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ABSTRACT
Year : 2016  |  Volume : 26  |  Issue : 8  |  Page : 52-136
 

Poster Presentation



Date of Web Publication1-Dec-2016

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How to cite this article:
. Poster Presentation. Indian J Nephrol 2016;26, Suppl S2:52-136

How to cite this URL:
. Poster Presentation. Indian J Nephrol [serial online] 2016 [cited 2020 Feb 27];26, Suppl S2:52-136. Available from: http://www.indianjnephrol.org/text.asp?2016/26/8/52/195072


1. To study the clinical profile; histopathological pattern and response to therapy in lupus nephritis patients and compare them between males and females in a tertiary care center in india

Sandip Kumar Panda, Santosh V, Vinoi G, Anjali M, Suceena A, Anna T, Shibu J, Shailesh K, Tamilarasi V


Christian Medical College; Vellore; India

Background: SLE is a multisystem disorder which has significant higher prevalence in females (M: F=1:10). Lupus nephritis(LN) develops in up to 60% of patients with SLE. In spite of treatment only 30-40% of LN patients attain complete remission with initial therapy and 8-15% progress to ESRD. Male gender has been observed as one of the poor prognostic factors in some studies. This study will tell us regarding the clinical course; outcome of LN and impact of gender on it.

Aim of the Study: To study clinical profile; histopathologic (HP) pattern of LN patientsTo look for response to therapy at 6 monthsTo compare between male and female LN patients.

Methods: Retrospective observational study conducted in the dept. of Nephrology; CMC; Vellore. Biopsy proven LN patients (as per SLICC) from Jan 2015 to Dec 2015 with minimum 6months of follow up was included in the study. Data was collected from OP and IP charts in CMC clinical work station. Onsets of disease; previous renal biopsy; treatment prior to CMC visit were documented. Clinical presentation to CMC including renal involvement (Proteinuria > 500mg/24hr; renal dysfunction {serumcreatinine>1.2 in females; >1.4 in males}; microscopic hematuria; red cell casts); disease activity; renal biopsy (ISN/RPS classification) and treatment offered were recorded. Clinical profile; disease activity; treatment were followed in subsequent visits.Response to therapy was documented as complete response (CR); partial response (PR); nonresponders (NR); and deterioration as per KDIGO 2012 guidelines.

Results: Total number of biopsy proven LN in 2015 were 185; out of which 23(12.4%) were males [M: F=1:8] and mean age of onset was 23.6+ 10.2 years. 13% patients lost follow up. Proteinuria wasthe most common (92%) renal manifestation in both genders. Renal dysfunction was more common in M (37%) than F (16.6%). Hypertension was found in 18% patients and there was no gender difference. Class IV LN was the most common pattern in both M (56%) and F(54.6%). Mycophelolatemofetil (MMF) based regimen was most commonly used in our center (M: 60%; F: 54%). At 6 months of therapy CR was achieved in 42% F and 27.4% M; PR was achieved in 19.5% F and 31% M; no response in 20% F and 33% M whereas deterioration was found in 10% Fand 8.5% M. There was no difference in response to therapy between MMF and IV Cyclophosphamide groups.5.5% patients expired; 3.8% progressed to ESRD during follow up and most common cause of death was bacterial infection.

Conclusions: Renal dysfunction wastending to be more common in males. Class IV LN was mostcommon in both genders. There was no difference in response to therapy between MMF and IV cyclophosphamide group. Remission(CR+PR) was achieved in 61.5% females and 58.4% male patients at 6 months of therapy.

2. Audit of vascular access in a hemodiaysis centre of tertiary care hospital from south india

Dr. BNR. Ramesh, Dr. Vijay Kiran, Dr. Sree Bhushan Raju


Nizams institute of medical sciences

Background: Vascular access is a sheet anchor in patients on maintainance hemodiaysis(MHD).

Aim of the Study: We aim to audit vascular access data of MHD program in our institute.

Methods: We evaluated all prevalent patients on MHD and collected the data.

Results: There were 201 patients (men-157/female=44) with 52(25.8%) diabetics and27(13%) HCV seropositive. Mean duration of MHD was 18.6±24.6 moths. Patients were on follow up with nephrologist prior to commencing MHD for 17.4±25.8 months. Serum creatinine at the time of referral for arteriovenous fistula(AVF) was 9.6±3.9mg/dl. Patients were referred for AVF 2.8±7.5 months prior to commencing MHD. At the time of first HD; 111(59%) patients were on double lumen jugular catheter; 66(33%) were on femoral catheter and 14 were on AVF.3 months after commencing HD; 99(68%) were on catheter; 33(23%) were on AVF; 4 on permacath and 1patient on AV graft. At the time of present study; 46 patients were on catheter and 90(59%) were on AVF. Left wrist was the most common site of AVF(n=80; 55%) followed by left elbow(n=29; 20%) and right wrist(n=18; 12%). Aneurysm of AVF was seen in 18 patients and most of them were less than 5cm in size. Thrombosis of AVF and abscess were seen in 31% and 2.5% respectively.

Conclusions: Significant number of patients were still on catheter at commencement of MHD which improved after 3 months. Complications with AVF like aneurysm; thrombosis and abscess were significant. Frequent audit of vascular access is essential in the success of MHD program.

3. Tenofovir disoproxil fumarate induced nephrotoxicity: A single centre descriptive study

Dr. Nithin. J, Dr. Renuka. S


St. Johns Medical College; Bangalore

Background: Tenofovir is associated with a small; but increased risk of nephrotoxicity. Renal toxicity includes acute kidney injury; chronic kidney disease (CKD); and proximal tubular injury; including Fanconi syndrome; isolated hypophosphatemia; and decreased bone mineral density.The most effective treatment being stoppage of drug.

Aim of the Study: To study the incidence of Tenofovir disoproxil fumarate induced nephrotoxicity.

Methods: This is retrospective descriptive study from 2010 till date. We recorded demographic data; clinical outcome of all the follow up patients in OPD on tenofovir. Serial monitoring of laboratory values were done. We included only those patients regular on treatment and follow up. In this case series we report 12 cases of tenofovir induced nephrotoxicity. 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: The mean age of cases was 49.25 years with 16 % of them being females and 74 % males.74% of cases were HRV cases started on tenofovir and 16 % were Hepatitis B on treatment with tenofovir. In patients who were HRV positive; the mean CD 4 on detection of tenofovir nephrotoxicity was 220.6 and the mean duration of treatment with tenofovir was 4 years. 66% of cases presented with Acute kidney injury with Acute tubulointerstitial nephritis; 33 % of cases with Chronic kidney disease - Chronic interstitial nephritis; 25% of the cases presented with proximal tubular dysfunction in the form of hypokalemia; hypomagnesemia; hypophosphatemia; normal anion gap acidosis and glycosuria. Renal biopsy was done in three cases - two showing ATIN and one CIN. Patients were treated by withdrawal of the drug. In the 6 cases with AKI ; withdrawal of the drug resulted in recovering renal function . Two patients with biopsy proven ATIN were initiated on steroids in addition to withdrawal of tenofovir.

Conclusions: Tenofovir is associated with increased risk of nephrotoxicity with most effective treatment being stoppage of drug.A new prodrug; tenofovir alafenamide (TAF); may reduce renal toxicity and will be the subject of future studies.

4. Predictive factors for severity and management strategies in emphysematous pyelonephritis

Karan Saraf, Ravindra Prabhu, Shankar Prasad, Dharshan R, Srikanth P, Sindhu K, Srinivas S, Mohan VB, Ashok


Kasturba Medical College; Manipal

Background: Emphysematous pyelonephritis (EPN) is a necrotizing kidney infection characterised by renal parenchymal gas; which may have a fulminating course with mortality if not treated promptly. Management has evolved from early empirical nephrectomy to renal salvage. Achieving optimum result requires prompt recognition of severity and graduated active management; to strike a balance between two strategies. This is a case record based observational study to look for predictive factors for severity of EPN.

Aim of the Study: To study the clinical profile of EPN; To analyse factors predicting the severity of EPN; To correlate severity with management strategies and outcome.

Methods: Hospital records of patients with EPN from Jan 2014 to May 2016 were reviewed. Data on demographic profile; clinical features; laboratory investigations; imaging studies; treatment; outcome of patients were recorded. Huang and Tseng class was used to grade severity into 4 types namely type 1; gas in the collecting system only; type 2; gas in the renal parenchyma without extension to extrarenal space; type 3; extension of gas or abscess to perinephric space (3A) or pararenal space (3B); and type 4: bilateral EPN or solitary kidney with EPN. Laterality; presence of hydrouretronephrosis or renal calculi was also noted. Type 1 and 2 formed less severe group (Group 1) and Type 3a; 3b; 4 formed severe group (Group 2). Differences between the groups were analysed using the student t test for continuous variables and chi-square for categorical variables; with P < 0.05 considered statistically significant.

Results: Of 31 patients; mean age was 58 ± 7.2 years; females 67.7%; 93.5% had DM with mean blood sugar 323 ± 154 mg/dl; and glycated hemoglobin (HbA1c) 11.7 ± 3.4%; reflecting a poor glycemic control in majority of patients. At admission; symptoms included fever (70.9%); flank pain (64.5%); nausea/vomiting (16.1%); dysuria (35.4%); altered sensorium (6.4%); oliguria (19.3%). Three patients presented with diarrhoea and all had more severe EPN (Group 2; p-0.04). Of those with positive urine culture (14; 45.1%); 54.8% had E.coli; 35.8% Klebsiella; 3.2% enterobacter and candida. Among group 1 and 2; bilateral disease was noted in 0%; 33.3% (p- 0.016); Hydronephrosis in 57.18%; 25% (p - 0.14); Renal calculi in 26.3%; 25% (p - 1.0). DJ stenting was done in 73.6%; 58.3% (p - 0.45). Six patients underwent PCN drainage; out of which five had severe disease (group 2; p - 0.02). The overall survival rate was 93.5% (29/31) and in all of them; renal unit was salvaged.

Conclusions: In EPN; presence of diarrhoea predicts severity. Urine and blood culture positivity is seen in 45.1 and 29% respectively with E.coli being most common organism. Medical treatment along with DJ stenting and PCN in severe EPN is able to salvage kidney. Mortality in this series was 7%.

5. Effect of hscrp and ferritin on renal anemia

Vamshi Krishna Nagalla, Sree Bhushan Raju. D


Nimshyderabad

Background: Inflammation plays a major role in the pathogenesis of anemia in patients of ESRD.

Aim of the Study: We aim to study the effect of hscrp an inflammatory marker in relation to iron profile in subjects with CKD stage 5 commencing MHD.

Methods: We retrospectively collected the data of patients ckd stage 5 commencing MHD. We excluded those patients on EPO; allopurinol and statin. Based on level of hscrp; subjects were categorised into group 1(hscrp<5; n=0); group 2 (hscrp-5 to 50; n=43) and group 3(hscrp>50; n=18).

Results: There were total 101 patients with mean age of 42.4±16.5 years(male-70/female-31). Hemoglobin; ferritin and   S.album Scientific Name Search  Scientific Name Search in levels in group1 were 8.2±2.2; 360±233 and 3.2±0.9 respectively; group 2 were 8.6±1.6; 462±30 and 3.1±0.8 respectively;group3 were 9.2±1.8; 759±661 and2.8±0.9 respectively.

Conclusions: Despite the presence of inflammation marked by increased hscrp; ferritin and decreased serum albumin; hemoglobin did not changed significantly with presence of inflammatory parameters suggesting need of further evaluation of renal anemia.

6. Analysis of lipid profile in relation to echocardiographic parameters in chronic kidney disease(ckd)stage5 commencing maintainance hemodialysis(mhd)

Vamsi Krishna Nagalla, Dr. sreebhushan Raju


NIMS Hyderabad

Background: Cardiovascular disease is important cause of morbidity and mortality in CKD.

Aim of the Study: We aim to analyse the major risk factor dyslipidemia in relation to echocardiographic parameters in CKD stage5 patients commencing MHD.

Methods: We retrospectively analysed the data of stable CKD stage 5 patients who were to be initiated on MHD between 2011 to 2015 and parameters like hemoglobin; RFT; LFT; calcium; phosphorus; uric acid; PTH; vitamin D; hsCRP; lipid profile and echocardiogram were collected. We excluded all those with an evidence of severe sepsis; respiratory failure and acute vascular events. We analysed the association between lipid profile and echocardiographic parameters after excluding those on statin therapy.

Results: There were total 394 patients with mean age of 47.6±18.2 years(male-264/female-130). Among them 148(37.6%) were diabetics and 255(64.7%) were hypertensive. There was history of CAD in 56(14.2%) and stroke in 10(2.5%). Mean levels of Total cholesterol(TC)-138.2±56.2mg/dl; HDL cholesterol (HDL C)-37.5±21.7mg/dl; LDL cholesterol (LDL C)-76.2±44.8mg/dl and triglycerides(TG)-120.1±75.6mg/dl. Concentric LVH was seen in 68(17%); systolic dysfunction in 28(7%); diastolic dysfunction in 55(14%) and aortic sclerosis in 30(7%). TC (mean-138.2±56.2mg/dl) and LDL C(mean-76.2±44.8mg/dl) levels were associated with both systolic and diastolic dysfunction.

Conclusions: Concentric LVH is the most common echocardiographic abnormality seen in our group of patients with relatively age commencing MHD.TC and LDL C are associated with both systolic and diastolic dysfunction.

7. Renal transplant recipients with hcv infection: Our early expirience with daa

Dr. Sridhar Nimmagadda, Dr. Rajesh Goli, Dr. Vijay Kiran, Dr. Sreebhushan Raju


NIMS; Punjagutta

Background: Treatment options for HCV infection in renal transplant(RTx) recipients are limited. the conventional treatment with INF and Ribavirin carries the risk of allograft rejection. The availability of second generation oral anti virals has opened the new avenues for HCV treatment.

Aim of the Study: To study the effectiveness of 2nd generation oral anti virals for treatment of renal transplant recipients with HCV infection.

Methods: 5 renal transpalnt recipients with HCV infection were treated with DAA(Direct acting antivirals.baseline viral load; genotype; RFT; LFT; CBP; fibroscan; US abdomen were donefollow up viral load; RFT; LFTs were done at the end of 1st month; at he end of treatment; 3 months after the completion of treatment were done.

Results: Among 5 patients; 4 were males.at base line 3 patients had stable graft function; 2 pt had CAN.1 patient had genotype 4; remaining 4 had genotype 1.2 patients were treated with Sofasbuvir + Ribavirin; both were developed anaemia; 1 patient later converted to Sofa+ledipasvir; 1 patient who had CAN lossed his graft.among 3 patients recieved Sofasbuvir+ledipasvir; 1 pt had transient worsening renal function4 patients were attained EVR; all pts were attained End of treatment response; SVR.

Conclusions: Direct acting antiviral drugs were safe and effective in patients with stable graft function; without any risk of rejction.

8. Clinical profile and outcomes of acute kidney injury in patients with cirrhosis of liver

Srinivas Shenoy, Ravindra Prabhu A, Shankar Prasad N, Dharshan Rangaswamy, Srikanth Prasad Rao, Sindhu Kaza, Karan Saraf


Kasturba Medical College; Manipal Manipal University

Background: Acute kidney injury (AKI) is an important adverse clinical event in patients with cirrhosis of liver . It is estimated that AKI occurs in around 20% of hospitalised cirrhotic patients. A systemic review of studies which evaluated the predictors of survival in cirrhosis has reported that parameters of renal dysfunction (creatinine and blood urea nitrogen) together with parameters of liver dysfunction like Child's score and MELDs score were important predictors of mortality in cirrhosis.

Aim of the Study: To study the clinical profile and outcomes of AKI in patients with cirrhosis of liver.

Methods: It is a retrospective cross sectional study done in a tertiary care hospital. 120 patients diagnosed with cirrhosis of liver with acute kidney injury (AKI) over a 2 year period were included in the study. AKI was diagnosed and staged as per Kidney Disease: Improving global Outcomes( KDIGO) guidelines (4) . Clinical factors affecting survival and prognostic factors like Child's score and Model for End stage Liver Disease (MELD) score were calculated. Descriptive statistics were used to characterize the baseline clinical factors. Univariate analysis and multiple logistic regression analysis was done to correlate the various clinical factors and outcomes.

Results: Mean age of the study population was 56.71 (+/- 11.71 SD).Mean Child's Score of the cohort was 10.73 (+/-1.63 SD). Sepsis was found to be the most common cause for AKI ( 53%) . Among patients with sepsis ; urinary tract infection(UTI) was the most common precipitating factor ( 43%). On univariate analysis presence of sepsis; encephalopathy; higher MELD and child Pugh scores; higher stage of AKI and low mean arterial pressure were associated with mortality. Multiple logistic regression analysis showed presence of AKI stage 2 and 3; presence of sepsis; were important predictors of in-hospital mortality. Overall mortality was high at 48% .One third of the patients required haemodialysis. (33 %). However only 20 % of the patients initiated on haemodialysis survived.

Conclusions: Acute Kidney Injury in cirrhosis of liver carries a high mortality. Sepsis was found to be the most common cause for AKI in cirrhosis. Strong clinical suspicion and prompt initiation of antibiotics and other measures maybe essential to survival and better outcomes.

9. Bile cast nephropathy secondary to obstructive jaundice due to choledocholithiasis: Case report

Dr. Vamsi Krishna Nagalla, Dr. Sreebhushan Raju. D


NIMS Hyderabad

Background: Bile cast nephropathy or cholaemic nephrosis is a rare cause of renal injury. Only a few cases of bile cast nephropathy have been reported over the past decade. The exact pathophysiological mechanism of bile cast nephropathy is as yet unknown.

Aim of the Study: We report here a case of obstructive jaundice with bile cast nephropathy.

Methods: A 65 year male presented elsewhere with history of fever; jaundice and pruritus. Lab investigations showed hemoglobin of 10.3g/dl; serum creatinine of 5.2mg/dl; hyperbilirubinemia with total bilirubin of 16mg/dl and direct bilirubin of 11mg/d. CUE was positive for bile salts and showed 3+protein with 30-35 RBC/hpf.24 hr urinary protein was 614mg. Renal biopsy; done to establish the etiology showed ATN with bile casts. He was managed conservatively with proper hydration; ursodeoxy cholic acid and oral bicarbonate. Serum creatinine gradually improved to 1.7mg/dl.

Results: He later underwent cholecystectomy and HPE was suggestive of adenocarcinoma of gall bladder.

Conclusions: Bile cast nephropathy can be suspected clinically when extreme hyperbilirubinaemia and acute kidney injury coincide. The diagnosis can be suggested by examining urine samples for bile crystals and confirmed by observing bile casts in kidney biopsy.

10. A changing pattern of hcv seroconversion from genotype 1 to genotype 3 among the patients on maintainence hemodialysis patients

Dr. Sridhar nimmagadda, Dr. Sreebhushan Raju


NIMS; Hyderabad

Background: HCV seroconversion was common among patients on logterm maintainence hemodialysis.

Aim of the Study: To study the type of genotype among patients of HCV seroconversion in mainainence hemodialysis.

Methods: Retrospective study of patients on maintainence hemodialysis from 2007 to 2016 who underwent HCV seroconversion.

Results: Among 41 patients who underwent HCV seroconversion during 2007 to 2011; 36 patients(87.8%) had genotype 3 and 5 patients had genotype 1(12%).among 37 patients who underwent HCV seroconversion during 2012 to 2016; 30 patients(81%) had genotype 1; 5 patients had genotype 3(13.5%) and 2 patients(5%) had genotype 4.

Conclusions: There was a significant change in the pattern of HCV genotype from 3 to genotype 1 during recent years.

11. Mars (molecular adsorbent recirculating system) experience in 5 cases of liver failure

Dr. Rajesh Goli, Dr. Sreebhushan Raju. D


NIMS

Background: Mortality rates in Acute hepatic failure or Acute on chronic hepatic failure reach up to 80% in cases in which liver transplantation is not possible. Dialysis fail to remove toxins accumulating in liver failure because of their high protein binding rate. MARS is the extracorporeal procedure now available for removal of these protein bound toxins.

Aim of the Study: The aim of the study1. To report our experience in use of MARS on 5 patients2. To improve the clinical condition of patients.

Methods: Five patients with acute liver failure and acute on chronic liver failure were included in this case series conducted at tertiary Centre at Hyderabad. In each of the patient's liver function kidney function arterial pressure; blood gas analysis; neurological status was evaluated before and after MARS. We treated the patients with medium length of 10+/- 1.5 hrs. The average number of applications for each patient was 1.8. MARS uses albumin enriched dialysate to facilitate removal of albumin bound toxins. We used MARS with a standard dialysis machine. Dialysis was used for all further treatments in the patients. Veno-venous access was used for blood supply. Blood flow rate was maintained between 150-250 ml/min depending on haemodynamic status of patient.

Results: Of the five patients; 3 are alcoholic cirrhotics with acute decompensation; one is paracetamol poisoning and one is carcinoma pancreas with obstructive jaundice.After treatment there was improvement in neurological condition and reduction in bilirubin and ammonia levels. The average ammonia level at onset of treatment was 383.5 μg/dl; at the end of the treatment the ammonia level was 259.3 μg/dl. The average bilirubin level at onset of treatment was 21.7 mg/dl; at the end of the treatment were 13.8 mg/dl. Of the 5 treated patients; one month survival was achieved in 4 patients; one patient was died in view of associated co-morbidities.

Conclusions: Despite the limited number of cases in our study; we believe that MARS is an extracorporeal hepatic assistance technique that can be used with complete tolerance for long periods of time; the most important clinical result was the improvement of neurological status.

12. Cadaver renal transplantation: Our experience without induction

Dr. Sridhar Nimmagadda, Dr. Sreebhushan Raju


NIMS

Background: Induction therapy is often considered to optimize outcomes; essentially in patients at high risk for poor short term outcomes.

Aim of the Study: We aimed to study the effect of no induction protocol in our patients undergoing cadaveric renal transplantation.

Methods: We retrospectively analysed the data of our transplant recipients who received cadaver renal transplantation.

Results: Total of 31 patients who underwent cadaveric renal transplantation from 2013-2016 were studied. The maximum follow up time was 40 months; the minimum follow up time was 4 months. The mean age of the patients was 34.7; 22 were male; 9 were females. The mean cold ischaemic time was 8 hrs. immediate graft function was attained in 14 patients; graft function was delayed in 17 patients. Out 17 with delayed graft function 5 patients had acute AMR. Out of 13 patients with immediate graft function 1 had acute AMR. Acute AMR incidence was 17.8%. Late AMR was developed in 1 (3.5%) patient. Out of 6 patients who developed AMR ; treated with plasmapheresis; low dose IVIG; one dose Rituximab 100 mg; one cycle of bortezomib; 2 patient had graft loss; 1 patient expired with sepsis; remaining 3 patients had recovered graft function. One patient who developed late AMR in 9th month after transplant; was succumbed in 14th month due to Pneumocystis and military TB.

Conclusions: No induction protocol was effective in prevention of early rejection.

13. Role of albumin dialysis (mars - "molecular adsorbent recirculating system") in paracetamol poisoning: A case report

Dr. Rajesh Goli, Dr. Sreebhushan Raju


NIMS; Hyderabad

Background: Paracetamol is a commonly used drug implicated in hepatorenal syndrome in case of overdose. The resulting acute liver failure is a therapeutic challenge.

Aim of the Study: There is little agreement on the optimal therapy in paracetamol overdose.Recently; use of liver dialysis showed promising results in the treatment of acute liver failure from various aetiologies.

Methods: We describe a case of paeacetamol poisoning in a 30-year boy; admitted 6 days after the ingestion of 208.3 mg/ Kg body weight of paracetamol for 1 day. We treated him successfully with one session of albumin dialysis (MARS - "Molecular Adsorbent Recirculating System")and 2 sessions of hemodialysis for fulminant liver failure ; grade II hepatic encephalopathy and renal dysfunction.

Results: After MARS dialysis; the patients had a spectacular clinical recovery. The patient was discharged 12 days after admission with normal liver enzymes.

Conclusions: Our case suggests that albumin dialysis may be feasible treatment option in acute liver failure due to paracetamol overdose.

14. Clinical and renal profile of voluntary kidney donors - A cohort study from a tertiary care center in india

Sumeet SD, Santosh V, Anna TV, Vinoi GD, Anjali M, Suceena A, Shibu J, Shailesh K, Tamilarasi V.


Christian Medical College; Vellore; Tamilnadu; India

Background: At present; renal transplant is the best modality of treatment for the end stage renal disease. Living donor transplantation is favoured over deceased donor transplant; in view of better outcomes and shorter waiting period. In a systematic review by AX Garg et al(2006); In 12% of donors GFR reduced to 30 and 59 ml/min (per 1.73 m2) and 12% developed proteinuria on follow up.

Aim of the Study: To study the clinical and renal profile of the voluntary kidney donors who underwent donor nephrectomy from 2006 Jan to 2007 Dec at the baseline and on follow up.

Methods: We studied all the donors who underwent donor nephrectomy in our institute from Jan 2006 to Dec 2007. Their baseline clinical and renal profiles were analyzed. They were followed up to study the trend of renal functions; proteinuria; blood pressure; blood sugars and lipid profile. In total 167 live donor renal transplants were done during that period of 2 years. Baseline and follow up data for all the consecutive patients was collected and analysed.

Results: Total number of patients having living related transplant in the year Jan 2006 to Dec 2007 were 167. Mean period of follow up was 3 years and 1 month (+ 3.3; with range of 1 month to 10 years). Average age of donor at the time of donation is 40.9 yrs (+11.5). The mean serum creatinine of the donors pre-donation was 0.86 mg (+0.15) and post-donation was 1.16 (+0.45). The mean 24 hr urine protein pre-donation is 0.065 g/day (+0.035) and post donation is 0.189 g/ day (+0.502). Donors having proteinuria more than 150 mg/24hr were 16%. The incidence of diabetes in the donors was 4.1% on follow up and more so in older donors. Hypertension was seen in 13.6% of the donors on follow up. 1 patient had AKI requiring hemodialysis. 1 patient underwent renal biopsy for dysfunction which showed Foamy vacuolisation suggestive of Fabrys disease.

Conclusions: Voluntary kidney donors form a healthy cohort due to their rigorous pre-selection. But there will be risk always for the renal dysfunction. But as adverse rate is less; we must continue to advocate living related kidney transplant whenever possible.

15. A case report on disseminated mucormycosis renal transplant recipient presenting as emphysematous pyelonephritis

Dr. Rajesh Goli, Dr. Sree Bhushan Raju. D


NIMS; Hyderabad

Background: Mucormycosis refers to different diseases caused by infection with fungi in the order of Mucorales. Involvement of a renal allograft in the isolated or disseminated form is rare and lethal complication of renal transplantation.

Aim of the Study: We report an extremely rare case of emphysematous pyelonephritis associated with invasive mucormycosis in a 26- yr-old man.

Methods: The patient was a 26 year male; a presumed chronic interstitial nephritis on MHD for 22 months. He received zero mismatch; cross match negative; a standard criteria deceased donor kidney transplant.No induction therapy was given. presented with fever; pain abdomen; decreased urine output 20 days after discharging from hospital. CT abdomen was suggestive of emphysematous pyelonephritis of renal graft.

Results: Postmortem renal graft biopsy and lung biopsy revealed mucormycosis.

Conclusions: Association with emphysematous pyelonephritis is an extremely rare; and only one such case has been reported. The multi-modality approach in the treatment of mucormycosis is essential and includes surgery; antifungal therapy; and management of risk factors.

16. A single centre experience of deceased donor transplantation

Kunal Kapoor, Ashish Sharma, Deepesh Benjamin Kenwar, Sarabpreet, Navdeep Singh, Soham Dasgupta


PGIMER; Chandigarh

Background: Deceased donor transplantation is the most novel way to expand the donor pool for solid organ transplantation and bridging the gap between demand and supply for the organs. Deceased donor transplant has been picking up pace in our country. As deceased donors do not undergo a rigorous evaluation as compared to living donors; it is important to know long term outcomes of transplantation from these patients.

Aim of the Study: The aim of the study is to study the outcomes of our deceased donor transplant program in a single tertiary care centre in North India.

Methods: The present study is a single centre experience of our institute; PGI Chandigarh from June 2001 to June 2016; during which 153 patients underwent deceased donor kidney transplant and 6 patients underwent deceased donor SPK transplants (all type 1 diabetics). 13 of these patients had kidneys retrieved from DCD donors while the rest were all from DBD donors. The demographics of both the deceased donors and the recipients were studied along with their outcome in terms of creatinine at 1 month and graft function and graft survival at 1 year. The effect of duration of cold ischemia time; use of induction agent (ATG vs Basiliximab) on outcomes was also studied in terms of mortality; incidence of delayed graft function (Defined by requirement of hemodialysis in the immediate postop period); rejection and infective episodes.

Results: The mean age of deceased donors was 36.3+16 years; whereas mean age of recipient was 38.9+11 years. Sex wise distribution of deceased donors was male: female 1:.55; and in case of recipients was male: female 1:.66. Average cold ischemia time was 4 hours and 45 minutes (range of 45 minutes to 12 hours); and 36% of the patients had delayed graft function requiring hemodialysis. Average creatinine at 1 month was 1.35mg% and average creatinine at 1 year was 1.21mg%. 51% of the recipients received ATG induction; 34% received Basiliximab induction; and 15% did not receive any induction immunosuppression. 1 year patient survival at was 7.0%. Incidence of post transplant infections was 29%; and incidence of rejection was 32% till the last follow up.

Conclusions: Deceased donor transplantation has provided good outcomes with acceptable rate of complications at our centre providing an opportunity to patients to undergo kidney transplant in the absence of a living donor.

17. Living related and spousal renal transplantation: Our experience without induction protocol

Dr. Sridhar Nimmagadda, Dr. Sree Bhushan Raju


NIMS; Hyderabad

Background: Induction therapy is often considered to optimize outcomes; essentially in patients at high risk for poor short term outcomes.

Aim of the Study: We aimed to study the effect of no induction protocol in our patients undergoing spousal renal transplant vis-à-vis the living related renal transplantation.

Methods: We retrospectively analysed the data of our transplant recipients who received living related (parents and siblings) and spousal transplant. All the recipients received standard triple immunosuppression ; none of them received induction therapy. all the parents were haplomatch; all spouses were nil match with the recipient. Data analysed for Patients whose data is available till date. Primary outcome was measured as mortality or graft loss due to rejection. Mortality due to sepsis; cardiac events and other causes were noted. Rejection was noted as cellular and antibody mediated rejection.all the living related recipients were categorised as group 1; spousal recipients were categorised as group 2.

Results: There were a total of 189 living related renal transplants during the period of july-2010 to july 2016. The mean age of recipients were 29.87±9.3. Mothers were the donors for 91 recipients; father in 27 recipients; sister in 14 recipients; brother in 4 recipients; wife in 48; husbends in 5. There was 19% mortality in group 1; 22.6% in group 2(p value =ns). Predominant cause of mortality was sepsis in 89%. There was biopsy proven acute rejections 4 in living related; 5 in spousal transplants. 4 patients in group 1 back in MHD.

Conclusions: No induction therapy irrespective of the donor; there is significant mortality among living donor transplantation. No induction protocol has less impact on biopsy proven acute rejection.

18. Successful isolated renal transplant in oxalosis

Dr. Deepak Kumar, Patel HV, Kute VB, Shah PR, Trivedi Hl


IKDRC-ITS ; Ahmedabad

Background: Oxalosis is a cause of end-stage renal disease in young people. The consequent urolithiasis and nephrocalcinosis result in renal impairment .Historically; renal transplantation has yielded very poor results in these patients because of recurrent oxalosis of the graft. Within the last 10 years; combined hepatorenal transplantation has been successfully applied; simultaneously correcting the metabolic lesion in the liver and replacing the damaged kidneys.

Aim of the Study: Case report of a patient diagnosed case of oxalosis having successful isolated renal transplant.

Methods: 40 yr male was admitted to ikdrc with renal failure .bone marrow biopsy and kidney biosy suggestive of oxalosis.later on b/l native nephrectomy was done and finally successful renal transplant was performed with prednisolone; tacrolimus and mycophenolate mofetil as maintainance immunosuppresant.

Results: Patient who was diagnosed case of oxalosis underwent renal tranplant & followed for 4 month post renal tx at the end of which serum creatinine was 1.0 mg/dl with normal functioning graft.

Conclusions: Renal transplantation alone may be feasible in selected patients OF OXALOSIS without significant extrarenal systemic oxalate deposition in spite of performing conventional liver and kidney tranpalnt as described.

19. Posterior reversible encephalopathy syndrome in an pediatric patient undergoing peritoneal dialysis: A case report

Mayur Patil,Patel HV, Kute VB, Shah PR, Trivedi Hl


Institute of Kidney Disease And Research Center; Ahmedabad

Background: Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological entity characterized clinically by headache; altered mental status; seizures; visual disturbances; and other focal neurological signs; and radiographically by reversible changes on imaging. A variety of different etiologies have been reported; but the underlying mechanism is thought to be failed cerebral autoregulation.

Aim of the Study: A case study of press syndrome.

Methods: A 14-year-old female receiving PD was brought to hospital after experiencing a generalized seizure. On presentation he was confused and hypertensive. An MRI brain was obtained and showed multiple regions of cortical and subcortical increased T2 signal; predominantly involving the posterior and paramedian parietal and occipital lobes with relative symmetry; reported as being consistent with PRES.

Results: Patient recovered with no neurological deficit.

Conclusions: Due to having a large number of endothelium-disrupting risk factors; including hypertension; uremia; and medications known to disrupt the cerebrovascular endothelium; we suggest that those with end-stage renal disease (ESRD) receiving PD are at high risk of developing PRES.

20. Single centre experience on treatment of antibody mediated rejection in renal transplant recipients

Dr. Soham Dasgupta, Dr. Sarbpreet Singh, Dr. Deepesh B. Kenwar, Dr. Ashish Sharma, Prof. Mukut Minz, Dr. Ritambhra Nada, Prof. Ratti Ram Sharma, Dr. Rekha Hans,

Prof. Krishan Lal Gupta


Post Graduate Institute of Medical Education and Research; Chandigarh

Background: Antibody-mediated rejection (AMR) has a reported incidence of 3-30% after renal transplantation depending on diagnostic criteria. Therapeutic plasma exchange (TPE) with IV Immunoglobulin alone or with combination with antiCD20 antibodies or bortezomib has been used as treatment for AMR although optimal treatment is unknown. These therapies are associated with significant cost and infectious complications.

Aim of the Study: In this study we have reviewed the response rates and clinical outcome of patients receiving treatment for AMR.

Methods: A total of 30 patients undergoing renal transplant from 2008 to 2016 who were diagnosed with AMR based on renal allograft biopsy findings and received TPE with IVIg at our Institute were evaluated retrospectively. Biopsy findings were interpreted as per the modified Banff criteria. Donor Specific Antibodies could be done only in a few patients because of high cost involved and non-availability in the earlier period. Patients were given additional Bortezomib (n=4) alone or along with Rituximab (n=2) as per the clinician's discretion. Renal function was monitored prior to starting therapy; at one month; and at one year after TPE or last follow up whichever earlier. Patients who received TPE for desensitisation to donor anti HLA antibodies; ABO incompatible donors; and other indications were excluded from the study.

Results: Out of 30 patients evaluated; 18 were males and 12 females. Mean age was 36.5 (+10.7) years. 13 patients had early (<1month) and 17 had late (>1month) AMR. The mean creatinine was 2.59 mg/dL (+1.41) before TPE; 1.8 mg/dL (+0.63) following one month and 2.22 (+1.1) following one year after TPE or last follow up whichever earlier. Patients with early AMR had a better outcome as compared to those with late AMR. Graft function was stable in 17 patients whereas 5 had declining graft function as shown by rise in serum creatinine; 4 had graft loss and 4 died all because of infectious complications. Infective complications were noted in 16 patients among whom 3 had pulmonary tuberculosis; 1 bacterial; 3 fungal (2 with mucormycosis; 1 with histoplasmosis) pneumonia; 4 CMV disease; 4 had UTI. One patient developed mycotic pseudoaneurysm of graft renal artery which required graft nephrectomy.

Conclusions: Therapy of AMR has a moderate therapeutic benefit and carries a high risk of infectious complications. Identification of risk factors for poor response to treatment can avoid unnecessary treatment.

21. Tuberculosis in renal transplant

Navdeep Singh, Ashish Sharma, Sarbpreet Singh, Deepesh B Kenwar, Soham Das Gupta, Kunal Kapoor


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

Background: Infections are common after renal transplantation. Tuberculosis is one of the leading infections after renal transplant in our country. While INH prophylaxis is routinely prescribed for patients with previous exposure to tuberculosis undergoing transplantation in the developed countries; its role in preventing tuberculosis in high endemic regions is unclear.

Aim of the Study: To know the incidence and the outcome of tuberculosis in renal transplant recipients.

Methods: Between 2006 to 2016; 1900 patients underwent renal transplantation at our centre. Patient data was screened from the transplant database to know the patients who received antitubercular therapy(ATT) during this period. 78 patients were identified to be on ATT giving an incidence of 4.1%. Out of 78 pts; 29 were excluded due to insufficient data and 49 patients were taken up for data analysis.

Results: Mean age of the patients was 35.6±10.2 years. M:F 44:5; 28.5% pts were already on antitubercular therapy prior to transplant. Mean duration (months) of diagnosis of Tb in patients with post transplant tuberculosis is 17.9±15.6 months. 19.2% patients had extrapulmonary tuberculosis16.3% pts received induction and 83.6% pts did not receive induction. Immunosuppression comprised of tac/mmf in 75.5% pts; cyclosporine/mmf in 10.2%; tac/aza 8.1%; cyclosporine/aza on 4%. 38.7% of patients had associated infections. Most of the patients were treated with modified ATT based on Levofloxacin and the duration of ATT was 12-18 months. 8/78(10.3 %) patients required treatment with Rifampicin either because of life threatening condition (5) or drug resistance (2) or side effects of other primary drugs (1).

Conclusions: Tuberculosis is still a major infection in ESRD and transplant population. Most of infections are detected in first 2 years. There is an urgent need to define role of INH prophylaxis in these patients.

22. The spectrum of pregnancy related aki with clinicopathological co-relation and outcome: A single centre experience in east india

Sandeep Saini, Dr. Dipankar Sircar,

Dr. Arpita Ray Chaudhary, Dr. Sambhunath Bandyopadhayay, Dr. Rajender Pandey


The Institute of Post Graduate Medical Education & Research and SSKM hospital; Kolkata

Background: Pregnancy related acute kidney injury (PRAKI) is always a very challenging riddle faced by clinicians. The incidence of PRAKI in the developed countries is 1-2.8%; whereas in the developing countries this is about 4.2-15%. PRAKI had contributed about 21% of AKI in previous study in our institution. It has been found to be associated with high incidence of fetal (39%); and maternal (20%) mortality in developing countries.

Aim of the Study: To study the etiological spectrum of pregnant patients presenting with AKI; clinicopathological correlation of the patient undergoing renal biopsy and its outcome at 1; 3 & 6 month interval.

Methods: It is a hospital based prospective observational study done under Department of Nephrology. Patients were recruited from February 2015 to February 2016. Their outcomes were noted at 1; 3& 6 month interval. Inclusion criteria was those patient satisfied the criteria of AKI as defined by KDIGO. Patient who had prior renal disease; small scarred kidney were excluded. Renal biopsy was done at 3 week if patient remained oliguric or non recovery of renal function and at earliest for anuric patient or if therapeutic intervention based on biopsy is planned. Outcomes were defined as complete recovery (CR) if eGFR > 60ml/min; partial recovery (PR) if eGFR <60ml/min but >50% recovery of eGFR and non recovery (NR)if eGFR improvement is < 50% of baseline.

Results: Total 66 Patients were enrolled of which 58 patients were followed for 3 month and 54 patients were followed up for 6 months. Age of patients ranged from 14 to 38 years. Causation of AKI was sepsis 36 (54.5%); atypical hemolytic uremic syndrome [aHUS] 11(16.7%); toxemia of pregnancy [TOP] 07 (10.5%); postpartum hemorrhage [PPH] 09(13.64%); malaria 01; acute fatty liver of pregnancy [AFLP] 01; chronic kidney disease 01. Renal biopsy 19 (28.8%) revealed acute tubular necrosis 05(26.3%); cortical necrosis 07(36.5%); aHUS 10(52.6%) & diffuse glomerulosclerosis 01(5%). Hemodialysis; plasmapheresis was done in 84.8% &7.5 %.respectively. At 1 month CR; PR; NR occurred in 11.3%; 24.2% & 30.6% respectively. At 6 month CR; PR; NR occurred in 33.3%; 16.7% & 13% respectively. In aHUS patients (11) CR; PR; NR occurred in 01; 02 & 06 respectively. Maternal deaths 16(24.2%) were caused by sepsis 08(50%); TOP 02(12.5%); PPH 02(12.5%) & AFLP 01 (6.25%). Fetal mortality was found to be 17 (25.75%).

Conclusions: Sepsis (54.5%) contributed to major proportion of AKI. aHUS (16.67%) emerged as an important irreversible cause of AKI. Puerperal sepsis is highly preventable cause of PRAKI. Hence we need to focus on the antenatal & postnatal care of the patient to avoid sepsis & its complications.

23. Case report: A young man with uncontrolled hypertension and hyperkalemia

Dr. Alok Gupta, Dr. Deepak Darshan, Dr. Luke Gaffany


Toowoomba Hospital; Darling Downs Health Service; Queensland Health

Background: In Gordon Syndrome (PHA-II); loss-of-function mutations in WNK1 or WNK4 prevents ROMK mediated K+ secretion by the kidneys resulting in hyperkalemia. Uninhibited NCCT activity in PHA-II; secondary to mutations of the kinases; causes increased reabsorption of NaCl resulting in hyperchloremia with ensuing volume expansion and hypertension. Volume expansion results in secondary hypoaldosteronism and; consequently; in hyporeninemia.

Aim of the Study: Pseudohypoaldosteronism Type II (Gordon Syndrome).

Methods: An otherwise healthy 25-year-old man was admitted after presenting with history of intractable hypertension and hyperkalemia after referred by his general practitioner. Four years prior to the current episode he was admitted for severe hypertension (SBP 240) detected during pre-employment screening. His echocardiogram showed severe global LVH with mild LV outflow tract obstruction and septal thickness of 1.7 cm. Ultrasound of the renal arteries did not reveal any stenosis. He was discharged on Prazosin and Verapamil with SPB of 190. Between the admissions he remained hypertension with BP ranging from 220/110 to 110/70. Hypertension was co-managed by his GP and a cardiologist with multiple anti-hypertensives including irbesartan; amlodipine; methyldopa and prazosin. Control of his blood pressure and potassium levels during this time remained sub-optimal. A follow up echocardiogram in 2014 showed mildly dilated LV with mild concentric LVH and normal systolic function.

Results: At current admission his BP was 140/80; HR 60/min. He remained asymptomatic during the entire admission. He denied any nocturia; polyuria; dysuria; haematuria; history of renal stones; childhood urinary tract infections or the use of NSIADs. USS of his kidneys showed increased echogenecity and loss of cortico-medullary differentiation however no obvious evidence of renal artery stenosis. Chest x-ray was essentially normal except for mild cardiomegaly. ABG; LFTs; BSL and lipid profile was grossly normal. Urine M/C/S; chemistry; ACR and osmolality were normal. Potassium levels fluctuated between 4.5 and 6.5 in days prior to the admission. Other electrolytes were with-in normal limits. Interestingly; serum Aldosterone levels were inappropriately low at 70 pmol/L (100-950) with normal Renin levels at 5.6 mU/L (3.3-41) and normal Aldosternone/Renin Ratio of 13. A provisional diagnosis of Gordon's Syndrome (PHA Type II; Familial hyperkalemic hypertension (FHHt)) was made.

Conclusions: The patient was initiated on Hydrochlorthiazide 12.5mg OD and dose optimised. Other anti-hypertensives were gradually tapered off. Both blood pressure and potassium levels normalised on Hydrochlorthiazide monotherapy.

24. A rae association of minimal change disease with polycythemia

Deepak Kumar, Patel HV, Kute VB, Shah PR, Trivedi Hl


IKDRC-ITS; Ahmedbad

Background: A 14-year-old male was admitted to our hospital for edema and severe proteinuria present with minimal change disease since the age of 7 years. Polycythemia was found during the last activation of nephrotic syndrome. The patient was placed on glucocorticoid therapy that caused disappearance of edema; proteinuria and polycythemia. Ten months later both hemoglobin and hematocrit levels were within normal range.

Aim of the Study: Case report of a patient having nephrotic syndrome due to minimal change disease and polycythemia.

Methods: A 14 yr old male who was diagnosed case of nephrotic syndrome since 7 yr of age presented with hypertension ; edema and nephrotic range proteinuria.Later after proper investigation he was diagnosed to have secondary polycythmeia.3 cycle of phlebotomy was done and hydroxyurea was also used.renal biosy was done report suggestive of minimla chnage disease . Prednisolone was started edema subsided and proteinuria came under normal range.1 yr after follow up pateint is having normal kidney function without any complication of polycythemia.

Results: Nephrotic syndrome-associatedsecondary polycythemia is a rare complication; and polycythemiahas been described with membranous glomerulonephritis.

Conclusions: This patient with nephrotic syndromedue to minimal change disease and polycythemiawas successfully treated with glucocorticoid.

25. Continuous ambulatory peritoneal dialysis programme: Experience of state run tertiary care centre

Dr. Raghavendra N, Dr. Umesh L, Dr. Shivaprasad SM, Dr. Leelavathi V, Dr. Sreedhara CG


Institute of Nephrourologybangalore

Background: Chronic ambulatory peritoneal dialysis (CAPD) is a form of renal replacement therapy in patients with end-stage renal failure in India; other than hemodialysis. Because of its cost and technical demand was mostly used in urban area in India.The objective of this paper is to report the experience with CAPD as a modality of renal replacement therapy from a tertiary care hospital in south India with predominant rural population.

Aim of the Study: To report the experience with CAPD as a modality of renal replacement therapy from a tertiary care hospital in south India with predominant rural and low socioeconomic population.

Methods: We report a prospective study in a large south indian tertiary hospital. This study involved the patients who were initiated on CAPD between april 2011 and january 2016 and who survived and/or had more than 6 months follow up on this treatment with last follow up till July 30; 2016 Infection rates as well as factors that may influence them were studied.

Results: Fourty five patients were enrolled. There were 24 males and 21 females. The mean age was 46±10 (range 5-70) years and mean duration on dialysis at the end of the trial period was 23 months. Shift to haemodialysis n=6). ).1 patient had exit-site occurred in 13.3% of patients ( infection.4 patient had peritonitis and all lead to removal of catheter. Other 2 cases catheter removal done for migration and in that one underwent reinsersion. 16 patients died in the study. The main cause of death was cardiovascular complications. Patient and technique survival at 1; 2 and 3 years was 90; 82 and 66%; respectively.

Conclusions: CAPD is a safe and viable mode of renal replacement in remote and rural places. The peritonitis rate and aetiology are similar to the developed world. It can use as procedure for ESRD patients dwelling in developing countries such as India.

26. Analysis of biopsy proven renal disease pattern from a single center in south india

Dr. Raghavendra N, Dr. Umesh L, Dr. Shivaprasad SM, Dr. Leelavathi V, Dr. Sreedhara CG


Institute of Nephrourologybangalore

Background: Ultrasound guided renal biopsy of native kidney is an essential tool in the diagnosis and management of renal disease. Information about the prevalence and incidence of pattern of renal diseases in India is lacking; because of non availability of registry and epidemiologic difference is evident in various parts of India. It is necessary to obtain rudimentary data regarding pathology of kidney diseases in a various parts of India.

Aim of the Study: To study the epidemiology of renal diseases in state run tertiary care centre.

Methods: From jan 2015 to dec 2015; 536 patients underwent renal biopsy procedure using real-time ultrasound guidance. All renal biopsies were studied by light and immunofluorescence microscopy. Data were collected prospectively.

Results: A total of 536 cases were included in the study. Patients were aged 39 ± 22 years; 62 were male; 38% were females. Serum creatinine (SCr) was 2.8 ± 1.6 mg/dl (>1.5 mg/dl in 70%). Adequate tissue for diagnosis was obtained in 99% of biopsies. The most common clinical syndrome as an indication for renal biopsy was renal failure and NS. Primary glomerular disease was the most common; accounting for 45.2 % of the cases. Focal segmental glomerulosclerosis (25.5%) was the commonest primary glomerular disease followed by IgA Nephropathy (23.2%) and membranous nephropathy (15.5%). Diabetic nephropathy (21.7%) was the commonest Secondary glomerular disease followed by lupus nephritis (5.2%). Minor complications occurred in 8.1% of biopsies (mainly gross hematuria; in 4%). No death resulted from post-renal biopsy bleeding.

Conclusions: Our study is an important contribution to understanding the epidemiology of pattern renal disease in South India. The incidence of FSGS and IgAN has been increasing since 1999. This study provides descriptive biopsy data and highlights the changing incidence of renal disease.

27. Pattern of non-diabetic renal diseases [ndrd] in patients with diabetus mellitus at state run tertiary care center

Dr. Raghavendra N, Dr. Umesh L, Dr. Shivaprasad SM, Dr. Leelavati V, Dr. Sreedhara CG


Institute of Nephrourologybangalore

Background: A wide spectrum of non-diabetic nephropathy; including both glomerular and tubulo-interstitial lesions are reported in patients with Diabetes mellitus. Their precise diagnosis requires histological examination of kidney tissue. We carried out this study to find the clinical; laboratory; and pathological features of NDRD in DM patients. We also examined if any significant differences in clinical profile between the NDRD and DMN groups.

Aim of the Study: We carried out this study to find the clinical; laboratory; and pathological features of NDRD in DM patients.

Methods: The demographic; clinical; and biochemical data of patients with DM (defined by ADA) who underwent renal biopsy in this institute for a duration of from 2012 august to june 2016 were analyzed prospectively. 260 patients were included in the study. Data were collected from inpatient file; monitor sheets; histopathological reports.

Results: In this study; incidence of NDRD was 38%; DMN 42% AND combined was 20%. CKD; NS and AKI were the most frequent clinical presentation. AIN; PIGN and CTID are commonest NDRD. These results suggest that prevalence of different category of biopsy-proven renal disease in diabetic patients depends on the usual prevalence of renal disease in the total population; according to the geographical area and ethnic characteristics and NDRD is merely a coincidental in DM. 58% of patients in the study had NDRD [either isolated or combined]. This study showed isolated NDRD in 38%; this result is similar to that reported in India and other regions with incidence of isolated NDRD were less than 50%.

Conclusions: Kidney biopsy is an important diagnostic tool to define underlying renal disease other than diabetic nephropathy in DM patients with prognostic value.

28. Early initiation of ace inhibitors in the post renal transplant period: A study from a state run tertiary care centre

Dr. Raghavendra Npost Graduate, Dr. Umesh L, Dr. Shivaprasad SM, Dr. Leelavathi V, Dr. Sreedhara CG


Institute of Nephrourology, Bangalore

Background: Angiotensin converting enzyme inhibitors (ACEI) comprise a drug class that inhibit theeffects of angiotensin II. ACEI are welldocumented to be potent antihypertensives with renoprotective effects but are grosslyunderutilized in renal transplant recipients1. However; these drugs have been reported to cause elevated potassium and creatinine levels in some renal transplant patients.

Aim of the Study: The purpose of this study is to assess the safety ofan ACEI class; when started in early posttransplantsetting.

Methods: We reviewed 84 kidney transplant patients during the period of January 2012 to April2016 at our institution. 72 patients were initiated on ACEI therapy. Patients who initiatedtherapy after day 5 and before day 365 of post transplant were included.

Results: Recipients were stratified into two groups according to the time of ACE inhibitors intoearly (within six months posttransplantation)and late (after six months aftertransplantation) group. For each patient haemoglobin; serum creatinine and potassiumlevels were analyzed at the beginning of ACE inhibitors and at the end of the first; sixthand twelfth month. In the 57(79.1%%) of the 72 patients; ACE inhibitors were initiatedwithin six months posttransplantationand in 15 (20.9%) patients ACE inhibitor wereinitiated after six months posttransplantation.There was no statistically significant difference between the two groups related to age or gender or the duration of dialysistreatment before the transplantation. Analyzing the haemoglobin; creatinine andpotassium serum levels after initiation of therapy with ACE inhibitors through theobserved period; we did not find any statistically significant difference in all measuredparameters.

Conclusions: ACEI can be used successfully in postrenaltransplant with beneficial long term impacton renal function. There is need for further randomized controlled studies to see theeffect of ACEI on Graft function and its survival.

29. A rare case of infective endocarditis and double valve replacement post renal transplantation

Dr. Varun Vijay Mahajan, Dr. Pradeep Deshpande, Dr. Aman Gupta, Dr. Shashank Dhareshwar, Dr. G. Sridhar


Global Hospitals Hyderabad

Background: 40 years old male underwent cadaver renal transplantation on 4-9-2015. 2 months post transplantation patient developed severe pain abdomen and fever. CT abdomen revealed spleenic infarct. Pretransplant echo was normal. subsequent echo post transplant in November was suggestive of vegetations over aortic valve and mitral valve involvement.Blood culture grew enterococcus. patient was treated with meropenem for 6 weeks. He underwent double valve replacement. Renal functions remained normal.

Aim of the Study: Rare complication after transplantation and successful double valve replacement after transplantation.

Methods: 40 year male underwent cadaver renal transplantation on 4-09-2015. cold ischemia time was 6 hours. Pretransplant echo and workup was normal.Induction was given with thymoglobulin and triple immunosupression was continued. patient had delayed graft function and renal biopsy was done which revealed ATN. had 3 sessions of HD post transplant. renal functions recovered and he was discharged with recovering renal functions. two months after renal transplantation he developed severe pain abdomen and fever. evaluated and found to have multiple spleenic infarcts on CT scan (oral Contrast). in view of splenic infarcts APLA and Homocystine levels were normal. 2d echo was done which showed Aortic valve vegetations with severe MR and severe AR. Blood culture grew Enterococcus fecalis; patient was treated with Meropenem for 6 weeks and discharged. for valvular incompetence Aortic and Mitral Valve replacement was planned and successfully done on 17-06-2016. now renal functions are normal.

Results: Cadaver transplantation individual developing bacterial endocarditis.Treated with meropenem for 6 weeks. As aortic and mitral valve remained incompetent; needed double valve replacement which was performed without any morbidity or mortality. patient had normal renal functions at discharge and he is on regular followup.

Conclusions: Unusual presentation as bacterial endocarditis which required antibiotics and ultimately successful mitral and aortic valve replacement.rarity of the case is emphasized.

30. Monday morning dialysis - One more reason to worry!!

Srinivas Nalloor, Madhu R


Apollo BGS Hospital; Mysore; Karnataka

Background: It has been well recognised that hemodialysis after a long gap is associated with increased morbidity and mortality. Though stated causes are many; electrolyte disturbances are implicated most commonly. Here we present an unusual cause for increased morbidity at our hemodialysis facility.

Aim of the Study: To highlight an unusual but potentially devastating cause for increased morbidity or even mortality in hemodialysis units.

Methods: Ours was a 4 station hemodialysis unit. As per protocol; the unit carried out hemodialysis from Monday to Saturday. Sunday was reserved for unit cleaning and disinfection of the RO water distribution system. RO water distribution system was of indirect feed type with pressure boost achieved by pumps. Dead ends were avoided to prevent bacterial growth and care was taken to use inert substances all along.Chemical disinfection of the the water distribution system was carried out using Puristeril. Puristeril contains per acetic acid which gets converted to hydrogen peroxide and acetic acid in presence of water. It has very good microbicidal action at low concentration and short exposure times. It is easily removed by rinsing. But patient exposure from inadequate rinsing results in hemolysis due to residual hydrogen peroxide.

