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Shankar Prasad Nagaraju, Srinivas Vinayak Shenoy, Indu Ramachandra Rao, Mohan V Bhojaraja, Dharshan Rangaswamy, Ravindra Attur Prabhu Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka, 576104, IndiaCorrespondence: Mohan V Bhojaraja, Email mohan.vb@manipal.eduAbstract: Chronic kidney disease (CKD) is extremely common all over the world and is strongly linked to cardiovascular disease (CVD). The great majority of CKD patients have hypertension, which raises the risk of cardiovascular disease (CVD), end-stage kidney disease, and mortality. Controlling hypertension in patients with CKD is critical in our clinical practice since it slows the course of the disease and lowers the risk of CVD. As a result, accurate blood pressure (BP) monitoring is crucial for CKD diagnosis and therapy. Three important guidelines on BP thresholds and targets for antihypertensive medication therapy have been published in the recent decade emphasizing the way we measure BP. For both office BP and out-of-office BP measuring techniques, their clinical importance in the management of hypertension has been well defined. Although BP measurement is widely disseminated and routinely performed in most clinical settings, it remains unstandardized, and practitioners frequently fail to follow the basic recommendations to avoid measurement errors. This may lead to misdiagnosis and wrong management of hypertension, especially in CKD patients. Here, we review presently available all BP measuring techniques and their use in clinical practice and the recommendations from various guidelines and research gaps emphasizing CKD patients.Keywords: ambulatory BP, office BP, chronic kidney disease, out-of-office BP, standardized BP

Shankar Prasad Nagaraju,1 Mohan V Bhojaraja,1 Ganesh Paramasivam,2 Ravindra Attur Prabhu,1 Dharshan Rangaswamy,1 Indu Ramachandra Rao,1 Srinivas Vinayak Shenoy1 1Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy Higher Education, Manipal, Karnataka, 576104, India; 2Department of Cardiology, Kasturba Medical College, Manipal, Manipal Academy Higher Education, Manipal, Karnataka, 576104, IndiaCorrespondence: Mohan V Bhojaraja Email mohan.vb@manipal.eduIntroduction: Pulmonary hypertension (PH) is an underestimated cardiovascular consequence and a mortality predictor in patients on hemodialysis (HD). Thus, we studied its prevalence, risk factors, association with inflammation/oxidative stress, and cardiac changes in HD patients.Methods: This was a single-center cross-sectional observational study conducted at a tertiary care hospital. Patients aged > 18 years on hemodialysis for at least three months were included and divided into those with and without PH; patients with secondary causes for PH were excluded. Clinical characteristics, HD-related factors, lab parameters (C-reactive protein and malondialdehyde with thiol assay were used as markers of inflammation and oxidative stress, respectively), and echocardiography details were compared. PH was defined as a mean pulmonary artery pressure of > 25 mmHg at rest, and it was further divided as mild (25– 40 mmHg), moderate (40– 60 mmHg), and severe (> 60 mmHg).Results: Of 52 patients, 28 patients had PH (mild 24, moderate 4, and none had severe PH) with prevalence of 54%. No difference was found in clinical characteristics, dialysis-related factors, biochemical parameters including inflammation (C-reactive protein; p=0.76), or oxidative stress (thiol; p=0.36 and MDA; p=0.46) between the groups. When compared to individuals without PH, HD patients with PH exhibited significantly more mitral regurgitation (p=0.002).Conclusion: Hemodialysis patients have a high prevalence of PH. PH was significantly associated with the presence of mitral regurgitation on echocardiography. Our study did not find differences in traditional risk factors, HD-related factors, and inflammation/oxidative markers between the groups with and without PH.Keywords: chronic kidney disease, hemodialysis, inflammation, oxidative stress, pulmonary hypertension

Ravindra Attur Prabhu,1 Srinivas V Shenoy,1 Shankar Prasad Nagaraju,1 Dharshan Rangaswamy,1 Indu Ramachandra Rao,1 Mohan V Bhojaraja,1 Deepak Nayak M,2 Sindhura Lakshmi Koulmane Laxminarayana,2 Karan Saraf,1,3 Ashok Ramaswamy1,4 1Department of Nephrology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India; 2Department of Pathology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India; 3Department of Nephrology, Excelcare Hospitals, Guwahati, Assam, India; 4Department of Nephrology, Saveetha Medical College, Chennai, Tamil Nadu, IndiaCorrespondence: Srinivas V ShenoyDepartment of Nephrology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, IndiaTel +91 9844374705Email shenoy.srinivas@manipal.eduPurpose: Diabetic kidney disease (DKD) represents a unique subset of patients with chronic kidney disease (CKD). Acute kidney injury (AKI) is implicated in DKD progression; however, their interplay is not studied well. We studied risk factors for AKI and the effect of AKI on disease progression in a homogeneous group of patients with DKD.Patients and Methods: We conducted a retrospective open cohort study of patients with DKD at a single tertiary care centre between August 2016 – August 2019. Patients with a minimum follow-up of 2 years were included in the study. The incidence, etiology and risk factors for AKI were studied. The primary outcome studied was the effect of AKI on reduction in estimated glomerular filtration rate (eGFR) in DKD. Loss in eGFR by 50% and need for renal replacement therapy or reaching CKD stage V were studied as secondary outcomes.Results: Two hundred and ninety-two DKD patients meeting the study criteria with a follow-up of 29.57 (± 4.3) months were included. The incidence of AKI was 31.1%. Sepsis was the most common etiology (61%). Proteinuria was an independent risk factor for AKI after adjusting for covariates (adjusted OR - 1.158; 95% CI (1.018– 1.316); p=0.025). In patients with AKI, median decline in eGFR was 10.29 mL/min/1.73m2/year (IQR-5.58– 13.84) which was significantly higher compared to patients with no AKI [eGFR 7.25 (IQR 5.06– 11.38); p-0.014]. On subgroup analysis, sepsis-induced AKI (versus non-sepsis AKI; p< 0.001) and higher AKI stage (stage 2/3 versus stage 1; p=0.019) were associated with a faster decline in eGFR.Conclusion: AKI is common in patients with DKD with sepsis being the most common etiology. AKI in diabetic kidney disease is associated with a faster decline in eGFR. Baseline proteinuria is an independent risk factor for AKI.Keywords: diabetic kidney disease, acute kidney injury, GFR decline, proteinuria, sepsis

