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Introduction: Kidney allograft survival has increased significantly in the past few decades. However, the more potent immunosuppression has also resulted in a higher incidence of infections including BK virus nephropathy (BKVN). The profile of kidney transplant (KT) recipients including age, basic kidney disease, comorbidities, dialysis vintage, and type of kidney donor in India is different from that of high-income countries. There are very few studies on the incidence and outcomes of BKVN from India. We studied the incidence, clinical features, and the impact of a screening strategy on patients with BKVN at our center. Materials and Methods: This was a single-center retrospective record-based study. We screened the medical records of all KT recipients at our center from March 2012 to December 2020 for patients who were diagnosed with BKVN. We compared the incidence of BKVN before and after the implementation of a proactive screening strategy in 2017. Results: From March 2012 to December 2020, a total of 212 KTs were performed at our center. Twenty-eight patients were diagnosed to have BKVN at this time. The incidence of BKVN in our study was 13.2%. The incidence of BKVN before routine screening was initiated at our center was 11.3% whereas it was 13.6% after routine screening was initiated. Graft loss from BKVN was 7.14%. Conclusion: The incidence of BKVN at our center is higher than previously reported in India; however, the rate of graft loss is low. A proactive screening strategy using nucleic acid test may allow early detection of BKVN and may have a beneficial impact on graft outcomes. [ABSTRACT FROM AUTHOR]

Background: India performed 7936 kidney transplantation operations in 2018 with living donor as the source in 85%. Identifying a living kidney donor (LKD) is difficult due to medical, social, and regulatory barriers. In addition, only a proportion of patients who volunteer may be able to donate eventually. Despite living donors being the predominant source, there are very few studies addressing the factors influencing living donor kidney donation in India. Methods: We analyzed data from our prospective LKD registry between July 1, 2011 and June 31, 2018. Demographic details, medical history, serum creatinine, and measured glomerular filtration rate (mGFR), blood pressure and the eventual outcome of LKD evaluation, including reason for noneligibility were collected. In a prospective cohort of 12 LKDs, renal functional reserve was studied using protein loading and dietary protein intake was measured from urine urea nitrogen excretion. Results: Over a period of 81 months, 316 LKDs were enrolled in our program. On 101 instances factors related to recipients prevented transplantation and on 92 occasions donor related factors precluded donation. Among 182 medically eligible LKDs with no evidence of CKD, only 33% had mGFR >90 ml/min/1.73 m2. Based on our institutional criteria, 22% of LKDs with mGFR <70 ml/min/1.73 m2 were ineligible solely based this criterion. Eventually, only 32% of enrolled LKDs were accepted for donation. Dietary protein intake was low in all 12 LKDs studied, only one had mGFR >90 ml/min/1.73 m2. Eight LKDs with mGFR <90 ml/min/1.73 m2 showed renal functional reserve of more than 20% with protein loading. Conclusion: Only one-third of voluntary kidney donors enrolled for evaluation were eventually able to donate their kidney. Low mGFR in otherwise apparently healthy LKDs was an important reason precluding kidney donation. Only 33% of individual found medically fit for donation had a mGFR ≥90 ml/min/m2 at our center. Low dietary protein intake may be a factor contributing to low mGFR in healthy LKDs. [ABSTRACT FROM AUTHOR]

Background: Although malignant hypertension begets multiple target organ damage, there is limited data on patients with severe renal injury and evident malignant hypertension in renal histopathology. Methods: We assessed the baseline demographic, histopathological findings and clinical outcomes in this retrospective analysis of patients with biopsy-proven malignant hypertension. Results: Thirty cases were analysed, the mean age of patients was 40 ± 11.5 years, 28 (93.3%) were males and the average systolic and diastolic blood pressures at hospitalisation were 197.04 ± 24.14 and 117.41 ± 18.31 mmHg, respectively. Severe retinopathy was seen in 10 (33.3%). The median eGFR at admission was 6.3 (IQR 4.4--9.15) mL/min and 21 (72.4%) needed dialysis. Nine (30%) cases with glomerular crescents were having the primary glomerular disease (7 IgAN, 1 C3 glomerulonephritis, 1 membranoproliferative glomerulonephritis) and 17 (56.6%) had thrombotic microangiopathy. Three-month ESRD free survival was 34.5% (n = 10) and the ESRD cohort had more incidence of dialysis requiring kidney injury at presentation (94.4% vs. 40% in the non-ESRD cohort). Patient survival at 1 year was 50%. Isolated malignant hypertension, differed from others with regard to lesser incidence of severe retinopathy, less glomerular sclerosis (29.61 ± 15.86 vs. 48.45% ± 30.78; P = 0.03), absence of crescents (P = 0.02), more incidence of tuft wrinkling (100% vs. 35%, P = 0.00) and total vessel occlusion (P = 0.02). Conclusion: Clinicopathologically, accelerated essential hypertension differs from hypertension of glomerular disease. Degree of kidney injury at presentation is risk predictor for long-term morbidity in malignant hypertension. [ABSTRACT FROM AUTHOR]

