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The use of remdesivir is not recommended in patients with end-stage renal disease (ESRD) with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection unless potential advantage offset disadvantage due to limited safety data. Our objective was to assess the safety of remdesivir in patients with end-stage renal failure and evaluate the outcome of this vulnerable group.We carried out a retrospective observational study in dialysis-dependent ESRD patients with SARS-CoV-2 infection who received a standard 5-day course of remdesivir (powder form) from June 2020 to December 2020. Oxygen requirement, hemogram, inflammatory markers, and liver function tests before and after remdesivir treatment were compared.We found thirty-nine such patients with mean age of patients 58.79 ± 12.13 years. Diabetes mellitus, hypertension, and cardiac diseases were present in 58.97, 87.17, and 23.07% of patients, respectively. Mean oxygen saturation on admission was 85.41% (±7.73). There were no events of hepatotoxicity, altered behavior, or infusion reaction. There was statistically significant improvement in total leukocyte count, absolute lymphocyte counts, and C-reactive protein (The use of remdesivir in end-stage kidney disease is safe. Improvement in oxygenation was significant when baseline oxygen requirement was less. It requires prospective controlled trials with larger population to assess its impact on mortality.Shah MK, Parikh M, Prajapati D, Kute VB, Bhende P, Prajapati A

Purpose of review Obesity is a risk factor for the development and progression of chronic kidney disease (CKD). In this review, we provide a comprehensive overview of various management options (lifestyle intervention, medications, and bariatric surgery) to address obesity in those with CKD. Recent findings Few clinical trials have examined the benefits of lifestyle modifications in those with preexisting CKD and suggest potential renal and cardiovascular benefits in this population. Yet, superiority of different dietary regimen to facilitate weight loss in CKD is unclear. Although medications could offer short-term benefits and assist weight loss, their safety and long-term benefits warrant further studies in this high-risk population. Observational studies report that bariatric procedures are associated with lower risk of end stage kidney disease. Clinicians should also recognize the higher risk of acute kidney injury, nephrolithiasis, and other complications noted with bariatric surgical procedures. Summary Lifestyle modifications and some weight loss medications may be recommended for facilitating weight loss in CKD. Referral to bariatric centers should be considered among morbidly obese adults with CKD.

Pantoea species-A Rare Cause of Central Venous Catheter Related Sepsis in Hemodialysis Patient Mital D. Parikh, Maulin K. Shah Shree Krishna Hospital, H. M. Patel Institute of Medical Care and Education, Karamsad, Gujarat, India ABSTRACT There has been a significant increase in nosocomial infections in Intensive Care Units and Oncology Department. Sepsis is a major cause of morbidity and mortality in chronic kidney disease patients. In hemodialysis patient, central venous catheter related blood stream infections are major cause for concern. Most common organisms isolated are gram positive which usually respond to antibiotics and sometimes needing catheter removal. However Pantoea species have been rarely reported as causative agent of CVC sepsis. Herein we report a case of Pantoea species causing CVC sepsis in hemodialysis patient. J Microbiol Infect Dis 2020; 10(2):103-105.

Background: Pregnancy-related acute kidney injury (PRAKI) remains a large public health problem, with decreasing incidences in developing countries like India. However, some single centred studies from United States and Canada revealed an increasing incidence of PRAKI. This increase could be due to higher rates of hypertensive disorders of pregnancy.Methods: To assess the management and outcome of PRAKI. In this prospective, observational study, total 1021 cases of acute renal failure were observed.Results: 96 (9.4%) were of obstetric origin and enrolled as per inclusion criteria. Regarding management of PRAKI, 78 out of 96 (81.25%) required haemodialysis. 67 (69.79%) among them were managed with intermittent haemodialysis (IHD) while 10 (10.41%) who had hypotension at presentation were dialysed with slow, low efficiency dialysis (SLED). Continuous renal replacement therapy (CRRT) was done in 1 (10.4%) patient. Maternal mortality in this PRAKI study was 19 of 96 patients (19.79%). Sepsis accounted for 52.63% of deaths. Foetal death was observed in 58 out of 96 patients (60.41%) comprising of intrauterine death in 55 (55.29%) and abortion in 3 (3.13%) patients. 38 of 96 (39.58%) patients gave birth to live born child out of which 27 were at full term and 11 were preterm.Conclusions: In order to avoid further increase in PRAKI in India, treating obstetrician should remain aware of management and outcome of PRAKI. The better awareness of diagnosis and management protocols will ultimately lead to further reduction in prevalence of PRAKI in our country.

