODS: We conducted an online survey among patients who underwent renal transplant in CMC between 2015 and 2019 using REDCap® software through a structured pro forma to collect data regarding access to medications and healthcare. Demographic and transplant data were obtained from medical records. Descriptive data were capture using an online questionnaire to assess the impact of lockdown on patients' access to transplant medications and access to medical care and other problems faced by the patients. The presence of depression and anxiety was assessed by asking patients to take self-administered diagnostic scales (PHQ-9 and GAD-7).

RESULTS: 282 renal-transplant recipients completed this online survey. 81% of patients had to postpone their visit to CMC due to lockdown. More patients had trouble in procuring immunosuppressive than nonimmunosuppressive medications (41% vs. 19%; P < 0.001). 16.3% of patients had difficulty getting prednisolone, 32.3% had difficulty in getting tacrolimus, and 28.4% had difficulty in getting MPA. Factors associated with difficulty in procuring immunosuppressive medications were inability to visit CMC (P < 0.001); longer duration of travel hours to CMC (P < 0.001); lower class on Kuppuswamy SES (P = 0.039); income loss during lockdown (P = 0.019); lower monthly income levels of the family (P = 0.017); and rural residence of the patient (P = 0.038). In multivariate analysis, the duration of travel to CMC (HR = 1.016–1.047; P ≤ 0.001) and the inability to come to CMC for checkup (HR = 5.35; 95% confidence interval 2.14–13.33; P ≤ 0.001) were significantly associated with inability to procure immunosuppressive medications.

CONCLUSIONS: During the lockdown period, transplant recipients had significant difficulty in getting immunosuppressive drugs. Travel time to CMC and inability to come to CMC were predictors of difficulty in procuring drugs. Patients' access to these medications needs to be addressed during periods of lockdown.


  Clinicopathologic Spectrum of Newly Diagnosed Multiple Myeloma Presenting with Renal Impairment: A Tertiary Care Center Experience from North India Top


Niranjan Gogoi, Geeta, Dhananjay Agarwal, Tushar Gupta, Seetaram Singh, Shashank Bharadwaj, Rakesh Gupta, Vinay Malhotra, Shubham Agarwal, Kavish Sharma

Department of Nephrology; Sawai Man Singh Medical College and Hospital; Jaipur; Rajasthan; India

E-mail: [email protected]

BACKGROUND: Multiple myeloma (MM) is a hematologic malignancy, characterized by the neoplastic proliferation of plasma cells producing monoclonal immunoglobulins. Patients present with signs and symptoms related to the infiltration of plasma cells into the bone or other organs or to kidney damage from excess light chains. Renal involvement with various presentations may be the first manifestation of the disease.

AIM OF THE STUDY: To study the clinical and pathological presentation of MM with renal involvement and its severity.

METHODS: All patients of MM presenting with renal dysfunction between July 2019 and June 2021 were included. Diagnosis of MM was made according to the 2014 guidelines of International Myeloma Working Group.

RESULTS: Out of total 144 cases of MM, renal involvement was present in 43 (29.8%). Mean age of the study population was 55.49 years with 72% of males. Most common clinical features were fatigue (59%), anorexia (47%), and edema (42%). Anemia was present in 79%, hypercalcemia in 16.2%, and hyperuricemia in 20.9% of patients. Renal failure was present in 72.1% with a mean eGFR 35.8 ml/min/1.73 m2. Serum protein electrophoresis revealed M band in 81.4% and all except one patient had increased light chains in serum. Most common histological lesions were myeloma cast nephropathy (39.5%), primary amyloidosis (30.2%), and monoclonal immunoglobulin deposition disease (14%). Primary amyloidosis group had maximum 24 h proteinuria and highest eGFR.

CONCLUSIONS: Typical clinical features of MM might not be seen in all the cases, and therefore, a high index of suspicion in unexplained renal failure cases might help in early diagnosis and timely management.


  Expression of Toll-Like Receptors, Cytokines, and Cell Adhesion Molecules in Peritonitis Patient on CAPD Top


Nida Fatima, Narayan Prasad, Chinmoy Sahu, Mantabya Singh

Departments of Microbiology and 1Nephrology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Peritonitis is a leading cause of technique failure and death in patients on CAPD. Studies on expressions of host genetic factors such as TLRs, CAMs, and pro- and anti-inflammatory cytokines and their link to peritonitis and other comorbidities and functional status are lacking throughout the world.

AIM OF THE STUDY: The study was done to determine the expressions of TLR2 and TLR4, CAMs, and inflammatory cytokines in patients on CAPD.

METHODS: A total of 110 ESRD patients categorized into three groups: Group 1 – CAPD patients (n = 45); Group 2 – CAPD with peritonitis patients (n = 35); and Group 3 – CAPD patients with recurrent/relapsing peritonitis (n = 30). The mRNA expression of TLRs, CAMs, and cytokines was examined at gene and protein levels by RT-PCR and ELISA. We performed microbiological culture for bacterial and fungal pathogens using automated BACTEC culture system.

RESULTS: Of 65 samples in peritonitis patients, 50 were culture positive and 15 were culture negative. mRNA expression of TLR-4, TLR-2, TNF-α, IFN-gamma, IL-1beta, IL-4, and IL-10 were upregulated in peritonitis and recurrent/relapse group. Level of IL-1Î2 and TNF-alpha was elevated in peritonitis and recurrent/relapse peritonitis patients compared to CAPD in sera and dialysate. IL-10 and IL-4 were observed to be elevated in peritonitis group followed by recurrent/relapse peritonitis in sera, whereas in dialysate, level of IL-4 was higher in both peritonitis and recurrent groups of patients, but IL-10 level was highest in peritonitis group. In sera, the level of ICAM-1 was higher in peritonitis patients. However, in dialysate, its level was observed to be almost similar. Level of LFA-1 was observed to be higher in peritonitis group in dialysate, but in sera, its level was higher in recurrent group with peritonitis.

CONCLUSIONS: Elevated level of IL-1beta, IFN-G, and TNF-a may be responsible for prolonged inflammation in PD patients with peritonitis


  Cutaneous Nontuberculous Mycobacterial Infection Followed by Pulmonary Histoplasmosis – A Tale of Two ACID-Fast Bacilli-Positive Lesions in a Renal-Transplant Recipient Top


Niveditha Pandit, Abhilash Chandra, Namrata Rao

Department of Nephrology; Dr. Ram Manohar Lohia Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Mixed infections with uncommon opportunistic pathogens can present with considerable diagnostic and management challenges in renal-transplant recipients. We present the case of a live renal-transplant recipient, who developed Mycobacterium ulcerans-related cutaneous infection 32 months after renal transplantation and pulmonary histoplasmosis 2 months subsequently.

AIM OF THE STUDY: This case highlights two different microbial etiologies presenting as AFB-positive lesions at two different sites in the index patient.

METHODS: Index case is a 40-year-old gentleman from Assam who received live-related renal transplant in April 2018 with kidney donor being his spouse. He received ATG as induction and tacrolimus, mycophenolate mofetil, and prednisolone as maintenance immunosuppression. He presented with fever, weight loss, and ulcerating lesions on bilateral upper limbs of 2 months duration. The ulcers were multiple, painless, sporotrichoid in distribution, with undermining edges and granulation tissue covering the base of ulcers. The patient underwent debridement of infected ulcer. Microbiological investigations revealed multiple acid-fast bacilli from the swab of ulcer base; CBNAAT for tuberculosis was negative. A presumptive diagnosis of Buruli ulcer was made. At 8 weeks, cultures did not yield any growth. The patient showed healing ulcers after 2 months of ethambutol 400 mg and azithromycin 500 mg daily and immunosuppressant modification. The fever had subsided, but no weight gain was recorded.

RESULTS: A month later, the patient had recurrence of fever, anorexia, and weight loss (cumulative of 10 kg over 4 months). On laboratory evaluation, he had anemia and thrombocytopenia. Plasma polymerase chain reaction (PCR) for CMV and BKV were negative; bone marrow aspiration was negative for opportunistic pathogens. A computed tomography (CT) scan of the chest revealed a soft tissue nodule 26 mm × 46 mm in the right upper lobe. Few pleural and parenchymal soft tissue nodules were seen in the left lung. He underwent CT-guided FNAC of the lesion in the lung. Cytology showed mycotic granulomatosis changes with fungal spores in both intracellular and extracellular spaces, suggestive of pulmonary histoplasmosis. The patient was managed with oral itraconazole for 3 months with tacrolimus dose modification to maintain trough levels. Upon the last follow-up, the patient has not had recurrence of fever and has had 4 kg of cumulative weight gain.

CONCLUSIONS: With the paucity of definitive investigations to establish the diagnosis of certain opportunistic infections in renal-transplant recipients, the clinician needs to maintain a high suspicion for the presence of multiple infections.


  Clinical Profile and Outcome of COVID in Renal-Transplant Recipients Top


Krishna Ravindran, Vathsalyan Paulpandian, Sajmi Shaji, Badri Srinivasan Kannan, Dolphin Solomon Jeyaraj, Goutham Kamalakannan, Tanuj Lamech, Sakthirajan Ramanathan, Dineshkumar Thanikachalam, Shivakumar Dakshinamoorthy, Sheik Sulthan Alavudeen, Padmaraj Rajendran, Gopalakrishnan Natarajan

Institute of Nephrology; Madras Medical College; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Renal-transplant recipients have increased mortality and morbidity associated with COVID-19 infection. However, there is a paucity of data on the outcome of COVID in renal-transplant recipients.

AIM OF THE STUDY: To study the clinical profile, impact on graft function, and outcome of COVID in renal-transplant recipients and compare the clinical profile and outcomes between two waves of COVID.

METHODS: We did a single-center prospective study of renal-transplant recipients who contracted COVID between March 2020 and February 2021 and compared their outcomes with renal-transplant recipients who contracted COVID between March 2021 and July 2021. We analyzed the oxygen requirements, graft dysfunction, CT severity, and mortality rates.

RESULTS: A total of 135 patients were included, of whom 72 belonged to the first wave and 63 to the second wave. Mean age of the patients in the first wave is 42.29 (±11.26) years and in the second wave is 39.82 (±11.14) years. Median transplant duration in the first wave is 72 (24.5–120) months and in the second wave is 60 (36–93) months. When comparisons were made with regard to the clinical characteristics and outcomes of patients admitted in the first and second waves, it was found that more patients in the second wave were symptomatic (100% vs. 91.3%) (P = 0.015); had new-onset diabetes after transplant (52.7% vs. 30.6%) (P = 0.03); had oxygen requirement (63.5% vs. 51.4%) (P = 0.93); had graft dysfunction (79.4% vs. 61.1%) (P = 0.03); and had CT grades 3 and 4 (60.5% vs. 39.5%) (P = 0.04), when compared to the patients treated during the first wave. It was also noted that the mortality rate was significantly higher in the second wave (30.2% vs. 12.5%) (P < 0.001).

CONCLUSIONS: Symptomatic illness at presentation, graft dysfunction, and mortality were significantly higher in kidney-transplant recipients during second wave when compared to first wave.


  Water Drinking Practices in Autosomal Dominant Polycystic Kidney Disease Patients: A Questionnaire-Based Study Top


N Prasanna Kumar, S Mathini, Lakshmi Aishwarya, M Murali, B N Alekhya, B Varalakshmi, B Sangeetha Lakshmi, Maria Bethasaida Manuel, M Raja Amarendra, K Naveen, N Sai Sameera, A Sunnesh, R Ram, V Siva Kumar

Department of Nephrology; Sri Venkateshwara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India

E-mail: [email protected]

BACKGROUND: Patients with autosomal dominant polycystic kidney disease (ADPKD) who have normal renal function (creatinine clearance; >90 ml per minute per 1.73 m2 of body surface area) might potentially benefit from frequent water intake that would be sufficient to reduce plasma AVP levels and decrease the average urine osmolality, bringing it closer to that of plasma.

AIM OF THE STUDY: (1) To study the diet recommendation offered to the patients of ADPKD. (2) To know the adherence to the diet recommendation by the patients of ADPKD.

METHODS: In this cross-sectional study; the patients of ADPKD and chronic kidney disease stages 1–5 were included. We formed a questionnaire on the dietary recommendation to the patients. The questions enquired whether the patients received the recommendation from the faculty and the postgraduates of the nephrology department that (a) they should consume at least 3000 mL of water per day; (b) that they should not consume coffee and tea; and (c) adherence of patients to the advice of the nephrologists.

RESULTS: Of 294 patients, 142 (48.2%) did not receive any dietary recommendation. The rest 152 (51.7%) were given the appropriate dietary recommendation. Majority of the patients mentioned that they lacked the access to the water when they intend to consume. Despite the advice from the nephrologists, 95 (32.3%) failed to observe the abstinence from coffee and tea. The reason expressed for not quitting coffee and tea was the force of the habit.

CONCLUSIONS: Treating doctors failed to inform 48% of patients the proper diet. Only 20.3% of patients consumed >3.0 l of water per day. The demand of the agricultural work at a place away from home deprived majority of the participants of the study from the potable water.


  Health-Related Quality of Life in Pediatric Chronic Kidney Disease and Caregiver Burden – A Prospective Mixed-Methods Study Top


Soumya Reddy, Tanvi Deshpande, Priya Pais

Department of Paediatric Nephrology; St Johns Medical College Hospital; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: Chronic kidney disease (CKD) reduces the health-related quality of life (HRQoL) of affected children and is associated with burden on caregivers. Data on HRQoL and caregiver burden (CB) in CKD from high-income countries may not reflect realities of patients and families in low-resource settings. Despite our center's expertise in providing pediatric CKD care, families frequently discontinue treatment for their child, resulting in poor patient outcomes and ethical challenges to the healthcare team. There are no data regarding HRQoL and CB for pediatric CKD in India.

AIM OF THE STUDY: (1) Measure HRQoL in children with advanced CKD and (2) assess CB in primary caregivers by quantitative scoring and qualitative analysis of novel factors pertinent to our low-resource setting.

METHODS: This was an IRB-approved prospective study in a tertiary referral pediatric nephrology center. Patients: All children (1-18 years) with CKD (Stage 4 and 5) on treatment >3 months. Caregivers: The parent/grandparent identified by the family as the patient's primary medical caregiver. HRQoL Tool: validated PedsQL; Version 4.0. Patient scores were compared with published control data mean scores (Indian [87.4 ± 11.1] and international [83.9 ± 12.5]). HRQoL scores were standardized by minimum–maximum normalization (range 0–1). “;Worse” HRQoL = standardized score ≤0.5. CB Tool: validated Pediatric Renal Caregiver Burden Scale and compared with previous data (120 ± 16.4). “;High” CB = CB scores > our study population mean. Analysis: Spearman rho was calculated to measure correlation of clinical and socioeconomic (SES) factors with HRQoL and CB. Reflexive thematic analysis of qualitative data (in-depth audiotaped interviews) was performed to capture family-prioritized factors affecting HRQoL and CB.

RESULTS: Patients: 40 CKD patients (26 male; median age 11 years; 30 on dialysis) and caregivers (38 mothers) were included. Families (65% lower middle/upper lower SES) had median income of INR 18,000/month. Patient HRQoL mean scores (63.1 ± 16.7) were lower than controls and previous pediatric CKD data (USA). “;Worse” HRQoL was associated with inability to attend school (65% vs. 13%; P = 0.001); anemia (57% vs. 23%; P = 0.031); longer duration of illness (55% vs. 15%; P = 0.008); and dialysis (58% vs. 18%; P = 0.034) but not with low SES (P > 0.5).Primary CB mean (143.9 ± 17.1) was higher than previously reported. “;High” CB was associated with CKD Stage 5 versus Stage 4 but similar for HD versus CAPD. Parent CB was inversely correlated with child's HRQoL (r = −0.58; P = 0.001). Qualitative themes generated were “;catastrophic healthcare expenditure,” “;taken loan/sold jewelery,” “;stigmatized by society,” “;stress, sleep disturbance,” and “;inability to attend family events,” especially in caregivers doing dialysis.

CONCLUSIONS: Children with CKD have low HRQoL and their caregivers have high CB. Factors contributing to CB were unique to our low resource settings and not elucidated by scoring tools alone. We intend to use these findings to improve counseling and provide better social and financial support to families.


  Clinical Profile and Outcomes of Patient on Maintenance Hemodialysis Hospitalized with COVID-19 at a Tertiary Care Center Top


M S Shashank, C G Sreedhara, A Kishan, V Leelavathi, S Mythri, L Umesh, Ricken Mehta

Department of Nephrology; Institute of Nephrourology; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: Coronavirus disease (COVID-19) caused by an enveloped RNA betacoronavirus, first identified in Wuhan, has had devastating effects worldwide which rapidly turned into a pandemic. Patients with kidney disease especially those are on maintenance hemodialysis have abnormalities in innate and adaptive immune response. Hence, the objectives of this study are to study the clinical profile and outcomes among these patients.

AIM OF THE STUDY: To study clinical profile and outcomes of patient on maintenance hemodialysis hospitalized with COVID-19 at a tertiary care center.

METHODS: 100 patients after screening medical records who are known case of chronic kidney disease on maintenance hemodialysis with COVID-19 who fulfill the inclusion criteria hospitalized at a tertiary care center in South India were included. Diagnosis of COVID-19 was confirmed by rapid antigen test or COVID-19 reverse transcriptase polymerase chain reaction (RT PCR). At the time of admission after noting the baseline characteristics, including all the comorbidities, clinical condition was categorized based on the ICMR COVID-19 National Task Force Guidelines as mild, moderate, and severe disease. Inflammatory markers such as ferritin, lactate dehydrogenase, C-reactive protein, procalcitonin, and interleukin 6 levels were done in relevant cases. Outcomes such as whether the patient condition improved or worsened or discharged with COVID-negative status or death at the end of 2 weeks were assessed.

RESULTS: Out of 100 patients, 70 were male and 30 were female. Mean age of the patients was 47.7 ± 14.58. Hypertension, diabetes, IHD, and other comorbidities were seen in 92, 38, 22, and 33, respectively. 42 had fever, 52 had cough, 70 had dyspnea, anosmia was found in 6, sore throat was found in 6, diarrhea was found in 13, 31 had vomiting, and 23 had myalgia. 5, 31, 29, and 35 patients had asymptomatic, mild, moderate, and severe disease, respectively. Median values of hemoglobin - 8.6; total leukocyte count - 6900; platelet count - 1.91; RBS - 156; urea - 126; creatinine - 8.1; CRP - 120; D dimer - 0.96; LDH - 427.5; ferritin - 1230; fibrinogen - 446; PT - 11.7; INR - 1.1; APTT - 31.0. At the end of 2 weeks, 16 patients expired and rest 84 were discharged. Patients with severe disease had higher inflammatory markers and multiple comorbidities. All 16 patients who expired had severe disease requiring mechanical ventilation. During the above study period, total number of COVID cases other than study subjects was 4891; deaths were 1133 among them, i.e., 25%, which is higher than the study subjects.

CONCLUSIONS: Patients with kidney disease on maintenance hemodialysis had higher inflammatory markers and higher comorbidity burden; they had higher odds of in hospital mortality. However, when compared to other population, mortality among study subjects was less.


  Thymic and Circulatory T-Cell Polarization in Murine Model of Snake Venom-Induced Acute Kidney Injury Top


Sreyasi Das, Farhat Nasim1, Pinaki Mukhopadhyay2, Roshnara Mishra, Raghwendra Mishra3

Department of Physiology; University of Calcutta; 1Department of Physiology; Ananda Mohan College; University of Calcutta; 2Department of Nephrology; Nil Ratan Sircar Medical College and Hospital; 3Department of Physiology; Ananda Mohan College; Kolkata; West Bengal; India

E-mail: [email protected]

BACKGROUND: Snake venom-induced acute kidney injury (SAKI) is a principal cause of morbidity and mortality in rural tropics. Immunoinflammatory responses, especially the importance of different subsets of T cells, are gaining momentum in the pathogenesis of AKI of various origins. Although splenic picture of T cell polarization after snake envenomation is limitedly available, reports regarding T cell status in primary lymphoid organ and peripheral blood have not been documented in SAKI.

AIM OF THE STUDY: The aim of the present study is to investigate the thymic and peripheral T regulatory cells polarization in murine model of SAKI.

METHODS: Adult male Swiss albino mice were selected for the study. AKI was induced by injecting Russell's viper venom at a dose of 20 μ/100 g body weight by intramuscular (i.m.) route. Sham control group received i.m. normal saline. Animals were sacrificed after 60 h of postvenom injection. Hematological indices including total leukocyte count, neutrophil count, and differential count were done by manual counting. Renal injury markers including creatinine, blood urea nitrogen (BUN), and microprotein were measured in plasma and urine by commercial kit method. Thymocytes were isolated and stained with anti-mouse CD4, CD8, CD25, and CD44 antibodies and apoptosis dye annexin V and 7-AAD. Mononuclear cells were isolated from whole blood and stained with anti-mouse CD4, CD8, CD25, and IL-10 antibodies. Stained cells were analyzed with BD FACS Verse flow cytometer. Statistical analysis was performed using statistical program packages Origin (Pro); Version number 9; OriginLab Corporation; USA.

RESULTS: AKI was confirmed by elevated plasma creatinine, BUN, and urinary microprotein with reduced urinary creatinine and prominent histological alterations. Snake venom-injected group showed significant alterations in inflammatory markers including neutrophilic leukocytosis, elevated neutrophil to lymphocyte ratio, and plasma C-reactive protein (CRP) concentration. Thymic immunophenotyping revealed significantly increased CD8+ cytotoxic T cell, CD4+CD25+ T cell, and CD8+CD25+ T cell population along with CD44−CD25+ double-negative (DN3) population. Simultaneously, peripheral immunophenotyping showed reduced CD4+ helper T cells with increased CD8+ cytotoxic T cells and CD25+ of both helper and cytotoxic T cell population. In association with that, a significantly elevated subset of CD25+IL-10+ and CD25−IL-10+ cells were found in SAKI group.

CONCLUSIONS: It can be concluded that thymic and peripheral T cells polarize toward CD8+ and CD25+ T cell subtypes at the peak of SAKI. The T cell status in response to venom components and/or secondary consequences shaped the reversible nature of SAKI.


  Clinical Spectrum of COVID-19 Patients Requiring Hemodialysis During Two COVID Waves - A Tertiary Center Experience Top


Asheesh Kumar, Ashish Chauhan, Ram Singh, Rajeev Sandal, Balbir Verma, Sunil Sharma, Dheeraj Sharma, Shivangi Negi, Naresh Chauhan, Ajay Jaryal, Sanjay Vikrant

Department of Nephrology and Medicine; IGMC; Shimla; India

E-mail: [email protected]

BACKGROUND: Patients with chronic kidney disease (CKD) are at an increased risk of severe coronavirus disease-19 (COVID-19) and consequent mortality due to their immunosuppressed state.

AIM OF THE STUDY: We aimed to describe the clinical characteristics and outcomes of COVID-19 in patients of CKD who received hemodialysis (HD) during the hospital stay.

METHODS: This was a single-center retrospective study from May 2020 to May 2021. The study population comprised patients of CKD who developed COVID-19 infection and received HD during their hospital admission. For comparison, we included another group of patients with acute kidney injury (AKI) as an organ failure and required dialysis during a hospital stay.

RESULTS: During the study period, 117 patients required HD, and among them, patients having CKD-5D, CKD not on dialysis previously, and patients having AKI were 59.8%, 29.9%, and 12.8%, respectively. The study population comprised 70% of males with a mean age of 52.35 ± 13.79 years. Hypertension and diabetes were seen in 86 (81.4%) and 43 (40.2%) of the patients. Overall, severe disease and mortality were seen in 68 (56%) and 54 (46%) of patients, respectively, and mortality in CKD with severe COVID was 43 (63.2%). There was no difference in mortality of patients of CKD-5D; CKD patients who were dialyzed for acute-on CKD; and patients dialyzed for AKI without preceding CKD (53.1% vs. 42.8% vs. 46.6%; P = 0.257).

CONCLUSIONS: Patients with CKD on HD contracting COVID-19 infection had similar mortality to the patients who developed AKI as an organ failure in severe COVID-19 infection.


  Secondary Thrombotic Microangiopathy – Clinical Profile and Outcome Top


Goutham Kamalakannan, Sajmi Shaji, Krishna Ravindran, Dolphin Solomon, Vathsalyan Paulpandian, Changanidi Aruyerchelven, Badri Srinivasan Kannan, Venkatesh Arumugam, Tanuj Moses Lamech, Shivakumar Dakshinamoorthy, Sheik Sulthan Alavudeen, Natarajan Gopalakrishnan

Institute of Nephrology; Madras Medical College; 1Rajiv Gandhi Government General Hospital; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Thrombotic microangiopathy (TMA) can present in the setting of drug intake, pregnancy, snake bite, malignant hypertension, pancreatitis, and underlying autoimmune disease. Several of these patients have underlying genetic defects in complement pathway. The risk of progression to end-stage kidney disease (ESKD) in TMA is high and it is known to recur posttransplant.

AIM OF THE STUDY: To study the etiology, clinical profile, and outcome in biopsy-proven secondary TMA occurring in diverse clinical settings.

METHODS: This is a single-center observational prospective study conducted at the Institute of Nephrology, Madras Medical College, between 2018 and 2021. All patients with biopsy-proven secondary TMA (fibrin thrombi in afferent arteriole and/or glomerular capillaries) were studied. Twenty-nine patients were found to have biopsy-proven secondary TMA (acute pancreatitis - 9; SLE - 6; pregnancy related - 5; snake bite - 4; malignant hypertension - 4; scleroderma - 1). Transplant-related TMA was excluded from the study. History, physical examination, and blood investigations were recorded. Patients were considered for dialysis based on the standard criteria. Therapeutic plasma exchange (TPE) was considered based on physician's discretion. Patient outcome at 90 days and follow-up data were recorded.

RESULTS: Twenty-three patients (79.3%) were initiated on dialysis within 48 h of presentation to hospital. TPE was done in 11 (37.9%) patients, of whom 3 (27.27%) patients remained dialysis dependent at 90 days. TPE did not confer benefit of renal recovery (P = 0.543). All the patients progressed to chronic kidney disease. At a median follow-up of 10 months (interquartile range [IQR] 3.5–18), 8 (27.6%) had died due to complications of ESKD, 5 (17.2%) were on maintenance hemodialysis, and 16 (55.2%) were dialysis independent. The median serum creatinine in the dialysis-independent group was 4.4 mg/dL (IQR 3.02–5). Genetic analysis was performed for 9 patients. Genetic defects were identified in 4 among 5 pregnancy-related TMA (CFH mutation in two patients; C3 gene mutation in one and ADAMTS13 mutation in one). Genetic study in other causes (acute pancreatitis, SLE, snake bite, and malignant hypertension) did not unmask any pathogenic genes.

CONCLUSIONS: Acute pancreatitis was the most common association with TMA. All patients progressed to chronic kidney disease. The incidence of ESKD was 44.88%. TPE did not confer benefit. Underlying genetic defects of complement system was documented in few patients.


  Proflou® - An Innovative Solution to Decentralize the Microalbuminuria Detection to Enable Efficient Mass Screening Top


Shivam Mishra, Neel Ratan Guria, Arijit Pattnayak, Sumona Karjee Mishra, Aseem Mishra

Research and Development Department (DSIR Recognized); Prantae Solutions Private Limited; Bhubaneswar; Odisha; India

E-mail: [email protected]

BACKGROUND: Chronic kidney disease (CKD) has severe implications on health and economic output. Considering its long preclinical latency, asymptomatic individuals screening for CKD will be a useful means of early detection. Urine microalbumin is an early biomarker. However, the low-cost point-of-care interventions such as dipsticks fail to detect while the immunodiagnostics are centralized and expensive. Thus, a novel sensitive and low-cost point-of-care method will be highly beneficial for early diagnosis of CKD.

AIM OF THE STUDY: To analyze a novel urine microalbuminuria diagnostic method for high sensitivity, cost-effectiveness, and potential suitability for point-of-care application.

METHODS: Urine sample collection: Random urine samples were collected from five healthy volunteers 5 times over a period of 20 days. Procedure for spiking: Each urine sample has been divided into 8 aliquots and spiked with 10 mg/ml HSA stock to make addition of 0, 30, 90, 180, 270, 540, 900, and 1200 mg/ml of the urine matrix. Data collection: The samples were analyzed with ProfloU® Microalbumin Analysis Kit according to the user instruction. 150 ul of spiked urine samples was added to the Cartridge 1 and mixed and transferred into the Cartridge 2. Placed the Cartridge 2 inside the sample chamber of ProfloUÂ Reader and read the amount of urine microalbumin through ProfloUÂ app on a smartphone as mg/dl concentration. A matrix of data points (results) has been plotted for sensitivity and reliability analysis. Point-of-care suitability: Systematic assessment for suitability in decentralized healthcare settings with a quantitative scorecard evaluated for ProfloU® microalbumin analysis kit on 22 parameters.

RESULTS: A matrix of 200 data points has been collected from 25 urine sample matrix for 8 different concentrations of HSA. Linearity of the assay obtained from 3 mg/dL to 120 mg/dL. Limit of detection has been estimated at 0.3 mg/dL and limit of quantification 0.50 mg/dL. The accuracy has been estimated at lower concentrations to be +10% (C.V.) while at higher concentration it improves to +4% (C.V.). The precision of the measurement has been estimated to be +4% (C.V.). Reliability of the estimation with spiked samples in the urine matrix gives a value of R2 = 0.997. In the systemic assessment for suitability in decentralized healthcare settings, it has able to satisfy the criteria for point-of-care suitability in 20 parameters, while in 2 parameters, it shows lag. The cumulative score obtained with scoring system of 5 (highest), 3 (moderate), and 1(least) for each parameter 98 out of 110 points.

CONCLUSIONS: ProfloU® microalbumin analysis kit has been analyzed with spiked urine matrix of 200 data points and has shown high sensitivity and accuracy. It has also been found suitable for point-of-care applicability with 22-parameter analysis.


  Impact of COVID Infection in Renal-Transplant Recipients During the Pandemic Top


P S Martin, N D Srinivasaprasad, M Edwin Fernando

Department of Nephrology; Stanley Medical College; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Coronavirus disease (COVID 19) is now considered a pandemic by the WHO. Renal-transplant recipients are a special population who can be affected by the COVID pandemic due to the immunosuppressant drugs they are on. They are also at risk because of the other comorbidities they have. Mortality in this population is found to be 20%–30%. This study is aimed at assessing the clinical profile of this population in a tertiary care center in South India.

AIM OF THE STUDY: To study the clinical profile of COVID-infected postrenal-transplant patients. To study the short-term follow-up of the survivors with respect to graft dysfunction.

METHODS: Prospective analysis and short-term follow-up of all COVID-19–infected postrenal-transplant patients admitted in this tertiary care hospital between May 2020 and July 2021 were studied. Clinical characteristics, laboratory data, and follow-up data were obtained. Factors affecting outcomes of death and graft dysfunction were studied. Data were presented as mean with standard deviation. Multivariate regression analysis was performed to identify independent risk factors that predicted graft dysfunction and death.

