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Background: The job profile of security officers in tropical countries involves prolonged standing in hot conditions causing heat stress as well as complications of sedentary lifestyle. The objectives of this study were to estimate the prevalence of noncommunicable diseases and heat stress in security officers and analyze factors affecting heat stress and estimated glomerular filtration rate (eGFR)., Materials and Methods: This was an observational cross-sectional study conducted among security personnel working at a tertiary care hospital in South India during the hottest months of March to May 2020. Screening camps were conducted during which anthropometric measurements were taken and blood was collected for hemoglobin, creatinine, and fasting glucose estimation. Urine dipstick analysis for glucose, protein, pH, and red and white blood cells were done on early morning voided sample. Heat stress was assessed by a validated 18-item questionnaire called heat strain score index (HSSI). A structured questionnaire was prepared for surveillance of risk factors of noncommunicable diseases., Results: A total of 678 security officers were screened. Majority (659/678, 97.2%) were men and mean age of the cohort was 45.4 ± 9.2 years. Fifty-two percent (355/678) of participants were engaged in outdoor work for a median duration of 6 (IQR, 0-8) hours/day. Prevalence of obesity, diabetes, hypertension, and chronic kidney disease (CKD) were 70.9, 25.5, 15.9 and 1.3 percentage, respectively. Half of the cohort (324/678) had definite heat stress and 0.9% (6/678) developed CKD of undetermined etiology. Heat stress was higher in those working outdoors and longer employment duration and lower in those with abdominal obesity. eGFR was lower in older officers, smokers, hypertensives, and those with longer employment duration, but was unaffected by HSSI scores., Conclusion: Kidney function was unaffected by high levels of heat stress experienced by security personnel working at a tertiary hospital in South India. Future studies are needed to understand the pathomechanisms of differential impacts of heat stress on kidney function of agricultural various worker categories., Competing Interests: There are no conflicts of interest., (© 2025 Indian Journal of Nephrology | Published by Scientific Scholar.)

Background: With significant advances in the understanding of transplant immunology and a reduction in rejection rates, significant improvements in kidney allograft survival have been seen. The problem of recurrent and denovo glomerular diseases after transplantation affecting graft outcomes remains and is poorly characterized. This study aimed to analyze the incidence, characteristics, and outcomes of glomerulonephritis (GN) after kidney transplant in the Indian subcontinent., Materials and Methods: Data on patients who underwent kidney transplants in our hospital from 1971 to 2018 was analyzed. Patients who had biopsy proven glomerulonephritis after transplant were included in the study. Demographic factors, characteristics of glomerulonephritis after transplant, and patient and graft outcomes were studied., Results: Post-transplant glomerulonephritis was seen in 177 out of 3630 (4.8%) patients. IgA nephropathy (IgAN) was the most common type, followed by focal segmental glomerulosclerosis (FSGS) and thrombotic microangiopathy (TMA). Patients with IgAN and FSGS were younger, and native kidney disease was unknown in the majority (70% in IgAN and 40% in FSGS). Glomerulonephritis was the most common cause of graft loss. A serum creatinine level of ≥2 mg/dL at 1 year post-transplant was significantly associated with the risk of death and graft loss. In addition, the occurrence of glomerulonephritis within a year of transplant and cytomegalovirus (CMV) infection were found to be significant risk factors for death and graft loss, respectively., Conclusion: Post transplant glomerulonephritis can significantly impact patient and graft outcomes. Understanding its etiology and pathogenesis is crucial to enabling its prevention and management and improving the outcomes of kidney transplantation., Competing Interests: There are no conflicts of interest., (© 2025 Indian Journal of Nephrology | Published by Scientific Scholar.)

The simultaneous occurrence of vasculitic glomerulonephritis and membranous nephropathy is unusual. We report two cases that presented to our outpatient department with rapidly progressive renal failure. On evaluation, in one patient, anti-myeloperoxidase (MPO) titers were high, and renal biopsy was suggestive of concurrent necrotizing and diffuse crescentic anti-MPO anti-neutrophil cytoplasmic antigen-associated glomerulonephritis with the circumferential cellular crescent formation and membranous glomerulopathy. He responded to plasmapheresis followed by maintenance immunosuppression with oral cyclophosphomide. Another patient was treated with Methylprednisolone and two doses of rituximab. Both the patients showed marked symptomatic improvement and became dialysis independent with stable creatinine at 3 months., Competing Interests: There are no conflicts of interest., (© 2025 Indian Journal of Nephrology | Published by Scientific Scholar.)

Background: There is a paucity of studies describing trabecular bone score (TBS) and bone mineral density (BMD) in kidney transplant (KT) recipients from developing countries., Study Setting: This prospective observational study, from a tertiary teaching hospital in India assessed clinical, biochemical parameters including bone turnover markers and dual-energy X-ray absorptiometry (DXA) for BMD/TBS, hip structural analysis (HSA) and vertebral fracture assessment (VFA) at pre-KT, 3 months and 12 months post-KT., Results: A total of 53 KT recipients (90.6% living related) were recruited from August 2019 to March 2020 and followed till 1-year post-KT. The mean age was 33.9±10.4 years, 71.7% were males, and 11.5% had a history of pre-KT steroid use. Baseline fractures pre-KT as assessed by VFA were seen in 4 patients (7.5%). Mean BMD at spine and femoral neck and HSA variables at narrow neck and femoral shaft continued to decline till 3 months, but stabilised and reached pre-KT values 12 months post-KT. However, TBS and bone turn over markers continued to decline till 12 months post-KT (p value <0.001). New onset vertebral fractures were seen in 2(3.7%) and 1 patient (2.3%) at 3- and 12-months post-KT respectively. Pre-KT BMD significantly influenced bone health at 12 months post-KT, with patients in each quartile maintaining a similar trajectory over the follow up period (p < 0.001)., Conclusion: Despite significant improvement in kidney function following transplant, TBS and BMD of the spine significantly decreased mainly in the early post-KT period suggesting the effect of immunosuppressants on the bone. Strategies to improve bone health in KT patients are warranted., Competing Interests: Conflict of interest Nil, (Copyright © 2024 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of the study was to study the clinical profile and outcomes of nocardiosis in renal allograft recipients., Methods: This was a retrospective study of clinical outcomes in consecutive renal allograft recipients with Nocardia infection over a 22-year period (2000-2022) from a tertiary care center in Southern India. The clinical data were obtained from electronic medical records and patient files., Results: A total of 1970 patients underwent renal transplantation at Christian Medical College, Vellore, India, between January 1, 2000, and December 31, 2022. During this period, 26 patients were diagnosed to have Nocardia infection. Half (50%) of the patients had fever and cough as their initial presentation, 7 (26.9%) patients presented with cutaneous abscesses, 2 (7.6%) patients were incidentally detected to have lung nodules during routine follow-up, 2 (7.6%) patients presented with headache accompanied by fever, and 3.8% had graft abscess. The diagnosis was made by isolating the organism in culture from one or more of the following samples: sputum, blood, pus, or lung biopsy (either computed tomography [CT]-guided or bronchoscopic aspirate culture). Eight patients required bronchoscopy and two patients required CT-guided biopsy for obtaining samples for diagnosis. All patients were similarly managed initially with a reduction of immunosuppression and appropriate antibiotics as per culture sensitivity. All 26 patients responded to induction treatment with meropenem (or imipenem) and trimethoprim-sulfamethoxazole (co-trimoxazole) followed by maintenance treatment with co-trimoxazole. Five (19.2%) out of 26 patients received Minocycline in induction and maintenance treatment regimens as in four patients isolates were resistant and one patient had allergic reaction to Cotrimoxazole. All patients had stable graft function. Two patients succumbed after 2 months of diagnosis with Gram-negative sepsis., Conclusions: At present, there exists no single serological test to diagnose Nocardia infection in patients. Multiple initially obtained cultures may be negative because of the slow growth of the organism and variable colony morphology. Hence, infected specimens should be obtained by aggressive approaches if the index of suspicion is high. Procedures such as bronchoscopic lavage and aspiration of abscess are invaluable toward making a diagnosis. In our study, eight patients required invasive diagnostic procedures such as bronchoalveolar lavage and CT-guided lung biopsy since initial Gram stain and sputum culture were negative. In conclusion, it is crucial to maintain a high level of suspicion and conduct thorough investigations among post renal transplant recipients. This approach facilitates early diagnosis, prompt initiation of appropriate treatment which helps prevent the spread of disease., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Global Infectious Diseases.)

