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The pandemic situation like COVID-19 worsened the medical situation in India, and the crisis of medical oxygen availability at hospitals in different parts of India has also been a deep concern. In this study, we analyzed the supply chain of medical oxygen from manufacturing units to the needy capital cities of states. A two-mode optimization model has been developed for better planning of transportation and supply of medical oxygen. Various industrial units with a liquid oxygen production facility have been considered as sources while road and rail routes have been considered as modes of transportation. Finally, the oxygen cylinders/tankers are transported by road to hospitals. The mathematical model tries to optimize the route and transport medium, considering various constraints. This paper identifies the challenges in Indian contexts and tries to address them by an optimal, cost-effective, and efficient planning for medical oxygen transportation.

Background: Mitochondria are semiautonomous cell organelles having its own nucleic acid. Mitochondrial DNA (Mt‑DNA) remain in hypomethylated (CpG) state and impose an immunogenic response by binding to the toll‑like receptor (TLR‑9) through the NF‑kB pathway. Innate immune cells recognize the hypomethylated pattern of mt‑DNA and quickly trigger the innate immune response. The immunomodulatory effects of urinary mt‑DNA derived from renal transplant recipients with COVID‑19‑associated acute kidney injury (AKI) have not been studied. Materials and Methods: Healthy donor peripheral blood mononuclear cell (PBMC) was cultured with the urinary Mt‑DNA derived from the renal transplant recipients, who previously developed SARS‑CoV‑2 infection associated AKI. Cell activation was measured by the flow cytometry. In cell pellets, interleukin IL‑6, IL‑10, and Myd88, TLR‑9 mRNA transcript expression was measured by the reverse transcription polymerase chain reaction. The IL‑6 and IL‑10 cytokine levels were measured by the enzyme‑linked immunosorbent assay in culture supernatants. Results: The urinary mitochondrial DNA (umt‑DNA) significantly induces the activation of > 75% of PBMCs. The m‑RNA transcript expression of the inflammatory gene in control versus umt‑DNA treated PBMCs was for IL‑6 (0.99 ± 0.05 vs. 2.18 ± 1.15 au; P = 0.004), MYD88 was (1.00 ± 0.05 vs. 1.55 ± 0.31; P < 0.001), TLR‑9 (1.00 ± 0.05 vs. 3.33 ± 1.37 au; P < 0.001) was upregulated, and the IL‑10 (1.00 ± 0.13 vs. −1.73 ± 0.58; P < 0.001) level was downregulated. However, in PBMC culture supernatants, IL‑6 level in control versus umt‑DNA‑treated groups were (37.50 ± 13.79 vs. 186.9 ± 15.50 pg/mL; P < 0.001), which was significantly higher in umt‑DNA‑treated groups and the IL‑10 (8.80 ± 2.16 vs. 7.60 ± 3.12 pg/mL; P = 0.32) level was similar between the control‑ and umt‑DNA‑treated groups. Conclusions: Urinary Mt‑DNA significantly induces the inflammatory cytokine IL‑6 secretion from the PBMCs through the Myd88‑dependent pathway. [ABSTRACT FROM AUTHOR]

Dichlorvos, an organophosphate compound, has the potential to cause acute kidney injury (AKI) besides its well-known neuromuscular complications. We report a case of severe-recurrent AKI that progressed to end-stage-renal-disease (ESRD) following accidental exposure to Dichlorvos. A 52-year-old male farmer presented with breathlessness after accidental exposure while spraying in the field. He required mechanical ventilation due to allergic pneumonitis and developed anuric AKI, requiring renal replacement therapy (RRT). Biopsy revealed severe acute tubulointerstitial nephritis (ATIN), which responded to steroids, and the patient became dialysis-independent by 4 weeks. Two weeks later, the patient had recurrent AKI requiring RRT. A repeat biopsy revealed severe ATIN. However, despite steroid treatment, he progressed to ESRD. Organophosphate compounds can cause renal injury with a wide spectrum of presentations, ranging from subclinical AKI to severe dialysis-dependent renal failure, which may eventually progress to end-stage renal disease. [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]

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]

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: 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]

Introduction: The management of active antibody-mediated rejection (ABMR) is evolving, and optimal treatment remains uncertain due to incomplete understanding of pathogenesis. Bortezomib is found to be useful in the treatment of active ABMR. We studied the efficacy and safety of bortezomib in renal-transplant recipients with active ABMR. Materials and Methods: We retrospectively included renal-transplant recipients with active ABMR, who received bortezomib as main management. Results: Eighteen live-related renal-transplant recipients of active ABMR were included. C4d was positive in 14 patients and negative in eight patients. Patients with active ABMR had a mean improvement in glomerular filtration rate (GFR) of 7, 10.5, and 15 ml/min/1.73 m2 at 3, 6, and 12 months, respectively, from baseline GFR. Improvement was significant at 3 (P = 0.009) and 6 months (P = 0.018) of follow-up. Conclusion: Bortezomib may be a safe and effective therapy in patients with active ABMR in patients. [ABSTRACT FROM AUTHOR]

Coronavirus disease-19 (COVID-19) affected everyone on the globe, including renal transplant recipients who are at increased risk of infection. The clinical manifestations, immunosuppressive modifications, and treatment protocol are not well defined. We are reporting a case of renal transplant recipient and reviewed all case reports and series (a total of 100 patients) published to date to comprehend the clinical manifestations, immunosuppression modifications, treatment given, and outcomes of the patients. A 57-year-old male kidney transplant recipient had a fever, headache, weakness, and positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. He became asymptomatic with the treatment of hydroxychloroquine, azithromycin, and oseltamivir. However, he remained persistently positive by reverse transcriptase-polymerase chain reaction for SARS-CoV-2 for 4 weeks and became negative only after Ivermectin therapy, a safer medicine than antivirals/antiretrovirals used for COVID therapy in renal transplant recipients. Of the 100 patients review of case series, fever was noted in 85%, cough 71%, diarrhea 10%, and radiographic abnormalities in 75% of cases. Only in 3% of cases, steroid was stopped, and in the rest of the cases, 63% either continued in the same doses or changed to methylprednisolone in 34%. Calcineurin inhibitors were temporarily stopped in 42% of cases, reduced in 9% of cases, and continued in the same doses in 49% of cases. The anti-metabolites were discontinued in 83%, reduced in 9% of cases, and not changed in 8% of cases. SARI was observed in 18% and acute kidney injury (AKI) in 26% of cases. Of all the AKI, 11% required renal replacement therapy. Mortality was observed in 21% of cases. COVID in renal transplant recipients may show an unusually longer positivity. Ivermectin may be used in the absence of any conclusive SARS-CoV-2 antivirals. Mortality is high in renal transplant recipients. [ABSTRACT FROM AUTHOR]