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ABSTRACTS
Year : 2016  |  Volume : 26  |  Issue : 8  |  Page : 31-51
 

Oral Presentations



Date of Web Publication1-Dec-2016

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How to cite this article:
. Oral Presentations. Indian J Nephrol 2016;26, Suppl S2:31-51

How to cite this URL:
. Oral Presentations. Indian J Nephrol [serial online] 2016 [cited 2020 Feb 27];26, Suppl S2:31-51. Available from: http://www.indianjnephrol.org/text.asp?2016/26/8/31/195071


Abstract Presented During Annual Conference Of Indian Society Of Nephrology, 2016, Held At Mumbai During 15-18 Dec

1. SAFETY OF METFORMIN IN DIABETICS WITH CKD (STAGE 3-5): AN OBSERVATIONAL FOLLOW UP STUDY

Neeraj Gopinath, Sandeep Barde, Ishanvi Dubey, Gopesh K Modi


Samarpan Noble Kidney Center; Hoshangabad Road; Bhopal; MP

Background: Metformin is recommended as the drug of first choice in patients diagnosed with type-2 diabetes. There are survival benefits associated with the use of metformin besides improvementsin cardiovascular outcomes and metabolic parameters. However; the use of metformin has been limited in patients with renal disease because of the perceived risk of lactic acidosis.

Aim of the Study: Till recently the use of metformin was restricted to subjects with serum creatinine (Cr) <1.5 in males and <1.4 in females.

Methods: In view of its potential benefits; recent guidelines have broadened the scope of use. It can be used when the eGFR is <60 mL/min but remains contraindicated in patients with an eGFR <30. For subjects with eGFR in 30-45 range; it is recommended not to start metformin. With this background; an observational cohort study was conducted to assess the short to medium term safety of metformin in diabetic CKD subjects with advanced CKD (Stages 3-5). The hypothesis was that metformin use in CKD does not cause worsening of acidosis or increase in serum lactate levels. Subjects who presented to the nephrology clinic and who were already on metformin and wanted to continue metformin were enrolled. The variables studied were venous bicarbonate; venous pH and serum lactate at baseline and after a follow up of six months.

Results: Study included 43 subjects with the respective means: age 60.4 yrs.; Cr 4.7 mg/dL; eGFR (CKD EPI) 16 ml/min and metformin dose 1081 mg/day. The proportion of subjects who were in Stage 3; 4 and 5 of CKD were 14; 25 and 61% respectively. No patient developed overt episode of acidosis or increase in lactate level beyond normal levels. It is noteworthy that majority of the subjects were in CKD stage 5 and two patients were on maintenance hemodialysis and did not show any worsening in the outcome variables.

Conclusions: This short-term study did not detect any worsening of lactate or pH levels in patients who were on metformin for diabetes control. Larger studies should be conducted for the safety of metformin in advanced CKD to deliver the benefits of this low cost effective drug.

2. Rituximab: Will it be helpful for difficult nephrotics?

Vishnuvardhan BR, Rajendra Pandey,

Arpita Roy Chowdhury, Arunangsu Banerjee,

Debabrata SenSanjay Dasgupta, Dipankar Sircar


IPGMER and SSKM; Kolkata

Background: Steroid dependent (SDNS) and Steroid resistant (SRNS) types of Idiopathic Nephrotic syndrome are most difficult to treat. There is constant search for Steroid sparing agents with less side effects and greater efficacy. We report efficacy and safety of Rituximab in these patients who are refractory to standard therapy.

Aim of the Study: 1. To assess Complete and Partial remission rates with Rituximab in Difficult SDNS and SRNS patients. 2. To assess Clinical toxicity of Rituximab.

Methods: It is a Hospital based Prospective Interventional Study; conducted in Department of Nephrology; IPGME&R; Kolkata. Patients with SDNS and SRNS; not responding to standard therapy or having serious toxicity; followed up for 12 months were included. Patients treated with Rituximab at a dose of 375mg/m2 once every week for four doses. Those cases who did not achieve complete remission by 6th month received another 2 doses of Rituximab at 1 week interval; unless they had progressed to CKD.

Results: Total 37 patients were included; Two patients did not complete 4 doses of Rituximab due to infusion reaction. one patient expired prior to study period. Another 4 did not follow up for 1 yr. Fourteen patients with SRNS (8 primary; 6 secondary) and 16 with SDNS; with mean ages of 18.42 ± 11.86 and 10.93 ± 5.73 years respectively; were included. Among SRNS patients 4 (28.57%) achieved complete remission; 1 (7.14%) achieved partial remission and 9 (64.28%) did not show any response. Among SDNS patients; mean number of relapses in 1 year prior to and after Rituximab was 2.31 ± 1.13 and 1.31± 0.94 respectively. It is found to be stastically significant (p=0.01). Among 16 patients; 9 patients maintained remission for period of atleast 10 months. Side effects noted were Potts spine (1case); Oral candidiasis (1case); two times lower respiratory tract infection(1case); Spontaneous bacterial peritonitis (1case); suspected fungal sepsis(1case) and 1 death due to sepsis.

Conclusions: Therapy with Rituximab was relatively safe and offers an acceptable second line option in immunosuppression for Difficult SRNS and SDNS.

3. Role of prediction model for risk of progression in idiopathic membranous nephropathy

Dr. Nithin. J, Dr. Renuka. S


St.Johns Medical College; Bangalore

Background: The outcome of idiopathic membranous nephropathy (IMN) in adults varies widely. Data required to obtain prognostic information should be available soon after diagnosis. Prediction of progression is desirable for treatment; given the wide variation in the natural history and potential toxicities of immunosuppressive therapies. Factors of the above model are easily available and being dynamic can be reapplied over the course of the disease.

Aim of the Study: Usefulness of prediction model for risk of progression as an aid in treatment and prognostication of the disease.

Methods: This is a descriptive study. We recorded demographic data; clinical outcome of all the follow up patients in OPD with membranous nephropathy. Serial monitoring of laboratory values were done. We included only those patients regular on treatment and follow up. The risk of progression was calculated using the logistic regression model -X= 1.26 + (0.3x lowest proteinuria in 6 months) -(0.3xslope of creatinine clearance)- (0.05x intial creatinine clearance) and risk (R) being R=ex /(1+ ex ). Categorical data was represented in the form of Frequencies and proportions. Chi-square was used as test of significance. Continuous data was represented as mean and standard deviation. P value <0.05 was considered as statistically significant.

Results: Mean age group in our study was 42.30 ± 13.2 yrs; with 73.9% being males. Mean risk of progression was 2.6 ± 1.8 % among subjects who had remission and 35.7 ± 24 % among subjects who had partial/no remission during the follow up. With <20% progression cut off the risk of progression was 25%; was 33.3% at 20-30% cut-off and almost 100% at cut off of >30%. This observation was statistically significant

Conclusions: The prediction model for risk of progression forms a valuable tool for assessing progression of IMN and aid in treatment and prognostication of the disease. This correlation between various cut off percentages and progression could prove useful in clinical assessment and management.

4. Randomized controlled trial of conventional versus supramaximal dosage of telmisartan for antiproteinuric effect in non diabetic and diabetic renal disease

Umesh Dubey, Dr. Arpita Ray Chaudhury, Dr. Avijit hazra, Dr. Rajender Pandey


Institute of Post Graduate Medical Education and Research and SSKM Hospital; Kolkata

Background: Proteinuria has been a marker of kidney disease and renal and cardiovascular outcomes seem to correlate with the reduction of proteinuria with treatment. On Target study has led to withdrawal of concept of combining ACEI and ARB as better antiproteinuric measure.This study was designed for better understanding of the potential benefits and risks of using dosages of telmisartan greater than those recommended for hypertension or heart failure treatment.

Aim of the Study: To evaluate Percentage change in proteinuria in response to conventional vs supramaximal dose of telmisartan and effect of two drug dosage on serum creatinine and MDRD eGFR.

Methods: Hospital based prospective interventional study done under Department of Nephrology. Patients were recruited from February 2015 to August 2016. Eligible patients had diabetic and non diabetic renal disease with 24 hour urine protein of ≥1 gram/day. Patients with eGFR <30 ml/min per 1.73 m2 [MDRD] and serum potassium level ≥5.5 mmol/L were excluded. All patients who met inclusion criteria received open-label telmisartan 40 mg/day with furosemide 10 mg/day for two weeks. Patients were allocated in two groups and were randomly assigned; to receive either telmisartan 80mg/day or 160 mg/day plus furosemide 10mg/day for 4 months. Primary end point was the percentage change in 24-h urine protein excretion from randomization to the 4th month. Secondary outcomes included effects on renal function as measured by serum creatinine levels and eGFR [MDRD]; BP; and the safety of supramaximal dosage of telmisartan.

Results:Total 100 patients were included in the study who had persistent proteinuria (≥1 gm/day) despite treatment with telmisartan 40 mg/day. Out of 100 patients most (63%) had diabetic nephropathy. After 4 months 79 patients completed the study. The mean difference of the percentage change in proteinuria for patients receiving 80 mg/day of telmisartan was -48.47% (P < 0.005) and those receiving 160 mg/day of telmisartan was -43.34% (P < 0.005). Dosage-related increase in adverse events like; hyperkalemia (K+ > 5.5 mEq/L) were comparable in both groups but decline in eGFR <30 ml/min per 1.73 m2 was more in patients (7 in 160mg dose group) compared to (1 in 80mg group) leading to exclusion of more patients from study in higher dose group.

Conclusions: Supramaximal dose had similar proteinuria reduction compared to conventional dose of Telmisartan ; and incidence of hyperkalemia is similar in both groups. However; creatinine rise and fall in eGFR leading to patient withdrawal from study was more in higher dose group.

5. A study of acute kidney injury in patients admitted to the intensive care unit in tertiary care hospital

Dr. Rahul Sood, Dr. Jasmin Das, Dr. Ashu Mathai


Department of Nephrology; Christian Medical College and Hospital; Ludhiana; Punjab

Background: Acute kidney injury (AKI) is a common complication in intensive care unit (ICU); with increasing incidence & carries a high mortality. Reliable data of AKI is necessary for optimizing management. However there is dearth of controlled studies regarding the epidemiology & prognostic scores to be used in AKI in ICU. This study aims at evaluating the incidence of AKI in ICU using RIFLE & AKIN criteria; assessing the utility of APACHE & Liano scoring in estimating patient mortality & renal recovery.

Aim of the Study: 1. To evaluate incidence of AKI in ICU and to compare RIFLE versus AKIN criteria in early diagnosis of AKI2.To evaluate the performance of APACHE II and Liano scores in predicting hospital mortality.

Methods: A prospective observational cohort study; included 109 patients admitted in ICU from June-August 2015. Patient <18yrs; underlying CKD & ICU stay < 48hr were excluded. Data was collected as per protocol and patients were followed up till discharge from the hospital. The incidence of AKI in ICU was determined by using RIFLE &AKIN criteria. For patients without known baseline; lowest creatinine value during hospitalization was used. For AKIN criteria a rolling baseline over the course of 48hr was used. APACHE II score was calculated from first 24hr of ICU admission & Liano score was assessed from first 24hr of renal replacement therapy (RRT) initiation. Mean; standard deviation was expressed for continous variables. Univariate analysis; one way ANOVA test; Chi square test was used. Multinomial and binary logistic regression analysis was done. A two tailed p value of ≤ 0.05 was considered significant. All statistical analysis was performed using SPSS version 20.

Results: Mean age 48.6 ±19.4yrs; M:F=2.3:1.AKI as per RIFLE - AKI 79pts(72.5%); risk(13.8%); injury(24.8%)& failure(34.9%); versus AKIN criteria- AKI 92pts(84.4%); stage 1(24.8%); stage 2(24.8%); Stage 3(34.9%); showed increased stage 1 AKIN as compared to risk.Patients with AKI- mortality(22%); left against medical advice(29.4%); recovery(48.6%); RRT 28(25.7%). Renal recovery- complete(28.3%); partial(27.3%); no recovery(45.1%).Inotropic requirement- significantly associated with(a/w) AKI(p-0.01)& need for RRT(p=0.004). APACHE II- AKI (23.1±0.7)v/s no AKI (17.3±0.7)(p-0.02) &significant a/w severity of renal dysfunction (17.2±6.4-Stage 1; 23.1±6.5-Stage 3)(p-0.02). High mean APACHE II (22.7±0.6) a/w mortality as compared to recovered(21.0±0.0)(p-0.000). APACHE II - no recovery/worsening(22.6±0.6) vs renal recovery(16.2±7.6)(p-0.000).Liano score- Death(0.8±0.15) vs patient recovery(0.5±0.2)(p=0.008) & significant a/w renal recovery(0.3±0.1) vs no recovery/worsening(0.8±0.2)(p=0.008).

Conclusions: In this cohort incidence of AKI in ICU is high. AKIN criteria help in early diagnosis against RIFLE. AKI and its severity can be predicted by APACHE II. Both APACHE II and Liano are predictive of mortality and renal outcome.

6. A study of acute kidney injury in cases of acute pancreatitis

Prem geovanni J, N Gopalakrishnan, T Balasubramaniyan, J Dhanapriya, T Dineshkumar, R sakthirajan


Institute of Nephrology; Madras Medical College; Chennai

Background: Acute kidney injury(AKI) in acute pancreatitis is multifactorial. Data on clinical profile and outcome of AKI is sparse.

Aim of the Study: To study the clinical and biochemical profile and outcome of acute kidney injury in patients presenting with acute pancreatitis.

Methods: It is a prospective study from September 2015 to august 2016. All patients presenting with acute pancreatitis and AKI were in included. Acute pancreatitis was confirmed by CT abdomen and elevated lipases. Patient with pre-existing kidney diseases were excluded. AKI was staged by AKIN classification. Detailed history; clinical examination; findings noted. Recent investigation ; including Sr. Amylase; lipase; ultrasound abdomen; CT abdomen done. Patient were treated symptomatically and Renal replacement therapy(HD/PD) was initiated for routine indications. Number of sessions of Hemodialysis and outcome at the discharge were noted.