Introduction: Chloride is the most abundant extracellular anion; however, abnormalities of serum chloride (dyschloremia) are often overlooked. This study aimed to study the association of dyschloremia with AKI and major adverse kidney events at Day 30 (MAKE30) in critically ill patients with sepsis. Materials and Methods: This prospective single-center cohort study included adult patients with sepsis admitted in a tertiary care hospital in India. Patients with advanced chronic kidney disease, requiring dialysis at admission, or with hospital stay of less than 72 h were excluded. Hyperchloremia and hypochloremia were defined as chloride levels of > 110 mEq/L and < 95 mEq/L, respectively. The primary outcome measure was MAKE30-a composite of death, need for dialysis, or sustained loss of kidney function at Day 30. Results: In a cohort of 400 patients with a mean age of 60 (±15) years, AKI was seen in 301 (75.2%) and MAKE30 in 171 (42.8%). Hyperchloremia and hypochloremia were seen in 19.3% ( n  = 77) and 32.3% ( n  = 129), respectively, in the first 72 h of ICU stay. Hypochloremia, but not hyperchloremia, was independently associated with both MAKE30 (OR: 2.56, 95% CI: 1.13-5.79; p =0.024) and new-onset or worsening AKI (OR: 2.52, 95% CI: 1.17-5.41; p =0.019). There was no association between hyperchloremia and either MAKE30 (OR: 1.07, 95% CI: 0.43-2.69; p =0.882) or new-onset/worsening AKI (OR: 0.89, 95% CI: 0.38-2.09; p =0.781). Conclusion: Hypochloremia, but not hyperchloremia, was associated with MAKE30 in this cohort of critically ill patients with sepsis. Trial Registration: Clinical Trial Registry identifier: CTRI//2022/02/040519., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Saurabh M. Thanekar et al.)

Percutaneous renal biopsy, although essential for renal disease diagnosis, is associated with a number of post-biopsy complications ranging from gross haematuria to AV fistula to death. In this study, we carried out an active haematoma surveillance and attempted to correlate renal sonological parameters-kidney length, renal parenchymal changes, renal cortical and parenchymal thickness for their potential use in prediction of post-renal biopsy complications., Methods: This was a prospective study done from April 2022 to April 2023 on all adult patients undergoing native or transplant kidney biopsy. Baseline clinical, laboratory and renal sonological parameters were noted prior to biopsy. USG-guided renal biopsy was done and any haematoma at 0 h, 12 h and 24 h post-biopsy noted. Biopsy complications including need for any interventions were noted., Results: Out of the 240 patients enrolled in the study, 58.3% experienced post-biopsy complications. Among these, 5% of patients encountered major complications, with 3.33% necessitating medical intervention following renal biopsy procedures. A high percentage, 98.89%, exhibited hematoma formation within 12 h post-biopsy. Furthermore, our analysis revealed that a hematoma size exceeding 1.2 cm at the 12-h mark exhibited a sensitivity of 100% and specificity of 71% in predicting the need for blood transfusion. Renal parenchymal changes were the most reliable sonological parameters for predicting post-biopsy complication on multivariate analysis., Conclusion: The incidence of major complications requiring interventions following renal biopsy is notably low. Our study highlights the significance of renal sonological characteristics, including parenchymal thickness, cortical thickness and parenchymal changes, in predicting these complications. Furthermore, we emphasize the utility of hematoma surveillance immediately post-biopsy and at the 12 h, as a valuable tool for predicting the necessity of post-biopsy interventions. This approach can aid in efficiently triaging patients and determining the need for further observation post-renal biopsy., (© 2024. The Author(s).)

Background: Haematological abnormalities following renal transplantation are frequently observed and have a significant effect on survival and graft outcomes. The pattern of haematological abnormalities varies globally. Few studies have been conducted in Asian countries. We aimed to evaluate the patterns of haematological abnormalities in post-transplant recipients in our center during the first year after post-renal transplant and the association of post-transplant anemia with graft function., Methods: This single-center retrospective study was conducted on renal transplantation recipients between 2014 and 2019. The study included all patients who received kidney transplants from live/cadaveric donors and had follow-up data collected up to 12 months after the transplant. The outcome studied was the prevalence of haematological abnormalities and the association between post-transplant anemia (PTA) and graft function in post-transplant recipients., Results: A total of 106 renal transplant recipients were included in the study. The prevalence of PTA was 98% in the first week, 75% at one month, 35% at three months, 32% at six months, and 27% at 12 months. The other cytopenia cases were leukopenia (43.4%), thrombocytopenia (33.2%), and pancytopenia (15.1%). Post-transplant erythrocytosis was observed in 17.9% of patients. 18 patients with severe PTA in the first week of transplant had significant allograft dysfunction (p=0.04). Patients with and without PTA had similar graft functions at six and 12 months (p=0.50)., Conclusions: Haematological abnormalities are common in renal transplant recipients. PTA is highly prevalent during the first week and improves over time. Other haematological abnormalities observed were leukopenia, thrombocytopenia, pancytopenia, and post-transplant erythrocytosis. Leucopenia was primarily drug-induced, and thrombocytopenia and pancytopenia were frequently caused by infections in our cohort. Additionally, severe PTA was significantly associated with graft dysfunction in the first week post-transplant, whereas similar graft function was observed at 6 and 12 months post-transplant, irrespective of the presence or absence of PTA., Competing Interests: No competing interests were disclosed., (Copyright: © 2024 Laxminarayana SLK et al.)

Introduction: Patients with chronic kidney disease (CKD) are at increased risk of developing tuberculosis (TB). These patients may also be at higher risk of developing antitubercular treatment (ATT)-associated adverse drug reactions (ADRs). Although dose modification has been recommended, data regarding the impact of impaired kidney function on ATT-associated ADRs is sparse. We studied the incidence and profile of ATT-associated ADRs in patients with CKD and compared them with those with normal kidney function., Methodology: This retrospective study analyzed all patients initiated on ATT from January 2016 to August 2019. Patients were grouped into CKD and normal kidney function based on their eGFR. Data on ATT-associated ADRs were collected from medical records. Predictors of ADRs were assessed using univariable and multivariable logistic regression. Additionally, Propensity score matching and analysis were done for CKD and normal kidney function in 1:3 ratio., Results: Of 1815 patients on ATT, 75 (4.1%) had CKD. ADRs were more frequent [36/75 (48.0%) vs. 239/1740 (13.7%), p  ≤ 0.0001] and more severe [15/46 (32.6%) vs. 43/283 (15.1%), p  = 0.010] in CKD than those with normal kidney function. The most common ADRs were hepatobiliary [23/75 (30.6%) vs. 156/1740 (8.9%), p  ≤ 0.0001], neuropsychiatric [8/75(10.6%) vs. 21/1740(1.2%), p  ≤ 0.0001], renal [4/75(5.3%) vs. 8/1740(0.4%), p  = 0.001], and gastrointestinal [5/75(6.6%) vs. 34/1740 (1.9%), p  = 0.020]. CKD was an independent predictor for ADRs (OR -4.96, 95% CI: 2.79-8.82; p  ≤ 0.0001). The matched cohort showed similar results., Conclusion: ATT-associated ADRs were more common and severe in patients with CKD, despite drug dose modifications. Optimal dosing of ATT in CKD needs to be further evaluated.