RESULTS: 51 cases of COVID-19–positive renal-transplant patients got admitted with a mean age of 40 years. There were 38 LRRTR and 13 DDRTR. 10 patients had a history of treatment for graft rejection recently. Most common comorbidity was diabetes (17.6%). Clinical severity ranged from asymptomatic (3.9%), mild (23%), and moderate (3.9%), to severe (68.6%). Overall patient mortality was 33.3% (17 of 51) and 100% (17 of 17) in patients requiring invasive ventilator support. Dyspnea and altered metal status at presentation, severe COVID, and need for RRT were risk factor for death. ISD regimen change, remdesivir, and oxygen therapy had significant effect on preventing mortality. Graft dysfunction was seen in 96.1% of patients. Net difference of SCr, dyspnea at presentation, and severity of COVID-19 were found to be risk factors for mortality. Of the 34 patients who survived; 15 had a higher degree of graft dysfunction after 4 weeks of follow-up.

CONCLUSIONS: COVID infection in posttransplant patients was associated with increased mortality and graft dysfunction. Dyspnea at presentation, the severity of COVID-19 pneumonia, and net difference of SCr were found to be risk factors for mortality. Graft dysfunction persisted even after 4 weeks in survivors.

[TAG:2]Vascular Access Outcomes in Large Cohort of Hemodialysis Patients – “;Can We Do Better?” [/TAG:2]

Ravi Brahmbhatt, Viswanath Billa, Manoj Kumar1, Narayan Rangaraj1, Shrirang Bichu, Deepa Usulumarty, Ganesh Sanap

Department of Nephrology; Bombay Hospital and Medical Research Center; 1Department of Industrial Engineering and Operations Research; IIT; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Planning of vascular access in chronic kidney disease (CKD) begins in the predialysis period. The choice of vascular access varies and is influenced by the stage of CKD, patient comorbidities, vascular factors, and economics. Vascular access complications account for significant morbidity and sometimes mortality in patients on hemodialysis (MHD).

AIM OF THE STUDY: This study has looked at outcomes of different types of vascular accesses.

METHODS: This is a multicenter retrospective observational study over 6 years from 2015. Three hundred and nineteen patients with CKD-V on MHD were included. Temporary catheters, Permcaths, and AV fistula (AVF) were the access options utilized for all these patients. We have studied the life cycle of each vascular access that these patients have undergone and calculated their complications, infection rates, and survival.

RESULTS: We included 319 patients (mean age - 58.3 ± 23.5 years; diabetics - 49%). The mean patient survival was 73 years. 50% of patients had a temporary catheter as their primary access. 8.7% of patients had a permanent catheter and 41.3% had an AVF as their primary access. 30% of temporary catheters had to be removed because they developed a premature complication. Infections constituted almost all of these premature complications. The mean duration before a temporary catheter got infected was 44.5 ± 26 days and for a Perm-Cath was 336 ± 300 days. A total of 343 AVF were created, i.e., 1.07 AVF/patient. 10 AVF failure occurred in 13.4% of patients. The time to maturation was 50 ± 20 days for radiocephalic AVF and 46 ± 16 days for brachiocephalic AVF. Each of these patients had 2 ± 1 complications in this temporary catheter. Most common complication was CRBSI. Of the patients who did not have a permanent access as the 10 access required 1.8 temporary catheters/patient. The cost of treating each complication was Rs. 29,312 ± 28,240.

CONCLUSIONS: It is important to plan a permanent vascular access in advance to initiation of hemodialysis to reduce morbidity and financial burden incurred by the patient for multiple catheter insertion and treatment of complications and it is imperative that extra efforts are put in patient counseling to convince them.


  Multiple Myeloma After Kidney Transplant in a Young Female Top


Saumya Vishnoi, Madhavi Dadwe, Virendra Chauhan, Vishwanath Patil, Hepal Vora, Zaheer Virani, Prashant Rajput, Shruti Tapiawala, Shrinath Kshirsagar, Abhay Bhave, Bharat Shah

Institute of Renal Sciences; Global Hospital; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Data regarding multiple myeloma (MM) that develops after kidney transplantation (KTx) are scarce. This is because MM after KTx is rare. It is even more rare in females and in those below 30 years. Further, KTx in MM patients continues to present challenges with risk of relapse. Whether kidney transplant should be performed in patients with MM currently remains debatable.

AIM OF THE STUDY: To present a case of young female developing MM developing after kidney transplant, loss of graft despite successful treatment of MM, and successful second kidney transplant.

METHODS: Case: A 33-year-old female experienced abdominal pain and consulted general physician in Nagpur in September 2015. Blood test revealed high level of creatinine. A kidney biopsy was performed in October 2015 which was reported as focal proliferative GN with changes of chronicity. She soon progressed to ESRD and underwent LRD kidney transplant on October 21, 2016, with mother as the donor. She did well after the transplant. In 2018, she developed allograft dysfunction. Biopsy revealed light-chain deposition disease, kappa type. Serum and urine protein electrophoresis revealed M band in the gamma region. Serum immunofixation electrophoresis was positive for kappa light chain and bone marrow aspiration and biopsy was consistent with diagnosis of MM. She was treated with bortezomib and dexamethasone followed by autologous stem cell transplantation. Her myeloma remained in remission, but there was progressive deterioration in graft function requiring initiation of dialysis in October 2020.

RESULTS: A second kidney transplant was performed on December 24, 2020, with haplotype matched brother as donor. She continues to do well. Our case illustrates months after second transplant.

CONCLUSIONS: Our case illustrates: (1) development of MM after kidney transplant; (2) successful treatment of MM with chemotherapy followed by autologous stem cell transplant; (3) progressive allograft dysfunction despite successful treatment of MM; and (4) successful second kidney transplant after treatment of MM.


  Incidence and Outcome of Critically Ill Patients with COVID-19 and Acute Kidney Injury Top


Shashank Bhardwaj, Rakesh Gupta, Dhananjai Agarwal, Vinay Malhotra, Pankaj Beniwal, Tushar Gupta, Seetaram Kulraj, Shubham Agarwal, Megha Agarwal

Department of Nephrology; Sawai Man Singh Medical College and Hospital; Jaipur; Rajasthan; India

E-mail: [email protected]

BACKGROUND: The clinical manifestations of the COVID-19 range from asymptomatic to a fulminant and rapidly fatal infection. Studies show that the incidence of acute kidney injury (AKI) in COVID-19 patients varies widely from 0.5%–80%. AKI has also been found to be an independent predictor of mortality. This study was conducted to describe the clinical characteristics and risk factors for AKI and death among critically ill patients of COVID-19 who were treated in intensive care unit (ICU) of our hospital.

AIM OF THE STUDY: To study the incidence and outcome of critically ill patients having COVID-19 infection along with AKI at a tertiary care center.

METHODS: It was a prospective cohort study done over a period of 1 month, i.e., from October 2020 to November 2020. In this study, all adult (>18 years) patients admitted in ICU and have tested positive for COVID-19 via RT-PCR test were included. Those patients who were on immunosuppressing agents, patients with preexisting chronic kidney disease, and renal-transplant recipients were excluded from this study. All patients found to have AKI were assessed for comorbidities such as diabetes, hypertension, coronary artery disease, and stroke. Patients were followed up during the hospital stay and were assessed for need of oxygen and mode of oxygen delivery. Proteinuria and hematuria were assessed using dipstick. Need of vasopressors/inotropes was assessed. Stage of AKI was calculated using KDIGO guidelines. Renal replacement therapy in the form of hemodialysis or peritoneal dialysis was used according to the standard practice guidelines.

RESULTS: The incidence of AKI among COVID-19 patients was found to be 32.3%. The incidence of AKI was highest among patients of age >60 years (56.4%) and males (36.4%). It was found that oxygen requirement was most commonly associated (92.5%) with AKI. The multivariate analysis showed that the incidence of AKI was 12.44 times significantly higher among patients of age >60 years than <30 years (adjusted odds ratio = 12.44; 95% confidence interval = 1.42–127.76; P = 0.03) when adjusted for dyspnea and high-flow mask. Dyspnea (P = 0.01) and high-flow mask (P = 0.0001) were also significantly associated with the incidence of AKI in multivariate model. In COVID-19 patients with AKI, the highest mortality was seen in stage 3 AKI patients. Other factors found to be significantly associated with mortality in these patients were invasive mechanical ventilation (P = 0.0001); history of hypertension(P = 0.03); use of face mask for oxygenation(P = 0.006); and history of cough (P = 0.01).

CONCLUSIONS: Clinicians should increase their awareness of kidney disease in patients with COVID-19. Early detection and effective intervention of kidney involvement may help to reduce deaths of patients. Provisions for renal replacement should be made when planning for care for critically ill COVID-19 patients.


  A Study of Clinical Profile and Outcomes of Infection-Related Glomerulonephritis in a Tertiary Care Centre from South India Top


Bhushan C Shetty, S Mythri, L Umesha, C G Shreedhara, A Kishan, V Leelavathi, M Ricken

Department of Nephrology; Institute of Nephrourology; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: Infection-related glomerulonephritis (IRGN) is an immunologically mediated renal injury. There is paradigm change with respect to its epidemiology, clinical features, and etiological agents with regional difference too.

AIM OF THE STUDY: (1) To study the clinical profile of patients with renal biopsy favoring IRGN at our hospital. (2)To study the outcomes of IRGN at the end of 3 months.

METHODS: It was an observational clinical study conducted at INU, Bangalore, between January 1, 2019, and May 31, 2021, which included all patients with renal biopsy favoring IRGN and were followed up for a minimum of 3 months. Exclusion criteria: (a) persistent low C3 beyond 8 weeks of renal biopsy; (b) patients with autoimmune diseases (as diagnosed by ANA profile and evidence from renal biopsy; and (c) plasma cell dyscrasias. Nephrological syndrome of the patient at presentation and risk factor evaluation such as smoking, alcohol, hypertension, and diabetes mellitus were noted. Outcomes of the patient at the end of 3 months posttreatment initiation were measured as follows: (1) normalization of RFTs; (2) persistent renal dysfunction not requiring dialysis; and (3) hemodialysis dependent. Various clinical features and relevant investigations were collected in a well-designed pro forma which was entered in Microsoft excel and analyzed by SPSS version 21.0 Software. Results were presented in descriptive statistics.

RESULTS: A total of 57 patients who fulfilled the inclusion criteria were included. 12 (21%) were in the age group of 51–60 years; 11 (19.2%) were <15 years. Clinical syndromes were acute nephritic syndrome 18 (31.5%); 11 (19.2%) acute kidney injury (AKI); 8 (14%) with rapidly progressive renal failure (RPRF); 11 (19.3%) had nephrotic syndrome with AKI; and 9 (15.7%) with nephrotic syndrome. Diabetes mellitus was noted in 12 (21%). 8 (14%) of the 57 cases had severe renal failure requiring hemodialysis. Focus of infection could be identified in 34 (59.6%) cases. We could isolate organisms only in 4 (7%) subjects. Patients were followed for a period of 3 months; 39 (68.4%) had normalization of RFTs; 11 (19.2%) had persistent renal dysfunction without dialysis; and 7 (12.2%) patients were dialysis dependent at the end of 3 months. IgA-dominant IRGN was seen in 3 patients and all were <15 years. Among the 8 patients who presented with RPRF, 4 (50%) were dialysis dependent and 4 (50%) had normalization of RFTs at the end of 3 months.

CONCLUSIONS: The study showed the varied manifestationd of IRGN and its outcomes in terms of renal recovery among our population subgroups with special importance to occult source of infection which could be as simple as dental caries that had ignited the process of IRGN.


  Renal Outcomes in Myeloma-Associated AKI - A Single-Center Experience Top


Sreenidhi Chandrashekar, Shivendra Singh, Manjitpal Singh, Kushbhoo Rani

Department of Nephrology; Institute of Medical Sciences; Banaras Hindu University; Varanasi; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Spectrum of renal presentation in multiple myeloma includes AKI, nephrotic syndrome, and CKD. AKI is the most common renal presentation. Poor renal outcome is associated with poor overall survival of patients. With the introduction of proteasome inhibitor-based chemotherapy, there is improved outcome in myeloma. The present study was done to determine renal outcome in myeloma-associated AKI.

AIM OF THE STUDY: To determine renal outcome in myeloma-associated AKI.

METHODS: A retrospective observational study was done from March 2017 to March 2021. Newly diagnosed myeloma patients presenting with AKI were included. Previously diagnosed and treated myeloma patients were excluded. Diagnosis of myeloma was done as per IMWG criteria. AKI diagnosis/staging and complete/partial renal response was defined as per KDIGO guidelines. Sepsis was defined and graded with SOFA score. Anemia was defined by Hb <10 gm/dl and hypercalcemia was defined by total serum calcium >11 mg/dl. Patients received chemotherapy regimen consisting of weekly bortezomib 0.7–1.6 mg/m2, oral dexamethasone 40 mg, and daily thalidomide 50–200 mg. Quantitative variables were analyzed using Student's t-test and qualitative variables with Chi-square test. Time to event (renal response) was analyzed using Kaplan–Meier analysis with log rank test for comparison. Statistical analysis was done with SPSS Statistics software version 28.

RESULTS: Number of patients included was 41; mean age 64.3 ± 8.1 years, and M:F was 26:15. Variables in the study group were serum creatinine - 5.2 ± 3.9 mg/dl; Hb - 8.7 ± 1.7 g/dl; serum calcium - 10.9 ± 0.99 mg/dl; serum albumin - 3.08 ± 0.59 g/dlb; urine protein - 574.93 ± 152.56 mg/day; serum LDH - 431.07 ± 919.92; serum kappa light chain - 7058.9 ±2453.17 mg/L; kappa/lambda ratio - 508.71 ± 196.65; and serum beta2 microglobulin 22.36 ± 3.03 mg/L. 6 (14.6%) were in Stage 1; 16 (39%) in Stage 2; and 19 (46.3%) in Stage 3 AKI. 27 (65.9%) had IgG kappa; 5 (12.2%) had IgA kappa and 9 (22%) had kappa light chain myeloma. 18 (43.9%) were oliguric and 19 (46.3%) required RRT. 7 had sepsis at presentation. Hypercalcemia was present in 17 (45%). With a median follow-up of 46 days, 9 (22%) expired and 25 (61%) had complete/partial renal response. Factors significantly associated with renal response were AKI stage, oliguria/RRT at diagnosis, serum creatinine, and type of myeloma.

CONCLUSIONS: Renal response in AKI-associated myeloma was 61%. Presence of oliguria, requirement of RRT, AKI Stage 3, and kappa light chain myeloma is associated with poor renal outcomes.


  Long-Term Outcomes of Peritoneal Dialysis Patients Developing Hydrothorax Due to Pleuroperitoneal Leak Top


Chilaka Rajesh, Elenjickal Elias John, Athul Thomas, Jeethu Joseph Eapen, Sabina Yusuf, Anna T Valson, Vinoi George David, Suceena Alexander, Santosh Varughese

Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Peritoneal dialysis (PD) is one of the renal replacement therapy modalities, which is preferable in patients with residual renal function. A rare but dreaded complication of PD is hydrothorax due to pleuroperitoneal leaks. This hydrothorax is usually right-sided and characteristically occurs early after starting PD. The causes of pleuroperitoneal fluid leak are congenital or acquired diaphragmatic defects, disorders of lymphatic drainage, or severe overfill with high pleuroperitoneal pressure gradients

AIM OF THE STUDY: To study long-term outcomes of PD patients developing hydrothorax due to pleuroperitoneal leak.

METHODS: This retrospective study was conducted in a tertiary care referral center in South India. A total number of 732 PD catheter insertions were done between 2000 and 2021. Of 732 patients, 4 developed hydrothorax in the 1st year of initiation of PD. Three (0.4%) out of 732 patients were diagnosed to have pleuroperitoneal leak.

RESULTS: Mean age of cohort was 51 ± 4.2 years with a male-to-female ratio of 2:1. The median time of developing hydrothorax from initiation of PD was 8 (1–11) months. Of the 3 patients, two presented with dyspnea and one patient had decreased PD outflow. All three cases of pleuroperitoneal leak had moderate-to-severe transudative pleural effusion. Pleuroperitoneal leak was diagnosed by peritoneal scintigraphy, CT peritoneography, and pleural fluid analysis in each of the cases. Out of three, two patients were switched to hemodialysis and one patient was managed with low-volume supine exchanges. All 3 patients were alive over a median duration of follow-up of 11.6 (3–15) years and one patient underwent renal transplantation.

CONCLUSIONS: Hydrothorax due to pleuroperitoneal leak, though rare, requires early evaluation and may require switching to hemodialysis if no response to conservative measures.


  Predictors of Mortality Among Women on Hemodialysis: A Case–Control Study of Large Dialysis Network Top


Suresh Sankarasubbaiyan, Venkatraman Ganapathi Subramanian, Kaparaboina K Kumar, S Guruvulu, Vikram A Sonawane, Devender Pandey, Sataynarayana R Puvvada, Kamal D Shah

Department of Quality; Nephroplus; Hyderabad; Telangana; India

E-mail: [email protected]

BACKGROUND: Mortality among women who form a minority of the hemodialysis (HD) population in India is not known. Clinical socioeconomic and dialysis factors could have variable influence on outcome among this special subset of patient population.

AIM OF THE STUDY: (1) To study characteristics of women who died on HD and (2) to understand predictors of mortality among women on HD.

METHODS: All deaths in a large dialysis network from January 1 to March 31, 2021, were reviewed. Among women who died, demographic, educational, socioeconomic, and dialysis factors were reviewed. An age-matched control population was selected. The variables of interest were compared between cases and controls using Chi-square method (P < 0.05 was significant).

RESULTS: 235 out of 797 deaths were women. Characteristics of nonsurvivors: Age: <40: 17%; 41–60: 43.4%; 61–80: 39.1%. Diabetics: 41.7%. Educational status: 50.4% illiterate, 33.6% school education, and 12.3% college education. Duration of HD: 21.2% <1 month; 33.5%: 1 month to 1 year; 20.3%: 1–2 years; and 24.6% >2 years. Duration on HD: 3.4% on 1/week; 51.9% on 2/week; 42.1% on 3/week. 38.7% were dialyzed by catheter; 82% had Hb <10 g%. 89/162 (54.9%) had serum albumin <3.5 g%. 10.2% had history of heart failure and 35.3% had been hospitalized in previous 3 months. Nonsurvivors were more likely to have lesser education; dialyzed in centers under public–private partnership (PPP); have a shorter duration of HD; be dialyzed by catheter; be severely anemic; have lower albumin level; and have a history of heart failure and hospitalized within 3 months. Significantly, diabetic status, hypertension; body mass index, dialysis frequency, and adequacy level did not predict mortality.

CONCLUSIONS: In our network, proportion of women among non survivors is like HD population. Lower education, HD in PPP facility, shorter HD duration, lower Hb and albumin, and temperature catheter predict mortality. Notably, HD frequency and adequacy do not predict mortality. Small sample size is a limiting factor.


  Severe Asymptomatic Hypokalemia in a Family Cluster Of Gitelman Syndrome Top


Durga Deorukhkar, Viswanath Billa, Deepa Usulumarty, Shrirang Bichu

Department of Nephrology; Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Gitelman syndrome (GS) is a benign variant of salt-losing nephropathies, with most cases presenting in adolescence and being mild or asymptomatic which is attributable to adaptive response by the body over years. To date, more than 100 mutations scattered throughout the SLC12A3 gene have been identified in GS. The mainstay of treatment included high-salt diet with oral potassium (maximum 100 mEq/day in severe cases should not exceed 3 mEq/kg/day) and magnesium supplements.

AIM OF THE STUDY: To the study the severe asymptomatic hypokalemia in a family cluster of GS.

METHODS: Two sisters, aged 25 and 23 years, born out of a consanguineous marriage in two consecutive generations, were incidentally found to be hypokalemic with serum potassium ranging between 1.4 and 2.1 mEq/L in both, when being evaluated for menstrual irregularities. They were normotensive and had no other symptoms. Other than intermittent episodes of generalized weakness on enquiry; the two sisters led a normal academic and professional life.

RESULTS: The only abnormal biochemical findings were persistent severe hypokalemia on laboratory tests over the past 7 years. Both of them had a normal renal function with eGFR >120 ml/min; sodium levels were normal; magnesium levels were 2 and 2.2 mg/dl, respectively. The urine K/Cr ratio was 33 and 202 mmol/g, respectively. There was no acid base disorder on ABG in both. The urine Ca:Cr ratio in the two sisters was 0.01 and 0.02 (N < 0.20). With this phenotype, the two sisters underwent genetic analysis and were found to have an identical SLC12A3 variant (p.Ile840Ter) in the homozygous state, hence establishing a diagnosis of GS. Both are on appropriate potassium replacements.

CONCLUSIONS: We present two cases of severe asymptomatic hypokalemia secondary to GS confirmed by genetic analysis which also supported marriage counseling for both girls to avoid consanguinity The mainstay of treatment included high-salt diet with oral potassium and magnesium supplements.

[TAG:2]Did the Use of High-Dose Steroids in Renal-Transplant Recipients with COVID-19 Increase The Risk Of Long-Term Fungal Infections? – “;Ripples After the Wave” [/TAG:2]

Vamsidhar Veeranki, Narayan Prasad, Jeyakumar Meyyappan, Dharmendra Singh Bhadauria, Anupma Kaul, Manas Ranjan Behera, Monika Yachha

Department of Nephrology; Sanjay Gandhi Post-Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: COVID-19 and its associated SIRS were dealt with by the use of high-dose steroids in both the pandemic waves, more so in wave-2. The use of steroids in COVID-19 has particularly increased after the results of the RECOVERY trial and many such re-affirmatory trials that followed. However, with the increased use of steroids, particularly with a background multitargeted immunosuppression in renal-transplant recipients (RTRs), the long-term complications are not known.

AIM OF THE STUDY: To study the long-term outcomes of RTRs with COVID-19 at 6 and 12 months post-COVID pneumonia in a prospective manner.

METHODS: In this prospective single-center study, RTRs who developed COVID-19 infection were followed up from the time they were admitted for COVID-19 infection for 12 months (wave-1) and 6 months (wave-2). The management strategies including titration of immunosuppression and use of antiviral agents were compared between the two waves. The primary outcomes analyzed were infectious complications (fungal infections; UTI) at 6 and 12 months post-COVID. The secondary outcomes include noninfectious complications (post-COVID lung sequelae) and 4- and 24-week mortality.

RESULTS: A total of 251 RTRs who developed COVID-19 infection in the first (101) and second waves (150) of the pandemic were treated and followed for 1 year and 6 months, respectively. Of 101 RTRs in wave-1, 27 (26.7%) had severe infection while 35 of 150 patients in wave-2 had severe infection (23.3%) (P = 0.399). While steroid dose was increased in 48 patients (47.5%) in wave-1, it was escalated in 141 (94%) patients of wave-2 (P ≤ 0.01). The 4-week mortality is 12 (11.9%) in wave-1 in comparison to 26 (17.3%) in wave-2 (P = 0.24). Among the 89 survivors in wave-1 and 124 in wave-2, 1 (1.1%) and 6 (4.8%) developed fungal infections (P = 0.04); 2 (2.2%) versus 15 (12%) developed severe UTI requiring hospitalization (P = 0.009) during 12- and 6-month follow-up, respectively. The mean duration of fungal infection post-COVID is 86.3 days (20–128 days). However, 3 (3.3%) in wave-1 versus 9 (7.2%) of wave-2 developed post-COVID lung sequelae (P = 0.06).

CONCLUSIONS: Among the RTRs with COVID-19, though there was no mortality difference found between the two pandemic waves, long-term fungal infection rate and severe UTI were higher among the wave-2 cohort where there was significantly higher use of steroids.


  Accommodation After ABO-Incompatible Kidney Transplant. How Soon Can it Develop? Top


Bharat Shah, R Nikte, S Tapiawala, P Rajput, Z Virani, H Vora, I Parekh, S Vishnoi, V Chauhan, M Dadwe, V Patil

Institute of Renal Sciences; Global Hospital; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: ABO incompatible (ABOi) kidney transplants are being performed with increasing frequency all over the world and India. Typically, there are 3 periods after transplant: (1) Silent period (first 2 days after transplant) when no HAR develops due to low levels of antibody; (2) critical period when there is risk of acute ABMR if antibody titers rise; and (3) stable period when no ABMR occurs despite rise in antibody titers as accommodation develops.

AIM OF THE STUDY: To show how soon after an ABOi kidney transplant does accommodation develop.

METHODS: We present two cases to show that accommodation can develop within 1st week after transplant. Case 1: A 42-year-old female, blood group O, underwent kidney transplant on October 10, 2017. Donor was her 42-year-old husband; blood group A1. Baseline anti-A IgG antibody titers were 1:1024. After desensitization with rituximab and plasmapheresis (PP) when IgG antibody titers dropped to 1:16, transplant was performed. Case 2: A 61-year-old female, blood group B, underwent kidney transplant on November 26, 2019. Donor was her 36-year-old daughter, blood group A1. Baseline anti-A IgG antibody titers were 1:64. For desensitization, 3 sessions of PP were carried out with 100 mg/kg IVIg given at the end of each PP. Transplant was performed with IgG antibody titers 1:8. In both cases; basiliximab induction and conventional immunosuppression were used and IgG antibody titers were monitored daily.

RESULTS: There was a rapid drop in creatinine in both cases and graft function remained stable despite progressive rise in antibody titers from 2nd posttransplant day. These cases suggest that accommodation had developed by 2nd posttransplant day.

CONCLUSIONS: Our cases illustrate that rapid allograft accommodation can develop and there may not be any need of PP if antibody titers rise even in the 1st week of ABOi kidney transplant if the allograft function is stable.


  Therapeutic Plasmapheresis – An Experience at a Tertiary Care Center in South India Top


S S Deepak Bala Kumar, M Edwin Fernando

Department of Nephrology; Government Stanley Medical College; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Plasmapheresis holds an effective therapeutic role in many disease conditions. Use in appropriate indication with close monitoring and intensive follow-up results in favorable outcomes. This warrants personalized audit assessing the utility of therapeutic plasma exchange (TPE) at every center. In this study, we have evaluated the utilization and outcome with TPE for different disease categories.

AIM OF THE STUDY: To evaluate the utilization of TPE for immunological and nonimmunological diseases

METHODS: This was a prospective observational study conducted in patients referred for TPE during a period of 8 months. Demographic data, clinical data, details of number of sessions, volume of plasma exchanged, patient tolerance, and complications during the procedure were systematically recorded, and descriptive statistics was applied for analysis

RESULTS: A total of 93 patients undergoing TPE were recruited in this study. Based on their diagnosis at the time of recruitment, the study population was divided into two groups as immunological disease group (n = 39) and nonimmunological disease group (n = 54). Patients with yellow phosphorus poisoning constituted the nonimmunological disease group. Median duration of hospital stay was 20 days in the overall population, and it was significantly longer in patients who underwent TPE for immunological cause (P < 0.0001) compared to non-immunological cause. The proportion of patients experiencing clinical improvement was significantly higher in nonimmunological group (P = 0.008). All-cause mortality was numerically higher in immunological group.

CONCLUSIONS: TPE was utilized more for nonimmunological diseases than immunological diseases. It was reaffirmed to be a safe and efficacious procedure in both immunological and nonimmunological diseases. Clinical outcomes were better in patients undergoing TPE for nonimmunological disease.


  Factors Predicting Postrenal-Transplant Tuberculosis: A Tertiary Care Center Experience Top


S Harshita, N Prasad, A Kaul, D S Bhadauria, M R Patel, R S Khushwaha, M R Behera, M Yachha

Department of Nephrology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Tuberculosis (TB) is one of the most common causes of morbidity and mortality in renal-transplant recipients in India.

AIM OF THE STUDY: We studied factors predicting TB in postrenal-transplant period and its impact on graft and patient outcomes.

METHODS: Demographic profile including history of TB of 350 renal-transplant recipients who received renal allograft between January 2016 and July 2019 was collected. Their posttransplant course including infectious and noninfectious complications was analyzed. Comparison was made between recipients with and without TB. Multivariate logistic regression analysis was used to determine the factors predicting posttransplant TB. Kaplan–Meier analysis was used to study the survival between the groups.

RESULTS: Of the 350 patients, pretransplant and posttransplant TB was present in 43 (12.3%) and 19 (5.4%) during follow-up (mean = 46.8 months), respectively. Pulmonary TB (36.8%) was the most common manifestation, treated for mean duration of 15.6 months. Posttransplant TB was significantly associated with CMV infection (OR = 6.47; 95% CI 1.822–22.985; P = 0.004); new-onset diabetes after transplant (NODAT) (OR = 5.89; 95% CI 1.883–18.45; P = 0.002); methylprednisolone therapy for acute rejection (OR = 4.58; 95% CI 1.611–13.02; P = 0.004). There was no difference in patient and graft survival between patient with and without posttransplant TB.

CONCLUSIONS: We conclude that CMV infection, NODAT, and methylprednisolone therapy given for rejection were found to be significantly associated with posttransplant TB. TB infection in either pre- or post-transplant period does not affect graft and patient survival.


  Spectrum of Renal Disease in Patients with Retroviral Disease at Tertiary Care Center Top


Harshavardhan Guptha, Manjusha Yadla

Department of Nephrology; Gandhi Hospital and Medical College; Secunderabad; Telangana; India

E-mail: [email protected]

BACKGROUND: Renal disease is relatively common complication in patients with HIV infection globally; the prevalence is around 5%–30%. Patterns of HIV-associated renal disease vary from acute kidney injury (AKI), HIV-associated nephropathy (HIVAN), immune complex-mediated, chronic kidney disease (CKD), and electrolyte and acid base disorders.

AIM OF THE STUDY: To analyze the spectrum of renal disease in patients with retroviral disease referred to nephrology department.

METHODS: Study design: Retrospective observational study. Setting: Tertiary care government teaching hospital. Inclusion criteria: all the patients with old and naive retroviral disease presented to the Nephrology Department, Gandhi Hospital, with renal dysfunction, and proteinuria with age more than 18 years between January 2016 and July 2021. All patients underwent investigations such as complete blood picture, complete urine examination, serum creatinine automated Jaffey's method, urine dipstick for proteins, 24 h urinary protein, ultrasound abdomen, and CD4 count (BD). Some patients underwent renal biopsy in view of >1 g 24 h proteinuria by 18G renal biopsy BARD cutting needle.

