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2013| May-June | Volume 23 | Issue 3
Online since
May 14, 2013
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ORIGINAL ARTICLES
Serum cystatin C as a marker of renal function in detection of early acute kidney injury
M. S. N. Murty, UK Sharma, VB Pandey, SB Kankare
May-June 2013, 23(3):180-183
DOI
:10.4103/0971-4065.111840
PMID
:23814415
In patients with acute kidney injury (AKI), serum creatinine level does not increase until moderate to severe reduction in glomerular filtration rate (GFR) occurs. Thus its use for estimating GFR in early AKI delays detection of kidney damage and making important therapeutic decisions. Moreover, serum cystatin C is not affected by gender, age, race, and muscle mass and also does not suffer from lag period for its rise in early AKI. We studied 200 healthy subjects and 130 AKI patients over a period of 2 years at a tertiary care hospital. Serum creatinine and serum cystatin C were studied and analyzed in relevance to early AKI. We found that 56.2% of patients of AKI group had normal levels of serum creatinine in early phase, while all patients had elevated serum cystatin C at same time. Multiple logistic regression analysis revealed cystatin C-based GFR reflecting decline in GFR with worsening AKI in better than creatinine-based GFR. Serum cystatin C is a better marker of renal function in early stages of AKI and is less affected by age, gender, muscle mass, and ethnicity. Its use helps in early therapeutic intervention and possibly favorable outcome.
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7,795
884
35
Retrospective analysis of 271 arteriovenous fistulas as vascular access for hemodialysis
P Sahasrabudhe, T Dighe, N Panse, S Patil
May-June 2013, 23(3):191-195
DOI
:10.4103/0971-4065.111845
PMID
:23814417
This report describes our experience of arteriovenous fistula (AVF) creation as vascular access for hemodialysis (HD). Study has been carried out in Deenanath Mangeshkar Hospital, Pune from January 2004 to December 2009. A total of 271 AVFs were created in 249 patients. Maximum follow up was 7 years and minimum was 1 year. In this study of 271 cases of AVFs, there were 196 (72.3%) successful cases and 75 (27.7%) failures. Basilic vein was used in 77 (28.4%) cases, cephalic vein in 186 (68.6%), and antecubital vein in 8 (3%) cases. End (vein) to side (artery) anastomosis was done in 170 (63%) cases. Side to side anastomosis was done in 100 (37%) cases. On table bruit was present in 244 (90%) and thrill in 232 (85.6%) cases. During dialysis, flow rate >250 ml/min was obtained in 136 (50.4%) cases. In complications, 16 (5.9%) patients developed distal edema, 32 (11.8%) developed steal phenomenon. Presence of on table thrill and bruit are indicators of successful AVF. If vein diameter is <2 mm, chances of AVF failure are high. During proximal side to side fistula between antecubital/basilic vein and brachial artery, breaking of first valve toward wrist helps to develop distal veins in forearm by retrograde flow. This technique avoids requirement of superficialization of basilic vein in arm.
