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Year : 2017  |  Volume : 27  |  Issue : 7  |  Page : 18-117

Poster Presentations

Date of Web Publication8-Nov-2017

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How to cite this article:
. Poster Presentations. Indian J Nephrol 2017;27, Suppl S1:18-117

How to cite this URL:
. Poster Presentations. Indian J Nephrol [serial online] 2017 [cited 2020 Sep 22];27, Suppl S1:18-117. Available from:

  Poster Presentation – 15th December 2017 - 12.00-13.00pm Top

1. Our Experience with Direct Acting Antiviral in Treatment of Hepatitis C in Maintenance Haemodialysis Patients

J Nitin, S Renuka

St. Johns Medical College; Bengaluru; Karnataka; India

Background: Patients on haemodialysis have poor tolerance and outcomes to interferon based regimens used to treat chronic HCV infection. Direct-acting anti-viral agents (DAA) have yielded exciting results in treatment of hepatitis C with sofosbuvir as its backbone. However; sofosbuvir is not approved in dialysis patients as it is eliminated via kidneys and there are is insufficient data regarding its safety and efficacy.

Aim of the Study: To assess efficacy and safety of Sofosbuvir (SOF) -based regimens in treating chronic hepatitis C virus (HCV) infection in patients on maintenance haemodialysis.

Methods: This is a descriptive study. Patients with chronic HCV infection on haemodialysis were included in this study. Routine clinical and laboratory data including the viral load; genotype; liver fibroscan; and endoscopy were performed in all patients. Patients were started on either sofosbuvir (400 mg)/daclatasvir (60 mg)/day. Primary outcome was sustained virological response at 12 weeks.

Results: A total of 6 treatment-naïve patients were included. Mean age was 46+10.2 years; Majority were men (83. 3%). Most common genotype was genotype 1 in 4 of them (66.6%); followed by genotype 3 in the rest (44.4%). By week 12; all achieved a sustained virological response with no impact of genotype. Sofosbuvir was well tolerated and no patient discontinued treatment due to side effects.

Conclusions: Sofosbuvir (SOF) -based regimens are safe and have good efficacy for treatment of hepatis C even in patients on hemodialysis.

2. Spectrum of Biopsy Proven Renal Diseases in the Elderly: An Experience from a Tertiary Care Center from South India

Arivazhagan S, N Gopalakrishnan, T Balasubramaniyan, T Dineshkumar, N Malathy, R Shakthirajan, J Dhanapriya, V Murugesan

Madras Medical College; Chennai; Tamil Nadu; India

Background: In spite of the ever-increasing elderly population worldwide and in India; the reluctance for invasive procedures and the prevalent tendency for clinicians to attribute renal diseases to aging process have resulted in a paucity of data regarding clinicopathologic correlation of renal diseases in the elderly. Kidney biopsy may be invaluable in identifying potentially treatable diseases; therapeutic decision making and prognostication.

Aim of the Study: To study the spectrum of biopsy proven renal diseases in the elderly patients (≥60 years age) over a period of six years (Jan 2010 to Dec 2016).

Methods: Retrospective analysis of records of 248 elderly patients (9.12% of all native kidney biopsies) who underwent renal biopsy was done. The following data were analysed: Age; gender; biopsy indications; clinicopathologic diagnosis. They were classified into glomerular (primary and secondary); tubulointerstitital; vascular and unclassified.

Results: This demographic subset with mean age 65.59±5.63 ranging from 60 to 85 years were predominantly males (M:F 1.98:1). Unexplained renal failure (42.7%); Nephrotic syndrome (20.5%) and acute kidney injury (13.7%) were the most common indications. Glomerular and tubulointerstitial diseases accounted for 53% and 34.2% of all renal pathologies. Membranous nephropathy (30.6%) and FSGS (25.8%) were the most common primary glomerular pathologies while infection related glomerulonephritis (22.6%) and diabetic nephropathy (14.5%) were the most common secondary glomerular pathologies. Acute tubular injury (35%) and myeloma cast nephropathy (32.5%) were the most common tubulointerstitial pathologies identified. Pigment ATI accounted for 50% of tubulointerstitial pathologies. In the very elderly subgroup (≥75 years); unexplained renal failure (30%) was the most common biopsy indication while pigment ATI and IRGN were the most common pathologies.

Conclusions: This is the largest geriatric renal biopsy series from India and the first of such kind from south India. The diverse renal pathologies and high prevalence of potentially treatable conditions justify lowering the threshold for kidney biopsy in the elderly.

3. Investigation on In-vitro Tracking of GFP-Tagged Rat Bone Marrow Mesenchymal Stem Cells and their Differentiation Ability upon Recellularization of Decellularized Scaffolds from Cryopreserved Kidneys

Sanjeev Puri, Baldeep Chani, Veena Puri, Ranbir C Sobti

Department of Biotechnology; Centers for Stem Cell & Tissue Engineering; Systems Biology & Bioinformatics; Biotechnology Branch University Institute of Engineering & Technology; Panjab University; Chandigarh; India

Background: The field of tissue engineering is fast progressing. Optimizing the methodologies & tissue state are being largelytargeted. Recellularizing whole organ scaffolds generated through decellularization of cryostored kidneys is fastevolving. Mesenchymal stem cells form bone marrow are being exploited for differentiation into other cell types. Aprocess optimization through decellularization/recellularization of cryostroed kidney would pave the way forcombating tissue shortage crisis.

Aim of the Study: Tracking the rat bone marrow mesenchymal cells and their differentiation ability upon recellularization of dcelluarized kidneys scaffolds from cryopreserved kidneys.

Methods: Kidneys were harvested from a rat and then cryopreserved in cryoprotectant solution at liquid nitrogen. After 3 month's cryopreserved kidney were thawed and decellularized by perfused with 1% SDS solution for 3 days along with fresh kidney taken as control. Decellularization was confirmed by staining with Haematoxylin & Eosin staining and SEM. Mesenchymal stem cells isolated from rat bone marrow and characterized by flow cytometery analysis of stem cell marker CD 106. The presence of GFP was confirmed by fluorescence microscopy. Then decellularized scaffold were repopulated with GFP tagged mesenchymal cells and cultured for different time periods. Immunohistochemistry with pax-2 was performed to check the differentiation of repopulated stem cells.

Results: The fluorescence microscopy confirmed the presence of stable GFP expression in rat bone marrow derived mesenchymal stem cells following sub-culturing. Mesenchymal stem cells characterized by flow cytometry confirmed that cells were these cells were expressing CD 106 a stemness marker. The renal scaffold generated following decellularization was found to be devoid of cellular structure as observed by light microscopy and by SEM. The recellularization results demonstrated that decellularized kidney scaffolds supported GFP mesenchymal stem cells. The day wise in-vitro tracking results showed that these cells were proliferating and migrating into different parts of kidney. Immunohistochemistry results showed subsequent differentiation (pax-2 positive) of these cells in three dimensional environments.

Conclusions: Cryostored kidneys can be exploited for generating an ideal scaffold for renal tissue regeneration.

4. Comparison of Arterial Stiffness Between Diabetic and Non-Diabetic Chronic Dialysis Patients

Rajesh Kumar, Rachana Jasani, Virendra Gupta, Mohd Shah Alam, Viswanath Billa, Shrirang Bichu, Jatin Kothari, Paras Dedhia

Apex Kidney Foundation; Mumbai; Maharashtra; India

Background: Pulse Wave Velocity (PWV) is recognized as a marker of large artery stiffness. Type 2 diabetes is known to be associated with increased arterial stiffness which in turn is associated with increased risk of cardiac mortality.

Aim of the Study: The aim of this study was to compare the pulse wave velocity between diabetic and non-diabetic dialysis patients.

Methods: Patients >18 years age; undergoing chronic hemodialysis thrice a week were selected in this study. Pulse wave velocity was estimated from brachial cuff-based oscillometric device Mobil-O-Graph on non-fistula arm after dialysis session. Independent t-test was used to assess the difference between PWV of diabetic and non-diabetic patients.

Results: PWV was assessed in 138 dialysis patients. Their mean age was 56.0 ±13.2 and 80 patients were males and 58 were females. Mean dialysis vintage was 2.5±2.5 years. Their mean Body Mass Index (BMI) was 23.9 ±5.4 kg/m2. Their mean PWV was 8.8 ± 1.8 m/s. Out of 138 subjects; 69 were diabetic. The mean PWV of diabetic patients (9.3 ± 1.7 m/s) was significantly higher than that of non-diabetics (8.41±1.8 m/s; p-value:0.002).

Conclusions: Arterial stiffness was found to be significantly greater in diabetic dialysis patients. Interventions to reduce arterial stiffness in order to reduce the risk of cardiovascular mortality may prove to be beneficial especially in patients with diabetes.

5. Correlation Between Ambulatory Arterial Stiffness Index (AASI); 44 Hours Pulse Pressure and Brachial Cuff-Based Oscillometric Pulse Wave Velocity in Chronic Dialysis Patients

Paras Dedhia, Rachana Jasani, Virendra Gupta, Mohd Shah Alam, Viswanath Billa, Shrirang Bichu, Jatin Kothari, Rajesh Kumar

Apex Kidney Foundation; Mumbai; Maharashtra; India

Background: Arterial stiffness is recognized marker of cardiovascular disease and associated with adverse clinical outcomes.

Aim of the Study: Our aim was to find correlation between two surrogate indices of arterial stiffness namely AASI and 44 hours pulse pressure (PP) with pulse wave velocity (PWV) in chronic dialysis patients.

Methods: ABPM was performed for 44 hours in between 2 dialysis sessions beginning immediately post-dialysis. ABPM was recorded every 20 min during the day (7 am to 11 pm) and every 30 min during night (11 pm to 7 am). Ambulatory arterial stiffness index calculated by 1 minus the regression slope of the regression line of diastolic plotted against systolic from 24 hours ABPM readings. Pulse wave velocity was estimated from brachial cuff-based oscillometric device Mobil-O-Graph on non-fistula arm after dialysis session. 44 hours Pulse pressure was obtained from averaged hourly means from ABPM readings. Relation among variables was assessed by Pearson correlation coefficient (r).

Results: Of 40 patients; average age was 54.6 ± 11.6 years; 70% were males. Average dialysis vintage was 2.6±2.7 years. Average AASI was 0.49 ±0.16 and pulse wave velocity was 8.7±1.6 m/s. Average 44 hours pulse pressure was 67.5±14.3 mm Hg. There was modest correlation between AASI and PWV (r=0.37; p=0.01) and no significant correlation between PP and PWV (r= -0.03; p=0.81).

Conclusions: AASI correlated better than 44 hours pulse pressure with brachial cuff-based oscillometric pulse wave velocity in chronic dialysis patients.

6. Neuropsychiatric and Cognitive Profile in End Stage Renal Disease Patients on Hemodialysis and Peritoneal Dialysis in a Tertiary Care Center in South India

Athul Thomas, Santosh Varughese, Vinoi G David, Suceena Alexander, Anjali Mohapatra, Anna T Valson, Shibu Jacob, Kakde Shailesh Tulshidas

Christian Medical College; Vellore; Tamil Nadu; India

Background: Studies have shown a high prevalence of depression and cognitive changes in end stage renal disease (ESRD) patients on dialysis. There is little data available on the cognitive and emotional changes in these groups of patients.

Aim of the Study: To estimate the prevalence of Neuropsychiatric and Cognitive alterations in ESRD patients on hemodialysis and peritoneal dialysis and so establish burden of disease that is often unaddressed.

Methods: 60 selected ESRD patients undergoing either hemodialysis or peritoneal dialysis in the last 5 yrs in our center were included in the study. They were subjected to a 60 min battery of Mini International Neuropyschiatry Interview (MINI) and Montreal Cognitive Assessment (MoCA) which identifies disorders in the domains of Neuropsychiatry and Cognition respectively. Those subjects aged >18 yrs and <70 yrs were included in the study. Patients within 3 months of initiation of dialysis were excluded from the study. Also patients with diagnosed Cerebrovascular accidents and Neurodegenerative disease were excluded from the study.

Results: Our study revealed 21% prevalence of Neuropsychiatric disorders with alterations in the various domains of Mood disorder; Anxiety disorder and Psychotic disorders in ESRD patients on dialysis. Analysis of neurocognitive functions revealed 8% prevalence of Neurocognitive decline.

Conclusions: There exists a hitherto unknown but alarmingly high prevalence of depression and Anxiety in ESRD patients on dialysis. It is essential to screen and to make an early diagnosis and initiate treatment that may result in improved quality of life.

7. Higher Mean Ambulatory Blood Pressure Correlates with Mortality in Hemodialysis Patients

Gajanan Kale, Tarun Jeloka, Manish Mali, Rajesh Badani

Aditya Birla Memorial Hospital; Pune; Maharashtra; India

Background: There is no consensus on which blood pressure reading (pre-; post- dialysis or 24 hour ambulatory) is ideal for the target blood pressure in HD patients. Ambulatory BP Monitoring (ABPM) has been suggested as the best method to estimate BP for its better reproducibility; and a better estimate of the “true BP load” to which a patient is subjected. However; the superiority of this method in predicting target-organ dysfunction; morbidity; and mortality in end stage renal disease is still debated.

Aim of the Study: To study the correlation of mean ABP with mean pre and post dialysis BP; the prevalence of dipping pattern in mHD; and the correlation of mean ABP and dipping pattern with morbidity and mortality.

Methods: This was a prospective single center study. Inclusion criteria included all adult dialysis patients beyond 18 years of age and ≥ 3 months on dialysis and free of acute events within last 1 month. Patients non compliant to dialysis or drugs were excluded. At screening phase; all patients were subjected to fluid optimization assisted by bioelectric impedance analysis and adjustment in their blood pressure medicines. All participants were subjected to 44-hour ambulatory blood pressure monitoring after mid-week HD. Blood pressure measurements pre-; post-; and during HD were also recorded. Mean BPs over 44-hours were noted. The different dipping patterns were also noted. Morbidity and mortality of these patients were observed over a period of 6 months and association with mean ambulatory BP and dipping pattern was estimated.

Results: After meeting inclusion and exclusion criteria; 91 participants were eligible. Mean age of study population was 55.5 + 10.8 years with 69.3% males. Diabetes was prevalent in 47% and hypertension in 90%. Mean systolic and diastolic BP over 44 hours was 136.5 + 18.3 and 78.3 + 10.9. Mean pre- and post- HD systolic and diastolic BP was 147.2 + 16.5; 74.8 + 9.7 and 151.4 + 20.7; 77.8 + 9.2 respectively. The dipping pattern showed 51.6% patients were non dippers. Pre- HD BP correlated with ABPM. Post HD SBP only correlated with ABPM. Nine patients expired and 24 patients required admission for non access morbidities. Those who expired had higher mean ambulatory BPs (p 0.004) while dipping pattern had no correlation with morbidity and mortality.

Conclusions: Mean higher ambulatory blood pressure correlates with higher mortality in hemodialysis patients. There is high prevalence of non-dipping in dialysis patients but it does not correlate with mortality or morbidity.

8. Assessment of Peritoneal Membrane Characteristics and Adequacy of CAPD Patients in a Tertiary Care Centre in India

Jaiju James Chakola, M Jayakumar

Sri Ramachandra University; Chennai; Tamil Nadu; India

Background: Peritoneal dialysis (PD) is a well-established modality for treatment of patients with end-stage renal disease; giving excellent patient and technique survival rates. PD uses peritoneal membrane as a semi-permeable membrane for dialysis. Its properties and quality vary among individuals and also within the same individual over time. So it is important to regularly evaluate its characteristics in order to determine the most appropriate prescription for each individual patient.

Aim of the Study: To assess and compare the peritoneal membrane characteristics of Continuous ambulatory peritoneal dialysis (CAPD) patients in a tertiary care centre.

Methods: In this retrospective study patients initiated on CAPD between June 2012 to May 2017 were included. Patients were divided into two study arm among which group one patient were undergoing 4 exchanges per day and group two patients were performing 2 exchanges per day due to financial constraints. Clinically uremic symptoms; residual urine output (RUO); ultra filtration details was analysed. Peritoneal dialysis equilibration test (PET) and PD adequacy was done on all patients.

Results: In our study totally 170 patients were included of them 100 (59%) were males and 70 (41%) were females. The age ranged from 18 to 71 years with the mean age of 56.3 years. 128 (75%) were on 4 bag exchanges (Group 1) and 42 (25%) (Group 2) were on 2 bag exchanges. Over all PET results showed 75 (44%) high transporter; 43 (25%). High average; 27 (16%) low average and 25 (15%) were low transporter. The mean PD total Kt/v was 1.8 + 0.6 and 1.3 + 0.7 in group 1 and group 2 patients respectively. 26 (62%) Group 2 patients with good RUO (> 500 ml) had higher Kt/v than patients with poor RUO.36 (21%) patients had ultrafiltration failure during the course of the study.

Conclusions: Most of our study population were high and high average transporters. The PD Total Kt/v is high for patients with good RUO. Even on 2 exchanges per day patients were doing better with CAPD with good RUO. We need a large multi centre study to confirm the above finding in Indian population.

9. HDAC 2 Down-Regulate P-gp Expression in Idiopathic Nephrotic Syndrome

Mantabya Kumar Singh, Harshit Singh, Saurabh Chaturvedi1, Akhilesh Jaiswal, Vikas Agarwal1, Narayan Prasad

Departments of Nephrology and 1Clinical Immunology; SGPGIMS; Lucknow; Uttar Pradesh; India

Background: The action of glucocorticoids is to switch off activated inflammatory genes. The activated glucocorticoid receptors (GR) interact with co-repressor molecules to impair NFκB-associated coactivator activity; reducing histone acetylation; chromatin remodelling. Reduction in histone acetylation occurs via recruitment of histone deacetylase (HDAC) 2 to the activated inflammatory gene complex by activated GR; resulting in efficacious suppression of activated inflammatory genes within the nucleus.

Aim of the Study: To evaluate the effect HDAC 2 on P-gp expression.

Methods: Total 25 subjects are considered in the study out of which 10 are patients with SSNS; 10 are patients with SRNS and 5 are healthy control. The mRNA expression was analyzed on blood samples in SR patients (mean age 8.43±3.8); SS patients (mean age 7.54±3.5) with healthy control (HC) (mean age 4.13±3.37). Peripheral blood mononuclear cells (PBMCs) were isolated from heparinized blood. Total RNA was isolated using trizol method from PBMCs. Real time quantitative PCR was performed using light cycler LC480 using SYBR green PCR technology with SYBR premix relative gene expression levels were calculated and normalized to the corresponding levels of the housekeeping gene (GAPDH). HDAC activity is also performed to analyze the activity of HDAC2 in SSNS and SRNS patients.

Results: Biochemical parameters were found to be significant different in Serum Albumin (SSNS=2.97±.88; SRNS= 2.17±.89; p=0.017) and proteinuria (SSNS=18.18±2.09; SRNS=283±173.45; p<0.001). mRNA expression of HDAC2 in SSNS patients no significant difference is found with healthy control (p=0.9894); while in SRNS patients expression of mRNA is downregulated which is significant (p=0.0018). Expression of Pglycoprotein in SSNS patients is downregulated to compared with healthy control (p=0.004); while in patients with SRNS mRNA expression is upregulated which is significant (p=0.035) with Healthy Control.

Conclusions: HDAC 2 is down-regulated by P-gp at mRNA level in steroid resistant patients and restoration of HDAC 2 by inducers might lead to regulate the expression of P-gp ultimately leading to better management of steroid resistance patients.

10. Putative Association of Microrna SNPs with Differential Expression of Target Genes in End Stage Renal Disease

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

Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

Background: microRNAs (miRNA) are short non coding (22 nucleotide long) regulatory elements of innate and adaptive immunity; nearly 97% of kidney function involving the activities of miRNA. Single nucleotide polymorphism (SNP) in miRNA contributes to genetic risk by altering the expression and structural conformation of respective gene. This in turn may affect the vascularization and various cytokine signaling pathways which cause end stage renal disease (ESRD).

Aim of the Study: This study is meant to assess the genetic association of 9 miRNA SNPs with ESRD and to correlate the incidence of mutant alleles with corresponding target gene expression with ESRD.

Methods: 528 ESRD and 528 age; sex; and ethnicity matched controls were recruited for this study. Polymerase chain reaction-sequence specific priming (PCR-SSP) based genotyping was performed for nine miRNAs. Cyber green based real time PCR was done (n=30) to evaluate mRNA level of corresponding target genes. The relative expression level of mRNA was analyzed by 2-ΔΔCt method. Statistical analysis was performed using SPSS v. 21 (Statistical Package for Social Science; IBM; NY) and Graphpad Instat (Graphpad Software Inc.; La Jolla; CA).

Results: Significant risk associations were observed for mutant genotypes of miRNA150 (OR=4.05; p-value≤0.0001; CI=2.72-6.02); miRNA let7e (OR=2.82; p-value≤0.0001; CI=2.05-3.88); miRNA124a (OR=4.01; p-value≤0.0001; CI=2.10-4.69); miRNA198 (OR=2.56; p-value≤0.0001; CI=1.62-4.05); miRNA210 (OR=5.17; p-value≤0.0001; CI=3.22-8.30); miRNA192 (OR=4.64; p-value≤0.0001; CI=2.63-8.19); miRNA296 (OR=8.88; p-value≤0.0001; CI=5.61-14.04); miRNA23a (OR=5.54; p-value≤0.0001; CI=3.78-8.13); and Let7a (OR=2.49; p-value=0.0114; CI=1.2-5.10). The transcriptional analysis revealed elevated level of mRNA expression for CD4 (2 fold); STAT3 (3 fold); VEGFA (6 fold); MAPK9 (4 fold); CDKN2A (6 fold); and TGF-β1 (9 fold) whereas low level of expression was concurred for IL-8 and KRAS. FGFR1 showed no change in expression due to presence of mutant allele in miR198.

Conclusions: Individuals are susceptible to ESRD in presence of mutant genotypes of miR23a; Let7e; miR150; miR210; miR296 and miR192. Presence of such mutated miRNA genotypes may cause higher mRNA expression in their corresponding target genes namely CD4; STAT3; VEGFA; MAPK9; CDKN2A and TGF-β1 with ESRD.

11. PEW and its Association with Frailty in NDD-CKD

Dayanand, Alpana Raizada, Amitesh Aggarwal, Rahul Sharma, Rajarshi Kar

University College of Medical Sciences - GTB Hospital; New Delhi; India

Background: PEW is the loss of somatic and circulating body protein and energy reserves; a marker of disability and mortality in CKD patients and has a prevalence of 20-25% in early to moderate CKD which progresses with the stage of CKD. Frailty is common in CKD patients; and may be associated with PEW. Thus frailty and PEW in NDD-CKD patients have significant effect on morbidity and mortality in CKD patients.

Aim of the Study: To assess the occurrence of PEW among NDD-CKD pts using International Society of Renal Nutrition and Metabolism criteria and to study the association between PEW and frailty among NDD-CKD patients.

Methods: It was a cross-sectional study where 90 patients of NDD-CKD Stages I-IV aged 18-65 years were recruited and divided into three predefined subgroups of CKD based on eGFRcr calculated by CKD-EPI equations. Considering attrition due to follow up; 10% extra patients were recruited. At 6 months 30 patients lost to follow up; 96 patients with inclusion of 32; 31 and 33 patients in group 1; group 2 and group 3 respectively were recruited. Baseline demographic; clinical; anthropometric data; laboratory findings and frailty score were collected from 90 patients of the earlier study population were recorded. At 6 months; 66 out of patients were followed up for assessment of PEW assessment. To make up for sample size 36 patients were recruited extra and demographic; clinical; anthropometric and biochemical parameters were noted and frailty assessment was done using Fried's criteria. At 6 months; 30 patients could be followed up for assessment of PEW. The data was analysed using SPSS version 20.0.

Results: The study population included 56 females and 40 males with mean age of 47.6±13.3 years. The occurrence of PEW was noted to be 59.4%. The proportion of PEW in CKD group 1; 2 and 3 was 59.4%; 58.1% and 60.6% respectively. The occurrence of frailty was observed to be 30.2%. PEW was observed in 53.7% and 72.4% non frail and frail patients respectively. A significant association between PEW and frailty was not seen however a higher proportion of PEW was seen in NDD-CKD patients who were frail. A significant association of frailty with age; education status and groups of CKD was seen. The association of PEW with education status and Prasad's socioeconomic status was significant with higher proportion of PEW among illiterate and lower socioeconomic classes. Age; sex; religion; marital status; family type and financial dependence did not show any association with PEW.

Conclusions: PEW and frailty have a significant effect on CKD patients. The occurrence of PEW in NDD-CKD is high and the proportion is almost similar among different stages. PEW is more common in CKD patients with frailty. Prompt identification and management of PEW and frailty can improve clinical outcomes.

12. Good Outcome of Kidney Transplant in Diabetic Patients

Mita Shah, Prashant Rajput, Zaheer Virani, Pawan Deore, Bharat Shah

Global Hospital; Mumbai; Maharashtra; India

Background: Type 2 diabetes (DM); is the most common cause of end stage renal disease (ESRD). Kidney transplant is the best renal replacement therapy for ESRD. However; type 2 diabetics are older and frequently have co-morbidities. How do they do after kidney transplant compared to non-diabetics?

Aim of the Study: To assess the outcome of kidney transplant in type 2 diabetic and non-diabetic subjects.

Methods: All renal transplants performed from August 1; 2013 to June 30; 2017 at our centre were included. These patients were divided into 2 groups: diabetic and non-diabetic. In all patients (except HLA full match patients); induction immunosuppression used was single dose thymoglobulin (1- 2 mg/kg) or 2 doses of basiliximab (20 mg). Maintenance immunosuppression included tacrolimus; mycophenolate sodium salt or azathioprine and tapering doses of steroids. Patient survival; graft survival and incidence of acute rejection and infections was determined in both groups. Acute rejection was suspected when there was >20% rise in serum creatinine from the baseline which responded to empiric steroids or was confirmed on kidney biopsy.

Results: Out of 234 patients; 73 (31%) were diabetic and 161 (69%) were non-diabetic. The mean (1 SD) age of diabetic subjects was 52 (9) years while that of non-diabetic subjects was 38 (11) years. The 1 year and 3 years patient survival was 95% and 90% in diabetic subjects and 93% and 93% in non-diabetic subjects. The 1 year and 3 years death censored graft survival was 97% and 95% in diabetic subjects and 96% and 96% in non-diabetic subjects. Fourteen (19%) diabetic subjects had acute rejection episode while 42 (27%) non-diabetic subjects had acute rejection episode. Eight (11%) diabetic subjects developed TB after transplant while 6 (4%) non-diabetic subjects developed TB after transplant. Four out of 6 non-diabetic subjects developing TB had developed new onset diabetes after transplant (NODAT).

Conclusions: Our study shows that short term results (1 and 3 years survival) of kidney transplant in diabetic subjects are like that in non-diabetic subjects. The rejections risk is lower while risk of developing TB is higher in diabetic subjects.

13. Incidence; Spectrum and Outcome of Pulmonary Infection in Renal Allograft Recipient – A Single Centre Study

G Pramod, S Renuka

St Johns Medical College; Bengaluru; Karnataka; India

Background: Infections are most common cause of morbidity and mortality post renal transplant and the lung isthe most common organ involved. Pulmonary infectionin renal transplant recipients is associated with a highmortality rate. Early diagnosis and specific treatment is essential for successful management.

Aim of the Study: (1) to study incidence and spectrum of pulmonary infection post transplant; (2) to study outcome of these patient.

Methods: This study was a retrospective descriptive observational single centre study done between 1995 to 2015. Sixty one renal transplant recipient who presented with features of pulmonaryinfection were included out of 269 regular follow up patients. Inclusion criteria was (1) patient on regular follow up (2) those who were on same immunosuppression (3) also patient who had steroid responsive acute cellular rejection. Exclusion criteria (1) those who had ABMR (2) those who for changed from AZA to MMF or visa versa (3) those who were not on regular follow-up. All these patients transplant follow up records were studied retrospectively. Demographic data; nature of infection and duration post-transplant for occurrence of infection were studied. All patients with Pulmonary infections were diagnosed by performing CT scans and underwent BAL. Statistical analysis was done using SPSS version 19. Student t test was done for non-categorical variable and chi-square test for categorical variable assessed.

Results: Out of 269 transplants 61 people had pulmonary infections; among them 81 episodes of pulmonary infection occurred; of those 10 were deceased donor recipients and 12 episodes of pulmonary infections were seen in them and 51 were live related transplants and 69 episodes of pulmonary infections were seen in them; during a 120 monthsfollow up period. The mean age of our patients was 38.1±11.9 year. Males were 50 and 1 female. The incidence of pulmonary infection in our study population was 30.1% and 18 (35%) patients in live related group had more than one episode of pulmonary infection. The spectrum of infection was predominantly bacterial in living donor transplant recipient; that is 57 episodes were bacterial (82.6%); fungal 41 episodes (59.4%); viral 22 episodes of 69 (31.8%). In total 31 patients recovered and 20 (37.03%) patients died. Among the patients who died 11 patients had mixed infections; followed by fungal (5) and bacterial (4).

Conclusions: In our study; incidence of pulmonary infection was 30.1%; the most common infection was predominantly bacterial followed by fungal. Mixed infections constituted to the maximum mortality.

14. Quality of Life of Patients with CKD: A Cross Sectional Analysis from the ICKD Cohort

S Bhansali, G K Modi1, A K Yadav, V Kumar, N Prasad2, M Sahay3, S Parameswaran4, S Gang5, S Varughese6, Shivendra Singh7, Dipankar Sircar8, J P Ojha7, R Pandey8, Jha V9

Postgraduate Institute of Medical Education and Research; Chandigarh; 1Samarpan Kidney Institute and Research Center; Bhopal; Madhya Pradesh; 2Jawaharlal Institute of Postgraduate Medical Education & Research; Puducherry; 3Sanjay Gandhi Postgraduate Institute of Medical Science; Lucknow; 7Institute of Medical Science; Banaras Hindu University; Varanasi; Uttar Pradesh; 4Osmania Medical College; Osmania General Hospital; Hyderabad; Telangana; 5Muljibhai Patel Urological Hospital; Nadiad; Gujarat; 6Christian Medical College; Vellore; Tamil Nadu; 8Institute of Post Graduate Medical Education & Research; Kolkata; West Bengal; 9George Institute for Global Health; New Delhi; India

Background: Improving symptoms and function in daily life are important patient centered outcomes in chronic diseases. Health-related quality of life (QOL) is a key indicator of how a condition affects patient's life. QOL is expressed as across the physical; psychological and social domains of functioning.

Aim of the Study: We report QOL in patients with early stages of CKD who have been enrolled in an on-going longitudinal multicentric study of subjects with early CKD in India.

Methods: All subjects; who had been enrolled till June 30; 2017 and had KDQOL-36TM survey data recorded at baseline were eligible. QOL is assessed by KDQOL-36TM; a validated Kidney Disease Quality of Life Instrument (KDQOL; RAND Corporation); available free for non-commercial use. Raw scores are converted to subscale scores using the Microsoft Excel tool (KDQOL-36TM Scoring Program; v 2.0). Mental Component Summary (MCS); Physical Component Summary (PCS); Symptoms; Effect and Burden subscales were scored between 0-100; with higher scores indicating better quality of life. Age; sex; BMI; marital status; educational status; residential setting; diet pattern; occupational exposure; addictions; presence of diabetes or hypertension or CVD; annual income and eGFR were studied for association with QOL. Low QOL was defined as subscale score that was 1 SD less than the mean for the respective subscale.

Results: The mean scores for KDQOL-36TM subscales were 48.81±9.93; 44.17±9.49; 65.29±31.40; 81.31±24.70 and 86.68±21.43 for PCS; MCS; burden; effects and symptoms; respectively. Urban residence; non-vegetarian dietary pattern; education below high school; occupational exposure and lower income were associated with lower scores across all subscales (p<0.05). Professional workers had high score across all subscales compared to farmers; housewife and unemployed subjects (p<0.01). Increasing quartile of annual income was associated with higher scores in all subscales (p<0.01). Higher score for older age (p<0.0001) and females (p=0.001) were noted in PCS subscale. Low QOL was observed in 7%; 10.1%; 23.7%; 17.1% and 17.7% of study population with respect to symptoms; effect; burden; PCS and MSC subscales; respectively. Education below high school; lower eGFR; low annual income and BMI <18 kg/m2 were associated with low QOL in all subscales (p<0.01) except in symptoms subscale.

Conclusions: We identified the association between a number of clinical and socio-economic variables related and one or more KDQOL-36TM subscales.

15. Clinical Audit on Management of Clabsi

S Ramakrishnan, Kiran Chandra Patro, Anitha, Ram Prasad, Bhargavi, Dilip Rangarajan, Doctors, Infection Control Nurse

NU Hospitals; Bengaluru; Karnataka; India

Background: A random observation that some patients on hemodialysis (HD) with central line associated blood stream infections (CLABSI) in our unit had not received appropriate treatment for the same as required for the condition or/and as specified in medical record was the trigger for this study Bart Rijnders et al. Clinical Infectious Diseases 2003; 37; 980-983 - Compliance with IDSA guidelines for treatment of CRBSI poor - 56%; interventions will help in improving compliance.

Aim of the Study: To assess compliance with protocol for management of CLABSI in patients on HD AND to evolve mechanisms to improve compliance if it is not good.

Methods: Center: NU Hospitals a tertiary care Nephrology Urology centerStudy population: Patients on HD with CLABSI Study period: January 2017 till June 2017 data collection - Retrospective from medical records of study population Compliance includes (a) use of antibiotic as per antibiogram (b) for appropriate duration and (c) removal of existing central vein catheter (CVC) (in case CLABSI is caused by Staphylococcus aureus Scientific Name Search  or  Pseudomonas aeruginosa Scientific Name Search  the patient has manifestations of sepsis or the patient continues to be febrile despite appropriate antibiotic therapy) with replacement by a new one if there is need for continuation of dialysis Definition of CLABSI based on CDC guidelines rather than IDSA guidelines (practical issues in implementation of IDSA guidelines).

Results: 14 episodes of CLABSI in 11 patients - tunnelled CVC cause of CLABSI in 2; removed in 1 as the organism grown in blood was fungus; not removed in other as infection managed successfully with antibiotic alone 3 episodes resulted in events (2 deaths and 1 withdrawal) - censored for analysis of appropriate element 3 patients had 2 episodes of CLABSI (first episode was caused by Staphylococcus aureus in all three); 2 of them had not undergone CVC removal - 1 was not compliant with the advice; an attempt was made to cannulate arteriovenous fistula while the catheter was in place (though in vain) for the other patientAntibiotic use was as per antibiogram in 92% of episodes; Duration of antibiotic was appropriate only in 55% episodes: Compliance with CVC removal was 73%: Compliance with all 3 elements in only 45% patient effect – recurrence of CLABSI in 2; association with mortality in 2 measures taken – (1) involvement of ICN in follow up (2) mandatory consultant visit at least once.

