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Introduction: People on renal replacement therapy (RRT) have a high risk of COVID‐19 infection and subsequent death. COVID‐19 vaccination is strongly recommended for those on RRT. Data are limited on the immune response of the ChAdOx1 nCoV‐19/AZD1222 (Covishield®) vaccine in patients on RRT. Methods: A prospective cohort of adult (age > 18 years), on RRT in the form of hemodialysis were included and received two intramuscular doses of Covishield®. A blood specimen of 5.0 mL was collected at two time points, within a few days before administering the first dose of the vaccine and at 4–16 weeks after the second dose. According to their prior COVID‐19 infection status, the participants were grouped as (i) prior symptomatic COVID‐19 infection, (ii) prior asymptomatic COVID‐19 infection, and (iii) no prior COVID‐19 infection. Results: A large proportion (81%) of participants had anti‐spike antibodies (ASAb) before vaccination, and a reasonable proportion (30%) also had neutralizing antibodies (NAb). The titer of ASAb was relatively low (207 U/mL) before vaccination. The ASAb titer (9405 [1635–25,000] U/mL) and percentage of NAb (96.4% [59.6–98.1%]) were markedly increased following the administration of two doses of the vaccine. The participants' prior COVID‐19 exposure status did not influence the rise in ASAb titer and NAb percentage. Further, administering two doses of the Covishield vaccine helps them achieve a high ASAb titer. Conclusion: Two doses of ChAdOx1 nCoV‐19/AZD1222 (Covishield®) vaccine, given 12 weeks apart, achieve a high titer of ASAb and a high percentage of NAb in people on hemodialysis. [ABSTRACT FROM AUTHOR]

Introduction: Lower respiratory tract infections (LRTIs) among renal transplant recipients (RTRs) are a significant cause of morbidity and mortality. This study aimed to analyse the aetiology, outcome, and risk factors associated with mortality. Methods: We analysed baseline transplant characteristics, symptoms, hospital course, laboratory, serological and microbial results, and their association with the outcome of all RTRs between January 2011 and December 2019. Results: A total of 206 LRTI patients out of 1051 RTRs were analysed. The incidence proportion was nearly 22 episodes per 1000 patients per year. The mean age was 39.3 years, with male predominance. Bacterial was the most common aetiology (53%), and staphylococcus was the most common species. Among the fungal causes (14%), 68% had aspergillus infection. More than one-third RTRs died during the hospital course mainly because of bacterial causes (42.6%). The aspergillus infection was the most common fungus associated with 50% mortality. On multi-variate analysis, sepsis, septic shock, and the need for mechanical ventilation independently predicted mortality. Conclusion: Bacterial aetiology was the most common cause; though the fungal aetiology was seen less, it was associated with higher mortality. Mortality in RTR with LRTI was associated with sepsis, septic shock, and the need for mechanical ventilation. [ABSTRACT FROM AUTHOR]

Liver stiffness (LS) may be falsely elevated in patients on maintenance hemodialysis (MHD) due to fluid overload. We measured LS change by transient elastography (TE) in MHD patients before and after successful renal transplantation. Adults on ≥2 years of MHD, without additional risk factors for liver fibrosis or fluid overload, and planned for renal transplantation were prospectively recruited. LS was measured on two occasions, i.e., within two weeks before transplantation (pre-Tx LS) and after ≥ 3 months after successful transplantation (post-Tx LS). The participants with pre-Tx LS ≤ 7.0 KPa and >7.0 KPa were classified as "Group I" and "Group II," respectively. Categorical and numerical data are expressed as ratio/proportions and mean (SD), respectively. Paired data from 43 participants (males 42 [97.7%]; age 32 [11] years) were analyzed. The pre-Tx and post-Tx LS of the entire cohort, measured at 307 (198) days of interval, were 8.5 (7.3) KPa and 6.7 (3.1) KPa, respectively. Before transplantation, 21 (49%) participants belonged to Group II and 22 (51%) to Group I. Among the Group II participants, 12 (57%) showed LS normalization after 312 (182) days of transplantation. Of the 22 participants in Group I, three (13.6%) showed LS elevation to >7.0 KPa after 303 (217) days of transplantation. The mean LS changes among the overall cohort, Group II, and Group I were −1.8 KPa, −4.1 KPa, and +0.2 KPa, respectively. LS in people on MHD may be falsely elevated, which is likely to normalize after successful renal transplantation. [ABSTRACT FROM AUTHOR]

Introduction BKV nephropathy (BKVN) is one of the major causes of graft loss with the advent of potent immunosuppressive drugs. The literature on the co-existence of acute rejection (AR) and BKVN is scarce. Materials and methods This is a single-center retrospective analysis, where the allograft biopsies of patients transplanted between 2011 and 2021 were reviewed. The biopsies, which showed evidence of coexistent AR and BKVN, were included. In addition, demographic profiles, clinical presentation, treatment details, response to therapy, and follow-up were analyzed. Results Out of 1175 live transplants done between January 2011 and March 2021, 49 had BKVN representing 4.17%. Only seven patients (0.59%) had coexistent BKVN with AR. The mean serum creatinine at presentation was 2.3 mg/dl. The mean duration to diagnosis from transplant was seven months (range 3–22 months). All had significant viremia at presentation (17450–4,750,000 copies/ml). All biopsies showed type 1 inclusion bodies with SV40 positivity except one. Coexistent acute T cell-mediated rejection (TCMR) was found in five and acute ABMR in two patients. Three patients received pulse IV methylprednisolone, five received 2 g/kg IVIG, two received plasma exchange as upfront therapies. Maintenance immunosuppression reduction was made in all. Viremia clearance was noted at a mean duration of 3.5 months. However, three patients lost their grafts on follow-up. Four had stable graft function with a mean serum creatinine of 1.54 mg/dl. Conclusion Intensifying immunosuppression to treat AR followed by a reduction in maintenance immunosuppression and IVIG and antiviral therapies seems better strategy and showed good long-term graft survival in patients with coexistent BKVN and AR. [ABSTRACT FROM AUTHOR]

Background: While the majority of bleeding complications after a percutaneous kidney biopsy (PKB) occur early (≤24 h), delayed onset bleeding complications (>24 h) have been rarely reported and can be catastrophic for the patient. Purpose: To describe the incidence, risk factors, and outcomes of delayed bleeding complications after PKB. Material and Methods: We retrospectively studied native and graft kidney biopsies in patients who developed delayed bleeding complications (>24 h) after the biopsy performed in the Department of Nephrology and Renal Transplantation of a tertiary care medical institution in north India between January 2014 to December 2018. Results: Of the 4912 renal biopsies reviewed, 20 patients (16 men, 4 women; 0.40%) had a delayed biopsy bleeding complication. Of these patients, 95% had major bleeding complications requiring blood transfusions and 85% needed intervention like gelfoam/coil embolization. Despite intervention, one patient (5%) had mortality due to complications of bleeding and sepsis. When compared to a control group of patients with early biopsy bleed, patients with the delayed biopsy bleed had similar demographic and clinical profiles except for higher pre-biopsy hemoglobin and lower systolic and diastolic blood pressure. Conclusion: A post-PKB delayed onset bleed is not uncommon, and the vast majority of these patients had major bleeding complications requiring blood transfusions and/or intervention like embolization. They had a similar demographic and clinical profile presentation as early bleed patients. Meticulous outpatient monitoring and patient education after discharge may be useful to detect this complication promptly and to intervene early to have good patient outcome. [ABSTRACT FROM AUTHOR]