Background and Aim: Plasma exchange (PLEX) improves survival in patients with rodenticidal hepatotoxicity. However, predictors of treatment response are unknown. We aimed at assessing predictors of response to PLEX treatment in these patients., Methods: Patients with rodenticidal hepatotoxicity from 2014 to 2023 managed in our department were included in this study. Kochi criteria (model for end-stage liver disease [MELD] score ≥ 36 or international normalized ratio [INR] ≥ 6 with hepatic encephalopathy [HE]) derived specifically for rodenticidal hepatotoxicity (PubMed IDentifier [PMID]: 26310868) were used to assess need for liver transplantation. We analyzed predictors of survival at one month. ∆Bilirubin, ∆MELD score and ∆INR were calculated as percentage change of the parameter after third PLEX session (or after last PLEX if < 3 PLEX sessions done) from baseline pre-PLEX value., Results: Of 200 patients with rodenticidal hepatotoxicity, 114 patients were treated with low-volume PLEX (PLEX-LV). No patient had liver transplantation. Of 78 patients who fulfilled Kochi criteria, 32 patients were PLEX-LV eligible and underwent PLEX-LV (M: 10; age: 20.5, 7-70 years; median, range; acute liver failure: 24). Twenty-two (69%; acute liver failure: 14) of the 32 patients were alive at one month. Presence of HE (p = 0.03) and ∆MELD (p < 0.001) were significant predictors on univariate analysis, while ∆MELD (aOR = 0.88, 95% CI: 0.79-0.98, p = 0.01) was the only significant independent predictor of one-month transplant-free survival. Area under receiver operating characteristic (ROC) for ∆MELD was 0.93 (95% CI:0.85-1.00) and a decrease of ≥ 20% in MELD score while on PLEX-LV had 90% sensitivity and 90% specificity in predicting one-month survival., Conclusions: Decline in MELD while on PLEX-LV independently predicted one-month transplant-free survival in rodenticidal hepatotoxicity patients. This may help guide decision on stopping PLEX-LV in patients predicted to respond to treatment and to consider alternate treatment options in non-responders., (© 2024. Indian Society of Gastroenterology.)

Background: Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a rare entity classified under the umbrella of monoclonal gammopathy of renal significance. The clinical implications of circulating monoclonal immunoglobulin (MIg), light chain restriction on immunofluorescence (IF) microscopy, histopathological pattern, and type of therapy on renal outcomes are not clearly defined., Materials and Methods: Sixteen patients of PGNMID diagnosed between 2013 and 2020 were included from a biopsy registry of 11,459 patients at a single center. Follow-up data was collected from electronic medical records until June 2021., Results: The mean age of the cohort was 41.7 ± 13.5 years. Forty-four (7/16) percent showed monoclonal protein on serum or urine electrophoresis, 25% (3/12) had IgG kappa by serum immunofixation electrophoresis (IFE) and 38% (5/13) had abnormal kappa: lambda free light chain (FLC) ratio. The predominant light microscopy pattern, membranoproliferative glomerulonephritis (MPGN) was seen in 7/16 (43.7%) patients. The predominant heavy chain detected by IF microscopy was IgG (13/16, 81.3%). Kappa and lambda light chain restriction were seen in 56.3 (9/16) and 43.8 (7/16) percent of patients respectively. Circulating monoclonal kappa light chains were detected in 50 and 29% of kappa-PGNMID patients by IFE and FLC assay respectively. None of the lambda-PGNMID patients had detectable circulating monoclonal lambda light chains. Patients with circulating MIg had more proteinuria, lower estimated glomerular filtration rate, and a higher percentage of plasma cells on bone marrow biopsy. Thirty-eight percent of our cohort (5/13) progressed to kidney failure over a median (range) period of 3 (IQR, 1-7) months. Of these, 4/5 received immunosuppression, and 1/5 were treated with plasma cell-targeted chemotherapy., Conclusion: PGNMID is a rare disease with a biopsy incidence of 0.1%. Only a quarter of patients with PGNMID have circulating MIg. Presence of circulating MIg, type of monoclonal light chain restriction in kidney biopsy, and type of therapy did not predict renal outcomes. Patients with MPGN pattern had favorable renal outcomes despite a higher degree of proteinuria at presentation., Competing Interests: Conflicts of interest There are no conflicts of interest.

Background: Low-volume plasma exchange (PLEX) and low-dose steroid improve survival in severe alcoholic hepatitis. We aimed to compare one-year survival of very severe alcoholic hepatitis (VSAH) patients treated with centrifugal PLEX (cPLEX), membrane PLEX (mPLEX) or standard medical treatment (SMT)., Methods: We retrospectively analyzed survival in consecutive VSAH patients treated at our department from November 2017 to September 2021. PLEX patients received low-volume PLEX along with low-dose steroid (tab. prednisolone 10 mg or 20 mg daily). To adjust for baseline differences between the three treatment (cPLEX, mPLEX or SMT) groups, propensity score (PS) matching was done. Acute-on-chronic liver failure (ACLF) was defined as per European Association for the Study of the Liver (EASL). The primary study outcome was one-year transplant-free survival of PS-matched VSAH patients treated with cPLEX compared to SMT., Results: Of 101 PLEX-eligible VSAH patients, 30 patients were treated with cPLEX, 21 with mPLEX and 50 with SMT. On comparing 30 PS-matched patients each in the cPLEX group vs. the SMT group, transplant-free survival in the cPLEX group was 86.7% at one month, 70% at three months and 52.4% at one year and in the SMT group was 33.3% at one month, 23.3% at three months and 16.7% at one year with hazard ratio (HR [95% CI]) in favor of the cPLEX group (0.29 [0.15-0.56], p < 0.001). Total 21 patients each (PS-matched) in cPLEX and mPLEX groups were compared and one-year survival was better with cPLEX (0.33 [0.16-0.69], p = 0.001). The sub-group analysis of VSAH (PS-matched cohort) patients with ACLF also showed better survival with cPLEX compared to SMT (0.38 [0.17-0.83], p = 0.003) and compared to mPLEX (0.43 [0.17-0.95], p = 0.03)., Conclusion: Better one-year transplant-free survival was noted among PS-matched VSAH patients treated with cPLEX (and low-dose steroid) compared to SMT (without steroid)., (© 2024. Indian Society of Gastroenterology.)

