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Coronavirus disease (COVID-19) vaccine and its utility in solid organ transplantation (SOT) needs to be revised timely and updated. These guidelines have been formalized by the experts -the apex technical committee members of the National Organ and Tissue Transplant Organization (NOTTO), and the heads of transplant societies for the guidance of transplant communities. In our general recommendations, we recommend that all personnel involved in organ transplantation should get vaccinated as early as possible and continue COVID-19 appropriate behaviour, despite a full course of vaccination. For specific guidelines of recipients, we suggest completing the full schedule before transplantation whenever the clinical condition permits. We also suggest a single dose, rather than proceeding unvaccinated for transplant, in case a complete course is not feasible. In case, vaccination is planned before surgery, we recommend a gap of at least 2 weeks between the last dose of vaccine and surgery. For those not vaccinated prior to transplant, we suggest waiting for 4-12 weeks after transplant. For the potential living donors, we recommend the complete vaccination schedule before transplant. However, if not feasible, we suggest getting at least a single dose of vaccine, 2 weeks prior to donation. We suggest that suitable transplant patients and those on the waiting list should accept a third dose of the vaccine when one is offered to them. In the context of Vaccine-induced thrombotic thrombocytopenia (VITT), we recommend organs from a deceased donor with suspected/proven VITT should be notified and best avoided and are justified only in case of emergency situations with informed consent and counselling.

As the COVID-19 pandemic scare fades in early 2022, governments throughout the world are now battling a fear of monkeypox outbreaks in various regions. The human monkeypox virus is a double-strand DNA virus that was first discovered in Africa. The 2022 monkeypox virus can spread from person to person and through infected animals. Nevertheless, the host or carrier for the same has not yet been cleared. The relatively low transmission rate has barred it from attracting attention on a global scale. However, as cases increase, the 2022 monkeypox virus creates a panic. Around 103 countries were affected due to this virus till September 2022. There is currently no global preventive or cure available for this virus. Only two vaccinations that were previously authorized for smallpox are licensed for this virus. Similarly, there is only one drug available for therapy. The article will give comprehensive knowledge regarding available virus epidemiology, morphology, immune invasion prevention, and treatment which help the researcher to come forward and develop a strategy for the disease prevalence.

This study is conducted to observe the association of diabetes (DM), hypertension (HTN) and chronic kidney disease (CKD) on the prognosis and mortality of COVID-19 infection in hospital admitted patients with above mentioned comorbidities. This is a single centre, observational, retrospective study carried out at Sir Ganga Ram Hospital, Delhi, India. The burden of comorbidities on the prognosis and clinical outcome of COVID-19 patients admitted patients from April 8, 2020, to October 4, 2020. Chi-square and relative risk test were used to observe the association of comorbidities and disease prognosis. A total of 2586 patients were included in the study consisting of 69.6% of male patients. All the comorbidities were significantly associated with ICU admission and mortality. The relative risk showed that CKD is most prone to severity as well as mortality of the COVID-19 infection followed by HTN and DM. Further with the increase in number of underlying comorbidities, the risk of ICU admission and mortality also increases. Relative risk of the severity of COVID-19 infection in younger patients with underlying comorbidities are relatively at higher risk of severity of disease as well as to mortality compared to the elderly patients with similar underlying condition. Similarly, it is found that females are relatively at higher risk of mortality as compared to the males having same comorbid conditions except for the hypertensive patients. Diabetes, hypertension and CKD, all are associated with progression of COVID-19 disease to severity and higher mortality risk. The number of underlying comorbid condition is directly proportional to the progression of disease severity and mortality.

Considering various factors, such as multiple co-morbidities, unsuitable vessels for access creation, non-maturation, vascular calcifications, the outcome of arteriovenous fistula (AVF) in the elderly population, may not be similar to the younger people. Our study aims to analyze the outcomes of AVF in elderly patients (> 65 year). It was a prospective observational study. Patients of more than 65 years of age in whom AVF was created from January 2012 to December 2015 were included in the study. These patients were followed up for 4 years. The primary endpoint of our study was to assess primary and secondary patency rates. A total of 450 AVFs were included in the study. The mean age was 68.5 years. The most common site of AVF was radiocephalic (RCAVF) in 70% (n = 315), brachiocephalic (BCAVF) in 24% (n = 108) and basilic vein transposition (BVT) in 6% (n = 27). At 48 months, the primary patency rate of RCAVF, BCAVF, and BVT was 55%, 61.6%, and 60.4%, respectively. The commonest cause of access failure was thrombosis followed by non-maturation. AVF remains the preferred vascular access for hemodialysis even in the elderly population. Failure to mature and thrombosis continue to be a concern with AVF. Location of the AV access does not seem to impact the long-term patency.