Background Sofosbuvir is not recommended in persons with estimated glomerular filtration rate (eGFR) <30 mL/min. We report the results of treatment with an off-label 8-week regimen of daclatasvir and half-dose sofosbuvir in patients with acute infection with hepatitis C virus (HCV) and eGFR <30 mL/min. Methods Clinic records were searched to identify treatment-naïve, noncirrhotic adults with acute hepatitis C (HCV viremia and a ≥10-fold elevation of serum alanine aminotransferase activity) and eGFR <30 mL/min, who had been treated with a sofosbuvir-based regimen. Treatment response was assessed using serum HCV RNA testing at 4 weeks of treatment, end of the 8-week treatment and 12 weeks after stopping treatment. Results Of the 31 patients with acute hepatitis C, 27 [median age (range): 36 (18–74) years; 20 (74%) male] were started on treatment with 200 mg sofosbuvir and 60 mg daclatasvir daily for 8 weeks, irrespective of HCV genotype. All the 27 completed the planned 8-week treatment. One patient died 10 weeks after completing the treatment of an unrelated cause. All the 27 patients had undetectable HCV RNA after 4 weeks of and at the end of treatment. At 12 weeks after completion of treatment, only one tested HCV RNA positive and 25 were negative, with sustained virological response rate of 25/27 (92.6%) and 25/26 (96.2%) on intention-to-treat and per-protocol basis, respectively. Conclusion Eight-week course of daclatasvir and half-dose sofosbuvir is effective for acute hepatitis C in patients with eGFR <30 mL/min and could be a useful alternative to costly, kidney-safe anti-HCV oral drugs in resource-constrained settings. [ABSTRACT FROM AUTHOR]

Acute pancreatitis after renal transplantation is seldom seen yet a dreadful complication. The causes include traditional causes and immunosuppressive medications and viral infections. Classical symptoms are not always present at onset, causing delay in diagnosis. The available literature on pancreatitis in renal transplants is either as case reports or case series. Large studies with longer follow-up periods and outcome in renal transplant patients with pancreatitis are lacking. We conducted this retrospective study to analyze the incidence, clinical features, and causes of pancreatitis in our institute in post-azathioprine era. We conducted a single center retrospective study of renal transplant recipients who suffered at least 1 episode of acute pancreatitis during a period from January 2002 to September 2018. We followed International Association of Pancreatology/American Pancreatic Association evidence-based guidelines for confirming diagnosis of acute pancreatitis and included only patients who fulfilled these criteria. Once the diagnosis is confirmed we retrospectively analyzed the etiology, clinical features, management and outcomes of renal transplant recipients with pancreatitis. Twenty-six patients (men 81%; mean age 38.5 years) were included. Etiology included gallstones (19.3%), structural lesions (11.5%), viral infections (7.8%), and drugs. Clinical presentations, laboratory parameters were like pancreatitis in non-transplant patients. Graft dysfunction was noted in 20 patients (77%) and all showed either partial or complete recovery. Patient survival was high with 88% of the patients surviving the episode. Pancreatitis after renal transplantation is a rare complication with outcomes better than what has been reported in the past. • Pancreatitis after renal transplantation is a rare complication with outcomes better than what have been reported in the past. • Etiology included gallstones (19.3%), structural lesions (11.5%), viral infections (7.8%), and drugs. • A significant number of patients presented with acute graft dysfunction. • Immediate survival is good after episode. [ABSTRACT FROM AUTHOR]

Aim: Sofosbuvir is a key agent for HCV treatment. It is not recommended for patients with chronic kidney disease (CKD) and estimated glomerular filtration rate (eGFR) <30 mL/min. We report real‐life experience of treating a cohort of CKD patients with eGFR <30 mL/min using daclatasvir and half‐daily dose of sofosbuvir. Methods: Adults patients who (i) had eGFR<30 mL/min and detectable HCV RNA and (ii) were treated with interferon and ribavirin free, DAA based regimens were included. All patients were treated with daily doses of daclatasvir 60 mg and sofosbuvir 200 mg. The planned duration of treatment was 12 weeks, except for 24 weeks in those with either clinical evidence of cirrhosis or on immunosuppressive drugs. The end‐points of the study were: (i) 12 weeks of follow‐up after treatment completion, (ii) treatment discontinuation, or (iii) death or loss to follow‐up. Results: Thirty‐six (88%) among 41 included patients (median [range] age: 48 [19–75] years; 25 [61%] male; genotype 1/3/4 were 17/ 22/2; cirrhosis 5) completed the treatment, two discontinued and three died during treatment. On an intention‐to‐treat basis, HCV RNA were undetectable at 4 weeks of treatment, treatment completion and after 12 weeks of follow‐up in 40/41 (97.6%), 37/41 (90.2%) and 37/41 (90.2%), respectively. None of the patients had a relapse. Conclusions: Daclatasvir and half‐daily dose of sofosbuvir was effective against genotype 1 and 3 HCV infection in patients with eGFR <30 mL/min. This combination could be a pangenotypic treatment option for such patients. Summary at a Glance: This is a real‐world report on the use of DAAs for pan‐genotypic HCV infection in patients with significant renal impairment in a resource constrained setting. It provides useful additional data for clinicians outside of clinical trial reports. [ABSTRACT FROM AUTHOR]

Background: Proteinuria and renal dysfunction is common in diabetic patients andmay occur due to variety of causes. Nondiabetic renal diseases (NDRD) account for 30% of the renal biopsies, and idiopathicmembranous nephropathy (iMN) is a common non diabetic glomerular disease that can exist alone or in combination with diabetic nephropathy (DN). Immunosuppressants used in iMN may be associated with complications of worsening glycemic control and recurrent infections. There is a paucity of literature on the clinical course, outcomes and treatment adverse effects of patients with iMN and diabetes. Methods: We retrospectively analyzed the data of all diabetics, evaluated for NDRD and found to have iMN, between January 2000 and June 2015 in our institute. Results: A total of 134 patients with diabetes were biopsied for NDRD and 16 patients had iMN. Mean 6 standard deviation age was 54611.77 years and the median duration of diabetes was 9.4 years. Twelve patients had isolated iMN and four patients had iMN coexisting with DN. Response rates of 18%, 35.71% and 63.63% were seen with Modified Ponticelli (MP) regimen, tacrolimus and mycophenolate mofetil (MMF), respectively. Five patients developed treatment-related adverse effects significant enough to necessitate a treatment change. Worsening glycemic control was the most common side effect. Adverse effects were less with the MMF compared with the MP regimen and tacrolimus. Conclusion: Patients with iMN coexisting with diabetes exhibit a poor response to the MP regimen. Treatment-related toxicity is less common with MMF in comparison with the MP regimen and tacrolimus-based regimen. An almost similar response was noted with MMF and tacrolimus-based regimen but there was more withdrawal from treatment due to toxicities observed in the latter. [ABSTRACT FROM AUTHOR]

Aim Treatment of hepatitis C virus (HCV) infection in patients with end-stage renal disease (ESRD) is difficult. Addition of ribavirin to pegylated-interferon (Peg-IFN) may help to improve the treatment response. Further, treatment duration could be shortened using a response-guided treatment (RGT) approach. Methods We retrospectively reviewed records of treatment-naïve adult patients with ESRD and chronic HCV infection who had been treated with Peg-IFN and low-dose ribavirin using a RGT approach. Rapid responders (undetectable HCV-RNA at 4 weeks) received treatment for 12 weeks, and slow responders (HCV-RNA detectable at 4 weeks, but undetectable or with >2.0 log10 reduction at week 12) for 24 (genotype 3; GT3) or 48 (genotype 1; GT1) weeks. In those without such reduction (null responders), treatment was discontinued. Results Of 26 non-cirrhotic patients (GT1 15, GT3 11) treated, four (15%; GT1 3, GT3 1) were null responders. Twenty-two (85%) patients had either rapid ( n = 14 (54%); GT1 10, GT3 4) or slow response ( n = 8 (31%); GT1 2, GT3 6). Of them, 21 patients had undetectable RNA at the end of treatment; one could not complete the treatment and was lost thereafter. There were no deaths during treatment. Three patients relapsed and three others died in 6 months after stopping treatment. Overall, 15/26 (58%) patients attained SVR24. Fourteen patients underwent transplantation beginning one month after treatment completion, and all were relapse-free after 17 (14-24) months of follow-up. Conclusion RGT using Peg-IFN and ribavirin was effective in ESRD patients on maintenance dialysis. Renal transplant was safely done within one month of completing such treatment. [ABSTRACT FROM AUTHOR]