RESULTS: We observed 72 patients with male being 72.2% (52) and female being 27.8% (20). Mean age of the population was 43.83 ± 9.66 (~44 ± 10) years. Clinical renal disease presentation such as anuria observed in 43.06%; oliguria observed in 52.78; pedal edema 75%; and SOB observed in 63.89%. Comorbidities such as diabetes in 20 and HTN in 22 were observed. Normoalbuminuria was seen in 37 (51.38%); moderately increased albuminuria 9 (12.5%); and severely increased albuminuria 17 (23.61%). CD4 count <50 in 1 (1.39) patient; <100 in 12 (16.67%) patients; <200 in 33 (45.83%); >200 in 24 (33). Intrinsic AKI was seen in 49 (68.05%): Postrenal - 7 (14.29%); sepsis related in 26 (53.06%); and AKI of unknown etiology 16 (32.65); CKD stage 5 in 17 (23.61%); glomerular involvement in 6 (8.33%); renal biopsy was done in 6 patients out which 1 (16.67%) HIVAN FSGS; 2 (33.33%) minimal change disease; 1 (16.67%) acute interstitial nephritis; and 2 (33.33%) diabetic nephropathy.

CONCLUSIONS: Prevalence of HIV AKI is 3.4% among all HIV admissions. Prevalence of HIV AKI accounts for 1% of all AKI cases. Age, CD4 count, diabetes, and liver disease were associated with increased mortality. Younger age and early renal recovery were associated with good outcomes.


  Impact of Hemodialysis on the Quality of Life Among Patients with End-Stage Renal Disease Top


Rajeev Bhatia, Suresh Chander Tiwari, Ajay Marwaha, Sweta Bhartdwaj1

Departments of Nephrology and 1Psychology; Shrimann Superspeciality Hospital; Pathankot Road; Jalandhar; Punjab; India

E-mail: rajivjbhatia[email protected]

BACKGROUND: In recent years, measuring the impact of end-stage renal disease (ESRD) treatment on patient's quality of life (QOL) has become increasingly well recognized as an important outcome measure.

AIM OF THE STUDY: To determine QOL standards in patients with ESRD undergoing twice per week hemodialysis.

METHODS: This was a multicenter cross-sectional study conducted in patients of either sex, aged above 18 years diagnosed with ESRD who were undergoing hemodialysis for at least 3 months in three hemodialysis centers. For QOL assessment, patients underwent KDQOL questionnaire survey. KDQOL is a disease-specific QOL questionnaire.

RESULTS: A total of 74 patients with ESRD (mean age: 54.7 years; men: 67.6%) undergoing hemodialysis enrolled. Overall, 53 (71.6%) patients had improvement in their life in comparison to last year. The majority of patients reported no bodily pain (66.2%). The majority of patients (68.9%) did not feel frustrated due to kidney disease. A total of 75.7% of patients did not feel like a burden on their family. More than half of the patients reported that they did not bother about dry skin (55.4%), sleep disturbance (66.2), and problem with access site (75.7%). Most of the patients reported that dialysis staff encouraged them to be as independent as possible (93.7%) and support them in coping their kidney disease (93.3%).

CONCLUSIONS: The present study was done to throw light on the status of QOL of Indian patients undergoing hemodialysis and might inspire the healthcare providers to endeavor for quality in the delivery of dialysis in the future.


  Outcome of Acute Kidney Injury Requiring Hemodialysis: A Single-Center Prospective Study from Eastern India Top


Amresh Krishna, Shalini Sinha, Prit Pal Singh, Om Kumar

Department of Nephrology; Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India

E-mail: [email protected]

BACKGROUND: Acute kidney injury (AKI) is being recognized as a major health problem globally. Majority of AKI occur in developing countries. It is associated with high rate of mortality and morbidity. In developed world, AKI occurs mostly in hospital setting in elderly population, while in developing nations, this is mainly community acquired usually associated with infections, obstetric complications, drugs, and dehydration.

AIM OF THE STUDY: (1) To analyze the outcome of hemodialysis (HD) requiring community-acquired AKI. (2) To study the etiology of HD requiring AKI.

METHODS: This study was conducted at Department of Nephrology, Indira Gandhi Institute of Medical Sciences, Patna, between July 1, 2019, and June 1, 2021. Inclusion: All patients with community-acquired AKI aged 18–65 years requiring one or more session of HD. Patients were managed for AKI as per standard treatment protocol. After discharge, patients were followed up in the nephrology outpatient department (OPD) at 1, 3, 6, and 12 months. Patients were also free to visit the OPD if they felt the need. Exclusion: (1) Those with AKI not requiring dialysis; (2) patients developing AKI in hospital; (3) those been discharged against medical advice; (4) those who fail to follow-up in OPD; and (5) those with preexisting CKD including renal-transplant recipients.

RESULTS: Among 102 patients, 57 were males (55.9%) and 45 were females (44.1%). The mean age of the patients was 39.31 ± 17.48 years. Mean duration of symptoms before hospitalization was 12.00 ± 6.80 days while mean session of HD received was 3.76 ± 3.20. At admission, the mean Hb was 11.411 ± 2.55 g/dl, while mean serum creatinine was 10.06 ± 4.42 g/dl. Multifactorial AKI was the most common etiology (22.5%) followed by PAKI (20.6%), AGE (14.7%), and sepsis (13.7%). At the time of discharge, 25.49% of patients died. 10.78% of patients were still dialysis dependent. 60.78% of patient were having renal dysfunction but were not requiring dialysis. Only 2.94% had full recovery of renal function. At 1 year of follow-up, 28.43% of patients died. 7.84% were dialysis dependent. 12.75% had CKD not requiring renal replacement therapy, and 50.98% showed full recovery of renal function. Most of the deaths were associated with PAKI, multifactorial AKI, and sepsis.

CONCLUSIONS: AKI requiring hemodialysis is associated with significant morbidity and mortality. Mortality is disproportionately high with PAKI, multifactorial AKI, and AKI associated with sepsis. In our study population, PAKI is still a common cause of AKI requiring HD.


  Etiology and Outcome of Acute Kidney Injury in Critical Care Patients - A Single-Center Experience Top


Kevin T John Keeppallil, J Jayannan, Aneesh Basheer, Georgi Abaraham

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Chennai; Tamil Nadu; 1Department of General Medicine; Pondicherry Institute of Medical Sciences; Puducherry; India

E-mail: [email protected]

BACKGROUND: Acute kidney injury (AKI) is a global health problem. AKI is a clinical syndrome formerly called acute renal failure (ARF). This nomenclature defines AKI as a functional or structural abnormality of the kidney which manifests within 48 h; as confirmed by blood, urine, or tissue tests or by imaging studies.

AIM OF THE STUDY: To determine the risk factors for poor outcome and to describe the clinical profile, etiology, and outcomes of patients with AKI admitted to the critical care unit.

METHODS: It was a prospective cohort study conducted in a tertiary care hospital in South India (Pondicherry Institute of Medical Sciences [PIMS]; Puducherry) from December 2016 to November 2019. All patients above 18 years of age attending PIMS casualty and admitted in intensive care unit (ICU) or critical care unit directly or who have been shifted to critical care unit on the same day or within 24 h of being seen in outpatient department/admitted in the ward were screened prospectively in the study to assess AKI using RIFLE criteria and those patients meeting AKIRIFLE criteria were enrolled in the study for etiology and outcome measurement. Known chronic kidney disease (CKD) patients and/or patients already on dialysis were excluded. 152 patients were taken for final analysis. All patients in the ICU were screened with creatinine, GFR, and urine output daily for 7 days. A follow-up at 3, 6, and 12 weeks was done to assess the outcome of AKI with physical examination, creatinine, GFR, and urine output values.

RESULTS: The mean age of the subjects was 44.15 years. Majority of the study subjects (55.9%) belonged to 26–50 years of age. Majority of the study subjects were females (51.3%). Sepsis was found to be present in 52% (79) followed by gastrointestinal (GI) loss 36.2% (55); crush injury 9.03% (15); snake bite 3.3% (5); poisoning 4.6% (7); and acute liver failure 1.3% (2). It was found that 62.5% (95) of the study subject's AKI had resolved after appropriate management. Among the rest of the study subjects, 27.6% required hemodialysis for recovery; 3.3% had persistence of AKI; 3.9% progressed to CKD; and 2.6% died. The latter three categories were considered as poor outcomes of AKI. In our study, 29.8% of people who had hypertension and 28.2% of people who had diabetes mellitus had poor outcome. It was found that in our study, sepsis and GI loss both contributes to poor outcome of AKI in univariate regression analysis whereas GI loss alone contributes to poor outcome of AKI with multivariate regression analysis.

CONCLUSIONS: Even though sepsis is the most common cause of AKI, GI loss independently contributes to poor outcome of AKI. Majority of the people recovered from AKI spontaneously with conservative management. Few people required dialysis for recovery of AKI and very few people progressed to CKD.


  Clinical Profile and Outcomes of COVID-19 Infection Among Renal-Transplant Recipients Top


Jeethu Joseph Eapen, Elenjickal Elias John, Athul Thomas, Sabina Yusuf, Anna Valson, Suceena Alexander, Vinoi G David, Prasanna Samuel1, Mahesh Moorthy2, K P P Abhilash3, Priscilla Rupali4, Binila Chacko5, Santosh Varughese

Departments of Nephrology; 1Biostatistics; 2Clinical Virology; 3Emergency Medicine; 4Infectious Disease and 5Critical Care; Christian Medical College and Hospital; Vellore; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: COVID-19 infection has a devastating effect among renal-transplant recipients. This study aimed to look at the clinical profile and outcomes of COVID-19 infection among renal-transplant recipients.

AIM OF THE STUDY: To study the clinical profile of renal-transplant recipients presenting to hospital with COVID-19 pneumonia.

METHODS: We prospectively analyzed all renal allograft recipients with COVID-19 infection between June 2020 and August 2021. Transplant details, clinical features of severity, outcomes of COVID-19 infection, and risk factors associated with mortality were studied.

RESULTS: We recruited 37 patients in this study with mean age of 40 ± 11.6 years. Males were 78.4% of the cohort; 75.7% were living donor-transplant recipients with average transplant vintage of 5.5 ± 3.5years. As per WHO Clinical Severity, mild infection was seen in 48.6% of patients, moderate infection in 13.5%, and severe infection in 37.8%. The overall mortality was 24.3%. Patients who presented in the second wave of COVID-19 infection had more severe disease (78.6% vs. 17.4% in first wave; P = 0.001). The mortality was higher though statistically not significant in those who presented in the second wave (40% vs. 13.6%; P = 0.075). In multivariate analysis, severity of infection was associated with mortality (HR for mortality in severe disease –27.25; 95% CI 1.07–693.7; P = 0.045).

CONCLUSIONS: Renal-transplant patients have higher mortality due to COVID-19 as compared to general population. Patients in the second wave of infection had more severe disease and higher mortality. Patients with severe disease at presentation had higher risk of mortality as compared to mild or moderate disease.


  Assessment of Quality of Life Using SF-36 Questionnaire in Patients on Maintenance Hemodialysis Following COVID-19 Infection Top


Tauseef Ahmed, Manjusha Yadla

Department of Nephrology; Gandhi Medical College and Hospital; Secunderabad; Telangana; India

E-mail: [email protected]

BACKGROUND: Coronavirus disease 2019(COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), primarily manifests as an acute respiratory illness, but it can affect multiple organs including kidney. Chronic kidney disease (CKD) and immunosuppression stand as one of the established potential risk factors for severe coronavirus disease 2019 (COVID-19). Case morbidity and mortality rates are higher in maintenance hemodialysis (MHD) patients than in the general population.

AIM OF THE STUDY: To study quality of life in MHD patients post-COVID-19 recovery using 36-item short form survey (SF36) questionnaires in a tertiary care hospital.

METHODS: All patients on MHD who were admitted in Gandhi Hospital for COVID-19 infection from April to July 2020 were included in this study; patients were contacted telephonically postrecovery for SF36; physical functioning, role limitation due to physical health, role limitation due to emotional problems, energy, emotional well-being, social functioning, pain, general health, and health change were assessed. 43 patients were taken as controls for whom SF36 was done. Inclusion criteria: those who are traceable and willing to undergo survey. Exclusion criteria: lost to follow-up; not willing for survey.

RESULTS: Totally, 11,527 patients were admitted for COVID-19 infection during 4 months of pandemic out of which 220 patients were referred to nephrology; of whom 134 were on MHD; 49 died during hospital stay; 42 patients lost to follow-up; and 43 were traceable for SF36 survey. Mean age of the patients 48.3 ± 13.1 years (range 24–76). Male to female ratio was 2.58; mean duration of hemodialysis was 2.48 years. Average duration of hospital stay was 18.04 days; average duration of viral clearance was 27.7 days. Mean age of the controls was 45.1 ±13; range 24–76; male to female ratio was 2.3; mean duration of hemodialysis was 5.3 years. Mean of physical functioning was 55.58%; role limitations due to physical health 34.3%; role limitations due to emotional problems 48.06%; energy/fatigue 40%; emotional well-being 50.5%; social functioning 60.1%; pain 55.6%; general health 32.55%; general health change 34.88%. Mean of physical functioning of controls was 57%; role limitation due to emotional problem 47.7%; energy 44.5%; emotional well-being 52.9%.

CONCLUSIONS: Role limitation due to physical health, energy, general health, and health change are worsened in cases as compared to controls. All the domains of SF36 are worsened with progressively increasing age in both cases and control. Pain, general health, and health change worsen in hypertensive COVID patients.


  Predictors of Dialysis Requirement in Acute Kidney Injury-3 Top


Rohan Raghuwanshi, Vipul Chakurkar, Sagar Kulkarni, Valentine Lobo

Renal Unit; KEM Hospital; Pune; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Prognosis of dialysis-requiring acute kidney injury (AKI) is worse than that of less severe stages. Trials on timing of initiation of dialysis in AKI-3 have shown that a significant proportion of AKI patients may not require dialysis. However, the literature on this subset of population is scarce.

AIM OF THE STUDY: To determine the predictors of dialysis requirement in AKI-3 patients.

METHODS: In this prospective observational study, we enrolled adult patients with AKI-3 who did not need dialysis on first nephrology consultation. Patients with obstructive uropathy and chronic kidney disease were excluded. Clinical and laboratory parameters were noted daily along with daily fluid balance and dialysis initiated whenever the standard indications of dialysis were met. The primary outcome was dialysis requirement within 7 days of AKI-3. Various parameters were analyzed for prediction of the dialysis requirement.

RESULTS: Fifty-three patients were enrolled; 39 (74%) were males. The mean (standard deviation) for age was 55 (16.63) years; while APACHE-II score was 15.09 (5.43). Sepsis was seen in 38 patients (71.7%). Over the follow-up period, 17(32.07%) required dialysis and 20 (37.7%) patients died. The mean APACHE-II score was significantly lower in those not requiring dialysis (13.72 [5.04] vs. 17.94 [4.28]; P = 0.008). Patients requiring dialysis had increasing trend of blood urea levels (BUL) compared to those not needing dialysis. On multivariate logistic regression analysis, only the slope of BUL was found to be an independent predictor of requirement of dialysis (P < 0.001); while cumulative fluid balance, vasopressor requirement, and diuretic use were not associated with the need for dialysis.

CONCLUSIONS: Higher APACHE-II score and rising BULs were associated with the need for dialysis in AKI-3 patients. Larger studies are required.


  Study of Clinical Significance of IGM and C3 Glomerular Deposits in Primary Focal Segmental Glomerulosclerosis Top


Prajit Mazumdar, Om Kumar, Amresh Krishna, Pritpal Singh, Chandan Kumar

Department of Nephrology; Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India

E-mail: [email protected]

BACKGROUND: Glomerular IgM deposition is commonly seen in primary focal segmental glomerulosclerosis (FSGS) and sometimes accompanied by C3 deposition. Clinical presentation and treatment outcomes of these patients are not investigated in detail.

AIM OF THE STUDY: To assess the significance of C3 and IgM deposits with remission rates and renal outcomes in primary FSGS.

METHODS: 120 consecutive patients with biopsy-proven primary FSGS from 2017 to 2021 were enrolled retrospectively. They were divided into three groups according to their histopathological features: IgM−C3−; IgM+C3−; and IgM+C3+. Clinical features and treatment outcomes were compared between patients with and without IgM/C3 deposition Primary outcome was defined as at least a 30% reduction in baseline estimated glomerular filtration rate (eGFR) or development of kidney failure; while complete or partial remission rates were the secondary outcomes.

RESULTS: Glomerular IgM deposits were found in 70 (58.3%) patients, out of total 120 patients, 22.5% of which had accompanying C3 deposition (IgM+; C3+) and 35.8% patients had no deposits of C3/IgM (IgM−; C3−). Patients in IgM+C3+ group had higher level of proteinuria; higher percentage of segmental glomerulosclerosis; and lower levels of eGFR and low serum albumin at the time of diagnosis (P < 0.05). Decline in EGFR >30% was seen in more in IgM+C3+ group compared with IgM−C3− or IgM+C3− group (P = 0.001). Combined IgM and C3 deposition was identified as an independent risk factor for renal dysfunction. Although patients received comparable immunosuppressive treatments, remission rates were lower occurred in patients with combined IgM and C3 deposition compared with patients with IgM deposition alone or no IgM deposition (P = 0.03). Multivariate analysis identified combined IgM and C3 deposition as an independent risk factor for refractory patients.

CONCLUSIONS: Patients with primary FSGS and IgM and C3 deposition showed unfavorable therapeutic responses and worse renal outcomes, which indicate that IgM and C3 deposition might involve disease progression via complement activation.


  Urine Neutrophil Gelatinase-Associated Lipocalin Measured in Chronic Kidney Disease Stage-3 as a Predictor of Progression of Chronic Kidney Disease Top


Kishor Kumar Rajasekaran, B Sreekanth Deshmukh, Rajeev A Annigeri, M K Mani, Prakash C Kowdle, Subba Rao Budithi, Rajagopalan Seshadri, S Balasubramainan, Vivek Vadamalai

Department of Nephrology; Apollo Hospital; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: There is a wide variation in the degree and rate of progression of chronic kidney disease (CKD) with diverse etiology and stages of CKD. Several clinical predictors of CKD progression such as poor control of hypertension, heavy proteinuria, or albuminuria are used in practice; however, a biomarker-guided prediction is another promising approach that is not sufficiently explored. We measured urine neutrophil gelatinase-associated lipocalin (uNGAL), a renal tubular injury marker, in patients with CKD stage-3 to determine its accuracy in predicting the progression of CKD.

AIM OF THE STUDY: To evaluate the role of uNGAL in predicting the progression of CKD stage-3 patients.

METHODS: We measured uNGAL in 91 patients with CKD stage-3. Demographic data such as age, sex, serum creatinine, blood urea, and urine protein–creatinine ratio were collected at the time of measurement of uNGAL and a level >150 ng/ml was considered high. Estimated glomerular filtration rate (eGFR) was calculated at baseline and the last follow-up using the 4-variable modification of diet in renal disease equation. The primary composite endpoint of our study was a decline in the eGFR >50% or renal replacement therapy initiation. The secondary outcome was the rate of decline of eGFR.

RESULTS: The mean age was 52.13 ± 11.89 years and 68% were males. The mean duration of follow-up was 34.3 ± 17.6 months. The mean uNGAL was 76.5 ± 130 ng/ml and 11 patients (12%) had high uNGAL. Nineteen patients (20.8%) reached the primary endpoint and the mean decline in the rate of eGFR was −2.27 ± 10.4 ml/min/year. The AUC of ROC to predict CKD progression was 0.621. The sensitivity and specificity of the uNGAL cutoff value 150 ng/ml to predict primary outcome were 45.5% and 82.5%, respectively. The rate of decline of eGFR in patients with elevated uNGAL and normal uNGAL were −5.8 ± 12.96 ml/min/year and −1.78 ± 10.0 ml/min/year, respectively (P = 0.234).

CONCLUSIONS: Our result suggests that uNGAL is a poor predictor of the progression of stage-3 CKD and hence may not be useful in clinical practice to predict the progression of CKD.


  Clinical Spectrum and Pathological Abnormalities of Paraprotein-Related Kidney Disease: A Single-Center Experience Top


Monica R Nayaka, A Kishan, L Umesha, C G Shreedhara, V Leelavathi, S Mythri, M Ricken

Department of Nephrology; Institute of Nephro-Urology; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: Spectrum of clinical manifestations in patients with paraproteinemia are diverse ranging from totally benign asymptomatic condition also called as monoclonal gammopathy of unknown significance to the malignant condition multiple myeloma.

AIM OF THE STUDY: We undertook this study to describe clinical manifestations and histopathological abnormalities in patients with paraprotein-related kidney diseases.

METHODS: We conducted a retrospective observational study between January 2018 and July 2021 at Institute of Nephro–Urology, Bengaluru, India. A total of 60 patients were included in the study fulfilling following criteria: (a) Biopsy-proven myeloma cast nephropathy; (b) renal biopsy findings suggestive of paraproteinemia such as immunofluorescence findings with light chain restriction as defined by International Myeloma Working Group. We collected clinical findings, laboratory findings, and imaging abnormalities in prespecified pro forma of these patients who were included in the study.

RESULTS: Of the 60 patients studied, maximum number of patients were in 5th and 6th decade accounting for 27% (n = 16) and 35% (n = 21), respectively, with a mean age of 53.4 years. Male to female ratio was 3:1. Acute kidney injury (AKI) is the most common clinical presentation accounting for 35% of cases followed by chronic kidney disease (CKD) which is seen in 33%; nephrotic syndrome in 11.6%; and rapidly progressive renal failure presentation in 8.3%. Most common renal histopathology was found was myeloma cast nephropathy 35%, followed by amyloidosis AL which is the second most common renal lesion seen in 18.3% of cases. 15% had proliferative glomerulonephritis with monoclonal immune deposition disease; 8.3% had nonamyloid deposition disease. Monoclonal immunoglobulin deposition disease was seen in 10% patients. 47.5% of patients required dialysis at presentation.

CONCLUSIONS: Paraproteinemia-related kidney diseases are associated with diverse clinical manifestations. AKI was the most common clinical presentation. Among histopathological spectrum Myeloma cast nephropathy was the most common pathological abnormality observed in our study followed by AL amyloidosis.


  A Short-Term Observational Study on the Pattern of Renal Injury Among Central Jail Inmates of Bangalore Top


Bhushan C Shetty, S Mythri, L Umesha, C G Shreedhara, A Kishan, V Leelavathi, M Ricken

Department of Nephrology; Institute of Nephrourology; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: Infection-related glomerulonephritis (IRGN) is an immunologically mediated glomerular injury. There are various medical problems faced by jail inmates as seen in one of the studies where 42% of inmates had health issues,

AIM OF THE STUDY: To study the various patterns of renal injury among central jail inmates of Bangalore.

METHODS: It was an observational clinical study conducted at INU; Bangalore, between April 1, 2020, and July 31, 2021. Inclusion criteria: All central jail inmates from Bangalore admitted to the nephrology department who underwent renal biopsy between April 1, 2020, and July 31, 2021. Clinical syndrome of the patient at presentation, requirement of renal replacement therapy, and relevant hematological, biochemical, and radiological investigations were done and documented in a well-structured pro forma after due consent; which were entered in Microsoft Excel and analyzed by SPSS version 21.0. Results were expressed as mean and percentages. Appropriate bar charts are drawn wherever required.

RESULTS: 14 patients who fulfilled the inclusion criteria were included of which all were males with mean age of 33 years. 6 (42.8%) had immune complex glomerulonephritis favoring IRGN; pigment nephropathy in 2 (14.2%); IgA nephropathy >50% IFTA in 2 (14.2%); pauci immune crescentic glomerulonephritis in 1 (7.14%); chronic interstitial nephritis >50% IFTA in 1 (7.14%); hypertensive glomerulosclerosis >50% IFTA in 1 (7.14%); chronic glomerulosclerosis >50% IFTA in 1 (7.14%). 12 patients were followed up for 3 months. 6 (42.8%)had IRGN. Among 6, clinical syndromes were acute nephritic syndrome in 3 (50%); rapidly progressive renal failure (RPRF) in 2 (33.3%); and nephrotic syndrome in 1 (16.6%). Focus of infection could be identified in only 2 (33.3%) of the 6 cases of IRGN and we could not isolate organisms in any of the 6 cases. 4 (66.6%) of the 6 cases had complete renal recovery; 1 (16.6%) was dialysis dependent and 1 (16.6%) had persistent renal dysfunction without dialysis at the end of 3 months.

CONCLUSIONS: Infections can cause or precipitate underlying renal dysfunction by many mechanisms. Our study showed the plausible mechanisms of infection-related renal injury among central jail inmates of Bangalore, which if corrected can prevent these kinds of kidney injury.


  Therapeutic Plasmapheresis – An Experience at a Tertiary Care Center in South India Top


S S Deepak Bala Kumar, M Edwin Fernando

Department of Nephrology; Government Stanley Medical College; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Plasmapheresis holds an effective therapeutic role in many disease conditions. Use in appropriate indication with close monitoring and intensive follow-up results in favorable outcomes. This warrants personalized audit assessing the utility of therapeutic plasma exchange (TPE) at every center. In this study, we have evaluated the utilization and outcome with TPE for different disease categories.

AIM OF THE STUDY: To evaluate the utilization of TPE for immunological and nonimmunological diseases.

METHODS: This was a prospective observational study conducted in patients referred for TPE during a period of 8 months. Demographic data, clinical data, details of number of sessions, volume of plasma exchanged, patient tolerance, and complications during the procedure were systematically recorded and descriptive statistics was applied for analysis

RESULTS: A total of 93 patients undergoing TPE were recruited in this study. Based on their diagnosis at the time of recruitment, the study population was divided into two groups as immunological disease group (n = 39) and nonimmunological disease group (n = 54). Patients with yellow phosphorus poisoning constituted the nonimmunological disease group. Median duration of hospital stay was 20 days in the overall population, and it was significantly longer in patients who underwent TPE for immunological cause (P < 0.0001) compared to nonimmunological cause. The proportion of patients experiencing clinical improvement was significantly higher in nonimmunological group (P = 0.008). All-cause mortality was numerically higher in immunological group.

CONCLUSIONS: TPE was utilized more for nonimmunological diseases than immunological diseases. It was reaffirmed to be a safe and efficacious procedure in both immunological and nonimmunological diseases. Clinical outcomes were better in patients undergoing TPE for nonimmunological disease.


  A Study of Long-Term Outcome of Mycophenolate Dose Modulation in Renal-Allograft Recipients with SARS-COV2 Infection During COVID-19 Pandemic - An Opportunity in Disaster Top


Jeyakumar Meyyappan, D S Bhadauria, V Vamsidhar, N Prasad, A Kaul, M R Patel, M R Behera, R S Kushwaha, M Yachha, M R Behera

Department of Nephrology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: A significant reduction of acute rejection rates was observed after using mycophenolate mofetil (MMF) in renal-transplant recipients (RTRs). However, side effects such as hematological and gastrointestinal intolerance often occur when MMF is used in routine doses. MMF dose reduction is required during its side effects or coexisting infection in RTR. The outcome of MMF dose modulation in RTR is not well established

AIM OF THE STUDY: COVID-19 pandemic has given an opportunity to study the effect of MMF dose modulation on graft function as large number of RTR who had COVID-19 received MMF dose reduction or discontinuation

METHODS: We prospectively collected data of RTRs developing COVID-19 infection during the first and second COVID waves. Management including decision on admission, immunosuppression modulation, and antibiotics were done based on clinician's discretion subject to logistics and the prevailing guidelines by the ISOT. All patients were followed up for minimum 6 months for graft dysfunction, biopsy rate and rejection rate, and infectious and pulmonary sequalae. The effect of immunosuppression modulation, especially MMF, reduction or cessation, and its bearing on the incidence of rejection was studied.

RESULTS: We prospectively studied a total of 251 patients; 101 (wave 1) and 150 (wave 2) followed for minimum 6 months. Of these, 167 of 251 (66.5%) had mild COVID-19 infection; 145 of 251 (57.7%) were admitted. MMF was reduced in 60.6% while it was stopped in 33.1% of patients. CNI was reduced or stopped in 22.3% and 6.3%, respectively. Steroids were increased in 75.3% of patients (oral wysolone 20 mg in 45% patients; methylprednisolone in 17.9%, and intravenous dexamethasone in 11.6%). The mortality rate was 15.1% at index admission. Among survivors, 17 (7.9%) patients developed either graft dysfunction or proteinuria on follow-up at 6 months. Of them, 14 (6.5%) patients underwent graft biopsy. A total of 9 (4.2%) patients had biopsy-proven rejection

CONCLUSIONS: MMF dose modulation to tackle an infectious episode may be associated with graft dysfunction and rejection on short-term follow-up. A delicate and immeasurable balance is required during immunosuppression adjustment which should be tailored to every patient and one size may not fit all!


  APOL1 Renal Risk Variants Compromised the Podocyte Differentiation by Downregulation Of Vitamin D Receptor Top


Vinod Kumar1,2, Ashwani Malhotra2, P C Singhal2

1Department of Dermatology; Venerology and Leprology; PGIMER; Chandigarh; India; 2Feinstine Institute for Medical Research; New York; USA

E-mail: [email protected]

BACKGROUND: APOL1 is endogenously expressed by human podocytes (HPDs). The molecular mechanism though which these APOL1 risk variants (RVs) cause PD disintegration is still undefined. Recently, we have reported that the APOL1 RV lost their ability to downregulate miR193a expression and causes PD dedifferentiation. We hypothesize that the supplementation of Vitamin D agonist helps in reducing the miR193a levels and rejuvenating the APOL1-RV PDs.

AIM OF THE STUDY: To study that APOL1 RV induces disruption of APOL1-miR193a axis through downregulation of Vitamin D receptor.

METHODS: hPDs expressing APOL1 nonrisk (NR - G0) and risk (G1 and G2) were cultured and maintained in proliferative state at 33°C. For differentiation or maturation, the proliferating HPDs were trypsinized and plated in collagen-coated coverslips. After 24 h of plating the cell at 33°C, cells were shifted to nonpermissive condition with HPD differentiation medium at 37°C. Cells were maintained under these conditions for 8–10 days and further subjected for experimental conditions. The expression of PD dedifferentiation markers was done by western blotting in culture PDs and mice model [Figure 1]. The luciferase assay was used to predict the potential binding of miR193a to VDR. That was further confirmed with immunoprecipitation assays.

RESULTS: The observation of the study suggests that APOL1 VR G1 and G2 have low expression of PD differentiation protein markers and VDR. This found to be associated with increased expression of miR193a in G1 and G2. The miR193a potential downregulated the VDR expression and turns off the efficient differentiation of PDs. It has been achieved successfully in APOL1-G0.

CONCLUSIONS: This study concluded that compromised differentiation of PDs in APOL1-G1 and G2 is mediated through the downregulation of VDR by miR193a.


  Prevalence and Severity of Malnutrition Inflammation Complex Syndrome Among Ambulatory End-Stage Renal Disease Patients on Maintenance Hemodialysis Top


Meena Patel, Prawash Kumar Chowdhary, Sanjeev Anant Kale, Sanjay Kumar

Department of Nephrology; Ramkrishna Care Hospital; Raipur; Chhattisgarh; India

E-mail: [email protected]

BACKGROUND: Malnutrition, inflammation, and the combination thereof are predictors of poor outcome in hemodialysis (HD) patients. Malnutrition inflammation complex syndrome is an accelerator of atherosclerosis and protends high mortality.