Conclusions: Substandard compliance rate is mainly related to the predominant nature of patient population (on outpatient dialysis; financial constraints for change of CVC; having sessions in late evening or night when consultant's opinion is taken over phone etc.) Effective management needs greater attention.

16. Spectrum of Renal Abnormalities in Moderate & Severe Psoriasis

A Long Debated Association; Ishwarya Annamalai, Aishwarya Jawahar, Srinivasa Prasad, Sujith Suren, Edwin Fernando

Government Stanley Hospital; Chennai; Tamil Nadu; India

Background: Psoriasis is an immune-mediated chronic inflammatory disorder of the skin. Association with kidney disease has been debated for a long time. There have been case reportsof glomerular diseases like IgA nephropathy; Membranous nephropathy; Secondary Amyloidosisseen in association with psoriasis. Moderate to severe Psoriasis has been linked to CKDindependent of traditional risk factors.

Aim of the Study: To evaluate the prevalence and type of urinary abnormalities in patients with Psoriasis & determine whether urinary abnormalities are more prevalent in Psoriasis patients than in the control group.

Methods: Prospective observational study.100 patients with moderate to severe psoriasis (based on PASI Score > 10) on follow up at Dermatology OPD from Jan to July 2016 constituted the study population.100 equal controls were chosen. Patients were subjected toclinical examination; urine analysis; other appropriate lab investigations and imaging with Ultrasonography. Frequency analysis; percentage analysis were used for categorical variables and continuous variables were calculated using mean and standard deviation. Significance in categorical data were assessed using Chi-Square test. The data analysis was computed with IBM. SPSS 23.0 Version.

Results: 58% patients had disease for 3 to 5 years while 35% patients had disease for 6 to 10 years. Based on the PASI score 39% patients had moderate psoriasis while 61% had severe psoriasis. Chronic plaque type was the most common type of psoriasis. Patients with psoriasis and controls were not significantly different with respect to the prevalence of abnormal urinalysis; renal parameters. A slightly higher prevalence of moderately increased albuminuria seen in patients with severe; long standing psoriasis though not statistically significant (n=7 vs 6). 78% treated with methotrexate; 11% with biologicals; 3% with cyclosporine & 7% with only topical steroids &emmolients. All the urinary abnormalities in our study group was seen in patients on methotrexate. Patients receiving cyclosporine did not show urinary abnormalities as they were receiving cyclosporine only as a crisis buster.

Conclusions: The presence of abnormal urinalysis was not more common in patients with psoriasis than in controls. Some urinary abnormalities were observed in a minority; these patients require long term follow up.

17. Renal Resistivity Index in Chronic Kidney Disease: A Prognostic Indicator

Animesh Gupta, Arvind Gupta, Sarita Bajaj, Poonam Gupta, Piyush Saxena

Moti Lal Nehru Medical College; Allahabad; Uttar Pradesh; India

Background: Renal resistive index (RRI) measured by Doppler ultrasonography has been found to correlate with renal vascular resistance; filtration fraction and effective renal plasma flow in chronic kidney disease patients. RRI is associated with severity; rate of progression and mortality in chronic renal failure.

Aim of the Study: To evaluate the significance of the renal resistive index (RRI) as a prognostic indicator in Chronic Kidney Disease patients.

Methods: 100 patients with chronic kidney disease were enrolled in this cross- sectional observational study. Doppler examinations were performed in the segmental arteries; RRI was calculated from the blood flow velocities and estimated glomerular filtration rate (eGFR) was calculated using Modification of Diet in Renal Disease (MDRD) equation.

Results: In our study; with increase in age; decrease in estimated glomerular filtration rate (eGFR) and advanced CKD stages higher values of RRI were observed. Significant correlation between RRI and eGFR (P value <0.05) was established using Spearman Rank-Order Correlation Coefficient.

Conclusions: RRI correlated to the severity of the renal disease; as reflected by eGFR. Higher values of RRI were indicative of poorer prognosis in Chronic Kidney Disease patients.

18. Sofosbuvir Based Regimens in Treatment of HCV Infected Renal Transplant Recipients

Hegde Umapati, Damani Priyesh, Gang Sishir, Rajapurkar Mohan

Muljibhai Patel Urological Hospital; Nadiad; Gujarat; India

Background: HCV infection is common post renal transplant. Interferon based therapies were poorly tolerated. Newer antivirals are efficient and safe in renal transplant.

Aim of the Study: To evaluate safety and efficacy of Sofosbuvir based regimens in Renal Transplant patients infected with Hepatitis C virus.

Methods: This was a prospective observational study performed between March 2015 till May 2017. 46 patients consented & found suitable for the study; 34 patients -Post Transplant; and 12 patients were treated 4 week prior to transplant. Initially patients were given Sofosbuvir (400 mg) and various dose of ribavirin as per eGFR and weight. Later as Ledipasvir/Daclatasavir were available as per Genotype either Sofosbuvir+Ledipasvir (90 mg) or Sofosbuvir+Daclatasavir (60 mg) was used for 12/24 week. Liver function tests; Creatinine and Complete blood count; Viral Load was done every monthly and 12 and 24 week after completion of treatment.

Results: Genotype-1 (n-35); Genotype-3 (n-10) and Genotype-4 (n-1). 27 patients were given Sofosbuvir+Ribavirin; 11 patients-Sofosbuvir+Ledipasvir and 8 patients Sofosbuvir+Daclatasavir. Overall response rate Rapid virological response rate was 84.78%; End of Rx response -94% and Sustained virological response-95%. Graft Function remained stable creatinine increased from 1.31±0.54 to 1.46±1.02 (p-0.181). SGOT and SGPT decreased from baseline 81.89±74.66 and 97.83±90.49 IU/ml respectively to end of treatment level of 22.12±8.23 and 20.74±11.42 IU/ml respectively (p<0.0001). Total Billirubin Level decreased from 1.04±1.11 mg/dl at baseline to 0.62±0.24 mg/dl at end of treatment. (p<0.0001). Relapse was seen in Sofosbuvir + Ribavirin treated patients as Ribavirn was reduced due to hemolysis.

Conclusions: Newer Sofosbuvir based regimens are safe and effective in treatment of Hepatitis C infection in renal transplant patients and not associated with interactions with immunosuppressant drugs or adverse effect on graft function.

19. Expanding Role of 'Stand Alone' Hemodialysis Units in Chronic RRT

Benil Hafeeque1&2, Jyotish Chalil Gopinathan2, Sajith Narayanan1, Feroz Aziz1&2, Ismail Naduvileparambil Aboobacker1

1Aster MIMS Hospital; 2Iqraa Hospital; Kozhikode; Kerala; India

Background: Hospital based hemodialysis units (HDU) have been the major mode of renal replacement therapy (RRT) in north Kerala till 2009. Subsequently “stand alone hemodialysis” units (SAU) associated with hospitals were established to facilitate RRT provision near patients' residence. With the number of patients requiring hemodialysis (HD) increasing and hospital based dialysis units encountering limitations of space constraints and costs; SAUs have assumed prominence in chronic RRT in the region.

Aim of the Study: To describe the provision of HD in SAUs associated with two tertiary care hospitals in north Kerala focusing on patient volumes; costs and safety safeguards.

Methods: Data of patients undergoing HD in 2017 at the 15 SAUs associated with two tertiary care hospitals in Kozhikode were retrospectively collected from the 31st July 2017. Hospital records were reviewed for information on the number of patients dialysed in HDUs in 2008. Descriptive statistics were used for quantitative analysis of data.

Results: In December 2008 the two tertiary hospital HDUs provided 1400 sessions of HD catering to 180 patients. The total number of sessions of HD in HDUs was 3984 in July 2017 and 12198 in the 15 SAUs (75.3% of sessions). Satisfying prespecified criteria set by the nephrology team was a stipulation for patient selection to SAUs. All patients were prescribed three sessions of HD per week; compliance was near universal. Each patient was monitored with monthly lab work. Dialysis data was communicated electronically to the nephrology team daily from 20% SAUs. Mean nephrology visits to SAUs during 2017 was seven per month. Patients requiring treatment for significant illnesses or hospitalisation were required to be cleared by the nephrology team for resumption of HD at SAUs. The mean patient cost of treatment per session in 2017 was Rs. 1900 in HDU1 and Rs. 900 in HDU2 compared to Rs 520 in SDUs. Costs were further subsidised in SAUs through community generated resources and Government schemes.

Conclusions: Stand alone HD centers help improve access to adequate dialysis for carefully selected and monitored patients. Relatively lesser overhead and establishment costs in SAUs translate to lower patient costs of treatment. Innovative resource generation can help broaden reach of care further.

20. Prevalence of Vascular Calcifications in CKD Patients on Maintenance Haemodialysis and its Correlation with Occurrence of Vascular Disease Events

Fayaz Ahmad, Syed Tauqueer, Manju Aggarwal

Artemis Hospital; Gurgaon; Haryana; India

Background: Vascular calcification is commonly found in haemodialysis patients; and has been associated with adverse outcomes including cardiovascular events; and cardiovascular and all-cause mortality. The main objective of this study was to find the prevalence of medial vascular calcification in patients on maintenance haemodialysis using a simple and inexpensive radiological test for diagnosis; and to find its correlation with vascular disease events over a follow up period of one year.

Aim of the Study: Prevalence of vascular calcifications in CKD patients on maintenance haemodialysis and its correlation with occurrence of vascular disease events in these patients; over 1 year follow up.

Methods: In this prospective; observational; comparative; follow up; single centre study; patients on maintenance haemodialysis for more than three months were included. A simple vascular calcification score (Adragao score) based on X-ray of pelvis and wrists was used for the diagnosis of linear medial vascular calcification. The pelvic X-ray films were divided into four sections by two imaginary lines and those of wrists into four sections; two sections for each wrist. The presence of linear calcification in each section was counted as 1 and its absence as 0. The final score ranged from 0 to 8. Those with no vascular calcification were taken as controls. Vascular disease events included cardiac; cerebral and peripheral vascular disease. CAD was diagnosed if patient had angina; positive stress test; ACS; RWMA; PTCA or CABG. Cerebrovascular disease included occurrence of TIA; stroke or infarct. PVD was based on h/o claudication; Doppler studies; ischemic ulcers or amputation.

Results: A total of 71 patients with mean age of 62±11 years (45 M; 26 F; 37% diabetic); median HD duration 14 months (3 to 98) were studied. Prevalence of vascular calcification (score of ≥ 1) was 56%. It increased with age; 60% in those ≥ 60 years and 50% in those < 60 years. The severity increased with age; score of ≥ 4 was present in 39% of those > 60 years and 28% in those ≤ 60 years. Prevalence was higher in diabetics (92%) compared to non-diabetics (35%). Prevalence was higher in those with CAD at baseline (P- 0.009). Thirty one patients with no calcification served as controls. During a follow up of 12 months; there were 9 total vascular events including 5 new CAD events. All the events occurred in calcification group. All-cause mortality was 15% (6/40); one patient died of cardiac cause. There were no deaths in control group. Vascular calcification score (P-0.009) was independently associated with occurrence of vascular disease events over 12 months follow up.

Conclusions: Prevalence of vascular calcification was 56%. Diabetes and CAD at baseline were significantly associated with vascular calcification. Vascular calcification was independently associated with vascular disease events. High mortality seen in calcification group did not reach statistical significance.

21. Chronic Kidney Disease of Unknown Cause (CKDU) in Villages of Srikakulum District

H S Mahapatra, S K Agarwal

Department of Nephrology; AIIMS; Department of Nephrology; PGIMER; Dr R.M.L. Hospital; AIIMS; New Delhi; India

Background: Recent reports from the coastal district of Srikakulam of Andhra Pradesh have indicated a high prevalence of CKD of unexplained etiology. However; it is still a debatable issue about the prevalence; aetiology and pattern of Kidney disease in these areas.

Aim of the Study: This study was done to assess the pattern of CKDu and to evaluate managerial ongoing corrective measures to the existing medical facilities for the target population.

Methods: On the directions of Government of India; a central team visited these areas and a detailed house to house survey was done through a questionnaire in a village Gunupalli at Uddanam area. Services of medical officer working in district were utilized for doing survey. Past medical records and other information such as socio demographic profile; smoking; eating habits; alcohol consumption; agricultural practices; use of fertilizers and pesticide were recorded. Medicines; clinical status and family history were also recorded.

Results: Of the Srikakulum district; 58 villages in 7 PHC have reported CKD cases. In which <15 cases in 42 mandals; 15- 30 cases in 11 mandals and more than 30 cases in 6 mandals and three villages have reported more than 60 cases. The Gunupalli village is having a population of approximately 1300. Affected patients were mostly farmers with few symptoms and disease progression was insidious A total of 47 patients of CKD were found during the survey. Of 47; 34 (72%) were females. Mean age of subjects with CKD was 58.4 ± 13.5 (range 32-100 years). Mean age in males was 55.3 ±9.4 and in females was 59.6 ± 14.7 years. All females were house wife only. Of 47 patients; 27 (57%) were hypertensive; 11 (23%) were diabetics; 32 (68%) had known proteinuria. None of them had known renal stone disease. Of the 32 patients who had proteinuria; 8 were diabetic and 19 had hypertension. Mean last serum creatinine at the time of survey was 3.9 ± 2.1 (range 1.5-9.8 mg%).

Conclusions: At present no single risk factor could be considered directly attributable to the CKD in these areas. Certain cases are due to known diseases like DM and HTN. However; clustering of CKD cases in certain pockets needs further study.

22. Acute Pyelonephritis in Type 2 Diabetes Mellitus – A Single Centre Experience

Ishwarya Annamalai, Priyadharshini, Srinivasa Prasad, Sujith Suren, Edwin M Fernando

Govenment Stanley Medical College and Hospital; Chennai; Tamil Nadu; India

Background: Diabetes mellitus is a common predisposing factor for UTI. Diabetic patients are more prone for severe forms of UTI caused by resistant pathogens compared to the general population.

Aim of the Study: To analyze the clinical features; microbiological profile and treatment outcome of pyelonephritis in type 2 diabetic patients at our centre.

Methods: This was a hospital based prospective study. Patients hospitalized from October 2015 to October 2016 with a diagnosis of Type 2 DM with pyelonephritis were subjected to symptom analysis; appropriate laboratory investigations; imaging with ultrasonography and CT Abdomen. Results on continuous measurements are presented as Mean +/- SD and results on categorical measurements are presented in percentage & cell frequencies. SPSS version 20.0 used for data analysis.

Results: Majority of our study population was females (78%). 79% had non emphysematous and 21% had emphysematous pyelonephritis. Patients with emphysematous pyelonephritis had poor glycemic control. E. Coli was the most common organism isolated in both the groups. Renal dysfunction (Serum Creatinine >1.5 mg/dl) at presentation was present in 60.78%. A total of 16 patients overall required dialysis of which 1 patient with emphysematous pyelonephritis and 6 with non emphysematous pyelonephritis continued to remain dialysis dependent. Majority of patients with stage I & II emphysematous pyelonephritis were treated conservatively with antibiotics alone. 2 patients with stage IIIb & 1 patient with stage IV required nephrectomy. Mortality was 2.4% (n =2) in the non emphysematous pyelonephritis group & 14.2% (n= 3) in the emphysematous group.

Conclusions: A higher prevalence of culture positive Non emphysematous pyelonephritis noted among Diabetic females. Gram negative bacilli were the most common organisms implicated. Recurrence of pyelonephritis was noted in one fifth of study population. Majority had reversible renal dysfunction.

23. The Effect of Higher and Lower Protein Intakes on Nitrogen Balance in Renal Transplant Recipients with Underlying Graft Dysfunction

M Neha, Shah Rasika A Sirsat, Alan F Almeida, Jatin Kothari, Mayuri Trivedi

P.D. Hinduja Hospital and Medical Research Centre; Mumbai; Maharashtra; India

Background: Graft dysfunction may be attributable to rejection; infection and calcineurin inhibitor toxicity. Loss of nephron mass and high protein intakes lead to glomerular hyper-filtration; proteinuria and progressive loss of renal function. Low protein diet in CKD patients slows the progression of disease. Hence; it would be essential to determine the optimum protein intake in transplant patients so that neutral nitrogen balance is achieved without affecting disease progression.

Aim of the Study: To study effect of higher (1.2 g/kg/d) and lower (0.8 g/kg/d) protein intakes on nitrogen balance; body composition; GFR and proteinuria in renal transplant recipients with low eGFR (15–44 ml/min/1.73 m2).

Methods: This prospective; open-labelled; randomized; cross-over; interventional study enrolled 35 patients who were ≥ 4 months post-transplant and who had an eGFR between 15 – 44 ml/min/1.73 m2. Thirty-two patients completed the study. The subjects were randomised to either Group 1 [Diet: proteins (1.2 g/kg/day); 35 kcal/kg/day] or Group 2 [Diet: proteins (0.8 g/kg/day) and 35 kcal/kg/day] for one month. The subjects crossed-over to the other diet for the second month. The body composition analysis; sr. creatinine; blood urea nitrogen; sr. protein; sr. albumin; 24 hours proteinuria; GFR measurement (24 hours creatinine clearance); three day diet recall and nitrogen balance estimation were performed at baseline and at the end of the first and second months. Statistical analysis was performed using SPSS version 21.

Results: The three day diet recall showed that the daily protein and energy consumption was 1.2 g/kg and 36.47 kcal/kg with the higher protein diet and 0.94 g/kg protein with 31.94 kcal/kg with the lower protein diet. The nitrogen balance was positive with both the diets; +3.61 g/d with the higher protein diet (p=0.0002) and +1.66 g/d with the lower protein diet. The waist hip ratio showed a significant decrease on the higher protein diet (p=0.011) and increase on the lower protein diet (p=0.011). There was significant gain in muscle mass (0.70 kg gain; p=0.0317) after consuming the higher protein diet. Significant increase was noted in blood urea nitrogen (p=0.0118) and GFR (p=0.0114) with the higher protein diet. 24 hours urinary protein excretion increased significantly after consuming the higher protein diet (320 mg/d; p=0.010).

Conclusions: Renal transplant recipients remained in positive nitrogen balance with both diets. Muscle mass and proteinuria increased significantly with higher protein diet.

24. Borderline Cellular Rejection: Clinical Co-Relates and Impact on Graft Outcome

Soumita Bagchi, Geetika Singh, D Bhowmik, Sandeep Mahajan, R K Yadav, Adarsh Barwad, A Dinda, S K Agarwal

All India Institute of Medical Sciences; New Delhi; India

Background: The Banff classification of renal allograft rejection classifies biopsies falling short of Banff type 1 acute T cell mediated rejection as borderline cellular rejection (BCR). However; there is considerable ambiguity about the clinical implications and management of BCR.

Aim of the Study: To evaluate the clinical co-relates and outcome of BCR after RTX.

Methods: Renal transplant recipients diagnosed as BCR on graft biopsy in our department between May 2011 to May 2016 were included in the study. Demographic characteristics; details of immunosuppression; treatment given and subsequent clinical outcome were obtained from their medical records.

Results: Of the 680 indicated graft biopsies done during the study period; 45 (6.6%) biopsies in 40 patients were labeled as isolated BCR. Their mean age was 33.0±10.5 yrs and 82.5% were males. 13 (32.5%) patients had received the graft from a spousal/unrelated donor and one from a deceased donor. One patient had pre transplant diabetes. 13 (32.5%) patients had been given induction therapy (10-Basiliximab; 3- Anti thymocyte globulin) and one had an ABO incompatible RTX. All patients were on triple drug immunosuppression (IS) comprising of steroids (100%); tacrolimus (87.5%)/cyclosporine (12.5%) and mycophenolate mofetil-MMF (95%)/azathioprine (5%). Nadir serum creatinine was 1.3±0.2 mg/dl. The median time of diagnosis of BCR was 9.2 (0.2-100.6) months after RTX. 23 (57.5%) patients were diagnosed within 12 months and 17 (42.5%) after 12 months of RTX. 15 (37.5%) patients had evidence of suboptimal IS: 2-noncompliant to medications; 5-recent discontinuation of MMF due to adverse effects and 8- suboptimal tacrolimus trough levels preceding the BCR. The median follow up after diagnosis of BCR was 15.7 (1.7-71.2) months. 23 (57.5%) patients received anti-rejection therapy with intravenouspulse methylprednisolone. Of these 23 patients; serum creatinine improved to baseline in 11 (47.8%); stablised in 3 (13.1%) and worsened in 9 (39.1%). 10 (43.5%) patients who received anti-rejection therapy subsequently developed serious infections. Of the 17 patients who did not receive therapy; serum creatine improved in 4 (23.5%); stabilized in 4 (23.5%) and worsened in 9 (53%). Of the total 18 (45%) patients who had worsening graft function; 3 had graft loss. Repeat biopsies were done in 17 patients; with the following diagnoses: acute rejection (cellular/antibody mediated)-5; persistent BCR-4; calcineurin inhibitory toxicity-2; high interstitial fibrosis and tubular atrophy-5; membranoproliferative glomerulonephritis-1.

Conclusions: BCR has variable significance in patients with graft dysfunction. It may transform to acute cellular or antibody mediated rejection and also lead to chronicity with progressive graft dysfunction. Close monitoring is needed in these patients.

25. Spectrum and Timing of Occurrence of Infection in Renal Allograft Recipient Comparing (Cyclo/AZA Group 1 vs TAC/MMF Group 2)

G Pramod, S Renuka

St. Johns Medical College; Bengaluru; Karnataka; India

Background: Post renal transplant infections are common cause of morbidity & mortality. Occurrence and cause of infections depends on type of immunosuppression & their duration of intake.

Aim of the Study: (1) to study the spectrum of infection in both group (2) to study timing of infection occurrence in both group.

Methods: Ours was retrospective descriptive study done between 1995 to 2015. A total of 269 patients were recruited in study out total 359 patients who were regular for follow up. In this 151 patients were in Group 1 and 108 patients were in group 2. Inclusion criteria was patient on regular follow up and those who were on same immunosuppression and no induction given. All these patients transplant follow up records were studied retrospectively. Demographic data; nature of infection and duration post transplant for occurrence of infection were studied. Statistical analysis was done using SPSS version 19. Student t test was done for categorical variable and chi-square test for non-categorical variable.

Results: The mean age of patients in group 1 was 42± 12.3 and group 2 38±10.6. Males were more in both groups. Chronic glomerular nephritis was most common cause of CKD in both groups followed by Diabetic nephropathy. A verage follow up period was 144± 13.4 months in group 1 compared to 96±10.4 in group 2. 12 patients in group 1 had steroid responsive acute rejection compared to 7 patients in group 2. In group 1; 44 patients had NODOT as compared to group 2 which had 55 patients with NODOT. In group 1; aspergillus infection of lung was more & statistically significant as compared to group 2. Whereas in group 2 incidence of CMV infection and herpes zoster were more & statistically significant. Mean duration of occurrence of infection in group 1 was 60.35 months as compared to 33.5 months in group 2.

Conclusions: Our results showed in group 2 infections occurred early as compared to group 1. Viral in infections in group 2 were more and occurred early; where as in group 2 fungal in infection in lung was more and occurred average after 36 months.

26. Post Transplant Diarrhoea; An Experience from a Centre in South India

D Rajasekar, T Dinesh Kumar, J Dhanapriya, R Shakthirajan, N Malathi, V Murugaesen, T Balasubramaniyan, N Gopalakrishnan

Madras Medical College; Chennai; Tamil Nadu; India

Background: Diarrhoea in renal transplant recipient is common. It can be various etiologies including infectious and non-infectious causes. Each diarrhoeal episode can result in graft dysfunction and it's important to identify the cause for appropriate treatmentand studies on diarrhea in renal transplant recipients are sparse.

Aim of the Study: To study the risk factors and causes of diarrhoea in renal transplant recipients. Also study the impact of diarrhoea episode on graft function.

Methods: A retrospective analysis of 829 renal allograft recipient records who underwent transplant between January 2006 to July 2017 in Madras Medical College; Chennai. Patients with severe diarrhoea requiring hospitalization were included in this study. As per institution protocol all patients with diarrhoea had undergone investigations including stool microscopy; stool culture; stool for modified AFB and CMV serology and colonoscopy as indicated

Results: Post-transplant diarrhoea admissions of 127 (15.3%) patients were analysed. Among 127 patients with post transplant diarrhoea; 103 (81%) were males and 25 (19.7%) were females; The risk factors present were NODAT (34 [27.8%]); anti-rejection therapy (50 [39.3%]); induction therapy (30 [23.6%]) and leukopenia (43 [33.9%]). The incidence in patients with induction therapy was 25.6% (50/195). Immunosuppressive regimens were TAC-MMF in 65 (51.1%); CSA-MMF in 26 (26%); CSA-AZA in 14 (11%); MMF alone in 12 (9.4%) and AZA alone in 6 (4.8%) patients. The causes for diarrhoeacould be identified in 59 (46.5%) patients. Identified causes were CMV in 31 (24.4%) patients; protozoal causes in 26 (20.4%) patients and bacterial in 6 (4.7%) patients. E. Coli 2 (1.5%); Klebshiela 2 (1.5%); Citrobacter 1 (1%) and Shigella 1 (1%) were grown in faecal culture. Entamoebahistolytica 9 (7%); Strongyloides 5 (3.9%); Giardiasis 4 (3.1%); Cryptosporidium 4 (3.1%); Anchylostoma 3 (2.3%) and Cyclospora 1 (1%) were diagnosed by stool microscopy examination.

Conclusions: Diarrhoea is one of the important cause of post-transplant morbidity and graft dysfunction in renal transplant recipients. Even with hospitalized evaluation; in 53.5% cases the cause for diarrhoea remains undiagnosed. CMV colitis causes significant morbidity in our study.

27. Optimization of Treatment Modality in Elderly End Staged Renal Disease Populations: Peritoneal Dialysis Verses Transplant

Manas Ranjan Behera, Anupma Kaul, Rishi Kishore, B Karthikeyan, Dharmendra Singh Bhaduaria, Prabhakar Mishra, Narayan Prasad, Amit Gupta, Raj Kumar Sharma

Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

Background: Despite kidney transplantation (KT) being considered as the best treatment modality for end-stage renal disease (ESRD); patient and graft survival in elderly population is poorer than younger individuals. Many authors argue on prolonged life expectancy outweighing the risks of remaining on dialysis; but few data compare the treatment modalities especially peritoneal dialysis (PD).

Aim of the Study: To compare outcome of elderly ESRD patients; who received KT and those continued on PD; and to evaluate the predictors of patient survival.

Methods: A retrospective study was conducted between at a tertiary care institute between periods of January 2001 and December 2015; to compare outcome of elderly ESRD patients; who received KT and those continued on PD; and to evaluate the predictors of patient survival.

Results: Patient survival at 1 year was (76.2% vs 91.1%); 5 year (53.7% vs 21.8%); 10 years (35.6% vs 0.00%) among KT and PD population respectively. Infection was most common cause of death among elderly transplant population [35 (41.2%) vs 34 (28.2%)] while cardiovascular mortality in elderly PD population [55 (46.2%) vs 7 (8.2%)]. Multivariate analysis showed BMI (HR-0.88; 95% CI-0.82-0.93; p<0.001); and albumin (HR-0.55; 95% CI-0.37-0.80; p=0.002) were significant predictors of survival. Death censored technique survival in PD was 92.8%; 58.5%; and 0% at 1; 5 and 10 years respectively. Death censored graft survival was 98.7%; 90.2% and 90.2% at 1; 5 and 10 years respectively in RT recipients.

Conclusions: Though first 1 year patient survival is better in PD than KT; but after adjustment for BMI and albumin; both short term and long term survival in elderly KT group was better than that of PD. Hence absolute age should not be a bar to KT.

28. To Study Effects of Low Calcium Dialysate on Biochemical Profile of Adynamic Bone Disease in Patients on Maintenance Haemodialysis

Sourav Goyal, Vikas Makkar, P M Sohal

Dayanand Medical College and Hospital; Ludhiana; Punjab; India

Background: Adynamic bone disease has become most common type of mineral bone disease in patients of CKD. Benefits of low calcium dialysate in treatment of ABD needs to be weighed against possible side effects.

Aim of the Study: To assess the effects of lowering dialysate calcium on biochemical parameters and cardiovascular calcification in patients of adynamic bone disease on regular maintenance haemodialysis.

Methods: Detailed history with emphasis pertaining to CKD MBD. Detailed physical examination Diagnosis of adynamic bone disease - intact PTH levels less than 100 pg/ml - and/or bone specific alkaline phosphatse (BAP) levels less than 27 U/L. Vitamin D analogues -stopped atleast 3 months prior to start of study. Total number of patients- 40 Divided in 2 groups of 20 patients each. One group will be dialysed with LCD (low calcium dialysate) of 1.25 mmol/l second group of patients will be dialysed with normal calcium dialysate concentration of 1.75 mmol/l Biochemical parameters will be collected at 0 months; 3 months and 6 months. No change in dialysis therapy except dialysate calcium concentrationAll adverse related to hypocalcemia would be recorded.

Results: 40% were males in cases and 47% were males in control group; correction of adnamic bone disease is seen in 80% patients of cases group and 70% in control group; mean increase in PTH levels in cases was 73 pg/ml and 50 pg/ml in control group; rate of complications was more in cases group.

Conclusions: There was an evolution towards parameters reflecting higher bone turnover in patients treated with dialysate calcium of 1.25 mmol/l. LCD might be considered a valuable therapeutic option for ABD patients but complications should be carefully monitored.

29. Hepatitis B Vaccination in Chronic Kidney Disease: Experience in a Tertiary Care Centre

B Pradeep, K A Arun, S Gomathy, Usha Samuel, Arpitha Chouksey

Government T.D. Medical College; Alappuzha; Kerala; India

Background: The prevalence of HBV infection in Dialysis population in India ranges between 3.4-43% which is several folds higher than the carrier rate in general population. Among HD patients susceptible to HBV infection the two year seroconversion HBV infection was 38.9% accounting for 19 seroconversions to HBsAg positivity per 100 patient years.

Aim of the Study: (1) To study the proportion of seroconversion after Hepatitis B vaccination in chronic kidney disease patients. (2) To study the factors affecting seroconversion.

Methods: This was a descritptive study and collected data from 235 consecutive eligible patients who attended the outpatient department; Department of Nephrology Govt. T D Medical College Alappuzha; a tertiary care hospital in central Kerala; India during the study period from July 2015 to July 2016. The study was begun after obtaining approval from institutional research committee and ethics committee. All patients had undergone vaccination with recombinant hepatitis B vaccine 2 ml (40 microgram) intramuscularly in deltoid region total of 4 doses scheduled at 0; 1; 2; 6 months. All patients underwent vaccination from our own hospital where potency of the vaccine is ensured before each dose. The study included patients who were vaccinated in the preceding three years. Anti HBS titre was done from a single laboratory between 6 weeks to 12 weeks after the last dose of vaccine using a sensitive assay where we used a cut off of 10 IU/L.

Results: 83% of the patients were seroconverted with titre ≥ 10 IU/L. eGFR and and age are inversely correlated with the titre. Aetiology of CKD and gender has no correlation with the sero conversion status.

Conclusions: HBV vaccination should be started to CKD patients at the earliest preferably in the first visit itself as the seroconversion rate declines with progression of CKD.

30. The Profile and Risk Factors of Infections Requiring Hospitalization in the First Year After Renal Transplantation

Vikraman Gopalakrishnan, Soumita Bagchi, Sandeep Aggarwal, Dipankar Bhowmik, Sandeep Mahajan, Sanjay Kumar Agarwal

All India Institute of Medical Sciences; New Delhi; India

Background: Few studies have assessed the impact of infections in the first year after renal transplantation (RTX) in low and middle income countries.

Aim of the Study: We aimed to delineate the profile and impact of infections requiring hospitalisation (IRH) occurring in the first year after RTX in India.

Methods: In a single center cohort study; patients who underwent RTX between July 2012 and June 2015 were followed up for 12 months after transplantation to evaluate IRH.

Results: 387 patients were included in the study. 60% patients had atleast one IRH in the first year post-RTX with 413 episodes of hospitalisation and 492 infections. Urinary tract infections (30.3%); gastrointestinal (17.1%) and pulmonary (11.2%) infections were most common. Viral etiology (33.3%) was most frequent; followed by bacterial (23.6%); parasitic (5.1%); tuberculosis (4.5%); and fungal infections (3.9%). CMV (19.3%) was the most common virus and  Escherichia More Details Coli (11.2%) the most common bacteria identified. Mean monthly income per family member < 5000 Rupees (75 USD) (OR-2.38; p=0.018); new onset diabetes after transplantation (OR-2.22; p<0.003); and biopsy proven acute rejection (OR-2.99; p=0.046) were risk factors for IRH. One year patient and death censored graft survival among recipients who had IRH compared to those who had no IRH were: 91.8% vs. 98.1% (log rank= 0.010) and 97.3% vs. 98.7% (log rank= 0.376) respectively. 19 out of 22 (86.4%) deaths were due to infections.

Conclusions: IRH is the predominant cause of one-year mortality and graft loss after RTX in India. The profile of IRH is unique involving opportunistic; community acquired and endemic infections seen in this country. Poor economic status is an important determinant of IRH in our population.

31. Calculation of Kt/V in Haemodialysis by Daugirdas Method and by Online Clearance Monitoring

Vivek Praveen, Sujit Suren, S A K Noor Mohammad, N D Srinivasaprasad, K Thirumal Valavan, S Thirumavalavan, M Edwin Fernando

Stanley Medical College; Chennai; Tamil Nadu; India

Background: The adequacy of the Hemo dialysis has a profound effect on patient morbidity and mortality. The widely applied index to prescribe as wells as assess the dialysis dose is the Kt/V calculated using Daugirdas formula Kt/V (D). On-line clearance monitoring (OCM) is an alternative non-invasive measurement of Kt/V and might be a useful and cost effective tool for measuring dialysis adequacy.

Aim of the Study: To compare the Kt/V ratio obtained with the formulas of Daugirdas (D) with those measured by an Online Clearance Monitor (OCM).

Methods: Our study is a prospective observational study done in 50 CKD-V patients on Hemodialysis. All patients underwent HD through AV fistula access with blood flow rates between 200-250 ml/min and Dialysate flow rate of 500 ml/min. Kt/V (D) was calculated by measuring BUN twice (T1 and T2). T1 blood sample was obtained from the arterial line of the extracorporeal system within the 1st minute of dialysis (Pre Dialysis Sample). T2 sample was obtained after the prescribed dialysis time was completed and alteration of settings to UF rate of zero; blood pump speed to 100 ml/min for 20 seconds followed by stopping and Dialysate rate to zero. Kt/V (OCM) was obtained from the Fresenius 4008S HD machines equipped with Online Clearance Monitoring on the same day blood sampling.