Background and objectives: Owing to changing epidemiology and therapeutic practices, a change in the spectrum of renal involvement in Type-2 diabetes mellitus (T2DM) has also been noted. The treatment of non-diabetic kidney disease (NDKD) differs from diabetic kidney disease (DKD) and the reversibility of NDKD in many cases to normal, prompts biopsy for rapid and accurate diagnosis. Data are scarce on kidney biopsy findings in T2DM. Study design & setting: In this observational study, we prospectively collected the data of kidney biopsies of patients aged ≥ 18 years with T2DM admitted between 1 August 2005 and 31 July 2022. The clinical, demographic and histopathological data were evaluated. The spectrum of kidney involvement in the form of DKD and/or NDKD was studied. The impact of these findings with the use of drugs retarding disease progression was also analyzed. Results: A total of 5485 biopsies were performed during the study period and of these 538 patients had T2DM. The mean age of the study population was 56.9 ± 11.5 years and 81% were males. The mean duration of DM was 6.4 ± 6.1 years. Diabetic retinopathy (DR) was noted in 29.7%. The most common indication for biopsy was an acute rise in creatinine (147, 27.3%). Amongst the 538 diabetic patients who underwent biopsy, histological features only of DKD were noted in 166 patients (33%), NDKD alone in 262 (49%) and NDKD with DKD lesions in 110 (20%). On multivariate analysis, duration of DM less than 5 years, absence of CAD, absence of DR, oliguria at presentation, an acute rise in creatinine and low C3 were associated with NDKD. Conclusions: The prevalence of NDKD among diabetics and ATIN in particular might be on an increasing trend in the current era of changing T2DM epidemiological patterns. The use of anti-pro-teinuric agents was associated with lesser degrees of histopathological chronicity in T2DM. [ABSTRACT FROM AUTHOR]

Phosphorus is a common anion. It plays an important role in energy generation. Renal phosphate handling is regulated by three organs parathyroid, kidney and bone through feedback loops. These counter regulatory loops also regulate intestinal absorption and thus maintain serum phosphorus concentration in physiologic range. The parathyroid hormone, vitamin D, Fibrogenic growth factor 23 (FGF23) and klotho coreceptor are the key regulators of phosphorus balance in body. [ABSTRACT FROM AUTHOR]

Cytomegalovirus (CMV) is the most common viral infection following kidney transplant, has been recognized as a major factor for graft loss and increased incidence of acute rejection. Different studies have reported a variable incidence of CMV disease with the use of Mycophenolate mofetil (MMF). We retrospectively analyzed our renal transplant recipients to review the results of CMV disease and to compare CMV disease in patient on Azathioprine and MMF for this purpose we retrospectively reviewed 521 live related kidney transplant recipients at our institute. 74 (14.2 %) live related allograft recipients developed CMV disease after a median interval of 7.18 ± 4.35 months from transplantation. The mean age was 36.15 ± 10.7 years. 63 of the patients were male. Malaise, fever and diarrhea were among most common symptoms. 20 (27.02 %) of the 74 recipients developed transaminitis, 13 (17.2 %) developed CMV gastritis, 5 (9.13 %) recipients developed pneumonia, and 3 (4.05 %) patient developed colitis. 59 (80 %) patients had leucopenia and 41 (56.5 %) developed thrombocytopenia. Mean serum creatinine level was 1.5 ± 0.4 (0.9-2.4) mg/dl before the disease, 1.9 ± 0.6 (1.3-3.6) mg/dl at the time of the diagnosis, and 1.7 ± 0.06 (0.8-4.2) mg/dl at the end of the treatment. CMV disease developed in 9 (36 %) of recipients who received basiliximab as induction therapy and 13 (30.24 %) of recipients who received ATG ( p > 0.05). The incidence of CMV disease was similar in cyclosporine based regimen (13.2 %) and Tacrolimus based regimen 27 (16.16 %) ( p = 0.137) and was also similar in Azathioprine 41 (9.5 %) and MMF group 33 (14.3 %) ( p = 0.163). There was no significant difference in severity of CMV disease in both groups, except a higher incidence of leucopenia in Azathioprine group (86 vs. 74 %, p < 0.05) as compared to MMF group. 51 (68.91 %) patient developed graft dysfunction during CMV disease. In conclusion we report a low incidence (14.2 %) and milder form of cytomegalovirus disease at our center. Use of universal cytomegalovirus prophylaxis was associated with a low incidence and milder form of the disease. Incidence of CMV disease was similar between Azathioprine and MMF groups. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) is associated with morbidity and mortality in COVID-19 patients. The incidence of AKI and its outcomes vary in different parts of the world. We aimed to analyze the AKI incidence, predictors of AKI, mortality, and renal function outcomes on follow-up in hospitalized patients with COVID-19. Materials and methods: The study was designed as a retrospective, observational study of electronically captured data on the hospital information system of laboratory-confirmed COVID-19 patients, with and without AKI, between March 2020 to June 2021. The predictor of AKI and mortality and residual damage in recovered AKI patients were analyzed. Results: Of the 3395 patients, 3010 COVID-19 patients were eligible. AKI occurred in 951 (31.5%); with stages 1, 2, and 3 in 605 (63.7%), 138 (14.5%), and 208 (21.8%) patients, respectively. AKI severity increased with COVID-19 severity. Of 951 AKI patients, 403 died, and 548 were discharged. AKI group had higher mortality (42.3%) than the non-AKI (6.6%). At discharge, complete recovery was noticed in 370(67.5%), while 178 (32.5%) had residual damage. At three months of follow-up, 108 (69.6%) of 155 patients showed complete recovery. Residual damage was observed in 47 (30.3%). In 14 (9%) patients, serum creatinine remained elevated above the baseline. Thirty-three (21.2%) patients showed proteinuria (n = 24) and microscopic hematuria (n = 9). Conclusions: AKI is common among patients hospitalized with COVID-19 and is associated with high mortality. Residual kidney damage post-COVID-19 in recovered AKI patients may increase the CKD burden. [ABSTRACT FROM AUTHOR]

Introduction: The most common complication of percutaneous renal biopsy is bleeding, which can be seen in up to one-third of cases. The aim of this study was to evaluate the effect of prebiopsy administration of intranasal desmopressin acetate in reducing the incidence of biopsy-related bleeding complications in patients with significant renal dysfunction who underwent renal biopsy. Methods: This was a retrospective, observational study of percutaneous native renal biopsies performed at our center from July 2014 to June 2018. Bleeding complication rates of patients with renal failure (estimated glomerular filtration rate [eGFR] <30 mL/minute/1.73 m2 ) who received desmopressin and those who did not receive desmopressin were compared. Results: Desmopressin administration before renal biopsy in patients with eGFR <30 mL/minute/1.73 m2 was associated with a significant reduction of bleeding complications (major and minor together; P = 0.025) and no significant reduction in major complications (P = 0.616) or intervention rates (P = 0.251) when compared with a group that did not receive desmopressin. Conclusions: While prebiopsy intranasal desmopressin use was associated with a significant reduction of overall bleeding complications including major and minor complications, there was no reduction in the rate of other major complications and interventions. [ABSTRACT FROM AUTHOR]

Clinical syndrome of refractory secondary hypertension, renal artery stenosis and secondary erythrocytosis could occur in the same patient. We report a rare case of refractory secondary hypertension, renal artery stenosis and primary erythrocytosis as an expression of polycythaemia rubra vera (PV) and suggest that erythrocytosis in a hypertensive renovascular occlusive disease may be primary due to underlying PV. This clinical syndrome should be excluded in such patients with refractory hypertension. [ABSTRACT FROM PUBLISHER]

