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Collapsing focal segmental glomerulosclerosis (cFSGS) is characterized by rapid progression to end-stage renal disease (ESRD). We evaluated the clinicopathological spectrum of cFSGS and compared its clinical behavior to steroid and tacrolimus (TAC)-resistant noncollapsing focal segmental glomerulosclerosis (FSGS). All patients (>14 years) diagnosed with cFSGS were enrolled in the study. Staining for differentiated podocyte markers such as WT 1, PAX and KI67 were performed in all patients. The outcome and histological features of cFSGS was compared with a prospectively followed cohort of steroid and TAC-resistant noncollapsing FSGS. The study included 22 cFSGS patients and 19 cases of steroid and TAC-resistant FSGS. Complete remission, partial remission, steroid resistance, progression to ESRD and death were observed in 13.6%, 4.5%, 27.3%, 36.4% and 18.2% patients, respectively. Patients with cFSGS had higher serum creatinine and more advanced tubulointerstitial changes compared to resistant FSGS. Twenty-six percent of therapy resistant noncollapsing FSGS progressed to ESRD after two years of stopping TAC. However, there was no difference in progression to ESRD between cFSGS and therapy-resistant noncollapsing FSGS at the end of two years. Glomerular collapse in the setting of FSGS is poorly responsive to treatment and has a high rate of progression to ESRD. The long-term prognosis of cFSGS and steroid and TAC-resistant FSGS are similar.

Acute kidney injury (AKI) can develop after multiple wasp or bee stings. The etiology is the acute tubular necrosis secondary to shock, pigment toxicity, interstitial nephritis, or direct nephrotoxicity of venom. We report a 40-year-old female who presented with oliguric AKI after a single wasp sting on her hand. Her history, examination, and investigations did not support any of the established causes of AKI in such settings. She did not improve with supportive management and dialysis, and kidney biopsy showed acute cortical necrosis (ACN). This is the first report of ACN after a single wasp sting.

The role of intravenous iron in contributing to oxidative stress and endothelial dysfunction in chronic kidney disease (CKD) is debatable. The present study assessed differences in fasting plasma malondialdehyde (pMDA) levels 30 minutes before and after intravenous infusion of low molecular weight iron dextran (ID) (n = 19), iron-sucrose (IS) (n = 20), and sodium ferrigluconate complex (SFGC) (n = 20) in stage 3 and 4 CKD patients. Post-infusion pMDA levels were significantly raised with respect to baseline (p < 0.001). pMDA was significantly higher in the SFGC group vs. IS (3.02 +/- 0.84 micromol/L vs. 2.82 +/- 0.44 micromol/L, p = 0.034) or SFGC vs. ID (3.02 +/- 0.84 micromol/L vs. 2.92 +/- 0.20 micromol/L, p = 0.048). There was no difference between IS vs. ID (2.82 +/- 0.44 micromol/L vs. 2.92 +/- 0.20 micromol/L, p = 0.21). To conclude, all forms of parenteral iron, especially SFGC, significantly raise pMDA levels in the immediate post-transfusion period.

The relative safety of parenteral iron preparations is a controversial issue in the management of anemia in chronic kidney disease (CKD), as direct head-to-head comparative trials are lacking. In this study, patients of CKD were randomized to receive intravenous low molecular weight iron dextran (ID), sodium ferrigluconate complex (SFGC), and iron sucrose (IS) at doses and infusion rates recommended by the product manufacturer. One time test dose was used only for ID and SFGC. A total of 2,980 injections (n = 339) of i.v. iron was given, and 49 patients (14.45% per patient) and a total of 56 adverse events (1.88% per infusion) were noted. Odds ratios (OR) of serious adverse drug events (ADE; i.e., death, anaphylaxis, or suspected immuno-allergic events) per patient was not significant between ID vs. SFGC (3.566) and SFGC vs. IS (2.129), whereas that between ID vs. IS (7.594) was highly significant (p = 0.034). OR of serious ADE exposure was significantly higher in ID vs. SFGC (OR = 5.670, p = 0.0147) and ID vs. IS (OR = 7.799, p < 0.001). No significant difference was seen between the three groups in terms of non-serious ADEs. Drug discontinuation occurred significantly more often with ID. One patient who developed anaphylactoid reaction with SFGC and ID tolerated iron sucrose well.

