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Diabetes mellitus is the most common cause of chronic kidney disease worldwide. The prevalence of nondiabetic renal disease (NDRD) among patients with type 2 diabetes mellitus (T2DM) varies widely. This study aimed to evaluate the renal biopsies performed on type 2 diabetic patients for suspicion of NDRD and to correlate clinicopathological findings. All T2DM patients aged > 18 years were included in this study, who had renal biopsy performed for the following reasons: recent-onset nephrotic syndrome, unexplained rapid deterioration of renal function, proteinuria not accompanied by retinopathy, and unexplained hematuria. Renal biopsy was analyzed by light microscopy and immunofluorescence. Based on biopsy findings, the patients were grouped into three: (i) isolated NDRD, (ii) NDRD ± diabetic nephropathy (DN), and (iii) isolated DN. A total of 140 patients were enrolled in this study. Recent-onset nephrotic syndrome was the most common indication for biopsy, followed by the presence of active urine sediment. Forty-two percent of the patients had isolated DN, while NDRD was seen in 34% and DN ± NDRD in 24%. Focal segmental glomerulosclerosis (FSGS) and IgA nephropathy were the most common causes of isolated NDRD, while chronic tubulointerstitial nephritis (CTIN) was common in NDRD plus DN. Short duration of diabetes, absence of diabetic retinopathy, and lower glycated hemoglobin were predictive of NDRD. NDRD was seen in 58% of the patients with atypical presentations. FSGS and CTIN were common in NDRD diseases. Judicious use of biopsy in diabetic patients with atypical presentation may help in the diagnosis of NDRD.

Background Preeclampsia is an important cause of pregnancy-related acute kidney injury (AKI). The objective of our study was to determine the incidence, characteristics, and maternal and neonatal outcomes of AKI in pregnant women with preeclampsia. Materials and methods A prospective, observational, single-center study from January 2019 to January 2020. Patients admitted with preeclampsia were included. Patients with obstetric complications were excluded. AKI was defined according to Kidney Disease Improving Global Outcomes (KDIGO) 2012 criteria. Results Total number of patients with preeclampsia was 104, out of which 25% developed AKI. Among those with AKI, nulliparity (61.5%) was the most common risk factor for preeclampsia followed by prior history of preeclampsia (15.4%), pregestational hypertension (11.5%), pregestational diabetes mellitus (3.8%), and chronic kidney disease (3.8%). There was no significant difference in maternal mortality between those with AKI (15.4%) and without AKI (7.7%). Intermittent hemodialysis was needed in 15.4%. At the end of 90 days follow-up, complete recovery of renal function occurred in 53.8%, partial recovery in 23.1% and end-stage kidney disease (ESKD) in 7.7%. Perinatal death occurred in 26.9%, preterm birth in 23.1% and stillbirth in 7.7% of those with AKI and was not significantly different from those without AKI. The mean of birth weight in newborns delivered by patients with AKI (2.53 ± 0.73 kg) was significantly lower compared to those without AKI (2.82 ± 0.58 kg). Conclusion AKI was associated with a lower mean birth weight of newborns. Complete recovery of renal function was seen in 53.8% of patients with AKI and preeclampsia.

Background and Aims SLE patients have 40% to 70% life time risk of developing lupus nephritis (LN). In LN patients rate of end-stage renal disease is 10%, remaining constant in the last 30 years, even after the emergence of various immunosuppressive therapy. SLE is an example of classical antibody-mediated disease and hence treatment with B cell depleting agent (like the use of Rituximab ) appears to be a promising approach for this unwinnable disease from the Roman era. The aim of this study was to analyze the outcome in terms of - no renal response (NRR), complete renal response (CRR) or partial renal response (PRR) at week 24 after rituximab treatment initiation in refractory LN. CRR considered, if serum creatinine (S Cr) level returned to baseline, with a decline in the 24 hour urinary protein to < 500 mg/day. PRR defined as stabilization (+/-25%), or improvement of S Cr, plus a 50% decrease in 24 hour urinary protein (which was < 3.5 gm/day). NRR considered, if participant did not achieve either a CRR or PRR. Method It is a single center prospective observational study, comparing short term (24 week) outcomes in resistant lupus nephritis patients of >18 year age group with weekly (total 4) dose of rituximab therapy. The study was conducted on 25 refractory lupus nephritis patients admitted in Nephrology Department (not responding to conventional immunosuppressive drugs like cyclophosphamide, MMF). Repeat renal biopsy was performed, all baseline investigations were done. Injection Rituximab 375 mg/m2 weekly 0,1,2,3 week along with premedication treatment were given to every patient. The clinical outcome was assessed monthly post-treatment. Results In the study maximum patients were of class IV, n=21 (84 %). Sustained (6 months post treatment) CRR was achieved in n=6 (24%) patients, n=7 (28%) patients achieved PRR, rest n=12 (48%) patients had NRR. Mean blood absolute CD-19 count was significantly negatively correlated with response to rituximab treatment ( p< 0.001) .Mean absolute CD-19 count was 2.33/microliter in CRR, 2.14/microliter in PRR group and 21.25 / microliter in NRR group . No significant side effects of rituximab were observed. Limitations –Small sample size, single center study, long term follow up not considered. Conclusion In refractory LN patients, 24 weeks after Rituximab treatment