BackgroundAnemia is associated with adverse outcomes in those with chronic kidney disease (CKD). We examined the association of absolute and functional iron deficiency anemia (IDA) with adverse outcomes (cardiovascular hospitalization, dialysis and mortality) in those with nondialysis-dependent CKD.MethodsNondialysis-dependent CKD patients followed in the US Veterans Administration with hemoglobin level measured within 90 days of the date of the second estimated glomerular filtration rate 100–500 ng/mL) IDA and the associations of absolute and functional IDA with mortality, dialysis and cardiovascular hospitalization.ResultsOf 933 463 patients with CKD, 20.6% had anemia. Among those with anemia, 23.6% of patients had both TSAT and ferritin level measured, of whom 30% had absolute IDA and 19% had functional IDA. Absolute IDA in CKD was not associated with an increased risk of mortality or dialysis but was associated with a higher risk of 1-year {risk ratio [RR] 1.20 [95% confidence interval (CI) 1.12–1.28]} and 2-year cardiovascular hospitalization [RR 1.11 (95% CI 1.05–1.17)]. CKD patients with functional IDA had a higher risk of mortality [hazard ratio (HR) 1.11 (95% CI 1.07–1.14)] along with a higher risk of 1-year [RR 1.21 (95% CI 1.1–1.30)] and 2-year cardiovascular hospitalization [RR 1.13 (95% CI 1.07–1.21)]. Ferritin >500 ng/mL (treated as a separate category) was only associated with an increased risk of mortality [HR 1.38 (95% CI 1.26–1.51)].ConclusionsIn a large population of CKD patients with anemia, absolute and functional IDA were associated with various clinical covariates. Functional IDA was associated with an increased risk of mortality and cardiovascular hospitalization, but absolute IDA was associated only with a higher risk of hospitalization.

Thrombotic microangiopathy (TMA) commonly presents as a triad of acute kidney injury (AKI), jaundice, and hemolysis; however, tropical infections such as malaria, dengue, leptospira, and drugs like antimalarials can also have a similar presentation. They can cause AKI for many reasons including pre-renal causes but an important yet not relatively uncommon genetic cause of hemolytic anemia, that is, glucose 6-phosphate deficiency (G6PD) manifesting as jaundice, hemolysis, and AKI secondary to pigment nephropathy after receiving offending drugs needs to be worked up while evaluating such patients. Ofloxacin is not usually included in the lists of unsafe drugs in G6PD deficiency. Herein, we report a patient developing intravascular hemolysis secondary to G6PD deficiency associated with ofloxacin administration presenting as a rare cause for pigment nephropathy.