Results: In our series (n=50); 33 were male patients (66%) and mean age was 38.74 ± 11.18. The duration of hemodialysis didn't have any statistical significance measured by Kt/V (D) and Kt/V (OCM). Independent sample t test showed that delivered Kt/V by brachio cephalic fistula was higher than radio cephalic fistula and p value was 0.01. The mean Kt/V measured by Daugirdas formulae was 1.53 ± 0.22 and Kt/V (OCM) measured by Online Clearance Monitor was 1.51 ± 0.21. Intra class correlation co efficient showed a strong agreement between both methods; r = 0.964.

Conclusions: In our study there is good correlation between Kt/V (D) and Kt/V (OCM). Online Clearance Monitor (OCM) is alternative methodology for daily use; to complement the other formulas in assessing the adequacy of the dialysis dose delivered.

32. Fibroblast Growth Factor 23 and Fetuin a Levels in Pre-Dialysis Stage 4-5 Chronic Kidney Disease Patients with and Without Aortic Calcification and Healthy Adults: Not what you Would Expect!

Anna T Valson, T S Vijayakumar, Betty Simon, John A Jude Prakash, Vinoi George David, Anjali Mohapatra, Suceena Alexander, Shibu Jacob, Shailesh Kakde, Santosh Varughese

Christian Medical College; Vellore; Tamil Nadu; India

Background: Circulating levels of factors that modulate vascular calcification (VC) play a role in determining individual susceptibility towards developing this complication. There have been conflicting reports regarding the association of Fetuin-A and VC.

Aim of the Study: The objective of the study is to study the levels of FGF-23 and Fetuin-A; two factors that modulate VC; in pre-dialysis CKD 4-5 patients.

Methods: Out of a pre-existing cohort of 710 pre-dialysis patients with CKD Stage 4-5; patients with AAC (Group 1; cases; n= 26) were compared with an equal number of age; gender and eGFR matched patients without AAC (Group 2; disease controls; n = 26) and voluntary kidney donors (Group 3; n = 22) with respect to their demographic and biochemical parameters; including FGF-23 and Fetuin-A. AAC in cases and disease controls was assessed by lateral abdominal X ray; while Fetuin-A and intact FGF-23 were estimated by ELISA in serum.

Results: Groups 1 and 2 were not significantly different with respect to risk factors for AAC such as presence and duration of diabetes; hypertension; smoking and obesity. Levels of calcium; phosphorus; PTH; 25 (OH) vitamin D; serum cholesterol; triglycerides; HDL and LDL were also comparable between the two groups. As expected; median FGF-23 levels in Group 1> Group 2 > Group 3 (p< 0.001). In contrast; median Fetuin A levels in Group 3 > Group 1 > Group 2 (p = 0.006) despite CRP levels in Group 1 and 2 being similar (p = 0.9).

Conclusions: Pre-dialysis CKD may be a transition period during which Fetuin-A may be upregulated in response to VC; leading ultimately to a stage of Fetuin-A deficiency.

33. Membranous Nephropathy Due to Chronic Mercury Poisoning from Traditional Indian Medicines

Manan Doshi, Rajeev A Annigeri, K C Prakash, B Subbarao

Apollo Hospitals; Chennai; Tamil Nadu; India

Background: Membranous nephropathy (MN) is the leading cause of nephrotic syndrome in adults. It is most often primary (idiopathic) which accounts for approximately 75% cases; while rest of the cases may be associated with various secondary causes. Here we report 5 cases of secondary membranous nephropathy caused by mercury poisoning secondary to chronic intake of traditional Indian medicines like Siddha and Ayurveda.

Aim of the Study: To evaluate mercury toxicity as a potential cause of secondary MN in patients on chronic traditional Indian medications like siddha and ayurveda.

Methods: All patients presented to Apollo Hospitals; Chennai with biopsy proven MN; Anti-Phospholipase A2 Receptor antibodies (Anti-PLA2R) negative and history of intake of traditional Indian medicines were evaluated for mercury poisoning as a cause of membranous nephropathy.

Results: Index case presented to us first with nephrotic and had biopsy proven MN. Anti-PLA2R antibody by ELISA was negative. The evaluation for common secondary causes of MN such as viral infections was negative. He retrospectively gave history of Siddha medications and on further investigations was found to have high urinary mercury levels. He was treated with dimercaptopropane-1-sulfonic acid (DMPS) and shown to have increased urinary excretion initially followed by disappearance from urine with gradual improvement in symptoms and stable renal functions. Hence high index of suspicion was observed when other 4 patients presented with biopsy proven secondary membranous with history of intake of indigenous medications and all were shown to have increased urinary mercury levels. One another patient was treated with DMPS with good response; while other were just observed off immunosuppression with variable response.

Conclusions: We suggest that MN with negative anti-PLA2R and history of traditional medicines; mercury induced MN should be suspected and investigated. Oral chelation by DMPS is effective and hence should be used as first line therapy in such cases.

34. Is Plasmapheresis Really Useful in Myeloma Cast Nephropathy

Jasmine Sethi, Raja Ramachandran, Vivek Kumar, Manish Rathi, H S Kohli, K L Gupta

PGIMER; Chandigarh; India

Background: Cast nephropathy is the most common cause of renal failure in multiple myeloma. The role of plasmapheresis (PLEX) in myeloma cast nephropathy is still controversial. This study was done to see the role of plasma exchange along with Bortezomib based chemotherapy in biopsy proven myeloma cast nephropathy.

Aim of the Study: This study was done to see the role of plasma exchange along with Bortezomib based chemotherapy in biopsy proven myeloma cast nephropathy.

Methods: A total of 20 patients with newly diagnosed MM and CN with persistent renal dysfunction (serum creatinine >2 times baseline or >2.0 mg/dL if baseline is not available) were included and given both PLEX (five sessions and 40 mL/kg persession) and bortezomib based chemotherapy. Patients were followed for a minimum period of 6 months. Seven patients were given only bortezomib based chemotherapy without plasmapheresis and served as control group.

Results: Mean age of entire studied population was 53.7 (30- 75) years. Male to female ratio was 4:5. Mean bone marrow plasmacytosis was 41.2% (range 7-98%). Eleven patients had light chain myeloma on immunofixation electrophoresis (10 kappa and 1 lambda); eleven had IgG myeloma (7 kappa and 4 lambda) and no band was detected in 2 patients. Out of 20 patients in PLEX group; 4 patients expired at the end of 6 months; 1 patient had complete renal response (serum creatinine <1.2 mg/dl); 11 patients had partial renal response (dialysis independent or decrease in serum creatinine >50%); 4 patients continued to remain on hemodialysis. Out of 7 patients in control group; 3 patients expired; 3 had partial renal recovery and 1 continued to remain on hemodialysis. Renal recovery was seen in 60% of patients in PLEX group and 42.8% in control group that was not statistically significantly different between two groups. (p=0.4).

Conclusions: There was no statistically significant difference between outcomes of patients who were treated with chemotherapy alone vs chemotherapy with PLEX. However the differences could have been statistically significant if the sample size was larger.

35. Prevalence of Immediate Post Transplant Anemia in Patients Undergoing Renal Transplantation at a Tertiary Care Centre in Kerala

Surabhi Talwar, Rajesh Nair, George Kurian, Anil Mathew, Zachariah Paul, Sandeep Sreedharan

Amrita Institute of Medical Sciences; Kochi; Kerala; India

Background: Kidney transplantation is a renal replacement modality for patients with ESRD. Various studies investigate anemia in patients with chronic kidney disease (CKD. However; studies of the prevalence and clinical relevance of posttransplantation anemia (PTA) are scarce. There is a large variablility in its prevalence in studies- 20 to 70%. Recent research mainly focuses on anemia in early (3-6 months) or late (>6 months) post-trasnplant period. Very less is known about PTA within the first 3 months.

Aim of the Study: To determine the prevalence of immediate post-transplant anemia in patients undergoing renal transplant at our tertiary care centre and to determine the possible associated factors.

Methods: It was a prospective cross-sectional study. 30 consecutive patients who underwent live renal allograft transplant at our centre were included in the study and were followed up for a period of 3 months post-transplant. Hemoglobin was recorded weekly after transplant for the first 3 months. Erythropoeitin levels were recorded pre and post-transplant. Other workup for anemia was done as per requirement; like; peripheral smear; LDH; Iron and ferritin levels; etc. Graft function and S. Tac levels were monitored.

Results: The prevalence of anemia in our subset of population; within 3 months of transplant was 80% (n=24). 40% of the patients who had anemia received treatment for the same. The main treatment received was in the form of packed red cell transfusion which was mainly within the first week of transplant. In our study; there was no association of anemia with age or gender of the recipient. It however correlated with ferritin levels and low hemoglobin levels prior to transplant (p<0.01). It was also associated with use of Anti-thymocyte globulin for induction. However there was no significant relationship with use of Mycophenolate Mofetil/Azoran for immunosupression. Also; it was found to be significantly associated with episodes of acute rejection and duration of hospitalisation post-transplant. There was no significant relationship of anemia with surgical blood loss as the amount of blood loss during surgery was almost similar in all the patients (<1 litre).

Conclusions: The prevalence of post-transplant anemia (<3 months) in our subset of the population is 80%. It was found to be independently associated with poor iron stores prior to transplant; duration of hospitalisation; episodes of rejection and agents used for induction. There was no association with age & gender.

36. Characteristics and Outcome of Postpartum Acute Kidney Injury Requiring Dialysis: A Single Center Experience from North India

Vinay Rathore, Rajendra Singh Tanwar, Dhananjai Agarwal, Rakesh Kumar Gupta, Pankaj Beniwal, Parvati Joshi, Vinay Malhotra

SMS Medical College; Jaipur; Rajasthan; India

Background: Postpartum acute kidney injury (AKI) is one of the serious complications of pregnancy and is associated with high mortality and morbidity.

Aim of the Study: To determine the characteristics and outcome of postpartum AKI requiring dialysis.

Methods: This prospective observational study was conducted in Sawai Man Singh (SMS) Medical College; Jaipur. All postpartum female suffering from AKI requiring dialysis between July 2014 to December 2016 were included in the study. Demographic; clinical and laboratory data of the patients were recorded. Outcome variables included “survival at hospital discharge” and “estimated glomerular filtration rate” (eGFR) at three months of follow-up.

Results: Sixty (88.2%) out of 68 women admitted with postpartum AKI required dialysis. The mean age was 26.5±4.3 years and the majority (80%) had institutional delivery. The mean Sequential Organ Failure Assessment (SOFA) score was 8.0±2.9. Puerperal sepsis (n=37; 61.6%.); preeclampsia (n=21; 35%); and antepartum hemorrhage (n=14; 23.3%) were the most common obstetric complication associated with postpartum AKI. Maternal mortality was 28.3%. Higher SOFA score (9.9±3.2 vs. 7.1±2.2; p=0.001) and diagnosis of sepsis (82.3%vs 53.4%; p=0.038) were associated with mortality. Out of 37 patients who were followed up at three months; 51.3% had eGFR <60 ml/min/1.73 m2. Duration of anuria (in days) predicted eGFR <60 ml/min/1.73 m2 (10; IQR: 6-18 vs. 5; IQR: 4-7.25. p=0.029).

Conclusions: Postpartum AKI requiring dialysis was associated with high mortality. More than half of the survivors had eGFR <60 ml/min/1.73 m2 on follow up highlighting the need of appropriate follow-up.

37. Efficay of Abo Adsopak® Columns in Reducing ABO Antibody Titers

Jitendra Khandge, Prashant Rajput, Zaheer Virani, Bharat Shah

Global Hospital; Mumbai; Maharashtra; India

Background: Before performing ABO incompatible kidney transplant it is important to achieve low anti-blood group antibody titers (ABGAT). In those with high baseline titers; plasmapheresis may not achieve adequate drop in titers and immunoadsorption columns may be required. These columns are expensive and cost goes very high if multiple columns are used. Recently; a new; reusable column [abo Adsopak® columns (POCARD Ltd. Moscow; Russia)] is available in the Indian market. Are these columns effective?

Aim of the Study: To assess efficacy and safety of abo Adsopak® columns.

Methods: The column was used in 4 ABO-incompatible cases (2 kidney transplants; 1 liver transplant and 1 bone marrow transplant). The patient's plasma was separated using plasma filter (PF 2000 N; Baxter) and then the plasma passed through the column at the rate of 30-50 ml/minute for 6 hours (longer if required). The columns were used several times after regeneration using the fluid N1 and N2 provided by the vendor. The antibody titres were monitored pre and post-procedure.

Results: In 1 case; where larger column (200 ml) was used; there was a significant drop in antibody titers after first use (1:1024 to 1:128) but no further drop could be achieved with reuses. In 1 case titers dropped further when plasmapharesis could not lower to desired level. In remaining 2 cases only partial drop in titers could be achieved despite multiple reuses. The procedure was well tolerated without any adverse event.

Conclusions: abo Adsopak® columns were effective at 1st use only when a larger column was used. The columns were not very effective when reused after regeneration.

38. CMV Viremia in Renal Transplant Recipients Receiving Basiliximab or ATG Induction – A Single Center Prospective Study

Pranaw Kumar Jha, Puneet Sodhi, Shyam Bihari Bansal, Saurabh Pokhariyal, Ajay Kher, Reetesh Sharma, Sidharth Sethi, Manish Jain, Salil Jain, Vishal Saxena, Ashish Nandwani, Vijay Kher

Fortis Escorts Hospital; New Delhi; Medanta - The Medicity; Gurgaon; Haryana; India

Background: Cytomegalovirus (CMV) is a common opportunistic infections in renal transplant recipients. Indian studies about CMV viremia in renal transplant patients especially in those receiving ATG or basiliximab induction are very few. Present study was conducted to prospectively assess CMV viremia in patients with quantitative CMV DNA PCR monitoring at regular intervals.

Aim of the Study: To prospectively assess CMV viremia in patients with quantitative CMV DNA PCR monitoring at regular intervals.

Methods: This was a single center prospective study. Nineteen patients in basiliximab and forty patients in ATG group were recruited. Follow up duration was 6 months post transplant. Quantitative CMV DNA PCR monitoring was done at the baseline; week 1; 2; 3; 4; 6; 8 and then months 3; 4; 5; 6. Primary outcome was the incidence of CMV infection and tissue invasive disease. Other outcomes studied were graft and patient survival; graft function and biopsy proven acute rejection (BPAR).

Results: Final analysis included 18 patients in basiliximab and 31 in ATG arm were. At baseline there was significantly higher HLA mismatch in basiliximab arm. CMV IgG was D+R+ for all. Incidence of CMV infection was comparable in ATG and basiliximab arm (26% vs 27%; p=1). Other outcome parameters including patient survival; graft survival; BPAR and serum creatinine at one and six months were comparable between the two arms. CMV infection occurred significantly earlier in ATG group. Outcome parameters were comparable between CMV and non-CMV infected groups.

Conclusions: Incidence of CMV viremia in the present study was 27%. CMV disease was rare. Not all with significant CMV viremia required antiviral treatment. There was no significant difference in CMV incidence in patients receiving ATG versus basiliximab induction.

39. 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 Nehprology; SGPGIMS; Lucknow; Uttar Pradesh; India

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.

40. Renal Involvement in H1N1 Influenza – A Retrospective Study in a Tertiary Care Centre

Vamsi Krishna Makkena, Indhumathi, M Jayakumar

Sri Ramachandra University; Chennai; Tamil Nadu; India

Background: Acute renal failure due to H1 N1 infection is rare. We assessed the incidence; risk factors; and outcome of acute kidney injury (AKI) in patients due to the H1N1 influenza virus.

Aim of the Study: To assess the incidence; risk factors; the demographic profile; clinical presentation; risk factors associated with AKI; requirement for Hemodialysis; and mortality were analysed.

Methods: 207 patients with a RT PCR -confirmed diagnosis of H1N1 influenza infection admitted in our centre from January to May 2017 were included in this study. Among this 37 patients (17.8%) developed AKI as per KDIGO guidelines. The demographic profile; clinical presentation; risk factors associated with AKI; requirement for Hemodialysis; and mortality were analysed. Mean age was 52 ± 2 years with females 136 (66%); chronic airway disease: 23 (11.1%); cardiovascular disease: 22 (10.6%); concomitant pregnancy: 15 (7.4%); diabetes mellitus: 71 (34.2%); hypertension: 54 (26.1%). All patients received oseltamivir within 48 hours of presumed diagnosis.

Results: Among 207 patients; 37 (17.8%) developed AKI. 15 patients (7.24%) needed renal replacement therapy. 27 patients (72.9%) recovered renal function. 5 patients (33.3%) on RRT became dialysis independent. 28 patients died (13.52%); 10 of whom had acute renal failure (4.83%). 10 out of 15 (66.6%) of the hemodialyzed patients died. Among the factors assessed; COPD was found to be a significant risk factor in the development of AKI (p value - 0.000).

Conclusions: The incidence of renaL failure was 17.8%; demanding RRT in 40% of cases. The need for HD was associated with an elevated risk of death. Mortality was mainly associated with MODS; AKI and a lack of recovery of renal function. Mortality rate among the patients with AKI was found to be high (27%).

41. Assessment of Nutritional Status by the 10 Point Mis Score in a Dialysis Unit in Tamilnadu

D Nithya, M Jayakumar, Indhumathi

Sri Ramachandra Medical College and Hospital; Chennai; Tamil Nadu; India

Background: Malnutrition inflammation complex syndrome (MICS) occurs commonly in maintenance hemodialysis patients and correlates with increased morbidity and mortality. The 10 point MIS score is superior to the conventional subjective global assessment (SGA); the dialysis malnutrition score (DMS) and individual laboratory parameters. The MIS is a comprehensive scoring system with significant associations with prospective hospitalisation; mortality and dialysis outcome.

Aim of the Study: To assess the severity of malnutrition with the 10 point MIS score and correlate with dialysis vintage.

Methods: 75 patients were selected for the study and history recorded pertaining to changes in dry weight over past 6 months; dietary recall for 24 hrs; presence of GI symptoms like decreased appetite; nausea and vomiting. Functional capacity including ambulation; well being and exercise tolerance. Physical examination includes height; weight; BMI; mid arm circumference; skin fold thickness; assessment of muscle wasting and subcutaneous fat loss. Laboratory assessment includes serum albumin and TIBC. Based on these the MIS score was calculated to a minimum of 0 and maximum score of 30. The severity was graded as score <5 mild; 5-15 moderate and >15 severe malnutrition. The severity of malnutrition was correlated with dialysis vintage.

Results: Among the 75 patients age ranges from 18 to 77 yrs with a mean of 52.7. Number of years on dialysis ranging from 0.3 to 5 yrs with an average of 2.44 yrs. The mean BMI of the study population was 25.31. The serum albumin values ranging from 1.2 to 5.4 g/dL with an average of 3; 5 g/dL. The TIBC values ranging from 102 to 333 with an average of 204. The MIC score ranged from 4 to 21. Mild malnutrition in 2.6% (n=2); moderate in 93.3% (n=70) and severe in 4% (n=3).

Conclusions: 93.3% of our dialysis patients are moderately malnourished irrespective of the socio economic status and in spite of nutritional counselling. This signifies the assessment of MIS and appropriate intervention to improve quality of life in HD patients.

42. Effectiveness of Sauna Baths in Chronic Kidney Disease Patients on Maintenance Haemodialysis as Adjunct Therapy for Fluid Removal: A Phase II Clinical Trial

C Niranjini, Anna T Valson, Ankita Priya, Sathya Subramani

Departments of Physiology and Nephrology; Christian Medical College; Vellore; Tamil Nadu; India

Background: Volume overload in HD patients leads to dyspnea and poor effort tolerance and requirement for additional sessions of ultrafiltration in order to achieve euvolemia. Sauna baths can be used to induce thermal sweating which may aid reduction in ECF volume.

Aim of the Study: To conduct a pilot study to establish the safety of sauna baths in patients with chronic kidney disease on haemodialysis; and to assess the effectiveness of sauna baths as an adjunct therapy for fluid removal in HD patients.

Methods: Prevalent adult CKD Stage G5D patients on hemodialysis for ≥3 months; with a well functioning AV fistula and ≥ 2 kg of interdialytic weight gain (IDWG) over a 2 week observation period were invited to participate in the study. Patients with history of any vascular event in the last one year and past history of heat stroke were excluded. After obtaining written informed consent; patients were advised to sit in a commercially available sauna bath at 40°C for 30-60 minutes (as tolerated) on all non-dialysis days for 2 weeks. The following parameters were assessed before and after each sauna session: weight; blood pressure; serum urea; creatinine; electrolytes; haematocrit; core body temperature. Thirst distress scale and thirst visual analogue scale was used to measure thirst between and during procedures respectively.

Results: A total of 6 patients volunteered to participate in the study. Median weight loss per session was 0.35 kg (p < 0.001) and mean per session fall in systolic and diastolic BP was 10.18 ± 12.07 (p < 0.001) and 6.18 ± 9.81 (p = 0.001) mm Hg respectively without a significant change in biochemical indices. Core body temperature increased from 36.18±0.47 t 0.37.21±0.83 (p < 0.001). Subjects did not experience a significant increase in thirst distress between or during sessions. Median IDWG decreased from 3.01 to 2.7 kg (NS) during the study period. There was a trend towards lower diastolic blood pressure (median 2.2 mm Hg; p = 0.45; NS) for upto 2 weeks after study conclusion; despite IDWG increasing to pre-treatment levels.

Conclusions: Sauna bath is an effective adjunct therapy for fluid removal in HD patients. The trend towards lower diastolic BP noted after cessation of therapy indicates that sauna baths may have the potential to induce physiological remodeling of the vascular system. Further studies in a larger patient population over a longer intervention period are required to confirm these findings.

43. Remote Ischemic Preconditioning for Prevention of Contrast Medium-Induced Nephropathy in Patients of CKD 3-4 Undergoing Coronary Angiography

Raju Kumar Sahu, Dipankar Sircar, Arpita Ray Chaudhury, Saroj Mondal, Rajendra Pandey

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

Background: Contrast medium–induced acute kidney injury (CI-AKI) is one of the leading causes of hospital-acquired acute renal failure. Preexisting renal dysfunction (eGFR) <60 mL/min/1.73 m2) is risk factors for CI-AKI. Unfortunately; resoundingly successful prevention options are lacking. In this respect; remote ischemic preconditioning (RIPC) may offer a novel; nonpharmacological prevention strategy for decreasing CI-AKI incidence in patients undergoing CA.

Aim of the Study: Incidence of contrast medium–induced kidney injury; defined as an increase in serum creatinine ≥25% or ≥0.5 mg/dL above baseline at 48 hours after contrast medium exposure.

Methods: Patients with impaired renal function (serum creatinine ≥1.4 mg/dL or eGFR ≤60 mL/min/1.73 m2) undergoing elective coronary angiography were randomized in a 1:1 ratio to standard care (hydration and N-acetylcysteine) with or without ischemic preconditioning (intermittent arm ischemia through 4 cycles of 5-minute inflation and 5-minute deflation of a blood pressure cuff). Overall; both study groups were at high risk of developing CI-AKI according to the Mehran risk score.

Results: Total 18 patients underwent CAG in each group till date. CI-AKI occurred in 03 patients (16.6%) in the control group and 01 (5.5%) in the RIPC group (odds ratio; 0.29; 95% confidence interval; 0.02–3.14; P< 0.311).

Conclusions: RIPC before contrast medium use prevents CI-AKI in high-risk patients. Our findings merit a larger trial to establish the effect of RIPC on clinical outcomes.

44. Plama Exchange in the Pediatric Population - Renal and Non-Renal Indications and its Outcome

L Mahendra Varman, M Saravanan

Apollo Children Hospital; Chennai; Tamil Nadu; India

Background: There is not much data availale regarding use of plasma exchange in pediatric population.

Aim of the Study: Role of plasma exchange in pediatric population.

Methods: Retrospective chart review of children admitted between January 2015 and December 2016 to the Apollo Childern Hospital; Chennai and requiring plasma exchange was undertaken. Demographic and clinical data were studied and descriptive statistics applied for analysis.

Results: 10 children were included in this study. 3 had acute disseminated encephalomyelitis; out of which 2 children recovered and 1 expired. 2 had snake bite with AKI and thrombotic microangiopathy and both improved and recovered renal function. 1 child had SLE with secondary antiphospholipid antibody syndrome with renal infarct and this child improved. 1 child had SLE with hemophagocytic lymphohistiocytosis and the child improved. 1 child had dengue with multiorgan dysfunction syndrome and child expired. Another child had dengue with hemophagocytic lumphohistiocytosis and child immproved.

Conclusions: Early presentation; high index of suspicion among treating physicians and early introduction of TPE along with dialysis may be promising in effectively decreasing morbidity and improving outcome in children.

45. Identifying Dysfunctional Cross Talk Between Calcitonin Generelated Peptides (CGRP) & Tumor Necrosis Factor α (TNFα) in Acute Kidney Injury

Veena Puri, Aprajita Gupta, Sanjeev Puri1,2

Centres for Systems Biology and Bioinformatics; 1Centre for Stem Cell Tissue Engineering and Biomedical Excellence; 2Biotechnology Branch; (UIET); Panjab University; Chandigarh; India

Background: High rate of morbidity & mortality due to AKI poses major health concern. Different inflammatory molecules have been implicated in disease pathpophysiology. In the present study role of TNF-α; & neuropeptide; calcitonin gene-related peptide (CGRP) have been analysed in the pathogenesis of AKI. Decoding their interplay in acute kidney injury by in vitro analysis powered by in silico methods could lead to identification of novel diagnostic as well as therapeutic targets.

Aim of the Study: To delineate the effect of crosstalk between TNF-α & CGRP signaling and associated interactome on the pathophysiology of Acute Kidney Injury.

Methods: The study was performed on male Balb/c mice by inducing acute kidney injury through the intraperitoneal injection of folic acid (250 mg/kg). Kidneys were harvested and the expression level analysis of CGRP was performed by quantitative real-time PCR analysis. The in-silico interactions between CGRP and TNF were observed through bioinformatics approach. STRING database was used to extract the mouse networks of TNF and CGRP. The networks were further analysed in the software CYTOSCAPE to find common partners of TNF and CGRP. The common partners and their respective signalling pathways were seen through KEGG database.

Results: With progression of injury till 48 hours; mRNA expression of CGRP in kidney tissue was observed with highest level at 1 h followed by a continuous decrease up to 48 h. Whereas a reverse was observed with respect to the levle of TNF. The in-silico analysis between CGRP and immunomarker TNF showed that 18 common interactors crosstalk and signal the neuro-immuno renal axis. Few of the notable common partners are Cst 3; LTF; PTGER; Pthlh; Adora and TRPV1. KEGG pathway analysis revealed that most of these communicators converse through the calcium signalling pathways.

Conclusions: Study unveils the route of the communication between CGRP and TNF on neuro-immune axis important in the pathogenisis of AKI. It was seen that most of the common mediators signal through the calcium channels; pointing towards one of the pilot routes between the two.

46. Incidence and Risk Factors for Post Transplant Diabetes Mellitus – Data from Government Tertiary Care Centre.

Jayanivash Jayam, B M Archana, G Chandramohan, S Thirumavalavan, N D Srinivasaprasad, S Sujit, M Edwin Fernando

Stanley Medical College; Chennai; Tamil Nadu; India

Background: International consensus guidelines regarding the definition of new-onset diabetes mellitus after transplantation were originally published in 2003. Studies prior to 2003 guidelines reported rates ranging from 7 to 46 percent. Indian literature reports rates between 16 – 30%. The epidemiology; risk-factors and the outcomes of PTDM is unknown in south indian population and it's important to study the epidemiology; risk-factors and the outcomes of PTDM in local population.

Aim of the Study: (1) To study the incidence and clinical profile of PTDM among the renal transplant recipients. (2) To assess the relevant risk factors contributing to the pathogenesis of PTDM.

Methods: With appropriate clearance from institutional ethics committee; this single centre retrospective analytical study of adult renal transplant recipients who underwent transplant between January 2012- December 2014 was done at Government Stanley Medical college hospital; Chennai. PTDM was defined according to the criteria outlined in the 2003 international consensus guidelines. The study population who did not develop PTDM till the period of observation acted as controls. Recipients who had diabetes before renal transplantation and those recipients who had transient hyperglycaemia while on intravenous steroids were excluded from the study. So were the recipients who died in the early post- transplant period or lost follow up before one year. Unadjusted univariate analysis was done using Chi-square or Fisher's exact test as appropriate. Multivariate analysis was done using logistic regression to determine the independent predictors of PTDM from the potential confounders.

Results: Of the total 149 patients who underwent renal transplant between 2012- 2014; 115 patients were enrolled for the study. The Incidence of PTDM was observed to be 22.6% (n=26) in this study population. Univariate analysis revealed age; smoking; history of diabetes mellitus; dialysis vintage; induction therapy; acute rejection to be significant risk factors. Dosage of tacrolimus and prednisolone at discharge; 3 and 6 months' post-transplant were also significantly higher in the PTDM group. Multivariate logistic regression analysis indicated age (OR=3.77); male gender (OR = 2.35); family history of diabetes (OR = 4.54); dialysis vintage of greater than 1 year (OR = 1.75) and use of induction therapy (OR=2.0) to be independent risk factors for PTDM. The incidence of infective complications was high in the PTDM group (61.5% versus 37.1%; P= 0.04).

Conclusions: The Incidence of PTDM was observed to be 22.6%. Age; male gender; family history of diabetes; dialysis vintage; and induction therapy were found to be independent risk factors for PTDM. Bacterial pneumonia; cytomegalovirus infection & urinary tract infection were higher in PTDM group.

47. Frailty: Introducing an Elephant in Dialysis Unit

Virendra Gupta, Rajesh Kumar, Rachana Jasani, Jatin Kothari, Shrirang Bichu, Viswanath Billa, Mohd Shah Alam, Paras Dedhia

Apex Kidney Foundation; Mumbai; Maharashtra; India

Background: Frailty is associated with overall decline in health and increased risk of hospitalization; disability and morbidities. Studies have shown high prevalence of frailty among patients on initiation of hemodialysis.

Aim of the Study: Aim of the study was to determine the prevalence of frailty among chronic hemodialysis patients.

Methods: 108 chronic maintenance hemodialysis patients were assessed for frailty. Frailty was assessed by a 5 point scoring system wherein SF (Short Form) 36 quality of life questionnaire was used. 2 components from the SF -36 questionnaires were utilized in the frailty scoring-physical functioning (PF) and fatigue. PF of <75 was used as a marker of slowness and fatigue <55 was used a marker for poor endurance. Serum albumin <3 g/dl and Timed Up and Go (TUG) test <12 sec was used as a marker of weakness. Overall frailty was graded as 0-1: non-frail; 2: intermediate frail and ≥ 3: frail.

Results: Out of 108 subjects; 58 were males. Average age was 47.2 ± 14.7 years and average serum albumin was 3.7 ± 0.4 g/dl. Their average PF score was 50.6 ± 26.8 and vitality score was 57.4 ± 14.1. Average TUG time was 12.4 ± 4.6 seconds. Their average dialysis vintage was 5.1 ± 4 years. The average percentage of non-frail patients was 25.9%; of intermediate frail was 21.3% and that of frail patients was 52.8%.

Conclusions: Frailty is very common among chronic hemodialysis patients. There is an urgent need to educate dialysis professionals in recognizing and evaluating frail patients and establishing target strategies.

48. One Year Outcome of Sensitized Kidney Transplant: A Single Centre Study

Kartikeya Kohl, G Sagar, A Bhel, S Puri, S Guleria, S N Mehta, V Rajkumari, M Chaudhary, S Jasuja

Indraprastha Apollo Hospital; New Delhi; India

Background: Renal transplantation in sensitized patients represents a major clinical challenge leading to long waiting periods on dialysis. But when a living donor is available; the use of different strategies to desensitize recipients with preformed human leukocyte antigen (HLA) antibodies can allow a successful transplantation.

Aim of the Study: The purpose of study is to assess 1 year outcome of sensitized renal transplants and compare it to the non-sensitized transplants.

Methods: We conducted a prospective case control study that included living donor (LD) kidney transplantation. In this study; 1 year outcome of 25 sensitized recipients was compared to 25 non-sensitized recipients with respect to graft function; incidence of rejection; incidence of major infections; incidence of new onset of diabetes after transplant (NODAT) and graft and patient survival. All the recipients with a negative Complement-dependent cytotoxicity (CDC) crossmatch were included in the study and antibodies to donor specific Class I and Class II HLA were detected by Luminex crossmatch. The sensitized patients before transplant underwent desensitization using Rituximab; Plasma Exchange (PLEX) and Intravenous Immunoglobulins (IVIg). Induction with Anti-Thymocyte Globulin (ATG) was used in case of patients who underwent a second kidney transplant. Both the study groups received maintenance immunosuppression with Tacrolimus; Mycophenolate Mofetil (MMF) and corticosteroids.

Results: There was an increased incidence of total rejection seen in sensitized recipients (21.7%) as compared to non-sensitized recipients (12%). In the sensitized group; 13% developed antibody mediated rejection (ABMR) whereas 8.7% developed acute cellular rejection (ACR). While in the non-sensitized group 4% developed ABMR and 8% developed ACR. However this observation did not achieve statistical significance (p value = 0.517). In the sensitized category; 1 patient lost the graft due to graft thrombosis whereas graft survival was 100% in the non-sensitized group (p value= 0.500). However the patient survival across both the groups was equal (96% across both the groups; p value = 0.755). The 1 year graft function; incidence of post-transplant infections and incidence for NODAT were comparable across both the groups. Nonetheless statistical significance was noted with respect to history of blood transfusion and pre-transplant dialysis duration (p value= 0.031 and p value = 0.022 respectively).

Conclusions: The combination of Rituximab; PLEX and IVIg ± ATG may prove to be an effective desensitisation regimen for sensitized renal allograft recipients without increasing the risk of post-transplant infections; graft failure as well as patient mortality.

49. Spectrum of Renal Involvement in Cancer Patients

Pideno S Ngullie, Alpana Raizada, Sunil Agarwal, R K GroverAlpana Raizada, Sunil Agarwal, R K Grover

University College of Medical Sciences - GTB Hospital; New Delhi; India

Background: Malignancy and renal disease are closely related to each other. Renal dysfunction can occur as a consequence of cancer (myeloma kidney; urinary tract obstruction); its treatment (acute tumor lysis; drug induced nephropathy) and associated complications (sepsis; hypercalcemia). The development of renal dysfunction may complicate the course of cancer. Hence; a good collaboration between oncologists and nephrologists is necessary to improve outcomes in such patients.