AIM OF THE STUDY: To determine the prevalence and severity of malnutrition inflammation complex syndrome (MICS) among ambulatory end-stage renal disease patients on MHD and its association with select determinant factors.

METHODS: This prospective, observational cross-sectional study is done in the Department of Nephrology, RKCH, Raipur. A total of 100 patients were included as per inclusion and exclusion criteria. All relevant demographic data, relevant history, and laboratory investigations were done in each patient. The total MIS score was calculated and patients were divided into three groups as per MIS score (Group 1 having no MICS; Group 2 with mild MICS, and Group 3 with moderate-to-severe MICS). The correlation between MIS and select determinant factors was calculated. Further, logistic regression was performed between Group 2 and Group 3.

RESULTS: A total of 100 MHD patients were included in the study. MICS was present in 58% of patients (33% - mild MICS; 25% - moderate-to-severe MICS). Increased age, rural residence, lower socioeconomic status, <3-day sessions/week, low body mass index (BMI), increased total duration on HD, and lower serum albumin were associated with increased prevalence of MICS (P < 0.05). On logistic regression analysis, patients with serum albumin <3.5 and BMI <18.5 had a significantly increased risk (13.8 and 5.2 times, respectively) of developing severe MICS.

CONCLUSIONS: MICS is highly prevalent in MHD patients. Low serum albumin and low BMI are associated with increased severity of MICS.


  Acute Kidney Injury and its Outcome in Patients with Liver Cirrhosis Top


P R Appan Prakash, A Deiva, E Ramprasad, M Jayakumar

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Renal failure is a common challenging complication in patients with chronic liver disease patients, and it is one of the most important risk factors associated with increased mortality. Renal failure typically occurs in conjunction with multiorgan involvement during an acute illness or as a part of advanced liver disease. AKI in patients with liver cirrhosis is often precipitated by factors such as infections, hypovolemia from gastrointestinal bleeding, use of nephrotoxic drugs, or development of HRS.

AIM OF THE STUDY: To determine prevalence of acute kidney injury (AKI) and its impact on clinical outcome in patients with liver cirrhosis and to study the impact of liver cirrhosis stage on renal function.

METHODS: This was cross-sectional study on consecutive patients admitted with cirrhosis liver at Sri Ramachandra Medical College and Hospital from January 2019 to December 2020 who were enrolled and followed up during their inpatient stay. Diagnosis of cirrhosis liver was confirmed by clinical features, liver biochemistry, and imaging (computed tomography and/or ultrasound). Liver biopsy was considered as optional. Patient details included age, gender, etiology (alcohol, known hepatotropic viral infections, alternative system of medicine, drug details, others), details of previous admissions, current medication including diuretics, use of non-selective Î2 blockers, adherence to salt and/or fluid restriction, Child–Turcotte Pugh score, model for end-stage liver disease sodium score, and information on cirrhosis-related complications such as variceal bleed, refractory ascites, diffuse abdominal pain suggestive of SBP, altered sensorium, dyspnea, and urine output while on medication.

RESULTS: Of 130 cirrhotic patients, there were 117 males (90%) and remaining were females. The overall mean age group in the study cohort was 50.43 years. The overall prevalence of AKI was 27.7%. There were no significant differences in the baseline demographic profile such as gender, etiology, and comorbidity between patients with and without AKI. However; age (P = 0.002), hepatic encephalopathy (P = 0.02), SBP (P = 0.02); sepsis (P < 0.001), shock (P = 0.002), and mortality (P < 0.001) were statistically significant compared to those without AKI. Patients with AKI belonged to CTP–C (P = 0.016) and with a high MELD Na score (P < 0.001). Further, the renal function tests both at baseline and at time of discharge were significantly deranged (P < 0.001). Patients with AKI had high serum sodium (P = 0.025); low serum potassium (P < 0.001); low serum bicarbonate (P < 0.001); and urine culture positive (P = 0.022) and these were statistically significant compared to those without AKI.

CONCLUSIONS: The prevalence of AKI in liver cirrhosis patients in this study was 27.7%. The factors significantly associated with AKI were older age, hepatic encephalopathy, sepsis, spontaneous bacterial peritonitis, urinary tract infection, shock, and the degree of severity of liver disease.


  COVID-19 Infection in Kidney-Transplant Recipients During the Second Wave of COVID Pandemic: An Experience from a Tertiary Care Renal Transplant Center Top


Amit Kumar Singh, Abhilash Chandra, S Namrata Rao, Vishal Pooniya

Department of Nephrology; Dr Ram Manohar Lohiya Institute of Medical Sciences; Gomti Nagar; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Coronavirus disease (COVID-19) started as a severe pneumonia of unknown cause in the late 2019 and spread throughout the world by the early 2020. COVID-19 is predominantly a respiratory disease; however, in severe cases, it can cause acute kidney injury and multiorgan failure. Kidney-transplant recipients are at a high risk of developing severe COVID illness attributable to several risk factors; both transplant-specific (induction and antirejection therapies) and other comorbid conditions.

AIM OF THE STUDY: In this case series, we present nineteen cases of COVID-19 infection in kidney-transplant recipients in a tertiary care teaching hospital in Northern India; during the second wave of COVID pandemic.

METHODS: Out of a total of 19 cases, 11 patients were classified as mild and 8 patients had severe illness at the time of presentation. Six patients succumbed during and in the 1 week following COVID illness. All the mild cases were managed with home isolation according to the existing Indian Council of Medical Research guidelines and received regular telemedicine consultation. All the patients with severe illness were hospitalized. The median duration of fever before hospitalization was 3 days. The median duration of SARS nCoV2 RT PCR positivity in the hospitalized patients was 7 days. The most common symptom was fever with 16 of 19 cases reporting fever at the time of presentation. All the seven patients who were hospitalized had shortness of breath at the time of presentation. All patients with severe illness were managed in intensive care unit (ICU) settings.

RESULTS: The median ICU stay was 5 days. Six patients received noninvasive ventilation with BiPAP, 2 patients received oxygen via high-flow nasal cannula, and ultimately, 6 patients required invasive mechanical ventilation. All the hospitalized patients received remdesivir and low-molecular-weight heparin. Azithromycin and piperacillin-tazobactum were the most commonly prescribed antibiotics. Immunosuppressive agents were modified. The dose of tacrolimus was reduced in 5 patients and was stopped in two patients later on. Of the eight hospitalized patients, four developed acute allograft dysfunction. Three patients were provided renal replacement therapy in the form of SLED on alternate day. Of the six reported deaths, five patients died during the ICU stay. Two patients developed mucormycosis. Two patients were discharged; both had only mild graft dysfunction, which recovered in the subsequent 2 weeks.

CONCLUSIONS: The patients with severe illness required hospitalization and mechanical ventilation and the mortality in such patients was increased. The mortality in our case series was high at 75%. Renal-transplant recipients with COVID-19 illness also carry a greater risk of developing acute kidney injury.


  A Study Association Between the Nutritional Risk Index And Creatinine Index for Nutritional Assessment in Hemodialysis Patients Top


G Geethanjali, M Keerthana, E Ramprasad, M Jayakumar

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Malnutrition in hemodialysis (HD) is a powerful predictor of morbidity and mortality. Assessment of nutritional status has been developed using SGA, MIS, PEW, CI, and GNRI. GNRI consists of body weight, height, and serum albumin; the score is predictive for mortality. CI is a simple formula based on patient demographics, single pool Kt/V of urea, and predialysis creatinine concentration developed and validated for HD patients.

AIM OF THE STUDY: The aim of the study is to assess the association between the nutritional risk index and creatinine index for nutritional assessment in HD patients.

METHODS: The study was conducted at the dialysis unit at SRIHER, Chennai, involving 180 patients. End-stage renal disease (ESRD) patients aged 18–65 years on maintenance HD for more than 3 months were considered for the study. Patients on PD, pediatric patients, and patients with acute kidney injury were excluded from study. Patients were included after obtaining informed consent. The dietary interview involved participant's qualitative and quantitative estimations of 24-h intake of usual food and fluid intake. The nutritional status of the maintenance HD patients will be analyzed by using two nutritional risk tools such GNRI and CI. They were calculated using the following formula: GNRI= [14.89 – albumin (g/dl) + [41.7 − (body weight/ideal body weight) CI (mg/kg/day) = 16.21 + 1.12 – [1 if male; 0 if female] – 0.06 – age (years) – 0.08 – spKt/v urea + 0.009 – Crpre (μmol/L). Results were analyzed using ANOVA software. Data were expressed in percentage, mean, and standard deviation.

RESULTS: Out of 180 patients, 124 (68.9%) patients had PI/IBW level <1.3 gm/day and 56 (31.1%) patients had PI/IBW level between >1.3 gm/day. 14 (7.8%) patients had GNRI <82 (severely malnourished); 30 (16.7%) patients had between 82 and 91 (moderately malnourished); 48 (26.7%) patients had between 92 and 98 (less malnourished); and 88 (48.9%) patients had >98 (no risk). Among patients having BMI between 18 and 24, 12.4% of them were having malnutrition, 20.2% of them moderate malnutrition, and 38.2% of them low risk of malnutrition (P < 0.05). Among the patients taking protein intake of <1.3 gm/day, 9.7% of them were having malnutrition; 21% of them having moderate nutrition, and 36.3% of them having low risk of malnutrition. Among the patients taking protein intake of >1.3 gm/dl, 3.6% of them were having malnutrition, 7.1% of them having moderate nutrition, 5.4% of them having low risk of malnutrition, and 83.9% of them having no risk of malnutrition (P < 0.05). Age of the patient and vintage of dialysis were associated with creatinine index (P < 0.05).

CONCLUSIONS: There was significant association between GNRI with age, BMI, dry weight, Hb, calcium, albumin, protein intake, energy intake, a significant association between CI with age, gender, and vintage. Elderly patients were found to have a higher risk of malnutrition when compared to the younger patients


  Noble Candidate Biomarkers for the Early Prediction of Acute Kidney Injury: A Systematic Review and Meta-Analysis Top


Sweta Chatterjee, Rinku Das Mamtora, Roshnara Mishra, Pinaki Mukhopadhyay, Raghwendra Mishra

Department of Physiology; Ananda Mohan College; 1Department of Physiology; University of Calcutta; 2Department of Nephrology; Nil Ratan Sircar Medical College and Hospital; Kolkata; West Bengal; India

E-mail: [email protected]

BACKGROUND: There is a recent surge in identification of noble biomarkers for early detection of acute kidney injury (AKI) of various origins, which is often compromised due to dependency on late-stage markers such as serum creatinine and/or urine output. During the last two decades, several new AKI biomarkers have been discovered and validated to improve early diagnosis. Despite these advancements, an agreement over a universal biomarker and its cutoff value for early prediction of AKI is still lacking.

AIM OF THE STUDY: The aim of the study is to quantitatively summarize the published data to identify the diagnostic potential of some recently reported candidate biomarkers for the early detection of AKI.

METHODS: Data sources and search strategy – This study was conducted in accordance with the MOOSE guidelines. Renowned databases were searched to identify potentially relevant articles. Articles were retrieved using the following keywords: one of the four selected injury markers (“NGAL,” “;KIM-1” “;Cystatin C,” or LFABP) and “;AKI,” “;AUC,” “;sensitivity,” “;specificity,” and “;cut-off value.” Study selection - The studies were included if they met the inclusion criteria, i.e., reporting of AUC, sensitivity, specificity, and cutoff value for the diagnosis of AKI, and the relevant information was extracted from the related articles according to previously made data sheet. Statistical analysis - The overall AUC, sensitivity, and specificity and relevant 95% CI were calculated using random-effect model. The effect of sample type and sampling time was also assessed. The reliability of the reported cutoff values was assessed using Youden index. All statistical analyses were performed with Stata version 16.

RESULTS: Among 3340 studies, 93 relevant studies reporting one or more selected biomarkers met the inclusion were included for the meta-analysis. The selected studies include plasma and urine levels of NGAL and cystatin C and only urine levels of KIM-1 and LFABP. The data from selected articles show marked heterogeneity probably to various AKI setup, age group, and ethnicity, and hence, the meta-analysis was done using the random-effect model using the restricted maximum-likelihood method. For different sample type; the overall AUC for all the assessed biomarkers was found to be >0.8 whereas both overall sensitivity and specificity for all biomarkers were found to be >0.7. The cutoff values for KIM-1 and cystatin C were found to be dispersed over a narrow range whereas that for NGAL and LFABP showed higher dispersion. The Youden index for urinary cystatin C was the highest followed by plasma and urinary NGAL (majorly >0.5) whereas that for KIM-1 and LFABP was majorly less than 0.5. All the selected biomarkers show comparable ability to serve as the biomarker for early diagnosis of AKI.

CONCLUSIONS: Among the studied biomarkers, urinary cystatin C shows comparatively better potential as an early diagnostic marker as it has the least dispersed cutoff value and high Youden index.


  A Study of Sle Patients with Biopsy Proven Lupus Nephritis – Their Clinical Profile and Outcome After COVID-19 Disease Top


S Mathini, Prasannakumar, P Aishwarya, M Murali, B N Alekya, Maria Bethsaida Manuel, R Ram, Sivakumar

Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India

E-mail: [email protected]

BACKGROUND: As COVID-19 established as a global threat, the studies on patients with SLE and COVID-19 emerged from the heaviest hit regions in the early phases of the pandemic. More than 20 studies had been published on SLE and COVID-19. We report the outcomes of renal biopsy-proven SLE nephritis patients after COVID-19 disease.

AIM OF THE STUDY: To study the clinical profile and outcome of SLE patients with biopsy-proven lupus nephritis after COVID 19 disease.

METHODS: Our institute has been declared as state COVID-19 hospital during the pandemic. We have admitted and managed 8 patients of SLE with COVID-19 disease. We included the demography, clinical features, laboratory data that included lymphocyte counts, serum complement levels, and results of anti-dsDNA, and treatment schedules of SLE.

RESULTS: Of the 8 patients, seven were females and one was a male. The mean age was 29.3 years. All eight patients had renal biopsy-proven SLE nephritis before contracting COVID-19 disease. The histological class was Class IV in 5; Class III + V in 2 patients and Class V in 1 patient. One of the Class IV patients had crescents on repeat biopsy; she was treated with pulse methylprednisolone and hemodialysis. The median duration of symptoms of COVID-19 disease before admission was 2 days; SpO2 at admission (%) was 90.8 ± 6.9. Of the total 8 patients, 4 patients required dialysis and eventually succumbed to the illness. 1 patient was diagnosed as disseminated tuberculosis after transferring out from isolation ward and succumbed after 3 weeks. The remaining 3 patients were discharged with a mean serum creatinine of 1.32 mg/dl and on regular follow-up.

CONCLUSIONS: Our results suggested that with the 50% mortality, the COVID-19 had a calamitous effect on SLE nephritis patients. The higher mortality in our patients could be explained by the analysis that these patients had been diagnosed SLE in the recent past and were on higher doses of immunosuppression.


  How Compatible Were Our ABO-Incompatible Renal Transplants? Top


Kavitha Mudaliar, R Dilip, S Ramakrishnan, S Padmanabhan, Kiran Chandra Patro, R Ramprasad, Shakuntala Modi, Nitin Nayak, Aashish Nayak

Department of Nephrology; NU Hospitals; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: To circumvent the shortage of organs available for transplants, ABO-incompatible transplants are on the rise. With the availability of advancing immunosuppression and desensitizing techniques, excellent outcomes have been achieved in this immunologically high-risk procedure.

AIM OF THE STUDY: To study the outcomes of ABO-incompatible renal transplantation at our center.

METHODS: Type - Retrospective. Study period - September 2016 to September 2021. Age group of recipients - 13–64 years. Gender - Recipients (6 males and 1 female); donor (4 females and 3 males). Anti-A/anti-B titers - IgM ranging from 1:8 to 1:16; IgG - 1:32 to 1:256 before desensitization. After initial clinical and biochemical evaluation of donors and recipients, desensitization of recipients was done with injection rituximab (day 28); tacrolimus and MMF (day 15), and prednisolone (day 7). The patients were hospitalized 1 week before transplant and underwent further desensitization with immunoadsorption/plasmapheresis (average of 1–4 sessions either or both to achieve a titer of less than 1:4 in all patients). Injection basiliximab (IL2RA) was used for induction. Regular monitoring of titers was done once in 2 days in the postoperative period, once a week postdischarge, once in 2 weeks for 3 months, and later in case of graft dysfunction. UTI and Cytomegalovirus prophylaxis given for 6 months.

RESULTS: n = 7; Blood group of recipients: A = 2; O = 2; B = 3; donors: AB = 2; A = 2; B = 3. All the patients had an uneventful transplant procedure with brisk diuresis. Total follow up period - 12.1 patient-years. Mean follow-up period was 22 months. Mean creatinine on day 3 was 1.66 mg/dl (0.45–4.7); mean creatinine on day 7 was 1.09 mg/dl (0.41–2.04); mean creatinine on the last visit was 1.11 mg/dl (0.75–1.56). Delayed graft function - None. Requirement of hemodialysis and renal biopsy in posttransplant period – None. Immediate outcomes – Infections - 2 (surgical site and herpes zoster), neurological - 2 (stroke with ventilatory requirement and seizures). All the patients, on regular follow-up, are having normal graft function and no proteinuria.

CONCLUSIONS: Appropriate desensitization protocol and judicious use of immunosuppressants with regular monitoring and follow-up can give good outcomes in ABO-incompatible renal transplants compared to ABO-compatible recipients.


  Postrenal-Transplant De Novo Membranous Nephropathy with Collapsing Glomerulopathy - A Rare Association Top


Vishal Pooniya, Abhilash Chandra, S Namrata Rao, Kiranpreet Malhotra1

Departments of Nephrology and 1Pathology; Dr. Ram Manohar Lohia Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Membranous nephropathy (MN) after renal transplant may be a recurrent disease (usually associated with serum anti PLA2R antibodies) or a de novo disease. De novo MN may be secondary to infections such as hepatitis B, hepatitis C, malignancies, or antibody-mediated rejection and is usually not associated with serum anti-PLA2R antibodies.

AIM OF THE STUDY: Association of collapsing glomerulopathy with MN in postkidney-transplant patients is extremely rare.

METHODS: We herein report a case of postkidney-transplant MN with collapsing glomerulopathy.

RESULTS: A 27-year-old male is a recipient of ABO-compatible live-related renal allograft from his mother 11 months ago, who developed nephrotic range proteinuria within 6 months of transplant. Allograft biopsy at 6 months posttransplant was suggestive of MN with collapsing glomerulopathy. Serum anti-PLA2R antibodies were absent and tissue PLA2R antigen by immunohistochemistry was also absent. His serum hepatitis-B surface antigen, antihepatitis-B core antibodies, antihepatitis C virus antibodies, HIV 1 and 2 ELISA, Parvovirus B19 DNA PCR, and CMV DNA PCR were negative. Donor-specific antibodies were also absent. He was managed with maximally tolerated doses of telmisartan after which proteinuria reduced from 6.5 g/day to 3.56 g/day over 2 months. A repeat allograft biopsy was done due to persistent nephrotic proteinuria, which also revealed MN with collapsing glomerulopathy. Now, he was treated with seven sessions of plasmapheresis followed by 2 doses of rituximab 1 g; 15 days apart.

CONCLUSIONS: This case highlights the occurrence of de novo MN with collapsing glomerulopathy as a cause of nephrotic proteinuria in a kidney-transplant recipient. No obvious secondary cause for his condition could be found, and hence, he was ultimately treated with plasmapheresis and rituximab.


  Retrospective Study of Clinical Profile of Patients with Biopsy-Proven Acute Interstitial Nephritis – A 3-Year Review Top


Seeta Mutalik, Ricken Mehta, C G Sreedhar, L Umesh, A Kishan, V Leelavathi, S Mythri

Department of Nephrology; Institute of Nephro-Urology; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: The incidence of biopsy-proven acute interstitial nephritis (AIN) has increased dramatically over the past decade. It is the third most common cause of acute kidney disease in hospitalized patients. It is associated with a variety of infections, drugs, and with unknown causes. The classic presentation of AIN includes fever, rash, arthralgias, eosinophilia, and acute kidney injury. Renal biopsy is considered the gold standard for diagnosis. Clinical data on AIN are very few in South India.

AIM OF THE STUDY: To analyze and to study the clinical profile of the patients with biopsy-proven AIN.

METHODS: 78 patients with AIN were identified by retrospective review of all native renal biopsies from January 2018 to July 2021. A pathologic diagnosis of AIN required the presence of prominent interstitial inflammation in the nonfibrotic cortex and tubulitis. We excluded patients with proliferative glomerulonephritis, biopsy consistent with cortical necrosis, and pyelonephritis and those with allograft biopsies. Analysis of medical records and biopsy was carried out, and data were collected on demographic characteristics, clinical features, history of drug intake, stages AKI (KDIGO), the need for RRT, severity of the disease, blood and urine investigations, kidney size, biopsy features of AIN, and associated other lesions on biopsy. All the results were expressed as the mean ± standard deviation for continuous variables. Values were expressed as medians (interquartile range) when the parameters did not follow a normal distribution.

RESULTS: 78 patients with biopsy-proven AIN were reviewed, 18 (23.08%) of whom were in the 6th decade and 16 (20.5%) in the 5th dacade. 8 (10.2%) cases were in the 1st 2 decades. 64 (82%) were males. The overall prevalence of AIN was 2.7%. Drug association was present in 24 (30.7%) cases (tenofovir - 11; NSAIDs - 7; cisplatin - 2; carboplatin - 1; rifampicin - 2; amikacin - 1 case). 8 (10.2%) patients had a history of native medication. Sepsis with AKI was present in 33 cases (42.3%). Unexplained AKI was seen in 9 (11.5%) cases. Snake bite was seen in 4 (5.1%) cases. Majority of the patients were in AKI stage III 34 (64.1%). None of the patients had classical triad of AIN (fever, rash, and arthritis). Fever was present in 20 (25.6%) cases. 11 (14.1%) patients required RRT. Additional findings on renal biopsy – 11 (14.1%) had associated ATN; 9 (11.5%) with FSGS; 4 (5.1%) had CIN; 4 (5.1%) had pigment nephropathy; 4 (5.1%) had DN; and 2 (2.5%) had MCD.

CONCLUSIONS: The prevalence of AIN has increased in recent years; majority of AIN cases are due to sepsis followed by drugs. Classical triad of AIN is rarely seen; conditions such as pigment nephropathy and snake bite also need to be considered.


  A Case of Autoimmune Limbic Encephalitis Associated with Contactin-Associated Protein-2 Antibodies in a Patient on Maintenance Hemodialysis Top


Durga Deorukhkar, Viswanath Billa, Deepa Usulumarty, Shrirang Bichu, Anil Venkatachalam

Department of Nephrology; Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Auto-immune encephalitis refers to a noninfectious neuroinflammation characterized by seizures, involuntary movements, and cognitive decline attributable to various subgroups of antibodies - the most prevalent ones being GAD65, MOG, LGI1 or contactin-associated protein-2 antibodies (CASPR2), CRMP5, and NMDAR. Treatment options were intravenous corticosteroids, first-line immunotherapy including intravenous immunoglobulin and plasmapheresis, second-line immunosuppression including rituximab and cyclophosphamide; and newer agents such as bortezomib.

AIM OF THE STUDY: A case of autoimmune limbic encephalitis associated with CASPR-2 in a patient on maintenance hemodialysis (MHD).

METHODS: A 64-year-old woman with a history of longstanding hypertension, type II diabetes mellitus, and end-stage renal disease due to diabetic nephropathy was on MHD for 2 years. She presented with a history of failure to thrive and weight loss for 2 months associated with cognitive and speech regression, lapses in memory, and insomnia. She was hospitalized and found to have a permanent catheter-related bloodstream infection due to Stenotrophomonas maltophilia. The catheter was removed and she was treated with a 2-week course of ceftazidime and levofloxacin. While the sepsis recovered, there was only minimal improvement in her neurological status. She had a persistent right eye droop and right gaze preference, with generalized fasciculations and myoclonic jerks. She was labeled to have metabolic encephalopathy. As a part of evaluation for weight loss, PET-CT was not contributory.

RESULTS: She was investigated for her neurological symptoms. CT brain revealed moderate periventricular ischemic changes and age-related cerebral atrophy. EEG showed bilateral slowing with no epileptiform activity. The biochemical parameters were also not contributory to the diagnosis. With a working diagnosis of metabolic encephalopathy, she was initiated on daily dialysis. Despite addressing the infection and nutrition and subjecting her to daily dialysis, her neurological status did not show any significant improvement. The serum and CSF auto-immune encephalitis workup was therefore sent. The CSF was clear, with protein 12.6 mg/dl, glucose 58 mg/dl, one leucocyte on smear, no AFB seen, with no growth on culture. The serum CASPR antibodies were positive. She was initiated on alternate day intravenous immunoglobulin (25 g for 5 days) and plasmapheresis. In 2 weeks she demonstrated a significant improvement with disappearance of most her presenting symptoms.

CONCLUSIONS: Neurological symptoms in dialysis patients are generally attributable to infections, vascular disease, metabolic causes, and toxins. However, in instances, when no discernible improvement is seen despite appropriate treatment possibility of autoimmune encephalitis must be considered and evaluated.


  Coinfection Of Pulmonary Tuberculosis, Nocardia, and CMV in Postrenal Transplant – A Rare Case Presentation Top


Rajesh Tarachandani, Himansu S Mahapatra, Muthu Kumar

Department of Nephrology; RML Hospital; New Delhi; India

E-mail: [email protected]

BACKGROUND: Nocardiosis is caused by Nocardia asteroid, an aerobic actinomycete, producing either local or disseminated disease. It is a systemic infection that usually begins in the lungs and may spread to brain. Mostly it affects solid organ-transplant recipients on immunosuppressive drugs. In India, nocardiosis was reported in 1.4% of renal-transplant recipients.

AIM OF THE STUDY: To keep differential diagnosis of Nocardia in renal-transplant recipients patients present with pneumonia not responding to usual antibiotics.

METHODS: We report a case of pulmonary nocardiosis and tuberculosis in a postrenal-transplant recipient. Patient presented with complaints of cough with expectoration and associated with shortness of breath, and on examination, the patient's blood pressure was 70/30 mmHg with crepitations being present over both sides mammary and inframammary areas. We made a diagnosis of pneumonia and empirically started antibiotics after obtaining cultures, but the patient was not responding to antibiotics. After routine blood investigations, sputum AFB, and Gram staining, CT chest followed by this bronchoscopy was done.

RESULTS: Initial sputum AFB and Gram staining was negative; CT chest was suggestive of patchy ground-glass opacities in bilateral lung fields with parahilar lymphadenopathy. Bronchoscopy was done which showed purulent secretion and BAL shows branching hyphae; AFB stain was positive suggestive of Nocardia and also showed the TB PCR a positive result. On further evaluation, CMV PCR was found positive with 1700 copies/ml. The patient was treated with co-trimoxazole, ATT, and oral valganciclovir. The patient responded well to treatment and pneumonia was resolved.

CONCLUSIONS: This patient had an isolated lung involvement without any clinically evident of dissemination. Nocardial infection is always kept in differential diagnosis in transplant recipients who are presenting with pulmonary symptoms and not responding to usual antibiotics.


  Outcome of Kidney Transplant in Human Immunodeficiencyvirus-Positive Cases Top


Vishwanath Patil, Ishan Parekh, Vijay Nandu, Prashant Rajput, Zaheer Virani, Hepal Vora, Shruti Tapiawala, Bharat Shah

Institute of Renal Sciences; Global Hospital; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: For human immunodeficiency virus (HIV)-positive patients, transplant was considered an absolute contraindication because of the concern that immunosuppressive drugs would lead to further immunocompromised state and higher risk of infection and malignancy. With advances in the treatment of HIV, renal transplantation is no longer considered a contraindication in properly selected patients.

AIM OF THE STUDY: The aim of our study is to report our experience with kidney transplant in 4 HIV-positive cases.

METHODS: The study includes 4 HIV-positive cases with ESRD. These cases had CD4 count >200/μL and undetectable viral load at the time of transplant. Tailored immunosuppressive protocol was used. This consisted of no induction or anti-interleukin-2 receptor antibody for induction and tacrolimus, mycophenolate mofetil (MMF), and prednisone for maintenance. Antiretroviral drugs were modified to prevent any interaction with immunosuppressive drugs.

RESULTS: There were 2 males and 2 females aged 24–53 years. All were LRD transplants (The donor was father in 2 cases, mother in 1 case, and son in 1 case). One was an ABO-incompatible transplant. No induction was used in 3 cases and basiliximab was used in 1 case. Tacrolimus, MMF, and prednisolone were used for maintenance immunosuppression. All 4 cases have had uneventful course after transplant with no episode of rejection. Except for 1 patient (BJ) who developed COVID, there have been no infections.

CONCLUSIONS: Our findings suggest that HIV+ patients on highly active antiretroviral therapy can undergo successful renal transplantation with a low incidence of both acute rejection and infections.


  Thrombotic Microangiopathy After COVID-19 Infection in Pregnancy Top


P Lakshmi Aishwarya, Ram, V Siva Kumar, M Murali, N Prasanna, Mathini, Alekhya, Maria

Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India

E-mail: [email protected]

BACKGROUND: Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury. The important causes of TMA in pregnancy are preeclampsia, HELLP syndrome, thrombotic thrombocytopenic purpura, hemolytic–uremic syndrome, and catastrophic antiphospholipid syndrome. TMA has been associated with a wide range of infections. Few case reports of TMA in patients with COVID-19 were reported.

AIM OF THE STUDY: We report a patient of TMA after COVID-19 infection in a pregnancy.

METHODS: A 26-year-old female with no comorbidities, primigravida presented at 32 weeks period of gestation with severe abdominal pain and bleeding per vaginum. Postdelivery patient developed acute kidney injury and had to undergo hemodialysis.

RESULTS: The patient underwent renal biopsy on day 14 in view of nonresolving acute kidney injury. It was suggestive of chronic TMA. The patient had renal-limited TMA with no systemic signs and symptoms. 6 sessions of plasmapheresis were done. ADAMTS 13 levels were normal and complement workup was also normal. The patient had no recovery of renal function and was continued on hemodialysis.

CONCLUSIONS: In our patient, COVID-19 infection in pregnancy could be the trigger for development of TMA. COVID-19 being a novel virus, enough evidence is not available to know the definite effect of this virus during pregnancy.


  Protective Effects of Hygrophila Spinosa on Snake Venom-Induced Acute Kidney Injury Top


Aishwarya Aich, Pinaki Mukhopadhyay, Raghwendra Mishra

Department of Nephrology; NRS Medical College and Hospital; 1Department of Physiology; Ananda Mohan College; Kolkata; West Bengal; India

E-mail: [email protected]

BACKGROUND: Snakebite envenoming is a crucial health problem affecting millions of people worldwide. Acute kidney injury (AKI) is one of the major secondary complications of snake envenomation. Nowadays, herbal treatment is used in various studies to cure AKI. Hygrophila spinosa (kulekhara) is one such plant which is reported for its nephroprotective activity against drug-induced AKI. Hence, in this study, we have investigated whether H. spinosa can ameliorate snake venom-induced AKI.