Tumor growth is intricately linked to the process of angiogenesis, with a key role played by vascular endothelial growth factor (VEGF) and its associated signaling pathways. Notably, these pathways also play a pivotal "housekeeping" role in renal physiology. Over the past decade, the utilization of VEGF signaling inhibitors has seen a substantial rise in the treatment of diverse solid organ tumors, diabetic retinopathy, age-related macular degeneration, and various ocular diseases. However, this increased use of such agents has led to a higher frequency of encountering renal adverse effects in clinical practice. This review comprehensively addresses the incidence, pathophysiological mechanisms, and current evidence concerning renal adverse events associated with systemic and intravitreal antiangiogenic therapies targeting VEGF-A and its receptors (VEGFR) and their associated signaling pathways. Additionally, we briefly explore strategies for mitigating potential risks linked to the use of these agents and effectively managing various renal adverse events, including but not limited to hypertension, proteinuria, renal dysfunction, and electrolyte imbalances., (© 2024. The Author(s).)

Objectives: The existing biomarkers used to promptly identify graft dysfunction after kidney transplantation lack consistency. Neutrophil gelatinase-associated lipocalin (NGAL) appears to be a promising biomarker but its levels measured from serum and urine have demonstrated varying predictive values. Our study aimed to explore the potential of NGAL as a biomarker in predicting graft dysfunction in kidney transplant patients, including live and deceased donor recipients., Methods: A single-centered observational cohort study with live and deceased kidney recipients as participants was conducted between 2018 and 2022 at a tertiary care hospital in Southern India. Serum creatinine levels were monitored daily; creatinine reduction on day two and day seven were calculated. The recipients were categorized based on graft recovery into three groups: delayed graft function (DGF), slow graft function (SGF), or immediate graft function (IGF). Analysis of serum and urine NGAL was conducted two hours after the transplant and their predictive values were evaluated by the area under the curves (AUC) method., Results: Of the 40 participants, 34 (85.0%) received their transplant from live-related donors, while six (15.0%) received kidneys from deceased donors. DGF occurred in four (10.0%) patients, SGF in 12 (30.0%), and 24 (60.0%) patients achieved IGF. Serum NGAL demonstrated higher sensitivity compared to urine NGAL. At a cut-off value of 678 ng/mL (AUC = 0.77), serum NGAL showed 90.0% sensitivity and 53.0% specificity. Urine NGAL had 70.0% sensitivity and 74.0% specificity at a cut-off value of 489 ng/mL (AUC = 0.72)., Conclusions: Kidney recipients in SGF and DGF categories had elevated levels of serum and urine NGAL compared to those without IGF. Although serum NGAL showed higher sensitivity than urine NGAL in predicting graft dysfunction, both markers lacked the specificity needed for accurate predictions., (Copyright © 2024, Oman Medical Journal.)

Background: Dialysis dysequilibrium syndrome (DDS) refers to neurological symptoms usually seen during or after new initiation or following reinitiation of haemodialysis (HD) after missing multiple sessions. DDS is associated with death and morbidity. We studied interventions aimed at preventing DDS., Objectives: To evaluate the benefits and harms of different types of interventions for preventing DDS., Search Methods: We contacted the information specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 8 May 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov., Selection Criteria: We included randomised controlled trials (RCTs) that compared any intervention against standard care, including individuals initiated on HD, regardless of age., Data Collection and Analysis: Two authors independently determined study eligibility, assessed quality and extracted data. Data were collected on methods, interventions, participants, and outcomes (DDS incidence, severe DDS, death, adverse events). Risk ratios (RR) and confidence intervals (CI) were calculated. Study quality was assessed using the Cochrane Risk of Bias 2 (ROB2) tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach., Main Results: We included two RCTs, enrolling 32 adult participants. Interventions included were slow dialysis, sodium modelling, standard sodium dialysate, and high sodium dialysate. The risk of bias was of some concern to high risk of bias in both studies. Slow dialysis compared to sodium modelling (1 study, 15 participants) may result in little to no difference in DDS, severe DDS, and death (low certainty evidence) and has uncertain effects on adverse events (RR 1.33, 95% CI 0.15 to 11.64; very low certainty evidence). Standard sodium dialysate compared to high sodium dialysate (1 study, 17 participants) has uncertain effects on the incidence of DDS (RR 0.07, 95% CI 0.00 to 1.12), severe DDS (RR 0.47, 95% CI 0.02 to 10.32), and adverse events (RR 0.29, 95% CI 0.08 to 1.02) (very low certainty evidence)., Authors' Conclusions: In HD patients, sodium modelling, compared to slow dialysis, may result in little to no difference in DDS and death (low certainty evidence) and has uncertain effects on adverse events (very low certainty evidence). The evidence is very uncertain for the effect of high-sodium dialysate and standard sodium dialysate on DDS, death and adverse events (very low certainty evidence)., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Background: A significant proportion of diabetic kidney disease (DKD) experience a rapid decline in eGFR, leading to end-stage kidney disease (ESKD) within months. This single-centered retrospective cohort study aimed to assess the prevalence, clinical profile, and predictors for rapid progression in type 2 diabetes mellitus (T2DM) patients with DKD., Method: Three hundred fifty-nine T2DM patients with DKD between January 2018 and 2022 were included and those with superimposed non-diabetic kidney disease, chronic kidney disease 5, and < 6 months follow-up were excluded. They were classified as rapid and non-rapid progressors based on the annual eGFR decline of > 5 ml/min/1.73 m 2 /year. The primary outcome analyzed was the progression to ESKD. The secondary outcomes were the onset of microvascular and macrovascular complications and predictors for rapid progression as well as ESKD., Results: In a median follow-up of 3.5 years, 61.3% were rapid progressors (mean eGFR decline of 15.4 ml/1.73m 2 /year) and 38.7% were non-rapid progressors (mean eGFR decline 1.8 ml/1.73m 2 /year. Among rapid progressors, 61.4% reached ESKD. Severe proteinuria, the presence of retinopathy, and acute kidney injury (AKI) episodes were strong predictors of rapid progression. Cardiovascular disease and diabetic retinopathy (microvascular complications) were significantly higher among rapid progressors and had a mortality rate of 7.2%., Conclusion: The majority of type 2 DKD patients were rapid progressors and two-thirds of them developed ESKD. The prevalence of hypertension, cardiovascular disease, diabetic retinopathy, AKI episodes, and mortality was higher in rapid progressors. Severe proteinuria and diabetic retinopathy were found to be strong predictors for rapid eGFR decline and its progression to ESKD., (© 2023. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