Introduction The incidence of post-transplant diabetes mellitus (PTDM) ranges from 2.5% to 20% in kidney transplant recipients. Diabetic retinopathy (DR), diabetic kidney disease (DKD), and distal symmetric polyneuropathy (DSPN) are the microvascular complications frequently seen in both type 1 and 2 diabetes mellitus (DM). However, the data regarding these complications in patients with PTDM is lacking. Method A retrospective and prospective observational study of PTDM conducted at a tertiary care hospital from November 2018 to December 2020. 115 kidney transplant recipients who had PTDM of ≥5 years duration were included and analysed. Results The mean duration of PTDM was 8.8 ± 3.0 years, and the mean of all available HbA1c values was 7.0 ± 0.9%. while none of the patients had evidence of diabetic retinopathy on direct ophthalmoscopy, 37.4% of patients (n = 43) had DSPN and this was associated with the duration of PTDM and age. The mean estimated glomerular filtration rate (eGFR) was 59.24 ± 21.82 ml/min/1.73m2, and patients had a median proteinuria of 620 mg/day (IQR 1290). Out of 115 patients, 20% of them (n = 23) underwent graft kidney biopsy, and 10 biopsies were diagnosed as de-novo DKD. Patients with biopsy proven DKD had a mean PTDM duration of 143.3 ± 52.4 months; a mean HbA1c level of 7.9 ± 1.3%; a mean eGFR of 44.8 ± 21.8 ml/min; and a median proteinuria of 2653 mg (IQR 2758). An additional analysis of all 23 biopsied patients showed that HbA1c level and degree of proteinuria were significantly associated with de-novo DKD. Conclusion PTDM in transplant patients had milder microvascular complications than usually expected in Type 1/2 diabetes in non-transplant patients. DR was not strongly associated with DKD in PTDM patients. Furthermore, de-novo DKD development was associated with poor glycaemic control and increased proteinuria. [ABSTRACT FROM AUTHOR]

Background: We analyzed differences in presentation and survival of Takayasu arteritis (TAK) with or without renal artery involvement (RAI) from a large monocentric cohort of patients with TAK. Methods: Clinical and angiographic features were compared between TAK with versus without RAI, with bilateral versus unilateral RAI, and with bilateral RAI versus without RAI using multivariable-adjusted logistic regression. Inter-group differences in survival were analyzed [hazard ratios (HR) with 95% confidence intervals (95%CI)] adjusted for gender, age at disease onset, diagnostic delay, baseline disease activity, and significant clinical/angiographic inter-group differences after multivariable-adjustment/propensity score matching (PSM). Results: Of 215 TAK, 117(54.42%) had RAI [66(56.41%) bilateral]. TAK with RAI or with bilateral RAI had earlier disease onset than without RAI (p < 0.001). Chronic renal failure (CRF) was exclusively seen in TAK with RAI. TAK with RAI (vs without RAI) had more frequent hypertension (p = 0.001), heart failure (p = 0.047), abdominal aorta (p = 0.001) or superior mesenteric artery involvement (p = 0.018). TAK with bilateral RAI (vs unilateral RAI) more often had hypertension (p = 0.011) and blurring of vision (p = 0.049). TAK with bilateral RAI (vs without RAI) more frequently had hypertension (p = 0.002), heart failure (p = 0.036), abdominal aorta (p < 0.001), superior mesenteric artery (p = 0.002), or left subclavian artery involvement (p = 0.041). Despite higher morbidity (hypertension, CRF), mortality risk was not increased with RAI vs without RAI (HR 2.32, 95%CI 0.61–8.78), with bilateral RAI vs unilateral RAI (HR 2.65, 95%CI 0.52–13.42) or without RAI (HR 3.16, 95%CI 0.79–12.70) even after multivariable adjustment or PSM. Conclusion: RAI is associated with increased morbidity (CRF, hypertension, heart failure) but does not adversely affect survival in TAK. Key Points •Renal artery involvement in TAK is associated with chronic renal failure. •TAK with renal artery involvement more often have heart failure and hypertension. •Bilateral renal artery involvement (compared with unilateral) is more often associated with hypertension and visual symptoms. •Renal artery involvement is not associated with an increased risk of mortality in TAK. [ABSTRACT FROM AUTHOR]

Background: Maintenance immunosuppressive regimens are speculated to hamper immunogenic response against severe acute respiratory syndrome‐coronavirus‐2 (SARS‐CoV‐2) in renal transplant recipients (RTRs) compared to the healthy population. Healthy people with SARS‐CoV‐2 infection often develop neutralizing antibodies and secret copious quantities of cytokines, leading to virus clearance and sometimes more severe immune‐related complications. Methods: RTRs, either acquired SARS‐CoV‐2 infection (infection group, n = 132) or were vaccinated with two vaccine doses (vaccination group, n = 78) against SARS‐CoV‐2, were recruited in the study. Thirty‐five unvaccinated RTRs, without anti‐SARS‐CoV‐2 spike protein‐specific antibodies, were also included as control. Cytokines interleukine‐6 (IL‐6), interferon‐γ (IFN‐γ), TGF‐β, and IL‐10 were measured using ELISA. The SARS‐CoV‐2 spike protein‐specific IgG‐titer was measured by chemiluminescent microparticle immunoassay methods. Results: The seroconversion rate in the infection group was 115/132 (87.12%), with a median antibody titer 706.40 au/mL (IQR, 215.45–1844.42), and in the vaccination group was 63/78 (80.76%) with antibody titer 1454.20 au/mL (IQR, 80.52–3838.75). The IL‐6, IFN‐γ, TGF‐β, and IL‐10 levels were significantly higher in both the infection and vaccination group compared to healthy control. In the infection group, pro‐inflammatory cytokines IL‐6 (55.41 ± 24.30 vs. 31.64 ± 16.98 pg/mL, p <.001) and IFN‐γ (91.21 ± 33.09 vs. 61.69 ± 33.28 pg/mL, p =.001) were significantly higher in the seroconverter group as compared to non‐seroconverter. Similarly, in the vaccination group, pro‐inflammatory cytokines IL‐6 (50.31 ± 25.67 vs. 30.00 ± 11.19 pg/mL; p =.002) and IFN‐γ (65.70 ± 39.78 vs. 32.14 ± 17.48 pg/mL; p =.001) were significantly higher in the seroconverter group compared to non‐seroconverter. In contrast, TGF‐β (820.96 ± 415.78 vs. 1045.57 ± 204.66; p =.046) was higher in non‐seroconverter. Conclusions: Pro‐inflammatory cytokines IL‐6 and IFN‐γ were significantly associated with seroconversion after SARS‐CoV‐2 infection and vaccination in RTRs. [ABSTRACT FROM AUTHOR]

Background: Posterior urethral valve (PUV) is obstructive uropathy that may lead to chronic kidney disease (CKD) and end-stage renal disease (ESRD) in children. Glomerular filtration rate (GFR) measurement remains the gold standard for renal function measurement. However, due to its less availability and cumbersome, it is not commonly used, and GFR is estimated utilizing various endogenous filtration markers. Objective: This study includes pediatric patients with PUV. We aimed to compare the measured GFR (mGFR) with various creatinine-based estimated GFR methods (eGFR). Materials and Methods: A single-center retrospective study included 62 treated cases of PUV, postvalve fulguration. The mGFR measured by 99mTc-diethylenetriaminepentaacetate in vitro method and compared with eight eGFR (Schwartz, Cockcroft-Gault [CG], Counahan-Barratt [CB], CKD Epidemiology Collaboration [CKD-EPI], full-age spectrum [FAS] age, FAS height (FAS Ht), Schwartz-Lyon [SL], and Ht independent). Patients were subdivided into different CKD grades and compared with various eGFR. Discussion: PUV is a common cause of CKD in children and needs special consideration as there is growth retardation associated with it. It decreases creatinine production and thus fallacies in eGFR measurement. There is a requisite to identify and closely monitor the subset of patients with baseline decreased renal function and therefore at risk of developing ESRD. Results: A total of 62 patients were included. Mean age and serum creatinine levels were 8.02 ± 5.53 years and 1.15 ± 0.95 mg/dl (range: 0.4-4.5), respectively. The mean mGFR was 61.6 ± 31.80 mL/min/1.73 m² and a positive variable correlation was 0.46-0.77 between mGFR and eGFR. Based on mGFR, there were 14 (22.6%), 21 (33.8%), 13 (20.9%), 9 (14.5%), and 5 (8.1%) patients in Grades I-V, respectively. The correct classification of the CKD grades was noted in 25 (40.3%), 16 (25.8%), 32 (51.6%), 16 (25.8%), 25 (40.3%), 27 (43.5%), 26 (41.9%), and 28 (45.2%) patients by Schwartz, CG, CB, CKD-EPI, FAS age, FAS Ht, SL, and Ht-independent equation. The eGFR overestimates GFR at the lower level and underestimates at higher levels. Conclusion: Our results confirm the considerable limitations of various creatinine-based clearance methods for estimating actual GFR. The creatinine clearance-based eGFR should not replace the measurement of the GFR. An initial measure of the mGFR followed by serial follow-up with the eGFR equation may be done. The most accurate eGFR equations are CB for Grade II, SL or Ht independent for Grade III, FAS age for Grade IV, and SL for Grade V CKD. [ABSTRACT FROM AUTHOR]