AIM OF THE STUDY: The aim of the study is to investigate whether kulekhara leaf extract can ameliorate Russell's viper venom (RVV)-induced AKI in an experimental murine model.

METHODS: The adult male Swiss albino mice were randomly divided into three groups. Control group received intramuscular (i.m) normal saline. Venom-treated group received i.m RVV at a dose of 30ug/100g body weight. Treatment group received 30ug/100g body weight i.m RVV with kulekhara aqueous extract orally once daily until sacrifice. After 60 h, animals were sacrificed and blood and urine were collected. Plasma creatinine, blood urea nitrogen (BUN) and urinary creatinine, and microprotein and urinary strip test were studied for the determination of kidney injury status. Renal histopathological investigation was also carried out. Inflammatory and stress parameters including total count (TC) and differential count (DC) of WBC, nitric oxide (NO), oxidative stress index (OSI), reduced glutathione content (GSH), and thiobarbituric acid reactive substances (TBARS) were measured.

RESULTS: Kulekhara treatment showed significant alterations of snake venom-induced renal impairments. Renal structural and functional markers such as plasma creatinine, BUN, urinary creatinine, and urinary microprotein levels were restored toward normal after treatment. Urine strip test analysis showed significant reduction in hematuria and proteinuria with oral kulekhara supplementation. Histopathological analysis showed that kulekhara treatment significantly attenuated signs of venom-induced renal injury. Along with this, inflammation and stress parameters such as TC, DC, NO, GSH, TBARS, and OSI were significantly reduced in treatment group compared to the venom-injected group.

CONCLUSIONS: Finally, we can conclude H. spinosa has immense role in ameliorating snake venom-induced AKI by reducing systemic inflammation and oxidative stress levels.


  Effect of Therapeutic Plasma Exchange on Anti-Neutrophilic Cytoplasmic Antibodies in Patients of Anti-Neutrophilic Cytoplasmic Antibody-Associated Rapidly Progressive Glomerulonephritis Top


Archana Bajpayee, M Arun, Nitin Kumar Bajpai1, Aasma Nalwa2

Departments of Transfusion Medicine and Blood Bank; 1Nephrology and 2Pathology and Lab Medicine; All India Institute of Medical Sciences; Jodhpur; Rajasthan; India

E-mail: [email protected]

BACKGROUND: TPE is indicated in patients presenting with either advanced kidney failure (SCr >5.66 mg/dl) and those with diffuse alveolar hemorrhage. The rationale behind therapeutic plasma exchange (TPE) is to lower the antibody titer involved in the pathogenesis of ANCA-associated vasculitis. Cochrane systematic review showed that TPE may be effective in this disease, specifically in reducing the development of end-stage kidney disease (ESKD) by approximately 40%.

AIM OF THE STUDY: The aim of treatment is to remove ANCA autoantibodies and therefore interrupt disease progression.

METHODS: This was a single-center cohort study carried out from January 2019 to December 2020. The primary end point is to monitor the effect of TPE on ANCA titers in ANCA-associated RPGN. Informed consent from all the patient and institutional ethics committee approval were taken. All patients aged more than 18 years with ANCA-associated RPGN in whom TPE was indicated were included in the study. Patients with autoimmune diseases other than ANCA-associated RPGN and pregnant and breastfeeding patients were excluded. A total of 20 patients with ANCA-positive vasculitis were selected in which 6 patients were excluded as per noneligibility criteria. A total of 14 patients are finally included in the study, in which six patients underwent TPE and standard treatment. The remaining eight patients were in the control group in which they are not willing for TPE are treated with routine standard of care immunosuppressive therapy. Baseline investigations and renal biopsy were done before initiating TPE.

RESULTS: Histological characteristics are as follows: 18% of glomeruli are normal; 12% of glomeruli are fibrinoid necrosis; 48% of glomeruli are presented with crescents; 22% of glomeruli are globally sclerosed; and IFTA is 33.5%. A paired t-test was conducted to compare initial/preprocedure ANCA titer and postprocedure ANCA titer in patient's samples who underwent plasma exchange. There was no statistically significant difference between the titers; for pre-ANCA (mean [M] = 27.32; standard deviation [SD] = 22.61) and post-ANCA titer (M = 20.9; SD = 24.75);t(5) = 1.95 ; P = 0.109. These results suggest that plasma exchange is not significantly reducing ANCA titer.

CONCLUSIONS: Our study concluded that plasma exchange offers no benefit in clinical outcome of the patient. Since our study also observed that plasma exchange is not significantly reducing the ANCA titres, the rationale of using PLEX to prevent end-organ damage was not observed


  Scrub Typhus with Renal Involvement - A Single-Center Retrospective Study Top


Sanjay Kumar, Prawash Kumar Chowdhary, Sanjeev A Kale, Meena Patel

Department of Nephrology; Ramkrishna Care Hospital; Raipur; Chhattisgarh; India

E-mail: [email protected]

BACKGROUND: Very few cases of scrub typhus had been reported from Central India, especially from Chattisgarh. Infection such as scrub typhus is important cause of acute kidney injury (AKI), especially in tropics, and one of the differential diagnoses for fever with AKI.

AIM OF THE STUDY: The aim of the study to evaluate the occurrence, clinical and renal manifestation, and outcome of scrub typhus.

METHODS: This study was done in the Nephrology Department, Ramkrishna Care Hospital, from July 2019 to July 2021. A total of 37 patients were included in the study. These patients were diagnosed as scrub typhus detected by IgM ELISA test (titer >0.5) and AKI as per the KDIGO guideline. These patients were divided into AKI and non-AKI groups. Data collection was done from hospital records and statistical analysis was done.

RESULTS: Out of 37 patients, 25 were male and 12 were female, with a mean age of 47.15 ± 15.6. Fever was themost prevalent clinical presentation present in all patients, 32 (86%) patients had jaundice, 28 (75%) patients had myalgia, and 29 (78%) patients had nausea-vomiting and eschar was present only in 16% of patients. AKI was present in 15 (40%) of patients in which 33% (5 patients) had stage 1, 20% (3 patients) had stage 2, and 46% (7 patients) had stage 3 AKI. Stage 3 was most prevalent. In urinary abnormality, albuminuria by dipstick was most common followed by microscopic hematuria. Average creatinine value in patients with AKI was 2.69 ± 2.42. Patients with AKI had average of 8.76 ±3.52 days stay at hospital whereas without AKI had 5.84 ± 3.27 days.

CONCLUSIONS: Scrub typhus is prevalent in Chhattisgarh and one of the differential diagnoses for fever with hepatic and renal involvement.


  A Rare Case of Heparin-Induced Thrombocytopenia with Thrombosis in a Hemodialysis Patient Top


Kavitha Mudaliar, R Dilip, S Ramakrishnan, S Padmanabhan, Kiran Chandra Patro, R Ramprasad

Department of Nephrology; NU Hospitals; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: Heparin-induced thrombocytopenia with thrombosis (HITT) is a life- and limb-threatening complication of heparin exposure. It is more common in females above 50 years of age; patients undergoing cardiovascular surgeries; with a mortality of up to 30%. The risk is more with unfractionated heparin than low-molecular weight heparin. The diagnosis of HITT is made on a combination of clinical and laboratory parameters. Treatment necessitates stopping of heparin and considering alternate anticoagulation.

AIM OF THE STUDY: A rare case of HITT in a hemodialysis (HD) patient.

METHODS: A 66-year-old female, with a history of diabetes mellitus, hypertension, and chronic kidney disease (CKD) for the past 8 years on regular follow-up, presented with acute pulmonary edema. She was initiated on HD via right internal jugular vein (IJV) catheter. Her routine investigations showed hemoglobin - 9.3 g/dl and normal platelet count. The patient developed thrombosis of right IJV after 12 days of HD inititation. Hence, HD was continued via right femoral access which developed poor flow after 3 days. Repeat platelet count showed a drop in counts to 34,000/cumm; hence, she was suspected to have HITT. Heparin was discontinued and was given heparin-free HD; trisodium citrate was used for locking HD catheter. She was switched over to newer oral anticoagulant apixaban. Her anti-PF4 IgG level was elevated. Platelet count showed recovery to normal after 4 days of stopping heparin and the patient was counseled for peritoneal dialysis.

RESULTS: The patient is stable and on regular follow-up with a creatinine of 7.5 mg/dl on conservative management of CKD and a platelet count of 188,000/cumm.

CONCLUSIONS: A high index of clinical suspicion is required in diagnosing HITT early to prevent mortality, reducing morbidity and limb loss.


  Myo-Inositol Oxygenase and Yes-Associated Protein in Community-Acquired Acute Kidney Injury Top


Jaskiran Kaur, Kajal Kamboj1, Prabhjot Kaur1, Jasmine Sethi1, Vivek Kumar1, Ashok Kumar Yadav

Departments of Experimental Medicine and Biotechnology and 1Nephrology; Postgraduate Institute of Medical Education and Research; Chandigarh; India

E-mail: [email protected]

BACKGROUND: Recent report shows high serum levels of myo-inositol oxygenase (MIOX) in patients with acute kidney injury (AKI) and may serve as early biomarker in the diagnosis of AKI. Beside MIOX, a recent study found an increased expression of yes-associated protein (YAP) in renal proximal tubule cells in patients with diabetic nephropathy. YAP plays an important role in epithelial cell regeneration during kidney recovery from AKI. However, it remains unclear whether MIOX and YAP are suitable biomarker for the diagnosis of community-acquired AKI (CA-AKI).

AIM OF THE STUDY: To investigate the association of MIOX and YAP with CA-AKI.

METHODS: In this prospective observational study, stable patients of either sex, aged between 18 and 70 years, with no underlying CKD, and with CA-AKI were enrolled at discharge from hospital. Similarly, healthy volunteers of either sex, aged >18 years, with stable clinical state were enrolled as a healthy control group. Levels of urinary and serum biomarkers –MIOX and YAP – between patients with CA-AKI at discharge and healthy volunteers were compared.

RESULTS: A total 124 subjects with CA-AKI and 50 healthy volunteers were enrolled. We found serum MIOX levels (3224 pg/mL; interquartile range [IQR] 2304.2–4381.5 versus 1362.5 pg/mL; IQR 1166.0–1619.7; P < 0.001) and YAP levels (917 pg/mL; IQR 337.2–1682.5 versus 127.8 pg/mL; IQR 52.1–252.5; P < 0.001) significantly higher in CA-AKI as compared to healthy control group. Further, the levels of urinary MIOX (1560.7 ng/mg; IQR 924.8–2494.1 versus 1023.7 ng/mg; IQR 528.7–1311.6; P < 0.001) and YAP (326.1 pg/mg; IQR 204.0–553.0 versus 274.5 pg/mg; IQR 151.3–382.5; P = 0.004) normalized to urinary creatinine were found to be significantly higher in CA-AKI as compared to healthy control. Receiver operating characteristic analysis shows that the area under the curve (AUC) values were 0.922 (95% confidence interval [CI] 0.873–0.971; P < 0.001) for serum MIOX; 0.709 (95% CI 0.619–0.798; P < 0.001) for urine MIOX/creatinine; and 0.864 (95% CI 0.804–0.925; P < 0.001) for serum YAP.

CONCLUSIONS: The levels of MIOX and YAP are high in subjects with of CA-AKI and may serve as a potential biomarker for the diagnosis of CA-AKI. Further research is needed for the evaluation of the potential use of MIOX and YAP as a kidney-specific biomarker in the early diagnosis of AKI.


  Outcome of Advance Renal Failure Patients not Opting for Renal Replacement Therapy and Factors Determining Their Survival Top


Chandan Kumar, Amresh Krishna, Om Kumar, Pritpal Singh, Prajit Mazumdar

Department of Nephrology; Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India

E-mail: [email protected]

BACKGROUND: Many patients with end-stage renal disease opt not to undergo dialysis for various reasons. However, little is known about the prognosis of these patients in terms of survival. We evaluated the outcomes of these patients with end-stage renal disease not opting for dialysis and also evaluated the factors determining their survival.

AIM OF THE STUDY: The factors determining survival of patients in different group who did not opt for dialysis were evaluated.

METHODS: It was a prospective cohort study done on 51 patients presenting with end-stage renal disease in the Department of Nephrology of IGIMS who opted not to undergo dialysis. Study population was divided into groups based on age band and defined group intervals and follow-up was done for a minimum of 6 months.

RESULTS: The median age of the study population was 45.5 ± 7.5 years, comprising predominantly males (70%). Out of 51 patients, 33 (64.7%) patients died during the follow-up period. The most common primary cause of kidney disease was diabetic kidney disease in 16 patients (31.3%). Study population was divided into three groups based on age: 18–39 years, 40–59 years, and >60 years. The number of patients who died was almost similar between the three age groups (P = 0.33). On univariate analysis, serum creatinine at baseline (P = 0.01), serum potassium at baseline, anemia at baseline and on follow-up, low serum albumin, and SCG score were the factors that affected survival of patients. However, on multivariate analysis, it was found that persistent anemia in follow-up and SCG score were the most important factors associated with mortality.

CONCLUSIONS: Patients who do not undergo dialysis have a poor prognosis. Serum creatinine at baseline, hyperkalemia, and anemia further increase the chances of mortality in these patients; hence, conservative management should aim to correct these parameters so as to prolong survival in these patients.


  Coexistence of Hemolytic–Uremic Syndrome with Acute Pancreatitis: “;The Dilemma Of Double Trouble” - An Analysis of Four Cases and Review of Literature Top


S Harshita, D S Bhadauria, A Kaul, N Prasad, M R Patel, R S Khushwaha, M R Behera, M Yachha

Department of Nephrology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Thrombotic microangiopathy (TMA) is a pathological description which presents clinically as microangiopathic anemia, thrombocytopenia, and organ damage. TMA can be classified on the basis of the underlying etiology such as ADAMTS13 deficiency (TTP), complement dysregulation (acute hemolytic–uremic syndrome [aHUS]), and secondary TMAs. There is a paucity of literature on the equivocal coexistence of HUS and AP, ranging from case reports to a few case series.

AIM OF THE STUDY: We hypothesize that there are multiple pathogenic mechanisms for this coexistence which might have different clinical presentation and outcomes.

METHODS: An analysis of 41 patients from literature and four patients from our institute with acute pancreatitis (AP) and TMA was done. We studied the chronology of the symptoms, their correlation with each other, underlying etiology, its management, and outcomes.

RESULTS: Our series had 4 young male patients aged between 13 and 22 years, who had AP of unknown etiology. Time of onset of symptoms involving two organs varied from few hours to few days. The cause of coexistence in three patients was a part of primary TMA involving pancreas and kidneys, and in one patient, AP caused secondary HUS. Intensive workup for the underlying etiology of TMA was done for three patients, which revealed anti-CFH antibody titers, inherited complement dysregulation, and MMACHC mutation related to cobalamin deficiency. All patients had stage 3 acute kidney injury (AKI). They received 5–6 cycles of plasmaphresis. Two patients had full recovery of renal function and two had partial recovery, attributing to recurrent episodes of pancreatitis in these patients. After reviewing the literature, three types of coexistence of HUS and AP are highlighted in this report: (1) Type 1 – AP-associated secondary HUS; (2) Type 2 – HUS triggered by AP; and (3) Type 3 – TMA associated with HUS and AP.

CONCLUSIONS: The coexistence of AP and HUS gives a dilemma about the index event; hence, it obscures the understanding of the pathophysiology, management, and prognosis of the disease. To make an appropriate approach to the inciting event seems to be the need of hour which is highlighted in this series.


  A Rare Report of Thymomaassociated Myasthenia Gravis Presenting as Steroid-Resistant Nephrotic Syndrome Top


Sutanay Bhattacharyya, Himansu Sekhar Mahapatra

Department of Nephrology; Dr. Ram Manohar Lohia Hospital; Delhi; India

E-mail: [email protected]

BACKGROUND: Association of minimal change disease (MCD) with myasthenia gravis (MG) may be related to the common pathophysiology of T cell dysfunction, with occurrence being quite rare (<1%). Thymoma is a rare mediastinal tumor having associations with different paraneoplastic syndromes, one of which is myasthenia gravis.

AIM OF THE STUDY: Here, we present a rare case report of early presentation of steroid-resistant nephrotic syndrome following diagnosis of thymoma-associated MG that responded to tacrolimus therapy.

METHODS: A 27-year-old male presented with dysarthria, dysphagia, and quadriparesis for 1 month. In suspicion of MG, acetylcholine antibodies turned out to be positive. He also had an electrodiagnostic test performed which showed decremental response of more than 10%. Radiological evaluation showed the presence of thymic mass. It was resected, and histopathological evaluation was conclusion of fibrocystic thymoma. 3 months later, he presented with anasarca, and on investigation, he was found to have dyslipidemia, hypoalbuminemia, and nephrotic range proteinuria. In view of nephrotic syndrome and normal-sized kidneys on ultrasonography, he underwent an uncomplicated renal biopsy. Renal biopsy report was suggestive of MCD.

RESULTS: After diagnosis of MG, he was started on pyridostigmine 60 mg four times a day, prednisolone 60 mg/day with tapering dose, and azathioprine 100 mg/day. His symptoms improved over the next couple of months. When he was found to have minimal change disease, later on, his prednisolone dose was increased to 60 mg/day. He was subsequently discharged. On follow-up after 2 months, his lower limb swelling had decreased with decreased proteinuria (2.2 g/day). However, on subsequent visit, couple month later, his proteinuria was persistent (3 g/day) and reappearance of swelling of both lower limbs. In view of this, he was labeled as steroid resistant and started on second-line therapy calcineurin inhibitors – tacrolimus at a dose of 0.05 mg/kg/day. Subsequent visits 1 and 2 months later, his proteinuria had decreased to 670 and 236 mg/day. He was labeled as in remission with continuation of tacrolimus.

CONCLUSIONS: Our patient developed MCD within 4 months of thymectomy. Other cases showed late onset after 10 years. In spite of its rarity, clinicians should keep in mind the association between MCD and MG; the delayed presentation of MCD after MG diagnosis and that MCD may present as steroid-resistant cases.


  Hypermagnesaemia, Maternal Quadriparesis, and Encephalopathy: A Case Report Top


Praveen Malavade, Kavitha1

Department of Nephrology; NU Hospital; Bengaluru; 1Shivamogganu Hospital; Shivamogga; Karnataka; India

E-mail: [email protected]

BACKGROUND: The incidence of any seizures due to different conditions is around 1%, with eclampsia being the most common cause in high-income countries. Initial treatment and prophylaxis of maternal seizures generally involve magnesium sulfate administration for prevention of recurrence, unless other causes, e.g., pre-existent epilepsy, are known. Compared to phenytoin, diazepam, and other anticonvulsants, magnesium sulfate has been shown to be superior in reducing incidence of recurrent eclamptic seizures.

AIM OF THE STUDY: (1) To highlight importance of adverse events associated with administration of often forgotten anion magnesium and (2) to make physicians familiar with pitfalls that may lead to magnesium sulfate overdosing.

METHODS: A 28-year-old female, G2P2 L1A0 detected preeclampsia at 24 weeks of gestation. She was placed on labetalol/long-acting nifedipine/aspirin 75 mg. At 34 weeks, he was brought to the emergency room with severe diffuse abdominal pain and intractable vomiting. BP was 250/150 mmHg; sinus tachycardia was 120/min. He was treated with antihypertensives (intravenous [IV] hydralazine and oral labetalol) and loading dose of IV magnesium sulfate 10 g for eclampsia prophylaxis was given. USG showed IUGR. 4 h after starting antihypertensives, BP remained persistently high. At this point, decision to perform LSCS was taken; a further 10 g IM of magnesium sulfate was given. 1400 g neonate was born and shifted to neonatal intensive care unit (ICU). The patient was continued on antihypertensives and magnesium sulfate was continued as 5 g every 4 h on alternate buttocks IM. 12 h post-LSCS, the patient became drowsy with GCS of 11/15. It was also noticed that patient was unable to move her all the extremities. Power was 0/5; with absent tendon reflexes.

RESULTS: Renal function was mildly reduced at admission (creatinine - 1.1). Hyperkalemia was ruled out as cause of quadriparesis (K - 3.5). She had rapid worsening in renal function (increased to 3.3 the next day); due to HELLP syndrome (deranged liver parameters, severe anemia, thrombocytopenia, and coagulopathy). MRI brain was normal. She received PRBC and FFP transfusion. Serum magnesium was found to be 13.2 mg/dl. She was treated with injection calcium gluconate and shifted to ICU. In view of quadriparesis, encephalopathy, severe hypermagnesemia, and AKI, the patient was taken up for dialysis. Postdialysis, the patient became conscious and oriented (GCS of 15/15). She had regained power (5/5) in her extremities. Repeat Mg+ 2 levels were 7.49. An additional session of dialysis was done. Subsequently, her renal function improved and magnesium levels declined. At end of the 2nd week, she had recovered from AKI (creatinine - 0.76) and magnesium levels were 1.8. Hypertension persisted till the last follow-up (end of 6th week).

CONCLUSIONS: The case presented emphasizes the fact that magnesium sulfate is not only a useful but also a potentially dangerous drug. Although rare, it may be lead to life-threatening complications. Close monitoring may guide clinicians toward appropriate use of this drug.


  Diabetic Fibrillosis: Is it Really an Innocent Bystander?? Top


Prajit Mazumdar, Om Kumar, Amresh Krishna, Pritpal Singh, Chandan Kumar

Department of Nephrology; Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India

E-mail: [email protected]

BACKGROUND: Diabetic fibrillosis was first described by Sohar et al. in 1970 as non-Congophilic PAS-positive fibrils of 10 nm size in patients with diabetic nodular lesions. Previously, diabetic fibrillosis had importance only in differentiation from other fibrillary glomerulopathies and had no prognostic significance. However, it needs to be differentiated from other fibrillary glomerulopathies as it may have a different disease-specific clinical and therapeutic implication.

AIM OF THE STUDY: To assess the different clinical course and outcome in our reported cases than the previously reported cases of diabetic fibrillosis.

METHODS: We report here two cases of diabetic fibrillosis which had a different clinical course and outcome than the previously reported cases of diabetic fibrillosis.

RESULTS: Case 1: A 70-year-old male with diabetic mellitus and hypertension for 20 years presented with fever, decreased urine output, and renal dysfunction (dysfx), for which he received five sessions of intermittent hemodialysis. Renal function improved, but serum creatinine remained above 4.0 mg/dl even after 21 days. Renal biopsy was done which was suggestive of diabetic fibrillosis. Renal function, however, gradually declined and became dialysis dependent, and he died of AMI within 8 months of follow-up. Case 2: A 55-year-old male with hypertension presented with worsening edema for 1 month, nephrotic range proteinuria (8 g/day), and renal dysfx. Fundus showed no evidence of NPDR and renal biopsy was done which was suggestive of diabetic fibrillosis. Clinical follow-up: The patient was managed conservatively. Renal function rapidly declined to end-stage renal disease and the patient became dialysis dependent. The patients died within 6 months due to cardiovascular complications.

CONCLUSIONS: Diabetic fibrillosis is a distinct disease entity from other fibrillary glomerulopathies with different clinical significance. Hence, it needs to be differentiated from other fibrillary glomerulopathies and also from nonspecific glomerulosclerotic mesangial deposits of no significance.


  Long-Term Benefits of Preserved Graft Functions After Late Withdrawal of Calcineurin Inhibitors in Live Donor Kidney-Transplant Recipients Top


Girish Narayen, Anuradha Raman1, Ratan Jha2, G Swarnalata3

Division of Nephrology; Udai Omni Hospital, 1Sunshine Hospital, 2Virinchi Hospital; 3Apollo Hospital; Hyderabad; Telangana; India

E-mail: [email protected]

BACKGROUND: With the use of calcineurin inhibitors (CNIs) and induction therapy, graft survival has reached over 90% at 1 year. Despite short- and medium-term improvement, long-term graft survival has not shown proportionate improvement. There is debate about role of CNI-induced nephrotoxicity and long-term graft dysfunction, and there is no uniformity in renal outcome after CNI minimization or withdrawal 1 year after transplantation, especially in live donor transplants and well-matched kidneys.

AIMS OF THE STUDY: These retrospective data analyze the long-term outcome of patient and graft survival after CNI withdrawal from triple-drug therapy of CNI, prednisolone, and azathioprine/mycophenolate mofetil.

METHODS: Twenty-two adults (M:F - 16:6) who had kidney from live donor and no rejections with stable renal function at 1 year after transplant were evaluated in this retrospective study. Six recipients for financial reasons opted for CNI withdrawal, done over 8 weeks. In the transition period, prednisolone and azathioprine dose were stepped up. In another 12 patients, CNI was withdrawn over 1–2-year posttransplantation for gradually rising serum creatinine. In the remaining 4 patients, CNI was withdrawn after graft biopsy revealed no evidence of rejection and histological changes, suggestive of CNI toxicity, 48–140 months (mean 90 ± 40) after transplant. Patients were followed up regularly for estimation of renal functions and to look for any complications and long-term survival.

RESULTS: Withdrawal of CNI after 12 months and even in the late withdrawal did not result in graft rejection and all patients tolerated the intervention well. At the time of early withdrawal at 12 months, in 6 patients (Group A), serum creatinine ranged from 1.12 to 1.6 mg/dl (mean 1.28 ± 0.16) and eGFR of 65.16 ± 12.81 ml/mt. In 12 patients (Group B) in whom CNI was withdrawn between12 and 24 months, serum creatinine ranged from 1.3 to 1.75 mg/dl (mean 1.51 ± 0.15) and eGFR 56.16 ± 7.1 ml/mt. In remaining 4 patients (Group C) who had evidence of toxicity, CNI was withdrawn 48–140 months after transplantation. Their serum creatinine was 1.3–1.75 mg/dl (mean 1.57 ± 0.19) and eGFR 47 ± 7.63 ml/mt. At the end of follow-up ranging from 60 to 348 months (mean 170 ± 72 months), all the patients had well-preserved renal functions with their mean GFR of 65, 56, and 47 ml/mt in the respective group with serum creatinine1.02–5.2 mg/dl (mean 1.86 ± 0.99). There were 9 deaths over a follow-up of 82–300 months (mean 200 ± 75.2) months. Three patients had developed carcinoma tongue, of whom one had achieved prolonged remission after therapy. During follow-up, this patient and two others reached ESRD and were initiated on hemodialysis. Cardiovascular events in 3 and infections in other 2 patients accounted for their mortality.

CONCLUSION: Recipients who had received kidney from live donors with at least 1 haplo match and who did not have rejections in the 1st year after transplant had excellent long-term graft survival with 2 drugs only after CNI withdrawal. In selected live donor transplant recipients who do not have rejection in the 1st year, calceinurin inhibitors can safely be withdrawn at least 1 year after transplant which helps in ameliorating CNI-induced renal injury and prevents further deterioration of renal functions. In patients with graft dysfunction with histological features of CNI toxicity, this beneficial effect of CNI withdrawal can sometimes be seen even many years after transplantation.


  A Case of Paroxysmal Nocturnal Hemoglobinuria with Hemosiderin Tubulopathy-Induced Acute Kidney Injury Top


Tushar Gupta, Dhananjai Agrawal, Rakesh Gupta, Vinay Malhotra, Pankaj Beniwal, Shashank Bhardwaj, Seetaram Singh, Shubham Agrawal, Megha Agrawal

Department of Nephrology; Sawai Man Singh Medical College and Hospital; Jaipur; Rajasthan; India

E-mail: [email protected]

BACKGROUND: Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired chronic disorder characterized by a triad of clinical features - hemolytic anemia, pancytopenia, and thrombosis. PNH has an estimated prevalence of 1–1.5 patients per million populations. Acute tubular necrosis (ATN) and thus acute kidney injury (AKI) due to PNH probably result from hemoglobin (Hb)-mediated toxicity on renal tubules due to hemolysis. Timely diagnosis and management of PNH will prevent progression of kidney disease.

AIM OF THE STUDY: To assess the cause of AKI in a patient with hemolytic anemia.

METHODS: Case description: A 39-year-old male with no comorbid illness presented with a history of right lower limb swelling for the last 15 days; as well as vomiting and decreased urine output with dark-colored urine for the last 4 days. He was diagnosed with anemia 5 months back when he developed generalized weakness, fatiguability, and dyspnea on exertion and was found to have Hb 5.7 mg/dl; peripheral smear showed dimorphic picture. On clinical examination, he was afebrile with regular pulse rate at 90 beats/min and blood pressure of 130/90 mm Hg. He had moderate pallor and right lower limb swollen. Review of his systems was normal.

RESULTS: Investigations revealed severe anemia (Hb 5.5 g/dl) with evidence of hemolysis. Doppler of right lower limb showed right popliteal and posterior tibial vein thrombosis. Hb electrophoresis and glucose 6 phosphate dehydrogenase levels were normal. Bone marrow was hypercellular with erythroid predominance. Flow cytometry was performed using gating antibodies and diagnosis of PNH was made. In view of advanced renal failure and oliguria, he underwent HD through a double lumen uncuffed right internal jugular vein HD catheter. Renal biopsy was suggestive of hemosiderin-induced tubulotoxicity with ATN. There was no evidence of vascular thrombosis. He showed improvement over 9 days and became dialysis independent. His serum creatinine came down to 1.1 mg/dL, and he had good diuresis at 2.5 L/day.

CONCLUSIONS: It is important that any patient with history of vascular thrombosis; evidence of hemolytic anemia and AKI should be evaluated for PNH. Even in the absence of visible hemoglobinuria, PNH is an important cause of reversible AKI.


  A Case of Dialysis-Dependant Oxalate Nephropathy Post ROUX-EN-Y Gastric Bypass in Carcinoma Stomach Top


Kumari Monika, Sanjeev V Nair, Karthikeyan Balasubramanian

Department of Nephrology; Saveetha Medical College and Hospital; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Oxalate nephropathy is a rare but important cause of acute and chronic kidney disease. Secondary hyperoxaluria may be because of (i) increased intake of dietary oxalate or oxalate precursor (such as ethylene glycol or ascorbic acid); (ii) fat malabsorption (chronic pancreatitis, pancreatectomy, Roux-en-Y gastric bypass surgery, short bowel syndrome, Crohn's disease); and (iii) decreased intestinal oxalate degradation secondary to reduced intestinal colonization with Oxalobacter formigenes.

AIM OF THE STUDY: To analyze the case to understand the need for early diagnosis and management and to prevent long-term adverse renal and patient outcome.

METHODS: A 51-year-old male patient came with complaints of vomiting, persistent hiccups, and decreased urine output for the last 1 week with a history of recent subtotal gastrectomy with Roux-en-Y gastric bypass 3 months back. He had a history of recurrent vomiting, loss of appetite, pain abdomen, and steatorrhea with normal baseline renal function in perioperative evaluation and follow-up. He was evaluated and found to have severe anemia with acute kidney injury with urine examination 2+ proteinuria with bland urinary sediments, with no evidence of obstruction or abnormality in USG KUB and CT whole abdomen plain. He was initiated on hydration and symptomatic therapy; however, renal parameters did not improve. He was initiated on hemodialysis and renal biopsy done with no postbiopsy complication.