Acute renal failure (ARF) occurs in wide range of conditions, making the evaluation of its prognosis a difficult task. Data regarding prognostic factors in ARF in a general population in developing countries are scarce. The objective of the study was to describe predictors of mortality in ARF that are relevant in the developing world. This prospective study was carried out over a one-year period; all hospitalized adults with ARF were included in the study. Predictors of mortality studied included causes of ARF, pre-existing diseases, and severity as well as complications of ARF. Of 33,301 patients admitted during the study period, 294 (0.88%) were either admitted with or developed ARF after hospitalization. Mean age was 43.9 +/- 16.9 (18-86 yrs). Sepsis was the most common cause (63.26%). Pre-existing diseases like cardiovascular disease (CVSD), respiratory system disease (RSD), central nervous system disease (CNSD), hypertension, diabetes mellitus (DM), and malignancy were significantly higher in elderly as compared to younger patients. On univariate analysis sepsis, hypoperfusion as a cause of ARF and hospital-acquired ARF were associated with higher mortality. Pre-existing diseases viz. RSD, CVSD, CNSD, and DM had higher mortality. Among the severity and complications of ARF, oliguria, bleeding and infection during the course of ARF and critical illness were predictors of poor outcome. Age > 60 yrs was associated with significantly higher mortality. However, on multivariate analysis, only critical illness (odds ratio 37.3), age > 60 years (odds ratio of 5.6), and sepsis as cause of ARF (odds ratio of 2.6) were found to be independent predictors of mortality.

Background: Rapid decline of renal function in a diabetic suggests the presence of a nondiabetic kidney disease (NDKD). We designed a prospective study to evaluate the factors associated with a rapid decline in renal function in patients with type 2 diabetes., Methods: Over a 2 and a half year period, all patients with type 2 diabetes who presented with documented doubling of serum creatinine in less than 4 weeks or recently diagnosed advanced renal failure were identified. Patients with prerenal causes, urinary tract obstruction, or systemic disease causing renal failure were not included. Renal histology was studied in all cases., Results: A total of 26 patients satisfied the inclusion criteria. Over 75% had serum creatinine >4 mg/dL at presentation and 62% were dialysis dependent. Renal histology showed mixed lesions of diabetic nephropathy (DN) and NDKD in 11 cases, only DN in nine, and pure NDKD in six. Diffuse proliferative glomerulonephritis (DPGN) was the commonest NDKD (27% cases), all on a background of DN. History of preceding cutaneous or pharyngeal infection was available in five cases. The proportion of postinfectious glomerulonephritis in diabetics with rapidly progressive renal failure was over six times that of the nondiabetic adult RPRF population during the study period. Four patients had acute interstitial nephritis and three showed crescentic glomerulonephritis. Other lesions included amyloidosis, atheroembolic disease, and renal papillary necrosis (one each). The frequency of microscopic hematuria and retinopathy was similar in those with pure DN and NDKD. Four out of seven cases with DPGN showed partial recovery whereas the other three remained unchanged., Conclusions: About two-thirds of patients with type 2 diabetes presenting with rapid decline of renal function in a tropical environment show NDKD. The high incidence of postinfectious glomerulonephritis in this group is possibly related to the high prevalence of skin and soft tissue infections; and could contribute to progressive kidney disease.

The occurrence of silent myocardial ischemia (SMI) and serious arrhythmias during hemodialysis (HD) has been well documented. However, it is unclear whether these changes are due to epicardial coronary artery disease (CAD). We conducted a prospective study to assess whether SMI and arrhythmias during HD correlated with angiographically demonstrable CAD. Twenty-three patients with end-stage renal disease on maintenance HD underwent 48-hour Holter monitoring, beginning 24 hours prior to a HD session. All patients underwent biochemical evaluation, coronary angiography, and echocardiography. Holter monitoring showed SMI during HD in 22% cases. A significant increase in the frequency of ventricular ectopics (VEs) was noted during and after HD. Patients who showed SMI during HD and VEs prior to initiation of dialysis were more likely to develop significant ventricular arrhythmias during and after HD. Epicardial CAD was documented in four patients, and it did not correlate with SMI. To conclude, HD is an arrhythmogenic process. SMI during dialysis is probably not due to epicardial CAD but predisposes to clinically significant ventricular arrhythmias during and after HD. The cause of SMI during HD in patients without demonstrable CAD needs further investigation.

Recurrence of amyloidosis secondary to chronic infections in the renal allograft is highly unusual. We report the recurrence of amyloid in the graft within one year after transplantation in a patient with systemic AA amyloidosis secondary to tuberculosis. The diagnosis of tuberculosis was made in the immediate post-transplant period on the basis of good therapeutic response of fever and chest infiltrates to anti-tubercular chemotherapy.