Introduction: There is a paucity of studies on asymptomatic bacteriuria (ASB) among kidney transplant recipients (KTR) in developing countries. This study assessed the clinical profile, risk factors, outcomes, and impact of treatment of ASB in KTRs with a normal genitourinary tract., Methods: Consecutive KTRs from 2009 to 2018 with no clinical or radiological evidence of obstructive uropathy were included. Urinary tract infection (UTI) after ASB was defined as occurrence of cystitis, pyelonephritis, or urosepsis, with ASB being the first bacteriuric episode., Results: Seven hundred ten out of 794 patients with median follow up of 47 months were included. The mean age was 35.5 ± 12 years. Eighty-one patients (11.4%) developed ASB at a median of 25 days (IQR 10, 134.5). Fifty-three percent and 4.9% of ASB episodes were extended-spectrum beta-lactamase (ESBL) positive and carbapenem-resistant organisms, respectively. Eighteen patients (32.1%) with early ASB (<3 months) and 5 (20%) with late ASB developed UTI on follow-up. Fifty-five percent of early and 16% of late ASB episodes were treated, with no significant difference observed in the risk of development of UTI when compared to untreated ASB episodes., Conclusion: The incidence of ASB as first bacteriuric episode in our cohort was 11.4%, with there being significant antimicrobial resistance. Female gender, pretransplant UTI, and delayed graft function were independently associated with development of ASB. Treatment of ASB episodes either early or late did not decrease the risk of development of UTI., Competing Interests: There are no conflicts of interest., (© 2024 Indian Journal of Nephrology | Published by Scientific Scholar.)

Aim: Diabetic patients are prone to infections, thus making them a unique cohort at risk of developing bacterial infection-related glomerulonephritis (IRGN)., Methods: In total, 1693 adult diabetic patients underwent kidney biopsy between 2005 and 2021 at our tertiary care hospital in South India. Of these, 121 consecutive cases which met criteria of bacterial IRGN were included in this study., Results: The mean age of the cohort was 53.1 ± 10.1 years and 83/121 (68.5%) were males. Majority (98.3%) had type 2 diabetes for a median duration of 6 (IQR, 2-12) years. The most common sites of infection were skin (47/121, 38.8%) and urinary tract (15/121, 12.4%). Fifty percent (58/121) of patients had underlying advanced diabetic kidney disease (DKD). Isolated C3 deposits (without immunoglobulin) occurred in 66/121 (54.5%) patients predominantly in advanced DKD patients. IgA-dominant glomerulonephritis occurred in only 9/121 (7.4%) patients. Short-course oral steroid was given to 86/121 (71.1%) patients. Steroid related dysglycemia and immunosuppression related infections occurred in 9/61 (14.8%) and 16/61 (26.2%) patients respectively. Of the 90 patients with follow up details >3 months, 46 (51.1%) progressed to kidney failure over a median period of 0.5 (IQR, 0-7.2) months. Patients diagnosed in the latter half of our study period (2013-2021) were older, less commonly presented with fever, had more pronounced hypocomplementemia and severe renal histology predominantly with a 'starry sky' immunofluorescence pattern., Conclusion: Superimposed bacterial IRGN on underlying DKD is associated with poor renal outcomes. Use of short course steroid was associated with significant toxicity., (© 2023 Asian Pacific Society of Nephrology.)

Introduction: Post hematopoietic stem cell transplant (HSCT), kidney can be subjected to injury by various causes. Of these, graft versus host disease (GvHD) affecting the kidney is an under-recognized entity with no clear guidelines on its diagnosis, clinicopathological manifestations, and outcomes., Material and Methods: Out of 2,930 patients who underwent HSCT at our center between 2005 and 2020, kidney biopsy was performed in 19 allogenic and 5 autologous recipients., Results: The mean age of the cohort at transplant was 33.2 ± 7 years, and 15 (62%) were males. Median time to kidney biopsy from HSCT was 14 (IQR, 9-30) months. Aplastic anemia was the most common underlying hematological disease (54.2%). All 19 allogenic recipients were classified based on clinicopathological manifestations into either thrombotic microangiopathy (TMA, 12/19 [63%]) or nephrotic syndrome (NS, 7/19 [37%]) pattern. Glomerular tuft "mesangiolysis" was the dominant pattern of injury noted in 9/12 cases of TMA pattern. There was a predominance of acute microangiopathic changes restricted primarily to the glomerular compartment. Of the 7 patients with NS pattern, membranous nephropathy was seen in 4 (57%) and minimal change disease in 3 (43%) patients. Thirty-nine percent (7/18) stained positive for C4d which was predominantly glomerular. Allogenic recipients who did not receive immunosuppression (IS) for renal disease had a lower eGFR at biopsy, a longer latency between withdrawal of GvHD prophylaxis and biopsy, and were significantly at a higher risk of kidney failure (IS: 2/11, 18.1% vs. no IS: 2/6, 33.3%, p = 0.04). "Associated extra-renal GvHD" occurred in 11/19 (57.9%) allogenic recipients. Patients with "associated extra-renal GvHD" had significantly more deaths (6/11, 60% vs. 0, p = 0.02) but comparable renal outcomes., Conclusion: Renal GvHD can present with or without "associated extra-renal GvHD" after a prolonged period of withdrawal of GvHD prophylaxis, requiring careful diagnostic vigilance and consideration of IS., Competing Interests: S. Varughese reports serving on the Kidney Medicine Editorial Board, the Indian Society of Nephrology Editorial Board, and the Indian Society of Organ Transplantation Editorial Board. All other remaining authors have nothing to disclose., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Background: In a prior report, no patient with rodenticidal hepatotoxicity who met Kochi criteria (MELD score ≥36 or baseline INR ≥6 with hepatic encephalopathy) (PMID: 26310868) for urgent liver transplantation survived with medical management alone. Plasma exchange (PLEX) may improve survival in these patients., Objectives: We describe our experience with low-volume PLEX (PLEX-LV) in treating rodenticide ingestion induced hepatotoxicity in children., Methods: From prospectively collected database of rodenticidal hepatotoxicity patients managed as in-patient with department of Hepatology from December 2017 to August 2021, we retrospectively studied outcomes in children (≤18 years). Hepatotoxicity was categorized as acute liver injury (ALI, coagulopathy alone) or acute liver failure (ALF, coagulopathy and encephalopathy). Kochi criteria was used to assess need for urgent liver transplantation. The primary study outcome was one-month survival., Results: Of the 110 rodenticidal hepatotoxicity patients, 32 children (females: 56%; age: 16 [4.7-18] years; median, range) constituted the study patients. The study patients presented 4 (1-8) days after poison consumption (impulsive suicidal intent:31, accidental:1). Twenty children (62%) had ALI [MELD: 18 (8-36)] and 12 (38%) had ALF [MELD: 37 (24-45)].All children received standard medical care, including N-acetyl cysteine; ALF patients also received anti-cerebral edema measures. None of the patient families opted for liver transplantation. Seventeen children (ALI: 6, ALF: 11) were treated with PLEX-LV (3 [1-5] sessions, volume of plasma exchanged per session: 26 [13-38] ml/kg body weight) and peri-procedure low dose prednisolone.At 1 month, 28 of the 32 children (87.5%) were alive (4 ALF patients died). Of 10 children who met Kochi listing criteria for urgent liver transplantation, two children were ineligible for PLEX-LV (due to hemodynamic instability) and of the remaining 8 children treated by PLEX-LV, 6 (75%) survived., Conclusions: PLEX-LV shows promise as an effective non-liver transplant treatment in children with rodenticidal hepatotoxicity., (© 2022 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Aim: To study the additional utility of pre-nephrectomy whole and cortical kidney volumes (WKV, CKV) in predicting long-term post-nephrectomy kidney function in Indian living kidney donors (LKDs)., Methods: This retrospective cohort study included all LKDs who underwent nephrectomy between 1 January 2006 and 31 December 2015 at our centre, had pre-nephrectomy height, weight and computed tomography (CT) angiography with arterial and nephrographic phase documented, and 5-year post-nephrectomy creatinine values measured. Correlation between body surface area (BSA) adjusted pre-nephrectomy total CKV, WKV and pre-nephrectomy CKD EPI eGFR; BSA-adjusted remnant pre-nephrectomy CKV (rCKV), WKV (rWKV) and 5-year post-nephrectomy CKD EPI creatinine eGFR (5yeGFR Cr ); predictors of 5yeGFR Cr  < 70% of pre-nephrectomy CKD EPI creatinine eGFR (pre-eGFR Cr ), and an equation to predict 5yeGFR Cr from pre-nephrectomy variables were calculated., Results: A total of 196 LKDs (74% female, mean age 41.7 ± 11.0 years) were included in the study. Total WKV showed higher correlation with pre-nephrectomy eGFR than CKV, the highest with CKD EPI cystatin eGFR. Remnant WKV showed higher correlation than rCKV with post-nephrectomy eGFR Cr and this increased over time. Older age, lower rWKV or rCKV, higher BSA, and higher pre-eGFR Cr identified LKDs with 5yeGFR Cr  < 70% of pre-eGFR Cr , with rCKV identifying a higher proportion (4.5%) of such LKDs. A model including rWKV or rCKV predicted 5yeGFR Cr better than one including age, gender, BSA and pre-eGFR Cr alone., Conclusion: Inclusion of pre-nephrectomy remnant CKV and WKV into models for 5yeGFR Cr and sub-optimal post-nephrectomy adaptation in Indian LKDs improves their accuracy. CKD EPI cystatin eGFR correlates better with functional renal mass., (© 2022 Asian Pacific Society of Nephrology.)