RESULTS: Renal biopsy report was suggestive of acute tubular injury with acute tubulointerstitial nephritis with intratubular oxalate crystal brightly birefringent on polarizing microscope with IFTA 5%–10%. Immunofluorescence was negative. He was started on hydration, calcium supplementation, and dietary modification; however, renal parameters did not improve and he is dialysis dependant.

CONCLUSIONS: Oxalate nephropathy secondary to post-Roux-en-Y gastric bypass is a well-known complication. We need to have high index of suspicion for early diagnosis and management to avoid CKD and dialysis dependency.


  Renal Cortical Necrosis in Transplant Patient with COVID Infection Top


E Indhumathi, B Karthikeyan, Sanjeev V Nair

Department of Nephrology; Saveetha Medical College and Hospital; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: The incidence of acute kidney injury has been reported to be higher in kidney-transplant recipients infected with SARS-CoV-2 compared with general population. The common renal biopsy findings of renal-transplant patients infected with COVID-19 are acute tubular necrosis (ATN) and acute rejection.

AIM OF THE STUDY: Here, we report a case of acute cortical necrosis in a COVID-19–positive renal-transplant patient.

METHODS: A 47-year-old male ABO-compatible renal-transplant patient with good graft function (baseline creatinine 0.9 mg/dl) for 17 years of duration got admitted with COVID-19 infection (CT score - 16/25). He was on triple immunosuppressive drugs (prednisolone 5 mg OD; cyclosporine 50 mg 1-0-1/2; and azathioprine 100 mg OD). On admission, serum creatinine was 2.7 mg/dl. CRP, D-dimer, and ferritin were elevated. Cyclosporine level was 79.5 ng/ml. CMV PCR was negative. He received injection methyprednisolone 125 mg IV for 3 days, 5 doses of injection remedesvir, and injection heparin 5000 units IV TDS. Azathioprine and prednisolone were stopped and tablet cyclosporine was continued. Next day, he became oliguric (creatinine - 6 mg/dl) and was initiated on hemodilaysis. There was no evidence of septic or ischemic ATN. Allograft Doppler was normal. He underwent renal biopsy which showed cortical necrosis and there was no evidence rejection in biopsy.

RESULTS: After 10 days, he was discharged with oral anticoagulant (tablet apixiban 2.5 mg 1-0-0) and a urine output 200 ml/day and remained dialysis dependent. He was on thrice weekly hemodialysis for a month and was on regular follow-up. When his urine output improved and creatinine showed downward trend, he was taken off dialysis and presently has a creatinine of 2.7 mg/dl. COVID infection is a prothrombotic state, and our patient developed RCN inspite on adequate anticoagulants. Data show that the common biopsy findings in renal-transplant patients with COVID infection are ATN, acute rejection, and TMA.

CONCLUSIONS: Cortical necrosis should be considered as a possible etiology for acute graft dysfunction with long-term graft deterioration in COVID patients.


  Chronic Kidney Disease Anemia: The Effectiveness of its Conventional Treatment and Association with Depression; A Survey-Based Study Top


Anusua Singh, Alfiya Yasmin, Pinaki Mukherjee1, Raghwendra Mishra2, Roshnara Mishra

Department of Physiology; University of Calcutta; 1Department of Nephrology; NRS Medical College and Hospital; 2Department of Physiology; Ananda Mohan College; Kolkata; West Bengal; India

E-mail: [email protected]

BACKGROUND: Chronic kidney disease (CKD), a worldwide public health issue, is a heterogeneous condition affecting the structure and function of the kidney. CKD patients generally suffer from iron deficiency anemia (IDA) and are simultaneously associated with depression. Several studies showed that depression is also evident in anemia. The conventional treatment for CKD anemia is erythropoietin or iron administration. However, the optimal management to cure CKD anemia and its association with depression still remain unclear.

AIM OF THE STUDY: The aim of this study is to observe the effectiveness of conventional treatment of CKD anemia and evaluate the impact of anemia on quality of life in dialysis-dependent CKD patients.

METHODS: To achieve our aim, a retrospective cross-sectional study was conducted in NRS Medical College and Hospital. The study was performed through a questionnaire-based survey with a face-to-face interview. A total of 42 patients participated voluntarily in this study. Inclusion criteria: Stage 5 CKD patients with hemodialysis and hemoglobin <12 gm/dl in female and <13 gm/dl in male were included in the study. Exclusion criteria: CKD patients with preexisting anemia and clinically diagnosed depression were excluded. Questionnaire: A predesigned questionnaire was used in this study which includes the following sections - socioeconomic condition, description of preexisting CKD and anemia, treatment for CKD and anemia, symptoms during dialysis, fatigue, and stress condition. All the data were analysed with appropriate parametric and nonparametric statistical tools using SPSS statistical software version 26. A P < 0.05 will be considered significant.

RESULTS: 40% of females and 60% of males participated in this study. 75% of the population belongs to the lower-middle-class strata. 58% of the population was found to be diabetic. From the survey study, it was found that IDA was evident in CKD patients as high plasma creatinine and low GFR were significantly associated with low hemoglobin levels. It was found that there was no significant improvement in anemia correction after administering erythropoietin-stimulating agent (ESA) or iron therapy in CKD patients. Fatigue; stress level, and depression were found to be significantly associated (P < 0.05) with CKD anemia.

CONCLUSIONS: It can be concluded that IDA was associated with CKD patients. After treatment with ESA or iron, IDA was not altered. Depression and associated symptoms were evident in CKD patients maybe due to the presence of anemia.


  Predictive Relation Between Estimated Glomerular Filtration Rate and Body Composition in Predialysis Chronic Kidney Disease Top


Prathiksha R Bhat, Asna Urooj

Department of Studies in Food Science and Nutrition; Manasagangotri; University of Mysore; Mysure, Karnataka; India

E-mail: [email protected]

BACKGROUND: A multitude of uremic symptoms, such as toxin accumulation, increased immune mediators, insulin resistance, and metabolic acidosis among others, leads to protein energy wasting in chronic kidney disease (CKD) patients. This accelerated muscle proteolysis prompts a decrease in muscle mass, predisposing the population to increased mortality and morbidity. Thus, assessing body composition to identify muscle wasting and changes in the fat compartment may have important implications for survival.

OBJECTIVES: The study aimed to assess various body composition parameters in predialysis CKD patients and to determine the relationship between the eGFR levels and the measured parameters.

METHODS: The study was conducted during January–March 2021 involving 40 patients (29 males and 11 females, aged: 30–80 years) with predialysis CKD. The multifrequency bioelectrical impedance analyzer, In Body 770, was used to measure various body composition parameters such as weight, body mass index, protein, minerals, total body water, extracellular water, intracellular water, percentage body fat (PBF), body fat mass, soft lean mass, fat-free mass, skeletal muscle mass, waist-hip ratio (WHR), visceral fat area, body cell mass, bone mineral content, fat-free mass index (FFMI), fat mass index, skeletal muscle index, and whole-body phase angle. The digital stadiometer BSM 170 was used to measure height. Serum creatinine levels were collected from the patients' clinical records and eGFR was calculated using the CKD-EPI creatinine equation (2009). Statistical analysis was done using SPSS 21.

RESULTS: The mean age and glomerular filtration rate of participants was 58.7 ± 12.2 years and 27.5 ± 16.7 ml/min/1.73 m2 respectively. As per BIA, 50% of the participants had low FFMI and 32.5% had low muscle mass. Classification of obesity by PBF 67.5% whereas only 57.5% were identified as obese by BMI. eGFR was positively and significantly correlated with weight (P = 0.022), WHR (P = 0.003), BFM (P = 0.05), VFA (P = 0.05), and phase angle (P = 0.006). eGFR was negatively and significantly correlated with the ratio of ECW to TBW (P = 0.013). Further, by multivariate regression analysis, it was noted that for every unit decrease in eGFR, weight decreased by 0.28 unit, BFM decreased by 0.20 unit, VFA decreased by 1.06 unit, and whole-body phase angle decreased by 0.02 unit, whereas changes in the ratio of ECW to TBW (negative correlation) and WHR were less than 0.001.

CONCLUSION: Low FFMI and low muscle mass were prevalent among predialysis CKD patients. Reductions in BFM, VFA, weight, WHR, and weight were related to eGFR decline. Meanwhile, reduction in eGFR was related to an increase in ECW:TBW suggesting a disruption in body water balance.


  An Observational Study of the Epidemiological, Clinical, and Laboratory Profile of Iga Nephropathy Top


Manjitpal Singh, H C Sreenidhi

Department of Nephrology; IMS BHU; Varanasi; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: IgA nephropathy is the most common glomerulonephritis in almost all parts of the world. However, there is no national glomerulonephritis registry in India. Most epidemiological studies on glomerulonephritis are single-center retrospective analyses of renal biopsy datasets.

AIM OF THE STUDY: To build up on the knowledge of primary IgA nephropathy in India by documenting the epidemiological, clinical, and laboratory spectrum of primary IgA nephropathy in the catchment area of IMS BHU.

METHODS: The study was conducted in the Department of Nephrology at IMS, Varanasi, India. All patients presenting to the nephrology department following history, clinical examination, and bedside urinary examination were screened for glomerular proteinuria or active sediments and planned for a renal biopsy and to participate in the study. All consenting patients were recruited before the renal biopsy procedure. Renal biopsy was done at SSH and reporting was carried out at subsidized rate at Dr Lal Path Labs due to nonavailability of DIF and EM facility at SSH. IgA nephropathy was diagnosed by the presence of IgA-dominant or codominant immune deposits within glomeruli, as shown by immunofluorescent staining of the renal biopsy tissue. The histological sections were reviewed along with the immunofluorescence findings, and the relevant clinical and laboratory data were then analyzed.

RESULTS: A total of 507 patients underwent renal biopsies; of these six patients were dropped due to loss to follow-up. Of the final 501 included, 101 had secondary glomerular disease (lupus nephritis 72; DN 11; secondary FSGS 6; secondary MGN 5; secondary amyloidosis 3; heavy chain disease 2; HSP 1; Fabry's disease 1); 18 had AKI; 4 had CIN; 2 had inconclusive biopsy; and 376 had primary glomerular disease. Out of 376 primary glomerular disease, disease distribution was: IgA GN in 96 (25.5%), an increasing trend in line with the previous studies; primary FSGS 95; primary MGN 55; podocytopathy 53; MPGN 19; C3GN 15; ANCA 15; DPGN 12; amyloidosis 10; anti-GBM 4; CIQ GN 2. In patients with primary IgAN, the sex ratio was 59 male:37 female. Most common presenting complaint was pedal swelling. The most common clinical presentation was nephrotic syndrome followed by chronic renal failure. IgA codeposition with C3 and lambda was the most common finding in the immunofluorescence study.

CONCLUSIONS: The high incidence of IgAN in our study is comparable with other reported series from India. The severe nature of clinical presentation can be explained by the fact that we do not have a proper policy for early detection of urinary abnormality to detect IgAN at early stage.


  A Case Series on Glomerular Diseases Following CORONAVIRUS-19 Vaccination with COVAXIN and COVISHIELD Top


U S Anaghashree, G Vijayshree, Budithi Subba Rao, K C Prakash, Rajagopalan Seshadri

Department of Nephrology; Apollo Main Hospital; Greams Road; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: The coronavirus 19 vaccination program in India with COVAXIN and COVISHIELD has reported an incidence of systemic adverse events following immunization (AEFI) to be <0.01%.Vaccination triggers an immune response and cytokine release which can produce new onset of glomerular disease or disease flare in predisposed individuals. There is an alarming increase in case reports describing development of minimal change disease and de novo glomerulonephritis in temporal association with COVID-19 vaccination.

AIM OF THE STUDY: We report a spectrum of glomerular diseases following COVID-19 vaccination comprising steroid-resistant MCD, relapse of FSGS, IgA nephropathy, anti-GBM disease, and P-ANCA glomerulonephritis.

METHODS: This is a single-center retrospective case series of five patients which reviews onset of glomerular diseases following vaccination with whole virion-inactivated COVAXIN and adenovirus vector-based COVISHIELD. The demographic details of patients, history of existing comorbidities, past history of COVID-19 infection, and baseline renal functions before covid 19 vaccination were retrieved. The details pertaining to dose and type of vaccination administered were obtained. The clinical details of temporal sequence of events leading to the onset of glomerular disease following vaccination were noted. The relevant laboratory investigations comprising renal function tests, urine analysis with urine protein creatinine ratio, anticytoplasmic antibody, and anti-GBM antibody titers were noted. The clinical findings, laboratory investigations, and renal biopsy consisting of light microscopy and immunofluorescence findings were analyzed. The presence of minor side effects and other systemic AEFI was documented.

RESULTS: The median age of presentation was 46 years, and the mean duration of onset of symptoms of glomerular disease following 1st dose or 2nd dose of vaccine was 10.6 days. 2 among 5 patients had received COVAXIN and 3 received COVISHIELD. 4 among 5 patients underwent a renal biopsy. 2 patients developed nephrotic syndrome. One had minimal change disease with acute kidney injury secondary to acute tubular necrosis. The other had prior FSGS (NOS) and was in clinical remission and now had a relapse of FSGS. 3 patients developed rapidly progressive glomerulonephritis with severe renal failure and initiation of hemodialysis. Renal biopsy revealed crescentic IgA nephropathy in 1 patient needing pulse cyclophosphamide and steroids. The second patient developed anti-GBM disease with elevated anti0GBM titers requiring plasma exchanges along with cyclophosphamide while the third patient had P-ANCA–associated necrotizing glomerulonephritis with cellular crescents requiring cyclophosphamide pulse with steroids.

CONCLUSIONS: The clinical and laboratory features noted in 5 patients in temporal sequence to thevaccination may propound a possible association between COVID-19 vaccine and occurrence of glomerular disease. However, further confirmation is necessary for establishing direct causation and biological plausibility.


  A Rare Case of Spine Mucormycosis in Chronic Hemodialysis Patient - Case Report Top


E Indhumathi, B Karthikeyan, Sanjeev V Nair, Ezhilarasi

Department of Nephrology; Saveetha Medical College and Hospital; Erode; Tamil Nadu; India

E-mail: [email protected] gmail.com

BACKGROUND: Infection is the most important cause for morbidity and mortality among chronic dialysis patient. Access-related infections are more common in dialysis patient followed by nonaccess-related infection. Fungal infection such as mucormycosis affecting spine is extremely rare.

AIM OF THE STUDY: Here, we report a case of spine mucormycosis in a hemodialysis patient.

METHODS: Case details: A 53-year-old female who is known case of diabetes, hypertension, and ESRD on thrice weekly maintenance hemodialysis for 7 years had presented with back pain for 1 month. The patient had a recent history of viral pneumonitis (COVID-19 PCR was Negative) 2 months back, which was treated with IV antibiotics. As patient had severe back pain in thoracolumbar region which is not improved with medication, further workup was done. MRI spine was done which showed heterogenous soft tissue seen in the prevertebral and paravertebral location from D8 to D10 vertebral level and infiltration of spinal cord from D8 to D10 vertebra with cord expansion.

RESULTS: Neurosurgery opinion was obtained and she underwent D8–D10 laminectomy with spinal stabilization and spine tissue was sent to histopathological examination. Biopsy was showing subacute necrotizing inflammation with osteomyelitis and features suggestive of invasive zygomycosis (mucormycosis). She was treated with amphotericin and posaconazole and her symptoms were improving. However, during the course of treatment, she had acute myocardial infarction followed by sudden cardiac arrest and she expired.

CONCLUSIONS: The infection at unusual sites can increase, especially in chronic dialysis patients. High vigilance in diagnosing and initiating early treatment may improve the morbidity and mortality in these patients.


  A Study of Outcomes of Paraquat Poisoning with AKI From A Tertiary Care Referral Hospital, South India Top


K Manu, Manjusha Yadla

Department of Nephrology; Gandhi Medical College; Hyderabad; Telangana; India

E-mail: [email protected]

BACKGROUND: Instestictide poisoning is commonly seen in our population as a suicidal attempt, among which paraquat poisoning and organophosphorus poisoning are known for high mortality. Paraquat posiosing is known to involve multisystem, especially lungs and kidney; this study was taken to study the effect of paraquat on kidney and the outcomes in paraquat posiosing with renal dysfunction.

AIM OF THE STUDY: To study the outcome of patients with acute kidney injury (AKI) following paraquat poisoning and role of RRT in patients with AKI.

METHODS: A retrospective observational study of 60 cases of paraquat poisoning with renal dysfunction from January 2019 to August 2021 referred to the Department of Nephrology, Gandhi Medical College, Secunderabad, were included in our study. Primary outcomes of the study are mortality, while secondary outcomes are renal recovery. Analysis was done regarding demographic parameters, initial presentation, need for ventillator support, indication, duration and outcomes of RRT, duration of hospital stay, and outcomes and cause of death.

RESULTS: In the study, there were 42 (70%) males and 18 (30%) females. Mean age of the population 27.32 ± 9.94 years. Suicidal – 52 (86.7%); accidental – 7 (11.7%). Clinical symptoms and signs: vomiting – 25 (41.7%); oral ulcer – 23 (38.3%); oliguria – 16 (26.7%); abdominal pain – 13 (21.7%); dysphagia – 8 (13.3%); and breathlessness – 4 (6.7%). Oliguric AKI was seen in 35 (58.78%), nonoliguria in 24 (39.52%), and anuria in 1 (1.7%) patient. Average duration of hospital stay was 7.77 ± 5.23 days. Mean serum creatinine at admission was 6.37 ± 2.49 mg/dl. Among these patients, 52 (86.7%) underwent HD, 2 (3.3%) patients were managed with both HD and PD, and 3 (5%) patients were managed with PD. No RRT was required in 3 (5%) patients. Out of the 66 patients, 25 (41.67%) required ventilator. 24 (40%) patients had liver/lung involvement; and 13 (21.7%) had both liver and lung involvement. Among the patients who were supported with RRT, 20 (33.3%) patients had complete renal recovery; 3 (5%) had partial renal recovery. Out of 60 patients, 22 (36.7%) had recovered, 38 (63.3%) patients expired.

CONCLUSIONS: Prevalance of paraquat AKI among all admissions was 1%. Prevalance of paraquat AKI among all paraquat admissions was 5%. Factors affecting mortality are amount of consumption, latency in referral, and MODS. Factors affecting renal recovery are presence of oliguria.


  ABOI Kidney Transplantation - The Known and the Unknown Top


Sanjay Kumar Sharma, Prawash Kumar Chowdhary, Sanjeev Anant Kale, Meena Patel

Department of Nephrology; Ramkrishna Care Hospital; Raipur; Chhattisgarh; India

E-mail: [email protected]

BACKGROUND: Thrombotic microangiopathy (TMA) is a debilitating complication of kidney transplantation that is associated with poor patient and graft outcomes. Posttransplant TMA can occur as a recurrence of the disease involving the native kidney or as de novo disease with no evidence of previous involvement before transplant.

AIM OF THE STUDY: Here, we describe a case of ABO-incompatible kidney transplantation (ABOiKT); developed posttransplant HUS and had multiple side effects of drugs. A 25-year-old young female underwent ABOiKT with her father as donor.

METHODS: CDC and flow cytometry cross-match were negative. Postoperative period was uneventful. On discharge, her UOP was 5 l and creatinine was 0.8 mg/dl. She was on triple maintenance immunosuppression. 3-month posttransplant, her graft function started deterioriating with pancytopenia. Bone marrow and viral studies were inconclusive. Graft biopsy was done, and postbiopsy, she developed hypotension. She was managed conservatively including PRBC. Biopsy was suggestive of TMA. 4 sessions of plasmapheresis were done. Then, she developed fever with SOB and decreased UOP. ECHO was suggestive of Takotsubo cardiomyopathy. RT-PCR for COVID-19 was positive. 2 sessions of hemodialysis were given. USG of graft showed moderate hydroureteronephrosis with collection adjacent to the graft. USG-guided aspiration was done. Double J (DJ) stent was placed and renal function started improving.

RESULTS: After 7 days, she developed fever with drop in UOP. Urine culture showed growth of MDR Pseudomonas and Klebsiella. DJ stent was removed. She was managed with AVYCAZ and fosfomycin. She developed altered sensorium. EEG was suggestive of nonconvulsive status. AVACAZ was stopped and antiepileptic leviteracetam was given. Colistinin was added. She complained of difficulty in deglutination. Examination revealed decrease bilateral palatal movement. MRI brain was normal. Colistine-induced myasthenia gravis was suspected. Drug was stopped for 2 days; her complained improved. Colistin was again restarted in low dose along with fosfomycin. She improved; fever get subsided. Improvement in renal function and platelet count was seen. After 1 week of follow-up (f/u) noticed to have pancytopenia. Thought to be due to pantoprazole. It was stopped. Her TLC and platelet count improved. At present, she is on regular f/u and is on prednisolone (20 mg) and MMF (360 mg morning and 180 mg). Serum creatinine is 2.3 mg/dl.

CONCLUSIONS: Calcineurin inhibitor is an important cause of de novo posttransplant HUS. Immunosuppressive drugs need to be used meticulously in posttransplant period. Need to balance between risk–benefit ratio. Watchful in identifying the side effect of drugs.


  Nutritional Assessment and Appetite Variations in Maintenance Hemodialysis Population Top


G Geethanjali, V Priya Darsani, E Ramprasad, M Jayakumar

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Porur; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Malnutrition is defined as the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions. It is associated with higher mortality and morbidity risk in hemodialysis (HD) patients. Main causes include decreased nutritional intake, increased losses, and increase in protein catabolism. Low levels of serum albumin are highly predictive of poor clinical outcomes in all stages of CKD.

AIM OF THE STUDY: To compare the nutritional status, patients' characteristics, and lack of appetite on MHD patients and to assess the lack of appetite in HD patients using the council on nutrition appetite questionnaire (CNAQ).

METHODS: The study was conducted at the Dialysis Unit of Department of Nephrology, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai, involving 180 patients on HD. ESRD patients aged <75 years on MHD for more than 3 months were considered for the study. Patients with AKI and on PD have been excluded from the study. Nutritional indicators such as albumin, creatinine, and BMI along with Kt/V were measured. The baseline survey included participant's characteristics (e.g., sex; height; weight and comorbid conditions) and a CNAQ. A score of less than 28 was a cause for concern. The results of the study were analyzed using SPSS software. The data were expressed in percentage, mean, and standard deviation; P < 0.05 was considered statistically significant.

RESULTS: Out of 180 patients, 10 (5.6%) participants had BMI below 18, 93 (51.7%) had BMI between 18 and 24, 54 (30%) had BMI between 25 and 30, and 23 (12.8%) had BMI more than 30. 136 (75.6%) patients were on twice weekly dialysis and 44 (24.4%) patients were on thrice weekly dialysis. 78 (53.3%) patients were on dialysis for more than 1.5 years; 65 (36.1%) patients for 1.5–3.5 years, and 37 (20.6%) patients for more than 3.5 years. 68 (37.8%) patients had Kt/V less than 1.2; 90 (50%) patients had Kt/V between 1.2 and 1.4; and 22 (12.2%) patients had Kt/V more than 1.4. 42 (23.3%) patients had albumin less than 3.4, 91 (50.6%) had between 3.4 and 4, and 47 (26.1%) had more than 4. Out of 180 participants, 18 patients (10%) had a CNAQ score between 8 and 16; 112 (62.2%) had a score between 17 and 28, and 50 (27.8%) had a score more than 28. Serum albumin was found to be associated with CNAQ score (P < 0.05).

CONCLUSIONS: Albumin is a direct predictor of mortality among patients on HD. We observed that the albumin is the major indicator for the association between the nutrional status and lack of appetite. Longitudinal study with larger sample size may require to ascertain the significance of above findings.


  A Study Association Between the Patient Characteristics, Nutritional Status, and Lack of Appetite on Maintenance Hemodialysis Patients Based on a Council on Nutrition Appetite Questionnaire Top


G Geethanjali, V Priya Darsani, E Ramprasad, M Jayakumar

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Porur; Chennai; Tamil Nadu; India

E-mail: [email protected] com

BACKGROUND: Malnutrition is defined as the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions. It is associated with higher mortality and morbidity risk in hemodialysis (HD) patients. Main causes include decreased nutritional intake, increased losses, increase in protein catabolism. Low levels of serum albumin are highly predictive of poor clinical outcomes in all stages of CKD.

AIM OF THE STUDY: To compare the nutritional status, patient's characteristics, and lack of appetite on MHD patients and to assess the lack of appetite in HD patients using the council on nutrition appetite questionnaire (CNAQ).

METHODS: The study was conducted at the Dialysis Unit of Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai, involving 180 patients on HD. ESRD patients aged <75 years on MHD for more than 3 months were considered for the study. Patients with AKI and on PD have been excluded from the study. Nutritional indicators such as albumin, creatinine, and BMI along with Kt/V were measured. The baseline survey included participant's characteristics (e.g., sex, height, weight, and comorbid conditions) and a CNAQ. A score of less than 28 was a cause for concern. The results of the study were analyzed using SPSS software. The data were expressed in percentage, mean, and standard deviation; P < 0.05 was considered statistically significant.

RESULTS: Out of 180 patients, 10 (5.6%) participants had BMI below 18, 93 (51.7%) had BMI between 18 and 24, 54 (30%) had BMI between 25 and 30, and 23 (12.8%) had BMI more than 30. 136 (75.6%) patients were on twice weekly dialysis and 44 (24.4%) patients were on thrice weekly dialysis. 78 (53.3%) patients were on dialysis for more than 1.5 years, 65 (36.1%) patients for 1.5–3.5 years, and 37 (20.6%) patients for more than 3.5 years. 68 (37.8%) patients had Kt/V less than 1.2, 90 (50%) patients had Kt/V between 1.2 and 1.4, and 22 (12.2%) patients had Kt/V more than 1.4. 42 (23.3%) patients had albumin less than 3.4, 91 (50.6%) had between 3.4 and 4, and 47 (26.1%) had more than 4. Out of 180 participants, 18 patients (10%) had a CNAQ score between 8 and 16, 112 (62.2%) had a score between 17 and 28, and 50 (27.8%) had a score more than 28. Serum albumin was found to be associated with CNAQ score (P < 0.05).

CONCLUSIONS: Albumin is a direct predictor of mortality among patients on HD. We observed that the albumin is the major indicator for the association between the nutritional status and lack of appetite. Longitudinal study with larger sample size may require to ascertain the significance of above findings.

A CASE OF DIALYSIS-DEPENDANT OXALATE NEPHROPATHY POST-ROUX-EN-Y GASTRIC BYPASS IN CARCINOMA STOMACH WITH BILE LEAK

Kumari Monika, Sanjeev V Nair, Karthikeyan Balasubramanian

Department of Nephrology; Saveetha Medical College and Hospital; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Oxalate nephropathy is a rare but important cause of acute and chronic kidney disease. Secondary hyperoxaluria may be because of increased intake of dietary oxalate or oxalate precursor (such as ethylene glycol or ascorbic acid); (ii) fat malabsorption (chronic pancreatitis, pancreatectomy, Roux-en-Y gastric bypass surgery, short bowel syndrome, Crohn's disease); and (iii) decreased intestinal oxalate degradation secondary to reduced intestinal colonization with Oxalobacter formigenes.

AIM OF THE STUDY: To analyze the case to understand the need for early diagnosis and management and to prevent long-term adverse renal and patient outcome.

METHODS: A 51-year-old male patient came with complaints of vomiting, persistent hiccups, and decreased urine output for the last 1 week with a history of recent subtotal gastrectomy with Roux-en-Y gastric bypass 3 months back with history of bile leak for 2 months and taking only liquid fruit juice and soup-based diet. He had a history of recurrent vomiting, loss of appetite, pain abdomen, steatorrhea with normal baseline renal function in perioperative evaluation and follow-up. He was evaluated and found to have severe anaemia with acute kidney injury with urine examination 2+ proteinuria with bland urinary sediments, with no evidence of obstruction or abnormality in USG KUB and CT whole abdomen plain. His serum sodium, potassium, calcium, phosphorus, and uric acid were low. He was initiated on hydration and symptomatic therapy; however, renal parameters did not improve. He was initiated on hemodialysis and renal biopsy was done with no postbiopsy complication.

RESULTS: Renal biopsy report was suggestive of acute tubular injury with acute tubulointerstitial nephritis with intratubular oxalate crystal brightly birefringent on polarizing microscope with IFTA 5%–10%. Immunofluorescence was negative. He was started on hydration, calcium supplementation, and dietary modification, renal parameters improved; and urine output improved; however, still, he requires dialysis.

CONCLUSIONS: Oxalate nephropathy secondary to post-Roux-en-Y-gastric bypass is a well-known complication. However, risk is further increased if associated with bile leak and high oxalate-containing diet. We need to have high index of suspicion for early diagnosis and management to avoid CKD and dialysis dependency.


  Clinical Characteristics and Short-Term Outcomes of End-Stage Kidney Disease Patients Undergoing Hemodialysis with COVID-19 Infection in Madurai, South India Top


Benoy Varghese, Niranjan Raja, Arul Rajagopalan, Jegan Arunachalam, Rakesh Durai, Arun Prasath, Shiva Kumar, Shanmuganathan Velu

Department of Nephrology; Madurai Medical College; Madurai; Tamil Nadu; India

E-mail: [email protected]

AIM OF THE STUDY: The objective of this study is to describe the clinical characteristics and the short-term outcomes in end-stage renal disease requiring hospitalization for COVID-19 and who underwent hemodialysis.

METHODS: In this retrospective, observational, single-center study, we analyzed the clinical course and outcomes of 116 consecutive ESKD patients hospitalized with laboratory-confirmed COVID-19 who underwent atleast one hemodialysis session in our hospital between June 26 and August 10, 2020. Baseline clinical features, laboratory data, and treatment given were compared between survivors and nonsurvivors to identify risk factors associated with mortality.

RESULTS: Among the 116 patients, males constituted 81% (n = 94). Many had underlying comorbidities of which hypertension (90.4%) was the most common. The most common symptoms were fever (76.1%), dyspnea (61.2%), cough (58.6%), and diarrhea (18.1%). 66.4% of patients were having arteriovenous fistula or grafts. Patients in nonsurvivor group were associated with increased total count, neutrophil lymphocyte ratio, and serum potassium levels. Inflammatory markers such as CRP and serum ferritin were significantly higher in nonsurvivors group. Mortality was around 27.5% in our cohort.

CONCLUSIONS: Mortality among hospitalized ESKD patients who underwent hemodialysis was higher when compared to general population. Presence of comorbid conditions such as hypertension, diabetes mellitus, and preexisting pulmonary diseses were having poor prognosis


  There is a New Villain in the Transplant World - Experience of Pheohyphomycosis in Renal-Transplant Recipients Over a Decade Top


Kevin T John Keeppallil, Pallavi Prasad, M Jayakumar

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Porur; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Invasive fungal infections are an important cause of morbidity in renal-transplant recipients. Pheohyphomycosis is a rare fungal infection in transplantation. Although the incidence of infection in our study was much lower than that in a previously reported study from South India, the proportion of invasive fungal disease is much higher than that in the TRANSNET cohort where merely 2.6% of all invasive fungal infections in renal-transplant recipients were due to phaeohyphomycosis.

AIM OF THE STUDY: To estimate the prevalence and describe here the clinical features, treatment, and outcomes of pheohyphomycosis presenting in renal-transplant recipients at a tertiary care center in South India.

METHODS: A retrospective analysis was done of all patients who underwent renal transplantation at our center from 2010 to 2020. Cases of invasive fungal infection by pheohyphomycosis were identified by ICD code. A case of pheohyphomycosis was deand#64257;ned as a culture positive for a dematiaceous mold or histopathological evidence of a dematiaceous fungus plus clinical and#64257;ndings consistent with infection. Data regarding clinical presentation, pathological findings, microbiological findings, treatment, and outcome were analyzed. Acute graft dysfunction was defined as rise in creatinine >25% from baseline. Outcomes were defined as complete resolution of infection (disappearance of lesions and symptoms directly related to lesion), partial resolution (decrease in size or dissemination of lesion), relapse (re-occurrence of lesions after 3 months of therapy), or treatment failure (no change in size/dissemination of lesion despite 3 months of therapy or occurrence of new lesions within 3 months of therapy).

RESULTS: There were 32 invasive fungal infections with five cases of pheohyphomycosis. Incidence of pheohyphomycosis was 1.6% and it constituted 15% of all invasive fungal infections. Median time from transplantation was 510 days. Mean age was 48.8 years. 80% presented with cutaneous manifestations, 50% of whom had multiple cutaneous lesions. One patient had fungal rhinosinusitis. Comorbid conditions included acute graft dysfunction in 80%, diabetes mellitus in 20%, and CMV disease in 20%. Mean tacrolimus trough level was 13.1 ng/dl; mean mycophenolate dose was 1.15 g; and mean wysolone dose was 12 mg. Diagnosis was made on histopathological examination in 100% of cases and fungal stain was positive in only 20% of cases. All patients received antifungals and surgical intervention. Outcomes included complete resolution of infection in 60%; partial resolution in 20%; and mortality in 20% cases. All patients with complete surgical excision had recovery of graft dysfunction and complete resolution of infection.

CONCLUSIONS: Pheohyphomycosis is an emerging menace in the realm of renal transplantation. Microbiological and histopathological evaluation of lesions helps in establishing a diagnosis. Response to surgical excision is remarkable, but it should be accompanied by antifungal therapy in immunocompromised patients.


  Mucormycosis Experience in Renal-Transplant Patients with COVID-19 Infection Top


Ranjit Singh, Abhilash Chandra, S Namrata Rao

Department of Nephrology; Dr RMLIMS; Lucknow; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Mucormycosis, also known as black fungus, is a serious fungal infection, usually in people who are immunocompromised. The current pandemic of COVID-19 has been associated with various reports of mucormycosis from different regions of the world. The rising incidence of mucormycosis following COVID-19 illness has been attributed to use of steroids and other immunosuppressive, along with associated comorbidities such as diabetes mellitus.

AIM OF THE STUDY: To see the incidence of mucormycosis.

METHODS: This is observational case series, in which we follow the renal-transplant recipient who infected with COVID-19. A total of 19 recipients had coronavirus infection. 11 patients were having minimal-to-mold symptoms and were managed with symptomatic therapy at home. A total of 8 patients required hospital admission. Out of these 8 patients, 7 were admitted in intensive care unit (ICU), while one was admitted in high-dependency unit (HDU). All patients were managed with standard COVID-19 treatment protocol. Out of these 9 patients, 6 were succumbed to their disease and two were discharged with normal allograft function. One patient was tested negative for COVID-19 but suddenly developed altered sensorium with shock and died; her allograft postmortem biopsy revealed allograft mucormycosis. One patient developed sudden-onset diplopia with ptosis followed by altered sensorium. His nasal swab is tested positive for mucormycosis and his CT head findings were suggestive of mucurmycosis.

RESULTS: Out of 19 COVID-19–infected renal recipients, 11 patients were mildly symptomatic and were managed with symptomatic and supportive therapy and home isolation. 8 patients required hospitalization, out of which one was admitted in HDU and 7 were admitted in ICU at level 3 COVID hospital. Two patients are discharged from COVID-hospital with normal allograft function. Two cases were found to be infected from mucormycosis. In these two cases, the first case report of renal allograft mucormycosis complicating severe COVID-19 pneumonia; which as per our knowledge is the 1st reported case.

CONCLUSIONS: In these two cases; the first case report of renal allograft mucormycosis complicating severe COVID-19 pneumonia; which as per our knowledge is the 1st reported case. As there are no specific manifestations, treating physicians should remain aware of this possibility in such a setting.


  A Repeat Kidney Biopsy in a Patient with Acute Kidney Injury Top


Vipul Chakurkar, Sagar Kulkarni, Valentine Lobo

Renal Unit; KEM Hospital; Pune; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Kidney biopsy plays an important role in the management of acute kidney injury (AKI) due to clinically unidentified cause. We presented a case where a repeat biopsy helped us in managing the patient.

AIM OF THE STUDY: To present a case of repeat biopsy in AKI.

METHODS: We present a case where two kidney biopsies were done for diagnosis in AKI.

RESULTS: A 43-year-old gentleman, hypertensive on amlodipine and aspirin, presented in March 2021 with increasing dyspnea and oliguria for the past 2 days and no hematuria, nephrotoxic medicines, or systemic symptoms. Urine showed 4+ proteins; plenty RBC. With serum creatinine of 8.64 mg/dl, he required hemodialysis (HD). A kidney biopsy done on day 7 of the illness showed acute tubular injury (ATI), with normal glomeruli with no interstitial infiltrates. Due to oliguria, he continued HD 3/week. At 20 days of the illness, urine output was 500 ml and doubled over the next week. At 6 weeks, urine output was about 2 l, but he remained dialysis dependent with pre-HD creatinine = 8.2 mg/dl. A second biopsy was done in the 8th week for nonrecovery of AKI and showed recovering ATI and dense mononuclear infiltrates with plenty of eosinophils suggesting acute interstitial nephritis. After 1 mg/kg prednisolone, creatinine improved to 4.2 mg/dl and he was off dialysis by 9th week.

CONCLUSIONS: A repeat kidney biopsy should be considered in a patient if the course of AKI is atypical.


  Directly Acting Antiviral Agents in the Treatment of Hcv-Infected Hemodialysis Patients – 4-Year Experience From a Tertiary Care Hospital Top


Sreenidhi Chandrashekar; Shivendra Singh; Manjitpal Singh; Khushboo Rani

Department of Nephrology; Institute of Medical Sciences; Banaras Hindu University; Varanasi; Uttar Pradesh: India

E-mail: [email protected]

BACKGROUND: HCV infection in hemodialysis (HD) population is associated with poorer prognosis when compared with seronegative HD patients. HCV infection is associated with relative immunosuppression and requires multiple transfusions. In the last decade with the discovery of DAA, there has been significant change in management of HCV in HD patients. The current study was done to evaluate the safety and efficacy profile of DAA for HCV infection in HD patients at a tertiary care hospital.

AIM OF THE STUDY: To study the safety profile and efficacy of DAA in newly diagnosed HCV-infected HD patients in a teritiary care hospital.

METHODS: This was a retrospective study. Study period: 4 years; from October 2016 to October 2020. HD patients aged >18 years who were newly detected with HCV infection and followed up for a period of 6 months were included. Both cirrhotic and noncirrhotic patients were included. Patients with coinfection of HepB/HIV, prior malignancy, pregnant females, and not consenting for study were excluded. HCV quantification was done by real-time PCR, and HCV genotyping was done by PCR sequencing. Clinical, hematological, and biochemical data were collected at initiation of therapy and every month till the end of the study period. Transient elastographic data of liver for cirrhosis were collected. Quantitative RNA PCR values at 12 and 24 weeks were collected. Data on treatment regimens, adverse effects, requirement of blood transfusion, or additional EPO during therapy period were collected. SVR was defined as undetectable viral RNA with real-time PCR. Statistical analysis was done using SPSS software, and P < 0.05 was considered significant.

CONCLUSIONS: All DAA have good safety profile. At 12 weeks of therapy, SVR is similar between ledipasvir and velpatasvir in gen1 and daclatasvir and valpatasvir in gen3. In the resource-poor setting, where HCV genotyping is difficult, pangenotypic sofosbuvir 400 mg + velpatasvir 100 mg combination can be considered for therapy.


  Emphysematous Pyelonephritis: A 2-Year Experience from a Tertiary Care Center in South India Top


S Veenaa Manjari, E Indhumathi

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Emphysematous pyelonephritis (EPN) is an acute necrotizing infection of the renal parenchyma associated with gas formation. A majority of cases occur in patients with diabetes mellitus. In EPN, early aggressive medical treatment may avoid nephrectomy.

AIM OF THE STUDY: The aim of this study was to determine the prevalence of EPN, clinical characteristics, treatment modality, and the influence of prognostic factors on the outcome.

METHODS: This is a retrospective study done in emphysematous pyelonephritis patients admitted from December 2018 to December 2020. Among 738 patients with pyelonephritis, 49 had emphysematous pyelonephritis. We reviewed the hospital records of patients with EPN for clinical, laboratory, radiological, and microbiological findings; treatments given; and outcome. The severity of EPN was graded as per the Huang classification. Certain factors have been associated with poor outcome in EPN; these poor prognostic factors include thrombocytopenia; azotemia; shock (systolic blood pressure <90 mmHg) on initial presentation; need for emergency hemodialysis; severe hypoalbuminemia (serum albumin <3 g/dl); polymicrobial infections; and extension of infection to the perinephric space. We applied these reported prognostic factors to our patients and tried to find whether these factors correlated with failure of conservative treatment.

RESULTS: Majority of the study subjects were females (n = 67%). Mean age was 58 years. Extensive EPN (Class 3 or 4) was present in 28.6% of patients. Most were diabetics (93.9%). 16.3% of patients had bilateral disease. Left kidney was predominantly involved in 49% of patients. 26.5% had renal calculi. 75.3% of patients presented with acute kidney injury (AKI), 28.6% with shock, and 22.4% with thrombocytopenia. 93.8% of male patients presented with AKI (P = 0.025). 26.5% of patients required hemodialysis. Escherichia coli was the most common causative organism involved in 30.6% of cases. Renal function did not improve in hemodialysis requiring patients (P = 0.002) and patients presenting with AKI (P = 0.000); during hospital stay. Factors such as hypoalbuminemia, leukocytosis, and radiological grading were not significant with respect to recovery of renal function. Around 81.8% of our patients responded to minimally invasive procedure; one required nephrectomy. One patient died due to septic shock.

CONCLUSIONS: In this study; nearly all were diabetics. E. coli was the most frequently isolated pathogen. Most patients presented with AKI. Patients with AKI and requiring hemodialysis had poor prognosis. Aggressive and early treatment will salvage kidneys.


  An Intriguing Case of Hypercalcemia: A Case Report Top


S Veenaa Manjari, S Manikantan, E Indhumathi, M Jayakumar

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Vitamin D intoxication is rarely observed in clinical practice. It occurs due to inappropriate use of high doses of Vitamin D supplements and causes hypercalcemia. Clinical manifestations are nonspecific, and hence, identification may be difficult.

AIM OF THE STUDY: Detailed history-taking with particular attention to the medication details and dosing schedule will aid in diagnosis.

METHODS: A 38-year-old male was admitted with complaints of fever for 20 days; loss of weight and appetite for 1 month; and dysuria for 2 weeks. He was treated for COVID-19 q month back. General examination was unremarkable; no lymphadenopathy was noted. Systemic examination was normal. His laboratories showed anemia (Hb 8.8); leukocytosis (13; 260); hypercalcemia (calcium 14.2); and renal failure (creatinine 3.4). Urine analysis revealed proteinuria (3+); 19 pus cells. Urine culture showed no growth. Blood culture yielded Staphylococcus infection and sensitive antibiotics were started. He was given intravenous hydration, furosemide, and calcitonin for hypercalcemia. iPTH was low. Vitamin D level was more than 100. The patient revealed that he was given oral Vitamin D tablets during treatment for COVID-19. Hypercalcemia and fever spikes persisted. No M band in the serum protein electrophoresis was noted. No lytic bone lesions were visible in X-rays. CT chest showed old healed lesions; no mediastinal lymphadenopathy was observed. ACE level was normal. In view of persistent fever spikes, hypercalcemia, and renal failure, a bone marrow biopsy was done.

RESULTS: Bone marrow biopsy showed normocellular bone marrow with plasma cells 6%. Repeat urine culture yielded Escherichia coli and sensitive antibiotic was started. Immunofixation electrophoresis was negative for monoclonal gammapathy. Injection denosumab was given. 1,25 hydroxy-Vitamin D was elevated (480 pmol/L). On further probing, the patient revealed that he was given liquid medication orally 1 week before hospitalization. After review of old records, the medication was found to be injection Vitamin D3. He was given 30 ampoules of injection Vitamin D3 (6 lakh IU) orally. His creatinine subsequently dropped to 1.4 and calcium to 11.6.

CONCLUSIONS: Fever in this patient was due to infection. Presence of fever and other symptoms evaded the correct diagnosis. Awareness of this entity and detailed history-taking with medication details can aid early diagnosis and treatment.


  Rituximab-Induced Serum Sickness – In a Case of Relapsed Primary Membranous Nephropathybranous Nephropathy Top


Kumari Monika, Sanjeev V Nair, Karthikeyan Balasubramanian

Department of Nephrology; Saveetha Medical College and Hospital; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Serum sickness is a type III or immune complex-mediated hypersensitivity disease, caused by immunization of the host by heterologous serum proteins and subsequent illness caused by formation of immune complexes. Serum sickness with rituximab has been described in various studies. There is no case report of rituximab-induced serum sickness in primary membranous nephropathy relapse patient after second dose with no any evidence of serum sickness or adverse reaction in previous doses.

AIM OF THE STUDY: To analyze the risk factors, precautions, and diagnosis of serum sickness in a relapsed case of primary membranous nephropathy treated with rituximab.

METHODS: A patient 48-year-old male, nondiabetic, nonhypertensive, with primary membranous nephropathy with renal biopsy tissue PLA2R positive, with fever, severe polyarthralgia with history of (h/o) administration of injection rituximab 500 mg 1 week back. He had history of failed response to modified Ponticelli and partial remission when started to CNI (Tacrolimus) plus steroid. Hence, he had received 1 dose of rituximab 2½ years back, without any h/o immediate or delayed adverse drug reaction as well no serum sickness. He did not have any lymphadenopathy rash, increase in proteinuria, gastrointestinal symptoms, oral ulcer, alopecia, genital lesion, any other recent drug or vaccine exposure, and no h/o insect bite or animal bite. He was evaluated for any systemic disease, leading to the same symptom and tropical infection. All reports came normal with no growth in the blood c/s with RA factor negative with negative test for dengue; anti CCP negative (1.7 RU/ml); ESR 36; CRP 77.6 raised; and normal C3; C4.

RESULTS: In view of typical clinical presentation, he was diagnosed as serum sickness though because of very dark skin color no rash could be found. He was started on injection methylprednisone 125 mg for 3 days; in view of severe debilitating polyarthralgia with inability to move even in bed. After 1st dose of steroid itself, his symptom completely subsided.

CONCLUSION: There is a risk factor with previous sensitization and need to explain the patient risk, symptoms, and precaution before drug administration, during hospital stay, and even after discharge. We should also rule out other differential diagnosis. Symptoms are usually mild and easy to manage.


  Bifurcation of the Split Tip Tunneled Cuffed Catheter 2-Year Postplacement Top


Saumya Vishnoi, Zaheer Virani, Virendra Chauhan, Madhavi Dadwe, Ishan Parekh, Prashant Rajput, Hepal Vora, Bharat Shah

Department of Nephrology; Global Hospital; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Malposition is a common cause of catheter dysfunction. However; it is more likely to occur during the placement of catheter, rather than later. We report here a case of bifurcation of split-tip tunneled cuffed catheter (TCC) after 2 years of insertion, with retrograde folding of the arterial tip.

AIM OF THE STUDY: To remove the malpositioned permcath and replace it with a permcath on the same side.

METHODS: A 66-year-old diabetic, hypertensive male, initiated on HD 2 years ago via right internal jugular vein (IJV) TCC, presented with its partial extrusion (including cuff). Chest X-ray and fluoroscopy showed bifurcation of tip of the catheter, with arterial tip folded into the right IJV [Figure 1], with filling defects [Figure 2]. This catheter was gently pulled out under fluoroscopy. Repeat TCC was inserted via a partially occluded right IJV (under USG guidance), to preserve left-sided veins.

RESULTS: Despite a lumen occluding thrombus also, we were able to cannulate the right IJV, by attempting a lower prick under USG guidance, after ascertaining patency of the SVC under fluoroscopy.

CONCLUSION: The reason for this delayed bifurcation is uncertain and there is a possibility of thrombosis (filling defect+), leading to malposition.


  Clinical Profile and Outcomes in Posttransplant Collapsing Glomerulpathy Top


A R A Changanidi, Natarajan Gopala Krishnan, Jayachandran Dhanapriya, Sheik Sulthan Alavudeen, Shivakumar Dakshinamoorthy, Tanuj Lamech Moses, Ravindran Krishna, Solomon Dolphin, Goutham Kamalakanan, Paulpandian Vathsalyan, Srinivasan Kannan Badri, Sajmi Shaji

Department of Nephrology; Madras Medical College; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Collapsing glomerulopathy is a podocytopathy with diverse etiologies but with uniformly poor prognosis

AIMS OF THE STUDY: To study the clinical profile and outcome in posttransplant collapsing glomerulopathy.

METHODS: A retrospective analysis of records of kidney-transplant recipients (KTRs) was done. KTRs with allograft biopsy revealing collapsing glomerulopathy during 2011-2021 were studied. Donor type, immunosuppressive regimen, serum creatinine, and viral profile (HIV, HCV, CMV) were analyzed.

RESULTS: All the six KTRs with collapsing glomerulopathy were males. Of them, two had received kidney from living donors and four from deceased donors. Two patients were on cyclosporine and four were on tacrolimus. Viral profile was negative in all patients, except one in whom CMV was positive. The age of the patients A, B, C, D, E, and F (in years) was 28, 29, 36, 19, 32, and 31. Serum creatinine at diagnosis of CG (mg/dl) was 3.8, 1.8, 11.3, 2, 2.2, and 3.9.

CONCLUSIONS: Etiology of collapsing glomerulopathy was uncertain in most KTRs. Outcome was poor in all patients.


  Clinical Profile, Histopathological Features, and Outcome of IGA Nephropathy in a Tertiary Care Hospital in South India Top


Sankara Avudayappan, Arul Rajagopalan

Department of Nephrology; Madurai Medical College and Government Rajaji Hospital; Madurai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: IgA nephropathy is reported to be one of the most common forms of glomerulonephritis worldwide.

AIMS OF THE STUDEY: It is more common among Asians and known to have an aggressive course. We report the clinical profile, histopathological features, outcome of patients diagnosed to have IgA nephropathy on renal biopsy and treated in a tertiary care hospital in south India.

METHODS: In this observational single-center study, we analyzed the clinical picture, histopathological features, and outcomes of 25 patients diagnosed with IgA nephropathy by kidney biopsy from January 2020 to July 2021 in our nephrology department. MEST–C score was assigned as per Oxford Classification. Baseline clinical features, laboratory data, and outcomes were analyzed.

METHODS: A total of 240 native kidney biopsies were done over a period of 17 months from January 2020 to July 2021. Among these, 25 had a diagnosis of IgA nephropathy (10.4%). Hypertension was found in 20 patients at presentation (80%). Hematuria was found in 20 patients (80%). Renal dysfunction was found in 18 patients (72%) at presentation, among them 12 patients (66%) had nephrotic range proteinuria. Observing the MEST–C scoring, 10 patients (40%) had M1 lesions, 4 patients (16%) had E1 lesions, 7 patients (28%) had S1 lesions, 2 patients (8%) had T1/T2 lesions, and 5 patients (20%) had crescentic lesions in biopsy. Among the 25 patients of IgA nephropathy diagnosed by biopsy, 4 patients (16%) progressed to ESRD. Hematuria, hypertension, and nephrotic range proteinuria are the more common presentations in our study.

CONCLUSIONS: Patients with nephrotic range proteinuria are more prone to progress to ESRD than those with subnephrotic range proteinuria. Mesangial proliferative lesions are predominant with lesser incidence of endocapillary proliferation and crescents in our study.


  Study of Disease Characteristics and Clinicopathological Correlation of Lupus Nephritis in a South Indian Tertiary Care Center Experience Top


Ibrahim Sameem Kan

Department of Nephrology; Madurai Medical College and Government Rajaji Hospital; Madurai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Systemic lupus erythematosus (SLE) is a multisystemic inflammatory disorder with frequent renal involvement. Renal manifestations are variable with a variety of symptoms and presentations causing high morbidity and mortality among the affected population. The clinicopathological features at the time of biopsy of lupus nephritis (LN) contribute to the overall prognosis of SLE in many patients.

AIMS OF THE STUDY: The main objective of this study is to determine the clinical and laboratory features at the time of biopsy in the South Indian population and to correlate them with histopathological classes as per the International Society of Nephrology/Renal Pathology Society (ISN/RPS) 2018 LN Modified Classification.

METHODS: 52 patients of SLE diagnosed with clinical/laboratory criteria and having renal abnormalities from Madurai Medical College, South India, were subjected to renal biopsy and data were collected. The biopsy results were interpreted according to ISN/RPS 2018 modified classification and were correlated with the clinical and laboratory findings. Pregnant women were excluded from the study.

RESULTS: Among the 52 cases studied, 48 were females (92.3%). Age range was between 10 and 49 years. The most common presenting clinical symptom was pedal edema (72% patients) followed by arthralgia (43%) and hematuria (40%). The mean GFR at presentation was 65 ± 36 (ml/min) and the mean creatinine was 1.51 ± 0.90 (mg/dl). The most common class at biopsy was Class IV. About 64% of the cases showed full-house immunostaining. Modified NIH activity index was highest in Class IV (mean 7.2) and the modified NIH chronicity index was also highest among Class IV (Mean 4.1). Tubulointerstitial deposits were present in 33% of cases with highest in Class IV.

CONCLUSION: Assessment of the biopsy results showed that strong positive correlation of various clinical findings with the biopsy results (52% had concordant clinical and biopsy diagnosis), hence guiding in treatment strategies and predicting long-term prognosis in such patients. Other than high prevalence of arthralgia in our area, there were nil significant geographical differences in symptoms/laboratory/biopsy parameters of LN patients when compared with similar studies in other areas.


  Xerostomia in Maintenance Hemodialysis Population Top


G Geethanjali, B Ragapriya, E Ramprasad, M Jayakumar

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Porur; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Oral dryness (xerostomia) can be subjective, especially when patients feel that their mouth is dry, but clinical examination does not reveal any abnormality or cause. This so-called subjective oral dryness can be related to transient causes; including dehydration and anxiety. This in turn causes increased intake of fluid in CKD where there occurs sustained feeling of oral dryness and thirst, leading to increased interdialytic weight gain in maintenance hemodialysis (MHD) patients.

AIMS OF THE STUDY: The study is intended to assess the fluid intake and intradialytic weight gain among diabetic and nondiabetic MHD patients by xerostomia intervention and thirst score.

METHODS: The study was conducted involving 200 patients at the Dialysis Unit at SRIHER, Chennai. ESRD patients aged below 85 years on MHD and not on PD were included. The study participants were divided into two groups (diabetic and nondiabetic). In both groups, patients were assessed for xerostomia with using visual analog score. This study analyzed contribution of xerostomia to interdialytic weight gain in percentage (%) among diabetic and nondiabetic MHD patients. Patients with CKD on hemodialysis have to maintain fluid restricted diet to prevent fluid overload between dialysis sessions. High fluid intake through diet results in interdialytic weight gain between dialysis sessions. Long-term noncompliance to the fluid restricted diet can induce complications such as hypertension, acute pulmonary edema, congestive heart failure, and cardiovascular morbidity. Statistical analysis was done with SPSS software.

RESULTS: The study population is divided into two groups; Group A (diabetics) and Group B (nondiabetics). In Group A, male:female ratio was 77:23. In Group B, it was 65:35, with predominant age of 55–85 years. <2 kg interdialytic weight gain in Group A was in 9% patients; 27.0% patients gained 2–3.5 kg; 64% gained >3 and 5 kg. In Group B; 35% gained <2 kg; 51% gained 2–3.5 kg; 14% gained >3.5 kg. In Group A, 11.0% consumed fluid <500 ml per day; 55% took 500 ml to 1 l/day; 34% consumed >1 l/day. In Group B, 28% consumed <500 ml per day; 70% took 500 ml to 1 l/day; 2% took >1 l/day. 70% diabetics had xerostomia score of moderate and severe; whereas 92% in Group B had normal score. Thirst score is severe in 56% of diabetics. In Group B, 69.0% were normal. There was an association between xerostomia and interdialytic weight gain with diabetics and nondiabetics (P < 0.05), and there was no association between urine output with diabetics and nondiabetics.

CONCLUSIONS: Xerostomia was found to be highly prevalent among the diabetics than nondiabetics, and there was a strong association between interdialytic weight gain and xerostomia among these patients on maintenance.


  Alstrom Syndrome - An Interesting and Rare Cause of CKD Top


Chaganti Sindhu, Jaya Kumar Matcha, Ram Prasad Elumalai, Manikantan Sekhar

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Alstrom syndrome is a rare genetic multisystem disorder. It is an autosomal recessive disorder resulting from mutations in the ALMS1 gene. Disease manifests in infancy characterized by vision and hearing loss, cardiomyopathy, and diabetes mellitus. Progressive kidney disease occurs in childhood, leading to end-stage renal disease.

AIMS OF THE STUDY: To eveluate cause of renal failure in young female with hearing and vision loss and fracture history.

METHODS: A 24-year-old female with childhood history of vision and hearing loss presented with fracture of right femur.

RESULTS: Blood investigations revealed renal failure and imaging showed bilateral contracted kidneys. Mineral bone profile showed Vitamin D deficiency and hyperparathyroidism which was attributed for fracture. Further investiagtions revealed diabetes mellitus and dilated cardiomyopathy. With high suspicion of Alstrom syndrome, genetic analysis was done which revealed mutation in ALMS1 gene. Diagnosis of Alstrom disease was confirmed. She is currently in stage 4 chronic kidney disease and is on follow-up with us.

CONCLUSION: Alstrom syndrome, though rare, should be considered for childhood chronic disease with visual and hearing abnormalities. Genetic analysis confirms the diagnosis. Management is conservative. Depending on the other system involvement, renal transplantation can be considered as a choice.


  Clinical Profile and Outcome of COVID-19 in Kidney-Transplant Recipients Top


Manzoor Ahmad Parry, Mohammad Ashraf Bhat, Imtiyaz Ahmad Wani, Muzaffar Maqsood Wani

Department of Nephrology; Sher i Kashmir Institute of Medical Sciences; Srinagar; Jammu and Kashmir; India

E-mail: [email protected]

BACKGROUND: Novel coronavirus 19 (coronavirus disease-19 [COVID-19]) disproportionately affects patients with various kidney diseases. Patients with kidney transplant can be at higher risk of complications of COVID-19 infection. There is a scarcity of data on the consequences of COVID-19 infections in kidney-transplant recipients (KTRs) from emerging countries.

AIMS OF THE STUDY: To study the clinical profile and outcome of COVID-19 infections in KTRs.

METHODS: Here, we present a cohort study of 46 KTRs with polymerase chain reaction-confirmed COVID-19 positivity from May 1, 2020, until May 1, 2021. We detailed demographics, immunosuppression regimen, clinical profile, treatment, and outcomes.

RESULTS: Median age of the patients was 41 years and median age of disease was 2.9 years after transplant. Most common comorbidities (94%) included hypertension (71%) and diabetes (35.7%); presenting symptoms at the time of COVID-19 included fever (92.8%) and breathlessness (64.3%). Clinical severity ranged from asymptomatic (12%), mild (38%), and moderate (24%), to severe (29%). Risk factors for mortality included older age, severe disease, allograft dysfunction before COVID-19 infection, acute kidney injury, higher levels of inflammatory markers including C-reactive protein, interleukin-6 level, and procalcitonin, and higher computerized tomography severity index. Acute kidney injury developed in 57.1% of patients out of which dialysis was needed in 14.3%. Overall patient mortality was 14.3%. At 3 months of follow0up; loss of graft function was seen in 7.1% of patients

CONCLUSIONS: Mortality rates in COVID-19-positive KTR appear to be higher than those in nonimmunosuppressed patients


  Assessment of Health-Related Quality of Life Among Dialysis Patients in a Tertiary Care Center in South Tamil Nadu Using KDQOL SF-36 Scoring Top


Rakesh Sebastin

Department of Nephrology; Madurai Medical College and Government Rajaji Hospital; Madurai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Kidney Disease Quality Of Life Questionnaire (KDQOL) survey is a kidney disease measure of the health-related quality of life (HRQOL) developed in 1994. The KDQOL SF-36 questionnaire explores the important factors that influence the quality of life in the hemodialysis patients.

AIMS OF THE STUDY: The KDQOL SF-36 questionnaire includes the physical competent summary (questions 1–12), mental competent summary (question 1–12), symptoms and problem subscale (questions 17–26), and effects of kidney disease on daily life subscale (questions 29–36).

METHODS: The study was conducted in Government Rajaji Hospital, Madurai. Participants were 162 (101 men and 61 women) hemodialysis patients. Physical and mental health composite score were derived from the KDOQL to examine factors that can be considered predictive of the quality of life in these patients.

RESULTS: By using backward regression, the scales most predictive of the mental and physical health were determined. For physical health, burden of kidney disease (P = 0.008), effects of kidney disease (P = 0.018) and sleep (P = 0.17) were the best set of predictors. For mental health, burden of kidney disease (P = 0.006), social support (P = 0.011), and cognition (P = 0.017) were the best predictors.

CONCLUSIONS: With a help of these statistical analyses, major factors influencing the physical and mental health can be determined. These developments may serve to improve the interpretation and implementation of the KDQOL-36 instrument for patients and providers.


  Efficacy of Sodium-Glucose CO Transporter-2 Inhibitors In Diabetic Patients in Retarding the Progression of Chronic Kidney Disease Top


Neil Saldanha, Supriya Jatal, Mita Shah, Hepal Vora, Zaheer Virani, Prashant Rajput, Shruti Tapiawala, Hitesh Gulhane, Ishan Parekh, Saumya Vishnoi, Bharat Shah

Department of Nephrology; Global Hospital; Parel; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Renoprotective effect of sodium glucose co transporter-2 inhibitors (SGLT2i) in diabetic kidney disease are under investigations.

AIMS OF THE STUDY: To study the renoprotective effects of SGLT2i in diabetic kidney disease.

METHODS: This prospective study included 102 diabetic kidney disease patients. Patients with an estimated creatinine clearance of and<30 ml mL/min were excluded. Fifty-two patients received SGLT2i and 50 patients did not receive SGLT2i. Patients were followed up for at least 12 months. BMI, blood pressure (BP), HbA1c, urine protein to creatinine ratio (UPCR), and rate of decline of the estimated creatinine clearance were compared between the two groups.

RESULTS: The two groups were comparable in terms of age, sex, duration of diabetes, hypertension, and degree of renal impairment. There was a significant reduction in BMI in SGLT2i group (P < 0.05). The BP and HbA1c control were similar in both groups, suggesting that renoprotective effect due to SGLT2 inhibition. Over 12 months, the UPCR decreased by 0.03 in SGLT2i group and increased by 1.1 in non-SGLT2i group (P < 0.05). The rate of decline of the estimated creatinine clearance in the SGLT2i group was 5.4 ml/min/year as compared to 9.1 ml/min/year in the non-SGLT2i group (P < 0.05).

CONCLUSIONS: Our study showed that the use of SGLT2i was associated with significant reduction in BMI, proteinuria, and rate of decline in estimated creatinine clearance.


  Lupus Nephritis in Males: Case Series Top


Bharathisezhian Anbuselvam, T Balasubramaniyan

Department of Nephrology; Kilpauk Medical College; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: SLE is an autoimmune disease which predominantly affects women of reproductive age group. This difference in sex predilection is explained by the hormonal effect of estrogen. Male patients with lupus have worser outcomes compared to females. Early detection and prompt management of these patients are important because lupus nephritis (LN) is one of the reversible causes of renal failure. We report a case series of five male lupus patients who presented with different clinical scenarios.

AIMS OF THE STUDY: Incidence of SLE is rare and it is 4%–22%. Only scanty number of male LN is diagnosed and reported annually. This inspired us to write this case series of five male SLE patients.

METHODS: Clinical features, presentation, and management details are summarized in Table 1. Images showing crescentic formation and full house pattern are attached.

RESULTS: LN typically develops early; generally within the first 6–36 months, and sometimes, it may be the initial presentation of SLE. Risk factors for the development of LN among SLE patients include younger individuals, males, and non-European ancestry. Our observation from the above five case series clearly depicts the same inference to the largest retrospective analysis of male LN from Spain and Uruguay by A Urrestaraz et al. Their case series clearly states that LN in males usually presents as nephrotic syndrome, type IV LN is the most frequent form, and estimated glomerular filtration rate < 60 ml/min at the time of renal biopsy is associated with poor renal outcomes.

CONCLUSIONS: We would like to emphasize the importance of considering lupus as one of the differential diagnoses, young male patients with unexplained renal failure.


  A Case of Familial Hypocalciuric Hypercalcemia Presenting as Bile Cast Nephropathy Top


H Aditya Shetty, S Mythri

Department of Nephrology; Institute of Nephrourology; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: Familial hypocalciuric hypercalcemia (FHH) is a rare autosomal dominant condition. It occurs as a result of mutations in the calcium-sensing receptor gene (CASR) that leads to decreased receptor activity. It is inherited in an autosomal dominant fashion with near-complete penetrance but variable expressivity. Symptoms of hypercalcemia, if present, are less severe than in primary hyperparathyroidism. Recurrent pancreatitis may be slightly increased in patients with FHH.

AIMS OF THE STUDY: A 19-year-old man with a history of recurrent pancreatitis came with oliguria and pancreatitis for 4 days.

METHODS: Urine analysis showed bile casts. On evaluation, deranged renal functions (urea - 271 mg/dl; creatinine - 9.42 mg/dl); direct hyperbilirubinemia (TB - 25 mg/dl; DB - 12.02 mg/dl); and raised pancreatic enzyme levels were found. Serum calcium was in the normal range (9.1 mg/dl) and raised serum PTH (221 pg/ml). Old reports showed high normal serum calcium and raised PTH (with normal renal functions) during episodes of pancreatitis. No abnormalities on MRCP. In view of high normal calcium and nonsuppressed PTH, hyperparathyroidism was suspected. Sestamibi T99m parathyroid scan showed no evidence of parathyroid adenoma. 24 h urinary calcium excretion was 50 mg. Cal/Cr excretion ratio was 0.009. Diagnosis of FHH was made taking in view clinical presentation, 24 h urinary calcium, and Ca/Cr excretion ratio. AKI was recovered with creatinine 0.79 mg/dl on follow-up.

RESULTS: FHH is a rare, lifelong, benign condition caused by an inactivating mutation, most frequently in the CASR gene, leading to a general calcium hyposensitivity, compensatory hypercalcemia, and hypocalciuria. The CaSR plays an essential role in the regulation of extracellular calcium homeostasis, by mediating the inhibitory actions of extracellular calcium on parathyroid hormone secretion and by influencing the rates of renal tubular calcium reabsorption and secretion of calcitonin by thyroidal C-cells. Measurement of the 24 h urine Ca and Ca/Cr clearance ratio helps to differentiate FHH and hyperparathyroidism. In FHH, the 24 h urinary calcium excretion is <100 mg/24 h. Patients with a Ca/Cr ratio of 0.020 or less should be tested for mutations in CaSR gene. Parathyroidectomy in FHH leads to hypoparathyroidism and is not recommended. Calcimimetics are allosteric modulators of CaSR, making it more sensitive to serum Ca. Response to cinacalcet is unpredictable.

CONCLUSIONS: Patient with pancreatitis and RPRF with bile cast in urine. On the background of recurrent pancreatitis with normal calcium levels and raised PTH, hypercalcemia-mediated pancreatitis was suspected. In view of urine Ca/Cr ratio of 0.09; and low urine calcium, FHH diagnosed and initiated on cinacalcet.


  Solitary Angiomyolipoma of Kidneys: Case Report of Management Options of Renal Angiomyolipoma Top


Seetaram Singh Kularaj, Tushar Gupta, Shubham Agarwal, Rakesh Gupta, Dhananjai Agarwal, Vinay Malhotra, Pankaj Beniwal

Department of Nephrology; Sawai Man Singh Medical College and Hospital; Jaipur; Rajasthan; India

E-mail: [email protected]

BACKGROUND: Renal angiomyolipoma (AML) is a rare neoplasm, which when grow to a size of >10 cm; they are referred to as “;giant” AMLs. Obvious clinical symptoms occur in the majority of giant renal AML cases; and protecting renal function is the main therapeutic target.

AIMS OF THE STUDY: To assess the management options of renal AML.

METHODS: A 45-year-old male presented with history of abdominal distention and bloating sensation for the past 3 months with no history of pain abdomen vomiting hematuria. On physical examination, a large nontender well-defined swelling was present in the left flank. CECT abdomen showed large (19.2 mm × 15.6 mm × 10.6 mm) heterogenous density mass lesion with internal fat densities and soft tissue densities involving left-sided retroperitonial space with involvement of renal parenchyma causing mass effect over gut loops, suggesting of large angiomyolipoma. Laboratory reports were within normal limits; DTPA scan suggested GFR (right kidney [RK] - 57 ml/min; left kidney [LK] - 8 ml/min). Left nephrectomy was done under general anesthesia, with histology findings of spindeled smooth muscle cells, islands of mature fat, and aggregates of epitheloid cells with clear cytoplasm adjacent to vessel wall, suggestive of AML.

RESULTS: A 55-year-old female known case of type 2 diabetes mellitus for the past 15 years; hypertension for the past 10 years, hypothyroidism for the past 5 years on treatment admiited with complaints of acute-onset pain abdomen with generalized weakness. On physical examination, BP was 80/50 mm Hg, PR was 124/min, andrespiratory rate was 16/min,with severe pallor; on lab reports, HB was 5.6, TLC was 6.5, serum urea was 13, Cr was 0.7, imaging suggestive of large-signal intensity lesion from mid and lower pole of RK, showing predominant fat density and soft tissue areas suggestive of angiomyolipoma with hemorrhage into surrounding perinephric region. DTPA study shows GFR of (RK - 49 ml/min; LK - 56 ml/min); the patient is managed consurvatively with 4 units of blood transfusion and watchfull wating.

CONCLUSIONS: Renal AML is a benign neoplasm arising from mesenchymal elements. A small AML can be safely followed; however, in giant AML tumors with persistent hemorrhage or suspicion of malignancy, partial or total nephrectomy is the treatment of choice.


  Impact of Using Reference Change Value of Serum Creatinine In The Diagnosis, Staging, and Outcome of Acute Kidney Injury in Critically Ill Children: An Exploratory Study Top


Swathi Shiri, Smitha Joseph1, A V Lalitha2, Anita Devanath3, Tinku Thomas1, Anil Vasudevan

Departments of Pediatric Nephrology; 1Biostatistics; 2Pediatric Intensive Care and 3Clinical Biochemistry; St John's Medical College and Hospital; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: The initial diagnosis and staging of AKI by KDIGO criteria is based on small increase of serum creatinine (sCr) from baseline that is significantly associated with morbidity and mortality. sCr is subjected to biological variation (CVi) which affects the reliability of diagnosis and staging of AKI. Reference change value (RCV) is defined as value that exceeds the critical difference between two sequential results, i.e., the true change which includes the total variation associated with both the results.

AIMS OF THE STUDY: Derivation set: A total of 199 children aged <1–10 years without any risk factors for AKI were analyzed for sCr and second sample measured within a duration of 30 days was selected to derive the 95th percentile RCV based on the age and initial creatinine.

METHODS: Validation set: AKI according to pROCK was defined as increase in sCr after adjusting for RCV. pROCK was applied in a cohort of 175 critically ill children(age <10 years) recruited from an ongoing observational study in pediatric intensive care unit. We compared the burden of AKI in 175 hospitalized children according to pROCK and KDIGO creatinine criteria 0.3 mg/dL or 50% increase from baseline; and their association with duration of ventilation and inotropes; length of stay in PICU; and hospital and risk of mortality in hospital.

RESULTS: The median age of the cohort was 2.8 years (0.3–10). The most common diagnosis was septic shock (60%) with mean PRISM III score 15 (8–26). The overall burden of AKI by KDIGO was 39.4% (n = 69). After reclassification of AKI staging by using pROCK, the overall burden of AKI reduced by17% (n = 39) (39.4% in KDIGO vs. 22.2% in pROCK). AKI Stage I, II, andIII by KDIGO changed from 42%, 33.3%, and 24.6% to 32%, 7.2%, and17.3%, respectively, on reclassification by pROCK. Majority (83%) with Stage I and 26% with Stage II AKI by KDIGO staging were reclassified as not having AKI using pROCK while74% with Stage II AKI were reclassified as Stage I AKI. There was no difference in patient outcome between KDIGO- and pROCK-based staging of AKI with duration of ventilation, inotropes, and ICUand hospital stay being significantly higher in those with AKI compared to those without AKI in both groups. Children with AKI by KDIGO as well as pROCK had higher mortality compared to those without AKI (OR = 4.32; 95% CI 1.88–9.94 and 3.32; 95% CI 1.46–7.7, respectively).

CONCLUSIONS: In critically ill children, the diagnosis and severity of AKI based on RCV adjusted serum creatinine are lower when compared to KDIGO criteria. However, there was no impact on morbidity or mortality.


  Renal Functional Reserve in Prospective Kidney Donors Top


Vipul Chakurkar, Shefali Gokhale1, Sagar Kulkarni, Valentine Lobo

Renal Unit; KEM Hospital; 1Department of Nuclear Medicine; Inlaks and Budhrani Hospital; Pune; Maharashtra; India

E-mail: [email protected]

BACKGROUND: To assess the normal range for renal functional reserve (RFR) in healthy individuals.

AIMS OF THE STUDY: We enrolled 20 prospective donors; 6 males and 14 females with median (interquartile range; IQR) age 45 (38; 53) years.

METHODS AND RESULTS: Four donors were hypertensive and mean (standard deviation; SD) proteinuria was 11.6 (8.3) mcg/mg creatinine. Mean (SD) serum creatinine was 0.75 (0.12) mg/dl with eGFR by CKD-EPI formula of 102 (10.5) ml/min/1.73 m2. Median (IQR) baseline GFR was 100 (91.75; 114.75) while the median (IQR) augmented GFR was 116.5 (108.5; 132.25) ml/min/1.73 m2. Median (IQR) RFR was 15.1% (3.93; 30.74). RFR was inversely correlated to BMI (R = −0.470; P = 0.036) and baseline GFR (r = −0.496; P = 0.026), while there was no statistical correlation between age and RFR.

CONCLUSION: We believe RFR more accurately assesses the kidney donor eligibility. Definition of a normal range will require larger studies.


  Acute Kidney Injury Secondary to Rhabdomyolysis in COVID 19-An Exquisite Top


N Prasanna Kumar, S Mathini, P Lakshmi Aishwarya, M Murali, B N Alekhya, Maria Bethsaida Manuel, M Raja Amarendra, K Naveen, R Ram, Siva Kumar Vishnubhotla

Department of Nephrology; Sri Venkateshwara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India

E-mail: [email protected]

BACKGROUND: COVID-19 can present with a variety of complications during the course of infection. Little is known about rhabdomyolysis and acute kidney injury (AKI) in the context of the COVID-19 infection. Recent reports suggest that AKI during COVID-19 infection could be associated with increased mortality. Rhabdomyolysis-associated AKI in the setting of COVID-19 is an uncommon complication of the infection.

AIMS OF THE STUDY: A 78-year-old gentleman with diabetic and hypertensive presented with weakness in both thighs and pain. He complained diffuse body aches. He admitted dry cough of 4 days duration. No other complaints wer observed.

METHODS: On examination, he had pedal edema and disorientation. He also had elevated blood urea and serum creatinine, low serum calcium, and high serum phosphorous and uric acid. We noticed the untypical derangement of renal function tests. In our patient, the blood urea to serum creatinine ratio was 11.08:1, which was disproportionate. Except rhabdomyolysis, the other causes are not possible. The context of the AKI with the disproportionate elevation of serum creatinine when compared to blood urea along with high serum phosphorous, high serum uric acid, low serum calcium, and raised serum potassium falls in the category of hypercatabolic acute renal failure. The chest radiograph showed patchy ground-glass opacity in bilateral peripheral zones. CPK was 9400 U/L; urine myoglobin was 24,418nmol/L; RT-PCR for COVID-19 infection turned positive and CT scan of the chest suggested CO-RADS-5. He required 3 sessions of hemodialysis for hyperkalaemia. His creatinine returned to normal on day 12.

RESULTS: Rhabdomyolysis could be the cause of hypercatabolic acute renal failure. The term rhabdomyolysis means the dissolution of striped (skeletal) muscle. As a consequence of the dissolution, muscle cell contents, such as electrolytes, myoglobin, and other sarcoplasmic proteins, shift into the circulation. The manifestations of the massive necrosis of the muscle are limb weakness, myalgia, swelling, and commonly gross pigmenturia without hematuria. The common causes of rhabdomyolysis fall in the categories of the trauma, exertion, muscle hypoxia, genetic defects, infections, body temperature changes, metabolic and electrolyte disorders, drugs and toxins, and idiopathic. In this exhaustive list of causes of rhabdomyolysis, the present patient had three possibilities – infections, drugs and toxins, and idiopathic. Indeed, the present patient had been on a statin. However, it is a rare adverse effect of statin. Our patient had only yeo risk factors advanced age and diabetes mellitus.

CONCLUSIONS: We conclude that this riddle (bilateral thigh weakness) wrapped in a mystery (hypercatabolic acute renal failure) inside an enigma (rhabdomyolysis) has a key (COVID-19 disease).


  Extracorporeal Therapy in Poisoning and its Outcome Top


S S Deepak Balakumar, N D Srinivasa Prasad, S Sujit, K Thirumal Valavan, M Edwin Fernando

Department of Nephrology; Government Stanley Medical College; 1The TN Dr. MGR Medical University; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Extracorporeal removal therapies effectively increase the clearance of certain toxins. In 1983; National Data Collection System gathered all poisoning data and modified as Toxic Exposure Surveillance System (TESS) 10 years later, and in 2007, it became National Poison Data System. Poisoning and drug toxicity is one of the common encounters in day-to-day practice; the purpose of this study is to see the effectiveness of extracorporeal therapy (ECT) in various dialyzable poisons and its outcome.

AIM OF THE STUDY: To study the role of ECT in case of dialyzable poisoning. Primary objective: To evaluate duration of hospital stay in poisoning cases undergoing ECT.

METHODS: 26 out of 28 patients (93%) recovered completely after ECT. 5 out of 28 patients (17.9%) died. Among the patients who died, 2 patients died due to late presentation, 2 patients died due to ventilator-associated pneumonia, and 1 patient died due to Steven–Johnson syndrome/sepsis.

CONCLUSIONS: ECT contributed to early recovery in patients with poisoning. Early presentation and early initiation of ECT contributed to better outcome. Mortality was mainly due to sepsis, mechanical ventilation, and late presentation.


  Nonparasitic Chyluria and Nephrotic Syndrome Top


Girish P Vakrani, K Y Yashavantha Kumar, Nambakam Tanuja1

Departments of Nephrology and 1General Medicine; Vydehi Institute of Medical Sciences and Research Centre; Bengaluru; Karnataka; India

E-mail: [email protected]

BACKGROUND: Chyluria is excreting chyle in urine, leading to white urine. Lymphangiopraphy or retrograde pyelogram can establish the diagnosis. Chyluria can cause proteinuria. Here, we discuss an interesting case of chyluria associated with proteinuria due to nonparasitic cause which was successfully treated.

AIMS OF THE STUDY: It is a case report to evaluate white urine and proteinuria which is caused by chyluria.

METHODS: It is a case report to evaluate white urine and proteinuria which is caused by chyluria.

RESULTS: White urine and proteinuria were evaluated in this case which was caused by nonparasitic originated chyluria. Kidney biopsy was done which showed minimal change disease. Nonparasitic chyluria is rare which has been in this case. We treated the case with installation of povidone iodine into renal pelvis. The resolution of chyluria and proteinuria suggests that abnormal lymphatic–urinary communications were causing chyluria. It was successfully treated with povidone-iodine

CONCLUSIONS: Chyluria presenting as white urine is mistaken to nephrotic syndrome. Nonparasitic chyluria is rare. Installation of povidone-iodine into renal pelvis caused resolution of chyluria and proteinuria suggesting abnormal lymphatic–urinary communications was causing chyluria.


  A Case of Hydatid Cyst Disease in a Renal-Transplant Recepient Top


S Mathini, P PrasannakumarAishwarya, M Murali, B N Alekya, Maria Bethsaida Manuel, R Ram, Sivakumar

Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India

E-mail: [email protected]

BACKGROUND: Hydatid disease is an important zoonotic disease caused by Echinococcus granulosus. It usually affects liver, less frequently lungs, kidney, bones, and brain.

AIMS OF THE STUDY: We report a case of hydatid cyst disease in a postrenal-transplant recipient.

METHODS: A 48-year-old female presented to our institute with breathlessness, pain abdomen, and anuria 10 years back with a history of gestational hypertension. On examination, she had pedal edema, facial puffiness, and bilateral basal crackles. The following were her reports. Serum creatinine was 15.7 mg/dL; blood urea was 229 mg/dL; serum potassium was 5.0 mEq/L; serum sodium was 136 mEq/L; hemoglobin was 4.2 g/dL; urine microscopy showed plenty of pus cells and 1–2 red blood cells; ultrasound abdomen showed bilateral small-sized kidneys. After a few sessions of hemodialysis, she underwent renal transplantation her mother being the donor. She received prednisolone, azathioprine, and cyclosporine. No induction therapy was given. Serum creatinine had normalized to 1.0 mg/dL on day 3. She has been on regular follow-up with no major complications. After 24 years of her renal transplant, she developed dull dragging pain on the right iliac fossa without any history of fever and dysuria.

RESULTS: Ultrasound abdomen showed the presence of transplant kidney in right inguinal fossa measuring 13 cm × 5.2 cm. There was a cyst in the parapelvic location. There were two multiseptate cysts each measuring 2.5 cm × 2.2 cm with in the parapelvic cyst. A computerized tomography of the abdomen showed a large exophytic cortical cyst of size; 5.2 cm × 4.7 cm in the upper pole of transplant kidney. Other investigations were as follows: serum creatinine: 1.3 mg/dL; blood urea: 18 mg/dL; hemoglobin: 12.5 g/dL; total leukocyte count: 7200/mm3; and blood and urine cultures were sterile. We suggested surgery, but the patient opted for conservative approach. She was prescribed oral albendazole tablets 400 mg twice daily for 28 days. The same was repeated for another cycle. As there was no reduction in the size of the hydatid cyst, we forestalled further doses.

CONCLUSIONS: We report this case since our patient is the first patient of hyadatid disease in the renal allograft.


  Post-COVID Mucormycosis in Chronic Kidney Disease Patients - Case Series Top


Meena Patel, Prawash Kumar Chowdhary, Sanjeev A Kale, Sanjay Sharma

Department of Nephrology; Ramkrishna Care Hospital; Raipur; Chhattisgarh; India

E-mail: [email protected]

BACKGROUND: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), has been an emergency global public health events. Prolonged hospital stay and comorbidities are setting the scenarios for opportunistic infections and coinfections with fungus and other pathogens. Mucormycosis which is caused by saprophytic fungi is one of the complications associated with COVID pneumonia. Mycormycosis frequently infects the sinuses, brain, or lungs.

AIMS OF THE STUDY: Case study of pulmonary mucormycosis and rhinocerebral mucormycosis.

METHODS: One case was known diabetic, hypertension, and CKD for the past 3–4 years presented a month after COVID-19 infection with complaints of worsening dyspnea. His HRCT showed cavitory lesion over left lower lobe Hence, after CTVS consultation, lobectomy was done but with waxing and waning course in hospital.

RESULTS: Second case was known hypertension with CKD presented to us with complaints of ptosis, pain, and redness in the right eye; on evaluation, she had rhinocerebral mucormycosis with caraticocavernous fistula. Debridment with amphotericin and posaconazole was started, and the patient discharged with minimal residual deformity.

CONCLUSIONS: Mucormycosis is not an uncommon infection. COVID pneumonia itself causes immunosuppression and immunomodulation in patients which predispose the patent for mucor infection. Though guidelines suggest many modalities for treatment of mucormycosis, mortality is still high in post covid patients.


  Scrub Typhus - The Kidneys? MITE-Y' FOE?: A 2-Year Experience of Scrub Typhus-Associated Acute Kidney Injury From a Tertiary Care Center in South India Top


Kevin T John Keeppallil, E Indhumathi

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research; Porur; Chennai; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Infection-related acute kidney injury (AKI) is an important preventable cause of morbidity and mortality in the tropical region. Scrub typhus, a reemerging zoonotic bacterial infection caused by bites of mites, affects about one million people annually and should be part of the differential diagnosis of acute febrile illness with AKI. AKI in scrub typhus is usually mild and nonoliguric, and renal recovery occurs in most patients. The mortality rate due to scrub typhus ranges from 1.7% to 7.92%.

AIMS OF THE STUDY: This study aimed to estimate the incidence of scrub typhus-associated AKI and to evaluate the clinical profile, parameters predicting renal involvement, and prognosis in scrub typhus infection.

METHODS: This study included all patients who were admitted and treated for scrub typhus infection for a study period of 2 years (from November 2018 to October 2020). Scrub typhus infection was diagnosed by enzyme-linked immunosorbent assay technique and AKI was defined as per KDIGO criteria.

RESULTS: Demographic, clinical, and laboratory data were compared between the groups and analyzed. Multivariate logistic regression analysis was used to identify significant risk factors for the occurrence of AKI from among the risk factors identified in univariate analyses.

CONCLUSIONS: The incidence of AKI associated with scrub typhus in our study was 22.7%. MODS, increased total counts, elevated liver enzymes, and hypoalbuminemia predicted AKI in our population. Morbidity and mortality associated with scrub typhus can be reduced by early detection and treatment of AKI.


  Steroid-Free Living Donor Kidney Transplants Top


Supriya Jatal, Prashant Rajput, Hepal Vora, Zaheer Virani, Mita Shah, Shruti Tapiawala, Hitesh Gulhane, Ishan Parekh, Neil Saldanha, Saumya Vishnoi, Bharat Shah

Department of Nephrology; Global Hospital; Mumbai; Maharashtra; India

E-mail: [email protected]

BACKGROUND: Steroids are associated with many side effects. On the other hand, there is a concern that steroid-free (SF) transplants are associated with a higher incidence of rejections. We undertook this study to see the outcomes of SF transplant in our select group of recipients.

AIMS OF THE STUDY: To see the outcomes of SF transplant in our select group of recipients.

METHODS: Four hundred patients who underwent renal transplant between August 2013 and February 2020 were part of this retrospective analysis.

RESULTS: Twenty-seven selected patients (low immunological risk, children in growth phase, elderly, diabetic) who did not receive steroids were analyzed in this study. Induction immunosuppression was used in 64.3% (r-ATG or IL-2 receptor antagonist) and 35.7% did not. All patients were followed for at least 6 months. Data were analyzed using descriptive statistics. Steroids were used for the first 5 days and then abruptly stopped. Maintenance immunosuppressive regimen consisted of tacrolimus and mycophenolate sodium or azathioprine.

CONCLUSIONS: In carefully selected patients, SF transplantation is safe. It is associated with significant improvement in hypertension, decreased risk of new-onset diabetes after transplant, and infectious complications and without increased risk of acute or chronic rejections.


  Long-Term Outcomes of Tunneled Cuffed Vascular Hemodialysis Catheters - A Single-Center Experience Top


Sreenidhi Chandrashekar, Shivendra Singh, Manjitpal Singh, Khushboo Rani

Department of Nephrology; Institue of Medical Sciences; Banaras Hindu University; Varanasi; Uttar Pradesh; India

E-mail: [email protected]

BACKGROUND: Hemodialysis (HD) is the most commonly used RRT in ESRD population. Less than 10% of ESRD population has working AVF at initiation of dialysis. Tunneled cuffed vascular catheters are one of the long-term accesses for HD in patients with immature or failed AVF. CRBSI continues to be the most common complication of vascular catheters limiting their utility. We conducted this study to know the long-term outcomes of tunneled cuffed vascular HD catheters and its complications.

AIMS OF THE STUDY: To study long-term outcomes of tunneled cuffed vascular HD catheters and its complications. To determine the factors associated with increased risk of CRBSI in tunneled cuffed vascular catheters.

METHODS: It is a retrospective observational study. Study period is 2 years (October 2018–October 2020). ESRD patients who were undergoing HD through tunneled cuffed vascular catheters for >3 months were included. ESRD patients using AVF for HD were excluded. Patient's clinical data, laboratory data, catheter duration, and complications were collected. CRBSI was defined as per the KDOQI 2006 guidelines using clinical presentation, catheter tip, and blood culture. Catheter dysunction was defined either as failure to maintain blood flow of 300 ml/min or sufficient to perform HD without prolonging duration.

RESULTS: Patients were divided into yeo groups CRBSI and non-CRBSI group. Clinical, laboratory, catheter duration, catheter type and frequency of HD were compared between the groups. Variables that showed statistical significant associations were analyzed using univariate and multivariate logistic regression. Statistical analysis was done using SPSS software and P < 0.05 was considered significant.

CONCLUSIONS: Tunneled catheters are important vascular access for HD. CRBSI is the most common complication. From our study, duration of catheter use is an independent predictor of CRBSI. It is important to follow fistula first policy to have working AVF at dialysis initiation and to limit catheter use for short term.


  Impact of COVID-19 in Patients Undergoing Maintenance Dialysis Top


Rajeev Bhatia, Ajay Marwaha; Shubha Sharma

Department of Nephrology; Shrimann Superspeciality Hospital; Pathankot road; Jalandhar; Punjab; India

E-mail: [email protected]

BACKGROUND: Patients on hemodialysis are more susceptible to coronavirus disease 2019 (COVID-19) due to their weakened immune system and frequent hospital visits. Further, presence of comorbid conditions in these patients may eventually increase the risk of developing severe and fatal COVID-19. Data from Indian studies reporting clinical aspects of patients on dialysis infected with COVID-19 are limited.

AIMS OF THE STUDY: This study assessed the clinical characteristics, management, and mortality-related risk factors in patients with COVID-19 undergoing maintenance dialysis.

CONCLUSIONS: Dyspnea and leukocytosis may be considered as prognostic factors of mortality in patients on maintenance dialysis with COVID-19 infection. Therefore, vigilant monitoring of white blood cell levels and breathing patterns by clinicians in patients on hemodialysis with COVID-19 is important.


  Reverter - Retrospectively Evaluating Determinants Of Graft Outcomes in Renal Transplant Top


Manish Lalwani, Rizwan Alam, Selvin Sundar Raj, Santosh Varughese

Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India

E-mail: [email protected]

BACKGROUND: Kidney transplant and restoring continuous renal functioning represent the best physiological replacement therapy for patients with chronic end-stage renal disease. The aim of our study was to analyze the characteristics of the recipient that impact kidney graft survival.

AIMS OF THE STUDY: To determine the factors affecting graft function in the cohort of transplantations done between 2008 and 2018.

METHODS: This retrospective cohort study was approved by the Institutional Review Board of Christian Medical College. Data from all patients who underwent kidney transplantation from live or deceased donors in our center between January 2008 and Dec 2018 were collected. Pre- and post-transplant events were recorded. DGF was defined as the need for dialysis in the 1st week after transplantation. All rejections included were biopsy proven. Statistical analysis: Graft survival was calculated using Kaplan–Meier (KM) analysis. To assess variables associated with transplant outcome, univariate and multivariate Cox proportional hazards regression models were employed. The association between outcomes and all covariables was tested separately in univariate Cox analyses.

RESULTS: Baseline characteristics: The data were collected from 794 patients who underwent renal transplant over a 10-year period of January 2008 to December 2018. 88.9% of recipients had transplants from live donor and 11.1% were from deceased donor. 97.4% of patients had ABO-compatible transplant. Graft survival: The graft survival at the end of 1, 3, and 5 years was 96.56%, 93.67%, and 91.67%, respectively. Overall survival as per KM survival analysis was 81.98%. The mean survival was 130 months (standard error 1.87). Based on the Cox multivariate analysis, the factors that were independently associated with graft survival were recipient weight gain till last follow-up (95% CI 0.906–0.902), absence of rejection (95% CI 1.44–5.18), and A blood group (95% CI 0.11–0.85). Graft loss: During the 10-year follow-up, the cumulative graft loss was 9.1%. 43% of the graft loss was attributed to recipient death with a functioning graft. The second most common cause of graft loss was rejections.

CONCLUSIONS: The results show an excellent graft survival in kidney-transplant recipients. Weight gain till last follow-up, absence of rejection and A blood group represent significant predictors of graft survival.






 

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Indian Journal of Nephrology
Published by Wolters Kluwer - Medknow
Online since 20th Sept '07