Depression and sleep disorders are more frequent in patients on maintenance hemodialysis (HD) than the general population, and are associated with reduced quality of life and increased mortality risk. The purpose of this study was to assess the prevalence of depression, sleep apnea, insomnia in patients on HD as well as depression in their primary caregiver and to correlate these with the demographic profile. A cross-sectional study was conducted among 69 patients on maintenance HD for more than 3 months. There was high p revalence of depression (47.8%), insomnia (60.9%), increased risk of sleep apnea (24.6%) and depression in caregiver (31.9%). Depression was significantly more in patients with low monthly income (P=0.03), those on dialysis for more than 1 year (P=0.001) and the unemployed (P=0.009). High-risk patients for sleep apnea tended to be males with low monthly income (P=0.02). Insomnia was significantly higher in patients who were on dialysis for more than 1 year (P=0.003).

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The prevalence of biopsy-proven glomerulonephritis varies according to the geographic area, socioeconomic condition, race, age, demography and indication of renal biopsy. This study analyzed the distribution of biopsy-proven renal disease (BPRD) and its changing pattern over a period of 19 years from a tertiary care hospital in south India. All the renal biopsies performed from 1990 to 2008 were reviewed retrospectively. Biopsies were evaluated by light microscopy and immunofluorescence microscopy and also special stains when warranted. A total of 1849 biopsies were analyzed. The mean patient age was 32.27 ΁ 18.38 (range 10-80) years. The male:female ratio was 1.4:1. The most common indications of renal biopsy were nephrotic syndrome (49%), followed by chronic renal failure (13.6%) and rapidly progressive renal failure (12%). Primary glomerulonephritis (PGN) comprised 1278 (69.1%) of the total patients. Among the PGN cases, the most common one was minimal change disease (21.8%), followed by focal segmental glomerulosclerosis [FSGS (15.3%)], membranous glomerulonephritis (10%), chronic glomerulonephritis (9.7%), postinfectious glomerulonephritis (8.1%), mesengioproliferative glomerulonephritis (7.5%), diffuse proliferative glomerulonephritis (6.7%), crescentic glomerulonephritis (6.5%), IgA nephropathy [IgAN (6.3%)], membranoproliferative glomerulonephritis (5.7%), focal proliferative glomerulonephritis (1.6%) and IgM nephropathy (0.5). Secondary glomerular disease (SGN) accounted for 337 (18.2%) of the cases. The most common SGN was lupus nephritis (80.1%), followed by amyloidosis (8%) and diabetic nephropathy (6.5%). Tubulointerstitial disease [124 (6.7%)] and vascular disease [60 (3.2%)] were less common. End-stage changes and miscellaneous disease were found in 37 (2%) and 13 (0.7%) cases, respectively. The incidence of FSGS and IgAN has been increasing since 1999. This study provides descriptive biopsy data and highlights the changing incidence of renal disease which is probably contributed by an increase referral due to increased awareness together with increased manpower and infrastructure.

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Nocardia is a rare pathogen of peritoneal dialysis-related peritonitis despite its universal presence in soil, organic matter, and water. Human infections are seen mostly in immunocompromized hosts. The usual primary site of lesions is lung. Nocardia can enter the peritoneal cavity through the Tenckhoff catheter. We describe the first case of nocardia peritonitis that had associated nocardia pneumonia. The Tenckhoff catheter was removed due to nonresolution of peritonitis. The organism was resistant to sulfamethoxazole-trimethoprim. The patient developed hypotension, disseminated intravascular coagulation, and respiratory failure and died.

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Histoplasmosis is a geographically restricted form of fungal infection. Adrenal involvement is seen in disseminated disease but sometimes it may be the only site of demonstrable disease. Early diagnosis and treatment may save the patient from catastrophic adrenal insufficiency. We present two patients showing bilateral adrenomegaly on ultrasonography and contrast-enhanced CT, and was diagnosed to have histoplasmosis on fine-needle aspiration cytology.