Parvovirus B19 is a small (26 nm), nonenveloped, single-stranded DNA (5.6-kb) virus. The only known host for parvovirus B19 is humans. Parvovirus B19 is directly cytotoxic to erythroid precursor cells of the colony- and burst-forming units. Human parvovirus B19 is the etiologic agent of erythema infectiosum and chronic pure red cell aplasia in immunocompromised individuals. Acute parvovirus B19 infection should be suspected in immunocompromised patients, who present with reticulocytopenic hemolytic anemia and thrombocytopenia. Intravenous immunoglobulin (IVIg) is the standard treatment for parvovirus-induced cytopenias. We report two cases of postrenal transplant who presented with reticulocytopenic anemia and were found to have parvovirus infection. They did not respond to conventional treatment with intravenous gamma globulin. Both patients were treated with rituximab with which they had improvement in clinical and hematological parameters. There was no previous documentation of using rituximab in the treatment of parvovirus-triggered autoimmune hemolytic anemia postrenal transplant patients. This article illustrates how rituximab will be helpful in this setting, of course, it is a new thought but requires further studies and validation., Competing Interests: Conflicts of interest There are no conflicts of interest.

Background: Difficulty in cannulation of arteriovenous fistula (AVF) can lead to inadequate dialysis, transient to permanent loss of access and increases dependency on bridging catheters. This study aimed to analyze the causes for difficult fistula cannulation, using various imaging modalities., Methodology: This was a retrospective single-center observational study conducted between October 2017 and June 2018. Patients whose fistulae were difficult to cannulate were initially evaluated by physical examination followed by doppler ultrasonography or/and fistulogram as necessary. The patients were divided into two groups that is, primary difficult cannulation (within first three months of creation of fistula) or secondary difficult cannulation (after three months)., Results: We encountered difficult cannulation in 43 patients. About 60% were primary difficult cannulations. Most common causes for difficulty in cannulation were cannulation zone (CZ) stenosis (23.3%), immature fistula (20.9%), outflow stenosis (18.6%), inflow stenosis (11.6%), anatomical abnormalities (11.6%), outflow plus CZ stenosis (9.3%) and inflow plus CZ stenosis (4.7%). Among patients with primary difficult cannulation, immature fistula (34.6%) was the most common cause, whereas CZ stenosis (47.1%) was the most common etiology for secondary difficult cannulation. Edema leading to difficult cannulation was found in 12 patients (27.9%), all of which was due to central vein stenosis. Cannulation resulted in hematoma, fistula thrombosis, failure of fistula and pseudoaneurysm in 83.7%, 27.9%, 16.3%, and 2.3% of cases respectively. Bridging temporary dialysis catheter placement was required in 67.4% patients. Ultrasound doppler had lower diagnostic value when compared to fistulogram (71.4% vs 93.9%, p  = 0.014)., Conclusion: Difficulty in cannulating the arteriovenous fistula is a common problem in hemodialysis patients. We suggest that patients whose fistulae are difficult to cannulate should undergo early radiological evaluation to decrease catheter dependency and access failure.

Background: Serial monitoring of tacrolimus and serum creatinine after renal transplantation is of vital importance. In this study, a liquid chromatography-tandem mass spectrometry (LC-MS/MS) assay for the estimation of tacrolimus and creatinine, obtained from dried blood spots (DBS) or by volumetric absorptive microsampling (VAMS) was validated and the two sampling strategies were compared with traditional venous sampling., Methods: The LC-MS/MS assay was validated using a shared extract for the estimation of tacrolimus and creatinine from DBS and VAMS independently. The relationship between the concentrations in DBS/VAMS specimens and in venous samples was assessed using Passing-Bablok (PB) analysis and the bias between the two methods was determined by the Bland Altman (BA) analysis., Results: The imprecision and bias of tacrolimus and creatinine estimated from DBS and VAMS samples was <12% and was independent of the hematocrit (Hct). Samples were stable for five days at ambient temperature. From the PB regression analysis, correction equations were generated for the prediction of tacrolimus and creatinine values from DBS and VAMS samples. In a separate cohort of patients for validation, the corrected DBS and VAMS concentrations had a mean (95% CI) bias for tacrolimus of -0.64 (-2.98 to 1.70)% and -0.92 (-3.69 to 1.85)% respectively and for creatinine of 1.00 (-2.73 to 4.72)% and -0.71 (-3.74 to 2.32)% respectively. Using DBS and VAMS respectively, for tacrolimus, 91.8 and 89.8% of patient values and for creatinine, 69.4 and 81.6% of patient values were within the limits of clinical acceptance (within 15% agreement against the venous samples)., Conclusion: We conclude that VAMS is the preferred single sampling option for estimating tacrolimus and creatinine in renal transplant patients., (Copyright © 2022 The Canadian Society of Clinical Chemists. All rights reserved.)