Aim of the Study: To study the diverse spectrum of renal involvement in cancer patients presenting to a tertiary care hospital by using urinary abnormalities; biochemical abnormalities; imaging and histopathology.

Methods: This was a cross-sectional study where 100 consecutive participants between the age group of 15-70 years diagnosed with any cancer with deranged kidney function were recruited. Detailed medical and treatment history like type of cancer- solid or haematological; cancer status- healed or terminal; treatment given- chemotherapy; radiotherapy or surgery was taken. Other associated co-morbidities like diabetes mellitus and hypertension which can lead to renal function impairment were also enquired. General physical and systemic examinations done. Routine and special investigations like urine ACR was done. The proportion of different causes of renal failure were then analysed.

Results: The study consisted of 63 male and 37 females; with mean age of 53.73±12.20. Of the 100 participants; 87 participants had solid cancer and 13 had haematological cancer. The most common solid cancer observed was Ca cervix and most common haematological cancer was lymphoma. At the time of recruitment 78 had kidney involvement due to AKI and 22 had CKD. Out of the 78 patients with AKI; 8 patients had pre-renal AKI; 48 patients had renal AKI and 22 patients had post-renal AKI. Sepsis was the common cause seen in patients with pre-renal AKI. The most common cause of pre-renal AKI was chemotherapy induced nephrotoxicity (n=46); with the most common drug associated being cisplatin (n=32) and carcinoma oropharynx (n=12) being the most common cancer associated. Obstructive uropathy secondary to cancer was the most common cause of post-renal AKI. In the CKD group the most common cause was attributed to diabetes; followed by hypertension and obstructive uropathy secondary to urogenital cancer.

Conclusions: The kidneys in cancer patients can be involved in a number of ways. Clinicians should closely observe changes in renal function and institute appropriate early preventive measures to reduce incidence of renal dysfunction and mortality in cancer patients.

50.  Nocardia farcinica Scientific Name Search Infection in Renal Transplant Recepient: A Great Masquerader

Mohit Madken, Vijay Kher, Vivekanand Jha, A S Narula, Ajay Kher, Pranaw Jha, Dinesh Bansal

Fortis Escorts Kidney and Urology Institute; New Delhi; India

Background: Nocardiosis is an opportunistic life threatening disease particularly seen in an immunocompromised host. Signs and symptoms are non-specific and delay in making diagnosis is common in nocardial infection. We describe a case of disseminated nocardiosis in renal transplant recipient with cerebral and subcutaneous involvement due to Nocardia farcinica.

Aim of the Study: We discuss the importance of early diagnosis and species identification in treating this life threatening infection in a transplant recipient.

Methods: 61 year-old male underwent live renal transplantation in 2002. He was referred with history of multiple abscesses in thigh; neck; and axilla since 6 months for which he had received multiple antibiotics over last 6 months with no improvement. Lab investigations showed leukocytosis with stable graft function. MRI right thigh revealed multiple pockets of collection. MRI Brain showed right temporal; left frontal and parietal lesions with white matter edema. He received empirical treatment with intravenous meropenem; vancomycin and oral trimethoprim/sulphamethoxazole pending sensitivity results. Incision and drainage of thigh abscess was done. Pus culture and staining was suggestive of Nocardia species by gram and modified AFB staining. Species identification was done using MALDI-TOF MS technique and the organism was identified as N. farcinia. Despite extensive debridement of thigh abscess and antibiotic regimen he died due to severe sepsis and septic shock.

Results: Nocardiosis is a rare infection but should always be suspected in transplant recipients presenting with multiple abscesses.

Conclusions: Need for laboratory notification by the treating physician to specifically look for nocardia is of utmost importance due to inherent difficulty in cultivating nocardia species. Species identification should be given paramount importance in managing nocardial infection.

51. Successful Management of Page Kidney by Endovascular Embolization

Sourav Goyal, J S Sandhu, Vikas Makkar

Dayanand Medical College and Hospital; Ludhiana; Punjab; India

Background: Page kidney is the external compression of a kidney usually caused by a sub capsular hematoma associated with high blood pressure and occasional renal failure. It is named after Dr. Irvin Page (1901-1989) who first demonstrated in 1939 that wrapping cellophane tightly around animal kidneys could cause hypertension. Acute Page kidney can be managed conservatively; surgically; endovascular embolization.

Aim of the Study: Sucessful endovascular embolization of acute page kidney.

Methods: 43 YEAR old male a known case of Type 3 RPGN; developed page kidney following USG guided renal biopsy; Patient developed massive blood loss and hpertension following biopsy. Patient successfully managed with endovascular embolization.

Results: Successful endovascular embolization of acute page kidney.

Conclusions: Prompt diagnosis of page kidney should be made and timely management with the help of endovascular embolization is a good option.

52. The Evolution of Pediatric and Adolescent Renal Transplantation in India: Twenty Five Years at a Pioneering Tertiary Centre In South India

Anjali Mohapatra, Anna T Valson; V M Annapandian, Gowrugari Venumadhav, Mercy Nahomi Deborah, Shibu Jacob, Shailesh Kakde, Vinoi George David, Suceena Alexander, Gopal Basu, Nitin Sudhakar Kekre1, Antony Devasia1, Veerasamy Tamilarasi, George Tharayil John, Santosh Varughese

Christian Medical College; Vellore; Tamil Nadu; India

Background: We report the patient and graft outcomes of pediatric renal transplants at a large tertiary referral centre in South India spanning various immunosuppression eras.

Aim of the Study: To look at the patient and graft outcomes of pediatric renal transplants at a large tertiary referral centre in South India spanning various immunosuppression eras.

Methods: In this retrospective analysis of prospectively collected data; all children ≤ 18 years who underwent renal transplantation at our centre between 1991 and 2016 were included. Data pertaining to their baseline characteristics; post transplant events and outcome were retrieved from transplant records and the hospital information system.

Results: 139 children underwent renal transplantation. Mean age was 15.2±2.9 yrs (range 6-18 yrs); M:F ratio was 2:1; 10.8% were pre-emptive & 94.8% live related transplants. Most common kidney disease was glomerular disease (24.4%) followed by urological causes (17.3%). 35.3% were given induction (86% Basiliximab). Biopsy proven acute rejection (BPAR) was 25.9%; 83% were acute cellular. Infectious complications included CMV disease (12.9%); UTI (26.6%); tuberculosis (8.6%); BK virus nephropathy (BKVN; 6.5%) and invasive fungal infections (3.6%). NODAT was seen in 12.9% & recurrence of kidney disease in 4.3% (FSGS = 3; IgAN = 2; oxalosis = 1). Patient survival at 1 & 5 years was 97% & 92%; graft survival at 1 & 5 years was 97% & 89%. Non-compliance was most important cause of graft loss. When Pred/CyA/Aza (PCA) era was compared to Pred/Tac/MPA (PTM) era; there was no difference in overall BPAR rate or patient loss; but graft loss was higher with PCA (p= 0.010) & BKVN in PTM group (p < 0.001).

Conclusions: Pediatric and adolescent renal transplantation has excellent long term graft and patient outcomes. The use of Prednisolone; Tacrolimus and MPA has led to an improvement in graft survival; however issues of compliance and infections such as BKVN still present a challenge.

53. Clinicopathological Correlation of IgA Nephropathy in a Tertiary Care Centre

P T Vipin Kaverappa, G K Prakash, Vishwanath Siddini, Ravi Jangamani, Mahesha Vankalakunti, Yashavanth Kumar, Sudarshan H Ballal

Manipal Hospital; Bengaluru; Karnataka; India

Background: IgA Nephropathy (IgAN) is the most common form of primary glomerulonephritis; and is defined by the characteristic deposition of IgA in the glomerular mesangium. The Oxford classification was developed as a pathological classification system to predict the risk of disease progression. This prospective study was undertaken to evaluate the clinical and pathologic relevance of the Oxford classification; at presentation; in patients with pathologic diagnosis of IgAN.

Aim of the Study: To correlate the clinical and laboratory parameters of the study subjects; with the biopsy findings in IgA nephropathy cases.

Methods: The study is a prospective; hospital-based; non-randomized; non-interventional study conducted in a tertiary care referral institute. Inclusion Criteria: All biopsy proven cases of IgAN. Exclusion criteria: Secondary causes of IgAN. 50 patients who fulfill the inclusion criteria were evaluated for the following: (1) General and demographic information. (2) Vitals and physical examination. (3) Biochemical Markers: BUN; Serum creatinine; Serum albumin. (4) Urine analysis: Urine routine and microscopy; urine 24-hour proteinuria/urine PCR levels. (5) Renal biopsy: Light microscopy findings and Immunofluorescence analysis. Grading was done as per the Oxford classification of IgAN (MEST: M-Mesangial score; E-Endocapillary hypercellularity; S-Segmental glomerulosclerosis; T-Tubular atrophy/interstitial fibrosis). The above observations were recorded; and the correlation between clinical; lab parameters and biopsy findings was analyzed.

Results: Most common clinical feature at presentation was hypertension (86%). Mean 24 hour proteinuria was 3.1 ± 3.3 gm/day. 57.5% of the subjects had M1; 67.5% had E1; 80.0% had S1 and 47.5% had ≥T1 respectively as per the Oxford- MEST pathological scoring. In the study mean SBP; DBP; and serum creatinine was significantly higher in subjects with M1 and T1/T2 score compared to those with M0 and T0 scoring; respectively. eGFR was significantly lower in this group. No significant difference in mean SBP; DBP; serum creatinine; and eGFR was found with respect to E score and S score. No significant difference was observed with proteinuria in relation to MEST scoring. Mean SBP; DBP; serum creatinine was significantly higher among those who had vascular changes in their renal biopsies; while eGFR was significantly lower. Presence and absence of crescents did not reveal any correlation with SBP; DBP; and serum creatinine; eGFR and proteinuria.

Conclusions: MEST scoring must be applied to all the renal biopsy with IgAN. Universal application of this classification will play a significant role in assessing treatment outcomes. We have observed that our cohort tend to present with advanced renal dysfunction.

54. Emphysematous Pyelonephrits- Changing Pattern

Ashish Nandwani, Aniket Hase, Shyam Bansal, Reetesh Sharma, Manish Jain, Dinesh Yadav

Medanta - The Medicity; Gurgaon; Haryana; India

Background: Emphysematous Pyelonephritis (EPN) is rare; severe; life threatening; necrotizing infection of renal parenchyma characterized by presence of gas within the renal parenchyma; collecting system and peri-renal tissue. Availability of imaging modality; early diagnosis and prompt treatment prognosis changing.

Aim of the Study: To study clinical; laboratory; microbiological; radiological spectrum and out-come in emphysematous pyelonephritis.

Methods: This is prospective observational study done in tertiary care multispecialty hospital Medanta: Medicity. All patient admitted to hospital with history suggestive of pyelonephritis underwent CT scan. Patient diagnosed as EPN were included in the study. They were classified according to Huang classification Class 1: Gas collecting in PCS system only. Class 2: Gas in renal parenchyma without extension to the extra renal space. Class 3A: extension of gas or abscess to perinephric space. Class 3 B: Extension of gas or abscess to para renal space. Class 4: Bilateral EPN or solitary kidney with EPN.

Results: Of 89 cases of APN 15% were diagnosed as EPN. Mean age of 50.7+15 years. 93% had fever. symptoms dysuria 57.1%; flank pain and back pain was present in 85.7% Diabetes Mellitus; 93% of patients. Diabetes was uncontrolled in 71.4% other risk factors renal calculi in 21.4% obstructive nephropathy 28.5% and Most lab common finding in our series was pyuria 93% followed by microhaematuria 50% only 35.7% gave history of turbid urine. Leukocytosis was present in 71.4%. In our series all patients EPN were diagnosed on CT scan. Class 1 (3); class 2 (4) class 3A and 3B (3 and 4 respectively). Urine culture positive in 50% of patients. Blood culture in 21%. Commonest organism was E. Coli. 4 ESBL producers and 2 resistant to carbapenems. 3 patients responded to IV antibiotics and percutenous draining were subjected to nephrectomy. Other patients were treated with percutenous drainage 2 and percutenous nephrostomy 3. Factors associated with poor outcome were late admission; shock; sepsis and thrombocytopenia.

Conclusions: All patients with complicated pyelonephritis particularly diabetic should have imaging CT scan. ESBL producer organisms are increasing. Prompt diagnosis; treatment with appropriate antibiotics& percuteneous drainage improves the outcome.

55. Role of Pretransplant Panel Reactive Antibody (PRA) In Immunological Risk Stratification in Prospective Renal Transplant Recipient in Live Donation Program: A Single Center Experience

Ashwini Gadde, Shyam Bihari Bansal, Ashish Nandwani, Aseem Tiwari, Manish Jain, Reetesh Sharma, Dinesh Yadav, Ajay Kher, Amit Mahapatra, Siddharth Sethi, Chetan Mahajan

Medanta- The Medicity; Gurgaon; Haryana; India

Background: PRA is an immunological screening test to detect presence of antiHLA antibodies; to identify a subset of sensitized host which help us formulate a further immunological workup plan & immunossuppression plan in a cost efficient manner. Its role in deceased donor program as a part of allocation system is well proven but its use in live related renal transplant is dubious.

Aim of the Study: To study the correlation of PRA with h/o sensitization & crossmatch results and to see its effect of transplant outcome.

Methods: This was a prospective; single center; observational study. All ESRD patients undergoing PRA testing as a part of pretransplant workup at our institute from 01.01.2016 to 01.10.2016 were included. Patient's sensitization history; other immunological work up were recorded. All the patients were followed up for 6 months as per treating nephrologist.

Results: Total 185 patients were included.22/185 (15.7%) were PRA+ve. Female sex (60.3% vs. 34.2%; p=0.001); longer duration RRT (8.17 ± 8.11 months Vs 6.08 ± 11.64 months; P=0.037) &HCV infection (p= 0.047) were significantly associated with PRA positivity. History of blood transfusion; pregnancy & previous transplant were significantly more common in PRA+ve group (p<0.0001). Only 3 (3.4%) patients developed PRA without “identifiable” sensitizing event. Significantly lesser number (12/29;41.4%Vs.143/156;91.7%) PRA+ve patients received transplant (P<0.0001); most common reason being immunological incompatibility (CDC/Flow cross match/DSA being positive). In transplanted patients; there was no difference between PR+ve and PRA negative group in terms of creatinine at 6 months (1.22 ± 0.26 mg/dl Vs 1.30 ± 0.38 mg/dl; p= 0.63); number of rejection (1 Vs 6; P =0.507). Overall rejection rates were 4.5%. These low rates can be attributed to better immunological workup; more use of ATG & short follow up.

Conclusions: Pregnancy; previous transplant &blood transfusions are important sensitizing events. PRA testing help us identify high risk individuals. With better immunological assessment & by maintaining higher net immunosuppression; better transplant outcomes can be achieved. Longer followup is required.

56. Role of Inflammatory Factors in Causing Proteinuria in Preeclampsia

Athar Habib Siddiqui, Rahul Negi, Vemananda Haritha1, N Kalyani1, Ramanan Durraiswami1, Nuzhat Aziz1

Laboratory of Integrative Physiology; School of Medical Sciences; University of Hyderabad; 1Fernandez Hospital Educational and Research Foundation; 4-1-1230; Hyderabad; Telangana; India

Background: Preeclampsia; PE; is a hypertensive disorder of pregnancy characterised by high blood pressure and Proteinuria. The reason for proteinuria in PE is due to glomerular endotheliosis; a classical glomerular lesion; a type of renal injury; which is not seen in Gestational Hypertension (GH). PE is a life threatening disorder that affects both the mother and the foetus. The only treatment remains the delivery of the baby; leading to the delivery before term; and accompanied with a number of complications.

Aim of the Study: Inflammatory intermediates have been shown to be a cause of renal dysfunction; including glomerular injury. The study was designed to identify the inflammatory factors; possibly causing Proteinuria.

Methods: In the present study; we determined the levels of 2 inflammatory markers; viz. C-Reactive Protein (CRP) and Interleukin-6 (IL-6) in the serum of the patients with hypertensive disorder of pregnancy (including Gestational Hypertension; GH and PE) and Normotensive (NT) pregnancy. Patients were enrolled at the Fernandez Hospital; Hyderabad for the study. Blood was drawn and serum was isolated from the blood samples and stored at -80°C for later use. All experimental protocols; including the consent form were approved by the Institutional Ethics Committee; both at the School of Medical Sciences; University of Hyderabad and at the Fernandez Hospital and Research Center. Commercially available ELISA kits obtained from R&D systems; Minneapolis; USA were used to determine the maternal serum concentrations of IL-6. PETIA method was used to determine CRP. Data; presented as Mean±SEM were subjected to statistical analyses using the Graph Pad Prism 6; (San Diego; CA; USA) and statistical significance was set at p<0.05.

Results: The levels of IL-6 were found to be significantly higher at term in the serum of Preeclamptic patients compared to GH; and NT pregnancy; (167.7±53.0 pg/ml; n=5 vs. 38.82±9.12 pg/ml; n=5 (GH); p<0.05; and 39.30±4.384 pg/ml; n=50 (NT); p<0.05. No difference was recorded in the IL-6 levels between the GH and the NT group. Surprisingly though; the levels of CRP; amongst the hypertensive group of pregnancy was found to be significantly higher at term in the serum of GH patients compared to PE (6.93±2.66 mg/dl; n=5 vs. 1.76±0.59 mg/dl; n=5; p<0.05). The levels of CRP were; however; found to be significantly decreased (p<0.05) in the NT group (1.07±0.094; n=34) compared to both the PE and the GH group. The levels of IL-6 and CRP were significantly increased (p<0.05) at term compared to the 3 trimesters. Within the hypertensive conditions of pregnancy; the BP increase at term was more in the PE patients compared to the GH patients (42±5.1/25±3.3 mm Hg vs 18±3.7/13±3.3 mmHg; p< 0.05); compared to the 1st trimester.

Conclusions: The inflammatory factor; IL-6; in addition to other factors; is able to induce a greater amount of downstream signalling molecules that is able to cause glomerular injury more than the CRP. The findings of the present study reveal a more potent role of IL-6; than CRP in causing Proteinuria in PE.

57. Etiology and Symptoms of Hyponatremia in Hospitalised Patients in a Tertiary Care Hospital

Mohd Iqbal, Tajamul H Mir, Abdul Khaliq, Heena Mir, J P Ojha

Institute of Medical Sciences BHU; Varanasi; Uttar Pradesh; India

Background: Hyponatremia is the most common electrolyte disorder among hospitalized patients. Severe hyponatremia has been defined differently from 110 to 125 mEq/L and it is associated with increased morbidity and mortality which may be because of hyponatremia itself; underlying disease or inappropriate treatment.

Aim of the Study: (1) To study the etiology of severe (Na <125) hyponatremia in hospitalized patients. (2) To study symptoms of hyponatremia in relation to plasma sodium concentration.

Methods: This Prospective Observational Descriptive study was conducted on hospitalized patients over a period of one year at GMC Srinagar. Patients with serum sodium of <125 were included in the study. Patients with pseudohyponatremia and hyponatremia because of laboratory errors were excluded. 85 patients satisfied the criteria and were included in the study. Detailed history; clinical examination and appropriate investigations were done. The data obtained was carefully scrutinized; categorised; coded and statistically analysed using SPSS software. Mean and median were used to measure central tendency. Standard deviation and range were used for dispersion. A P-value of <0.05 was considered statistically significant.

Results: The mean age of the patients was 54.7 + 10.6 years (range 30 to 78 years). 58 (68.2%) were females and 27 (31.8%) were males with female to male ratio of 2.1:1. Drowsiness was the most common symptom (43.5%) followed by restlessness (37.6%); headache (24.7%); lethargy (18.8%); confusion (15.3%); seizures (11.8%); anorexia (10.6%); vomiting (4.7%); gait instability (4.7%); coma 4.7%; hiccups (2.4%); nausea (2.4%) and asymptomatic (27.1%). Associated co morbidities included Hypertension (62.4%) diabetes mellitus (18.8%); pneumonia (11.7%); CKD (9.4%); stroke (8.2%); psychiatric disorders (5.9%); CLD (4.7%); COPD (4.7%) CCF (4.7%); hypothyroidism (3.5%); seizure disorder (1.2%); myocardial infarction (1.2%) and restrictive lung disease (1.2%). 72.9% patients were clinically euvolemic; 17.7% hypervolemic and 9.4% hypovolemic. Causes included thiazides (49.4%); SIADH (18.8%); gastrointestinal loss (8.2%); SSRIs and other drugs (7.1%); CKD (5.9%); CLD (4.7%) and CCF (4.7%).

Conclusions: Hyponatremia is a common electrolyte disorder especially in the elderly and females. Hypertention is the most common associated comorbidity and thiazides which are used as antihypertensives are the most common cause of hyponatremia. Elderly patients on thiazides should be monitored for hyponatremia.

58. Percutaneous Re-Positioning of Peritoneal Dialysis Catheter Accidentally Placed in the Pre-Peritoneal Subcutaneous Space Leaving the Tunnel and Exit-Site Intact - A Novel Idea

Santosh Varughese, Varun Agarwal

Christian Medical College; Vellore; Tamil Nadu; India

Background: Percutaneously placed peritoneal dialysis (PD) catheters may be accidentally be left behind in the pre-peritoneal subcutaneous space if the introducer needle does not pierce the peritoneal membrane in the initial part of the procedure. If this happens; the catheter insertion has to be redone either percutaneously or surgically. The catheter often has to be replaced as part of it has been externalized and is unsterile.

Aim of the Study: We describe the case of a 70 year old man with end stage renal disease who underwent bedside PD catheter insertion.

Methods: Unfortunately; the catheter was accidentally placed in the pre-peritoneal subcutaneous space. The inflow and outflow of PD fluid was present as the pre-peritoneal subcutaneous space had expanded with the PD fluid; but was slow. The problem was identified on CT scan and PD catheter re-insertion was planned.

Results: A week later; a novel technique was attempted in which the exit site and tunnel were untouched. The skin and subcutaneous sutures over the original catheter insertion site were undone and the deep cuff of the catheter was dissected and the intra-abdominal part of the catheter was exteriorized. A Veress needle was advanced till it reached the peritoneal space; the position of which was confirmed using a guidewire. The track was dilated using a peel-away sheath-dilator assembly. The dilator was removed and the intra-abdominal portion of the catheter was slid in. The wound was closed in layers after ensuring good inflow and outflow. Peritoneal dialysis exchanges were begun the same day.

Conclusions: Compared to using a new PD catheter and tunnel; this novel technique allows for a simple bedside repositioning technique; saving time; operating room time; reducing hospital stay and possibly avoiding unnecessary hemodialysis.

59. Clinical and Pathological Profile of Patient of IgA Nephropathy and Treated Lepromatous Leprosy Presenting as Rapidly Progressive Glomerulonephritis

Sourav Goyal, Vikas Makkar, J S Sandhu

Dayanand Medical College and Hospital; Ludhiana; Punjab; India

Background: IGA nehropathy is widely regarded as slowly progressing disease; however minor population of patients present with rapid progressive form of glomerulonephritis.

Aim of the Study: Clinical and pathological profile of patient of IGA nephropathy and treated lepromatous leprosy presenting as rapidly progressive glomerulonephritis.

Methods: This 51 year old male is a biopsy proven case of IGA nephropathy; and also treated case of lepromatous leprosy. He was evaluated for gradually rising creatinine; USG guided biopsy was done which revealed crescentric glomerulonephritis.

Results: There was amelioration of renal functions after IV steroid pulse and oral steroids.

Conclusions: Possibility of RPGN in IGA nephropathy with gradual worsening of renal functions should be kept along with normal progression of course of IGA nephropathy.

60. Non-Invasive Monitoring of End-Stage Renal Disease Patients During Hemodialysis

Santanu Mandal, Chiranjit Ghosh, Prabuddha Mukhopadhyay1, Manik Pradhan

S. N. Bose National Centre for Basic Sciences; 1Vivekananda Institute of Medical Sciences; Kolkata; West Bengal; India

Background: The ESRD patients under HD are at high risk for a numerous complications. Moreover; repeated measurements of serum urea to evaluate renal urea reduction along with analysis of serum creatinine levels are not feasible to understand individual's response to dialysis treatment. And it is also difficult to understand the dialysate effect on patients during dialysis. Therefore; there is a pressing need for non-invasive evaluation of physiological parameters to monitor ESRD patients during HD.

Aim of the Study: Investigation of the role of 13-C and 18-O isotopes of exhaled breath CO2 regulated by erythrocytes Carbonic Anhydrase (CA) activity as a new non-invasive strategy to determine dialysis efficacy.

Methods: Pre-dialysis & post-dialysis breath and blood samples were collected from the HD patients. Blood samples were analysed to measure the carbonic anhydrase activity spectro-photometrically. Blood ion concentrations were measured using arterial blood gas (ABG) test. The blood samples were also used for the measurement of serum urea and creatinine level. The concentrations of 13-C and 18-O isotopes of exhaled breath CO2 are extremely low. Therefore; a laser based high-precision cavity ring-down spectroscopy technique is used to determine the ultra-low concentration exhaled breath CO2 isotopes.

Results: Post-dialysis CA activity had significantly enhanced in all HD patients. The changes in blood ion concentrations [H+ (32.0 to 56.7 nmol/L); K+ (5.73 to 4.3 mmol/L); Cl- (105.0 to 101.8 mmol/L)] in the post-dialysis state may be responsible for this alteration in CA activity during dialysis. Each patient exhibited markedly enhancement of 18-O and 13-C isotopes of breath CO2 in the post-dialysis state. Increased CA activity facilitates 18-O production; whereas the changes in the blood pH (7.25 to 7.49) may be responsible for the enhanced 13-CO2 production. Next we obtained a linear correlation between Kt/V (used to specify dialysis efficacy) and 18-O & 13-C isotopes of exhaled breath CO2. The optimal cut-off points for efficient dialysis treatment were determined to be δDOB18O‰ = 2.9-3.5‰ and δDOB13C‰ = 4.5-5.3‰.

Conclusions: We have established a potential link between 18-O and 13-C isotopes of breath CO2 and ESRD patients undergoing HD. Our findings suggest that monitoring breath CO2 isotopes could be used as novel biomarkers for non-invasive assessment of dialysis efficacy.

61. Mirror Mirror on the Wall: Which is the Best Immunological Test of Them All?

Ajay Kher, Pranav Dorwal, Ashwini Gadde, Ashish Nandwani, Shyam B Bansal, Pranaw Jha, Dinesh Bansal, Manish Jain, Reetesh Sharma, Vijay Kher

Flow Cytometry; Waikato Hospital; Hamilton; New Zealand; Fortis Escorts Kidney and Urology Institute; New Delhi; Medanta Kidney and Urology Institute; Gurugram; Haryana; India

Background: Immunological evaluation is a critical part of evaluation of transplant recipients. Tests available include complement dependent cytotoxic crossmatch (CDC XM); Flow cytometric crossmatch (Flow XM); Flow panel reactive antibody (Flow PRA); Single antigen bead (SAB). In the developed world; most use CDC XM; Flow XM and SAB in all potential recipients for complete evaluation. Due to cost constraints this is not feasible in India. This study was conducted to assess CDC XM; Flow XM and Flow PRA.

Aim of the Study: This study was conducted to assess CDC XM; Flow XM and Flow PRA.

Methods: All potential transplant recipients undergoing transplant evaluation at our center from May 2015 to August 2016 underwent evaluation by CDC XM; Flow XM and Flow PRA. Those with any positive tests were recommended to undergo SAB testing. 241 patients underwent this evaluation and 206 (85%) underwent transplantation. After transplantation; patients were followed and any biopsy proven rejections were noted and classified as cellular or antibody rejections.

Results: All 7 (2.9%) CDC positive were also Flow XM and Flow PRA positive and none got transplanted. Of 32 (13.3%) Flow XM positive; 11 were T+B+; 14 were T-B+; 7 T+B-. 6/32 (19%) were SAB negative and hence false positive and transplanted. 5 Flow XM positive with low level donor specific antibodies were desensitized and transplanted and did not have any rejections. 12 were flow XM + but flow PRA -; of these 3 desensitized; 7 false positive and 2 not transplanted due to SAB positivity. Of 29 Flow PRA positive; 10 were PRA 1+2+; 15 PRA 1+2-; 4 PRA 1-2+. Of these 29; 12 were transplanted; 2 with desensitization (flow XM positive); remaining without desensitization. Those not transplanted were also flow XM positive.

Conclusions: Flow XM in conjunction with judicious use of SAB provides the most robust and cost effective immunological evaluation of transplant recipients.

62. Study of Cognitive Impairment in Patients on Maintenance Hemodialysis

Abhishek Dixit, Deepa Usulumarty, Shrirang Bichu, Parag Tilve, Viswanath Billa

Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

Background: Cognitive impairment increases in prevalence with chronic kidney disease potentially affecting up to 60% of them. Uremia; anemia; BP and blood sugar fluctuations; intradialytic hypotension are some of the causes of cognitive impairment. This often ignored problem can severely impact the quality of life of hemodialysis patients.

Aim of the Study: To estimate degree of cognitive impairment in HD population objectively by Montreal Cognitive Assessment score (MOCA) & study effect of Coenzyme Q supplementation on improvement of cognitive scores.

Methods: Total of 21 incident HD patients with age >18 years; follow-up >6 months; with no residual renal function; using the same dialyzer configuration and same dose of heparin were selected. The study excluded patients with who were on diuretics; with CNS disorders; severe IHD; cirrhosis; on dialysis with catheters and AV grafts. Clinical evaluation and documentation of cognitive scores were done by the MOCA questionnaire. Coenzyme Q (CoQ) was started in the dose of 10 mg twice a day for 1 month. At the end of this period the MOCA scores were reassessed.

Results: All of the 21 patients had a MOCA score less than 26 (Normal > 26). The mean MOCA score for these patients was 18.23±2.25. This score increased to 24.14+2.97 (p<0.05) after CoQ supplementation.

Conclusions: Cognitive dysfunction is an important under-noticed problem in hemodialysis patients. An attempt should be made for timely diagnosis and treatment of this ailment with a multipronged approach. Supplementation of Coenzyme Q for a longer duration may help to attenuate this problem.

63. Single Centre Experience of Post Renal Transplant Malignancy in Renal Transplant Recipient

Denish Savalia, G Hardik, M Somasekher

Apollo Hospital; Hyderabad; Telangana; India

Background: Sepsis; cardiovascular diseases and neoplasms are the main causes of death with normal function of the graft in the long-term follow-up of patients who have received kidney transplants. The presence of neoplasms is a major threat and cause of morbidity in kidney transplant patients. malignancy mainly occurs due to Cumulative exposure to immunosuppression; and certain drugs which can be carcinogenic through independent mechanisms or as a result of immunosuppression and viral infections.

Aim of the Study: The Aim of this study is to determine the incidence of cancer in the recipients of renal transplants performed in the APOLLO HOSPITALS; JUBILEE HILLS; HYDERABAD during the period between 2001-2016.

Methods: During the study period 815 kidney transplants were performed. Patients with malignancy prior to the transplant will be excluded. Retrospective; single centre study; information included donor and recipient characteristics; patients and graft survival; cancer incidence after transplantation; type and doses of immunosuppressant for each patient. Incident cancer is considered as new cases of cancer after the transplant with histopathological confirmation. Competing risk survival analysis methods will be applied to estimate the cumulative incidence of cancer and to identify demographic variables associated to its occurrence like age; gender; body mass index; smoking status; type and doses of immunosuppression; graft status; donor kidney source; HLA mismatches.

Results: All cases of renal transplant had received Induction agent either Rabbit type thymoglobulin 1.5 mg/kg for 3 doses or basiliximab 20 mg on day 0 and day 4. Discharge on maintenance immunosuppressant including (mycophenolate mofetil; prednisolone; and either cyclosporine or tacrolimus. We found n=12 cases of malignancy in 815 cases (1.47%). Out of those; Non hodgkin's lymphoma cases n=4 (0.49%); Renal cell carcinoma case n=1 (0.12%); pancreatic adenocarcinoma cases n=2 (0.24%); Kaposi's sarcoma case n=1 (0.12%); Carcinoma tongue case n=1 (0.12%); Nasopharyngeal cancer case n=1 (0.12%); carcinoma stomach case n=1 (0.12%); Graft lymphoma case n=1 (0.12%). Out of 12 cases; females were n=5 (0.61%) and males were n=7 (0.85%). Mean Body mass index was 25.5 kg/m2. Mean Age at presentation was 48 year. Mean duration of detection of malignancy after transplant was 10 year.

Conclusions: It is important to advise patients before transplantation in regard to malignancy complications provide regular follow-up and tailor immunosuppressive regimen to minimum doses to be compatible with good graft function.

64. Outcome of Acute Kidney Injury in Non Cardiac Surgery Setting

Ashwathy Haridas, Tukaram Jamale, Niwrutti Hase

Department of Nephrology; Seth GSMC and KEM Hospital; Mumbai; Maharashtra; India

Background: AKI is a frequent complication in surgical setting carrying substantial risk for adverse events including mortality. Few studies have evaluated AKIoccurring in setting of non cardiac surgery. Various studies have given incidence of AKI ranging from 1% to 31%. We examined incidence; risk factors and mortality in patients with AKI in setting of non-cardiac surgery.

Aim of the Study: (1) To assess incidence of acute kidney injury in patients admitted in surgical wards. (2) To evaluate predictors of in-hospital mortality in patients with acute kidney injury admitted in surgical wards.

Methods: A single centre; prospective; observational study done at a tertiary care referral centre in Western India where 223 adult patients with AKIin non-cardiac surgery setting admitted in surgical wards referred for nephrology consultation were enrolled from August 2015 to June 2016. Patients with underlying chronic kidney disease were excluded. Acute kidney injury was defined and graded using KDIGO AKI Work group guideline. Primary outcome studied was in-hospital mortality and its predictors. Setting was divided into following groups involving Skin and soft tissue Orthopaedic Polytrauma Abdominal cavity viscus involvement including small and large bowel surgery Hepatobiliary system Pancreatitis Vascular Demographic; clinical; biochemical; surgical parameters; and SOFA score were studied. Parameters related to severity of acute kidney injury and it's complications were studied. Logistic regression analysis was used to determine independent predictors of mortality.

