Anti-human leukocyte antigen (HLA) antibodies are recognized as an important problem in organ transplant recipients. This is because antibodies formed against a graft months or years after implantations are the major cause of late allograft failure, and also because protocols allow the transplantation of some grafts across pre-formed HLA antibodies. Advances in our understanding of anti-HLA antibody- mediated rejection (AMR) have occurred because of a better understanding of the histological findings during AMR; more sensitive and specific methods to measure anti-HLA antibodies; and through clinical investigation of patients transplanted across an HLA barrier. Despite advances in therapy and investigation, AMR remains a major problem and treatment protocols often fail to treat it successfully. This review aims to describe the issues in each of these areas and to suggest how clinicians may be able to improve the management of patients with anti-HLA antibodies.

We investigated the role of hepcidin in ameliorating anemia in hemodialysis patients with hepatitis. A total of 72 hemodialysis patients with hepatitis were classified according to their requirement of erythropoietin (EPO). Anemia parameters, C-reactive protein (CRP), and biochemical measurements were recorded along with the hepcidin. The number of patients receiving no EPO was higher among patients with liver disease when compared with those without liver disease (P = 0.002). The mean hepcidin levels of the patients who did not receive EPO did not differ statistically from those of the patients who received the maximum dose (P = 0.5). The hepcidin levels of patients with liver disease who received no EPO were lower compared to those patients without liver disease who received the maximum dose (P = 0.04). There was a positive correlation between hepcidin and mean platelet levels (r = 0.26, P = 0.027) and annual intravenous iron dose (r = 0.31, P = 0.007). In hemodialysis patients with hepatitis, liver disease may be one of the factors affecting erythropiesis, related with decreased hepcidin levels and iron hemostasis. Further studies are needed to verify these associations.

Nutrition is one of the key parameters in predicting morbidity and mortality in patients with end-stage renal disease (ESRD) on hemodialysis. Body weight, body mass index, and visceral protein levels (serum protein, albumin, prealbumin, and transferrin) have traditionally been used as markers for nutritional status. Serum leptin and C-reactive protein (CRP), have been recently added to the list of markers for nutritional status. This study was a comparative assessment of serum leptin and CRP for nutritional status in patients with ESRD on maintenance hemodialysis. A total of 40 patients with ESRD on maintenance hemodialysis and a similar number of age-, gender-, and BMI-matched healthy individuals were studies. Complete medical history was obtained and relevant clinical examination including anthropometry was carried out. All the individuals were subjected to routine investigations and special investigations (serum leptin and CRP). Data were analyzed using Student's t-test and correlation was found using Pearson's correlation coefficient. Mean value of serum leptin for the study group (1.44 ± 0.72 ng/ml) was found to be significantly higher than that of the control group (0.68 ± 0.55 ng/ml). In addition, we also observed a positive correlation between serum leptin and BMI (r = 0.350, P<0.05). For CRP, we observed that the study group (3.93 ± 1.20 mg/ml) had a significantly higher value vis-à-vis the control group (0.28 ± 0.24 mg/ml). However, CRP and BMI did not show a significant correlation. Based on the above observations, we conclude that serum leptin is a better biomarker than CRP for assessing nutritional status in patients with ESRD on maintenance hemodialysis.

The Care Pathway project used a multilevel and multimethod approach to explore access to the care pathway for diabetic renal disease. Taking what was known about the outcomes of ethnic minority patients with diabetic renal disease; the study sought to explore and further understand how and why South Asian patients' experiences may be different from the majority of population in relation to access. Through improved understanding of any observed inequalities, the study aimed to inform the development of culturally competent diabetes services. The design incorporated audits of patient indicators for diabetes and renal health at key points in the pathway: Diagnosis of diabetes and referral to specialist renal services in two years- 2004 and 2007, and qualitative individual interviews with patients and providers identified through the 2007 samples. This article describes the care provider perspective of access to diabetes care from a thematic analysis of 14 semistructured interviews conducted with professionals, at three study sites, with different roles in the diabetes pathway. National policy level initiatives to improve quality have been mirrored by quality improvements at the local practice level. These achievements, however, have been unable to address all aspects of care that service providers identified as important in facilitating access to all patient groups. Concordance emerged as a key process in improving access to care within the pathway system, and barriers to this exist at different levels and are greater for South Asian patients compared to White patients. A conceptual model of concordance as a process through which access to quality diabetes care is achieved and its relation to cultural competency is put forward. The effort required to achieve access and concordance among South Asian patients is inversely related to cultural competency at policy and practice levels. These processes are underpinned by communication.