Early-start peritoneal dialysis (PD) (use of PD catheter within 48 hours of insertion) is an innovative approach for prompt initiation of PD.This study was conducted to analyze the outcomes of early-start PD.A total of 100 patients on PD were retrospectively analyzed. Patients were grouped according to the "break-in period":48 hours (PD1) and ≥ 14 days (PD2). PD was initiated with low dwell volumes (500 mL) in a recumbent position within 48 hours of surgery. PD prescription was gradually incremented over 10 days to minimize any complications.In our study, there were 48 patients in the PD1 group and 52 in the PD2 group. The most common cause of end-stage kidney disease (ESKD) was diabetes mellitus in both groups. Incidence of early mechanical complications (within 30 days of catheter insertion), such as catheter obstruction, early catheter leakage, catheter malposition, tip migration, and infectious complications, were not found to be higher in the PD1 group. 1- and 4-year catheter patency rates were 97.0% and 96.2% in the PD1 group, respectively. These rates were comparable with those in the PD2 group. Early-start PD was not associated with an increased incidence of catheter failure (HR = 1.0, 95% CI 0.28 - 3.47).An early break-in period of48 hours is a feasible option for ESKD patients without any significantly increased risk of mechanical or infectious complications. It offers a safe and efficacious option for renal replacement therapy.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are the latest introduction into the armamentarium of diabetes care in the present decade. By virtue of their beneficial effects, such as blood pressure-lowering, bodyweight reduction and significant renal and cardioprotective effects which extends beyond their glycaemic control effects, SGLT2i have become one of the most preferred oral antihyperglycaemic agents of recent times. However, they can influence tubular handling of electrolytes that can result in some electrolyte disturbances such as alteration in the serum levels of magnesium, potassium and phosphate levels. Some of these changes are mild or transient and may not have significant clinical implications. The underlying putative mechanism(s) responsible for disturbances of electrolytes are yet to be deciphered. In this review, we aim to describe electrolytes and acid–base abnormalities due to SGLT2i as well as to elucidate the underlying mechanism.

The most common glomerulonephritis seen in the world is immunoglobulin A nephropathy (IgAN). It can be primary or secondary associated with various conditions like Chronic Liver disease, Crohn's disease, neoplasms, etc. However, IgAN secondary to Wilson's disease is very rare. A 9 year old boy presented with gross hematuria and proteinuria. He had a history of recurrent jaundice in the past. Ultrasonography (USG) whole abdomen showed altered echotexture of the liver with normal-sized kidneys. An extended workup for liver disease was done, and the diagnosis of Wilson's disease was confirmed with decreased serum ceruloplasmin levels, increased urinary copper, and the Kayser–Fleischer ring. Urine routine microscopy showed numerous red blood cells, few red blood cell casts, and mild proteinuria. Renal biopsy showed IgAN. The patient was started on D-penicillamine. On follow-up at 3 months, he showed complete resolution of proteinuria and hematuria. Thus, we suggest that Wilson's disease should be considered as one of the causes of secondary IgAN in pediatric patients with hematuria, proteinuria with liver dysfunction.

Introduction: In a developing country with a predominantly young population, the valid assumption is directed toward medical care toward the young. However, as medical technology has advanced, quality care has ensured better survival for the elderly population also. The aim of this study was to determine the clinical outcomes in elderly patients undergoing kidney transplantation. Materials and Methods: A retrospective analysis of 1150 patients who had undergone live related renal transplantation was done from January 2006 to December 2014. These patients were divided into two groups; Group 1: age >60 years (N = 150), Group 2: age 18–60 years (N = 1000). The clinical outcomes were compared. Results: The mean age in Group 1 was 69 ± 7.5 years (SD ± 7.5), and group 2 was 41 ± 8 years. In groups 1 and 2, males were 80% and 82%; death censored graft survival at 5 years was 82% and 87%; patient survival at 5 years was 86% and 94%, respectively. The incidence of biopsy-proven acute rejection was similar in both groups (11.3 vs. 10.2%, P = 0.12). Urinary tract infection was the most common infectious complication. Sepsis was the primary cause of death in both groups. Conclusion: In the elderly patients who underwent kidney transplantation, satisfactory graft function, and patient survival were maintained over a period of 60 months. Urinary tract infections were common, and sepsis was the most common cause of death with a surviving allograft. The acute rejection and mortality rates were comparable to the literature published from India so far.

With low rates of rejection with current immunosuppression consisting of steroids, mycophenolic acid and tacrolimus, the question arises whether induction offers any additional benefit in low-risk renal transplant recipients. This study evaluated outcomes with and without induction in low-risk renal transplant recipients. A prospective observational study in which 100 low-risk renal transplant recipients were included and divided into two groups - one that received induction (IND) and another that did not (NO IND). They were followed for 1.5 years. Three endpoints were compared - efficacy of induction, patient and graft survival, and adverse effects. Incidence of rejection in early posttransplant period did not differ (4% NO IND vs. 6% IND; P = 0.171). Rejection as cause of late graft dysfunction was seen in 16% in IND vs. 20% NO IND; (P = 0.603). No difference in serum creatinine at end of 1.5 years was seen. Graft survival was also similar. Relapsing and recurrent urinary tract infections (46% IND vs. 16% NO IND; P = 0.09), hospitalization requiring infections (76%IND vs. 64% NO IND; P = 0.119 NS) were more common in IND. Cytomegalovirus infection affected only IND (6% vs. none; P = 0.07). Patient survival at 1.5 years was comparable (94% IND vs. 96% NO IND; P = 0.646). The study showed comparable results between IND and NO IND with however an increased incidence of infections and hospitalizations in the IND group. The use of induction may be avoided in low-risk renal transplant recipients.

