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COMMENTARY |
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Rituximab use in late antibody-mediated rejection |
p. 315 |
SB Bansal DOI:10.4103/0971-4065.179305 PMID:27795622 |
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ORIGINAL ARTICLES |
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Rituximab in the treatment of refractory late acute antibody-mediated rejection: Our initial experience |
p. 317 |
M Surendra, SB Raju, N Raju, S Chandragiri, KK Mukku, MS Uppin DOI:10.4103/0971-4065.177207 PMID:27795623Antibody-mediated rejection (AMR) is not uncommon after renal transplantation and is harder to handle compared to cell-mediated rejection. When refractory to conventional therapies, rituximab is an attractive option. This study aims to examine the effectiveness of rituximab in refractory late acute AMR. This is a retrospective study involving nine renal transplant recipients. Four doses of rituximab were administered at weekly interval for 4 weeks, at a dose of 375 mg/m 2. The mean age of patients was 35.3 ± 7.38 years. The median period between transplantation and graft dysfunction was 30 ± 20 months. Mean serum creatinine at the time of discharge after transplantation and at the time of acute AMR diagnosis was 1.14 ± 0.19 mg/dl and 2.26 ± 0.57 mg/dl, respectively. After standard therapy, it was 2.68 ± 0.62 mg/dl. One patient died of Pseudomonas sepsis and three patients progressed to end-stage renal disease (ESRD). Four biopsies showed significant plasma cell infiltrations. Mean serum creatinine among non-ESRD patients at the end of 1 year progressed from 2.3 ± 0.4 to 3.8 ± 1.2 mg/dl (P value 0.04). eGFR prior to therapy and at the end of 1 year were 34.4 ± 6.18 and 20.8 ± 7.69 ml/min (P value 0.04), respectively. Only one patient showed improvement in graft function in whom donor-specific antibody (DSA) titers showed significant improvement. Rituximab may not be effective in late acute AMR unlike in early acute AMR. Monitoring of DSA has a prognostic role in these patients and plasma cell rich rejection is associated with poor prognosis. |
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Rifampicin and anti-hypertensive drugs in chronic kidney disease: Pharmacokinetic interactions and their clinical impact |
p. 322 |
A Agrawal, SK Agarwal, T Kaleekal, YK Gupta DOI:10.4103/0971-4065.176145 PMID:27795624Patients on dialysis have an increased incidence of tuberculosis (TB). Rifampicin, a first-line antitubercular therapy (ATT) drug, is a potent inducer of hepatic cytochrome P450 (CYP). There is potential for pharmacokinetic interaction between rifampicin and anti-hypertensives that are CYP substrates: amlodipine and metoprolol. Therefore, hypertensive patients receiving rifampicin-based ATT are at risk for worsening of hypertension. However, this hypothesis has not yet been systematically studied. In this prospective study, hypertensive CKD 5D patients with TB were followed after rifampicin initiation. Blood pressure (BP) was ≤140/90 mmHg with stable anti-HT requirement at inclusion. Serum amlodipine, metoprolol, and prazosin levels were estimated by high-performance liquid chromatography at baseline and 3, 7, 10, and 14 days after rifampicin initiation. BP and anti-HT requirement were monitored for 2 weeks or until stabilization. All 24 patients in the study had worsening of hypertension after rifampicin and 83.3% required increase in drugs to maintain BP <140/90 mmHg. Serial amlodipine levels were estimated in 16 patients; metoprolol and prazosin in four patients each. Drug levels declined by >50% in all patients and became undetectable in 50-75%. Drug requirement increased from 4.5 ± 3.6 to 8.5 ± 6.4 units (P < 0.0001). Mean time to first increase in dose was 6.5 ± 3.6 days. Eleven (46%) patients experienced a hypertensive crisis at 9.1 ± 3.8 days. Three of them had a hypertensive emergency with acute pulmonary edema. In two patients, rifampicin had to be discontinued to achieve BP control. In conclusion, rifampicin caused a significant decrease in blood levels of commonly used anti hypertensives. This decrease in levels correlated well with worsening of hypertension. Thus, we suggest very close BP monitoring in CKD patients after rifampicin initiation. |
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A prospective audit of complications in 100 consecutive pediatric percutaneous renal biopsies done under real-time ultrasound guidance |