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

RATIONALE & OBJECTIVE: Atrial fibrillation is common in patients with kidney failure treated by maintenance dialysis. Whether the incidence of AF differs between patients receiving hemodialysis and peritoneal dialysis is uncertain. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Using the United States Renal Data System we identified older patients (≥67 years) with Medicare Parts A+B who initiated dialysis (1996–2011) without a diagnosis of atrial fibrillation during the prior 2 years. EXPOSURE: Dialysis modality at incident end-stage renal disease (ESRD) and maintained for at least 90 days. OUTCOME: Patients were followed for ≤36 months for a new diagnosis of atrial fibrillation. ANALYTICAL APPROACH: Time-to-event analysis using multivariable Cox proportional hazards regression to estimate cause-specific hazard ratios while censoring at modality switch, kidney transplantation, or death. RESULTS: Overall, 271,722 older patients were eligible; 17,487 (6.9%) were treated with peritoneal dialysis and 254,235 (93.1%) with hemodialysis at the onset of ESRD. During 406,225 person-years of follow-up, 69,705 patients were newly diagnosed with atrial fibrillation. Since the proportionality assumption was violated, we introduced an interaction term between time period (first 90 days vs. thereafter) and modality. The atrial fibrillation incidence during the first 90 days was 187/1,000 person-years on peritoneal dialysis and 372/1,000 person-years on hemodialysis. Patients on peritoneal dialysis had an adjusted 39% (95%CI; 34–43%) lower incidence of atrial fibrillation than those on hemodialysis. From day 91 onwards, the atrial fibrillation incidence was ~140/1,000 person-years with no major difference between modalities. LIMITATIONS: Residual confounding from unobserved differences between exposure groups; ascertainment of AF from billing claims; study of first modality may not generalize to patients switching modalities; uncertain generalizability to younger patients. CONCLUSIONS: While patients initiating dialysis using peritoneal dialysis had lower atrial fibrillation incidence during the first 90 days of ESRD, there was no major difference in atrial fibrillation incidence thereafter. The value of interventions to reduce the early excess atrial fibrillation risk in patients receiving hemodialysis may warrant further study.

The prevalence of CKD is increasing worldwide. There is tremendous imbalance in organ supply and demand worldwide. India is having mainly living donor (up to 90%) kidney transplantation program. Majority (up to 45%) of the living donors, although healthy and willing, are rejected due to ABO incompatibility. Deceased donation contributes to

Hypernatremia in the geriatric population is a common disorder associated with significant morbidity and mortality. Older people are predisposed to developing hypernatremia because of age-related physiologic changes such as decreased thirst drive, impaired urinary concentrating ability, and reduced total body water. Medications may exacerbate this predisposition. Hypernatremia and dehydration occurring in nursing homes are considered indicators of neglect that warrant reporting, but there are other nonavoidable causes of hypernatremia, and consideration at time of presentation is essential to prevent delay in diagnosis and management. We describe a case illustrating the importance of the consideration of alternate explanations for hypernatremia in a nursing home resident, followed by a review of hypernatremia in the elderly population, to underscore that neglect is the etiology of exclusion after alternatives have been considered.

Purpose To evaluate quantitative cerebral blood flow (qCBF) with traditional time-based measurements or metrics of cerebral perfusion: time to peak (Tmax) and mean transit time (MTT) in stroke patients. Materials and Methods Nine ischemic stroke patients (four male, five female, 63 ± 16 years old) were included in the study which was Health Insurance Portability and Accountability Act compliant and institutional review board approved. Cerebral perfusion was quantified using the Bookend method. Mean values of qCBF, Tmax, and MTT were determined in regions of interest (ROIs). ROIs were drawn on diffusion weighted images in diffusion positive, critically ischemic (CI), in ipsilateral normal region immediately surrounding the critically ischemic region, the presumed penumbra (PP), and in contralateral diffusion negative control, presumed normal region (PN) of gray and white matter separately (GM and WM). Results In both GM and WM, qCBF measures distinguished the studied brain regions with the most markedly reduced values in regions corresponding to extent of likely ischemic injury. In planned comparisons, only qCBF measurements differed significantly between CI and PP tissues. ROC analysis supported the utility of qCBF for discriminating brain regions differing in the likely extent of ischemic injury (CI and PN regions – qCBF: area under the curve [AUC] = 0.96, Tmax: AUC = 0.96, MTT: AUC = 0.72). Importantly, qCBF afforded the best discrimination of CI and PP regions (qCBF: AUC = 0.82, Tmax: AUC = 0.65, MTT: AUC = 0.52). Conclusion This initial evaluation indicates that quantitative MRI perfusion is feasible in ischemic stroke patients. qCBF derived with this strategy provide enhanced discrimination of CI and PP compared to time-based imaging metrics. This approach merits investigation in larger clinical studies. J. Magn. Reson. Imaging 2010;32:796–802. © 2010 Wiley-Liss, Inc.

Objective: The aim of this study is to analyze the body composition of patients receiving emergent dialysis and compare their body cell mass (BCM) and fat-free mass (FFM) with those of normal subjects. The care of patients receiving sporadic, emergent dialysis treatment is a growing public health concern and the magnitude of muscle wasting that occurs in this population is not known. Design and Methods: We used a cross-sectional design with matching to determine differences in total body potassium - an indicator of both BCM and FFM - between emergent dialysis patients and healthy normal subjects. We studied 22 subjects using a 40K counter that measures BCM and FFM and compared them to controls after matching with sex, height and weight. Results: In the matched comparison, BCM and FFM were significantly lower in subjects with end-stage renal disease (ESRD). Unadjusted BCM was 4.7 kg lower and FFM was 8.8 kg lower for those with ESRD compared to those without ESRD (p < 0.001, p < 0.001, respectively). Comparison with unmatched controls who underwent 40K analysis also revealed significantly lower BCM (4.1 kg) and FFM (7.7 kg) in the ESRD subjects (p = 0.004). After adjusting for age, height, weight and gender, BCM and FFM were lower by 4.2 and 7.8 kg, respectively (p < 0.001). Repeated observations were available for a subset of ESRD subjects, and the rate of FFM loss over time was significant, with the ESRD subjects demonstrating 2.2 kg per year decline (p = 0.01). Conclusion: We conclude that among other consequences, muscle wasting indicated by decline in BCM and FFM is a significant concern in the growing emergent dialysis population.

Guillain–Barre syndrome is acute, frequently severe fulminant polyradiculoneuropathy characterized by areflexic motor paralysis with/without sensory disturbance. We report a rare case of post-renal transplant (RT) Guillain–Barre syndrome (GBS) in a 34-year-old male, who presented with sudden onset of ascending pattern paralysis of lower limbs (LL) without bowel/bladder involvement. The diagnosis was confirmed by neurological examination and nerve conduction velocity (NCV) studies. He was treated with IV immunoglobulin and recovered completely.

Purpose To evaluate an algorithm based on algebraic estimation of T1 values (three-point estimation) in comparison with computational curve-fitting for the postprocessing of quantitative cerebral perfusion scans. Materials and Methods Computer simulations were performed to quantify the magnitude of the expected error on T1 and consequently cerebral perfusion using the three-point estimation technique on a Look-Locker (LL) EPI scan. In 50 patients, quantitative cerebral perfusion was calculated using the bookend method with three-point estimation and curve-fitting. The bookend method, a novel approach for calculating quantitative cerebral perfusion based on changes in T1 values after a contrast injection, is currently being validated. The number of computations was used as a measure of computation speed for each method. Student's paired t-test, Bland-Altman, and correlation analyses were performed to evaluate the accuracy of estimation. Results There was a 99.65% reduction in the number of computations with three-point estimation. Student's t-test showed no significant difference in cerebral perfusion (P = 0.80, 0.49, paired t-test N = 50, quantitative cerebral blood flow–white matter [qCBF-WM], qCBF–gray matter [qCBF-GM]) when compared to curve-fitting. The results of the two techniques were strongly correlated in patients (slope = 0.99, intercept =1.58 mL/(100 g/minute), r = 0.86) with a small systemic bias of −0.97 mL/(100 g/minute) in Bland-Altman analysis. Conclusion The three-point estimation technique is adequate for rapid calculation of qCBF. The estimation scheme drastically reduces processing time, thus making the method feasible for clinical use. J. Magn. Reson. Imaging 2008;28:1258–1265. © 2008 Wiley-Liss, Inc.

Since the introduction of contrast-enhanced MR angiography (CE-MRA) (1), the technique has evolved to achieve higher image quality in terms of spatial resolution and signal-to-noise ratio (SNR). Recently, much effort has been directed at trying to increase temporal resolution so that a multiphase acquisition will always have an uncontaminated arterial phase volume, eliminating the need for contrast bolus timing. Further, time-resolved CE-MRA, if fast enough, can follow the first pass of contrast through the vasculature to show flow dynamics, which is necessary in certain clinical scenarios such as arteriovenous shunting, retrograde flow, or delayed vessel enhancement. Currently, x-ray digital subtraction angiography (DSA) (2) is the clinical standard for time-resolved angiography. However, unlike MRI, x-ray DSA utilizes ionizing radiation and nephrotoxic contrast material and carries the small but definite risk of introducing embolic material. In addition, MRI can provide true 3D imaging, not just projection imaging, in order to visualize the complex 3D geometry of blood vessels. The combination of 3D and time-resolved imaging is also known as “4D” imaging. CE-MRA would be a viable option for time-resolved angiography if the SNR, spatial resolution, and temporal resolution were sufficient for the clinical problem. However, there is an inherent trade-off between these three parameters in MRI, given a fixed field-of-view (FOV). In recent times, the research community has developed a great number of novel acceleration, or undersampling, techniques to increase spatial and temporal resolution at the expense of SNR. These techniques can be broadly classified as temporal and/or spatial undersampling. Temporal undersampling involves the estimation of missing k-space samples from past and future acquired samples at the same spatial frequency. The “sliding window” technique was among the first acceleration strategies to be developed (3,4). It involves the repeated acquisition of N segments of a whole volume such that frames can be formed by any contiguous set of N segments. The frame rate is increased by N, but the data are low-pass filtered in the temporal dimension. The “keyhole” technique first acquires a high-resolution volume, and subsequently only updates the low-frequency information, where most of the image lies (5). BRISK (6), TRICKS (7), and STBB analysis/acquisition (8) techniques built on previous ideas by acquiring the central k-space lines at a higher sampling rate than peripheral lines. Spatial undersampling techniques involve the estimation of missing k-space lines from other acquired lines at different spatial frequencies in the same time frame. One technique, in use for many years now, involves the asymmetric sampling of k-space. Spatial frequencies higher than a certain threshold are not acquired on one side of k-space, and the missing data are either zero-filled or extrapolated. This concept can be extended by applying it in multiple dimensions for large overall undersampling factors. Parallel imaging is comprised of a group of techniques which use multiple receiver coils to speed up acquisition. The SMASH technique was one of the first described (9), and it has matured into GRAPPA (10), which is presently state-of-the-art. Another class of parallel imaging approaches is based on SENSE (11). Alternative k-space trajectories may have their own specific undersampling techniques. For example, the radial trajectory can be angularly undersampled (12,13). Combinations of temporal and spatial undersampling, such as PR-TRICKS (14), k-t SENSE (15), and TSENSE (16) can be used, and may even be preferable to a single acceleration technique alone. Another concern in developing a time-resolved CE-MRA sequence relates to ordering the acquisition of k-space lines. Since lines are acquired in a serial fashion, the passage of contrast causes a modulation of the signal according to the order in which the lines are acquired (17). Better ordering methods, such as elliptical centric ordering (18), will minimize the artifact associated with serial measurement. Subtraction for CE-MRA is conventionally performed using a single time frame as the mask. The mask is chosen at a time prior to the arrival of contrast. For timed CE-MRA, the acquisition typically consists of three volumes: the mask, arterial phase, and venous phase. Time-resolved acquisitions open up a new set of applications and, therefore, the way in which subtraction is performed may need to be reconsidered. In the context of time-resolved imaging, this article attempts to address these issues of undersampling, ordering, and subtraction with a CE-MRA technique combining a 3D radial trajectory (cylindrical sampling), sliding window reconstruction, pseudorandom ordering, and a sliding subtraction mask. The goals are to demonstrate with simulations and healthy volunteer studies that 1) for the sliding window reconstruction, the artifact associated with the radial trajectory is less severe than that for the spin-warp trajectory (Cartesian sampling); 2) proper ordering is essential when combining the radial trajectory with the sliding window method; and 3) the sliding mask subtraction technique better depicts the wash-in and wash-out of contrast than conventional subtraction.