Background:C3 glomerulopathy is caused by dysregulation of the alternative complement pathway. Association with solid organ tumors is rare. However, there have been a few case reports of membranoproliferative glomerulonephritis secondary to gastrointestinal neoplasms.Case:A 38-year-old female presented with abdominal distension, loss of appetite, amenorrhea, and easy fatigability. She had been diagnosed 8 months back with C3 glomerulopathy and had received immunosuppression. On evaluation, she was incidentally detected to have Krukenberg tumor. The primary site of malignancy was gall bladder.Conclusion:Our case report highlights a possible association between C3 glomerulopathy and Krukenberg tumor secondary to gall bladder carcinoma and emphasizes the fact that even in cases of C3 glomerulopathy, occult malignancy should be considered as an underlying pathology.

Objectives This study is conducted to observe the association of diabetes (DM), hypertension (HTN), and chronic kidney disease on the prognosis and mortality of COVID-19 infection in hospital admitted patients.Methods This is a single centre, observational, retrospective study carried out at Sir Ganga Ram Hospital, Delhi, India. the burden of comorbidities on the prognosis and clinical outcome of COVID-19 patients admitted patients from April 8, 2020, to October 4, 2020. Chi-square and relative risk test were used to observe the association of comorbidities and disease prognosis.Results A total of 2586 patients were included in the study consisting of 69.6% of male patients. All the comorbidities were significantly associated with ICU admission and mortality. The relative risk showed that CKD is most prone to severity as well as mortality of the COVID-19 infection followed by HTN and DM. Further with the increase in comorbidity, the risk of ICU admission and mortality increases.Conclusion Diabetes, hypertension and CKD, all are associated with progression of COVID-19 disease to severity and higher mortality risk. The number of underlying comorbid condition is directly proportional to the progression of disease severity and mortality.

Metastatic pulmonary calcification (MPC) has been described in the literature to affect up to 60% of dialysis patients. Several case series of MPC were described in 1960s and 1970s. Patients are generally asymptomatic or may present with acute respiratory distress. This entity is associated with up to 60% mortality. We hereby report a case of chronic kidney disease on maintenance hemodialysis who presented with unexplained recurrent dyspnea despite adequate hemodialysis. She was evaluated and found to have a rare presentation of calciphylaxis.

Bladder carcinoma is a relatively rare carcinoma reported in renal allograft recipients. While many oncogenic viruses have been implicated as causative factors for certain malignancies, questions have been raised about possible role of BK virus in pathogenesis of urothelial cancers. In this report, we have described a patient who developed BK virus nephropathy followed 3 years later by bladder carcinoma. Interestingly, while the tumor tissue demonstrated BK virus, the adjacent normal urothelium was stained negative for BK virus. Considering the viral potential to inhibit tumor suppressors and its differential localization within tumor tissue, it is possible that the virus contributes to tumorigenesis.

Objectives Renal transplant with ABO-incompatible donors expands the donor pool. Earlier studies have focused the use of protocol biopsies in ABO-incompatible transplant patients. Our study described outcomes of indication (for cause) renal biopsies and clinical outcomes in patients with ABO-incompatible renal transplant. Materials and methods This retrospective study included 164 patients from January 2012 to June 2019. Biochemical parameters, serial immunoglobulin G anti-ABO titers, and class I and II donor-specific antibody findings were obtained from hospital records, and renal graft biopsies were reviewed according to the Banff 2017 update. Results We analyzed the results of 65 biopsies from 54 patients. Biopsy-proven acute antibody-mediated rejection (12.8%) was found to be more prevalent than acute cellular rejection (1.8%). Patients with antibodymediated rejection all had microvascular inflammation (g+ptc score of 2 or more, where g+ptc is the sum of the glomerulitis and peritubular capillaritis scores) and were positive for C4d. Acute tubular injury per se was seen in 10.3% of patients; 65% of these patients had C4d positivity in peritubular capillaries, and only 1 patient developed chronic active antibody-mediated rejection on follow-up. Patient and death-censored graft survival rates were 92% and 98% at 1 year after transplant and 88% and 91% at 3 years, respectively. Patients with an episode of antibody-mediated rejection had lower rates of patient (76.5%) and deathcensored graft survival (84.6%) at 1 year. Conclusions The microvascular inflammation score (g+ptc score of 2 or higher) is more reliable than diffuse C4d positivity to determine antibody-mediated rejection in ABO-incompatible transplants because diffuse C4d positivity may also be seen in etiologies unrelated to antibody-mediated rejection. Acute tubular injury with C4d positivity without microvascular injury does not confirm antibody-mediated rejection. We suggest that Banff classification be updated in ABO-incompatible transplants to include diagnostic criteria for the diagnosis of antibody-mediated rejection.