Results: Mean age was 56.42 years and males were 175/223 (78.5%). Operated patients were 180/223 (80.7%). Most common setting was skin and soft tissue (30%). Sepsis was present in 131/223 patients (58.7%) and shock in 52/223 patients (23.3%). Oliguria was present in 53/223 (23.8%). Mean SOFA score at admission was 4.5 (SD 3.74). Overall in-hospital mortality was 106/223 (47.5%). Mean SOFA scoreof patients who expired was 6.170±4.43 and of who recovered was 3.128±2.1 (p<0.001). Among who expired; 70.8% (n=75) had sepsis (p=0.001); 61.3% (n=65) had Shock (p<0.001); 63.2% (n=67) had oliguria (p<0.001); among 65 patients who had worsening of SOFA Score; 96.6% (n=63) expired. Mean SOFA score of patients who expired was 6.170±4.43 and of patients who recovered was 3.128±2.1 (p<0.001). We used bivariate analysis with competitive risk model to study associations.

Conclusions: Acute kidney injury is associated with adverse outcomes in non cardiac surgery setting. Following were independently associated with mortality (1) shock (2) sepsis (3) worsening of SOFA score.

65. Surgical Patchplasty for Swing Point Stenosis in AV Fistula: Experience of 11 Cases

Himanshu Verma, D K Sinha, M N Singh

Varenyam Vascular - Day Care Vascular Services Providers; New Delhi; India

Background: Swing point stenosis is a well known common cause of fistula failure. AV fistula Angioplasty is costly and had low primary patency. We present our experience of surgical patch pasty in patients with swing point stenosis.

Aim of the Study: To report experience of surgical patchplasty for swing point stenosis in AV fistula.

Methods: Retrospective analysis of prospectively collected data performed (November 2014- July 2017). 11 patients were selected who underwent surgical patch-plasty of swing point stenosis. Demographics; surgical details and follow up data was obtained.

Results: Surgical pachplasty in 11 patients (7 Radiocephalic AVF; 4 Brachiocephalic AVF). All had swing point stenosis detected on duplex. Mean length of stenotic segment was 2.6 cm (2-3.5 cm). 8/11 had recurrence after previous angioplasty; 3 were performed primarily. Technical success was 100%. Mean time to cannulation was 13 days (8-22 days). 6 month primary patency was 100%. 5 out of 6 available one year follow up patients had patent fistula.

Conclusions: Surgical patch-plasty across swing point stenosis is a feasible and safe option. Patients with recurrent stenosis after failed endovascular could be suitable candidate.

66. Can Home Blood Pressure Monitoring Replace Ambulatory Blood Pressure Monitoring in Chronic Dialysis Patients?

Paras Dedhia, Rachana Jasani, Virendra Gupta, Jatin Kothari, Viswanath Billa, Shrirang Bichu, Mohd Shah Alam, Rajesh Kumar

Apex Kidney Foundation; Mumbai; Maharashtra; India

Background: Hypertension in dialysis population is associated with increased cardiovascular mortality and morbidity. Interdialytic 44 hours ambulatory blood pressure monitoring is considered as a gold standard method for BP monitoring in dialysis patients. Limited data available regarding timing; method of home blood pressure monitoring in dialysis patients.

Aim of the Study: We aimed to explore correlation between ABPM and home blood pressure monitoring in chronic maintenance hemodialysis patients.

Methods: Ambulatory BP monitoring (ABPM) was performed for 44 hours in between 2 dialysis sessions beginning immediately post-dialysis. ABPM was recorded every 20 min during the day (7 am to 11 pm) and every 30 min during night (11 pm to 7 am) on non-fistula arm. Less than 70% readings were excluded from the study. Home BP monitoring was performed 3 times daily for 2 days between dialysis sessions. Patients were asked to record their BP in the morning; afternoon and before going to bed with a validated home BP monitor. Correlation between two methods was measured by Pearson correlation coefficients.

Results: Of 40 patients; 68% were males. Average age was 54.5± 12.3 years. Mean dialysis vintage was 2.85± 2.9 years. 67.5% were males and 32.5% were females. The mean 44 hour BP obtained from ABPM was 148.4 ±18.6/82.1 ±13.8 mm Hg. The mean BP obtained from HBPM was 154.2 ±21.6/87.7 ±14.7 mm Hg. There was a strong correlation between systolic blood pressure by ABPM and home blood pressure monitoring (r= 0.86 and p <0.0001) and diastolic blood pressure by ABPM and home blood pressure monitoring (r= 0.84 and p <0.0001).

Conclusions: Although ABPM remains the instrumental tool in making therapeutic decisions in dialysis patients; owing to its practical challenges; HBPM can be considered as an option to replace ABPM in selected dialysis patients.

67. Urine Output in Twice Weekly Hemodialysis Patients: Clinically Significant?

Suresh Sankarasubbaiyan, Magesh Vasudevan, Dennis John, Kritika Kalro, Avinash Ignaitius, Tanmay Pandya, P Vidyashankar, Geetha Sambandamurthy

Davita Care; Chennai; Tamil Nadu; India

Background: Twice weekly hemodialysis is the most commonly practiced renal replacement modality in India. Elsewhere in the world there is a growing interest to explore this therapy option as an incremental option prior to thrice weekly HD. The clinical significance of residual renal function measured as urine output is yet to be ascertained. In Indian context this aspect of twice weekly HD has not been systematically studied.

Aim of the Study: To study distribution of urine output in twice weekly patients. To compare demographics; clinical characteristics and dialysis outcome in patients > & < 500 ml urine output.

Methods: Patients in 5 dialysis clinics across 4 cities patients were asked to estimate urine output among categories of options thrice over 3 months. Patients demographics; clinical characteristics; and vintage time on HD were reviewed. All patients were dialyzed twice weekly on Polysulfone dialyzers; using standard dialysate concentration for 4 hours each session. Hemoglobin; dialysis adequacy measured as Std Kt/V; Serum Albumin; dialysis access were noted. Number of antihypertensive drugs prescribed and interdialytic weight gain and ultrafiltration as% of body weight were reviewed. Data is presented as mean±sd and proportion. Comparison was done using t test or Chi squared test as appropriate. p value less than 0.05 was considered significant.

Results: Grp 1 UO > 500 ml: N=52 & Grp 2 U 0 < 500 ml: N=114. Data presented as Grp 1 vs Grp 2. Age (yrs): (N=166) 57.7 ± 12.9 vs 55.1 ± 14.1 (p.266); Sex (M:F) (N=166)- 32:20 vs 78:36 (P-0.384); DM (%) (N=159) 45% vs 55% (p-0.0001); Dialysis vintage time in days (N=166) 796.6 ± 50.1 vs 768.4±56.2 (p-0.756); Hb (g%) (N=163): 9.6± 1.6 vs 9.5± 1.5 (p- 0.680); Std Kt/V: (N=161) 1.3±0.3 1.5±0.3 (p-0.005); Alb (N=153) 3.8±0.4 3.5±0.6 (p-0.003); Access- AVF/AVG:IJVC (N=166) 94.6%/5.4% vs 90.2%/9.8% (p-0.294); No of Anti Htn (N=162) 1.1±1.2 2.08 ± 2.1 (p-0.003); Average weight gain (%): (N=112) 5.4±3.1 6.1±2.7 (p-0.229); Average Ultrafiltration (%) (N=141) 3.6±1.8 vs 4.4±1.7 (p-0.014).

conclusions: (1) UO is well preserved for considerable duration in subset of 2x HD patients (2) Pts with > 500 ml: likely non- diabetic with higher Albumin; lesser dose of anti hypertensive drugs and lesser ultra filtration volume. (3) Salient findings in small study group warrants more systematic understanding.

68. Study of Clinical Profile; Management; and Outcome of Stroke in CKD Patients at a Tertiary Care Center

P Srinivas, Manjusha Yadla

Gandhi Medical College; Secunderabad; Telangana; India

Background: CKD is associated with a high risk for stroke. Hypertension; diabetes mellitus; atherosclerosis; heparin usage; hyperlipidemias; hyperhomocystenemia; and protein malnutrition were cited as risk factors for stroke by several studies. Stroke may manifest as infarction and hemorrhage Stroke in chronic dialysis patients is associated with high mortality.

Aim of the Study: To assess the clinical profile; management; and outcome of cerebrovascular accidents in CKD patients.

Methods: All patients of stroke with chronic kidney disease admitted over one year are the subjects of this study. The diagnosis of stroke was made on the basis of history; physical examination and CT BRAIN. MRI BRAIN was done depending on the clinical need. The causes of stroke were broadly subdivided into ischemic and hemorrhagic categories depending on radiological appearance. Patients were carefully assessed for their risk factor status. Management was according to the standard protocol of the institution; and the outcome status was assessed.

Results: Total number of patients admitted with stroke in CKD are 34. Male to female ratio is 24:10. Mean age in males is 52.2±1.18 yrs and in females it is 45.4±1.12 yrs. Ischemic stroke in 19 and hemorrhagic in 15 patients. Mean age in ischemic stroke is 54.8±1.29 yrs and in hemorrhagic stroke is 45.6±9.49 yrs. Mean SBP in ischemic patients is 145.7±3.45 and in hemorrhagic patients is 168.6±3.96. Mean DBP in ischemic patients is 88.4±1.97 and in hemorrhagic patients is 99.3±1.66. 17 patients recovered and 11 patients did not recover after treatment. Mean serum creatinine in mg/dl in recovered patients is 7.34±4.04. Mean SBP in recovered patients is 144.7±2.16 and in unrecovered patients is 166.3±3.50. Mean DBP in recovery group is 87.6±1.75 and unrecovered group is 102.7±2.00 with a significant p value = 0.04. In ischemic group 70.6% recovered and in hemorrhage group 45% recovered. 14 Patients who received hemodialysis as mode of treatment recovered with significant p value < 0.001.

Conclusions: Males are more affected with stroke in CKD. Hypertension and anemia combined are major risk factors in stroke in CKD. Ischemic stroke (56%) is more common than hemorrhagic stroke. Lower diastolic BP and hemodialysis as mode of treatment are associated with recovery with significant p values.

69. Can a CBC Test Help to Differentiate Infection from Rejection in a Kidney Transplant Recipient?

Tushar Dhakate, Mihir Wagle, Parag Tilve, S Bichu, V Billa

Bombay Hospital Institute of Medical Science and Research; Mumbai; Maharashtra; India

Background: A rise in serum Cr is frequently encountered post kidney transplant. Astute clinical & biochemical evaluation is essential to differentiate between the various possibilities & confirm the diagnosis like drug levels; cultures; & a transplant kidney biopsy. While these tests are reliable & reproducible; there is a latent period before he results become available. While a CBC tests can suggest bacterial infection reasonably reliably; its use for differentiating amongst other possibilities is not known.

Aim of the Study: Hypothesis:To see if there is any relation between two DLC values (stable vs. at the time of insult-rejection or infection) by SVM & statistically.

Methods: 53 kidney transplant patients were included in the study. These were divided into control Group A (n=27) with stable graft function; Group B; those who presented with infection at some time (n=27); Group C who had an episode of rejection (n=17) & Group D who had CNI toxicity (n=10). The laboratory data was collected at a baseline point when he had stable graft function which were compared to the values at the time of an acute rise in serum creatinine of diverse etiologies; but before any specific intervention was done. The data was firstly run through an SVM (Support vector machine) with a rbf kernel in “Scikit Learn” to observe accuracy of interaction between data. An SVM is a supervised learning tool using machine learning that allows us to linearly divide data into various classes and then predict the class of new input data. It was then analyzed statistically to ascertain the utility of DLC in discriminating between acute infection; acute graft rejection & CNI toxicity.

Results: SVM analysis shows no significant interaction between total leucocyte count; lymphocyte counts (L); neutrophil (N) & monocyte (M) counts (per mm3) & Group A; B; C and D (accuracy test 0.4-0.5). However when the script was run to see interaction between N/L & N/M and various groups; we see significance (accuracy of 0.5-0.7). After running the script; we run a statistic analysis. The result shows that Absolute counts either N; L or M do not differentiate between the rejection; infection; CNI toxicity. However the ratios N/L & N/M help to differentiate between these conditions. The value of N/L & N/M in the four groups as follows: For A (3.7±2.28 & 9.26±5.5); for B (27.04±22 &21.41± 19.03); for C (9.77±7.89 & 19.90±17.86) & for D (8.5±5.22 &21.70±18.08) respectively. The ratio of N/L & N/M increases in groups B; C; D as compared to group A. When event B occurs; the ratio of N/L as compared to A is significant. When event C or D occurs; the ratio of N/M as compared to A is significantly different.

Conclusions: The differential leucocyte count; especially the ratios N/L and N/M; can help to predict whether an instance of AKI is due to rejection; infection or drug toxicity.

70. FGF23 and its Correlates in Indian CKD Population

Muhammed Shakeel, Sonika Puri, Sanjiv Jasuja, Gaurav Sagar, Anupam Bahl, S Chatterjee, Abha Gupta, Satish khanna

Indraprastha Apollo Hospital; New Delhi; India

Background: Recent studies have highlighted the importance of FGF-23 as a major phosphaturic molecule. It also inhibits 1 alpha hydroxylase activity thereby lowering the levels of 1; 25 dihydroxy vitamin D. The levels of FGF-23 have been shown to rise with declining in GFR. There are limited studies in Indian CKD patients looking at levels of FGF-23 in various stages of CKD and its correlation with other parameters of bone mineral metabolism.

Aim of the Study: To study the levels of FGF-23 in various stages of CKD and its correlation with levels of iPTH; calcium; phosphorus and vitamin D 25 (OH).

Methods: We looked at 48 patients in various stages of CKD (1-5 D) who were > 18 years of age who were visiting the Renal OPD at Indraprastha Apollo Hospital. Patients with renal transplantation; primary hyperparathyroidism; cirrhosis; or use of bisphosphonates; estrogens or SERM in past 3 months were excluded. A detailed clinical history was taken and medications were verified. Blood samples were drawn for CBC; KFT; Vitamin D and iPTH levels. The data was analyzed by statistical software SPSS-20. The chi-square test applied to find the association of CKD stage and gender. One-way analysis of variances was performed to compare the mean of age; BMI; Calcium (Ca.); and Phosphorus (Ph.) among the four CKD stages. Levenes test was applied to test the homogeneity of variance across the four groups. Since the distribution of FGF-23 iPTH; and VD was skewed; non-parametric test Kruskal Wallis test was performed to compare the distribution of these variables among the four CKD stages.

Results: Total of 47 patients were enrolled; of which 17 (36%) had an eGFR <15 ml/min/1.73 m2 and 13 (27%) had a egfr > 60 ml/min/1.73 m2. Overall percentage of females was 42%. Mean age increased and BMI decreased with increasing CKD stage: 48.0±15.1 years and 26.6±3.36 kg/m2 respectively (CKD Stage 1 and 2) to 54.3±17.5 years and 22.9±3.7 kg/m2 respectively (CKD 5). Ca. levels decreased from 9.3±0.5 mg/dl to 8.5±0.9 mg/dl and ph. Levels increased from 3.9±1.1 mg/dl to 5.1±1.9 mg/dl on moving from CKD 1 and 2 to CKD 5. Only the trend for ph. was significant. Median FGF-23 levels increased from 4.29 (1.43-11.43) pg/ml in CKD 1 and 2 to 76.67 (31.1-225.8) in CKD 5 while iPTH levels increased from 77 (48-108) pg/ml in CKD 1 and 2 to 219 (130 - 729) pg/ml in CKD 4; with a decline to 144.2 (66 - 664) pg/ml in CKD 5. There was a significant and positive correlation of FGF-23 levels with both ph. and iPTH levels while insignificant correlation was seen with Ca. and VD levels.

Conclusions: In a small; mixed population of Indian CKD patients FGF-23 levels increased with declining GFR. A decline in iPTH in CKD 5 could be a result of medical management of secondary hyperparathyroidism. A positive correlation between FGF-23; phosphorus and iPTH is consistent with known literature.

71. Living Related Kidney Donation in India: Not So Good if You'Re Male!

Sumeet S Dang, Anna T Valson, Mercy N Deborah, Shibu Jacob, Shailesh Kakde, Anjali Mohapatra, Vinoi G David, Suceena Alexander, Antony Devasia1, Nitin S Kekre1, T S Vijayakumar, Veerasamy Tamilarasi, Santosh Varughese

Christian Medical College; Vellore; Tamil Nadu; India

Background: Kidney transplant programs in India rely almost exclusively on a living donor organ pool; yet renal outcomes in this population with high prevalence of metabolic syndrome have not been adequately reported.

Aim of the Study: To study the renal and metabolic outcomes of living related kidney donors at a tertiary centre in South India.

Methods: This retrospective cohort study included all donors who underwent nephrectomy at our centre from January 1st 2006 to December 31st 2015. Clinical; laboratory and imaging data at baseline and follow up were collected and analyzed. The trend of post donation eGFR (4 variable aMDRD) and proteinuria; percentage of pre-donation eGFR (%eGFR) achieved at last follow up; peak value of %eGFR; time to attain peak %eGFR; prevalence of new onset hypertension and diabetes were studied.

Results: A total of 726 donors; mean age 42.0 + 11.3 years; 64.9% female; mean duration of follow up 27.1 ± 29 months; underwent nephrectomy during the study period. Prevalence of eGFR < 60 ml/min/1.73 m2; proteinuria > 150 mg/day; diabetes and hypertension at last follow up were 31.7%; 19.5%; 5.4% and 11.9% respectively. Mean% of predonation eGFR achieved at last follow up was 79.4% and peak%predonation eGFR achieved during follow up was 82.4% at a median of 6 months. Males had a larger fall in eGFR and increase in proteinuria and lower mean and peak%eGFR despite being younger and having a higher baseline aMDRD GFR.

Conclusions: Post donation renal and metabolic outcomes in Indian voluntary kidney donors; especially males; are a cause for concern. This information needs to be disseminated to potential donors during their evaluation and counseling.

72. Study of Acute Kidney Injury in a Tertiary Care Hospital

D Nagraj Naik, S Kishore Babu, Shilpa Shetty, Snkararn Sundar, Rohan Augustine, Sanjay Rampure, V Deepesh Chakravarthy, Sudarshan Ballal

Manipal Hospital; Bengaluru; Karnataka; India

Background: Acute kidney injury is characterized by sudden impairment of kidney function. AKI affects an estimated 13–18% of hospitalised patients and has emerged as a major public health problem that affects millions of patients worldwide and leads to decreased survival. There is increasing awareness of the poor outcomes of AKI. Poor outcomes include increased mortality and development of chronic kidney disease. The factors associated with long-term prognosis are poorly understood.

Aim of the Study: To study the etiology; clinical features and outcome of acute kidney injury in our hospital.

Methods: Study was conducted at Manipal Hospital; Bangalore. 150 consecutive patients admitted to wards and ICU and fulfilling the inclusion criteria were included. Inclusion criteria included patients >18 years with written informed consent diagnosed to have AKI according to the criteria and protocols of the 2005 Acute Kidney Injury Network. Patients with pre-existing CKD; congenital malformations or birth defects; genetic metabolic diseases and renal transplant recipients. The outcome parameters were defined as complete and partial recovery of renal function; CKD; ESRD and mortality. Requirement of RRT and outcomes were recorded. Surviving patients were followed up at discharge with s. creatinine and urine routine and then every 3 months for 1 year wherever possible. The CKD stage was determined at the end of 3 and 6 months by eGFR calculation based with CG formula. Statistical software SPSS 20.0 was used for the analysis of the data.

Results: Mean age of the patients was 55.46 years. 64% were males. Diabetes mellitus was the most common comorbid condition. Most common primary diagnosis causing AKI in our study was infection/sepsis in 68%. Biopsy was done in 13 patients. Among the 5 patients who developed ESRD 2 had cortical necrosis. Majority had ICU stay. 64% of the patients were in AKIN stage 3. RRT was required in 52%. 41 patients died during hospitalization. Among the surviving patients 29.3% developed some form of CKD. 4.59% developed ESRD and required RRT at the end of 3 months.

Conclusions: Infection was the most common cause for AKI. The mortality rate was 27.33%. 29.3% developed CKD. Male gender; ICU stay; higher AKIN stage and requirement of RRT influenced the mortality. Higher AKIN stage and requirement of RRT was associated with the development of CKD.

73. Clinicopathologic Profile of BK Polyoma Virus Nephropathy: Experience from 56 Biopsies

Mahesha Vankalakunti, L Umesh1, B T Anil Kumar2, Ravindra Prabhu3, Sanjeev Hiremath4, Arvind Canchi4, Saumil Gaur5, Deepak Ray6, S K Bhattacharya7, Lalit Agarwal8, Gokulnath9, Kishore Babu10, Sundar S11, Sudarshan Ballal10

Department of Nephropathology; Manipal Hospital; 1Nephrologists from Institute of Nephro Urology, 2BGS Hospitals; 3Kasturba Medical College; Manipal; 4Sagar Hospital; 5Rainbow Hospital; 9Apollo Hospital; 11CAYH; 10Manipal Institute of Nephrology & Urology; Bengaluru; Karnataka; 6RTIICS; 7CMRI; 8Woodland Hospital; Kolkata; West Bengal; India

Background: Allograft dysfunction due to BK polyoma virus is one of the dreaded complications in current Immunosuppression era. Allograft biopsies provide diagnostic and prognostic information; & remain gold standard for assessment of irreversible chronic organ damage.

Aim of the Study: To study the clinicopathologic profile of BK polyoma virus nephropathy (BKPVN) in allograft patients.

Methods: Allograft biopsies during the period of Jan 2012 to Aug 2017 were screened for biopsy proven BKPVN. Clinical; laboratory parameters & management were noted from medical records. A total of 236 cases out of 3317 allograft biopsies referred to our center were morphologically suspected for BK Polyoma infection requiring SV40 Immunoperoxidase stain. Light microscopy; Immunohistochemistry (SV40; C4d) were performed and pathological lesions studied. Immunofluorescence (IgG; IgA; IgM; C3; C1q; kappa & lambda) were done in 22 cases.

Results: 44 patients with 56 episodes were positive accounting for 1.7% incidence. Clinically; slow progressive graft dysfunction (Sr creat range 0.8-5.9 mg/dL) was the noted in all; except for one that was diagnosed in protocol biopsy at 3 mon. On histology; typical tubular epithelial inclusions were seen in 46 cases (82%); and rest were depicting nuclear enlargement with hyperchromasia. All of them were accompanied with tubulointerstitial inflammations (t1-t2 & i1-i2 Banff score). Immunofluorescence had fine granular deposits with IgG (3+) along the TBM in 7/22 cases (31%). Patchy granular deposits were noted with C4d IHC stain in 6/56 cases (10%). Immunosuppression was reduced in all of them; with addition of Quinolones/Leflunomide. Cidofovir was added in 5 cases. Details on graft survival are available in only 4 patients (1 CR; 1 PR; 2 graft loss).

Conclusions: BKV screening in urine is recommended every 3 months during first 2-yrs post-Tx period; followed by biopsy in positive cytology. We suggest IHC-SV40 in case of granular deposits with IgG/C4d along TBM in biopsy; akin to presence of IgM-plasma cells in PC-rich infiltrate with PTC C4d negativity.

74. Renal Involvement in Lupus: Clinical Features; Histological Patterns; Treatment Options & their Impact on the Outcome

Divya Bajpai, N K Hase, Tukaram Jamale

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

Background: Renal involvement in SLE is known to be associated with most unsatisfactory outcomes. There remains controversy in the predictive value of clinical features; histological patterns & treatment options. This is further complicated by the influence of race and ethnicity which averts the generalization of existing data to our population. We thus aimed to assess the predictors of clinical outcome in lupus nephritis.

Aim of the Study: To assess the predictors of clinical outcomes in lupus nephritis. primary outcomes: clinical response (complete; partial; no response) & renal function at 1 yr. 2 yr outcomes: flares; ESRD & mortality.

Methods: All patients satisfying diagnostic criteria for SLE with evidence of lupus nephritis (active urinary sediments; proteinuria >300 mg; decreased GFR) with a minimum of 1 year follow up at glomerulonephritis clinic in a tertiary referral center in western India were included. Records were screened for demographic details; clinical features; relevant investigations; renal histology & treatment details. Clinical response and serology was recorded at 1 yr; 5 yr and the last follow up available. Descriptive statistics were reported as frequency and percentage for categorical variables & mean & SD for continuous variables. One way ANOVA (continuous variables) & chi sq test (categorical variables) were used to detect differences in among pts for complete response; partial response or no response (as defined by EULAR consensus criteria) at 1 yr & renal function defined by creatinine level (primary outcome) and 5 yrs. Logistic regression analysis was used to determine predictors of clinical outcome.

Results: Of 173 patients; 86.8% were females. Mean follow up duration was 5.65 ± 5.42 yrs. Most common extrarenal manifestation was skin & mucous membrane (76.3%). Presenting renal syndrome were: Acute nephritis (4.6%); Nephritic-nephrotic syndrome (10.4%); Rapidly progressive renal failure (21%); Nephrosis (58.3%; of which 10.9% had AKI); subnephrotic proteinuria (7.5%). Class 4 (49.7%) was most common with mean activity index was 5.42 ± 3.31 & chronicity index was 1.79 ± 2.1. At 1 yr; 39.3% had complete response (CR); 36.4% had partial response (PR). Baseline S. creat <1 mg/dl; absence of anemia & leucopenia; negative dsDNA & normal C3 were associated with CR. 75.7% of pts had S. creat <1.5 mg/dl at 1 yr of follow up. Factors associated were: Age 18-35 yr; Absence of HTN; S. creat <1 mg/dl and low chronicity index. 107 episodes of renal flares occurred; associated with drug noncompliance and AZA maintenance. 12.7% progressed to ESRD. Mortality was in 8.6%. 19 pregnancies occurred outcomes of which were analysed.

Conclusions: Most common presentation was nephrotic syndrome & majority had Class 4 LN. S. creat <1 mg/dl; absence of anemia & leucopenia; negative dsDNA & normal C3 were associated with CR at 1 yr. Age 18 y -35 yr; normal BP; S. creat <1 mg/dl and low chronicity index were associated with S. creat <1.5 mg/dl at 1 yr.

75. Coronary Angiography Profile at the time of Hemodialysis Initiation in Esrd Population - A Retrospective Analysis

B N R Ramesh, Sree Bhushan Raju, Surendra Vijay Kiran, Vamsi

Nizams Institute of Medical Sciences; Hyderabad; Telangana; India

Background: Cardio vascular disease (CVD) is associated with increased mortality in dialysis population. However, there are very few studies that assessed the prevalence of coronary artery disease (CAD) at the time of initiation of hemodialysis (HD). The present study was aimed to assess the prevalence of CAD in End stage renal disease (ESRD) patients at the time of initiation of H and the risk factors for CAD in this population.

Aim of the Study: To assess the prevalence of CAD in End stage renal disease (ESRD) patients at the time of initiation of H and the risk factors for CAD in this population.

Methods: This was a single center retrospective study and included ESRD patients who underwent Coronary Angiography (CAG) at the time of initiation of HD. Inclusion criteria were age >18 years and those who were subjected to CAG within two weeks of initiation of HD. According to the findings on CAG; patients were divided in to No CAD and CAD groups. Clinical and laboratory parameters between these two groups were analyzed.

Results: 97 patients were included in the study based on the inclusion criteria. 44 (45%) patients were diagnosed with CAD. Patients who developed CAD were younger compared to no CAD group (50.7+10 vs 55.8+9.3 yrs; P=0.01). Majority of them weremales. Diabetic nephropathy was associated with increased risk of CAD 60% vs 40%; P=0.007). H/o of Smoking; high hsCRP; low total cholesterol; low HDL were associated with increased risk of CAD. Gender; symptoms of CAD; Serum LDL; VLDL & TG were not associated with increased risk of CAD. Neither Calcium; phosphorous nor CaxPO4 products were associated with an increased risk of CAD. Resting ECG abnormalities had no significance in predicting CKD (32% in CAD & 19% in No CAD group P=NS). Echocardiography showed RWMA/Global hypokinesia in 18% patients of CAD group and 3.8% patients of No CAD group (P= 0.03). Single vessel; double vessel & TVD was documented in 17 (38%) 13 (29.5%) and 14 (32.5%) patients respectively&the most common vessel involved was the left anterior descending artery.

Conclusions: At initiation of HD in ESRD pts; CAD was seen in almost 1/2 of the pts. DNsignificant r/f for CAD. Other r/fs include smoking; low cholesterol & HDL & high hsCRP. Symptoms of CAD; Serum VLDL; TG; LDL; ECG changes&gender were not a/w increased risk. screening for CAD should be considered in all HD initiation Pts.

76. Clinico Pathological Study of Rapidly Progressive Renal Failure (RPRF) in Adults

T Aswini Dutt, Manisha Sahay, Kiran Mai Ismail1, Sharma S Valli1

Department of Nephrology; Osmania Hospital; 1Osmania Medical College and Hospital; Hyderabad; Telangana; India

Background: Rapidly progressive renal failure is an initial clinical diagnosis in patients who present with progressive renal impairment of short duration from few days to three months. The etiology may be a primary renal or systemic disorders. Good history taking; clinical examination and investigations like serology and kidney biopsy are helpful in clinching the diagnosis.

Aim of the Study: The aim of present study is to analyse the various clinical parameters and histopathological spectrum of rapidly progressive renal failure in adults.

Methods: Patients (>18 years old) with RPRF presented to Osmania general hospital and underwent a kidney biopsy from 2011 to 2016 were included in this study. All biopsies were subjected to light microscopy and immunofluorescence.

Results: This study includes renal biopsy specimens from 135 cases of adult RPRF. Out of which 87 (64%) patients were male and 48 (36%) were female. The average age at presentation was 38 +/- 3 years. The clinical features among patients were rash (8%); anemia (16%); Diabetes (2%); Hypertension (34%); oliguria (12%); proteinuria (24%). Among the patients 89 (66%) were presented with renal failure and 46 (34%) with systemic disease. The most common histological lesions among isolated renal failure were Acute tubulointerstitial nephritis (25%) followed by Ig A nephropathy (19%). Among patients with systemic disease the most common histological lesions were post infectious glomerulonephritis (24%) and benign nephrosclerosis (17%). The other causes of RPRF includes thrombotic microangiopathy (10%); vasculitis (9%); lupus nephritis (8%) and one case each of granulomatous nephritis; anti GBM disease and myeloma cast nephropathy.

Conclusions: Early definitive diagnosis of RPRF by renal biopsy; serology is essential to reverse the otherwise relentless progression to ESRD.

77. Persistent Metabolic Acidosis in Patients who are on Regular Haemodialysis and Peritoneal Dialysis

Goutham Krishna, K T Harichandrakumar, Dhanin Puthiyottil, P S Priyamvada, Satish Haridasan, Sreejith Parameswaran

JIPMER; Puducherry; India

Background: Metabolic acidosis contributes to protein-energy wasting; inflammation; bone disease; and disturbance in endocrine function in CKD. The correction of acidosis by dialysis depends on factors like dialysis prescription; dietary habits etc. Due to resource limitations; dialysis centres in developing countries often perform haemodialysis twice a week instead of thrice and three exchanges of peritoneal dialysis per day; instead of four. This may be resulting in metabolic acidosis in our patients.

Aim of the Study: To study the serum bicarbonate levels in patients undergoing regular HD and PD and the extent of change of serum bicarbonate levels in patients before and after haemodialysis sessions.

Methods: The study was conducted in the Department of Nephrology; JIPMER; Puducherry between 1st June and 31st July 2017. Patients ≥18 years of age and undergoing regular haemodialysis at the JIPMER outpatient Haemodialysis centre were recruited after obtaining consent. Blood samples were collected before and after a haemodialysis session to measure bicarbonate levels. Peritoneal Dialysis patients ≥18 years of age were recruited from the Dialysis clinic. Patients who were on irregular dialysis and those who had technical complications with dialysis treatment were excluded. Blood samples were collected from patients on peritoneal dialysis to measure serum bicarbonate levels. The mean serum bicarbonate level before and after dialysis was calculated.

Results: We recruited 141 subjects in the study; 100 were on haemodialysis and 41 on peritoneal dialysis. 37.5% were females and 89.4% were non-vegetarian. 61% of subjects were on haemodialysis schedule of two sessions per week and only 7% of patients on peritoneal dialysis performed 4 exchanges/day. 73% of all patients on haemodialysis had pre-dialysis serum bicarbonate less than the level of 22 mEq/l. 41% continued to have bicarbonate <22 mEq/l even after haemodialysis session. 62% of patients on thrice a week HD had pre-HD bicarb <22 mEq/l. The dialysate bicrabonate was 34 mEq/l. Only 12% of patients on peritoneal dialysis had bicarbonate <22 mEq/l; which was significantly less than HD patients (p<0.05).

Conclusions: A very high proportion of patients on HD continue to have uncorrected metabolic acidosis. Persistent metabolic acidosis significantly lower in PD.

78. To Identify Risk Factors for Development of Post Transplant Diabetes Mellitus (PTDM) in Post Renal Transplant Indian Population

Abhishek Garg, Manish Jain, Ashish Nandwani, Sunil Mishra, Shyam Bansal, Reetesh Sharma, Dinesh Yadav, Amit Mahapatra, Chetan Mahajan

Medanta - The Medicity; Gurgaon; Haryana; India

Background: Renal transplantation is standard of care for ESRD. With increasing understanding of transplant immunology and advent of newer drugs and therapies; graft survival has improved over the course of last few decades. However; at times post transplant course is complicated by development of adverse effects secondary to long term immunosuppression. One such important adverse effect is Post Transplant Diabetes Mellitus (PTDM) which can have detrimental effect on both patient and graft outcomes.

Aim of the Study: To identify risk factors for development of Post Transplant Diabetes Mellitus (PTDM) in post renal transplant Indian population.

Methods: This was a single centre; prospective; observational study done at Medanta Hospital. A total of 66 first time ABO compatible kidney transplant recipients were included in this study who were followed up for 6 months post transplant and monitored for development of PTDM. Demographics; immunosuppression and various risk factors were noted. OGTT was done at 3 months and 6 months post transplant.

Results: Incidence of PTDM in this study was 21.21%. Those who developed PTDM were significantly older than those who did not develop PTDM (44.07 + 9.69 years vs 35.98 + 11.17 years; p=0.013). Family history was significantly more prevalent in those who developed PTDM (57.14% versus 15.38%; p=0.001). Even though pre transplant fasting blood sugar was normal in both the groups; it was significantly higher in the PTDM group (93.86 + 8.59 mg/dL versus 86.21 + 7.53 mg/dL; p=0.007). Similarly pre transplant HbA1c though normal was also significantly higher in PTDM group (5.2 + 0.39% vs 4.9 + 0.52%; p=0.006). We also found that post transplant treatment with steroid pulse therapy was associated with higher chances of developing PTDM (21.43% vs 3.84%; p=0.027). We did not find any significant association with gender of recipient; pre transplant weight or BMI; pre transplant lipid profile; hepatitis C infection; type of induction; CMV infection; tacrolimus trough levels and graft function (p=NS).