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9
The spectrum of glomerular diseases in a single center: A clinicopathological correlation
V Golay, M Trivedi, A Abraham, A Roychowdhary, R Pandey
May-June 2013, 23(3):168-175
DOI
:10.4103/0971-4065.111833
PMID
:23814413
We report the spectrum of biopsy-proven glomerular disease (GD) in a single center in Eastern India. Medical records of 666 patients with biopsy-proven GD over a period of 2 years from July 2010 to July 2012 were retrospectively analyzed. The clinical, laboratory, and histological data were recorded. All biopsy specimens were examined by the same pathologist with light and immunofluorescence microscopy. Electron microscopic analysis was performed only in selected cases. Histologic spectrum of various GDs was studied along with its correlation with the clinical and laboratory parameters. The clinical diagnosis was nephrotic syndrome (NS) in 410 (61.56%), rapidly progressive renal failure/glomerulonephritis in 130 (19.52%), subnephrotic proteinuria/asymtomatic urinary abnormalities in 52 (7.81%), acute kidney injury/acute nephritic syndrome in 40 (6.01%), and macroscopic hematuria in 4 (0.6%) patients. Male: Female ratio was 1.05; 27.92% (
n
= 186) were < 18 years, 68.47% (
n
= 456) were 18-59 years, and 3.6% (
n
= 24) were ≥ 60 years of age. The most common GD was minimal change disease (MCD) (20.12%,
n
= 134); others were focal segmental glomerulosclerosis (FSGS) (18.02%,
n
= 15.32%), lupus nephritis (LN) (15.32%,
n
= 102), membranous nephropathy (MN) (12.01%,
n
= 80), and IgA nephropathy (IgAN) (8.11%,
n
= 54). Primary GD was present in 79.13% (
n
= 527) and common histologies were MCD (25.42%), FSGS (22.58%), MN (14.42%), and IgAN (10.25%). Secondary GD was present in 20.87% (
n
= 139), with the most common being LN (73.38%,
n
= 102). Among the NS (
n
= 410), the most common GD was MCD (31.46%), followed by FSGS (25.6%), MN (15.58%), LN (7.8%), IgAN (6.09%), and membranoproliferative glomerulonephritis (4.88%). FSGS was the most common primary GD in adults, MCD in children, and MN in the elderly patients. The spectrum of GD varies according to the area of study and changes over time. A biopsy registry is needed for documenting this variation.
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10
Noninvasive assessment of bone health in Indian patients with chronic kidney disease
Z Jabbar, PK Aggarwal, N Chandel, N Khandelwal, HS Kohli, V Sakhuja, V Jha
May-June 2013, 23(3):161-167
DOI
:10.4103/0971-4065.111831
PMID
:23814412
Abnormalities in mineral and bone disease are common in chronic kidney disease (CKD). Evaluation of bone health requires measurement of parameters of bone turnover, mineralization, and volume. There are no data on bone health in CKD patients from India. In this cross-sectional study, we evaluated serum biomarkers of bone turnover: Bone-specific alkaline phosphatase (BAP) and total deoxypyridinoline (tDPD) along with parathyroid hormone, 25(OH) vitamin D, and bone mineral density (BMD) using dual absorption X-ray absorptiometry in a cohort of 74 treatment-naive patients with newly diagnosed stage 4 and 5 CKD (age 42 ± 14.5 years, 54 men) and 52 non-CKD volunteers (age 40.2 ± 9.3 years, 40 men). Compared to the controls, CKD subjects showed elevated intact PTH (iPTH), BAP, and tDPD and lower BMD. There was a strong correlation between iPTH and BAP (
r
= 0.88,
P
< 0.0001), iPTH and tDPD (
r
= 0.51,
P
< 0.0001), and BAP and tDPD (
r
= 0.46,
P
= 0.0004). The iPTH elevation was greater than twice the upper range of normal in 73% cases, and BAP was >40 U/L in 66% cases. The combination of these markers suggests high turnover bone disease in over 60% cases. The prevalence of osteopenia and osteoporosis was 37% and 12%, respectively. Osteoporotic subjects had higher iPTH, BAP, and tDPD, suggesting a role of high turnover in genesis of osteoporosis. Vitamin D deficiency was seen in 80%, and another 13% had insufficient levels. Vitamin D correlated inversely with BAP (
r
= −0.3,
P
= 0.009), and levels were lower in those with iPTH >300 pg/ml (
P
= 0.0.04). In conclusion, over 60% of newly diagnosed Indian stage 4-5 CKD patients show biochemical parameters consistent with high turnover bone disease. High turnover could contribute to the development of osteoporosis in CKD subjects. Deficiency of 25 (OH) vitamin D is widespread and seems to have a role in the genesis of renal bone disease. Studies on the effect of supplementation of native vitamin D are needed.