Results: TWENTY FIVE patients of acute pancreatitis had AKI; all were males.twenty one(84%)were chronic alcoholics; in others no obvious cause for acute pancreatitis was evident. At presentation 18( 72%)patients had renal failure; remaining developed renal failure within 5 days of admission.mean peak serum creatinine 5.5 mg/dl. Twenty pts were stage III and 5 in stage II AKIN.sixteen (64%)required RRT(HD-14; PD- 2)mean number of HD given 4.5(range1-13); Thirteen(52%)had serum creatinine <1.5 and 5(20%)had serum creatinine >2 mg/dl at discharge. .outcome includes complete recovery in 13(52%)patients; partial recovery in 5(20%) and death in 7(28%)patients.In our study the mortality rate was 28%.Cause of death were MODS in 4(16%)and hypovolemic shock in 3(12%)patients. Two(8%)patients had pseudocyst as pancreatitis complication. Among the surviving patients length of hospital stay more than 10 days predicted poor recovery (serum creatinine >2.0 mg/dl at discharge).

Conclusions: 1. In our study 13 pts (52%) of AKI with Acute pancreatitis recovered .2. Mortality was - 28%3. Length of hospital stay predicted recovery from AKI.

7. Study of response to calcineurin inhibitors in childhood onset and adult onset steroid resistant nephrotic syndrome

Dr. Sukanya Govindan, Dr. K.L.Gupta, Dr. Raja Ramachandran, Dr. Surjit Singh,

Dr. RItambara Nada


Postgraduate Institute of Medical Education and Research; Chandigarh

Background: Calcineurin inhibitors (CNI) are commonest agents used in the management of steroid resistant nephrotic syndrome (SRNS) due to minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) in children and adults.

Aim of the Study: The present prospective study was undertaken to evaluate the efficacy of CNIs in the management of SR-MCD/FSGS and its correlation with suPAR levels and b3- integrin staining on kidney biopsy.

Methods: In this prospective observational study; we screened 90 patients of SR-MCD/FSGS of which included 76 patients were enrolled in to the study (age: 1-60 years) and started on CNI therapy. All patients were given either tacrolimus (TAC) or cyclosporine (CsA). All patients underwent kidney biopsy before starting CNIs; serum suPAR was measured before starting treatment and at 6 months of therapy in 30 patients and b3- integrin staining was done on kidney biopsy in these patients. Primary outcome: Remission with CNIs (complete remission (CR); partial remission (PR) and no response to therapy was assessed at 3 months; 6 months and 12 months). The secondary outcomes assessed were time required for complete and partial remission; eGFR at end of therapy; adverse effects and correlation of suPAR levels and b3- integrin expression on kidney biopsy.

Results: The commonest histological lesion in our patients with SRNS was FSGS (71.1%) followed by MCD (28.9%). The CR and PR achieved was 22.4% and 22.4% at 3 months; 48.7% and 35.5% at 6 months; 65.8% and 14.5% at 12 months. Children achieved remission earlier (children vs adults = 3.8±3.6 (0-12) months vs 6.02±4.8 (0-12) p= 0.028). Similarly more patients with MCD attained CR at 1 year of therapy compared to patients with FSGS (81.8% vs 59.3%; p = 0.041). The change in eGFR was significantly more in patients with NR compared to patients who achieved CR with CNIs. The baseline suPAR values and those at 6 months did not correlate with response to therapy and did not vary significantly between MCD and FSGS. b3 -integrin staining was negative in all patients.

Conclusion: CNIs are very effective agents in the management of SR nephrotic syndrome due to MCD and FSGS in both adults and children. There was no correlation of serum suPAR and b3-integrin staining on tissue with proteinuria.

8. Il-17/ifn-g double-positive th17 cells selectively express p-glycoprotein and are refractory to glucocorticoid in minimal change disease

Akhilesh Jaiswal 1 , Naraya Prasad 1 , Vikas Agarwal 2 , D R Modi 3

1 Department of Nephrology; 2 Clinical Immunology; SGPGIMS; India; Department of Biotechnology3; BBAU; Lucknow; India

Background: Th17 cells and cytokine IL-17 are involved in many autoimmune diseases. Recently; IL-17/IFN-g double-positive Th17 cell were found to be allied with inflammatory diseases. P-glycoprotein (P-gp) positive Th17 cells are refractory to steroid. P-gp on lymphocyte effluxes out steroid and prevents its action. We conducted this study with hypothesis that P-gp positive IL-17/IFN-g double positive Th17 are one of key pharmacokinetic and pharmacodynamic modulator liable for steroid resistance in nephrotic syndrome.

Aim of the Study: We planned to study the frequency of P-gp expressing pathogenic Th17 cells in steroid sensitive (SSNS) and steroid resistant (SRNS) patients.

Methods: We analysed the frequency of pathogenic IL-17/IFN-g double-positive Th17 lymphocytes and P-gp expression on their surface by flowcytometry in SSNS (n=32; mean age 9.06±5.84) and SRNS (n=28; mean age 11.29±3.73) patients. We also included 15 age and sex matched healthy controls. All patients were biopsy proven MCD and all patients were treated with steroid. All patients were recruited as per criteria of ISKDC.

Results: We found a significant increase in the frequency of Th1 (p=0.001); Th17 (p=0.006) and IL-17/IFN-g double-positive Th17 (p<0.001) cells in SRNS as compared to SSNS patients and healthy controls (p<0.001). Of the total Th1; Th17 and pathogenic Th17; 78.45%; 72.37% and 95.8% cells expressed P-gp on their surface in SRNS;45.0%; 30.27% and 30.1% cells expressed P-gp in SSNS group; and 30.91%; 15.51% and 15.62% in healthy control respectively.

Conclusions: Higher frequency of IL-17/IFN-g double-positive Th17 cell with P-gp expression may be associated immunological and pharmacological factor for steroid resistance in minimal change disease.

9. Establishment of a novel inflamed animal model of diabetic nephropathy

Sumit Kumar, Amrendra Singh, Bal Krishna Negi, Sushila Dogri, Madhulika Bhagat


School of Biotechnology; Jammu University; J and K

Background: It has been demonstrated that diabetic nephrology (DN) is a chronic inflammatory disease. Inflammatory stress plays crucial roles in the progression of DN.Therefore; an inflamed model of DN would be helpful to clarify the pathogenesis of DN.However; an adequate reliable inflamed model of DN is currently lacking.

Aim of the Study: This study aimed to establish a novel inflamed animal model of DN and evaluate its significance in DN.

Methods: Twenty male db/db mice were randomly divided into two groups for eight weeks (n=10; each group): mice with daily distilled water injection (Control) or mice with every one day 10% casein injection (inflamed group). Body weight and 24-hour urinary protein were measured every week. The plasma levels of serum amyloid A (SAA) and tumor necrotic factor-a (TNF-a) were checked by enzyme-linked immunosorbent assay.The morphological changes of renal pathology and ultra-microstructures were checked by pathological staining and electron microscope. Immunofluorescent staining and Western blotting were used to check the protein expression of podocyte specific molecules and inflammatory cytokines in kidneys.

Results: The 24-hour urinary protein; plasma levels of SAA and TNF-a; as well as the protein expression of inflammatory cytokines in kidneys were significantly increased ininflamed group compared to the control. Moreover; there were more significant mesangial expansion; collagen accumulation; and foot process effacement in inflamed group compared to the control. Further analysis showed that inflammation markedly decreased the expression of wilims tumor-1 and nephrin; which were specific biomarkers of podocyte; suggestingaccelerating injuries of podocyte induced by inflammation.

Conclusions: An inflamed animal model of DN was successfully established. This inflamed model may provide a useful tool for investigating the pathogenesis of DN under inflammatory stress.

10. Asssessment of telomere length and mitochondrial dna damage in male patients with chronic kidney disease

Dr. Prasanta Debnath, Dr. Om Parkash Kalra, Dr. Ashish Goel, Dr. Rajarshi Kar


University College of Medical Sciences and GTB Hospital; New Delhi

Background: Patients with CKD have accelerated aging process which may be reflected by reduced telomere length and increased mitochondrial DNA damage. The present study was intended to evaluate telomere length and mitochondrial DNA damage in male CKD patients and compare the same with age matched healthy controls and elderly healthy controls in the age group 61-70 years.

Aim of the Study: To evaluate and to compare telomere length and mt DNA damage between young male CKD patients(31-40 years) with i)healthy male controls of same age ii)elderly male healthy controls (61-70 years).

Methods: A case-control study which included 35 male patients with CKD between ages 31-40 years as the cases; an equal number of age matched healthy male controls and an equal number of elderly healthy male controls in age group 61-70 years; was conducted. Telomere length was measured by Real Time Polymerase Chain Reaction (RT-PCR) for which telomere specific primer was used. Number of copies of mtDNA was estimated by real time PCR using specific primers.

Results: The median (Inter-quartile range) values of relative telomere length in CKD was found to be 15 (6.25-27); and that in elderly controls to be 19 (10-35) and that in age matched controls it was found to be 103 (70-202). Comparing CKD with age matched controls revealed significant difference in telomere length (p<0.001) while on comparing CKD with elderly healthy controls revealed similar results. The median (Inter-quartile range) values of mitochondrial DNA copy number in CKD was found to be 123 (73.75-282.25); and that in elderly controls to be 139 (76-185) and that in age matched controls it was found to be 289 (214-541). Statistical study revealed significant difference in number of copies of mtDNA between CKD and age matched healthy controls but comparable results between CKD group and elderly healthy control group. Further comparing telomere length with number of copies of mtDNA did not reveal significant relationship in any of the study groups.

Conclusions: In our study it was found that telomere length and number of copies of mitochondrial DNA; a marker of mtDNA damage; was markedly reduced in CKD males when compared with healthy male controls of same age group but was comparable with that of elderly healthy controls.

11. Long term outcomes in children transplanted with abnormal lower urinary tract: A single centre experience

Hamsa V, Anil Vasudevan, Priya Pais, Nivedita Kamath, Arpana Iyengar, Bijo T Jose, Anthony Rozario, Shubha AM


St Johns National Academy of Health Sciences; Bangalore

Background: Lower urinary tract abnormalities of various origins are a common cause of ESRD in children. Renal transplantation in children with lower urinary tract dysfunction (LUTD) is a challenging issue and in addition; the optimal urological treatment for such children pre and post renal transplant remains unclear. Although there are conflicting reports about clinical outcomes of renal transplantation in this group of children in the past; favorable outcomes have been reported in recent years.

Aim of the Study: Aim of retrospective study is to review our long-term experience with pediatric renal transplantation and compare clinical outcomes of renal transplant recipients with and without dysfunctional LUT.

Methods: Between 1999 and 2015; 75 renal transplants (28 girls; 47 boys) were performed; 23 renal transplants in 21 children with dysfunctional lower urinary tracts and 52 transplants in 52 patients with normal lower urinary tracts. Demographic features; clinical course; pre- and post -transplant incidence of UTIs; episodes of delayed graft function and acute rejections and graft and patient survival were compared between the two groups. Pre transplant lower tract management strategies included CIC (n=10); bladder augmentation (n=2); and continent cutaneous urinary diversion (n=4). Unilateral or bilateral nephrectomy was performed in 28 children (3 had medical nephrectomy using embolization). Ten children received pre-emptive renal transplant. Six of the patients received kidneys from deceased and 69 from living donors. All patients received CNI based triple immunosuppression with 40 patients receiving induction therapy with Basiliximab. Two children received sirolimus as rescue therapy.

Results: The mean age at transplantation was 12.0 + 4.7 years (95 %CI 11.20-12.90) with a median follow-up after transplantation of 60 months (IQR 34-110). Children who had LUT disorders included PUVs (n=9); reflux nephropathy (n=7) and neuropathic bladders (n=7) with FSGS (n= 16) and isolated hypo-dysplasia (n=9) being the common etiology of ESRD in normal LUT. Twenty two episodes of acute rejection in 19 patients were recorded with no statistically significant differences in rejection episodes between the 2 groups. Twenty eight patients had delayed graft function which was not statistically different between the 2 groups. A higher proportion of UTI was observed in children with LUTD as compared to those with normal LUT (6 & 2 children with 2 or more episodes of UTI post transplantation; p= 0.04). The graft actuarial survival at 1; 5 and 10 years was 94.1 %; 87.0 %; 68 % and 94.1 %; 90.0 %; 85.7 % in with and without LUTD respectively. A similar trend was observed with patient survival.

Conclusions: The presence of abnormal LUT is associated with poorer graft and patient outcome when compared with patients with normal LUT in our cohort. UTIs seem to be more common in those with LUTD. We need to determine the modifiable risk factors associated with poor graft function in these children.

12. Safety; efficacy and outcomes of slow low efficiency dialysis (sled) in critically ill patients with acute kidney injury (aki) in medical intensive care units: A prospective study

Mayur Makasana, Reetesh Sharma,

SB Bansal Manish Jain, Pranaw Jha, Ashish Nandwani, Vijay Kher


Medanta Kidney and Urology Institute; Division of Nephrology and Renal Transplant Medicine; Medanta the Medicity; Gurgaon; India

Background: Sustained low efficiency dialysis (SLED) is increasingly used as a renal replacement therapy in hemodynamically unstable; critically ill patients with acute kidney injury (AKI). SLED decreases the hemodynamic instability seen during conventional intermittent hemodialysis; while reducing resource demands of CRRT. Despite its widespread use; very few studies have evaluated its safety; efficacy and clinical outcomes.

Aim of the Study: To demonstrate safety; efficacy and outcome of SLED in hemodynamically unstable patients in medical ICUs.

Methods: We included hemodynamically unstable patients with AKI from medical ICUs with age more than 18 years of either gender. We excluded patients with AKI who could tolerate conventional hemodialysis or ESKD patients who were on MHD.Blood and dialysate flows were kept at 150 ml/min and 300 ml/min respectively. Net fluid removal and duration of SLED were based on need and hemodynamic status of the individual patient as decided by treating nephrologist. SOFA score was used as severity illness score.efficacy of SLED was assessed in terms of ability to achieve UF goal; correction of acidosis and urea reduction ratio; safety of SLED in terms hemodynamic stability and cardiovascular stability and complications during and after SLED.Outcomes of SLED were assessed at time of discharge and six months later in terms of dialysis dependence; renal parameters(if dialysis independent) and mortality (In hospital and 6 month following discharge).

Results: We analyzed 228 patients with AKI in medical ICUs who underwent 576 SLED sessions over period of six months. Mean age was 57.48 yrs.74% (n=169) were male. Comorbidities were HTN(56%); DM(43%); CKD(33%) and CVD(28%). Sepsis (93%) and hypoperfusion (68%) were most common causes of AKI.Refractory fluid overload (91%) and refractory metabolic acidosis (79%) were most common indication for initiation of SLED. Mean SOFA score was 12.2 ± 7.75. 21/576 sessions required pre mature termination because of hemodynamic instability and death.Planned ultrafiltration goal was achieved in 94% of SLED sessions. SLED was able to correct metabolic acidosis in majority of patients (86.1%).34.8 % of SLED sessions were associated with hemodynamic instability.No documented arrhythmias developed after starting SLED. There were 20 (9 %) patients who experienced bleeding episodes.In hospital mortality occurred in 61% pts and another 13% died on 6month followup.