Results: On that particular Monday; 4 patients who started hemodialysis on the first shift developed haemolytic anaemia of variable degree. 3 required hospitalisation; blood transfusions; oxygen support; and ICU stay. However there was no mortality. Patients on the second shift had minimal manifestations and none were hospitalised.Root Cause Analysis was carried out and it was recognised that a new team of facility engineers were recruited the previous week. Though they were aware of the need for RO water distribution system disinfection every Sunday; that particular week they had compromised on the rinsing process following disinfection. As a result of which residual hydrogen peroxide was left behind which resulted in hemolysis in the exposed patients in a concentration dependent manner.

Conclusions: HD though commonly done is associated with complications. Maintenance of HD unit is a team effort and every member needs to be aware of the criticality of his contribution. Here hemolysis resulted from residual hydrogen peroxide exposure due to inadequate rinsing following Puristeril disinfection.

31. Spectrum of non diabetic renal disease in type 2 diabetes mellitus: A single center experience

Dr. Samuel Raju Palli, Dr. Manisha Sahay, Dr. Kiranmai Ismal, Dr. PS Vali


Osmania General Hospital; Hyderabad 500029

Background: Diabetic nephropathy (DN) constitutes a majority of cases of kidney disease in diabetics; but Non diabetic renal disease (NDRD) is seen in a number of cases.Biopsy is performed if hematuria; absence of DR and proteinuria; rapid onset or progression of kidney disease are present. However; NDRD is often diagnosed during these biopsies.The clinicians need to consider renal biopsy in diabetics with atypical presentations as they have better response to therapy.

Aim of the Study: To study the spectrum of NDRD in atypical presentations of renal disease in Type 2 diabetics. The clinical and pathological profile of NDRD would be documented and utility of renal biopsy assessed.

Methods: Type 2 diabetics with atypical presentation (Active urine sediment; rapid deterioration of S. Creatinine; rapid onset proteinuria; renal dysfunction without proteinuria) who were subjected to renal biopsy to rule out NDRD from January 2012 to June 2016 were included in the study. The patients with Type 1 DM; malignancy; immunologic disease; obstructive uropathy and infections were excluded from the study. Clinical details like age; sex; duration of diabetes; HTN; diabetic retinopathy; 24 hour urine for proteins and urine microscopy were noted for all the patients. The patients were grouped into three categories based on the biopsy results; Isolated NDRD; combination of NDRD and DN and isolated DN.

Results: Isolated NDRD was seen in 32.7%(n=40) NDRD with DN in 11.4%(n=14) and isolated DN was seen in55.7%(n=68). NDRD was seen in total 54 patients(44.2%).Mean age in 3 groups (Isolated NDRD; NDRD with DN and DN alone) was 47.2±10; 50.1±9 & 50.1±8yrs respectively. Duration of DM was 3.2; 6.1 and 7yrs(p < 0.05).S.Creatinine was (mg/dl) 4.9; 5.2 and 4.7 respectively. 24 hour urine proteins were .9g; 1.7g and 1.6g per day. Active urine sediment was seen in 27.7% in patients with NDRD (n=15).DR was present in 22.5% with isolated NDRD compared to 46.4% in DN. The most common presentation in NDRD patients was AKI (33.3%) followed by NS (25.9%); RPRF(22.2%); AGN(7.5%); CKD and Asymptomatic urine sediment were seen in 3 cases each (5.5%).The biopsy diagnoses were ATIN(20.3%); ATN(12.9%). PIGN and IgAN (9.2%); MN and CTIN (n=4; 7.4%). FSGS; Crescentic GN; CKD and MCD (3.7% each); cholesterol embolism and amyloidosis(1.8%).Active urine sediment and duration of DM were better predictors of NDRD.

Conclusions: The overall incidence of NDRD) was 44.2%. The NDRD patients were younger than patients with DN and had a shorter duration of diabetes. The clinicians need to consider renal biopsy in diabetics with atypical presentations as they have better response to therapy.

32. Successful isolated renal transplant in oxalosis

Deepak Kumar, Patel HV , Kute VB , Shah PR, Trivedi Hl


IKDRC-ITS Ahmedabad

Background: Oxalosis is a cause of end-stage renal disease in young people. The consequent urolithiasis and nephrocalcinosis result in renal impairment; with further reduction in oxalate excretion and eventual systemi Historically; renal transplantation has yielded very poor results in these patients because of recurrent oxalosis of the graft.

Aim of the Study: Case report of a patient diagnosed case of oxalosis having successful isolated renal transplant.

Methods: 40 yr male was admitted to ikdrc with renal failure and with history of rucurrent renal stone formation .bone marrow biopsy and kidney biosy suggestive of oxalosis.later on b/l native nephrectomy was done and finally successful renal transplant was performed with prednisolone; tacrolimus and mycophenolate mofetil as maintainance immunosuppresant.

Results: Patient who was diagnosed case of oxalosis underwent renal tranplant.pt was followed for 4 month post renal tx at the end of which serum creatinine was 1.0 mg/dl with normal functioning graft.

Conclusions: Renal transplantation alone may be feasible in selected patients OF OXALOSIS without significant extrarenal systemic oxalosis deposition in spite of performing conventional liver and kidney tranpalnt as described.

33. Renal transplant in idiopathic thrombocytopenic purpura

Dr. Mayur Patil, Patel HV, Kute VB , Shah PR , Trivedi Hl


Institute of Kidney Disease and Research Centre; Ahmedabad

Background: Idiopathic thrombocytopenic purpura(itp) is rare disorder and such a condition with renal failure is extremely rare situation.Low platelet counts is a seemingly difficult condition for any surgery. We successfully performed a renal transplant in patient of itp.

Aim of the study: Case report of renal transplant in a patient of idiopathic thrombocytopenic purpura.

Methods: A patient of itp with renal failure was admitted to the institute. Patient had platelet count in range of 15; 000-20; 000. A fistula was created and patient started on hemodialysis. Prior to transplant; steroids with ivimmunoglobulins 100mg/kg were used for five days followed by rituximab 200mg as an induction agent. Patient was taken for transplant.

Results: Post renal transplant patient did well. S.Creatinine was 1.12Mg/dl and significant improvement in platelet counts was seen around 1.70 Lakhs/cumm.

Conclusions: Renal transplantation in a patient with itp is recommended with a well-designed strategy to prevent potential complications. Our experience may thus; be helpful to manage patients with itp waiting for renal transplantation.

34. Existing of candida species in various phases of renal failure

Dr. Sridhar Nimmagadda, Dr. Sreebhushan Raju


NIMS; Hyderabad

Background: Oral colonization with yeast entails acquisition from the environment.host defence acts to remove or kill invading yeast; but this function is hampered in renal failure.

Aim of the Study: 1) To identify presence of candida species in three stages of renal failure with the help of CHROMagar candida. 2) to compare abundance of candida in 3 stages of renal failure.

Methods: The study comprises of total of 60 patients; which includes 20-CKD; 20- ESRD; 20- post renal transplant patients from department of nephrology; NIMS; Punjagutta; Hyderabad 2) sterile bottles for sample collection3) chromagar candida for culturewhole saliva sample is collected and cultured by streakin on Chromagar candida; which were incubated for 48-72 hrs at 37 degrees for isolation of candida species; Gram staining for conformation for candida.

Results: Each group showed positivity for candida species with positivity of 80% in post renal transplant patients.

Conclusions: Highest positivity observed in post renal transpalnt patients.

35. Observational study of clinical and histopathological correlation of diabetic nephropathy

Dr. Sridhar Nimmagadda, Dr. Sreebhushan Raju


Nizams Institute of Medical Sciences; Hyderabad; Telangana

Background: Diabetic nephropathy is classified by Renal Pathological Society(RPS) in 2010 into 4 classes of glomerular lesions with a separate scoring for tubule-interstitial and vascular lesionsvery few studies classified DN as per new classification system.

Aim of the Study: To claasify DN on biopsy as per RPS classification system and correlate the clinical profile with histology.

Methods: Diabetics who underwent biopsy for various indications(August 2013-Aug 2015) were included in the studyDN on histology was classified according to Tervaert classificationclinical; biochemical profile of patients was correlated with histopathological lesions of DNThe indications for renal biopsy include-1)persistent nephrotic range protienuria2)sudden onset of overt protienuria3)hematuria with dysmorphic RBC in urine4)rapidly progressing renal failure5)suspecion of other nephropathies secondary to coexisting systemic diseases like hepatitis B; Rheumatoid arthritis; hepatitis C infction.

Results: 267 patients included in this studyNDRD was seen in 65(24.34%); DN in 161(60.29%)most common NDRD-AINindications for biopsy 1) RPRF-182(76.79%)2)Nephrotic syndrome-44(16.47%)3)hematuria-5(1.87%)4)non resolving AKI-2(0.74%)class I was seen in 4(1.98%); class II was seen in 27(13.36%)class III was seen in 83(41.08%)class IV was seen in 88(43.56%)most common glomerular class was class IV. In those with coexisting NDRD the most common class was class IIIinterstitial eosinophilic aggregates were seen in 18% of biopsies with pure DN.

Conclusions: Most common NDRD is AIN. interstitial inflammatory infiltrates and interstitial eosinophilic aggregates is a common finding on biopsy in DNHigher the tubulointerstitial chronicity; lower was the eGFR but not so with arterial chronicitymost common class is class IV.

36. Histopathological patterns in srns in children

Dr. Prabhucharan, Dr. ManishaSahay, Dr. Kiranmai Ismal, Dr. Sharmasvali


Osmania Generral Hospital; Hyderabad

Background: Nephrotic syndrome (NS) is among the most common paediatric kidneydiseases with a high risk of morbidity and mortality.Approximately 10 to 20 percent of patients will fail to respond to initial steroidtreatment(SRNS).This study is done to analyse various histopathological patterns in SRNS in children.

Aim of the Study: To determine the histological type of steroid resistant nephrotic syndrome in children and to find any deviation from local and international patterns.

Methods: A retrospective analysis was done of all children (with age of onset between 1 to 16 years) with SRNS ; who underwent Renal biopsy over the last 4 (2012 -2016) years ; presenting to department of nephrology of osmania general hospital. Inclusion criteria were: (1) children up to age of 16yrs; not responding to steriods up to 8 wks. We excluded children with (i) underlying secondary causes; (ii) hepatitis B surface antigen (HBsAg) seropositivity; human immunodeficiency virus (HIV) seropositivity or anti HCV seropositivity; (iii) SDNS All the patients' (70) clinical ; biochemical profile & histology( LM and IF)were analysed.

Results: The study group comprised of 70 children with SRNS. 1)60% were males: 40% females. 2)65% pts were less than 10yrs of age; 22%(16) pts were less than 5yrs; 3)45%(32) pts had HTN; 4)98% pts had nephrotic range proteinuria ( avg mean of 3 to 4g /day). 5)16% (11) Pts had mild to moderate renal insufficiency with grade 1 to 2 renal parenchymal changes on ultrasound. 6) out of 70 pts ; 40% pts(28) had FSGS; 42%(30) had MCD ; 5.7%( 4) pts had mesangio proliferative GN eithIgM deposits; 4%(3) ptswith hadc3 glomerulopathy; 4%(3pts) had DMS; 1 pt had DPGN; 1 pt had membranous nephropathy. 7)15.7% pts had IFTA OF 15 -20. %8) Out of 11 pts with renal insufficiency; 54% had FSGS(NOS); 18% pPts had C3 glomerulopathy; 9% had DPGN/MPGN on histology.

Conclusions: Our study showed most common histopatholgy in SRNS is MCD ; followed by FSGS(NOS); IgM nephropathy; and C3glomerulopathy; Pts with renal insufficiency in SRNS had FSGS (NOS) as most common histopathology followed by C3 glomerulopathy; and MPGN/DPGN. Thus histology may not always predict outcome.

37. Incidence of restless leg sindrome in ckd patient on maintenance hemo dialysis - A clinical study

Dr. P.Kumaraswamy, Dr. Manjusha Yadla


Gandhi Medical College

Background: RLS is disorder characterized by the following features;(i)An urge to move the legs causing restlessness;(ii) Uncomfortable sensations in the legs at same time;(iii) Symptoms become worse during rest and(iv) Motor (and often mental) activity leads to a temporary partial or complete relief of symptoms.Clinical diagnostic criteria for RLS were established by the International RLS Study Group (IRLSSG).In patients on dialysis; the reported RLS prevalence is between 5% and 83%.

Aim of the Study: Assessment of incidence of restless leg syndrome in chronic kidney disease patients on maintenance heamodialysis.

Methods: Setting: Gandhi HospitalPeriod of study : 6 monthsInclusion criteria: age between 18 & 60 years Maintenance hemodialysis min duration of 6 monthsExclusion Criteria: patients who had Diabetic NeuropathyThose patients who are having History of Restless Legs Syndrome prior to the Development of CKD.

Results: The total number of patients examined were 60 ; 9 of them satisfied RLS criteria (15%) 2 patients had mild RLS; 2 patients had moderate RLS; 5 patients had severe RLS; mean age of the patients 40.5 +/- 2; mean duration of Dialysis 3.6 years; 2 patients had Diabetes; 7 of the patients on antihypertensive drugs(CCB's).

Conclusions: Our study has confirmed that incidence of restless leg syndrome is high in patients of ckd on maintenance heamodialysis.

38. Controversial issues in kidney donation/ transplantation: Attitude of medical professionals

Almeida N, Fernandes Almeida RS, Almeida AF


PD Hinduja Hospital and Medical Research Centre

Background: A dire need to augment kidney donation and explore ethical concerns in facilitating the same served as an impetus for the current study.

Aim of the Study: To examine the attitude of medical professionals towards controversial issues in kidney donation.

Methods: The sample consisted of 140 doctors (Males=44.3%; Females=55.7%) practicing in Mumbai. Their ages ranged from 21 to 80 years (M= 38.1). Most were family physicians. A questionnaire; presenting ethical issues relating to kidney donation/ transplantation; in an agree/ disagree format with supporting reasons was employed.The data was analyzed both qualitatively (theme extraction) and quantitatively (percentages).

Results: Majority of doctors (75.7%) agreed that unrelated transplants should be promoted by the government as this would help save lives (16.4%) and remedy the organ donor shortage (16.4%). A majority (77.1%) endorsed the idea that kidney selling should not be made legal; with 41.4% expressing concern that this would lead to unethical practices. Quite a few (60%) favoured younger individuals being given preference for transplantation as they were likely to have a longer life expectancy (20%).Those in favour of the statement (45.7%); "Families of cadaver donors should be given incentives" voiced that incentives motivate donation (22.9%); while those against it (54.3%) argued that incentives could lead to criminal activities (20.7%). The statement; "Kidney donation should be made compulsory after death" elicited a mixed response.Those in favour (44.3%) maintained that it would save lives (26.4%); while those opposed (55.7%); upheld that coercion in relation to donation was unacceptable (44.3%).

Conclusions: This study is relevant in view of the dearth of Indian research; particularly qualitative methods of research. Having a platform where doctors; and particularly nephrologists; can deliberate about medical; ethical and legal issues pertaining to donation/transplantation is the need of the hour.

39. Deflazacort versus prednisolone in renal transplant recipients: A comparative study

Almeida AF, Fernandes Almeida RS, Kulkarni A, Kothari JP, Sirsat RA


PD Hinduja Hospital and Medical Research Centre

Background: Deflazacort ( DEF) ; a derivative of the old molecule (PRD); reported to have a similar efficacy and a more favourable adverse effect profile; has not been evaluated adequately in Indian transplant recipients.

Aim of the Study: To compare DEF with PRD with respect to efficacy and safety in kidney transplant recipients.

Methods: Out of 103 archived medical records that were available for review; 60 patients (30 on DEF; 30 on PRD) fulfilled the inclusion criteria. Patients included had been transplanted at least a year before; had received a CNI based immunosuppression (tacrolimus /cyclosporine) along with an anti-proliferative agent (mycophenolic acid /azathioprine) with either DEF or PRD. Retrospective analysis of clinical; biochemical; histological and radiological data was performed. Patients were started on DEF (1.2 mg/ kg/ day ) or PRD (1mg/kg/day ) and were tapered to a maintenance dose of 6-12 mg (DEF ) and 5-10 mg (PRD ) by the end of the I month. For efficacy; interval serum creatinine ; graft and patient survival ; presence of acute and chronic rejection; were examined. For safety; BMI gain; new onset diabetes; cataract; cosmetic appearance; dyslipidemia; osteoporosis and post transplant infections were analysed. Statistical analysis was conducted using Students t tests and Fisher's exact test.

Results: The groups were similar in age; sex; pretransplant BMI and HLA mismatches. The patients on DEF were followed up for a period of 3.13+/-0.93years and those on PRD for 3.46+/-0.97years. There was no significant difference between the two groups in parameters related to efficacy. However; there was a significant difference in the incidence of steroid facies (p=0.025); new onset diabetes (p=0.036); cataract (p=0.010); osteoporosis (p=0.0001); chest infections (p=0.025) and a percentage increase of BMI over baseline at 180 days (p=0.03) and 1 yr (p=0.02) and those on DEF demonstrating higher levels of safety.

Conclusions: As DEF has a more favourable adverse effect profile; it could be the preferred option in the Indian set up. However; further research is required to substantiate these findings.

40. Cryofibrinogenemic glomerulonephritis: A case report

Hilal Ahmed 1 , Urmila Anandh 1 , Bharat Shah 2 , Jai Radhakrishnan 3 , Sandeep Sethi 4

1 Department of Nephrology Yashoda Hospitals Secunderabad; 2 Department of Nephrology Global Hospitals Mumbai; 3 Prof of Medicine; Presbyterian Columbia College of Physicians and Surgeons NY; 4 Department of Pathology Mayo Clinic Rochester

Background: A 76 year old gentleman with a past history of prostatic adenocarcinoma (treated ) hypertension and hepatitis B carrier state presented with progressive pedal edema; worsening renal function and proteinuria. The proteinuria progressively increased over 18 months.

Aim of the Study: His investigations showed a creatinine of 2.2 mg/dl and a haemoglobin of 9.8 g/dl. His urine showed 4 plus proteinuria and hematuria.

Methods: His 24 hour urine protein was 8.8 gram.His ANA; dsDNA; C3/C4 ANCA; APLA ; cryoglobuins were all normal. He underwent arenal biopsy which was reported as MPGN pattern of injury with suboptimal tissue for IF and EM..A repeat biopsy confirmed the histopathological diagnosis. IF showed capillary and mesangial wall staining of Ig M; C1q; C3; kappa and lambda light chains. Electron microscopic study revealed intramembranous and subendothelial electron dense depositis.These deposits had a tubular substructure. These hollow tubules were arranged focally in parallel arrays. The mean thickness of these tubules was 44.9 nm. A pathological diagnosis of immunotactoid glomerulopathy was made.

Results: Extensive evaluation for a monoclonal gammoppathy was done which was non contributory..Laboratory evaluation for cryofibrinogen levels tested positive in 3 separate occasions. A diagnosis of cryofibrinogenemic glomerulonephritis was made . He was treated with monthly pulse cyclophosphamide for 6 months with tapering doses of steroids.He was offered Mycophenolate Mofetil following the cyclophosphamide injections.Currently his renal functions are normal and his proteinuria is less than 1 gm/day.

Conclusions: Cryofibrinogenemic glomerulonephritis should be treated in HBsAg carrier with prostatic cancer patients.

41. Outcome of pediatric rpgn at tertiary care center

Alok Kumar, Dorchhom Khrime, Nitin Bansal, Amit Verma


Shri Gururam Rai Institute of Medical and Health Sciences; Dehradun

Background: Rapidly progressive glomerulonephritis (RPGN) is an emergency as delay in diagnosis results in suboptimal outcome.Early diagnosis and management is crucial to salvage renal function.Rapidly progressive glomerulonephritis (RPGN) is an uncommon entity in pediatric population.But poses great challenges to early diagnosis and management.

Aim of the Study: We conducted study to look for clinical presentation and etiology of RPGN in children. We analyzed outcome of RPGN and factors associated with poor recovery.

Methods: We included patients (<18 years) with clinical presentation of RPGN from July 2008 to December 2014. Patients with > 50% crescents in renal biopsy were diagnosed with crescentic glomerulonephritis. Information about hypertension; oliguria; need of dialysis and data at last follow up was also collected. Complete recovery was defined as return of s. creatinine to normal range and partial recovery was taken as discontinuation of dialysis or fall of serum creatinine > 50% from baseline.

Results: There were 24 patients with gender ratio of 1.4:1(male: female). Mean age was 12.7 years. Patients had mean s. creatinine of 2.8±1.9mg%. Majority cases (87.5%) were due to Immune complex glomerulonephritis (GN) and 12.5% were due to pauci immune GN. Hypertension and oliguria was seen in 83% and 75% cases. Dialysis was needed in 33.3% cases. Nephrotic range proteinuria was present in 37.5% .45.8% patients recovered and 33.3% had partial recovery. 21% showed no recovery. Multi variate analysis showed that s. creatinine > 5mg%; crescents > 75%; fibrous crescents > 25% and anuria were predictor of poor recovery of renal function. Mean follow up was 11.2± 8.2 months. Mean s. creatinine was 2.1mg% and 66% patients had hypertension. Significant proteinuria > 1gm was seen in 42.8%.

Conclusions: RPGN in children is due to Immune complex GN in majority. Long term outcome remains suboptimal. Hypertension and chronic kidney disease were observed in more than 2/3 cases.

42. Oxidative and carbonyl stress in pathogenesis of snake bite and malaria induced aki

Dr. Pinaki Mukhopadhyay, D. Mukherjee, R. Mishra, M. Kar, R. Mishra


Nrs Medical College and Hospital; Kolkata

Background: Malaria and snake bite are two common causes of AKI in tropics with lot of morbidity and mortality.Carbonyl and oxidative stress is not well studied as pathogenesis of AKI.

Aim of the Study: 1. To evaluate the carbonyl and oxidative stress in these group and their pathogenesis link. 2.Prognostic predictability of carbonyl and oxidative stress marker in this AKI.

Methods: All cases of falciparum malaria mediated AKI (FMAKI)(n=50); confirmed by antigen and/or in peripheral blood smear and snake bite mediated AKI(SAKI)(n=58) were included. AKI was calculated as per RIFLE criteria. Demographical; clinical and biochemical data were analyzed and they are followed from hospitalization to discharge/death. Oxidative and carbonyl stress markers Advanced oxidation protein product (AOPP); Advanced Glycation End product (AGE); Pentosidine; Dityrosine; Thioberbituric acid reactive substance (TBARS) and Methyl glyoxal (MG)] were measured consecutively according to standard protocol. Predictive importance was assessed from trend analysis; ROC curve analyses and multiple logistic regression with AKI as positive response.

Results: The Oxidative stress index of FMAKI patients were 1.89 times higher than normal controll. The TBARS; MG level were 6.49 and 5.56 times higher indicating a significant carbonyl stress. AOPP level was 2.33 times higher. Areas under the curves(AUC) for AOPP and MG were (0.735; p= 0.001); (0.691; p= 0.005) .In SAKI pts increased total oxidative stress(TOS) (p=0.002) with decreased total anti oxidant stress(TAS) (p=0.048) leads to increased oxidative stress index values (p<0.001). MG was increased by 3.48 times (p<0.001). When they compared among the survived and expired only AOPP (248.64±17.4 vs. 168.75±12.56; p=0.001) and MG (39.93±2.11 vs. 28.89±2.41; p=0.004) were found to be significantly elevated in expired patients .AUC or receiver operated curve for AOPP (AUC 0.822; CI 0.699-0.945; p<0.001) and MG(AUC 0.83; CI 0.714-0.946; p<0.001) were significantly higher indicateing their predictive power for the adverse outcome.

Conclusions: 1. Methyl Glyoxal the carbonyl stress marker along with oxidative stress marker AOPP are significantly raised and possibly linked to the pathogenesis of Acute Kidney Injury.2. MG and AOPP can be used as a surrogate marker in these tropical AKI.

43. An unusual complication of malposition of left internal jugular catheter in a patient of chronic kidney disease

Dr. P Kumaraswamy, Dr. Y Manjusha


Gandhi Hospital/Gandhi Medical College

Background: One of the important complications of temporary venous access is malposition. Straight descent of left internal jugular catheter is unusual. Massive hemothorax is one of the dangerous complication of central venous cannulations. We report an unusual case of straight descent of left internal jugular catheter; the removal of which lead to development of massive hemothorax.

Aim of the Study: An unusual complication of malposition of left internal jugular catheter in a patient of chronic kidney disease.

Methods: A 56 years aged woman was admitted with complaints of altered sensorium.Evaluation revealed serum creatinine of 6 mg/dl; bilateral contracted kidneys. CT scan brain was within normal limits.

Results: We report an unusual case of straight descent of left internal jugular catheter; the removal of which lead to development of massive hemothorax.

Conclusions: The points of interest in this case are three fold: 1. Need for check x-ray after central venous catheter placements. 2. Lateral chest xray to be done if straight descent of catheter is seen on PA view. 3. Early recognition and apt management of massive hemothorax is life saving.

44. A prospective study of peripheral neuropathy in chronic kidney disease and electrophysiological - Pathological correlation

Pinaki Mukhopadhyay, B. Sholanki, S.P. Saha


Dept of Nephrology; Dept of Neurologynrs Medical College; Kolkata

Background: Prevalence of peripheral neuropathy in Chronic Kidney Disease(CKD) is common but electrophysiological and pathological changes in these patients are not well studied.

Aim of the Study: To study spectrum and severity of peripheral neuropathy in CKD patients and correlate electrophysiological findings with estimated Glomerular filtration rate and nerve pathological changes.

Methods: This is a prospective cross-sectional observation study where 60 consecutive patients with CKD (eGFR <60 mi/min) were enrolled excluding patients having malignancy; liver cirrhosis; alcoholism; hypothyroidism; autoimmune disorder; HIV or Hepatitis B infection; history of drug exposure causing significant nuropathic symptoms and hereditary or acquired neuropathy due to any other causes except diabetes. Detail history and clinical examination including neurology symptom score (NSS) score and electrophysiological examinations were done. Sural nerve biopsy was done and correlated with severity and progression of CKD using suitable statistical tool.

Results: Out of 60 Pts M:F was 1.6:1. Age was 49.38+13.12yrs.About 81.6% had distal symmetric polyneuropathy and NS Score was 1.75+1.36.In 25% Mononeuropathy; 3.33% (CTS) Cranial Neuropathy and 11.6% Autonomic involvement were found. Among 49 neuropathy positive(Np+) patients; 48.97% had sensory motor polyneuropathy and 51.03% had pure sensory polyneuropathy. Neuropathic group were having higher (NSS)(p-0.0002) and also having higher s. creatinine level(p- 0.012). Hyperkalemia was more in neuropathic group with mean serum.K+ level of 5.39 compared to non neuropathy group (mean s.K+ 4.93) (p-0.17). Diabetics had higher risk of neuropathy with odds ratio of 6.89 .Paresthesia/dysesthesia and absence vibration sence was commonest findings. NCV study revealed sural sensory action potential (81.66% abnormal) was the most common abnormal parameter. Sural nerve biopsy revealed mostly axonopathy in advanced CKD and in few cases demyelination which closely correlated with EP study.

Conclusions: 1.Peripheral neuropathy is common and linearly correlated with severity of CKD.2. Axonopathy is common in advanced CKD and there is a clear relationship between electrophysiological - pathological study.

45. Clinico-demographic study of cutaneous manifestations in patients of chronic kidney disease in eastern india with special emphasis for cutaneous markers of kidney disease

Pinaki Mukhopadhyay, A. Samanta, A. Roy


Nrs Medical College; Kolkata

Background: Incidence of chronic kidney disease is increasing rapidly. Many Patients presented with different symptoms including cutaneous manifestation either for the first time or in late stage of the disease.This is not well studied in eastern India.

Aim of the Study: To evaluate spectrum and frequency of dermatological manifestation and to compare between patients on dialysis and non dialysis and establish the cutaneous markers of CKD.

Methods: It is an institution based cross-sectional observational study. All CKD Patients having cutaneous symptoms or manifestation were included from skin OPD ; admitted patient of NRSMCH from March 2015 to Feb 2016 .Epidemiological and demographical data of all patients were collected. Detailed history were taken in all patients and thoroughly examined and investigated accordingly and analyzed in appropriate statistical tool. Skin biopsy were done in uncommon and remote lesion to identify the lesion. Patients having cutaneous manifestations prior to CKD; less than 18 years of age; renal transplant patient were excluded.Severity of pruritus and xerosis was assessed with appropriate scoring system and relationship was established with serum urea; creatinine; Parathyroid hormone level ; duration of CKD; stage of CKD; effect of hemodialysis and response to treatment.

Results: Out of 180 patients M:F ratio 1.5:1. Age range (12 - 68yrs); mean age 46.8 years. Majority(30%) belong to age group(50-70) years. Means of hemoglobin ; blood urea ; serum creatinine were 8.9 gm% (S.D=2.05 gm%) ; 98.07 mg/dl (S.D= 63.2 mg/dl) ; 5.03mg/dl (S.D= 3.77 mg/dl) respectively. Most common cutaneous manifestation were pruritus (80) followed by infections (38); xerosis (24); acquired perforating dermatosis (12); vesicobullous disease (8); papulosquamos disease (6); tendinous xanthoma (2); lichen amyloidosus(2); adenoma sebaceoum; acneifom eruptions (6); pseudoxanthoma elasticum (1). Bacterial infections was commoner than fungal and viral infections .No significant differences (p<0.05) was observed between HD and non HD group in terms of spectrum and severity of skin disease.Pruritus ; xerosis; and acquired perforating dermatosis found to be cutaneous markers of CKD.

Conclusions: Skin manifestations in chronic kidney disease is common and need proper diagnosis .Pruritus ; xerosis; and acquired perforating dermatosis though common ; no significant difference was found between dialysis and not on dialysis.

46. Pregnancy related acute kidney injury-a clinical study

Dr. Aravind Reddy, Dr. Manjusha Yadla


Gandhi Medical College

Background: Acute kidney injury (AKI) is a rare but an important complication during pregnancy.It is still a relatively common cause of AKI in developing countries. There are only a few studies in our country addressing this issue. It is observed that the frequency of PRAKI is on the decline in our country too.

Aim of the Study: To study the clinical profile; management and outcome of the patients with pregnancy related acute kidney injury. (PRAKI).

Methods: Period of my study:4 yearsInclusion criteria:Patients with AKI as per AKIN(acute kidney injury network) criteria. Exclusion criteria:Patients with CKD. Patients with underlying glomerular disease.

Results: Total number of women with PRAKI was 160. The mean age of the patient is 25±1.2. It has been observed that sepsis is the most common cause of PRAKI(54%; 86/160); followed by preeclampsia-eclampsia(46%; 73/160); and hemorrhages in pregnancy (18%; 28/160). Dialysis was initiated in 65%(104/160){AKIN III}of the patients.Conservative treatment was done in 35%(55/160){AKIN I/II} Hemodialysis was done in 80% (128/160)and peritoneal dialysis in 20%(32/160).Mean no of dialysis sessions are 5±1.3.Partial renal recovery is seen in 7%(11/160)Mortality was seen in approximately 18%(28/160)of the patients.

Conclusions: PRAKI is commonly caused by septic abortion in early pregnancy and by toxemia of pregnancy; hemorrhages during pregnancy (antepartum and postpartum); and ischemic acute tubular necrosis in late pregnancy 4.

47. An unusual case of extra pelvic extension of psoas abscess in a case of adpkd

Dr. Aravindreddy, Dr. Manjusha Yadla


Gandhi Medical College

Background: Psoas abscess due to pyelonephritis in ADPKD was reported by Sweet etal. But Psoas abscesss with extensive extension into lateral abdominal wall and gluteal region has not been reported. Early recognition and proper drainage of pus would yield optimistic outcome.

Aim of the Study: An unusual case of extra pelvic extension of psoas abscess in a case of adpkd.

Methods: A 45 years aged woman ; a known case of ADPKD presented with right loin pain and low grade fever of one month duration. She had history of increasing painful movements of right hip joint. History of painful swelling near the right loin area extending to right gluteal region. On examination; her vitals were stable. Her temperature was 100 F .Local examination of hip joint showed partial flexion with decreased range of movements.There was a swelling in the right loin area of 10x10 cm extending to right gluteal region.(fig1) Tenderness and inflammatory edema were present. Renal angle tenderness could not be elicited on right side due to diffuse swelling.

Results: Her hemoglobin was 6.2gm/dl; serum creatinine was 7.1mg/dl; ESR was 130 mm at the end of first hour.Her TLC was 23; 000 cells/mm3 and platelets were adequate. CUE showed traces of albumin and bland sediment.Ultrasound abdomen showed enlarged bilateral kidneys with multiple cortico medullary cysts ; RK was 15cm and LK was 16cm.Psoas muscle showed altered echogenicities. In view of suspicion of Psoas abscess; plain CT scan abdomen was done. There was evidence of 13x8 cm abscess in right Psoas muscle extending into right paraspinal area and into right gluteal reagion. There was 8x3 cm abscess collection in right gluteus muscle and 5x3 cm collection in right iliacus muscle. Lower part of right kidney and the collection were abutting each other though no apparent communication between the kidney and the hypo density could be made out(fig2). Spine and vertebral bodies were normal. Bowel loops were apparently normal.Echocardiography did not show features of endocarditis.

Conclusions: 1.Unusually large Psoas abscess with extra pelvic extension due to Pseudomonas in a case of ADPKD2.Early ; and apt treatment may yield favourable outcome.

48. Magnitude and determinants of restless legs syndrome in patients with chronic kidney disease admitted in a rural tertiary care hospital

Dr. Amrish Saxena, Dr. Rajdeep Nath


Mahatma Gandhi Institute of Medical Sciences; Sevagram

Background: Restless legs syndrome (RLS) is a common and extremely distressing problem experienced by chronic kidney disease (CKD) patients. Reported prevalence of RLS in CKD patients varies from 6 to 60 percent which is significantly higher in comparison to general population. RLS is also associated with poor sleep; impaired quality of life; increased incidence of cardiovascular events and higher mortality in CKD patients.

Aim of the Study: To assess the magnitude of restless leg syndrome in CKD inpatients and to analyze the association of demographic; clinical and biochemical variables with restless leg syndrome in CKD patients.

Methods: A cross-sectional hospital-based study was performed in CKD patients admitted in the department of Medicine of a rural teaching tertiary care hospital in central India. In all consecutive CKD inpatients; presence of RLS or its severity was assessed by a trained person through a questionnaire [International Restless Legs Syndrome Study Group (IRLSSG) criteria] who is blind of the diagnosis and investigations of the patient. Another study person collected the data including demographics; co-morbid diseases or risk factors; clinical and laboratory parameters.

Results: Of the total 206 CKD patients; 143 (69%) were males and 63 (31%) were females. Forty-eight (23%) of the 206 CKD patients had RLS. Of the 206 CKD patients; 4 (1.9%) had mild RLS; 15 (7.3%) had moderate RLS; 18(8.7%) had severe RLS and 11(5.3%) had very severe RLS. The age; co-morbidities; alcohol-intake and hemodialysis dependency of the CKD patients were not associated with RLS. The association of gender and serum ferritin level with RLS was found to be statistically significant (P < 0.05).

Conclusions: RLS was present in 23% (approximately one quarter) of patients with CKD and was related to female gender and serum ferritin levels.

49. An unusual cause of hematuria following coronary intervention

Dr. Vikram Kumar, Dr. Manjusha Yadla


Gandhi Medical College; Secunderabad; Hyderabad

Background: Complications seen during percutaneous coronary intervention (PCI) include those related to cardiac catheterization and diagnostic coronary angiography. Gross hematuria is rare in such patients.

Aim of the Study: We present a case of Hematuria following coronary intervention.

Methods: A 45 years aged woman known diabetic and hypertensive presented with sudden onset of breathlessness. On examination she had tachycardia; tachypnea and blood pressure was 220/130 mm of Hg; On laboratory evaluation; blood urea was 30 mg/dl and serum creatinine was 1mg/dl. She underwent coronary angiogram which showed 70%stenosis of LAD and 80%stenosis in LCx. PTCA was done to LCx .One day after PTCA; she developed oligoanuria; gross hematuria and breathlessness. Her serum creatinine increased to 2.3mg/dl; serum potassium was 6meq/l.Blood gas analysis showed metabolic acidosis. In view of hyperkalemia; metabolic acidosis and anuria; CUE showed 40-50 pus cells; plenty of RBCs. Ultrasound abdomen showed normal sized kidneys with mild dilatation of pelvicalyceal system in left kidney. Plain CT scan abdomen was done which showed retained contrast in the right kidney ; areas of hypo densities in the left kidney. Serum LDH was 464 IU/ml.

Results: A diagnosis of renal infarction was made based on the presence gross hematuria; absence of features suggestive of acute pyelonephritis. She was supported with hemodialysis. Over the next 24-48 hours her urine output improved to 4litres and serum creatinine decreased to 2.7mg/dl. At the time of discharge; her serum creatinine was 1.4mg/dl.

Conclusions: 1. Renal infarction following endovascular procedure is not uncommon.2. Renal infarction to be considered as one of the differential diagnosis in case of gross hematuria following vascular intervention.

50. Anuric acute kidney injury as presenting manifestation of carcinoma cervix- A clinical study

Dr.vikram Kumar B, Dr. Manjusha Yadla


Gandhi Medical College; Secunderabad; Hyderabad

Background: Cervical cancer is the most common cancer in women In the developing countries and its Incidence in India is about 32 per 1; 00; 000 Women. Over70% of the cases present in advanced stages of the disease with associated poor prognosis and high mortality rates. In many of them it is difficult to offer definitive treatment as they present in Uremia due to associated obstructive uropathy.

Aim of the Study: To study the Anuric AKI as presenting manifestation of Carcinoma Cervix patients.

Methods: Setting : Gandhi Medical college; Hyderabad.Period of study: 2012-2016.Inclusion Criteria: Anuric AKIExclusion Criteria: Oliguric AKI; Known Case of Carcinoma Cervix; Underlying Chronic Kidney disease.

Results: Total number of patients with Anuric AKI as presenting manifestation is 19; mean age of patients is 48±1.6 years. Clinical presentation is Anuria in 100% of these patients; bleeding Per Vaginum in 40% of cases. Mean Serum Creatinine is 7±0.8 mg/dl. All the patients were in AKIN Stage III. Carcinoma cervix was detected either on Gynaecological examination or on Ultrasonography or CT KUB. Bilateral HDUN was present in all the cases on radiography. Mean Dialysis sessions received were 6±2.7; Mean duration of urology intervention is 11±3 days; unilateral PCN was placed in 3 patients and Bilateral PCN was placed in 16 patients. Cervical mass biopsy was done in 5 patients which turned out to be Squamous cell Carcinoma. Complete renal Recovery is seen in 18% patients; partial renal recovery is seen in 70% patients; 12% patients continued to be Dialysis Dependent.

Conclusions: Anuric AKI can be presenting manifestation of Carcinoma Cervix which can be Recovered with Percutaneous Nephrostomy.

51. Concurrent cryptococcal meningitis and rhinocerebral mucormycosis in post renal transplant: A case report

Dr. Hemanth Kumar, Dr. J.S. Sandhu, Dr. Elenjickal Elias


Department of Nephrology , Dayanand Medical College and Hospital; Ludhiana

Background: Mucormycosis is a rare but devastating infection. We present a case of fatal cryptococcal meningitis with rhinocerebral mucormycosis infection in a renal transplant patient. The most common fungal infection after renal transplant is the candidiasis followed by aspergillosis and cryptococcosis. Estimated risk of developing fungal infections range from 1.4-9.4%.

Aim of the Study: To report concurrent cryptoccocal meningitis with rhinocerebral mucormucosis causing orbital cellulitis; cavernous sinus thrombosis with fatal mycotic fungal aneurysm of ICA with SAH.

Methods: Renal Allograft Recepient (Date of transplant-9/8/2011) with basic disease CGN; Donor Husband on triple immunosuppressants prednisolone; azathioprine; tacrolimus presented with rise in creatinine from 1.1 to 9.6 following stopping all immunosuppressants for 10 days.Was given pulse steroids 1gm/day for 5 days in suspicion of acute cellular rejectionA week later presents with headache; blurring of vision; pain around left eye and fever of 4 days durationExamination revealed normal fundus but diminished sensation in left periorbital area.MRI Brain was normal and CSF analysis showed cryptococcal meningitis. Was started on liposomal amphotericin B & fluconazole.On day 3; revealed proptosis of left eye with 6th N. palsy which increased the next day. Repeat MRI revealed Cavernous sinus thrombosis with left ethmoidal sinusitis & left orbital cellulitis.

Results: ENT examination revelaed gross necrotic area in bilateral nasal cavity and scrapings sent for KOH smear. KOH smear revealed broad hyaline aseptate hyphae which was sent for fungal culture.Endoscopic nasal debridement with sinus clearance done.Subsequently develops GTC seizures. Intubated and given ICU care.MRI repeated reveals mycotic aneurysm of internal carotid artery with subarachnoid hemorrhage with intraventricular extension with multifocal infarcts in left cerebral hemisphere and basal ganglia suggestive of fungal vasculitis.Planned for radical surgery of maxillectomy with orbital exentration with clipping of aneurysm.refused by patient attenders and went DAMA.

Conclusions: Immunosuppression following renal transplantation leads to increased risk of various opportunistic infections. However simultaneous occurance of multiple infections are rare.

52. A rare case of kidney transplantation from hepatitis b positive donor to hepatitis b negative recipient

Dr. Hozefa Runderawala, Dr. Rushi Deshpande, Dr. Saifee Plumber


Saifee Hospital; Mumbai

Background: Kidney transplantation is the treatment of choice for end stage renal disease. A successful kidney transplant improves the quality of life and reduced the mortality risk for most patients when compared with maintenance dialysis. However; patient requires close follow-up after transplantation since they are on complex immunosuppressive regimen. We report a rare case of successful kidney transplantation from hepatitis B positive mother (donor) to hepatitis B negative son (recipient).

Aim of the Study: To study the success of transplantation and disease free survival in Hepatitis B negative recipient receiving Hepatitis B positive kidney.

Methods: The Donor incidentally found to be HBsAg positive and recipient was HBsAg negative. Anti HBs titre of the recipient was done and it was increased to more than 1000mIU/L by giving hepatitis B vaccination. As patient could not afford intravenous immunoglobulins; he was administered hepatitis B vaccination. The Hepatitis B viral load of the donor was done; she was given prophylactically antiviral treatment and the viral load was brought to an undetectable level.

Results: Successful Kidney Transplantation was done with no intra operative and post operative complications.Follow up Hepatitis B surface antigen (HBsAg) of the recipient was done after 3 months which was negative.

Conclusions: Due to scarcity of organ donation and increasing demand for kidney transplantation; the criteria which were earlier considered to be contraindicated; has been effectively used in our case of transplantation from HBsAg positive Donor to HBsAg Negative Recipient.

53. Dalteparin is a safe and effective alternative to unfractionated heparin for extra-corporeal anti coagulation

Dr. Magesh Thirunavukkarasu, Dr. M. Sivalingam


Sundaram Medical Foundation; Dr Rangarajan Memorial Hospital; Anna Nagar; Chennai-40

Background: Unfractionated heparin (UFH) has been the main anticoagulant for hemodialysis (HD) for many years. Low molecular weight heparin such as Dalteparin can be given as a single bolus injection to prevent extra-corporeal clotting and has number of advantages including ease of administration; less risk of heparin induced thrombocytopenia and hair loss compared to UFH.

Aim of the Study: The aim of the study was to assess the efficacy and safety of Dalteparin for extra-corporeal anticoagulation as an alternative to unfractionated heparin in hemodialysis.

Methods: Patients undergoing chronic HD for more than 3 months at Sundaram Medical Foundation were recruited for the study. Patients were given a single bolus injection of Dalteparin at the beginning of dialysis. Dosing was determined as per patients' dry weight - 2500 IU for those weighing <65 kg; 5000 IU for those weighing between 65 and 90kg and 7500 IU for those weighing >90 kg. Dosing was subsequently adjusted if patients developed clotting of the dialyser or the tubing or excess bleeding post dialysis. Multi dose vial containing 1lac unit of Dalteparin was used in order to minimise the cost. Patients with acute kidney injury and those underwent or planned for surgical intervention within the preceding or next 24 hours were excluded from the study.Thirty eight patients were given 2500 units of Dalteparin; fourteen were given 5000 units and remaining two patients received 7500 units at the beginning of their hemodialysis session.

Results: 54 patients took part in the study. Majority (73.5%) of them were male with a mean age of 61.5± 11.9years. 24 of the patients were taking Clopilet and 15 were taking Aspirin. Majority of the patients (96%) were dialysing using an AVF and 1 each had graft and catheter. Patients were dialysed for 4 hours with the blood flow of 200 to 250mls and the dialysate flow of 500mls. Majority of the patients (70%) were undergoing HD thrice a week whilst the remainder doing twice a week. F60S was the most commonly used (72%) dialyser; followed by F80S (11%) whilst others using low flux dialysers.In view of clots in the bubble trap; arterial chamber or dialyser; dose of Dalteparin was increased to 5000units for 8 patients who received 2500units; to 7500units for 1 patient who received 5000units and to 10000units for 2 patients who weighed in excess of 100kg with no further dose adjustments.Dalteprin is used now in our unit for chronic HD patients who require extra-corporeal anticoagulation.

Conclusions: Dalteparin is a safe and effective anticoagulation for patients undergoing chronic hemodialysis. Dosing as per dry weight as utilised in our study was appropriate for most of our patients with no major complications.

54. Role of high-sensitivity c-reactive protein as a marker for estimation of overall health status among hemodialysis patients

Dr. Sachin Sasidharan, Sandeep S, Zachariah Paul, Anil Mathew, George Kurian, Rajesh Nair


Amrita Institute of Medical Science.Cochin; India

Background: Elevated levels of inflammatory factors have been associated with an increased risk of mortality and morbidity in CKD. hsCRP is considered to be the prototype biomarker of inflammation.The accurate assessment of hsCRP gives an estimation of the overall health status during the period of the measurement. hsCRP is increased 5-10-folds higher in haemodialysis patients than in healthy controls; and is multifactorial in origin.

Aim of the Study: This study attempts to analyze the association between the inflammatory markers; hsCRP and renal outcomes in ESRD patients on maintenance hemodialysis.

Methods: High-sensitivity C-reactive protein (hs-CRP) level was measured in 85 patients without any active infections; undergoing maintenance hemodialysis at Amrita Institute of Medical Science. Cut-off level of 0.4 mg/dl was used as an indicator of high levels of hs-CRP. Patients were divided into two groups; depending upon their hs-CRP levels being higher or lower than 0.4 mg/dl. A multivariate analysis was used to identify correlations between hs-CRP with anaemia; response to EPO; albumin levels. Only patients whose dialysis sufficiency was quantified and found to be adequate were included in the study. The dialysis malnutrition score was used to assess the nautritional status. Serum calcium; phosphorus and PTH levels were used to evaluat for association between inflammation and bone mineral disorder.

Results: 58% of cases had an elevated level of hs-CRP (mean 2.84mg/dl; median 0.04) . Blunted response to EPO and lower Hb levels were significantly higher in the high hs-CRP group and showed a worsening trend as hs-CRP values increased (p:.006 and 0.013 respectively). This negative co-relation was stronger with hs-CRP than s.ferritin. Serum Calcium; phosphate; and PTH did not differ significantly among the two groups. Serum albumin level had a strong and negative correlation with hs-CRP levels( p <0.01). There was no correlation between hsCRP and mineral bone disease. The nutrition status when assessed with Dialysis Malnutrition score (DMS) was significantly positively correlated with serum CRP (p<0.02).

Conclusions: Increased plasma hsCRP concentrations are independently associated with anaemia and hypo-responsiveness to EPO among ESRD patients on maintenance HD. High hsCRP was associated with poor clinical outcomes; nutritional status and low albumin levels.

55. Nephrogenic diabetes insipidus presenting as bilateral non obstructive urinary tract dilatation

Dr. Hilal Malla, Dr. V Suresh Babu, Dr, Chaitanya Sawant


Yashoda Hospital; Secunderabad

Background: Diabetes insipidus (DI) is characterized by impaired urinary concentration mechanisms due to defect in vasopressin action resulting in polyuria and polydipsia. Central diabetes insipidus is caused by inadequate secretion of vasopressin from the posterior pituitary in response to osmotic stimulation. Nephrogenic diabetes insipidus (NDI) is characterized by excessive water loss (up to 20 L of dilute urine per day) via the kidneys.

Aim of the Study: DI presenting as dilatation of upper urinary tract and bladder is uncommon. We present a case report of Nephrogenic DI with significant dilatation of urinary system.

Methods: We present a case report of young girl who presented with gross dilatation of renal pelvis; ureters and urinary bladder and on subsequent evaluation was found to have nephrogenic diabetes insipidus.

Results: 19 years female; presented to our hospital with complaints of bilateral flank pain for last 1 year. Patient had significant past history of polyuria and polydipsia since 2 1/2 years of age. Patient used to pass about 12-15 litres of urine/day. Upon admission; patient was found to have normal renal functions (s.creat. 0.6mg/dl). USG abdomen suggested bilateral moderate hydronephrosis and right proximal hydroureter. CT-KUB was suggestive of bilateral moderate hydronephrosis with over distension of urinary bladder. DMSA scan was suggestive of normally function cortical mass with no scarring and no evidence of reflux. She underwent water deprivation test which was suggestive of Nephrogenic DI. She was started on Hydrochlorothiazide 12.5mg/day and Amiloride 2.5mg twice a day. After 3 months of follow up patient had mild improvement in symptoms (urine output 8-9 litres/day) without significant radiological improvement. Patient continues with normal renal functions and is on follow-up.

Conclusions: Dilatation of urinary tract is a rare complication of Diabetes insipidus resulting due to the pressure effects of high urine volume.

56. Clinical profile of aki in hiv patients

Dr. P. Jaganathan, Jaganathan, Dr. T. Dhinesh Kumar,

Dr. R. Sakthi Rajan, Dr. J. Dhanapriya, Dr. V. Murugesan,

Dr. N. Malathi, Dr. T. Balasubramaniyam, Dr. N. Gopalakrishnan


Madras Medical College

Background: AKI is a common cause of morbidity and mortality in HIV patients.

Aim of the Study: AKI is more common in HIV infected individuals than their non-infected counterparts. In this study; we analysed the causes; risk factors; outcome of AKI in HIV infected patients.

Methods: This is a prospective study done from 2012 to2016. HIV patients with AKI who were admitted in our Nephrology department from were included in the study. Patients with pre-existing kidney disease were excluded. History; clinical findings; relevant investigations and kidney biopsy findings were noted. AKI was defined by AKIN criteria.

Results: Thirty four patients were included in the study..Twenty one patients (63.64%) were in advanced stage of HIV with CD4 count <250 cells /microlitre.Among them 6 had hypovolemia and 9 had sepsis.Acute diarrhoea disease was the cause of AKI in 5 patients .Snake bite was the cause of AKI in one patient. Drug induced acute kidney injury was suspected in 5 patients.Renal biopsy was done in 21 patients with active urinary sediments or proteinuria. Among them; 8 had acute tubulo interstitial nephritis; 4 had acute tubular necrosis; 2 had acute interstitial nephritis . Two patients had endocapillary proliferative glomerulonephritis with celluar crescents.

Conclusions: Majority of patients (63.64%) presented with AKI were in advanced stages of HIV. Pre- renal azotemia (45.45%) was the commonest cause of AKI in our study. Acute tubular injury was the most frequent finding in renal biopsy.

57. Role of em in histology of renal disease- "Essential or extravagant"

Dr. Srikanth B., Dr. Manisha Sahay, Dr. Kiranmai Ismal, Dr. P.S. Vali


Osmania General Hospital; Hyderabad

Background: The role of routine use of EM in Renal Biopsy specimens has been debated; more so considering its high cost and unavailability to a wide population in developing countries as India. Various studies have categorized EM usefulness and put estimates of EM being essential for diagnosis; EM Significantly contributing to diagnosis and EM not useful for diagnosis. The current study evaluates the usefulness of routine EM in Renal Biopsies in a Tertiary Care Government Hospital in South India.

Aim of the Study: To identify the Role of routine EM in Native Kidney Renal Biopsies.To find relative contribution of EM in Renal Biopsy in establishing and/or changing a Diagnosis.

Methods: Prospective¬ Study comprising patients who underwent Native Kidney Renal Biopsy 50¬between January 2014 and August 2016 were involved in the study. patients who had a valid indication for Renal Biopsy underwent Renal Biopsy were randomly selected and subjected for Electron Microscopy routinely. Inclusion Criteria:All Patients with a valid indication for¬ renal biopsy with prior informed consent.Exclusion Criteria:Patients LM;¬who did not want to be a part of the study. IF and EM was done in all cases regardless of the case characteristics to prevent selection The results were divided into groups:Category I: EM Required for¬bias. Confirmation of diagnosisCategory II: EM contributed for Diagnosis Category III: EM Added to LM FindingsCategory IV: EM not of ValueThe Results were analyzed for statistical Significance using SPSS Statistical Software.

Results: Patients included¬ 24 Males (48%) and 32(64%)were children;¬26 Females (52%). while 18 Most common indication for renal biopsy in the study¬(36%) were adults. Category I: EM Required for Confirmation of diagnosis:¬was SRNS (42%). 11(22%) patients required EM for confirmation of LM Diagnosis (MCD-8 cases (16%); FSGS-2 Cases (4%)Collagen Fibrotic GN-1 Case Category II: EM Changed Diagnosis: In 9 (18%) patients EM Changed¬(2%). the Diagnosis. List of Cases in Which Diagnosis was changed by EM (9)S. No LM DIAGNOSIS EM DIAGNOSIS FINAL DIAGNOSIS1. MCD Thin GBM Disease Thin BM Disease2. MCD FSGS FSGS3.MCD ALPORT'S DISEASE ALPORT'S DISEASE4. ? Storage Disorder PIGN PIGN5. Class I Lupus Nephritis Lupus Podocytopathy Lupus Podocytopathy6. ? CLASS V LN IDIOPATHIC MN IDIOPATHIC MN7. ? FSGS PIGN PIGN8. ? PIGN FSGS FSGS9. MCD FSGS Category III: EM Added¬FSGS to LM Findings: In 4(8%) Patients; Category¬EM added to LM Features. IV: EM not of Value: In 26(52%) patients.

Conclusions: Our study demonstrated a high Contribution of EM to LM(48%).EM was invaluable in 18% of cases; where it changed the diagnosis; whereas it was useful to confirm LM diagnosis in 22% of individuals.Thus; EM has a pivotal role to play when employed routinely in Renal Biopsy.

58. Differential leucocyte count as a marker for differential diagnosis between infection and acute graft rejection

Dr. Tushar Dhakate, Dr. Shweta Khurana, Dr. P. Tilve, Dr. S. Bichu, Dr. V. Billa


Bombay Hospital Institute of Medical Science and Research; Mumbai

Background: Differential leucocyte count (DLC) often help in diagnosis of infection and sepsis by looking after neutrophil cound and band form. .Acute infection versus acute graft rejection is a frequently encountered diagnostic and therapeutic dilemma in kidney transplant recipients; but little is known about the clinical usefulness of DLC In the differentiationof the two conditions.

Aim of the Study: To compare DLC in three Group :Group A -Control; Group B- Acute inection; Group C-Acute cellular rejection.