Introduction: Immunoglobulin A nephropathy (IgAN) is the most common glomerulonephritis worldwide, but there is a marked geographic difference in its prevalence and prognosis. IgAN is known to have an aggressive course in Asians. However, its exact prevalence and clinicopathologic spectrum in North India are not well documented. Materials and Methods: The study included all patients aged above 12 years with primary IgAN on kidney biopsy from January 2007 to December 2018. Clinical and pathological parameters were noted. Two histopathologists independently reviewed all kidney biopsies, and MEST-C score was assigned as per the Oxford classification. Results: IgAN was diagnosed in 681 (11.85%) out of 5751 native kidney biopsies. The mean age was 32 ± 12.3 years, and the male to female ratio was 2.5:1. At presentation, 69.8% had hypertension, 68% had an estimated glomerular filtration rate (eGFR) of less than 60 ml/min, 63.2% had microscopic hematuria, and 4.6% had gross hematuria. The mean proteinuria was 3.61 ± 2.26 g/day, with 46.8% showing nephrotic range proteinuria and 15.2% showing nephrotic syndrome manifestation. Histopathologically, 34.4% of patients had diffuse global glomerulosclerosis. Oxford MEST-C scoring revealed M1 in 67%, E1 in 23.9%, S1 in 46.9%, T1/T2 in 33%, and crescents in 19.6% of biopsies. The mean serum creatinine was significantly higher in cases with E1, T1/2, and C1/2 scores (P < 0.05). Hematuria and proteinuria were significantly higher (P < 0.05) with E1 and C1/2 scores. Coexisting C3 was associated with higher serum creatinine at presentation (P < 0.05). Conclusion: IgAN patients with late presentation and advanced disease became less amenable to immunomodulation in our cohort. The implementation of point-of-care screening strategies, early diagnosis, and retarding disease progression should be prioritized in the Indian strategy. [ABSTRACT FROM AUTHOR]

The present study compares disease characteristics, imaging modalities used, and patterns of treatment in two large cohorts of Takayasu arteritis (TAK) from Italy and India. Clinic files were retrospectively reviewed to retrieve information about initial choices of vascular imaging and immunosuppressive therapies. Unpaired t-tests compared means, and proportions were compared using Fisher's exact test or Chi square test [Odds ratios (OR) with 95% confidence intervals (95%CI) calculated where appropriate]. The cohorts comprised 318 patients [Italy (n = 127), India (n = 191)] with similar delays to diagnosis. Ultrasound (OR Italy vs. India 9.25, 95%CI 5.02–17.07) was more frequently used in Italy and CT angiography in India (OR 0.32, 95%CI 0.20–0.51). Corticosteroid use was more prevalent and for longer duration in Italy. TAK from Italy had been more often treated with methotrexate, leflunomide or azathioprine, as opposed to tacrolimus in TAK from India (p < 0.05). Biologic or targeted synthetic disease-modifying agents were almost exclusively used in Italy. Survival on first immunosuppressive agent was longer from Italy than from India (log rank test p value 0.041). Considerable differences in the choice of initial vascular imaging modality and therapies for TAK from Italy and India could relate to prevalent socio-economic disparities. These should be considered while developing treatment recommendations for TAK. [ABSTRACT FROM AUTHOR]

Introduction: The corticosteroid dosing modulation in renal transplant recipients (RTRs) with coronavirus disease‐19 (COVID‐19) is not well defined. We aimed to analyze the outcomes and infectious and non‐infectious sequelae in RTR with COVID‐19 with reference to corticosteroid dosing and the first and second pandemic waves of COVID‐19. Materials and methods: This study included RTRs admitted during two pandemic waves between March 25, 2020, and July 31, 2021. Patients were categorized into mild, moderate, and severe COVID‐19. The outcomes and predictors of survival at 4 weeks were analyzed. The survivors were also followed for 6 months and were studied for mortality, readmission rates, and infectious and non‐infectious sequelae with reference to high‐dose and standard‐dose corticosteroids. Results: A total of 251 RTRs, 104 during the first wave and 147 during the second wave, were treated. Overall mortality was 15.1% (11.5% in the first wave vs. 17.5% in the second wave, p =.23). The use of high‐dose steroids was also significantly high in non‐survivors (85.8% vs. 11.3%, p =.001). On multivariate analysis, the severity of COVID‐19, graft dysfunction, and high dose of corticosteroid therapy were associated with increased odds of mortality. Among survivors, 6‐month mortality (17.3% vs. 0.5%, p =.001), readmission rate (91.3% vs. 23.7%, p =.001), fungal infection (30.4% vs. 2.2%, p <.001), and post‐COVID lung sequelae (21.7% vs. 4.4%, p =.008) were significantly higher in the high‐dose corticosteroid group than in the standard‐dose group. Conclusion: High‐dose corticosteroid dosing in RTRs with COVID‐19 was associated with increased infections, particularly fungal infections, and non‐infectious sequelae with higher mortality on subsequent follow‐up. [ABSTRACT FROM AUTHOR]

Fabry disease (FD) is a rare, lysosomal storage disorder characterized by multi-organ accumulation of predominantly globotriaosylceramide (GL3) and its metabolite. Resulting renal, cardiac, and cerebrovascular complications are crucial causes of morbidity and mortality in FD. Enzyme replacement therapy (ERT) shows promising outcomes for these patients, provided that therapy is initiated early. Thus, precise and early diagnosis of the disease is a pivotal factor determining the corollary of the disease. We report two cases of young adult males who presented to the nephrology department with proteinuria. A kidney biopsy was performed in both cases, which was suggestive of FD. The final conclusive diagnosis of FD was provided by electron microscopy. [ABSTRACT FROM AUTHOR]

Background: The data on long-term outcomes of posttransplant immunoglobulin A nephropathy (IgAN) are confounding and vary with geography and ethnicity worldwide. We aimed to study the long-term graft outcomes of patients with posttransplant IgAN in the northern Indian cohort. Methods: The long-term graft outcomes of 51 live donor renal transplant recipients with biopsy-proven posttransplant IgAN (recurrence/de novo) were analyzed. The risk factors for graft failure in the posttransplant IgA groups were analyzed using the Cox regression analysis. Results: Out of the total of 51 patients who had posttransplant IgAN, 40 patients had a biopsy-proven native kidney IgAN. The mean duration of the clinical presentation of posttransplant IgAN was 62.4 months (5.2 years) posttransplant. Proteinuria at the time of biopsy was 3.03 ± 2.2 g/day, and 41.2% had proteinuria of more than 3 g/day at the time of biopsy. The estimated 1, 5, 10, and 20 years patient survival was 98%, 95.4%, 75.9%, and 25.2%, respectively, and the estimated 1, 5, 10, and 20 years graft survival was 98%, 88.5%, 44.6%, and 11.9%, respectively, in patients who had posttransplant IgA. Many of the traditional risk factors associated with progression in native kidney IgAN, such as the degree of proteinuria, Oxford MEST (mesangial and endocapillary hypercellularity, segmental sclerosis, and interstitial fibrosis/tubular atrophy) scoring, recipient's age, and sex were not predictive of early graft failure among patients with posttransplant IgAN. In our cohort, the only significant graft failure predictor was serum creatinine at 5 years. Chronic antibody-mediated rejection (ABMR) was seen in 21.6% of patients with posttransplant IgAN. Whether this coexistence of chronic ABMR is an incidental finding or posttransplant IgAN predisposes to chronic ABMR requires further investigation. Conclusion: Posttransplant IgAN is associated with poor long-term graft outcomes in live donor renal transplants. Proteinuria and MEST scoring were not predictive of graft failure in living donor posttransplant IgAN. [ABSTRACT FROM AUTHOR]