Diabetic kidney disease (DKD) is the most devastating complication of diabetes mellitus. Identification of patients at the early stages of progression may reduce the disease burden. The limitation of conventional markers such as serum creatinine and proteinuria intensify the need for novel biomarkers. The traditional paradigm of DKD pathogenesis has expanded to the activation of the immune system and inflammatory pathways. Monocyte chemo-attractant protein-1 (MCP-1) is extensively studied, as a key inflammatory mediator that modulates the development of DKD. Recent evidence supports the diagnostic role of MCP-1 in patients with or without proteinuria in DKD, as well as a significant role in the early prediction and risk stratification of DKD. In this review, we will summarize and update present evidence for MCP-1 for diagnostic ability and predicting the progression of DKD., (Copyright © 2023 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Background: Uremic pruritus has an impact on the quality of life and sleep of hemodialysis patients, but the majority of cases go unreported and untreated unless severe, due to a lack of awareness. The purpose of this study is to determine the prevalence, associated factors, and impact on health-related quality of life (HR-QOL) and sleep in hemodialysis patients., Methodology: A single-center observational study of 3 months wherein 120 adults on maintenance hemodialysis were included. Baseline characteristics, dialysis-related factors, and lab parameters influencing uremic pruritus were recorded. Those with uremic pruritus completed "12-item pruritus severity scale (12-PSS)", "SKINDEX10", and "Itch-MOS" questionnaires to evaluate severity, impact on HR-QOL, and sleep respectively., Results: Sixty seven over one hundred twenty (55.83%) patients had pruritus and majority were mild (40.83%) as per 12-PSS. Those with pruritus (n=67) had a mean age of 56.5±11.3 years, most were males (82%), chronic glomerulonephritis (29.1%) was the commonest cause of end-stage kidney disease, 3 active smokers, and 4 seropositive. 65(97%) patients were on twice-weekly dialysis, 36/67 had <5 years' dialysis vintage and acceptable adequacy. There was no significant association between uremic pruritus and dialysis-related/laboratory parameters. Patients with uremic pruritus demonstrated significantly worse "HR-QOL" (p<0.001) on the "SKINDEX-10", and patients' "Itch-MOS" scores demonstrated a significant decline in sleep quality with increasing pruritus severity (p<0.001)., Conclusion: The majority of patients on maintenance hemodialysis experience uremic pruritus. None of the clinical characteristics, dialysis-related factors, and laboratory parameters affected uremic pruritus. Uremic pruritus patients had the worst HR-QOL & their sleep quality significantly declined as pruritus severity escalated., Trial Registration Number and Date of Registration: Study approval was obtained from Institutional Research Committee and Institutional Ethical Committee (IEC 642/2021). Clinical Trial Registry of India (CTRI) registration (CTRI/2022/01/039143) was also obtained., (© 2023. The Author(s).)

Hydroxychloroquine is one of the oldest disease-modifying anti-rheumatic drugs in clinical use. The drug interferes with lysosomal activity and antigen presentation, inhibits autophagy, and decreases transcription of pro-inflammatory cytokines. Owing to its immunomodulatory, anti-inflammatory, anti-thrombotic effect, hydroxychloroquine has been an integral part of therapy for systemic lupus erythematosus and lupus nephritis for several decades. The therapeutic versatility of hydroxychloroquine has led to repurposing it for other clinical conditions, with recent studies showing reduction in proteinuria in IgA nephropathy. Research is also underway to investigate the efficacy of hydroxychloroquine in primary membranous nephropathy, Alport's syndrome, systemic vasculitis, anti-GBM disease, acute kidney injury and for cardiovascular risk reduction in chronic kidney disease. Hydroxychloroquine is well-tolerated, inexpensive, and widely available and therefore, should its indications expand in the future, it would certainly be welcomed. However, clinicians should be aware of the risk of irreversible and progressive retinal toxicity and rarely, cardiomyopathy. Monitoring hydroxychloroquine levels in blood appears to be a promising tool to evaluate compliance, individualize the dose and reduce the risk of retinal toxicity, although this is not yet standard clinical practice. In this review, we discuss the existing knowledge regarding the mechanism of action of hydroxychloroquine, its utility in lupus nephritis and other kidney diseases, the main adverse effects and the evidence gaps that need to be addressed in future research. Created with Biorender.com. HCQ, hydroxychloroquine; GBM, glomerular basement membrane; mDC, myeloid dendritic cell; MHC, major histocompatibility complex; TLR, toll-like receptor., (© 2023. The Author(s).)

The term chronic kidney disease of unknown aetiology (CKDu) refers to chronic kidney disease (CKD) in the absence of diabetes, long-standing hypertension, glomerulonephritis, obstructive uropathy or other apparent causes. An increasing number of CKDu cases have been reported from Latin America, Sri Lanka, India and others over the last two decades. These regional nephropathies share the following common attributes: (a) they affect low-to-middle income countries with tropical climates, (b) involve predominantly rural agricultural communities, (c) male predilection, (d) absence of significant proteinuria and hypertension, and (e) chronic tubulointerstitial nephritis on kidney biopsy. The current body of literature suggests that CKDu may be caused by heat stress, agrochemicals, contaminated drinking water or heavy metals; however, considerable regional disparities in CKDu research make it difficult to establish a common causal link. In the absence of a definite aetiology, specific preventive and therapeutic interventions are lacking. Improvement of working conditions of farmers and labourers, provision of safe drinking water and changes in agricultural practices are some of the measures that have been implemented; however, there is lack of data to assess their impact on the incidence and progression of CKDu. There is a need for a concerted global effort to address the current knowledge gaps, and to develop effective and sustainable strategies to tackle this devastating disease., (© 2023 John Wiley & Sons Ltd.)

