Introduction: C4d is a biomarker of the complement cascade and has a primary role in the diagnosis of antibody-mediated rejection in solid organ transplantation. The present study was undertaken to investigate the role of C4d in the diagnosis and prognosis of native renal diseases. Methods: An observational cross-sectional study was conducted in the Department of Pathology from September 2017 to September 2019. In this study, we applied C4d staining by immunohistochemistry in 51 native renal biopsies. Semiquantitative scoring was done on the basis of intensity of C4d staining along the glomerular capillary wall (0–3) and mesangium (0–3), tubules (0–3), and arteries (0–3). These individual scores were added to get the total C4d score (0–12) which was correlated with chronicity index, serum urea and creatinine levels. Glomerular C4d score was correlated with 24 h urinary protein as well as with immunofluorescence deposition of immunoglobulins and complements. Results: We found a linear positive correlation (P < 0.05) between the total C4d score and serum creatinine; tubular C4d score and serum creatinine; and glomerular C4d score along capillary wall and 24 h urinary protein. A positive correlation (P < 0.05) was found between glomerular C4d score along the capillary wall with immunofluorescence deposits of immunoglobulins and complements, suggesting the efficacy of C4d as a surrogate marker in the diagnosis of native renal diseases. Conclusions: C4d deposition is associated with a poor prognosis in renal diseases and an accelerated deterioration of renal function. It also plays a role as a surrogate marker in diagnosis of native renal diseases.

Introduction: Atherosclerotic cardiovascular disease is a major cause of mortality and morbidity in dialysis patients. Compared to general population, dialysis patients have lower lipid levels and higher vascular events. This paradox is popularly known as reverse epidemiology. Present study is an attempt to understand reasons for low lipids in dialysis patients. Subjects and Methods: This was a prospective observational multicentric study involving three stages across six dialysis units with Care Hospitals, Hyderabad. Maintenance hemodialysis patients were studied with fasting lipid profiles [TC, LDL-c, HDL-c, and TG], pre- and post-dialysis blood lipids and effluent water lipid profiles. Other parameters studied were use of statins, interdialytic weight gain, and ultrafiltration. All patients had uniform dialysis protocols regarding filter used and dialysis duration. Results: Of the 91 patients studied, we observed significant rise in post-dialysis TC, LDL, and HDL [P < 0.01] and lower lipids [P < 0.01] just before the next dialysis. Lipids were least filtered across the membrane except HDL, which was found in effluent water for more than 60% of patients. Single use of dialyser was associated with higher rise in post dialysis lipids as well as HDL getting filtered in effluent [P = 0.24]. Rosuvastatin was associated with lower lipid values [P = 0.08] and BMI [P = 0.19]. Conclusions: Low lipid levels in dialysis patients are due to dilutional hypolipidemia and needs correction with an equation proposed in present study. Corrected lipids should be used for risk stratification and deploying treatment.

Introduction: Since COVID-19 has been announced as a pandemic, outcome of dialysis patients in terms of morbidity and mortality from India is lacking. We studied the clinical, epidemiological features of COVID-19 along with outcome in terms of mortality in our dialysis cohort. Methods: Data of End-Stage Kidney Disease (ESKD) patients who were admitted in COVID-19 designated hospital block as positive and suspected patients from 1^st April 2020 to 31^st July 2020 was retrieved. Data about epidemiological characteristics, clinical features, mortality outcomes of COVID-19 positive and negative patients were analyzed. Results: A total of 97 ESKD patients were admitted during the study period, of which 44 (45.4%) and 53 (54.6%) patients were found to be COVID-19 positive and negative respectively. The mean age of COVID positive patients was 46 years with 54.5% being female. Only three patients (6.8%) remained asymptomatic throughout the course of illness. Amongst COVID-19 positive, 20 (45.45%) were severely ill while 18 (40.9%) were having mild illnesses. Breathlessness (65.9%) and fever (61.4%) were common symptoms. The death occurred in 17 (38.6%) and 25 (47.1%) COVID-19 positive and negative ESKD patients respectively. 14 (82.3%) patients who expired amongst COVID-19 positive were having severe illness and significantly more were associated with negligible residual renal function. Conclusions: Breathlessness and fever were common symptoms amongst COVID-19 ESKD patients. Very few patients remained asymptomatic in our cohort and significantly more mortality is observed in severely ill patients and those with negligible residual renal function.