Clinical features and risk factors for renal failure in patients with reflux nephropathy (RN) as seen in an adult nephrology service are likely to be different than those seen in a pediatric service. There are only a few studies on adults with vesicoureteric reflux (VUR) and RN and data on RN as seen in developing countries is still evolving. Retrospective analysis of records of patients diagnosed to have VUR by conventional micturating cystourethrogram over a 13 year period, as seen in the adult nephrology services of this tertiary care hospital in north India was carried out. Results are presented as mean +/- 2 SD. Unpaired t-test was used to compare means, chi-square test to define associations, and logistic regression analysis was done to define risk factors. Out of 86 patients diagnosed to have VUR, 69 (80.2%) were males and 22 (25.6%) were children. The mean age at presentation was 24.3 +/- 14.5 years and at onset of symptoms was 19.64 +/- 14.8 years. Sixty-nine (80.2%) patients had chronic renal failure (CRF) at presentation, including 33 (38.4%) patients who already had end stage renal failure (ESRF) at presentation in whom reflux was diagnosed during routine pretransplant evaluation and these constituted 5.5% of all ESRF patients. The clinical features at presentation were hypertension in 51 (59.3%), recurrent urinary tract infection (UTI) in 31 (36.1%), history of stones in 7 (8.1%), and gross hematuria in 4 (4.7%). Patients with history of recurrent UTI were more likely to be females (p < 0.01) and to present without renal failure (p < 0.05). Proteinuria > 1 g/day was significantly associated (p < 0.02) with hypertension at presentation. Patients who presented with renal failure were more likely to be males (p < 0.05), not to have history of recurrent UTI (p < 0.05), have proteinuria > 1 g/day (p < 0.02) and higher grades (grades IV and V) of reflux (p < 0.05). On logistic regression analysis, higher age of onset (odds ratio 4.6, p < 0.03), proteinuria > 1 g/day (odds ratio 3.8, p < 0.05), and male gender (odds ratio 3.5, p < 0.05) were significant risk factors for presentation for the first time with renal failure. The clinical features and course of VUR and RN as seen in India are different from those reported from elsewhere. The vast majority of patients in India are males and almost two thirds do not have a past history of UTI. Renal failure is present in more than three fourths of patients when a diagnosis of reflux is made and one third of all patients present with ESRD. Patients with a prior history of UTI are more commonly females and are less likely to have renal failure at presentation. Higher age of onset of symptoms, proteinuria > 1 g/day and male gender were risk factors for the development of renal failure. It is likely that these asymptomatic patients remain undetected during childhood, presenting late only after having incurred severe renal damage.

Mitomycin-C is used widely in the treatment of malignancies and is associated with serious dose related adverse effects including the occurrence of hemolytic uremic syndrome. We report a patient with a colonic adenocarcinoma who developed hemolytic uremic syndrome after receiving 85 mg/m2 of the drug. The patient was left untreated and died 5 months after this diagnosis was made, of a second malignancy. Differential diagnosis and treatment of this condition are discussed.

Snakebite induced acute renal failure continues to occur in many tropical areas of the world. Renal histological lesions other than acute tubular necrosis and acute cortical necrosis as the cause of acute renal failure are rare. Only 3 cases of acute interstitial nephritis in patients with snakebite induced acute renal failure have been previously reported. We report a patient with acute renal failure following viperine snakebite due to acute interstitial nephritis. After a prolonged oliguric phase, there was complete recovery of renal function without institution of steroids. Interstitial nephritis may result from a hypersensitivity reaction to some component of the snake venom.

Cardiac arrhythmias are noted in a significant proportion of chronic renal failure (CRF) patients on hemodialysis (HD), and may contribute to cardiovascular mortality. A number of factors have been implicated in the genesis of these arrhythmias. The role of silent myocardial ischemia (SMI), however, has not been evaluated systematically. We prospectively studied 38 unselected CRF patients on regular HD by continuous Holter monitoring starting 24 hours before HD, lasting through the dialysis session and continued for 20 hours thereafter. The recordings were analyzed for frequency, timing and severity of supraventricular and ventricular arrhythmias and SMI as identified by ST-segment depression. Ventricular arrhythmias during HD were noted in 11 (29%) patients (group I), and were potentially life-threatening (Lown Class III and IVa) in 13%. The remaining 27 patients (group II) had no ventricular arrhythmias during HD. There was no difference in the age, sex ratio, duration of HD, blood pressure, fluctuations in weight, hematocrit, predialysis creatinine, sodium, potassium, calcium or inorganic phosphate levels between patients in the two groups. The number of patients with clinical ischemic heart disease was significantly greater in group I. SMI was noted in 72% and 33% of group I and II patients respectively (p = 0.026). 46% of those with and 25% of those without ST changes during HD developed ventricular arrhythmias during HD. Both SMI and ventricular arrhythmias were noted most frequently during the last hour of dialysis. Hypertension, diabetes mellitus and ischemic heart disease were observed more frequently amongst patients with SMI. Ventricular arrhythmias are detected in a significant proportion of CRF patients on HD. These are probably related to coronary artery disease since silent myocardial ischemia is also noted more frequently during HD in these patients. Further studies incorporating coronary angiography are needed in a larger number of patients to establish a definite causal relationship.