Conclusions: In our study we found that recipient age; pre transplant fasting blood glucose & HbA1c; family history and treatment with steroid pulse were significantly associated with development of PTDM at 6 months post transplant.

79. Acute Kidney Injury in Patients with Carcinoma Cervix: A Study in 73 Patients from a Tertiary Care Referral Hospital in South India

Pradeep Khandavalli, Manjusha Yadla

Gandhi Hospital; Secunderabad; Telangana; India

Background: Cervical cancer is common cancer. It is difficult to treat as they present in uremia. We observe the frequent progression to obstructive urinary complications. Urinary diversion by PCN is the method to relieve obstruction. Patients with BUO receive urgent intervention. AKI may lead to longer hospital stay; decreased functional status; quality of life and exclusion from further cancer therapy. Early detection of AKI is crucial in patients with cancer.

Aim of the Study: To study the clinical presentation; treatment modality and recovery in AKI secondary to bilateral uretric obstruction in carcinoma cervix.

Methods: This is a observational study of patients with AKI and either newly diagnosed or known case of carcinoma cervix over a period of 3 years. Inclusion criteria: Patients with AKI; Denovo or known cases of carcinoma cervix; Those who gave consent. AKI was defined based on AKIN criteria. Exclusion criteria: Those who did not give consent; K/C/O CKD or underlying renal diseaseSTUDY POPULATION: All female patients with AKI admitted under Nephrology were included in the study. PLACE OF STUDY: Nephrology department; Gandhi hospital; Secunderabad; Telangana. Detailed history of present illness and past history regarding previous surgery; radiotherapy or chemotherapy was noted. All patients with AKI were included in study and data was evaluated regarding course in hospital stay; RRT for AKI; recovery or RRT dependent; mode of urinary diversion technique used and these patients were followed up after discharge in regular OPD.

Results: 3105 female patients were included in study; 73 patients (2.3%) has cancer cervix; mean age among these 73 patients was 52.69 ± 1.07 years. Mean serum creatinine value at admission was 9.86 ± 4.41 mg/dl. Of these 73 patients 33 (45.20%) patients has AKI as presenting manifestation of carcinoma cervix. HD was initiated in 67 (91.7%) of patients as mode of RRT. Mean sessions of HD in this study was 6.28±3.52. Mean duration of hospital stay was 13.98±6.52 days. 51 patients (69.86%) underwent PCN and among them 45 patients had renal recovery during hospital stay. Renal recovery was found statistically significant among those who underwent PCN compared to those who denied PCN treatment (p<0.04). Among those patients who had renal recovery younger age; lower serum creatinine at admission; more mean HD sessions and hospital stay were statistically insignificant whereas PCN procedure was statistically found significant (p=0.04).

Conclusions: 1. 2.3% of AKI in female patients contributed to AKI secondary to cancer cervix.2. 45.2% of patients had AKI as presenting manifestation of carcinoma cervix.3. 100% patients had B/L HDUN4. Renal recovery was observed in 61.6% of patients.

80. Parathyroidectomy in Tertiary Hyperparathyroidism

C G Jyotish2, N Sajith1&2, H Benil1&2, N A Ismail1, A Feroz 1&2, K Rojan2

1Aster MIMS; 2Iqraa Hospital; Kozhikode; Kerala; India

Background: Tertiary hyperparathyroidism is emerging as a major long term complication of chronic hemodialysis patients. Despite optimal medical therapy which includes Calcimimetics many patients have refractory disease and require surgical intervention.

Aim of the Study: Parathyroidectomy is an effective option for patients with tertiary hypeparathyroidism who are refractory or intolerant to medical treatment.

Methods: Retrospective data of 12 patients who underwent total parathyroidectomy were analyses. Demographic characters; indication; dialysis duration. Modality surgery and post operative follow up at 6 mths were analysed.

Results: 15 patients underwent surgery.

Conclusions: Pararthyroidectomy is an important treatment option in patients with severe hyperparathyroidsim.

81. Long Term Outcomes of Kidney Donors- A Study from South India

Raj Shekar, K C Gurudev, Manns Manohar John, E Mahesh

Ramaiah Medical College; Bengaluru; Karnataka; India

Background: Living kidney donation benefits recipients and society but carries short-term and long-term risks for the donor. The wide use of healthy persons as kidney donors calls for awareness of risks associated with donation. Long-term data on these issues are generally lacking in the donor population.

Aim of the Study: Thus we aimed to investigate long-term health outcomes of kidney donors in a cohort of south Indian population.

Methods: Total of 220 renal transplants which were performed from a period of 1994 to 2014; out of them 76 donors had completed 10 years of post-kidney donation period. Out of 76 donors; 26 of them had regular OPD visits and periodic evaluation of renal function tests for a period of more than 10 years. We retrospectively analysed data of these 26 donors.

Results: None of them had CKD; 3 developed proteinuria (11.5%); all of which were subnephrotic range. Eight (30.7%) of them had dyslipidemia requiring therapy with statins. 3 (11.5%) of them developed Hypertension requiring therapy with a single anti hypertensive drug. The mean kidney size was 10.4 cm. None of them had diabetes milletus nor any cardiac ischemic events or cardiac failure events.

Conclusions: Even though recent studies have shown some long term adverse health outcomes following kidney donation; our study in a cohort of south Indian population shows that kidney donation is quite safe and has very little adverse health outcome on the donating individual.

82. Multianalyte Point of Care [PoC] Biosensor Diagnostic Device: Clinical and Community Applications in Diabetes Care

Urmila Anandh, Vinay Kumar1, Navakant Bhatt1, S S Srikanta2

Department of Nephrology; Yashoda Hospitals; Hyderabad; Telangana 1Centre for Nanoscience; Indian Institute of Science; 2JS Medical Centre; Bengaluru; Karnataka; India

Background: Chronic Kidney disease is particularly of major importance in a developing country like India where there is an epidemic of new onset type 2 diabetes mellitus patients. An early detection and strategies for prevention of progression of diabetic kidney disease will make a major difference for these patients. Consequently; point-of-care (PoC) diagnostics for CKD that are cost effective remain an important goal in health care delivery in India.

Aim of the Study: To study the efficacy of a multianalyte electrochemical biosensor in early diabetic kidney disease at the community level.

Methods: A PoC designed in IISc Bangalore was tested in two phases –Analytical phase and Validation phase. The duration of this prospective study was from January 2014 to January 2017. The biomarkers tested were related to diabetes management in early diabetic kidney disease: Hemoglobin; HbA1c; serum albumin; urine albumin; urine creatinine and urine albumin to creatinine ratio (UACR). PoC device used in this study is based on novel non-enzymatic and non-antibody based electrochemical biosensing technology. Standard laboratory testing was done for the above mentioned analytes. A correlation coefficient was constructed between the samples tested in reference laboratory and the PoC device. In the clinical validation phase the demographic details; presence of comorbidities and; the eGFR were noted. Correlation testing; ROC curves and a Bland Altman plot was were constructed in the clinical validation phase.

Results: In the analytical phase the total number of samples tested were 9317. The correlation coefficient was as given Hemoglobin-0.917; HBA1c-0.832; Serum Albumin-0.832; Urine Albumin-0.85 and Urine Creatinine-0.95. All the values have p<0.0001. In the clinical validation phase the total number of samples tested were 236 (Males= 119; Females=117). The mean age (± SD) was 56.4 (± 34.2) years. There were 132 type 2 DM and 86 type 1 DM and 18 non DM patients. The duration of diabetes in Type 1 DM was (7.6± 4.7 years) and in Type 2 DM it was 10.7 (± 7.6) years. The range of eGFR in this cohort was 19 ml/min to 129 ml/min. The statistical analyses of the various tests in the clinical validation phase shows a correlation as given Hemoglobin-0.803; HbA1c -0.72; Serum Albumin-0.83; Urine Albumin-0.94; Urine Creatinine-0.83. All values have a p<0.0001. There is a strong correlation between the results obtained by standard laboratory methods and the PoC device.

Conclusions: The indigenously developed point of care biosensor shows excellent correlation with standard tests. This device can be used in remote underserved areas of developing countries in patients with early diabetic kidney disease.

83. Detection of Coagulopathy in Chronic Renal Disease Using Thromboelastography and its Comparison with Conventional Tests

Suman Nayak, Kelika Prakash, Chandra Kant Pandey

Institute of Liver and Biliary Sciences; New Delhi; India

Background: Thromboelastography provides a holistic picture of blood coagulation including fibrin formation; cross linking and fibrinolysis.

Aim of the Study: The present study evaluated the thromboelastographic profile of end stage renal disease patients and compared it to conventional tests of coagulation.

Methods: Fifty end stage renal disease patients and 50 controls were recruited for the study. Venous samples were withdrawn and platelet count; International Normalization Ratio and fibrinogen levels were measured. Simultaneously a thromboelastography (TEG) was performed. All samples were drawn prior to initiation of dialysis.

Results: The fibrinogen concentration was higher in the end stage renal disease group compared to control (455.51±83.39 vs. 233.84±71.71 mg/dl; P<0.05). The maximum amplitude in end stage renal disease group was 76.94 ± 15.11 mm; which was significantly higher than control group 65.10±10.31 mm (P<0.05). Out of 50 patients; 39 had maximum amplitude (MA) >73 mm; 3 had MA <55 mm while 8 patients had normal MA. Further; it was seen that in four out of the five patients whose INR was greater than 1.5; TEG was hypercoaguable. Also; three patients whose platelet count was less than 1 × 105/dl had normal thromboelastographs. Two patients who had normal platelet count; fibrinogen and INR. had hypercoaguable thromboelastographs. Thromboelastography could detect fibrinolysis in 5 patients of end stage renal disease.

Conclusions: The present study demonstrated that INR; platelet count and fibrinogen levels do not reflect the actual coagulation status in patients of end stage renal disease. Thromboelastography is a better tool to detect coagulopathy in this group of patients.

84. Generic Sofosbuvir Based Direct-Acting Antiviral Therapy in Hepatitis C Virus Infected Patients with Chronic Kidney Disease

Suman Nayak, Manoj Sharma, Ekta Gupta, Ashish Kataria, S C Tiwari

Institute of Liver and Biliary Sciences; New Delhi; India

Background: There is scant data on safety and efficacy of sofosbuvir containing directly acting anti-viral (DAA) regimens in chronic kidney disease (CKD) patients. Recently generic versions of DAAs have become available in low income countries including India.

Aim of the Study: to study the efficacy and safety of generic sofosbuvir in combination with generic ribavirin; ledipasvir; or daclatasvir in HCV infected patients with CKD stage 4 or 5 and 5D.

Methods: Seventy one CKD patients (76% male; 84.5% on maintenance hemodialysis; 23.9% cirrhosis) with HCV infection were included in the study. Full dose sofosbuvir was used in combination with ribavirin (N= 26; for 24 weeks; 69.2% genotype 1; 30.8% genotype 3); ledipasvir (N=26; for 12 weeks; all genotype 1) and daclatasvir (N=19; for 12 weeks; all genotype 3).

Results: Sustained virological response (SVR) (HCV RNA <12 IU/mL) at 12 weeks after stopping treatment was seen in 100% of the patients in all the three groups. At 24 weeks of follow-up after end of therapy; one patient in sofosbuvir plus ledipasvir group relapsed. At 48 weeks of follow-up after end of therapy; one more patient in sofosbuvir plus ribavirin group relapsed. No patient discontinued treatment because of side effects. Anemia developed in 17/26 (65.4%) patients in sofosbuvir plus ribavirin; 2/26 (7.7%) in sofosbuvir plus ledipasvir; and 2/19 (10.5%) in sofosbuvir plus daclatasvir group.

Conclusions: Full dose sofosbuvir based DAA therapy using generics is highly effective for individuals with HCV infection and CKD including advanced CKD (CKD stage 4 or 5 with an e-GFR <30 mL/min or those on dialysis).

85. The Incidence of Acute Antibody Mediated Rejection in Kidney Transplantation & its Risk Factors

Smarak Panda, C R Kar, S B Rout, P K Sahu, Bishwaranjan Mohanty

Department of Nephrology; SCBMCH; Cuttack; Odisha; India

Background: Acute rejection is a common complication of renal transplantation. Incidence of acute rejection varies from 15% to 20%. The incidence of Antibody mediated rejection varies from 3.5-9%. It has many risk factors such as Age; Type of donor; HLA matching; induction agent & type of immunosupression used.

Aim of the Study: The present study was undertaken with objective to calculate the incidence of acute AMR in our hospital and possible risk factors responsible for rejection.

Methods: We have studied all the patients undergoing renal transplantation in Dept of Nephrology & Transplantation from October 2014 to September 2016. Total 52 cases were taken. Male comprises 92.3% of cases and females 7.7%. Average age of the recipients and donors were 35±8.68 yrs & 45±8.88 years respectively. Chronic glomerulonephritis contributes most of the ESRD cases undergoing renal transplantation (76.92%); followed by diabetic nephropathy in 19.32%. Mother as donor comprises 55.67% and wife in 28.84%. Total 21 cases (40.38%) have received induction agent prior to transplantation. Basiliximab is used in 20 cases.

Results: The incidence of acute AMR is 26.92%. Most of the acute AMR are diagnosed within two weeks after transplantation. Most of the recipients of age group 31-50 years suffered AMR (85.7%). The incidence of the acute AMR is highest in blood group O i.e. 43.75%. We found no significant correlation with number of HLA mismatch and acute AMR. Most of the AMR occurred in patients received kidneys from donor aged more than 50 years (56.25%). We found a higher incidence of acute AMR which may be multifactorial. Possible risk factors are retransplantation; Blood transfusion pretransplantation; presence of antibody to non HLA antigens; Older donors (>50 years).

Conclusions: These findings stress the importance of modifying risk factors to prevent acute AMR which remains the main determinant in developing IFTA. The drawbacks are small no of patients; DSA levels are not done. Thus a large study will throw more light on this entity.

86. Shearwave Sonoelastography (SSE) Evaluation of Renal Allograft Dysfunction - A Novel Noninvasive Option

R Rao, S Jasuja, Mohita , Nitin P Ghonge, G Sagar, A Bahl, S Puri

Indraprastha Apollo Hospital; New Delhi; India

Background: Although the incidence of acute rejection has diminished. Graft Dysfunction diagnosed based on clinical and laboratoty findings. Graft Biopsy is gold standard. Nevertheless biopsy cannot always be performed; both for anatomical and coagulation related issues. SSE is a non invasive method & is strongly correlated with grade of fibrosis; providing an assessment of the tissue stiffness in kPa or m/s.

Aim of the Study: To evaluate if SSE could differentiate stable renal graft from acute or chronic graft dysfunction.-To correlate SSE values with RI; Creatinine; eGFR and biopsy findings.

Methods: Prospective study; Conducted in the Departments of Nephrology Radio diagnosis; and Pathology between periods of 1st October 2014 to 31st March 2016. The 60 Post renal transplant patients studied by SSE for normal follow up or with a clinical suspicion of allograft dysfunction The SSE was performed PHILIPS EPIC7G USG machine using a 5-1 convex probe. Patients were categorized into three major groups (stable graft; acute graft dysfunction; chronic graft dysfunction); before the commencement of examination; in the Nephrology department; On the basis of clinical parameters like eGFR; serum creatinine and urinary protein (dipstick assay). Inclusion Criteria: All renal allograft recipient of age 18 years and above. Exclusion Criteria: (1). Skin-Allograft distance > 3 cms; (2); Renal Allograft parenchymal thickness < 1 cm; (3). Peritransplant fluid collection (4). Patients lost to follow up.

Results: 60 post renal transplant patients were included in this study. 9 (15%) were females and 51 (85%) were males. Mean age of subjects was 40.78 ± 11.31 years (Range 20 - 73 years). Among these subjects 30 (50%) have stable graft function; 19 (31%) have acute graft dysfunction; 11 (19%) have chronic graft dysfunction. The mean Shearwave sonoelastography parenchymal stiffness (Kpa) was 8.51±2.44 in stable group; 11.08±2.91 in acute rejection group; 24.50±4.49 in chronic rejection group. Mean eGFR was 83.11±10.47 in stable group; 47.71±8.05 in acute rejection group; 31.28±7.30 in chronic rejection group. The mean Shearwave sonoelastography parenchymal stiffness (Kpa) correlated well with eGFR; RI and Serum creatinine levels (p<0.01).

Conclusions: SSE can be successfully used for the assessment of parenchymal stiffness of renal allografts. SSE follow up of the renal allograft can be of high value to identify patients with sub clinically progressive interstitial fibrosis and facilitate patient's selection for biopsy.

87. Renal Involvement in Multiple Myeloma and its Clinicopathological Correlation: A Single Centre Experience

Gaurav Shekhar Sharma, Dhananjai Agrawal, Alok Kumar Pandey, Pankaj Beniwal, Sanjeev Sharma, Rajesh Johrawat

Department of Nephrology; SMS Medical College; and Hospital; Jaipur; Rajasthan; India

Background: Multiple myeloma is a hematologic malignancy characterized by the neoplastic proliferation of plasma cells producing a monoclonal immunoglobulin. Renal involvement is it's common feature and includes myeloma cast nephropathy (MCN); AL amyloidosis; light chain/heavy chain deposition disease (LCDD/HCDD) etc. There is a strong correlation between the presence and severity of renal function impairment and patient survival. Survival is particularly poor among dialysis dependent patients.

Aim of the Study: To examine kidney biopsy findings in patients with multiple myeloma and correlate them with their clinical renal and hematologic characteristics.

Methods: All cases of multiple myeloma; diagnosed on the basis of 2014 the International Myeloma Working Group; who presented with renal impairment between July 2016 and June 2017 in the Department of Nephrology; SMS Hospital; Jaipur were enrolled in this study. Patient's demographic; hematologic and renal parameters were assessed. Necessary investigations to confirm myeloma were carried out in suspected cases. Renal biopsy was done in all those patients who were either having renal impairment (Serum creatinine > 2 mg/dl) or dip stick proteinuria of more than 2+ with kidney size >8.5 cm on ultrasound. Those patients having kidney size < 8.5 cm or who were not willing to give consent for renal biopsy were excluded from the study.

Results: A total of 34 patients were included in this study with male:female ratio was 1.83:1. The mean age of study population was 55.5 ± 12.1 years. The most common symptom was the loss of appetite (57%) followed by swelling all over the body (41%). On renal biopsy; all of the patients found to have myeloma related renal injury. The most common lesion was MCN (n=26; 76%) followed by LCDD (n=6; 18%) and amyloidosis (n=2; 6%). Patients with LCDD were younger than that of MCN and amyloidosis. The mean S. creatinine of MCN patients was higher than that of LCDD patients (12 versus 4.7 mg/dl; P=0.007). The mean 24 hours urinary protein was higher in amyloidosis in comparison to LCDD and MCN patients (4.6 versus 2.8 versus 0.9 gm; P < 0.0001). Kappa was the predominant light chain in LCDD patients while amyloidosis patients had only Lambda light chain involvement. MCN patients had involvement of both chains in almost equal frequency (6:7).

Conclusions: In our study; the most common presenting symptom was the loss of appetite (57%) and on renal biopsy; the most common lesion found was MCN (76%). The mean S. creatinine of MCN patients was higher than that of LCDD patients. The mean 24 hours urinary protein was highest in amyloidosis patients.

88. Renal Response to Bortezomib Based Therapy in Patients with Multiple Myeloma with Severe Renal Impairment

Alok Kumar Pandey, Dhananjai Agarwal, Vinay Malhotra, Pankaj Beniwal, Gaurav S Sharma, Vinay Rathore

SMS Medical College; Jaipur; Rajasthan; India

Background: Renal impairment is common in multiple myeloma patients (up to 50%) and is an independent factor for poor prognosis. Renal complications are mainly because of deposition of monoclonal immunoglobulins (paraproteins) in the glomeruli or tubules. Severe renal impairment requiring dialysis is common in myeloma cast nephropathy (MCN). Bortezomib-based therapy has improved the survival of patients with renal impairment with acceptable side effect profile.

Aim of the Study: To evaluate the response of bortezomib based therapy in patients with multiple myeloma with severe renal impairment requiring dialysis.

Methods: This study was done in nephrology department of SMS medical college and hospital; Jaipur; from July 2016 to June 2017. In this study we included patients of multiple myeloma with severe renal failure (S. creatinine > 5 mg/dl or requiring dialysis). Renal biopsy was done to find out the cause of renal impairment in patients having normal kidney size. Every patient was treated with injection bortezomib 1.4 mg/m2 plus injection dexamethasone 40 mg intravenously given once a week for an average of 12 weeks in addition to supportive treatment and hemodialysis. Before each injection; every patient was examined and investigated to rule out any contraindication for bortezomib therapy. The renal response is categorized according to International myeloma working group renal response criteria (Complete response – baseline eGFR improved to ≥60 mL/min; Partial response – baseline eGFR improved to 30 to 59 mL/min). This study was approved by ethics committee of our hospital.

Results: Total 30 patients were included in the study in which after renal biopsy 26 patients (87%) were found to have myeloma cast nephropathy (MCN) and remaining 4 (13%) patients have Light chain deposition disease (LCDD). Two patients lost to follow up during the 1st month of the study period. Out of 28 patients; 20 patients (71%) became dialysis free after an average of 4 injections of bortezomib. Out of which 14 (50%) patients showed complete response while 6 (21%) patients showed partial response after completion of therapy. Four (14%) patients did not show any response to therapy and remain dialysis dependent even after completion of therapy while another 4 (14%) patients succumbed during study period (3MCN+1LCDD). Treatment response was found to be similar in both MCN and LCDD patients without any significant difference (P=0.51). None of the patient developed any serious side effect requiring discontinuation of therapy.

Conclusions: This study revealed that myeloma cast nephropathy is the most common cause of severe renal failure in multiple myeloma patients followed by light chain deposition disease. Bortezomib based therapy has very good renal response in myeloma patients without any serious side effect.

89. To Study the Timeline of Complications with Respect to Graft and Patient Outcomes in ABO Incompatible Transplant Recipients in the First Year Post Transplantation

Lovy Gaur, A K Bhalla, Gupta Ashwani, Malik M, Shingada Aakash, A Gupta, V Bhargava, V Ranjan1, K Khillan1, H Jauhari2, D S Rana

Departments of Nephrology; 1Blood Transfusion Medicine; 2Urology; Sir Ganga Ram Hospital; New Delhi; India

Background: In India; living donor kidney transplantation accounts for vast majority of the 2% patients of ESRD undergoing renal transplantation. ABOi transplants are thought to be at a greater risk for rejections and infections as a result of greater immunosuppression. Understanding the timeline of complications particularly during the first year post transplant is critical for early recognition and timely intervention for improving outcomes with respect to graft function as well as patient survival.

Aim of the Study: A retrospective and prospective observational study aimed to analyse the outcomes of ABO incompatible transplantation with analysis of timeline of complications in the first year post transplant.

Methods: From June 2012-2017; 95 patients underwent ABOi-KT at our centre. We present data of 61 patients who have completed 1 year of treatment. Desensitisation protocol consisted of rituximab 500 mg 2 weeks prior to transplantation. Tacrolimus (0.05 mg/kg/day) and mycophenolate mofetil (1000 mg/day) were also initiated. Plasma exchanges were initiated a week prior to transplantation targeted to IgG <1:8 (Gelcard method). Immunodsorption was done as deemed necessary. 2 days prior to surgery dose of tacrolimus was escalated to 0.1 mg/kg/day targeting trough levels 8-12 ng/dl; target mycophenolate mofetil was 1.5-2 gm/day. Glucocorticoids were administered as solumedrol 250 mg/day in divided doses intiated a day prior to transplantation and continued for next 3 days following which oral prednisolone was started. ATG was used in all but 5 patients in whom Basiliximab was administered as induction agent. Patients were followed up twice a week in the first 12 weeks; once a week till week 16 and monthly thereafter.

Results: 49 were male and 12 were female. Mean age -39.2±25.2 years. Baseline titres ranged 1:2 – 1:512 (Median-1:16). Mean sessions of plasma exchange required prior to transplantation was 4.45; immunoadsorption was needed in 24 patients.7 patients required plasma exchange post transplant;5 had ABMR;2 patients had TMA.1 year patient survival was 91.8%. 2 patients succumbed to sepsis; 1 each due to CNS aspergillosis; mucormycosis.1 death was due to cardiovascular cause. Death censored graft survival was 94.6%; 3 patients returned to dialysis. Biopsy proven rejection occurred in 7 patients (11%)–graft recovery occurred in all except one. 55 infectious episodes occurred over 1 year–most common being UTI (40.8% of total infections). UTI was most common in first 2 weeks; E. coli accounted for most cases (38.3%). LRTI (15%) were more common in first 6 months (2nd quarter). CMV viremia (6 patients) occurred mostly in 2nd quarter. BK viremia and viruria occurred in 1 patient at 3 month post surgery.

Conclusions: ABOi KT is an important strategy to increase donor pool at the cost of higher immnosuppresion. Anticipating complications and timely intervention directing at reversing rejection and treating infections may further improve outcomes with respect to graft and patient survival.

90. Abdominal Aortic Calcification as a Surrogate Marker for Cardiovascular Risk and Long Term Clinical Outcome in ESRD Patients

Amit Langote, Mayuri Trivedi, Jatin Kothari, Rasika Sirsat, Alan Almeida

P.D Hinduja Hospital and medical research Centre, Mumbai, Maharastra, India

Background: Patients with CKD 5D have a greatly increased atherosclerotic burden which explains in part why cardiovascular mortality is increased 20- to 30-fold in this group compared with an age-matched population. We used the lateral abdominal X-ray to identify the presence of abdominal aortic calcification; MDCT to assess coronary calcification in CKD5D patients and correlated that to the occurrence of cardiovascular event over 7 year period.

Aim of the Study: (1) To quantify AAC by lateral lumbar X-ray me. (2) To correlate AACS and CACS for prediction of cardiovascular disease risk (3) To Corelate AAC score with long term vascular events.

Methods: All the patients enrolled in this study were undergoing maintenance hemodialysis in a tertiary care hospital. Information on age; gender; duration of dialysis; diabetic and hypertensive status and smoking status was collected. Lateral radiography was performed in the standing position using standard radiographic equipment Abdominal aorta calcification (AAC score) was graded using a previously validated system in which both the location and the severity of calcific deposits at each lumbar vertebral segment (L1–L4) were evaluated. All patients underwent MDCT coronary artery calcium scoring (CACS); which was calculated by automated GE software workstation version 4.3 and manually corrected. The recorded vascular events included coronary events (MI; angina pectoris; unstable angina; CABG; PTCA) cerebrovascular events (stroke and TIA) and PVD (Intermittent claudication; abdominal aortic aneurysm; angioplasty; vascular surgery and amputation).

Results: A total of 50 patients were included in this study (58% males; 54.5± 13.67 years). The mean AAC score was 3.48 ± 0.84. The mean CACS was 438.51 ± 765.8. The presence and extent of abdominal aorta calcification were associated with progressively higher likelihood ratios of CACS. The AUC for AAC score was >0.6 for predicting each CACS level indicating fair to good discriminatory value. Over a mean period of follow up of 64.1±30.9 months; 21/50 patients had a cardiovascular event (15 coronary events; 4 cerebrovascular events and 2 PVD events). However the AAC score had a negligible correlation with the occurrence of the event (rpb= -0.08; p=0.29) and CACS has a low correlation with occurrence of events (rpb=0.28; p=0.02).

Conclusions: Even though AACS (Xray) showed good correlation with CACS (MDCT) & can be used as a surrogate marker in a resource limited setting like India; it showed poor correlation with hard clinical outcomes in the form of occurrence of cardiovascular events over the long term follow up.

91. Emphysematous Pyelonephritis: A Retrospective Observational Study to Predict the Factors Associated with Severity and Management Strategies

Anvesh Golla, Vijay Kiran, Sree Bhushan Raju

NIMS; Hyderabad; Telangana; India

Background: Emphysematous pyelonephritis (ePN) is a severe; necrotizing renal parenchymal infection that is characterized by the production of intraparenchymal gas. It carries a much higher mortality than conventional cases of pyelonephritis. High-dose antibiotic therapy alone or with percutaneous drainage in contrast to bilateral nephrectomy may be a preferable approach to salvage kidney function.

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 are reviewed from Jan 2012 to June 2017. Demographic data; clinical features; laboratory parameters; imaging; treatment and outcomes are analysed. Huang and Tseng CT grading 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. 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 unpaired t test for continuous variables and chi-square for categorical variables; with P < 0.05 considered statistically significant.

Results: Of the 30 patients diagnosed; mean age is 51.5±14.7. Male to female ratio 1.1:1 diabetes seen in 76%; renal stone disease in 33%; congenital anamoles in 6%. Mean HBA1c in group 1 is 6.6±1.2; in group 2 is 7.68±1.2 suggesting poor glycemic control in severe grade. At admission; symptoms included fever (93%); flank pain (96%); nausea/vomiting (63%); dysuria (73%); altered sensorium (16%); oliguria (33%). Mean serum albumin in group 1 is 3.04±0.47; in group 2 is 2.36±0.4. Urine culture shows positive growth in 43% out of which Ecoli seen in 77%. Medical management alone given in 26%; RRT support given in 43%; DJ stenting done in 23%; PCNL in 52%. Dialysis dependent in 15%.

Conclusions: In EPN; presence of low serum albumin is associated with severity; blood culture and urine culture positivity seen in 17% and 43% with Ecoli being common organism identified. Medical treatment along with DJ stenting and PCN in severe EPN is able to salvage kidney.

92. Crith Study: Catheter Related Infection in Tunneled Hemodialysis Catheters

R Bansal, D K Yadav, D Bansal1, A Mahapatra, A Nandwani, M Jain, S B Bansal, V Kher1

Division of Nephrology; Medanta Kidney and Urology Institute; Medanta - The Medicity; Gurgaon; Haryana; 1Division of Nephrology; Medanta Kidney and Urology Institute; Fortis Escorts Hospital; New Delhi; India

Background: Catheter – related bloodstream infections (CRBSI) are major cause of hospitalization and mortality in haemodialysis patients. The incidence of CRBSI with tunnelled- cuffed dialysis catheters (TDC) varies from 1.6-5.5 episodes/1000 catheter days. The major culprit is CRBSI is Gram positive bacteria and hence the guidelines for empirical antibiotic therapy recommend use of vancomycin along with coverage for gram-negative bacilli; based on the local antibiogram.

Aim of the Study: The aim of the study was to assess incidence and outcome of catheter related blood stream infection in hemodialysis patients in India.

Methods: 750 tunneled dialysis catheters were placed in a cohort of 718 patients in a tertiary care hospital in North India by a nephrologist between February; 2014 till April; 2017. The follow up period was 3 months to 3 years. 68 patients were lost to follow up. Two sets of blood culture- from the peripheral vein and the catheter along with CBC were sent for any patient having signs and symptoms of CRBSI. All patients were started empirically on injection vancomycin and amikacin/ceftazidime. Tunnelled catheter was removed in patients with severe sepsis or requiring ICU care/inotropes as well as those with poor response even after 72 hours of antibiotic therapy.

Results: A total of 228 episodes of CRBSI occurred in 176 catheters. The incidence of bacteremia in our study was 1.9 episodes/1000 catheter days. The median time (range) to the first episode of CRBSI was 63.5 days. 112 (49.1%) episodes were culture positive with highest frequency noted for gram negative bacteria (64.3%) followed by gram positive bacteria (28.5%) and fungi (2.7%). 5 (4.5%) patients had polymicrobial (≥2 organisms) line sepsis. Pseudomonas sp. was the most commonly isolated organism followed by Klebsiella. We also observed growth of Candida tropicalis in 4 catheters. 82 catheters were removed due to sepsis out of which 17 patients expired due to CRBSI even after removal of TDC.

Conclusions: In the present study; the incidence of CRBSI was 1.9 episodes/1000 catheter day which is comparable to the other studies. The rising trend in gram negative bacteremia may have a bearing on our current antibiotic policy. If the patient is in septic shock; early catheter removal must be attempted.

93. Assessment of Functional Dependency and its Clinical and Socio-Demographic Determinants Among Patients with Chronic Kidney Disease on Hemodialysis

P S Priyamvada, Viswanath Narendiran, K T Harichandrakumar

JIPMER; Puducherry; India

Background: Functional (FS) is a key factor which contributes to the quality of life. There is only limited data on FS in dialysis patients from developing countries like India; where optimal dialysis delivery is often limited by suboptimal resources. There is no kidney disease specific tool for assessing FS in dialysis patients. It is not clear whether the generic tools validated elderly CKD patients would perform well in younger dialysis patients.

Aim of the Study: Assess the functional status in hemodialysis using 3 generic instruments - Functional Independence Measure TM; seven domains and five levels (7D5L) and Activities of Daily Living (ADLQ).

Methods: All adult patients on Hemodialysis; attending the dialysis clinics were enrolled between April 2017 - July 2017 were eligible for enrollment. A dialysis vintage of more than three months was required for inclusion Patients with severe liver disease; cardiac failure; stroke or other mobility disorders; HIV with AIDS; malignancy; tuberculosis or any other chronic illness and significant cognitive disturbance were excluded. FS was assessed using FIM (Scores 18-126); 7D5L (Scores 0-28) and ADLQ (Scores 0-6) scales. A higher FIM and ADL scores indicated functional independence where as a lower 7D5L scores suggested functional independence. All assessments were made by a single trained person by a personal interview. The comparison of the FIM score; 7D5L score and ADLQscore between the categorical variables were carried out by using Independentstudents to test/Mann Whitney U test or One Way Analysis of Variance/KreskasWallis test whichever is appropriate.

Results: The mean age of patients was 41.28 ± 15.44 years. About 77.6% were males and 80.2% were unemployed. About 67.2% were receiving twice weekly haemodialysis and 28.4% were receiving thrice weekly dialysis. The mean scores were 119.05 ± 11.42 with FIM; 6.44± 4.26 with 7D5L and 5.51 ± 1.19 with ADL instruments. More than 80% showed full functional independence with ADLQ instrument. With FIM; the overall scores showed a tendency for functional independence; but the subdomains involving locomotion/mobility was impaired to a greater extent. The proportion of patients with full independence was less with 7D5L. Majority of participants had mild to moderate limitations in independence; but not requiring assistance by a helper. Majority of patients complained of profound delay in performing the motor tasks; which interferes with their daily activities; but none of the instruments had a time specific component. Age>40 and low albumin levels were associated with poor FS by 7D5L (p=.05).