Introduction: Optimal induction for kidney transplantation in patients with previous nonrenal organ transplantation is unclear. We aimed to evaluate the impact of induction therapy on the outcomes following kidney transplantation in patients who underwent prior heart or liver transplantation. Methods: Using the UNOS database, patients who underwent isolated heart or liver transplant from 2000 to 2016 followed by subsequent kidney transplant and maintained on calcineurin inhibitor (CNI)/mycophenolic acid (MPA) regimen were identified and stratified into three groups according to the induction used for kidney transplant: No induction, induction with interleukin-2 receptor antibody (IL-2RA), or T-cell depleting induction with Thymoglobulin. The outcomes were compared between no induction vs. IL-2RA and T-cell depleting induction, and IL-2RA vs. T-cell depleting induction. Results: Adjusted risk for delayed graft function was significantly higher for T-cell depleting vs. no induction (OR 4.56, 95% CI 1.14–18.3, P = 0.03) and trended higher for IL-2RA vs. no induction (OR 2.96, 95% CI 0.84–10.33, P = 0.08) among kidney after heart group and significantly higher for T-cell depleting vs. no induction (OR 2.88, 95% CI 1.40–5.95, P = 0.004) and IL-2RA induction (OR 1.88, 95% CI 1.12–3.17, P = 0.02) among kidney after liver patients. Adjusted graft failure and patient death risks were similar in patients who got IL-2RA or depleting inductions vs. no induction and IL-2RA vs. depleting induction groups in kidney after heart and kidney after liver groups. Conclusions: The use of induction was not associated with graft or patient survival benefits for kidney transplantation in patients who had prior heart or liver transplants and maintained on CNI and MPA regimen.

Introduction: Proton pump inhibitors (PPIs) are liberally used over the counter medication and is largely considered safe. Off late, there are many reports that suggest increased incidence of chronic kidney disease with long-term PPI use. PPIs are often prescribed in patients with diabetes mellitus (DM) and one of the well-known complications of DM is diabetic nephropathy (DN). Thus, the aim of our study was to evaluate association between PPI use and DN. Methods: It was a case-control study conducted over a 2-year period (April 2017–March 2019). Cases were outpatients with type II DM and associated DN. Controls were age and sex-matched type II DM without DN. Results: A total of 200 participants, 100 each in the case and control group, were recruited. The proportion of participants using PPI was 62% in the cases and 42% in the controls (P = 0.005). The most common PPI used was pantoprazole. Increased duration of PPI use was significantly associated with DN [adjusted odds ratio: 1.171; 95% confidence interval: 1.022, 1.341; P = 0.023]. Conclusion: There is a significant association between the use of PPIs and DN in patients with type II DM. Since PPIs have other beneficial effects in patients with DM such as glycaemic control and relief from gastro-oesophageal symptoms, need for risk benefit assessment for long-term use of PPIs in DM is warranted.

Introduction: Angiographic procedures are underused in patients with chronic kidney disease (CKD), who present with acute coronary syndromes, due to risk of contrast-induced acute kidney injury (CI-AKI). In this study, we assessed the change in estimated glomerular filtration rate (eGFR) over 3 months following coronary procedures in CKD patients. Methods: This observational study was done from July 2017 to January 2019 in patients undergoing elective coronary procedures with an eGFR <60 mL/min/1.73 m². CKD-EPI equation was used to calculate eGFR pre and post coronary procedure at 24, 48, and 72 hours as well as 30, 90 days. AKI was diagnosed and patients were given prophylaxis for CI-AKI as per KDIGO recommendation (intravenous normal saline and oral N-acetyl cysteine). Results: Patients studied were 282 (225 males, 57 females) of which 68.1% were diabetics. Mean eGFR was 42.91 ± 10.51 mL/min/1.73 m² and mean hemoglobin was 12.08 ± 1.51 gm/dL. Coronary angiogram (CAG) was done in 174; percutaneous transluminal coronary angioplasty (PTCA) was done in 108. Mean contrast volume in CAG was 55.17 ± 34.45 mL and in PTCA was 156.94±±47.99 mL. CI-AKI was seen in 66 (23.4%) patients. The incidence of CI-AKI increased with severity of underlying CKD. The variability of eGFR at 1 and 3 months after coronary procedures showed no significant change from baseline, even in the patients who developed CI-AKI. Conclusions: CI-AKI is self-limiting and has no major detrimental effects on eGFR at 1 and 3 months after contrast exposure.