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1
CASE REPORTS
Renal transplantation across ABO barrier
PN Gupta, S Pokhariyal, S Bansal, S Jain, V Saxena, R Sharma, M Jain, P Jha, SK Sethi, P Ghosh, A Tewari, R Ahlawat, V Kher
May-June 2013, 23(3):214-216
DOI
:10.4103/0971-4065.111857
PMID
:23814422
In India, patients without a compatible blood group donor are usually excluded from renal transplantation. For young patients, it is a difficult therapeutic choice to stay on long-term dialysis. We describe the case of a 19-year-old male patient who had blood group O +ve and had no compatible donor in the family. His mother was B +ve and was willing to donate. The patient had an initial anti-B antibody titer of 1:512 and underwent antibody depletion with plasmapheresis (11 sessions) and intravenous immunoglobulin (IVIG) 100 mg/kg after every plasmapheresis. He also received rituximab 500 mg for 3 days prior to transplant and was induced with basiliximab. At the time of transplant, his anti-B titers were <1:8. Post-operatively, he required four sessions of plasmapheresis and IVIG as his titers rebounded to 1:64. The titers then spontaneously subsided to <1:16 and have stayed at the same level for 6 months post-transplant. The patient continues to have normal renal function with a creatinine of 1.4 mg/dl% and has had no episodes of rejection.
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3,575
203
3
Congenital anomalies of kidney and urinary tract in siblings: An uncommon condition
M Mantan, GR Sethi
May-June 2013, 23(3):217-219
DOI
:10.4103/0971-4065.111858
PMID
:23814423
Congenital anomalies of kidney and urinary tract (CAKUT) are important causes of chronic kidney disease (CKD) in childhood. Most do not have a definite identifiable genetic defect and occur in isolation. Rarely, familial occurrence of CAKUT has been reported. The burden of CKD to a family in a developing country is enormous, and if more than one child is afflicted with the condition, the situation is almost catastrophic. We present here two families with siblings having upper and lower urinary tract obstruction.
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TECHNICAL NOTE
Retrieval of kidney tissue for light microscopy from frozen tissue processed for immunofluorescence: A simple procedure to avoid repeat kidney biopsies
I Tyagi, K Majumdar, S Kamra, VV Batra
May-June 2013, 23(3):206-210
DOI
:10.4103/0971-4065.111851
PMID
:23814420
We highlight a method that is helpful in situations where the tissue sent for LM is inadequate whereas the tissue sent for IF showed glomeruli useful for interpretation. We utilized the leftover frozen tissue after the sections for IF were taken. This tissue was post-fixed in formalin for the purpose of light microscopic diagnosis. The glomerular pathology could be commented upon with a fair degree of accuracy and a repeat biopsy was avoided in 74.7% of the cases. However, the tubules showed marked fixation artefact and tubular pathology was distorted. This procedure can help to reach a correct diagnosis in large percentage of cases otherwise labeled as inadequate biopsy and hence, save the patient from the trauma of a repeat biopsy.
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ORIGINAL ARTICLES
General practitioners' knowledge and approach to chronic kidney disease in Karachi, Pakistan
S Yaqub, W Kashif, MQ Raza, H Aaqil, A Shahab, MA Chaudhary, SA Hussain
May-June 2013, 23(3):184-190
DOI
:10.4103/0971-4065.111842
PMID
:23814416
Due to lack of adequate number of formally trained nephrologists, many patients with chronic kidney disease (CKD) are seen by general practitioners (GPs). This study was designed to assess the knowledge of the GPs regarding identification of CKD and its risk factors, and evaluation and management of risk factors as well as complications of CKD. We conducted a cross-sectional survey of 232 randomly selected GPs from Karachi during 2011. Data were collected on a structured questionnaire based on the kidney disease outcomes and quality initiative recommendations on screening, diagnosis, and management of CKD. A total of 235 GPs were approached, and 232 consented to participate. Mean age was 38.5 ± 11.26 years; 56.5% were men. Most of the GPs knew the traditional risk factors for CKD, i.e., diabetes (88.4%) and hypertension (80%), but were less aware of other risk factors. Only 38% GPs were aware of estimated glomerular filtration rate in evaluation of patients with CKD. Only 61.6% GPs recognized CKD as a risk factor for cardiovascular disease. About 40% and 29% GPs knew the correct goal systolic and diastolic blood pressure, respectively. In all, 41% GPs did not know when to refer the patient to a nephrologist. Our survey identified specific gaps in knowledge and approach of GPs regarding diagnosis and management of CKD. Educational efforts are needed to increase awareness of clinical practice guidelines and recommendations for patients with CKD among GPs, which may improve management and clinical outcomes of this population.