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Hennekam lymphangiectasia syndrome is a rare disorder comprising of intestinal and renal lymphangiectasia, dysmorphic facial appearance and mental retardation. The facial features include hypertelorism with a wide, flat nasal bridge, epicanthic folds, small mouth and small ears. We describe a case of a multigravida with bad obstetric history and characteristic facial and dental anomalies and bilateral renal lymphangiectasia. To our knowledge this is the first case of Hennekam lymphangiectasia syndrome with anodontia to be reported from India.

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Hyperphosphatemia is an important modifiable risk factor for death and cardiovascular events in patients on hemodialysis (HD). As nicotinamide has been shown as an inhibitor of sodium-dependent phosphate co-transport in rat renal tubule and small intestine, we examined whether nicotinamide reduces hyperphosphatemia in patients undergoing HD. The study was conducted in 30 end-stage renal disease (ESRD) patients [20 (66.7%) males and 10 (33.3%) females; mean age 54 ± 14.9 years] undergoing twice/thrice weekly HD for more than 3 months. Patients on other phosphate binders were given a 2-week wash-out period. Nicotinamide 250 mg capsules were given twice daily for 25 patients with serum phosphorus greater than 5 mg/dL and thrice daily for 5 patients with serum phosphorus greater than 8 mg/dL immediately after food for 8 weeks. Serum phosphate and calcium levels were estimated every month prior to HD session, and complete blood count, blood sugar, renal profile, liver function tests were estimated at beginning and end of the study. Patients were regularly monitored for side effects. There were significant decreases in the serum phosphate (6.85 ± 1.35 mg/dL at the baseline to 5.74 ± 1.18 mg/dL at the 4 ^th week and to 4.54 ± 0.86 mg/dL at the 8 ^th week), the serum calcium-phosphorus product (57.8 ± 12.21 at the baseline to 48.3 ± 10.71 on 4 ^th week and to 38.201 ± 8.21 at the 8 ^th week), and alkaline phosphatase levels (130.23 ± 50.13 IU/L at the baseline to 116.40 ± 48.27 IU/L after 8 weeks) on treatment with nicotinamide (P < 0.001). Other parameters remained unchanged. Watery stools reported by seven patients resolved during the course of the therapy. Nicotinamide is safe, cheap and effective in controlling serum phosphorus, Ca × P product and alkaline phosphatase levels in patients on maintenance HD.

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Gitelman's syndrome is a rare autosomal recessive, renal tubular disorder, characterized by chronic hypokalemia, hypomagnesemia, metabolic alkalosis, hypocalciuria, and normal blood pressure. Patients usually present at a later age with episodic mild muscle weakness. Unexplained hypokalemia arouses suspicion. The diuretic loading test with furosemide and thiazide and the use of Bartter's normogram provides a practical and simple tool in comparison to the complex and costly genetic analysis, to confirm the diagnosis. Here we report a case of Gitelman's syndrome to show the utility of these simple techniques to explain the pathophysiology of the disease, as well as to localize the site of the renal tubular defect, to confirm the diagnosis.

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There are conflicting data regarding the comparative efficacy of mycophenolate mofetil (MMF) versus azathioprine (AZA) as maintenance immunosuppressive agent in kidney transplantation. The data are even less in combination with tacrolimus (TAC) in living donor kidney transplantation. A total of 205 living donor kidney transplants, on TAC-based triple drug immunosuppression were included in the study. A total of 113 patients received AZA and rest 92 were on MMF based protocol. TAC levels were monitored and graft biopsy was done whenever rejection was suspected. The outcomes were evaluated in terms acute rejection (AR) episodes at 1 year, infections, renal function, graft loss, and death between two groups. The study group comprised 163 males (79.5%) and 42 (20.5%) females. The mean age of patients was 42.4±11.8 years in the AZA group and 39.4 ±13.4 in the MMF group (P=0.09). The mean duration of follow-up was 491.7±240.7 and 478.8±334.4 days respectively in the AZA and MMF groups (P=0.75). Thirty-seven of 92 (40.2%) patients in the MMF group and 70/113 (61.9%) patients in the AZA group received IL-2 RAb induction (P=0.002). 32 patients (15.6 %) developed AR within a year. The incidence of AR was similar in patients who received MMF (12/92, 13%) and those who received AZA (20/113, 17.5%), (P=0.36). There was no difference in the incidence of AR in the subgroup of patients who received IL-2 RAb compared to those who did not receive induction in the two groups (5/37 vs. 7/55 in the MMF group and 10/70 vs. 10/43 in the AZA group, P=0.72).The incidence of infections was similar in the two groups (19/92, 20.6% vs. 25/113, 22.1%, P=0.79). Three patients developed CMV disease, of which two were in the MMF group. Graft loss occurred in 7/205 (3.4%) and death in 8/205 (3.9%) patients. Six of eight patients who died had functioning grafts. The rate of graft loss (3/92 vs. 4/113, P=0.97) and death (5/92 vs. 3/113, P=0.27) was similar in two groups. The overall patient survival was 94.5% and death censored graft survival was 97.4%. Cost comparison suggests AZA to be 6-10 times cheaper than MMF. This study suggests that, in tacrolimus-based immunosuppression, azathioprine may be as good as MMF as maintenance immunosuppressive drug in living donor kidney transplantation. It is also a more cost-effective immunosuppression.