Aims: The mass quarantine measures adopted to control the COVID-19 pandemic greatly impacted the lives of patients on haemodialysis in India. We used a mixed methods approach to study its effect on dialysis outcomes and the lived experience of haemodialysis patients during the lockdown., Methods: Quantitative data was collected from 141 subjects using a structured proforma to determine the impact of the lockdown on dialysis outcomes and travel expenses. Qualitative data collected through in-depth interviews with 9 patients by purposive sampling were recorded and transcribed to explore the lived experience of haemodialysis patients during lockdown. The cohort was followed up till October 31 st 2020 for incidence of COVID-19, deaths, and dropouts., Results: The median increase in per day travel expense was 25%. Due to decrease in dialysis frequency, patients previously on thrice weekly haemodialysis experienced significant increase in pre-dialysis systolic blood pressure ( P = 0.005) compared to those on twice weekly haemodialysis. Between March 25 th and July 15 th 2020, 12 patients (8.5%) required emergency dialysis sessions, and 4 patients (2.8%) required admissions for hypertensive emergencies. Four main themes emerged from thematic analysis of transcribed interviews: Travel inconveniences, uncertainty resulting in anxiety, financial burden and frequency change in dialysis leading to worsening of symptoms. Twenty-two patients (15.6%) were diagnosed with COVID-19, the first case diagnosed 33 days after the first 'unlock' phase., Conclusion: The lockdown was successful in delaying infection transmission but had unintended physical and psychosocial effects on haemodialysis patients., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Indian Journal of Nephrology.)

Competing Interests: There are no conflicts of interest.

Background: Alcohol-related acute on chronic liver failure (A-ACLF) patients have high short-term mortality and are poor candidates for steroid therapy. Plasma exchange (PLEX) improves survival in ACLF patients. We analyzed our experience with low volume PLEX (50% of plasma volume exchanged per session) and low dose steroids to treat A-ACLF patients., Methods: We retrospectively compared the efficacy of low volume PLEX and low-dose steroids with standard medical treatment (SMT) in A-ACLF patients treated at our center between November 2017 to June 2019. The primary study outcome was one-year survival., Results: Twenty-one A-ACLF patients in PLEX group [age 40 (29-56) years, median (range); MELD score 31 (29-46)] and 29 A-ACLF patients in SMT group [age 41.5 (28-63) years, MELD score 37 (21-48)] were studied. All 50 study patients had severe alcoholic hepatitis [mDF 84.7 (50-389)]. PLEX group patients had 3 (1-7) PLEX sessions with 1.5 (1.4-1.6) liters of plasma exchanged per session and oral Prednisolone 20 mg daily, tapered over 1 month. Kaplan Meier analysis showed better survival over 1 year in the PLEX group compared to the SMT group ( P  = 0.03). There was renal dysfunction in 10 patients in the PLEX group, which normalized in six patients after PLEX., Conclusion: In this preliminary report, compared to SMT, low volume PLEX and low dose steroid improved survival over one year in A-ACLF patients with severe alcoholic hepatitis. In patients with renal dysfunction, 60% showed improvement in renal function with PLEX. Studies with a larger number of patients are needed to validate these results., (© 2021 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Introduction: Skin colonization is a risk factor for multi-drug resistant (MDR) catheter-associated bloodstream infections (CABSI). This study aimed to determine the prevalence and spectrum of skin colonizing MDR organisms in incident HD patients and their correlation with CABSI., Methods: This single-center prospective cohort study included consecutive adult incident HD patients who underwent tunneled or non-tunneled internal jugular vein HD catheter insertion between June 1, 2017 and October 31, 2017. Nasal, axillary, and exit site swabs were obtained prior to catheter insertion, at 14-21 days, and 28-35 days after catheter insertion., Results: Forty-three patients (69.7% male, 32.5% diabetic) were included and provided baseline swabs, while 29 and 10 patients respectively were available for follow-up swabs. MDR bacterial colonization, MRSA colonization, and MDR gram-negative colonization on the baseline set of swabs were seen in 76.7%, 69.7%, and 9.3% patients respectively. Of the 29 patients with at least two consecutive sets of swabs, 79.3% showed persistent colonization by MDR gram-positive organisms, most commonly by MRSA. Six patients developed a CABSI during the follow-up period (incidence rate 3.7 per 1000 patient days), 83.4% were gram negative, and in only one instance (16.6%) was the bacterial strain identical to that which had previously colonized the skin., Conclusions: Three-fourths of HD patients were colonized by MDR bacteria prior to HD initiation. Despite the majority being persistently colonized by MDR gram-positive organisms, CABSIs were predominantly gram negative., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Indian Journal of Nephrology.)

Introduction: Glomerular Research And Clinical Experiments-IgA Nephropathy in Indians (GRACE-IgANI) is the first prospective South Asian IgA nephropathy (IgAN) cohort with prespecified objectives, protocolized longitudinal follow-up, and extensive biosample collection. The baseline risk scores predicted high risk of kidney disease progression., Methods: A total of 195 of 201 patients (97%) completed 3-year follow-up in September 2020. All patients received optimized supportive care, and those at high risk of progression were offered systemic corticosteroids., Results: A total of 76 patients (76 of 193, 39.4%) had rapid progression in 3 years (≥5 ml/min per 1.73 m 2 decline in estimated glomerular filtration rate [eGFR] per year). A total of 72 patients (72 of 195, 36.9%) experienced the composite outcome (CO), defined as ≥50% fall in eGFR, eGFR < 15 ml/min per 1.73 m 2 , commenced kidney replacement therapy or death, in 3 years. At each scheduled follow-up, achievement of proteinuria level < 1 g/d significantly delayed the time to the CO. The receiver operating characteristic curve of average annual decline in eGFR ≥ 5 ml/min per 1.73 m 2 had 86% sensitivity and 89% specificity for CO in 3 years and had good discrimination from 1 year onwards (area under the curve 0.8, SE 0.04, 95% CI 0.7-0.9, P  < 0.0001). The significant predictors of CO by Cox proportional-hazards model were as follows: baseline MEST-T2 score (hazard ratio [HR] 3.3, 95% CI 1.7-6.5, P  < 0.001), along with 24-hour urine protein level ≥ 1 g/d (HR 2.1, 95% CI 1.1-3.9, P  = 0.02), eGFR < 60 ml/min per 1.73 m 2 (HR 2.9, 95% CI 1.1-7.6, P  = 0.03), and rate of eGFR decline ≥ 5 ml/min per 1.73 m 2 /yr (HR 2.7, 95% CI 1.6-4.8, P  < 0.001) all measured at 6 months. Mortality was 11 of 195 (5.6%)., Conclusion: We identified longitudinal clinical variables measured at 6 months and ≥5 ml/min per 1.73 m 2 annual fall in eGFR after kidney biopsy as important predictors for composite outcome in addition to baseline histology., (© 2021 International Society of Nephrology. Published by Elsevier Inc.)

Background: We report pediatric PAKT patient and graft outcomes at a large tropical tertiary center spanning two transplant eras., Methods: In this retrospective cohort study, all children ≤18 years who underwent kidney transplantation at our center between 1991 and 2016 were included. Data pertaining to their baseline characteristics, post-transplant events, and outcome were retrieved from transplant records and compared between transplant eras (1991-2005 and 2006-2016)., Results: A total of 139 children (mean age 15.2 ± 2.9 years) underwent PAKT during this period. The incidence of UTIs, CMV disease, BKVN, invasive fungal infections, new-onset diabetes after transplant, leucopenia, and recurrent NKD was higher in the 2006-2016 era (P < .001 for all), while 1-year cumulative BPAR was comparable (P = .100). Five-year graft and patient survival in the two eras were 89.9% and 94.2% (P = .365) and 92.1% and 95.3% (P = .739), respectively. Incidence of CMV disease, BKVN, graft loss, and death was lower in the calcineurin withdrawal group. Non-adherence accounted for 36% of graft loss; infections caused 43.7% of deaths. On multivariate Cox proportional hazards analysis, independent predictors for graft loss were UTIs and blood transfusion naïve status and for death were serious infections and glomerular NKD., Conclusions: PAKT in India has excellent long-term graft outcomes, though patient outcomes remain suboptimal owing to a high burden of infections. Current immunosuppression protocols need to be re-examined to balance infection risk, graft, and patient survival., (© 2021 Wiley Periodicals LLC.)