Methods: 20 post kidney transplant patients included in study .These were divied into control (n=7); Group B ; those with infection (n=5) and Group C ; with episode of rejection (n=8) We performed retrospective analysis of demographic; clinical; and laboratory parameters data. Data were analyzed statistically to ascertain the utility of DLC in discriminatingbetween Acute infection and acute graft rejection.

Results: As compared to group A; Group B have low lymphocyte counts (per mm3 )(863 ± 142.38 vs 1857.71 ± 903.98 ) (p 0.02); but neutrophil and monocyte counts were statistically insignificant.Whereas in Group C as compared to group A have higher neutrrophil count but not statistically significant (p=0.05).The ratio of Neutrophil to lymphocyte count (N/L); neutrophil to monocyte (N/M)and neutrophil to monocyte plus lymphocyte counts (N/L+M) were insignificant between group A and Group B.But as compared to Group A ; Group C have significantly high ratio of L/M and N/L+M (p<0.05).

Conclusions: The differential leucocyte count can help to distinguished infection from ejection although detail study of lymphocyte subset required to diagnosed subclinical rejection beforehand.

59. Double filtration/cascade plasmapheresis - A single centre experience

Dr. Jagdish. K, Dr. Suceena Alexander,

Dr. Shibu Jacob, Dr. Santosh Varughese, Dr. Vinoi. G. David,

Dr. Anjali Mohapatra, Dr. Anna. T. Valson, Dr. Shailesh. K. Tulsidas, Dr. V. Tamilarasi


Christian Medical College Vellore

Background: Double filtration/Cascade Plasmapheresis is a phenomenal invention by Agishi et al from japan in 1980; to preferentially remove Immunoglobulin during ABOIKT.The need for plasma is minimal and the need for periodic substitution of calcium and albumin should be less. Its Use is far more and good knowledge of sieving of various substances is essential to devise strategies to minimize adverse events ; and maximize its benefit to use it as "Poor man's Imunoadsorption".

Aim of the Study: To analyze; the removal of Immunoglobulin and various plasmacomponents with clinical outcome and it's complications in Double filtration plasmapheresis.

Methods: 1.It is designed as Prospective observational cohort study with patients who require Cascade/double filtration plasmapheresis as a part of their treatment schedule are enrolled after consent.2.All patients undergoing double filtration plasmapheresis from December 2015 to December 2016 will be included and collection will be carried out either in the ward or AK lab or from work station. No exposure and no long term follow up is required. Patient data will be collected from work station and hemodynamic data will be collected from AK lab progress/Monitoring form3.Pre and Post plasma pheresis calcium; phosphate; albumin; Immunoglobulin; potassium and magnesium; along with Effluent fluid albumin; were be sent.4.Hypotension; Tachycardia are noted periprocedurally and documented.Infections; Bleeding Diathesis during in hospital stay were documented along with clinical outcome.

Results: Overall number of patients enrolled during the study period - 14.No Attrition1.Percentage of Immunoglobulin G removal(Median) - 70%; 73.5%; 77%; Percentage of Immunoglobulin A removal(Median) - 88%; 90%; 93%; Percentage of Immunoglobulin M removal(Median) - 91%; 96.98%; 98%2.25% albumin fall from Preplamapherseis albumin levels at the end of three sessions3.Effluent albumin concentration is approximately 1.8 - 2 folds of the Preprocedural albumin concentration4.Percentage of fibrinogen removal(Mean + SD) were 76.1% + 12.1%; 82.6% + 10% at the end of first and second session without components supplementation5.25 % of patients required Plasma components supplementation and 20% of the sessions had a episode of Hypotension 6.Mean(+SD) Plasma volume processed was 2.26(+0.46) times the calculated plasma volume7.Three minor bleeding episodes and 1 major bleeding episode(during Surgery) were encountered during the study period8.12 out of 14 patients attained clinical end point succesfully.

Conclusions: DFPP effectively removes Immunoglobulin without much blood components support. The Achilles heel of the procedure is fibrinogen removal which can be carefully combated without bleeding; if the procedure is properly spaced. The Replacement Albumin concentration approximates the effluent concentration.

60. Do not waste kidneys

Shrikant Adate, Zaheer Virani, Prashant Rajput, Nitin Deote, Jitendra Jagtap, Pradeep Rao, Bharat Shah


Global Hospital; Mumbai; India

Background: There is a large gap between the demand and supply of organs. In India; barely 2% of patients developing ESRD get transplant. Therefore; no kidney should be wasted.

Aim of the Study: To show successful outcome of kidney transplant with deceased donor kidneys rejected by other centers

Methods: Three cases are studied. A 70 years old female with history of diabetes and hypertension for 2 years but normal kidney function; was brain dead following intracerebral bleed in 1999. No center was willing to accept including the center where kidneys were harvested considering donor profile and based on guidelines. Rather than wasting kidneys; we performed dual kidney transplant. An 18 months old female child was brain dead due to severe head injury following fall from a height. Based on the donor profile and guidelines; kidneys were considered unacceptable. Dual en-block kidney transplant was performed in a 45 years old diabetic with ESRD. A 55 yrs old deceased donor had on ultrasound; a mid pole (1 cm) and lower pole (1.1 cm) calculus in one kidney without hydronephrosis . No center was willing to accept this kidney. We accepted the kidney. Bench endoscopic pyelolithotripsy was performed before transplanting the kidney

Results: Recipient1; 52 years old male; did well and died 17 years after transplant with normally functioning transplant kidney. Recipient 2; a 45 years old diabetic with ESRD did well until he died 5 years after transplant from acute myocardial infarction with functioning transplanted kidney. Recipient 3; a 59 years old male had an uneventful course after surgery and is doing well

Conclusions: We conclude that no kidney should be wasted. When single kidney may not be enough based on kidney donor profile; dual kidney transplant should be performed. If there is a calculus with normal function of the kidney; it should be accepted

61. Efficacy and safety of canagliflozin in kidney transplant patients with type 2 diabetes mellitus (t2dm)

Mita Shah, Monika Dalal, Zaheer Virani, Prashant Rajput


Global Hospital; Mumbai

Background: Canagliflozin is a sodium glucose co-transporter 2 inhibitor developed for the treatment of patients with type 2 diabetes mellitus (T2DM).

Aim of the Study: To study efficacy and safety of canagliflozin in kidney transplant patients with type 2 diabetes mellitus (T2DM).

Methods: The study included 18 kidney transplant patients (HbA1c > 6.5%) on other hypoglycemic agents. Fourteen patients were diabetic before transplant and 4 patients had new onset diabetes after transplant (NODAT). Canagliflozin was used in the dose of 100 mg/day. One patient did not tolerate while one patient did not want to continue after slight rise in creatinine. Thus; 16 patients were studied. The parameters monitored were HbA1c; body weight; and requirement of other hypoglycemic drugs; as well as hypoglycemia incidence. Safety was assessed by adverse event (AE) reports. All patients were monitored for at least 3 months.

Results: There were 15 males and 1 female. The mean (1SD) age of the patients was 53 (7.4) years. The mean (SD) HBA1c before and after introduction of Canagliflozin was 8.5 (1.7)% and 7.7 (1.17)% respectively. The mean body weight before and after canagliflozin was 79.2 (12.8) kg and 76.5 (11.5) respectively. The requirement of other hypoglycemic drugs reduced in all patients. Hypoglycemia was not seen in any case. No adverse events were seen in any patient.

Conclusions: Canagliflozin provided reductions in HbA1c; body weight; and reduction in requirement of other hypoglycemic agents with no increase in hypoglycemia. There were no adverse events.

62. Regular-Nsaid Use In Spondyloarthritis Patients Induces Kidney-Injury

Mohit Kumar Rai 1 , Anuj Shukla 1 , Akhilesh Jaiswal 2 ,

Ravi Mishra 1 , Narayan Prasad 2 , Vikas Agarwal 1

1 Department of Clinical Immunology and 2 Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; India

Background: NSAIDs consumption associated with 2-8-fold risk of chronic-kidney-disease. The rise in serum creatinine often represents irreversible kidney-injury.

Aim of the Study: We have studied the changes inkidney-injury-biomarkers with regular NSAID-use.

Methods: Urine and serum samples were collected from 37-healthy controls with minimal-NSAID-exposure; 41-spondyloarthritis (SpA) patients using regular-NSAIDs for >3 months. In another group; 25 SpA-patients with minimal-baseline-NSAID-exposure were treated with regular-NSAIDs for 6-weeks. Urine and serum samples were collected at 0; 1 and 6-weeks. 12th week sample was collected from 10-patients who stopped the drug at 6-weeks. Normal-baseline-kidney-function was ensured in all the subjects. Early Biomarkers for kidney injury e.g.: NGAL; KIM1; cystatin-C and micro-albumin were measured.

Results: Kidney-injury-biomarkers were 2 to 3-fold higher in NSAID-users compared to healthy controls while there was no difference in serum creatinine and eGFR (uKIM-1 and uNGAL p<0.0001; sKIM-1 and sNGAL p=0.001). In longitudinal analysis; biomarker levels started rising at 1-week and showed a significant rise at 6-weeks. Subgroup that stopped NSAID-use demonstrated reversibility of biomarkers level at 12-weeks.

Conclusions: Regular-NSAID use in SpA-patients induces subclinical-kidney-injury represented by rise in biomarkers.

63. Impact of kidney transplant on hypertension in diabetic end-stage renal disease (esrd) patients

Nitin Deote, Shrikant Adate, Zaheer Virani,

Prashant Rajput, Hepal Vora, Bharat Shah


Global Hospital; Mumbai; India

Background: Hypertension is common in patients with diabetes and chronic kidney disease (CKD). The prevalence of hypertension increases with progression of diabetic kidney disease and almost 90% of diabetic patients with CKD stage V-D are hypertensive. There is no data about what happens to blood pressure in these patients after kidney transplantation.

Aim of the Study: To determine impact of kidney transplant on hypertension in diabetic end-stage renal disease (ESRD) patients.

Methods: The study included 40 hypertensive patients with diabetes and ESRD who underwent kidney transplant at our center and were followed for at least 6 months. All patients were on standard triple immunosuppression including calcineurin inhibitor; MMF and steroids. Office blood pressure readings and all anti hypertensive medications before transplantation and at 6 months after transplant were reviewed. Students paired t test was used to compare BP before transplant and at 6 months after transplant. Considering normal BP to be 130/80 mm Hg; outcome of hypertension was categorized as 'completely improved' (normal BP without need for medication); 'partially improved' (better BP control and/or reduced number of medications); or 'worsened' (worse blood pressure control and/or increased requirement of anti hypertensive drugs).

Results: There were 33 males and 7 females. The mean (SD) age was 51.22 (11.61) years. The mean (SD) systolic BP before transplant was 148.07 (22.32) mmHg and after transplant 134.82 (13.60) mmHg (p=0.002). The mean (SD) diastolic BP before transplant was 87.3 (10.25) mmHg and after transplant 76.92 (9.82) mmHg. (p=0.01). Mean (SD) no. of anti-hypertensive drugs required per day before transplant were 2.6 (1.1) and after transplant; 1.23 (1). Nine patients (22.5%) completely improved; 24 (60%) partially improved and seven (17.5%) worsened.

Conclusions: Both systolic as well as diastolic Blood pressure significantly improved in majority of diabetic ESRD patients after renal transplant. No.of anti-hypertensive drugs decreased post transplant.

64. Recovery from end stage renal disease (esrd)?

Bharat Shah, Zaheer Virani, Prashant Rajput


Global hospital; Mumbai

Background: A diagnosis of ESRD implies life-long dialysis or kidney transplant. This means a huge cost and a great change in the life of the patient and the family. Therefore; caution should be applied while making diagnosis of ESRD. We present a series of dialysis patients who had significant recovery of renal function after being labeled to have ESRD.

Aim of the Study: To determine factors that could suggest possibility of recovery of renal function in those presumed to be dialysis dependent.

Methods: The study includes series of patients who presented to us with diagnosis of ESRD. These patients had AV fistula made and were advised maintenance dialysis. A detailed history and review of past investigations was done to consider possibility of an acute reversible insult. Thereafter; detailed clinical examination and further evaluation was done to identify reversible acute insult. A simple exercise of holding dialysis and monitoring weight; BUN; creatinine and potassium was 3 consecutive days was done. Stability or improvement in parameters was considered to suggest possibility of recovery of renal function.

Results: There were 16 patients (11 males and 5 females) with a mean (SD) age of 60 (6.7) years. The patients had been on dialysis for 1 month to 1 year. All patients had a short history or rapid decline in renal function and good urine output. The causes of acute insult in these patients were ischemic or drug induced acute tubular necrosis; allergic interstitial nephritis; multiple myeloma and obstructive uropathy. The mean creatinine and BUN levels were 5.21 ± 0.6 mg/dl and 72.12 ± 11.12 mg/dl; respectively before stopping dialysis and 2.85 ± 0.57 mg/dl and 29.62 ± 5.26 mg/dl; respectively after stopping dialysis. These patients remained dialysis free for 6 months to more than 3 years.

Conclusions: Recovery of renal function must be considered in patients diagnosed as ESRD but having good urine output; short history and rapid decline in renal function. This is very important in a country like ours where renal replacement therapy is not available and affordable to many.

65. Histologic patterns of primary adult onset nephrotic syndrome and their clinical characteristics: a single centre study from South India

Dr. Sujeeth Reddy Bande, Dr. Gurudev K C,

Dr. Vijay Varma, Dr. Rakesh M, Dr. E Mahesh


M S Ramaiah Medical College and Hospitals; Bangalore

Background: The histologic pattern causing nephrotic syndrome (NS) and their clinical outcome varies depending on age; sex; race; socioeconomic status and geographic location. There has been a changing trend in the histologic spectrum of NS in the last few decades; in India as well as worldwide.

Aim of the Study: The aim of the present study was to see the histologic spectrum of adult NS in our institution and to compare it with data from other centers.

Methods: All adults (≥ 18 years) with nephrotic range proteinuria; who underwent renal biopsy over the 2 year period from August 2014 to July 2016; were consecutively included in this prospective study. NS caused by diabetes and other secondary glomerular diseases were excluded.

Results: Eighty (65.4%) patients were males and 42 (34.4%) were females. The median age at the time of biopsy was 36 years (interquartile range (IQR): 24.8 - 45). The most common lesions were minimal change disease (MCD) in 40.2%; membranous nephropathy (MN) in 24.6% and focal segmental glomerulosclerosis (FSGS) in 16.4% of the patients. MCD was observed mostly commonly in the age group 18-35 years and MN was seen mostly commonly in age group 36-55 years.

Conclusions: MCD still continues to be leading cause of NS in south Indian adults as evidenced from previous studies from this region. Other common causes include MN and FSGS. The incidence of MPGN is on the decline.

66. Impact of post cardiac surgery acute kidney injury (AKI) on renal outcomes at one year

Shrikant D, Vigna Charan S*, Annigeri R A, Girinath M R*


Departments of Nephrology and *Cardiothoracic Surgery; Apollo Hospitals; Chennai

Background: Recent studies from developed countries indicate that even minor degrees of acute kidney injury (AKI) after cardiac surgery have a significant adverse impact on short as well as long-term renal outcomes. However; long term renal outcomes following an episode of AKI after cardiac surgery in Indian population has not been studied.

Aim of the Study: We compared renal outcomes in patients who developed AKI after cardiac surgery and who did not at one year.

Methods: 170 patients who underwent cardiac surgery between May 2013 and December 2014; were studied prospectively. The glomerular filtration rate (GFR) was estimated by 4-variable modification of diet in renal disease (MDRD) equation. The patients who had impaired GFR prior to surgery were excluded from the study. AKI was defined as per AKI network (AKIN) criteria. The outcome studied was renal function (GFR) and incidence of CKD stages 3-5 at one year.

Results: 170 patients who underwent cardiac surgery between May 2013 and December 2014; were studied prospectively. The glomerular filtration rate (GFR) was estimated by 4-variable modification of diet in renal disease (MDRD) equation. The patients who had impaired GFR prior to surgery were excluded from the study. AKI was defined as per AKI network (AKIN) criteria. The outcome studied was renal function (GFR) and incidence of CKD stages 3-5 at one year.

Conclusions: AKI stage-1 was common and was seen in 46% of patients after cardiac surgery. Estimated GFR and incidence of CKD stages 3-5 were similar at one year between patients who had AKI and no AKI soon after surgery. Our results indicate that AKI after cardiac surgery had no significant impact at one year.

67. Outcomes of dual induction therapy in renal transplant

Dr. Prashant Rajput, Dr. Zaheer Virani, Dr. Hepal Vora, Dr. Shrikant Adate, Dr. Pavan Deore, Dr. Jitendra,

Dr. Bharat Shah


Institute of Renal Sciences; Global Hospital; Mumbai

Background: Rituximab is a chimeric anti CD 20 monoclonal antibody that leads to B cell depletion. Its successful use in ABO-incompatible renal transplant recipients has resulted in better 10 year survival. T cell induction is routinely used and has significantly reduced the number and severity of acute cellular rejection episodes in renal transplantation. Does adding rituximab induction to T cell induction further improve outcome of renal transplants.

Aim of the Study: To evaluate the effectiveness of Rituximab and T cell induction agent (rATG or Basiliximab) in renal transplant recipients.

Methods: 161 patients who underwent renal transplant between 27th August 2013 to 1st April 2016 were part of this retrospective analysis. 48 patients who did not receive any induction agent were excluded. Of the remaining 113 patients; 72 received Rituximab & rATG (group A) while 41 received Rituximab & Basiliximab (group B). Maintenance immunosuppressive regimen consisted of Tacrolimus; Mycophenolate sodium and Corticosteroids. Data was analyzed using descriptive statistics; mean and standard deviation (SD) for continuous variables and frequency and percentages for categorical variables. Patient and graft survival was calculated as per Kaplan-Mier analysis. Chi-square test was used to compare the outcome of two groups. A p value of <0.05 was considered statistically significant.

Results: There was no significant difference in age; sex; etiology of CKD and HLA Mismatches in the two groups. In group A there was a significantly lower incidence of ACR (11.1% Vs 17 %) & AMR (1.3 Vs 7.3%) (p=<0.01). However; a higher incidence of late onset neutropenia; and invasive fungal infections was observed. The patient & graft survival at 24 months in group A was 90.6% & 94.7% and in group B it was 96.1% % 96.1% respectively.

Conclusions: Rituximab in addition to rATG as induction; was associated with a lower incidence of ACR & AMR as compared to Rituximab & Basiliximab induction regimen. However it was associated with higher incidence of late onset neutropenia resulting in severe fatal infections & lower patient survival.

68. Limitations to intiation of capd as a treatment modality for esrd in kashmir valley

Dr. Muzafar Maqsood Wani, Dr. Imtiyaz Wani,

Dr. Khurshid Banday, Dr. Ashraf Bhat


Department of Nephrology; SKIMS; Soura; Srinagar; J and K

Background: CAPD as a form of RRT has also grown in Kashmir with about 120 patients presently on this modality. However because of various reasons the use of CAPD has not grown to its full potential. With technical consideration being the same anywhere; a major issue for success of CAPD is the affordability; availability and approachability.

Aim of the Study: To ascertain possible reasons for the lesser use of CAPD as an initiating modality of RRT in Kashmir valley.

Methods: J&K is a state embedded in the Himalayas with connectivity to rest of India via the sole mountainous highway -NH 1A.SKIMS the only tertiary care institute in Kashmir that caters to about 12 districts with a population of about 7 million. Patients from far flung areas of Kargil; Ladakh; Doda; Kupwara and adjacent districts of Jammu- Poonch and Kistawar report to the Nephrology department. Some of these areas are at least 200-300 km from the summer capital; cutoff for more than 3 months in winter months. Temperature falls to below -30°C at some areas. The incidence of CKD to be 800 PPM with 200 PPM in need of RRT gathers to about 2000 patients/year in need of RRT. However only 5-10% of these are fortunate to have RRT out of which a meager 1% is on CAPD. We circulated a questionnaire to 100 field doctors in the respective districts about their awareness of RRT options to CKD patients. We also interviewed 50 stage 4 &5 CKD patients to know about their limitations in initiating CAPD.

Results: Though CAPD is a good option for patients in remote hilly areas with limited access to HD centers; yet its penetrance has been suboptimal in Kashmir. Lack of awareness amongst the doctors in the periphery and limited number of Nephrologists is a reason. There are only 10 nephrologists in the valley (with only 4 encouraging CAPD) for a catering population of 7 million; coming to 0.8/million against the standard of 20/million. Higher cost because of transportation; high taxes and fear of infection preclude its usage. Training teams for this modality are limited.

Conclusions: Large scale proliferation of HD units; lack of insurance and reimbursement issues is a hinder to the usage of CAPD. Patient awareness; general practitioners awareness and understanding; with cut in costs and more specialists in the field to further propagate this modality are required.

69. Clinical presentation ; histopathological profileand renal outcome of anca associated vasculitis

Padmakumar.C, Dineshkumar T, Dhanapriya J, Sakthirajan R Malathy N, Balasubramaniyan T, Gopalakrishnan N, Anila A


Institute of Nephrology; Madras Medical College; Chennai

Background: Antineutrophil cytoplasmic antibody (ANCA)associated vasculitides usually affect various organ systems. Renal involvement usually presents as rapidly progressive renal failure . The clinico-pathological variants are Microscopic polyangitis (MPA); Granulomatosis with polyangitis(GPA) and renal limited vasculitis.

Aim of the Study: To study the epidemiology ; clinical profile; clinico-histopathalogical correlation and renal outcomes of ANCA associated vasculitis.

Methods: It was a retrospective and prospective observational study from Jan 2012 to Dec 2015. Patients with active vasculitis; ANCA positive serology and necrotizing crescentic pauciimmune glomerulonephritis in biopsy were included. Patients aged<13 years were excluded. Risk factors for renal outcome was analysed by Cox regression multivariate analysis.

Results: Thirtynine patients were studied. ANCA associated glomerulonephritis contributed to 2.8% of native kidney biopsies. Common age group was between 51 -60 years. Male to female ratio was 1:1.6 .Fever(54%); joint involvement (54%); oliguria (69%) skin involvement 21(54%) and hypertension(46%) were the common clinical features. pANCA was present in most MPA (87.5%) patients and cANCA was positive in all GPA patients. Anti GBM antibody was positive in 8 patients.Among 39 patients; 24(61.5%) had MPA; 11 had GPA; four had renal limited vasculitis. Crescent (93%); fibrinoidnecrosis(49%); interstitialmononuclearinfiltration(82%); interstitialgranuloma(5%) and fibro intimal proliferation in arterioles(18%) were noted. Histological class were focal(18%); crescentic(42%) ; sclerotic(21%) and mixed category in 13% patients. By multivariate analysis; joint involvement and sclerotic histological category in ANCA associated vasculitis had poor renal prognosis. Six patients expired (15%).

Conclusions: ANCA associated glomerulonephritis contributed to 2.8% of the native kidney biopsies. Microspic polyangitis(MPA) was the most common variant (61.5%). Joint involvement and sclerotic histological category in ANCA associated vasculitis had poor renal prognosis.Mortality was 15% in our study.

70. Low body weight (lbw) renal transplantation: a challenging feat

Dr. Arpana Iyengar 1 , P Pais 1 , A Vasudevan 1 , V Upadhyaya 2 , M Deb 3 , Shubha AM 3 and A Rozario 4

1 Department of Pediatric Nephrology; 2 Department of Anesthesia; 3 Department of Pediatric Surgery; 4 Department of Surgery; St. John's Medical College Hospital; Bangalore 560034; Under the International Society of Nephrology-Sister Transplant Centre- The Transplant Society Program

Background: Low body weight transplantation (body weight 10kgs) in the Indian context includes children in ESRD who have severe growth retardation due to delayed detection of chronic kidney disease and inability to use growth hormone due to high cost. Technical difficulties; discrepancy between donor graft and recipient body size; increased risk of delayed graft function and vascular thrombosis are the main challenges.

Aim of the Study: To report challenges encountered while transplanting a multi-vessel adult sized kidney into a low body weight child weighing 9.8kgs.

Methods: A 7year old girl; born preterm with birth weight of 1.8 kgs was diagnosed to have Congenital Rubella Syndrome.She was diagnosed to have ESRD at 4 years of age secondary to bilateral hypodysplastic kidneys.She was prepared for a preemptive renal transplantation; donor being her 57yr old maternal grandmother with a one haplotype HLA match. Induction therapy and triple immunosuppression with a higher dose of CNI were initiated pretransplant.

Results: Donor kidney; with 3 renal arteries and 2 renal veins was retrieved by open laparotomy and placed extraperitoneally in the recipient. Vascular anastomosis was laborious with 2 main renal arteries in close proximity were anastomosed to the aorta and the 3rd artery supplying the lower pole was anastomosed to the common iliac artery. Both renal veins were anastomosed to the common iliac vein. Special protocol was followed to maintain high CVP and MAP intra-operatively. With a total of 5500 ml of fluid and dopamine infused; brisk diuresis was achieved. to prevent vascular thrombosis; a heparin infusion was initiated once hemeostasis was achieved. The heparin infusion was continued for 48 hours followed by low molecular weight heparin. Post transplant she developed hypertensive seizures with a peak rise in serum creatinine of 1.3mg/dl. At 3 months of follow up her serum creatinine is 0.57mg/dl.

Conclusions: LBW kidney transplantation in children demands skilled surgical hands. It is also critical to follow specific medical protocols addressing higher immunosuppression; intraoperative fluid management and post operative anticoagulation therapies in LBW transplantation.

71. Unexplained liver dysfunction post kidney transplant

Dr. Tushar Dhakate, Dr.Shweta Khuran, Dr. P. Tilve,

Dr. S. Bichu, Dr. V. Billa


Bombay Hospital Institute of Medical Science and Research; Mumbai

Background: Nephrologist often faced problem with an increase in liver enzyme levels in renal transplant recipients.In few cases; the etiologic agent remains unknown and requires liver biopsy after ruling out classic viral hepatitis & drug related hepatitis. We report a case of acute hepatitis associated with renal function impairment that was found to be related to HEV infection in a renal transplant recipient.

Aim of the Study: Case report of acute Hepatitis E infection in post kidney transplant patient.

Methods: Lab report of patient

Results: 32 Years old male case of chronic IgA nephropathy undergone live related kidney transplant. Injection ATG was given for induction followed by standard triple immunosuppressant .Patient had immediate graft function. But after 2 days of transplant his liver enzyme started rising to reach peak level of 299 mu/ml and 835 mu /ml of SGOT & SGPT respectively on day 9.There was also gradual rise of serum bilirubin & alkaline phosphatase level from day 6.After all work up His IgM anti HEV antibody came positive.Considering risk of fulmitant hepatitis ; his tacrolimus dose was reduced .Fortunately with reduction of immunosuppressant ; his liver enzyme show down trend after 2-3 days.Also there was stable graft function despite reduction of immunosuppressant.

Conclusions: Nephrologist must be aware that in cases of unexplained hepatitis in organ transplant recipients & in the absence of evident drug hepatotoxicity; HEV should be considered an etiologic agent for hepatitis.In transplant patients; HEV might be responsible for fulminant hepatitis.

72. Outcomes of deceased donor renal transplant recipients from a developing country

Dr. Ravi Sankar Yalamarty, Dr.Swarnalatha,

Dr. Gangadhar, Dr. Uttara das, Dr. Raja karthik,

Dr. Raghavendra, Dr. Bharati, Dr. Siva parvathi,

Dr. Deepthi


Nizams Institute of Medical Sciences; Hyderabad

Background: Renal transplantation is the best theurapetic modality for patient suffering from End stage renal disease.Deceased donor transplantation accounts for less than 0.08 per million population per year in India. Telangana is a small state in south India comprising 35.19 million population. This is a multicentre observational study to evaluate the outcome of deceased donor renal transplant recipients who received organs under Jeevandan programme.We report two year experience of this programme.

Aim of the Study: To evaluate the outcomes of deceased donor transplantation in the form of prevalence of infections; rejection rate; graft survival rate and patient survival rate.

Methods: It was a multicentric observational study conducted at various hospitals in the city of Hyderabad under Jeevandan proramme between January 2014 and December 2015. There is a central registry for patients who are undergoing dialysis and waiting for the deceased donor renal transplantation in Jeevandan programme. The online organ allocation system to the recipients was started in January 2014. From January 2014 to December 2015 there were 140 brain death donations which resulted in 240 deceased donor renal transplantations. we analyzed 130 patients who underwent deceased donor renal transplantation. Patient data were obtained by reviewing the inpatient and outpatient medical records and from patients follow up.

Results: In the state of Andhra pradesh and Telangana under the deceased donor transplantation programme called 'Jeevandan' from January 2013 to December 2015 total 181 brain deaths have taken place with donation rate of 1.7 per million population per year. In Hyderabad city the donation rate came to 7.8 in the year 2015. The deceased donation rate in India is as low as 0.08 per million population per year.Mean recipient age was 39.7 years. The commonest blood group was 'O'positive(48.36%). The commonest recipient diseases leading to ESRD were chronic kidney disease with unknown etiology (52.3%); Diabetes mellitus (25%); Glomerular diseases(12.3%).Mean dialysis duration was 37.4 months.Mean cold ischemic time was 3.6 hours. Induction therapy was given in 83.84% patients. Delayed graft function was observed in 35% of patients.Infection rate was 29.5%; rejection rate 10.76%; mortality 10% and mean graft survival and patient survival rates were 89.52% and 86.15%.Mean serum creatinine was 1.1mg %.

Conclusions: In deceased donation rate of our state is very high when compared to the donation rate in India. The outcomes of deceased donor renal transplantation is comparable to live related renal transplantation in graft survival; patient survival; infection and rejection rate over 2 years of follow up.

73. Sequential liver and kidney transplantation in primary hyperoxaluria

L. Mahendra varman, M.Saravanan, Anil Vaidya, Mahesh Gopichetty


Department of Nephrology; Apollo Main Hospitals; Chennai

Background: PRIMARY HYPEROXALURIA is a rare inborn error of metabolism characterised by overproduction of oxalate which gets deposited in various organs including kidney leading to end stage renal disease ESRD. It is an autosomal recessive disorder with 3 different types with estimated prevalence of 1-3 cases per million populations.

Aim of the Study: Liver and kidney transplantation in primary hyperoxaluria

Methods: 7 year old boy was diagnosed as having medullary nephrocalcinosis. His gene mutation revealed primary hyperoxaluria type 1 as alanine glyoxalate aminotransferase AGXT was deficient. He was started on dialysis and pyridoxine. His dialysis was intensified with hemodiafiltration; the first of a kind being done in children in Chennai at that time as his serum oxalate levels remained high. Liver transplantation was done as he overproduced oxalate due to the enzyme deficiency as the level of oxalate did not come below the supersaturation level which could cause oxalate deposits in the allograft kidney. After liver transplantation; the serum oxalate level decreased to 25 mmol/L. Later he was taken up for kidney transplantation. He attained normal renal functions with a serum creatinine of 0.4 mg%.

Results: He has normal liver and renal functions with a serum creatinine of 0.4 mg%. His serum oxalate level was 11.9 mmol/L

Conclusions: Primary hyperoxaluria is a devastating disease and it can be slowed down if diagnosed early. Otherwise combined liver and kidney transplantation is the treatment of choice; particularly in type I.

74. AKI complicating pregnancy specific disorders: hospital based study

Vivek Ganiger, Jai Prakash, Iqbal, Ashish Verma,

Usha Singh


Institute of Medical Sciences; BHU; Varanasi

Background: Data on AKI in Pregnancy specific disorders are sparse in India

Aim of the Study: To determine the incidence; causes and prognosis of AKI complicating pregnancy specific disorders

Methods: From November 2014 to June 2016; 2340 pregnant women were attended the Obstetrics Department of SSH; BHU; Varanasi . Pregnant women meeting the criteria of AKI in pregnancy were included in the analysis. These patients were subjected to clinical analysis to define the causes of AKI and were followed up for 3 months or longer to define recovery or progression to CKD. Fetal outcome were noted in all pregnant women

Results: Incidence of AKI in pregnancy(P-AKI) was 132/2340(5.6%) with respect to total pregnancy. Mean age of the patients was 26.9 years. Fifty percentage of the patients had dialysis requiring AKI at admission. Most common cause of AKI in pregnancy was preeclampsia in 41(31.1%) patients; antepartum eclampsia and post partum eclampsia were noted in 12(9.1%) and 6(4.5%) patients respectively. HELLP syndrome contributed to AKI in 9(6.8%) patients . Hyperemesis gravidarum was not observed in our study. Possible AFLP was observed in 5(3.8%) patients as a cause of AKI. No case of AKI related to TTP or aHUS were noted in our study. Various obstetrical complications and miscellaneous cases of AKI were seen 81(61%) and 10(7.6%) of the patients respectively. Patchy cortical necrosis was noted in 4/2340 (0.17%) patients.

Conclusions: AKI in pregnancy was seen in 5.6% of pregnant women. The preeclampsia-eclampsia was the most common cause of AKI followed by HELLP syndrome. AFLP is a rare cause of AKI in pregnancy. We have not observed hyperemesis gravidarum and pregnancy associated thrombotic microangiopathy in our study.

75. Report of three case series of successful simultaneous pancreas-kidney transplant at apollo hospital; jubilee hills; hyderabad in india

Dr.Gajera Hardik Jamanadas,Dr.T.K.ShahaDr.Manish VermaDr.M.SomasekharDr.Denish Savalia


Apollo Hospital; Jubilee Hills; Hyderabad

Background: Simultaneous cadaveric pancreas kidney transplant were performed on three patients with insulin dependent type 1 diabetes mellitus; hypoglycaemic unawareness; diabetic retinopathy with renal failure on maintenance haemodialysis.

Aim of the Study: To Assess quality of life and survival benefit after combine simultaneous pancreas kidney transplants.

Methods: A series of Three pancreas-kidney transplant performed on Type 1 diabetes with chronic kidney diseases on hemodialysis between 2015 to 2016 are presented.

Results: Good pancreas and kidney allograft function recovery was achieved within 48 hours of anastomosis of cadaveric pancreas to right iliac fossa and kidney to left iliac fossa anastomosis with back table procedure from same cadaveric procurement organ. The recovery of renal allograft function was delayed of 72 hours in one case which needs one cycle hemodialysis whereas other two cases achieved good graft function without RRT. Up to the writing of this paper no acute rejection of organs and other complications such as pancreatitis; thrombosis; and localized infection occurred. The patient became insulin independent with normal pancreas and renal function. One case was re- explored for the GI Bleeds post transplant which requires 5 units of PRBCs; bleeding point was identified & sutured and successfully discharged. Total no of stays in hospital on an average 12 days. The serum amylase; lipase and serum creatinine was monitored daily which was reducing satisfactory after transplant.

Conclusions: Simultaneous pancreas-duodenum and kidney transplantation can be a good method for the patients with insulin- dependent type 1 diabetes. There is increase quality of life and survival benefit after combine simultaneous pancreas kidney transplant.

76. Are we ready to transition maintenance hemodialysis out of hospitals in india?

Suresh Sankar, Topoti Mukherjee, Gayathri Bala,

Geetha Sambanadan, Mary Magadelene Santa,

Swathi SNaksha Jagannath Anchan


DaVita Kidney Care

Background: Hemodialysis is the most common modality option for CKD-V in India. As the health system is battling the challenge there is an urgent need to demonstrate new models of effective; safe care outside hospitals.The dominant hospital based care may not be sustainable in the future due to a multitude of hurdles for patients; clinicians and hospital operations. While there is provision in the voluntary sector; there is little we know about clinical outcome in such setting.

Aim of the Study: In free standing center contextTo study the profile of patients undergoing maintenance HD (MHD)To study practice pattern of MHDTo study clinical outcome of of patients.

Methods: Retrospective study of all patients who underwent MHD at our free standing centres in Chennai and Bengaluru between Jan 1; 2014 and Dec 31; 2015 were includedInclusion criteria: Age > 18 years; MHD for CKD V; Duration greater than 30 days of RXExclusion criteria: Age < 18 years; HD for AKI; temporary HD for less than 30 days Age; gender; diabetic status; type of access; duration of HD; total number of sessions were reviewed. Hemoglobin; dialysis adequacy; S.Albumin; S.Calcium; S Phosphorus; S.Potassium were reviewed. Clinical outcome were characterized as death; shifted out to other centres; continued. Data is presented as mean and standard deviation. Cumulative follow up period was calculated in patient years and sessions were averaged to no per week. Mortality rate and hospitalizations were calculated as number per patient year.

Results: N=242; Age:57±14 yrs; F:M- 78:164(32.2%; 67.8%). Diabetics:97(40%); HCV:8 (2%); HIV:.8%; Hepatitis B:.8%. Incident:133(54.9%); Prevalent:109(44.1%). Duration of HD: 3 mon: 48(20%); 3-6 months: 30(12%); 6 months to 1 year:58 (24%); >1yr 106 (44%). Total sessions: 25404; Cumulative follow up: 210 patient years. HD freq prescribed:Once/ Twice/thrice= 2.1%/51.6%/46.2%. Delivered frequency: <2:110 (45.5%) >2:132(54.5%). Hb-9.8±1.48g% Std Kt/v:1.83±0.44S Alb-3.6±0.39g%; S Ca-8.0±1.19mg%; S Ph-5.3±1.11mg%; S K:5.3±0.71m Eq/l. Continued:80(33%); Shifted:121 (50%); Transit:8 (3%); died:34 (14%). Mortality rate was 0.14/patient year. 92 hospitalizations at rate of 0.38/patient year.

Conclusions: Patients with clinical profile similar to MHD. Diabetes is the most common etiology. Access is dominantly permanent and twice weekly MHD is common. Hb; adequacy and albumin were fair. Mortality is within acceptable range. Hence MHD can be safely and effectively delivered in out of hospital setting.

77. Single centre experience of tunnelled catheter insertions done by nephrologists

Abhishek Garg, Amit Mahapatra, Shyam Bansal,

Manish Jain, Reetesh Sharma, Pranaw Jha,

Ashish Nandwani, Dinesh Yadav, Siddarth Sethi


Medanta; The Medicity

Background: In developing countries due to lack of patient education & poor follow up; initiation of haemodialysis via AVF is not possible in all patients. A tunnelled rather than non tunnelled catheter for haemodialysis has advantage of less infection; better cosmetics & longer shelf life. It also helps patients awaiting transplantation or maturation of AVF.Tunnelled catheter insertion can be done by vascular surgeons; intervention radiologists & nephrologists; latter are preferred for continuity of care.

Aim of the Study: Aim of the study was to share the experience of tunnelled catheter insertion done at our centre in last 15 months.

Methods: This is a retrospective study done at our institute. This study includes all patients aged more than 18 years who underwent tunnelled catheter insertion by a nephrologist during specified period. Follow up data was collected from electronic records; physical records and OPD prescriptions. Data was collected telephonically in those patients who did not followed up post procedure.

Results: There were321 tunnelled catheter insertions.296 (92.21%) were right IJV catheters.19 were left IJV and 6 were femoral catheters.230 (71.65%) were males and 81(28.35%) were females.Mean age was 51.07 yrs.122(38%)patients had no follow up. 32patients (9.97%)died with a working catheter.Of the remaining 167patients; 118patients had catheters removed. 103 patients had used catheter as a bridge to AVF(n-30); transplant(n-70)or CAPD(n-3). 3patients had recovery of AKI. 49 patients are on dialysis.2 patients who had cardiac arrest during procedure and were revived. Two patients had arrhythmia.In 12 patients catheter was removed because of complications. Early removal of catheter was done in two cases. In first case catheter was malposition & venography revealed venous malformation. In second case catheter was removed after 2 days because of poor flows.In 9 patients catheter removal was due to infection. 4 had Klebsiella; 4 had staph aureus and 1 patient had pseudomonas infection.

Conclusions: Tunnelled catheters can act as an useful bridge therapy while patient is awaiting renal transplant or maturation of AVF. It has a good shelf life and possibly less infection rates as compared to temporary catheters. On table complications are rare but can occur.

78. A rare serious opportunistic infection in a renal transplant receipient

Sabarinath C, Jacob George, M K Mohandas, Sajeevkumar, Noble Gracious, Vineetha N S


Govt. Medical College; Trivandrum

Background: Opportunist infections have become a great threat to the post transplant patients due to the intense immunosupression used by them.The early diagnosis and treatment of these infections is crucial for reducingthe mortality and morbidity caused by them.

Aim of the Study: To study the clinical picture of a rare but serious opportunistic infection in a post renal transplant receipient.

Methods: :53 year old male was presented with fever andnasal stuffiness about 3 months after renal transplantation. His native kidney disease was chronic kidney disease due to diabetic nephropathy. His nadir creatinewas 0.9 but he had fluctuating blood sugar levels after the transplant. ENTevaluation due to persistent nasal symptoms revealed a black necrotic mass in the right nose. The mass was debrided and sent for histological examination.

Results: The histological examimation revealed the presence of mucormycosis tissue in the nose. He was started on iv liposomal amphotericin and given for 14 days which was followed by syp.posaconazole till the full fungal tissue was debrided in multiple sittings. There was mild worsening of renal function which was resolved with the treatment.

Conclusions: Mucormycosis is a life threatening infection which can lead to mortality and morbidity which may end up in graft loss. But early diagnosis and treatment with complete surgical debridement can completely cure the disease in spite of high treatment cost.

79. Tuberculosis in renal transplant

Navdeep Singh, Ashish Sharma, Sarbpreet Singh, Deepesh B Kenwar, Sunil Kumar


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

Background: Infections are common after renal transplantation. Tuberculosis is one of the leading infections after renal transplant in our country. While INH prophylaxis is routinely prescribed for patients with previous exposure to tuberculosis undergoing transplantation in the developed countries; its role in preventing tuberculosis in high endemic regions is unclear.

Aim of the Study: To know the incidence and the outcome of tuberculosis in renal transplant recipients.

Methods: Between 2006 to 2016; 1900 patients underwent renal transplantation at our centre. Patient data was screened from the transplant database to know the patients who received antitubercular therapy(ATT) during this period. 78 patients were identified to be on ATT giving an incidence of 4.1%. Out of 78 pts; 29 were excluded due to insufficient data and 49 patients were taken up for data analysis.

Results: Mean age of the patients was 35.6±10.2 years. M:F 44:5; 28.5% pts were already on antitubercular therapy prior to transplant. Mean duration (months) of diagnosis of Tb in patients with post transplant tuberculosis is 17.9±15.6 months. 38.7% patients had extrapulmonary tuberculosis; 61.2% had pulmonary tuberculosis.16.3% pts received induction and 83.6% pts did not receive induction. Immunosuppression comprised of tac/mmf in 75.5% pts; cyclosporine/mmf in 10.2%; tac/aza 8.1%; cyclosporine/aza on 4%. Most of the patients were treated with modified ATT based on Levofloxacin and the duration of ATT was 12-18 months. 8/78(10.3 %) patients required treatment with Rifampicin either because of life threatening condition (5) or drug resistance (2) or side effects of other primary drugs (1).

Conclusions: Tuberculosis is still a major infection in ESRD and transplant population. Most of infections are detected in first 2 years. There is an urgent need to define role of INH prophylaxis in these patients.

80. Thyroid hormone profiles in patients with chronic kidney disease

Dr. Sujeeth Reddy Bande, Dr. E Mahesh,

Dr. Rakesh Madyastha


M S Ramaiah Medical College and Hospitals; Bangalore

Background: CKD has reached epidemic proportion in many countries with an incidence of approximately 12.5 % in India. Thyroid dysfunction including hypothyroidism; hyperthyroidism and non-thyroidal illness has been reported in CKD patients. Non thyroidal illness or low T3 syndrome has been shown to worsen CKD by increasing cardiovascular morbidity and mortality and has been reported as an independent predictor of the cardiovascular mortality in these CKD patients.

Aim of the Study: The study determined the thyroid hormone profiles in patients with chronickidney disease in M S Ramaiah Hospital.

Methods: A total of 406 study participants with CKD were recruited. Demographic and medical data were obtained from the participants using a questionnaire designed for this study. Patients were evaluated for thyroid function.

Results: A total of 406 participants were recruited into the study. 247 (60.6%) were males and 159 (39.4%) were females. Majority of the participants 166 (40.9%) were in stage 5D of CKD and only 6 (1.5%) were in stage 2. 121 (29.9%) and 66 (13.8%) were in CKD stage 3 and stage 4 respectively. 66 were in CKD stage 5 on conservative management. Majority of the participants (58%) were euthyroid; while 42% had abnormal thyroid results; of these; 13.9% had non-thyroidal illness and 15.3% and 12.4% had hypothyroidism and hyperthyroidism respectively. The difference in mean duration of CKD amongst the thyroid hormone categories was not statistically significant (p=0.345).

Conclusions: In this study; abnormalities in the thyroid profile were found in 42% of the participants. The most common thyroid derangement was isolated low T3 values. Nonthyroidal illness was shown to increase with increased severity of CKD.

81. Renal involvement in patients with hiv/aids-a single center experience

Sreejith M G, Jacob George, M K Mohandas,

Sajeev Kumar, Noble Gracious, Vineetha N S


Government Medical College; Thiruvananthapuram; Kerala; India

Background: Around 2.1 million people are living with HIV/AIDS in India according to 2015 data and this comes to around 0.3% adult HIV prevalence.HIV infection affects multiple organs and kidney is a common target. Abnormal renal function in HIV comes to around 30%.This study was conducted in the Department of Nephrology; Medical college; Thiruvananthapuram to find the spectrum of renal involvement based on histology in HIV/AIDS patients attending the Nephrology Department.

Aim of the Study: To find the spectrum of renal involvement based on histology in HIV/AIDS patients attending Department of Nephrology; Government Medical college; Thiruvananthapuram.

Methods: The study was an observational study conducted over a period of 6 months in Department of Nephrology; Government Medical College; Thiruvananthapuram from 10/2015 to 03/2016. Adults with retroviral illness; with renal dysfunction( S Cr >1.5) and/or 24 hour urine protein >500mg attending the department were included in the study.Patients with pre-existing chronic renal disease not related to HIV were excluded from the study. During the study period we came across 11 HIV positive patients with features of renal involvement. 3 patients who fulfilled the inclusion criteria were subjected to renal biopsy after informed consent and samples were processed at Amrita Institute of Medical Sciences; Kochi.

Results: Of the 3 patients; 2 were males and 1 was female; with age ranged from 30-55 yrs. All were diagnosed cases of HIV on HAART. Mean duration of illness was 3 years and mean duration of treatment was 1 ½ years. Mean CD4 counts when they presented with renal involvement were 300. All them were having edema and frothing of urine as presenting complaints. On evaluation 2 were having new onset hypertension and renal dysfunction; all were having 3+ proteinuria. Other comorbidities were absent. Biopsy showed features of FSGS in one patient and membranous glomerulonephritis in other two. Both the patients with renal dysfunction were having features suggestive of chronic changes in biopsy. All the patients treated with ARB; tolerated well and clinically improved.

Conclusions: Membranous nephropathy is described as rare in association with HIV.The classical HIV associated nephropathy was not found in our study even in patients with renal dysfunction. Large sample sizes needs to be done to confirm the findings.

82. Comparative clinical efficacy and safety of erypeg®; a biosimilar of pegylated erythropoietin (pegepo) in the treatment of adult patients with anaemia of ckd who were not on dialysis: A prospective; r

Dr. Kapil Dev Mehta


On Behalf of ERYPEG Study Group; Intas Pharmaceuticals Limited

Background: Erythropoiesis stimulating agent (ESA) therapy remains the mainstay of therapy for anemia in patients with CKD. Innovator's pegylated erythropoietin (Mircera®) is already approved by the various regulatory agencies for the treatment of anemia of CKD. Intas Pharmaceuticals Ltd. has developed ERYPEG®; which in preclinical studies demonstrated comparable pharmacokinetic and pharmacodynamic profile to innovator's PegEPO.

Aim of the Study: The current study aimed to compare the clinical efficacy and safety of ERYPEG® with innovator's pegylated erythropoietin in adult patients with anaemia of CKD who were not on dialysis.

Methods: In this prospective; multicentre; randomized; open-label; phase III trial of 10 weeks; a total of 126 eligible ESA naive patients were randomized into two groups; ERYPEG® and innovator's pegylated erythropoietin in the ratio of 3:1 respectively. All patients initially received subcutaneous injection of 0.6 mcg/kg; once every 2 weeks. Dosage adjustments were performed according to a predefined protocol but no more frequently than once every four week. Primary end point was to compare the proportion of patients in each group who achieved prespecified Hb target (Hb ≥11 g/dl or rise in Hb by ≥ 2 g/dl) at the end of the study. Secondary efficacy endpoint was to compare the mean dose required to achieve target Hb. All subjects were monitored for adverse event during study as a part of safety evaluation. Chi square (χ2 ) test and unpaired 't' test were used for statistical analysis of primary and secondary endpoints. P value < 0.05 was considered to be statistically significant.

Results: Of total 165 screened patients; 126 patients were randomized. Data of 109 patients were included in the per protocol (PP) analysis of primary and secondary efficacy endpoint as described in the protocol. The proportion of patients achieving a pre-specified Hb target (Hb ≥ 11 g/dl or rise in Hb by ≥ 2 g/dl) were 70.24% in ERYPEG group and 68% patients in innovator's pegylated erythropoietin group (p=0.83). In PP analysis; mean dose required to achieve pre-specified Hb target (Hb ≥11 g/dl or rise in Hb by ≥ 2 g/dl) was 183.05 ±105.39 mcg in ERYPEG® group as compared to 176.47 ±147.01 mcg in innovator's pegylated erythropoietin group (p=0.83). Majority of the adverse events reported during the conduct of the study were mild in nature. Overall both study drugs were found to be safe and well tolerated.

Conclusions: The results of this study demonstrated that ERYPEG® has comparable efficacy and safety to that of innovator's pegylated erythropoietin in treatment of adult Indian patients with anaemia of CKD who were not on dialysis.

83. Cyclophosphamide based treatment regimen for severe lupus nephritis - Therapeutic outcomes and adverse effects profile

Dhanasekaran Rajashekar, Jayaprakash V,

Natarajan Gopalakrishnan, T. Balasubramaniyan, Thanigachalam Dineshkumar,

Jeyachandran Dhanapriya, Ramanathan Sakthirajan


Department of Nephrology; Madras Medical College and Rajiv Gandhi Government General Hospital; Chennai

Background: Among the various histological classes of lupus nephritis(LN); focal proliferative glomerulonephritis and diffuse proliferative glomerulonephritis carry the worst prognosis. Cyclophosphamide (CYC) is commonly used in the management of severe forms of LN and treatment with CYC based regimen has proven to have long term preservation of renal function. Adverse effects including alopecia; hematological abnormalities; infertility and fulminant infections can occur.

Aim of the Study: To study the therapeutic response and adverse effects of CYC based treatment regimen in severe LN (Class III A; Class III A + V; Class IV A; Class IV A + V; based on ISN/RPS classification) patients.

Methods: It is a retrospective and prospective study. All patients newly diagnosed with severe proliferative forms of LN; who were treated with CYC based treatment regimen and had not received other immunosuppressants prior to CYC therapy were included in the study. After necessary clinical examination; urinalysis; blood biochemistry; serological investigations and imaging; renal biopsy was performed. Patients with severe forms of LN were given fixed 500 mg of intravenous (IV) CYC as infusion monthly; after excluding septic foci and obtaining written consent. Pulse methylprednisolone (MP) in doses of 1 gram was given for 3 consecutive days prior to the first CYC dose and it was followed by 1 mg/kg body weight of oral prednisolone for 1 month; followed by tapering doses. Renal remission was assessed at the end of 6 months. Adverse effects during CYC therapy were identified; treated and the events were documented.

Results: Out of 41 patients; Females were 92.68% and the mean age group was 27.1 ± 9.24 years. The mean duration of the onset of lupus nephritis was 13.34 ± 27.19 months. Nephrotic syndrome(53.66%); Rapidly progressing renal failure(14.63%); Systemic hypertension(48.78%); Crescentic GN(14.65%) and Extrarenal features(90.24%) were the clinical manifestations.The mean blood urea and serum creatinine were 53.15 ± 24.4 mg/dl and 2.25 ± 1.45 mg/dl respectively.Class IV A/ Class IV +V lesions constituted 82.93% and Class III A/ Class III A + V constituted the remaining 17.07% of population. At the end of induction treatment period; the mean blood urea and serum creatinine were 28.64 ± 4.7 mg/dl and 0.96 ± 0.2 mg/dl.Renal remission was observed in 65.85% (Complete CR-31.7% and Partial PR-34.14% of cases). Infections(48.4%); alopecia; DVT; alveolar hemorrhage; steroid induced diabetes and cataract were the adverse events. Male gender and sepsis were significant risk factors associated with mortality.

Conclusions: 1)Renal remission(CR+PR) was observed in 65.85% of patients.2)Age ≤ 25 years was a significant risk factor for poor renal outcomes and male gender and development of sepsis during induction therapy were significant risk factors associated with mortality.3)Infections occurred in 48.4% of patients.

84. Mtor inhibitors in renal transplantation: A single center experience

Kartik Ganesh, Rajesh Nair, George Kurian,

Anil Mathew, Sandeep Sreedharan, Zachariah Paul


Amrita Institute of Medical Sciences; Kochi

Background: Immunosuppressive regimens with few toxic effects are desirable. The cornerstone of most immunosuppressive regimens in renal transplantation are centered around calcineurin inhibitors. These drugs are nephrotoxic and contribute to reduced graft survival due to CNI toxicity and chronic allograft nephropathy. MTOR inhibitors have been introduced as a possible replacement for a CNI based regimen. We attempted to assess the efficacy of mTOR inhibitors in renal transplantation

Aim of the Study: To assess the outcomes of renal transplant recipients whose regimen included an mTOR inhibitor- and compare the outcomes with a separate cohort on calcineurin inhibitors

Methods: 20 renal transplant recipients were retrospectively analysed over 2003 to 2015 and followed up for 3 years after starting the drug as of 1st May 2016. The duration of mTOR therapy; indications to start and stop the drugs were analysed. We assessed the effect on graft function as the change in S. Creatinine one year after starting the drug and 1 year after stopping the drug. We compared this to a similar change in S. Creatinine in 2 separate cohorts of patients on CNI based regimens. The rates of acute rejection and graft loss were also assessed and compared. We analysed the side effect profile of the mTOR inhibitors.

Results: 1 patient was started on the drug de novo and the rest were converted from CNI regimen. Indications: CNI toxicity (30%); worsening graft function (20%); DM (15%); hirsutism (15%); tremors(10%) and gum hypertrophy (5%).18 patients were tapered off after 27.4 months after starting the drugs. Affordability (45%); stable graft function at 24-30 months of starting (25%); proteinuria (5%); pulmonary toxicity (5%) and leukopenia (10%). Rejection rates; graft loss and mortality were 15%; 0 and 0% in the mTOR inhibitor group and were 16%; 4.6%; 6% and 15.6%; 9.6%; 11% respectively in the two CNI cohorts (n=43 and 31). Hypercholesterolemia was seen in 30% with a mean of 282.5mg/dl; a peak of 325mg/dl and a mean time of 27 months after starting the drug. There was 1 case of pulmonary toxicity hemoptysis at 14 days after starting the drug. 15% developed proteinuria. 1 year; 3 year and 5 year graft survival rates were similar between the mTOR and the two CNI based cohorts.

Conclusions: mTOR regimen may not be inferior to CNI based regimens of immunosuppression. Both had equal rates of rejection and the CNI cohorts had higher rates of graft loss; chronic allograft nephropathy and mortality. MTOR inhibitors may be an option in CNI avoidance regimens. Larger studies are required.