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4
CASE REPORTS
Native valve
Escherichia
coli
endocarditis following urosepsis
D Rangarajan, S Ramakrishnan, KC Patro, S Devaraj, V Krishnamurthy, Y Kothari, N Satyaki
May-June 2013, 23(3):232-234
DOI
:10.4103/0971-4065.111866
PMID
:23814428
Gram-negative organisms are a rare cause of infective endocarditis.
Escherichia coli
, the most common cause of urinary tract infection and gram-negative septicemia involves endocardium rarely. In this case report, we describe infection of native mitral valve by
E. coli
following septicemia of urinary tract origin in a diabetic male; subsequently, he required prosthetic tissue valve replacement indicated by persistent sepsis and congestive cardiac failure.
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3,138
135
2
D-penicillamine-induced glomerulonephritis with crescent formation: Remission following drug discontinuation
S Mokuda, M Onishi, K Takasugi
May-June 2013, 23(3):226-228
DOI
:10.4103/0971-4065.111862
PMID
:23814426
We report a 71-year-old female who presented with rheumatoid arthritis complicated by proteinuria. She had been receiving D-penicillamine (D-Pc) for two years prior to presentation. A urinalysis showed proteinuria and hematuria which disappeared within 3 months after D-Pc was stopped. The renal histological findings showed focal proliferative glomerulonephritis with crescent formation. A total of 10 cases of D-Pc-induced glomerulonephritis with crescent formation without alveolar hemorrhage have previously been reported in the literature. To the best of our knowledge, this is the first case report in which the patient did not require any treatment.
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3,131
107
3
Successful conservative treatment of bilateral emphysematous pyelonephritis in autosomal dominant polycystic kidney disease
K Jaisuresh, R Bavaharan
May-June 2013, 23(3):229-231
DOI
:10.4103/0971-4065.111864
PMID
:23814427
Emphysematous pyelonephritis is a rare, potentially lethal complication of polycystic kidney disease. Treatment mostly includes emergency nephrectomy of the affected kidney. We report a case of bilateral emphysematous pyelonephritis in a 57-year-old diabetic male with autosomal dominant polycystic kidney disease, who recovered with conservative treatment.
Escherichia coli
was cultured from the cyst aspirate. He was treated with percutaneous needle aspiration of infected cysts and intravenous antibiotics (meropenem and pazufloxacin) for 3 weeks.
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3,105
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1
Rhabdomyolysis induced acute renal failure secondary to statins
R Ram, G Swarnalatha, V Ramesh, K Nageswar Rao, KV Dakshinamurty
May-June 2013, 23(3):211-213
DOI
:10.4103/0971-4065.111853
PMID
:23814421
Rhabdomyolysis is a syndrome characterized by muscle necrosis and the release of intracellular muscle contents into the systemic circulation. We report a patient with chronic kidney disease who had deterioration of renal function due to combination of risk factors like hypothyroidism and interaction of amlodipine and clopidogrel with statins.