Aim: Kidney biopsy (KBx) is the gold standard for evaluation of kidney disease, but is associated with a higher risk of complications in patients with reduced glomerular filtration rate (GFR). We studied the safety and utility of KBx in patients with eGFR <30 ml/min/1.73 m 2 ., Methods: Consecutive adult patients with eGFR <30 ml/min/1.73 m 2 , who were planned for a KBx and consented to participate were prospectively enrolled. Patients with solitary/transplant kidney or acute kidney injury were excluded. Haemoglobin was checked on the day of KBx and repeated 18-24 h later along with a screening ultrasound. Post-KBx complications were noted and their risk-factors analysed. The utility of the KBx was graded as effecting significant, some, or no change to subsequent management., Results: Of the 126 patients included, 75% were male, 27.7% were diabetic, and the median eGFR was 13.5 ml/min/1.73m 2 . Major complications occurred in 5.6%. Peri-renal haematomas were detected in 37.3%, and haematomas ≥2 cm were significantly more frequent in those with eGFR <15 ml/min/1.73 m 2 (29.2% vs. 13%, p = .032). Dialysis was a risk factor, while pre KBx blood transfusion, diabetes and higher serum albumin were protective against any complication. KBx was more likely to make a significant difference in management in those with eGFR 15-29 ml/min/1.73m 2 (44.1% vs. 11.1%, p < .001). Increasing age, lower serum creatinine and albumin were independently associated with KBx utility., Conclusion: KBx is relatively safe in severe kidney disease but its risk to benefit balance needs to be carefully considered when eGFR is <15 ml/min/1.73m 2 ., (© 2021 Asian Pacific Society of Nephrology.)

Background and Objectives: Bacterial infection-related GN occurs concurrent to or after known or unknown infections. It is important to understand the clinical implications of the bacterial isolates, antimicrobial resistance patterns, and effect of latency-based classification on kidney and patient outcomes., Design, Setting, Participants, & Measurements: In total, 501 consecutive adults diagnosed with bacterial infection-related GN between 2005 and 2017 were included from a biopsy registry of 15,545 patients at a single center in South India, and follow-up data were collected from electronic medical records until December 2019. Latency was defined as time between resolution of infection and onset of GN, which was classified as parainfectious, peri-infectious, or postinfectious GN. Longitudinal kidney and patient outcomes were studied., Results: The mean age of the cohort was 40 (± 15) years, 6% were above 65 years, and 330 (66%) were men. Diabetes was present in 93 (19%) patients. Seventy percent (353 of 501) of patients had known infections, with the median latent period for parainfectious (115 of 353, 33%), peri-infectious (97 of 353, 27%), and postinfectious (141 of 353, 40%) GN being 0, 5 (4-7), and 15 (10-31) days, respectively. The most common predisposing organism was Streptococcus pyogenes (137 of 353, 39%). Drug-resistant nonstreptococcal bacteria were methicillin-resistant Staphylococcus aureus (25%, four of 16), extended-spectrum β -lactamases (20%, 12 of 59), and carbapenem-resistant organisms (10%, six of 59). Twenty of 22 (91%) of the drug-resistant organisms were isolated from the parainfectious group. The most common site of infection was skin in peri- (23 of 97, 24%) and postinfectious GN (61 of 141, 43%), and urinary tract in parainfectious GN (35 of 115, 30%). Of 321 patients with >3 months of follow-up, 48 (15%) developed kidney failure over a median period of 10 (2-37) months and 14 (4%) died. Parainfectious GN, eGFR<30 ml/min per 1.73 m 2 , moderate-to-severe interstitial fibrosis and tubular atrophy, and nontreatment with renin-angiotensin system blockers were significant risk factors for progression to kidney failure by a Cox proportional-hazards model., Conclusions: Along with clinical and histologic predictors, parainfectious GN caused predominantly by nonstreptococcal and drug-resistant bacterial infections was associated with poor kidney prognosis., (Copyright © 2021 by the American Society of Nephrology.)

Catheter malfunction in peritoneal dialysis (PD) patients may lead to technique failure. Surgical repositioning is sometimes required for resumption of PD and is associated with additional costs of procedure and hospitalization. Meanwhile, patients may need hemodialysis via a temporary vascular catheter with increasing costs and risk of catheter-associated bacteremia. We describe an innovative technique of blind bedside PD catheter repositioning as a possible alternative to surgical repositioning when there is catheter malfunction. In 29 patients over a period of 3 years, we attempted blind bedside PD catheter repositioning with immediate successful inflow and outflow in all of them after repositioning. At 1 month, 21 (72.4%) patients had good catheter function and at 6 months, 19 (65.5%) patients were continuing successful PD. This bedside innovative procedure allowed for catheter salvage without constructing a new exit site or tunnel and without the requirement of a break-in period. The benefits to the patient in terms of cost and shortened hospital stay make it ideal for resource-poor settings. We suggest that this innovative technique be attempted before resorting to the open surgical method of PD catheter repositioning., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Indian Journal of Nephrology.)

Background: The prevalence of HCV infection is high and it is a major cause of liver-related morbidity and mortality in hemodialysis and renal transplant patients. Diagnosis of hepatitis C virus (HCV) infection requires both HCV antibody screening and confirmatory nucleic acid testing (NAT). Hepatitis C virus core antigen (HCVcAg) is a reliable direct viral marker to identify active HCV infection., Aim: To assess the clinical utility of HCV core antigen to identify active HCV infection in hemodialysis and renal transplant patients., Methods: A representative total of 231 plasma samples with a predominance of low viral load were included for HCVcAg testing and its performance characteristics were compared with the gold standard HCV RNA., Results: Comparison of HCVcAg with HCV RNA showed an excellent specificity of 99% (95% CI: 94.7 to 100%) and sensitivity of 80.62% (95% CI: 73.59 to 87.7%). Likewise, the PPV and NPV of HCVcAg were 99.1% (95% CI: 93.7% to 99.9%) and 80.2% (95% CI: 74% to 85.2%) respectively. The correlation between HCVcAg and HCV RNA was found to be good (R2 = 0.86, p<0.0001). Among common Indian HCV genotypes (1, 3 & 4), good correlation was observed between HCV RNA and HCVcAg (R2 = 0.81, p <0.0001)., Conclusions: It is the first Indian study to show that HCVcAg is a reliable, cost-effective direct marker to identify active HCV infection in hemodialysis and renal transplant patients. Implementation of HCVcAg testing could improve the accessibility to efficacious and affordable disease management in hemodialysis and renal transplant patients. In HCVcAg negative cases, sequential testing with anti-HCV antibody followed by HCV RNA could be a reliable and cost-effective approach., Competing Interests: The authors declare that they have no competing interests.