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We evaluated important nontraditional cardiovascular risk factors, endothelial function and oxidative stress (OS) among stable peritoneal dialysis (PD) patients. Their association with carotid intimal medial thickness (CIMT) was also assessed. Thirty-eight adult patients (13 diabetics, 20 males) on PD for >6 months and 15 age and sex-matched controls were studied. Duration of dialysis (DOD), residual urine output (UO), weekly Kt/V urea, detailed biochemical and lipid profile were noted. OS was measured by serum concentration of antioxidants; vitamin C and ferric reducing ability of plasma (FRAP) and pro-oxidant; thiobarbituric acid-reactive substances (TBARS). High-resolution ultrasonography was used to determine CIMT and flow-mediated dilatation of brachial artery [endothelium-dependent dilatation (EDD)] and dilatation subsequent to nitrate spray [endothelium-independent dilatation (EID)]. Mean age, DOD, UO and Kt/V of study population were 49.3 ± 11.6 years, 19.4 ± 11.8 months, 508.2 ± 422.9 ml/day and 1.73 ± 0.24, respectively. As compared to controls PD patients had higher CIMT (0.46 ± 0.05 vs 0.50 ± 0.07 mm, P = 0.003) and TBARS (1.5 ± 0.4 vs 5.1 ± 2.3 nM/ml, P < 0.001) but lower Vitamin C (1.7 ± 0.3 vs 0.6 ± 0.2 mg%, P < 0.001), FRAP (990.8 ± 78.1 vs 328.7 ± 183.5 ΅M/L, P < 0.001) and EDD (26.2 ± 5.4 vs 9.8 ± 4.6 %, P < 0.001). TBARS correlated positively with DOD and negatively with hemoglobin. Vitamin C and FRAP correlated positively with serum albumin. EDD correlated positively with UO, Kt/V and hemoglobin. CIMT correlated negatively with Kt/V and hemoglobin. Among themselves CIMT correlated negatively with EDD and vitamin C. EDD correlated positively with vitamin C, while FRAP correlated positively with vitamin C and negatively with TBARS. PD patients have higher OS, poorer endothelial function and higher structural atherosclerosis. These parameters are closely linked to each other, hemoglobin, DOD, residual UO, serum albumin and small solute clearances.

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IgA nephropathy is being recognized as the commonest glomerular disease worldwide. The prevalence and clinical picture varies from region to region. A retrospective analysis of 400 native renal biopsies performed over a period of 3 years at our center was done to know the prevalence and clinicopathological profile of patients with IgA nephropathy. All the biopsies were processed for both light microscopy and immunofluorescence studies. Patients with predominant IgA deposits were labeled as IgA nephropathy and further classified histopathologically into five subclasses according to the Haas classification. We noted a prevalence of 7.8% (31 cases) of IgA nephropathy. Nephrotic syndrome and chronic renal failure were the most common mode of presentation. Majority of cases fell into subclass III (focal segmental glomerular sclerosis) with 35.5% followed by subclasses IV (diffuse proliferative glomerular sclerosis) and V (global sclerosis) with 25.8% and 22.6% prevalence, respectively. As about 50% cases presented with varying degree of renal insufficiency, many ending with ESRD, IgA nephropathy can be considered as a serious problem in India.

