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To study the additional utility of pre-nephrectomy whole and cortical kidney volumes (WKV, CKV) in predicting long-term post-nephrectomy kidney function in Indian living kidney donors (LKDs).This retrospective cohort study included all LKDs who underwent nephrectomy between 1 January 2006 and 31 December 2015 at our centre, had pre-nephrectomy height, weight and computed tomography (CT) angiography with arterial and nephrographic phase documented, and 5-year post-nephrectomy creatinine values measured. Correlation between body surface area (BSA) adjusted pre-nephrectomy total CKV, WKV and pre-nephrectomy CKD EPI eGFR; BSA-adjusted remnant pre-nephrectomy CKV (rCKV), WKV (rWKV) and 5-year post-nephrectomy CKD EPI creatinine eGFR (5yeGFRA total of 196 LKDs (74% female, mean age 41.7 ± 11.0 years) were included in the study. Total WKV showed higher correlation with pre-nephrectomy eGFR than CKV, the highest with CKD EPI cystatin eGFR. Remnant WKV showed higher correlation than rCKV with post-nephrectomy eGFRInclusion of pre-nephrectomy remnant CKV and WKV into models for 5yeGFR

Introduction: Post hematopoietic stem cell transplant (HSCT), kidney can be subjected to injury by various causes. Of these, Graft versus Host Disease (GvHD) affecting the kidney is an under-recognized entity with no clear guidelines on its diagnosis, clinicopathological manifestations and outcomes. Material and Methods: Out of 2930 patients who underwent HSCT at our centre between 2005 and 2020, kidney biopsy was performed in 19 allogenic and 5 autologous recipients. Results: The mean age of the cohort at transplant was 33.2 ± 7 years and 15 (62%) were males. Median time to kidney biopsy from HSCT was 14 (IQR, 9-30) months. Aplastic anemia was the most common underlying hematological disease (54.2%). All 19 allogenic recipients were classified based on clinicopathological manifestations into either thrombotic microangiopathy [TMA, 12/19 (63%)] or nephrotic syndrome [NS, 7/19 (37%)] pattern. Glomerular tuft ‘mesangiolysis’ was the dominant pattern of injury noted in 9/12 cases of TMA pattern. There was a predominance of acute microangiopathic changes restricted primarily to the glomerular compartment. Of the seven patients with NS pattern, membranous nephropathy (MN) was seen in 4 (57%) and minimal change disease (MCD) in 3 (43%) patients. Thirty nine percent (7/18) stained positive for C4d which was predominantly glomerular. Allogenic recipients who did not receive immunosuppression (IS) for renal disease had a lower eGFR at biopsy, a longer latency between withdrawal of GvHD prophylaxis and biopsy and were significantly at higher risk of kidney failure (IS: 2/11, 18.1% vs. No IS: 2/6, 33.3%, p=0.04). ‘Associated extra-renal GvHD’ occurred in 11/19 (57.9%) allogenic recipients. Patients with ‘associated extra-renal GvHD’ had significantly more death (6/11, 60% vs. 0, p=0.02) but comparable renal outcomes. Conclusion: Renal GvHD can present with or without ‘associated extra-renal GvHD’ after a prolonged period of withdrawal of GvHD prophylaxis, requiring careful diagnostic vigilance and consideration of immunosuppression.

Background and objectives Bacterial infection-related glomerulonephritis occurs concurrent to or following known or unknown infections. It's important to understand the clinical implications of the bacterial isolates, anti-microbial resistance patterns and impact of latency-based classification on kidney and patient outcomes. Design, setting, participants, and measurements 501 consecutive adults diagnosed with bacterial infection-related glomerulonephritis between 2005-2017 were included from biopsy registry of 15545 patients at a single center in South India and follow up data collected from electronic medical records till December 2019. Latency was defined as time between resolution of infection and onset of glomerulonephritis and was classified as para-infectious, peri-infectious and post-infectious glomerulonephritis. Longitudinal kidney and patient outcomes were studied. Results The mean age of the cohort was 40 (15) years, 6% were above 65 years and 330 (66%) were men. Diabetes was present in 93 (19%) of patients. 70% (353/501) patients had known infections, with the median latent period for para-infectious (115/353, 33%), peri-infectious (97/353, 27%) and post-infectious (141/353, 40%) glomerulonephritis being 0, 5 (4-7) and 15 (10-31) days respectively. The most common predisposing organism was Streptococcus pyogenes (137/353, 39%). Drug resistant non-streptococcal bacteria were methicillin resistant Staphylococcus aureus 25% (4/16), extended-spectrum beta-lactamases 20% (12/59) and carbapenem resistant organisms 10% (6/59). 20/22 (91%) of the drug resistant organisms were isolated from para-infectious group. The most common site of infection was skin in peri- (23/97, 24%) and post-infectious glomerulonephritis (61/141, 43%), and urinary tract in para-infectious glomerulonephritis (35/115, 30%). Out of 321 patients with more than three months follow-up, 48 (15%) developed kidney failure over a median period of 10 (2-37) months and 14 (4%) died. Para-infectious glomerulonephritis, eGFR

Introduction Glomerular Research And Clinical Experiments–IgA Nephropathy in Indians (GRACE-IgANI) is the first prospective South Asian IgAN cohort with protocolized follow-up and extensive biosample collection. Here we report the baseline clinical, biochemical, and histopathologic characteristics of GRACE IgANI and calculate baseline risk of progression for the cohort. Methods 201 incident adults with kidney biopsy–proven primary IgAN were recruited into GRACE-IgANI between March 2015 and September 2017. As of April 30, 2020, the cohort had completed a median follow-up of 30 months (interquartile range [IQR] 16-39). Results The commonest clinical presentation in GRACE IgANI was hypertension, with or without proteinuria, and nephrotic-range proteinuria was present in 34%, despite, Graphical abstract

Introduction: We previously showed that patients with chronic kidney disease (CKD) Stage G4-5 have normal bleeding times. This made us question whether hemodialysis (HD) initiation was really necessary solely to improve platelet function. Methods: In this prospective observational study, two 5 ml citrated blood samples and one 2 ml EDTA blood sample were collected from incident HD patients fulfilling inclusion criteria prior to HD initiation (baseline sample) and after three sessions of short duration, low flow, counter-current HD. In each instance, one sample was used to perform Collagen adenosine diphosphate closure time (CADPCT) using the Platelet function analyzer (PFA 200, normal range 68-142 seconds) and the second for light transmission aggregometry (LTA) with ADP as agonist (normal ≥50%). Results: This study included 20 patients between October 2017 and February 2019. Overall, and in the subgroup with normal baseline CADPCT or LTA, there was no statistically significant improvement after HD. However, of the 30% of patients who had an abnormal baseline CADPCT, 50% attained a normal value after three HD sessions, and the overall reduction in CADPCT in this group was statistically significant (P = 0.02). Of those with a baseline normal CADPCT, 21% developed abnormal prolongation post HD. Conclusion: HD for the sole purpose of improving platelet function is only of benefit in the subgroup of patients with an abnormal CADPCT at baseline, with close to 50% normalizing their platelet function after three sessions of low flow, short duration, counter-current HD.

BackgroundNontunneled hemodialysis catheters (NTHCs) remain the preferred vascular access at hemodialysis (HD) initiation in developing countries. We studied the incidence, risk factors and microbiological spectrum of jugular NTHC-associated bloodstream infections (CABSIs) at a tertiary care center in South Asia.MethodsIn this retrospective cohort study, all adult (≥18 years) incident patients who underwent jugular NTHC insertion for HD between January 2016 and June 2017, had no prior history of temporary vascular access insertion and were followed up for ≥14 days were included.ResultsA total of 897 patients underwent NTHC insertion during the study period and 169 patients fulfilled the inclusion criteria and contributed 7079 patient days of follow-up. CABSI incidence was 7.34 episodes per 1000 catheter days and median infection-free survival and time to CABSI were 96 and 24.5 days, respectively. In multivariate Cox regression analysis, immunosuppressive medication {hazard ratio [HR] 2.87 [95% confidence interval (CI) 1.09–7.55]; P = 0.033} and intravenous cefazolin use [HR 0.51 (95% CI 0.28–0.94); P = 0.031] was independently associated with CABSI. The cumulative hazard of CABSI was 8.3, 13.3, 17.6 and 20.9% at Weeks 1, 2, 3 and 4, respectively. Gram-negative organisms were the most common etiological agents (54.7%) and 40.3% of CABSIs were caused by drug-resistant organisms. Gram-negative and Gram-positive CABSIs were associated with neutrophil left shift and higher procalcitonin compared with coagulase-negative staphylococcal CABSIs.ConclusionIn South Asia, NTHC-associated CABSIs occur early and are predominantly Gram negative. We hypothesize that poor hygiene practices may play a role in this phenomenon.

Aim: The outcome and long-term adverse events associated with induction agent use for living donor (LD) kidney transplantation (KT) in India were studied. Materials and Methods: Consecutive LD kidney transplant recipients (KTRs) from 2005 to 2013 were studied. They were divided based on induction agent use, into induction group and no induction group. The induction group was further subdivided into those receiving antithymocyte globulin (ATG group) and those receiving basiliximab (IL-2RB group). Study subjects were also classified into high and low immunological risk groups. Outcomes evaluated were patient and graft survival, acute rejections, infections, leucopenia, malignancy, new-onset diabetes mellitus, antibody-mediated rejections, and 1-year serum creatinine. Results: Of 605 LD-KTRs, 445 (73.6%) received induction. 403 (90.6%) received basiliximab induction. There was significant improvement in patient and graft survival in induction group (log rank P = 0.041 and 0.024, respectively), but this benefit disappeared when adjusting for immunosuppressive regimen as well as when only patients on tacrolimus-mycophenolate (Tac-MPA) were considered. There was significant reduction in acute rejections, tuberculosis (TB), and BK viremia in the induction group even in patients receiving Tac-MPA. There was no significant difference between basiliximab and ATG except for increased risk of BK viremia with ATG. Conclusions: The use of induction agents is associated with reduced incidence of acute rejections and serious infections (TB and BK viremia). The survival benefit of induction agent use is lost with the Tac-MPA-based immunosuppression. Thus, induction agent use is not essential for better survival if using Tac-MPA-based regimen.

Background and Aims The infections in kidney transplant recipients has been well defined. The timeline of infections and type of infection among patients who received anti-rejection therapy for acute rejection when compared to the patients who did not develop an acute rejection. Method Renal transplant recipients with post-transplant median follow up of four years from July 2009-June 2018 were included in a retrospective cohort study at a tertiary care hospital. Demographic characteristics, biopsy proven rejections, infections and graft and patient outcome were collected from transplant records and the hospital clinical workstation. Early and late acute rejections were defined as less than and more than 3 months respectively. The rates of various infections, type and time to develop an infection in the acute rejection group were compared with the patients who did not develop any rejection. Results A total of 794 patients underwent kidney transplant during the study with mean age of 35.5±12 years and 78% being male. Two hundred and eight four patients (35.8 %) had one or more biopsy proven rejections during the median follow up of 48 months (IQR 28,77). 213 patients (75%) developed early acute rejection (less than 3 months) while the remainder developed late acute rejection. The median time to develop the first acute rejection was 12 days (IQR 6,93.3). Majority of the patients (176, 62%) developed biopsy proven acute cellular rejection, 77 patients (27.1%) acute antibody mediated rejection and rest (10.9%) either mixed or borderline rejection who were treated. The proportion of BKV infection and infective diarrhea were more in rejection group when compared to no rejection group which was statistically significant (refer Table 1). At follow up, the patients who developed rejection had more graft loss (p value 0.010) but no increase in mortality. The predictors of infection among the patients who received anti-rejection therapy were identified. The median time to develop any infection in both groups were also compared. The spectrum of infections and outcome following early and late rejections were compared. Subgroup analysis was done to look at the eGFR, proteinuria trend, graft outcomes in patients with no rejection, rejection without any infection at follow up and rejection with any infection at follow up. The effect of type of anti-rejection therapy on spectrum of infections was also studied. Conclusion This is one of the few studies which looked at the effect of anti-rejection therapy in kidney transplant recipients. Anti-rejection treatment received post kidney transplant resulted in increased rates of BKV infection and infective diarrhea. Patients with acute rejection had more graft loss during follow up with no significant effect on mortality.

AIM Kidney biopsy (KBx) is the gold standard for evaluation of kidney disease, but is associated with a higher risk of complications in patients with reduced glomerular filtration rate (GFR). We studied the safety and utility of KBx in patients with eGFR

Kidney biopsy (KBx) is the gold standard for evaluation of kidney disease, but is associated with a higher risk of complications in patients with reduced glomerular filtration rate (GFR). We studied the safety and utility of KBx in patients with eGFR30 ml/min/1.73 mConsecutive adult patients with eGFR30 ml/min/1.73 mOf the 126 patients included, 75% were male, 27.7% were diabetic, and the median eGFR was 13.5 ml/min/1.73mKBx is relatively safe in severe kidney disease but its risk to benefit balance needs to be carefully considered when eGFR is15 ml/min/1.73m

BACKGROUND We report pediatric PAKT patient and graft outcomes at a large tropical tertiary center spanning two transplant eras. METHODS In this retrospective cohort study, all children ≤18 years who underwent kidney transplantation at our center between 1991 and 2016 were included. Data pertaining to their baseline characteristics, post-transplant events, and outcome were retrieved from transplant records and compared between transplant eras (1991-2005 and 2006-2016). RESULTS A total of 139 children (mean age 15.2 ± 2.9 years) underwent PAKT during this period. The incidence of UTIs, CMV disease, BKVN, invasive fungal infections, new-onset diabetes after transplant, leucopenia, and recurrent NKD was higher in the 2006-2016 era (P

BackgroundThe spectrum and outcomes of crescentic glomerulonephritis in South Asia is vastly different from that reported worldwide and there is a paucity of information.MethodsIt was an observational cohort study of renal biopsies done in the largest tertiary center in South India over a period of 10 years with ≥50% crescents on histology.ResultsA total of 8645 kidney biopsies were done at our center from January 2006 to December 2015, and 200 (2.31%) were crescentic glomerulonephritis. Patients were categorized into three etiological groups - anti-GBM (type I), immune complex (type II) and pauci-immune (type III). The most common was type II (96, 46.5%), followed by type III (73, 38%) and then type I (31, 15.5%). Female preponderance was seen across all three types. About half of all the three types presented with recent onset hypertension. Type II had the highest median proteinuria (4.2 (2.1-6) g/day, p=0.06) and the median eGFR was lowest in type I (5 (4-8) ml/min/1.73m2, pConclusionsANCA negative vasculitis as well as double positive types are reported for the first time from South-Asia. Prevalence of ANCA negative vasculitis (type III subgroup) was much higher in our population. Renal survival was significantly worse in type I & III compared to type II. Types I/III, moderate to severe IFTA, presence of oliguria/anuria and increasing percentage of crescents in renal biopsy were significant predictors of dialysis dependence at index visit or of end stage kidney disease at follow-up in our cohort.

Traditionally, sensitizing events such as previous pregnancies, previous transfusions and prior transplants result in the production of anti-Human Leukocyte Antigen (HLA) antibodies. However, it has been observed that, anti-HLA antibodies have been detected in many patients with no prior history of sensitizing events. This retrospective study analysed the most recent 100 consecutive Single Antigen Bead (SAB) assay results performed on 100 patients. The SAB assay is used routinely to detect anti-HLA antibodies in transplant recipients. Results of the SAB assay were analyzed and subsequently studied to see if a correlation existed between sensitizing events, the type of events and presence of antibody. Analysis showed that 77% (77/100) had anti-HLA antibodies. 61 out of 100 patients had prior sensitizing events while the remaining 39 had none. Both these groups showed an almost equal percent of patients with anti-HLA antibodies 77% (47/61) and 76.9% (30/39) respectively. A single sensitizing event was seen in 54.1% (33/61) patients including previous transfusions in 29.5% (18/61), pregnancies in 11.4% (7/61) and prior transplant in 13.1% (8/61). Our study suggests that irrespective of whether patients have prior sensitizing events or not, patients run the risks of alloimmunization, and therefore appropriate screening tests should be included in the pre-transplant compatibility algorithm.

Aim We report findings from a large single centre paediatric renal biopsy cohort in South Asia. Methods We analyzed all renal biopsies performed on children aged ≤18 years between 1996 and 2015 at our centre. The clinical characteristics and histological diagnosis pertaining to each case, distribution of renal diseases in children with various clinical presentations, and changes in the pattern of kidney disease during the study period were analyzed. Results A total of 1740 paediatric kidney biopsies were performed during the study period. The mean age was 12.8± 4.9 years (8 months to 18 years) and the male: female ratio was 1.5:1. The most common indication for renal biopsy was nephrotic syndrome (63.2%) followed by acute nephritic syndrome (13%). Minimal change disease was the most common cause of nephrotic syndrome while endocapillary proliferative glomerulonephritis (65.7% infection related), remained the commonest cause of acute nephritic syndrome. IgA nephropathy was the commonest cause of chronic kidney disease. Contrary to trends in European paediatric cohorts, the frequency of lupus nephritis increased over the two decades of the study, while that of endocapillary proliferative glomerulonephritis did not show any appreciable decline. Conclusions This study provides the largest data on biopsy proven renal disease in children from South Asia published till date and highlights important differences in the spectrum and trends of kidney disease compared to data from other regions.

Percutaneous renal biopsy is a minimally invasive procedure in the work up of a chronic kidney disease patient. However, it is not free from the complications. Hematuria and abdominal haemorrhage due to intra-renal artery injury are the common complications. We report and discuss the management of a rare case of retroperitoneal haemorrhage resulting from dual arterial injury involving left testicular artery and intra-renal artery.

Double filtration plasmapheresis (DFPP) was historically used for blood group incompatible renal transplantation. Very few studies are available worldwide regarding its efficiency in removing specific plasma components, and safety. We conducted a prospective observational cohort study over 1 year on patients undergoing DFPP for various renal indications. There were 15 patients with 39 sessions. The pre- and post-procedure plasma samples of serum IgG, IgA, IgM, fibrinogen, calcium, phosphate, potassium, and magnesium were analyzed. The effluent albumin concentration was also measured, and complications during the hospital stay were recorded. Cumulative removal of serum IgG, IgA, IgM, fibrinogen, and albumin at the end of four sessions were 72%, 89%, 96%, 88.5%, and 21.3%, respectively and effluent albumin concentration was 1.75 - 2.0 times (range: 6.3 g/dl - 7.2 g/dl; mean ± standard deviation (SD) - 7 g/dl ± 0.3 g/dl) the preprocedural serum albumin (mean ± SD - 3.5 g/dl ± 0.5 g/dl). Removal of other plasma components were not statistically significant. Hypotensive episodes were observed only 16.6%, with the usage of effluent concentration albumin as replacement fluid despite an average 2.4 (mean ± SD - 2.4 ± 0.4 l) liters of plasma volume processing each session. DFPP removes IgG, IgA, IgM, fibrinogen, and albumin. The cumulative removal IgG (72%) is suboptimal, whereas IgA (89%) and IgM (96%) are comparable to historical controls. We observed lesser episodes (12.5%) of hypotension with effluent albumin concentration as replacement fluid, and all bleeding complications were observed when serum fibrinogen level was

BACKGROUND Although multiple variables have been shown to affect outcomes in pediatric lithotripsy (ESWL), there is no consensus on the same. Nomograms combine multiple variables and provide an objective prediction of outcomes. Two nomograms have been previously described and validated in two studies from the same geographical area. External validation in multiple settings is needed, as a nomogram's performance may vary with time, geographical area and clinical scenario. OBJECTIVES This study aimed to identify variables influencing pediatric ESWL outcomes, validate published nomograms and describe the clinical and metabolic profile of Indian children treated with ESWL. DESIGN This retrospective cohort study included all children who underwent ESWL from 2002 to 2019 at a single centre. ESWL was performed under general anaesthesia. Mid and lower ureteric calculi were treated in prone and the rest in supine position. 1500-2000 shocks were delivered at a voltage of 12-16 kV. Data pertaining to patient characteristics, metabolic evaluation, imaging, ESWL details and post-procedure outcomes were obtained from the hospital information system and these variables, along with Onal and Dogan scores, were correlated with stone clearance. Cut-offs for Onal and Dogan scores were determined using receiver operator characteristic (ROC) curve analysis and compared with area under the curve (AUC). Complications, ancillary procedures and metabolic abnormalities were recorded. RESULTS A total of 66 children (76 renal units) were included. Mean age was 5.5 years (Range 6 months-14 years) and median stone size, 12 mm (IQR 9, 15.25). Average treatment sessions were 1.8 ± 0.99. Median shocks in the stone-free group and those who failed treatment were 1750 (IQR 1500, 3000) and 3250 (IQR 1750, 4750) respectively. The remaining variables are depicted in Table 1. The stone free rate was 63.2%. Fragments

Catheter malfunction in peritoneal dialysis (PD) patients may lead to technique failure. Surgical repositioning is sometimes required for resumption of PD and is associated with additional costs of procedure and hospitalization. Meanwhile, patients may need hemodialysis via a temporary vascular catheter with increasing costs and risk of catheter-associated bacteremia. We describe an innovative technique of blind bedside PD catheter repositioning as a possible alternative to surgical repositioning when there is catheter malfunction. In 29 patients over a period of 3 years, we attempted blind bedside PD catheter repositioning with immediate successful inflow and outflow in all of them after repositioning. At 1 month, 21 (72.4%) patients had good catheter function and at 6 months, 19 (65.5%) patients were continuing successful PD. This bedside innovative procedure allowed for catheter salvage without constructing a new exit site or tunnel and without the requirement of a break-in period. The benefits to the patient in terms of cost and shortened hospital stay make it ideal for resource-poor settings. We suggest that this innovative technique be attempted before resorting to the open surgical method of PD catheter repositioning.

Background There are no large studies that have examined ultra-short break-in period with a blind, bedside, midline approach to Tenckhoff catheter insertion. Methods Observational cohort study of 245 consecutive adult patients who underwent percutaneous catheter insertion for chronic peritoneal dialysis (PD) at our center from January 2009 to December 2013. There were 132 (53.9%) diabetics and 113 (46.1%) non-diabetics in the cohort. Results The mean break-in period for the percutaneous group was 2.68 ± 2.6 days. There were significantly more males among the diabetics (103 [78%] vs 66 [58.4%], p = 0.001). Diabetics had a significantly higher body mass index (BMI) (23.9 ± 3.7 kg/m2 vs 22.2 ± 4 kg/m2, p < 0.001) and lower serum albumin (33.1 ± 6.3 g/L vs 37 ± 6 g/L, p < 0.001) compared with non-diabetics. Poor catheter outflow was present in 6 (4.5%) diabetics and 16 (14.2%) non-diabetics ( p = 0.009). Catheter migration was also significantly more common in the non-diabetic group (11 [9.7%] vs 2 [1.5%], p = 0.004). Primary catheter non-function was present in 17(15%) of the non-diabetics and in 7(5.3%) of the diabetics ( p = 0.01). There were no mortality or major non-procedural complications during the catheter insertions. Among patients with 1 year of follow-up data, catheter survival (93/102 [91.2%] vs 71/82 [86.6%], p = 0.32) and technique survival (93/102 [91.2%] vs 70/82 [85.4%], p = 0.22) at 1 year was comparable between diabetics and non-diabetics, respectively. Conclusions Percutaneous catheter insertion by practicing nephrologists provides a short break-in period with very low mechanical and infective complications. Non-diabetic status emerged as a significant risk factor for primary catheter non-function presumed to be due to more patients with lower BMI and thus smaller abdominal cavities. This is the first report that systematically compares diabetic and non-diabetic patients.

Two cases are described of previously unreported false positivity on the Luminex crossmatch assay due to non HLA specific antibodies directed against the beads. In both cases the Luminex crossmatch indicated the presence of donor specific antibodies to class II HLA antigens, which was not substantiated by the clinical scenario or other assays. We could demonstrate the non specificity of these antibodies through using the same assay in a modified form where beads were unexposed to cell lysate and therefore did not carry HLA antigens at all. These cases further serve to emphasize the absolute necessity of correlating positive results with the priming history, and confirming their relevance using other platforms.

Filarial glomerular disease has been attributed to circulating immune complex deposition. We report here a rare manifestation of filarial nephropathy with microfilariae documented in glomerular capillaries in addition to immune complex glomerulonephritis, thus suggesting that direct toxicity may also contribute to the pathogenesis of this entity.

We report on a patient presenting with persistent chyluria due to filariasis, whose clinical course was complicated by massive proteinuria and severe hypoalbuminemia. Treatment with dietary manipulation, antifilarials, and sclerotherapy resulted in successful reversal of the above abnormalities. It has been reported that chyluria is not associated with massive proteinuria, or that even in cases of massive proteinuria, hypoalbuminemia is not seen and implies a glomerular pathology. We argue that chyluria is always associated with proteinuria, which may be massive, and does not warrant a kidney biopsy unless proteinuria persists despite resolution of chyluria.

Peritoneal dialysis (PD) penetration in India remains low despite the huge chronic kidney disease burden and unmet need for renal replacement therapy (RRT). In order to understand the socioeconomic reasons that govern patients’ preference for hemodialysis (HD), we carried out an opinion survey among prevalent in-center HD patients at our institution using a multiple response questionnaire that was verbally administered to them at the dialysis facility by the investigators. Close to 80% were self-financed and 49.5% were on twice weekly HD. Despite the majority (95%) receiving RRT education from a nephrologist, 43.4% were not aware of PD as an RRT modality. The treating nephrologist's recommendation was the most important reason given for choosing HD (77.8%) and not choosing PD (69.7%). Other reasons for not choosing PD included lack of a dedicated caregiver or “clean area” at home (15.1%), fear of infection (15.1%), disruption of work (14.1%), and the high cost of PD (7%). The perceived advantages of HD over PD were greater convenience because of need for only twice or thrice weekly sessions (61%), supervised care received in a hospital setting (28.8%), and less disruption of the patient's and family's routine (22%). We discuss the implications of these findings and what policy makers and nephrologists in India and other developing countries can do to improve PD penetration and utilization.

Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation is currently recommended for the estimation of glomerular filtration rate (GFR). This retrospective study aimed to evaluate the correlation between creatinine and cysC-based estimated GFRs and measured GFR in healthy adults. Consecutive healthy adults who were accepted as voluntary kidney donors at our center between January 2008 and December 2012 were included in the study. The 336 individuals who comprised the study population had a mean age of 41.6 ± 11.8 years, male:female ratio 1:1.7, mean creatinine 0.9 ± 0.1 mg/dl, and mean cysC 0.8 ± 0.1 mg/dl. Mean measured GFR by Tc-99m diethylenetriaminepentaacetic acid using Gates method was 98.4 ± 21.2 ml/min/1.73 m2. The mean ± standard deviation of eGFRs by various formulae were as follows: Cockcroft–Gault (CG) = 88.1 ± 15.9 ml/min/1.73 m2, Modification of Diet in Renal Disease (MDRD) = 78 ± 14.7 ml/min/1.73 m2, CKD-EPI creatinine = 88.1 ± 15.5 ml/min/1.73 m2, CKD-EPI cysC = 97 ± 19.9 ml/min/1.73 m2, CKD-EPI creatinine-cysC (CKD-EPI cr-cysC) = 92.5 ± 14.1 ml/min/1.73 m2. The CKD-EPI cr-cysC equation had the highest accuracy, with 43% and 72% of values lying within ±10% and ±20% of the measured GFR, respectively. Bland–Altman analyses for levels of agreement showed least bias with CKD-EPI cysC overall and among females, while among males, CKD-EPI creatinine equation had the least bias. The CKD-EPI equation showed a higher performance than the MDRD and CG equation in GFR estimation of a healthy population. Among CKD-EPI equations, CKD-EPI cr-cysC had the highest accuracy and CKD-EPI cysC the least bias.

IgG4-related disease (IgG4-RD) is a systemic fibro-inflammatory disease. This disease may be associated with elevated serum and tissue IgG4 levels. Early treatment prevents fibrosis and organ damage. We retrospectively studied the clinicopathologic correlation and outcome of treatment in IgG4-RD. This single-center retrospective study was done using electronic records of patients subjected to assay of serum IgG4 levels in our laboratory by nephelometry. There were 473 patients with suspected IgG4-RD. Of them, 41 patients fulfilled comprehensive diagnostic criteria for IgG4-RD and 432 had diseases other than IgG4-RD. Clinical and histopathological data including tissue IgG4/IgG ratio, other relevant laboratory findings as well as management data of 41 patients with IgG4-RD were analyzed. There were 29 males and 12 females with mean age of 44.1 ± 2.19 years. Thirteen patients had definite, 19 had probable and 9 had possible IgG4-RD. Male predominance, multiple organ involvement and IgG4 responder Index were significantly higher in definite IgG4-RD as compared to probable and possible IgG4-RD. Serum IgG4 level was elevated in 37 patients (90.2%). Glucocorticoids were used in 35 patients (85.4%) and second-line immunosuppressive agent in 23 patients (65.7%). Of the 21 patients on follow-up, 19 (90.7%) had clinical improvement at the first follow-up visit. Nine (90%) out of the ten patients who were assessed by IgG4 responder index, also had shown improved score with treatment. Patients with IgG4-RD in our series showed favorable responses to treatment with glucocorticoids and addition of steroid sparing immunosuppressive agents (mainly mycophenolate mofetil) helped successful tapering of steroids, while maintaining the improvement.

Hepatitis C virus (HCV) infection in kidney transplantation is an important issue with effects on patient and graft survival. The current standard of care involves using oral Direct Acting Antiviral drugs. Till recently, pre-transplant treatment with interferon was the only option for treatment. We studied 677 consecutive kidney transplant recipients with HCV infection. 5.2% patients had evidence of HCV infection. 2.0% were newly detected to have HCV infection after transplant (de novo HCV group). Nearly 28.6% had negative antibody tests but positive Nucleic Acid Test at the time of diagnosis. Eighty-five percent of pre-transplant HCV-positive patients were treated with interferon-based regimens. Early virologic response was seen in 66.6%. End of treatment response was achieved by 94.1%. Sustained virologic response was seen in 81.2%. Overall, patient and graft survival were not different between HCV and control groups (log-rank P = 0.154). Comparing HCV and control groups, there was a tendency toward increased fungal (11.4% vs. 5.6%, P = 0.144) and CMV infections (25.7% vs. 17.1%, P = 0.191) in the HCV group, though it did not reach statistical significance. Eighty-percent of the interferon-treated patients suffered side effects. On comparing, the pre-transplant HCV-positive group (85% treated) with the de novo HCV group (none treated), the de novo group had significantly reduced patient survival (P = 0.020) and NODAT (35.7 vs 4.8%, P = 0.028), and a tendency toward higher CMV infections (35.7% vs 19%, P = 0.432). In addition, death and hepatic complications (decompensated liver disease, fibrosing cholestatic hepatitis) occurred only in de novo HCV group. These results highlight the need for continued post-transplant treatment of HCV positive patients. The newer anti-HCV drugs are expected to fulfill this felt-need in kidney transplantation but long-term results are awaited. This study can serve as a benchmark for future studies to compare the long-term effect of Direct Acting Antiviral drugs.

Peripartum acute renal failure is an important complication related to pregnancy leading to significant morbidity and mortality. Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma, with formation of gas within the collecting system, renal parenchyma, or perirenal tissues. EPN is common in persons with diabetes or urinary tract obstruction. Herein we report a case of bilateral emphysematous pyelonephritis in a postpartum lady who had no evidence of diabetes or urinary tract obstruction. Management of this condition has traditionally been aggressive, and surgery has been considered mandatory. Our patient was managed successfully with antibiotics and supportive measures alone.

We describe the first case from India of ALECT2 amyloidosis. An adult Punjabi male presented with progressive renal dysfunction and non-nephrotic range proteinuria. Serum protein electrophoresis and Immunofixation were normal, with mildly elevated serum free light chain ratio. Renal biopsy confirmed the presence of amyloid. Immunohistochemistry was negative for monoclonal light chains. Proteomic analysis confirmed the presence of ALECT2 amyloid. The present case highlights the need for confirmatory testing for typing of amyloid.

Non-O1, non-O139 Vibrio cholerae is an encapsulated bacterium, ubiquitous in the marine environment and generally considered to be non-pathogenic. However, it is known to cause diarrheal illness, wound infection, and bacteremia in immunocompromised hosts. Here we have describe non-O1, non-O139 V. cholerae sepsis in a patient with nephrotic syndrome following exposure to sea-water. Interestingly, the exposure occurred remotely 4 months prior to the onset of nephrotic syndrome. The occurrence of florid sepsis after a prolonged interval from the time of exposure is peculiar and raises the possibility of an association between occult Vibrio sepsis and nephrotic syndrome.

and immune studies were negative. Chest x-ray showed right hilar enlargement. Serum ACE levels and serum calcium were normal. The biopsy from the purpura yielded a histological diagnosis of leukocytoclastic vasculitis and direct immunofluorescence (DIF) was negative. Computed tomography (CT) disclosed significant mediastinal lymphadenopathy and matted lymph nodes in the lesser sac. Montoux test was highly positive. In view of high ESR, lymphadenopathy and positive montoux test, antitubercular treatment (ATT) was started. After oneweek of starting ATT, the skin lesions and fever completely resolved. CT chest and abdomen repeated after 2 months showed significant regression of lymphadenopathy. ATT continued for 6 months. Complete resolution of the lymphadenopathy was noted on Magnetic Resonance Imaging of chest and abdomen done 1 year later. Conclusion: Although incidence is rare, tuberculosis should be considered the possible underlying cause of vasculitis.