85. Plasma cell dyscrasias - A clinico pathological profile

Surabhi Talwar,Rajesh Nair, George Kurian,

Anil Mathew, Sandeep Sreedharan, Zachariah Paul,

N. V .Seethalekshmy


Amrita Institute of Medical Sciences

Background: The spectrum of renal disease in plasma cell dyscrasias; includes Amyloidosis; Monoclonal immune deposition disease; Cast nephropathy; Cryoglobinemia; tubular injury and plasma cell infiltration. Prognosis from the renal perspective depends on the type of renal involvement and the treatment for the primary plasma cell dyscrasia. Here we report the kidney biopsy findings and it's correlation with clinical presentations; renal functions; urinary finding and outcomes in our set of patients.

Aim of the Study: To compare the biopsy finding with the clinical presentation; urinary finding; renal functions and response to treatment for the patients with plasma cell dyscrasias.

Methods: We analysed data from 42 patients with plasma cell dyscrasias; who underwent renal biopsies from January 2010 to December 2015 at our centre. Renal biopsy findings of all the patients were noted. Patient's presenting creatinine values; BP; urine finding; proteinuria were noted. Patient's treatment history and response to treatment were noted.Patients were divided into four groups based on the biopsy finding - Amyloidosis; Cast nephropathy ; LCDD and miscellaneous. The S.Cretinine and proteinuria ; presence of microhematuria at presentation were compared in all the 4 groups. The progression of renal dysfunction; need for dialysis; mortality were compared in all the 4 groups.

Results: Out of the 42 patients who were included in our study; renal biopies were suggestive of amyloidosis in 43% (n = 18); cast nephropathy in 42% (n = 17) ; LCDD in 10% (n=4) and miscellaneous 5% (n=2). Nephrotic syndrome at the time of presentation was seen only in amylodosis patients (77%).Renal dysfunction was seen in all patients of LCDD and in 94% of patients with cast nephropathy which was significantly more when compared to 38% in patients with amyloidosis (p - 0.02 ) .Microhematuria was seen in 25% of patients with LCDD which was significantly lower when compared to 52% of patients with cast nephropathy and 78% of patients with amyloidosis. Total all cause mortality was 16.6% (n=7); out of which 57% (n=4) had amyloidosis. Dialysis dependence was seen in 19% of the total patients (n=8); who had ended up on maintainence hemosialysis one or more years after their presentation. Out of these 8 patients; 75% (n=6) had cast nephropathy while one patient each had LCDD and Amyloidosis.

Conclusions: Features favouring amyloidosis in our subset of patients; are nephrotic syndrome; nephrotic range proteinuria; microhematuria and absence of renal dysfunction. Cast nephropathy resulted in more dialysis dependence; while amylodosis had higher mortality rate.

86. Validity of serum procalcitonin and c-reactive protein as a screening test for sepsis in patients with chronic kidney disease

Vikas Chandel, Ilangovan VeerappanRamasamy, Sethuraman Sonu, Singh Shidram K


KG Hospital and post graduate institute

Background: Serum procalcitonin is an established marker of sepsis with a sensitivity of 70 to 90% and specificity of 80 to 96%.Evidence in chronic kidney disease (CKD).Therefore; we think that it is important to investigate the baseline levels of serum PCT in CKD patients with or without evidence of sepsis to utilize PCT for CKD patients in clinical settings.

Aim of the Study: To demonstrate the usefulness of procalcitonin as a marker of sepsis in CKD patients.To identify the cut-off with best diagnostic accuracy in sepsis with CKD.

Methods: Retrospective analysis was done betweeen march 2016 and august 2016. All patients with age > 18 with eGFR< 60 ml/min/1.73m2( MDRD eGFR ) based on age ; geneder and sr. creatinine with a clinical diagnosis of sepsis were selected. Sepsis was suspected in such patients who presented with systemic inflammatory response syndrome as defined by the American College of Chest Physicians and the Society of Critical Care Medicine.The procalcitonin and CRP samples were sent before the administration of first dose of antibiotics. The patients already on antibiotics were excluded from the analysis.Exclusion were also made of any patient who underwent any major surgery; cardiac surgery; trauma patients; severe burns; cardiogenic shock; acute coronary syndrome; medullary carcinoma thyroid; islet cell tumor.

Results: Of the 144 patients admitted with suspected sepsis over 6 months study period; 81 had CKD. Of this 79 patients had eGFR ≤ 60ml/min/1.73m2. Fifty five were males and 26 were females.the mean age was 60.5 years. The mean eGFR of the population was 27.34ml/min/1.73m2 Of the 79 patients; 28 (35%) patients had either a positive blood or urine culture showing significant growth. Based on the ROC curve (95%confidence interval) for procalcitonin at a cut-off of 0.89ng/ml (0.814-0.971) [ p<0.001]; the sensitivity and specificity was 94% and 73% respectively. Similarly the ROC curve (95%confidence interval) for CRP at a cut-off of 0.770(0.646-0.893) [p=0.001] the sensitivity and specificity was 68% and 68% respectively.

Conclusions: These observations led us to conclude that procalcitonin has a significant value in predicting sepsis in CKD patients albeit at a higher than normal cut-off of 0.89 ng/ml. CRP is an inferior marker compared to PCT. Henceforth we suggest serum procalcitonin can be used as a marker of sepsis in CKD.

87. Spectrum of renal involvment in type 2 diabetes mellitus with significant proteinuria

Uday Raj, Sarvesh Chaudhary, Ashutosh Ranjan,

Amit Banerji, Narendra Sarkari


Department of Medicine; BRD Medical College; Gorakhpur; UP; India

Background: Diabetes mellitus is assuming epidemic proportion with about 295 million people affected by it worldwide. Its prevalence is increasing worldwide and global burden of disease is expected to be doubled between 2000-2030. Parallel to increasing incidence of diabetes proportion of NDRD (non diabetic renal disease) is also increasing. The incidence of NDRD in type 2 diabetes mellitus (T2DM) ranges from 12-80% in various studies.

Aim of the Study: To study the spectrum of renal disease in pts of T2DM with significant proteinuria; to assess the proportion and cause of NDRD; and to correlate clinical and lab parameters which can predict NDRD.

Methods: 262 consecutive T2DM patients with proteinuria were screened and 100 patients with urinary ACR ≥ 500 mg/g were recruited. Detailed history taking and clinical examination was performed and the recruited subjects underwent routine and special investigations. These patients were divided into two groups on the basis of diabetic retinopathy (DR). Group A (n=14) had absence of DR whereas group B (n=86) had presence of DR. Various indications used for doing biopsy were absence of DR; rapid decline in GFR; heavy proteinuria; hematuria of glomerular origin etc. Among group A; out of 14 patients; biopsies of 7 patients could be done as 4 patients did not give consent and 3 had contracted kidneys. In group B; 3 patients underwent biopsy. On the basis of histopathological examination by a single pathologist these biopsied patients were divided into group I (DGS); group II ( DGS+ NDRD) and group III ( NDRD).

Results: Among the 100 recruited patients 53 were male and 47 were female. Mean age was 54.44±7.68 years. Out of the 10 biopsies which were done; group I; II and III had 4 (40%); 5 (50%) and 1 (10%) respectively.7 biopsied individuals had absence of DR ( 2 patients had NDRD+DGS; 1 had NDRD alone; 4 had DGS alone) against 3 with DR all of whom had NDRD+DGS. Among NDRDs the most common was was hypertensive nephrosclerosis (30%) followed by tubulointerstitial nephritis(20%) and multiple myeloma(10%).

Conclusions: Shorter duration of diabetes; rapidly declining GFR; nephrotic range proteinuria; high value of serum creatinine and urea could be considered as clinical indicators for NDRD.

88. Induction in deceased donor renal transplants- "a bane or a boon"?

Dr. A Ayyappa, Dr. Manisha Sahay, Dr. Kiran Mai Ismail, Dr. Sharmas Vali


Osmania Medical College; Hyderabad; Telangana

Background: kidney transplantation is considered the treatment modality of choice for majority of patients with ESRD.In india; there are large number of ESRD patients waiting for renal tranplant.Two sources of kidneys for transplantation are deceased and live donor .Rejections are an important cause of poor graft outcomes. Acute rejection episodes are considered as a risk factor in the development of chronic rejection.Induction therapy is recommended for deceased donor transplants but the cost of is high.

Aim of the Study: To study and compare the complications and outcome of 40 cases of deceased donor renal transplantation in patients with and without induction theraphy.

Methods: Prospective study of 40 cases of CKD patients who underwent cadaveric renal transplantation at tertiary care government hospital. 19 patients received basiliximab induction ; while remaining 21 patients did not receive induction . Induction therapy was given to patients who consented for obtaining the drug. All patients recieved standard triple drug immunosupression (prednisolone ; tacrolimus and MMF) . All were 1st transplants. The baseline and donor characteristics were comparable among the two groups. HLA typing for donor and recipient was not done.Primary endpoint was the incidence of acute rejection at 6 months .Secondary endpoints include the safety and tolerability of basiliximab ; 1- year patient and graft survival ; and significant medical events upto 12 months.

Results: Mean age group - 35.08 years +/- 9.2 years ; M:F ratio-3.2:1 .Mean cold ischaemic time was 6.14 hours +/-3.42 hours .In induction theraphy group 3 (15.8%) had rejection; 2 AMR and one cellular rejection.While in non- induction group 7 cases (33.33%) had rejection; 4 cellular and 3 AMR (antibody mediated rejection) in the first 6 months ; these rejections responded to anti rejection theraphyIncidence of infections in induction group included 9 (47.4%) cases- bacterial in 6 cases ( UTI in 3 ; pneumonia in 1; perineal and gluteal abscess in 1 and leg ulcer in 1cases .Fungal infections-mucormycosis in 1case ; pneumonia in 1 . CMV in 1 case.Incidence of infections in non induction group included 11(52.4%) cases - bacterial in 4 cases (2 uti ; 2 pneumonia) .viral - CMV colitis in 4 cases.herpes zoster in 1 case.Fungal- oral candidiasis in 1 case; mucormycosis 1 case.1year graft and patient survival in induction and non induction was 94.74 %& 100 % and 90.48 % & 95.2 %respectively.

Conclusions: Basiliximab in combination with tacrolimus; steroids&MMF theraphy was highly effective in reducing the incidence of acute allograft rejection; without increasing incidence of infections.adverse effects of patients with basiliximab- indistinguishable from that of patients treated without induction.

89. Posr transplant thrombotic microangiopathy (TMA)

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


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

Background: Post renal transplant TMA is of diverse aetiology with significant negative impact on graft survival.

Aim of the Study: To study the Aetiology; clinical presentation and outcome of TMA in renal allograft recipients.

Methods: This is a retrospective study of renal allograft recipients with biopsy proven TMA done at Institute of Nephrology Madras Medical College from Sep 2012 to Aug 2016. Clinical presentation; hemogram ; biochemical investigations; serum complement level and CNI trough level were noted. C4d staining was done in all the graft biopsies.

Results: Twelve cases of post transplant TMA were studied .Ten were living related donor renal transplant recipients and 2 were deceased donor recipients. Native kidney disease was known in 5 patients (41.5%).The timeline of occurrence of TMA ranged from 14 days to 22 months post renal transplant Aetiology of post transplant TMA : CNI related 8; AMR 1 and 3 uncertain.Out of 8 CNI associated TMA ; 7patients had isometric renal tubular cytoplasm vacuolation in graft biopsy. There was no correlation between trough level of CNI and TMA in 6 out of 8 patients. For patients with CNI associated TMA ; dose reduction or switching over to other CNI was done. Two out of 8 patients with CNI associated TMA progressed to ESRD. One case of Antibody mediated rejection (AMR) associated TMA became dialysis dependent. Out of 3 patients with uncertain cause 2 became dialysis dependent; and 1 had chronic graft dysfunction.

Conclusions: 1.The common aetiology for post transplant TMA was CNI.2.41.6% of patients developed chronic graft dysfunction.

90. Total serum lactate dehydrogenase (LDH) pattern in immediate post renal transplant recipients

Dr. Sonusing Patil, Dr. Ilangovan V, Dr. Ramasamy S, Priyadarshini, Vijaylakshami, Rekha


K.G Hospital and post graduate teaching institute; coimbtore;

Tamil nadu

Background: Pathogenesis of increased LDH serum activity following renal transplantation is not yet clear. Serum LDH is traditionally used as one of the markers suggesting a diagnosis of thrombotic microangiopathy. This study attempts to explore the role of serum LDH level in the first one week in predicting thrombotic microangiopathy and to identify other factors that determine serum LDH level.

Aim of the Study: To evaluate if serum LDH level in the first one week is predictive of thrombotic microangiopathy And to identify the factors that determine the serum LDH levels.

Methods: Consecutive patients who underwent live and beating heart deceased donor [DDT] renal transplant were included. For all patients total serum LDH; haemoglobin; platelet count; serum creatinine were measured daily for first week post transplant. The cold ischemia time; number of session of hemodialysis post transplant; number of blood transfusions during the first week and first week of tacrolimus trough data were collected.

Results: A total of 28 transplants were done over 6 months. Of which 20 (71%) patients received DDT and 8 (29%) patients underwent live renal transplant. Males were 22 and females were six. The mean age was 50.64 years; diabetes mellitus in 18 patients; cold ischemia time [CIT] in DDT was four hours of the 20 DDT recipients; two recipients developed haemolytic uremic syndrome (HUS) in the first week proven by kidney biopsy. One had HUS and acute antibody mediated rejection and one tacrolimus induced HUS. First week trend of LDH level was similar with low LDH level at 3rd in live and 4th day in DDT. There was no significant difference in serum LDH level in patients with DDT; live and HUS groups. The mean LDH values in DDT vs live vs HUS groups were 411.8±168.6 U/l; 275.8±58.8 U/l and 435.4 ± 53.4 U/l respectively (p-0.087). By multi-variate analysis none of the factors like age; gender; CIT; tacrolimus level were significantly different in the three groups. (p-0.977).

Conclusions: Total serum LDH not a good marker to diagnose HUS in early post transplant period. None of the conventional factors predicted the serum LDH.

91. Utility of urinary neutrophil gelatinase associated lipocalin (NGAL) as a prognostic marker of acute kidney injury in cirrhosis of liver

Sai Krishna Reddy


Mukta Wyawahare; JIPMER

Background: Serum creatinine in chronic liver disease (CLD) can be spuriously low secondary to low body mass and decreased liver synthesizing capacity. Acute kidney injury (AKI) is associated with 3-10 fold risk of mortality in them. The current diagnostic criteria's of AKI relying on serum creatinine levels may underdiagnose AKI in CLD. NGAL is an early and sensitive biomarker which is synthesized from injured renal tubules.

Aim of the Study: To check whether urinary NGAL (uNGAL) based criteria with a cut off of 53.3 ng/ml is superior to existing KDIGO criteria for AKI in predicting short term mortality in patients with CLD.

Methods: 120 patients with CLD were included in the study after applying inclusion and exclusion criteria. Patients with underlying CKD; UTI in preceding two weeks; malignancy and who received nephrotoxic medications in preceding four weeks were excluded . The baseline biochemical and clinical parameters were documented in all patients. uNGAL was estimated on day1 and 3 of admission for all patients. Patients were followed up for 90 days. AKI was diagnosed according to KDIGO creatinine criteria and uNGAL based criteria. A cut-off value for uNGAL (> 53.3 ng/ml) on day 1 as was taken from previous studies on contrast-induced nephropathy. The primary end point was 90-day mortality. The outcomes were compared between KDIGO criteria and uNGAL criteria by ROC curves and Odds ratios. A logistic regression analysis was done to identify the independent predictors.

Results: Of 120 patients recruited for the study follow-up data was available for 107. 60 patients satisfied AKI definition by KDIGO criteria whereas 85 patients satisfied the uNGAL criteria for AKI. Hepatorenal syndrome (HRS) was the most common cause (45%). The 90-day mortality was 50 % .The nonsurviors had significantly higher MELD scores and serum creatinine levels. The median uNGAL levels on day 1 were higher in non-survivors (209 ng/ml vs 103 ng/ml; p = .019). The ROC curves for uNGAL showed a better correlation with mortality. uNGAL> 53.3 ng/ml on day 1 was associated with an OR 3.55 (CI 1.31- 9.84) for 90-day mortality whereas OR for AKI by KDIGO criteria was not significant. On binary logistic regression analysis uNGAL > 53.3 ng/ml on day 1 ( p= .007) and MELD( p= .015 ) score were independent predictors of mortality( p= .007); but KDIGO criteria for AKI was not predictive.

Conclusions: Serum creatinine based diagnostic criteria's underestimate the prevalence of AKI in patients with CLD. Urinary NGAL > 53.3 ng/ml on day one is superior to KDIGO criteria in predicting 90 day mortality in patients with CLD with renal failure .

92. Acute kidney injury following snake and insect bite-its long term follow-up

Dr. Aswini Prasad Patnaik, Dr. Debadutta Dash,

Dr. Nikunja Kishore Rout, Prof. (Dr.) Suresh Chandra Dash


Kalinga Institute of Medical Scienceskiit University; Bhubaneswar; India

Background: Acute Kidney Injury due to snake & insect Envenomation is common in tropical countries like India.

Aim of the Study: This is a prospective study to objectively assess the pathogenesis; morbidity; mortality and outcome in a tertiary care hospital.

Methods: Thirteen patient with Acute Kidney injury were subjected for studies in six years. Eight out of Thirteen were bitten by Russel Viper; three were scorpian; one by bees and the other one was unknown venom. Majority patients came to hospital after 03 days of onset of oligo-anuria.

Results: All 08 in Russel Viper group & 02 from Scorpion group needed dialysis.; rest had milder renal dysfunction; improved with conservative management.Intravascular hemolysis and disseminated intravascular coagulation (DIC) were the dominant pathologic mechanism in 09 cases. Direct tubulo-toxicity with ATN and evidence of DIC was observed in 03 patients. Two showed overlapping features of HUS. One of these had pulmonary vasculopathy. Intrinsic heart failure and hepatocellular toxicity were present in 02 and 03 patients respectively. Renal biopsy revealed confluent symmetrical acute cortical necrosis; one case had partial cortical necrosis and one had severe tubular necrosis as well as acute interstitial nephritis. None with acute cortical necrosis survived.They are on follow up in renal clinic since 1½ - 2 years with CKD III. Clinically those patients had associated prolif glomerulonephritis and AIN did not have typical diuretic phase; they recovered over longer period of time.

Conclusions: Russel viper bite is the commonest cause of Acute Renal failure due to animal envenomation in India. These toxins in addition to kidney injury can potentially involve lungs; heart and liver. They severely alter hemotologic and vascular system causing ischemic and toxic injur.

93. To evaluate the role of ngal and KIM-1 in plasma and urine after intravenous contrast induced acute kidney injury in adult icu patients

Ravi Mishra 1 , Narayan Prasad 2 , Saurabh Chaturvedi 1 , Harshit Singh 2 , Mohan Gurjar 3 , Vikas Agarwal 1 ,

Pralay Ghosh 3 , Sai Saran PV 3 , Arvind K Baronia 3

1 Department of Clinical Immunology; SGPGIMS; India; 2 Department of Nephrology; SGPGIMS; India; 3 Department of Critical Care Medicine; SGPGIMS; India

Background: AKI (Acute Kidney Injury) is a common clinical condition associated with a number of adverse outcomes. More timely diagnosis would allow for earlier intervention. The goal of early identification of AKI has been the primary impetus for AKI biomarker research; and has led to the discovery of numerous novel biomarkers. However; in addition to facilitating more timely intervention; AKI biomarkers can provide valuable insight into the molecular mechanisms of this complex and heterogeneous disease.

Aim of the Study: NGAL and KIM-1 have been found early and sensitive marker of AKI. These biomarkers have not been evaluated simultaneously in plasma (P) and urine (U)after intravenous contrast in adult ICU patients.

Methods: Prospectively all adult ICU patients with normal renal function; requiring radiographic contrast for computed tomography (CT scan); were considered for inclusion. Exclusion criteria includes: presence of AKI/CKD; recent exposure to contrast within 3 days; and pregnancy. Samples of 5 ml blood and 5 ml urine were collected before contrast exposure and at 04 h; 24 h and 48 hafter contrast exposure. Neutrophil Gelatinase-Associated Lipocalin (NGAL) and Kidney Injury Molecule 1 (KIM-1) assay done by ELISA; and urinary levels normalized as per UCr values for each sample. CI-AKI is defined as a rise in SCrof ≥0.3 mg/dl within 48 hrs.

Results: 20 medical patients with 24 CT scans included. Median age 36 yrs and 54% male.Sites of CT scan were abdominal (75%); chest (15%) and head (10%). Incidence of CI-AKI was 20%. Mean values at pre-contrast; 4 h; 24 h and at 48 h after contrast for P NGAL (ng/ml): 802.35±539.05; 1008.9±811.87; 816.75±693.32 and 1088.90±648.39; U NGAL (ng/mg of UCr): 371.02±436.87; 481±104.64; 778.24±906.10 and 479.96±703.50; P KIM-1 (ng/ml): 1.27±0.73; 1.61±0.67; 1.63±0.65 and 1.52±0.58; U KIM-1 (ng/mg of UCr):.15±0.18; 0.10±0.09; 0.11±0.09 and 0.26±0.46.After contrast; P NGAL levels were not increased significantly either at 4 h; 24 h or at 48 h (p=0.25; 0.89 and 0.11); and U NGAL was significantly raised at 24 h only (p=0.04).While; P KIM-1 levels were significantly increased at 4 h; 24 h and 48 h (p=0.003; 0.001 and 0.002);U KIM-1 were not increased significantly at any point of time ((p=0.63; 0.21; 0.80).

Conclusions: In critically ill adult patients; there is significant increase in P KIM-1 levels as early as at 4 h and continued to remain high even at 48 h; while P NGAL is not increased either at 4 h; 24 h or at 48 h after contrast exposure.

94. Measuring quality of life of patients using EQ-5D-3L and EQ-VAS in a large national dialysis cohort in india

Kamal D. Shah, Dr. Balaraman V,

Dr. Ilangovan Veerappan, Dr. Hithaishi C,

Dr. Vivekanand Jha, Venkatraman G, Sumathi K


NephroPlus Dialysis Centres

Background: Patient-centred care means providing care that is respectful of and responsive to individual patient preferences; needs; and values and ensuring that patient values guide all clinical decisions.EQ-5D is a standardised measure of health status developed by the EuroQol Group in order to provide a simple; generic measure of health for clinical and economic appraisal.Rather than relying on laboratory tests alone; patient Quality of Life is also considered during evaluation and treatment.

Aim of the Study: To use the EQ-5D-3L descriptive system and the EQ Visual Analogue Scale to determine the Quality of Life of the patients of the cohort and use this to guide treatment decisions.

Methods: This study was done with 2; 631 patients that were getting dialysis at 75 centres spread across the country.A questionnaire was developed with the EQ-5D-3L descriptive system that comprises of 5 questions around mobility; self-care; usual activities; pain/discomfort and anxiety/depression. Patients were asked to pick one from among three options for each question which indicated their assessment of their status pertaining to that aspect. The single score EQ-VAS was also administered which requires the patients to rate their current health status on a scale of 0 to 100.The results were then correlated to various demographics and other parameters such as Gender; City Tier (I; II; III); Zone (North; South; East; West); education level; age; duration on dialysis; distance from dialysis centre; dialysis adequacy; number of comorbidities; viral status; payment types; cause of kidney disease and dialysis frequency.

Results: Males reported better health status than females. Younger patients; patients staying in urban cities; graduates and post graduates and patients staying closer to their dialysis centres reported better health status than older patients; patients staying in semi-urban and rural locations; less educated patients and those staying farther away from their centres respectively.Patients with a lower number of comorbidities reported better health status than others.Patients with Diabetic Nephropathy seemed to report the worst health status when compared with patients with Hypertensive Nephrosclerosis. Patients grouped under Other Causes reported best health status.Patients with higher dialysis frequency reported better health status than those with lower frequencies.There was no clear correlation between adequacy of dialysis as measured by Kt/V; duration on dialysis; payment type or virology status with reported health status.

Conclusions: The EQ-5D and EQ-VAS are simple yet powerful tools to measure QoL. By including patient-reported outcomes in the overall treatment plan; the problems that are more important for the patients can be addressed and their QoL thus improved.

95. Understanding the economic profile of patients of a large national dialysis cohort in india

Kamal D. Shah, Dr. Satish Chhabra,

Dr. Deepak Dewan, Dr. Vivekanand Jha,

Dung Doan, Alexis Geaneotes, Kathleen Mignano, Venkatraman G, Sumathi K


NephroPlus Dialysis Centres; International Finance Corporation; The World Bank

Background: It is important that any health care program; particularly one related to dialysis addresses the needs of the poorer sections of the society. India has a number of schemes rolled out by the central and state governments that offer free dialysis to certain segments of the population. By offering quality dialysis to these segments; a part of the access problem can be successfully resolved.It is therefore important to monitor the economic profile of the patients in the program.

Aim of the Study: To determine average consumption levels of patients of the cohort; and what proportion of the patients being treated fall in various economic quintiles and within certain consumption thresholds.

Methods: A questionnaire was developed using the World Bank's SWIFT (Survey of Wellbeing via Instant; Frequent Tracking) methodology. Patients are often reluctant to share income and consumption data directly. Also; it has been argued that consumption is a better indicator to determine economic status rather than income. Therefore; this method collects consumption data (rather than income data) and does this in an indirect manner.It uses data from India's National Sample Survey 2011-2012 (68th round) to develop a formula to predict household consumption based on household demographic characteristics; such as household size; dependency ratio; gender and education of the head of household; and ownership of durable assets. Demographic data was collected directly from patients through an in-person 10-minute survey conducted during the patient's treatment. Once the demographic information was collected from the patients; their household consumption was estimated based on the SWIFT formula.

Results: 356 patients were surveyed from 18 dialysis centres across the country. 69%; 22% and 9% of the patients paid for their treatment out of pocket; were covered by Government-sponsored schemes and by private insurance respectively.85% of the patients belonged to the top 20% population quintile in India and had an average daily household consumption per capita of Rs. 153.81 ($7.55 Purchasing Power Parity (PPP) terms); 9% belonged to the next 20% with a consumption of Rs. 46.71 ($2.29 PPP); while 3% each belonged the next 20% and the bottom 40% with a consumption of Rs. 35.68 ($1.75 PPP) and Rs. 25.81 ($1.27 PPP) respectively. The average daily household consumption per capita was Rs. 135 or $6.62 (PPP).67% of the patients surveyed were estimated to earn below Rs. 5; 229 or $ 8.44 (PPP) per day. 1.54% were Below India's Poverty Line. For 2011-12; the national poverty line was set at Rs. 816 (rural) and Rs.1; 000 (urban) per month.

Conclusions: The SWIFT method is a valuable tool for classifying populations into economic quintiles in a dialysis cohort. This tool demonstrated that the program is able to effectively reach all economic classes of society.

96. Improving compliance with investigation protocols in a large national dialysis cohort in india

Kamal D. Shah, Dr. Ashok Baidya, Dr. Rekha Dubey,

Dr. Vivekanand Jha, Venkatraman G, Sandhya C


NephroPlus Dialysis Centres

Background: Affordability is one of the main obstacles to optimum treatment of patients on dialysis in a country like India. Often patients do not have the resources to get even three dialysis sessions per week. The additional financial burden of investigations; medications (ESAs); consultation fees for nephrologists and others can be onerous.It is however important for some basic investigations to be done regularly in order to ensure that issues are caught early and proactive interventions initiated.

Aim of the Study: To study the impact of systematic counselling of patients on the importance of investigations by a team of nurses and technicians on the compliance levels among patients of the cohort.

Methods: Two teams were assigned the specific responsibility of improving Investigations Protocol compliance levels for dialysis patients. All investigation results were entered into an online portal by the dialysis centre staff. One team would monitor the progress of investigations done at each centre while the other team would interact with the centre staff (using in-person visits and a daily call). Both teams would interact with each other as needed.3; 552 patients (68% male; 32% female) from 76 centres distributed across the country were studied over 88; 988 patient months from January 2015 to June 2016. The age of the patients was 53.02 ± 13.44 years (range 12 - 93). 3 BONENT certified nurses performed the monitoring role and had between 24 to 26 centres each to monitor. A combination of nurses and technicians with experience in dialysis of 4 to 10 years were assigned between 6 to 12 centres each to implement the program using a combination of in-person and telephonic interactions.

Results: The protocol required at least quarterly testing of Hemoglobin; Kt/V; SGPT (ALT); Serum Calcium and Serum Phosphorus. Quarterly numbers were monitored and recorded.Across the cohort; Hemoglobin testing increased by 79%; Kt/V by 308%; SGPT by 182%; Serum Calcium by 66% and Serum Phosphorus by 55% between January-March 2015 and April-June 2016. These figures were 73%; 9%; 2%; 88% and 55% for PPP centres and 78%; 382%; 209%; 62% and 56% for non-PPP centres.For urban centres; the figures were 60%; 499%; 71%; 39% and 40%. For semi-urban centres; these figures were 183%; 168%; 922%; 147% and 109%; while for rural centres; these figures were 67%; 266%; 314%; 77% and 55% respectively.

Conclusions: Concerted efforts towards improving compliance by counselling patients on the importance of investigations in the overall treatment plan can yield excellent results even in a resource-constrained country like India.

97. Studying the impact of dialysis frequency on anemia management in a large national dialysis cohort in india

Kamal D. Shah, Dr. Dilip Bhalla, Dr. Kamlesh Parikh,

Dr. Vivekanand Jha, Venkatraman G, Guruvulu S


NephroPlus Dialysis Centres

Background: Anemia management is a major challenge in dialysis patients especially in a country like India where patients often find it difficult to bear the cost of ESAs. In fact many patients find it difficult to pay for their dialysis sessions itself. Therefore; compliance to ESA dosage is poor among many patients.Better clearance is associated with better anemia management. By getting patients to dialyse as close to thrice a week as possible; better outcomes may be possible.

Aim of the Study: To study the effect of dialysis frequency on anaemia management measured by Hemoglobin in dialysis patients.

Methods: 6; 730 patients (69% male; 31% female) with an average age of 53.06 ± 13.9 years (range 15 - 93) and on dialysis for 21.48 ± 23.22 months from 75 dialysis centres of the cohort distributed across the country were studied over 52; 286 patient months; from January 2015 to June 2016. 60% of the patients funded their healthcare expenses out of pocket. 32% of them were covered by a Government sponsored scheme while 8% were covered by some kind of private insurance.The dialysis frequency of each patient was noted along with the ESA dosage and Hemoglobin from January 2015 to July 2016. For simplicity; only patients on Erythropoietin were included. 183 patients on other ESA types like Darbepoetin were excluded.The patients were divided into four groups based on Erythropoietin dosage per week. A multivariate analysis was performed on the data to examine covariate effect.

Results: 65%; 18% and 17% of the patients were on twice weekly; thrice weekly and once weekly dialysis.70%; 21%; 6% and 2% of the patients were not taking any ESA; taking less than 4; 000; between 4; 000 and 8; 000 and more than 12; 000 units per week respectively.The average Hemoglobin for those on 1; 2 and 3 dialysis sessions per week was 6.67 ± 3.86 (range 4 - 19); 7.86 ± 3.52 (range 4 - 18) and 8.42 ± 3.78 respectively. The doses of Erythropoietin (units per week) in the three groups were 3; 116 ± 3; 587 (range 196 - 28; 000); 3; 396 ± 2; 989 (range 159 - 22; 050) and 5; 172 ± 4; 138 (range 352 - 28; 000) respectively.On application of multivariate analysis i.e. linear regression where haemoglobin was taken as dependant variable while frequency of dialysis and ESA dose per week taken as independent variables; the frequency of dialysis showed significant association (F= 32.6; p = 0.001) with haemoglobin level while no significant association was noted in the ESA dose per week.

Conclusions: Better clearances due to optimal dialysis can lead to better anemia management. This could be an important area to focus on to try and improve patient outcomes. Patients should be counselled that by getting adequate dialysis; their spend on ESAs could reduce apart from the other obvious benefits.

98. Nacetyl cysteine versus allopurinol in the prevention of contrast nephropathy in patients with chronic kidney disease: A randomized controlled trial

Dr. Raghvendra Sadineni, Dr. G. Swarnalatha


Nizams Institute of Medical Sciences; Hyderabad; India

Background: Contrastenhanced imaging services have been widelyused over the past decade. Contrast media can leadto acute deterioration in renal function particularly inpatients with preexisting chronic kidney disease.Several protocols have been tested for the prevention of radiocontrast induced acute kidney injury.Very few studies compared NAC and allopurinol in theprevention of CIN.

Aim of the Study: compared the efficacy of NAC versus allopurinol in addition to intravenous hydration withnormal saline (NS) as prophylaxis for CIN in patients withwithimpaired renal function.

Methods: prospective; randomized controlled openlabelparallel group study was undertaken at Nizam's Institute of Medical Sciences; Hyderabad; from June 2015 to December 2015.

Results: There was no significant difference between NAC and allopurinol in the prevention of contrast nephropathy. However; when compared with placebo alone only allopurinol was proved to be superior.an association was found between baseline serum creatinine and CIN; which was statistically significant;Upon odds ratio analysis of the treatment groups; an association between uric acid and development of CIN was observed in ALL + NS group and placebo; however without statistical significance in ALL + NS group and it was statistically significant in the NS group.

Conclusions: No significant difference between NAC and allopurinol in the prevention of contrast nephropathy in patients with impaired renal function.Hyperuricemia and baseline serum creatinine were the only risk factors associated with CIN.

99. The prevalence of pulmonary hypertension in patients on maintance hemodialysis

Dr. Sujeeth Reddy Bande, Dr. E Mahesh,

Dr. K C Gurudev, Dr. M S Gireesh, Dr. Manns J,

Dr. Rakesh M, Dr. Sarita


M S Ramaiah medical college and hospitals; Bangalore

Background: Pulmonary hypertension in patients with CKD may be induced and/or aggravated by left ventricular disorders and risk factors typical of CKD; including volume overload; an arteriovenous fistula or graft; sleep-disordered breathing; exposure to dialysis membranes; endothelial dysfunction; vascular (pulmonary artery) calcifications secondary to hyperparathyroidism and stiffening; and severe anemia.The prevalence of pulmonary hypertension ranges from 9 -39% in individuals with stage 5 CKD; 18.8 - 68.8.

Aim of the Study: To primary objective of this prospective observational was to study the prevalence of Pulmonary arterial hypertension (PAH) in patients undergoing hemodialysis.

Methods: A detailed clinical examination including age; sex; smoking habits; associated comorbidity particularly diabetes mellitus and hypertension; age at the time of CKD; etiology of renal failure; duration of dialysis treatment; and AV access type [fistula/ graft]; the location of AVF [brachial or radial]. Our study included a total of 267 Chronic kidney disease patients who were undergoing hemodialysis at M S Ramaiah Hospital; Bangalore over a period of one year; in between June 2015 and May 2016.Transthoracic Doppler echocardiography: Every patient underwent a complete two-dimensional and Doppler echocardiography study on the day post dialysis within 8 hours after completion of dialysis .Laboratory investigation included levels of hemoglobin; hematocrit; serum calcium; phosphorus; serum alkaline phosphatase; parathyroid hormone level. Average levels measured at least twice during the study period were calculated.

Results: Pulmonary hypertension was seen in 209 (78.2%) patients; of which 102 (38.02 %) patients had mild to moderate pulmonary hypertension (PASP 26 - 45mmHg ); severe pulmonary hypertension (PASP > 45 mm Hg )was found in 107 ( 40.07 %) patients. Of all the patients who had severe pulmonary hypertension 107 (40.07 %) patients; 77 (71.9%) were aged above 45 years; 45 (42.05%)patients aged between 46 to 60 years and 32 (29.9%) patients aged more than 60 yr.Of all the patients with severe pulmonary hypertension; 66 ( 61.68%) patients were diabetic; 31 (28.9 %) had ischemic heart disease; 101(94.3%) patients had anemia ( hemoglobin < 11 gm/dl); 89 (83.1 %) patients were undergoing hemodialysis via AV fistula; 18 (16.8%) via AV graft. Additional cardiac features that were noted in the study are left ventricular hypertrophy in 56 patients ( 20.9 %); patients; diastolic dysfunction noted in 97 ( 36.2% ).

Conclusions: This study demonstrated a high prevalence of pulmonary hypertension among patients with CKD on hemodialysis.The factors contributing to the severity of PAH are the age of the patient; duration of dialysis treatment; higher AV fistula flow; cardiac output; the degree of anemia.

100. Efficacy of sofosbuvir and ledipasavir in hcv positive dialysis and renaltransplant patients.

Dr. Bharathi, Dr. G. Swarnalatha, Dr. Karthik, Dr. Uttara, Dr. Gangadhar


Nizam's Institute of Medical Science

Background: Hepatitis C virus (HCV) infection prevalence is elevated in hemodialysis (HD) patients. After kidney transplantation; HCV infection can worsen; however; antiviral treatment increases the risk of acute rejection. Data on newer drugs sofosbuvir and ledipasavir in dialysis and transplantation is very few. Hence; present study is done to know efficacy and side effects of sofosbuvir and ledipasavir drugs in dialysis and renal transplant patients.

Aim of the Study: To study the efficacy of sofosbuvir and ledipasavir combination therapy in dialysis and renaltransplant patients.

Methods: Patients who are seropositive for antihepatitis C; HCV RNA positive undergoing hemodialysis in NIMS Hospital and; renal transplant patients who became seropositive after transplantation were included in the study. Demographic; clinical profiles of patients are collected. Complete hemogram; liverfunction tests; HCV viral load; genotype; renal function tests; coinfections; sugarlevels; time of seroconversion were collected and analysed. All these patients were given sofosbuvir 400mg once daily and ledispasvir 90mg once daily for a period of 3 months. The response to therapy; time to attain remission; duration of sustained remission; treatment failures; and complications were analysed.

Results: There were total 18 patients who are received sofosbuvir and ledipasavir therapy; of which 3 were female all were on Hemodialysis and 15 male patients of which 10 were sreoconverted after transplantation and 8 were on hemodialysis. All the patients were detected to have HCV serocnversion on evaluation for elevated SGOT and SGPT. Most common genotype was genotype-I seen in 15 (83.33%) patients. Out of 8 Patients on hemodialysis; 3 patients received prior PEG INFand Ribavirin therapy and had treatment failure; anemia and. All the 18(100%) patients achieved early virological response by the end of first month. There was no intereference with graft function during the course of therapy. One renal transplant recipient developed varicella zoster during 2nd month of treatment. No significant sideeffects were encountered in study population. Of the 10 renal transplant patients; 2 developed NODAT during seroconversion.

Conclusions: Sofosbuvir and ledipasavir are effective in treatment of hepatitis C in dialysis and renaltransplant patients with minimal side effects. But; large sample of population is necessary to strongly establish this association.

101. Spectrum of histopathological findings in renal allograftdysfunction

Dr. K. Srinivasulu, Dr. K. Praveen Kumar,

Dr. K. Varaprasad Rao


Narayana Medical College; Nellore

Background: Renal transplantation is the treatment for patients with ESRD worldwide. In the last few decades the transplant scenario improved due to better surgical techniques; medical care; prevention & treatment of infections &advanced immunosuppressive treatment. Allograft dysfunction is common after transplantation & is due to acute rejection; chronic rejection; CNItoxicity; infections.Renalbiopsy is the gold standard to establish the cause of allograft dysfunction as clinical diagnosis is unreliable.

Aim of the Study: To evaluate the causes of renal graft dysfunction as detected on renal allograft biopsies in renal transplant recepients.

Methods: It is a retrospective review of 55 biopsies from 42 renal transplant patients ; carried out over a period of 2 years . Renal allograft biopsies were performed when there was unexplained graft dysfunction (rise in serum creatinine of ≥ 20% over baseline) and/ or proteinuria; fulfilling the established indications of graft biopsies. Two cores of renal graft tissue are obtained with automated biopsy gun under real-time ultrasound guidance. The histological changes are interpreted and classified according to Banff working classification of renal allograft pathology.

Results: A total of 52 biopsies were performed on 42 patients. Males were predominant among the recepients.Regarding pathological lesions acute rejection was seen in 19 (36%) cases followed by acute tubular injury and CNI toxicity ( Tacrolimus ) in 16 (31%) and 4 ( 8% ) cases respectively. Chronic allograft nephropathy (CAN) with variable degree of tubular atrophy was seen in 3 ( 6%) cases. One case ( 2% ) of acute pyelonephritis was detected on graft biopsy. Rare lesions was also found including 2 ( 4%) cases of recurrent /denovo renal disease and 2 (4%) of Polyoma virus infection.

Conclusions: The incidence of acute rejection and acute tubular injury was comparable to many western studies. Recurrent /Denovo renal disease is uncommon in our patients.

102. Treatment of hepatitis c in kidney transplant recipients (KTRS) in the era of directly acting antiviral agents(DAAS)

Ashwathy Haridas


Senior Resident; Department of Nephrology; KEM Hospital; Tukaram Jamale; Associate Professor; Department of Nephrology; KEM Hospital;NK Hase Professor and HOD; Department of Nephrology;KEM Hospital; Seth GS Medical College and KEM Hospital

Background: HCV-infected transplant recipients have decreased patient and allograft survival. Until last 30 years interferon based regimens have been the mainstay of treatment prior to transplant though it is associated with low efficacy and poor tolerability.It is not recommended in KTRs due to increased risk of allograft loss. Directly acting antiviral agents have been approved in Kidney transplant recipients although there is limited data on their safety and efficacy.

Aim of the Study: 1.To assess efficacy of DAAs in treatment of HCV in KTRs2.To assess the safety and tolerabilty of DAAs in KTRs3.To determine impact of treatment on allograft function.

Methods: 11 kidney transplant recipients with Hepatitis C on DAAs were studied from April 2015 to Aug 2016 .Demographic and clinical parameters including age; sex; duration post transplant; induction and maintenance immunosuppression; calcineurin inhibitor trough levels; presence or absence of cirrhosis; liver function tests; ; HCV genotype and viral load; viral response at weeks 4 and 12 ; presence of diabetes and allograft function were evaluated. Drug tolerabilty and side effects were also studied.

Results: 11 patients were studied.8/11(72.7%) were male. Median age of patients was 46 yrs (range 34-70 yrs).All had high viral load (defined as HCV RNA greater than 800; 000 IU/mL).4/11(36.36%) had cirrhosis and 1 had liver decompensation.All patients had stable calcineurin inhibitor trough levels during treatment. Mean creatinine clearance at initiation was 52.22 ml/min and was 56.12 ml/min after 12 weeks of treatment.3 patients had been treated with sofusbovir+ribavirin of which all 3 had developed anemia which necessitated treatment discontinuation in 1 patient and blood transfusion in another.1 of the 3 patients treated with sofusbovir+ribavirin had treatment failure after 6 months treatment and was switched to alternative regimen ( sofusbovir+daclatasavir) after which she achieved RVR at 4 weeks. 7/11(63.6%) had genotype 1 and remaining had genotype 3.All patients achieved RVR at 4 weeks and SVR at 12 weeks..None of the patients developed significant side effects.

Conclusions: The high safety ; efficacy and tolerability of directly acting antivirals holds great promise in the treatment of post transplant hepatitis C for improving their outcomes.

103. Spectrum of renal disease by biopsy in a tertiary care centre

Ashok Varma Bhupathiraju, Dr. K. Praveen Kumar, Dr. K. Varaprasad Rao


Narayana Medical CollegeNellore; Andhra Pradesh

Background: Renal biopsy is an invasive ; yet definitive diagnostic test in patients with renal parenchymal disease.Renal biopsy is helpful in diagnosis ; treatment planning and prognostication.Analysis of renal biopsy data can give some insight into the spectrum of clinically significant renal disease and basic epidemiological data on renal disease in the community.The incidence and prevalence of biopsy proven renal disease has geographic; demographic variance.

Aim of the Study: The aim of the present study is to analyze the epidemiological distribution and pattern of biopsy proven renal diseases over two years duration in a tertiary care hospital at nellore; andhra pradesh.

Methods: A retrospective analysis of all renal biopsies were performed from 2013 to 2015 at our centre. Automated biopsy guns with real time ultrasound guidance were used for all the biopsies.All biopsies were evaluated by light microscopy; immunofluorescence & electron microscopy (if needed).The Incidence of different types of renal diseases were calculated. The indications for renal biopsy were categorized in to syndromes like nephrotic syndrome; acute nephritic syndrome; AKI; hematuria; RPRF and asymptomatic urinary abnormalities.

Results: A total of 162 biopsies were performed in 158 patients.The most common indication for renal biopsy was nephrotic syndrome 70(43%); RPRF 52(32%); AKI 24 (15%); acute nephritic syndrome 13 (8%); hematuria 3(2%) Among primary glomerular diseases; MCD (23.7%); Membranous nephropathy(17.3%); FSGS(15.6%); IgA N(13.4%); DPGN(5.6%); FPGN(6.2%); CRESCENTIC GN(4.6%); MPGN(4.8%); CHRONIC GN(7.4%); HUS (1.8%).

Conclusions: This study documented the incidence of Biopsy proven renal disease at our centre . MCD was the predominant glomerular disease followed by FSGS and membranous nephropathy.

104. A positive cdc crossmatch in an abo incompatible renal transplant; that wasn't…

Dr. Keyur Dave, Dr.
. Rushi Deshpande,

Dr. Rachel Shahdr Ashwin


Jaslok Hospital And Research Centre; Mumbai

Background: Blood group and immunologic barriers are considered difficult to breach and can prevent optimal utilization of kidneys from living donors. To breach the ABO barrier; chimeric antibodies like Rituximab is used in immunosuppression protocol however can lead to false positive crossmatch results. Pronase treatment to recognise such false positive cross matches is currently not available in India ; hence the need for solid phase assays in transplants using therapeutic antibodies.

Aim of the Study: To highlight possible positive CDC crossmatch due to monoclonal chimeric antibodies; recognition of which would prevent refusal of organs and can lead to successful high risk renal transplants.

Methods: 33 year old female c/o CKD on HD cause being lupus nephritis with blood group O+ and donor father A+ was planned for ABO iKT Patient had no prior history of antigen exposure. Pretransplant workup had negative CDC crossmatch and haplotype HLA match.She received Rituximab 375mg/m2 on Day -10 and Tacrolimus; MMF; Prednisone on Day -7 and 3 plasma exchanges after which anti A titres decreased from 16 to nil. Repeat CDC T cell and B cell cross match on Day -2 was found to be positive; value of 26%. surgery was postponed and Auto cross match performed to r/o auto antibodies was negative with CDC cross match >20%. To rule out false positive result; Pronase treatment was found unavailable. DSA testing with the qualitative bead - based immunoassay on Luminex platform revealed negative result for both anti HLA Class I and Class II antibodies as MFI values < 50. Patient underwent successful transplant with S creatinine remaining 0.9 mg/dl after 1 month of follow up and negative Anti A titres.

Results: Transplantation across ABO barrier and presence of Anti HLA antibodies poses risk of hyperacute AMR and graft loss. Crossing two barriers may be impermissible. CDC crossmatch may be false positive due to "irrelevant" binding of recipients' antibodies to Fc-receptors highly expressed on B-lymphocytes. Humanized monoclonal antibodies is increasingly used for high risk transplants which may influence CDC crossmatch. Rituximab is IgG1 isotype which is capable of inducing activation of complement system. Rituximab and Basiliximab have been described to have false positive flow cytometry results. Schalf et al have described 27 and 4 patients receiving Rituximab and Basiliximab for ABOiKT were found to have false positive B cell and T cell CDC crossmatch confirmed with solid phase assays and ELISA based crossmatch as in our case. Pronase reduces expression of CD 20 reducing binding of antibodies and in turn reduced activation of complement dependent lysis but is not available in India.

Conclusions: There is an urgent need to implement solid phase assays for reliable exclusion of DSA (i) in ABOiKT (ii) any transplant with therapeutic antibodies making CDC ineffective especially that Pronase treatment is not available in our country to ensure successful renal transplant.

105. Clinical and histopathological profile of lupus nephritis and response to treatment with cyclophosphamide- a single centre study

Dr. Himanab Jyoti Das, Dr. Manjuri Sharma,

Dr. Anup Kumar Barman, Dr. P. J. Mahanta,

Dr. S. Kakaty, Dr. B. D. Medhi, Dr. P. Bordoiloi, Dr. P. K. Doley,

Dr. G. Pegu, Dr. A. Mahanta, Dr. B. Agarwalla


Gauhati Medical College and Hospital

Background: Lupus nephritis is an immnune complex glomerulonephritis that is a common and serious feature of systemic lupus erythematosus. Lupus nephritis is usually manifested by proteinuria; active urinary sediment; hypertension and renal failure.

Aim of the Study: The aim is to study the clinical and histopathological profile of lupus nephritis and the response to treatment with cyclophosphamide.

Methods: This was a retrospective study conducted in a tertiary care centre in Assam; India where 176 lupus nephritis patients who underwent renal biopsy were included. The presenting features; laboratory parameters and the histopathological class of the patients were studied. 102 patients received i.v cyclophosphamide as initial treatment of which 40 received the Eurolupus regimen and 62 received the NIH regimen. The number of patients who underwent remission in both the regimen were compared.

Results: Among the 176 patients; 89.8% were female and 10.2% were male and maximum patients (61.3%) were in the age group 20- 40 years. Pedal edema was present in 100% of the patients; decreased urine output in 60.8 %; hair loss in 63%; joint pain in 42%; hypertension in 41.4%; malar rash in 38%; oral ulcer in 31.8%; seizure in 17% and psychosis in 13% of patients. Proteinuria was present in 100% of the patients; microscopic hematuria in 78.4%; anaemia in 72.1%; thrombocytopenia in 51.1% and leucopenia in 31.7% of patients. ANA was positive in all patients and anti dsDNA was positive in 70.5% of the patients. The most common histopathological type was class IV (50%); followed by class III (17.6%). The respose rate of initial treatment with cyclophosphamide in the Eurolupus group was 62.5% and in the NIH group was 64.5% (p>0.05).

Conclusions: Systemic lupus erythematosus is an important cause of morbidity in this part of the country; which commonly involves the kidneys. Majority of the patients had proliferative lupus nephritis in this study. Patients with lupus nephritis should be evaluated and treated for better outcome of the patients.

106. Post renal transplantation hypophosphatemia is associated with high fgf23 level

Mantabya Singh 1 , Akhilesh Jaiswal 1 , Narayan Prasad 1 , Vikas Agrawal 2 , Sashi Kumar 1 , Mohit Rai 2 , Harsit Singh 1 , Saurabh Chaturvedi 2

1 Department of Nephrology and Renal Transplantation; and 2 Clinical Immunology; SGPGIMS; Lucknow; India

Background: The onset of hypophosphatemia in early post renal transplant period is of vital clinical significance. We look at the hypothesis that high Fibroblast growth factor-23 (FGF23) "phosphatonin"hormone contributes to the hypophosphatemia; independently of parathyroid hormone (PTH) and other factors regulating phosphate metabolism in early post transplantation.

Aim of the Study: We aimed this study to dtermine the predictors of post renal transplant hypophosphatemia in living donor transplantation.

Methods: Intact PTH(iPTH); calcidiol; biointact FGF-23; albumin corrected calcium; and inorganic phosphorus (iP) were analyzed in 63 ESRD (Male 58; mean age 35.65±11.79 years) patients who underwent living donor renal transplantation before and at month 1(M1) after transplantation. The native kidney diseases of these patients were chronic glomerulonephritis (n=36); interstitial nephropathy (n=20); diabetic nephropathy (n=6) and polycystic kidney disease (n=1). The upper normal cutoff value of iPTH was considered as >65 pg/ml; and iFGF23 >50 pg/mL; hypo and hyperphosphatemia was defined with iP <2.5 and >5.5mg/dl respectively; hypo and hypercalcemia with corrected for serum albumin <8.5 and >10.8 mg/dL; respectively.

Results: The mean iP was 2.92±0.85 and hypophosphatemia was observed in 17(27%) patients at M1. Hypophosphatemic patients had higher FGF23 (p<0.001) and iPTH (p=0.272) compared to normophosphatemic. Mean FGF23 level was 82.40±69.78 and were normalized in 63.5% patients; however mean iPTH levels was 112.3±84.38 and normalized only in 36.5% reciepients at M1. Serum calcium normalized in all except one patient at M1. Serum criatinine; BUN; uric acid and alkaline phosphatase were in normal range in all patients. On univarriate linear regression serum iP was significantly correlated with FGF23; uric acid and eGFR; however on multivarriate linear regression using a backward stepwise model; serum iP was significantly associated only with FGF23 levels (p<0.001) independent of iPTH and other factors regulating phosphate metabolism at M1.

Conclusions: In conclusion; our data indicate that FGF23 is strongly associated with hypophosphatemia; independently of iPTH.

107. Acute Kidney Injury Following Snake and Insect Bite-Its Long Term Follow-Up

Dr. Aswini Prasad Patnaik, Dr. Debadutta Dash,

Dr. Nikunja Kishore Routprof, Dr. Suresh Chandra Dash


Kalinga Institute of Medical Scienceskiit University; Bhubaneswar

Background: Acute Kidney Injury due to snake & insect Envenomation is common in tropical countries like India.

Aim of the Study: This is a prospective study to objectively assess the pathogenesis; morbidity; mortality and outcome in a tertiary care hospital.

Methods: Thirteen patient with Acute Kidney injury were subjected for studies in six years. Eight out of Thirteen were bitten by Russel Viper; three were scorpian; one by bees and the other one was unknown venom. Majority patients came to hospital after 03 days of onset of oligo-anuria.

Results: All 08 in Russel Viper group & 02 from Scorpion group needed dialysis.; rest had milder renal dysfunction; improved with conservative management.Intravascular hemolysis and disseminated intravascular coagulation (DIC) were the dominant pathologic mechanism in 09 cases. Direct tubulo-toxicity with ATN and evidence of DIC was observed in 03 patients. Two showed overlapping features of HUS. One of these had pulmonary vasculopathy. Intrinsic heart failure and hepatocellular toxicity were present in 02 and 03 patients respectively. Renal biopsy revealed confluent symmetrical acute cortical necrosis; one case had partial cortical necrosis and one had severe tubular necrosis as well as acute interstitial nephritis. None with acute cortical necrosis survived.They are on follow up in renal clinic since 1½ - 2 years with CKD III. Clinically those patients had associated prolif glomerulonephritis and AIN did not have typical diuretic phase; they recovered over longer period of time.

Conclusions: Russel viper bite is the commonest cause of Acute Renal failure due to animal envenomation in India. These toxins in addition to kidney injury can potentially involve lungs; heart and liver. They severely alter hemotologic and vascular system causing ischemic and toxic injury.

108. Congestive heart failure in haemodialysis patient: A single centre study

Dr. Gayatri Pegu, Dr. Manjuri Sharma, Dr. Anup Kumar Barman, Dr. P J Mahanta, Dr. S kakaty, Dr. B Das Medhi, Dr. P Bordoloi, Dr. P K Doley, Dr. H J Das, Dr. A Mahanta, Dr. B Agarwalla


Gauhati Medical College and Hospital

Background: Cardiovascular diseases represent a well defined cause of mortality and morbidity in CKD patients. Congestive heart failure is a common finding in ESRD population . Presence of heart failure prior to initiation of dialysis as well as recurrent heart failure while on dialysis therapy is associated with poor outcome.

Aim of the Study: To evaluate the incidence and clinical profile of heart failure in CKD-ESRD patients who were on haemodialysis support .