Background and Aims Acute kidney injury (AKI) is rare in women during pregnancy and puerperium. Although sepsis remains the predominant cause of AKI in pregnancy in developing countries, pre-eclampsia and eclampsia are important causes and can be life threatening. The primary focus of this study was to analyze the clinical profile as well as maternal and fetal outcomes of AKI in pregnant females with pre-eclampsia and eclampsia. Method A prospective study of patients admitted with pre-eclampsia or eclampsia and AKI in Gauhati Medical College Hospital from June 2018 to June 2019. Clinical profiles and outcome data were recorded. AKI was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Results A total of 26 cases were recorded. The mean maternal age at delivery was 27.5 ± 5.1 years. At least one recorded preexisting medical condition, including hypertension, diabetes mellitus, or chronic kidney disease was present in 5 cases (19.2%). Cesarean section was performed in 9 cases (34.6%). Eighteen patients (69.2%) developed AKI in third trimester and 6 (23.1%) within 12 weeks postpartum. Four patients (15.4%) were treated with dialysis. Four women (15.4%) died and 2 (7.7%) remained dialysis dependent 12 weeks after delivery. Low birth weight ( Conclusion AKI in pregnancies with pre-eclampsia or eclampsia can not only lead to maternal mortality and morbidity but also poor perinatal outcomes. Preeclampsia or eclampsia presenting with AKI early during gestation had worse fetal outcomes.

Background Children with nephrotic syndrome (NS) are at risk for the development of acute kidney injury (AKI) through a variety of mechanisms.The frequency of NS hospitalizations complicated by AKI has almost doubled in the last decade. Children with AKI have longer hospital length of stay and increased need for intensive care unit admission. The main objectives of this study were to determine the incidence, clinical characteristics, risk factors and short-term outcome of AKI in children hospitalized with NS. Methods In this retrospective study, 355 children ≤18 years of age with a clinical diagnosis of NS admitted in the Department of Nephrology, Gauhati Medical College and Hospital from January 2012 to December 2015 were reviewed. Results The incidence of AKI in children with NS was found to be 23.66%, 11.24%, 7.95% and 4.48% of children entered Pediatric Risk, Injury, Failure, Loss, End-Stage Renal Disease (pRIFLE) Stages R, I and F, respectively. Infection {odds ratio [OR] 2.53 [95% confidence interval (CI) 1.52–4.22]} and nephrotoxic medication exposure [OR 7.8 (95% CI 4.06–15.01)] were common factors associated with AKI. Children with steroid-dependent NS (SDNS) and steroid-resistant NS (SRNS) were more likely to develop AKI compared with children with steroid-sensitive NS (SSNS). The mean time to recovery for groups pRIFLE Stages R, I and F were 15 ± 2 , 22 ± 3 and 28 ± 5 days, respectively. Children with NS who were hypertensive, had higher urinary protein excretion and low serum albumin were more prone to develop AKI. Conclusions AKI is not uncommon in children with NS. Infection and exposure to nephrotoxic drugs are common factors associated with AKI. AKI is more frequent in SDNS and SRNS compared with SSNS. The mean time to recovery is prolonged with more severe AKI.