Conclusions: Our study demonstrated efficacy and safety of SLED in critically ill AKI patients as it was able to achieve planned UF goal and corrected metabolic acidosis in majority of AKI patients and had good hemodynamic tolerability. Hence it is a reasonable and economical option to CRRT.

13. Crescentric glomerulonephritis: An observational cohort on the clinicopathological features; follow up and outcome from a centre in south india from january 2006 to december 2015

Gautam Rajan,Suceena Alexander, G Vasanth, Vinoi George David, Anjali Mohapatra, Shibu Jacob, KakdeShaileshTulsidas, Santosh Varughese, V Tamilarasi


Christian Medical College; Vellore

Background: Crescentic glomerulonephritis (CrGN) is a well defined pathological lesion occurring in a range of renal and systemic diseases in which patient can progress from normal renal function to end stage renal failure within weeks. There is paucity of Indian data regarding crescentic GN. Outcome of the disease varies as the spectrum of the disease varies. Knowing the spectrum of the disease as it is prevailing in our area and the corresponding outcomes will help us to manage patients more effectively.

Aim of the Study: The aim of this study is to evaluate etiology; clinical; biochemical and histological features of crescentic glomerulonephritis with respect to their outcomes on follow up.

Methods: Patients aged more than 18years whose renal biopsy reported as having ≥10% crescents from Jan 2006 to December 2015 were included in the study.Data regarding their clinico-demographic profile; biochemical parameters; histopathological reports; treatment details at index visit; dialysis schedules; morbidity and mortality were retrieved from patient records. Follow up data regarding their dialysis requirement; serum creatinine; proteinuria; albumin and complications if any were collected till January 2016 at each review visit. Data was analyzed for whole cohort and compared separately after dividing the diagnosis into immune complex crescentic glomerulonephritis (IC-CrGN) and non immune complex mediated crescentic glomerulonephritis (NIC-CrGN). Data was analysed using SPSS software 16.0. Data was also analyzed separately for those having > 50% crescents and less than 50% crescents.

Results: A total of 400 patients between Jan 2006-Dec 2015 were included in this study. The mean age was 43 ± 14.3 years with a female: male ratio of 1.3:1 The commonest cause of crescentic glomerulonephritis in this study was lupus nephritis in 28% of patients followed bypauci immune ANCA negative glomerulonephritis in 18% of patients.54.3% of patient had more than 50% of crescents. Most common type of non immune complex type of disease was ANCA negative pauci immune crescentic glomerulonephritis (46.2%). In immune complex type most common cause was lupus nephritis (45%). During index visit discharge 2/3rd of patients in NIC-CrGN were in CKD stage 5/DD; but in IC-CrGN group only 37% were in CKD stage 5/DD which was statistically significant (p=0.000).Oliguria at presentation; Hb< 9 g/dl with hemoptysis; index visit eGFR<15 ml/min; crescents > 60%; moderate to severe interstitial fibrosis in renal biopsy were independent risk factors for dialysis dependency at index visit discharge.

Conclusions: IR-CrGN was the commonest type with lupus nephritis being the commonest cause of CrGN. NIC-CrGN patients were older; anuric and had less extra renal manifestation except hemoptysis; lesser proteinuria; severe renal failure and more glomerular necrosis and severe IFTA in biopsy at presentation.

14. Clinical profile of adpkd patients and role of total kidney volume measurement in estimating renal outcomes

Dr. Krishna Somani, Dr. Hardik Shah,

Dr. Neha Shah, Dr. D. A.Kirpalani, Dr. A.Dixit,

Dr. S. Devikar, Dr. A. L. Kirpalani


Department of Nephrology and Department of Radiology; Bombay Hospital Institute of Medical Sciences; Mumbai

Background: Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disorder that leads to ESRD.Serum creatinine levels rise late in the course of the disease; only after the noncystic parenchyma has incurred serious; irreversible damage.Hence; GFR do not alone adequately assess disease severity in ADPKD.In the present study; we quantified renal enlargement; the hallmark of ADPKD; by CT imaging and evaluated its correlation with conventional renal function parameters.

Aim of the Study: To study the clinical profile of patients with ADPKD and identify factors associated with decline in eGFRTo determine the significance of estimation of Total kidney volume (TKV)

Methods: 30 consecutive pts. with ADPKD underwent detailed assessment as per prescribed format .The eGFR at time of diagnosis and at the last follow up was calculated by CKD-EPI equation and net decline in eGFR was noted. Using plain CT Scan volume of each kidney was determined by manual tracing of ROI (region of interest) in contiguous 1mm thick axial CT slices. The total area of each kidney was then calculated by a computer generated application. The volume of both right and left kidney was added to calculate the TKV and was adjusted for height to make data comparable

Results: Mean age:43.16+-9.61yrs.;M:F=14:16; Mean BMI was 26.03+-8.42 kg/sqm.5 patients were diabetic; 21 were hypertensives.24 patients had liver cysts also.Maximum TKV noted was 2563 ml and minimum was 394 ml with a mean of 1435+-436 ml.Higher values of height adjusted TKV (htTKV) had significant correlation with lower eGFR(r=0.94) and higher Urine Protein to Creatinine ratios (r=0.75) at presentation.Also; Mean htTKV was higher (2165.2+286 ml) in those who were on 3 antihypertensives (n=5) as compared to those (n=8) who were on 2 antihypertensives(1196.6+396 ml); although it was not stastically significant.Comparison between Group A(n=14;decline of eGFR>0.5 ml/min/month)& Group B (n=16; decline of eGFR <0.5 ml/min/month) revealed that factors such as history of cyst haemorrhage; presence of diabetes and NSAID abuse were significantly associated with a rapid decline of eGFR.

Conclusions: Historyofcyst haemorrhage and presence of diabetes accelerates the decline in GFR in ADPKDpts.Volumetric imaging of kidneys and estimation of Total Kidney Volume strongly correlates with declining GFR and degree of proteinuria and should be used as an tool in prognostication and risk stratification.

15 A study of clinicopathological correlation in patients with unexplained and non resolving aki

Dr. Alla Hima Deepti, Dr. Manisha Sahay, Dr. Kiranmai, Dr. P.S.Vali


Osmania Medical College and General Hospital; Hyderabad

Background: A possible strategy aimed at gaining better insight into the pathogenesis of AKI could be based on developing a clearer appreciation of the histopathological changes that occur in this condition. Regrettably; however; no comprehensive review of the histopathological features of AKI has yet been performed.It is particularly important when clinical assessment and laboratory investigations suggest a diagnosis that requires confirmation before disease-specific therapy is instituted.

Aim of the Study: To study the clinicopathological correlation in unexplained and non resolving AKI in patients presenting to the department of nephrology at Osmania General Hospital from January 2012 to August 2016.

Methods: 536 patients who had either non resolving AKI; AKI of unknown cause or AKI with active urinary sediment were biopsied (after taking consent)in the department of Nephrology at Osmania General Hospital over 4 years from January 2012 to August 2016. Patients above the age of 12 years were included in the study. Their clinical presentation and renal biopsy findings were studied and correlated.

Results: Females were 36.9% of the total patients and 63.1% were males.The average age was 55.39+/- 3 years.The most common clinical presentation was unexplained AKI with active urinary sediment(62.1%).Non resolving AKI was the indication for biopsy in 37.9%. Pregnancy related AKI was seen in 8% patients. Snake bite was the cause of AKI in 2.76%. Sepsis was the most common cause of AKI. 11.6% were diabetics with unexplained renal failure.Acute tubulointerstitial nephritis was the most common biopsy finding (19.35%) in sepsis AKI and snake envenomation and pregnancy related AKI; followed by Acute tubular necrosis (17.67%). IgA nephropathy was seen in 8.28% of the cases who presented with unexplained renal failure with active urinary sediment. Hypertensive changes were seen in 6.9% biopsies. TMA was seen in 6.35% patients and DPGN in 7.45%. Other findings included Crescentic GN; CKD (15.46%); MPGN; DDD; diffuse and patchy cortical necrosis.

Conclusions: Renal biopsy is a useful diagnostic tool in patients with non resolved AKI and unexplained renal failure. It helps in prognosticating and guiding the treatment. A complete understanding of the histopathology of a disease is a fundamental step in comprehending its pathogenesis.

16. Mineral and bone disorder in indian dialysis patients - A south indian single centre cross sectional study

Sajeesh Sivadas, S Renuka


St.John's Medical College; Bangalore

Background: Mineral and bone disorder (MBD) in patients with chronic kidney disease is associated with increased morbidity and mortality. Studies regarding the status of MBD treatment in developing countries; especially in Indian dialysis patients are extremely limited.

Aim of the Study: To compare the MBD parameters among PD and HD patients. To compare MBD parameters among various transporters in PD. To look for parameters while addressing P control in HD and PD patients.

Methods: A cross-sectional study of 280 haemodialysis (HD)pts and 55 peritoneal dialysis (PD)pts were enrolled.CKD-MBD status among PD pts according to membrane charecteristics were assesed.Parameters related to MBD; including serum phosphorus (P); calcium (Ca); intact parathyroid hormone (iPTH) were analyzed. Factors associated with hyperphosphatemia were examined. Inclusion criteria-Adult ESRD pts receiving stable hemodialysis (HD) or peritoneal dialysis(PD)for at least 3 months were included. Exclusion criteria -Pts with renal tubule acidosis; multiple myeloma; idiopathic hypercalcemia or metastatic carcinoma of bone were excluded. All participants gave written informed consent prior to data collection. Data collection - Information of sociodemographic status; personal and family health history; dialysis prescription; and medication for MBD collected.Parameters related to MBD; including S.P; Ca and iPTH were measured .Corrected Ca was calculated as total calcium(mg/dL)+0.8×(4 - serum albumin).

Results: Total 335 pts; including 280 HD and 55 PD.Average age was 48.5 ±7.5yrs; 58.5% males.Mean vintage of HD and PD were 38.6±28.2 and 30.6±16 mnts.PDpts were older; and had higher % of females.Main cause of ESRD was diabetic nephropathy in both HD(47.6)and PDpts(44.2).Among PDpts 5(9%)were High; 22(40%)were high avg; 25(45.4%)were low avg and 3(5.4%)were low. Only 40.5%; 41.6%and 33.6% of pts had optimal level of P; Ca andiPTH. There was no statisly signi. diff between P level and % of pts with hyperphosphatemia in both PD and HD. Ca was higher in PDpts compared with HDpts; but no signnt diff in % of pts with hyper or hypocalcemia. Among PD pts lower P seen among high and high avg though not statistically signi. iPTH level statis. higher in the HD pts with those of PD pts P=0.03. In PD pts there was no diff in Ca and iPTH among various transp. More pts in HD were prescribed P binders than those of PD 88.2%vs 58.0%; P=0.03. More HDpts given vitD than PD 78.6% vs 62.2%; P<0.01.

Conclusions: Better control of MBD parameters seen with pts undergoing PD than HD.Among PD pts better Phosphorous control seen among high and high avg though statistically not significant.There are multiple parameters to be looked in to while addressing phosphate control than mere values of Ca; P or iPTH.

17. Aki in decompensated chronic liver disease etiology and outcome

Arun Varghese T, J. Dhanapriya, T.Dineshkumar, R. Sakthirajan, N.Malathy, T.Balasubramaniyan, N. Gopalakrishnan


Madras Medical College

Background: AKI in decompensated chronic liver disease is associated with significant mortality ranging from 55-91%.

Aim of the Study: To study the etiology and outcome of acute kidney injury (AKI) in patients with decompensated chronic liver disease (DCLD).

Methods: A prospective study of AKI in patients with decompensated chronic liver disease admitted from August 2015 to July 2016 was done. AKI was diagnosed and staged as per the revised international club of ascites (ICS-AKI) criteria. Patients with underlying chronic kidney disease were excluded. Demographic data; etiology; mode of renal replacement therapy and outcome were analyzed.

Results: Out of the 89 patients studied 40 were males. Age range was from 28 to 62 years (Mean-42 years). Thirty four patients (38.20%) had hepato renal syndrome (HRS).Septic shock was the dominant cause in twenty five patients (28.08%). Nine patients had upper GI bleed. Fifteen patients had spontaneous bacterial peritonitis. Ethanol use was the most common cause of DCLD in fifty four patients (61%). At presentation nine patients had stage 1 AKI. Eighteen patients developed AKI after hospital admission. Seventy four (84.4%) patients received renal replacement therapy. Eleven (13.3%) patients received IPD and hemodialysis On follow up overall mortality was 72 %( 64/89). Mortality in patients requiring RRT was 86% (54/63). Presence of ascites; hepatic encephalopathy; high MELD score and hyponatremia (p<0.05) showed poor prognosis.

Conclusions: Hepatorenal syndrome is the most common cause of AKI. The mortality rate of AKI patients with DCLD was 72%.

18. Genetic association of mirnas and their corresponding target genes with end stage renal disease

Pradeep Jaswani 1 , Swayam Prakash 1 , Suraksha Agrawal 2 , Narayan Prasad 1 , R.K.Sharma 1

1 Department of Nephrology; and 2 Medical Genetics; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow-226014; Uttar Pradesh

Background: Post transcriptional events account to nearly 97% of kidney function involving the activities of non-coding RNA elements like miRNA. miRNAs are short RNAs of 22-25 nucleotides which regulate cytokine and chemokine expression affecting innate and adaptive immunity. Being a negative regulator; miRNA may suppress or up-regulate the target gene expression. This in turn may affect the vascularization process causing end stage renal disease (ESRD).

Aim of the Study: The aim of the present study was to investigate 20 miRNA and synergistic association of ten significant miRNA with their target genes to find out susceptible and protective alleles of these miRNA's.

Methods: 528 ESRD and 528 age; sex; and ethnicity matched controls were recruited for the current study. Polymerase chain reaction-sequence specific priming (PCR-SSP) based genotyping was performed for twenty miRNAs. Amplification refractory mutation system (ARMS) PCR was carried-out for corresponding target genes of ten significant miRNAs. Statistical analysis was performed using SPSS v.16 (statistical package for social science) and Graphpad Instat.