Conclusions: The patients on hemodialysis were functionally independent as assessed by FIM and ADLQ. 7D5L showed mild to moderate limitations in daily activities in the majority. Addition of a time-related component would enhance the sensitivity of existing tools in assessing FS of younger dialysis patients.

94. Double Kidney Transplant with Extended Criteria Donors - Single Center Experience

Ilangovan Veerappan, Ramasami Sethuraman, N M Balakrishnan, Selvakumar Thilagarani, G Bakthavathsalam

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

Background: Kidney transplant offers best chance of long term survival in patients with end stage kidney disease. More than half of the organs available for transplant are from donors aged > 50 years in India and elsewhere. When these patients have hypertension (HT) or diabetes mellitus (DM) or abnormal kidney function; the decision to allocate the organs becomes complex as the graft survival of these marginal kidneys are lesser than the graft survival from standard criteria donation (SCD).

Aim of the Study: To study the feasibility and outcome of single versus double kidney transplantation in the setting of marginal kidney transplantation using histological scoring.

Methods: A prospective study between Jan 2015 and July 2017 was done in a single center. All deceased donor kidneys from SCD and marginal kidneys as defined by UNOS were included in analysis. All kidneys were subjected to pre implantation biopsy with two cores of kidney biopsy from both poles. Histological scoring was done by modified Remuzzi scoring system following rapid processing with H&E staining. Remuzzi score of ≤ 3 = single organ transplant; 4 to 6 = double kidney transplant; >6 = discarded. Kidney Donor Risk Index (KDRI) at time of transplant were calculated. The MDRD eGFR (at 1 and 2 years) were calculated for SCD and marginal donors. Patient and graft survival were tabulated with SCD recipients as reference group. All the patients were treated with prednisolone; mycophenolate mofetil and tacrolimus. All received rATG or Basilixumab induction.

Results: The 2 year patient survival in 62 SCD; 32 ECD and 8 DKT were 96.8%; 87.5% and 100% respectively (p<0.05). The 2 year death censored graft survival in SCD; ECD and DKT were 98.4%; 96.9% and 100% respectively (p>0.05). In the 40 patients with includes ECD and DKT; the mean recipient age was 51.7±11.5 yr; mean donor age was 60±9.9 yr; 21 (52.5%) had both diabetes and hypertension while the rest had diabetes or hypertension. The mean donor creatinine on the day of donation was 2.2 ±2.8. The KDRI was 2.1 ± 0.4. The mean cold ischemia time was 7.0±3.9. rATG was given in 36 (90%) and rest received Basiliximab. There was poor correlation between histological score (modified Remuzzi's) and clinical score (KDRI); r=0.3. Histological score was done in 18/32 ECD and 5/8 DKT and the mean score was 2.1±0.5 and 3.5±1.1 respectively. The mean serum creatinine (MDRD eGFR) in SCD; ECD and DKT were 1.1±0.4 mg% (60±12 ml/min); 1.5±0.5 mg% (52±15 ml/min) and 1.2±0.4 mg% (59±10 ml/min) respectively (p<0.05).

Conclusions: DKT offers safe allocation of marginal kidneys which otherwise are discarded. The graft and patient survival are excellent in the 2 years of follow up and is better than single organ ECD transplant. The clinical scoring system like KDRI is not useful in predicting quality of ECD kidneys.

95. Novel Tacrolimus-Azathioprine Combination Regimen as Induction Therapy in Proliferative Lupus Nephritis

Atanu Pal, A Roy Chaudhury, D Sircar, S Dasgupta, D Sen, R Pandey

IPGME&R and SSKM Hosital; Kolkata; West Bengal; India

Background: The management of proliferative lupus nephritis is still evolving. Considering the complicated pathogenesis of lupus nephritis involving humoral as well as cellular immunity; a multidrug multitarget regimen may be a rational approach. Recent trials showing benefit in class IV and V lupus using multitarget approach used Tacrolimus and Mycophenolate mofetyl which is replaced here by Azathioprine considering cost appropriacy and a lesser potential for sepsis.

Aim of the Study: The primary end point was achievement of complete renal remission. Secondary end points included partial remission of lupus nephritis; decrease of proteinuria; disease activity scoring and safety.

Methods: Study design and settings:This open label randomized control trial compares the tacrolimus-azathioprine combination regimen (Group 1) and intravenous cyclophosphamide (IVC) (Group 2) as induction treatment for proliferative lupus nephritis. Considering the study significance level fifty eight patients were randomized following random number table in two arms (Group 1 and Group 2). Intervention: Fifty eight patients with lupus nephritis classes III and IV; with or without evidence of class V lesions; were randomly assigned to tacrolimus (0.075 mg/kg) with azathioprine (2 mg/kg) or monthly IVC (750 mg/m2). Both groups received prednisolone 0.5 mg/kg/d for one month and then tapered as tolerated to 10 mg or less by 3 months. The patients were subsequently followed up every monthly and disease activity was measured at 0; three and six months.

Results: Complete remission occurred in 77.41% patients on the Group 1 arm and in 72.7% patients in the Group 2 arm (p=0.9). Secondary end points were also similar between treatment groups- Group 1 & Group 2 respectively (reduction in proteinuria 80.6% vs 81.8%; achievement of partial remission 12.9% vs 9.0%). Major infective complications requiring hospital admission in the Group 1 (3.2% vs.18.1%) were less and the two groups had non-significant differences in safety and adverse events.

Conclusions: The Tacrolimus-Azathioprine combination regimen is at least as efficacious and safe as the IVCY regimen.

96. A Study of Outcomes of Patients with IgA Nephropathy with Crescents

N Sai Sameera, Sunnish Reddy Ram, Sangeetha Lakshmi, Sarath Chandra, Praveen Hari, Anil

Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India

Background: Crescentic IgA nephropathy has been associated with worse renal outcomes; but little is known about IgA nephropathy with less than 50% crescents. This study aimed at investigating the epidemiology; clinical and pathological characteristics; renal outcomes and risk factors; mortality; response to therapy; in patients of IgA nephropathy with less than 50% crescents.

Aim of the Study: To study the clinical outcomes of patients with IgA nephropathy with different proportion of crescents in terms of doubling of creatinine and or ESRD; death; risk factors for worse outcomes.

Methods: In this retrospective cohort study 40 patients with Biopsy proven IgA nephropathy with crescents are followed up over a period of 26 years. Patients with age less than 14 years; secondary IgA nephropathy; patients with ESRD at admission were excluded. Patients are divided in to four groups based on percentage of crescents as <5%; 5-9%; 10-24%; >25% crescents. Primary end point is doubling of serum creatinine and or end stage renal disease and secondary end point is death.

Results: Median crescent proportion in the population is 10%. Increasing crescent proportion is associated with low hemoglobin; reduced eGFR; increased proteinuria. After the median follow up the end point event free survival of 4 groups is 60%; 40%; 35%; 30% respectively. Multivariate cox regression analysis after adjusting for eGFR; hypertension; proteinuria and Oxford MEST classification demonstrated that increasing crescent proportion is associated with renal mortality (HR 1.61; 95% CI; P=0.01).

Conclusions: An increasing crescent proportion is associated with worse clinical outcomes and is of prognostic value in IgA nephropathy.

97. Tunneled Dialysis Catheter Insertion by Nephrologist- A Single Center Experience

Ravi Bhadania, Amit Gupta, Anupama Kaul, Dharmendra Bhadauria, Manas Ranjan Patel, Narayan Prasad

Department of Nephrology; SGPGIMS; Lucknow; Uttar Pradesh; India

Background: Tunneled Dialysis Catheter (TDC) is increasingly used for vascular access as a bridge to Arterio-Venous fistula maturation and in patients who have exhausted their other accesses. It may be preferred access in patients planning for early renal transplantation. Owing to their ease of insertion; immediate utilization for dialysis and low complication rates; they have gained popularity among nephrologists as first access particularly in developing country like India where patients present late.

Aim of the Study: We aimed to study the outcomes of TDCs over 5½ years.

Methods: All patients who underwent TDC insertion by nephrologist from October 2011 to June 2017 were analyzed. Total 574 number of catheter were inserted in 555 patients. Of them 67 patients were lost on follow-up. Total 73882 cumulative catheter days were analyzed. The main indication of TDC insertion was to start maintenance haemodialysis and to bridge up to AVF (70.2%) formation. Insertion was successful in 98.7% patients. The most common site of TDC insertion was right IJV (97.5%) followed by left IJV (1.4%). Catheter survival (CS) was analyzed using Kaplan-Meier survival method. Complications and patient risk profiles were analyzed using Cox proportional hazards model.

Results: The cumulative survival for all TDCs inserted; as defined by the time to non-elective removal of a TDC; at 3; 6 and 12 months were 83.7%; 78.4% and 42% respectively. Median CS was 293 days. The most common reason for catheter removal was working AVF (40.4%) followed by death with functioning catheter (20.9%) and catheter related sepsis (12.7%). 8.9% patients had TDC as the only access till transplantation. The most common early complication was exit site ooze (10.5%). Most (86.6%) of early complications could be rectified without catheter removal. The most common late complication was catheter related infections (16.6%) followed by cuff extrusion (6.4%). The median time to the first episode of catheter-related bacteremia was 160 days. Symptomatic central vein stenosis was found in 7 patients (1.4%). There was no bearing of age; gender; catheter site; and etiology of CKD on survival.

Conclusions: TDC is viable bridge up to AVF for patients starting on maintenance hemodilysis with fewer complications.

98. Study on Peritonitis in Capd Patients in a Tertiary Care Center

R Prabhucharan, Manisha Sahay, Kiran Mai Ismail, Sharmas Vali

Osmania General Hospital; Hyderabad; Telangana; India

Background: Peritonitis is a common complication of peritoneal dialysis. Peritonitis is associated with significant morbidity; catheter loss; transfer to hemodialysis; transient loss of ultrafiltration; possible permanent membrane damage; and occasionally deathTimely diagnosis and & proper training prevents recurrent infections; loss of function of membrane and loss of catheter. In this study we tried to evaluate incidence of peritonitis; there outcomes and factors influencing recurrent infections.

Aim of the Study: To study the incidence of peritonitis; its outcomes and factors influencing infections in patients on CAPD.

Methods: Cross sectional observational study Inclusion criteria All CKD patients (n=50) who are on CAPD at Osmania general hospital are included in study. Exclusion criteria-pts who refused to give informed consent -Pts who are on irregular follow upAll pts are evaluated for -Incidence & Etiology of peritonitis -Factors influencing infections & outcomes -Final outcome (recovery; loss of catheter; death).

Results: Majority of pts on CAPD are between 20 -40 yrs of age group (44%); 32% are below age of 20 yrs. Total no peritonitis episodes were 56. 60% of pts had at least one episode of peritonitis; 52% had more than 1 episode of infection. 40% of pts with peritonitis are between 40 yrs of age group. Out of 57 infective episodes 32% were culture negative; 60% had gram-ve; 3% gram +ve; 3% had fungal infections. 2% had TB peritonitis. Klebsiella was most common gram –ve organism. Infective rate is seen nearly equal in both percutaneous (53%) and laproscopic techniques (47%). In pts with prior IPD; 72% pts had peritonitis. 67% of pts with catheter infections had low BMI. 44% pts with diabetes had peritonitis on CAPD. 50% of pts nil or below primary level of education 68% recovery; 24% pts required catheter removal; 8% pts expired. Most common cause of catheter removal was due to recurrent peritonitis with gram _ve followed; with fungal inf; TB peritonitis.

Conclusions: Incidence of peritonitis in CAPD pts was high (60%) in our study. Most common organism was Klebsiella (gram-ve). Factors like catheter insertiontechniques&diabetes status did not influence rate of inf significantly. Ptswithpooreducationalstatus; low BMI; low alb & priorIPD had higher rates of infection.

99. A Case of Maffucci Syndrome Presenting with Bilateral Renal Stones with Obstructive Nephropathy

M K Hemanth Kumar, J S SANDHU

Dayanand Medical College & Hospital; Ludhiana; Punjab; India

Background: Maffucci syndrome is characterized by enchondromas with venous malformations with or without spindle cell hemangiomas. It is associated with heterozygous somatic mutations in the isocitrate dehydrogenase 1 and 2 genes. It manifests usually around age 4-5 years. It affects the skin and the skeletal systems.

Aim of the Study: To report a case of suspected Maffucci syndrome in a 26-yr old female presenting with bilateral multiple renal stones with obsrtuctive nephropathy with sepsis with acute on CKD.

Methods: A 26- yr old female Ms. SJK presented to our emergency department with history of fever since 1 week and altered sensorium since 2 days. She was referred from an outside hospital where she was diagnosed to have bilateral renal pelvic calculi and bilateral DJ stenting was done. On examination she had multiple soft vascular swellings involving right upper limb and lower limb involving the fingers; toes; forearm and leg. These were also found in anterior chest wall. She was short statured and had multiple bony deformities involving both forearms; legs and chest. On presentation she had a S. Cr of 19 mg/dl; TLC of 36000 with 98% polys. She was in shock and hence she was started on acute peritoneal dialysis; inotropes and IV antibiotics.

Results: Her ultrasound revealed impending rupture of right kidney lower pole. Hence and emergency bilateral PCN was also done. Her sensorium and hemodynamics gradually improved. PCN culture revealed growth of Candida albicans and was also started on antifungals. Peritoneal fluid creatinine was done to rule out rupture of kidney. Her other metabolic work up was normal. She was ultimately discharged with PCN in situ to get PCNL at a later date when sepsis subsided.

Conclusions: Here we report a case of Maffucci syndrome with multiple hemangiomas and bony deformities with a rare presentation of multiple renal stones.

100. Spectrum of Biopsy Proven Renal Diseases in Infants

Anuradha Kavadi, Manisha Sahay, Kiran Mai Ismail, SharmasVali

Osmania General Hospital; Hyderabad; Telangana; India

Background: Renal biopsy has adefinite role in confirmation of diagnosis in various renal diseases. Histopathological diagnosis is not only helpful in diagnosis but also usefull in treatment and prognostication. Renal biopsy has special role in infants as it directs us towards genetic studies.

Aim of the Study: To study the spectrum of clinical profile of biopsy proven renal disease in infants presented to the department of nephrology.

Methods: Retrospective analysis of the histopathlogical reports of all renal biopsies performed from 2012-2017 in children below 1 yr of age. All renal biopsies were studied byLight microscopy and IF microscopy.

Results: A total of 2008 renal biopsies were done from 2012 to 2017 among them peadiatric cases were 340 out of which 25 cases were analysed age ranged from as early as 1 month to 1 yr. Male to female ratio was 3:1. The most common clinical indication for renal biopsy was infantile nephrotic syndrome. Commnest BPRD was primary glomerulonephritis. MCD was commnest accounting for 40% followed by diffuse mesangial sclerosis accounting for 12%; FSGS accounting for 12%.; IgM nephropathy was noted in 8% of cases; primaryhyperoxalosis was notedin another 8%cases; rare case of glomerulocysticdisease was reported in 1 case. RPRF presentation was seen in 12% of cases. Congenital nephrotic syndrome was seen in 16%; finninish Congenital nephrotic syndrome was seen in one case; torch profile was negative in cases of congenital nephrotic syndrome; all the babies screened were non syndromic in our study.

Conclusions: Our study represents an important contribution to understanding renal diseases in infants.

101. To Establish the Relationship of Progression of Early Stage of Diabetic Nephropathy with Urinary Biomarkers in Normative Pre-Diabetics and Type 2 Diabetes Patients- An Ongoing Study

Anamika Kumari, Himansu Sekhar, Mahapatra Bindu, Kulshreshtha Parul, Goel Anubhuti

PGIMER; Dr R.M.L. Hospital; New Delhi; India

Background: Study in renal progression in early diabetics and pre diabetics are few. There is also insufficient evidence on the urinary biomarkers in both. Current study is to evaluate; progression of early biomarkers of renal damage in pre diabetics and early diabetics. Here we are presenting as an interim result as Nephropathy in pre diabetes and early type 2 DM.

Aim of the Study: To study association between urinary tubular biomarkers (NGAL; IL-18; Angiotensinosen; Cystatin C) with ACR on progression from early to overt nephropathy in pre-diabetic and type 2 diabetes patients.

Methods: Systematic gathering of patients attending endocrinology and medicine OPD of our hospital were screened. All pre diabetic and diabetic patients went under detailed clinical examination such as BP; routine blood and urine examination by multi sticks; ACR and serum creatinine for calculation of e-GFR. Inclusion criteria was Diabetic and Pre-diabetic patients with eGFR ≥120 ml/min/1.73 m2 with unrestricted ACR value; Diabetic and Pre-diabetic patients with eGFR≥60 ml/min/1.73 m2 and ACR 30-300 mg; have included. The causes of Nephropathy other than Diabetes have been excluded. The prevalence of Nephropathy in pre diabetes and early type 2 diabetes seem studied.

Results: In four months of study; 423 patients were screened. Pre-diabetic were 27 (6.3%) and Diabetes were 277 (65.4%). Nephropathy was detected in 9 (33.3%) among pre diabetics and 93 (33.5%) among Diabetec patients. Mean and Standard deviation observed for the included patients was RBS 200.46±84.25; FBS 164.45±70.51; PPBS 215.82±87.06; Protein 4.79±1.2; Glucose 4.79±1.0; Micrialbumine 61.95±101.76; ACR 0.06±0.10; Urine creatinine 104.16±59.1; Urine albumine. 62±94.72; S. cr.66±0.164; eGFR 146.22±33.610.

Conclusions: Our interim study shows there is high prevalence of nephropathy in both early diabetic and pre diabetic patients. Our ongoing study will estimate the progression of disease with respect to urinary biomarkers.

102. Prevalence and Factors Associated with Intradialytic Hypertension (IDH) in CKD-5D: A Single Center Observational Study

V B Mohan, Ravindra Prabhu, Shankar Prasad, Dharshan Rangaswamy

Department of Nephrology; Kasturba Medical College; Manipal; Karnataka; India

Background: IDH is a common complication of HD that is under-recognized and is associated with higher hospitalization rates. The prevalence ranges from 5-20% with most studies based on western population and Indian studies are sparse. Although there are several definitions; there is no unifying criterion for the diagnosis of intradialytic hypertension. Hence this study was performed to know the prevalence of IDH based on various definitions and factors which are closely associated with IDH.

Aim of the Study: To study the prevalence of IDH based on various definitions and the factors associated with IDH in CKD-5D patients at a tertiary care hospital.

Methods: Single center; cross sectional; observational study; a total of 136 CKD-5D patients on twice weekly hemodialysis were studied after ethical committee clearance Inclusion criteria: Stable CKD-5D patients above 18 years with a minimum of 3 months on MHD Exclusion criteria: Patients with AKI and patients on PD. Baseline characteristics were collected as per proforma. In this study the prevalence of IDH was studied using following 3 definitions: 1. ≥10 mmHg rise in SBP between pre- and post-dialysis in at least four of six previous consecutive dialysis sessions 2. >15-mm Hg rise in MAP between the start and the end of the dialysis session 3. Any symptomatic rise in blood pressure during dialysis. Systolic blood pressure; mean arterial pressure and pulse rate were measured using standardized online electronic BP monitors before dialysis; hourly during dialysis and up to half an hour after dialysis. The factors associated with IDH were analyzed using SPSS version 16.0.

Results: In this study a total of 136 CKD-5D patients were studied. The prevalence of IDH based on SBP rise was 57.3% whereas based on MAP rise was 24%; and symptomatic IDH was only 8%; indicating that the prevalence of IDH significantly varied with varying definition. Among factors influencing IDH; males had a significantly higher prevalence. In this study; IDH was found to be more prevalent in patients with younger age; lower BMI; diabetics; higher IDWG and on longer vintage but they were statistically insignificant. Limitations: (1) Cross sectional study; Single center (2) Dialysate composition; dialysate temperature and dialysate conductivity were not studied (3) Serum albumin level were not measured.

Conclusions: This study has indicated that the prevalence of IDH varied with different definitions; hence a “Unified definition/criterion” for IDH is the need of the hour at both national and international level. Large prospective studies are needed so as to improve our knowledge on factors associated with IDH.

103. Weight Adjusted Heparin Dose Calculation in Hemodialysis- A “Win Win” Situation

Pankaj Jawandhiya, Deepa Usulumarty, Ganesh Sanap, Jatin Kothari, Rajesh Kumar, Shrirang Bichu, Parag Tilve, Viswanath Billa

Apex Kidney Care; Sushrut Hospital; Mumbai; Maharashtra; India

Background: Anticoagulation is necessary during hemodialysis; to maintain optimal blood flow; prevent thrombosis of the circuit. The anticoagulants commonly used are conventional heparin; LMWH & citrate. Also; ESRD patients are at increased risk of bleeding due to uremia related platelet dysfunction. Conventional heparin has adverse effects including elevation of liver enzymes; osteoporosis; HIT; fractures; and bleeding diathesis. Hence optimum dosing of anticoagulation during hemodialysis is important.

Aim of the Study: To compare the effects of using a heparin sliding scale dosing as per body weight versus a standard 7500-10000 IU dosing on the dialyzer clotting tendency and Kt/V.

Methods: 81 patients in a single hemodialysis centre were studied. Any patient having a temporary or permanent catheters were excluded. All of them were on a fixed dose anticoagulation of 7500 U heparin till 27th Feb 2017. For subsequent dialysis sessions; the anticoagulation doses were weight adjusted. An initial heparin loading dose was 50 u/kg dry weight followed by a continuous infusion of 15 u/kg/h as a individualized to each patient. Patients having signs of clotting in the circuit were given an extra bolus and were excluded from study.

Results: Weight based calculated heparin dose required in patients was 5992+1442 IU as compared to regular dose of 7500 IU. We found that 85.2% patients were receiving greater than calculated dose while 14.8% were receiving less than calculated dose when compared to a fixed regimen was used. Mean KT/V was 1.2±0.24 with fixed dose heparin; while it was 1.44±0.22 with weight based heparin. Mean blood flows achieved were the same at 300 ml/min. Fixed dose mean monthly single patient expenditure on heparin was Rs.331.50 as compared to Rs.261.75 for the weight based regimen. The cost savings is approximately Rs. 70 per patient per month.

Conclusions: Heparin is essential for anticoagulation during hemodialysis but has a varied side-effect profile. Also heparin adds to the dialysis cost. Titrating the dose of heparin to body weight is a more scientific and cost saving option for dialysis patients.

104. Study of Intradialytic Hypertension in Hemodialysis Patients at a Tertiary Care Hospital

Gajanan Kale, Tarun Jeloka, Rajesh Badani, Manish Mali, Amit Bhangale

Aditya Birla Memorial Hospital; Pune; Maharashtra; India

Background: Intradialytic hypertension (IDH); defined as increase in systolic blood pressure > 10 mm Hg from pre- to post- hemodialysis; is associated with increased risk of short (6 months) and long-term (2 years) morbidity and mortality. There is no data available in literature from our country. Hence; we planned to study about Intradialytic hypertension in Indian subjects.

Aim of the Study: To determine (1) the prevalence and factors associated with IDH (2) impact of IDH on morbidity and mortality and (3) effect of pre dialysis ARB on IDH in Indian dialysis patients.

Methods: It was a randomized prospective study. Inclusion criteria were all adult dialysis patients > 18 years of age and 3 months on dialysis and free of acute events within last 1 month. At screening phase; patients were subjected to fluid optimization assisted by BIA. Participants were subjected to 44-hour ambulatory BP monitoring to ensure control. BP measurement during HD was recorded half-hourly to look for IDH. IDH was defined as one or both of the following criteria: an increase in systolic BP > 10 mmHg from pre- to post- dialysis or after 2-hours of dialysis when significant ultrafiltration has taken place; for 3 consecutive sessions. The prevalence and factors associated with IDH were determined. Morbidity and mortality of these patients were compared to those without IDH over a period of 6 months. Further; patients with IDH were randomly divided into two groups – one to receive a dose of ARB just prior to HD; to study the effect of ARBs on IDH; as compared to the other group.

Results: After meeting inclusion and exclusion criteria; 91 participants were eligible. The prevalence of IDH was 20/91 (21.9%) patients. The baseline demographic parameters of patients in both the groups including age; sex; access; duration of dialysis and comorbidities were similar. Laboratory parameters were similar except serum potassium and serum phosphorus; which were low in patients with IDH. Out of all the variables studied; only low serum phosphorus was associated independently with IDH (p = 0.022); the significance of which is unclear. Mortality was similar in both the groups irrespective of presence of IDH (7% in non IDH and 20% in IDH; p = 0.103). However; morbidity in terms of non-access related admissions were higher in patients with IDH (26% in non IDH patients and 60% in IDH; p = 0.006. There was no difference in pre; post and delta SBP between the two randomized IDH groups over the use of ARB.

Conclusions: IDH is a common complication seen in 21.9% of maintenance hemodialysis patients. Patients with IDH have increased risk of non-access related admissions leading to higher morbidity but no increase in mortality. ARB pre-hemodialysis does not benefit in management of IDH.

105. Outcome of Paraquat Self-Poisoning -A Case Series in South India

B N R Ramesh, Sree Bhushan Raju, Vijay Kiran, Surendra Babu Mandarapu, Vamsi Krishna

NIMS, Hyderabad; Telangana; India

Background: Paraquat is a rapidly-acting; nonselective herbicide. Ingestion can be lethal despite immunosuppression with cyclophosphamide & steroids & antioxidants. We present a case series from a tertiary care hospital; consisting of 8 patients admitted from Aug 2015 to Jul 2017 with history of paraquat ingestion. The survival rate was 3 out of 8 patients; which clearly indicates that high survival chances are there in patients who present early (6-8 hours) and with lesser amount of ingestion in our study.

Aim of the Study: Clinical profile and outcome of patients with paraquat poisoning with aki and MODS.

Methods: The present study includes the data of eight patients of paraquat poisoning over 2 years. In ER; patients were stabilized by securing airway; breathing and circulation. Oxygen supplementation was avoided as far as possible unless saturation fell below 70%. IV Methylprednisolone 30 mg/kg/day for 3 consecutive days; IV Cyclophosphamide 15 mg/kg/day for 2 consecutive days followed by Iv Dexamethasone 8 mg/tid until recovery or death. They also given IV N-Acetyl cysteine 2 g/day for 3 days. VitC (500 mg/tab) 2 tabs/tid.VitE (400 IU/tab) 2 tabs/tid. Triamcenolone paste for oral ulcerations. Patients were monitored for development of respiratory distress as evidenced by tachypnoea or fall in oxygen saturation to below 90% and renal dysfunction as per KDIGO clinical practice guideline for acute kidney injury. Hepatic dysfunction was taken as >2 fold rise in transaminases. All patients received supportive measures including hemodialysis whenever necessary. Patients were followed up till recovery or death.

Results: Age of patients ranges from 14 to 56 years; 6 men and 2 women. The commonest symptoms were vomiting (100%) followed by oral ulceration or dysphagia (60%); dyspnoea (51%) or loose stools (34%). All patients developed acute renal failure with a peak serum creatinine of 5.0 mg/dl. All patients needed dialytic support. The indications for dialysis was serum creatinine > 2.5 mg/dL and impending hyperkalemia and severe metabolic acidosis and oliguria. Five out of eight patients expired. All 5 taken large dose >20 ml and presented late to our institute and were died because of ARDS/MODS. 3 patients survived. 2 female patients and case 8 taken less than mouthful and vomited immediately and they presented early to our institute and all 3 developed AKI and two developed hepatitis and given hemodialysis and immunosuppression. Case 1 underwent CRRT but he developed ARDS and MODS and expired. Case 3 underwent hemoperfusion with a special catridge and given immunosuppression but he developed MODS and expired.

Conclusions: Patients presenting early to the ER within 6-8 hours of paraquat poisoning have high rates of survival. Lesser the quantity of ingestion (20 mg/kg) of paraquat; better is the survival rates. Combination of immunosuppression and antioxidants is the key to the management apart from other supportive measures.

106. Clinical Profile and Outcome of Pigment Nephropathy - A Single Centre Experience

K Saravana Kumar, Dinesh Kumar, Dhanapriya, Sakthirajan, Murugesan, Gopalakrishnan, T Balasubramaniam

Madras Medical College; Chennai; Tamil Nadu; India

Background: Pigment nephropathy represents one of the most severe complications of rhabdomyolysis or hemolysis. Rhabdomyolysis induced pigment nephropathy is common. Etiology of rhabdomyolysis and pigment nephropathy differ in western and tropical countries. There is paucity of data in Indian literature. We undertook this study to analyze the same.

Aim of the Study: To assess the etiology; clinical manifestation; laboratory profile and outcome in patients with pigment nephropathy in renal biopsy.

Methods: Patients admitted to the department of nephrology; Madras Medical College with various causes of AKI (of known and unknown cause) and renal biopsy showing pigment nephropathy during Jan 2011 to July 2017 were included in the study. Perls staining for iron and immunostaining for myoglobin has been done in selected patients. History; clinical examination findings; laboratory investigations and outcome were recorded. The various causes were documented and the mode of renal replacement therapy and duration of therapy were all recorded. Patients were followed up regularly and renal function was regularly monitored.

Results: Fourty nine patients were included of which 32 patients (63.26%) were males. Pigment deposition was due to rhabdomyolysis in twenty seven patients (55%) and due to hemolysis in twenty two patients (45%). The most common etiology of rhabdomyolysis was due to envonomation (snake bite – 7; wasp sting - 2). Other causes were due to seizures; strenuous muscular activity; one patient had scrub typhus. Hemolysis causing pigment deposition was predominantly due to rifampicin induced hemolysis causing AKI present in nine patients. Malaria/G6PD deficiency; mismatched blood transfusion; sepsis/DIC; acute pancreatitis and PNH were causes of hemolysis other patients. Three patients had pigment deposition in association with IgA nephropathy. Forty eight patients (98%) required dialysis during hospital stay of which two patients recovered with peritoneal dialysis. All patients except three (with sepsis/DIC) had recovering renal function at discharge and on follow up.

Conclusions: Pigment nephropathy due to rhabdomyolysis and hemolysis is a cause of renal failure requiring hemodialysis. Snake envenomation is the most common cause of rhabdomyolysis and rifampicin is the most common cause of hemolysis causing pigment nephropathy. It has a relatively good prognosis.

107. The Safety and Efficacy of Mycophenalate Mofetil (MMF) in Children and Adolescents with Steroid Dependant Nephrotic Syndrome (SDNS) – Single Centre Study

K Saravana Kumar, Dinesh Kumar, Dhanapriya, Sakthirajan, Murugesan, Gopalakrishnan, T. Balasubramaniam

Madras Medical College; Chennai; Tamil Nadu; India

Background: Steroid dependant nephrotic syndrome comprises more than 30% of idiopathic nephrotic syndrome in children. Patients presenting with SDNS experience frequent relapse or adverse effects on long term treatment with steroids or cyclophosphamide. There has been few studies in our population regarding utility of mycophenolate mofetil (MMF) in such situations for which the study has been undertaken.

Aim of the Study: The study assessed the efficacy and side effect profile of MMF therapy in children with nephrotic syndrome in our population on long term follow up for a minimum period of 1 year.

Methods: A retrospective study was performed on children with steroid dependant nephrotic syndrome who were on MMF therapy for a minimum period of 1 year and were on regular follow up in the Department of Nephrology at the Institute of child health and hospital for children attached to Madras Medical College. The patients clinical and biochemical remission were monitored and cause of relapses were recorded. The steroid dose required for remission before and after initation of MMF were recorded. The patients were also regularly monitored for any adverse events induced by MMF therapy. Failure of MMF therapy defined as frequent relapse while on MMF was also recorded. The patients were monitored fortnightly for a minimum period of 1 year.

Results: Eightyseven patients included in the study; with a male to female ratio of 2:1. The median age at diagnosis of nephrotic syndrome was 3 yrs; the median age of commencement of MMF therapy was 7 yrs; while the median duration of follow up after initiation of MMF therapy was 3 yrs 3 mons – 95% CI [1 yr 3 mons – 6 yrs 6 mons]. At initial evaluation 31 patients presented with SDNS. MMF was initiated as first line therapy only in 4 patients; iv cyclophosphamide was used as first line therapy in 82 patients. The median duration of treatment with MMF was 2 yrs 6 mons – 95% CI [1 yr 3 mons – 4 yrs 6 mons]. 72 (83%) of patients were MMF sensitive; these patients had a reduction in mean prednisolone dose from 1.28 mg/kg to 0.35 mg/kg [ p <0.05]. relapses occuring were due to noncompliance; infection and rapid steroid tapering. Stopping MMF relapse occured within a median period of 5 months. MMF failure occurred in 15 (17%) patients. The adverse events were documented in 19 (22%) patients.

Conclusions: (1) Continous MMF therapy achieved remission in 83% of patients (2) MMF was well tolerated in study population (3) Discontinuation of MMF resulted in 100% relapse.

108. Role of Kim-1 in Plasma and Urine After Intravenous Contrast Induced Acute Kidney Injury in Adult ICU Patients

Kritika Singh, Saurabh Chaturvedi, Harshit Singh1, Ravi Mishra, Mohan Gurjar2, Vikas Agarwal, Narayan Prasad1

Departments of Clinical Immunology; 1Nephrology and 2Critical Care Medicine; SGPGIMS; Lucknow; Uttar Pradesh; India

Background: Acute Kidney Injury (AKI) is a common clinical condition despite progress inmedical 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: KIM-1 has been found early and sensitive marker of AKI. This biomarker has 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 h after contrast exposure. 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 SCr of ≥0.3 mg/dl within 48 hrs.

Results: 40 medical patients with 30 CT scans included. Median age was 36 yrs and 54% male. On the day of inclusion; median SOFA score was 3.16% were on mechanical ventilation; and 10% on vasopressor. 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 KIM-1 (ng/ml): 0.96±0.52; 0.93±0.57 (0.39); 1.51±0.43 (0.006) and 1.66±0.46 (0.012); U KIM-1 (ng/mg of UCr): 0.37±0.21; 0.24±0.08 (0.73); 0.23±0.21 (0.07) and 0.31±0.15 (0.49). After contrast; P KIM-1 levels was significantly raised at 24 h (p=0.006) while U KIM-1 was not significantly raised at any point of time.

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

109. Emphysematous Pyelonephritis: A Retrospective Observational Study to Predict the Factors Associated with Severity and Management Strategies

Anvesh Golla, Vijay Kiran, Sree Bhushan Raju

NIMS; Hyderabad; Telangana; India

Background: Emphysematous pyelonephritis (ePN) is a severe; necrotizing renal parenchymal infection that is characterized by the production of intraparenchymal gas. It carries a much higher mortality than conventional cases of pyelonephritis. High-dose antibiotic therapy alone or with percutaneous drainage in contrast to bilateral nephrectomy may be a preferable approach to salvage kidney function.