Introduction: We previously showed that patients with chronic kidney disease (CKD) Stage G4-5 have normal bleeding times. This made us question whether hemodialysis (HD) initiation was really necessary solely to improve platelet function., Methods: In this prospective observational study, two 5 ml citrated blood samples and one 2 ml EDTA blood sample were collected from incident HD patients fulfilling inclusion criteria prior to HD initiation (baseline sample) and after three sessions of short duration, low flow, counter-current HD. In each instance, one sample was used to perform Collagen adenosine diphosphate closure time (CADPCT) using the Platelet function analyzer (PFA 200, normal range 68-142 seconds) and the second for light transmission aggregometry (LTA) with ADP as agonist (normal ≥50%)., Results: This study included 20 patients between October 2017 and February 2019. Overall, and in the subgroup with normal baseline CADPCT or LTA, there was no statistically significant improvement after HD. However, of the 30% of patients who had an abnormal baseline CADPCT, 50% attained a normal value after three HD sessions, and the overall reduction in CADPCT in this group was statistically significant ( P = 0.02). Of those with a baseline normal CADPCT, 21% developed abnormal prolongation post HD., Conclusion: HD for the sole purpose of improving platelet function is only of benefit in the subgroup of patients with an abnormal CADPCT at baseline, with close to 50% normalizing their platelet function after three sessions of low flow, short duration, counter-current HD., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Journal of Nephrology.)

Introduction: Glomerular Research And Clinical Experiments-IgA Nephropathy in Indians (GRACE-IgANI) is the first prospective South Asian IgAN cohort with protocolized follow-up and extensive biosample collection. Here we report the baseline clinical, biochemical, and histopathologic characteristics of GRACE IgANI and calculate baseline risk of progression for the cohort., Methods: 201 incident adults with kidney biopsy-proven primary IgAN were recruited into GRACE-IgANI between March 2015 and September 2017. As of April 30, 2020, the cohort had completed a median follow-up of 30 months (interquartile range [IQR] 16-39)., Results: The commonest clinical presentation in GRACE IgANI was hypertension, with or without proteinuria, and nephrotic-range proteinuria was present in 34%, despite <10 months of lead time to kidney biopsy. The GRACE-IgANI kidney biopsy data demonstrated a disproportionate absence of active glomerular lesions and overrepresentation of segmental sclerosing lesions and tubulointerstitial fibrosis at presentation, often coexistent with relatively well-preserved estimated glomerular filtration rate (eGFR) and low levels of proteinuria, especially in males. Baseline risk of progression was calculated for each evaluable patient using 2 different risk prediction tools. The median 5-year absolute risk of end-stage kidney disease (ESKD) was 19.8% (IQR 2.7-57.4) and median 5-year risk of progression to the combined endpoint of 50% decline in eGFR or ESKD was 35.5% using the 2 tools., Conclusions: The predicted risk of progression in this cohort was considerable. Over the next 5 years, we will dissect the pathogenic pathways that underlie this severe South Asian IgAN phenotype., (© 2020 International Society of Nephrology. Published by Elsevier Inc.)

Traditionally, sensitizing events such as previous pregnancies, previous transfusions and prior transplants result in the production of anti-Human Leukocyte Antigen (HLA) antibodies. However, it has been observed that, anti-HLA antibodies have been detected in many patients with no prior history of sensitizing events. This retrospective study analysed the most recent 100 consecutive Single Antigen Bead (SAB) assay results performed on 100 patients. The SAB assay is used routinely to detect anti-HLA antibodies in transplant recipients. Results of the SAB assay were analyzed and subsequently studied to see if a correlation existed between sensitizing events, the type of events and presence of antibody. Analysis showed that 77% (77/100) had anti-HLA antibodies. 61 out of 100 patients had prior sensitizing events while the remaining 39 had none. Both these groups showed an almost equal percent of patients with anti-HLA antibodies 77% (47/61) and 76.9% (30/39) respectively. A single sensitizing event was seen in 54.1% (33/61) patients including previous transfusions in 29.5% (18/61), pregnancies in 11.4% (7/61) and prior transplant in 13.1% (8/61). Our study suggests that irrespective of whether patients have prior sensitizing events or not, patients run the risks of alloimmunization, and therefore appropriate screening tests should be included in the pre-transplant compatibility algorithm., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

The renal diseases commonly associated with myeloma include primary amyloidosis, cast nephropathy, and light chain deposition disease. Less frequent forms of renal involvement encountered in the course of myeloma are crystalline and non-crystalline proximal tubulopathies, neoplastic plasma cell infiltration, and immunoglobulin crystallization in interstitial histiocytes and glomerular cells including podocytes. Light chain proximal tubulopathy (LCPT) caused by aggregation of non-crystalline and rarely crystalline deposits of monoclonal light chains in the cytoplasm of proximal tubular epithelial cells, accounts for less than 5% of monoclonal gammopathy-associated kidney diseases. We report the case of a 48-year-old Indian woman with multiple myeloma, who presented with acute kidney injury and nephrotic syndrome, in whom the renal biopsy revealed widespread crystalline inclusions in extraglomerular and glomerular compartments. We present illustrative light microscopic (LM) and diagnostic electron microscopic (EM) findings of this case which enabled a diagnosis of crystalline LCPT, crystal storing histiocytosis, and crystalline podocytopathy occurring synchronously with myeloma cast nephropathy. While documenting this unique juxtapositioning of multicompartmental paraproteinemic renal injury in multiple myeloma, diagnosed after EM analysis of the patient's renal biopsy, we discuss the pathogenetic pathways of this condition along with the clinical implications. Due to intrinsic structural properties of the crystals, they frequently escape detection by routine LM, necessitating EM analysis for their diagnosis. Given the prognostic implications of tubulopathies complicating myeloma, LCPT is a critically important diagnosis, highlighting the need for a comprehensive renal biopsy evaluation inclusive of EM for the practice of precision medicine in such scenarios.

Collagenofibrotic glomerulopathy (CFG) is a rare idiopathic kidney disease characterized by abnormal deposition of atypical Type III collagen fibers in the glomerulus causing subendothelial and mesangial expansion, manifesting as progressive renal dysfunction accompanied by proteinuria. The majority of CFG cases reported in literature are from Japan where this disease entity was initially recognized. There is an increased awareness and diagnosis of this rare renal disease in India with the recent increase in utilization of electron microscopy (EM) in clinical diagnostic settings. We describe a 28-year-old Bangladeshi woman who presented with hypertension and nephrotic range proteinuria not amenable to treatment with steroids and cyclophosphamide, whose renal biopsy demonstrated diagnostic ultrastructural features of CFG. This illustrative case is presented to highlight the role of EM analysis for diagnostic accuracy in renal biopsy evaluation in addition to demonstrating the unusual renal biopsy findings of this rare entity., Competing Interests: None

Nephropathic cystinosis is a rare autosomal recessive lysosomal disease characterized by accumulation of pathognomonic cystine crystals in renal and other tissues of the body. Cystinosis is caused by mutant cystinosin, the cystine transport protein located in lysosomal membranes, leading to systemic deposits of cystine and resultant end organ damage. Cystinosis is rarer in Asians than Caucasians with only a handful of cases reported from India to date. Due to its extreme rarity and clinically insidious presentation in contrast to the infantile form, the diagnosis of juvenile nephropathic cystinosis is frequently delayed or overlooked. Moreover, routine processing and sectioning of paraffin embedded tissues dissolves cystine crystals, making it difficult to diagnose this condition on light microscopic examination alone, mandating electron microscopic (EM) analysis of renal biopsies for an accurate diagnosis of this condition. We describe a case of juvenile nephropathic cystinosis presenting with uveitis and photophobia in a 17-year-old Indian male, diagnosed after EM examination of the patient's renal biopsy for evaluation of nephrotic syndrome. While highlighting the diagnostic utility of EM, we describe a few histopathologic clues which can prompt inclusion of EM analysis of renal biopsies in this setting., Competing Interests: There are no conflicts of interest

Background: Nontunneled hemodialysis catheters (NTHCs) remain the preferred vascular access at hemodialysis (HD) initiation in developing countries. We studied the incidence, risk factors and microbiological spectrum of jugular NTHC-associated bloodstream infections (CABSIs) at a tertiary care center in South Asia., Methods: In this retrospective cohort study, all adult (≥18 years) incident patients who underwent jugular NTHC insertion for HD between January 2016 and June 2017, had no prior history of temporary vascular access insertion and were followed up for ≥14 days were included., Results: A total of 897 patients underwent NTHC insertion during the study period and 169 patients fulfilled the inclusion criteria and contributed 7079 patient days of follow-up. CABSI incidence was 7.34 episodes per 1000 catheter days and median infection-free survival and time to CABSI were 96 and 24.5 days, respectively. In multivariate Cox regression analysis, immunosuppressive medication {hazard ratio [HR] 2.87 [95% confidence interval (CI) 1.09-7.55]; P = 0.033} and intravenous cefazolin use [HR 0.51 (95% CI 0.28-0.94); P = 0.031] was independently associated with CABSI. The cumulative hazard of CABSI was 8.3, 13.3, 17.6 and 20.9% at Weeks 1, 2, 3 and 4, respectively. Gram-negative organisms were the most common etiological agents (54.7%) and 40.3% of CABSIs were caused by drug-resistant organisms. Gram-negative and Gram-positive CABSIs were associated with neutrophil left shift and higher procalcitonin compared with coagulase-negative staphylococcal CABSIs., Conclusion: In South Asia, NTHC-associated CABSIs occur early and are predominantly Gram negative. We hypothesize that poor hygiene practices may play a role in this phenomenon., (© The Author(s) 2019. Published by Oxford University Press on behalf of ERA-EDTA.)

Introduction: Ocular Pulse Amplitude (OPA) is the fluctuation of IOP with the cardiac cycle which is equal to the difference between systolic and diastolic IOP. These variations in IOP are thought to be caused by the blood volume that is pumped into the eye, mainly the choroidal bed during each cardiac cycle. In patients with end stage renal disease (ESRD), Choroidal perfusion has been found to be reduced as determined by Indocyanine Green Angiography (ICG) which is an invasive procedure. OPA is recorded by Dynamic Contour Tonometer (DCT) which represents a potential new technology for measuring choroidal blood flow indirectly & non-invasively especially in patients with suspected compromise in perfusion as in ESRD. In this study we postulate that measurement of OPA can be used to assess the choroidal perfusion inpatients with ESRD., Objectives: To measure OPA in non-diabetic patients with ESRD on hemodialysis and to compare it with that of OPA in age matched normal individuals., Materials & Methods: It was a prospective Cross-sectional study and was done in a clinical set up during the period of January 2013 to October 2013. OPA among 44exposed and 44 non exposed individuals were measured using Dynamic Contour Tonometry (DCT) and analysis done., Results: The mean OPA in non diabetic patients with ESRD was 1.945mm Hg (CI:1.847 - 2.043) and the mean OPA in age matched normals was 2.16mm Hg (CI: 2.08- 2.24)., Conclusion: OPA in non diabetic ESRD patients was statistically significantly lower than that of age matched normals (p=0.03). There was no correlation between OPA and other parameters like age, gender, intraocular pressure, blood pressure or serumcreatinine levels., (© NEPjOPH.)

Introduction: Literature regarding the outcomes of renal transplant in patients with abnormal lower urinary tracts (LUTs) is conflicting. The study aimed to determine the graft outcomes and complications of renal transplantation in an optimized abnormal LUT as compared to those with a normal LUT., Materials and Methods: In this single-center retrospective-matched cohort study, we identified 31 patients with an optimized abnormal LUT in our transplant database between 2006 and 2016 (Group A) and selected an equal number of matched controls (Group B). The primary outcome was graft survival, and secondary outcomes were overall survival and complications., Results: The median age was 24 years (range: 12-45), and the median duration of follow-up was 36 months in both groups. On Kaplan-Meier analysis, the estimated mean graft survival was 106 months (confidence interval [CI]: 91-120) in Group A versus 128 months (CI:117-139) in Group B ( P = 0.47, log-rank analysis). On subgroup analysis of Group A, augmented bladders had the poorest mean survival (81 months, CI: 56-106), P = 0.09). The mean estimated patient survival was comparable between Group A and B (109 months, CI: 96-122 versus 139 months, CI: 134-144), P = 0.13). Infective complications (27 episodes vs. 1) and re-admissions (77 vs. 30) were significantly higher in Group A ( P = 0.04 and P < 0.01). Clean intermittent catheterization was a risk factor for infections (63% vs. 37%, P = 0.033, odds ratio: 5)., Conclusions: The graft and overall survival was comparable at 3 years in both groups. Infective complications were higher in Group A., Competing Interests: There are no conflicts of interest.

Aim: We report findings from a large single centre paediatric renal biopsy cohort in South Asia., Methods: We analyzed all renal biopsies performed on children aged ≤18 years between 1996 and 2015 at our centre. The clinical characteristics and histological diagnosis pertaining to each case, distribution of renal diseases in children with various clinical presentations, and changes in the pattern of kidney disease during the study period were analyzed., Results: A total of 1740 paediatric kidney biopsies were performed during the study period. The mean age was 12.8 ± 4.9 years (8 months to 18 years) and the male: female ratio was 1.5:1. The most common indication for renal biopsy was nephrotic syndrome (63.2%) followed by acute nephritic syndrome (13%). Minimal change disease was the most common cause of nephrotic syndrome while endocapillary proliferative glomerulonephritis (65.7% infection related), remained the commonest cause of acute nephritic syndrome. IgA nephropathy was the commonest cause of chronic kidney disease. Contrary to trends in European paediatric cohorts, the frequency of lupus nephritis increased over the two decades of the study, while that of endocapillary proliferative glomerulonephritis did not show any appreciable decline., Conclusion: This study provides the largest data on biopsy proven renal disease in children from South Asia published till date and highlights important differences in the spectrum and trends of kidney disease compared to data from other regions., (© 2017 Asian Pacific Society of Nephrology.)

Pregnancy offers a precious window of opportunity to diagnose previously undetected or new onset kidney diseases in emerging countries like India, where access to medical, educational and health care facilities are not equitably distributed across varied sections of society. We report a case of a 33 year-old primi gravida who had a successful pregnancy following what was initially considered to represent preeclampsia at 38 weeks of gestation, in whom a subsequent kidney biopsy for persistence of pregnancy-related acute kidney injury (Pr-AKI) revealed light chain deposition disease (LCDD). The etiological evaluation of LCDD led to the detection of an underlying plasma cell dyscrasia which was treated effectively with chemotherapy and autologous stem cell transplant. In this report, we explore the hitherto uncharted pathophysiological relationship between LCDD and pregnancy-related kidney injury by transmission electron microscopic (TEM) studies of endothelial injury in this setting, and underscore the benefits of medical care in a multidisciplinary environment which yielded gratifying results in preservation of maternal kidney health and fetal outcome.