Results: Significant risk association was observed for mutant genotypes of miRNA23a (OR=5.54; p-value=<0.0001; CI=3.78-8.13); miRNA150 (OR=4.05; p-value=<0.0001; CI=2.72-6.02); miRNA let7e (OR=2.82; p-value=<0.0001; CI=2.05-3.88); miRNA124a (OR=4.01; p-value=<0.0001; CI=2.10-4.69); miRNA198 (OR=2.56; p-value=<0.0001; CI=1.62-4.05); miRNA210 (OR=5.17; p-value=<0.0001; CI=3.22-8.30); miRNA192 (OR=4.64; p-value=<0.0001; CI=2.63-8.19); miRNA296 (OR=8.88; p-value=<0.0001; CI=5.61-14.04); miRNA423 (OR=1.65; p-value=0.0153; CI=1.11-2.46); and miRNA30a (OR=2.49; p-value=0.0114; CI=1.2-5.10) with ESRD. Four corresponding target genes of the above ten significant miRNAs showed susceptibility against variant genotypes of FGFR1 (rs7012413: OR=13.86); STAT3 (rs4796793: OR=29.23); CDK92A (rs3088440: OR=3.90); TGFB1 (rs139977837: OR=4.07).

Conclusions: Mutant genotypes representing SNPs of miRNA198; let7e; and miRNA296 their corresponding target genes were found to be susceptible against ESRD. Functional evaluation of these target genes will reveal there role of these miRNA in disease condition.

19. Peripheral lymphocytes and immunoglobulins in patients with end stage renal disease: A single institutional experience

Ravi Dhital, Mukut Minz, Ranjana W. Minz, Ashish Sharma, Sarbpreet Singh, Deepesh Kenwer and Sunil Kumar


Post Graduate Institute of Medical Education and Research; Chandigarh; India-160012

Background: End Stage Renal Disease (ESRD) refers to an irreversible loss of normal kidney functions and has the prevalence of 13-17% in India. Patients with ESRD are associated with immune dysfunction characterized by impairment in the cellular and humoral immunity and are; therefore; at high risk for infectious complications. No substantial investigation of peripheral immune parameters; in north- Indian patients with ESRD; has been reported.

Aim of the Study: We aimed to monitor peripheral percentage of lymphocyte populations and immunoglobulin levels in north Indian patients with ESRD.

Methods: The study population incorporated 75 consecutive HIV; HBsAg and HCV negative ESRD patients registered for renal transplantation in the department of Transplant Surgery of this institute between July 2013 and August 2014. Two ml of peripheral blood were collected from every patient. In addition; blood samples were collected from 40 age and sex matched healthy controls. EDTA blood samples were used to evaluate the percentage of peripheral Plasma cells (CD20-CD38+CD138+); Total B- cells (CD20+); Naïve B- cells (CD20+CD27-CD38-); Activated B- cells (CD20+CD38+CD138-); Memory B- cells (CD20+CD138-CD27+); Total T- cells (CD3+); T- helper cells (CD4+); Cytotoxic T- cells (CD8+) and Regulatory T- cells (CD4+CD25+FoxP3+)using multicolour flowcytometry. Serum sample was used to quantify total serum IgG; IgA; IgM; IgG1; IgG2; IgG3 and IgG4 using Nephleometry. Results were expressed as Mean ± Standard Error of Mean.

Results: In our cohort of 75 ESRD patients; activated B- cells and Memory B- cells were significantly higher than controls (20.81 ± 0.7616 % vs. 14.37 ± 0.5972%; P<0.0001 and 10.56 ± 0.5813% vs 7.658 ± 0.6626%; P= 0.0025 respectively) while Naïïve B- cells were comparatively lower (61.04 ± 1.691% vs 73.62 ± 1.320%; P<0.0001). We could not demonstrate significant difference in the percentage of peripheral CD3+; CD4+; CD8+ and FoxP3+ T- cells between ESRD patients and Control(P=0.38; P= 0.47; P= 0.18 and P= 0.45 respectively). Serum IgA and IgM levels were decreased in these patients as compared to healthy controls (2.573 ± 0.1002 g/l vs. 7.127 ± 0.0842 g/l; P<0.0001 and 1.620 ± 0.1306 g/l vs. 6.752 ± 0.1025 g/l; P<0.0001 respectively). On the contrary; Serum IgG levels were significantly increased (20.86 ± 0.7859 g/l vs. 17.55 ± 0.5957 g/l; P= 0.0059) along with increase in IgG3 fragment (2138 ± 141.8 mg/l ± 1215 ± 78.65 mg/l; P<0.0001)in these uremic patients.

Conclusions: We could not demonstrate impairment in T- cell compartment in ESRD patients however; they exhibited increase memory and activated B- cells phenotypes. Further; increased level of IgG and IgG3 suggested that there is a strong dysfunction of humoral immune response in patients with ESRD.

20. Study of oxidative stress biomarkers to predict ischemia reperfusion injury and its effects in renal allograft transplant recipients

Sunil Kumar, Ravi Dhital, Ujjawal Sharma, Navdeep Singh, Soham Dasgupta, Seetharam Tejavath, Kunal Kapoor, Jivtesh Singh, Vinay, Praveen, Sarbpreet Singh, Deepesh Benjamin Kenwar, Ritambhra Nada, Ashish Sharma, Rajender Prasad, Mukut Minz


Department of Renal Transplant Surgery; Post Graduate Institute of Medical Education and Research; Chandigarh

Background: Renal transplantation is associated with ischemia reperfusion injury (IRI) of the allograft that further induces Oxidative Stress (OS) in the transplant recipient. OS can lead to lipid peroxidation; increased inflammation; protein oxidation; and DNA damage in the reperfused kidney. Research query: Is OS associated with an increased rate of acute rejection in the allograft? Hypothesis: We hypothesised that significant OS at the time of kidney transplant increases the incidence of acute rejection.

Aim of the Study: a. Evaluation of OS biomarkers in renal allograft recipients before; during and after transplant. b. To look for biopsy proven acute rejection (BPAR) in the recipients and correlate with OS biomarkers.

Methods: This was a prospective study conducted at PGIMER Chandigarh and study duration was 24 months. Thirty seven end stage renal disease patients undergoing living or deceased donor renal transplant were included. Written informed consents were taken and blood samples were drawn at different intervals: before transplant (baseline); 5; 10; 30 min post-perfusion and 2 weeks after transplant. The blood samples were processed for measuring following OS biomarkers: 8-iso-PGF2a (marker of lipid peroxidation); AOPP (marker of protein oxidation); 8-OHdG (marker of Oxidative DNA damage); 3-NT (marker of nitrosative stress) and IL-1b (marker of Inflammation). Patients having early allograft dysfunction (as defined by acute kidney injury network) underwent allograft biopsies and were reported according to the Banff classification of renal allograft pathology. Patients with BPAR (rejection group) were statistically compared with stable graft function (non-rejection group) with respect to OS biomarkers.

Results: The mean age of 37 subjects was 34.57±12.67 years; 83.78% were males and glomerulonephritis was the basic disease in 86.48% subjects. The mean warm ischemia time and cold ischemia time was 4.78±1.54 min and 85.32 ±63.43 min; respectively. Plasma IL-1b levels increased from a baseline value 75.54 ± 66.87 pg/L to 81.91 ± 69.81 pg/L at 5 min post-perfusion of allograft; p<0.05 and then progressively fell down to 65.20 ± 61.41 pg/L at two weeks post transplant; p<0.05. Plasma 8-IsoPGF2a levels also showed increase at 5 min post-perfusion with subsequent fall but change was not statistically significant. Other biomarkers i.e 3-NT; AOPP; 8-OHdG did not show any significant change. 9/37 (24.3%) patients had early allograft dysfunction. 6/9 patients had BPAR; 2/9 had acute tubular necrosis and 1/9 patients had drug toxicity on biopsy. The rejection group (6/37; 16.2%) and the stable graft group (31/38; 83.8%) did not show any significant change when correlated with OS biomarkers.

Conclusions: End stage renal disease patients undergoing renal transplant suffer OS and inflammation after reperfusion of allograft kidney. However this OS tends to normalize after transplant and doesn't increase the incidence of acute rejection in the recipients.

21. Spectrum of renal manifestations in patients with psoriasis

Chandrasekaran K,Dinesh Kumar T, Dhanapriya J, Sakthirajan R, Malathi N, Balasubramaniyan T, Gopalakrishnan N


Institute of Nephrology; Madras Medical College; Chennai

Background: Psoriasis is an immune mediated systemic inflammatory disorder.The prevalence of renal disease in psoriatic patients is unknown.Certain glomerular diseases; including IgA nephropathy; reactive systemic amyloidosis; membranous nephropathy and membrano proliferative glomerulo nephritis have been reported to be more common in psoriatic patients than in the general population.The higher dose of methotrexate may also play a role in nephrotoxicity.

Aim of the Study: To study the spectrum of renal manifestations in patients with psoriasis.

Methods: Patients with psoriasis and renal disease referred to Institute of Nephrology; Madras Medical college were included in this prospective study.The study period was from October 2015 to July 2016.

Results: Nineteen patients were studied; of them 14 were men and 5 were women.Mean age was 50years.Mean duration of psoriasis was 6.3 years and mean psoriasis area and severity index(PASI) was 4.9.Nephrotic syndrome was seen in two(10%)patients; acute kidney injury[AKI] was seen in six[32%] patients and chronic kidney disease[CKD] was seen in eleven[58%]patients.Nine[47%]patients had consumed alternative medicines and four[21%]had taken NSAID.Seven[37%]patients were on methotrexate with a mean cumulative dose of 1080mg..Kidney biopsy findings:two were membranous nephropathy with negative antibodies to M type phopholipase A2 receptor and had consumed alternative medicines; one was IgA dominant post infectious glomerulonephritis[PIGN]; one was lupus nephritis and two were chronic interstitial nephritis.among AKI; three were NSAID related; one was due to hyperuricemia; one was lupus nephritis and one was IgA dominant PIGN.

Conclusions: AKI was the commonest renal manifestation in patients with psoriasis.Nine [47%] had been on alternative medicines.

22. Scrub typhus and acute kidney injury

D.Surendar, T. Dineshkumar, J. Dhanapriya, N. Malathy, R. Sakthirajan, T. Balasubramaniyan N. Gopalakrishnan.


Madras Medical College; Chennai

Background: Scrub typhus is an important cause of acute febrile illness and acute kidney injury/ multi-organ dysfunction.

Aim of the Study: To study the clinical presentation ; complications and outcomes of patients affected by scrub typhus related acute kidney injury.

Methods: Patient who presented to the department of Nephrology ; Madras Medical College; Chennai between January 2012 and August 2106 with acute febrile illness ; acute kidney injury and tested positive for IgM ELISA for Scrub typhus were included in the study. The clinical manifestations; laboratory data including urine analysis; complete hemogram; liver function test; LDH; CPK; peripheral smear study ; CXR; USG; complications and outcome in these patients were studied.

Results: Acute Kidney Injury was staged based on AKIN criteria.Twenty nine patients (65.90%) belonged to Stage III; 9 (20.45%)belonged to stage II and 6(13.63%) to stage I at presentation .Eschar was seen in 33 ( 75 %); jaundice in 22 ( 50 %) and oliguria in 32 ( 72.72%) patients. Twenty eight patients ( 63.63%) presented with multi-organ dysfunction including liver failure in 28 ( 63.63%) ; acute lung injury in 11 (25%) ; CNS manifestations in 15(34.09%) ; shock in 9( 20.45 %) and DIC in 2(4.54%). Leucocytosis was seen in 12(27.27%); thrombocytopenia in 32 (72.72 %); hypoalbuminemia in 26(59.09%) and hypokalemia in 14 (31.81%) patients. Twenty seven patients(61.36%) required renal replacement therapy. Forty two patients were treated with Doxycycline and two with Azithromycin.

Conclusions: 1. Twenty nine patients (65.90%) were in renal failure AKIN Stage 3 and required renal replacement therapy.2. Mortality was seen in 9 patients (20.45%).3. Mortality was high in those who developed dialysis requiring renal failure; hypotension ; hypoalbuminemia and hyokalemia.

23. Igg4 immunostaining in membranous nephropathy

Kawaskar. K,Murugananth S, Anila A, Dinesh Kumar T, Dhanapriya J, Sakthirajan R, Malathi N, Balasubramaniyan T, Gopalakrishnan N


Institute of Nephrology; Madras Medical College; Chennai.Centre for Renal and Urological Pathology; Chennai

Background: Differentiation of idiopathic membranous nephropathy (iMN) from secondary MN(sMN) is sometimes difficult. Various studies have documented 60 -70 % prevalence of serum Anti - Phospholipase A2 receptor antibody ( APLA2RAB) in iMN. Dominance of IgG4 subclass of IgG over GBM in kidney biopsy in iMN has been observed. Hence IgG4 staining of kidney biopsy may aid in analysis of APLA2RAB negative patients with MN in whom potential secondary causes have been ruled out.

Aim of the Study: To study the IgG4 staining pattern in renal biopsy in patients with MN.

Methods: A retrospective study of 17 patients with biopsy proven MN. Investigations including serum APLA2RAB were done. Those who tested positive for APLA2RAB were considered as iMN. Those with identifiable secondary causes were considered to have sMN . Immunoflorescence study for the presence of IgG4 in glomerular capillaries was done from archival paraffin kidney biopsy block.

Results: Of the 17 patients 9 were males. Mean age was 37 years (Range : 13 - 65). Of the four patients of iMN ( serum APLA2RAB -positive) 3 showed positivity for IgG4 staining (75%). Five patients had secondary causes (lupus nephritis -3; hepatitis B -1; history of native medicine intake -1 ). Of these only one patient had positivity for IgG4 staining (20%). Of the eight patients with presumed iMN ( secondary causes ruled out by appropriate tests and followed for atleast 6 months; but serum APLAR was negative) 6 had positivity for IgG4 staining (75%).

Conclusions: 1. There is significant concordance between serum APLA2R antibody positivity and IgG4 staining (75%)in kidney biopsy can be considered as a marker of iMN.2. Glomerular basement membrane for igG4 in kidney biopsy can be considered as a marker of iMN.

24. B-type natriuretic peptide as predictor of mortality in chronic kidney disease patients admitted in nephrology intensive care unit

Bhawane Amol Rameshrao, Narayan Prasad, R K Sharma, Amit Gupta, Anupama Kaul, Dharmendra Bhadauria


Department of Nephrology; SGPGIMS; Lucknow

Background: The role of B-type natriuretic peptide (BNP) and other cardiac biomarkers like CK-MB and troponin I (cTnI) as a prognostic factor in chronic kidney disease (CKD) patients admitted to the nephrology intensive care unit (ICU) is not yet established.