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3,022
191
5
ORIGINAL ARTICLES
Study of CC chemokine receptor 5 in renal allograft rejection
R Ghosh, A Sharma, DK Mitra, SK Agarwal, AK Dinda, Ankit Saxena
May-June 2013, 23(3):196-200
DOI
:10.4103/0971-4065.111848
PMID
:23814418
Allospecific recruitment of T cells is primary to the pathogenesis of renal transplant rejection. Chemokines and their receptors inducing a Th1 cytokine response play a central role in this recruitment. Renal allograft biopsies of 28 patients with acute cellular rejection and 10 protocol biopsies (controls) were examined in accordance with Banff grading 2007 schema. Immunohistochemistry for CD3 and CC chemokine receptor 5 (CCR5) in sequential sections was performed and quantitatively assessed in the glomeruli, tubules, and interstitium. Histopathologic and clinical correlations were carried out. CD3- and CCR5-positive cells were observed in significantly higher numbers in rejection cases than in controls (
P
= 0.010). A larger proportion of CCR5-positive cells were noted in the foci of tubulitis compared to the interstitial infiltrates and glomeruli in all cases, and it correlated with the grade of cellular rejection (
P
= 0.010). A greater number of CCR5-positive cells were seen in early rejection (<6 months posttransplant) compared to late rejection. No clinical correlation with serum creatinine levels was found. CCR5-positive cells represent the alloaggressive subset of T cells in ACR, and their numbers correlate with rejection severity. CCR5 may be used as a marker of early acute rejection and may be an important target for future antirejection therapies.
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3,021
108
1
Histological pattern of primary glomerular diseases among adult Sudanese patients: A single center experience
WK Nadium, HH Abdelwahab, MA Ibrahim, M MT. Shigidi
May-June 2013, 23(3):176-179
DOI
:10.4103/0971-4065.111838
PMID
:23814414
In Sudan, like most developing countries, the incidence and histologic patterns of primary glomerulonephritis (GN) remains undetermined. A cross-sectional hospital-based prospective study was performed to determine the pattern of primary GN among adult Sudanese patients. The study was conducted at Khartoum Teaching Hospital from September 2010 to August 2011. It included all adult patients with suspected primary glomerular disease and who underwent native kidney biopsy. A total of 83 adult patients were biopsied with 71 patients (85.5%) being diagnosed as having primary GN. Among those with primary GN the mean age was 34.6 ± 18 years and males represent 54.9%. In 46.5% kidney biopsy was indicated by the presence of nephrotic syndrome, whereas in 33.8% biopsies were performed due to unexplained elevations in renal parameters. Primary focal segmental glomerulosclerosis (FSGS) was diagnosed in 29.6% of patients, followed by membrano-proliferative glomerulonephritis (MPGN) in 26.8% and minimal change disease in 16.9%. IgA nephropathy was observed in 5.6%. Complications following kidney biopsies were reported in 9.6% of biopsied patients. Nephrotic syndrome in an adult was the most common indication for kidney biopsy in our unit. A large number of patients were biopsied due to elevated renal parameters, which reflected the increasing awareness toward thoroughly diagnosing patients with suspected reversible kidney damage. In conclusion, FSGS and MPGN make the most common causes of primary GN among Sudanese adults. Creation of a national renal registry is essential for obtaining more specified epidemiological data.
[ABSTRACT]
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2,879
190
2
Prevalence and risk factors of hyperuricemia among kidney transplant recipients
B Einollahi, H Einollahi, M Nafar, Z Rostami
May-June 2013, 23(3):201-205
DOI
:10.4103/0971-4065.111849
PMID
:23814419
Hyperuricemia is common in renal transplant patients (RTRs), especially those on cyclosporine (CsA)-based therapy. We conducted a retrospective study to determine the prevalence of hyperuricemia and its risk factors among RTRs. A total of 17,686 blood samples were obtained from 4,217 RTRs between April 2008 and January 2011. Hyperuricemia was defined as an uric acid level of ≥7.0 mg/dl in men and of ≥6 mg/dl in women that persisted for at least two consecutive tests. Majority (68.2%) of RTRs were normouricemic. Hyperuricemia was more frequent in younger and female RTRs. On multivariate logistic regression, we found high trough level of cyclosporine to be a risk factor for hyperuricemia. In addition, female gender, impaired renal function, and dyslipidemia (hypercholesterolemia, hypertriglyceridemia, and elevated LDL) were also associated with higher probability of hyperuricemia. Hyperuricemia is a common complication after renal transplantation. Risk factors implicated in post-transplant hyperuricemia include high trough level of cyclosporine, female gender, renal allograft dysfunction, and dyslipidemia.