Lupus nephritis (LN) is an immune-complex glomerulonephritis that is usually manifested by proteinuria, active urinary sediment, hypertension, and renal failure. The objective of this study is to study the clinical and histopathological profile of LN and the response to treatment with cyclophosphamide. This was a retrospective study conducted in a tertiary care center in Assam, India, where 176 LN patients who underwent renal biopsy were included. The presenting features, laboratory parameters such as proteinuria, hematuria, and the histopathological class of the patients were studied. Among the 176 patients, 89.8% were female and 10.2% were male and maximum patients (61.3%) were in the age group of 20–40 years. Pedal edema was present in 100% of the patients, decreased urine output in 43.7%, malar rash in 38%, joint pain in 42%, hair loss in 63%, hypertension in 41.4%, oral ulcers in 31.8%, seizures in 17%, psychosis in 13%, hematuriain 78.4%, anemia in 72.1%, thrombocytopenia in 51.1%, and leukopenia in 31.7% of patients. The anti-nuclear antibody was positive in all patients and anti-dsDNA was positive in 70.5% of the patients. The most common histopathological type was class IV (50%), followed by class III (17.6%). One hundred and two patients received intravenous cyclophosphamide as initial treatment of whom, 40 received the Eurolupus regimen and 62 received the NIH regimen. The number of patients who underwent remission in both the regimen was compared. The response rate of initial treatment with cyclophosphamide in the Eurolupus group was 62.5% and in the NIH group was 64.5% (P >0.05). Majority of the patients had proliferative LN in this study, of which class IV was the most common. Proliferative LN, if not detected and treated early, leads to poor outcome in terms of patient and renal survival. Hence, patients with systemic lupus erythematosus should be evaluated for kidney involvement and treated accordingly for better outcome.

The aim of this study is to investigate the distinctive clinicopathological characteristics of acute kidney injury (AKI) in immunoglobulin A (IgA) nephropathy and identify the possible risk factors for AKI in IgA nephropathy. This study was a hospital-based retrospective analysis of clinicopthological data of IgA nephropathy. The study was conducted in the Department of Nephrology, Gauhati Medical College and Hospital, Assam, India from the period from January 2012 to December 2016. A total of 169 patients who met the inclusion or exclusion criteria were included in the study. Patient data (clinical/demographic and laboratory data including renal biopsy) were collected and were analyzed to assess the risk factors for AKI in IgA nephropathy. For the purpose of analyses, the patients were divided into two groups, AKI (n = 28) and non-AKI group (n = 141). Twenty-eight patients out of 169 developed AKI. The prevalence of AKI in IgA nephropathy patients in our center was 16.5% (28/169). Most AKI patients were hypertensive, hyperlipidemic, had pre-existing impaired kidney function, and higher baseline serum creatinine, higher serum uric acid, and proteinuria, with lower serum albumin and hemoglobin (P

Background: IgA nephropathy (IgAN) is one of the most common glomerular diseases with varied presentations. We aimed to study clinical presentation and outcome of IgAN and correlate with histopathology at the time of presentation. Methods: This is a retrospective study in which we analyzed kidney biopsy data, clinical manifestations and outcome of 137 patients with a diagnosis of primary IgAN from 2012 to 2016. Kidney biopsies were reviewed as per Oxford classification assessing mesangial hypercellularity, endocapillary hypercellularity, segmental sclerosis/adhesion, tubular atrophy/interstitial fibrosis. Correlation analysis was done for biopsy findings and clinical presentation/outcome. P score less than 0.05 was taken as significant. Results: Mean age for presentation was 27.35 years with 83 males and 54 females. Asymptomatic urinary abnormality was the most common clinical presentation (28.5%). Mean serum creatinine was 2.23 ± 2.06mg/dl with mean proteinuria of 1.49 ± 1.43g/day. Mesangial hypercellularity (M) and Endocapillary hypercellularity (E) lesions were significantly associated with proteinuria at the time of biopsy (p=0.02& 0.04 respectively). Segmental glomerulosclerosis (S) and tubular atrophy (T) were significantly associated with eGFR and mean arterial pressure at the time of biopsy. Mean time of follow up was 1.6 years. M1, E0, S1, T0 were the most common lesions. M, S and T lesions in biopsy were significantly associated with decrease in GFR at the end of follow up. Conclusion: In our study, most common presentation of IgAN was AUA with rarity of macroscopic hematuria. M, S and T lesions were associated with decreased GFR on follow up. Key words: IgA Nephropathy, Nephrotic Syndrome, Oxford MEST classification

Till the early 1990s there was no standardized international classification of renal allograft biopsies resulting in considerable heterogeneity in reporting among the various centers. A group of dedicated renal pathologists, nephrologists, and transplant surgeons developed a schema in Banff, Canada in 1991. Subsequently there have been updates at regular intervals. The following review presents the evolution of the Banff classification and its utility for clinicians.