Aim of the Study: We aimed to determine whether these cardiac biomarkers are predictive of ICU mortality in critically ill CKD patients.

Methods: It is an observational study that involves 140 CKD patients admitted in nephrology ICU from January 2015 to July 2015. The median age was 56.5 years (range; 19-76 years); and 98 (70%) patients were male. Patient's data; parameters including BNP; CK-MB and cTnI levels; SOFA and APACHE II score were recorded prospectively.

Results: Study showed median BNP level at presentation was 997.5 pg/ml(range 8-5000); median troponin I level at 0.28 (range 0.01-10) ng/mL and CK-MB level at 1.42 ng/mL (range 1-17.6). The median APACHE II score was 25.5 (range 10-39) and SOFA 15 (range 4 -21). The ICU mortality rate was 49.3 %. Study revealed lower BNP values for survivors (567 pg/mL; range 5-5000 pg/mL) as compared to non-survivors (1980 pg/mL; range 287-5000 pg/mL) and lower CK-MB values (1.3 ng/mL; range 1.0-17.6 ; p<0.001) in survivors as well. However; troponin I was non-significant. The area under curve (AUC) observed was 0.81 (95% CI=0.73-0.88) for BNP; 0.54 (95% CI=0.45-0.64) for troponin I; and 0.66 (95% CI=0.57-0.75) for CK-MB. Univariate logistic regression to predict ICU mortality revealed significant predictive power for APACHE II (p=0.001); SOFA (p<0.001); CK-MB (p<0.001) and BNP (p<0.001) but not for troponin I (p=0.10). Multivariate regression revealed significance only for BNP (p < 0.001) and CK-MB (p=0.03).

Conclusions: In conclusion; level of cardiac biomarkers increases in CKD patients. Also; BNP and CK-MB level was significantly elevated in non survivors in critically ill CKD patient admitted in nephrology ICU. These two cardiac biomarkers also help to predict the ICU mortality in critically ill CKD patient.

25. Etiological profile clinical andhistopathological correlation and outcome of 'glomerulonephritis with dominant c3 deposits' in renal biopsy

Murugananth S, Rajasekar D, Dinesh kumar T, Dhanapriya J, Sakthirajan R, Balasubramaniyan T, Gopalakrishnan N, Anila A 1


Department of Nephrology; Madras Medical College; Chennai; 1 Renopath Center For Renal and Urological Pathology; Chennai

Background: 'Glomerulonephritis with dominant C3' is used as a morphological term for those cases with dominant staining of complement component C3.[(Dominant is defined as either lone C3c deposits or intensity ≥2 orders of magnitude more than any other immune reactant on a scale of 0 to 3.

Aim of the Study: To study the etiological profile; clinical and histopathological correlation and outcome of 'glomerulonephritis with dominant C3 deposits.'

Methods: It was a retrospective and prospective study. All patients who were diagnosed to have'glomerulonephritis with dominant C3' in renal biopsy were included.Electron microscopy(EM) showingintensely osmiophilic deposits in the glomerular basement membrane were considered to have dense deposit disease(DDD).Patients with sub endothelial and or mesangial deposits on EM or persistent hypocomplementemia beyond 12 weeks or MPGN pattern with dominant C3 deposits in kidney biopsy were considered to have C3 glomerulonephritis(C3GN). Patients were considered to have infection related glomerulonephritis(IRGN) if they have evidence of past or concurrent infection or normalisation of serum complement levels at three months of diagnosis.Relevant investigations and renal biopsy were done in all patients. EM was done only in 17 patients. Hemodialysis was done when required. Drug therapy included intravenous methyl prednisolone; oral prednisolone or supportive management with ACEI; ARB and statins.

Results: Ninety patients were studied. Mean follow up period was 12.3 months. Etiology were IRGN in 66 (73.3%); C3GN in 22 (24.4%)pts and DDD 2 (2.3%)patients. Of C3GN renal failure was seen in 14(63%) and Low complement in 9(41%) patients. In C3GN 1 (4.5%) had complete remission; 4(18%) had persistent proteinuria; 9(41%) developed CKD 3 & 4 and eight (36.5%) progressed to ESRD. Dialysis requirement and low serum C3 level at presentation were significant for progression to ESRD. Two patients had DDD - one presented with proteinuria and other with renal failure. Common presentation in IRGN were edema and hypertension. Renal failure was present in 69%. In 28 (42%) patients steroids were used. Of them 10 achieved remission. In total 37(56%) had complete remission; 6(18%) had persistent proteinuria; 12 (18%) had CKD 3 & 4 and nine (13.6%) progressed to ESRD in IRGN group. Infective focus; renal failure requiring dialysis; and crescents in renal biopsy were significant to progress to CKD in IRGN.

Conclusions: 1. Etiology of 'glomerulonephritis with dominant C3' in our study was IRGN -73% and C3 glomerulopathy - 27%. 2. Progression to ESRD was 38% and 14 % in C3 glomerulopathy and IRGN respectively.

26. Blindspots in hla antibody testing

Ajay Kher, Pranav Dorwal Vijay Kher


Fortis Escorts

Background: Single antigen bead (SAB) is used to assess presence of donor specific antibodies pre and post transplant and for antibody mediated rejection. Patients with a positive crossmatch (XM) with no identified donor specific antibody (DSA) by SAB testing are thought to be false positive (non HLA antibodies) and taken for transplant with no additional interventions. HLA is polymorphic and SAB cannot include all possible HLA alleles.

Aim of the Study: This study was conducted to assess Indian population frequency of alleles missing from single antigen bead (SAB) panels & frequency of allelic antibodies (Abs).

Methods: All positive SAB results in last 6 months were analyzed. Abs were defined as allelic (eg: A*11:01 positive; A*11:02 negative); antigenic (both A*11:01 & A*11:02 positive) or undefined (if the SAB only had one allelic bead for the antigen eg: A*23:01 positive; no other A*23 allele bead). Class II analysis was limited to DRB.Missing HLA alleles were identified by comparing SAB panels from 2 companies (Immucor and One Lambda) to alleles present in 185; 391South Asian Indians typed by National Marrow Donor Program (USA) (Source: allelefrequencies.net). Alleles absent from both or at least one of the 2 panels were included.

Results: Indians had many missing alleles and though their individual frequency was rare; combined together this was frequent. For HLA A 11 alleles were missing with 25% frequency; HLA B 25 alleles were missing with 58% frequency; HLA C 13 alleles were missing with 71% frequency; HLA DRB1 22 alleles were missing with 40% frequency. 42 patients had 396 Class I antibodies; of which the majority 267 (67%) were undefined. Of the 129 defined antibodies; 33 (26%) were allelic antibodies. 25 patients had 91 class II antibodies of which 38 (42%) were undefined. Of the 53 defined class II antibodies; 10 (19%) were allelic antibodies.

Conclusions: Many HLA alleles are missing in SAB panels. Each missing allele may be rare but collectively missing alleles are common.Allelic antibodies are about 19-25% of defined HLA antibodies. This combination of blindspots need to be recognised.

27. Profile and clinicopathological predictors of outcomes of patients with membranous nephropathy

Sindhu Kaza, Ravindra P, Shankar P, Dharshan R


Kasturba Medical College; Manipal

Background: Membranous nephropathy (MN) is a slowly progressive disease of the kidney and is the second most common cause of nephrotic syndrome in adults after FSGS.Primary MN accounts for 75-80% cases.Mtype phospholipase A2 receptor (PLA2R) is a major human antigenic target in adult IMN.Immunosuppressive agents should be used for patients who suffer from refractory proteinuria or complications associated with nephrotic syndrome.

Aim of the Study: 1.To study the clinical profile of patients presenting with MN.2. Treatment received by the patients; response to therapy and side effects of therapy.3. Clinicopathological predictors of outcomes.

Methods: Retrospective observation study carried out for 2 years from 2014-2016 on all biopsy proven MN patients. Demographic; clinical; biochemical and histopathological data were noted. Treatment received by the patient; side effects of therapy; time to remission (complete/partial); relapses; treatment of relapse and outcomes (complete remission; partial remission; CKD) were studied. Clinicopathological factors like proteinuria; renal function; antiPLA2R levels at presentation and glomerulosclerosis and IFTA on biopsy and their association with remission were studied.Statistical analysis was done using SPSS version 16. Mean of continuous variables were compared by independent sample t test; categorical variables by chi square test. p value < 0.05 was considered significant.

Results: 96 patients were included.89 patients (92.7%) had primary MN; 7(7.3%) secondary MN. 1 secondary to Hepatitis B; 1 thyroid malignancy and 5 Lupus nephritis. Mean age of study population was 44 ±2.3; males constituted 60.4%.Common presenting complaint was pedal edema and most common presentation was nephrotic syndrome.Least serum albumin was 1.2 gms/dl with maximum proteinuria being 14gms/24 hours.Modified Ponticelli was the first immunosuppressive regimen of choice in 90% (Patients and physicians choice).Most common side effects of therapy were steroid induced diabetes followed by endoxan induced cytopenias and ACEIs/ARBs induced hyperkalemia. Proteinuria; renal failure; AntiPLA2R antibody levels at presentation; glomerulosclerosis and IFTA on biopsy had significant correlation with outcomes (p value < 0.05).

Conclusions: Idiopathic MN is the most common form of the disease.High levels of nephrotic range proteinuria; renal failure and chronicity on biopsy had unfavorable outcomes.Anti PLA2R antibodies may help in predicting response to therapy.

28. Familial hypomagnesemic hypercalciuric nephrocalcinosis (fhhnc) type i due to claudin 16 mutation

Dr. Mahajan Sameer Ashok, Dr. Saravanan M, Dr. Doshi Manan Virendra, Dr. Patil Rohit.


Apollo Hospitals; Chennai

Background: Nephrocalcinosis is characterized by calcium deposition in the kidney parenchyma and tubules. The incidence in pediatric patients is likely to be underestimated but is considered to be approximately 10% of that in adults. Children are more likely to have an underlying metabolic disorder and carry a higher risk of stone recurrence or progression of nephrocalcinosis to ESRD. Identification of metabolic abnormalities that predispose to nephrocalcinosis is thus imperative.

Aim of the Study: Here we discuss a 10 year old female child born out of non-consanguineous marriage; presented with mild azotaemia and medullary nephrocalcinosis diagnosed as FHHNC type I due to claudin 16 mutation.

Methods: She was diagnosed to have medullary nephrocalcinosis due to hyperparathyroidism elsewhere and came for further workup. She had a family history of brother passing gravels in urine. On evaluation she was malnourished and stunted with normal blood pressure. Eye and ENT examination was normal. On investigation she was found to have normal calcium; phosphorus levels; slightly elevated PTH and Uric acid levels. ABG and Vitamin D levels were normal. Parathyroid scintigraphy was normal. On further probing; she had hypomagnesemia with hypercalciuria and renal magnesium wasting.

Results: On genetic analysis; she was found to have claudin 16 mutation. Hence final diagnosis of FHHNC type I was made. She was treated with thiazide diuretics; potassium and magnesium supplements and salt restriction with high fluid intake.

Conclusions: She was diagnosed to have FHHNC type I based on genetic analysis and presentation. This is the first case report in India where the diagnosis of FHHNC type I was proved based on genetic analysis. Prior to this there have been two case reports of FHHNC from India.

29. Efficacy of oral ascorbic acid in improving anemia in chronic kidney disease patients

Sarat Chandra V, Sangeetha B, Praveen N, Harikrishna M, Anil Cv Kumar, Ram R, Siva Kumar V


Sri Venkateswara Institute of Medical Sciences; Tirupati

Background: Anemia in chronic kidney disease is multifactorial with chronic inflammation and oxidative stress being one of the major factors. Ascorbic acid (vitamin C) in addition to its antioxidant property; has shown to mobilise iron from its stores; making it available for erythropoiesis and thereby improving anemia.

Aim of the Study: To study the role of ascorbic acid in improving anemia in chronic kidney disease patients when given along with parenteral iron therapy.

Methods: IV-FER;:Iron sucrose iv administration is a dark brown solution of pH: 10.5 to 11.1 with an osmolarity ranging from 1150 to 1350 mOsmol/L. Vitamin C given as oral chewable tablet Limcee containing 100 mg of L-ascorbic acid plus 450 mg of sodium ascorbate in each 500 mg tablet.We conducted an open-label randomised parallel study on the effects of 3 months of 500 mg oral ascorbic acid plus intravenous iron sucrose given 3 times a week(n = 108) compared with intravenous iron sucrose alone given thrice a week (n = 83) on haemoglobin and serum ferritin levels in 191 chronic kidney disease patients not on haemodialysis. A total of 227 patients were enrolled in the study; 11 patients were excluded as they did not consent for the study. The remaining 216 patients were randomised openly with 101 patients receiving only IVFER and 115 patients receiving both IVFER plus LIMCEE. 18 from IVFER only group and 7 from IVFER plus LIMCEE group lost follow up and were hence excluded from the study.

Results: The male to female ratio in IVFER only group and IVFER plus Limcee group is 2.32:1 & 1.51:1 respectively. The mean eGFR (through MDRD) in IVFER only and IVFER plus Limcee group is 51.2±12.8 & 47.9 ± 14.3 ml/min/1.73m2 respectively. The mean haemoglobin before and after therapy in IVFER only group was 9.5 & 10.1 mg/dL respectively while it is 9.8 & 11.3 mg/dL before and after therapy in IVFER plus Limcee group respectively. The p-value for haemoglobin is < 0.0001 which is extremely statistically significant on T test.The mean serum ferritin before and after therapy is 81.1 & 325.73 ng/mL in IVFER only group and 61.8 & 291.58 ng/mL in IVFER plus Limcee groups respectively. The p-value is 0.1727 which is not statistically significant on T test.

Conclusions: Mean haemoglobin rise was higher when ascorbic acid is added compared to iv iron alone which is statistically significant. Mean serum ferritin rise with addition of ascorbic acid to iv iron was not statistically significant. Hence routine use of ascorbic acid in renal anemia needs further studies.

30. Emphysematous pyelonephritis - A case series from a single centre in southern india

Dr. Phanisri Alaparthi, Dr. Shobhana Nayak,

Dr. Pradeep Shenoy M, Janardhan Kamath


K. S. Hegde Medical Academy ; Medical Sciences Complex; Derlakatte Mangalore 575013; Karnataka; India

Background: Emphysematous pyelonephritis (EPN) is a rare; severe form of infection of the renal parenchyma and the collecting system characterized by gas production.Over the last decade; the mortality associated with this condition has improved due to advances in medical care as well as increasing awareness and decreased threshold of use of imaging techniques in patients with severe urinary tract infection. We present our case series of patients EPN from a single centre.