Methods: Retrospective study of 282 patients; undergoing Haemodialysis in the department of Nephrology ; Gauhati Medical College and Hospital; Guwahati; Assam; for a minimum period of 6 months were evaluated for presence of heart failure both prior to initiation of RRT and after initiation of dialysis.

Results: Study population comprised of 196 (69.5%) males & 86 (30.5%) females. Mean age of the patients is 43.78 years. Ninety four (33%) patients had heart failure prior to initiation of dialysis.172 (61 % ) had developed one or more episodes of heart failure after initiation of haemodialysis. 106 (37.6%) patients were diabetics and hypertension was present in 187 (66.31%)patients. Left ventricular hypertrophy was found in 63 (67.02%) patients ; who had heart failure prior to initiation of Haemodialysis. Diabetes (OR-5.434; 95% CI-3.598-8.207) and anaemia (OR-1.825; 95%CI- 1.155-2.885) were associated with early occurrence of heart failure in our study.

Conclusions: Heart failure is very common in ESRD population ; and is present even before initiation of dialysis therapy .Recurrent heart failure was very high in dialysis patients. In CKD-ESRD ; all patients should be evaluated for presence of cardiac condition and aggressively treated.

109. Outcome of paediatric acute kidney injury

Amar G Sultan, Tukaram Jamale, N K Hase,

Ashwathy Haridas, Rahul Deshpande, Sayali Thakre, Dinesh Mahajan


Department of Nephrology; Seth G.S.M.C and K.E.M. Hospital; Mumbai; India

Background: There is limited data on outcomes of paediatric acute kidney injury.

Aim of the Study: To study the outcomes of acute kidney injury in paediatric patients at tertiary care referral centre in Mumbai.

Methods: 72 patients with AKI were enrolled in study from July 2015 till August 2016. Demographic details; clinical and biochemical parameters and SOFA score were recorded. Outcomes studied were: In-hospital mortality; need and mode of RRT; renal function at the time of discharge and on follow up. Organ dysfunction severity was assessed using SOFA score.

Results: 72 paediatric patients with AKI from July 2015 till August 2016 were referred to nephrology for consultation.43(59.2%) of them were males. 6(12%) were neonates. 32(44.4%)were admitted in ICU out of which 3 were from surgical ICUs. Mean age of the study population was 6years 5months. Most common etiology of AKI in these patients was tropical infections (47 out of 72 i.e. 65%); 9(1.12%) had sepsis due to other etiologies. 6(0.8%)had AKI due to cardiogenic shock. 45; 10; 17patients had KDIGO stage 3; 2; and stage 1 AKI respectively. 30 (41.66%) were oliguric; 29 (40.27%) had sepsis and 29 (40.27%) had shock at presentation. Complications of renal failure at presentation were metabolic acidosis (24/72); fluid overload(13/72); hyperkalemia (6/72) and uraemia(4/72). 12(16.66%) received RRT(8: hemodialysis and 4:acute peritoneal dialysis). Most common indication for RRT was volume overload (8/12)In hospital mortality was 43.05%(31/72).

Conclusions: Higher SOFA at presentation; need of ventillatory support and severity of AKI were independent predictors of mortality in paediatric patients.

110. Twice weekly vs thrice weekly HD - Influence on residual kidney function (RKF)

Dr. M. Sreedhar sharm, Dr. K. Praveen Kumar,

Dr. K. Varaprasada Rao, Dr. Srinivasulu, Dr. Ashok, Dr.Bhargav


Narayana medical college hospital; Nellore

Background: Patients on maintenance dialysis have a better quality of life and survival when they have RKF.RKF confers advantage in terms of better volume control & clearance of middle molecules not cleared by HD .The FHN nocturnal trial showed that frequent nocturnal dialysis may be beneficial in patients with little RKF but this benefit decreases when there is significant RKF.Studies showed that increased HD frequency & intradialytic hypotension episodes were associated with RKF loss.

Aim of the Study: To study the influence of twice weekly vs thrice weekly standard HD sessions (for 6 months) ; in two cohorts of hemodialysis patients ; on residual kidney function.

Methods: 100 dialysis patients were selected with dialysis vintage less than or equal to 6 months and with residual urine output of 500ml or greater. Residual Kidney Function was measured with residual renal urea clearance KRU(ml/min) .KRU (ml/min) = urinary urea (mg/dl) X urinary volume(ml) / collected time(min)X [0.9 X serum urea(mg/dl)] These 100 patients were randomly assigned to two cohorts of 50 each . One cohort received standard duartion thrice weekly HD while the other received standard duration twice weekly HD. RKF measured as KRU (ml/min) was calculated at the end of 6 months. The Decline in RKF as defined by decrease in urine output to 200ml/day or lower / decrease in KRU(ml/min) by 2ml/min; was compared in both the cohorts .

Results: The decrease in RKF in twice weekly and thrice weekly HD group after 6 months was 32% and 51% respectively. Male patients in both the groups have lower risk (62%) of RKF loss compared to females . RKF loss was also associated with intradialytic hypotension episodes.

Conclusions: Twice weekly HD is associated with lower degree of RKF loss compared to thrice weekly HD in patients with significant RKF.So initiation of twice weekly HD would help preserve RKF with consequent better patient quality of life; possible better outcomes & costeffective in developing nations like India.

111. A case series of anca negative vasculitis

Dr. Satyaki Dey, Dr. Abhijit Taraphder; Dr. E M Khan,

Dr. Ayan, Dr. Sujit, Dr. Padmini; Dr. Tanmay, Dr. Arnab


Apollo Gleneagles Hospitals; Kolkata

Background: Pauci-immune crescentic necrotizing glomerulonephritis (GN) is defined by rapidly progressive glomerulonephritis and histologically by the presence of focal glomerular necrosis and crescent formation in the absence of significant glomerular immune deposits. Anti neutrophil cytoplasmic antibody (ANCA) negative vasculitis is a subset of pauci-immune GN. Management of ANCA negative vasculitis is still not streamlined. This case series tries to address this issue in the Indian context.

Aim of the Study: We present a series of three cases of rapidly deteriorating renal function; who subsequently tested negative for ANCA.

Methods: We present a series of 3 cases (M:F::1:2) with an average age of 23 years presenting with rapidly deteriorating renal function (Avg Creatinine- 6.7 mg/dl ) over a period of days to weeks; necessitating the initiation of dialysis. ANCA & anti- GBM was negative. After stabilization; the patients were subjected to renal biopsy which revealed the presence of crescents; neutrophilic infiltrates along with mild interstitial fibrosis. IF was negative. The patients were treated as crescentic GN and were started on Inj Methylprednisolone (1gm IV for 3 days) followed by oral Prednisolone (1 mg/kg). Cyclophosphamide was not considered as the 2 female patients were young and had still not completed their family. The male patient had new onset infection. Rituximab was not used due to financial constraints. Serial estimation revealed improving renal function in the female patients who were discharged with a Creatinine of 2.2 mg/dl. The male patient however needed continuation of haemodialysis.

Results: About 10 % of the patients of systemic vasculitis test negative for ANCA. Increasing age carries an adverse prognosis. ANCA negative patients had fewer systemic symptoms compared to patients who were ANCA positive. No specific treatment guidelines for ANCA negative GN exist; and they are treated as ANCA positive cases. Case reports however recommend the use of steroids along with cyclophosphamide or rituximab as an adjunctive therapy.In this series; we demonstrate the improvement in renal function with steroid administration; without the use of other immunosuppressant medications. Serial follow up with tapering steroids; over a period of more than 16 months still shows a stable renal function with an average creatinine of 1.8 mg/dl in 2 out of 3 patients. The presence of infection or fertility concerns are important issues that need to be addressed while treating ANCA negative vasculitis in the Indian context. Whether females respond better to steroids alone remains to be seen.

Conclusions: This series highlights the effective management of ANCA negative vasculitis with steroids alone. However this case series cannot be generalized and each patient needs to be treated individually.

112. Reversible isoniazid(INH) induced neurotoxicity in end stage renal disease (ESRD).

Dr. Padmini Sirkanungo, Dr. Abhijit Taraphder,

Dr. Somnath Chaterjee, Dr. Satyaki, Dr. Ayan, Dr. Sujit, Dr. Tanmay, Dr. Anab


Apollo Gleneagles Hospitals; Kolkata

Background: 77 year diabetic male; ESRD; on a background of completely cured carcinoma larynx (2006); with a recent history of being diagnosed with tubercular pleural effusion was admitted with altered sensorium and oliguria for 3 days. He was on anti-tubercular therapy (ATT) 4 drug regimen comprising of rifampicin(450mg/day); isoniazid(INH)(300mg/day); ethambutol(800mg/day) and pryrazinamide(1 gm/day) with pyridoxine supplementation 40 mg/day for 10 days.

Aim of the Study: To approach a case of altered sensorium in an ESRD diabetic patient on Anti Tubercular Therapy.

Methods: On admission; he was hemodynamically stable; drowsy but following simple commands.Biochemical evaluation revealed a serum creatinine of 6 mg/dl with serum urea 230 mg/DL; serum potassium of 5.5 meq/ml; serum sodium 136meq/ml; complete hemogram was normal & hepatitis B; hepatitis C and HIV were negative.Liver function tests (LFT) showed serum albumin 2.3gm/dl. Rest was normal.He was immediately initiated on hemodialysis. A complete neurological work up was carried out. MRI Brain Flair Diffusion Weighted Images revealed symmetrical hyperintense signals in bilateral dentate nuclei probably secondary to INH toxicity in background of chronic kidney disease. Cerebral and cerebellar atrophy was seen.Inspite of adequate hemodialysis; sensorium of the patient did not improve.INH was withdrawn following which sensorium showed remarkable improvement. Repeat MRI Brain revealed resolution of features of INH toxicity while the chronic changes of generalized diffuse atrophy persisted.

Results: Drugs with primary hepatic clearance can cause untoward side effects in CKD patients with normal LFT. INH is backbone of ATT along with rifampicin. No dose modification in renal failure patients is advised for INH as the drug is primarily having hepatic clearance. Neurotoxicity as peripheral neuropathy is known and it is a usual practise to give pyridoxine supplementation as preventive measure. Neurotoxicity has a gradual onset and slow progression caused by INH. In paediatric population; sudden onset neurotoxicity manifesting as seizures has been reported; however in adults; such manifestation is rare. INH toxicity has been noticed in hemodialysis patients as duration of action of INH is increased. In our case the patient had manifested INH toxicity before commencement of hemodialysis .This is because of protective effect of pyridoxine is lost because of altered phosphorylation of pyridoxine decreasing amounts of pyridoxal phosphate.

Conclusions: Uremic milieu contributes for the altered clinical manifestations seen in ESRD; however search for reversible causes can improve the outcome. As seen in our case INH induced neurotoxicity was reversible; leading to clinical improvement along with radiological resolution.

113. "Trisodium citrate 46.7% Effectively reduces and controls catheter-related blood stream infection (CRBSI) when compared to heparin as catheter locking solution in hemodialysis patients"

Dr. Bhargav Bhimavarapu, Dr. K. Praveen Kumar, Dr. K. Varaprasada Rao


Narayana Medical College and Hospital; Nellore

Background: Patients undergoing hemodialysis via central venous catheters are at a 10 fold increased risk of infections when compared to AV fistulae. Trisodium citrate(TSC) chelates Ca++ and Mg++ so it prevents biofilm formation & colonization of bacteria. TSC(46.7%) is shown beneficial when compared to heparin & other catheter locking solutions in many studies. Currently there is limited experience with TSC in India & other developing nations; so the safety & efficacy of TSC needs to be established.

Aim of the Study: To evaluate the efficacy of Trisodium citrate 46.7% in reducing catheter-related blood stream infection(CRBSI) when compared to heparin as catheter locking solution in hemodialysis patients.

Methods: From 1st february 2016; the locking solution for the central venous catheters (normal dialysis catheter; not tunneled) was changed from 5000IU/ml heparin to SEROCITTM (46.7%) TSC in all hemodialysis patients on CVC at Narayana medical college and hospital; Nellore. Blood culture data was collected serially 6 months before the changeover to TSC and 6 months during the TSC adminstartion. Patients with a newly inserted; well positioned dialysis CVC who were expected to get the dialysis for > 1 week are included; CVC was used only for dialysis purpose. Exclusion criteria are: systemic bacterial infection; uncontrolled diabetes; prior heparin induced thrombocytopenia; suspected allergy to TSC; and pregnancy. TSC tolerability was excellent with no withdrawals ; no major adverse events occurred.

Results: A significant decrease in the CRBSI rates was observed when changed from heparin to TSC. A total of 115 patients were selected after the analysis based on exclusion criteria; 56 patients were in heparin group from august 2015 to jan 2016 & 59 patinets were enrolled during feb 2016 to july 2016 in the TSC group. The CRBSI rate was (3.4%/100 catheter days) for heparin and for TSC(0.8%) therby clearly proving its efficacy.CRBSI rates were analysed month by month i.e 6 months before introducing TSC and 6 months after; was continued for a total of 12 months. CRBSI were analysed for methicillin-resistant S.aureus (MRSA); S.epidermidis(coagulase -ve); MSSA; and other gram+ve and gram -ve organisms. In the TSC locked group there was a statistically significant reduction of MRSA; S.aureus and S.epidermidis infections when compared to heparin.

Conclusions: In this study we clearly found that 46.7% TSC is highly effective & safe when compared to heparin; in reducing CRBSI; by preventing staphylococcal infections; as it is a major organism causing serious disseminated infections; TSC will be a worthy alternative for dialysis units; especially in India.

114. A comprehensive approach with case based correlation of nephrocalcinosis

Dr. Sujit Kumar, Dr. Abhijit Taraphder, Dr. Manish Jain, Dr. Satyaki Dey, Dr. Ayan Dey, Dr. Padmini Sirkanungo, Dr. Tanmay Mukherjee, Dr. Arnab Duari


Apollo Gleneagles Hospital; Kolkata

Background: Nephrocalcinosis is an important condition frequently encountered by nephrologists in their daily practice. It is a clinical condition with significant spectrum of presentation with commonest presentation being incidental USG findings; calcuria; obstructive uropathy; hypercalcemia with AKI or asymptomatic renal dysfunction. It is predominantly a radiological abnormality; albeit defined by raised calcium levels in the kidney. This article addresses this issue with a case based study correlation.

Aim of the Study: To approach a case of Nephrocalcinosis and attempt an algorithmic approach for nephrocalcinosis.

Methods: A 44 year old male presented with incidental ultrasound finding of nephrolithiasis on routine health check up. Serum creatinine was 1.1 mg/dl; electrolytes like serum sodium; potassium and bicarbonate were normal. Serum Calcium was 8.2 mg/dl with a serum albumin of 3.8 mg/dl. Hb was 12.3 gm/dl with no other abnormalities detected on hemogram. Clinical examination did not reveal any specific findings. He was a vegetarian with no food fads and was not on any medications. There was no significant past medical or surgical history. Hence; 24 hour urine calcium estimation was done which was high at 430 mg/24 hours. Due to this; further workup was undertaken. 24 hour urinary magnesium was normal but citrate came to be low at 220 mg/24 hours. The diagnostic algorithm in this context showed a possibility of medullary sponge kidney. Hyperuricosuria and hyperoxaluria were ruled out. Confirmation was done by an excretory urogram which showed tell tale signs of medullary sponge kidneys (MSK).

Results: Initial radiological confirmation starts the workup with serum calcium assessment.Normocalcemia with hypercalciuria needs serum potassium estimation. Hypokalemia needs ruling out RTA; Liddle's; Bartter's syndrome or loop diuretic use. Normokalemia needs 24 hour urine magnesium & citrate levels which would suggest MSK if hypocitraturia. Hyperkalemia strongly suggests antenatal Bartter syndrome or Hyperprostaglandin E syndrome.If hypercalcemia is noted; then iPTH values are assessed. Raised iPTH necessitates 24 hour urine calcium. Hypercalciuria suggests primary or tertiary hyperparathyroidism. Hypocalciuria points to familial hypocalcemic hypercalciuria. Low iPTH warrants PTHrP & Vitamin D levels. High vitamin D confirms Vitamin D toxicity & low levels suggest milk alkali syndrome or thyrotoxicosis. Hypocalcemia warrants 24 hour urinary calcium & phosphorus estimation. Both being high; points to Dent's or Lowe's disease; but isolated hyperphosphaturia points to rickets & its variants.

Conclusions: This case study throws light on the commonest presentation of nephrocalcinosis and chalks out a simplified comprehensive algorithmic approach to this important entity. It will help in streamlining the causes and management of nephrocalcinosis.

115. Crossing double barriers: abo incompatible renal transplant in a patient with donor specific antibody (DSA): A case report

Bahl A, Kakkar B, Choudhary M, Sagar G, Jasuja S


Indraprastha Apollo Hospital; New Delhi-76

Background: Both HLA alloimmunization and ABO incompatibility are two major histocompatibility barriers to a successful renal transplantation and graft survival. Several studies quote that presence of either of ABO or HLA incompatibility increases the risk of AMR and longterm graft survival.Advances in immunosuppression and desensitization have led to successful outcomes in renal transplantation.Desensitization protocol varies from centre to centre.

Aim of the Study: ABO incompatible renal transplantation in a pt with DSA.42yr female known hypertensive presented in advanced uraemia. Evaluation confirmed CKD. Mother donor; Bld grp A +. Recipient Bld Grp O+.

Methods: Pretransplant AntiA titre > 1:1024; anti B 1:32; CDC(AHG)crossmatch - negative; DSA classI 293MFI & class II 9883 MFI. Pre-transplant desensitization protocol - patient was given Rituximab (RTX); Bortezomib; PP/IVIG treatment and immunosuppressant's until the anti-A/B antibody level decreased to <1:4 and DSA became negative.Patient was also started on Valgancyclovir prophylaxis.Initial immunosuppression was MMF 1gm BD & tacrolimus at 0.1mg/kg.11 sessions of PLEX & 120gm IVIG was given pre-op. Postop pt received 2PLEX sessions & IVIG 20gm. POD2 pt had decreased output. Graft Bx showed Acute cellular rejection for which 2 doses of ATG 1mg/kg was given with which pt improved.She was discharged on POD14 with serum creatinine 1mg/dl; Anti A titre 1:512.

Results: She was discharged on POD14 with se creat 1mg/dl & Anti A titre 1:512. Se Creat at 6 month follow-up was 1.1mg/dL and one year followup was 1.2mg/dL. There was no episode of infection or rejection in the follow up period.

Conclusions: This study reinforces that renal transplants are feasible in patients with both donor-specific anti-HLA & ABO antibodies although both are formidable barriers. Luminex aided charactersiation of HLA antibodies & better desensitisation protocols help in reducing AMR & improving graft survival.

116. Percutaneous interventions in hemodialysis access dysfunction

Sagar G, Bhat FA, Khanna NN, Bahl A, Jasuja S


Indraprastha Apollo Hospital; New Delhi

Background: The haemodialysis access is lifeline for ESRD patients; so any dysfunction that leads to its improper or inadequate functions; becomes great cause of morbidity or mortality in these patients. The AVF circuit or Central (superior vena cava; Brachiocephalic; or subclavian) venous stenosis (CVS) are a major impediment to long-term arteriovenous access in the upper extremities. The purpose of this study is to determine the outcomes of Percutaneous Interventions (PCI) in these patients.

Aim of the Study: The purpose of this study is to determine the outcome and safety of percutaneous interventions for AVF dysfunction and central venous stenosis.

Methods: Our study was prospective; observational study; 35 consecutive; ESRD patients with haemodialysis access dysfunctions; referred from dialysis department in view of inadequate dialysis or extremity swelling; which was considered for percutaneous intervention. Out of these; 27 constitutes our study population; from June 2014 to December 2015. Fistulography/ Angiography was performed in all patients. Intervention in the form of angioplasty (PTA); stenting (PTS) or thrombolytic therapy was examined. The immediate and short term outcome at 3 and 6 month was noted with any procedure related complication. The data were expressed as percentages or Mean (±SD) value as necessary. Statistical methods involved included Student's t-test for normally distributed continuous variables and the Pearson Chi-square test or two-tailed Fisher Exact test for categorical variables. P value <0.05 was considered statistically significant.

Results: Of 27 patients; half were men and two-third Indian. The mean age of the patients was 53.4±16.18 years. The commonest co-morbidities included hypertension (89%) and diabete mellitus (44%). Most of the patients presented with inadequacy of dialysis (55.6%) and extremity swelling (44.4%). Radio-cephalic was the commonest site of hemodialysis access (40.7%) and most of patients had previous central vein cannulations (92.5%). Angiographic findings revealed; CVS (55.5%); and in CVS Subclavian vein (SCV) being the common site (22.2%) and AVF circuit stenosis (22.2%); in which Juxta/asnatomatic site being the common site. Besides; we had some cases of thrombus in AVF; outflow vein and right Atrium (RA). In total 23 patients had interventions; PTA (43.4%); PTS (34.7%); AVF closure (8.6%) and coiling (4.3%) (P-0.01).The clinical and non-invasive assessment at 3 and 6 months for vessel patency showed PTS (100%); PTA (80%)(p-0.06) and PTA (60%) and PTS ( 60%)( p-0.07) respectively.

Conclusions: The overall immediate success rate in effectively treating haemodialysis access related complications in the present study was 91%.There were no major complications in our patients. Few dissections (11.2%) and small hematomas (7.4%) were encountered. PCI is safe and durable for access dysfunction.

117. Urinary interleukin-6 as a marker of disease activity in lupus nephritis

Dr. Deba Prasad Kar, Prof. R. G. Singh


Institute Of Medical Sciences; Banaras Hindu University

Background: Lupus nephritis (LN) is a frequent complication of SLE which is related to high incidence of mortality and morbidity. There is controversy regarding the value of C3 and C4 levels and anti-dsDNA antibody titre in predicting clinical fares of LN. We tried to measure the urinary IL-6 levels in active LN patients as a marker for disease activity.

Aim of the Study: The present study aimed to evaluate the clinical significance of urinary IL-6 and its usefulness as markers of disease activity in LN.

Methods: The study included 32 patients of SLE diagnosed based of Systemic Lupus International Collaborating Clinic (SLICC) criteria ; who presented with renal involvement. They were compared to 20 healthy controls. Urinary IL-6 levels were assessed in both patients before initiation of therapy and controls by quantitative sandwich ELISA technique. In addition; renal biopsy was done prior or shortly after urine sampling; the results were classified according to the International Society of Nephrology/Renal Pathology Society classification of LN by recording the activity score and chronicity score for each sample. Treatment was started in all patients according to class of LN based on renal biopsy findings according to KDIGO guidelines. Urinary IL-6 levels were again assessed in all patients after 6 months of induction phase treatment.

Results: The study included 32 patients; female to male ratio was 7:1 with a mean age of 28.68 ± 9.28 . 31 out of 32 patients with active lupus nephritis have significantly high urinary IL-6 levels ( 301.59 ± 483.96 pg/ml ) as compared to 20 healthy controls (4.7±2.285 pg/ml). In patients of LN urinary IL-6 levels correlated with active renal disease diagnosed by renal biopsy. But; urinary IL-6 did not show any linear correlation with serum creatinine; protienuria and presence of active urinary sediment. In our study 2 patients (6.25%) died; 5 patients (15.6%) lost follow up; 16 patients (50%) achieved remission; 6 patients ( 18.75%) achieved partial remission and 3 patients (9.37%) did not show any improvement after 6 months treatment. Urinary IL-6 levels were near normal among 12 patients (75%) out of 16 patients who achieved remission; but remained elevated in all 9 patients (100%) who did not improve or achieved partial remission.

Conclusions: Urinary IL-6 may provide a simple noninvasive potential marker of disease activity in lupus nephritis in adult patients and can be used in monitoring the response to therapy.

118. Pediatric renal transplantation- overcoming the age barrier

Dr. Kanav Anand, Dr. Shivani Bansal,

Dr. Shraddha Lohia; Dr. P K Pruthi


Sir Ganga Ram Hospital

Background: The optimal timing for renal transplantation in children remains controversial; as very young children face hurdles of age; weight and issues of accommodation of large kidney in their small abdominal cavity.

Aim of the Study: CKD in a child causes number of metabolic derangements like growth failure; anemia; metabolic acidosis & neuro-developmental delay; which can be prevented if early renal transplantation is done.

Methods: 3 years old CKD child; weighing 11 kg and Height=95 cm; with native kidney disease of reflux nephropathy; on continuous ambulatory peritoneal dialysis for 6months; with serum creatinine of 5.05 mg/dl was planned for renal transplantation. Donor was his father (age= 36 years; height= 180.5cm) with 3/6 HLA mismatch. Induction was done with basiliximab and child was started on triple immunosupression(steroids; tacrolimus and mycophenolate mofetil) as per institutional protocol. Post operatively; child achieved serum creatinine= 1.7 mg/dl by 24 hours and 0.28 mg/dl after 48 hours and urine output of 12 ml /kg/hour. At discharge; his creatinine was 0.27 mg/dl and urine output was 7ml/kg/hour.

Results: At 3 months of follow up; child has stable graft function (creatinine= 0.34 mg/dl); with urine output= 1.5 ml/kg/hour and has gained weight of 1.2kg and height of 1.5 cm.

Conclusions: To the best of our knowledge and as per literature search; this child is the youngest to undergo a successful renal transplantation from India.

119. ABO Incompatible pediatric renal allograft transplantation-a new ray of hope

Dr. Shivani Bansal, Dr. Kanav Anand; Dr. Shraddha Lohia; Dr. P K Pruthi


Sir Ganga Ram Hospital

Background: ABO incompatible renal transplantation was once considered as an absolute contraindication for patients with End Stage Renal Disease (ESRD); but advent of newer immunosuppressive agents; has helped to overcome this hurdle of incompatibility; especially in the settings where a child has no ABO compatible donor and is kept on a long wait in the deceased donor program.

Aim of the Study: To improve the quality of life in a child with chronic kidney disease; who had no ABO compatible donor.

Methods: CASE1-10 yr girl got her rt kidney nephrectomised post Wilms Tumor; developed FSGS; 2 years post chemoRx which progressed to CKD.Bld gp ( O+) & donor(grandmother)bld gp B+. Anti B titres IgM (1:32) IgG (1:4); so preconditioning was done with rituximab; tac & MMF (day -15)alongwith 8 sessions of plasmaphresis & IvIg.Pretransplant titres were IgM(1:4)IgG(1:4).Induction was done with ATG f/b triple immunosupression(steroids; tac & MMF).She was discharged at Cr =0.28 mg/dl & titres IgM(1:2) IgG(1:2).CASE2- 14 yr male child (bld gp O+)case of CKD with native kidney disease -right solitary dysplastic kidney. Donor his mother (bld gp B+). Anti B titres were IgM(1:32) & IgG(1:8).Preconditioning was done with rituximab; tac and MMF (day-15) followed by 6 sessions of plasmaphresis and IVIg.Induction was done with ATG f/b triple immunosupression (steroids; tac & MMF). Pretransplant titres were IgM( 1:4)IgG (1:2).He was discharged with S Cr= 0.86 mg/dl & titres IgM (1:4) and IgG(1:2).

Results: CASE 1- Child has stable graft function at 3 months of follow up. She had one episode of Urinary tract infection which was treated on OPD basis. Presently; her creatinine is 0.67 mg/dl and antiB IgM (1:2) IgG(1:2).CASE2- At 7 months of follow up; his S creatinine is 1.03mg/dl and anti B IgM (1:4) and IgG(1:2).

Conclusions: ABO incompatible pediatric renal transplant is not a far- fetched dream anymore and should be considered as a viable option in developing countries like India. These case series is first such case series from India.

120. Assessment of response to direct antiviral agents in treatment of hcv infection in renal transplant recipients

Dr. Sourabh Sharma, Dr. Debabrata Mukherjee,

Dr. Ranjith K Nair, Dr. Bhaskar Dutt, Dr. Dhawal Arora, Dr. Ananth Rao


Army Hospital Research and Referral; Delhi

Background: HCV infection remains important health problem; which is associated with deleterious consequences in renal transplant recipients. Treatment of HCV infection in India is still interferon alpha(IFNα) based; which has been associated with higher renal allograft rejection rates. IFN free treatment regimens; like Direct Antiviral Agents; because of their greater efficacy; reduced toxicity and minimal interaction with immunosuppressants currently represent promising and attractive therapeutic options.

Aim of the Study: To study the efficacy of Sofosbuvir (Direct Antiviral Agent) and Ribavirin in Hepatitis C positive renal transplant recipients in achieving end treatment response

Methods: This single centre observational pilot study was conducted from June 2015 to May 2017 at the Department of Nephrology; Army Hospital Research & Referral; New Delhi. Thirty patients transplanted at a tertiary care hospital; which had replicating HCV infection 1 month post-transplant with stable graft function (Serum creatinine < 1.5 mg/dl) were included in the study. All patients were treated with 400 mg daily of Sofosbuvir along with weight based Ribavirin (1000 mg daily if weight ≤ 75 Kg or 1200 mg daily if weight > 75 Kg) for 24 weeks. HCV RNA level was done at 12 week for early virological response (EVR) and at 48 week for end of treatment response (ETR). The primary end point was fall in HCV RNA level to less than 25 IU/mL at week 24 of therapy (End treatment response).

Results: Out of 30 patients; 29(96.7%) showed EVR and 29 showed ETR. One patient expired due to nocardiosis after achieving EVR. Mean age of patients was 41.23±12 years. Females compromised 53.3%(16/30) of study group. Twenty one patients were diagnosed of HCV post-transplantation while 9 CKD patients with active HCV infection were started on therapy post-transplantation. Nineteen patients(63.3%) were infected by HCV genotype 1 while 11 (36.7%) by genotype 3. Mean baseline HCV RNA level was 4125774.2 copies/ml. 3(10%) patients were cirrhotic at initiation of therapy. 94.1% (16/17) patients with abnormal alanine aminotransferase(ALT) levels at baseline had it normalized by end of treatment. One patient (3.3%) developed graft dysfunction and decline in GFR at end of treatment. Most common side effect was anaemia(36.6%) followed by diarrhoea(30%); headache(20%) and nausea(13.3%). There was no impact on response by HCV genotype; initial HCV RNA level; age or sex of the patient or age of the graft.

Conclusions: DAA like Sofosbuvir have much higher response; lower side effect or drug interaction than IFN based therapy in setting of pre and post-transplant HCV infection. Every HCV infected patient waiting for transplantation should be considered for DAA to reduce HCV associated morbidity and mortality.

121. Fungal infection in renal diseases

Indranil Ghosh, Jai Inder Singh Aditya Gupta


Command Hospital (WC); Panchkula; Haryana 134107

Background: Various therapies in renal diseases renders the patient immunocompromised; thereby making him vulnerable to a vast spectrum of opportunistic infections which can have an adverse clinical outcome. Two cases - a case of anti-GBM glomerulonephritis who presented with RPGN which got complicated with cryptococcal meningitis within 2 months of successful management and secondly a case of laryngeal histoplasmosis 10 yrs following renal transplant who had presented with debilitating odynophagia.

Aim of the Study: Report unusual Fungal Infections in renal diseases

Methods: Case reports and review of literature

Results: RPGN presentation; biopsy proven anti GBM disease; improved with immunosuppression. Course complicated with cryptococcal meningitis 2 months post therapy.Invasive Fungal Infections occurred more than 10 yrs after renal transplant in the second case. There was isolated infection of the larynx. Diagnosis was established by laryngeal biopsy.

Conclusions: Immunosuppressive and the disease renders a patient immunocompromised; making him vulnerable to opportunistic infections. Fungal infections are a rare but frequently fatal disease in such scenarios. Impaired cell-mediated immunity is causal. High index of suspicion prevents adverse outcome.

122. Fungal pneumonia and nocardiosis in renal transplant recipients seen in a tertiary care hospital

Sahil Bagai, Sukanya Govindan, Raja Ramachandran, Vivek Kumar, Manish Rathi, Ashish Sharma, H.S. Kohli, K.L. Gupta


Postgraduate Institute of Medical Education And Research; Chandigarh

Background: Renal transplantation may sometimes be associated with the invasive fungal infection and nocardiosis particularly in the developing countries. The incidence of pulmonary involvement in this category of patients is 2.9-30%.

Aim of the Study: To study the risk factors; clinical profile; treatment and outcomes of post renal transplant fungal pneumonia and nocardiosis.

Methods: Renal transplant recipients who were admitted in Postgraduate Institute of Medical Education And Resarch; Chandigarh between November 2014 to June 2016 and were diagnosed of fungal pneumonia or nocardiosis were included and were followed up for outcome.

Results: Out of total 400 renal transplants in the last 18 months; 40(30 M and 10 F) patients had fungal pneumonia or nocardiosis. Mean age of patients at presentation was 37.3 years and the mean duration at diagnosis was 38.1 months.Fever was the commonest symptom (90%) followed by cough(77.5%) .Pneumocystis jiroveci was the most common fungal infection 12(30%) followed by Aspergillosis 8(20%); Mucormycosis 5(12.5%); Cryptococcosis 3(7.5%) and Phaeohyphomycosis 1(2.5%). Four (10%) patients had pulmonary nocardiosis. Two patients (5%) had dual infection with aspergillosis and mucormycosis. Transbronchial lung biopsy 14(35%); CT guided-FNAC 13(32.5%); Broncho-alveolar Lavage 7(17.5%) and Trans-Bronchial lymphnode aspiration 1(2.5%) were used for diagnosis. Anti-thymocyte Globulin 17(42.5% ); NODAT and CMV infection 11(27.5 %)each; prior rejection episode 9 (22.5%) and HCV infection 5(12.5%) were identified risk factors. Out of 40 patients; 9(22.5%) expired amongst which 6(66.6%) had mucormycosis.

Conclusions: Fungal pneumonias and nocardiosis are serious opportunistic infection in post renal transplant patients in India.A high index of suspicion helps in early diagnosis and prompt treatment.

123. A study on ultrasound assessment of vena caval diameter and compressibility index ; compared with conventional method of clinically determining adequate volume removal in patients of chronic kidney

Desai A.J. Sharif, Dr. Ravi Andrews, Dr. Sanjay Maitra, Dr. Somashekar M


Apollo Hospital Hyderabad

Background: Accurate assessment of a patient's volume status; is an important aspect in critically ill patients as well as patients on hemodilaysis ; however most decisions regarding fluid therapy are made either empirically or with limited and poor data. Given recent data highlighting the negative impact of either inadequate removal or overaggressive fluid therapy; understanding the tools and techniques available for accurate volume assessment is critical.

Aim of the Study: Determine the utility of ultrasound guided dry weight assessment in chronic kidney disease dialysis patients.To determine the effect of such an intervention upon quality of life and symptom profile.

Methods: MATERIALS AND METHODSStudy location - Apollo Hospital Jubilee Hills Hyderabad Study period - 2 year January 2014 to July 2016Study population - CKD patients requiring maintenance HD Study area - OPD and HD unit of Apollo Hospital Hyderabad Nephrology unit Sample size - 30 patients Study DesignPatients newly diagnosed as CKD ESRD needing HD for Maintenance and also those already on HD for maintenance; 30 such patients will be evaluated at baseline by clinical methods such as blood pressure;

Results: Majority of the patients in the study reported better symptom profile with reduced breathlessness ; or cough ; dizziness on dialysis and non dialysis days . quality of life improvements as per the questionnaire compared to start of the study with end of study period . 70% of the patients in the study had a change in dry weight based on the inferior vena cava diameter and compressibility index .30% had maintained the same dry weight as determined by the conventional methods ; and did not find much of a difference in quality of life pre and post study period .blood pressure of most patients in both group remained same as measured using ambulatory blood pressure monitoring pre and post study period ; only about 10% patients in the study group on ambulatory blood pressure showed a 5-10mm hg betterment in systolic blood pressure .There was no major difference in the symptom profile ; blood pressure control ; and other variables based on comorbidities; sex and age.

Conclusions: We conclude that inferior vena cava diameter and compressibility index is a very useful and easily reproducible method at the bedside for dry weight assessment in patients of chronic kidney disease undergoing dialysis.

124. The spectrum of renal changes in patients with chronic liver diseases: A clinico pathological study

Dr. Rajesh Goli, Dr. Sreebhushan Raju


Nims; Hyderabad

Background: There are divergent observations on renal function tests and renal morphology in patients with liver diseases.The present study was designed (1) To study the morphological changes in kidney in patients with various types of Liver diseases; (2) To suggest the possible mechanisms of renal injury secondary to liver diseases.

Aim of the Study: (1) To study the morphological changes in kidney in patients with various types of Liver diseases; (2) To suggest the possible mechanisms of renal injury secondary to liver diseases.

Methods: This is a retrospective; one-point-in time study; carried out at the department of nephrology of a tertiary care center in Hyderabad. A total of 40 patients admitted with chronic liver disease were included in the study who underwent renal biopsy for proteinuria >0.5g/day and /or unexplained renal impairment (serum creatinine >1.5mg/dl). All renal biopsy samples were evaluated by light microscopy and immunofluorescence microscopy.

Results: Renal biopsy revealed injury to glomeruli in 70% of cases; most common being IgA nephropathy (22.5%); diabetic nephropathy (20%) and c3 glomerulonephritis (12. 5%).Partial cellular crescents are seen in two cases. Acute tubulo interstitial injury is seen in 40% of cases most common being acute interstitial nephritis (12.5%) and bile cast nephropathy (10%).Chronic tubulo interstitial injury is present in 13 cases (32. 5%).Most common renal vascular lesion is fibrous endarteritis.

Conclusions: There is a wide spectrum of renal morphological lesions in patients with chronic liver disease and various types of renal injuries are frequently combined. Immune deposits were commonly present in these patients.

125. Cmv viremia in transplant recipients receiving basiliximab or low-dose antithymocyte-globulin induction without valganciclovir prophylaxis

Mayur Makasana, Reetesh Sharma, SB Bansal,

Manish Jain, Pranaw Jha, Ashish Nandwani,

Amit Mahapatra


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

Background: CMV is a major cause of morbidity in transplant recipients and manifests as tissue invasive diseaseor CMV viral syndrome. Controversy exists regarding best method for CMV prevention.

Aim of the Study: To evaluate incidence of CMV viremia and symptomatic CMV infection in adult KTR with basiliximab or antithymocyte globulin (ATG) induction without the use of valganciclovir prophylaxis.

Methods: A prospective; open-label; single centre study. Patients were monitored for CMV DNA-PCR twice a week for month 1 post-transplant; once a week in month2; and then every 2 weeks in month 3; and then once a month from month 4 to 6.Inclusion Criteria:First living related donor (LD) kidney transplant; age > 18yr Exclusion Criteria:second or more transplants; Hepatitis B or C infection; CMV D+/R- and Pregnancy.Induction therapy:ATG 1.5mg/kg:day 0 and 2Basiliximab 20 mg:day 0 and 4 Maintenance:Tac+MMF+steroids in standard doses.Asymptomatic CMV infections: PCR> 2000 copies/ml without organ dysfunctionSymptomatic CMV infection/disease: PCR> 2000 copies/ml with organ involvement Valganciclovir was started if CMV PCR > 2000 copies/mL in ≥ 2 consecutive samples.

Results: We included 40 patients with low-dose ATG induction (group1) and 20 patients with Basiliximab induction (group2) Mean recipient age was 40.95 and 45.9 yr in group 1 and 2; mean donor age was 49.53 and 51.6 yr resp. Male recipients were 67.5% and 65% in group 1 and 2 respectively; male donors were 22.5% and 20% respectively (not signficant). Average HLA mismatches were 4.1/6 and 3.7/6 (not sign). In group1 average transfusions per patient were 2.3 units (vs 1.7units in group 2) and 24.13% pts in group1 had >3 units transfusion. Mean follow-up was 26.1 and 32.7 months respectively.Incidence of acute rejection was 7.5% (3/40) and 10% (2/20) in group 1 and 2 respectively. (not significant).Incidence of CMV viremia requiring valganciclovir therapy was 1.25% (5/40) and 10% (2/20) in group 1 and 2 respectively. (not significant). No patient developed CMV disease.Mean serum creatinine was 1.12 and 1.09 mg/dL at 1 month and 1.2 and 1.14 mg/dL at 3 months (not sign).

Conclusions: The incidence of CMV viremia is low and not significantly different in patients receiving basiliximab or low dose ATG induction in living donor KTR on tacrolimus based immunosuppression.Hence universal prophylaxis with valganciclovir may not be required with basiliximab and low dose ATG induction.

126. Dengue fever among renal allograft recipients: A case series during 2015 outbreak

Arun Kumar S, Soumita Bagchi, D. Bhowmik,

S. Mahajan, R. K. Yadav, Yogesh Chhabra, S.K. Agarwal


All India Institute of Medical Sciences (AIIMS); New Delhi

Background: Dengue viral infection is an important cause of morbidity and mortality in tropical and subtropical countries especially the Indian subcontinent. Its manifestations in renal allograft recipients haven't been reported widely in literature.

Aim of the Study: To report the manifestations and review the impact of dengue in 20 renal transplant recipients from India during the dengue outbreak from August 2015 to December 2015.

Methods: All renal transplant recipients with confirmed dengue infection who presented to AIIMS; New Delhi during the dengue outbreak from August 2015 to December 2015 were included in this retrospective analysis. Case definition was according to CDC 2015 definition. Laboratory diagnosis of dengue infection was made by immunoglobulin M (IgM) capture enzyme-linked immunosorbent assay (ELISA) or detection of dengue nonstructural protein-1(NS1) antigen. Epidemiologic & clinical data were obtained from the admission records. Details regarding transplant status; immunosuppressive drugs & corresponding dosage; coexisting infections were also collected. With respect to dengue infection; details regarding the duration of febrile illness; associated symptomatology ; bleeding manifestations and presence of oliguria were documented.

Results: All patients were males with a median of 378.5 days post transplantation. Two patients developed dengue in the immediate post transplant period. Eighteen patients had dengue fever and 2 patients had severe dengue. One had recurrent dengue infection. Clinical presentation included short febrile illness (100%); myalgia (65%); headache (30%); retro-orbital pain (10%) and mucocutaneous bleeding manifestations (10%). Three patients (15%) had third space fluid accumulation and 2 (10%) had hypotension. Seventeen patients (85%) had thrombocytopenia. Eight patients had severe thrombocytopenia and 4 received platelet transfusion. Leucopenia was seen in 10 (50%) patients with 7 of them requiring G-CSF injections. Nine patients (45%) had transient transaminitis. One patient had dengue shock syndrome and received IVIg therapy following which he recovered. Renal dysfunction occurred in 13 (65%) patients; which recovered with conservative management in all patients.

Conclusions: Dengue in renal allograft recipients is similar to the general population. However; leucopenia with withdrawal of immunosuppression was more common. Renal dysfunction is frequent but reversible. Though overtly benign; severe fatal cases do occur and needs timely care for successful outcome.

127. Nephrotoxicity profile of critically ill patients treated with colistin

Madhav Venkatesan, Sandeep Sreedharan,

Zachariah Paul, Anil Mathew, George Kurian,

Shyam Sundar, Rajesh Nair


Amrita Institute of Medical Sciences; Kochi

Background: In recent times; there has been an increase in emergence of multidrug resistant organisms; especially in the critically ill patients. As a result there has been an increase in the use of colistin. Recent reports have suggested lower rates of nephrotoxicity when compared to earlier reports. In view of varying definitions of AKI in the earlier studies; various routes of administration and increased use of colistin; further studies regarding the nephrotoxicity profile of colistin are needed.

Aim of the Study: To study the nephrotoxicity profile of intravenous colistimethate sodium (colistin) in critically ill patients.

Methods: A prospective observational study of all patients for whom intravenous colistin was given during the study period was included in the study. Patients who were given inhaled colistin; patient who were on RRT prior to start of colistin and patients those who received colistin for less than 72 hours were excluded from the study. The patient's baseline characteristics; indication for colistin; renal functions at the time of initiation; use of concomitant nephrotoxic drugs; use of contrast; vasopressors and duration of colistin use were noted. Patients renal functions at Day 3; 7; 14; 30; 90 days; need for RRT and frequency of withdrawal of drug in view of nephrotoxicity were also noted. GFR was estimated using MDRD equation. AKI was classified based of RIFLE criteria. Patient's physiological profile was calculated using Acute Physiology and Chronic Health Evaluation (APACHE) IV score. Primary outcome were incidence of AKI and cessation of treatment in view of nephrotoxicity.

Results: 66 patients with no previous renal dysfunction and 22 patients with decreased GFR(upto eGFR<60ml/min/1.; 73m2) prior to start of treatment were included in the study. Among patients with normal GFR patients; 21(31%) and 15(22.7%) had AKI and cessation of therapy in view of nephrotoxicity respectively. There was a significant difference in duration of colistin use between the group with AKI and without AKI. Uses of vasopressors were associated with significant increase in frequency of AKI. The average onset of AKI occurred at 5 days since start of treatment.7 patients needed RRT. Among the patients who survived and was on follow up (41/66); 5 patients and 3 patients had raised renal functions at Day 30 and Day 90 respectively. No patient became dialysis dependent. Among the group with prior existing raised GFR; 8 patients (36%) had worsening renal functions on colistin. (S.creatinine increase by 0.3mg/dl) and 2 needed RRT. There was no significant difference between the frequency of CKD.

Conclusions: Patients started on colistin had reversible renal dysfunction and none needed long term hemodialysis.Need for vasopressors and duration of colistin were risk factors.There was no difference in the frequency of worsening renal functions in those with normal GFR and patients with mild renal failure.

128. Clinical spectrum and short-term outcomes of lupus nephritis: Experience from a state run tertiary care centre in southern india

Shashank Shetty, Umesh L, Shivaprasad SM,

Leelavathi V, Sreedhara CG


Department of Nephrology; Institute of Nephro-Urology; Victoria Hospital campus; Bangalore; Karnataka; India

Background: Lupus nephritis (LN) occurs in up to 40-50% of patients with systemic lupus erythematosus (SLE). Renal involvement remains the strongest predictor of morbidity and mortality among patients with SLE.

Aim of the Study: To Study the clinical features and histopathology of patients with lupus nephritis and also to look for risk factors; prognostic markers and short term renal outcomes.

Methods: This study is a ongoing prospective observational clinical study between February 2012 to May 2016. Patients with clinical features of lupus nephritis satisfying at least four of the ARA criteria for SLE. And newly diagnosed at the time of renal biopsy were included. Descriptive statistics; One way ANOVA and Chi square test was applied during analysis.

Results: 100 patients were studied.The mean age at presentation was 27.3±9.8.Majority were females.Arthritis(78%); rash(62%); and fever(68%) were the most common manifestations.Leucopenia (21%); thrombocytopenia (18%); nephrotic range proteinuria (34%) serum creatinine (2.12±1.7); low C3(77%); low C4(38%); eGFR 49.11±15.1; activity index (7.45±11.5); chronicity index (1.56±1.6); serum albumin (2.27±0.70) at presentation. Majority belonged to class IV(76%)lupus nephritis followed by class III(10%); class II(4%); class V (4%)class V+VI(3%) V+III(3%). Majority (53%) presented with an eGFR between >60 ml/min; 10% with eGFR 15-30 ml/min and 8 % patients presented with an eGFR of <15 ml/min. Among outcomes; 41(%) complete remission; (27%) partial remission and (32%) no remission to treatment.Eight patients had crescents in the histopathology and two patients had thrombotic microangiopathy and three patients had APLA syndrome.All achieved only partial remission.Eight patients reached ESRD; with mortality of 10%.

Conclusions: Younger age at diagnosis; low GFR and high serum creatinine at presentation; high activity with chronicity index and classIV±V lupus in histopatholgy were poor prognostic markers.Outcome of patients with standard immunosuppressive regimens is reasonable; but was associated with a high rate of infection.

129. Microbiological spectrum and clinical outcomes in acute pyelonephritis

Aniket N Hase, Ashwini Gadde, Pranaw K. Jha, Shaym B Bansal, Reetesh Sharma, Manish Jain, Siddharth Sethi, Ashish Nandwani, Amit Mahapatra, Vijay Kher


Medanta-The Medicity

Background: Urinary tract infections(UTIs)are one of the commonly diagnosed infection worldwide; spectrum ranges from asymptomatic bacteriuria to systemic sepsis.Gram -ve bacilli (E.coli)are most common pathogens .However recently the major concern is antibiotic resistance.ESBL producing organisms are increasing.This study was conducted to know the current pattern of clinical presentation; risk factors involved &outcomes in present era of multi-drug resistant UTIs.

Aim of the Study: To study Microbiological Spectrum in terms of culture positivity and antibiotic resistance pattern.To analyse Clinical outcomes in terms of deterioriation of renal functions in Acute Pyelonephritis.

Methods: The study was conducted from January 2016 till August 2016. All the patients more than 18 years of age suspected to have acute pyelonephritis being admitted at our center were included. Their demographics details; presenting clinical features; risk factors and baseline renal functions were noted. Laboratory data including hemogram; renal functions; urine analysis; cultures and imaging studies done were recorded. Treatment given and interventions done were noted. Outcomes in terms of recurrences; relapse and renal functions were followed till 1 and 3 months post discharge.

Results: During the study period total 46 patients with suspected pyelonephritis were enrolled in the study. 27(58%) were males and 19(42%) were females. 31(67.3%) were diabetic; 17(36.9%) had history of previous renal calculi; 13(28.2%) had history of obstruction in form of BPH; papillary necrosis or stricture urethra. 13(28.2%) had recurrent UTI while 6(13%) had any previous urological intervention. 26(56.5%) had positive urine or blood culture of which 10 (38.4%)were ESBL producers. Of ESBL producers 3(11.5%) were Carbapenem resistant. Of the complicated UTI 11 (28.9%) had renal calculi; 6(13%) had renal abscess and 8(17.3%) had HUN.Total 14 patients required any intervention.Of these 2 required nephrectomy; percutaneous nephrostomy was done in 9 patients while DJ stenting was done in 3. 24(52%)patients had deterioration of renal function. 3(6%) patients had recurrence of UTI; relapse was seen in 4(8.6%). 5(10%) patients were lost to follow up and 2(4%) death due to UTI associated sepsis.

Conclusions: Incidence of ESBL producing organisms is increasing; with alarming resistance to carbapenems. Significant numbers of patients with acute pyelonephritis were associated with deterioration of renal function on follow up.

130. Analysis of vascular access (VA) in hemodialysis patients- single center experience

Bharti Gupta, Shyam B Bansal, Pranaw Jha,

Aniket Hase, Ashwini Gadde, Amit Mahapatra,

Ashish Nandwani, Reetesh Sharma, Manish Jain, Siddhart Sethi


Medanta; The Medicity

Background: Vascular access(VA) is the key to successful management of chronic hemodialysis(HD) pts.The choice of VA in HD is considered to be arterio-venous fistula(AVF) but still most of the pts are initiated through temporary VA& subsequently undergo permanent VA placement like AVF& arteio- venous graft(AVG).However with increasing period in HD there are complications with these VA & many pts require intervention to correct them. This is a single center experience in same aspect in ESRD patients.

Aim of the Study: Aim of the study is to analyze the vascular acces(VA)s in terms of initial vascular access; the total no of vascular accesses and complications associated with it.

Methods: This is a retrospective study conducted at our institute. All the patient who are on MHD at our centre for more than 3 months were enrolled. Their vascular access (VA) history were retrospectively taken which included the initial vascular access; total no of vascular accesses till enrollment; duration of vascular accesses and complications associated with it.

Results: Total 63pts were enrolled.M:F 38:25.Mean age59±15yrs; median dialysis vintage 16mnth.8 pts(12.6%) initiated through AVF; 23(36.5%)through rt IJV nontunnelled catheter (NTC); 24(38%)with femoral NTC & 8(12.6%)with rt IJV tunnelled catheter(TC).63pts had total of 213VA.Mean no.of VA in pts who were initiated via NTC were4.2; as opposed to 2.6 in tunnelled &2.2 in AVF group.Mean duration of IJV NTC was37.5±28days; 5±5days in femoral; 227±247.9days in TC; 639.3±621days in RC-AVF; 360.1±406days in BC-AVF & 460±391days inAVG.37/46 AVF had complications most common being stenosis(70.2%)f/b primaryfailure(24.3%); thrombosis(24.3%); pseudoaneurysm rupture(5.4%)&steal(2.7%).43/74 TC had complications(linesepsis(100%); thrombosis(18.6%); central venous stenosis(6.9%); delayed fibrosis of cuff(6.9%)_.17/87NTC had complications[Line sepsis(52.9%); thrombosed(47%)catheter].In3AVG ; 1had sepsis &1 required 4times stenting&venoplasty.2pts died during study period; line sepsis being the cause of death in1.

Conclusions: It has been observed that late presentation and delayed diagnosis may lead to most of patient to initate with temporary catheters; which will further increase the burden of another vascular accesess and it is also associated with more complications; morbidity and cost.

131. Risk factors for new-onset diabetes mellitus after living donor kidney transplantation in a tertiary referral center in eastern india - A prospective single center study

Santosh Kumar, Pratik Das, Deepak Shankar Ray,

Rohit Rungta, Deepak Kumar, Shankar Kumar Chatterjee,

Soumava Gupta, Kaustuv Mukherjee, Anupam Majumdar,

Sushma Bala, Nikhil Shinde, Anand Prasad, Sujit Kumar


Rabindranath Tagore International Institute Of Cardiac Sciences; Mukundapur; Kolkata

Background: New onset diabetes after transplantation (NODAT) is a common and serious complication of renal transplantation and is associated with poor patient and graft survival rates. A number of factors affect the development of NODAT such as high body mass index (BMI); calcineurin inhibitors; corticosteroids; old age; family history of diabetes; hypomagnesemia and cytomegalovirus infection. However; data on the risk factors for NODAT in Indian transplant populations are lacking.

Aim of the Study: Analysis of pre-transplant risk factors of NODAT in renal allograft recipients with special consideration on unconventional and newer risk factors.

Methods: We prospectively reviewed patients; who underwent living donor kidney transplantation at Rabindranath Tagore International Institute of Cardiac Sciences; Mukundapur; Kolkata between July 2014 to June 2016. Patients were excluded if they; 1) were younger than 18 years of age; 2) were diagnosed with diabetes before transplantation and 3) developed graft loss or patient loss within 1 month of transplantation. Patients were classified as having a diagnosis of diabetes within 1 year or not. This study was approved by the Ethics committee of our institution.A diagnosis of NODAT was defined according to the American Diabetes Association criteria All patients included in the study group underwent evaluation for the risk factors for NODAT during one year post transplantation follow-up. All pre-transplant risk factors were evaluated at the end of the study to assess their strength of associations. All the above variables further compared with non NODAT post-transplant recipients.

Results: 100 patients were included in the study. Of these; 24%(19 male and 5 female) developed NODAT at 1 year post-transplant. 19(79 %) patients developed NODAT within 3 months of transplantation. There were no statistical differences in sex; polycystic kidney disease; between two groups. Older age; high BMI; family history of diabetes; prediabetics; dyslipidemia were more associated with NODAT.Mean Fasting Blood Sugar on 5th POD(peri-operative hyperglysemia) was 166.92±57.11 mg/dL and 133.83±51.17 mg/dL in NODAT and Non-NODAT respectively (P = 0.00096).Mean Magnesium levels was 1.66±0.27 mEq/L and 1.94±0.46 mEq/L in NODAT and Non-NODAT respectively (P = 0.0057). ABO incompatible transplants were more associated with NODAT(p = 0.0282).In correlation between pretransplant Homeostasis model assessment of insulin resistance (HOMA-IR) and the development of NODAT; the point Biseriel correlation coefficient was + 0.52 and p < 0.001. Higher HOMA IR values in patient who developed NODAT.