p. 329 |
R Sinha, B Maji, B Sarkar, S Meur DOI:10.4103/0971-4065.171232 PMID:27795625Despite being a common procedure, percutaneous renal biopsy (PRB) carries the potential for complications. The British Association of Paediatric Nephrologist (BAPN) has published standards for pediatric PRB. As Indian data are scarce, we conducted a prospective audit of 100 consecutive pediatric renal biopsies (60% males) under real-time ultrasound guidance. Nephrotic syndrome was the most common indication for PRB (68%) with minimal change disease (30%) and focal segmental glomerulosclerosis (25%) being the most common histopathological lesions. Gross hematuria was observed in six cases. Major complications was noted in one case, who needed longer hospital stay. The result of the audit demonstrated achievability of BAPN standards. In addition, we also show the usefulness of 16 gauge biopsy needle over 18 gauge biopsy needles (median number of glomeruli 25, range 3-90 vs 13, range 6-46, P = 0.001) without any increase in complications. Being a single center study, we do hope that our results will encourage a wider survey on the current state of pediatric PRB. |
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Anti-glomerular basement membrane crescentic glomerulonephritis: A report from India and review of literature |
p. 335 |
A Gupta, V Agrawal, A Kaul, R Verma, R Pandey DOI:10.4103/0971-4065.172227 PMID:27795626Anti-glomerular basement membrane (anti-GBM) disease is an autoimmune disease that most commonly presents as rapidly progressive glomerulonephritis with or without pulmonary involvement. It is characterized by the presence of antibodies directed to antigenic targets within glomerular and alveolar basement membranes. This study was performed to evaluate the clinicopathological features and outcome in anti-GBM crescentic glomerulonephritis (CrGN) at a tertiary care center in North India over a period of 9 years (January 2004 to December 2012). A diagnosis of anti-GBM CrGN was made in the presence of >50% crescents, linear deposits of IgG along GBM, and raised serum anti-GBM antibody titer. Of 215 cases of CrGN diagnosed during this period, 11 had anti-GBM CrGN. Anti-GBM CrGN was found at all ages but was most common in the third to fifth decade with no gender predilection (mean age 48 +/- 15 years, 13-67 years). Patients presented with a mean serum creatinine of 10.2 +/- 5.3 mg/dl and sub-nephrotic proteinuria. Pulmonary involvement was present in two patients. Myeloperoxidase-antineutrophil cytoplasmic antibody was positive in two (2/11) elderly patients. Follow-up was available in four patients for a range of 30-270 (mean 99.5 ± 114.5) days, two remained dialysis dependent while two died due to uremia and sepsis. Our findings show that anti-GBM disease is a rare cause of CrGN in India, accounting for only 5% of patients. It usually presents as a renal-limited disease and is associated with a poor renal outcome. |
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Hemodialysis among pregnancy related acute kidney injury patients: A single center experience in North-Western Nigeria |
p. 340 |
AM Makusidi, HM Liman, A Yakubu, M Hassan, MD Isah, A Chijioke DOI:10.4103/0971-4065.171224 PMID:27795627Pregnancy related acute kidney injury (PRAKI) patients that underwent hemodialysis (HD) between May 2007 and April 2015 were studied with specific reference to clinical features, laboratory values, duration of pregnancy at the diagnosis of acute kidney injury and outcome. It involved 38 patients aged between 15 and 30 years. The main clinical features were fever, edema and oliguria. The leading etiological factors included ante/postpartum hemorrhage, septic abortion, and toxemia of pregnancy. The majority of cases occurred during the third trimester. PRAKI is a dreaded complication of pregnancy with high morbidity and mortality. HD improved patient survival in our study. |
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Swan-neck versus straight peritoneal dialysis catheter: Long-term effect on patient and method survival |
p. 343 |
