Renal failure is a potent risk factor for stroke, which is a leading cause of morbidity and mortality worldwide. The risk of stroke is 5–30 times higher in patients with chronic kidney disease (CKD), especially on dialysis. Case fatality rates are also higher reaching almost 90%. It is therefore important to understand the factors that predispose to stroke in this vulnerable population to better apply preventive strategies. The heightened risk of stroke in CKD represents the interplay of the vascular co-morbidities that occur with renal impairment and factors specific to renal failure such as malnutrition-inflammation-atherosclerosis complex, the effect of uremic toxins, dialysis techniques, vascular access, and the use of anticoagulants to maintain flow in the extracorporeal circuit. Old age, hypertension, diabetes, and previous cerebrovascular disease are all risk factors for stroke with the period of dialysis initiation constituting the highest risk period for developing new stroke. Patients with CKD-stage 3–5 have worse survival and diminished functional outcomes following stroke. Thrombolytic therapy for stroke in CKD has shown an increased risk of symptomatic intracranial hemorrhage or serious systemic hemorrhage, and the therapeutic effects may be attenuated. Benefit of statin therapy in dialysis patient as preventive therapy has not been shown to be beneficial. Control of hypertension and the judicious use of antiplatelet agents form the mainstay of stroke prevention. The benefit of antiplatelet therapies and oral anticoagulants has to be balanced against the real and increased risk of bleeding that is most evident in dialysis cohorts. An increased risk of vascular calcification particularly intracerebral vascular calcification has been seen in patientsreceiving warfarin as prophylaxis in atrial fibrillation. Newer anticoagulants have not been tested in patients with glomerular filtration rate <30 ml/min and hence have to be used with caution. This article is a review of stroke in patients with CKD and approach to managing it.

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In patients unsuitable for radiocephalic fistula creation, the next option is brachiocephalic fistula. In such patients, we exploited the venous interconnections in the cubital fossa for median cubital vein-Brachiocephalic arteriovenous fistula (AVF) creation. In this article, we describe our experience in the creation of such technical variant of the brachiocephalic fistula AVF, its success and associated complications. A retrospective review of such AVF created between September 2014 and August 2015 was done. The data collected included demographics, co-morbidities, basic disease, operative details, patency, complications, and mortality. A total of 68 vascular access surgeries were done which included 26 (38.2%) brachiocephalic AVF using the median antecubital vein. The mean cephalic vein diameter and mean flow rate were 7.18 mm and 1415 ml/min, respectively 2 months after fistula creation. The primary and secondary failure rates were 3.87% and 7.69% respectively. Complications included aneurysm (7.69%), edema (19.23%), hematoma (11.53%), and wound infection (3.8%). Using reverse flow in the median antecubital vein is a safe and simple way to perform brachiocephalic AVF before brachiobasilic AVF and grafts.

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Renal replacement therapy (RRT) options and practice varies in countries worldwide and is influenced by patients' choice, nephrologists' practice patterns, health system, payer practice, public policy, and socioeconomic factors. In India, hemodialysis (HD) remains the dominant RRT modality, and the practice is largely influenced by socioeconomics of the region of practice since third party payer is limited. Resource stretch to maximize outcome benefit is essential and HD session twice weekly is an improvized and cost-effective clinical practice. However, within the country, the patient characteristics, practice patterns, and outcomes of twice-weekly HD compared against patients dialyzed thrice weekly remain unclear. We did a retrospective analysis of patients who underwent twice- and thrice-weekly HD in a single center under similar settings. The patients on thrice a week dialysis were older and with a higher proportion of diabetics and were insured by private payers. Weight gain, ultrafiltration rates, blood pressures, and hemoglobin remained more favorable in the thrice-weekly patients. There was no significant difference in the hospitalization rates or mortality rates in the two groups. Patients who undergo twice-weekly HD have poorer intermediate measures of the outcome; although, morbidity and survival were not different in a small study population with short follow-up. The small sample size and the short duration of follow-up may limit the scope of findings of our study.

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Pregnancy-related-acute kidney injury (PR-AKI) had decreased from 40% to 20% in 1960 to <10% in recent series, mostly due to meticulous antenatal management. Postpartum-AKI (PP-AKI) resulting from late obstetric complications has become more apparent after improvement in antenatal care and legalization of medical termination of pregnancy. Women with renal injury in peripartum period admitted to our hospital over a period of 2 years (April 2013 to May 2015) were studied. Of 713 patients of AKI admitted, 61 had PR-AKI with an incidence of 4.27%. Out of the 61 patients, 28 had PP-AKI with an incidence of 1.96%. The mean age of patients with PP-AKI was 26.10 ± 4.3 years. Sepsis was the most common cause accounting for 11 (39.28%) cases followed by postpartum hemorrhage (PPH) in 7 (25%) cases. Renal biopsy was done in nine patients, out of whom four were having cortical necrosis. Patients having diffuse cortical necrosis remained dialysis-dependent. High contribution of sepsis and PPH to PP-AKI in our setting makes it an ideal target for rectification. Protocolized peripartum monitoring and standard clinical practices of asepsis will go long way in decreasing the incidence of PP-AKI and maternal morbidity in our valley.

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Crystal-induced acute kidney injury (AKI) is caused by the intratubular precipitation of crystals, which results in obstruction and kidney injury. Ciprofloxacin, a commonly used antibiotic, causes AKI secondary to immune-mediated interstitial injury. Rare mechanisms of ciprofloxacin-induced renal injury include crystalluria, rhabdomyolysis, and granulomatous interstitial nephritis. Clinical and experimental studies have suggested that crystalluria and crystal nephropathy due to ciprofloxacin occur in alkaline urine. Preexisting kidney function impairment, high dose of the medication, and advanced age predispose to this complication. We report a case of ciprofloxacin-induced crystal nephropathy and granulomatous interstitial nephritis in a young patient with no other predisposing factors. The patient responded to conservative treatment without the need for glucocorticoids.

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Amelogenesis imperfecta (AI) is a heterogeneous group of inherited dental enamel defects. It has rarely been reported in association with multiorgan syndromes and metabolic disorders. The metabolic disorders that have been reported in association with AI include hypocalciuria, impaired urinary concentrating ability, and Bartter-like syndrome. In literature, only three cases of AI and distal renal tubular acidosis (dRTA) have been described: two cases in adults and a solitary case in the pediatric age group. Here, we report a child with AI presenting with dRTA; to the best of our knowledge, our reported case is the only second such case in pediatric age group. Our case highlights the importance of recognizing the possibility of renal abnormalities in patients with AI as it will affect the long-term prognosis.

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In recent years, immunological barriers historically considered as absolute contraindications to transplantation are being reevaluated. One such barrier is the ABO blood group incompatibility. With better understanding of immunological mechanisms and effective various regimens for controlling it, ABO-incompatible (ABO-I) kidney transplantation is now being performed with increasing frequency. For good outcome, most important is to achieve and maintain low anti-blood group antibody titers (ABGATs). Twenty-two patients with ABO-I donors have been studied. The anti-A and anti-B antibody titers (IgG and IgM) were estimated by column agglutination technology using Automated Ortho BioVue System. For desensitization, pretransplant plasmapheresis and/or immunoadsorption and rituximab were used. ABGAT was determined before transplant and periodically after transplant. It was observed that one-third of the patients have low baseline ABGAT. In these cases with low ABGAT, transplant can be performed without any desensitization. In those with titers <1:256, rituximab (two doses of 200 mg weekly) and 3–6 sessions of plasmapheresis can bring down titers to <1:32. In those with titers >1:256, immunoadsorption may be used from the beginning to reduce ABGAT. After transplant, the titers drop to <1:8 in majority. Rise in titers to >1:64 require close observation and biopsy. If there is evidence of antibody-mediated rejection, treatment should be promptly started. Rise in titers 4–6 weeks after transplant is not associated with any graft dysfunction, and hence not of any clinical significance.

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Donation after circulatory death (DCD) has never been attempted in India because of legal constraints and lack of guidelines for the withdrawal of life support in end-of-life situations. The present report describes the initial experience of transplantation of organs from DCD donors in a tertiary care center in India. Between 2011 and 2015, five donors had kidneys retrieved after cardiac arrest. These patients were declared dead after waiting for 5 min with no electrocardiographic signal on monitor following cardiopulmonary resuscitation (CPR), which was restarted in three patients till organ retrieval. All donors received heparin and underwent rapid cannulation of aorta, infusion of preservative cold solution, and immediate surface cooling of organs during retrieval surgery. 9/10 kidneys were utilized. Mean donor age was 29.6 ± 16.3 years, M:F 4:1 and mean age of recipients was 38.7 ± 10.8 years, M:F 7:2. Seven patients required dialysis in postoperative period. Mean postoperative day 0 urine output was 1.9 ± 2.6 L. Baseline creatinine achieved was 1.38 ± 0.35 mg/dl after a mean duration of 26.12 ± 15.4 days. Kidneys from donors where CPR was continued after the declaration of death (n = 3) had better recovery of renal function (time to reach baseline creatinine 21.2 ± 7.2 vs. 34.3 ± 23.7 days, baseline creatinine 1.36 ± 0.25 vs. 1.52 ± 0.45 mg%). In donors without CPR, one kidney never functioned and others had patchy cortical necrosis on protocol biopsy, which was not seen in the kidneys from donors with CPR. Kidneys from DCD donors can serve as a useful adjunct in deceased donor program. Continuing CPR after the declaration of death seems to help in improving outcomes.

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The progressive loss of kidney function is accompanied by metabolic acidosis. The relationship between metabolic acidosis, nutritional status, and oral bicarbonate supplementation has not been assessed in the Indian chronic kidney disease (CKD) population who are on maintenance hemodialysis (MHD). This is a single-center prospective study conducted in the Western part of India. Thirty-five patients, who were receiving MHD were assessed for metabolic acidosis along with various nutritional parameters at the baseline and at the follow-up after 3 months, postcorrection of acidosis with oral sodium bicarbonate supplements. The relationship between the correction of metabolic acidosis with oral bicarbonate supplements and changes in dietary and various nutritional parameters were evaluated. Metabolic acidosis at the baseline evaluation was found in 62.86% cases of the cohort with a mean serum bicarbonate value of 20.18 ± 4.93 mmol/L. The correction of acidosis with increment in the mean dosage of oral sodium bicarbonate supplements from 0.69 ± 0.410 mmol/kg/day at baseline to 1.04 ± 0.612 mmol/kg/day, significantly reduced the prevalence of metabolic acidosis to 23.33% cases at the follow-up. Improvement in serum bicarbonate level showed significant dietary, anthropometric, and nutritional improvements in these patients. Hence, we conclude that correction of metabolic acidosis with optimal oral bicarbonate supplementation plays a pivotal role in the treatment of malnourished CKD patients on MHD.

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Primary hyperoxaluria (PH) has heterogeneous renal manifestations in infants and children. This often leads to delay in diagnosis. In the past 3 years, genetic samples were sent for seven children with a clinical diagnosis of PH. Their medical records were reviewed for clinical presentation and outcomes. Of the seven children, three were males. The median age of presentation was 4.9 years with the youngest presenting at 3 months of age. Nephrolithiasis, the most common presentation was associated with renal dysfunction in two children. Two children with no significant history presented in end-stage renal disease (ESRD). The sibling of one of the children in ESRD, with a history of consanguinity in parents, was screened for asymptomatic nephrolithiasis. Bilateral multiple renal calculi were found in majority of children followed by echogenic kidneys on ultrasound examination. Genetic analysis suggested PH Type 1 in five children and type 2 in two children. The mutations detected in our cohort were different from the previously reported common mutations. There was no obvious genotype-phenotype correlation noticed. Three children in ESRD are on maintenance dialysis. Nephrolithiasis being a common presentation of PH needs prompt evaluation. Mutations are generally population specific, and whole gene sequence analysis is critical in diagnosis.

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A renal allograft recipient developed cough with hemoptysis on the 1^st postoperative day. A chest X-ray was performed which was suggestive of fluid overload. His fluid was restricted and diuretics were added. On the same day, his pulmonary infiltrates worsened and a computed tomography (CT) of the chest was carried out, which was suggestive of the right lower lobe consolidation and left pleural effusion. He underwent a bronchoscopy and the lavage was sent for cultures, which did not grow any infective organism. Besides routine antibiotics, treatment for possible cytomegalovirus, fungal infections, and pneumocystis infection was instituted. Noninvasive ventilation was started on day 8. A repeat CT of the chest on the postoperative day 8 showed further worsening of the pulmonary infiltrates. As all the initial cultures and serology were negative, a possibility of interstitial pneumonitis was considered. Mycophenolate sodium was considered as a possible cause of the lung infiltrates and was withdrawn. The patient showed progressive improvement. His antibiotics were withdrawn. He was discharged on day 14. A repeat CT 4 weeks post transplant showed significant improvement in his pulmonary pathology. The acute lung injury was considered to be a drug reaction secondary to mycophenolate sodium. In a renal allograft recipient with persistent pulmonary infiltrates, interstitial involvement secondary to drugs should be considered if the patient does not improve with the standard treatment measures.

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Tuberous sclerosis complex frequently results in the formation of renal angiomyolipomas (AMLs). Sirolimus (SIR) or everolimus can be used to treat large AMLs, although this treatment has rarely been described in children, particularly for multiple renal AMLs. A 15-year-old girl presented with bilateral severe chronic flank pain coinciding with increased renal size and hundreds of renal AMLs. We opted to treat her with SIR over the course of 3.5 years. Following her treatment, her renal size had substantially decreased and the AMLs had shrunk. The patient's pain subsided as well. Our case, which has never been described in published literature, demonstrates that a child with multiple renal AMLs can be treated with SIR, and suggests that this treatment may be a viable option for preventing the development of secondary morbidities such as chronic pain.

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Avoidance of hand ischemia in the construction of prosthetic access for hemodialysis in diabetics that have no suitable vein for arteriovenous fistula is appreciated. Taper type may be an appropriately matched conduit to prevent its occurrence. This is a prospective controlled trial of 38 selected diabetics requiring hemodialysis, who were referred to our clinic during a period of 6 months. The aim of the study was to evaluate the efficacy of tapered grafts in preventing distal hand hypoperfusion and determining its most likely contributors. In 18 intervening cases, taper 4 mm × 7 mm and in twenty cases (control group), standard 6 mm polytetrafluoroethylene as straight Brachial-Axillary access was used. Graft flow rates, artery and vein diameters, and mean arterial pressure were included for evaluation. Within the control group, 11 patients (55%) (7 cases Grade 1, 3 Grade 2, 1 Grade 3) and in intervening group, 2 cases (11%) (Grade 1, Grade 3) developed Steal syndrome. There was no significant difference in the mean flow rates (P = 0.82). Increased risk of distal hypoperfusion was observed in the control group when flow rates were more than 1000 ml/min. Arterial diameters (P = 0.011) and mean arterial pressure (P = 0.05) were found to be important contributing factors. Taper grafts causes reduced incidence of distal hand hypoperfusion. When artery diameter was <6 mm and mean arterial pressure lower than 100 mmHg and the index (brachial artery diameter × mean arterial pressure) was under 500, distal hand ischemia occurred in standard and tapper type. We therefore recommend selective usage of taper grafts in diabetics with diminished distal hand pulses, considering the contributing factors when fistula first is not feasible.

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Chylothorax is defined as accumulation of chyle-containing lymphatic fluid within the pleural space. Chylothorax is very rarely seen in hemodialysis patients. We report a case of a patient on hemodialysis who developed chylothorax secondary to left innominate vein stenosis, with other features of venous hypertension such as arm edema successfully treated with angioplasty and pigtail drainage.

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Well-recognized association between HIV 1 infection and collapsing glomerulopathy (CG) raises the possibility that intrarenal infection by other viruses may also contribute to the development of this lesion in native or post-transplant kidneys. There is evidence in literature about association of these lesions with cytomegalovirus, Epstein–Barr virus, hepatitis C virus, and parvovirus B19 infections. Here, we present a case report of post-transplant BK virus nephropathy in a male child who was found to have CG in subsequent biopsy 2 months later. His renal function and proteinuria were stabilized on elimination of viremia.

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Transplant recipients are vulnerable to a horde of infections and neoplastic conditions due to immunosuppression. Posttransplant lymphoproliferative disorder (PTLD) is a condition unique to the transplant recipient occurring due to monoclonal lymphocytic proliferation. It may affect any organ system with reportedly highest incidence in the gastrointestinal tract. The incidence of adenocarcinoma of the colon, however, has not been shown to be uniformly higher in transplant recipients. We report here an unusual case of adenocarcinoma of the ascending colon presenting with liver, lymph node and skin metastasis in a transplant recipient, which simulated PTLD both clinically and radiologically. For any gastrointestinal lesion in transplant recipient, the possibility of carcinoma must be considered. However, a high index of suspicion for PTLD facilitates early diagnosis since the treatment of the two conditions is starkly different.

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