Search

Chronic kidney disease (CKD) not associated with known risk factors has been reported from parts of India and is presumed to be similar to CKD of unknown etiology (CKDu) that has been described from Central America. The reports from India have been fragmented without clear description of the disease phenotype or its determinants. This paper summarizes the current state of knowledge around CKDu in India based on a review of literature, multi-stakeholder consultation, and a survey of Indian nephrologists. We also contacted individual research groups to solicit data. Our findings suggest that that CKDu is reported from most regions in India; however, it is interpreted differently from the phenotype described from Central America and Sri Lanka. The differences include lack of a clear demographic or occupation group, older age of affected participants, and presence of mild hypertension and low-grade proteinuria. Well-designed prospective field studies with appropriate diagnostic workup are needed to establish the disease burden and identify etiologies, along with socioeconomic and health consequences, the intersection with the environment, and the public health response. Community-based research should phenotype the entire CKD population rather than be restricted to cases with presumed CKDu based on predefined criteria. Guidelines are needed for clinical evaluation, referral, management, and harmonization of clinical documentation and health records. More data are needed to support the existence of a unique CKDu phenotype in India.

Methotrexate is an anti-metabolite, anti-cancer drug frequently used in the treatment of extensive chronic plaque psoriasis. Psoriatic plaque erosion is a rare toxic side effect of single-dose methotrexate and is described as a sign of impending pancytopenia. Here, we report a case of a 48- year-old male presented with multiple oral and genital erosions, accompanied by fissuring over palm and soles for 5 days. His laboratory tests revealed severe pancytopenia and nephropathy. He had a history of chronic plaque psoriasis for which he took a single dose of 15 mg methotrexate. During the hospital stay, the patient needed folate antagonist, granulocyte colony-stimulating factor (G-CSF), intravenous fluids, blood transfusions, and platelet transfusions. He recovered within 12 days of admission.

Parasitic infections do not usually present with rapidly progressive renal failure but can provoke glomerular lesions which are mostly proliferative. In filarial infection, glomerular involvement is usually mild and transient, and presentation with renal failure is rare. We report occult filariasis presenting as rapidly progressive renal failure due to immune-complex mediated membranoproliferative glomerulonephritis. Our patient responded to treatment with diethylcarbamazine and a short course of steroid. This case highlights the importance of thorough workup to identify the cause and consideration of filariasis in an endemic area.

The severe respiratory disease COVID-19 (coronavirus disease 2019) was first reported in late December 2019 in Wuhan City, China. Soon thereafter, the World Health Organization (WHO) officially declared it a pandemic. The adult population is highly affected by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2); however, infants and children are also not spared. Transmission in the pediatric population appears to be primarily from COVID-19–positive adults, largely from family contacts through droplets, direct contacts, and aerosols. There is also evidence of fecal-oral route of transmission. The incubation period of COVID-19 in children ranges from 2 to 10 days. Most children are asymptomatic. The most common symptoms amongst symptomatic children are fever and cough. Shortness of breath, sore throat, rhinorrhea, conjunctivitis, fatigue, and headache are other common symptoms. Diarrhea, vomiting, and abdominal pain are the common gastrointestinal symptoms that may be present with or without respiratory symptoms. Very few children are likely to develop severe disease.Supportive care is the mainstay of treatment. Though data are limited, antiviral therapies such as remdesivir, favipiravir, lopinavir/ritonavir, and other drugs like hydroxychloroquine/chloroquine have been used for severe COVID-19 cases, with remdesivir showing the greatest promise. A few children may develop an exaggerated immune response, characterized by exaggerated cytokine release and manifests with features similar to Kawasaki disease. The syndrome has been referred to by many names including pediatric inflammatory multisystem syndrome (PIMS) and more recently, as multisystem inflammatory syndrome in children (MIS-C); this life-threatening condition often requires a multidisciplinary team effort and use of immunomodulators.