V Filiopoulos, D Biblaki, L Takouli, A Dounavis, D Hadjiyannakos, D Vlassopoulos DOI:10.4103/0971-4065.167274 PMID:27795628Peritoneal dialysis (PD) is limited mainly by a higher technique failure rate as compared to hemodialysis (HD), catheter malfunction being an important reason. Intra- and extra-peritoneal catheter configuration may be associated with mechanical and infectious complications affecting method survival. We report our experience with two extra-peritoneal catheter configurations: the straight and the swan-neck (SN) catheters. A total of 85 consecutive patients, 58 males and 27 females were included in the study. Among them, 26 were diabetics; 52 were treated with automated PD (APD) and 33 with continuous ambulatory PD (CAPD). Straight catheters were used in 38 patients (straight group) and SN catheters in 47 patients (SN group). Straight catheters were mostly used in the first 6-year period while SN catheters in the last 6-year period. The baseline demographics were similar between the two groups. A significantly higher frequency of APD use was observed in SN group. Technique survival was better with SN versus straight (log-rank test, P = 0.01) while patient and catheter survival were similar. A better technique survival is noted in our group of patients with SN catheters. An additional factor could be the significantly higher frequency of APD use in this group. Changes in PD solutions' composition could also contribute to improvement in technique survival. The outcome for patients and catheter types used was similar. |
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Clinicopathological correlation and treatment response of primary focal segmental glomerulosclerosis in adults and adolescents |
p. 347 |
J Dhanapriya, T Dineshkumar, N Gopalakrishnan, R Sakthirajan, T Balasubramaniyan DOI:10.4103/0971-4065.167283 PMID:27795629The incidence of focal segmental glomerulosclerosis (FSGS) is approximately 10% in children <6 years, 20% in adolescents, and 20-25% in adults. A retrospective observational study was done to document clinicopathological correlation, treatment response, and risk factors in the progression of chronic kidney disease (CKD) of primary FSGS in adults and adolescents. A total of 170 patients were studied with a mean follow-up of 4.32 ± 1.2 years. FSGS not otherwise specified was the most common subtype (56%) followed by tip variant (24%). About 32% had complete remission (CR) at a mean time of 6.4 months, 23% had partial remission (PR) at a mean time of 5.7 months, and 45% had no response to steroids. Persistent nephrotic proteinuria at 3 rd and 6 th month and presence of interstitial fibrosis and tubular atrophy >30% in renal biopsy are the independent predictors of poor response to treatment. Presence of anemia, interstitial fibrosis, and tubular atrophy of >30% in renal biopsy and the absence of remission after treatment were the independent predictors of CKD progression. Overall renal survival was 78% at 3 years and 54% at 5 years. Renal survival difference with or without nephrotic proteinuria at onset was 39% and 69% at 5 years. Renal survival was higher in patients with normal renal function (66%) compared with those who had renal failure (42%) at 5 years. Renal survival at 5 years for CR was 69%, PR was 49%, and no remission was 42%. |
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High hemodialysis vascular access flow and impaired right ventricular function in chronic hemodialysis patients |
p. 352 |
S Yilmaz, M Yetim, BK Yilmaz, T Dogan, E Aksoy, N Yuksel, I Dogan DOI:10.4103/0971-4065.164232 PMID:27795630There are limited data showing right ventricular preload increase due to high-flow arteriovenous fistulas (AVFs). This cross-sectional study investigated whether high AVF flow had an impact on right ventricular function in patients undergoing hemodialysis. Sixty-four patients aged between 18 and 85 years who were on routine hemodialysis with >2 hemodialysis sessions per week for at least 3 months via an AVF were studied. Patients with inadequate flow fistulas, severe chronic obstructive pulmonary disease, history of pulmonary embolism, primary pulmonary hypertension, severe mitral, aortic or pulmonary regurgitation, and/or stenosis were excluded. After an initial evaluation, 44 patients (mean age: 58.50 ± 16.84, male:female = 23:21) were considered eligible. Right ventricular function was assessed by tricuspid annular plane systolic excursion (TAPSE). AVF blood flow was measured with duplex ultrasound. There were 15 patients (34.1%) with a TAPSE of <16 mm. AVF blood flow was significantly higher in patients with impaired versus normal right ventricular function (1631.53 ± 738.17 vs. 1060.55 ± 539.92 min/ml, respectively, P = 0.003). Low left ventricular ejection fraction (odds ratio [OR]: 1.15, 95% confidence intervals [CI]: 1.007-1.334, P = 0.04), high interventricular septum thickness (OR: 1.64, 95% CI: 1.104-2.464, P = 0.01), and high AVF blood flow (OR: 1.00, 95% CI: 1.000-1.003, P = 0.03) were independent predictors of impaired right ventricular function. In addition to known risk factors that predominantly increase right ventricular afterload, excessive AVF blood flow was found to be independently associated with impaired right ventricular function, possibly by increasing right ventricular preload. |