Conclusions: NODAT is a multifactorial disease. Besides conventional risk factors the new risk factors like hypomagnesaemia; prediabetes; perioperative hyperglycemia; insulin resistance(high HOMA IR) are also associated with increased risk of NODAT. The newer risk factors can be used for early diagnosis of NODAT.

132. Hiv associated renal disease: Experience from a state run tertiary care centre in southern india

Dr. Shashank Shetty, Dr. Umesh L,

Dr. Shivaprasad SM, Dr. Leelavathi V, Dr. Sreedhara CG


Institute of Nephro-urology; Victoria Hospital campus; Bangalore; India

Background: About 2.3 million people in India were estimated to be infected with HIV in 2009 and the estimated adult prevalence was 0.31 percent. However; data on HIV associated renal disease is sparse.

Aim of the Study: This study focuses on analyzing demographic profile; clinical spectrum and various causes for HIV associated renal disease in our institute.

Methods: A prospective cohort study from july 2014 to july 2016. All inpatients found serologically positive for HIV and patients who were referred to us from various government hospitals for renal dysfunction were included in the study. Renal biopsy was performed whenever indicated.

Results: A Total of 56 patients were evaluated.Among them 46 were males and 10 were females who had a Mean age of 47+_3years.The most probable mode of transmission was sexual route(87.5%).Of fifty six patients 43 (76.72 %) were on HAART regimen.Among them 36 (83.72%) were on tenofovir based regimen.Five patients were diabetic and two had coinfection with hepatits B.Mean proteinuria was 1.28 gm per day. Of all patients 40(71.42%) underwent renal biopsy all Most common renal biopsy finding was acute interstial nephritis 17(42.5%) all of them were on tenofovir based anti retro viral based regimen. Six were FSGS (15%); Four had NOS type and two had collapsing variant.others included; diabetic nephropathy 4(10%); chronic glomerulosclerosis 3 (7.5%); hypertensive nephrosclerosis 3(7.5%)and chronic interstial nephritis 2 (5%)Ig A nephropathy 2(5%); ATN 2(5%)PIGN with cresents 1 (2.5%).Among fifty six; 16 (28.57%) has acute kidney injury; ten had urosepsis; fourhad pneumonia and two had prerenal AKI.

Conclusions: HIV associated renal disease has a wide spectrum. With the advent of newer anti retroviral therapy; acute interstial nephritis was commonly seen especially with tenofovir therapy.However; other glomerular diseases were also seen.Hence; HIV patients with renal dysfunction require detailed evaluvation.

133. Effect of rifampicin on blood pressure control in (end stage reanl stage disease) esrd patients on dialysis: Single center experience

Dr. Ashwini Gadde, Dr. Manish Jain, Dr. Bharti Gupta,

Dr. Ashish Nandwani, Dr. Shyam Bansal, Dr. Pranaw Jha, Dr. Reetesh Sharma, Dr. Amit Mahapatra, Dr. Siddharth Sethi


Medanta-The Medicity

Background: Incidence of tuberculosis in ESRD patients is 10-25 times higher than the general population. In India; the reported incidence have been around 105 per 1000 patient year. Most of the ESRD patients are on multiple antihypertensive medications. Few case reports of accelerated hypertension after addition of rifampicin have been documented. Though the exact cause is unclear; theoretically it was attributed to the enzyme inducer effect of rifampicin. But studies in this aspect of ESRD are few.

Aim of the Study: The aim of the study was to assess the incidence of increase in blood pressure after adding rifampicin. Effect on dose & number of BP meds; & admissions for accelerated hypertension was also studied.

Methods: This was the single center prospective study. All the patients on maintenance hemodialysis at medanta who had been started on rifampicin based antitubercular therapy from May 2015 to July 2016 were enrolled. There previous antihypertensives ; time & indication for ATT were recorded. Blood pressure was monitored regularly on dialysis for duration of maximum 6 months or till the 1month after discontinuation of rifampicin whichever is earlier. Change in antihypertensives in the form of increase in number or dose of antihypertensives and time required for this change were noted. Patients having accelerated hypertension during study period were admitted and there medications were optimized. In patients with difficult to control hypertension; decision of discontinuing rifampicin was taken as per attending nephrologiest's opinion. These events are recorded.

Results: Total 23 pts were included in the study.Most common reason for ATT was TB lymphadenitis(12/23; 52%); followed by empirical ATT for PUO(8/23; 34.7%)& tubercular effusion(7/23; 30.4%).Mean age was 49± 18 yrs; predominantly male(M:F= 21:2). Mean dialysis vintage was 4 months(± 19).All the pts were hypertensive with mean no.of antihypertensives before starting ATT being 2.13(±1.25). 16/23pts(69.5%)had increase in BP from baseline. Mean duration from addition of rifampicin to increase in BP medications was 9.4 days. No. of antihyprtensives were increased from 2.18±1.25 to 4.3±1.7. 9/16 pts achieved control of BP with optimization of antihypertensive. In7/16(43.7%)pts; rifampicin was discontinued. 6 pts achieved BP control after that. During study period; 7(30.4%) pts required total of 8 admissions for accelerated hypertension. After comparing patients with post ATT HTN Vs no HTN group; no significant difference was found between the type of antihypertensives being used before starting ATT.

Conclusions: Significant number of patients had loss of Bp control after addition of rifampicin. In patients with difficult to control hypertension; stopping rifampicin helped which might indicate cause effect relationship. But studies with larger number and details of pharmacokinetics are needed.

134. Kinetics based role of cystatin-c after intravenous contrast for ct scan in adult icu population

Saurabh Chaturvedi 1 , Narayan Prasad 2 , Harshit Singh 2 , Vikas Agarwal 1 , Mohan Gurjar 3 , Akhilesh Jaiswal 2 ,

Ravi Mishra 1 , Pralay Ghosh 3 , Sai Saran PV 3 ;

Dharmendra Bhadauria 2 , Hira Lal 4 , Arvind K Baronia 3

1 Department of Clinical Immunology; 2 Nephrology; 3 Critical Care Medicine; 4 Radiology; SGPGIMS; India

Background: Acute Kidney Injury (AKI) is a common clinical condition associated withhigh morbidity and mortality despite progress in medical care. The goal of early identification of AKI has been the primary impetus for biomarker research. Although AKIN (Acute Kidney Injury Network) criteria; based on Serum Creatinine and urine output; were a step forward in diagnosing AKI; reliable biomarkers to differentiate in clinical practice is still lacking.

Aim of the Study: Cystatin-C has been found early and sensitive marker of AKI; but it has not been evaluated simultaneously in plasma (P) and urine (U) after intravenous contrast in adult ICU patients.

Methods: After ethical approval; prospectively all adult ICU patients with normal renal function; requiring radiographic contrast for computed tomography (CT scan); were considered for inclusion. Exclusion criteria includes: presence of AKI/CKD; recent exposure to contrast within 3 days; and pregnancy. Samples of 5 ml blood and 5 ml urine were collected before contrast exposure and at 04 h; 24 h and 48 hafter contrast exposure. Cystatin-C assay was done by ELISA; and urinary levels normalized as per UCr values for each sample. CI-AKI is defined as a rise in SCr of ≥0.3 mg/dl within 48 hrs.

Results: 16 medical patients with 20 CT scans included. Median age was 36 years and 44% were male. On day of inclusion; median SOFA score 5; 80% on mechanical ventilation; and 30% on vasopressor. Sites of CT scan were abdominal (70%); chest (20%) and head (10%). Incidence of CI-AKI was 20%. Mean values at pre-contrast; 4 h; 24 h and at 48 h after contrast; P Cystatin-C (ng/ml): 1.17±0.53; 1.71±0.47; 1.93±0.45 and 2.14±0.48; U Cystatin-C (ng/mg of UCr):.11±0.12; 0.13±0.10; 0.19±0.09 and 0.22±0.26. After contrast P Cystatin-C levels were significantly increased at 4 h; 24 h and 48 h (p=0.003; 0.001 and 0.002); while U Cystatin-C were not increased significantly at any point of time ((p=0.63; 0.21; and 0.80).

Conclusions: In critically ill adult patients; there is significant increase in P Cystatin-C levels as early as at 4 h and continued to remain high even at 48 h; while U Cystatin-C level does not changes significantly.

135. Influence of initial mechanical complications on peritonitis and other clinical outcome of indian pd patients

Archana Sinha, Narayan Prasad, Amit Gupta, Dharmendra Bhadauria, Anupama Kaul, R K Sharma


Department of Dietetics* and Department of NephrologySanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; India

Background: PD is an established renal replacement therapy that has grown considerably worldwide in the past two decades An important aspect of treatment success in continuous PD is the rate of catheter - related treatment failures. There is paucity of data on effect of initial mechanical complications on clinical outcomes of Indian PD patients where initiation of renal replacement therapy is usually very late.

Aim of the Study: We undertook this study to see the incidence of initial mechanical complications and its effect on peritonitis and other clinical outcomes in PD patients.

Methods: In this prospective observational study; 567 ESRD patients on PD were prospectively followed for mechanical complications. Of the 567 (age 49.8±15 yrs; male 424) patients; 297 were diabetics and 270 non diabetics. Mechanical complications were noted in 177(31.2%) patients [diabetic 33% versus non-diabetic 29.3% patients (P=0.365)].All patients had double cuffed straight Tenckhoff inserted by surgical technique. PD was started after break-in period of 12±2 days. The incidence of mechanical complication and outcome of PD after this complication were analyzed.

Results: Exit site bleeding was seen in 37(6.5%); bleeding from incision site 22(3.9 %); malposition and poor outflow 72(12.7%); different hernias 19(3.4%); pleuroperitoneal communication 6(1.1%); scrotal swelling 2(0.5%); bowel injury in 2(0.4%) ; intestinal obstruction 8(1.4%); and wound dehiscence 8(1.4%). Higher proportion of patients with mechanical complication developed peritonitis (78%) as compared to patients without complications (179/390(45.9 %) P< 0.001). Multiple episodes of peritonitis (≥2 episodes) was also significantly high in patients with mechanical complication 62/138 (44.9%) as compared to patients without complication 20/179(11.2%) p=0.001. Peritonitis rate(episodes/patient-year) in patients with complication was 1.1 as compared to 0.35 without complications. The mean technique survival was 44.4 patient-months (95 % CI 39.1-49.7) in patients with mechanical complications compared to 57.7 patients-months (95% CI 54.9-60.7) in patients without complications (p=0.001).

Conclusions: Both incidence and frequency of peritonitis is common and high in patients with initial mechanical complication. Initial mechanical complication may result into catheter removal and technique failure in such patients.

136. Factors predicting mortality in diabetic peritoneal dialysis patients in india

Archana Sinha, Narayan Prasad, Amit Gupta,

Anupama Kaul, Dharmendra Bhadauria, R.K. Sharma


Department of Nephrology and department of Dietetics *Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow

Background: Diabetes mellitus is the most common cause of end-stage renal diseases (ESRD). Malnutrition is a major cause of morbidity and mortality in the ESRD patients on PD. Survival of the diabetic PD patients is inferior to non diabetic PD patients probably because of higher prevalence of cardiovascular diseases (CVD) and high prevalence of malnutrition associated with diabetes.

Aim of the Study: we undertook this study to evaluate the impact of CVD and other risk factors individually or in combination on mortality in diabetic PD patients.

Methods: 342 PD patients (179 diabetics; 250 male; age 51 14 years) were followed for 22 14 months. All patients underwent assessment of nutritional status; adequacy of dialysis; residual renal function (RRF); peritoneal transport characteristics and comorbid diseases (Davies comorbidity Index).

Results: 87(25.44%) had normal nutritional status; 229 (66.96%) had mild-moderate malnutrition; and 26 (6.7%) had severe malnutrition based on SGA. On Davies Index; 45.6% patients had low risk; 49.1% patients had medium risk and 5.3% had high risk of. On Kaplan-Meier analysis; patient survival was significantly lower in female DM patients compared to other groups. Estimated patient survival (patient months) in diabetic female (27.2) was significantly lower compared to Diabetic male (40); non diabetic female (49) and non diabetic male (59)[p<0.001]. Hazard ratio for risk of mortality in diabetic female PD patients was significantly higher [HR 3.8[CI 0.71-3.12; p=0.001] than diabetic male [ HR 2.7(CI 1.5-4.9); p=0.001] and non diabetic female [HR 1.5(95% CI 0.71-3.1).p=0.293] compared to non diabetic male. On multivariate Cox hazard analysis malnutrition; CVD and GFR were significant factors predicting survival not diabetes. In DM patients; low RRF was independent predictors of mortality.

Conclusions: DM per se was not a risk factor for mortality in this group of PD patients. The higher mortality rate in diabetic PD patients; in particular among female was mainly because of concurrent morbidity such as CVD and PEW; together with low RRF.

137. Ranking of common errors in urban dialysis units

Dr. Virendra Gupta, Dr. Rajesh Kumar, Rachana Jasani, Dr. Mohd Shah Alam, Dr. Jatin Kothari, Dr. Shrirang Bichu, Dr. Viswanath Billa


Apex Kidney Foundation

Background: Small errors in dialysis units can turn into dangerous complications leading to death. Each dialysis unit should adopt to protocols that mandate strict vigilance to establish highest level of patient safety.

Aim of the Study: The main aim of this study was to identify frequently observed errors in dialysis units. The secondary aim was to propose a practical model that can help overcome these errors.

Methods: We interviewed 167 Dialysis Technologists from 16 dialysis units of Apex Kidney Care. Written interviews were conducted by 4 trained dialysis professionals in the period of March to June 2016. A total of 10 broad spectrum categories were enlisted including pre-dialysis; dialysis machine; RO; reprocessing; termination; intra-dialysis; post-dialysis; dialyzer-tubing and patient education based errors and respondents were asked to rank each category. Each broad spectrum category was subdivided to narrow spectrum options and further ranking was carried out. Technicians were asked to rank these options on the basis of their experience with rank 1 being error with highest frequency and rank 10 being least frequency.

Results: Out of 167 respondents; 59% were males and 41% were females. The average age of the technicians was 27 years. The average qualification was Higher Secondary School. 19% respondents had an experience of above 10 years; 14% between 5-10 years; 19% between 3 -5 years and 48% < 3 years. Amongst the broad spectrum errors; on rank 1 was RO plant based errors; rank 2 was reprocessing based errors and rank 3 was patient safety based errors. Least ranking was given to patient assessment based errors followed by patient education errors. Within the RO category; failure to give chemical wash to membrane was given highest ranking. Within the reprocessing category; hitting the dialyzer with harsh objects was given highest rank. In the patient safety category; needle recapping was given highest rank.

Conclusions: As the demand for dialysis is increasing there is a need for Continuous Dialysis Education (CDE) to help Dialysis Technologists upgrade their knowledge and avoid adverse events in the dialysis units.

138. Assessment of dialysis therapy related knowledge in urban dialysis patients

Rachana Jasani, Dr. Rajesh Kumar, Dr. Shrirang Bichu, Dr. Jatin Kothari, Dr. Viswanath Billa, Dr. Virendra Gupta, Dr. Mohd Shah Alam


Apex Kidney care

Background: As against questionnaires on quality of life or patient satisfaction level; patients awareness and knowledge about dialysis therapy have been rarely studied. Self awareness and knowledge are important not only in improving the dialysis outcomes but also to alleviate the rate of hospitalization.

Aim of the Study: To assess dialysis therapy related awareness and knowledge amongst urban dialysis patients. To compare this knowledge across standalone; institutional and charitable centres.

Methods: 985 patients undergoing hemodialysis across 16 centres in Mumbai were interviewed. Amongst them; 356 from charitable (C); 330 patients were from standalone (S) and 299 from Institutional (I) centres. In all there were 30 structured; dichotomous questions including awareness and knowledge about pre dialysis fluid and BP status; dialyzer; vascular access patency; renal profile; vaccination; renal diet; quality of life; dialysis adequacy and renal transplantation. This study was conducted by 26 trained dialysis professionals. An ANOVA test was applied to compare the responses of three categories of centres.

Results: I group had better awareness about pre-dialysis parameters(UF goal-C:.7; S:.7; I:.7; p value=0.03;dialyser type-C:.3; S:.5; I:.7; p value=0.0000) Awareness about high flux dialysis was significantly higher in S group(C:.2; S:.4; I:.3; p value=0.000). I group had significantly better knowledge about hemoglobin (Hb); potassium (K+) and albumin (Hb-C:.6; S:.5; I:.7; p value=0.0000;K+-C:.2; S:.2; I:.5; p value=0.0000;albumin-C:.0; S:.0; I:.1; p value=0.000). Knowledge about dietary sources of K+ was significantly higher in the I group (C:.7; S:.7; I:.8; p value=0.02). However; awareness about increasing the protein consumption once on dialysis was significantly better in S group(C:.6; S:.7; I:.4; p value=0.00000). Knowledge about Hepatitis B vaccination was higher in S group(C:.7; S:.8; I:.6; p value= 0.000). Awareness about cadaver transplant was low (average 47%) in all study groups and that about swap transplant was higher in I group(C:.16; S:.40; I:.59; p value= 0.0000).

Conclusions: Level of awareness of institutional centres was higher in majority of categories. However; in several categories like transplantation; adequacy of dialysis; access patency and vaccinations; the current level of knowledge needs to be improved through continuous patient education.

139. A comprehensive approach with case based correlation of nephrocalcinosis

Dr. Sujit Kumar, Dr. Abhijit Taraphder, Dr. Manish Jain, Dr. Satyaki Dey, Dr. Ayan Dey, Dr. Padmini Sirkanungo, Dr. Tanmay Mukherjee, Dr. Arnab Duari


Apollo Gleneagles Hospital; Kolkata

Background: Nephrocalcinosis is an important condition frequently encountered by nephrologists in their daily practice. It is a clinical condition with significant spectrum of presentation with commonest presentation being incidental USG findings; calcuria; obstructive uropathy; hypercalcemia with AKI or asymptomatic renal dysfunction. It is predominantly a radiological abnormality; albeit defined by raised calcium levels in the kidney. This article addresses this issue with a case based study correlation.

Aim of the Study: To approach a case of Nephrocalcinosis and to attempt an alogrithmic approach.

Methods: A 44 year old male presented with incidental ultrasound finding of nephrolithiasis on routine health check up. Serum creatinine was 1.1 mg/dl; electrolytes like serum sodium; potassium and bicarbonate were normal. Serum Calcium was 8.2 mg/dl with a serum albumin of 3.8 mg/dl. Hb was 12.3 gm/dl with no other abnormalities detected on hemogram. Clinical examination did not reveal any specific findings. He was a vegetarian with no food fads and was not on any medications. There was no significant past medical or surgical history. Hence; 24 hour urine calcium estimation was done which was high at 430 mg/24 hours. Due to this; further workup was undertaken. 24 hour urinary magnesium was normal but citrate came to be low at 220 mg/24 hours. The diagnostic algorithm in this context showed a possibility of medullary sponge kidney. Hyperuricosuria and hyperoxaluria were ruled out. Confirmation was done by an excretory urogram which showed tell tale signs of medullary sponge kidneys (MSK).

Results: Initial radiological confirmation starts the workup with serum calcium assessment.Normocalcemia with hypercalciuria needs serum potassium estimation. Hypokalemia needs ruling out RTA; Liddle's; Bartter's syndrome or loop diuretic use. Normokalemia needs 24 hour urine magnesium & citrate levels which would suggest MSK if hypocitraturia. Hyperkalemia strongly suggests antenatal Bartter syndrome or Hyperprostaglandin E syndrome.If hypercalcemia is noted; then iPTH values are assessed. Raised iPTH necessitates 24 hour urine calcium. Hypercalciuria suggests primary or tertiary hyperparathyroidism. Hypocalciuria points to familial hypocalcemic hypercalciuria. Low iPTH warrants PTHrP & Vitamin D levels. High vitamin D confirms Vitamin D toxicity & low levels suggest milk alkali syndrome or thyrotoxicosis. Hypocalcemia warrants 24 hour urinary calcium & phosphorus estimation. Both being high; points to Dent's or Lowe's disease; but isolated hyperphosphaturia points to rickets & its variants.

Conclusions: This case study shows the commonest presentation of nephrocalcinosis and chalks out a simplified comprehensive algorithmic approach to this important entity. It will help in streamlining the causes and management of nephrocalcinosis. A definite flowchart & algorithm helps in this regard.

140. Spectrum of histopathological findings in renal allo graft dysfunction

Dr. K.Srinivasulu, Dr. K. Praveen Kumar,

Dr. K. Varaprasada Rao, Dr. B. Ashok, Dr. Bhargav,

Dr. Sreedhar


Narayana Medical college Hospital ; Nellore

Background: Renal transplantation is the treatment for patients with ESRD worldwide. In the last few decades the transplant scenario improved due to better surgical techniques; medical care; prevention & treatment of infections & advanced immunosuppressive treatment. Allograft dysfunction is common after transplantation & is due to acute rejection; chronic rejection; CNItoxicity; infections.Renalbiopsy is the gold standard to establish the cause of allograft dysfunction as clinical diagnosis is unreliable.

Aim of the Study: To evaluate the causes of renal graft dysfunction as detected on renal allograft biopsies in renal transplant recepients.

Methods: It is a retrospective review of 55 biopsies from 42 renal transplant patients ; carried out over a period of 2 years . Renal allograft biopsies were performed when there was unexplained graft dysfunction (rise in serum creatinine of ≥ 20% over baseline) and/ or proteinuria; fulfilling the established indications of graft biopsies . Two cores of renal graft tissue are obtained with automated biopsy gun under real-time ultrasound guidance. The histological changes are interpreted and classified according to Banff working classification of renal allograft pathology

Results: A total of 55 biopsies were performed on 42 patients. Males were predominant among the recepients.Regarding pathological lesions acute rejection was seen in 19 (36%) cases followed by acute tubular injury and CNI toxicity ( Tacrolimus ) in 16 (31%) and 4 ( 8% ) cases respectively. Chronic allograft nephropathy (CAN) with variable degree of tubular atrophy was seen in 3 ( 6%) cases. One case ( 2% ) of acute pyelonephritis was detected on graft biopsy. Rare lesions was also found including 2 ( 4%) cases of recurrent /denovo renal disease and 2 (4%) of Polyoma virus infection.

Conclusions: The incidence of acute rejection and acute tubular injury was comparable to many western studies. Recurrent /Denovo renal disease is uncommon in our patients.

141. Intradermal vs itramuscular hepatitis b re-vaccination in non-responsive chronic dialysis patients: A prospective randomized study

Elenjickal Elias John, J.S. Sandhu


Dayanand Medical College and Hospital; Ludhiana

Background: Studies haver shown that 30% of chronic hemodialysis patients fail to produce antibodies to hepatitis B vaccination.Low dose intradermal inoculations and supplementary intramuscular injections have been reported to improve response rates in non responders.

Aim of the Study: To compare safety and immunogenecity of intradermal vs intramuscular re-vaccination in a cohort of chronic dialysis patients non-responsive to a reinforced intramuscular vaccination protocol.

Methods: We re-vaccinated 40 chronic dialysis patients; who did not have any detectable anti-HBs antibody after a reinforced protocol of Hepatitis B vaccine given by IM route; with hepatitis B recombinant DNA yeast vaccine (80 mcg) by intradermal (20 patients) or intramuscular (20 patients) administration (randomly allocated).We used the same amount of HBsAg in order to exclude the confounding effect of the dose on immune response of uremic patients. We studied over 10 month follow up; the persistence of anti-HBs antibodies in our responder vaccines.

Results: 1 month after completion of re-vaccination protocol; seroconversion rates (100% vs 40%; p=0.08) and proportion of patients who elicited protective anti-HBs titres (96% vs 36%; p=0.002) were significantly higher in id compared to im patients.The mean level of anti-HBs titre was significantly more in id than im group ( 96 vs 28 mIU/ml). At month 10 the seroconversion rates were 84 vs 22 % in id and im groups respectively.At month 10; the mean Anti-HBs titres in id patients was higher than that of im group ( 68 vs 16mIU/ml).

Conclusions: Our results show that the unresponsiveness to recombinant yeast derived vaccine may be mostly reversed by repeated low dose id injections.In spite of an equal amount of HBsAg received; id hepatitis B re-vaccination shows higher immunogenicity compared to im administration over 10 month observation.

142. Study of spectrum of clinical and histopathological diagnosis in cases of rapidly progressive renal failure

Neha Jain, Neha Jain, Abhijeet Kumar, D S Rana,

Anil K Bhalla, Ashwani Gupta, Manish Malik,

Anurag Gupta, Vinant Bhargava, Pallav Gupta


Sir Ganga Ram Hospital

Background: Rapidly progressive renal failure (RPRF) is a clinicopathological syndrome characterized by rapid loss of renal function over a period of few weeks. There is a paucity of data regarding the histopathological and clinical findings of such patients from the Indian subcontinent.

Aim of the Study: To study the clinical profile of patients presenting with rapidly progressive renal failure with normal sized kidneys and to study the histopathological findings of such patients.

Methods: This prospective cross-sectional study was conducted between June 2014 and December 2015 at a tertiary center. Consecutive patients presenting with renal failure of recent onset and rapidly progressing over the duration of weeks to less than 3 months with normal sized kidneys on ultrasound examination were included in the study. Pregnant patients and patients who did not consent to the study were excluded. Laboratory investigations were done which included complete blood count; renal and liver function tests; urine routine examination; urine spot protein/ creatinine ratio; HBsAg; anti-HCV; HIV I and II; ANA; C3 and C4 levels; p-ANCA; c-ANCA; anti-GBM titer; ASO titre; PT and aPTT. Ultrasound-guided kidney biopsy was performed in each case. Samples were sent for histopathology for examination by both light microscopy and immunofluorescence staining.

Results: 100 patients were studied; 65 were males. The mean age was 44 ± 15.5yrs(16-71). 72% patients had hypertension and 13% diabetic. Mean S. Creatinine was 5.0 mg/dl. Proteinuria was seen in 83% and nephrotic range proteinuria in. On histopathology; glomerular disease was seen in 65%; tubulointerstitial disease in 27%; plasma cell dyscrasias in 5% and thrombotic microangiopathy in 3%. Histological diagnosis was not significantly associated with age; gender; gross hematuria; fever; joint pains; malar rash and oral ulcers. However; it significantly correlated with oliguria; edema; and hypertension (p-value < 0.05). ANA was positive in 10% and in 66.7% of lupus nephritis. 78% cases of lupus nephritis had low C3 and C4 titers. 57% of C3 glomerulonephritis had low C3 levels. p-ANCA was positive in 8(57%); c-ANCA in 2 (14%) and both c and p-ANCA in 1(7%). ANCA positivity; ANA positivity and low C3; C4 levels did not have a significant correlation with the histological diagnosis.

Conclusions: dsvf;HFV;khv

143. Body composition analysis in predialysis chronic kidney disease - A longitudinal study compariong dual energy absorptiometry (DXA) and anthropometry

Dr. Avinash Kumar Dubey, Dr. P S Priyamvada,

Dr. Jayaprakash Sahoo, Dr. Sreejith Parameswaran,

Dr. Satish Haridasan


JIPMER; Puducherry

Background: Malnutrition is common in predialysis CKD which needs serial monitoring of body composition; as conventional markers are often unreliable.DXA is the gold standard; but costlier and availability is restricted. Anthropometry with skinfold thickness (SFT)is less expensive and quicker alternative to DXA; which can be done in outpatient clinics. There is a lack of longitudinal studies on nutritional indices & body composition in pre-dialysis Chronic Kidney Disease (CKD ) in Indian patients.

Aim of the Study: 1. To assess the reliability of SFT compared to the gold standard DXA to assess body composition over a period of six months in patients with predialysis Chronic Kidney Disease.

Methods: Sixty-two clinically euvolemic patients with stable renal function with CKD stage 3 & 4 were recruited from outpatient clinics by systematic random sampling.Patients with edema; chronic liver disease; CCF ; HIV; Malignancy and solid organ transplants were excluded .All patients received nutritional advice from renal dietician; prior to enrollment . The clinical; anthropometric & biochemical indices of malnutrition were documented at entry and six months. DXA was done at baseline and six months. All patients were subjected to measurement of skinfold thickness with a slim guide skin fold caliper at entry and end of 6 Months. The mean value of three consecutive measurements was taken. Body density was calculated using Durnin-Womersley equation; and the value was converted to body fat percentage using the Siri equation. Agreement between DXA and SFT at baseline and six months were assessed by paired t-test; intra-class correlation coefficients (ICC) and Bland -Altman plots.

Results: The study cohort comprised of 35 patients with CKD 3 & 27 patients with CKD 4.Sixty five percent were males. The mean e-GFR at entry was 32.2 ± 11.47 ml. There was a significant reduction in creatinine; e GFR and Hb over six months (p <.001). There was a non-significant decrease in weight; albumin levels; and fat-free body mass measured by DXA and SFT at the end of 6 months compared to baseline. SFT significantly underestimated body fat compared to DXA. The inter-method difference of DXA vs. SFT at baseline was 3.51± 3.64 ( P<.001). After six months the inter-method difference between DXA vs. SFT was 3.82 ± 3.21;( P <.001). Both DXA and SFT showed excellent correlation at baseline and six months. The ICC of DXA and SFT at baseline was .875; and regression plots showed an R2 of .80. At six months the ICC was .871 and R2 was .863. The Bland- Altman plots also showed similar inter-method differences . Similar results were obtained when the analysis was stratified by gender.

Conclusions: Body fat measured by SFT by a Slim guide skin fold caliper shows good correlation with body fat measured by DXA over a period of time . SFT can be used as a reliable alternative to DXA to assess changes in body composition in predialysis patients with chronic kidney disease.

144. Rituximab for treatment of steroid resistant nephrotic syndrome

Shri Ram Kabra


Sarvodaya hospital; Faridabad

Background: Amongst idiopathic nephrotic syndrome; 40% show steroid dependence (SDNS) and 10 to 15% are steroid resistant (SRNS). There are very limited therapeutic options for such patients. There have been case reports of remission achieved with Rituximab in Steroid dependent and steroid resistant nephrotic syndrome. KDIGO guidelines recommend its usage only in steroid dependent nephrotic syndrome.We share our experience of Rituximab usage in 9 patients with steroid resistant nephrotic syndrome.

Aim of the Study: Retrospective analysis of SRNS and SDNS patients receiving Rituximab after being adequately treated for more than 2 years with multiple medications including Prednisolone; CNI and alkylating agents.

Methods: Last 1 year records of patients with SRNS and SDNS who became unresponsive to steroids; CNI and alkylating agents during their treatment who were then treated with Rituximab were reviewed. The minimum follow up was 5 months and maximum was 8 months. All the patients were administers 4 weekly doses of 375mg/m2 . All received prednisolon in tapering doses. CNI were stopped after first dose of Rituximab. Records of renal functions; serum proteins; CBC and urine protein creatinine ratio monitoring was done during the therapy every week. Urine protein creatinine ratio was measured once every month after the last Rtuximab dose. Remission was defined as complete (Up/Uc <0.2) or partial (Up/Uc between 0.2 and 2; serum albumin >2.5 g/dl; and no edema). No response was the presence of nephrotic range proteinuria (Up/Uc >2); serum albumin <2.5 g/dl; or edema.Proportion of patients who achieved complete and partial remission were calculated. Percentage and time to relapse was analyzed.

Results: 6SRNS and 2 SDNS with secondary unresponsiveness to steroids between ages 10 and 57 years who were administered 4 dosesof Rituximab were retrospectively analyzed. Histopathology of 5 SRNS was FSGS and one was MGN. One SDNS was FSGS and other MCD. Five out of six (5/6) SRNS had complete remission (CR) which was observed between 2nd and 4th week after last dose of Rituximab. One SRNS had partial remission (PR) with >50% reduction in proteinuria at 1 month post therapy. Both (2/2) SDNS had remission by 2nd week post therapy. In a follow up between 5 to 8 months; none with CR showed rise in proteinuria beyond 300 mg/day. CNI was stopped at the start of Riuximab therapy and steroids tapered to minimum dose. All the patients were maintained on Prednisolone 5 mg on alternate days during follow up. One patient developed Herpez Zoster after the first dose. Rituximab was re started after Zoster was cured. Rituximab infusion was well tolerated. CD 19 monitoring was not done in any.

Conclusions: These observations confirm the efficacy of Rituximab in difficult to treat nephrotics. CR was achieved in 7/8 & 1/8 had PR. Contrary to the conventional recommendation using Rituximab in SDNS only; it worked well in SRNS as well. This needs to be further investigated with larger prospective trials.

145. Related but not matched; matched but not related: conundrums of hla typing for proving relationship

Ajay Kher, Pranaw Jha, Vijay Kher


Fortis EscortsMedanta-Medicity

Background: HLA typing is also used in India for proving relationship. With continuing presence of organ trafficking despite laws and use of HLA typing for proving relationship; it is important for the transplant physician to recognize the limitations of HLA typing for this purpose. Organ traffickers can use knowledge of HLA typing to hoodwink transplant physicians and programs into transplanting unrelated donors who are presented as related donors.

Aim of the Study: To show limitations of HLA typing in proving relationship by presenting two cases: who present as brothers; one of whom is related but not HLA matched and one that is HLA matched but not related.

Methods: Case 1: A 30 year old man with ESRD from Nigeria with his brother to undergo renal transplant. HLA typing (A; B; DR) had one match for A and B but not DR. Y chromosome analysis as well as HLA C; DQ and DP typing was done; their relationship was confirmed and transplant performed Case 2: A recipient and his brother as donor appeared to be a haplotype match with only 1/6 mismatch. However; some red flags were raised when the recipient and donors father would not let the donor speak during his interactions with the transplant coordinator. On further assessment it was found that there was significant difference in the level of education between the brothers. Hence; additional HLA typing was done with the father and and mother and the haplomatch was found not to be a haplotype match and the supposed brother was found not to be related and the transplant was cancelled.

Results: Case 1 HLA typing: Recipient: A 2; 23 B 42; 49 C 7; 17 DRB1 8; 9 DQA1 3; 5 DQB1 2; 3 Donor A2; 33 B 15; 42 C 3; 17 DRB1 3; 13 DQA1 2; 5 DQB1 2; 2 This shows that a crossover happened and a 1 haplotype match was transformed and a new haplotype created. Crossovers happen between HLA A/B at a rate of 5/1000 and between B/DRB1 at 7/1000 and hence this may make related people appear not matched.Case 2 HLA typing. Recipient A 2; 26 B 7; 40 DRB1 11; 15Donor A 2; - B 40; - DRB1 1; 15.Father A 2; 24; B 27; 40 DRB1 4; 11Mother A 2; 26 B 7; 27 DRB1 11; 15This shows that the donor is not the son of the parents while the recipient is. It shows that if someone knows that HLA typing will be only done between donor and recipient they can find unrelated donors who match recipients and make them appear related to hoodwink physicians and transplant programs to get a transplant done.

Conclusions: HLA typing has limitations in its use for proving relationship and these need to be understood. Organ traffickers may use HLA knowledge to find unrelated donors who match recipients and present them as related donors. It may be time to switch to DNA testing or high res typing.

146. A study to compare the kt/v by daugirdas 2 formula with other bedside formuale in hemodialysis patients

Dr. Praveen Nallamothu, Sarat Chandra,

Chaitanya Vemuri, Sangeeta Lakshmi,

Hari Krishna Reddy, Anil Kumara Venkata,

Sandeep Peddi, Ram Rapur, Siva Kumar Vishnu Botla


Sri Venkateswara Institute of Medical Sciences

Background: Dialysis dose plays a key role in determining the longevity on dialysis. We wanted to test the gold standard daugirdas 2 formula with various short cut bed side formulae and to see whether these bedside forumale based methods can predict the dialysis adequacy/not .

Aim of the Study: To evaluate the bedside short cut simplified formulae by comparing with daugirdas2 formula and to test the precision and accuracy of these bedside methods.

Methods: Nine bedside formulae for calculation of kt/v urea were compared with daugirdas 2 formulae in a 1 month long study involving 294 dialysis sessions in 98 patients of a single centre in patient hemodialysis unit at srivenkateswara institute of medical sciences hospital.

Results: For patients with daugirdas 2 kt/v < 1.4 (median = -1.17 ; n=94 ); simplified formulae had a difference (delta) of 0.082 - 0.284 . from the daugirdas 2 formula ; resulting in an inter-method variability ranging from 12 to 52 %.The least difference was seen with calzavara formula (p= non significant ); maximum difference with the jindal formulae P <0.05.No statistically significant differences were when comparing daugirdas 2 with daugirdas 1 ; keshaviah for patients with kt/v <1.For patients with the highest Daugirdas 2 kt/v values ( >1.4 median ; n=4 ) all simplified formulae gave kt/v values lower than daugirdas 2 .; the minimum difference was seen with barth formula ; (p= ; inter method variability of %)and the maximum was seen with calzavara formula .there was no statisticall significant difference between kerr and basille methods.

Conclusions: The best correlations were seen with the daugirdas 1 formula( r2 =0.756 ). Using non logarithmic bedside formulae can be time saving often lead to errors in dialysis dosing .Finally no bed side formulae had the accuracy of daugirdas2 kt/v.

147. A case report of lupus vasculitis with c anca positivity

Dr. Praveen Nallamothu, Dr. Sarat Chandra,

Chaitanya Vemuri, Hari Krishna Reddy, Anil Kumar, Sangeeta Lakshmi, Sandeep Peddi, Ram Rapur,

Svia Kumar Vishnubotla


Sri Venkateswara Institiute Of Medical Sciences

Background: Systemic lupus erythematosus (SLE) and small sized vessel vasculitis are two well defined clinical entities.There are very few case reports of systemic lupus erythematosus overlapping with c-anca posotive vasculitis decribed till now int he literature.

Aim of the Study: TO elucidate the severity of presentation and its worse prognosis despite the best possible treatment in a patient of systemic lupus erythematosus with canca posotive vasculitis.

Methods: A 55-year-old woman was admitted for complaints of both for 3 months; easy fatigue with exertional breathlessness and reduced urine output for 3weeks. She had repeated episodes of hemoptysis during this period. Investigations were suggestive of serum creatinine: of 7.4 mg/dl withserial fall in haemoglobin from 9.8 mg/dl to 7.7 mg/dl ; PO2 70% on arterial blood gas analysis . HRCT thorax was suggested bilateral lower lobe consolidation with pulmonary haemorrhage. On bronchoscopy there was bleed from right lower lobe. She had anti dsDNA- positive with more than ANA 2+ positive ;5 fold rise in anti ds dna antibody titres; speckled pattern; CANCA positive 57( <15 u/ml); PANCA 5.7( <15 u/ml) ; C3 low- 26.9 mg/dl( R.R-90-180) and C4 low < 6.5 mg/dl(R.R - 10-40); direct coomb's was 2+ positive; lupus anticoagulant positive .

Results: Renal biopsy was suggestive of diffuse proliferative sclerosing glomerulonephritis with cellular to fibrocellular crescents in 4 out of 6 glomeruli and a concomitant focus of acute necrotisng vasculitis of a medium sized interlobular artery; IF- granular deposits of IgG on the capillary walls 1+ to 2+ . Focal trapping of IgM in a glomerular tuft; focal granular mesangial c3 deposits 1+. classIV; with a final impression of crescentic glomerulonephritis; activity score being 21out of 24.She was treated with 3 doses; 500 mg of iv pulse methylprednisolone; 1 dose 500mg of iv cyclophosphamide; 6 sessions of plasmapheresis and intravenous imminuoglobulin 30 grams in 5 divided doses . Despite these efforts the patient continued to have recurrent episodes of hemoptysis with respiratory failure requiring artificial ventitlatory efforts. ; but finally could not be revived.

Conclusions: We stress here that a patient of systemic lupus erytemtosus; lupus nephritis; with vasculitis; positive for c-ANCA had severemanifestations; dismal prognosis despite extensive treatment.

148. Cuff based central aortic blood pressure measurement in CKD-Utility and advantages in office practice

Dr. Abhishek Dixit, Dr. Hardik Shah, Dr. Ashok Kirpalani, Dr. Dilip Kirpalani, Dr. Krishna Somani, Dr. Shyam Devikar


Bombay Hospital; Mumbai

Background:•Central & Brachial systolic BP simultaneous estimation is a simple method of assessing aortic stiffness.•High Brachial BP patients obviously have or will have in future development of atherosclerosis and therefore will need aggressive medical intervention and are easily identified.•Patients who are at target BP on treatment or pre hypertensive on Brachial blood pressure monitoring are the ones that need early identification of arterial stiffness.

Aim of the Study: To• assess the clinical profile and identify subpopulation of CKD patients in whom central blood pressure measurement would provide additionally essential and relevant information.

Methods: Using PULSECOR device; 500 CKD (stage 1-5) patients (pts) underwent Brachial BP measurement by Oscillometry technique and Central aortic BP measurement by suprasystolic oscillometry technique. Relevant data was recorded.

Results: Mean Age:50.8 + 11.6 years;M:F=315:185; Mean BMI: 26.3 + 4.3 kg/m2. Mean Brachial Systolic BP [BSBP]:126.3 +11.2 mmHg; Mean Central Systolic BP [CSBP] : 114.7+9.7 mmHg. In younger (Age<50; n=250); diabetics(n=173) & obese (BMI>25; n=290) pts; Delta (i.e. Mean BSBP-Mean CSBP) was 8.1; 7.8 and 6.1 respectively which was statistically significant as compared to Older (Age>50; n=250); nondiabetics(n=227) & those with BMI<25(n=210) {Delta: 12.1; 12.4 and 10.8 respectively}. Pts on betablockers (n=195) had significantly higher CSBP(125.3 +6.8 ) than those not on betablockers (n=305;CSBP- 108.4 + 7.2).Pts on RAS blockers (n=127)had lower CSBP (106.6 + 6.9) as compared to those not on them (n=373;CSBP-123.2 + 9.4).In hypertensives (BSBP>140 mmHg; n=118) & "normotensives"(BSBP<120; n=207);CSBP was appropriately high(133.6 +9.8) and normal (133.6 +9.8) respectively; but in the "pre-hypertensives" & "well controlled" hypertensives (BSBP :120-139; n=175); mean CSBP was inappropriately high (120.3+6.6).

Conclusions: In CKD patients with BSBP at target; the CSBP may be high(Δ <10) indicating arterial stiffness•CSBP was higher in Diabetic; obese & younger CKD pts•Pts on beta-blockers with "target" BSBP had paradoxically high CSBP•RAAS blockers lowers CSBP more effectively•Hence CSBP evaluation is recommended.

149. Predictors of short term outcomes in renal allograft recipient's:a prospective study

Elenjickal Elias John, J.S. Sandhu, P.M. Sohal,

B.S. Aulakh


Dayanand Medical College and Hospital; Ludhiana

Background: Over the last 2 decades there has been a tremendous improvement in short term outcomes of renal transplant patients. Various studies have linked various donor and recipient factors with graft outcomes.Donor factors playing contributory roles include donor age; sex; basic disease; dialysis vintage; CMV status.Other factors include induction therapy; compliance to treatment; rejection episodes etc.

Aim of the Study: Primary outcomes:6 month and 1 year patient and graft survival.Secondary outcomes: Prevalence of DGF; NODAT; post transplant infections; PTLD; Polycythemia. Donor & recipient factors affecting outcome.

Methods: All patients undergoing live related renal transplantation at our institute between January 2015 to June 2016 were included in this study.A detailed history regarding baseline donor and recipient factors was taken.All patients were followed prospectively for a minimum of 6 months duration.A detailed record of primary and secondary outcomes were made.Graft biopsies were done whenever indicated and classified as per latest BANFF classification.

Results: A total of 96 live related transplants were done between the specified time period.Mean duration of follow up was 9 months and 6 patients lost to follow up.At 6 months graft survival and death censored graft survival was 96% and 98%.At 1 year graft survival and death censored graft survival was 96% and 94%.A total of 24 graft biopsies were done of which 12 were cellular rejection; 6 AMR; 4 ATN and 2 BK virus nephropathy. Prevalence of Delayed graft function was 8.5 %; NODAT 12%; polycythemia 6.4%.Post transplant infections occurred in 18% of patients of which UTI followed by fungal infections were most common.1 patient developed gastric Maltoma.Donor factors associated with poor graft outcomes were advanced donor age (p value 0.02) and female sex (p value 0.02).Recipient factors associated with poor outcomes were Diabetes Mellitus (p value 0.02) and prolonged dialysis vintage (p value 0.04).Other factors associated with poor outcomes are rejection episodes and CMV.

Conclusions: Our study showed excellent short term patient and graft outcomes.Patients with poor graft outcomes were advanced donor age; female sex; basic disease of diabetes; prolonged dialysis vintage; rejection episodes and CMV infection.

150. Knowledge; attitude and practices of relatives/spouse(s) of patients with esrd towards organ donation

CS Aggarwal, OP Kalra, A Raizada, S Agrawal


University College of Medical Sciences (Delhi University); Delhi

Background: A strong relationship between knowledge & organ donation has already been established. Majority of the patients with ESRD do not receive any RRT.In the absence of a well-organized deceased donor program; living donors constitute the major donor source.With this premise; a cross sectional study was done to assess the knowledge; attitude and practices(KAP)in immediate blood relatives and spouse(s)of ESRD patients and to assess the factors influencing KAP.

Aim of the Study: To assess KAP relating to organ donation in immediate blood relatives/spouse(s) of patients with ESRD To identify factors that may persuade/dissuade an individual to donate an organ.

Methods: The study was conducted in the Department of Medicine (Division of Nephrology) at UCMS and GTB Hospital. The total duration of study was from November 2014 - April 2016. It was a cross sectional study. Considering a figure of 60% who have knowledge about kidney donation and 62% who have a positive attitude towards donation; to estimate an absolute difference of 5% on either side in knowledge and attitude at α = 5%; a sample of 370 subjects was required. A total of 379 subjects were recruited from the immediate blood relatives / spouse(s) of 238 ESRD patients. A pre-designed questionnaire was initially pre-tested in blood relatives/spouse(s) of 15 patients with ESRD and inputs received after the pre-test were incorporated in the final questionnaire. Assessment of factors influencing the KAP was done using Pearson Chi-Square test. Further evaluation of variables with a significant p value was done using multiple logistic regression analysis.

Results: 91.8% attendants had heard about organ donation.67.5% had knowledge about organ donation which was significantly associated with the relationship with patient [spouse (p=.001); son (p=.005)]; education status [graduates and above (p=.001)] and higher socioeconomic status (p=.004). 50.6% had positive attitude towards organ donation which was significantly associated with gender [females (p=.002)]; relationship with the patient [mother (p=.0254); spouse (p=.001); son (p=0.02)] and the number of dependants (6-8 (p=.04)). 41.2% subjects had positive attitude towards practicing organ donation which was significantly associated with marital status [Single (p=.04)-more motivated]; education status [graduates and above (p=.001)].

Conclusions: More knowledge about organ transplantation can be transformed into better attitude which can lead to increased number of organ donations. More and more people should be educated and made aware of the importance of organ donation.

151. Endovascular management of a giant arteriovenous fistula following kidney biopsy in a renal donor

Dr. Mahajan Sameer Ashok, Dr. Prakash K. C,

Dr. Doshi Manan, Dr. Satheesh Ramamurthy


Apollo Hospitals; Chennai

Background: Most common complications of renal biopsies are gross hematuria; perirenal hematoma and arteriovenous fistulas(AVFs). In these; AVFs are mostly of good prognosis and usually disappear spontaneously. Selective embolisation is one of the treatment of choice in post renal biopsy AVFs. The issue is highly relevant for transplant patients; as they are biopsied much more frequently. Another consideration; not well discussed in literature is safety of biopsy in a patient with native solitary kidney.

Aim of the Study: We report a case of a large post renal biopsy arteriovenous fistula managed by endovascular embolization in a patient with a solitary kidney after renal donation.

Methods: We report a case of a large post renal biopsy arteriovenous fistula managed by endovascular embolization in a patient with a solitary kidney after renal donation. He was detected to have chronic kidney disease after 7 years of renal donation. Renal biopsy of the solitary kidney revealed focal and segmental proliferative glomerulonephritis. Following biopsy; he developed hemodynamically relevant intrarenal AV fistula which would need treatment. The technical difficulty in this case was the large size of the fistula and the chronically dilated AV communication of approximately 1.3cm size which was large enough to preclude the usage of the gel foam or coils considering high likelihood of displacement. An amplatzer vascular plug; a relatively novel device has the advantage of being available in large diameter and the ability to recapture and redeploy till satisfactory position is confirmed. Hence; an Amplatzer vascular plug type 2 size 18mm was used for embolisation.

Results: Post embolisation angiogram showed complete obliteration of the fistula with patent posterior division supply.On follow up; he had a mild rise in the level of azotemia with serum creatinine level increased from 2.2 to 2.6 mg/dl; possibly due to contrast nephropathy which later resolved to 2.2mg/dl. Repeat Doppler study 24 hours after the procedure confirmed the position of the vascular plug and absence of flow into the venous sac. His renal function is stable with latest serum creatinine value being 2.0mg/dl and 24 hours urine protein excretion being 0.86gm/day on 15/07/2016; approximately 6 months after the procedure.

Conclusions: This is a case of a large post renal biopsy AVF in a patient with a solitary kidney after renal donation. It is unique due to co incidence of existence of CKD in a post renal donor and development of hemodynamically significant AVF after renal biopsy; needing endovascular embolisation.

152. Drug induced severe hyperkalemia requiring temporary cardiac pacing and dialysis - A case series

Dr. Muzafar Maqsood Wani, Dr. Ajaz A Lone,

Dr. Imtiyaz A Wani, Dr. Khurshid A Banday


Department of Nephrology and Cardiology; SKIMS; Soura; Srinagar; Kashmir

Background: Many elderly patients are on cardio/reno protective medications (ACEIs; ARBs; β blockers and K sparing diuretics); which may precipitate or worsen hyperkalemia in them. Given its potential life threatening nature; identifying patients prone to develop hyperkalemia is imperative. Rarely emergency temporary cardiac pacing may be required to thwart cardiac arrest while potassium is being lowered.

Aim of the Study: To assess patients admitted with severe hyperkalemia who required temporary cardiac pacing in addition to the treatment to decrease serum K.

Methods: We describe the profile of 26 patients from among more than 1100 patients admitted because of hyperkalemia over a three year period who; besides medications and dialysis; needed temporary cardiac pacing.

Results: The mean age of these 26 patients (17 males; 9 females) was 64+/- 11 years. Twelve patients (46%) were diabetics. On admission; the mean serum potassium was 6.7 ±1.4 mmol/L; mean serum creatinine was 2.8 ± 1.6 mg/dL; mean arterial pH was 7.1 ± 0.5 and the mean plasma bicarbonate was 12 ± 4 mmol/L. The main causes for acute kidney injury (AKI) and hyperkalemia were dehydration (n = 14) and worsening heart failure (n = 7) with concomitant use of ACEIs ; ARBs ; β blockers; K sparing diuretics either alone or in combination. The patients in the drug induced hyperkalemia group who required pacing were elderly; had been on a combination of K elevating medications and had worsening of their renal functions. Twenty two patients received peritoneal dialysis; two hemodialysis; while two received both. Six patients were admitted to the intensive care unit; two of whom died. The duration of hospitalization ranged from 1-12 with a mean of 7 days.

Conclusions: K elevating drugs should be considered with caution in elderly patients with renal insufficiency; diabetes mellitus or worsening heart failure or are at risk for dehydration. In places with limited availability of emergency HD; peritoneal dialysis is an effective alternative for lowering serum K.

153. Prevlaence of depression and its relationship to quality of life in hemodialysis patients

Dr. Borse Manmohan, Dr. Padmavati, Dr. M Sivalingam


Sundaram Medical Foundation; Dr Rangrajan Memorial Hospital; Chennai 600040

Background: Prevalence Rates of depression varies in different studies from 18% to 72% in patients with ESRD; undergoing hemodialysis. There is existing literature with number of studies assessing the prevalence of depression in ESRD patients on hemodialysis from other countries but there is paucity of such data from our country. The present study was therefore undertaken to evaluate the actual prevalence of depressionin ESRD patients on hemodialysis and its impact on quality of life.

Aim of the Study: The aim of the study is to determine the prevalence of depression and its impact on quality of life in patients with end stage renal disease (ESRD) on hemodialysis (HD) in two community hospitals.

Methods: It is a hospital-based Prospective cross-sectional observational study done at two hospitals. Patients >18 years of age and who were on hemodialysis for more than 3 months were recruited. Patients were asked to complete Beck Depression Inventory-II (BDI-II) and Short Form-36 (SF-36) self questionnaire to assess depression and quality of life respectively. Data entered into a constructed proforma. Mean and standard deviation was calculated for age; BDI-II and SF-36 scores. Test of significance- Chi-square test was used for comparison of categorical variables and the student t-test was used for comparison of means. Correlation was assessed using linear correlation by calculating Spearman's correlation coefficient. Also one sample t- test was done to correlate BDI-II and SF-36 scores. 'p' value less than or equal to 0.05 was considered statistically significant.

Results: The total of 143 patients with ESRD on hemodialysis was recruited. 67% (96) were male and 33% (47) were female. Mean age was 26±5 years. 63% were studied till higher secondary school; 8% were post graduates. 29% had history of alcohol or smoking and 16 of these patients had used both. 21% had both diabetes mellitus and hypertension.Majority of our patients (59%) had hypertension. Twenty six patients (18.2%) met with the criteria for depression as evidence by BDI ≥16.The mean BDI score in depressed group was 18±2 and 5.1±3 in non-depressed group. Depression was significantly prevalent in post graduates (p:.036) and in patients who had history of alcohol and smoking (p:.034) The total SF-36 score was statistically significant low in depressed patients as compared to non depressed patients. (p: <0.001).Spearman's correlation coefficient (R-linear- 0.417)was significant and it showed that patients who have high BDI-II score their SF-36 score is low.

Conclusions: The prevalence of depression in our patients with ESRD on hemodialysis was 18.2%.Depression was associated with decreased quality of life. There was strong inverse correlation between the degree of depression and the quality of life; which was highly significant.

154. A rare but emerging infection among diabetic population in South India

Sheik Sulthan Alavudeen, Abeesh P, R.P. Senthil Kumar, Sanker. P, Vasudevan. C, Balraman.V


Government Kilpauk Medical College; Chennai

Background: Melioidosis formerly called pseudo glanders disease caused by the gram-negative bacterium  Burkholderia pseudomallei Scientific Name Search s endemic in Thailand and Australia but may be under-diagnosed and under-reported in the Indian subcontinent. In the recent past there has been increase in reporting of this disease in south India especially in the south-western coastal belt of India.

Aim of the Study: To report cases of melioidosis among diabetic foot patients..

Methods: We have retrospectively collected 3 cases of melioidosis in diabetic foot patients who have treated at our centre.

Results: We had 3 culture proven cases of Melioidosis at a tertiary care hospital in Chennai between August and December 2015.All were admitted during heavy rainfall season.Patient age varied from 49 to 61 years with a median age of 55.3 years. All three patients were males and from rural areas. Two of them were alcoholic.Fever was the presenting symptom (100%) and mean duration of symptoms was 1.21 months before diagnosis. Two of them presented as disseminated disease with the one patient had localised disease in the form of septic arthritis. All of them were treated successfully on follow-up; with a regimen of IV ceftazidime followed by oral doxycycline and cotrimoxazole.

Conclusions: Melioidosis is an emerging infection in south India from rural areas; with diabetes and alcoholism being the commonest risk factors. As there was an excellent response in these patients; early suspicion; culture confirmation and therapy is warranted.