Various factors interplay when it comes to successful containment of pandemic. In last one year, we have witnessed various countries formulating and practicing their own unique ways to tackle coronavirus. We have seen the most developed countries failing terribly and unable to slow the COVID-19 spread, but at the same time also endorsed the comparatively less resourceful countries outperforming in terms of reduced disease morbidity and mortality. Current review is about two regions from India (Dharavi and Kerala) who were different in their approach as compared to rest of the country and were able to keep the COVID-19 cases to the minimum.

BACKGROUND: The present study is planned to assess etiologies, course, and outcome in patients with acute-on-chronic liver failure (ACLF). METHODS: Two hundred and eight (182 males and 26 females) patients of ACLF fulfilling modified Asia Pacific Association For Study Of Liver Consensus criteria 2009 admitted to the gastroenterology department of SMS Medical College and hospital, Jaipur, between October 2015 and December 2017 were included. We evaluated etiology of underlying chronic disease and the acute event precipitating decompensation in ACLF. RESULTS: Most common etiology of chronic liver disease (CLD) was alcohol with 133 (63.94 %) patients. Viral hepatitis, cryptogenic cirrhosis, autoimmunity, nonalcoholic steatohepatitis, and Wilson disease as causes of CLD were present in 32 (15.4%), 29 (13.94%), 9 (4.3%), 3 (1.4%), and 2 (1%) cases, respectively. Alcohol, sepsis, bleeding, reactivation of hepatitis B, hepatitis E, antitubercular drugs, and autoimmune hepatitis as the causes of acute event were present in 100 (48.08%), 34 (16.35%), 19 (9.1%), 17 (8.2 %), 15 (7.2%), 13 (6.25%), and 2 (0.96%) patients, respectively. In 8 (3.85%) patients, the precipitating event could not be known. Mortality (in-hospital) in this study was 37.5%. Higher model for end-stage liver disease score and high Child-Turcotte-Pugh score score were significantly associated with mortality (P

This paper presents a new high gain, multilevel, bidirectional DC-DC converter for interfacing battery energy storage systems (BESS) with the distribution grid. The proposed topology employs a current-fed structure on the low-voltage (LV) BESS side to obtain high voltage gain during battery-to-grid mode of operation without requiring a large turns ratio isolation transformer. The high-voltage (HV) side of the converter is a voltage-doubler network comprising two half-bridge circuits with an intermediary bidirectional switch that re-configures the two bridges in series connection to enhance the boost ratio. A seamless commutation of the transformer leakage inductor current is ensured by the phase-shift modulation of HV side devices. The modulating duty cycle of the intermediary bidirectional devices generates a multilevel voltage of twice the switching frequency at the grid-side dc link, which significantly reduces the filter size. The presented modulation strategy ensures zero current switching (ZCS) of the LV devices and zero voltage switching (ZVS) of the HV devices to achieve a high power conversion efficiency. Design and operation of the proposed converter is explained with modal analysis, and further verified by detailed simulation results.

Background: With an increase in the prevalence of risk factors for chronic kidney disease, the prevalence of end-stage renal disease (ESRD) is increasing in India, adding 1.75 lakh ESRD patients each year. Renal transplant is one of the best modalities of renal replacement therapy; however, it is available only in a few centers. Despite an increase in trend, deceased-donor renal transplant (DDRT) rate is only 0.34/million populations, one of the lowest rates in the world. Materials and Methods: We analyzed 25 DDRT recipients transplanted in the last 3 years. The patients were followed till death or graft loss whichever was earlier. Posttransplant outcome and complications were evaluated. Results: The patient survival was 84% (21/25), and death-censored graft survival was 84% (21/25). 16% (4/25) had the second renal transplant with a history of failed previous live renal transplant. Delayed graft function (DGF) and biopsy-proven acute rejection were seen in 16% and 12%, respectively. The mean posttransplant creatinine in recipients with functioning graft on the last follow-up was 1.14 ± 0.2 mg/dl. The most common medical complication was sepsis (40%, 10/25). Conclusion: The short-term outcome of DDRT in our center is comparable to other centers in India. DGF was the most important determinant of graft survival.