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Clinicopathological correlates of chronic kidney disease of unknown etiology in Sri Lanka |
p. 357 |
M Selvarajah, P Weeratunga, S Sivayoganthan, N Rathnatunga, S Rajapakse DOI:10.4103/0971-4065.167280 PMID:27795631Chronic kidney disease of unknown etiology (CKDu) is a major healthcare issue in Sri Lanka. This study included 125 consecutive patients with a diagnosis of CKDu undergoing renal biopsy at one hospital from 2008 to 2012. Associations between renal outcome parameters, epidemiological data, and histopathological findings were examined and regression models constructed based on univariate associations with outcome variables as serum creatinine >1.2 and stage of CKD >3. The mean patient age was 46.21 years (standard deviation = 11.64). A marked male predominance was noted. A positive family history of CKD was seen in 35.8%. Prominent histopathological features were glomerular sclerosis (94.8%), interstitial infiltration (76%) with lymphocytic infiltration, interstitial fibrosis (71.2%), and tubular atrophy (70.4%). Importantly, significant histological changes were seen in patients with early CKDu. For CKD stage >3 independent associations were: interstitial fibrosis [P = 0.005; odds ratio (OR) =0.153] and interstitial infiltrate (P = 0.030; OR = 0.2440. For serum creatinine >1.2, independent predictors were >50% glomerular sclerosis (P = 0.041; OR = 0.92), tubular atrophy (P = 0.034; OR = 0.171, and more than 40 residential life years (P = 0.009; OR = 9.229). Chronic tubulointerstitial nephritis (TIN) appears to be the predominant histopathological finding in patients with CKDu, with significant renal pathology established early on in the course of the disease. Interstitial infiltration appears to be an independent association of advancing CKD, CKDu, histopathology, histology, and TIN. |
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CASE REPORTS |
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A novel heterozygous missense mutation in uromodulin gene in an Indian family with familial juvenile hyperuricemic nephropathy |
p. 364 |
D Saxena, P Srivastava, SR Phadke DOI:10.4103/0971-4065.167277 PMID:27795632Familial juvenile hyperuricemic nephropathy (FJHN), characterized by early-onset hyperuricemia, reduced fractional excretion of uric acid, and chronic renal failure is caused due to mutation in uromodulin (UMOD) gene. We identified a novel mutation in a family with multiple members affected with FJHN. Ten coding exons of UMOD gene in three family members with clinical and biochemical features of FJHN and one unaffected family member were sequenced, and sequence variants were analyzed for the pathogenicity by bioinformatics studies. A heterozygous novel missense mutation (c. 949 T >G) in exon 5 leading to the replacement of cysteine by glycine at position 317 was identified in all three affected family members. This mutation has not been reported earlier in Human Gene Mutation Database, Human Genome Variation, Clinvar, and 1000 Genome. The mutation lies in the cysteine-rich 2 domain of the protein, and the affected residue is evolutionary conserved in other species. To our knowledge, this is the first report of the identification of UMOD mutation in an Indian family. |
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Renal infarct following varicella infection |
p. 368 |
D Arora, A Jairam, D Mahapatra DOI:10.4103/0971-4065.181477 PMID:27795633Renal infarction usually occurs against a background of heart disease or a thromboembolic tendency and rarely is associated with infections. Here we present a case of a young boy who reported with painless gross hematuria following primary Varicella infection and was found to have an isolated renal infarct. |