Objectives: Currently, there is limited data regarding the outcomes of lupus nephritis (LN) with moderate to severe renal failure at presentation (defined by low glomerular filtration rate; GFR <30 mL/min). Methods: Sixty‐four patients with biopsy‐proven LN and estimated GFR (eGFR) <30 mL/min were prospectively analyzed. Outcome measure of persistently low eGFR, end‐stage renal disease (ESRD) or death at 365 days were grouped as Major Adverse Kidney Events (MAKE365). Results: Diagnosis of lupus was simultaneous with onset of renal disease in 60% of cases. Histologically, 82.3% (n = 51) were class IV, the median serum creatinine was 4 mg/dL (interquartile range [IQR] 3.1‐5.9 mg/dL), median eGFR was 13.75 mL/min (IQR 9.25‐19 mL/min) and 42.2% (n = 27) required dialysis at presentation. Induction regimens included National Institute of Health (68.2%), Eurolupus protocol (10.9%) and mycophenolate mofetil (8%). Over 365 days, 23 (37.5%) subjects died, while 41 (62.5%) survived. The majority of deaths were due to infection and sepsis (14/23). Among the survivors, 70.7% had good renal outcome, 12.1% had persistently low GFR (<30 mL/min), while 17% developed ESRD. In this group, treatment response rate was 84.6% (complete response 25.6%, partial response 59%). Those with a better renal function at presentation had a good treatment response (100% vs. 40%). Altogether, n = 35 (54.6%) were included in the MAKE365 category. Between the renal survival group (n = 29) versus the MAKE365 group (n = 35) there was no difference in clinical or histological parameters. Conclusion: The current treatment protocols had a good response rate in patients with LN even with severe kidney injury at presentation. However, the risk of serious infections and subsequent mortality was high. [ABSTRACT FROM AUTHOR]

Background Snakebite is a common occupational hazard in tropical countries. To date, the literature on snakebite-related acute kidney injury (AKI) has been limited by retrospective study designs, lack of uniformity in case definitions of AKI and limited follow-up. This study aims to identify the in-hospital outcomes and long-term changes in kidney function that follow haemotoxic envenomation. Methods All adult patients admitted with AKI following haemotoxic envenomation from January 2016 to June 2017 were recruited and followed up until July 2018. Predictors of in-hospital mortality was assessed. Long-term follow-up data on kidney function were collected from survivors. Results In total, 184 patients with haemotoxic envenomation and AKI were recruited. The mean age of the subjects was 42.2 years [95% confidence interval (CI) 40.3–44.7]. The majority were male (71.2%). The mortality of patients with haemotoxic envenomation was 21.5%. The mortality was considerably higher in patients with Kidney Disease: Improving Global Outcomes (KDIGO) Stage 3 AKI [relative risk (RR) 4.45 (95% CI 1.14–17.42)] and those who met KDIGO urine output criteria [RR 20.45 (95% CI 2.84–147.23)]. A Cox regression model identified mechanical ventilation [odds ratio (OR) 5.59 (95% CI 2.90–10.81)], hypotension [OR 2.48 (95% CI 1.31–4.72)] and capillary leak syndrome [OR 2.02 (95% CI 1.05–3.88)] as independent predictors of mortality. Long-term follow-up data were available for 73 patients. A total of 21 patients (28.7%) developed adverse renal outcomes (glomerular filtration rate <60 mL/min/1.73 m2, urine albumin excretion >30 mg/g and new-onset hypertension or prehypertension). Conclusions AKI resulting from snake envenomation is associated with considerable risk of mortality. The greater the AKI stage the greater the likelihood of mortality. One-third of patients with AKI developed long-term complications like chronic kidney disease, prehypertension and hypertension over the follow-up period. [ABSTRACT FROM AUTHOR]