Background Renal graft cortical necrosis (GCN) is a catastrophic cause of graft failure. We evaluated the incidence, causes, management, and outcome of GCN across two decades from our center. Methods This is a retrospective analysis of transplant patients who had biopsy-proven GCN transplanted between 2000 and 2020. The clinical details, immunological workup, induction, maintenance regimen, causes of cortical necrosis, and the outcomes were compared between the first period 2000–2012, and the second period 2013–2020, when Flow cytometric and Luminex based crossmatch were included in the workup plan. Results Among 2333 live ABO-compatible renal transplants, 37 (0.015%) patients (36 patients between 2000 and 2012 and 1 between 2013 and 2020) developed GCN (60% had diffuse and 40% patchy GCN) at a median of 8 days after transplantation.Twenty-six (60%) received ATG, 4 received plasmapheresis and ATG (10.8%) as antirejection therapy. The cyclosporine-based regimen was associated with a higher risk of GCN (RR 2.54; 95% CI 1.26 to 5.12, p = 0.009), whereas tacrolimus-based therapy had a lower risk (RR 0.39; 95% CI 0.19 to 0.79, p = 0.009). The introduction of flow cytometry and DSA assay has significantly decreased the incidence of acute rejection and GCN. Only one patient had GCN during the 2013–2020 period because of graft's mucormycosis. Twenty-five (67.56%) patients had no recovery, and 12 (32.43%) had partial recovery of graft function. Conclusion GCN is mainly associated with rejection, and cyclosporin-based maintenance regimen had a higher incidence. The remarkable decrease in GCN after 2012 onwards could be attributed to the use of Flowcytometry, Luminex-based DSA assays, and tacrolimus-based regimens. [ABSTRACT FROM AUTHOR]

Aim: Primary objective of this study was to compare R2* value of the post-stenotic kidney with contralateral kidney, kidneys of essential hypertensive patients, and healthy subjects using blood oxygen level-dependent magnetic resonance imaging (BOLD MRI) technique. The secondary objective was to study the effect of severity of stenosis and viability of kidneys on R2* value. Methods: We compared 4 groups of kidneys including 92 with renal artery stenosis, 37 normal contralateral kidneys of unilateral renal artery stenosis patients, 62 kidneys of essential hypertensive patients, and 40 kidneys of healthy controls using BOLD MRI. Deoxyhemoglobin level represented by R2* was calculated before and after giving furosemide and was compared among different groups. Results: Baseline means cortical R2* value did not differ between groups. Response to furosemide was reduced in stenotic kidneys as compared to essential hypertensive and healthy control groups (p < 0.001). The mean R2* value of the contralateral normal kidney group was not significantly different from the stenotic group. Baseline R2* value and delta R2* values did not differ between different degrees of stenosis. Higher mean cortical R2* was seen in stenotic kidneys which were small (< 7 cm) in size (24.27 ± 5.65 vs 21.7 ± 3.88; p value 0.02) or with poor corticomedullary differentiation (24.64 ± 5.8 vs 20.74 ± 3.34; p value 0.006) as compared to other stenotic kidneys. Similarly, the delta R2* value was also blunted in these small shrunken kidneys (p value < 0.001). Conclusion: R2* values on BOLD MRI are significantly different between kidneys with and without renal artery stenosis and can potentially also predict the utility of revascularization. [ABSTRACT FROM AUTHOR]

A repeat renal transplantation is believed to confer the best survival advantage for allograft failure. The scarcity of matching donors at one end, coupled with the expanding pool of ABO-incompatible (ABOi) donors at the other end, lead us to consider the option of ABOi kidney re-transplantation. However, ABOi kidney re-transplantation is associated with heightened immunological risk due to the presence of two substantial immunological barriers. Concern, queries, and uncertainty exist over the course and outcome of this option. We prospectively studied five patients who underwent live-related ABOi re-transplantation after a failed previous transplant. Four patients (mean age 40.8 ± 6.6 years, 4 males) underwent a second renal transplant, whereas one patient had a third renal transplant. All patients received desensitization with rituximab, plasmapheresis, and intravenous immunoglobulin as per routine protocol. One patient required immunoadsorption to achieve the desired Anti-ABO titer. All five patients had good graft survival. One of them developed combined antibody and cell-mediated rejection and another antibody-mediated rejection. Live-related ABOi kidney re-transplantation could be a viable option for patients with a previously failed graft. [ABSTRACT FROM AUTHOR]

Continuous ambulatory peritoneal dialysis (PD)-related hydrothorax (PDRH) is uncommon; however, it is associated with a high discontinuation rate and morbidity. We report clinical characteristics, pleural fluid chemistry patterns, diagnostic modality, management options, and outcomes in 12 patients who have confirmed pleuroperitoneal communication after the inception of the PD program at our institute. The incidence of PDRH in our study was 0.64%. The interval between initiation of PD and hydrothorax ranged from 7 weeks to 40 weeks (average 20.6 weeks). Ten (83.3%) had right-sided, one (8.3%) left-sided, and one (8.3%) bilateral hydrothorax. Most patients (83.3%) had dyspnea with chest symptoms, but two (16.6%) patients were asymptomatic. All patients had confirmed communication either by peritoneal scintigraphy or computed topography peritoneography. PD had to be stopped in two patients and patients were shifted back to hemodialysis. Pleurodesis, through thoracostomy with tetracycline or betadine, was used for four patients. Three patients underwent video-assisted thoracoscopy (VATS) with surgical repair of the diaphragmatic defect, and one underwent VATS assisted talc pleurodesis. All four patients who underwent VATS repair of the defect had successful outcomes. With availability and experience with VATS, most patients had successfully returned to PD with no recurrence and with minimal morbidity. [ABSTRACT FROM AUTHOR]

Introduction: Asymptomatic maintenance hemodialysis patients with acute respiratory corona virus‐2 (SARS‐COV‐2) are missed with pre‐dialysis screening without testing. The possible ideal strategy of testing each patient before each shift with reverse transcription polymerase chain reaction (RT‐PCR) is not feasible. We aimed to study the effectiveness of fortnightly screening with RT‐PCR for SARS‐CoV‐2 in curbing transmission. Methods: Between July 1, 2020 and September 30, 2020, all 273 patients receiving hemodialysis were subjected to fortnightly testing for SARS‐Cov‐2 in the unit to detect asymptomatic patients. The cost and effectiveness of universal testing in preventing transmission were analyzed using susceptible‐infectious‐removed (SIR) modeling assuming R0 of 2.2. Results: Of 273 MHD patients, 55 (20.1%) found infected with SARS‐CoV‐2 over 3 months. Six (10.9%) were symptomatic, and 49 (89.1%) asymptomatic at the time of testing. Six (10.9%) asymptomatic patients develop symptoms later, and 43 (78.2%) remained asymptomatic. A total of seven (6.1%) HCWs also tested positive for the virus. Fortnightly universal testing is cost‐effective, and SIR modeling proved effective in preventing person‐to‐person transmission. Conclusions: Repeated universal testing in maintenance hemodialysis patients detected 89% of asymptomatic SARS‐CoV‐2 patients over 3 months and appeared to be an effective strategy to prevent person‐to‐person transmission in the dialysis unit. [ABSTRACT FROM AUTHOR]

Purpose: In this study, we compared non-contrast MR angiography (NC-MRA) with conventional 3D contrast-enhanced MRA (CE-MRA) in patients suspected to have renal artery stenosis (RAS). Methods: From March 2014 to March 2020, patients who were evaluated for RAS and had a glomerular filtration rate > 30 ml/min/1.73 m2 underwent MR imaging on a 3T MR Scanner (Signa Hdxt General Electrics, Milwaukee, USA) using a Torso PA coil. The NC-MRA sequence was performed using a 3D fat-suppressed inflow inversion recovery balanced steady state free precession (SSFP) sequence (Inhance 3D Inflow IR, GE Medical) whereas the CE-MRA sequence was a 3D fast spoiled gradient echo (FSPGR). Overall quality of images was rated 1 to 4. Stenosis was reported as grade 1 (Normal), 2 (< 50% narrowing), 3 (> 50% narrowing) and 4 (Total occlusion). Grade 3 and 4 were considered haemodynamically significant. Results: During the study period, 201 patients were enrolled (400 renal arteries). For hemodynamically significant (grade 3/4) stenosis, NC-MRA correctly diagnosed 72 patients (95 arteries) while in 2 patients (2 arteries), NC-MRA underdiagnosed the stenosis as grade 2 (these were found to have grade 3 stenosis on CE-MRA). The kappa value of agreement between NC-MRA and CE-MRA for detection of RAS showing excellent agreement (p < 0.001). Conclusion: In one of the largest series of patients so far, we found that NC-MRA is a viable alternative to CE-MRA for detection of RAS, highly correlating with CE-MRA for grade of stenosis and with additional advantage of lack of gadolinium based contrast agents toxicity. [ABSTRACT FROM AUTHOR]