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Complete remission of nephrotic syndrome and acute kidney injury in crescentic IgA nephropathy: Role of mycophenolate sodium |
p. 370 |
D Bhandari, KD Jhaveri, HH Shah DOI:10.4103/0971-4065.175985 PMID:27795634Optimal therapy and prognosis of crescentic-IgA nephropathy (C-IgAN) are not known. Reported treatment options for C-IgAN include combination of corticosteroids and cyclophosphamide for 6 months. The role of mycophenolate sodium in C-IgAN is unknown. We report a case of C-IgAN that was successfully treated with combination immunosuppressive therapy. |
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Collapsing glomerulopathy associated with pulmonary tuberculosis |
p. 373 |
ND Srinivasaprasad, G Chandramohan, V Praveen, ME Fernando DOI:10.4103/0971-4065.175981 PMID:27795635Collapsing glomerulopathy (CG) usually presents with reduced glomerular filtration rate, heavy proteinuria and has unfavorable prognosis. Numerous associations with CG are found. We encountered a case of CG associated with pulmonary tuberculosis presenting with proteinuria and dialysis-requiring severe renal failure. Our patient made partial recovery of his renal function and became dialysis-independent after antituberculous therapy and oral steroids. Long-term follow-up is needed to assess the progression of the disease. |
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Two consecutive recurrences of crescentic immunoglobulin A nephropathy in a renal transplant recipient |
p. 376 |
N Gopalakrishnan, S Murugananth, T Dineshkumar, J Dhanapriya, R Sakthirajan, T Balasubramaniyan DOI:10.4103/0971-4065.169565 PMID:27795636We report a 21-year-old male who developed end-stage renal disease, probably due to immunoglobulin A nephropathy (IgAN), received a renal transplant from his mother, which was lost due to crescentic IgAN after 18 months. Two years later, he received a second transplant from a deceased donor. He developed rapidly progressive graft dysfunction 3 years later. Allograft biopsy revealed crescentic IgAN, which was successfully treated with intravenous steroids and cyclophosphamide. Recurrence of IgAN in two successive allografts in one patient has not been reported previously. |
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Septicemic melioidosis in a transplant recipient causing graft dysfunction |
p. 379 |
S Sathiavageesan DOI:10.4103/0971-4065.168142 PMID:27795637Melioidosis, an infectious disease caused by Burkholderia pseudomallei, is endemic in the Northern Australia and South-East Asia. It is an emerging disease in the Indian subcontinent. Melioidosis tends to run a potentially lethal course in immunocompromised individuals and data in renal transplantation are scarce. The clinical presentation of melioidosis is diverse, mimicking several other infectious diseases. Diagnosis could be delayed in transplant recipients. Choice and duration of antimicrobial therapy, management of immunosuppression, and patient and graft outcomes are other issues to be addressed. We report septicemic melioidosis with pulmonary involvement in a 32-year old renal transplant recipient that caused acute allograft dysfunction. |
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IMAGES IN NEPHROLOGY |
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Bilateral nephrocalcinosis in primary hyperoxaluria type 1 |
p. 383 |
CA Mansoor, A Jemshad, DS Milliner, N. K. N. Bhushan DOI:10.4103/0971-4065.189317 PMID:27795638 |
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Mega-fistula |
p. 385 |
B Sangeetha, V Chaitanya, MH Reddy, A. C. V. Kumar, R Ram, V Sivakumar DOI:10.4103/0971-4065.175979 PMID:27795639 |
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LETTERS TO EDITOR |
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Large hemorrhagic ovarian cyst in postmenopausal patient with autosomal dominant polycystic kidney disease |
p. 387 |
VV Mishra, S Nanda, R Agarwal, R Aggarwal DOI:10.4103/0971-4065.181476 PMID:27795640 |
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Outreach activities for kidney diseases in children |
p. 388 |
U Ali, P Shanbag DOI:10.4103/0971-4065.181474 PMID:27795641 |
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Incidence of diabetes and hypertension in indigenous Amerindian village in Guyana, South America |
p. 389 |
RM Jindal, R Soni, K Mehta, TG Patel DOI:10.4103/0971-4065.181471 PMID:27795642 |
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