Background Metabolic acidosis (MA) is associated with a loss of muscle mass and faster deterioration of kidney function in patients with chronic kidney disease (CKD). A few single-centre randomized trials have reported favourable outcomes following correction of MA. Additional good quality evidence on the safety and efficacy of alkali supplementation is required in epidemiologically different patient subsets with CKD. Methods A single-centre, open-label, randomized, prospective parallel-group study was conducted to assess the effect of correction of MA on body composition and kidney function. A total of 188 patients with CKD stages 3 and 4, with venous bicarbonate levels <22 mEq/L were randomized. The intervention arm received standard care as per Kidney Disease: Improving Global Outcomes (KDIGO) 2012 guidelines along with oral sodium bicarbonate supplementation to maintain venous bicarbonate levels at 24–26 mEq/L, whereas the control group received standard care alone. The mid-arm muscle circumference (MAMC), lean body mass (LBM) and estimated glomerular filtration rate (eGFR) were compared between the groups at the end of 6 months. Results The intervention arm showed a higher LBM {36.8 kg [95% confidence interval (CI) 36.5–37.1] versus 36 [35.7–36.4]; P = 0.002} and MAMC [22.9 cm (95% CI 22.8–23) versus 22.6 (22.5–22.7); P = 0.001] when compared with the control group. The GFR in the intervention arm was higher [32.74 mL/1.73 m2 (95% CI 31.5–33.9) versus 28.2 (27–29.4); P ≤ 0.001]. A rapid decline in GFR was documented in 39 (41.5%) patients in the control arm and 19 (20.2%) patients in the intervention arm (P = 0.001). Conclusions Alkali supplementation to increase venous bicarbonate levels to 24–26 mEq/L is associated with preservation of LBM and kidney function in patients with CKD stages 3 and 4. [ABSTRACT FROM AUTHOR]

There is only limited information on the functional status (FS) of patients receiving hemodialysis (HD) from developing countries where the etiology of chronic kidney disease (CKD) and demographic profile are different. The study aims to assess the FS in patients with CKD using three validated generic instruments. A total of 116 adult patients on HD with a dialysis vintage >3 months were enrolled. FS was assessed using three generic tools -- Functional Independence Measure (FIM) (scores 18-126), Seven domains and five levels (7D5L) (scores 0-28), and Activities of Daily Living Questionnaire (ADLQ) (scores 0-6) scales. A higher FIM and ADLQ scores and lower 7D5L score indicated good FS. The mean age of patients was 41.28 ± 15.44 years. About 77.6% were males and 80.2% were unemployed. About 67.2% were receiving twice-weekly HD, and 28.4% were receiving thrice-weekly dialysis. The mean scores were 119.05 ± 11.42 with FIM, 6.44 ± 4.26 with 7D5L, and 5.51 ± 1.19 with ADL instruments. More than 80% showed full functional independence with ADLQ instrument. With FIM, the overall scores showed a tendency for functional independence, but the subdomains involving locomotion/mobility were impaired to a greater extent. The proportion of patients with full independence was less with 7D5L. We observed an inferior FS in individuals <40 years. Patients on HD were functionally independent as assessed by FIM and ADLQ instruments. However, 7D5L appeared to be better in identifying mild to moderate limitations in daily activities. The domains involving motor tasks seem to be affected to a greater extent. The current scales for assessing FS do not incorporate a time-dependent component. [ABSTRACT FROM AUTHOR]

Glucose-6-phosphate dehydrogenase (G6PD) deficiency leading to acute intravascular haemolysis and acute kidney injury (AKI) is a known clinical presentation. However, there is a paucity of information regarding the occurrence of rhabdomyolysis and myoglobinuria in G6PD-deficient individuals, especially children. An 11-year-old south Indian Tamil girl presented with severe anaemia and anuric AKI following a short febrile illness. Investigations demonstrated evidence of intravascular haemolysis and rhabdomyolysis, and on histopathology myoglobin deposits (casts) were detected in the renal tubules. She was successfully managed with repeated sessions of haemodialysis and blood transfusions. Follow-up estimation of G6PD levels after 3 months confirmed severe G6PD deficiency (0.003 nkat/g haemoglobin). Although there are anecdotal reports of myoglobinuria in G6PD-deficient individuals, the occurrence of severe anuric AKI in this clinical setting has not been reported. It can be speculated that myoglobinuria (in addition to haemoglobinuria) can contribute towards jeopardising renal function in G6PD deficiency-related acute haemolytic crisis. [ABSTRACT FROM AUTHOR]

Adverse Event: Warfarin‐related nephropathy. Drug Implicated: Warfarin. The Patient: A 31‐year‐old female, managed with warfarin for rheumatic heart disease with atrial fibrillation. Evidence that Links the Drug to the Event: There were no alternative causes of nephropathy that could have caused the adverse event in this patient. Management: Shifting the drug from warfarin to acenocoumarol. Mechanism: Difference in renal elimination between warfarin and acenocoumarol. Implication for Therapy: Clinicians should be aware of this rare adverse effect of warfarin, and acenocoumarol can be considered as an alternative therapy for this condition. Hypotheses to be Tested: Further prospectively designed studies are needed to consider acenocoumarol as an alternative therapy in warfarin‐related nephropathy. [ABSTRACT FROM AUTHOR]

Introduction: Patients with Chronic Kidney Disease (CKD) needs to modify their lifestyle chiefly focusing on diet and fluid intake as the prognosis of these patients largely depends on adherence to the recommended nutritional regime. Non adherence to the suggested diet and fluids regime leads to rapid worsening of the condition. Methods: Cross sectional survey was conducted to determine the level of adherence to the dietary and fluids restriction among CKD patients. Inclusion criteria's was, age between 18- 65 years, patients with CKD for at least 6 months and received dietary counseling. Consecutive sampling technique was used to select 100 patients. Data was collected with self-reported Dialysis Diet and Fluid non adherence Questionnaire (DDFQ). Results: Majority (73%) of the subjects was males, 64% belongs to 40-60 years age, majority of them were unemployed. Mean Body Mass Index (BMI) was 20.52 kg/m2, the mean duration of the treatment is 2.15 years and mean fluid intake was 2153ml ml/day and inter-dialytic weight gain was 1.48 kg. Regarding adherence, 20% of them had mild deviation and 69% of them had moderate deviation from dietary restrictions and similarly 69 % of the participants had moderate deviation, and 22% of them had mild deviation from fluid restriction guidelines. Low level of adherence to fluid and diet restrictions was noted in illiterate patients which was significant P<0.05. Conclusion: In spite of the dietary counseling, considerable proportions of the patients were non adherent to the diet and fluid restrictions which necessitate regular counseling to patient and family members. [ABSTRACT FROM AUTHOR]

Background Superficial and deep fungal infections are more frequent in transplant recipients primarily because of the failure of cell-mediated immunity and lesser amount of antigen-presenting Langerhans cells in their epidermis. Here, we report seven cases of post-renal transplant subcutaneous phaeohyphomycosis, all of which manifested within 1 year after transplantation and were unresponsive to prolonged courses of itraconazole. This is the first case series, to our knowledge, of phaeohyphomycosis in transplant recipients in India. Method We performed a retrospective review of cases of phaeohyphomycosis among kidney transplant recipients for type of transplant, immunosuppression, histopathology, and treatment, with prospective follow-up of healed lesion. Results An overall incidence of 8.3% was noted, with a median duration of approximately 6 months post transplant to the onset of skin lesion. None of the lesions responded to itraconazole alone and 6/7 lesions were surgically excised. Histopathology showed various lesions and culture could isolate Neocytalidium and Exophiala jeanselmi in two cases. Conclusion Dematiaceous fungi are increasingly implicated in cutaneous lesions in transplant recipients. Histopathology and surgical excision are the appropriate tools for diagnosis and treatment, respectively. [ABSTRACT FROM AUTHOR]

Thrombotic microangiopathy (TMA) is an uncommon but serious complication in renal transplant recipients. Posttransplant TMA can either be due the recurrence of the pre-transplant disease or it may occur de-novo. Amongst pre-transplant TMA, majority of the atypical HUS usually lead to renal insufficiency and end-stage kidney disease, while the typical or shiga toxin associated HUS has good prognosis. Post-transplant recurrence is <1% in shiga toxin associated HUS, whereas it is around 80–100% in certain forms of atypical HUS. Due to this high recurrence rates, previously the renal transplant was contraindicated in such patients, however, with better understanding of the pathogenesis of disease and progress in genetic analysis, renal transplant may now be possible in some of these patients. In view of the lack of controlled trials, plasma exchange remains the primary modality of treatment, while further options include isolated kidney transplant, liver transplant, combined liver-kidney transplant, prophylactic and therapeutic eculizumab and judicious use of immunosuppressant. In this review, we have discussed various causes of posttransplant TMA, their pathogenesis, outcomes and different therapeutic options. [ABSTRACT FROM AUTHOR]

Systemic lupus erythematosus is associated with renal involvement in almost 50–80% of cases. Although proliferative lupus nephritis is the most common form, isolated membranous lupus nephritis (MLN or class V lupus nephritis) accounts for 11–20% of cases while mixed proliferative and MLN (Class III + V/IV + V) can be seen in another 21–30%. MLN can present as either sub-nephrotic or nephrotic proteinuria with or without microscopic hematuria or renal dysfunction. These patients are at high risk of cardiovascular and cerebrovascular complications due to thrombotic tendency, dyslipidemia and hypertension. Uniform evidence regarding prognostic factors, outcome and therapy of MLN are still elusive. Systematic analysis of several studies have shown that sustained nephrotic proteinuria, failure to achieve complete remission and associated proliferative lesions denotes poor prognosis. In general, the long term renal survival rate is 50–90%, while end stage renal disease occurs in 12–22% cases. Transformation to proliferative nephritis is also well known, thus a close follow up is warranted in all pure MLN cases. Those with persistent nephrotic proteinuria, renal dysfunction and mixed histology should be treated aggressively with immunosuppressive agent while less severe cases can be managed with adjunctive therapies. [ABSTRACT FROM AUTHOR]

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright of Clinical Kidney Journal is the property of Oxford University Press / USA and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. [Extracted from the article]

Background: Snakebite is a common occupational hazard in tropical countries. To date, the literature on snakebite-related acute kidney injury (AKI) has been limited by retrospective study designs, lack of uniformity in case definitions of AKI and limited follow-up. This study aims to identify the in-hospital outcomes and long-term changes in kidney function that follow haemotoxic envenomation., Methods: All adult patients admitted with AKI following haemotoxic envenomation from January 2016 to June 2017 were recruited and followed up until July 2018. Predictors of in-hospital mortality was assessed. Long-term follow-up data on kidney function were collected from survivors., Results: In total, 184 patients with haemotoxic envenomation and AKI were recruited. The mean age of the subjects was 42.2 years [95% confidence interval (CI) 40.3-44.7]. The majority were male (71.2%). The mortality of patients with haemotoxic envenomation was 21.5%. The mortality was considerably higher in patients with Kidney Disease: Improving Global Outcomes (KDIGO) Stage 3 AKI [relative risk (RR) 4.45 (95% CI 1.14-17.42)] and those who met KDIGO urine output criteria [RR 20.45 (95% CI 2.84-147.23)]. A Cox regression model identified mechanical ventilation [odds ratio (OR) 5.59 (95% CI 2.90-10.81)], hypotension [OR 2.48 (95% CI 1.31-4.72)] and capillary leak syndrome [OR 2.02 (95% CI 1.05-3.88)] as independent predictors of mortality. Long-term follow-up data were available for 73 patients. A total of 21 patients (28.7%) developed adverse renal outcomes (glomerular filtration rate <60 mL/min/1.73 m 2 , urine albumin excretion >30 mg/g and new-onset hypertension or prehypertension)., Conclusions: AKI resulting from snake envenomation is associated with considerable risk of mortality. The greater the AKI stage the greater the likelihood of mortality. One-third of patients with AKI developed long-term complications like chronic kidney disease, prehypertension and hypertension over the follow-up period., (© The Author(s) 2019. Published by Oxford University Press on behalf of ERA-EDTA.)