Renal involvement in 204 cases with multiple myeloma admitted over a 10-year period to this tertiary care center in north India was retrospectively examined. Renal involvement occurred in 55 cases (27%); the vast majority of whom (94.5%) had presented with renal failure and 7.3% had nephrotic syndrome. The diagnosis of multiple myeloma was made after admission in 51 of the 55 (92.7%) cases. Oliguria was seen in 23.6% and two-third patients required dialysis. Factors precipitating renal failure were identified in 53% and included dehydration (33%), hypercalcemia (24%), nephrotoxic drugs (16%), sepsis (9%), recent surgery (5%) and contrast media (2%), Severe anemia, hypercalcemia, Bence Jones proteinuria and skeletal abnormalities were more frequent in those with renal involvement. Patients with renal involvement were more likely to have a high tumor burden. The myeloma was of light chain type in 68% of those with renal involvement whereas IgG myeloma was commonest (57%) in those without evidence of renal disease. Renal histology was studied in 27 cases with myeloma cast nephropathy seen in over 60%. Tubulointerstitial nephritis was seen in 14% cases, 11% had amyloidosis, 7% had acute tubular necrosis and 3.6% each had nodular glomerulosclerosis and plasma cell infiltration. In 8 cases (14.6%), renal biopsy provided the first clue to the diagnosis of myeloma. Renal function improved in 33% cases. Only 22% of patients on dialysis survived over 6 months. Median survival in those with renal involvement was only 4 months. Development of unexplained renal failure in an elderly individual with normal sized kidneys, in association with disproportionate anemia even in the absence of skeletal lesions should alert the physician to the diagnosis of multiple myeloma.

Ethylene-di-bromide is a popular fumigant. Delayed long-term effects of this chemical include carcinogenicity and genotoxicity in animals. Only a few cases of acute ethylene-di-bromide toxicity have been reported and all of them have resulted in a fatal outcome. We report the first case of ethylene-di-bromide poisoning presenting with acute renal failure and toxic hepatitis that was managed successfully.

A 35 year old apparently immunocompetent farmer developed isolated bilateral renal aspergillosis. He presented with acute renal failure due to granulomatous interstitial nephritis and had bilateral renal abscesses on CT scan. Diagnosis came from renal histology and was confirmed on serology. The patient responded quite satisfactorily to single agent antifungal chemotherapy with IV amphotericin B.

Clinical use of fingernail creatinine estimation to predict duration of azotemia is yet to be validated. We studied the fingernail creatinine concentrations in 48 subjects: seven controls, nine with acute renal failure, five with rapidly progressive glomerulonephritis, 12 with chronic renal failure and 15 with end-stage renal failure on maintenance hemodialysis. The creatinine concentration in aqueous eluates of powdered nail clippings was determined by the alkaline picrate reaction. The mean fingernail creatinine concentration was significantly higher in patients with chronic renal failure (93.7 +/- 83.7 micrograms/g) and end-stage renal disease on maintenance hemodialysis (118.4 +/- 46.8 micrograms/g) as compared to those with acute renal failure (36.6 +/- 23.7 micrograms/g) and rapidly progressive glomerulonephritis (35.8 +/- 20.6 micrograms/g). The creatinine concentrations did not differ significantly between normal subjects (27.2 +/- 28.7 micrograms/g) and those with acute renal failure and rapidly progressive glomerulonephritis. However because of large variability in the values of fingernail creatinine concentrations within each group, the test lacked specificity. Therefore, this investigation is an unreliable indicator of duration of azotemia in individual patients and is not likely to be of much clinical use.

Corticotropin-dependent Cushing's syndrome was detected in a 32-year-old male suffering from membranous nephropathy and chronic renal failure. Cortisol dynamics revealed high basal cortisol, loss of circadian rhythm, and nonsuppressibility with low-dose dexamethasone. However, the latter was suppressible with high-dose dexamethasone. Treatment with ketoconazole led to a remarkable response both clinically and biochemically. The occurrence of Cushing's syndrome in a patient with chronic renal failure is extremely rare and poses significant diagnostic and therapeutic problems.

We report the characteristic CT scan findings of renal cortical necrosis in a patient of acute renal failure, which was confirmed on renal biopsy. CT scan is a useful, noninvasive investigative modality for an early diagnosis of renal cortical necrosis.