Introduction: Lupus nephritis (LN) has a considerable impact on the morbidity and mortality of systemic lupus erythematosus (SLE) patients. Long-term comparative outcome data from the Indian subcontinent on treatment regimens with cyclophosphamide (CYP) and mycophenolate mofetil (MMF) are sparse. We assessed renal and patient survival for these patients in terms of the types of induction – CYP or MMF – and the two maintenance therapies – MMF or azathioprine (AZA). Methods: We retrospectively analysed outcomes of 100 LN patients, 67 treated with CYP (26 class III, 25 class IV, 6 class III + V and 10 class IV + V; 40 Euro lupus regimen and 27 National Institutes of Health regimen) and 33 treated with a MMF-based regimen with steroids between July 2008 and June 2018. Data regarding demographic, clinical and histopathological features and the treatment given to all patients were extracted. Outcomes between the two regimens CYP and MMF were compared in terms of remission, dialysis and patient survival. Results: The clinical characteristics were similar in both groups, except that the activity index was higher in CYP patients (6.13 ± 4.48 vs. 4.61 ± 2.80). However, the chronicity index was similar. The overall remission rate was 70% at the end of induction. The rates of complete remission, partial remission and non-responders in the CYP group were 46.2%, 23.9% and 29.9%, respectively. However, in the MMF group, the corresponding rates were 57.6%, 12.1% and 30.3%, respectively. The 1-, 2-, 3-, 4-, 5- and 10-year patient survival rates in the CYP group were 89.5%, 86.2%, 86.2%, 83.8%, 83.8% and 83.8%, respectively. In the MMF induction group, the corresponding rates were 93.9%, 93.9%, 89%, 89%, 89% and 89%, respectively. At the end of the study, rates of end-stage renal disease in the MMF group and CYP group were 7.5% and 12.1%, respectively. The death-censored and non-censored renal survival rates were also similar in the long term. With regard to maintenance therapy, 3/56 (5.3%) in the MMF group and 7/34 (20.5%) in the AZA group experienced doubling of serum creatinine (p = 0.03). Conclusions: Long-term outcomes in terms of patient and renal survival of LN patients treated with CYP and MMF induction are similar. Doubling of serum creatinine occurred more with AZA-based maintenance therapy than with MMF-based maintenance therapy. Most deaths occurred during induction, and sepsis was the most common cause of death. [ABSTRACT FROM AUTHOR]

Background: Peritoneal dialysis (PD) is the preferred modality of dialysis among children with end-stage renal disease. Methods: To study the incidence of technique failure and survival among children with end-stage renal disease on continuous ambulatory peritoneal dialysis (CAPD), we included children younger than 18 years of age who commenced and continued PD for more than 3 months as their primary form of dialysis between 1st January 2005 and 31st December 2016. Kaplan–Meier survival analysis was applied to analyze the CAPD outcomes. Results: A total of 68 Tenckhoff (58 double cuffs, and ten single cuffs) catheters were inserted in 66 patients (mean age 12.3 ± 3.91 years) during the study period. Of the 66 children, 31 (47%) experienced 45 episodes of peritonitis. The total duration on CAPD was 107.58 years with a peritonitis rate of 0.42 episodes per year. Overall, the mean patient survival was 41 (95% confidence interval (CI) 29–54) months, with mean patient survival of 72% at 12 months, declining to 30% at 36 months and then remaining stable until the end of follow-up (106 months). The overall mean technique survival was 55 (95% CI 40–69) months, with mean technique survival of 69% at 12 months, declining to 44% at 36 months and then remaining stable until the end of follow-up (106 months). Conclusion: CAPD is a viable option for end-stage renal disease in children from developing countries with a lack of access to automated PD and pediatric hemodialysis centers. [ABSTRACT FROM AUTHOR]

The outcomes of the elderly population on peritoneal dialysis (PD) in developing countries are less known. In this study, we intended to study the clinical characteristics and patient and technique survival of elderly patients on PD. In this study, data of 148 elderly patients with end-stage renal disease who initiated PD between January 2001 and December 2015 were collected. Baseline clinical characteristics and events during the study period were recorded. Overall patient and technique survival rates of diabetic and non-diabetic elderly patients on PD were analyzed. Around 128 patients who were initiated PD during the study period were included for final analysis. The mean age of the study group was 70.3 ± 5.1 years, and 94 (80%) were males. Among these, 79 (65.8%) had diabetes. At the end of the study period, only 20 (16.6%) patients were remained on PD. Eighty-four (70%) patients died during PD and 15 (12.5%) patients were transferred to hemodialysis during the study period. The main reasons for death were cardiovascular (56.6%) and sepsis due to peritonitis (18.8%). The mean patient survival time was 38.2 ± 2.6 months. The patient survival rates were 91.2%, 45.3%, and 22.8% at 1, 3, and 5 years, respectively. Predictors of mortality were increased serum phosphorus, peritonitis episodes, urine output <400 mL, and ultrafiltration <1000 mL/day at beginning of PD. The mean technique survival time was 92.0 ± 5.1 months. Technique survival rates at 1, 3, and 5 years were 94.8%, 85.3%, and 71.7%, respectively. None of the factors was found to be predictive of technique survival. We found no significant difference between diabetic and non-diabetic patients in terms of technique and patient survival. Mortality was higher in elderly patients on PD. Factors affecting mortality in elderly patients on PD are low urine output, low ultrafiltration at beginning of PD, high serum phosphorus, and presence of peritonitis episodes. Patient and technique survival rates were comparable between diabetic and non-diabetic elderly patients on PD. [ABSTRACT FROM AUTHOR]

Early graft dysfunction after renal transplantation manifests as acute rejection (AR) or acute tubular necrosis (ATN). Blood oxygen level-dependent (BOLD) magnetic resonance (MR) imaging is a noninvasive method of assessing tissue oxygenation, which may be useful for predicting acute allograft dysfunction. This was a prospective study involving 40 patients scheduled for renal transplantation from August 2012 to August 2014. In addition, 15 healthy donors were also enrolled in this study. All recipients underwent BOLD MR imaging (MRI) and R2* mapping 10-20 days after transplant, and additionally within 48 h of biopsy if there was any evidence of graft dysfunction. The healthy donors underwent BOLD MRI 1-2 days before surgery. The biopsies were grouped into AR, ATN, and no evidence of AR or ATN. The mean medullary R2*, cortical R2*, corticomedullary gradient, and medullary: cortical R2* ratio were compared between groups using one-way analysis of variance. Spearman's correlation and multinomial linear regression were applied to determine the influence factors of R2* value. Overall, nine patients had graft dysfunction. Six were reported as AR, two as ATN, and one as no evidence of ATN or rejection. The mean medullary and cortical R2* were significantly higher in ATN group compared with AR and normal group, whereas the mean medullary and cortical R2* of AR group were significantly lower than normal group. The corticomedullary gradient of AR group was significantly lower compared with ATN and normal group. Medullary R2*:cortical R2* ratio was significantly lower in AR group compared with normal group. No significant difference was noted between the 15 donors and patients with normal graft function. R2* values on BOLD MRI are significantly decreased in AR allografts and increased in an early stage of ATN allografts, suggesting that BOLD MRI can become a valuable tool for discriminating between AR and ATN. [ABSTRACT FROM AUTHOR]