155. Hyperkalemia in post renal transplant and chloride shunt mechanism

Dr. V. Nagendran, Dr. Abeesh P, Dr. Balaraman.V,

Dr. Vasudevan C, Dr. Sheik Sulthan Alavudeen


Department of Nephrology; Kilpauk Medical College and Hospital; Chennai

Background: Hyperkalemia is commonly encountered in patients who receive a renal transplant and the immunosuppressive drug cni.Hyperkalemia also resistant to treatment.Need evalution for diagnosis of causes hyperkalemia and probable mechanism responsible.

Aim of the Study: To find most possible mechanism linked with post transplant hyperkalemia caused by CNI.

Methods: Step 1-to calculate ttkg for given patient; step 2-followed with fludocortisone 100 microgram 4 hours later then to calculate again ttkg.If inappropriate response to aldosterone. Step 3- ttkg calculated again followed with azetazolamide 250 microgram.To calculate ttkg again to see response.

Results: To test this hypothesis chloride shunt mechanism as possible cause hyperkalemia; total 3 patient where studied.Prior calculating ttkg.All drugs causing hyperkalemia where withheld.The rise in the rate of excretion of potassium and the ttkg that occurred when sodium was delivered distally with bicarbonate suggests the inappropriate renal response to hyperkalemia and tubular insensitivity to mineralocorticoids may be due in part to an inability to generate a favourable electrical chemical gradient in a cortical distal nephron in absence of bicarbonaturia or to an direct effect of bicarbonaturia over apical membrane k+ channels.Hence chloride shunt mechanism is possible reason for hyperkalemia.

Conclusions: Hyperkalemia caused by cni is resistance to aldosterone; following bicarbonaturia potassium reduced. Hence chloride shunt mechanism mostly likely reason for hyperkalemia was proved.

156. Frailty in non-dialysis-dependent chronic kidney disease

Dr. Luv Bansal, Dr. Alpana Raizada, Dr. Rahul Sharma, Dr. Amitesh Aggarwal, Dr. Rajarshi Kar, Dr. Ashish Goel


University College of Medical Sciences (Delhi University); Delhi-95

Background: Frailty is defined as vulnerability to adverse outcomes. Its correlation with chronic diseases like CVD and CKD is well established. The prevalence of frailty in non-dialysis-dependent (NDD) CKD patients approaches 14-15% compared to 6-7% in general geriatric population. There is lack of literature on prevalence of frailty and its associations in NDD CKD patients in Indian subcontinent which is a potential group in which recognition of frailty may decrease the risk of adverse clinical outcomes.

Aim of the Study: To study the overall occurrence and difference in proportion of frailty between different groups of NDD CKD patients and the association between the number of deficits in health and eGFRcr and UACR.

Methods: This was a cross sectional study conducted on 90 NDD CKD Stage 1-4 patients aged 18-65 years receiving tertiary hospital care. They were divided into 3 groups of 30 participants each based on their eGFRcr calculated by CKD-EPI equation and micro-albuminuria assessed by spot UACR. A detailed case record form assessing personal profile; psycho-social profile; depression; clinical profile; Fried's frailty; MMSE; Barthel's ADL; WHO QOL and deficits in health was used. Frailty was assessed using modified Fried's frailty criteria by Wilhelm Leen and deficits in health was calculated using a list of 74 deficits based on the study by Searle et al. The occurrence of frailty and proportion of frailty in various CKD groups was calculated. The association of Fried's frailty withCKD groups; age; sex; BMI; marital status; financial status; family type; depression; MMSE; Barthel's ADL; WHO QOL and deficits in health was studied using appropriate statistical tests of significance.

Results: The study consisted of 51 females and 39 males and the mean age of participants was 49 years. The occurrence of Fried's frailty was 21.1% while 43.3% participants were pre-frail. The most common Fried's frailty components werelow physical activity; weakness and exhaustion. The proportion of Fried's frailty in CKD groups 1; 2 and 3 was 10%; 13.3% and 40% respectively and the association between Fried's frailty and CKD severity was statistically significant.The association of deficits in health with UACR; eGFRcr and CKD stages was not statistically significant. The mean deficit score was 8.5 and increased across advanced CKD severity groups. HTN and DM were the most common co-morbidities.A significant association of Fried's frailty with deficits in health; depression; Barthel's ADL and WHO QOL was seen. The association of Fried's frailty with age; sex; BMI; religion; marital status; financial status; MMSE; family type; DM; HTN and anemia was not statistically significant.

Conclusions: Frailty was found to have a significant association with CKD and the proportion of frailty increased as the severity of CKD increased (p value=0.005). Frailty had a negative impact on life in CKD patients and correlated with worse scores in depression; quality of life and activities of daily living.

157. Antithymocyte globulin vs basiliximab in abo incompatible renaltransplants: an indian experience

Dr. Keyur Dave, Dr. Bhupendra Gandhi,

Dr. Rushi Deshpande, Dr. Vilesh Kalthoonical,

Dr. Amjad Khan Pathan, Dr. Chandan Chaudari,

Dr. Sameer Vyahalkar, Dr. Madan Bahadur,

Dr. Sudirranjan Dash


Jaslok Hospital and Research Centre; Mumbai

Background: Kidney transplantation across the ABO blood group barrier has the potential to expand the pool of donor and increase availability of transplantable organs.Long-term results of ABOi KT reported by western and Japanese transplant centers have shown that ABOi KT is equivalent to ABO-compatible KT.The main aim of the induction therapy is to avoid early rejection to improve graft survival with immunosuppresion risk.ATG and Basiliximab have been compared in our study as induction agents in ABOiKT.

Aim of the Study: To determine the incidence of rejection episodes; 1 year patient and graft survival incidence of complications in induction groups of ATG and Basiliximab in ABO incompatible renal transplants.

Methods: Study Population - 28 patients undergoing live donor ABO iKT at our centre of 18 to 60 years excluding patients with previous transplants; malignancies or HIV; HBsAg; HCV infectionsATG group had 16 and Basiliximab group had 12 patients inductionStudy duration : 2 yearsMethods:Donors and Recepients were assessed completely as per our hospital protocol.Anti A/ Anti B titers were measured as baseline at Day -7 and then daily from the day of starting Plasma exchange (Day -5) till Day +5. All patients received Rituximab (375mg/m2)on Day -7.All received Tacrolimus; MMF and Prednisolone from Day -7. Plasma exchange started on Day -5 daily till AntiA/B titres are < 1:4 presurgery and on Day +1 and Day +3.On Day 0 patient received induction agent either ATG (1mg/kg) single dose or Basiliximab (20mg) on Day 0 and Day 4.Renal transplant was done with standard technique. All received cotrimoxazole and valgancyclovir. Observations were made and recorded as per study protocol.

Results: Both groups had maximum male recepients and female donors with maximum recepients of Blood group OBasiliximab group had more acute rejections 25% (3/12) than patients of ATG group 18.75% (3/16) with 1 in ATG group having a graft loss due to renal vein thrombosis Mean serum creatinine in Basliximab and ATG groups at 1 month; 6 months and 1 year was 1.20 ± 0.366 mg/dl; 1.26 ± 0.187 mg/dl; 1.65 ± 1.160 mg/dl and 1.24 ± 0.250 mg/dl; 1.37 ± 0.301 mg/dl; 1.41 ± 0.365 mg/dl respectively with no statistical significant differenceBasiliximab group had lesser patients with infections (25%) compared to 50% ATG group patients with UTI as the most commonATG group had 2 patient deaths both were infection related deathsATG group had 1 isolated graft loss compared to Basiliximab group due to renal vein thrombosis secondary to acute humoral rejectionNon infectious complications like NODAT; erythrocytosis were found numerically more in patients of ATG group than Basiliximab group patients.

Conclusions: Basiliximab induction may have more acute rejections but lesser infections and related deaths compared to ATG induction1 year graft function is similar in both induction groups.

158. Delayed graft function in live related kidney transplant

Dr. Dhawal Arora, Maj Gen A K Hooda, Col A Jairam,

Col D Mukherjee, Col R K Nair, Dr. Saurabh Sharma


Army Hospital R and R; Delhi

Background: DGF is described as clinical state where there is a failure of the transplanted kidney to function immediately after transplantation due to I/R and immunological injury. It can be considered as an acute kidney injury (AKI) in post-transplant period. Incidence of DGF varies from 4 to 10% in living donor transplants and 5 to 50% in deceased donor kidney transplants .

Aim of the Study: To find the incidence of and factors associated with delayed graft function in live donor renal transplant and its effect on short term graft outcome.

Methods: The study was prospective and retrospective observational study done at tertiary care hospital. All the living donor transplant recipients who underwent transplants from from Jan 2010 till March 2015 were included in the study. Total 260 patients were included in the study and 15 pateints were excluded as they had acute rejection in first week of renal transplant. All the patients who were transplanted from 2010 till Dec 2014; there data was retrieved from hospital records. Those who underwent transplant from Jan 2014 till Mar 2015 were followed prospectively. The recipient data; surgical details immunosuppression was collected along with donor details. Those patients who developed DGF in first week of transplant were grouped as cases and rest formed the controls.

Results: 260 patients were studied. 35 patients were found to be having DGF as per predefined criteria. 225 patients served as contols. Majority of our donors population were females. Most of the patients underwent open donor nephrectomies. Basiliximab was induction agent of choice among our recipients. Comparing ATG and Basiliximab there was no difference incidence among DGF. Tacrolimus based triple drug immunosuppression was or maintenance regimen among most of the recipients. The use CNI was not associated with delayed recovery of DGF in our study. The eGFR at day +7 calculated using MDRD formula was 35.46 among cases and 72.23 in control group. At the end of 1st year; the difference of eGFR among cases and controls was statiscally significant. The average eGFR at the end of 1st year calculated using MDRD formula was 46.5 in case population and among controls it was 68.87.

Conclusions: This study highlightens the fact that those kidneys which are effected in early phase of post transplant due to I/R injury leading DGF tend to have poor graft outcomes. This finding is relevant even in living donor renal transplant.

159. Leaching and boiling of vegatables and lentils for potassium-How effective is the strategy !

Prem P Varma, Anuradha Sharma, Elly Varma,

S Bhardwaj, RP Mathur, Suman Lata, SK Sarin


ILBS; Vasant Kunj; N Delhi 110070

Background: Hyperkalemia is a life threatening emergency in end stage kidney disease. To reduce the potassium intake; NKF recommends leaching and boiling of vegetables.

Aim of the Study: Present study was done to quantify the potassium loss by leaching and boiling of commonly consumed 14 Indian vegetables and 9 lentils.

Methods: We adopted the commonly practiced method of cooking in Indian homes. Rinsing /Leaching was done for all vegetables and split pulses for 10 min. Whole lentils were soaked overnight for 8 hours. After rinsing/washing water was drained out and sent for potassium testing. All vegetables and lentils were then boiled and after first boil water was again sent for potassium testing.

Results: After leaching median and average K loss from vegetables was 0 mg and 4.36 mg respectively (p=1.00) and after boiling median and mean K loss was 18 mg and 23.14 mg respectively (p =0.04). Mean K loss in lentils following leaching and boiling was 183.22 mg (34-346 mg) {p=0.001} and 267 mg (146-591 mg) {p=0.001} respectively. Boiling of vegetables was useful (p=0.04) but not leaching (p=1.00). Both leaching (0.001) and boiling (p=0.001) of lentils was beneficial.

Conclusions: Leaching of lentils is useful but not of vegetables. But boiling of both vegetables and lentils and draining out water from them results in significant potassium loss.

160. Antithymocyte globulin vs basiliximab in abo incompatible renaltransplants: An indian experience

Dr. Keyur Dave, Dr. Bhupendra Gandhidr Vilesh Kalthoonical, Dr. Amjad Khan Pathan,

Dr. Chandan Chaudaridr Sameer Vyahalkar,

Dr. Rushi Deshpandedr Madan Bahadur,

Dr. Sudhiranjan Dash


Jaslok Hospital and Research Centre; Mumbai

Background: Kidney transplantation across ABO blood group barrier has the potential to expand the pool of donora; increase availability of transplantable organs and decrease prolonged time on waiting list for a kidney. Long term results of ABOi KT reported by western and Japanese transplant centres have shown ABOiKT equivalent to ABO KT. Main aim of induction therapy is to improve graft survival but over immunosuppresion can cause complications.ATG and Basiliximab have been used for induction in ABOIKT.

Aim of the Study: To determine the incidence of acute rejection episodes; 1 year graft and patient survival and complications in induction groups of ATG and Basiliximab in ABO incompatible renal transplants.

Methods: Study Design and Duration: Prospective observational Study of 2 years durationStudy population : 28 patients undergoing live donor ABO incompatible renal transplant at our centre of age group 18 to 60 years excluding patients with previous renal transplants; positive for HBsAg; HIV; HCV and previous malignanciesSample size: ATG group had 16 patients and Basiliximab group had 12 patients.

Results: Both groups had maximum male recepients and female donors with maximum recepients of Blood group OBasiliximab group had more acute rejections 25% (3/12) than patients of ATG group 18.75% (3/16) with 1 in ATG group having a graft loss due to renal vein thrombosis Mean serum creatinine in Basliximab and ATG groups at 1 month; 6 months and 1 year was 1.20 ± 0.366 mg/dl; 1.26 ± 0.187 mg/dl; 1.65 ± 1.160 mg/dl and 1.24 ± 0.250 mg/dl; 1.37 ± 0.301 mg/dl; 1.41 ± 0.365 mg/dl respectively with no statistical significant differenceBasiliximab group had lesser patients with infections (25%) compared to 50% ATG group patients with UTI as the most commonATG group had 2 patient deaths both were infection related deathsATG group had 1 isolated graft loss compared to Basiliximab group due to renal vein thrombosis secondary to acute humoral rejectionNon infectious complications like NODAT; erythrocytosis were found numerically more in patients of ATG group than Basiliximab group patients.

Conclusions: Basiliximab induction may have more acute rejections but lesser infections and related deaths compared to ATG induction1 year graft function is similar in both induction groups.

161. Collagenofibrotic glomerulopathy

Sarat Chandra V, Harikrishna Reddy M, Praveen N,

Anil C V Kumar, Sangeetha B, Ram R, Siva Kumar V


Sri Venkateswara Institute Of Medical Sciences; Tirupati

Background: The collagenofibrotic glomerulopathy was first described by Arakawa in 1979. Till now thirteen patients were reported from India in three publications. We present a patient of collagenofibrotic glomerulopathy from our institute. We also present an overview of all patients reported from India.

Aim of the Study: We present a patient of collagenofibrotic glomerulopathy evaluated and diagnosed in our institute.

Methods: A 54-year-old lady; non-diabetic and hypertensive for the last one year. About two years ago; she had swelling of feet; facial puffiness and abdominal distension over a period of one month.She was evaluated at another nephrology facility and underwent a renal biopsy and was treated a membranoproloferative glomerulonephritis. he presented to our Institute with the history of worsening anasarca. The blood pressure was 150/100 mm Hg. The investigations were; serum creatinine: 2.3 mg/dL; blood urea: 54 mg/dL; haemoglobin: 6.3 g/dL; total serum proteins: 4.8 g/dL; serum albumin: 2.0 g/dL; 24 hour urine protein: 9.3 g. The peripheral smear revealed normocytic; normochromic anaemia. She showed negative serologies for ANA; hepatitis C; hepatitis B and HIV and had normal serum C3 and C4 levels. ANCA serologies were negative. There was no previous family history of renal disease or signs/symptoms of nail-patella syndrome. A second renal biopsy was performed in view of worsening proteinuria.

Results: Light microscopy:10 glomeruli present. 1 was globally sclerotic. The remaining were enlarged with deposition of a pale PAS & silver negative material in the mesangium in a diffuse and nodular pattern. This material is also focally deposited over the capillary loops It was blue on trichrome stain. The Congo red stain for amyloid was negative. The capillary loops showed double contours. There was no endocapillary proliferation; necrotising lesions or crescent formation. The interstitial fibrosis and tubular atrophy involved 25% of the core. Prominent arteriolar hyalinosis was present. Immunoperoxidase stain for collagen III was positive.Immunofluorescence staining was negative for IgA; IgG; IgM; kappa & lambda light chains.Electron microscopy: there is expansion of mesangium by stacked frayed collagen bundles. The glomerular basement membrane was globally thickened. Visceral epithelial cells show severe foot process effacement. No immune type electron dense deposit was visible.

Conclusions: Renal biopsy showing pale PAS & silver negative nodular lesions; blue on trichrome & congo red negative; positive with immunofixation to type III collagen & electron microscopy showing stacked; curvilinear; bfrayed bundles are characteristic of type III collagen & collagenofibritic glomerulopathy.

162. Renal transplatation in haemophilic

Dr. Padmini Sirkanungo, Dr. Mohan Chand Seal,

Dr. Lalit Kumar Agrawal, Dr. Shubhankar


Apollo Gleneagles Hospital Kolkata

Background: CAS SUMMARY :27 year old haemophillic with ckd on mhd was admitted at Apollo Gleneagles in November 2015 for live ABO compatible renal transplant from altruistic donor. Pre transplant factor VIII level was 3% which was supplemented preoperatively; intra operatively and in immediate post operative period. Induction was given in the form of thymoglobulin (r-ATG) and triple immunosuppression (Tacrolimus/Mycophenolate Mofetil/Prednisolone) started preoperatively was continued.

Aim of the Study: Surgical details: donor renal artery sutured end to side with external iliac artery.Kidney perfused immediately after declamping.Good hemostasis achieved.Cold ischemia time 10 minutes.

Methods: Post operative triple immunosuppression in the form of tacrolimus; mycophenolate mofetil and oral prednisolone was continued; he also received r-ATG till pod 5 and was discharged with normal renal function and serum creatinine of 1.4mg/dl.Two weeks post transplant ; he presented with profuse hematuria. He had tachychardia and hypotension with decreased urine output. His haemoglobin levels had dropped; coagulation parameters were deranged with a slight rise in serum creatinine. Ultrasonography revealed large haematoma at upper pole of transplanted kidney. Factor VIII levels had declined to 6 percent . Patient was managed conservatively; factor VIII supplementation; blood transfusion and other conservative management given; he improved with the same without requiring any surgical intervention.On follow up 6 months post transplant he is maintaining normal renal function and normal haemoglobin levels

Results: Discussion Haemophilia A is a genetic X-linked bleeding disorders; caused by mutations in genes encoding factor VIII.Renal failure was believed to be a rarity inhereditary clotting disorders; but it has now been observed that haemophilic patients requiring hemodialysis or renal tranplantation is on the rise.The biggest challenge in our case was the fact that our patient was undergoing heparin free dialysis and had undergone only a minor surgery in the form of arterio venous fistula under factor VIII cover; would he be able to tolerate a major surgery as renal transplantation was the big question.However as is evident in our case the surgery when done in experienced hands meticulously and with proper pre operative precautions is no different from the routine and does not expose the recipient to any extra risk factor.Immune suppressive protocol can remain same.

Conclusions: We would like to conclude that haemophiliacs with ckd should be provided with the option of renal transplantation as other chronic kidney disease patients as with due care good results can be achieved.

163. Prospective study on prediction of the outcomes of rapidly progressive glomerulonephritis. A single centre experience

Dr. Deepak Sharma,Dr. Sony John, Dr. Suman Sethi,

Dr. Simran Kaur, Dr. Sourav Goyal, Dr. Hemanth Kumar Mk,

Dr. J S Sandhu, Dr. vikas Makkar; Dr. P M Sohal


Dayanand Medical College and Hospital Ludhiana; Punjab

Background: Rapidly progressive glomerulonephritis (RPGN) is a disease of the kidney characterized clinically by a rapid decline in the glomerular filtration rate (GFR) of at least 50% over a short period; from a few days to 3 months It is classified pathologically into three categories (1) Anti-GBM antibody disease (2) Immune complex disease (3) Pauci-immune disease. The aim of the study is to evaluate clinicopathological features and study the predictors of outcome in RPGN.

Aim of the Study: To study the Clinico-Pathological profile and to determine the predictors of renal outcome in Rapidly Progressive Glomerulonephritis.

Methods: The study was conducted in the Department of Nephrology at Dayanand Medical College and Hospital; Ludhiana. All patients of RPGN from 15 Feburary 2015 to 31 March 2016 were enrolled in the study. Biopsy-proven cases of RPGN (i.e.; >50% crescents in glomeruli) were included in the study and were followed up for 6 months after giving standard treatment.

Results: The mean age of the studied patients was 47 +/- 25 years. Out of 40 patients 23 (57.5%) are males and 17(42.5%) are females. Immunological profile showed pauci immune disease in 24 (60%) {MPO - 41.6%; PR3 - 25%; Both- 4%}; Immune complex disease in 11(30%) and Anti GBM disease in 4(10%). After giving standard immunosuppressive treatment patients were followed up for 6 months. No response (dialysis dependent/ Mortality/ Lost to follow up/Drug related side effects) seen in 65%; Partial remission( dialysis independence/increase in GFR) in 27.5% and Complete remission in 7.5% of the followed patients. Entry creatinine was found as an important predictor of outcome as those presenting with creatinine of > 5.7 mg/dl and those having more number of sclerosed glomeruli in renal biopsy had poorer outcome.

Conclusions: RPGN carries poor prognosis. Majority of our patients reported in advanced stages of renal failure which has a strong bearing on outcome. Early recognition and timely intervention are required to prevent progression to CKD/ESRD.

164. Fatal type-b lactic acidosis in association with hiv associated lymphoma

Dr. Asif Salim, Dr. Shobhana Nayak


Postgraduate Student in General Medicine; K.S Hegde Medical AcademyDerlakatte; Mangalore 575018

Background: Hyperlactemia is defined as whole blood lactate levels > 2mmol/L. Type-B lactic acidosis refers to conditions wherein overproduction of lactate is not related to the reduction in tissue oxygen. The occurrence of severe lactic acidosis in malignancies is a rare and often pre-terminal complication. The underlying pathogenesis is poorly understood. We present two HIV + patients with type-B lactic acidosis as a preterminal event after being diagnosed with non -Hodgkins' lymphoma.

Aim of the Study: See below.

Methods: Desription of case details of two HIV positive patients disgnosed to have severe type-B lactic acidosis after diagnosis of non-Hodgkin's lymphoma.

Results: The first patient was a 45 year old male; HIV positive since 2012 on antiretroviral therapy admitted with pedal edema; generalised weakness and decreased appetite. Ultrasound scan of the abdomen revealed Bilateral moderate hydroureteronephrosis with large left sided pleural effusion. Pleural fluid cytology revealed malignant lymphoma confirmed by supraclavicular lymph node biopsy. Before initiation of chemotherapy; his general condition rapidly worsened with onset of lactic acidosis(10mmol/L) and he expired 2 weeks after hospitalization .The second patient was a 59 yr old male who presented with history of acute hematemesis.Evaluation revealed a diagnosis of diffuse B large cell lymphoma extending from gastric fundus to pylorus with diffuse and extensive disease in the stomach with splenic; peritoneal and lung metastasis.Two days after chemotherapy; he had a massive hematemesis; severe metabolic acidosis and hyperlactemia of 19mmol/L and died despite all supportive care.

Conclusions: Type-B lactic acidosis is a rare event in hematological malignancies most often described in lymphomas and often is a poor prognostic factor determining survival

165. "I have got this life with a lot of difficulty; i don't want to lose it.": A qualitative study of recipients and caregivers on life before and after renal transplant; mumbai; india

Rajesh Kumar, Rachana Jasani, Nilesh Chatterjee, Mukesh Shete, Shrirang Bichu, Jatin Kothari,

Viswanath Billa


Apex Kidney Care

Background: End-stage renal disease (ESRD) is rising in India; an estimated 100; 000 new patients enter renal replacement programs annually. Kidney transplant provides benefits such as end to dialysis; and recovery of lost renal functioning. However; transplantation poses challenges: non-compliance with immunosuppressant medication can lead to graft rejection; there are restrictions to diet and physically strenuous activity; regular hygiene measures; changes to appearance and body image issues.

Aim of the Study: To explore perceptions; practices and subjective experiences of ESRD patients and their caregivers with respect to life before and after transplant to improve quality of care and support services.

Methods: An exploratory qualitative study conducted with 23 respondents selected using non-probability purposive sampling from a specialized renal care center in Mumbai. In-depth interviews lasting an hour were completed with 12 transplant recipients and 11 caregivers. Questions probed patients and caregivers subjective perceptions and experiences of initial diagnosis; dialysis; life after transplant; and barriers and facilitators to lifestyle change and desired behaviors. All interviews were audio-recorded; transcribed; and read independently by investigators. Thematic analysis was conducted stepwise starting with familiarization with data; generating initial codes; searching for and reviewing themes; defining and naming themes; and producing the final report. Of patients; four were female and 11 married; and of the caregivers only 2 were men. Respondents' ages ranged from 18-60 years with varied educational and occupational backgrounds. Annual family incomes were from INR 3 to 15 lakhs.

Results: Recipients described ESRD diagnosis as life-shattering; evoking the question: "Why me?" Life on dialysis was described as a harrowing experience. Faith; prayer; coping techniques; other ESRD patients provided strength during dialysis. In contrast; renal transplant was considered a new lease of life. After transplant; immunosuppressant medicine regimens are strictly followed with reminder systems. However; recipients complained that dietary advice is most difficult to adhere to followed by travel restrictions; inability to go to crowded places; play sports; and weight gain. Recipients complained about caregivers exerting control through the lifestyle change regimens and treating recipients as a sick person; which affects normalization of life and interpersonal relationships. Unresolved issues of families blaming patient for getting sick and patient's guilt on receiving an organ were found. Caregivers' lives are also significantly affected in order to provide attention to the patient.

Conclusions: Challenges in adjusting to post-transplant lifestyle; diet; travel restrictions; body image and control exerted by caregivers indicate need for behavior change counseling and support groups for recipients and post-transplant education and family counseling for caregivers and families.

166. Community accquired versus hospital acute kidney injury in critically ill patients: Clinical charecterstics and outcomes

Dr. P S Priyamvada, Dr. R Jayasurya, Dr. Vijayshankar, Dr. Sreejith Parameswaran, Dr. Satish Haridasan,

Dr. R P Swaminathan


Department of Nephrology; Department of Medicine; JIPMER

Background: Acute kidney injury is common in critically ill patients; and it contributes significantlly to mortality and morbidity. There is only little comparative literature available on the epidemiology; outcomes and risk factors for mortality in Hospital-acquired AKI(HA AKI) and Community-acquired AKI (CA-AKI) from developing countries like India. The current study intends to compare the clinical characteristics & outcomes in a mixed population of critically ill patients with HA & CA-AKI.

Aim of the Study: 1. To compare the characteristics and outcomes of CA-AKI with HA-AKI in critically ill adult patients 2. To assess the predictors of mortality in critically ill patients with acute kidney injury.

Methods: The study was conducted in a 1500 bed strength tertiary care centre; from June 2013 -2015 October (30 months). All adult patients with acute kidney injury (AKI) admitted in various medical and surgical intensive care units ( 5 medical and 8 surgical); were included in the study.AKI was defined according to the KDIGO criteria.Those with previously documented chronic kidney disease(GFR <60 ml/1.73m2 or albumin-creatinine ratio >.3); solid organ transplant recipients; obstetric AKI; history of receiving renal replacement therapy before admission to ICU and readmissions to ICU were excluded. The baseline clinical & biochemical parameters were documented and patients were followed up for 30 days post admission.Complete recovery of AKI was defined as urine output of >1 ml/kg/hr with serum creatinine < 1.4 mg/dl .Partial recovery was defined as fall in serum creatinine by ≥ 50 % of peak values and urine output ≥ 0.5 ml/kg/hr.For those on RRT ; dialysis independence was also needed.

Results: 236 patients were recruited from medical (43.7%) & surgical (66.3%) ICU'S.Median age was 50 ; with 73.3% males.53.4% patients HAD CA-AKI whereas 46.6% were having HA-AKI .Patients admitted in surgical ICU's had a high proportion of HA- AKI (69.2% vs 46% ; p=.00).Etiology was comparable ; except for high proportion of patients with HA-AKI with diagnosis of cardiac disease& trauma (p < .05) . Patients with CA-AKI had lower urine output; higher creatinine ; higher SOFA score; low bicarbonate level; higher need for RRT & higher prevalence of AKI stage 3 compared to those with HA-AKI(P<.05). The 30-day crude mortality rate was 52.54% ( n=124).Mortality and death-censored median ICU stay was comparable between HA-AKI and CA-AKI . There was no difference in mortality rates with increasing stages of AKI. On cox regression analysis ; the independent predictors of mortality was age >50 years(1.537; CI 1.024-2.306) and use of vasopressors(4.803 CI 3.039-7.591).

Conclusions: AKI in critically ill patients is associated with a high mortality. Mortality rates of HA-AKI & CA-AKI are comparable. Even early stages of AKI contribute significantly to mortality. Older age and use of vasopressors are independent risk factors.

167. Incidence Of Pleural Effusion; Consolidation/; T. B And Cardiomegaly In Geriatric Ckd Stage V Patients On Long - Term Haemodialysis - A Single Centre Study

Dr. Nagineni Bhasarrao, Prof. P. V. Prabhakar Rao


MNR Medical College And Hospital; Sangareddypost:telangana; Statepincode:502529

Background: Geriatric Patients Of Ckd Stage V On Longterm Hemo Diyalysis At A Rural Based Medical College In South India.

Aim of the Study: To study the incidence of pleural effusion; consolidation (pneumonia); Tuberculosis and cardiomegaly among Geriatric CKD stage V patients on long term haemodialysis in rural India.

Methods: 124 CKD stage V patients got registered for MHD at Dialysis unit of Nephrology Dept. of MNR Medical college Hospital; Sangareddy (Post); Medak Dist; Telangana state; India; Pin: 502294 during the period from 05.11.2009 to 31.01.2016. Out these patients 32 (Thirty two ) are Geriatric; CKD stage V on MHD patients and are selected for the study. These patients are on long-term haemodialysis and were followed from time to time at the center periodically about the complications occur during long-term haemodialysis. Complications occurred among these patients are seen with Table no:1. Out of 32; 14 (Fourteen) Geriatric patients developed complications like consolidation (pneumonia); pl. effusion; TB; and Cardiomegaly; and treated as per the medical science.

Results: Out of fourteen Geriatric CKD stage V on MHD patients - nine patients got (64.2%) consolidation (pneumonia); (8) eight patients (57%) got plural effusion; five(5) patients got Tuberculosis (35.7%) and Fourteen (14) patients got cardiomegaly (100%). Some patients developed ascitis and diagnosed as TB Abd and was put on ATT drugs under DOTS. Another pul.koch's & was put on ATT drugs under DOTS.

Conclusions: 32 Geriatric CKD stage V patients long-term haemodialysis of which 14 of them developed pleural effusion-8 patients 57% consolidation-(pneumonia) 9 patients 64.2%; TB (5 pts) 38.7% and Cardiomegaly (14) 100%. These patients were given appropriate treatment along with adequate dialysis prescription.

168. Knowledge; Attitudes And Perceptions Of Hemodialysis Patients Toward Renal Transplantation: Did We Counsel Our Patients Enough?

Dr. Deepak Sharma, Dr. Sony John, Dr. Sourav Goyal, Dr. Hemanth MK, Dr. Suman Sethi, Dr. Simran Kaur,

Dr. J S Sandhu, Dr. Vikas Makkar, Dr. P M Sohal


Dayanand Medical College and Hospital Ludhiana; Punjab

Background: Treatment decisions made by patients with chronic kidney disease are crucial in the renal transplantation process.These decisions are influenced; amongst other factors; by attitudes towards different treatment options; which are modulated by knowledge and perceptions about the disease and its treatment.

Aim of the Study: The aim of the present study was to evaluate Hemodialysis (HD) patients' knowledge about ; Attitudes towards and Perceptions for Kidney Transplantation (KT).

Methods: 72 patients on maintainance hemodialysis in Dayanand Medical College Ludhiana were enrolled in the study. The questionnaire was made ; that included questions on socio demographic data and dialysis vintage; willingness to undergo KT; knowledge about KT ; choice of donor; perceptions about KT etc.

Results: Mean age of the study population was 48 ± 12 years; 63.8% were male and the prevalence of diabetes was 40.2%.Of the 72 respondents; 50 stated that they were willing to be transplanted. However; 22 thought transplantation not a good option because of Fear of life after transplant (31.8%); Age(31.8%); Fear for donor(18.1%); Financial constraints (9.0%) and co- morbidities(9.0 %) . Origin of information regarding transplant were from Doctors (76.3%); Nurses (9.7%); Internet (11.11%) and others (2.7%) . 41.6 % patients were aware of cadaveric transplantation and 11.11% were enrolled in Deceased donor programe.

Conclusions: Negative attitudes to renal transplantation are associated with potentially modifiable factors. There is a need to increase awareness about KT among HD patients and their families.

169. An epidemiological assesment of av fistulae in patients undergoing maintainance hemodialysis;a single center experience

Soumava Gupta, Pratik Das, D.S. Roy, Biplab Ghosh, Sharmila Thukral


R.N.Tagore InternationalInstitute of Cardiac Sciences(NHRTIICS)

Background: AV Fistula(AVF) is the lifeline of patients on maintainance hemodialyss.An AV Fistula is a continous circuit which begins at heart and ends at heart.Initiative of elective canulation of AVF; 'fistula first'' is currently on; which focusses on early construction of an AVF in CKD Stage4.Amongst all the acces an AVF is considered the gold standard.Lack of a proper AV Fistula will not only affect the quality of hemodialysis but also incurr recurrent health expences.

Aim of the Study: To find out and asses the various types of AVF and AV Graft among the study population.To find out the incidence of prior vein mapping; elective canulation of AVF; fistula failure and its etiology.

Methods: This is a cross sectional study carried out at the Dialysis Unit of NHRTIICS.Patients on maintainence hemodialysisMHD) via an AVF were included in the study.Seriously ill and moribund patients were excluded.History of the disease; comorbidities; drug history; fistula surgery; complications viz.bleeding; fistula failure etc were obtained in a pretested and predesigned questionnire.Fistula was examined by the "look; feel and ausculcate" method.Armelevation test(AET); Pulse augmentation test(PAT) were performedto asses any distal obstruction.Suction of the rotary pump was used as a surrogate marker for bloodflow assesment.Urea reduction ratio(URR) at apump speed of 250ml/min with F6 dialyzer was calculated.The gdata thus obtained were tabulated and analyzed.

Results: 355 patients were enrolled for MHD at the study center.Amongst them 31 and 18 patients were excluded for usage of alternate access and severe morbidity respectively.210(68.6%); 70(22.8%); 20(0.65% and 6(0.1%) had radiocephalic; brachiocephalic; basiloulnar AVF anf AV Graft respectively.Chronic Glomerulonephritis was the commonest cause of CKD(50%); followed by Diabetic Nephropathy(45%) and others(5%).200 patients were male and 106 female(p=0.6).AVF was in dominant arm in nondominant arm in 175 patients and in dominant arm in 131 patients.(p=0.04).Thrill was present in all patients; systolic in 250(81.6%)patients.AET was positive in 226(73.8%) patients and PAT was positive in 190(62%)patients at a mean distance of 3.5cm from the anastomosis site.Secondary fistula failure was seen in 22(7.1%)patients and AVF was postponed in 13(3.9%) patients due to ksmall venous caliber.There is a linear logistic regression between URR and PAT(OR=2.2; CI=-3.1to-0.08); Venous pressure(OR=1.16; 0R=0.35 to0.1).

Conclusions: Radiocephalic AVF in nondominant arm is the commonest AV Fistula.Most of the fistula has evidence of upstream obstruction which necessitates regular surveillance of the AVF and intervention at the earliest.Only a small proportion of subject had an elective AVF Canulation.

170. Spectrum of chronic kidney disease in a tertiary care hospital in haryana

Dr. Vikram Kala, Dr. Prerna Panjetasr, Dr. Nityanand


Bhagat Phool Singh Govt Medical College For Women; Khanpur Kalan; Sonepat (Haryana)

Background: Chronic kidney disease (CKD) is a problem of epidemic proportions in India with an increasing diabetes burden; hypertension and growing elderly population. The present study highlights the spectrum of CKD in a tertiary care hospital in Haryana.

Aim of the Study: To study the spectrum of chronic kidney disease in a tertiary care hospital in haryana.

Methods: It included 1463 patients of CKD admitted between May 2004 to May 2009 being retrospective for 4 years and prospective thereafter for 1 year. Records of all these patients were analysed and patients were grouped in various categories of CKD.

Results: The mean age of presentation of CKD was 46.66±16.60 years with male patients being predominant. Chronic glomerulonephritis was the commonest presentation (34.72%) followed by diabetic nephropathy (23.44%). Other presentations were hypertensive nephropathy (14.08%); chronic interstitial nephropathy (9.22%); obstructive nephropathy (6.9%); Renal amyloidosis (5.54%); APCKD (4.17%) and RAS (0.61%). In patients age group >40 years; diabetic nephropathy was the commonest cause of CKD seen in seen in 34.52% cases. 85.51% presented in stage V CKD or end stage renal disease and 9.8% patients presented in stage IV CKD indicating that >95% of CKD patients presented in CKD stage IV or V; those patients who requires renal replacement therapy. Only 1.57% presented in CKD stage I and II.

Conclusions: India has heavy burden of CKD patients but the resources are meagre to tackle the problem. Once large scale studies of the spectrum of CKD are available; it will be helpful in better resource management and be fruitful in planning preventive programmes to decrease the ever increasing burden of CKD.

171. Emergency ward visit by patients on dialysis

S. Ramakrishnan, Dilip RKiran Chandra Patro,

Santosh Roopa Jitendra


NU Hospitals, Bengaluru

Background: Visits to emergency ward by patients on maintenance dialysis may harbinger hospitalization or admission into intensive care unit or access failure or sentinel events including death. An analysis of the same is very likely to provide insight into the preventive aspects of such visits.

Aim of the Study: To study the causes and outcome of emergency ward visits by patients undergoing maintenance hemodialysis.

Methods: Prospective study Period of study: March 16; 2016 till June; 15; 2016Patients undergoing maintenance hemodialysis in our Hospital and patients on peritoneal dialysis under regular follow up with us only were included in the studyData pertaining to clinical profile of patients included in the study were entered along with the purpose and outcome of the visit in Microsoft excel sheet.

Results: Patient profile:37 patients (30 on HD and 7 on PD) had visited emergency ward 81 times; mean age (in years) was 57.4 and males were 21; 23 had DM; 36; hypertension and 14; IHD. Vascular access was CVC in 7; tCVC in 6 and AV in 19Visit details:9 patients (1 on PD and the rest on HD) visited emergency ward thrice or more times and 11 (2 on PD and the rest on HD) patients; twice during this period 24 visits followed a particular session of HD; 6 of them had high blood pressure; 4 fever; 3 each had tiredness and hypotension and 2 each had itching and head acheCommon causes of visit: Dyspnea 16; Fever 11; Abdominal pain 9; Tiredness 8; Hypertension 8; Abdominal discomfort 7; Vomiting 6; Loose stools 4; Access problems 3; Hypotension 3; Itching 3 Management:17 visits - out of schedule hemodialysis22 visits (19 patients) needed admission; 2 of them in intensive care unit (1 patient died); 14 visits (12 patients) were by patients on HD; all 7 patients on PD had got admitted.

Conclusions: Visits by patients on PD to emergency ward were more likely to result in hospital admission - though patients on HD visited emergency ward more frequently; they improved to a great extent following emergency HD and symptomatic measures.

172. Effect of pentoxifylline on renal function in proteinuric chronic kidney disease: a systematic review and meta-analysis

Vaibhav Keskar, Laila Sadagah, Arsh Jain,

Swapnil Hiremath, Brendan McCormick


Division of Nephrology; The Ottawa hospital; Univeristy of Ottawa; Canada; University of Western Ontario; London Health Science Centre; London; Ontario; Canada

Background: Pentoxifylline has been reported to decrease proteinuria in diabetic nephropathy. Its effect on kidney function is unclear.

Aim of the Study: To evaluate the effect of pentoxifylline on renal function in patients with proteinuric chronic kidney disease.

Methods: We performed a systematic review and meta-analysis of randomized controlled trials. We retrieved relevant articles from MEDLINE; EMBASE and Cochrane CENTRAL until August 2015. The trials had to enrol adult patients with proteinuric chronic kidney disease comparing oral pentoxifylline with control arm receiving active comparator; placebo or usual care. The primary outcome measure was the effect of pentoxifylline on renal function as measured by estimated glomerular filtration rate; creatinine clearance or serum creatinine. Secondary outcomes were proteinuria; blood pressure and other adverse events. Pooled outcomes were calculated using random effects model; with weighted mean differences for continuous outcomes and summary odds ratio for binary outcomes.

Results: We identified 18 trials including a total of 1211 patients. Median duration of follow up was six months. The daily dose of pentoxiphylline varied from 400 to 1200 mg (median 1200 mg/day). Compared to the control arm; pentoxifylline was associated with a slower decline in eGFR (weighted mean difference; WMD= -3.8 ml/min per 1.73 m2; 95% CI -1.5 to -6.0). The difference in creatinine was significant; favoring pentoxifylline group (WMD= -0.08 mg/dl; 95% CI -0.01 to -0.16). Pentoxifylline also reduced proteinuria significantly (24 hour urine protein: WMD-101.2 mg/day CI -15.29 to -187.12; urine albumin excretion rate: WMD -192.69 μg/min; 95% CI -94.24 to -291.15). Pentoxifylline group had significantly lower blood pressure (systolic BP WMD -2.5 mmHg; CI -0.62 to -4.31; diastolic BP WMD -1.79; CI -0.91 to -2.68). Only three studies reported incidence of end stage renal disease. The most common adverse events reported were gastrointestinal symptoms.

Conclusions: Pentoxifylline may slow the progression of chronic kidney disease. However; the data are limited by quality; size and duration of trials included. Little data exist on the effect of pentoxifylline on hard clinical outcomes such as need for dialysis or death.

173. Microbiological profile of peritonitis in continous ambulatory peritoneal dialysis patients

Marsook Ali, M.Sreelatha, T.P.Noushad, Jayakumar.E.K.


Govt. Medical College; Kozhikode; Kerala

Background: Peritonitis is a frequent complication of continuous ambulatory peritoneal dialysis (CAPD) and the most common cause of CAPD failure. CAPD peritonitis is associated with catheter loss; adhesions; increased protein loss; return to hemodialysis; and considerable morbidity. Improved diagnosis; increased awareness of causative agents in addition to other measures will facilitate prompt management of PD associated infection and salvage of PD modality.

Aim of the Study: 1.Toidentify the pathogens in CAPD peritonitis2.To determine the antibiotic susceptibility pattern of the isolated pathogens.

Methods: 125 patients with CAPD peritonitis as defined by International Society of Peritoneal Dialysis; undergoing CAPD at department of nephrology ; MCH Kozhikode were included. The baseline data was collected. The patients exchange bags containing effluent dialysate were collected and sent to department of microbiologywhere detailed analysis including gram staining; KOH mount; Ziehl-Neelsen staining; culture(for bacteria; fungi and mycobacteria)and antibiotic sensitivity were conducted. The data regarding the response to treatment and the need for PD catheter removal were collected.

Results: The most common presentation was cloudy effluent (90%) followed by abdominal pain. A history of change in hand was present in 30%. 81% cultures were positive and 19% negative. Monomicrobial infections accounted for 92% and 8% were polymicrobial Among the isolates 44% were gram negative bacilli and 29% gram positive cocci; 7% fungi and 1 mycobacterial. Among the gram positive; CONS predominated (24 patients) followed by Staph aureus (8 patients).  Acinetobacter baumannii Scientific Name Search atients) predominated among the gram negative; followed by E.coli (13).The mycobacteria was identified as  Mycobacterium abscessus Scientific Name Search traplex PCR.Among the 9 fungal isolates 6 were Candida tropicalis.Except for few Acinetobacter all other gram negative organisms were sensitive to 3rd generation cephalosporins and carbapenems. Among the 115 bacterial peritonitis cases 67% responded to antibiotics.23% had recurrent episodes of peritonitis during the study period. 4.8% patients required removal of PD catheter.

Conclusions: Gram negative bacilli were mainly responsible for CAPD peritonitis. Acinetobacter baumanni was identified as the most common organism. All gram negative pathogens were sensitive to 3rd generation cephalosporins except for few ESBL producing A.baumanni. All gram positive were sensitive to Vancomycin.

174. An interesting case of secondary mpgn-poems syndrome

Krishnakumar K, Sreelatha M, Noushad TP,

Jayakumar E K


Government Medical College; Kozhikode; KERALA

Background: 56 year old male without any previous comorbid illness presented with grade II dyspnoea on exertion; progressive numbness and paraesthesias involving both lower limbs below knee; and polyarthralgia for a duration of 1.5 years. The patient was referred for the evaluation of the aforesaid symptoms in association with eczematous skin lesions and cervical; inguinal and axillary lymphadenopathy.

Aim of the Study: He also manifested nephrotic syndrome; hepatosplenomegaly; acute kidney injury ; right sided pleural effusion and gross ascites.

Methods: Urine routine revealed nephrotic range proteinuria and microhematuria.There was anemia ; raised ESR and deranged renal function test. Usg showed normal sized kidneys. Further investigations showed a low C3. RA factor; S.cryoglobulins; screening for HbsAg and HCV; ANA; mantoux; skeletal survey and serum electrophoresis turned out to be negative. Nerve conduction studies was suggestive of bilateral axonal sensorimotor neuropathy. Bone marrow study showed normal maturation of all cell lines with 5-6% plasma cells.

Results: Renal biopsy revealed membranoproliferative glomerulonephritis. Lymph node biopsy showed that the findings were compatible with Castleman's disease; hyaline vascular type. With this clinical and lab picture a diagnosis of multicentric castlemans disease with secondary mpgn suggestive of POEMS syndrome was considered.He satisfied both the mandatory criteria; one major and three minor criteria required for the diagnosis of POEMS syndrome.(Mayo clinic criteria).In both Castleman's disease and POEMS syndrome; cytokines (eg; IL-6 and VEGF) are implicated in pathogenesis.

Conclusions: our patient was initially treated with steroids. In view of persisting proteinuria; he was given 4 doses of Rituximab. Still patient was not in remission and he is now on nonspecific antiproteinuric measures.

175. Why is iga nephropathy aggressive in indians? The grace igani study: epidemiology at diagnosis

0Suceena Alexander 1 , 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

1 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: Unlike the slow progressive nature of the IgA nephropathy (IgAN) seen among Caucasian and East Asian patients (actuarial survival of 80-85% over 10 yrs); in India about 30-40% of patients have nephrotic syndrome and renal dysfunction at presentation1.

Aim of the Study: To study the epidemiology and disease characteristics of IgA nephropathy in South Asia.

Methods: This is a single center prospective longitudinal cohort study being conducted in South India. The recruitment started in March 2015. There were 154 adult (≥18 yrs) patients (pts) with IgA nephropathy (IgAN).

Results: Hypertension (htn) was present in 128/154 (83.1%) of pts before bx and the median time to bx from the diagnosis of htn was 7.5 (IQR; 2 to 36) mo. 92.9% (n=143) of pts had S Cr checked before presenting to our center and 83.2% (n=119/143) had renal impairment with median time to bx being 2 (IQR; 1 to 6) mo. The median time to bx from symptom onset was 8.5 (IQR; 2.8 to 35) mo. The mean age was 35.74±9.6 yrs; BMI was 24.6±4.4kg/m2 and the M:F ratio was 102:52. At renal bx (baseline); the mean serum creatinine (S. Cr) was 3.06±2.9mg/dl with 75% of pts having S. Cr >1.49mg/dl. Similarly the mean serum cystatin C (S. CysC) (n=80) was 2.06±0.9mg/dl (normal range:.53 - 0.95mg/dl).The mean 24 hour urine protein was 2.9±2.1g/day with 39.7% having nephrotic proteinuria (>3g/day). Serum IgA was elevated only in 20.5% of pts. 42.2% of pts had concomitant C3 deposition in bx. MEST scoring in 116 pts showed M1 in 9.6%; E1 in 42.9%; S1 in 84.2%; T1 in 31% and T2 in 57.8%.

Conclusions: IgA nephropathy has an aggressive presentation in South Asians with 50% of pts diagnosed within 8.5 mo of onset of symptoms. Sclerosing variants are more common than endocapillary proliferation.Sponsor: Early Career Fellowship; Wellcome UK Trust/ DBT India Alliance

176. Why is IGA nephropathy aggressive in indians? The grace igani study protocol

Suceena Alexander 1 , 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

1 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: Unlike the slow progressive nature of the IgA nephropathy (IgAN) seen among Caucasian and East Asian patients (actuarial survival of 80-85% over 10 yrs); in India about 30-40% of patients have nephrotic syndrome and renal dysfunction at presentation1.

Aim of the Study: To investigate the association between serum and tissue biomarkers and the rate of progression of IgAN. To analyze time trends of biomarkers and propose an IgAN renal prediction score.

Methods: This is a single center prospective longitudinal cohort study being conducted in South India. The recruitment started in March 2015. Adult patients with biopsy proven primary IgA nephropathy and an estimated glomerular filtration rate (eGFR) > 10ml/min/1.73m2 who are treatment naοve are included with informed consent. The study aims to recruit >200 patients over two years and follow up each patient for at least three years with longitudinal biomarker analyses. The patients are divided into low risk or high risk group based on Absolute Renal Risk (ARR) score2. Patients are treatment naοve at baseline and given RAAS blockade and/or immunosuppression according to protocol.

Results: The primary clinical outcome in IgAN patients will be either rapid-progression or slow/non-progression based on the rate of decline in eGFR during the three year follow-up. Association between levels of serum biomarkers and tissue biomarkers collected longitudinally will be correlated with clinical outcomes at follow-up.

Conclusions: References: 1. Chacko et al. Nephrology (Carlton) 10; 496-503 (2005). 2. Tanaka et al. Clin J Am Soc Nephrol 8; 2082-90 (2013).Sponsor: Early Career Fellowship; Wellcome UK Trust/ DBT India Alliance

177. Management and outcomes of emphysematous pyelonephritis- A study of 30 cases

Dr. Shakthi Kumar, Dr. Sampath Kumar K, Dr. Andrew D,

Dr. Adithya Nayak


Meenakshi Mission Hospital and Research Centre; Madurai

Background: Emphysematous Pyelonephritis(EPN) is an infection characterised by Gas in renal parenchyma and surrounding tissues; it is rapidly progressive ; requiring appropriate therapy to salvage the infected kidney.

Aim of the Study: To elucidate the clinical features; radiological classification and prognostic factors of EPNTo compare the modalities of management and outcomes among various radiological classes of EPN.

Methods: The present study was conducted among the patient s who were admitted between MAY 2015 to MAY 2016. 30 cases diagnosed as Emphysematous pyelonephritis were included in the studyThe baseline characteristics ; laboratory data ; Abdominal CT scan was taken.Based on CT scan staging ; Hydronephrosis(HDN)/Hydroureteronephrosis(HDUN)/Collection was managed with PCN/DJ stenting/PCD/nephectomy and results were noted.

Results: The mean age of our patients was 52 years with male to female ratio of 1: 1.2 .The most common predisposing factors was Diabetes mellitus(82%) followed by urolithiasis(14.7%). 5 patients had bilateral involvement .2 patients recieved antibiotics alone; 3 had an early nephectomy; 24 recieved PCD/PCN/DJ Stenting alone and one had delayed nephrectomy after initial PCD.Urine culture was positive in 22 patients. E.Coli was the most common organism isolated (15 patients); followed by Klebsiella(7 cases).blood culture was positive in 9 patients which were similar to urine culture.All were E.coli. The overall survival rate was 85%(26/30 patients).

Conclusions: our clinical experience and data suggest that early goal directed therapy with antibiotics and fluid resuscitation along with less invasive interventions such as PCD/PCN/DJS can provide alternatives to Nephrectomythere by attempting to salvage kidney and Nephrectomy resevered for morefulminant cases.

178. Deceased donor kidney transplantation in government medical college kozhikode- our experience

Smitha Vijayan, M. Sreelatha, T.P. Noushad,

E.K. Jayakumar


Government Medical College; Kozhikode

Background: Deceased donor kidney transplantation has been taking place in our centre since 2012.We have total of 30 transplant receipients.

Aim of the Study: To study the clinical profile of deceased donor kidney transplant recipients of our centre.

Methods: Details regarding recipient age; sex; cold ischemia time; native kidney disease; induction agent; delayed graft function; rejection; type of treatment; spectrum of infection; and other post transplant complications were collected and analyzed.

Results: Maximum number of patients are in the age group of 30-39yrs.The most common cause of native kidney disease is chronic glomerulonephritis followed by diabetic kidney disease.30% had delayed graft function and another 30% had slow graft function.10 patients had rejection; 11 had infection; 2 had renal artery stenosis; 1 had renal vein thrombosis; 2 had foot drop; 3 with post transplant diabetes mellitus.Patient survival was 90% and graft survival was 83% at discharge.1 year patient survival was 83% and graft survival was 80%.

Conclusions: In our study 33% had rejection; 37% had infection.Delayed graft function was present in 30%; slow graft function in 30%; immediate graft function in 40%. 1 year patient survival is 83% and graft survival is 80%

179. Glomerulonephritis with dominant c3 and long term remission with rituximab

Dr. Sonia Sharma, Dr. Ankur Gupta, Dr. Deepak Jain,

Dr. A.J Chitkara


Max Superspeciality Shalimar bagh

Background: C3 glomerulopathy is the term given recently to the pathogenesis where abnormal activation of the alternate complement pathway either acquired or inherited results in deposition of complement C3. It is observed that infection episode very often triggers the onset of diseases and results in persistent proteinuria despite trials of treatment and progress to chronic kidney disease. Presentation as crescentic glomerulonephritis even more severe and leads to early CKD.

Aim of the Study: We report here long term remission in crescentic GN with predominant complement C3 deposits in a young girl who clinically presented as post-infectious GN with AKI stage 3 as per AKIN criteria.

Methods: 8 yrs. - girl admitted with progressive generalized swelling and gross hematuria for 2 days. H/o mild cough and corhyza was present & passed 0.6 ml/kg/hr of urine in next 24 hr. On Ex: She had mild pallor; pitting edema & BP at 95th centile. Non-tender ascites noted & rest systems were within limits. Investigations revealed B.Urea:192 mg/dl; S.creatinine:4.2 mg/dl; albumin:2.7 gm/dl; cholesterol:192 mg/dl; urine r/m 3+ protein; plenty RBC; active sediments; urine protein/creatinine ratio:16; Hb: 8.6 gm/dl; TLC:17.5 thou/cumm; Platelets: 408600/cumm; Compliment C3: 66 mg/dL; C4: 39 mg/dL; ASO titer: 1532; ANA/ANCA/Procalcitonin: negative. Hence labeled with post-infectious GN. Due to persistence of significant proteinuria & deranged creatinine at 2 wks of illness; renal biopsy was done.

Results: Histopathology suggested that 97% glomeruli had cellular & circumferential crescents & 7/11 glomeruli showed fibrinoid tuft necrosis. IF suggested significant glomerular; mesangial & capillary wall C3 deposits. EM could not be done due to limitations. Induction with I.V methylprednisolone (20 mg/kg) was given for 3 days & then shifted to oral steroids. 375 mg/m2 of rituximab was given after consent explaining option for cyclophosphamide.After 4 doses of rituximab; significant drop of proteinuria to 3.7 gm/day & s. albumin: 2.9 gm/dL; urea: 65 mg/dL; creatinine :.45 mg/dL; normal C3 level were noted. Mycofenolate mofetil and steroid were then continued. Her proteinuria came to 0.5 gram/day in next 6 months and complete remission was achieved on low steroid doses & mycofenolate at 9 months of illness. She remained in complete remission now for 2.5 yrs. on maintenance therapy.