Aim of the Study: To elucidate the predisposing factors; clinical course and outcomes of patients with emphysematous pyelonephritis and to compare the prognostic factors and modalities of treatment among them.

Methods: Retrospective chart review of patients diagnosed with EPN between January 2014 to May 2016 was done and relevant patients were included. Demographic characteristics; imaging modality and CT grading; clinical presentations as well as and biochemical parameters; course of illness and outcomes were assessed.

Results: We had a total of 12 patients; mean age of 59.9years. The mean serum creatinine at admission was 3.19 mg/dl. 11 patients (91.6%) were diabetic with poor glycemic control .5 patients (41.6%)also had obstructive uropathy as an additional risk factor. E.coli was the predominant infective organism in 10 (83.4%) patients.10 patients (83.3%) had renal failure at presentation among which 3 (25%) patients were in septic shock and 3 (25%) required renal replacement therapy. 7 (58.7%) patients had grade I; 2 (16.6%) patients had grade II; 3 (25%) had grade III emphysematous pyelonephritis according to CT. All were treated with IV antibiotics ; of these 6 (50%) patients required DJ stenting and 3 (25%) patient required percutaneous drainage. 10 (83.4%) patients recovered.Our analysis did not show any significant risk factor predicting outcome such as thrombocytopenia; renal failure at presentation or hypoalbuminaemia which has been described.

Conclusions: With the limitation of our study design and small sample size; we can conclude that patients with CT grade 2 and below can be managed successfully with minimal intervention.

31. Imbalanced th17/treg cell frequency is associated with chronic active antibody mediated rejection in renal allograft recipients

Brijesh Yadav, Narayan Prasad 1 , Vikas Agarwal 2 , Vinita Agarwal 3 Manoj Jain, R K sharma 1

1 Nephrology and renal transplantation; 2 Clinical immunology; 3 Pathology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; India

Background: Chronic antibody mediated rejection (CABMR) poses challenges for the clinicians and researchers as well. Th17 cells function as B-cell helpers for the survival; proliferation and differentiation into immunoglobulin-secreting Plasma B cells. IL-17 defiecient mouse impaired to develop antibody. Tregs suppress inflammatory cell and promote graft survival. However; Treg and Th17 cells share a differentiation pathway involving TGFb with IL-6 serving as a switch favoring Th17 differentiation.

Aim of the Study: To compare the frequency of Th1; Th2; Th17 andTregs; soluble and biointact cytokines in blood; PBMCs culture supernatant; mRNA transcript (T-bet; GATA-3; RORCand FoxP3) expression in allograft of patient.

Methods: Total 42 allograft recipients; 10 with SGF and 32 of CAABMR were recruited. The mean in SGF vs CAABMR of age was(40.90±12.67 vs 37.93±12.78 years); Post-transplant interval at biopsy was (49.70±22.71 vs 70.18±34.4; months); Serum creatinine (1.23±0.18 vs 2.40±0.8; P=0.001. mg/dl); 24hrs proteinuria (0.13±0.10 vs 2.94±1.53; P<0.001 g/day). SGF was defined with<10% cortical surface area with IF/TA on biopsy and stable graft function in last 6 months. CAABMR was defined per Banff 2013 criteria. Frequency of Th1; Th2; Th17 and Treg was analyzed by flow cytometry and IFN-g; IL-4; IL-17A; IL-6 and IL-10 level was analyzed from Serum and PBMCs culture supernatents by ELISA and intragraft mRNA transcript expression by Taqman Real time PCR from graft specimen. Fold change was calculated by 2^^-ct method relative to SGF.

Results: Circulating frequency in CAABMR vs SGF of Th1 cell was 23.65±5.93and 22.2±8.79; P=0.55; Th2 2.28±1.0 and 2.51±0.80; P=0.52; CD4+Th17 7.84±1.99 and 4.73±1.22; P<0.001; and CD4+CD25+FoxP3+ Treg was 2.25±1.02 and 3.70±1.55; P<0.001; respectively. Ratio of circulating Th17/Treg was higher in CABMR (4.30±2.30) than SGF patients (1.80±1.65; p<0.001). Soluble cytokines level (pg/ml) in CABMR vs SGF of IFN-g 109.8±23.7 and 82.36±24.97; P=0.003; IL-17 ; 66.97±18.27 and 42.09±15.9; P<0.001; and IL-6; 57.11±12.92 and 42.94±12.20; P=0.004 ; and IL-10 ; 98.91±17.0 and 149.85±22.51; P<0.00; respectively. Similarly; biointact soluble IFN-g; IL17A; IL-6; level was higher in CAABMR and IL-10 level was higher in SGF. Intragraft mRNA transcript expression in CAABMR vs SGF of T-bet was 2.79±1.62 and 1.03±0.05 ; P<0.002; RORc 2.53±0.98 and 1.02±0.076; P<0.001; FoxP3 1.69±0.83 and 0.98±0.069; P=0.011 respectively. Intragraft RORc/FoxP3 ratio was also higher in CABMR than that of SGF patients.

Conclusions: Greater mRNA tissue transcript of Th17; circulating Th17 frequency; and IL-17in serum and culture supernatant; and lower Tregs in CABMR as compared to SGF suggests that Th17 is associated with CABMR.

32. Multiplex polymerase chain reaction based detection in culture negative peritonitis

Ilangovan Veerappan 1 , R Balasubramaniam 2 , S Ramasamy 1 , Ranjini 1


KG Hospital and Post Graduate Institute; Coimbatore; Tamil Nadu; India; Kavery Hospital; Chennai; Tamil Nadu; India

Background: Culture negative peritonitis is the Achilles heel in the treatment of CAPD peritonitis. The use of multiplex polymerase chain reaction based diagnosis has not been tested systematically.

Aim of the Study: To evaluate if multiplex polymerase chain reaction [mPCR] based detection method can be used in isolation of organism in peritoneal dialysis[PD] peritonitis.

Methods: All patients with PD peritonitis in addition to routine culture techniques with inoculation in automated blood culture and enriched blood agar; mPCR based detection by commercially available 'Xcyton' was done. The samples were collected to avoid contamination and transported at room temperature to the lab located in Bengaluru.

Results: The study period was 30 months with 85 patients; eight died; 11 received transplantation; five transfered to hemodialysis and two were lost to follow up. The mean age was 60.3±2 yr; 30/38 [79%] males; 23/38 [61%] diabetes mellitus. The mean patient survival and technique survival were 30 and 24 months respectively. There was 49 episodes of peritonitis in 38 patients which included two relapse in two patients. The peritonitis rate was one in 80 patient-months. The mPCR was sent in 27 episodes and consent was denied in 22 episodes of peritonitis. The culture positive rate by routine technique alone was 36/49 [73%]; mPCR technique alone was 21/27 [78%]. When both techniques were combined; the positive rate was 44/49 [90%]. The concordance between routine and mPCR detected organism was 10/12 [83%]. Gram negative bacilli was seen in 23 episodes [59%]; gram positive was seen in 12 episodes [31%]; Aspergillus in three [8%] and Tuberculosis in one patient [2%].

Conclusions: The mPCR technique significantly increased the culture positive rates. The mPCR technique is accurate and mPCR based testing may be used centers with high culture negative rates by routine culture technique.

33. Cryopreservation preserved the mechanical properties of kidneys after decellularization

Baldeep Channi, Veena Puri, Ranbir Chander Sobti and Sanjeev Puri


Panjab University; Chandigarh-160014; and BBAU lucknow

Background: Without compromising mechanical integrity a decellularization protocol was carried to store rodent kidneys so that effect of storage does not interfere with decellularization process. In this study we used a method for cryopreservation of kidney in cryroprotectant solution to maintain its mechanical and other properties after decellularization. The scaffold thus generated could be used in renal tissue regeneration.

Aim of the Study: To study the effect of Cryopreservetion on mechanical properties of decellularized renal bioscaffold.

Methods: Kidneys were harvested from a rat and then cryopreserved in cryoprotectant solution at liquid nitrogen. After 3 month's cryopreserved kidney were thawed and decellularized by perfused with 1% SDS solution for 3 days along with fresh kidney taken as control. Decellularization was confirmed by staining with Haematoxylin & Eosin staining and SEM. Mechanical testing of the cryopesreved decellularized kidney scaffold was carried out by measuring the stress to strain ratio. and compared with the whole wild type kidneys. The GFP labelled stem cells were exploited to observe the extent of recellularization of the renal tissue. Histogical analysis was exploited to characterize the cell specific lineage of the recellularized structures.

Results: ssessment of the mechanical properties of the both freshly isolated and cryopreserved kidneyshowed a progressive rise in tensile strength after decellularization.The maximum stress that the decellularized kidneys whether cryopreserved or not; could withstand before rupture was higher as compared to the native kidney. The maximum load withstood by cryostored kidney and freshly isolated kidney was 1.55Mpa and .66 Mpa respectively which was higher as compared to native which withstood only .20 Mpa load. These variations are justified as after the loss of nuclear and cellular components; decellularized scaffolds left with only extracellular matrix nothing to hold anything (cells) and become more flexible so withstand more load before rupturing. Overall results showed cryo preservation did not affect mechanical strength of kidney after decellularization. The GFP Labelled Stem cell could find their niche and expressed the PAX as lineage marker of Kidney.

Conclusions: This work presents approaches for the process analysis and non-destructive evaluation of cryopreservation on decellularization process. Cryopreserved kidney can be used for production of decellularized scaffold for regeneration of whole organ kidney as alternate to kidney transplant in ESRD.

34. Tuberculosis in renal transplant recepients: Our story over a decade!!

Dr. Manns Manohar J, Dr. E Mahesh


M S Ramaiah Medical College and Hospitals

Background: Tuberculosis (TB) is a common and an important infective complication affecting renal transplant patients especially in a developing country like India. TB in transplant recipients poses a challenge to the physician owing to its atypical and extra-pulmonary manifestations; drug interactions between anti-tubercular drugs and immunosuppressant's; side-effects from the drugs and increased mortality rate amongst those affected.

Aim of the Study: Our objective was to describe the pattern and risk factors of TB infection and the prognosis in our transplant recipients.

Methods: 0 In this retrospective study; of the 244 patients who underwent renal transplant at our center; between the years 2004 to 2015; 21 patients were diagnosed to have TB and received treatment. Diagnosis of TB was made on bacteriological; histological; and/or therapeutic proof. Patient's demographic data; Statistical analysis was done using SPSS software version 17.0 Values were expressed as mean; median ± standard deviation.

Results: 244 patients underwent Renal transplant at our center between the year 2004 till 2015. Of these; 21 patients were diagnosed with TB; incidence being 8.6%.The occurrence of TB in the post transplant period was highest between 2-3 years post transplant; with a median age of 2.5yrs. Most common clinical symptomatology at presentation was fever; followed by weight loss and cough with expectoration. One-third of the patients had received induction with basiliximab; ATG and Dacluzimab. 09 patients had concurrent opportunisitic infections like Hepatitis B; Hepatitis c; CMV; Candida and Mucormycosis. Diagnostic modality which aided the diagnosis of TB were radio-imaging (n=12); sputum smear (n=7); culture (n=03); Polymerase chain reaction (n=05) and histology (n=2)Pulmonary TB was the most common type of TB in these patients (57%); extra-pulmonary TB was seen in 43%; The crude mortality rate that can be attributed to TB was 19%.

Conclusions: Indian renal transplant patients face a high risk of TB owing to their immunocompromised status and epidemiological prevalence of the disease; the challenge being the atypical presentation with a high frequency of extra-pulmonary and disseminated forms of TB seen in transplant recipients.

35. Clinical spectrum of diarrhea in renal transplant recipients

Dr. Amit Katyal, Dr. Vishal V Ramteke, Dr. Madan M Bahadur, Dr. Rushi V Deshpande


Jaslok Hospital and Research Centre; 15 Dr. G Deshmukh Marg; Mumbai- 400026

Background: Diarrhea post renal transplantation is common. Infective diarrhea due to C.difficle is seen in early post transplant period; while later it could be due to viral ; parasitic; bacterial infections. Drugs like MMF; CNI; m-Tor inhibitors; Monoclonal antibodies too can cause diarrhea. It can lead to graft dysfunction due to increased CNI levels and dehydration. The study aims at investigating causes of diarrhea post renal transplant and its impact on CNI levels and renal allograft function.

Aim of the Study: To study 1.The risk factors and causes of diarrhea in renal transplant recipients2.The effect of diarrhea on tacrolimus levels3.The effects of diarrhea on graft function.

Methods: 0 A prospective study was conducted on 152 renal allograft recipients transplanted between April 2013-Oct 2014; followed up till April 2015 at Jaslok Hospital; Mumbai. Patients with severe diarrhea (>3 stool per day for 7 days and/or >3 stools per day with weight loss >= 2 kg and/or fever and/or mucus and/or blood and/or requiring hospitalization for evaluation/treatment) were cases while rest were controls. Patients with chronic diarrhea and malabsorption were excluded. Induction agents; Triple maintainance immunosupression; infection prophylaxis was as per centre protocol. Those with severe diarrhea were admitted & stool microscopy+ culture done. Infective diarrhea was treated with pathogen specific drugs & hydration was done. Tacrolimus trough levels and RFT were done during diarrhea and dose of tacrolimus adjusted. SPSS Ver 17 was used for data analysis.Binary logistic regression analysis was done for risk factors for diarrhea.P value < 0.05 was taken as level of significance.

Results: 1.21% recipients had severe diarrhea with mean time of onset from transplant-5.94 mon.2.The mean duration was 14.7 days.3.Those with severe diarrhea had a)raised sr creatinine (pre-diarrhea 1.19mg%-SD 0.28 & during diarrhea 2.31 mg%-SD 0.93; p value < 0.05)b)reduced weight (pre-diarrhea 57.5 kg- SD 12.20 & after diarrhea 53.3 kg SD 11.60; p value < 0.05)4.Incidence of diarrhea was 11.18; 20.75 and 24.13 % at 6; 12 & 18 months.5.53% were infective while 47 % non-infective.6.Infective diarrhea were CMV-6%;  Salmonella More Details-12%; Giardia-12%; E.histolytica-18%;  C.difficile Scientific Name Search -17% & non-specified-35%.7.Association of diabetes & advanced age with diarrhea was statistically significant while gender; induction agent & immunosuppression was not found to have any association.8.Tac level significantly increased during diarrhea & normalised to baseline after 2 weeks 9.Rise in Sr.creatinine during diarrhea was not significant as those without diarrhea.10.Patient outcome too was similar.