Background The objectives of this pilot study were to assess the efficacy and safety of an interferon-free sofosbuvir and ribavirin combination regimen to treat chronic hepatitis C virus (HCV) infection in kidney transplant recipients and to study the impact of sofosbuvir on calcineurin inhibitor (CNI) drug levels. Methods A total of 10 kidney transplant recipients with chronic HCV infection were included in the study. All received sofosbuvir and ribavirin combination therapy. The virological response to therapy and the adverse effects of the drugs were studied. The area under the curve (AUC) and pharmacokinetic data of levels of CNI were compared while the patients were receiving sofosbuvir and ribavirin drugs and when they were no longer on these drugs. Results In all, 9 of 10 patients (90%) achieved rapid virological response (RVR) with undetectable HCV RNA at 4 weeks and the remaining patient achieved undetectable HCV RNA at 8 weeks. A sustained virological response was seen at 3, 6 and 12 months and was maintained in all 10 patients (100%). The important aspect of the study is the effect of treatment with the sofosbuvir–ribavirin combination regimen on the CNI AUC levels, which resulted in a reduction in the CNI AUC. While used as part of triple-drug immunosuppression, no change in the dose of CNI (tacrolimus and cyclosporine) was required based on measurement of C0 levels. Conclusions The sofosbuvir and ribavirin combination therapy is effective and safe to treat HCV infection in the post-renal transplant setting. There is a need for close CNI level monitoring while these patients are on sofosbuvir therapy. With therapy and viral clearance, there could be reduction in CNI levels due to increased clearance of CNI drugs, which is shown by the AUC measurements. This could be important for patients at high risk for rejection. [ABSTRACT FROM AUTHOR]

Background: We aimed to longitudinally analyse changes in the levels of serum fibroblast growth factor 23 (FGF23), intact parathyroid hormone (iPTH) and associated minerals in patients undergoing renal transplantation. Methods: Sixty-three patients with end-stage renal disease (ESRD) who underwent living donor transplantation were recruited. Serum FGF23, iPTH, uric acid, inorganic phosphorous (iP), blood urea nitrogen and serum creatinine were measured pre-transplant and at 1 (M1), 3 (M3) and 12 months (M12) post-transplantation. Results: FGF23 levels were decreased at M1, M3 and M12 by 93.81, 96.74 and 97.53%, respectively. iPTH levels were decreased by 67.95, 74.95 and 84.9%, respectively. The prevalence of hyperparathyroidism at M1, M3 and M12 post-transplantation was 63.5, 42.9 and 11.1%, respectively. FGF23 and iP levels remained above the normal range in 23 (36.5%) and 17 (27%) patients at M1, 10 (15.9%) and 5 (8%) at M3 and in none at M12 post-transplantation, respectively. A multivariate regression model revealed that, pre-transplant, iP was positively associated with iPTH (P = 0.016) but not with FGF 23; however, post-transplant, iP level was negatively associated with FGF23 (P < 0.001) but not with iPTH. Conclusions: Post-transplant FGF23 levels settle faster than those of iPTH. However, 11% of patients continued to have hyperparathyroidism even after 12 months. [ABSTRACT FROM AUTHOR]

Aim Delayed graft function is an early complication leading to impaired creatinine clearance, urine formation and determinant of long term graft outcome. The aim of the present study was to determine the earliest predictive cut-off value of uKIM-1 level in patients with delayed graft function and acute tubular necrosis. Methods We have determined the serial urinary KIM-1 normalized to urinary creatinine ( uKIM-1, pg/mg) level at 0, 6, 12, 18, 24 and 48 h of post-transplant by ELISA methods. Result The normalized uKIM-1 and AUC-ROC, of uKIM-1 were progressively increased up to 48 h in both delayed graft function ( DGF) and immediate graft function ( IGF). The u KIM-1 values were significantly high at 6, 12, 18, 24 and 48 h in patients with DGF as compared to that of IGF except at half an hour post-transplant values. Although, progressive increase in uKIM-1 values were observed in both groups of patients; there was an overlap of values between two groups up to 12 h. The earliest non-overlapping values of uKIM-1 between the groups were observed at 18 h onwards and minimum difference of 923.43 pg/mg. The earliest predictive AUC-ROC of uKIM-1 in patients with DGF without overlap with IGF was also observed at 18 h post-transplant with specificity of 100% and sensitivity of 89.9%. Conclusion Serial uKIM-1 measurement can be used as non-invasive diagnostic biomarkers to predict the incident of DGF in living donor renal transplant recipients. At 18th post-transplant hour uKIM-1 can predict DGF with 100% specificity and 89.9% sensitivity with a cut-off value of normalized KIM-1 of 923.43 pg/mg. [ABSTRACT FROM AUTHOR]

Background. Percutaneous renal biopsy (PRB) can result in serious complications. The study is aimed to compare the biopsy yield and complications rate of the real-time ultrasonagram (USG)- guided PRB and needle tracking with and without needle guide in two different study periods. Methods. We compared the yield and complications of 2138 kidney biopsies performed in two different periods, 1510 biopsies during the first period from April 2004-December 2010 and 628 biopsies during second period from January 2011-March 2013. All biopsies in both periods were performed by nephrologists. Radiologists provided the real-time image without needle guide during the first period while nephrologists performed both imaging and biopsy with needle guide during the second period. Results. Of all the 2138 patients, 226 (10.5%) patients developed 118 minor and 108 major complications. Only 13 (2.1%) major complications occurred in the second period and 95 (6.7%) in the first period (P < 0.001). The relative risk of developing a major complication without guide was 3.04 times greater than that of the biopsies performed with use of the guide. The mean number of glomeruli per biopsy obtained during the second period (17.98 ± 6.75) was significantly greater than that of the first period (14.14 ± 6.01) (P = 0.004). The number of passes to acquire adequate tissue (P = 0.001) and percentage of cortex on biopsy (P = 0.001) were also significantly better in the second period. The optimal observation period post biopsy is 24 h. Conclusions. Real-time USG imaging supported by needle guide device is associated with better biopsy yield and fewer complications. [ABSTRACT FROM AUTHOR]

Isolated renal mucormycosis is a rare entity in children. It is potentially fatal when not detected and managed early with antifungal therapy, and surgery as and when needed. We present two immunocompetent children who developed this infection and subsequently succumbed to it. The diagnosis was established postmortem on renal biopsy specimens. We also discuss the 9 cases of isolated renal involvement in children published in literature. [ABSTRACT FROM AUTHOR]

Acute kidney injury (AKI) is an independent variable for poor outcome in critically ill patients. The pathophysiology of septic AKI is distinct from that of non-septic AKI. We studied the clinical profile and outcome of septic AKI since such data is sparse in Indian patients. In this single-center retrospective, observational, cohort study, septic AKI has been found with high incidence (31%) and overall mortality was 52%. Age, number of non-renal organ failure, and APACHE II score were found as significant predictors of outcome in this population. [ABSTRACT FROM AUTHOR]

Organochloride insecticides are chlorinated cyclic hydrocarbons. One of such insecticides is endosulfan (6,7,8,9,10-10 hexachloro 1,5,5a,6,9,9a-hexahydro-6-methano-2,4,3- hexadithioxanthiep in 3-oxide) and it has been widely used in agriculture since 1960. The uncontrolled use of these compounds in developing countries has resulted in the deaths of animals and humans. Characteristic clinical signs following acute exposure are indicative of CNS disturbances or overstimulation. Mortality and morbidity rates are high and there is no specific antidote. We present an uncommon presentation of endosulfan poisoning in a 32-year-old male with high anion gap severe refractory metabolic acidosis. The patient was treated with continuous renal replacement therapy and was salvaged. Till date, there is no case report from India for endosulfan poisoning with severe metabolic acidosis and hypotension. Through this case report, we emphasize the role of continuous renal replacement therapy as a rescue therapy for endosulfan poisoning with severe refractory metabolic acidosis and hypotension, even though it is a non dialyzable poison. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 53-year-old man with diabetes and with end-stage renal disease. The hemodialysis patient had a six-week history of fever, multiple swellings over chest and lower limbs, cough, and dyspnea. Aspiration of the swellings over his chest and foot as well as blood cultures and sputum cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA).