The aim of this study was to estimate the direct costs of medical care among hospitalized type 2 diabetic patients with chronic kidney disease (CKD). A total of 209 (M:F, 133:76) patients were divided into groups based on the severity of kidney disease. Group 1 subjects had undergone renal transplantation (n = 12), group 2 was CKD patients on hemodialysis (n = 45), group 3 was patients with CKD, prior to end-stage renal disease (ESRD) (n = 66), and group 4 (n = 86) consisted of subjects without any complications. Details about expenditure per hospitalization, length of stay during admission, direct medical and nonmedical cost, expenditure for the previous two years, and source of bearing the expenditure were recorded in a questionnaire. Diabetic patients with CKD prior to ESRD spend more per hospitalization than patients without any complications. [Median ₹ 12,664 vs. 3,214]. The total median cost of CKD patients on hemodialysis was significantly higher than other CKD patients (INR 61,170 vs. 12,664). The median cost involved in kidney transplantation was ₹ 392,920. The total expenditure for hospital admissions in two years was significantly higher for dialysis than transplantation. Patients on hemodialysis or kidney transplantation tend to stay longer as inpatient admissions. The source of funds for the expenditure was mainly personal savings (46%). The expenditure on hospital admissions for CKD was considerably higher, and so, there is a need to develop a protocol on a cost-effective strategy for the treatment of CKD.

There is no information on the frequency and clinicopathological correlations of the histopathological variants of primary focal segmental glomerulosclerosis (FSGS) in children presenting with idiopathic nephrotic syndrome (INS) in Pakistan. All consecutive children (≤17 years) who presented with INS, and in whom the histological diagnosis of FSGS was made on renal biopsies, were included in this prospective study. Their clinical, laboratory, and histopathological features at the time of presentation were noted from the case files and the biopsy reports for analysis and clinicopathological correlations. Out of 138 children, 93 (67.4%) were males and 45 (32.6%) were females. The mean age was 8.95 ± 4.14 (range: 1.5-17) years. All had NS, with steroid dependant NS (SDNS) in 45 (32.6%) and steroid resistant NS (SRNS) in 93 (67.4%) cases. Renal dysfunction at the time of presentation was found in six (4.3%) children. Global glomerulosclerosis was found in 68 (49.3%) cases. The mean number of glomeruli involved by segmental scarring was 2.98 ± 2.44. FSGS, not otherwise specified (NOS) was the most prevalent variant, comprising 89.1% of all cases. Collapsing variant comprised 8%, tip variant 1.4%, perihilar 0.7%, and cellular 0.7%. Hyaline arteriolosclerosis was found in 13 (9.4%) cases. Mild interstitial fibrosis/tubular atrophy was found in 95 (68.6%) cases, moderate in 18 (13%), and severe in two (1.4%) cases. In conclusion, FSGS, NOS variant was the highly prevalent variant, while collapsing type was also found in small but significant number of cases. Remaining three variants were distinctly rare in our children.

Blood pressure (BP) control at home is difficult when managed only with office blood pressure monitoring (OBPM). In this prospective study, the reliability of BP measurements in renal transplant patients with OBPM and home blood pressure monitoring (HBPM) was compared with ambulatory blood pressure monitoring (ABPM) as the gold standard. Adult patients who had living-related renal transplantation from March 2007 to February 2008 had BP measured by two methods; OBPM and ABPM at pretransplantation, 2 ^nd , 4 ^th , 6 ^th , and 9 ^th months and all the three methods : OBPM, ABPM, and HBPM at 6 months after transplantation. A total of 49 patients, age 35 ± 11 years, on prednisolone, tacrolimus, and mycophenolate were evaluated. A total of 39 were males (79.6%). Systolic BP (SBP) and diastolic BP (DBP) measured by OBPM were higher than HBPM when compared with ABPM. When assessed using OBPM and awake ABPM, both SBP and DBP were significantly overestimated by OBPM with mean difference of 3-12 mm Hg by office SBP and 6-8 mm Hg for office DBP. When HBPM was compared with mean ABPM at 6 months both the SBP and DBP were overestimated by and 7 mm Hg respectively. At 6 months post transplantation, when compared with ABPM, OBPM was more specific than HBPM in diagnosing hypertension (98% specificity, Kappa : 0.88 vs. 89% specificity, Kappa : 0.71). HBPM was superior to OBPM in identifying patients achieving goal BP (89% specificity, Kappa : 0.71 vs. 50% specificity Kappa : 0.54). In the absence of a gold standard for comparison the latent class model analysis still showed that ABPM was the best tool for diagnosing hypertension and monitoring patients reaching targeted control. OBPM remains an important tool for the diagnosis and management of hypertension in renal transplant recipients. HBPM and ABPM could be used to achieve BP control.

The incidence, risk factors and outcome of graft pyelonephritis are variably described in literature. All patients who had been transplanted at our center between January 2002 and November 2006 and had presented with acute graft dysfunction were subjected to biopsy. Those patients who had neutrophilic casts and interstitial inflammation with predominant neutrophils were included in the study. Out of the 265 patients, 110 were transplanted in the period and underwent biopsy for graft dysfunction. Out of the 110 patients, 26 had biopsy proven acute graft pyelonephritis (AGPN). Nine patients had early AGPN (within 6 months) and the other 17 had late AGPN. Nearly 19% of patients were culture negative and five patients had no clinical features of urinary tract infection; AGPN being a surprise finding on biopsy. Among the risk factors, only hepatitis C virus infection was significantly associated with AGPN. All patients received 4-6 weeks of antibiotics with at least 3 weeks of parenteral antibiotics. Majority (75%) of our patients experienced relapse of AGPN. Graft function was significantly lower 6 months after onset when compared to baseline, portending a poor outcome for these patients. Out of 26, 7 (27%) of our patients had biopsy features of concomitant acute cellular rejection. The treatment of acute rejection, however, did not improve the outcome.

Leptospirosis is a zoonosis of global importance caused by Leptospira interrogans. The aim of this study was to compare the data between children, adolescents and adults with leptospirosis. This is a retrospective study including a total of 373 consecutive patients with leptospirosis, admitted to tertiary hospitals in Northeast of Brazil, from May 1985 to August 2010. The patients were divided into two groups (age ≤21 years and >21 years). The adults were 304 (81.5%) of the population, with a mean ge of 41 ± 13 (range 22-84) years. The pediatric group was 16 ± 3 (range 9-21) years. Signs and symptoms where similar between the groups, excepting arrhythmia, which was more frequent in adults and vomiting, more common in children (16% vs. 0%, P = 0.04 and 65% vs. 79%, P = 0.02), respectively. Adult group presented with higher serum urea (137 vs. 97 mg/dl, P = 0.002) and creatinine (4.3 vs. 3.0 mg/dl, P = 0.007). Acute kidney injury (AKI) was observed in 80%, mainly in adults (83% vs. 70% P < 0.005). Adults required renal replacement therapy more frequently than children (38% vs. 11%, P < 0.0001). Mortality was higher in adults (14.8% vs. 2.8%, P = 0.005) and in adults with AKI (93% vs. 7%, P < 0.05). There are important differences between the adults and children with leptospirosis. AKI was more frequent in adults and it was associated with increased mortality.

We report a 16-year-old boy who presented with weakness of lower limbs. He was diagnosed to have Wilson's disease, renal tubular acidosis and osteoporosis. Screening of siblings showed that his younger sister was also affected by the disease.

Primary hypoparathyroidism can occur due to an activating mutation of calcium sensing receptor (CaSR). Most patients remain asymptomatic and therefore not diagnosed until adulthood. We present a 38-year-old lady who had a history of muscle cramps since 8 years. She presented with vomiting, abdomen pain and body ache, showed clinical evidence of hypovolemia, severe hypocalcemia, hypokalemia, hypomagnesemia, hyperphosphatemia and metabolic alkalosis. Her 24 h urinary phosphorus was low and 24 h urinary excretion of sodium, potassium and chloride were high. Her intact parathormone was on the lower side of the normal range. She improved once we had corrected her biochemical abnormalities. By excluding acquired causes of hypoparathyroidism, we are able to conclude that this may be a case of primary hypoparathyroidism due to activating mutation of CaSR.

Arteriovenous fistula (AVF) is an anomalous communication between an artery and a vein, caused by an iatrogenic or traumatic etiology. Surgically created upper limb AVF remains the preferred vascular access for patients on maintenance hemodialysis. Nonetheless central vein cannulation for hemodialysis is a common procedure done in patients who need hemodialysis. We incidentally detected a thyrocervical artery - jugular fistula in a patient on maintenance hemodialysis. He underwent a successful intra arterial coil embolization of the feeding vessel. Review of literature has shown that, a thyrocervical artery - internal jugular vein arteriovenous fistula following a central venous catheterization has not been reported so far.

Immunoglobulin A (IgA) dominant postinfectious glomerulonephritis (IgA PIGN) is a distinct clinical entity increasingly recognized in adult. It usually presents with reduced glomerular filtration rate, heavy proteinuria, and has unfavorable prognosis. Immunofluorescence study of renal biopsy specimens have IgA as dominant or codominant antibody. We encountered two cases of IgA dominant PIGN recently presenting as rapidly progr essive glomerulonephritis and managed conservatively. Both the patients are on follow-up and do not have complete recovery of renal function till date. Long-term follow-up is needed to assess the progression of the disease in these patients.

A brachiocephalic arteriovenous fistula was complicated by a central venous stenosis, which could not be relieved. A cephalojugular bypass was performed using an interpositoned graft, which later developed tight stenoses at both ends of the graft. This was successfully treated with endovascular intervention, extending the longevity of the vascular access.

Non-tubercular bacterial osteomyelitis is a rare infection. We report on a renal allograft recipient with osteomyelitis complicating urosepsis, manifesting as a multifocal infection poorly responsive to appropriate antibiotics and surgical intervention and culminating in graft loss.