BACKGROUND The phenomenon of focal segmental glomerulosclerosis (FSGS) in idiopathic membranous glomerulonephritis (IMGN) has not been adequately studied. There is also a paucity of detailed glomerular morphometric and stereologic analyses data on renal biopsy in this association. METHODS Twenty-three (23) patients with IMGN and superimposed FSGS were compared to 35 patients with IMGN alone with respect to the clinical and laboratory features, light microscopic findings and stereologic parameters (glomerular cross-sectional area and estimated glomerular volume). RESULTS In the clinical parameters, patients with IMGN-FSGS had a significantly higher incidence of hypertension, raised serum creatinine and microscopic haematuria. The mean 24-h urinary protein excretion was higher in the group with IMGN-FSGS (7.4 +/- 1.36 g) as compared to IMGN alone (3.85 +/- 0.7 g, P < 0.001, Mann-Whitney test). On light microscopy, biopsies with IMGN-FSGS frequently had mesangial hypercellularity and more extensive tubulo-interstitial disease than those with IMGN alone. Stereological analysis showed that the non-sclerosed glomeruli in biopsies with IMGN-FSGS had a higher mean cross-sectional area (185466.7 +/- 32493.3 micro(2)) and higher estimated volume (855200 +/- 152640 micro(3)) as compared to glomeruli in cases with IMGN alone (76000 +/- 14719.2 micro(2) and 576666.7 +/- 131233.3 micro(3), respectively). CONCLUSION The present study is probably the first systematic analysis of stereologic parameters in renal biopsies of IMGN with FSGS. Our results objectively demonstrate the glomerular enlargement in the non-sclerosed glomeruli in cases of IMGN with FSGS. This detection of enlarged glomeruli may serve to alert the renal pathologist to the possibility of coexisting FSGS, which is a poor prognostic factor in IMGN.

Starfruit (Averrhoa carambola) and its juice are popular in the Indian subcontinent as an indigenous medicine. Oxalate concentration in this fruit and it's freshly prepared juice is very high. We present a report of patients presenting with acute kidney injury due to oxalate nephropathy admitted in a single center. All patients had history of ingesting star fruit. Patients became symptomatic after 10–12 h of eating and main symptoms were pain abdomen and decrease in urine output. Three patients needed hemodialysis. All improved with complete renal recovery. Taking star fruit in large amount on an empty stomach and in a dehydrated state is a risk factor for nephrotoxicity.

Focal and segmental glomerulosclerosis (FSGS) in renal allografts may occur as a recurrence of primary FSGS, as a de novo phenomenon or as a complication of calcineurin inhibitor toxicity. There are very few studies in the literature describing the clinico-pathologic characteristics of FSGS in renal allografts. To the best of our knowledge, no such study exists from the Indian subcontinent. Thirty-seven cases showing FSGS, of 426 transplant biopsies performed over a 4-year period (2006-2009), were included in this study. The pre- and post-transplant clinical data were noted. FSGS was classified as per the Columbia scheme. Appropriate statistical tests were applied. The age of the study patients ranged from 13 to 54 years, with a male preponderance. Thirty-five patients (94.6%) were diagnosed as FSGS more than 12 months after transplantation. All the patients presented with renal dysfunction (median serum creatinine 2.8 mg/dL) and detectable proteinuria at the time of diagnosis. Histologically, FSGS-NOS (70.3%) was observed as the most common subtype, followed by collapsing and perihilar varieties (13.5% each). Most of the biopsies (83.7%) showed grade-2 to -3 interstitial fibrosis and tubular atrophy. Follow-up data were available in 27 patients (73%), of whom 12 (44.4%) had graft loss with dialysis-dependent state at last follow-up. FSGS is one of the important causes of graft dysfunction, especially late in the post-transplantation period in cases of de novo FSGS. The long-term outcome of renal allografts developing this glomerular pathology is quite dismal, with a significant proportion of patients suffering graft loss.

This study was aimed at evaluating the clinicopathologic features of plasma cell-rich acute rejection (PCAR) of renal allograft and comparing them with acute cellular rejection (ACR), non-plasma cell-rich type. During a 2-year period, eight renal allograft biopsies were diagnosed as PCAR (plasma cells >10% of interstitial infiltrate). For comparison, 14 biopsies with ACR were included in the study. Detailed pretransplant data, serum creatinine at presentation, and other clinical features of all these cases were noted. Renal biopsy slides were reviewed and relevant immunohistochemistry performed for characterization of plasma cell infiltrate. The age range and duration of transplantation to diagnosis of acute rejection were comparable in both the groups. Histologically, the proportion of interstitial plasma cells, mean interstitial inflammation, and tubulitis score were higher in the PCAR group compared with cases with ACR. A significant difference was found in the outcome at last follow-up, being worse in patients with PCAR. This study shows that PCAR portends a poor outcome compared with ACR, with comparable Banff grade of rejection. Due to its rarity and recent description, nephrologists and renal pathologists need to be aware of this entity.