Background and Aims Glomerular filtration rate (GFR) is estimated traditionally from 24-hour urinary creatinine clearance. Creatinine is mainly filtered by glomerulus. The collection of 24-hour urinary sample is a difficult task with many patients fail to collect all the urine samples. As measuring GFR is cumbersome, expensive, and not easily available in all centers, various equations are developed for estimating GFR from creatinine like MDRD, CKD EPI creatinine. GFR obtained from serum creatinine shows wide variation as muscle mass and dietary protein intake are important determinants of serum creatinine concentration. Literature shows very few studies with GFR estimation with reference to age in Indian population. Hence, this study is planned to develop age specific nomogram for GFR in healthy kidney donor population as well as to study agreement between GFR obtained by 99m Tc DTPA three sample method and GFR estimated by 24-hour urinary creatinine. The aim of this stidy was to develop age-specific nomogram GFR in healthy kidney donor population and to study the agreement between the GFR measured by Technetium-99m diethylene triamine pentaacetic acid (99m Tc DTPA) and 24-hour urinary creatinine method. Method This study was conducted at Sir Ganga Ram hospital, New Delhi. All healthy individuals aged more than 20 years and less than 65 years, undergoing evaluation as prospective kidney donor at our hospital were the part of this study. GFR was measured by 99m Tc DTPA clearance using 3 sample method. GFR measured by DTPA method was used to develop nomogram. Creatinine Clearance was calculated from 24-hour urinary creatinine by formula U x V/P where, U is urinary creatinine level, P is plasma creatinine level and V is total volume of urine. Nomogram was developed with respect to these 3 Age groups; namely, 20 to 40 years, 40 to 50 years and 50 to 65 years Results Total 100 kidney donors were included in this study. Enrolled subjects were divided into 3 age groups; 20 to 40 years (n=28), 40 to 50 years (n=46) and 50 to 65 years (n=26). Majority of the donors were females (n=80). The agreement between GFR obtained by 99m Tc DTPA and 24-hour urinary creatinine clearance methods was 92.6 vs. 94 ml/min, 80.4 vs. 76 ml/min and 76.3 vs. 70 ml/min in respective age groups. Conclusion In the younger age group (20 to 40 years), there is better agreement in GFR measured by 99m Tc DTPA method and 24-hour urinary creatinine clearance methods.

Renal dysfunction is very common among patients with chronic liver disease, and concomitant liver disease can occur among patients with chronic kidney disease. The spectrum of clinical presentation and underlying etiology is wide when concomitant kidney and liver disease occur in the same patient. Management of these patients with dual onslaught is challenging and requires a team approach of hepatologists and nephrologists. No recent guidelines exist on algorithmic approach toward diagnosis and management of these challenging patients. The Indian National Association for Study of Liver (INASL) in association with Indian Society of Nephrology (ISN) endeavored to develop joint guidelines on diagnosis and management of patients who have simultaneous liver and kidney disease. For generating these guidelines, an INASL-ISN Taskforce was constituted, which had members from both the societies. The taskforce first identified contentious issues on various aspects of simultaneous liver and kidney diseases, which were allotted to individual members of the taskforce who reviewed them in detail. A round-table meeting of the Taskforce was held on 20–21 October 2018 at New Delhi to discuss, debate, and finalize the consensus statements. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong and weak) thus reflects the quality (grade) of underlying evidence (I, II, III). We present here the INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease.

Moderate levels of endogenous reactive oxygen species (ROS) are important for various cellular activities, but high levels lead to toxicity and are associated with various diseases. Levels of ROS are maintained as a balance between oxidants and antioxidants. Accumulating data suggest that oxidative stress is a major factor in deterioration of renal function. In this review, we highlight the possible mechanism by which oxidative stress can lead to chronic kidney disease (CKD). This review also describes therapies that counter the effect of oxidative stress in CKD patients. Numerous factors such as upregulation of genes involved in oxidative phosphorylation and ROS generation, chronic inflammation, vitamin D deficiency, and a compromised antioxidant defense mechanism system cause progressive detrimental effects on renal function that eventually lead to loss of kidney function. Patients with renal dysfunction are highly susceptible to oxidative stress, as risk factors such as diabetes, renal hypertension, dietary restrictions, hemodialysis, and old age predispose them to increased levels of ROS. Biomolecular adducts (DNA, proteins, and lipids) formed due to reaction with ROS can be used to determine oxidative stress levels. Based on the strong correlation between oxidative stress and CKD, reversal of oxidative stress is being explored as a major therapeutic option. Xanthine oxidase inhibitors, dietary antioxidants, and other agents that scavenge free radicals are gaining interest as treatment modalities in CKD patients.

Starting from December 2019 in China, SARS-CoV-2, a novel coronavirus strain has rapidly spread to involve more than 150 countries. SARS-CoV-2 is not only responsible for causing pneumonia, but there are also concerns regarding the involvement of other organs such as the heart, liver, and kidneys. Here, we review kidney involvement in COVID 19, the mechanism of kidney injury, and its impact on mortality. Lastly, we focus on the challenges of COVID19 in dialysis and renal transplant patients.

Background and Aims Symptomatic intradialytic hypotension is the most frequent complication in patients receiving hemodialysis. It complicates 5 to 30 percent of all dialysis treatments. In our study, we aimed to compare the effect of sodium and ultrafiltration modeling versus low-temperature dialysate on the occurrence of intradialytic hypotensive episodes. Method Single center, prospective, randomized trial. Patients with chronic kidney disease (CKD) stage V on maintenance hemodialysis (HD) for at least twice weekly for a minimum of 3 months were observed for the occurrence of ≥1 intradialytic hypotensive episode per month. After full filling the inclusion and exclusion criteria, patients were randomized 1:1 ratio into two groups based on computer-generated randomization numbers allotted to them by the dialysis coordinator. Group 1: Underwent dialysis with sodium and Ultrafiltration modeling (Linearly decreasing dialysate sodium from 141 mmol/L to 128 mmol/L and linearly decreasing ultrafiltration rate). Group 2: Underwent dialysis with low-temperature dialysate (36 degrees Celsius). Primary outcome was number of hypotensive episodes per month. Secondary outcomes were interdialytic weight gain and ultrafiltration volume per session. Results A total of 320 patients were observed for 3 months in our centre. Intradialytic hypotension was found in 18.75 % of patients. Diabetic nephropathy (61.66%) was the leading cause of end-stage renal disease in these patients. There was no significant difference between the two groups in mean arterial blood pressure, hemoglobin, cardiac status, and serum albumin before dialysis. Both groups had a similar incidence of intradialytic hypotensive episodes (P >0.05). Interdialytic weight gain and ultrafiltration volume removed per session were also similar in both groups. Conclusion Sodium and ultrafiltration modeling and low-temperature dialysate were both equally effective in the prevention of intradialytic hypotensive episodes.

Background and Aims Nocardiosis is a localized or disseminated bacterial infection caused by aerobic Actinomyces that commonly affects immunocompromised hosts. This study aimed to retrospectively review the clinical course and outcome of nocardiosis in renal transplant recipients at our center Method Data was obtained from hospital records retrospectively. Sixteen cases of nocardiosis were identified in a series of more than 1800 consecutive renal transplants performed at Sir Ganga Ram Hospital in the last decade from the year 2010 to 2019. Results Thirteen out of Sixteen patients(81.25%) had developed nocardiosis within a 1-year post-renal transplant. The diabetic population constituted 31.3%. CMV disease was present in 25% of patients six months prior to the diagnosis of Nocardiosis.56.3% of patients were on Trimethoprim-sulfamethoxazole prophylaxis while they were diagnosed with nocardiosis. Pleuropulmonary nocardiosis was the most common form of infection(68.75%). Primary cutaneous nocardiosis was identified in one patient(6.25%). cerebral nocardiosis and disseminated nocardiosis was diagnosed in two patients each(12.5%).In the last 3 years with the introduction of MALDI-TOF led to the identification of the subspecies of Nocardia which was not possible earlier. In the last 3 years, 6 patients were diagnosed with nocardiosis, in which 4 were infected with Nocardia farcinica, one patient with Nocardia Asiatica and one with Nocardia cyrigeorgica. Nocardia farcinica was resistant to cotrimoxazole, which used to be first-line therapy against Nocardiosis before subspecies identification and sensitivity testing. With the help of proper identification of subspecies by MALDI-TOF and antibiotic susceptibility by E-testing, 5 out of 6 patients could be treated while earlier 6 out of 10 patients could be treated. Conclusion Nocardiosis is a rare, difficult-to-diagnose-and-treat infection following kidney transplantation. Trimethoprim-sulfamethoxazole prophylaxis was not effective in the prevention of disease. The Subspecies identification and modification of the plan of management according to antibiotic sensitivity results in improved outcomes.

Background and Aims Peritoneal dialysis (PD) widely practiced as the first-line modality for renal replacement therapy in end-stage renal disease (ESRD) patients. Urgent-start PD (use of the PD catheter within 14 days of insertion) is an effective approach to prompt initiation of PD after catheter insertion. However, there is a paucity of data regarding complications of urgent-start PD. We investigated the outcomes of urgent-start PD in our subset (Indian population). Method All patients in whom PD was initiated between 01 January 2015 and 31 July 2019 (54 months) were included. Patients were grouped according to the initiation of PD (break-in period) as 14 days (PD3). Results In 100 patients included in the study, 57.5% were males. Among them, 75%, 10%, and 15% patients were in the PD1, PD2, PD3 break-in groups respectively. The most common cause of ESRD was diabetes mellitus. Functional catheter malfunction was the most frequent complication in PD1. The incidence of mechanical complications during the first six months was similar in all three groups (p = 0.06). No significant differences with respect to the catheter dysfunction requiring surgical intervention (p > 0.05) were observed. In PD1 group, catheter patency rate at the end of the 1-month and 1-year was 98.6% and 95.4% respectively. No significant differences were found in the rate of peritonitis among the three groups. Female sex, low haemoglobin, and low albumin levels were independent risk factors for peritonitis. Conclusion Early break-in period of less than seven days is a feasible option for patients requiring urgent dialysis with no increased risk of mechanical or infectious complications. It offers a safe and efficacious option for unplanned ESRD patients.

Background and Aims With the increase in the line expectancy of chronic kidney disease in the older population (>60 years), the numbers requiring haemodialysis is progressively rising. The elderly population may be different from the younger in terms of non-suitable vessels for access creation, non-maturation, and vascular calcifications, and this may alter the outcomes of use of arteriovenous fistula (AVF). This study was conducted to analyse the outcomes of AVF in elderly patients (>60 years). Method Retrospective study was conducted in the Department of Nephrology at Sir Ganga Ram Hospital, New Delhi. Patients of more than 60 years of age in whom AVF was created from 1st January 2012 to 31st December 2016 were included in the study. Follow-up data of 3.5 years was analysed. The primary endpoint was to assess primary and secondary patency rates. Results A total of 300 patients were included in the study. The mean age was 63.8 years. Radiocephalic AVF (RCAVF) was the most common site of [69.8% (n = 210)], followed by brachiocephalic (BCAVF) in 25.2% (n = 75) and basilic vein transposition (BVT) in 5% (n = 15). At 12 months, overall survival of the AVF was 66.8%. At 42 months, the primary patency rate of RCAVF, BCAVF, and BVT was 50.6%, 52.6%, and 50.4% respectively. The commonest cause of access failure was thrombosis (20.4%) followed by non-maturation (9%). Vascular access abandonment was found least in BCAVF. Conclusion AVF remains the preferred vascular access for haemodialysis in the elderly population. Brachiocephalic AVF has higher primary and secondary patency rates. Thrombosis and failure of maturation are major concerns in the elderly AVF.

Background and Aims Infections in renal transplant recipients are a major cause of morbidity and mortality. It is the one of the major cause of patient death with functioning graft. Hence this project was done to study the profile of non-bacterial infections specific to renal transplant recipients and to determine the risk factors associated with such infections. Method Renal-transplant recipients admitted to the department of nephrology with suspected infection were included in the study. Results : A total of 342 patients were included in the study. The mean age of the patients was 45.2 ± 13.3 years. 17.5% had ABO incompatible renal transplant. 91% (87% received leukocyte depleting and 4% received non-leukocyte depleting agents) had received induction as majority had three or more HLA mismatch (70%) and the most common donor was wife. 12.8% had history of graft rejection. A total of 147 infectious episodes were encountered in 121 patients. The incidence of non-bacterial infections was 35% (121/342). Viral infections (68/147 = 46%) and invasive fungal infections (44/147 = 30%) were the most common. Cytomegalovirus infection was the most common 35%. Other viral infections encountered were BK virus associated nephropathy (2.3%) and reactivation of Hepatitis B or C virus (2.6%). The most common site of invasive fungal infection were lower respiratory tract, urinary tract, CNS cryptococcosis, soft tissue infection or cellulitis and oesophageal candidiasis in 41%, 32%, 9%, 9% and 9% respectively. Aspergillus (61%) and Rhizopus (33%) was the most common organism causing fungal pneumonia. Four patients were diagnosed with Pneumocystis jirovecii pneumonia. Majority (60%) of the infections were detected after one year post-transplant. Risk factors found to have statistically significance were ABO incompatibility, diabetes mellitus (pre or post-transplant) and history of graft rejection. Nine patients (7%) died of non-bacterial infections specific to renal transplant recipients. Conclusion Non-bacterial infections are not uncommon in Indian scenario and the timeline of such infections has changed.