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Renal transplant recipients who have sickle cell disease are at risk of infection, recurrent graft disease, and sickling crisis that affects the long-term outcome. We report a patient of sickle cell trait who developed patchy cortical necrosis in the perioperative period but had a good long-term outcome. The renal cortical necrosis was presumed to be secondary to cyclosporine-basiliximab interaction in the backdrop of sickling trait. The patient additionally had spontaneous closure of vascular access and severe hypertension immediately following transplantation suggestive of vaso-occlusive crisis. Cyclosporine and basiliximab drug interaction needs to be recognized and steps need to be taken in patients to avoid perioperative graft dysfunction.

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Post-transplant lymphoproliferative disorders are mostly B-cell neoplasms that develop as a consequence of immunosuppressive therapy. Plasma cell myeloma occurring after solid organ transplant is rare. We report here a case of plasma cell myeloma variant of post-transplant lymphoproliferative disorders developing after 15 months of live related renal transplant in a 41-year-old female. We compare clinicopathological features of this case with few cases reported in literature.

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Antiphospholipid syndrome (APS) often presents as a multisystem disorder characterized by recurrent arterial and venous thrombosis and pregnancy loss. We present a 46-year-old female who was admitted with oliguric acute renal failure. APS was suspected due to prolongation of activated partial thromboplastin time and history of miscarriages. Investigations for secondary causes were normal. Renal biopsy findings revealed thrombotic microangiopathy. A complete recovery of renal function was attained with a combination of plasma exchange and pulse methylprednisolone followed by oral steroids and warfarin. The case is presented for its rarity and therapeutic implications.

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Due to increased survival among hemodialysis (HD) patients, new problems including concerns of oral health have appeared. In this study, we aimed to evaluate the oral health status and related risk factors in Iranian HD patients. Demographic information, medical history, laboratory findings, and dental health status were gathered. The decayed, missing and filled teeth (DMFT) index in accordance with the World Health Organization (WHO) criteria was obtained. Kt/V was calculated for patients. A P-value of <0.05 was considered statistically significant. Seventy-two patients were evaluated, with a mean age and HD time of 53.4±15.3 years and 36.9±33.8 months, respectively. Thirty-five (48.6%) complained of dry mouth, 33 (49.3%) of taste change, 22 (31%) of malodor mouth, and 30 (46.9%) had dental calculus. The overall mean DMFT score was 18.6±9.9. DMFT score had a negative significant correlation with Kt/V (r=-0.4, P=0.004). Women and singles as well as patients with a low educational level and/or lesser dialysis time had a significantly higher DMFT score (P<0.05). Kt/V was significantly lower in patients suffering from dry mouth and dental calculus (P<0.05). Interestingly DMFT score was significantly lower in patients with dental calculus compared to patients without it (P=0.001). It seems that our patients have a poor dental hygiene level and high DMFT score especially women, singles, patients with low Kt/V and a low education level. The oral health maintenance program for a patient receiving dialysis should be reinforced in our centers.

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Renal allograft biopsy is the gold standard for diagnosis of rejection. Incorporation of C4d as a marker for humoral rejection is a major addition for Banff Schema, 2005. We evaluated the pattern of C4d staining in indicated renal allograft biopsies from January 2005 to December 2009. Of the 67 biopsies analyzed, 21 were C4d-positive. They were 11 cases of acute rejection, seven chronic rejection and one biopsy each of acute tubular necrosis, BK virus nephropathy and normal biopsy. Morphologic features like peritubular capillary dilatation, tubulitis and interstitial inflammation were seen more frequently in C4d-positive biopsies and this was statistically significant. C4d positivity was noted in 50% of the chronic rejection cases indicating a humoral component in the pathogenesis of chronic rejection. There was no significant difference in the serum creatinine levels of C4d-positive and -negative patients, either at the time of biopsy or during the follow-up. This study supports the role of C4d immunostaining in confirming histologically diagnosed acute and chronic humoral rejections and in detecting histologically unsuspected cases.

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