Conclusions: 1. Diarrhea is a common complication post transplant. 2. 53% are of infective etiology and most common are protozoal. 3. Sinificant rise in TAC levels during diarrhea returns to baseline after 2 weeks. 4. Rise in creatinine during diarrhea does not have any significant impact on graft or patient outcome.

36. A prospective study on the evaluation of sexual dysfunction in male patients with chronic kidney disease

Dr. Ayan Kumar Dey, Dr. Abhijit Taraphder


Apollo Gleneagles Hospitals; Kolkata

Background: Sexual dysfunction is an underreported finding in chronic kidney disease patients. Common problems include menstrual disturbances in women; erectile dysfunction (ED) in men & decreased libido & infertility in both sexes. Organic factors along with psychological factors & depression are important causes. 40% of male & 55% of female dialysis patients do not achieve orgasm. ED can be due to a number of problems. Thus; this study was conducted to address the specific issue in the Indian context.

Aim of the Study: To study the prevalence & the causes of sexual & gonadal dysfunction in male patients with chronic kidney disease.

Methods: A prospective; observational cohort study of 30 male patients attending the OPD or IPD of the Department of Nephrology & Department of Endocrinology; Apollo Gleneagles Hospital; Kolkata with Chronic Kidney Disease (CKD) was conducted over a period of 18 months. They were given the International Index of Erectile Function (IIEF) questionnaire for evaluation of erectile dysfunction. They were evaluated further for the possible pathogenetic mechanisms responsible for the symptoms; after taking due consent. Chi square test was used to test the degree of significance of the various factors in the study population contributing to erectile dysfunction. Patients were selected for the study as per the following inclusion & exclusion criteria:INCLUSION CRITERIA: (1) Adult Male CKD patients.(2) Patients from both Outpatient & Inpatient Department.EXCLUSION CRITERIA:(1) Unwilling patients.(2) Diabetic patients.Diabetics were excluded in this study to prevent confounding.

Results:0 The average age (+ S.D.) was 46.3 years (+ 7.7) of which 73% were from OPD. Maximum number of patients were in CKD stage 3 (43.3%) followed by CKD stage 5 (27%) & 4 (20%) of which 20% were on hemodialysis. Hypertension (90%) & Anemia (43.3%) were the most significant co-morbidities. Anxiety & depression were important causes of sexual dysfunction. The association of Domperidone use & its statistically significant correlation (p0.05) with high serum prolactin levels was an important eye opener. Hormonal profiling showed trend towards low testosterone & high prolactin levels; corroborating with other studies. 43.3 % of patients however refused hormonal testing due to high cost. There were no patients with autonomic dysfunction. Abdominal Xray did not reveal any vascular calcifications. The IIEF questionnaire revealed that the average score across all the domains of sexual function was very low. 1 patient was found to have chyluria causing him depression contributing to sexual dysfunction.

Conclusions: This study throws light on the causes of sexual dysfunction in the CKD non diabetic Indian male patients. Domperidone causing high prolactin levels was shown to be a cause. Hormonal profiling supports testosterone supplementation in CKD patients. Reluctance for evaluation remains a big concern.

37. Leukocyte esterase reagent strip as a bedside tool to detect peritonitis in patients undergoing acute peritoneal dialysis

Vinay Rathore, Piyush D. Kimmatkar, Harshal Joshi, Vinay Malhotra, Dhananjai Agarwal, Pankaj Beniwal, Romika Dawra, Pooja Gupta


Sawai Man Singh Medical College; Jaipur; Rajasthan; India.

Background: Peritonitis is a common and life threatening complication of acute Peritoneal Dialysis (PD). Diagnosis requires presence of clinical signs of peritonitis which are nonspecific and laboratory investigations (Total leukocyte count; gram stain and culture of PD effluent fluid) which are time consuming and not available at the bed-side. In this study; we evaluated the usefulness of Leukocyte Esterase Reagent Strip (LERS) as a bed- side test to diagnose peritonitis in patients undergoing acute PD.

Aim of the Study: To evaluate the efficacy of Leukocyte Esterase Reagent Strip to diagnose peritonitis in patients undergoing acute PD.

Methods: 0 Patients undergoing acute PD were monitored for signs and symptoms of peritonitis. PD effluent fluid analysis included total leukocyte count; absolute neutrophil count; gram stain and culture for the diagnosis of peritonitis. LERS (Multistix 10SG) was simultaneously dipped in PD effluent fluid and read at 2 minutes. Reading of + was considered as indicative of peritonitis.

Results: Twenty-one out of 166 (12.6%) patients undergoing acute PD developed peritonitis. LERS detected peritonitis in 20 patients. The sensitivity; specificity; positive predictive value and negative predictive value of LERS were 95.2%; 95.2%; 74.1% and 99.3% respectively.

Conclusions: LERS has very high sensitivity and negative predictive value and can be used as a rapid bedside tool to exclude peritonitis in patients undergoing acute PD.

38. Post renal transplantation hypophosphetemia and hyperparathyroidism and their effect on graft outcome

Dr. Vishal V Ramteke, Dr.Amit Katyal, Dr. Arun Halankar, Dr.SudhiRanjan Dash, Dr.Bhupendra Gandhi, Dr. Madan M Bahadur, Dr.Rushi Deshpande, Dr. Aseem Thamba


Jaslok Hospital and Research Centre; 15 Dr Gopal Rao Deshmukh Marg; Mumbai; Maharashtra - 400026

Background: Post renal transplantation hypophosphatemia is frequent and is seen in 50%-93% of recipients in first 3 months.It is rarely symptomatic and guidelines for treatment are poorly defined.The PTH levels decline rapidly after transplant and normalise by 1 year. Persistent hyperparathyroidism may cause hypophosphetemia and ATN in renal allograft. We study the incidence; manifestation and need of therapeutic intervention in hypophosphatemia and hyperparathyroidism in renal transplant recipients.

Aim of the Study: 1. Pattern; manifestation & risk factor of hypophosphetemia & hyperparathyroidism over 3 month post transplant. 2. Effect of phosphate metabolism on involution of parathyroids &••allograft outcome.

Methods: Prospective study was done on 100 renal allograft recipients at Jaslok Hospital; Mumbai for 2 years from JUNE 2013-2015 and followed up for 3 months. Allograft recipients except past parathroidectomy and with DGF and acute rejection were included.Phosphate and calcium levels were done on day 1; 7; 14 followed by monthly for 3 months. PTH levels were done on day 14; 1 month and 3 month post transplant. RFT was done as per unit protocols.Induction immunosupression was rabbit ATG; Basiliximab or none. Maintainance immunosupression was with Tacrolimus + MMF + Steroids as per weight. Hypophosphetemia was managed with diet rich in phosphate and no pharmaceutical preparation was given. Data analysis was done with SPSS Software ver. 15 and Sigmaplot Ver. 11. Linear regression analysis was used to estimate the factors responsible for the posttransplant hypophosphetemia and the rate of change in phosphate and PTH level.Statistical significance was assumed at a P value less than 0.05.

Results: 1. Hypophosphatemia was noted in 62% reciepeints. 2. Factors predisposing for post transplant hypophosphetemia werea)pretransplant hyperparathyroidism(p=0.041)b)pretransplant hyperphosphetemia(p=0.048)c)young age of recipient(p=0.045). 3. Mean time to hypophosphetemia was 10 days with 50 % reduction in pretransplant values by 1st week. 4. Hypophosphatemia tend to resolve with diet rich in phosphate by 12 weeks. 5. Muscle weakness was the most frequent manifestation of hypophosphetemiaLife threatening manifestation are rare and mostly self limiting. 6. Pre and post transplant hyperphosphetemia has no statistically significant impact on therenal allogaft function. 7. Normalisation of pretransplant hyperparathyroidism is notedby 12 weeks post transplant. 8. 40 % reduction in PTH levels is noted in 1st 2 weeks after transplant. 9. Pretransplant hyperparathyroidism has no statistically significant impact on the renal allogaft function.

Conclusions: 1. HypoPO4 post renaltx is common; more so in young or with pretx hyperPO4 or hyperPTH. 2. Severe HypoPO4 is rarely life threatening in recipeints & can be managed with diet rich in PO4. 3. Parathyroids involute by 3 months. 4. Allograft outcome is unaffected by pre/post transplant hyperPO4 or hyperPTH.

39. Why is iga nephropathy aggressive in indians? The grace igani study: Longitudinal follow up

Suceena Alexander, Rajan Babu 1 , Anila Korula 1 , Smitha M Mathai 1 , Visalakshi Jeyaseelan 1 , Vijayakumar Theophilus 1 , Gagandeep Kang 1 , Vinoi George David 1 , Anjali Mohapatra 1 , Anna T Valson 1 , Shibu Jacob 1 , Shailesh T Kakde 1 , Babu Ponnusamy 2 , Charles Pusey 3 , Terence Cook 3 , Mohamed R Daha 4 , Marc Seelen 4 , Jonathan Barratt 5 , John Feehally 5 , Santosh Varughese 1 , George T John 6


Christian Medical College; Vellore; India; 2 C-CAMP; Bangalore; India; 3 Imperial College London; UK; 4 University Medical Center Groningen; The Netherlands; 5 University of Leicester; UK; 6 Royal Women's Hospital; Brisbane; Australia

Background: In India about 30-40% of IgA Nephropathy (IgAN) patients (pts) have nephrotic syndrome and renal dysfunction at presentation1.

Aim of the Study: To study the baseline and follow-up associations among low and high risk groups scored by ARR criteria2.

Methods: This is a single center prospective longitudinal cohort study in South India started from March 2015. 111 out of 154 adult (≥18 yrs) pts diagnosed to have IgAN among 1400 native kidney biopsies till March 2016; were included in the study.

Results: Out of the 43 excluded pts; 14 did not consent; 6 had eGFR<10ml/min/1.73m2; 10 were on HD; 5 had diabetes; 8 had prior immunosuppression and one had chronic pulmonary infection. 60 (54.1%) &51 (45.9%) were in the low risk (ARR score <22) high risk groups (ARR score ≥22) respectively. 40 (66.7%) of low risk and 37 (72.5%) of high risk pts have at least one follow up visit and the median (IQR) duration of follow-up was 5.5mo (3 to 7) and 3mo (3 to 6) respectively.

Conclusions: There was significant decrease in proteinuria and improvement in eGFR with treatment in low risk group. RRT was started in 7.8% and 3 died on follow up.Sponsor: Early Career Fellowship; Wellcome UK Trust/ DBT India Alliance

40. Iga nephropathy: Clinicopathological correlates and response to immunosuppression

Dipin S, Sreelatha M, Noushad TP, Jayakumar EK


Govt. Medical College; Kozhikode

Background: IgA nephropathy is the commonest primary glomerular disease. Prevalence; clinical course and outcomes are highly variable with varied histology. Though immunosuppression in IgA and role of MMF has not gained much ground till now; definite improvement in proteinuria after immunosuppression (steroid and MMF) has been a major observation in our institution. This study attempts to correlate clinical features and treatment response; to the histological characteristics.

Aim of the Study: 1. To study clinical characteristics and histological correlates2.To assess the immune deposits and their influence on clinical behavior 3. To assess response to immunosuppression on follow up.

Methods: 104 patients attending nephrology OPD of our institution with biopsy proven IgAN were chosen. Their clinical characteristics; with their course on follow up; was noted in detail. Patients given steroid/ MMF immunosuppression; according to the institutional practice were followed up. Further the clinical characteristics; follow up and response to treatment were assessed against their histological correlates and immune deposits.

Results: Most common clinical presentation noticed was microscopic hematuria and hypertension; gross hematuria being more common in younger age groups. More than 60% had >25% tubular atrophy; T scores being significantly associated with hyperuricemia; hypertension; renal dysfunction at presentation and GFR fall. Immune deposits failed to show any clinical correlations except for C3 and C1q being associated with crescents in biopsy.74 patients in the study group received steroid +MMF ; 2 patients received cyclophosphamide ; 83 % having proteinuria >1 gm. 82 patients completed 6 months followup and 2 completed 1 year. Substantial reduction of proteinuria was noticed at 6 months(mean reduction 64%) and even at 1 yr follow up(54%). Reccurence of proteinuria to more than 1 m/day was noticed in a subset of patients(20%) and patients with high T scores had persistant proteinuria. 3 major infective complications occured in 3 patients during the study group.

Conclusions: E and T scores in biopsy has influence on the clinical behavior; course and treatment response. Immune deposits showed no correlation with clinical behavior. Immunosuppression shows a definite improvement in short term; but proteinuria relapsed in a subset of patients after withdrawal of therapy.

41. Effectiveness of safety practices in haemodialysis unit

Dilip Rangarajan,Ramakrishnan Skiran Patrosanthosh, Kumarpushpanjaliuma Maheswari


Nu Hospitals; Ca6; 15 th Main; 11 th Cross; Padmanabha Nagar Bangalore 560070

Background: Haemodialysis is a life saving procedure for patients with severe renal failure.There are multiple areas in the delivery of this treatment where things could go wrong if proper attention is notgiven.Having a check list and corrective actions in place play an important part in ensuring safety for patients.We have evolved some safety practices in dialysis and have been implementing the same for few years now.We have looked at the efficacy of the safety practices in this study.

Aim of the Study: To evaluate the effectiveness of safety practices in haemodialysis unit.

Methods: The following safety practices have been put into place 2 years ago in haemodialysis unit.Training of the staff; implementation and auditing of compliance of protocols evolved.Data collected on a daily basis shift wise regarding missed blood pressure recordings; extravasations; catheter related infections.Monitoring of hand hygiene and surface cleaning -direct and cctv.Daily audit of patient files; machine fluid removal status; disinfection status and erythropoietin usage.Daily morning summary report of previous days patients details Training of staff for cannulation in OT and on mannequinMonthly review meetings and implementation of changes with deadlinesEffect of practice evaluated at 1 and 2 yearsStatistical analysis done by comparison of means and difference between two independent proportions (vassarstats).