Conclusions: Long term remission in disease crescentic GN with dominant C3 deposits was encouraging and allowed us to report here.

180. Solitary kidney with ipsilateral cakut and anasarca

Dr. Sonia Sharma, Dr. Sanjiv Saxena, Dr. Atul Gosowmy


Max and PSRI Hospital

Background: Congenital solitary kidney with ipsilateral congenital abnormality in kidney and urinary tract (CAKUT) is not uncommon and usually progress to chronic changes earlier as compared to without CAKUT. Compensatory mechanism of hypertrophied nephrons initially maintains good function but persistence of abnormality results in their loss. Reporting here case of an infant who had right hydronephrosis with good functioning kidney and left multi-cystic non-functional kidney with sudden onset Anasarca.

Aim of the Study: To report a well growing child with Congenital solitary kidney; ipsilateral CAKUT and sudden onset Anasarca which subsided with timely surgical intervention.

Methods: 5 m/ boy/age appropriate anthmpometry & milestones presented with initial puffiness of eyes that progressed to anasarca. He had pedal edema & ascites. Rest of the systemic examination was within normal limit. Investigations revealed Urine Pr/creat : 2.6; Blood urea: 22 mg/dl; Serum creatinine:.2 mg/dl; Serum albumin 2.2 gm/dl; cholesterol: 298 mg/dL Hemoglobin: 9.5 gm/dL; Total leukocyte count: 7500 /cumm; Platelets: 3.5 lakhs/L. CMV serology was negative & TSH was within normal limit. History of antenatally detected gross right hydronephrosis and left multicystic dysplastic kidney was present. Micturating cystouretherogram was negative for reflux and function study done previously suggested partial obstruction. Right hydronephrosis was resolving with the growth of child. He also had an episode of urinary tract infection while on prophylactic antibiotic; 15 days prior to this present concerns and was treated successfully with oral antibiotic.

Results: USG (KUB) suggested right pelvis AP diameter of 12 mm. DTPA scan suggested right side PUJ obstruction with Time to max (T1/2) of 101 min. and GFR 82 and no uptake on left side. Considering significant max T ½; child had undergone right dismembered pyeloplasty (Anderson-Hynes) through an extraperitoneal; transverse; subcostal; muscle-splitting incision.Swelling disappeared on post op day 2 and subsequently proteinuria also disappeared completely on postop day 5 and Serum albumin came to 3.7 mg/dl during hospital stay. No recurrence in proteinuria is noted after 6 months of follow up till date.

Conclusions: Sudden and early appearance of anasarca never been reported in an infant with solitary kidney which disappeared completely with the timely intervention for PUJ obstruction. Case highlights the need of expert guidelines for surgical indications in Solitary kidney with CAKUT.

181. Effect of sensitization on graft outcome in live related renal transplant programe

Sourabh kuvera, Ravi Bansal, Rajesh Goel, Sanjev Saxena


Ushpawati Singhania Research Institute Press Enclave Road New Delhi

Background: Sensitization of renal transplant recipient because of blood transfusion; pregnancy and unknown factors are major hurdle in renal transplant.With availability of potent induction medicines it is believed that we can overcome this hurdle.In this study we tried to see the graft outcome in patients with varying degree of sensitization.

Aim of the Study: To see the effect of sensitization and induction medicines on graft outcome and post transplant infections.

Methods: This was retrospective observational study performed in a tertiary care hospital.We enrolled150 sequential renal transplant patients and collected data on baseline parameters and panel reactive antibodies(PRA).One year follow up for graft outcome ; occurrence of rejection and infectious episodes was done .Patients were divided into sensitized and non sensitized groups.Which were further divided into low sensitized(LS) PRA 4-≤10%; moderately sensitized (MS)PRA 10-50% and highly sensitized (HS)PRA>50% group.

Results: Out of 150 patients 28 were females and 122 were males. Mean age of recipients was 37 years and donor was 44 years. PRA was positive in 51 patients.Out of these; 25 were LS; 18patients were MS and 8 patients were HS. Non sensitized patients had higher mean GFR( 96.01±0.36 ; 83.5 ± 30.85) then sensitized patients(84.56±35.88; 71.11±26.33) at 1 and 6 month.(p<0.05).Among the sensitized patients the graft outcome was worse in HS group ( GFR 46.81±20.98) when compared to MS group (77.07±20.4 )and LS group(74.59±28.03) at 6 month (p<0.05).Inspite of receiving induction in 96.08% of sensitized patients versus 64.65% in non sensitized group ; outcome in sensitized patients was still worse at 1 and 6 months and this trend persisted to 1 year.

Conclusions: Sensitization is important marker of graft outcome .Inspite of using potent induction medicines graft outcome in sensitized patients remains worse.

182. Spectrum of renal injury in pregnancy induced hypertension: Experience from m.S. Ramaiah medical college

Dr. Saritha Suryadevara, Dr. E Mahesh,

Dr. Rakesh Madhyastha, Dr. Sujith Bande;

Dr. Gurudev K C, Dr. Gireesh M S,

Dr. Manns Manohar John


M S Ramaiah Hospitals

Background: Pregnancy Induced Hypertension is an important complication of late pregnancy and is an important cause of maternal and fetal morbidity and mortality. Data on clinical profile; especially renal profile of preeclampsia and eclampsia in Indian women is lacking.

Aim of the Study: The aim of our study was to examine the renal profile and clinical outcomes of patients diagnosed with PIH in our institution with focus on the spectrum of acute kidney injury.

Methods: n this prospective; observational study; 347 pregnant patients with a diagnosis of PIH were admitted to our institution from 2010-2014. M.S. Ramaiah hospitals; attached to M.S Ramaiah Medical College; are a major tertiary care referral center; catering to patient population from North Bangalore; state of Karnataka and adjacent states. Records were analyzed for demographic characteristics; obstetric history and clinical profile onadmission. Obstetric history included parity; history of antenatal follow up; location; nature of delivery; pregnancy; maternal and fetal outcomes. Patients with pre-existing diabetes mellitus; hypertension; chronic kidney disease defined as s.cr > 1.5mg/dl or presence of proteinuria > 1+ on dipstick or renal transplant recipients; contracted kidneys on ultaasound were excluded from analysis.

Results: Laboratory parameters were notable for AKI in 56 patients (16%). Oligo-anuria was seen in 42 patients (12%) and microscopic hematuria was notable in 32 patients (9%). Mean 24 hour proteinuria was 2.8 gm. Other significant laboratory parameters pertaining to PIH are mentioned in Table 2. In the 56 patients with AKI; 19 (34% of AKI cohort) required RRT. Persistent renal failure; either in the form of raised s.cr or persistent proteinuria was seen in 9 (2.5%) patients. Patients with persistent proteinuria were found to have various glomerulonephritides where as the incidence of cortical necrosis in this cohort was 1.1% (Table 3). In terms of other maternal outcomes; 164 patients (47%) required lower abdominal caesarean section. Fetal outcomes were notable for 12 intrauterine deaths (3.4%). Maternal mortality was 2.5% (9 patients) of which majority was attributable to sepsi.

Conclusions: In conclusion; PIH remains an important cause of maternal morbidity and mortality. Identification of high-risk population; close follow up and an integrated management between obstetricians and nephrologists are important for improving maternal and fetal outcomes.

183. The association of anticoagulation; ischemic stroke and hemorrhage in elderly adults with chronic kidney disease and atrial fibrillation

Vaibhav Keskar, Eric McArthur, Ron Wald, Ziv Harel, Deborah Zimmerman, Amber Molnar, Amit Garg,

Ngan Lam, Megan McCallum, Sarah Bota, Jeffrey Perl, Manish Sood


The Ottawa Hospital and University of Ottawa; Canada. Institute for Clinical Evaluative Sciences; Wald; Ron; St. Michael's Hospital; St. Michael's Hospital; Nephrology ; University of Ottawa; McMaster University; University of Western Ontario; University of Alberta Hospital; Medicine (Nephrology) Western University; Epimdemiology; Institute for Clinical Evaluative SciencesPerl; University Health Network-University of Toronto; Nephrology; University of Ottawa; Nephrology and Medicine

Background: Although well established in the general population; the clinical utility of anticoagulants for ischemic stroke prophylaxis in elderly patients with chronic kidney disease and atrial fibrillation remains uncertain.

Aim of the Study: To determine the association of anticoagulant use with ischemic stroke or hemorrhagic events in elderly patients with advanced chronic kidney disease and atrial fibrillation.

Methods: In this population-based retrospective cohort study using linked administrative databases from Ontario; Canada; we determined the association of anticoagulant use with ischemic stroke or hemorrhagic events in elderly patients (>66 years) with advanced chronic kidney disease (eGFR < 45/ml/min) and atrial fibrillation. We followed 6; 544 patients with chronic kidney disease and new onset atrial fibrillation; of whom 1; 475 (23%) filled a prescription for an anticoagulant from 2002 to 2015. We used propensity-score matched Cox proportional hazards model to determine the time to first event of ischemic stroke; hemorrhage or all-cause mortality.

Results: After propensity-score matching to examine exposure to anticoagulants; 1; 417 matched pairs were identified. The crude rates with/without anticoagulants for ischemic stroke were 41.3 and 34.4 and for hemorrhage were 61.3 and 34.3 per 1000 patient-years respectively. The hazard ratios of ischemic stroke; hemorrhage; and all-cause mortality for receipt of an anticoagulation prescription were 1.10 (95%CI 0.78-1.56); 1.42 (95%CI 1.04-1.93); and 0.74 (95% CI 0.62-0.88) as compared to non-receipt of anticoagulation. After accounting for the competing risk of death; the hazard ratios for ischemic stroke and hemorrhage were 1.12 (95%CI 0.90-1.39) and 1.60(95%CI 1.31-1.97); respectively.

Conclusions: In conclusion; in older patients with chronic kidney disease and atrial fibrillation; receipt of an anticoagulant prescription was not associated with a lower risk of ischemic stroke but with a higher risk of hemorrhage.

184. Peritonitis as the first presentation of disseminated listeriosis in a patient on peritoneal dialysis- A case report

Vaibhav Keskar, Weiwei Beckerleg, Jolanta Karpinski


Division of Nephrology; The Ottawa Hospital; affiliated with the University of Ottawa Faculty of Medicine; Ottawa; Ontario; Canada.

Background: Peritonitis is a leading cause of technique failure and mortality in patients on peritoneal dialysis (PD). Combination of vancomycin or cefazolin and aminoglycoside or ceftazidime is commonly used as initial empiric antibiotic therapy. Although appropriate for common organisms; this approach leads to treatment failure in peritonitis due to unusual organisms; such as Listeria monocytogens. In absence of appropriate antibiotic therapy; Listeria PD peritonitis can be life threatening.

Aim of the Study: We present a unique case of a Listeria monocytogens PD peritonitis associated with disseminated systemic infection.

Methods: A 59-year-old lady with ESRD due to diabetes presented with history of cloudy PD effluent. She was febrile but systemically well. Her abdomen was diffusely tender. The PD catheter exit site was clean and there was no tunnel tenderness. PD fluid cell count was 1541/mm3; with 70% neutrophils. She received IP vancomycin and ceftazidime. Within 24 hours; she developed altered level of consciousness. There were no signs of meningeal irritation. CT head was normal. CSF had elevated proteins (339 mg/dl); a high cell count of 1165 / mm3; with 58% being neutrophils. CT abdomen showed multiple hypodense lesions in the liver. Preliminary PD fluid cultures available by then showed gram-positive bacilli in peritoneal fluid. Infection with  Listeria monocytogenes Scientific Name Search nes was suspected because of no response to initial therapy. Due to history of penicillin allergy; IV sulfamethoxazole -trimethoprim was used for empiric coverage. The PD fluid and blood culture at 36 hours confirmed L. monocytogenes.

Results: IP ceftazidime and vancomycin were discontinued. The patient deteriorated despite treatment; and she required mechanical ventilation. After intubation; her antibiotic regimen was changed to IV ampicillin and gentamicin. There were no clinical features of allergy after administration of ampicillin. Despite appropriate treatment; the patient's general condition deteriorated. Care was withdrawn after the request from her family; and she passed away soon afterwards. L. monocytogenes is an intracellular pathogen rarely causing PD peritonitis. Most such cases are reported as isolated peritonitis episodes. In this case; peritonitis heralded a serious disseminated systemic infection in the form of sepsis; meningitis and possibly liver abscesses. First-line treatment for listeriosis is ampicillin in combination with gentamycin. Penicillin-allergic patients are treated with trimethoprim-sulfamethoxazole. Cephalosporins are ineffective and failure to respond to vancomycin has been documented.

Conclusions: We present a rare case of disseminated listeriosis presenting as PD peritonitis. This case underscores the rare limitation of conventional empiric antibiotic therapy. High index of suspicion is warranted in case of severe infections with gram positive bacilli.

185. To assess depression and anxiety in ckd patients undergoing maintanence haemodialysis

Dr. Arya Jith, Dr. Dinesh Narayanan


Department of Psychiatry; Amrita Institute of Medical Science; KochiAmrita Institute of Medical Sciences; Ponekkara; Kochi-682041

Background: Chronic kidney disease (CKD) encompasses processes associated with abnormal kidney function; and a progressive decline in glomerular filtration rate (GFR).A patient with CKD is more vulnerable to acting on feelings of depression; anger; hopelessness. A study from Japan reported a one-year 10.6 percent incidence of psychiatric disorders in dialysis patients.Major depression and anxiety were the most common.Major depressive disorder is a very common psychiatric disorder seen in CKD.

Aim of the Study: To assess the prevalence of depression and anxiety in CKD patients undergoing maintenance haemodialysis.

Methods: Cross sectional study using Hospital and Anxiety Depression Scale.

Results: Results are being analysed.

Conclusions: Results are being analysed.

186. A cross-sectional study of psychiatric morbidities in hemodialysis patients in a tertiary care hospital

Dr. SreeRag**, Dr. K. S. Arun Narayan Pradeep*, Dr. K. Krishnakumar**, Prof. R. Padmanabhan**,

Prof. M. Thiurnavukarasu;


M.d**Departments Of Psychiatry and **Nephrology Srm Medical College Hospital and Research Centre

Background: Various psychiatric morbidites have been reported in Hemodialysis(HD) patients.

Aim of the Study: To study the prevalence of Psychiatric Morbidity in HD Patients.To assess prevalence of Anxiety; Depression and cognitive function in HD patientsTo study Suicidal risk of patients on HD.

Methods: A total of 100 patients who were undergoing haemodialysis were randomlyselected for the study. Socio demographic and clinical details like diabetes; hypertension and alcohol use were collected.Following tools were used: Mini International Neuropsychiatry Interview; Mini Mental Status Examination; General Health Questionnaire; Hamilton Anxiety Rating Scale; Hamilton Depression Rating Scale; and Beck's Suicide Intent Scale• Over all time taken was around 1 hour for each patientAppropriate descriptive statistics were used.

Results: 37 patients gave history of alcohol use whilst 33 had diabetes and hypertension and 38 patients had hypertension aloneDepression was the most common co-morbidity noted in 74 (74%)Anxiety was seen in 59(59%) and Cognitive decline was noted in 29 patients(29%)Older age and diabetes were associated with cognitive decline but not with alcohol use or hypertensionSuicidal ideations were seen only in 9 patients and the intent is not severe.Seventeen patients had one of the psychiatric illness studied.Seventy eight patients had more than one psychiatric co-morbidity.

Conclusions: Psychiatric co-morbidity was seen in a majority of patients (95%) who undergo hemodialysis. This study shows that psychiatry morbidity is commonly seen in and adequately addressing them will go a long way in improving the quality of life of patients with CKD.

187. Rituximaab in steroid dependent/resistant nephrotic syndrome

Sooraj Y S, Georgy K Nainan, Vilesh K V


Cochin Kidney Centre; SA Road; kadavanthra; Kochi

Background: Despite the advances in Nephrology; Steroid Dependent/Resistant Nephrotic Syndrome (SD/RNS) remains a challenge to treat. The toxicity of long term steroids have been well documented. Drugs like Calcineurin Inhibitors (CNIs) have been shown to be of use but relapses happen in a number of such patients when the dose is reduced. Rituximaab is a newer agent which has shown much use in such situations. This is our experience with Rituximaab in patients with SD/RNS.

Aim of the Study: To study 1. The efficacy of rituximaab as an agent inducing remission in Nephrotic Syndrome2. To study its side effects.

Methods: 15 children (age less than 18 years) and 3 adults were included in the study. All were SDNS /SRNS who had undergone treatment with steroids; cyclophosphamides; CNIs; Mycophenolate but without response were included in the study.They were given Rituximaab of a minimum 2 doses and were followed up for a minimum duration of 3 months.

Results: The average duration of nephrotic syndrome was 67.2 +/- 41.13 months.. Renal biopsy was done whenever possible. 8 children and all 3 adults underwent renal biopsy . 7 children and 2 adults had MCN on biopsy and the others had FSGS. The parents of 7 children did not opt for renal biopsy. All of them received Rituximaab at the dose of 375 mg/sq.m body surface area. A minimum of 2 doses and maximum of 4 doses were given. They were then followed up for a minimum of 3 months. The average followup period was 7.56 +/- 3.42 months. The immunosuppression was gradually tapered and remissions were looked for. Out of the 18; all patients except one achieved remission. Another person had a relapse. But responded to an increase in steroids. Out of the 16 patients who achieved remission; we were able to stop steroids in 7 (38%). The other 9 (50%) are in varying levels of reduced immunosuppression with significant reduction in the steroid dose.

Conclusions: Rituximaab is a safe and effective therapeutic agent in patients with SDNS/SRNS. We were able to achieve a steroid free life in 38 % patients and significant reduction in steroid dose in 50%. However more studies and larger trials and longer follow up is required.

188. Renal tubular acidosis in sjögren's syndrome: A case series

limesh M, Dr. Renuka S


Department Of Nephrology; St.johns Medical College; Bangalore

Background: The exact frequency of renal tubular acidosis (RTA) in Sjögren's syndrome is unknown.

Aim of the Study: The aim was to retrospectively study the clinical features and outcome of RTA in Sjögren's syndrome.

Methods: The present study is a retrospective consecutive case series of patients who presented with a history suggestive of RTA and Sjögren's syndrome from January 2014 to May 2016. The diagnosis of RTA was by Arterial Blood gases analysis. The diagnosis of Sjögren's syndrome was according to the American-European classification system (modified by Tzioufas and Voulgarelis: Best Pract Res Clin Rheumatol 2007;21:989-1010).

Results: The total number of Sjögren's patients diagnosed during this period was 113. RTA occurred in 9.7% (11 of 113) of Sjögren's patients. The important symptoms and laboratory parameters were oral and ocular symptoms in 7 of 11 patients with Sjögren's with RTA; mean serum pH 7.12+/- 0.12; mean serum bicarbonate; 13.03 ± 2 mmol/l . Serum potassium was ranging between 1.5 to 2.8 mmol/L. All patients were treated with oral potassium and alkali solutions.

Conclusions: The clinical implication of the present study is that RTA is a common feature of Sjφgren's syndrome. It may be missed if the presentation is not due to oral and ocular symptoms.

189. Pregnancy related acute kidney injury - A single centre experience in rajasthan

Dr. Rajendra Singh Tanwar, Dr. Rakesh Kumar Gupta,

Dr. Pankaj Beniwal, Dr. Vinay Malhotra,

Dr. Dhananjai Agarwal


Department of NephrologySMS Medical CollegeJaipur SMS Medical College; Jaipur

Background: Pregnancy related acute kidney injurymay comprise upto 25 % of the referrals to dialysis centers in developing countries and is associated with substantial maternal and fetal mortality.There is a marked decline in the incidence of pregnancy related acute kidney injury over the past 50 years in developed countries as a result of improved antenatal care and obstetric practices. In contrast; it is still a relatively common cause of ARF in developing countries.

Aim of the Study: To study the clinical profile; management; outcome and to determine the factors predicting patient and renal survival in patients with pregnancy related acute renal failure.

Methods: All the Pregnancy associated AKI cases admitted in Department of Nephrology between August 2014 d and Feb 2016 were analyzed. Acute renal failure was diagnosed when there was oliguria (24 hour urine output < 400 ml) or anuria with serum creatinine elevated to > 1.5 mg %. Women with no history of oliguria or renal disease prior to gestation; normal sized kidneys on ultrasound and no urological complication were included in the present study.Detailed history; clinical examination and investigations were performed in all patientsSpecific inquiries were conducted regarding the mode of delivery; need for blood transfusion and surgical intervention. Renal biopsy was performed if a patient was oliguric or required dialysis at the end of three weeks; provided there were no contraindications and patients were ready to give consent. Patients who became dialysis independent with good urine output and renal function were discharged and followed-up every fortnight for three months.

Results: A total of 92 patients with mean age of 26.6 years were included. The main etiologies of pregnancy related acute renal failure were puerperal sepsis (68.75%); ante partum hemorrhage (26.08%); Pre-eclampsia/eclampsia/HELLP (16.3%) and post partum hemorrhage (10%). Acute cortical necrosis was seen in 6.52% (6/92) of patients. Death occurred in 26 cases (28.26%). Factors affecting patient survival were sepsis and DIC. Factor affecting renal survival was anuria at presentation.

Conclusions: Sepsis (73.3%) was the most common cause of Pregnancy related Acute kidney injury. Maternal mortality was seen in 28.26% of patients.Factors affecting patient survival were sepsis and DIC (p<0.05); whereas anuria on presentation was associated with poor renal survival (p 0.01).

190. Profile of glomerular diseases associated with hepatitis b and c-a single center study

Dr. Nishad Raveendran, Dr. Rajendra Singh Tanwar, Dr. Pankaj Beniwal, Dr.Vinay Malhotra


Department of NephrologySMS Medical College; Jaipur

Background: Hepatitis B and C associated nephropathies are one of the most common extra hepatic manifestations of hepatitis B and C. . Almost all forms of glomerulonephritis are reported with hepatitis B and C. The most important mechanism involved in the development of glomerular disease is immune complex mediated. In this retrospective study we analyzed clinical; biochemical; serological and pathological profile of 27 patients with hepatitis B or C infection.

Aim of the Study: To analyze clinical; biochemical; serological and pathological profile of patients with hepatitis B or C associated Glomerulonephritis.

Methods: Retrospective renal biopsy registry of 534 patients from2013 January from 2015 December were analyzed. The demographic; clinical; biochemical; serological and treatment data of the cases were analyzed by standard analytical methods.All the serological markers of Hepatitis B(HBsAg; HBeAg; IgM antiHBcAg and IgG antiHBcAg) and the Hepatitis B and C viral loads and compliment levels were also done in all cases. The kidney biopsies were studied by light microscopy using hemotoxylin and eosin; Congo red; Masson's trichome; period acid Schiff; silver methenamine stain and by Immunofuroscence for antibodies against IgG; IgM; IgA and C3. Immunohistochemical staining for serum amyloid -A was done in two cases of amyloidosis. Immunohistochemical staining for viral particles in biopsy specimens were not done. Electron microscopic studies were not done as the facility is not available in our centre.

Results: Among 534 biopsies available for analysis 16(2.9%) patients were hepatitis B surface antigen positive and 11(2.05%) patient were Anti HCV positive. Among hepatitis B patients; the most common morphological picture on biopsy was Membranous nephropathy (MN) which was seen in 6 of 16(37.6%) patients followed by Membranoproliferative glomerulonephritis(MPGN) and Focal segmental glomerulosclerosis (FSGS) (both 3/16 i.e. 18.75% patients). Two patients had IgA nephropathy and one patient each had amyloidosis and Minimal Change Disease(MCD) on biopsy. Among five patients with possible acute hepatitis B (HBsAg; HBeAg; IgM AntiHBc positive) and 2 each had MPGN and MN. Among patients who are probable chronic asymptomatic carriers (HBsAg; IgG AntiHBc positive; HBeAg negative) 40%(4/11) patients had MN on kidney biopsy.Among HCV positive patients; 5 out of 11 patients(45.45%) had MPGN and 4 of 11 patients(36.36%) had MN. One patient each had IgA nephropathy and amyloidosis in biopsy.

Conclusions: In our study the most common form of GN in hepatitis B positive patients were MN and in hepatitis C positive patients were MPGN. Our study also showed a relatively increased frequency of FSGS in hepatitis infected patients even though we couldn't ascertain a causative association for the same.

191. Identification of hemoglobin in organic matrix of surgically removed renal stones - A pilot study

Dr. Pragasam Viswanathan, Badrinathan S 1 ,

Yogita Mehra 1 , Karthikeyan A 2 , Pragasam Viswanathan 1 *

1 Renal Research Lab; Biomedical Research Centre; School of Biosciences and Technology; VIT University; Vellore - 632 014; Tamil Nadu; India; 2 Department of Urology; Sri Narayani Hospital and Research Centre; Sripuram; Vellore - 632055; Tamil Nadu; India

Background: Renal stone is an inorganic component with inner organic core known as stone matrix mainly constituting proteins that originate from various sources. Proteins embedded in renal calculi are mainly from renal origin and they are suspected to play an important role in stone formation. Apart from various crystal inhibiting proteins; various pathological proteins were also found to be embedded in the matrix.

Aim of the Study: Hence; the study was aimed to isolate and identify various urinary proteins from surgically removed renal stones.

Methods: Surgically removed human renal stone samples were obtained from 'Sri Narayani Hospital and Research Centre; Vellore (n=12). Inorganic analysis was done by X-ray diffraction; which analyses the mineral constituents based on their crystal structure without destroying samples. Collected renal stones were crushed and stone matrix was extracted. The protein and carbohydrate contents were estimated in the stone extracts. Proteins were separated in SDS-PAGE and presence of various normal and pathological proteins by staining with silver nitrate. ELISA was performed to identify haemoglobin chains and it was validated through mass spectrometric analyses.

Results: All 12 samples were identified as the calcium oxalate monohydrate (COM). In sample 19; a combination of calcium oxalate monohydrate and uric acid crystals were observed. All the samples were extracted for protein; but only from 8 of the 19 samples significant amount of proteins were extracted. We were able to find albumin; THP and transferrin based on comparison with the urinary macromolecules. Haemoglobin chains were identified in the stone matrix by sandwich ELISA and Mass spectrometric analyses revealed complete proteomic profile of the stone matrix and it was found that haemoglobin chains were found to be present predominantly in two samples.

Conclusions: Hemoglobin was found to be consistently present in almost all the samples; which shows that it can be a promoter of stone formation. Further studies on isolation and crystal aggregation property of haemoglobin have to be carried out to substantiate the role played by it in stone formation process.

192. Incidence and risk factors for HCV seroconversion in end stage renal failure patients on maintenance haemodialysis

Dr. Manik Kataruka, Dr. Kishan Lal Gupta,

Dr. Raja Ramachandran, Dr. R K Dhiman, Dr. Mini P Sngh


Post Graduate Institute Of Medical Education And Resarch

Background: Renal replacement therapy in the form of either dialysis or transplantation is the only option for end stage renal disease. Blood borne infections are the main concern for haemodialysis. Among these; Hepatitis B and C are of special concern due to their high incidence.This present study was undertaken to estimate the seroconversion rate and to identify the risk factors for seroconversion for Hepatitis C.

Aim of the Study: Incidence of seroconversion of HCV among newly initiated ESRD subjects on haemodialysis.To evaluate the risk factors for the HCV infection after initiation of haemodialysis.

Methods: All ESRD subjects newly initiated on hemodialysis at the Department of Nephrology; PGIMER; Chandigarh between January 2015 and October2015 were included in the study. All the subjects were initially screened for HCV and HBV serology status and subsequent HCV and HBV status on follow up at the end of 6 months and evaluated by standardized precoded history; questionnaires and biochemical and serological test like HCV-ELISA and HCV- RNA quantitative and HBsAg at the end of 6 months. Patients who have HCV or HBV serology positive before initiation of dialysis and those patients who had HCV infection and had attained sustained viral response after treatment and who had stopped dialysis or changed to CAPD within one month of initiation were excluded from study. Patients were dialysed in different dialysis centers at their convenience. Univariate and multivariate analysis was done to identify the risk factors for seroconversion.

Results: A total of 196 patients were recruited for the study after confirming seronegative status. At the end of 6 months; 61 patients lost to follow up and remaining were included for final analysis. Out of 135; 22 (16.3%) sero-converted to HCV RNA positive and 1(0.7%) patient turned out to be HBsAg positive. Presence of isolation room; isolated dialysis machine and isolated nursing staff was associated with significantly lower seroconversion in univariate analysis. Sharing of blankets found to be an independent risk factor higher seroconversion. Renal transplant; blood transfusion and dialyzer reuse was not associated with higher seroconversion. Serum AST and ALT levels were significantly higher in seropositive group. Out of 22 HCV RNA positive patients; only 5 were anti-HCV antibody positive. Anti- HCV antibody had shown moderate association to HCV RNA testing at the end of 6 months by kappa test.

Conclusions: HCV seroconversion was high (16.3%). Strict implementation of universal precaution rather than isolated dialysis machine and isolated room for seropositive patients can reduce seroconversion to HCV in patients on maintenance haemodialysis.

193. Clustering of non traditional cardiovascular risk factors in chronic kidney disease (CKD) patients with and without diabetes mellitus

Dr. Prabal Rajvanshi, Dr. Surendra Kumar Naik,

dr Gangadhar buduga; dr sahil arora


Vardhaman Mahavir Medical College And Safdarjung Hospital New Delhi

Background: Diabetes and CKD are both cardiovascular risk factors and very high mortality rates have been seen in diabetes kidney disease (DKD) patients that cannot be accounted by traditional risk factors alone;so with traditional; novel cardiovascular risk factors have been explored.

Aim of the Study: Aim of this study is to analyze clustering of these novel cardiovascular risk factors in predialysis CKD patients with and without diabetes mellitus in india.

Methods: In this study 160 adult CKD patients with diabetes who did not require dialysis and have eGFR <60 ml/min were randomly selected. Staging of these patients were done according to eGFR using MDRD formula. Novel cardiovascular risk factors including malnutrition and inflammation were analyzed.

Results: Out of 160 adult CKD patients 104 were males and 56 females. Mean age of study group was 48+-8 years. Characteristics of novel cardiovascular risk factors of diabetic CKD patients compared with non diabetic CKD patients were- Uric acid (8.74+-2.12 vs 7.82+-1.84; p<.05)Hscrp (6.10+-2.88 vs 3.88+-2.6; p<.05)Haemoglobin(8.21+-.92 vs 9.4+-1.38 p<.05)Phosphate levels(6.4+-1.2 vs 5.6+-.8; p<.05)Clustering of these risk factors were seen with atleast 3 of these risk factors present in 64.8% of CKD patients with diabetes.

Conclusions: There is clustering of non traditional cardiovascular risk factors in predialysis diabetes kidney disease patients that may explain the very high cardiovascular mortality in diabetes CKD patients.

194. Gauging awareness of ncd affliction; its impact on renal health and relation with nutritional status- A tertiary care hospital health survey

Dr. Nancy Sahni, KL Gupta, S. DT. Sunita Malhotra,

DT. S. Chowdhury, DT. L. R. Georg, Dr. Vivek Kumar


PGIMER; Chandigarh; INDIA

Background: In India; diabetes and hypertension today account for 40-60% cases of CKD. As per recent Indian Council of Medical Research data; prevalence of diabetes in Indian adult population has risen to 7.1%; (varying from 5.8% in Jharkhand to 13.5% in Chandigarh) and in urban population it is as high as 28%. Prevalence of hypertension in the adult population is 17% (14.8% from rural and 21.4% from urban belt). With rising prevalence of NCD's in India; prevalence of CKD is expected to rise.

Aim of the Study: To screen for obesity; diabetes; hypertension & its relation with renal disease; nutritional status amongst participants of a health checkup camp on occasion of world kidney day.

Methods: Out of 984 participants coming for screening in camp; 272 subjects qualified for analysis (mean age 44.90±14.89 years). Blood glucose; blood pressure; urinary albumin excretion; serum creatinine were evaluated along with nutritional status (BMI; nutritional intake via 24 hour recall; bio electrical impedance for fat mass& muscle mass).

Results: 24% of total subjects were renal patients (11% known renal; 13% diagnosed on spot); 34% diabetic (18% known diabetic; 16% diagnosed on the day of screening) & 50% hypertensive (21% known hypertensive; 29% diagnosed on the day). Of all renal patients 33% were diabetic and 36% hypertensive. 19% of the total renal patients were observed to be having diabetes along with hypertension.Obesity and excess energy intake from carbohydrates and fats was significantly more (p=<0.001**) amongst diabetics& hypertensive subjects. Muscle mass was significantly less (p=0.05) in renal patients as compared to non renal subjects. Positive correlation was found between BMI and energy intake via carbohydrates and fats as well as fat intake and body fat percentage (p=<0.01**).

Conclusions: Life style ailments like hypertension &diabetes are becoming the root cause for renal disease pandemic. Nutrition knowledge &awareness about the right diet along with other life style management techniques at grass root level is the need of the hour to curb NCD's and resultant kidney disease

195. Analysis of quality of life (QOL) in kidney transplant recipients

R. Vivek Praveen, S.A.K. Noor Mohamed,

Fathima Mufsina, M. Edwin Fernando, S.Thirumavalavan, N.D. Srinivasaprasad, S. Sujit, V. Abhinesh


Department Of Nephrology; Govt. Stanley Medical College and Hospital; Chennai; Tamilnadu

Background: WHO has defined QOL as; "An individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals; expectations; standards and concerns".

Aim of the Study: Study aims to measure Health Related QOL after kidney transplantation in socio-demographic; clinical and psychological aspects.

Methods: Study Design: It's a cross sectional single centre comprehensive type of study.Type of Study: Analytical type. Study Site: Department of Nephrology; Govt. Stanley Medical College and Hospital; Chennai; Tamilnadu. Duration of Study: 2 months (august and September of 2015). Study Population: Total of 52 renal transplant(live related and deceased donors) patients those who are attending post transplant op clinic in Govt Stanley hospital randomly selected; transplantation being done at least a year ago. Transplanted patients even after 15 years also showed up. Total population is divided into 2 groups.GROUP A = 1-6 years post transplantgroup b=more than 6 years transplant.

Results: Mean age=36.25years. Employment status of both the groups were comparable. Hours working per day is also reduced.40.4 % of people were engaged in jobs for 4-8 hours a day. Apart from severe infections; another indication which needs hospital admission is graft dysfunction. Health problems follows the order General (tiredness>pain>muscularweaknness).Mentalhealth(sleepdisorders>anxiety>depression). Changes in body modification ; Weight gain common. SF-36 SCORE Highest value among physical health components is achieved by bodily pain.Group B got higher scores in bodily pain as compared to group A. In mental health components; social functioning got highest value of all and group B score is higher than group A. Lowest value in physical health is for role physical lower score being carried by group A . Lowest in case of mental health components goes for role emotional group A having lower.

Conclusions:• female gender; unemployment ; not doing same job as before transplantation influence our group of patients.• systemic hypertension is the most common predicting factor.• Side effects in general health and mental health significantly affect quality of life.

196 Prevalence and risk factors for new onset diabetes mellitus after renal transplantation

Manokaran, Archana BM, Abhinesh V,

Vivek Praveen R, Jayanivash, Aishwarya,

Chandramohan G, Thirumavalavan S,

Noor Mohammed SAK, Srinivasaprasad ND, Sujit S, Edwin Fernando M


Stanley Medical College; Chennai-1; Tamilnadu

Background: New Onset Diabetes Mellitus After Transplantation (NODAT) is a conditionwherein; the patient develops diabetes mellitus after the transplant procedure. NODAT is an important factor that increases the cardiovascular morbidity and mortality ; the chance of graft rejection and graft infection which in turn causes reduction in graft function. this study was conducted to study the difference in pattern of NODAT between live related anddeceased donor renal transplant recipients.

Aim of the Study: To a) study the prevalence of NODAT among the patients who underwent renal transplantation b) assess the relevant risk factors contributing to the pathogenesis of NODAT.

Methods: The study was carried out by retrospective analysis of the data of patients whounderwent renal transplantation in Stanley Medical College; Chennai; from January 2012 toDecember 2014. The data analysed were: history of smoking; family history of Diabetes; native kidney disease; type and duration of dialysis; Hepatitis-B virus infection; Hepatitis-C virus infection; CMV infection; fasting blood sugar; lipid profile; urine routine; graft type; induction therapy; recovery of graft function; acute rejection history; immunosuppressant regimen. The data was analysed using SPSS version 16.

Results: N=115. The prevalence of NODAT was 22.6% (n=26The incidence of smoking was more in NODAT group comparedto the non NODAT group. In patients belonging to NODAT group; 23.08 %(n=6) had family history of diabetes; whereas in non NODAT group it was 1.12%(n=1). All 3 patients in the study group who had CMV positivity developed NODAT. Only few in the NODAT groupwere given induction therapy (n=4; 15.38%) . In the non NODAT group patients; majority of the patients were given induction therapy (n=25; 28.09%). There is increased incidence of acute rejection history inNODAT group (30.77%; n=8). 7 patients (26.92%) of NODAT group received pulsemethylprednisolone therapy versus15 (16.85%) in the non NODAT group . In patients belonging to NODAT group; the mean dose of tacrolimus is 6.65mg as against 5.89 mg in non NODAT group. In patients belonging to NODAT group; the mean dose of prednisolone is21.73 mg versus 18.76 mg in non NODAT group.

Conclusions: The prevalence ofNODAT was observed to be 22.6%. The following risk factors were found to be significantly associated withNODAT :age; smoking history; family history of diabetes; acute rejection history; post-transplant blood sugar levels; dose of tacrolimus; dose of prednisolone.

197. Prevalence of subclinical hypothyroidism in patients with chronic kidney disease

Aishwarya, Siva Somana J, Srinivasaprasad ND Sujit S,

Vivek Praveen R, Chandramohan G,

Thirumavalavan S, Noor Mohammed Sak, Jayanivash, Manokaran, Abhinesh V, Edwin Fernando M


Stanley Medical College; Chennai-1; Tamilnadu

Background: Subclinical hypothyroidism is found to be 4 - 10% prevalent in the general population. In the third NHANES participants; CKD was found to be associated with a higher prevalence of clinical and subclinical primary hypothyroidism. At present there is scarcity of Indian data about the prevalence and the factors associated with subclinical hypothyroidism in persons with non dialyticCKD.

Aim of the Study: 1.To evaluate the prevalence of subclinical hypothyroidism in patients with CKD.2.To study the correlation between thyroid dysfunction and the various stages of CKD.

Methods: This analytical study was conducted in nephrology clinic between Dec 2014 and May 2015. Study population consisted of 50 controls (healthy persons aged more than 20yrs who had master health checkup) and 50 CKD patients undergoing treatment for at least 6 months in nephrology clinic. The study population was tested for serum urea; creatinine; total protein; free T4 and TSH. GFR was calculated using MDRD formula. STATISTICAL METHODS: Students unpaired t test; Chi square test and Pearson coefficient of correlation were used.

Results: There exists significant difference in TSH; urea; creatinine; BP; total protein and eGFR values between cases and controls.50% of patients were in stage IV. Thyroid abnormalities are 42% among males and 24% among females. Prevalence of thyroid abnormalities increases as the duration of CKD increases. Thyroid abnormalities are found in 66% of CKD patients. SubclinicalHypothyroidism(SCH) was found in 6% of controls and 40% of cases. 6% of cases have lower FT4 values and 2% have higher FT4 levels. The TSH levels in CKD patients range from 0.14 to 30 mIU/ml. Among CKD patients the prevalence rates of SCH; hypothyroidism; subclinical hyperthyroidism and hyperthyroidism were 40%; 20%; 4% and 2% respectively. 34% of CKD patients have normal thyroid functionPearson's correlation coefficient shows that TSH varies directly with urea and inversely with eGFR and free T4 varies directly with eGFR and inversely with urea and creatinine.

Conclusions: 1. The prevalence of Subclinical Hypothyroidism is high among all the stages of CKD patients.2. The prevalence of thyroid abnormalities increases with increasing stage of CKD.

198. Biomarkers in preeclampsia - Are they good enough?

Abhinesh V, Monica K, Abhinesh V, Vivek Praveen R, Chandramohan G, Thirumavalavan S,

Noor Mohammed SAK, Srinivasaprasad ND, Sujit S, Edwin Fernando M, Vasanthamani, Srinivasa Raman


Stanley Medical College; Chennai-1; Tamilnadu

Background: Pre-eclampsia is a pregnancy-specific hypertensive disorder that may lead to serious maternal andfetal complications.Recently Soluble fms like tyrosine kinase(SFLT) and Placental growth factor(PlGF) and and the ratio between these two were found to be sensitive biomarkers.

Aim of the Study: To study the maternal biomarkers SFLT &PlGF in pregnant mothers to predict preclampsia.

Methods: Case cohort prospective study in the antenatal clinic.High risk normotensive normoglycemicpregnant women between 15 to 20 weeks of gestation were subjected to this study.Inclusion criteria included Primigravida; less than 20yrs ; elder more than 30; previous preeclampsia; BadObstetric history; Obese -BMI more than 30 .Exclusion criteria - prexistinghypertension; Chronic Renal Failure; multiple pregnancies; DiabetesMellitus; otherautoimmune diseases.Blood was drawn between 15-20 weeks for these biomarkers and patients were followed till delivery.The data was analysed using SPSS version 16.ROC curves were obtained and positive predictive and negative predictive value for the tests were obtained.

Results: 50 patients were studied; mean 5.4. 5 patients were lost to followup; 6 developed±age was 25 preclampsia by ACOG criteria of 2013.SFLT was done by ELISA and Time resolved fluoroimmunoassay by DELPHIA method was used forPlGF.Kits manufactured by Qayee - Bio.6 pts developed preeclampsia.None of these 6 patients had any abnormalities of the biomarkers.SFLT AUC 0.48CUT OFF 174.6SENSITIVITY 50.00%SPECIFICITY 49.70%PPV 52.60%NPV 48.40%ACCURACY 49.85%PlGFAUC 0.679CUT OFF 192SENSITIVITY 66.70%SPECIFICITY 56.40%PPV 56.50%NPV 44.20%ACCURACY 61.50%.

Conclusions: Novel biomarkers like SFLT andPlGF did not pick up preclampsia in the population studied.

199. Pattern of acute kidney injury and itsout come seen in medicalwards in atertiary care referral hospital

Jayanivash, Jennie S, Sujit S, Vivek Praveen R, Chandramohan G, Thirumavalavan S,

Noor Mohammed SAK, Srinivasaprasad ND, Abhinesh V, Jayanivash, Aishwarya, Manokaran Edwin Fernando M


Stanley Medical College; Chennai-1; Tamilnadu

Background: In hospitals requiring acute care admissions; Acute Kidney Injury (AKI) affects 5-7 % of patients. In critical units it accounts for 30 % of admissions. AKI is associated with a increased risk of death ; particularly in patients admitted to the critical care unit where the hospital mortality exceeds 50%.

Aim of the Study: To study the pattern of AKI seen in medical wards in our tertiary care hospital.To study the outcome of AKI .

Methods: Prospective observational study. We prospectively observed our patients hospitalized in our general medicine ward during January 2015 to August 2015 for any elevation in serum Creatinine as per KDIGO guidelines and symptoms suggestive of AKI. we excluded chronic kidney disease patients. Patients selected were subjected to symptom analysis ; clinical examinations; appropriate laboratory investigations and imaging. The outcomes of the study were analysed using multi variate logistic regression analysis to predict recovery in AKI.

Results: N= ±102 patients. 62% were males. Mean Age was 49.9 8.09. About 91 patients recovered (89%) and 11 patients deteriorated (11%). Majority of the recovered group patients belonged to the male gender (57.14%). In the deterioration group too sepsis was the major etiology (n=5; ; 45.45%). Hemodialysis was offered to (7.69%) 7 recovered patients and to 8 deteriorated patients (72.72%). Peritoneal dialysis was offered to 1recovered patient (1.1%) and to 1 deteriorated patient (9.09%). The risk of deterioration / non recovery in patients with AKI having peak s. Creatinine > 4.5 mg/dl is 4.29 times significantly more than in patients with AKI having peak s. Creatinine <4.5 mg/dl with statistical significance p-0.0039. the risk of deterioration / non recovery in patients with AKI having peak urine output values<400ML/DAY is 2.45 times significantly more than in patients with AKI having peak urine output values > 400 ml/day with statistical significance p-0.0450.

Conclusions: Common cause of AKI is sepsis.Among the patients who had AKI due to sepsis; Scrub typhus topped the listfollowed by Leptospirosis and Falciparum malaria.Higher values of serum creatinine at admission and oliguria were the most significant factors that contributed to non recovery from AKI.

200. Study on the incidence and outcome of acute kidney injury in patients with acute pancreatitis

Vivek Praveen R, P.uma Maheswari,

S. A. K. Noor Mohamed; M. Edwin Fernando, V. Abinesh;


Stanley Medical College; Chennai-1; Tamilnadu

Background: acute pancreatitis is a life threatening illness.when AKI occurs in the setting of acute pancreatitis mortality increases multifold.hence this study was conducted To determine the severity of AKI in these patients based on the KDIGO criteria; based on urine output and the serum creatinine level.

Aim of the Study: 1. To identify the incidence of AKI in patients admitted with acute pancreatitis.2.To assess the mode of management and outcome of the renal dysfunction in these patients.

Methods: STUDY DESIGN: Cross sectional study.STUDY PERIOD: January 2015 to June 2015CASE DEFINITION: Patient diagnosed to have acute pancreatitis clinically; based on the Atlanta classification. Presence of two among the following three criteria is considered.1. Abdominal pain suggestive strongly of pancreatitis2.Serum Amylase or Lipase activity at least 3 times greater than the upper limit of normal.3. Characteristic finding of acute pancreatitis on trans-abdominal ultrasound scan or CT scan.SAMPLE SIZE: 100 patients .Grouped into two 1)Acute pancreatitis (AP) with AcuteKidneyInjury(AKI) 2)AP without AKI.Pulse; blood pressure; urine output; blood urea; serum creatinine; blood sugar; liver function test; serum calcium and complete blood count checked for all patientsSTATISTICAL METHODS: The data was analysed using SPSS version 16.

Results: The incidence of AKI in Acute pancreatitis in this study was 32%.M:F-29:3. mean age of 41.97 years. Majority of the Patients who developed AKI were alcoholic (78.13%). The increased incidence of diabetes in AP with AKI Group compared to the AP without AKI Group is statistically significant (p-0.0041). In patients belonging to AP with AKI Group; the majority were alcoholics(n=27; 84.34%).Majority of the AP with AKI group patients had stage 1 according to the KDIGO guidelines (n=26; 81.25%) followed by stage 2 ( n=4; 12.50%) and stage3(n=2; 6.25%).93.75% patents managed conservatively; 2 cases needed hemodialysis; mortality was 12.50%..The increased mean serum creatinine; decreased mean urine output levels in AP with AKI Group compared to AP without AKI Group is statistically significant.The association between the study groups; Systemic Hypertension ; Smoking; Elevated Serum Amylase; Serum Lipase level not statistically significant.

Conclusions: One third of patients with acute pancreatitis developed acute kidney injury. Majority of the Diabetes mellitus and ethanol use were patients were in stage-1. significantly related with development of AKI. Dialysis support was required only in a minority of patients. Mortality was low.

201. Graft function and outcomes in deceased donor kidney transplant patients in tertiary care centre: our experience

Dr. S. Sujit, Dr. R. P. Senthil Kumar, Dr. S. Thirumavalavan, Dr. S. A. K. Noor Mohamed. M.edwin Fernando


Stanley Medical College; Chennai-1; Tamilnadu

Background: In India; more than 175; 000 individuals are diagnosed with end-stage renal disease (ESRD) every year. Among them; only 2.4% receive renal transplantation. One of the main reasons for the huge gap between demand and supply is the limited availability of live donors. Cadaveric renal transplantation may thus prove to be a potential solution for this problem.

Aim of the Study: To assess outcomes in cadaveric renal transplantation - patient/graft survival; graft function in terms of s. creatinine; rejection episode; post transplant complications.

Methods: We conducted a retrospective analysis of renal transplant patients (n=105) who underwent deceased donor renal transplantation in the period between January 1996 to March 2016 at Stanley Government Hospital; Chennai. All donors and recipients were ABO compatible and all recipients had a negative donor T-cell cross-match. Statistical AnalysisStatistical analysis was performed using R Software. Demographic characteristics were summarized with descriptive statistics. The Friedman test; a non-parametric alternative to the one-way ANOVA with repeated measures was performed to compare the serum creatinine on various time points. A p-value of <0.05 was considered statistically significant.

Results: N=105.81 men (77.14%) and 24 women (22.85%) were included in our analysis. The mean duration of our follow up was 38.14±46.41 months. Our recipient age ranged between 18-57 years. The mean age of donor was 33.51 (± 13.3) years. Main cause of brain death was road traffic accident (RTA) in 77 grafts (73.35). In house organ-41.First renal transplant-104. 21 of our grafts had double renal artery (20%). 8 of our patients had triple renal arteries (76.19%).). the mean Cold Ischemic times (C.I.T.) was 8.01 (± 2.73) hours in deceased donor renal transplantation. The mean serum creatinine levels were 2.43 ± 2.07 mg/dL at week 1 after transplant; 1.49 ± 1.05 mg/dL at month 1 and 1.24 ± 0.48 mg/dL month 6. Normal graft function in 56.19% (n=59) patientsTwenty nine (27.6%) patients expired during follow up.

Conclusions: One year survival of recipients was 75% and 89.58% for graft.the BPAR in our study was 17.14%.Our mortality rate was 27.6%.The majority of the deaths occurred within the early transplant period Sepsis contributed to the majority of mortality.

202. Modifiable risk factors to prevent cognitive impairment in indian predialysis chronic kidney disease patients

Dr. Prabal Rajvanshi, Dr. Gangadhar, Dr. Sahil Arora, Dr. Surendra Naik


Vardhaman Mahavir Medical College and Safdarjung Hospital; New Delhi

Background: cognitive and executive function impairment is common in predialysis CKD patients and occurs in even young patients. It is a major cause of morbidity. It impairs quality of life; hampers decision making and self management of patients. Although initially subtle but may herald future ; more debilitating impairment and increasing burden on caregivers. Hence modifiable risk factors for cognitive impairment needs to be identified.

Aim of the Study: To identify modifiable risk factors to prevent cognitive impairment in predialysis CKD patients.

Methods: 70 CKD as defined by K/DOQI guidelines (kidney disease outcome quality initiative group) having an estimated GFR (eGFR)<60ml/min/1.73sq.mrtre; who had not undergone renal replacement therapy at the time of presentation were chosen as subjects of the study. They were compared with equal number of age and sex matched controls were studied. Cognitive and executive functions of all cases and controls were assessed by using 6-item cognitive impairment test; MMSE (Hindi version); Trail making test-A and Trial making Test-B. All subjects were investigated extensively (complete hemogram; KFT; LFT; serum calcium and phosphate; vitamin D level; Blood sugar; Uric Acid; Lipid Profile; Serum Testosterone level; Urine routine microscopy; 24 hr Urinary protein; USG abdomen and ECG. Testosterone level (samples were taken at 9 Am after overnight fasting) was done by a solid-phase enzyme immune assay by XEMA kit.

Results: Serum testosterone mean value among cases was 1.94±1.17 and among control was 6.04 ±3.16 (p= 0.0005). Cognitive impairment significantly correlated with testosterone levels statistically (P value<0.005). Similarly; hyperuricemia was associated with cognitive impairment in patients of CKD. (HMSE P =0.0001; 6CIT P =0.043 & TRAIL A &B P =0.0001). vitamin D level in study group was 12.5±3.18 ng/ml with control group was 17.8±4.15 with significant association with cognitive impairment (P<0.01). Impairment of cognitive function did not correlate statistically with any other parameter in this study. Multivariate regression analysis revealed that hyperuricemia was the most important factor affecting cognitive function in predialysis CKD patients.

Conclusions: Early treatment of hyperuricemia; vitamin D deficiency and testosterone replacement therapy may go a long way in preventing the cognitive impairment in CKD patients.

203. Prevalence of depression; anxiety and insomnia in chronic kidney disease patients

H K Aggarwal, D Jain, G Dabas, P Chhabra


Pt BDS; University of Health SciencesRohtak -124001 (Haryana)

Background: Chronic kidney disease (CKD) is an emerging health problem in both developed and developing countries. Depression; anxiety and sleep disturbances are highly prevalent in patients with chronic disease; but remain undertreated despite significant negative consequences on patients' health. Assessment of key components of mental health early in disease course will help to identify high risk subjects in whom modifying these predictors will help in providing active and healthy life in CKD patients.

Aim of the Study: To study the prevalence of depression; anxiety and insomnia in chronic kidney disease patients.

Methods: This was a cross sectional study done in 200 patients of CKD stage III to V-D fulfilling the eligibility criteria who were on follow up in a single tertiary care center in the state of Haryana; India. We assessed the prevalence of anxiety; depression and insomnia and their correlation with demographic variables in these patients. The structured questionnaire used in this study gathered information on respondent demographic and disease characteristics; and information obtained from the HADS and PSQI questionnaire. Factors associated with anxiety; depression and insomnia were examined by multiple logistic regression analysis.

Results: The prevalence of anxiety; depression and insomnia were found to be 71%; 69% and 86.5% respectively. As the CKD stage advanced; the prevalence as well as severity of these parameters increased. Anxiety; depression and sleep quality were found to be significantly correlated to unemployment; low income; low education; urban residence and presence of co-morbidities. The anxiety; depression and insomnia scores were found to have a strong negative correlation with eGFR; hemoglobin; serum calcium (p <0.01) and a positive correlation with TLC; blood urea; serum creatinine and serum phosphate (p <0.05).

Conclusions: We observed a high prevalence of anxiety; depression and insomnia in CKD patients.By identifying CKD patients with high risk of developing these mental health related issues; healthcare provider may be better able to ensure the provision of appropriate rehabilitation to this population.

204. Evaluation of health-related quality of life in different stages of chronic kidney disease

H K Aggarwal, D Jain, G Dabas, P Chhabra


Pt BDS; University of Health SciencesRohtak -124001 (Haryana)

Background: Improved survival of chronic kidney disease (CKD) patients has led to an increased focus on health-related quality of life (HRQoL) for evaluating treatment effectiveness and assessing health outcomes of these patients.

Aim of the Study: To evaluate HRQoL in patients in different stages of CKD and to explore possible correlating and influencing factors.

Methods: Cross-sectional design with 200 patients from India in CKD stages 1-5 assessed for HRQoL through 36-item short form together with biomarkers. Patients were divided into four groups according to their estimated Glomerular Filtration Rate (eGFR); group A with GFR range>90 ml/min/1.73m2; group B with GFR range 30-59 ml/min/1.73m2; group C with GFR range 15-29 ml/min/1.73m2 and group D with GFR<15 ml/min/1.73m2.

Results:: HRQoL scores in all dimensions were impaired progressively and significantly across renal function levels and CKD stages. A statistically significant decreasing trend in physical composite summary and mental composite summary scores was found in patients from group A to D (P<0.001). Patients with eGFR<30 ml/min/1.73m2; Diabetes Mellitus; Cardio vasculardisease (CVD); C-reactive protein (CRP) ≥5 mg/l; Haemoglobin ≤ 90 g/l; erythrocyte sedimentation rate ≥ 20 and mean arterial pressure ≥ 100mmhg had significantly lower scores on all HRQoL dimensions. Among these CRP; reduced GFR and CVD were the most important predictors of impaired HRQoL.

Conclusions::Considering the worldwide growing prevalence of CKD and increasing importance of HRQoL in chronic diseases; improving our knowledge about HRQoL and its predictors in CKD patients is important.




 

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