Background: Hepatitis C virus (HCV) infection is common in chronic kidney disease (CKD) patients on dialysis, causes chronic liver disease, may increase the risk of death, and impacts kidney transplant outcomes. Direct-acting antivirals have replaced interferons because of better efficacy and tolerability. This is an update of a review first published in 2015., Objectives: We aimed to look at the benefits and harms of interventions for HCV in CKD patients on dialysis: death, disease relapse, treatment response/discontinuation, time to recovery, quality of life (QoL), cost-effectiveness, and adverse events. We aimed to study comparisons of available interventions, compared with placebo, control, with each other and with newer treatments., Search Methods: We searched the Cochrane Kidney and Transplant's Specialised Register to 23 February 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE and EMBASE, handsearching conference proceedings, and searching the International Clinical Trials Register Portal (ICTRP) and ClinicalTrials.gov., Selection Criteria: Randomised controlled trials (RCTs), quasi-RCTs, first period of randomised cross-over studies on interventions for HCV in CKD on dialysis were considered., Data Collection and Analysis: Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach., Main Results: Three studies were included in this update, therefore 13 studies (997 randomised participants) met our inclusion criteria. Overall, the risk of bias was judged low in seven studies, unclear in four, low to unclear in one, and high in one study. Interventions included standard interferon, pegylated (PEG) interferon, standard or PEG interferon plus ribavirin; direct-acting antivirals, and direct-acting antivirals plus PEG interferon plus ribavirin. Compared to placebo or control, standard interferon may make little or no difference to death (5 studies, 134 participants: RR 0.89, 95% CI 0.06 to 13.23) or relapse (low certainty evidence), probably improves end-of-treatment response (ETR) (5 studies, 132 participants: RR 8.62, 95% CI 3.03 to 24.55; I² = 0%) (moderate certainty evidence), and probably makes little or no difference to sustained virological response (SVR) (4 studies, 98 participants: RR 3.25, 95% CI 0.81 to 13.07; I² = 53%), treatment discontinuation (4 studies, 116 participants: RR 4.59, 95% CI 0.49 to 42.69; I² = 63%), and adverse events (5 studies, 143 participants: RR 3.56, 95% CI 0.98 to 13.01; I² = 25%) (moderate certainty evidence). In low certainty evidence, PEG interferon (1 study, 50 participants) may improve ETR (RR 1.53, 95% CI 1.09 to 2.15) but may make little or no difference to death (RR 0.33, 95% CI 0.01 to 7.81), SVR (RR 2.40, 95% CI 0.99 to 5.81), treatment discontinuation (RR 0.11, 95% CI 0.01 to 1.96), adverse events (RR 0.11, 95% CI 0.01 to 1.96) and relapses (21/38 relapsed) (RR 0.72, 95% CI 0.41 to 1.25) compared to standard interferon. In moderate certainty evidence, high-dose PEG interferon (alpha-2a and alpha-2b) may make little or no difference to death (2 studies, 97 participants: RR 4.30, 95% CI 0.76 to 24.33; I² = 0%), ETR (RR 1.42, 95% CI 0.51 to 3.90; I² = 20%), SVR (RR 1.19, 95% CI 0.68 to 2.07; I² = 0%), treatment discontinuation (RR 1.20, 95% CI 0.63 to 2.28; I² = 0%) or adverse events (RR 1.05, 95% CI 0.61 to 1.83; I² = 27%) compared to low-dose PEG interferon. High-dose PEG interferon may make little or no difference to relapses (1 study, 43 participants: RR 1.11, 95% CI 0.45 to 2.77; low certainty evidence). There were no significant subgroup differences. Standard interferon plus ribavirin may lead to higher treatment discontinuation (1 study, 52 participants: RR 2.97, 95% CI 1.19 to 7.36; low certainty evidence) compared to standard interferon alone.  In low certainty evidence, PEG interferon plus ribavirin (1 study, 377 participants) may improve SVR (RR 1.80, 95% CI 1.46 to 2.21), reduce relapses (RR 0.33, 95% CI 0.23 to 0.48), slightly increase the number with adverse events (RR 1.10, 95% CI 1.01 to 1.19), and may make little or no difference to ETR (RR 1.01, 95% CI 0.94 to 1.09) compared to PEG interferon alone. The evidence is very uncertain about the effect of PEG interferon plus ribavirin on treatment discontinuation (RR 1.71, 95% CI 0.69 to 4.24) compared to PEG interferon alone. One study reported grazoprevir plus elbasvir improved ETR (173 participants: RR 174.99, 95% CI 11.03 to 2775.78; low certainty evidence) compared to placebo. It is uncertain whether telaprevir plus ribavirin (high versus low initial dose) plus PEG interferon for 24 versus 48 weeks (1 study, 35 participants) improves ETR (RR 1.02, 95% CI 0.67 to 1.56) or SVR (RR 1.02, 95% CI 0.67 to 1.56) because the certainty of the evidence is very low.  Data on QoL, cost-effectiveness, cardiovascular outcomes and peritoneal dialysis were not available., Authors' Conclusions: In dialysis patients with HCV infection grazoprevir plus elbasvir probably improves ETR. There is no difference in ETR or SVR for combinations of telaprevir, ribavirin and PEG interferon given for different durations and doses. Though no longer in use, PEG interferon was more effective than standard interferon for ETR but not SVR. Increasing doses of PEG interferon did not improve responses. The addition of ribavirin to PEG interferon may result in fewer relapses, higher SVR, and higher numbers with adverse events., (Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

The global burden of diabetic kidney disease (DKD) is escalating, and it remains as a predominant cause of the end-stage renal disease (ESRD). DKD is associated with increased cardiovascular disease and morbidity in all types of diabetes. Prediction of progression with albuminuria and eGFR is challenging in DKD, especially in non-proteinuric DKD patients. The pathogenesis of DKD is multifactorial characterized by injury to all components of the nephron, whereas albuminuria is an indicator of only glomerular injury. The limits in the diagnostic and prognostic value of urine albumin demonstrate the need for alternative and clinically significant early biomarkers, allowing more targeted and effective diabetic treatment, to reduce the burden of DKD and ESRD. Identification of biomarkers, based on multifactorial pathogenesis of DKD can be the crucial paradigm in the treatment algorithm of DKD patients. This review focuses on the potential biomarkers linked to DKD pathogenesis, particularly with the hope of broadening the diagnostic window to identify patients with different stages of DKD progression., (© 2022. The Author(s).)

Objectives: End-stage kidney disease (ESKD) is a life-limiting illness that leads to significant health-related suffering for the patients and their caregivers. Moreover, disease-directed options such as dialysis and renal transplant might not be universally accessible. Inadequate assessment and management of symptoms often lead to diminished quality of life. For evaluating symptoms and their associated distress, various tools have been identified. However, these are not available for the native Kannada-speaking population for assessing ESKD symptom burden. In this study, we determined the reliability and validity of the Edmonton Symptom Assessment System Revised Renal (ESAS-r: Renal) in Kannada-speaking ESKD patients., Materials and Methods: ESAS-r: Renal English version was translated into Kannada using the forward and backward method. The translated version was endorsed by Nephrology, Palliative care, Dialysis technology and Nursing experts. As a pilot study, 12 ESKD patients evaluated the content of the questionnaires for appropriateness and relevance. The ESAS-r: Renal Kannada version was validated by administering this tool to 45 patients twice a fortnight., Result: The translated ESAS-r: Renal Kannada version questionnaire had an acceptable face and content validity. Experts' opinion was assessed by content validity ratio (CVR), and the value of CVR of ESAS-r: Renal Kannada version was-'1'-. Internal consistency of the tool was assessed among Kannada-speaking ESKD patients; its Cronbach's α was 0.785, and test-retest validity was 0.896., Conclusion: The validated Kannada version of ESAS-r: Renal was reliable and valid for assessing symptom burden in ESKD patients., Competing Interests: There are no conflicts of interest., (© 2023 Published by Scientific Scholar on behalf of Indian Journal of Palliative Care.)

This study aimed to compare the differences in echocardiographic and strain parameters in patients with diabetic kidney disease (DKD) and non-diabetic kidney disease (NDKD) in a cohort with pre-dialysis chronic kidney disease (CKD) and normal ejection fraction (EF). In this single-center prospective study, patients with CKD stages 3-5 and EF > 55% were included. We compared cardiac structure and function using conventional and speckle-tracking strain echocardiography among DKD and NDKD groups. Cardiovascular outcomes were assessed at the end of the study. Of the included 117 patients, 56 (47.9%) had DKD, and 61 (52.1%) had NDKD. Patients with DKD had higher ratios of early mitral inflow velocity and mitral annular early diastolic velocity (E/e') (11.9 ± 4.4 vs. 9.8 ± 3.5; p = 0.004), lower septal e' velocity (7.1 ± 2.5 vs. 8.2 ± 2.8; p = 0.031), lower lateral e' velocity (9.2 ± 2.9 vs. 10.4 ± 3.8; p = 0.045) and longer deceleration times (209.2 ± 41.5 vs. 189.1 ± 48.0; p = 0.017), compared to those with NDKD. Left ventricular mass index (LVMI), global longitudinal strain (GLS), early diastolic strain rate (SR E), and E/SR E were similar. At a median follow-up of 239 days, 3-P MACE (11.5% vs. 4.9%; p = 0.047) and 4-P MACE (28.6% vs. 11.5%; p = 0.020) were observed to be higher in the DKD group. Diastolic dysfunction was more common in patients with DKD, compared to those with NDKD, although both groups had similar LVMI and GLS. Those with DKD also had poorer cardiovascular outcomes. This highlights the importance of the assessment of diastolic function in CKD, particularly in those with diabetic CKD., (© 2022. The Author(s).)

Methods: A systematic search was conducted on PubMed, Embase, and the Google scholar for eligible studies through September 2021. The quality of selected articles was assessed using JBI checklist. Higgins and Thompson's I 2 statistic was used to see the degree of heterogeneity. Based on degree of heterogeneity, fixed or random effects model was used to estimate pooled effect using inverse variance method. Results were expressed as hazard ratios and odds ratios with 95% CIs., Results: After scrutinizing 18017 articles, data from ten relevant studies (seven prospective and three retrospective) was extracted. DR was significantly associated with DKD progression with a pooled HR of 2.42 (95% CI: 1.70-3.45) and a pooled OR of 2.62 (95% CI: 1.76-3.89). There was also a significant association between the severity of DR and risk of progression of DKD with a pooled OR of 2.13 (95% CI: 1.82-2.50) for nonproliferative DR and 2.56 (95% CI: 2.93-.33) for proliferative DR., Conclusion: Our study suggests that presence of DR is a strong predictor of risk of kidney disease progression in DKD patients. Furthermore, the risk of DKD progression increases with DR severity. Screening for retinal vascular changes could potentially help in prognostication and risk-stratification of patients with DKD., Competing Interests: MG and Dr. GB are employees in Carl Zeiss Pvt. Ltd. Dr. SPN, Dr. SVB, and Dr. IRR declare consulting work for Carl Zeiss Pvt. Ltd. for a research project on DR and artificial intelligence. The statistical analysis in this study was undertaken by a consultant biostatistician, Dr. JG. The fees for the biostatistician were paid to her institution by Carl Zeiss India Pvt. Ltd., (Copyright © 2022 Mansi Gupta et al.)

Introduction: Hyponatremia is a frequent finding in hospitalized patients and is associated with poor clinical outcomes. While hyponatremia is known to commonly occur in certain infections, its association with melioidosis has not been studied previously. We studied incidence and impact of hyponatremia on clinical outcomes in melioidosis., Methods: This was a retrospective analysis of a single-center hospital registry of culture-positive patients with melioidosis hospitalized during a 10-year period (January 01, 2010, through January 31, 2021). Hyponatremia was defined as serum sodium of <135 mmol/L, and severe hyponatremia as serum sodium <120 mmol/L. The association of hyponatremia with in-hospital mortality, need for intensive care unit (ICU) stay and mechanical ventilation was studied., Results: Of 201 patients with melioidosis, 169 (84.1%) had hyponatremia, with severe hyponatremia in 35 (17.4%) patients. Older age (adjusted odds ratios [OR] 1.03, 95% confidence intervals [CI]: 1.00-1.06; P = 0.049) and acute kidney injury (AKI) (adjusted OR 3.30, 95% CI: 1.19-9.19; P = 0.02) were independently associated with hyponatremia. Twenty-two patients had been evaluated for cause of hyponatremia and of these, 11 (50%) had syndrome of inappropriate antidiuresis. Severe hyponatremia was associated with in-hospital mortality (adjusted OR 3.75, 95% CI: 1.37-10.27; P = 0.01), need for ICU stay (adjusted OR 7.04, 95% CI: 2.88-17.19; P < 0.001) and mechanical ventilation (adjusted OR 3.99, 95% CI: 1.54-10.32; P = 0.004)., Conclusion: Hyponatremia occurs in 84.1% of hospitalized patients with melioidosis. Older age and AKI are associated with a higher incidence of hyponatremia. The presence of severe hyponatremia is an independent predictor of in-hospital mortality, need for mechanical ventilation and ICU stay., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Global Infectious Diseases.)

Purpose: Arteriovenous fistula(AVF) is preferred vascular access for hemodialysis but has primary failure in 20-60%. Studying predictors of AVF failure would help plan appropriate management.We studied AVF outcomes, clinical and vascular factors predicting their failure in patients requiring hemodialysis., Methods: Retrospective study of patients with AVF creation from January 2017 to December 2018. Outcomes studied were immediate (< 72 h), primary (3 months) AVF failure, six-month/one-year patency, analyzed for predictive clinical, vascular factors as assessed using Pre-operative Doppler Ultrasound(DUS)., Results: Of 530 AVFs in 460 patients, DUS was done in 426/530 (80.4%), 349/460 (75.8%) were males, mean age was 53.10 ± 14.54 (18-91), 215/460(46.7%) had Diabetes mellitus(DM), 423/460(92%) hypertension. AVFs were radiocephalic in 79/530 (14.9%), brachiocephalic 418/530 (78.9%), brachiobasilic 33/530 (6.2%). AVF Immediate/Primary failure was seen in 64/530 (12.1%), 90/352 (25.6%); Patency at six months/one year in 253/352(71.8%),191/305 (62.6%), respectively. Older age had less immediate failures (AOR 0.97, CI 0.95-0.99, p 0.03). Feeding arterial diameter predicted immediate and primary failure on univariate analysis [OR 0.64 (95% CI 0.49-0.83), 0.62 (95% CI 0.47-0.89), respectively], but not multivariate. Artery diameter of > 4.0 mm had less failures [immediate (p 0.01), primary (p 0.02)], < 2.0 mm had specificity 95.9% and 95.4% for immediate, primary failure respectively., Conclusion: AVF failure is 12.1%, immediately; 25.6% three months after construction, Patency at 6 months is 71.8%, one year 62.6%. Immediate failures decrease with age. Artery diameters > 4.0 mm had less, < 2.0 mm had more failures., (© 2021. The Author(s).)

Background: Melioidosis is a potentially fatal tropical infection caused by Burkholderia pseudomallei. Kidney involvement is possible, but has not been well described., Aim: This study aimed to assess the risk of acute kidney injury (AKI) and its outcomes in melioidosis., Methods: A retrospective observational cohort study was performed. Case records of consecutive patients with culture-confirmed melioidosis, observed from January 1st, 2012 through December 31st, 2019 were analysed for demographics, presence of comorbidities, including chronic kidney disease (CKD), diabetes mellitus (DM), and presence of bacteraemia, sepsis, shock, AKI, and urinary abnormalities. The outcomes we studied were: mortality, need for hospitalisation in an intensive care unit (ICU), duration of hospitalization. We then compared the outcomes between patients with and without AKI., Results: Of 164 patients, AKI was observed in 59 (35.98%), and haemodialysis was required in eight (13.56%). In the univariate analysis, AKI was associated with CKD (OR 5.83; CI 1.140-29.90, P = 0.03), bacteraemia (OR 8.82; CI 3.67-21.22, P < 0.001) and shock (OR 3.75; CI 1.63-8.65, P = 0.04). In the multivariate analysis, CKD (adjusted OR 10.68; 95% CI 1.66-68.77; P = 0.013) and bacteraemia (adjusted OR 8.22; 95% CI 3.15-21.47, P < 0.001) predicted AKI. AKI was associated with a greater need for ICU care (37.3% vs. 13.3%, P = 0.001), and mortality (32.2% vs. 5.7%, P < 0.001). Mortality increased with increasing AKI stage, i.e. stage 1 (OR 3.52, CI 0.9-13.7, P = 0.07), stage 2 (OR 6.79, CI 1.92-24, P = 0.002) and stage 3 (OR 17.8, CI 5.05-62.8, P < 0.001), however kidney function recovered in survivors. Hyponatremia was observed in 138 patients (84.15%) and isolated urinary abnormalities were seen in 31(18.9%)., Conclusions: AKI is frequent in melioidosis and occurred in 35.9% of our cases. Hyponatremia is likewise common. AKI was predicted by bacteraemia and CKD, and was associated with higher mortality and need for ICU care; however kidney function recovery was observed in survivors., (© 2021. The Author(s).)

The therapeutic options for preventing or slowing the progression of chronic kidney disease (CKD) have been thus far limited. While angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) are, without a doubt, safe and effective drugs, a significant proportion of patients with CKD still progress to end-stage kidney disease. After decades of negative trials, nephrologists have finally found cause for optimism with the introduction of sodium-glucose cotransporter-2 (SGLT2) inhibitors and non-steroidal mineralocorticoid receptor antagonists (MRAs). Recent trials such as EMPA-REG OUTCOME and CREDENCE have provided evidence of the renal benefits of SGLT2 inhibitors, which have now found widespread acceptance as first-line agents for diabetic CKD, in addition to ACEi/ARBs. Considering results from the DAPA-CKD study, it is expected that their use will soon be expanded to other causes of albuminuric CKD as well, although confirmation from further trials, such as the EMPA-KIDNEY study is awaited. Likewise, although the role of mineralocorticoid receptor overactivation in CKD progression has been known for decades, it is only now with the FIDELIO-DKD study that we have evidence of benefits of MRAs on hard renal endpoints, specifically in patients with diabetic CKD. While further research is ongoing, given the evidence of synergism between the three drug classes, it is foreseeable that a combination of two or more of these drugs may soon become the standard of care for CKD, regardless of underlying aetiology. This review describes pathophysiologic mechanisms, current evidence and future perspectives on the use of SGLT2 inhibitors and novel MRAs in CKD., (© 2021 Asian Pacific Society of Nephrology.)

Accordion or concertina effect is the angiographic appearance of pseudostenosis caused by interaction of a stiff guidewire with a tortuous vessel during endovascular procedures. This phenomenon may often mislead the interventionist into performing unnecessary and potentially harmful procedures in a bid to treat the 'stenotic' lesion. The resolution of 'stenosis' on withdrawal of the guidewire clinches the diagnosis. While well described in coronary vessels, the occurrence of this phenomenon in arteriovenous fistula or graft has not been reported. We describe a case of accordion effect observed during endovascular intervention for arteriovenous graft salvage.

The decision regarding dialysis initiation is complex. Awareness that renal replacement therapy should not be regarded as default therapy for every patient with advanced renal failure is necessary. Decision to initiate dialysis and modality should be individualized in a shared decision-making process involving the treating nephrologist and the patient. Patients should receive predialysis education early in the course of chronic kidney disease so as to help prepare them well in advance for this eventuality. Withholding dialysis may be a reasonable option in a certain subset of patients, especially elderly patient with multiple co-morbid illnesses. Comprehensive conservation care should be offered in all patients where the decision to not dialyze is taken., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Indian Journal of Palliative Care.)

Objective: Little is known about the risky sexual behaviors, attitudes, beliefs, and sources of information regarding sexual health among young adult Indian males. Currently, students in Indian secondary schools do not receive a structured comprehensive sexual health education. This qualitative study explored the sources of information, knowledge, and attitudes around sexual behaviors among young men in Mysore, India., Materials and Methods: Between May and June 2011, 23 semi-structured qualitative in-depth interviews with males aged 18-25 years were conducted to explore their views on sexual norms, attitudes, and their sources of information to gain knowledge about sexual health. Interviews were audio recorded and transcribed verbatim. Thematic analyses were conducted., Results: Participants shared a desire for quality sex education in schools but described their current sexual health curriculum as inadequate. Since social taboos dictated the space in which students gained awareness on sexual topics, the participants resorted to the outside information from both reliable and unreliable sources., Conclusions: These findings have important implications for laying the groundwork for culturally specific sexual health education interventions to meet the needs of a growing youth population in India., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Journal of Sexually Transmitted Diseases and AIDS.)

Introduction: Thrombotic microangiopathy (TMA) as a cause of snake-bite-induced acute kidney injury (AKI) is rarely reported. Very little is known about the clinical course, optimal management, and prognosis of this entity. We describe a series of snake-bite-induced TMA and compare their outcomes with those without TMA., Methods: This was a single-center retrospective study of patients with AKI following snake envenomation admitted between January 2012 and December 2017. Demographic profile, clinical parameters, and outcomes were studied. TMA was diagnosed based on presence of triad of microangiopathic hemolytic anemia, thrombocytopenia, and AKI, and groups with and without TMA were compared., Results: Of 103 patients with AKI following snake bite, 19 (18.5%) had clinical evidence of TMA. All patients with TMA had advanced azotemia (mean peak serum creatinine 9.5 ± 3.0 mg/dL), with 18 (95%) requiring renal replacement therapy (RRT). Thirteen (68%) had either complete or partial recovery of renal functions, two (10%) progressed to end-stage renal disease, and one died (three patients were lost to follow-up). Age ≥50 years, presence of oliguria/anuria, anti-snake venom dose ≥10 vials, and urea ≥80 mg/dL at presentation were independently associated with TMA ( P < 0.05). RRT requirement (95% vs. 57%), mean number of RRT sessions (18 vs. 4.5 sessions), and hospital stay ≥7 days (84% vs. 58%) were higher in patients with TMA ( P < 0.05), but patient outcomes did not differ., Conclusions: In conclusion, TMA was seen in 18.5% of patients with snake-bite-related AKI in our study and was associated with almost universal need for RRT, longer duration on RRT, and hospital stay compared with patients without TMA., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Indian Journal of Nephrology.)