Results: CLABSI (per 1000 catheter days) was 7.2 in 2013; 5.68 in 2014 and 2.25 in 2015;p= 0. 04; Hepatitis C conversion happened in 4 patients in 2013; none in 2014 and 1 in 2015; Extravasation at AVF site was 0.2%in 2014 and 0.1% in 2015;p=0.17; Wrong dialyser identity was 0 in 2014 and 2015; BP misses were 2.1%in 2014 and 1.4%in 2015;p=0.13; Average Hb(g/dl) was 8.5 in 2014 and 11 in 2015;p=0.19; Average   S.album Scientific Name Search  Scientific Name Search in(g/dl) was 3.2 in 2014 and 2.8 in 2015;p=0.58; Average S.potassium(mEq/L) was 5.4 in 2014 and 5.7 in 2015;p=0.44; Average kt/v was 1.17 in 2014 and 1.3 in 2015;p=0.45; central line rates were 24.5%in 2014 and 30.9% in 2015;p=0.15.

Conclusions: Safety practice in haemodialysis is effective in maintaining standard of care for most parameters like control of infection; preventing BP misses; preventing wrong dialyser identity but has not helped in limiting usage of temporary dialysis catheters.

42. Impact of residual renal function on clinical outcome and quality of life in patients on peritoneal dialysis

Dr. Manns Manohar John, Prof. Amit Gupta, Prof. RK Sharma, Prof. Narayan Prasad, Dr. Anupama Kaul, Dr. DS Bhaduria.


Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow

Background: The preservation of residual renal function(RRF) has gained momentum amongst nephrologists in the last decade. Amongst the various benefits of preserving RRF; fluid balance equilibrium; phosphorous control; removal of middle molecular uremic toxins and cardio-protective effects of RRF; emphasize the need for measures to preserve RRF; even on dialysis.

Aim of the Study: To look at the differences in outcomes of various clinical and biochemical parameters in patients who were initiated on CAPD who were divided into 2 groups{with RRF(Residual Renal) & with out RRF}.

Methods: End Stage Renal Disease patients requiring dialysis; who opted for peritoneal dialysis as the modality of choice for initiation of RRT; were identified between the period of January 2012 till December 2013 and followed up till January 2015 consecutively for study purpose. The study was carried out at Sanjay Gandhi Post-graduate Institute of Medical Sciences; Lucknow; India; which is a tertiary referral center. A total number of 61 patients were enrolled; with due consent taken. They were assigned to two groups; at the time of initiation of PD; based on their eGFR; as assessed by Modified Diet in Renal Disease (MDRD 4 variable equation); namely; High RRF group having eGFR ≥ 5ml/min/1.73m2 and Low RRF group having eGFR <5ml/min/1.73m2.At each visit a record of relevant clinical and biochemical parameter were made which included patients weight; body mass index (BMI); BP; Urine output; eGFR with biochemical investigations.

Results: The number of patients who discontinued CAPD were 06in high RRF group and 10in low RRF group. 10(33.3%) patients in high RRF group had at least 1 episode of peritonitis(either culture positive or negative requiring minimum of 2 weeks IP antibiotics) where as 11(35.4%) patients in Low RRF group had peritonitis.Incidence of Lower respiratory tract infections was 15(50%) in high RRF group and 16(51.6%) in low RRF group.In terms of other infections (cellulites; gastroenteritis; sepsis) 10(33.3%) patients in high RRF group had other infections; where as in low RRF group it was 19patients (61.3%).3 patients (10%) in high RRF group died during the study period; where as in low group 6 patients (19.4%) died.eGFR at 3 rd month which was high in high RRF group; depression as assessed by BDS with patients in high RRF group having less incidence of depression; albumin at 6 th month being low in low RRF group and Alkaline phosphatase level at 1 yr with levels low in high RRF group.

Conclusions: Our study concludes that preservation of RRF is an essential marker of patient survival and; to a lesser extent; technique survival during chronic PD therapy. This emphasizes the usefulness of strategies oriented to preserve both RRF and the long-term viability of the peritoneal membrane.

43. Evaluation of glycemic repercussions during the days of hemodialysis; done using dialysis solutions with and without glucose

Nagendran. V, Abeesh. P, Balaraman. V


Govt. Kilpauk Medical College; Chennai

Background: Asymptomatic hypoglycemia (HG) has been documented during regular hemodialysis sessions. Studies show that rebound hyperglycemia can also occur few hours after hemodialysis [H.D] akin to somogyi effect.

Aim of the Study: The aim of our study was to evaluate the glycemic fluctuations in diabetic [DM] and non-diabetic [NDM] ESRD patients during hemodialysis days done using glucose free and glucose containing dialysate.

Methods: We conducted a non randomized interventional study in which 32 ESRD patients (16 DM and 16 NDM) were included. All the patients underwent two hemodialysis sessions with glucose free bicarbonate solution (phase 1) and next two hemodialysis sessions done with 100 mg/dl glucose containing dialysate (phase 2). Serum glucose was measured using continuous glucose monitoring system [CGMS] at 1st hour; 2nd hour and 4th hour in both the phases. Percentage of time above and below preset target range (70 to 140 mg/d)l in 24 hours on HD days in both phases was noted. Glucose loss in effluent fluid from dialyzer also was estimated at 1st hour; 2nd hour and 4th hour.

Results: Four patients (one episode each) had symptomatic hypoglycemia out of total 128 sessions. Twenty patients (DM-15; NDM-5) had 22 episodes and 5 patients (DM-4; NDM-1) had 5 episodes of hypoglycemia in phase 1 and 2 respectively P=0.002 (number of patients); P=0.0036 (number of hypoglycemic episodes).Glucose loss (g/h) in the effluent was lower in phase 2 (5.91 vs 7.08;P<0.0002). In CGMS; hypoglycemia occurred in 50 sessions in phase 1 (DM-23; NDM -27) {78%} as compared to 13 sessions (DM-11; NDM-2) {20%} in phase 2. The mean percentage of time above target on H.D days was significantly higher in phase 1 (21.1% vs 9.3%; P= 0.0001). This was also observed among DM subgroup (18.8% vs 8.6 %; P= 0.0001). Most of the hyperglycemic period occurred as rebound phenomenon during post H.D period.

Conclusions: Glucose containing dialysate reduced the frequency of hypoglycemic episodes. Glucose loss in the effluent dialysate was higher during glucose free dialysate. Diabetic patients dialyzed with glucose free dialysate had rebound hyperglycemia during post H.D period on hemodialysis days.

44. Cholecalciferol supplementation improves vascular function in non-diabetic chronic kidney disease patients with vitamin d deficiency: A self-controlled study

Ashok Kumar Yadav,Vivek Kumar, Manphool Singhal, Anupam Lal, Vivekanand Jha


Departments of Nephrology and Radiodiagnosis; PGIMER; Chandigarh; India

Background: Vitamin D deficiency is common and associated with mortality in chronic kidney disease (CKD) patients. Cardiovascular disease (CVD) is the most common cause of mortality in CKD patients. Vitamin D supplementation might favorably modify CVD risk in CKD patients by improving endothelial and vascular function.

Aim of the Study: We studied the influence of vitamin D supplementation on vascular & endothelial function and inflammatory biomarkers in vitamin D deficient patients with non-diabetic stage 3 and 4 CKD.

Methods: In this self-controlled study; 31 patients with non-diabetic stage 3-4 CKD and vitamin D deficiency [defined as serum total 25(OH)D levels <20 ng/ml] were assessed at 0; 16; and 32 weeks. All patients received directly observed cholecalciferol supplementation (300; 000 I.U.) at 16 and 24 weeks. Endothelium dependent brachial artery flow mediated dilatation (FMD); pulse wave velocity (PWV); circulating endothelial and inflammatory markers (E-Selectin; vWF; hsCRP and IL-6); 1; 25(OH)2D and FGF-23 were analyzed at 0; 16 and 32 weeks. The primary outcome was change in FMD at 16 and 32 weeks.

Results: Serum total 25(OH)D levels remained similar to baseline at 16 weeks but significantly increased at 32 weeks (13.0±5.4; 15.7±9.8 and 34.7±15.2 ng/ml at 0; 16 and 32 weeks; respectively; p<0.0001). FMD; PWV and circulating biomarkers were similar at 0 and 16 weeks. However; after cholecalciferol supplementation at 16 and 24 weeks; FMD increased significantly at 32 weeks (13.8±4.3% vs 8.0±2.7%; p<0.0001). Similarly; significant changes in 1; 25(OH)2D (40.1±18.9 pg/ml vs 21.4±20.2 pg/ml; p=0.001); IL-6 (3.3±2.5 pg/ml vs 5.0±4.0 pg/ml; p=0.002) FGF-23(48.9±45.6 pg/ml vs 70.3±50.5 pg/ml; p=0.005) and PWV (7.3±1.3m/sec vs 8.0±1.3m/sec; p=0.005) were seen at 32 weeks (table 1).

Conclusions: Cholecalciferol supplementation corrected vitamin D deficiency; improved FMD and PVW; and decreased serum levels of FGF-23 and IL-6 in subjects with non diabetic CKD.

45. Combined role of iron and vitamin d in acute kidney injury

Chandrashekar A,Badrinathan S, Ashish Rao, Rajesh NG, Pragasam Viswanathan


Renal Research Lab; School of Biosciences and Technology; VIT University; Vellore - 632014; Tamil Nadu; India; Department of Pathology; JIPMER; Puducherry - 605006; India; Department of Nephrology; KIMS Superspeciality Hospital; Bilaspur - 495001; Chhattisgarh; India

Background: Iron and iron-containing proteins cause direct renal tubular injury in in vitro and in vivo models. Kidneys get exposed to extra-renal iron due to systemic iron overload (hemosiderosis) resulting from hemolysis or rhabdomyolysis and to renal heme-proteins following ischemic or toxic insults. Also; vitamin D has been noted to have several pleiotropic effects including cytoprotection. The relative roles of iron and vitamin D in the context of acute kidney injury (AKI) are still under exploration.

Aim of the Study: We intend to induce contrast-induced AKI in experimental animal and understand the gene expression patterns involving iron-regulating genes and 1-a hydroxylase.

Methods: 36 male Wistar rats were selected for the study. AKI was induced in 30 rats by intraperitoneal administration of Iohexol; a radiocontrast agent; at a concentration of 3 g I/kg body weight and the remaining six were included in control group. From the case group; six animals were sacrificed each at 6th; 12th; 24th; 48th hour & 7th day to observe biochemical and histological changes. mRNA expression analyses involving iron-regulation including transferrin; transferrin receptors; ferritin; hepcidin and ferroportin as well as 1-a hydroxylase were studied by qPCR technique.

Results: Contrast-induced AKI was induced in the rats as evident by significant raise in the serum creatinine levels and proteinuria 6 hours following Iohexol injection. Histopathological and ultrastructural changes of renal tubular injury observed on light and electron microscopy; respectively further confirmed the presence of AKI. Hemosiderin deposits were visible on Perl Prussian Blue staining. A significantly altered expression of iron-regulating genes was documented along with a rapid expression of 1-a hydroxylase gene in the renal tubular cells.

Conclusions: Intrarenal presence of iron together with altered gene expression of iron-regulating proteins supports nephrotoxic potential of iron. Concomitant increased 1-a hydroxylase gene expression hints at cytoprotective role of vitamin D in AKI. These need further exploration.

46. Role of p-glycoprotein; multidrug resistance-associated protein-1 on different t-cell subsets in steroid resistant nephrotic syndrome in children

Harshit Singh, Narayan Prasad 1 , Saurabh Chaturvedi 2 , Vikas Agarwal 2 , Akhilesh Jaiswal 1 , Ravi Mishra 2 , Brijesh Yadav 1

1 Department of Nephrology; 2 Clinical Immunology; SGPGIMS; India

Background: Idiopathic nephrotic syndrome represents the most common type of primary glomerular disease in children.Glucocorticoids remain the mainstay of therapy.However; 60-80% of patients become resistant to steroid.Overexpression of P-glycoprotein (P-gp) and Multidrug resistance associated protein 1 (MRP-1) might be responsible for steroid resistance due to their ability to modulate the pharmacokinetics of steroids.We aimed to investigate the role of P-gp andMRP-1 in resistance to steroids.

Aim of the Study: To evaluate the differential alteration of P-gp and MRP-1 on CD4+ and CD8+ T-cell subsets in steroid resistant as well as steroid sensitive patients.

Methods: After ethical approval; all paediatric patients who matched the inclusion criteria were recruited. P-gp and MRP-1 expression were evaluated on whole blood and functional activity on peripheral blood mononuclear cells (PBMCs) in steroid sensitive nephrotic syndrome (SSNS) (n=40; male 29; mean age=7.54±3.5) and steroid resistant nephrotic syndrome(SRNS) (n=40; male 24; mean age=8.43±3.8)patients. SSNS patients were in sustained remission for at least 6 months without steroid. All definitions are as per the criteria of ISKDC.P-gpand MRP-1 expression were analyzed by Flow Cytometery. The absolute values were calculated using formula (% of positive cells × Relative Fluorescent Intensity (RFI)); Multi resistance activity factor (MAF) for each transporter; was calculated using formula (MAFMDR1=100×(FMDR1-F0)/FMDR1). All data are expressed as mean±s.d.

Results: Among 80 patients; demographic significant difference were inS.Albumin (SSNS=2.87±.98; SRNS=2.27±.79; p=0.012) and proteinuria (SSNS=14.38±3.09; SRNS=273±183.45; p<0.001).The % of P-gp and MRP-1 positive cells were significantly higher in SRNSas compared toSSNS(11.07±4.17v/s 5.80±2.77; p<0.001); (15.32±6.80 v/s 7.75±3.53; p<0.001). Absolute P-gp and MRP-1 expression was significantly high in SRNS (67.01±24.01 v/s 33.58±22.40; p<0.005); (68.04±21.40 v/s 39.20±19.07; p<0.005)respectively.P-gp expression on CD4+ and CD8+cells were significantly high in SRNS(6.48±1.93v/s 3.01±1.06; p=0.008) ; (6.92±1.09v/s2.12±0.91; p<0.001)respectively .MRP-1 expression on CD4+ and CD8+cells were significantly higher in SRNS (10.74±5.33v/s3.86±1.11; p=0.043) ; (5.36±0.79v/s 1.70±0.63; p<0.001)respectively.Functional activity of P-gp and MRP-1was significantly increased in SRNS as compared to SSNS(47.10±19.10 v/s 93.94±33.07; p<0.001); (87.49±36.72v/s 52.10±32.83; p<0.001) respectively.

Conclusions: We conclude that overexpression of P-gp and MRP-1 on CD4+ and CD8+ cells may contribute to resistance to corticosteroids in idiopathic nephrotic syndrome in children.




 

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