Background and Aims Pauci-immune crescentic glomerulonephritis is rare form of glomerulonephritis that frequently presents as rapidly progressive renal failure. The histopathological classification proposed by Berden a decade earlier described difference in the outcomes of patients in the focal, crescentic, mixed and sclerotic category with best prognosis for focal and worst for sclerotic group. The newly proposed renal risk score (Brix SR at al.) takes into account both the histopathological parameters (% of normal glomeruli, tubular atrophy and interstitial fibrosis) and clinical parameter (eGFR) which influence outcome in these patients. Present study was undertaken to determine outcomes of pauci-immune crescentic glomerulonephritis based on both of these prognostic systems and also to determine effect of individual risk factors on renal outcome. Method 64 patients diagnosed as pauci-immune crescentic glomerulonephritis from January 2013 to December 2018 were retrospectively analyzed. There histopathological slides were reviewed for percentage normal glomeruli, extent of interstitial fibrosis and tubular atrophy and biopsies were also grouped according to histopathological classification into focal, crescentic, mixed and sclerotic categories. The clinical parameters including serum creatinine, eGFR at time of biopsy and follow-up, and status of ANCA positivity were obtained from electronic records. Renal biopsies were scored based on renal risk score depending on the % of normal glomeruli (>25%,10-25% and 25%) and eGFR(>15ml/min,≤15ml/min) into 3 risk categories. Results There were 61 adult patients and 3 pediatric patients. Two patient with insufficient glomeruli ( Conclusion In our study of Pauci-immune crescentic glomerulonpehritis ANCA was negative in 35% cases. Percentage of normal glomeruli, IFTA and eGFR at time of biopsy were important histopathological and clinical risk factors influencing renal survival in these patients. Results of our study validate that recently proposed renal risk score is a better predictor of survival (p=0.002) as compared to histological classification proposed by Berden (p=0.046).

Background and Aims Acute gastroenteritis is an unwelcome and harmful yet unavoidable complication in the renal transplant patient. Infections, especially atypical organisms like Norovirus, Cryptosporidium, along with typical microorganisms like E. coli and Giardia, form the significant players in the pathogenesis of diarrhea. Standard methods of staining and culture have reduced sensitivity as well as require considerable time for the reports. Stool Polymerase Chain Reaction (PCR)is a quick, sensitive, and hassle-free method that diagnoses more than 20 organisms within 1 hour. This study aims to determine the infective etiology of acute gastroenteritis in the transplant population as well to compare the yield of stool PCR with conservative methods. Method We retrospectively analyzed all renal transplant patients admitted between 2015 to 2018 with complaints of diarrhea (>3 stools/day with loose consistency). The sample was tested for conventional microbiological methods, including a stool routine for microscopy and culture. A stool sample was also sent for Multiplex PCR, which was analyzed by Bio Fire FilmArray GI Panel, which identifies 22 enteropathogens. Endoscopic procedures were also undertaken in suspected cases for CMV colitis and pseudomembranous colitis. Results 110 diarrheal events (admission for diarrhea) were recorded in 82 patients, with 181 organisms isolated in all samples. 16 events did not reveal any organisms in stool PCR. 85% sample yielded a positive result. The conventional method yielded a positive result in only 32.3% as compared to stool PCR. Co-infections were common, as 71.2% of events were associated with 2 or more organisms. Conventional methods failed to diagnose any co-infections. Norovirus G1/G2(20%) was the most common organism isolated from the stool, followed by Giardia (17%) and Enteropathogenic E. coli (16%). Giardia Lamblia with Norovirus G1/G2 was the most common co-infection in 19% of patients. Conclusion Stool PCR significantly improves the diagnostic yield in diagnosing enteric pathogens. Stool PCR is especially sensitive in detecting multiple organisms where conventional microbiological methods were completely unsuccessful. Norovirus is the most common enteropathogen, which is not picked by the conventional method. Giardia with Norovirus was the most common co-infection among post-transplant patients.

The coronavirus disease-19 (COVID-19) pandemic has affected 1,029,968 people in Asia as of May 16, 2020. Although Asia was the first continent to be affected, many countries in the region continue to battle COVID-19, which challenges the way transplant programs provide their services. Given the diversity of healthcare systems in Asia, the countermea sures in response to COVID-19 are as potentially diverse. This review reports the experi ences of transplant services in member countries of the Asian Society of Transplantation (AST) as well as provides a platform for sharing of best practices during the COVID-19 pandemic. AST invited member countries to provide a short description of their trans plant experiences during the COVID-19 pandemic. Whenever information is available, countries were asked to provide information on COVID-19 related statistics, status of transplant programs, mitigation measures taken to prevent COVID-19, and other areas of transplant programs impacted by COVID-19. Ten countries responded to the invita tion of which seven still have active transplant programs at varying levels of activity. All countries have protocols for donor/recipient screening and countermeasures to prevent COVID-19 infections in recipients and healthcare providers. Interestingly, these countries report only 16 transplant recipients with COVID-19 infection but no cases of donor-trans mitted COVID-19 infection. Despite the diversity of healthcare systems in Asia, transplant centers in Asia have taken appropriate precautions to avoid COVID-19 infections, though the long-term impact of COVID-19 remains unclear.

Kidney transplantation is the preferred treatment modality in patients with ESKD. However, there are associated complications that arise from immunosuppressive medications, infections, and associated comorbidities. Neurologic disorders frequently develop in patients who have received a kidney transplant, which in turn increases the associated morbidity and mortality. This review discusses the common neurologic disorders after kidney transplantation, including infections, cognitive decline, drug-related conditions, malignancy, seizure, and other neurologic complications.

HIV-related renal diseases have become more evident and easier to treat due to the prolonged survival of patients with HIV infection on antiretroviral therapy (ART). There are multiple factors involved in the pathogenesis of this entity. However, very little has been described regarding secondary membranoproliferative glomerulonephritis and especially a crescentic disease in these patients. Herein, we describe a patient who was incidentally detected to have HIV infection while evaluating for a rapidly progressive renal failure and was detected to have crescentic glomerulonephritis. We have reviewed the literature pertinent to the case in the present report.

Background: Infections in renal allograft recipients, especially urinary tract infections (UTI), are an essential factor leading to an increase in morbidity, graft failure, and degrading the health-related quality of life. Aims and Objectives: Our objective is to assess the causes, risk factors, microbiological profile, and antibiotic sensitivity pattern of UTI in renal transplant recipients. Material and Methods: It was a prospective observational study, conducted at the Department of Nephrology, Sir Gangaram Hospital, New Delhi, India. Three hundred ten renal transplant recipients were enrolled. Results: Out of 300 transplant recipients, 107 (35.6%) had UTI. The mean age of patients with UTI was 32 ± 10.5 years. Females have a higher incidence of UTI than males. 64.5% of all diabetic patients had UTI. Escherichia coli (41%) was the most common causative agent. Gram-negative bacilli attributed the majority (88.5%) of cases. Klebsiella pneumonia was found to be multidrug-resistant in most cases. 61% of patients with reflux kidney disease before transplant suffered from UTI. Conclusion: On multivariate analysis in our study, diabetes (P=0.01), prolonged urethral catheterization (p=0.002), and double J stent kept in situ (p=0.03) and reflux kidney disease before transplant (p < 0.02) were independently associated with UTI prolonged.

As the life expectancy is increasing, there is a rise in elderly population and consequent increase in the patients with renal disease. There is an inconsistency between clinical and histopathological diagnosis in elderly, and so renal biopsy is important in these patients to decide appropriate clinical management and prognosis. This study outlines the importance of renal biopsy in elderly and describes the clinical and pathologic spectrum of renal diseases in patient ≥60 years. All patients (age ≥60 years) undergoing renal biopsies from January 2011 to December 2014 were included in this retrospective study. The clinical presentation and biochemical findings were recorded, and the patients were grouped based on their clinical presentation. Renal biopsies were also evaluated. The mean age of patients was 67.7 ± 6.4 years with a male:female ratio of 3:1. The most common clinical manifestation was nephrotic syndrome (37.4%) followed by rapidly progressive renal failure (RPRF) (20.6%). Amyloidosis and membranous nephropathy were two most common diagnoses in patients with nephrotic presentation whereas pauci-immune crescentic glomerulonephritis and cast nephropathy were common in patients presenting with RPRF. Clinical diagnosis differed from the histopathological diagnosis in 32% cases of nephrotic syndrome. There was good agreement between clinical diagnosis and histology in cases with RPRF. In 73% cases of elderly with (Type II) diabetes suspected of having nondiabetic renal disease clinically, renal biopsy showed evidence of diabetic nephropathy. Renal biopsy is essential in the diagnosis of renal diseases even in elderly. Amyloidosis and membranous nephropathy are common causes of nephrotic syndrome in elderly. Renal biopsy is very useful in diagnosing cast nephropathy and amyloidosis as they are not suspected clinically. It is also helpful in elderly diabetics without retinopathy to differentiate between diabetic and nondiabetic kidney diseases.

Background There is a rising incidence of chronic kidney disease that is likely to pose major problems for both healthcare and the economy in future years. In India, it has been recently estimated that the age-adjusted incidence rate of ESRD to be 229 per million population (pmp), and >100,000 new patients enter renal replacement programs annually. Methods We cross-sectionally screened 6120 Indian subjects from 13 academic and private medical centers all over India. We obtained personal and medical history data through a specifically designed questionnaire. Blood and urine samples were collected. Results The total cohort included in this analysis is 5588 subjects. The mean ± SD age of all participants was 45.22 ± 15.2 years (range 18–98 years) and 55.1% of them were males and 44.9% were females. The overall prevalence of CKD in the SEEK-India cohort was 17.2% with a mean eGFR of 84.27 ± 76.46 versus 116.94 ± 44.65 mL/min/1.73 m2 in non-CKD group while 79.5% in the CKD group had proteinuria. Prevalence of CKD stages 1, 2, 3, 4 and 5 was 7%, 4.3%, 4.3%, 0.8% and 0.8%, respectively. Conclusion The prevalence of CKD was observed to be 17.2% with ~6% have CKD stage 3 or worse. CKD risk factors were similar to those reported in earlier studies. It should be stressed to all primary care physicians taking care of hypertensive and diabetic patients to screen for early kidney damage. Early intervention may retard the progression of kidney disease. Planning for the preventive health policies and allocation of more resources for the treatment of CKD/ESRD patients are imperative in India.