Context: Hypertension in chronic kidney disease (CKD) is an important modifiable cardiovascular risk factor. Patients with CKD can have clinically significant white coat effect (WCE), making routine clinic blood pressure (BP) measurements an unreliable indicator of actual BP control. Automated BP monitoring is useful in identifying WCE. The utility of automated BP monitoring has seldom been part of clinical practice in developing countries., Aim: The goal of this study was to estimate the prevalence and determinants of WCE in adult patients with CKD in an outpatient setting using an automated BP device., Materials and Method: In this prospective observational study, patients with CKD attending the nephrology clinic over a period of 6 months (January 2016 to July 2016), who were suspected to have WCE by the treating physician, were assigned to measurement of BP by both the standardized manual BP recording by a single nephrologist and with automated machine as per a defined protocol. Clinical, demographic characters that would influence outcomes were also studied., Results: Among 118 patients with CKD with suspected WCE, 57.6% showed WCE. The mean systolic and diastolic BPs were significantly lower with automated machine when compared with manual BP recordings in patients with WCE ( p = 0.04). WCE was seen in all stages of CKD. Occurrence of WCE in CKD was not dependent on factors such as old age, sex, diabetes mellitus, or smoking status in our study., Conclusion: WCE is a highly prevalent and underdiagnosed entity in patients with CKD. Automated machine is a useful and time-saving tool in detection of WCE in patients with CKD attending the outpatient clinic and guide management., Competing Interests: There are no conflicts of interest.

Background: Acute kidney injury (AKI) is a common complication of liver cirrhosis and is associated with poor survival. We studied the clinical profile and predictors of in-hospital mortality in patients with cirrhosis of the liver with AKI., Methods: This retrospective cohort study examined patients at a tertiary care hospital. AKI staging was done based on the new 2015 Ascites Club Criteria. Patients were grouped into three types of AKI: pre-renal azotemia (PRA), hepatorenal syndrome (HRS), and acute tubular necrosis (ATN)., Results: Data of 123 patients with cirrhosis and AKI were analyzed. Most patients had AKI stage 3 (57.7%). ATN (42.3%) and HRS (43.9) were the predominant types of AKI followed by PRA (13.8%). The overall in-hospital mortality in our study was 44.7%. The mortality increased with increasing severity of AKI (p = 0.0001) and was the highest in AKI stage 3 (p = 0.001) and those who required hemodialysis (p = 0.001). There was a significant in-hospital mortality in patients with ATN and HRS in comparison to PRA (p = 0.001). On multivariate analysis, the factors predicting in-hospital mortality were AKI stage 3, and oliguria (p = 0.0001)., Conclusions: Acute kidney injury in cirrhosis of liver carries high in-hospital mortality. Pre-renal AKI has a better survival compared to ATN and HRS. The higher stage of AKI at presentation and the presence of oliguria are two important predictors of in-hospital mortality.

Unlabelled: There is very little data on the value of specialized intensive care unit (ICU) care in the literature. To determine if specialize ICU care for the trauma patient improved outcomes in this patient population. Level I Trauma Center Compared outcomes of trauma patients treated in a surgical trauma ICU (STICU) to those treated in non- trauma ICUs (non-STICU). Retrospective review of trauma registry data., Statistical Analysis: Wilcoxon Rank Test, Fischer's Exact test, logistic regression. There were 1146 STICU patients compared to 1475 non-STICU. In all ISS groups there were more penetrating trauma patients in the STICU (32.54% STICU vs. 18.15% non-STICU, P<0.0001 (ISS< 15)), (21.03% STICU vs. 12.98% non-STICU, P=0.0074 (ISS between 15-25)), and (19.42% STICU vs. 11.35% non-STICU, P=0.0026 (ISS> 25)). All groups had similar lengths of stay. The blunt trauma patients were sicker in the STICU (20.8 ISS +/- 12.2 STICU vs. 19.7 ISS +/- 11.9 non-STICU, P=0.03) yet had similar outcomes to the non-STICU group. Logistic regression identified penetrating trauma and not ICU location as a predictor of mortality. Sicker STICU patients do as well as less injured non-STICU patients. Severely injured patients should be preferentially treated in a STICU where they are better equipped to care for the complex multi-trauma patient. All patients, regardless of location, do well when their management is guided by a surgical critical care team.

Industrial development in Visakhapatnam is conspicuous to urban agglomeration and the city is located in a topographical bowl formed by two-hill ranges. A major portion of the city is within the bowl area wherein most of the industrial and commercial activities are existing and lies within a distance of 10 km from the shore of the Bay of Bengal. Due to the peculiar geographic location of city, wind movement is either eastern or western and is engulfed within the hill ranges. Hence, there is a possibility of buildup of air pollution levels within the city. Due to gravity of prevailing situation, air quality status of Visakhapatnam on indices basis is analyzed using a non-linear equation for variable parameters i.e. Suspended particulate matter (SPM). Sulfur dioxide (SO2) and Oxides of nitrogen (NO(x)), which are main criteria pollutants in India. For current analysis seasonal air quality data is used, which indicates SPM values in winter at most of the sites and in summer at few sites are exceeding the prescribed standards. Calculated indices reveal that, in winter as well as in summer, most of the locations experienced poor or bad air quality, which is mainly due to higher concentration of SPM and certain extent of SO2 values. Application of Oak Ridge Air Quality Index (ORAQI) type equations (non-linear) are helpful for air quality management plan in the region on long-term basis and it has been also observed that there are certain lapses of weightage assignment for individual pollutant in application.

Panchayat Raj Engineering Department (PRED), Government of Andhra Pradesh installed package water treatment plants on a trial basis, in some villages in Krishna district of Andhra Pradesh. These plants with a design capacity of 6000-12000 lph were supplied and erected by a firm in Hyderabad. These plants consist of three stage treatment comprising of pulverized quartz filter bed, activated carbon bed and micro filter unit followed by disinfection. At the request of PRED, comprehensive studies were carried on individual plants which includes a detailed appraisal of the performance of the individual components of the plant, infrastructure at the village level for routine O&M of the plants as also views of the community regarding their acceptability of the system. This paper presents the findings and conclusions of the performance evaluation study.

There is now a better understanding of the scope and process of rehabilitation. The approach recognizes the impact of leprosy on the individual, aims to understand the needs and concerns of those affected, their families and community in the rehabilitation process, and that aims to restore the person to normal social life. LEPRA India has undertaken socio-economic rehabilitation (SER) activities in its projects in Andrah Pradesh and Orissa States in India with a holistic approach that has been evolutionary, developmental and participatory. A SER Officer (SERO) was posted to each project. A plan was formulated by the SERO with participation of all project staff. The main emphasis of the programme was on active participation of the affected person in the rehabilitation process. A needs-assessment study was conducted in the target population using a semi-structured questionnaire. Information was elicited about social and economic status, before and after the disease, and the current rehabilitation needs of the persons affected. The next step was meeting the needs through interventions by the SER staff. The impact of the programme on restoration of social and economic status of the affected persons was analysed. The paper stresses the importance of assessing the needs of persons affected by leprosy, structuring a rehabilitation programme with the active participation of the affected person and evaluating the impact of the interventions in restoring normal social and economic life.