Abdominal aortic calcification (AAC), cardiac valvular calcification (CVC), and atherosclerotic carotid plaque (CP) are known cardiovascular risk factors. The accuracy of the AAC score in predicting CP and CVC in patients with end-stage renal disease (ESRD) is assessed in this study. Twenty-two consecutive prevalent dialysis patients (group 1) and 26 consecutive nondialysis stage V chronic kidney disease patients (group 2) were assessed for their demographic and laboratory variables. Lateral radiograph of the lumbosacral spine was used to assess the AAC score. CP and CVC were assessed using carotid sonography and echocardiogram, respectively. Prevalence of AAC, CP, and CVC in groups 1 and 2 was, respectively, 72.7%, 81.8%, and 72.7% and 76.9%, 80.8%, and 57.7%. AAC was strongly associated with CP and CVC in both groups (P < 0.001). Tests of accuracy for the AAC score as a predictor of CP and CVC showed sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio of a positive test, and likelihood ratio of a negative test, respectively, in group 1: 83%, 75%, 93%, 50%, 3.32, and 0.23 and 85%, 77%, 87%, 70%, 4.5, and 0.29, and in group 2: 90%, 95%, 83%, 69%, 3.9, 0.41, and 82%, 91%, 77%, 71%, 4.1, and 0.21. Reproducibility of the AAC score among observers was acceptable. The AAC score can predict CP and CVC with moderate accuracy in ESRD patients. However, as our study was underpowered, the findings need validation in larger, adequately powered studies.

The burden of noncommunicable diseases is rising in India. A high prevalence of lifestyle-related diseases in perimenopausal women in the community makes them vulnerable to chronic kidney diseases (CKD). A cross-sectional community-based study was carried out among women >35 years of age in the village of Ballabgarh, Haryana (north India). Eligible women were selected by the probability proportionate to size sampling method. Estimation of glomerular filtration rate (GFR) was carried out by using the age- and body surface area (BSA)-adjusted Cockcroft-Gault (CG) and modification of diet in renal disease (MDRD) equations. Association of risk factors such as obesity, hyperlipidemia, hypertension, and diabetes mellitus with CKD was also assessed using multivariate logistic regression analysis. A total of 455 women were studied. The prevalence of low GFR (<60 mL/min/1.73 m ² ) by the CG/BSA equations and MDRD equation was found to be 18.2% (95% confidence interval 14.6, 21.8) and 5.9% (95% confidence interval 3.7, 8.1), respectively. Obesity (odds ratio 15.5) ( P = 0.002), hyperlipidemia (odds ratio: 2.5) ( P = 0.017), and age ( P < 0.001) were significantly associated with reduced GFR on multivariate logistic regression analysis. This study observed a high prevalence of CKD and its risk factors among perimenopausal women in a rural community in north India. The study highlights the need of a multipronged, community-based intervention strategy that includes a high-risk screening approach and awareness generation about CKD and its risk factors in the community.

Several studies have evaluated cytoskeletal proteins as prognostic factors for some types of nephrotic syndrome. However, studies concerning children with FSGS are scarce. This study was done to evaluate the glomerular, tubular, and interstitial expression of vimentin, desmin, and alpha smooth muscle actin (α-SMA) in kidney specimens of children with FSGS. Clinical and histologic data of 31 children with FSGS were reviewed. Thirty one formalin-fixed, paraffin-embedded kidney biopsy sections (3 μm) were selected for immunohistochemical staining. Double immunohistochemistry using a microwave-based two-color staining was applied. The mean age at onset in male and female was 56.3 ± 41.4 and 78.0 ± 60.4 months, respectively. The duration of follow-up was 46.3 ± 56.5 months. Interstitial fibrosis and tubular atrophy were reported in 42% and 54% of the patients, respectively. The latest evaluated mean blood pressure was significantly correlated with the expression of both vimentin and α-SMA in the interstitium (P < 0.05). However, we were not able to demonstrate any cytoskeletal protein expression as an independent predictor for renal survival. Further studies with larger sample size and longer follow-up periods are warranted to investigate the prognostic values of other histopathologic features in pediatrics with FSGS.