Background SARS-CoV-2 binds to membrane-bound angiotensin-converting enzyme 2 (ACE2) which may result in downregulation of membrane-bound ACE2. ACE2 is a key regulator of the renin-angiotensin system (RAS) and is responsible for degrading angiotensin II and thereby counteracting its pro-inflammatory, pro-fibrotic effects mediated through the angiotensin II type 1 receptor (AT1R). As AT1R is directly blocked by angiotensin receptor blockers (ARBs), these agents may offer a safe, low-cost solution for reducing COVID-19 respiratory outcomes. Methods and discussion CLARITY is a pragmatic, adaptive, two-arm, multi-centre, comparative effectiveness phase III randomised controlled trial that examines whether ARBs reduce COVID-19 severity among high-risk patients. Recruiting in India and Australia, the trial will compare treatment with a maximum tolerated daily dose of an ARB to standard of care. Treatment allocation is blinded in India but open-label in Australia due to interruptions to placebo supply in the latter. The primary endpoint is a 7-point ordinal scale of clinical states, ranging from no limitation of activities (category 1) to death (category 7), assessed on day 14. Secondary outcomes include the 7-point scale assessed at day 28 and 28- and 90-day mortality. The design adapts the sample size based on accumulating data via frequent interim analyses and the use of predictive probability to determine whether the current sample size is sufficient or continuing accrual would be futile. The trial commenced recruitment on 18 August 2020. Trial registration ClinicalTrials.gov, NCT04394117. Registered on 19 May 2020. Clinical Trial Registry of India: CTRI/2020/07/026831)

This paper proposes an isolated multilevel DC-DC converter topology and modulation scheme to interface the high voltage (HV) battery pack and propulsion inverter in electric vehicles. The proposed topology is based on two switched capacitor networks in a half-bridge configuration. This converter provides bi-directional power flow and outputs multilevel DC voltage at the propulsion inverter side terminal. The multilevel voltage provides a significant reduction in the size of the LC filter and reduces the ripple content in the output voltage. In addition to the reduction in filter size, the proposed converter achieves higher efficiency due to the soft switching of full-bridge side devices connected to the battery bank. The converter modulation strategy and detailed operation during regenerative mode have been presented in this paper. The converter performance is validated through a simulation study and experimental evaluation in a laboratory prototype.

This paper proposes a soft-switched isolated multilevel DC-DC converter topology to interface the high voltage battery pack and the traction inverter in the electric vehicles. Compared to existing topologies, the proposed converter provides higher DC voltage gain. The multilevel voltage obtained by virtue of the circuit configuration results in a significant reduction of the output DC voltage ripple. Consequently, a substantial reduction in filter sizing can be obtained which accounts for the higher power density of the converter. The soft-switching of the primary side devices further boosts the efficiency of the converter. A detailed analysis of the various modes of operation and the proposed switching scheme is presented in this paper including a design guideline for the selection of output filter parameters. The performance of the proposed converter is evaluated through relevant simulation and experimental verification on a 1kW laboratory prototype.

Introduction India is witnessing high hepatitis C virus (HCV) infection burden in patients of chronic kidney disease. Due to unavailability of costly Kidney Disease Improving Global Outcomes-recommended directly acting antiviral drugs, a widely available pan-genotypic combination of Sofosbuvir and Velpatasvir can become an economical option. Data regarding treatment experience of sofosbuvir–velpatasvir combination in chronic kidney disease is scarce. No data from India have been published in patients on renal replacement therapies till now. Methods This retrospective analysis included all patients of end-stage renal disease on maintenance hemodialysis with treatment-naive chronic HCV infection treated with sofosbuvir (400 mg) and velpatasvir (100 mg) fixed-dose combination. Pretreatment routine investigations were performed, which included HCV viral load, genotype, fibro scan, endoscopy for esophageal varices, and portal vein Doppler. The patients were followed up with HCV viral load to declare sustained virologic response. Result patients were included with a mean age of 39.8 ± 10.8 years, and 77.4% were male. Genotype 1 was found to be most prevalent (67.7%), with a median viral load of 106copies/ml. Six (19.3%) patients had hepatitis B virus co-infection. Three (9.7%) patients had cirrhosis. Sustained virologic response (SVR12) was achieved in 30 (96.8%) patients, and one (3.2%) patient had relapse. Furthermore, 14 (45.2%) patients underwent renal transplantation, and none of them had relapsed. Dyspepsia (9.7%) was the most common side effect observed with no major adverse effect. Conclusion Our study showed excellent efficacy with the safety profile of this drug combination in end-stage renal disease patients. However, larger prospective studies and multicenter randomized controlled trials are needed for further confirmation.

Brain abscesses due to Enterobacteriaceae in immune-competent children are rare, and those due to Enterobacter cloacae are even rarer. We report an interesting case of community-acquired E. cloacae neuroinfection resulting in multiple brain abscesses in a young child with no underlying risk-factors. A 10 year-old-boy presented with low-grade fever, headache, neck pain and progressive deterioration of sensorium. On examination, he was conscious but drowsy with photophobia, normal fundii, meningeal signs, mild hypertonia, brisk muscle stretch reflexes and extensor plantar responses. Magnetic resonance imaging of brain showed bilateral, multiple pyogenic abscesses. Culture of the abscess material aspirated at the time of surgical drainage showed growth of E. cloacae. He received intravenous imipenem for 18 weeks guided by clinical and radiological response. A pragmatic approach combining early surgical drainage, targeted antimicrobial therapy and patient-tailored duration based on the clinico-radiological response is needed in such difficult cases. Keywords: Neuroinfection, Enterobacter, Brain abscess, Pyogenic, Carbapenems

This paper proposes a bidirectional three phase single stage ac-dc converter for applications like Electric Vehicle (EV) chargers. AC side of the proposed converter consists of current fed half bridge converter for each of the three phases and the DC side has three phase full bridge converter. The primary and secondary side of the converter are connected through star connection of high frequency transformer. The proposed converter achieves zero current switching (ZCS) of primary side switches and zero voltage switching (ZVS) for secondary side devices, while feeding power from grid to the dc side. The converter has soft switching on the primary side switches when transferring power from the dc side to the grid. The paper also presents a novel modulation and control scheme for the bidirectional power flow. The converter is evaluated using PSIM simulation tool for its operation in all the four quadrants of the PQ plot. The design of the converter, control strategy and the results are presented for a 10KVA converter for EV charger. Qatar National Research Fund (a member of Qatar Foundation) - NPRP grant #NPRP 8-627-2-260.

Background:: Data on outcome of children undergoing in-hospital cardiopulmonary resuscitation (CPR) in low- and middle-income countries are scarce. Aims:: To describe the clinical profile and outcome of children undergoing in-hospital CPR. Methods:: This prospective observational study was undertaken in the Advanced Pediatric Center, PGIMER, Chandigarh. All patients aged 1 month to 12 years who underwent in-hospital CPR between July 2010 and March 2011 were included. Data were recorded using the ���Utstein style���. Outcome variables included ���sustained return of spontaneous circulation��� (ROSC), survival at discharge and neurological outcome at 1 year. Results:: The incidence of in-hospital CPR in all hospital admissions (n = 4654) was 6.7% (n = 314). 64.6% (n = 203) achieved ROSC, 14% (n = 44) survived to hospital discharge and 11.1% (n = 35) survived at 1 year. Three-quarters of survivors had a good neurological outcome at 1-year follow-up. Sixty per cent of patients were malnourished. The Median Pediatric Risk of Mortality-III (PRISM-III) score was 16 (IQR 9���25). Sepsis (71%), respiratory (39.5%) and neurological (31.5%) illness were the most common diagnoses. The most common initial arrhythmia was bradycardia (52.2%). On multivariate logistic regression, duration of CPR, diagnosis of sepsis and requirement for vasoactive support prior to arrest were independent predictors of decreased hospital survival. Conclusions:: The requirement for in-hospital CPR is common in PGIMER. ROSC was achieved in two-thirds of children, but mortality was higher than in high-income countries because of delayed presentation, malnutrition and severity of illness. CPR >15 min was associated with death. Survivors had good long-term neurological outcome, demonstrating the value of timely CPR.

Background: Currently, allograft renal biopsy is the only reliable tool available to detect fibrosis in the transplanted kidney. However, it is an invasive procedure and is associated with complications. Therefore, a noninvasive tool to detect renal allograft fibrosis is needed. Aims: The aim of the study was to evaluate the usefulness of real-time sonoelastography (RTS) in the diagnosis of renal allograft fibrosis. Subjects and Methods: We studied 15 renal allograft recipients who had chronic allograft nephropathy. RTS was performed by an experienced radiologist to semi-quantitatively determine cortical and medullary stain ratio. These parameters were compared with the degree of fibrosis as assessed by allograft renal biopsy. For comparison, patients were divided into two groups based on the degree of fibrosis: those with mild fibrosis (interstitial fibrosis and tubular atrophy [IFTA] 25%). A receiver operating characteristic (ROC) curve analysis was performed to evaluate the accuracy of cortical strain ratio to discriminate between patients with mild fibrosis versus patients with moderate-to-severe fibrosis. Results: The mean cortical strain ratio was significantly higher in those who had mild fibrosis as compared to those who had moderate-to-severe fibrosis (2.46 ± 0.55 vs. 1.78 ± 0.15, P = 0.01), while the medullary strain ratio was comparable between the two groups. The diagnostic accuracy of cortical strain ratio, as evaluated by area under the curve of ROC analysis, was 0.96. Conclusion: RTS can differentiate between mild fibrosis and moderate-to-severe fibrosis with high accuracy.

Familial hypercalcemia is an important cause of episodic hematuria in children and can lead to nephrolithiasis if untreated. Elucidation of proper family history and screening of family members can help in clinching the diagnosis. An 8-year-old boy presented with episodic painless hematuria for 3 years, with a history of small renal stones in parents, which was managed conservatively. Ultrasound showed concretions in the renal pelvis, and urinalysis revealed hypercalciuria in the absence of renal tubular acidosis in index case as well as parents. He was started on thiazides, oral citrate supplementation, and adequate hydration, following which he became asymptomatic.

Chylous ascites is a rare complication of peritoneal dialysis (PD) and is often mistaken for peritonitis. It usually resolves following conservative management and does not pose any risk to the dialysis procedure. We report the case of a 2-year-old boy, who developed chylous ascites at 36 hours of PD and spontaneously resolved within the next 48 hours.

Kidney transplantation is the treatment of choice for patients suffering from end-stage renal disease. We report a case of living kidney transplantation in which the donor had monoclonal gammopathy of undetermined significance, a condition having possible implication for both donor and recipient. Both donor and recipient had an uneventful course in short-term follow-up of 1 year following kidney transplantation.

Introduction: Asymptomatic bacteriuria (AB) is not uncommon after renal transplantation with limited data from developing countries; we did this study to assess the microbiological spectrum and its short-term graft outcome in our tertiary care center. Materials and Methods: It is a prospective observational study. We included all the patients who underwent renal transplantation over a period of 18 months, from January 2016 to June 2017. Patients who had indwelling urinary catheter beyond 5 days posttransplant and those with persistent graft dysfunction within 6 months of transplant were excluded from the study. Results: A total of 67 patients were included in the study with a mean age of 33.78 ± 8.91 years and a male-to-female ratio of 7:1; live-related donors were 36 (53.73%), live unrelated were 19 (28.35%), and 12 (17.91%) were cadaveric renal allograft recipients (RARs). Twenty-eight (41.79%) patients had 42 episodes of AB over 6 months of follow-up. The maximum episodes occurred within 1 month of postrenal transplantation, and 42 out of 67 (62.68%) RARs had bacterial growth in their double-J ureteral stents (USs). The most frequently isolated pathogen from urine was Escherichia coli (n = 14, 33.33%), whereas Pseudomonas aeruginosa (n = 10, 23.80%) was in US culture (USC). The prevalence of AB was higher in cadaveric RARs compared to live RARs (83.33% vs. 32.72%, P = 0.001) and with bacterial growth in the USC compared to those who did not show any growth in USs (57.14% vs. 16.0%, P = 0.001). However, the estimated glomerular filtration rate between those with AB and those without at 6 months of follow-up (66.36 ± 14.98 vs. 66.10 ± 13.83 ml/min/1.73 m2, P = 0.943) was not different. Conclusion: AB is not uncommon in RARs and it is more common in cadaveric RARs and those with growth in US culture without compromise in allograft function at 6 months postrenal transplant.

Chronic kidney disease in immune thrombocytopenia (ITP) is uncommon, and renal transplant in this setting is especially rare. We present a case of successful renal transplantation in a patient with chronic ITP refractory to steroid and intravenous immunoglobulin (IVIg). A 27-year-old female suffering from ITP was referred to our center for renal transplant with her mother as a donor. Her platelets count failed to improve despite treatment with prednisolone (1 mg/kg/day for 4 weeks) and IVIg (1 g/kg/day for 2 consecutive days). She was then treated with eltrombopag (50 mg/day), a thrombopoietin receptor agonist, following which her platelet counts improved and allowed kidney transplantation to be performed safely. At 1 year of follow-up, her graft was functioning normally. The case report highlights that renal transplantation is feasible in patients with ITP, even if the disease is refractory to first-line agents. Eltrombopag may be used to increase the platelet count and decrease the risk of bleeding during the peritransplant period.

Postpartum acute kidney injury (AKI) is one of the serious complications of pregnancy and is associated with high mortality and morbidity. We conducted this study to determine the characteristics and outcome of the most severe form of postpartum AKI requiring dialysis. This prospective, observational study was conducted in Sawai Man Singh Medical College, Jaipur. All postpartum female suffering from AKI requiring dialysis between July 2014 and December 2016 were included in the study. Demographic, clinical and laboratory data of the patients were recorded. Outcome variables included survival at hospital discharge and estimated glomerular filtration rate (eGFR) at three months of follow-up. Sixty (88.2%) out of 68 women admitted with postpartum AKI required dialysis. The mean age was 26.5 ± 4.3 years and the majority (80%) had institutional delivery. The mean sequential organ failure assessment (SOFA) score was 8.0 ± 2.9. Puerperal sepsis (n = 37, 61.6%), preeclampsia (n = 21, 35%), and antepartum hemorrhage (n = 14, 23.3%) were the most common obstetric complication associated with postpartum AKI. Maternal mortality was 28.3%. Higher SOFA score (P = 0.015, odds ratio [OR]: 1.99, confidence interval [CI]: 1.14–3.45) and diagnosis of sepsis (P = 0.048, OR: 26.3, CI: 1.03–678.3) were the independent predictors of mortality. Out of 37 patients who were followed up at three months, 51.3% had eGFR

Peritonitis is a common and life-threatening complication of acute peritoneal dialysis (PD). Diagnosis requires the presence of clinical signs of peritonitis which are nonspecific and laboratory investigations [total leukocyte count (TLC), Gram-stain, and culture of PD effluent fluid] which are time-consuming and not available at the bedside. In this study, we evaluated the use of leukocyte esterase reagent strip (LERS) as a bedside test to diagnose peritonitis in patients undergoing acute PD. Patients who underwent acute PD were monitored for signs and symptoms of peritonitis. PD effluent fluid analysis included TLC, absolute neutrophil count, Gram-stain, and culture for the diagnosis of peritonitis. LERS (Multistix 10SG) was simultaneously dipped in PD effluent fluid and read at two minutes. Reading of + was considered as indicative of peritonitis. Twenty-one out of 166 (12.6%) patients undergoing acute PD developed peritonitis. LERS detected peritonitis in 20 patients. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of LERS were 95.2%, 95.2%, 74.1%, and 99.3%, respectively. LERS has very high sensitivity and NPV and can be used as a rapid bedside tool to exclude peritonitis in patients undergoing acute PD.