Introduction: Chronic hemodialysis (CHD) remains the most "resorted to" renal-replacement option in India. Pursuit for accessible and affordable dialysis has resulted in setting up standalone centers (SACs). We need more Indian data on the profile of CHD population and outcome of SAC compared to hospital-based units (HBUs). Material and Methods: We analyzed the clinical profile of patients on CHD for >5 years, compared the outcome between HBU and SAC, and analyzed the factors associated with mortality. Patients initiated between January 1, 2006 and December 31, 2012 and who have survived 5 years on CHD at HBU or SAC were enrolled and followed up prospectively for 2 years. Their clinical and biochemical profile, comorbidities, long-term complications, and mortality were analyzed. Results: The study included 137 patients, 41 (30%) from HBU and 96 (70%) from SACs. In both groups, the patients were predominantly male, aged 51–70 yrs, diabetic, unplanned initiation through catheters, and had average-dialysis vintage between 83 and 85 months. SAC had more patients with hemoglobin (> 11 gm/dL) and hyperparathyroidism with elevated SAP levels (P < 0.05). Both groups had comparable iron stores, serum calcium, and phosphorus. Comparable between groups, infections, coronary artery disease, and access complications accounted for most hospitalizations and sudden cardiac death and sepsis accounted for most mortality. A trend of better survival was seen in SAC. Multivariate analysis showed anemia, DM and hospitalizations were associated with mortality. Conclusion: We conclude that the outcomes of long-term CHD at SACs are not inferior to HBUs. Anemia, diabetes, and hospitalizations were associated with overall mortality. Benefits of SACs in cost, QOL, and employment opportunities need to be studied in the Indian context.

Background: Systemic lupus erythematosus (SLE) is an autoimmune systemic disorder, more common in females of reproductive age-group as compared with males. There are very few studies regarding lupus nephritis (LN) in males. Hence, we decided to study the clinical and pathological findings of LN in males. Materials and Methods: We carried out a retrospective study over a period of 5 years (January 2014–December 2018) on indicated native renal biopsies from male patients with LN. We analyzed the clinical, laboratory, and histological findings of these patients. Results: Renal biopsies were performed on 228 patients with LN, of which 29 (12.72%) biopsies were in male patients. The mean age at presentation was 28.3 ± 12.98 years. Edema (65.5%) was the most common clinical feature followed by arthritis (27.58%), fever (27.58%), and skin rash (24.1%). The mean values for 24 hours urinary protein, serum double-stranded DNA, serum antinuclear antibody, and serum complement C3 were 4.98 ± 2.91 g, 137.7 ± 91.93 IU/mL, 2.96 ± 1.78, and 65.07 ± 36.30 mg/dL, respectively. On histology, the most common class of LN was Class IV (34.48%) followed by Class V (20.68%), combined Class IV + V (20.68%), Classes II, III, and III + V. Conclusion: LN can affect males, although the prevalence is lower than in females. The incidence of LN in our study was 12.7% with the most common histological class being diffuse proliferative LN.

Introduction: Histologic assessment of interstitial fibrosis and tubular atrophy is an accepted method of assessing chronic damage to the kidney and correlates with renal function in native and allograft renal biopsies. The challenge, however, is to quantify the interstitial fibrosis and tubular atrophy with accuracy and to minimize the inter-observer variability. Though “eyeballing” on light microscopy is the most commonly practised method used for the quantification of tubular atrophy, it may not be very accurate. To complement this method, Whole Slide Imaging (WSI) techniques that have more accurate results and have a higher reproducibility can be used. There is not much data on the correlation of the results obtained by the 'eyeballing' technique with those by digital WSI. Methods: Tubular atrophy in 151 consecutive adequate native kidney biopsies were graded 0 to III by 'conventional' eyeballing by a single experienced renal pathologist. These results were compared with the grades obtained on the same cases by WSI and digital marking of the atrophy. Results: The concordance of the two groups in the entire cohort was only 66.2% with over grading in 30.4% and under grading in 3.3%. Whilst accuracy of grading was over 74% in all grades, the sensitivity in grades I and II were low at 52% and 47.3% respectively as was the positive predictive value at 32.5 and 44% respectively. Conclusion: Assessment of tubular atrophy on digital images will be the way forward for accurate quantification.

Glomerular diseases are one of the most challenging entities in terms of diagnosis and management, especially when associated with systemic illnesses such as malignant disorders. Herein, a case of crescentic glomerulonephritis (CrGN) associated with polycythaemia vera (PV) in a 50-year-old female is described. She presented with bilateral pedal oedema, splenomegaly, renal dysfunction and severe proteinuria. On evaluation, we found PV and CrGN. Renal involvement in PV is rare and generally considered as a manifestation of hypervolemia or high-viscosity-induced renal hyper-perfusion and hyper-filtration. This is a unique case of immunologically-mediated renal disease in PV.

Hemorrhage is the most frequently encountered post renal biopsy complication; reported in 12% to 14% of patients. Although the vast majority of these are due to renal artery injury, involvement of gonadal arteries is also rarely seen. These may be managed by the endovascular route, which has several limitations in this subset of patients. We report a case of a 69-year-old male with rapidly progressive glomerulonephritis, who underwent renal biopsy and developed a testicular artery pseudoaneurysm (PA). Successful embolization of this PA was performed under ultrasound guidance using a direct percutaneous approach. This is the first such case reported in the literature.