Self-injection of mercury can be life-threatening. We report a case of attempted suicide by self-intravenous injection of elemental mercury. The patient suffered from two side effects : membranous nephropathy and aplastic anemia. She was treated and the systemic effects of mercury were reversed after 4 years. The toxicology of mercury, mechanisms of renal and systemic toxicities, and the various therapeutic measures for mercury poisoning are discussed.

Nephrotic syndrome in infancy and childhood can be associated with thromboembolic complications. We describe two cases of nephrotic syndrome who presented with non-specific findings. Magnetic resonance imaging brain with magnetic resonance venography showed thrombosis of multiple venous sinuses. Patients were successfully treated with anticoagulants and there was complete resolution of thrombosis on repeat imaging.

Primary hyperoxaluria is an autosomal recessive disorder caused by deficiency of alanine-glyoxylate aminotransferase, which is encoded by the AGXT gene. We report three Indian children with primary hyperoxaluria type1 having a common mutation in this gene. All patients had evidence of chronic kidney disease at the time of diagnosis, with subsequent progression to end-stage renal disease. The detection of an identical mutation in the AGXT gene suggests that specific genetic screening for this mutation may be useful when considering the diagnosis of primary hyperoxaluria type1.

Although mucocutaneous candidiasis is a common infection in renal transplant recipients, disseminated candidiasis is rare. Candida pnemonia causing miliary mottling on X-ray chest with the central nervous system involvement is still rarer. We report an unusual case with disseminated candidiasis that presented 18 years after renal transplantation and improved on conventional antifungal therapy; the relevant literature is reviewed.

Renal tubular acidosis (RTA) is a group of transport defects in the reabsorption of bicarbonate, the excretion of hydrogen ion (H ⁺ ), or both, resulting in systemic acidosis and hypokalemia with a normal glomerular filtration rate. Although isolated proximal (type 2) or distal (type 1) tubular pathologies are well characterized, a combined pathology leading to type 3 RTA is very rare. Here, we report a case of type 3 RTA, using an algorithmic approach to classify a scenario of hypokalemic metabolic acidosis in the setting of episodic flaccid paralysis.

The most common pattern of renal involvement in infective endocarditis is infection-associated glomerulonephritis. Due to clinical symptoms and signs that overlap with vasculitis, the diagnosis of infective endocarditis may be delayed. The unusual combination of reduced complement with positive antineutrophil cytoplasmic antibody should raise the suspicion of infections such as infective endocarditis.

Atheroembolic renal disease is characterized by renal failure secondary to occlusion of renal vasculature by cholesterol containing atheromatous plaques. Clinical presentations of this disease entity are myriad, with limited therapeutic options and unfavorable outcomes. This report describes an elderly male patient with peripheral vascular disease who developed acute renal failure during hospital admission for rectal bleed, and was diagnosed with atheroembolic renal disease on renal biopsy. The patient was managed with pulse steroid therapy and had a favorable outcome.

Gastric antral vascular ectasia (GAVE), also called watermelon stomach, is a rare cause of gastrointestinal (GI) bleeding. GAVE is associated with a number of conditions, including portal hypertension, chronic kidney disease (CKD), and collagen vascular diseases, especially scleroderma. Limited reports of GAVE are present in CKD patients. Argon plasma coagulation (APC) is an effective therapy for GAVE. We describe the case of a CKD, stage V patient, who presented with recurrent blood loss in stools and transfusion-dependent anemia. Her endoscopy revealed GAVE, which was managed uneventfully with APC.

Vascular anomalies increase the difficulty during live donor nephrectomy. We herein report a left-sided retroperitoneoscopic living donor nephrectomy performed in a donor with a duplicated inferior vena cava (IVC). Computed tomography angiography provided accurate delineation of the venous anatomy and allowed preoperative planning. The duplicated IVC was clipped and divided just below its confluence with the left renal vein. The length of the left renal vein was sufficient for anastomosis in the recipient, and the recipient's serum creatinine was 1.21% on day 7. The donor made an uneventful recovery. Duplicated IVC is not a contraindication for left retroperitoneoscopic donor nephrectomy.