[ABSTRACT]
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2,797
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3
CASE REPORTS
An unusual case of "renal failure"
S Baikunje, SR Prakasha, SV Acharya, M Anoop
May-June 2013, 23(3):220-221
DOI
:10.4103/0971-4065.111859
PMID
:23814424
Myopathy is common in hypothyroidism, but a very high creatinine kinase (CK) level in the range commonly seen with inflammatory myopathy is rare. Reversible elevation of creatinine is known to occur in hypothyroidism due to a decrease in the glomerular filtration rate, but it can also occur rarely due to enhanced creatinine production. We present a case of severe hypothyroidism with massively elevated CK levels and high creatinine levels, both of which reversed on treatment of hypothyroidism.
[ABSTRACT]
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2,627
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1
Syndrome of rapid-onset end-stage renal disease in two consecutive renal transplant recipients
MA Onuigbo
May-June 2013, 23(3):222-225
DOI
:10.4103/0971-4065.111861
PMID
:23814425
A syndrome of rapid-onset end-stage renal disease (SORO-ESRD) following acute kidney injury (AKI) in native kidneys was described recently. To what extent this syndrome of unanticipated and rapidly irreversible ESRD impacts renal allograft survival is unknown. Over 6 months, we managed two deceased donor renal transplant recipients (RTRs) with rapid acceleration of previously stable allograft chronic kidney disease to abruptly terminate in irreversible ESRD following AKI. These are the first reports of SORO-ESRD in RTRs. More research is needed to ascertain the contribution of SORO-ESRD to renal allograft loss.
[ABSTRACT]
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2,673
99
1
IMAGES IN NEPHROLOGY
Chromoblastomycosis in a renal allograft recipient
YS Sooraj, GK Nainan, M Eapen, AJ Immanuel, RR Pillai
May-June 2013, 23(3):235-236
DOI
:10.4103/0971-4065.111868
PMID
:23814429
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EDITORIAL COMMENTARY
Toward establishing a renal biopsy registry: A step in the right direction
M Mubarak
May-June 2013, 23(3):159-160
DOI
:10.4103/0971-4065.111830
PMID
:23814411
[FULL TEXT]
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2,383
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LETTERS TO EDITOR
Renal cortical necrosis in a renal transplant recipient
M Eswarappa, V Ravi, V Mysorekar
May-June 2013, 23(3):238-239
DOI
:10.4103/0971-4065.111873
PMID
:23814432
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2,425
102
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Salt substitutes: Are they safe?
P Sunil, A Goel, YS Rizvi
May-June 2013, 23(3):238-238
DOI
:10.4103/0971-4065.111871
PMID
:23814431
[FULL TEXT]
[PDF]
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2,239
126
1
Concurrent renal tuberculosis and renal cell carcinoma: A coincidental finding
NS Mani, MG Manoj, A Malik
May-June 2013, 23(3):237-237
DOI
:10.4103/0971-4065.111869
PMID
:23814430
[FULL TEXT]
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2,113
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2
Proliferative glomerulonephritis causing acute renal failure in a child with Salmonella septicemia
GS Dhooria, HS Bains, D Bhat
May-June 2013, 23(3):240-241
DOI
:10.4103/0971-4065.111875
PMID
:23814433
[FULL TEXT]
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2,084
99
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© Indian Journal of Nephrology
Published by Wolters Kluwer -
Medknow
Online since 20
th
Sept '07