Sickle cell nephropathy is one of the long-term complications of sickle cell disease (SCD). About a quarter of SCD patients who survive up to 40 years of age will require some form of renal replacement therapy in their lifetime. Organ transplantation in SCD patients poses great challenges, particularly in lower middle income countries (LMIC) like Nigeria. This report highlights the management of three SCD patients who successfully underwent renal transplantation. The patients were aged 39, 47, and 58 years, respectively, with similarly previous history of multiple blood transfusions, recurrent vaso-occlusive crises, and had all progressed to end-stage renal disease. Preoperative exchange blood transfusion and plasmapheresis were offered in one and two of the patients, respectively. One of them required preoperative vaccination against encapsulated organisms due to autosplenectomy. Antithymocyte globulin was used as induction therapy in two of these patients while basiliximab was used in the third. All patients are alive with good renal function 18, 24, and 48 months post transplantation, respectively. In conclusion, kidney transplantation can be safely carried out on SCD patients with a satisfactory outcome.

TAFRO (thrombocytopenia, anasarca, fever, renal dysfunction, and organomegaly) syndrome is a subtype of Castleman's disease and has been described in recent years. In this case, a middle-aged woman was admitted to our clinic with a 2-week history of fever, weakness, cough, shortness of breath and edema all over the body. Physical examination on admission revealed pale conjunctiva, tachycardia, coarse crackles over left lower lung fields, pitting edema in the extremities, tense ascites, axillar, and bilateral inguinal lymph nodes measuring less than 2 cm. Inguinal lymph node excisional biopsy was compatible with TAFRO syndrome. We started corticosteroid treatment. The patient's general condition and physical findings improved. Laboratory values returned to normal limits. This case will help understand the clinical course and treatment strategy in TAFRO syndrome.

Cardiovascular disease is a leading cause of death in children with chronic kidney disease (CKD). A strong correlation exists between disturbed calcium–phosphate metabolism and cardiac dysfunction. Studies with use of cinacalcet in CKD are few and limited to older children and adults and in improving growth and bone deformities. We present three children with CKD on CAPD with cardiac dysfunction with refractory hyperparathyroidism. Patients were initiated on lowest adult weight-adjusted dose of 0.2 mg/kg/day. Dose was titrated every 30 days to achieve decline in iPTH to a goal of 200– 300 pg/ml. Serum calcium, phosphorus and iPTH levels were checked monthly. Complications of therapy related to cinacalcet monitored. Monthly echocardiography done to monitor cardiac dysfunction. None of them experienced significant adverse effects of cinacalcet therapy.

Tenofovir disoproxil fumarate is part of the first-line antiretroviral therapy and can lead to Fanconi syndrome, acute kidney injury, chronic kidney disease, and reduced bone mineral density. We report the first case of simultaneous occurrence of nephrolithiasis, urolithiasis, Fanconi syndrome, and bone fracture in a 54-year-old lady who presented with pain and inability to bear weight on the right lower limb following a trivial fall. She was diagnosed with human immunodeficiency infection in the year 2000 and was on tenofovir, lamivudine, and efavirenz for the past 6 years. On evaluation, she had azotemia, glycosuria, proteinuria, normal anion gap metabolic acidosis, multiple renal stones, and a proximal ureteric calculus causing right-sided hydroureteronephrosis. The patient developed sepsis following the double “J” stenting procedure. She was managed with intravenous bicarbonate therapy and the substitution of tenofovir to abacavir with a favorable outcome.

Portal-systemic venous shunts can rarely develop without any intrinsic liver diseases. However, the cause of shunt formation in these cases are not very clear. Literature suggests that hemodialysis can precipitate symptoms in patients with asymptomatic portal-systemic venous shunts (PSVS). Rare presentations of recurrent encephalopathy due to PSVS in the absence of liver dysfunction has been described in patients undergoing hemodialysis. We report a rare case of recurrent Hemodialysis Related Porto-Systemic Encephalopathy (HRPSE) in a 50-year old male during maintenance hemodialysis secondary to a PSVS between the portal vein and left renal vein. Shunt embolism by an 18 mm Amplatzer vascular plug (AVR II) was done and follow up CT showed complete occlusion of collaterals. Post-procedure, he is undergoing thrice-weekly Hemodialysis of 4 hours duration till date with no further incidence of encephalopathy. Our report indicates that recurrent encephalopathy can occur in dialysis patients due to symptomatic PSVS and HRPSE should be considered even in non-cirrhotic cases for early detection and effective management.