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 are reviewed from Jan 2012 to June 2017. Demographic data; clinical features; laboratory parameters; imaging; treatment and outcomes are analysed. Huang and Tseng CT grading 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. 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 unpaired t test for continuous variables and chi-square for categorical variables; with P < 0.05 considered statistically significant.

Results: Of the 30 patients diagnosed; mean age is 51.5±14.7. Male to female ratio 1.1:1 diabetes seen in 76%; renal stone disease in 33%; congenital anamoles in 6%. Mean HBA1c in group 1 is 6.6±1.2; in group 2 is 7.68±1.2 suggesting poor glycemic control in severe grade. At admission; symptoms included fever (93%); flank pain (96%); nausea/vomiting (63%); dysuria (73%); altered sensorium (16%); oliguria (33%). Mean serum albumin in group 1 is 3.04±0.47; in group 2 is 2.36±0.4. Urine culture shows positive growth in 43% out of which Ecoli seen in 77%. Medical management alone given in 26%; RRT support given in 43%; DJ stenting done in 23%; PCNL in 52%. Dialysis dependent in 15%.

Conclusions: In EPN; presence of low serum albumin is associated with severity; blood culture and urine culture positivity seen in 17% and 43% with Ecoli being common organism identified. Medical treatment along with DJ stenting and PCN in severe EPN is able to salvage kidney.

110. Outcomes of Tunneled Dialysis Catheters in Hemodialysis Patients

D K Yadav, D Bansal1; R Bansal, A Mahapatra, A Nandwani, M Jain, S B Bansal, R Sharma, P Jha1, C Mahajan, V Kher1

Division of Nephrology; Medanta Kidney and Urology Institute; Medanta - The Medicity; Gurgaon; Haryana; 1Division of Nephrology; Medanta Kidney and Urology Institute; Fortis Escorts Hospital; New Delhi; India

Background: Establishing and maintaining vascular access is essential for patients undergoing hemodialysis. Double-lumen tunneled-cuffed dialysis catheters (TDC) are being increasingly utilized in patients awaiting transplant; vascular access maturation or unfeasible veins for AV fistula creation. However; this interim period is commonly complicated by catheter related infections and catheter dysfunction.

Aim of the Study: The aim of our study is to determine catheter-related complications and catheter -survival in hemodialysis patients in India.

Methods: It was a single- center; prospective; observational study. We inserted 750 catheters in a cohort of 718 patients under ultrasound guidance in a dedicated Nephrology procedure room at tertiary care hospital in North India from February; 2014 till April; 2017. These patients were followed for a period of minimum of 3 months to 3 years till 31 July 2017.

Results: The most common site of TDC insertion was right IJV (93.1%). The frequency of immediate complications was 7.2% with cardiac arrhythmia being most common. 68 patients were lost to follow up. Total 603 (88.4%) catheters were removed. Elective removal was done in 412 (60.4%) patients due to transplantation (29.7%); maturation of AVF (26%); recovery of AKI (2.3%); initiation of CAPD (1.3%). 114 (16.7%) catheters were removed due to late complications. Incidence of delayed catheter dysfunction was 0.5 episodes/1000 catheter days. The incidence of catheter related bacteremia was 1.9 episodes/1000 catheter days. 82 (12%) catheters were removed due to line sepsis; out of which 4 had tunnel infection also. 81 (11.8%) catheters are still functional. 85 (12.4%) patients expired with a functioning catheter. Using Kaplan-Meier analysis; catheter survival at the end of 1 year; 2 year and 3 year was 66%; 50% and 46% respectively.

Conclusions: Our study highlights the significance of using TDC as the first vascular access in patients requiring short term hemodialysis like prospective renal transplant recipients; AKI; patients awaiting fistula maturation or CAPD initiation.

111. Case Series of Double Glomerulopathy

C Shakthi Kumar, K Sampath Kumar, Andrew Deepak, S P S Anandhan

Meenakshi Mission Hospital and Research Centre; Madurai; Tamil Nadu; India

Background: Occasional case reports have been issued on ADULTS with double glomerulopathy; involving either the coexistence of two different glomerulopathies or superimposition of a second glomerulopathy onto a first.

Aim of the Study: Superimposed glomerulopathy should be suspected if the clinical course of a glomerulopathy changes are atypical.

Methods: We are reporting 3 patients who presented with clinical features of rpgn; later on surprisingly all 3 patients found to have anti -gbm nephritis in common; and each one of them had superimposed different glomerulopathy.

Results: We treated 2 of the patient s with agrresive immunosupressive protocol (steroids; plasmapheresis; cyclophosphamide) for antigbm disease; one patient due to very late presentation; we were less aggressive and only treated her with oral steroids.

Conclusions: The pattern of double glomerulopathy was considered to be due to the chance occurrence of two different glomerulopathieswithout a common pathogenesis. Superimposed glomerulopathy was diagnosed by a second renal biopsy IN SOME cases.

112. Pilot Study for Survival Analysis of HD and CAPD Patients

Prem Mohan Jha, H S Mahapatra, Himanshu Verma, Lalit, Abhishek Pandey

DR RML Hospital; New Delhi; India

Background: Studies comparing patient survival of HD and PD have yielded conflicted results from many countries of the world but no such study was perform in INDIA. Several different studies have shown that PD yields a better survival rate than HD ion the first and second yrs of treatment; especially in younger Pts and non-diabetic patients with low comordity whereas HD produces better results results in Diabetic Pts; elderly Pts and in Pts with greater comordity.

Aim of the Study: To study the comparative survival rates among pts adopting CAPD and HD as methods of Dialysis.

Methods: Pts who had undergone either CAPD and HD in the past were contacted to ascertain the duration for which the patient underwent the procedures till their eventual death. A total of 31 pts were contacted using CAPD procedures and 30 pts using HD procedure. Other parameters such as age; gender; Anemia; Calcium; Phosphorous etc were also collected. However; since the number of pts under the different categories were not adequate; the analysis is restricted to overall survival analysis between the 2 procedures. The analysis includes overall comparision using LOG Rank; Breslow; and Tarone- Ware stastic to check whether the difference between two procedures result in any significant finding. A p-value of 5% is being used to decide whether the procedures are significantly different.

Results: 95% Confidence Interval of 25.137-50.799. For HD; the average survival period for pts were found to be 55.4 months with a 95% Confidence Interval of 40.279-70.52. Since the interval has an overlap; there is no significant difference in the overall survival pattern between the two procedures. Further the significance test indicate LOG Rank (p-value 0.110); Breslow Stastics (p-value 0.081); Tarone-Ware (0.073). All these stastics indicate there is no significant difference between the two procedures.

Conclusions: From the above result; it is clear that the two procedures have similar survival rates and therefore CAPD procedure also is as good as HD procedures.

113. Epidemiological Profile; Clinical Presentation & Pathological Profile of IgA Nephropathy

A Prakash, Dinesh Kumar, Dhanapriya Sakthirajan, Murugesan N Malathy, N Gopalakrishnan, T Balasubramanian

Madras Medical College; RGGGH; Chennai; Tamil Nadu; India

Background: IgA nephropathy is considered to be the most common form of primary glomerulonephritis in the world. Available evidence suggests an increasing incidence in India. At presentation IgA nephropathy can be of any known renal syndrome.

Aim of the Study: To assess the epidemiological profile; clinical presentation and pathological profile of IgA nephropathy.

Methods: Patients admitted to the Institute of Nephrology; Madras Medical College; Chennai from January 2014 to June 2017 whose renal biopsy revealed IgA nephropathy were included in the study. History; clinical examination findings; laboratory investigations and renal biopsy were recorded.

Results: Out of 1660 native kidney biopsies performed during the study period; 150 patients (9.03%) had IgA nephropathy. Of them 100 (66.6%) were males; with male to female ratio of 2:1. The mean age of patients was 34 years (ranging from 13 to 68 years). Majority of the patients were in the 20 – 29 years age group (33.3%) followed by 30 – 39 yrs age group (28%). Among these; 18 (12%) patients presented with hematuria; 106 (70.7%) presented with edema; 54 (36%) presented with oliguria and 77 (51.3%) had hypertension. On classifying the patients based on clinical syndromes; 100 (66.6%) presented with nephrotic syndrome; 46 (30.6%) presented with subnephrotic proteinuria; 113 (75.3%) patients presented with renal failure. Of them 44 (29.3%) had chronic kidney disease. Renal biopsy revealed advanced IgA nephropathy in 44 patients.

Conclusions: IgA Nephropathy constituted 9.03% of native kidney biopsies performed. Majority of patients with IgA Nephropathy presented with renal failure. Nephrotic syndrome was the commonest classical presentation (66.7%).

114. Hepatitis B Screening and Vaccination in CKD Patients Visiting Nephrology Outpatient Department

Kiran Chandra Patro, Shilpa, Pusphpanjali, Mataf, S Padmanabhan

Department of Nephrology; NU Hospitals; NU Hospitals; Bengaluru; Karnataka; India

Background: Hepatitis B preventable disease and in India with significant prevalence (7.6%) and incidence (3.2%) of Hepatitis B in dialysis population; requires adequate measures in ensuring early screening for Hepatitis B and vaccination prior to initiation of dialysis so as to ensure protective antibody titers. Our study looks at implementation of Hepatitis B screening and vaccination among chronic kidney disease (CKD) patients visiting the (OPD).

Aim of the Study: To study the effective implementation of Hepatitis B screening and vaccination in CKD patients visiting the nephrology OPD in a tertiary care Nephrology-Urology centre in Bangalore.

Methods: All new CKD patients visiting nephrology OPD between December 2015 and December 2016 were audited.

Results: Total number of CKD patients 428 Screening for HBsAg done 365 (85.3%) (363 negative; 2 positive); Screening not done 63 (14.7%); Vaccinated against Hepatitis B 236/363 (65%) (55.1% of the total patients); Not vaccinated 127/363 (35%) (117 (92.1%) no follow up; 10 (7.9%) other); 10 not vaccinated: 6 (60%) on immunosuppression; 3 (30%) vaccinated late; 1 (10%) death.

Conclusions: Despite being a Nephrology Urology hospital we had not screened 14.7% of our patients for Hepatitis B and we could vaccinate only 65% of screened patients against Hepatitis B as 35% of our screened CKD population was lost to follow up!

115. Role of Cystatin-C in Plasma and Urine After Intravenous Contrast Induced Acute Kidney Injury in Adult ICU Patients

Ravi Mishra, Saurabh Chaturvedi, Harshit Singh1, Mohan Gurjar2, Vikas Agarwal, Narayan Prasad1

Departments of Clinical Immunology; 1Nephrology and 2Critical Care Medicine; SGPGIMS; Lucknow; Uttar Pradesh; India

Background: Acute Kidney Injury (AKI) is a common clinical condition despite progress inmedical 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. This biomarker has 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 h after contrast exposure. NGAL assay 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: 40 medical patients with 30 CT scans included. Median age was 36 yrs and 54% male. On the day of inclusion; median SOFA score was 3.16% were on mechanical ventilation; and 10% on vasopressor. 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 Cystatin-C (ng/ml): 4694.85±572.71; 4714.57±1142.87 (0.02); 4424.85±1132.73 (0.03) and 4286.85±435.8 (0.17); U Cystatin-C (ng/mg of UCr): 346.06±224.7; 219.66±72.18 (0.91); 470.21±536.28 (0.99) and 633.61±811.77 (0.23). After contrast; P Cystatin-C levels were significantly raised at 4 h and 24 h (p=0.02; 0.03) while U KIM-1 was not significantly raised at any point of time.

Conclusions: In critically ill adult patients; we found that earliest (4 h) significantly increased biomarker was plasma Cystatin C. In urine; there was no significant increase in any biomarker after intravenous contrast.

116. Clinicopathology and Outcome of Patients Presenting with RPRF: A Single Centre Experience

Bhaskara Rao Beesetty, G Prasad, V Ramesh Chandra, Ranga Rao, S K Chaitanya, Praveen S. Srinivasa Rao Sirisa

Andhra Medical College; Visakhapatnam; Andhra Pradesh; India

Background: In clinical medicine physicians encounter patients who present with progressive renal impairment of seemingly unknown etiology. These patients are neither Acute Kidney Injury nor Chronic Kidney Disease. The initial clinical diagnosis of these cases may be called Rapidly ProgressiveRenal Failure (RPRF). Early definitive diagnosis of RPRF is essential to reverse the otherwise relentless progression to end-stage kidney disease.

Aim of the Study: The aim of the study is to know the clinicopathological pattern and outcome of rapidly progressive renal failure presented to tertiary hospital in Visakhapatnam; Andhra Pradesh.

Methods: It is prospective observational study among patients presented with features of RPRF to the tertiary referral hospital in Visakhapatnam over period of 2 years between 2015 January to December 2016 with 3 months of follow-up.

Results: A total of 66 patients were included in the study among them 6 patients lost followup. Male to female ratio 1.27:1. Patient underwent renal biopsy and they showed Crescentic pattern in 51 of 66 patients. Most common lesion are immune complex GN followed by c3glomerulopathy. After applying ANNOVA test to find out relationship of varies clinical parameter to outcome there is significant difference in the mean values of diastolic BP; blood urea and hemoglobin between the groups (Death; Dialysis Dependence and Recovery). Death occurred in 17%; 30% patients become dialysis dependent. Common histopathological lesion associated with death are pauciimmune GN followed by SLE. Common histopathological lesion associated with non recovery/dialysis dependency are immune complex GN followed by C3 glomeropathy and MPGN pattern. Among varies lesion ATN/ATIN has best prognosis for outcome. Out of 8 patient who found to have ATN/ATIN showed either complete or partial recovery.

Conclusions: Most common lesion in patients presenting with RPRF is immune complex GN. There is significant difference in the mean values of diastolic BP; blood urea and hemoglobin between different outcome groups.

117. Study of Clinical Profile of Capd Patients at Department of Nephrology; SCB Medical College; Cuttack; Odisha- A Single Center Experience

Bishwaranjan Mohanty, C R Kar, S B Rout, P K Sahu, Smarak Panda, D Hota

SCB Medical College; Cuttack; Odisha; India

Background: Worldwide >200; 000 patients are undergoing treatment with CAPD; accounting for about 15% of the dialysis population worldwide. Currently about 7000 patients (≈ 20%) in India are on PD.

Aim of the Study: Forty (40) ESRD patients admitted to Department Of Nephrology SCB Medical College Cuttack between August 2014 and October 2016 and who were put on CAPD were included in this study.

Methods: At our centre more than one third of the patients on hemodialysis preferred and choose CAPD only because of better counseling; proper training and door to door visit and supervision even in the remote areas.

Results: All our clinical profile study and outcome (such as correction of anemia; nutritional status; clinical well being; absence of edema) and biochemical parameters (for e.g. Peritoneal Equilibrium Test; weekly KT/V) to access the adequacy were consistent to results of various other studies. About two third patients have mild to moderate pallor requiring ESAs once weekly or every two weekly instead of twice weekly. Nutritional status measured by BMI; skin fold thickness and weight loss measurement revealed less PEW. Our study revealed that edema was significantly (p<0.001) associated with D/P2cr value (i.e.≥ 0.5) and low KT/V value (i.e. <2).

Conclusions: In our study out of 40 patients only 22.5% had peritonitis and catheter exit site infections Peritonitis was significantly (p<0.05) associated with increased age; diabetes mellitus and low residual kidney function.

118. Pattern of Acute Kidney Injury and its Long-Term Outcome in a Tertiary Care Hospital in India: A Single Center Study

S Arunkumar, S K Agarwal, D Bhowmik, S Bagchi

All India Institute of Medical Sciences; New Delhi; India

Background: Acute Kidney Injury (AKI) is an important determinant of outcomes in hospitalized patients. There is also a risk for future development of Chronic Kidney Disease (CKD). Though the long-term impact of AKI has been studied in developed countries; there is a paucity of data in this field from the Indian subcontinent.

Aim of the Study: The present study was done to assess the pattern; clinical spectrum and long-term outcome of AKI from a single center.

Methods: A prospective; cohort study was carried out from January 2015 to July 2016 at our hospital. All subjects older than 14 years of age with AKI; based on AKIN criteria; seen in Nephrology Department were included. Renal allograft recipients and patients with preexisting CKD were excluded. Detailed demographic and clinical data at presentation and follow-up were recorded in a predesigned proforma. The patients were managed as per standard clinical practice by the treating physician. After discharge from the hospital; patients were followed up prospectively at 1; 3; 6 and 12 months for assessment of long-term outcomes. Statistical analysis was performed using the appropriate tests of significance.

Results: AKI was diagnosed in 476 patients. Majority of the cases; 395 (83%) were community-acquired AKI. The mean age was 44.8±18.7 years and males were 56.3%. Etiology groups included medical (84%); surgical (10%) and obstetric (6%). Sepsis (176/476; 36.9%) was the most common cause. 71.6% of patients belonged to AKIN stage 3; 19.8% to stage 2 and 8.6% to stage 1. The in-hospital mortality rate was 38%. Age >60 yrs; oliguria and need for ventilator and/or inotropes were predictors of mortality. At discharge; 146 (30.7%) patients had complete renal recovery while 149 (31.3%) had partial renal recovery. Oliguria; hypoalbuminaemia and need for RRT were associated with partial recovery. Of the 295 patients on follow-up (mean 7 ± 4.9 months); 211 (71.5%) patients had normal renal function; 4 (1.4%) died and 33 (11.2%) lost to follow up; 41 patients (14%) developed CKD while 6 (2%) were dialysis dependent. The need for RRT was the single most important factor predicting the risk of CKD.

Conclusions: Hospitalized patients with AKI have 38% mortality. Though a fairly good percentage of cases recovered; there is a definite risk of CKD especially in patients who required renal replacement therapy during hospitalization.

119. Association Between Depression and Malnutrition Inflammation Complex Syndrome in Capd Patients- A Cross Sectional Study

A Deepthi, G Swarnalatha, T Gangadhar, Uttara Das, K Raja Karthik, Siva Parvathi, D Keerthi, T Ramachander

Nizams Institute of Medical Sciences; Hyderabad; Telangana; India

Background: Depression; the most common psychological disorder among patients with end-stage renal disease (ESRD); is associated with poor survival. The incidence of depression among dialysis patients is reported to be around 25-50% in various western studies. The present study was therefore undertaken to look at; the prevalence of depression among Indian PD patients and the factors associated with depression.

Aim of the Study: We have studied the prevalence of depression and its relation with the malnutrition–inflammation complex syndrome (MICS) in continuous ambulatory peritoneal dialysis (CAPD) patients.

Methods: A total of 25 patients on CAPD for >3 months in NIMS Nephrology department were enrolled in the study. Demographic and malnutrition–inflammation factors were compared among patients with and without depression. Nutritional assessment is done through anthropometric measurements (height; body weight and skin fold thickness) and biochemical parameters like haemoglobin; total proteins; albumin; total cholesterol and CRP were analysed. Triceps skin fold (TSF) thickness was measured using skin fold caliper. Mid arm circumference (MAC) was measured using an inch tape. The Hamilton Depression Scale (HAMD) and the malnutrition–inflammation score (MIS) were used for depression and MICS evaluation; respectively. Binary regression analysis was performed to investigate the independent association between depression and MICS.

Results: Total 25 patients were analysed of which no. of males were 16 (64%) and 9 (36%) females. The mean age of patients was 51.68+/- 17.12 yrs. The mean BMI score was 23.63+/-5.221 kg/m2. The mean triceps skin fold thickness was 11.8+/- 4.67 mm; MAC was 27.6+/- 5.537 cm. The mean total proteins and albumin were 6.29 +/- 0.74 g/dl and 3.024+/- 2.687 g/dl. The mean haemoglobin was 10.47 +/- 1.97 g/dl. CRP positive in 5 (20%) patients. The mean HAMD and MIS scores were 9.08 ± 6.217 and 7.96 ± 3.98; respectively. According to HAMD15 patients (60%) had depression and 10 patients (40%) had no depression. Compared to non-depressed patients; the depressed ones also showed lower levels of serum albumin but not statistically significant. According to MIS 7 (28%) patients had malnutrition. Correlation results showed that the HAMD scores were significantly and positively correlated with MIS (P<0.001). Binary regression analysis showed that MIS was the only independent risk factor for depression.

Conclusions: Depression is prevalent in 60% of patients and malnourishment seen only in 28% of patients. But almost all patients with depression had poor nutrition. The lower prevalence of malnourishment could be due to selection bias of the patients who were on regular follow up.

120. Vascular Access Surveillance: Considerations and Initial Steps in Developing Countries

Sonika Puri, Anupam Bahl, Ramesh Jain, Vivekanand Jha, Vijay Kher, Himanshu Mahapatra, Rezvi Sheriff, Fazal Akhtar, Hemant Mehta, N K Hase, J Balasubramanium, Sachin Soni, Arjuna Marasinghe, Sanjeev Gulati, Tushar Vachharajani, Bharat Sachdev, Gaurav Sagar, Harun Rashid, T Krishna Prasad, Mahibur Rahman, Manisha Sahay, Vinant Bhargav, Manish Rathi, Sampath Kumar, Sanjiv Jasuja

Association of Vascular Access and Interventional Renal Physicians - AVATAR Foundation; New Delhi; India

Background: SouthAsia (SA) region faces a large burden of CKD/ESRD. Hemodialysis is the common modality for renal replacement therapy in this region. There is little epidemiologic data on HD patients and practices regarding vascular access (VA) creation and monitoring regarding this region is available. The AVATAR Foundation in July 2017; convened a meeting of eminent nephrologists from across India; Sri Lanka; Bangladesh; Nepal and USA to discuss the current situation of HD and VA in developing nations.

Aim of the Study: (1) To identify current practices of HD and VA creation and monitoring in SA (2) To identify roadblocks to timely VA creation; infection control; in data collection; research and collaboration.

Methods: After deliberations the main points highlighted by participants: (1) Current Scenario: Notably; late referral to nephrologists; poor insight into disease and its implications; low incident AV fistula creation and high incidence of use of non tunneled catheter for incident HD and poor emphasis on AV access clinical exam (2) Research and collaboration Options: Pooling of Regional or National database on incident and prevalent HD patients; Possible access intervention training collaboration and data collection.

Results: (3) Proposed interventions: Data collection on key demographic characters of incident HD and VA access utilization to be initiated in the participating hospitals. Data sharing at the local; regional and international level using a common; simplified data base. Identifying and training dialysis technicians and nurses to be team leaders in VA care; who would be involved in implementing regular VA clinical exam; disseminating knowledge regarding VA care and quality improvement. Future goals: Using AVATAR as a platform for continuing medical education of dialysis staff.

Conclusions: The meeting has laid a platform for fostering an environment conducive to regional; national and international collaboration in research and data collection in field of HD and VA creation; monitoring as well as development of VA team leaders. We welcome all those interested in our endeavour.

121. Clinical; Radiological; Microbiological Profile and Outcomes of Patients with Acute Pyelonephritis (APN)

Aniket Hase, Ashish Nandwani, Shyam Bansal, Reetesh Sharma, Manish Jain

Mednta - The Medicity; Gurgaon; Haryana; India

Background: Urinary tract infections are second most common infectious disease in clinical practice. UTI spectrum ranges from asymptomatic bacteriuria to severe urosepsis. Acute pyelonephritis is a common cause for hospital admissions and its clinical and microbiological pattern is changing.

Aim of the Study: To study the microbiological spectrum of patients of Acute Pyelonephritis (APN) and correlate clinical outcomes in a Tertiary care institute.

Methods: We prospectively studied 89 patients who were diagnosed as APN during period from February 2016 to May 2017 for clinical; laboratory; microbiological spectrum with drug sensitivity; radiology and outcomes at 3 months.

Results: Of 89; 55 were males and 34 females; mean age 50.3 ± 13.90. Fever was present in 90%; flank pain; abdominal pain in 1.91%. 76.91% had history of lower urinary tract symptoms. Costovertebral tenderness present in 50.5% and 3% presented in shock. Impaired renal function was present in 48.3%. Diabetes mellitus was risk factor in 72% followed by renal calculi in 22 24.7% obstructive uropathy in 12 13.4%; previous urological intervention was in 5.61% and 4 4% were immunosupressed. Urine culture was positive in 55% and blood culture in 22%. E. Coli was isolated in 53% followed by Klebsiella 24.4%; Entrococci 12.24%; pseudomonas 4.08% proteus in 1 and candida in 2. 58% isolates were ESBL producers.12.20% were resistant to carbapenems and two were pan resistant in 23.5% there was total recovery of renal function to baseline. Factors leading to poor outcome on univariate analysis were older age; poorly controlled diabetes; EPN and patients in whom cultures grew ESBL organisms had poor out come.

Conclusions: There is changing pattern of APN. Gram negative organisms are still common but they are more ESBL producer and resistant. Recommend nitrofuratoin or fosfomycin for lower urinary tract infection. Admitted in hospital receive pipercillin+tazobactum or cefoperazone plus sulbatum or aminoglycosides.

122. The Effect of Night Time Dosing of Antihypertensives on Non Dipping Pattern by ABPM in CKD Stage III and IV Patients

Vaibhav Tiwari, Arpita Ray Chaudhary, Diapnkar Sircar, Sanjay Dasgupta, Rajendra Pandey

The Institute of Post Graduate Medical Education and Research and SSKM Hospital; Kolkata; West Bengal; India

Background: Nocturnal hypertension and non dipping of blood pressure (BP) during sleep are regarded as important harbingers of poor cardiovascular prognosis; probably secondary to abnormal renal sodium handling and altered nocturnal sympathovagal balance. These are strongly associated with all cause mortality; cardiovascular events; and progressive loss of renal function independent of daytime and 24 hour BP.

Aim of the Study: To study the effect of night time dosing of antihypertensives on nocturnal BP and CKD progression.

Methods: It is a prospective interventional study done under department of nephrology. Patients were recruited from February 2016 to May 2016. Inclusion criteria were the patients with eGFR <60 ml/min with controlled hypertension (BP < 150/90). Patients with secondary hypertension other than CKD; CKD 5D were excluded. They underwent ABPM at the recruitment and those with non dipping pattern were included in the study. Antihypertensive were adjusted to the night time. Patients were followed up for every two months and underwent another ABPM at end of 6 months. Non Dippers were defined as failure of BP to fall by 10% during sleep. Reversion to nondipping pattern and fall of eGFR was measured at the conclusion of study.

Results: 44 patents were enrolled for ABPM of which 5 patients were found to have dipping pattern. Rest 39 patients were followed up for 9 months. 7.6% (n=3) patients were reverted to dipping pattern; there was a significant nocturnal systolic BP reduction (-5.79 mmHg; p<0.0001). There was also a significant reduction in 24 hours systolic BP (-3.9 mmHg; p<0.003). There was a non significant increase of serum creatinine (+0.02 mg/dl; p<0.34) and decrease in eGFR (-0.18 ml/min; p<0.42). There was non significant decrease in daytime systolic BP; diastolic BP; nocturnal diastolic BP; 24 hour diastolic BP.

Conclusions: This study shows that night time administration of antihypertensives has resulted in better control of BP; with reversion of 3 patients to dipping pattern. There was also no appreciable decrease in eGFR at 9 months.

123. Use of Ulinastatin in Renal Failure Patients Developing Sepsis

Pavan Kumar Rao N, Subhramanyam SV, K S Nayak

The Deccan Institute of Nephrology and Renal Transplantation, Deccan Hospital, Hyderabad, India

Background: Urinary trypsin inhibitor (Ulinastatin) is a protease inhibitor,believed to play an important anti-inflammatory rolein the systemic inflammatory processes. Ulinastatin has already been used in acutepancreatitis,severe sepsis and TEN (Toxic epidermal necrolysis).

Aim of the Study: However,the potential utility of Ulinastatin inrenal failure patients who develop sepsisis yet to be explored and we tried to evaluate the use of this.

Methods: We performed a prospective observational study over a period of 35 months from October 2014 to August 2017. All renal failure patients (acute kidney injury,chronic kidney disease either medically managed, on dialysis or post-renal transplant), who developed sepsiswere included in the study. We calculated APACHE II scores at baseline for all these patients. All patients in the study were counselled about the use of Ulinastatin as an adjunctive therapy and were included in the study based on their willingness to accept the addition of the drug to the existing therapy. Our study finally included a total of 225 renal failure patients (87 received Ulinastatin therapy and 138 remained in the control group) who had developed sepsis during the observation period. 87 patients in the treatment groupwere started on 200,000 IU of Ulinastatin intravenous twice a day for 5 days in addition to standard care according to the institute protocols which was used for all 225 patients. The treatment was initiated within 48 hrs of admission. 20/225 (4 in the Ulinastatin group and 16 in the control group) did not complete treatment. At baseline, 88/225 patients (39.1%) were on mechanical ventilation, 157/225 (69.7%) were on vasopressor support and 74/225 (32.8%) had multiple organ dysfunction.

Results: We observed that the 14 day all-cause mortality was significantly lower in the Ulinastatin group in comparison to the control group.(18/87(20.68%) vs 50/138(36.2%), p=0.0010). The incidence of new onset of organ failure was significantly lower in the Ulinastatin group than in the control group. (15/87 (17.2%) vs 52/138(37.6%),p=0.0001). Significantly more ventilator free days were observed in the Ulinastatin group than in the control group.(8.7±4.2(SD) days vs 4.4 ± 5.1, p=0.0001).Lesser vasopressor support (1.7±2.1 days vs 3.2± 1.9, p=0.0001) and shorter hospital stay(7.2±3.5 days vs 13.6±3.7 days, p=0.0001) were also reported in the Ulinastatin group. Serum C-reactive protein and serum procalcitonin levels were monitored at baseline and at the end of therapy in Ulinastatin group.

Discussion and Conclusion: Ulinastatin can be considered as a good adjunctive therapeutic agent in patients of sepsis with renal failure with regard to decrease in morbidity and mortality as observed in our study. Previous studies have already shown that Ulinastatin may help in mortality reduction in severe sepsis, however none of these studies describe its usage in the renal failure patients. A full course of Ulinastatin is associated with an incremental cost of USD 850 to the patient which is fairly economical as there is significant reduction in morbidity and mortality. Although our study had a limited number of patients, it has encouraging results which prompts further research into the use of Ulinastatin in renal failure.

  Poster Presentation – 16th December 2017 - 12.35-13.35pm Top

1. Out of the Blue-A Rare Case of Methemoglobinemia in a Chronic Hemodialysis Patient

Abhishek Dixit, Deepa Usulumarty, Shrirang Bichu, Parag Tilve, Viswanath Billa

Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

Background: Hemodialysis is a complex treatment and ESRD patients are fragile carrying a huge burden of co-morbidities. The low rate of dialysis emergencies can be attributed to numerous safety features in modern dialysis machines and meticulous treatment and testing of the dialysate solution. We describe a rare medical emergency of acute onset methemoglobinemia in a chronic maintenance hemodialysis patient (MHD).

Aim of the Study: To create awareness regarding rare medical emergencies like acute methemoglobinemia which can happen on hemodialysis.

Methods: A 73 year old gentleman on 3/week MHD complained of profound weakness and sweating post hemodialysis. The current dialyzer was used 9 times prior to this. Quick examination of his vitals revealed heart rate of 100/min; BP 160/80 mm of Hg; RBS 120 mg% and normal ECG. However the patient who was of a relatively fair complexion seemed to have a dusky look with bluish discoloration of fingers and nails. ABG revealed pH 7.4; PO2 100; O2 saturation 97; HCO3 19.3; PCO2 30.5.

Results: Blood draws were suggestive of a Hemoglobin 8 gm% (previous 10.9); Total bilirubin 8.9 mg/dl with Indirect bilirubin of 5.6 mg/dl; ALT/AST 25/41 U/L; Retic count 0.2%; G6PD normal; LDH 186; CPKMB 10 U/L and TROP I negative. Methemoglobin levels sent in view of sudden onset cyanosis was 27.98% (N 0-2%). The patient was treated with Methylene blue in the dose of 10 ml (50 mg) (1 mg/kg) given in 100 ml saline over 30 mins. Two such doses given in 48 hours. This treatment was accompanied by 50 mg of leucovorin factor and ascorbic acid.

Conclusions: The patient completely recovered and was discharged after 4 days with a methemoglobin level of 3% and hemoglobin 10.5 gm%. He asymptomatically continues his 3/week maintenance Hemodialysis.

2. Acute Carotid Vasculitis

Abhishek Dixit, Deepa Usulumarty, Shrirang Bichu, Parag Tilve, Viswanath Billa

Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

Background: Large vessel vasculitis is a rare condition characterized by inflammation within the walls of the aorta and its major branches. While we often see Vasculitis involving large vessels in chronic stage when stenosis and fibrosis sets in; it is unusual to identify this in acute phase. We here present a case of large vessel vasculitis in patient with CKD who presented with unusual nature of neck pain and diagnosis of carotid arteritis was made on ultrasonography.

Aim of the Study: Carotid tenderness as a specific sign of large vessel vasculitis.

Methods: Case: A 47-year-old lady presented with complaints of bilateral neck pain with low-grade fever for 15 days. She is diagnosed case of CKD (etiology unknown) on conservative management. On examination there was significant tenderness at anterior triangle of neck. There was no evident lymphandenopathy or thyroid tenderness. Laboratory studies showed Hemoglobin 10.1 g/L; TLC 12300/cumm; CRP150 mg/L; ESR 55 and creatinine 3.8 mg/dl. Immunological workup was normal. Kidney sizes were borderline at 8 cm each; with evidence of chronicity. USG neck demonstrated diffuse intimo-medial thickening of distal common carotid arteries with overlying probe tenderness suggestive of arteritis. FDG-PET scan demonstrated intense patchy FDG avid concentric mural thickness in bilateral carotid arteries and intense patch in arch of aorta.

Results: She was treated with methylprednisolone and subsequently commenced on methotrexate and prednisone. She remained well over the following 1 month and repeat ultrasonography showed resolution of inflammation in carotid arteries. Patient's creatinine reduced to 3.1 mg/dl reflecting Vasculitis as possible etiology to the underlying CKD.

Conclusions: Large vessel vasculitis can present with vascular tenderness secondary to inflammation in the acute phase. Eliciting tenderness of large vessels where palpable; is a simple and important clinical test to identify this condition.

3. Renal Function in Patients with Severe Hypothyroidism: A Prospective Cohort Study

Aarthi Chandrasekaran, Ashu Rastogi, Ashwani Sood, K L Gupta, Vivek Kumar

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

Background: Fall in glomerular filtration rate (GFR) or excess urine protein/albumin excretion are two objective criteria used for assessment of renal function. Hypothyroidism is associated with reversible fall in GFR. The relationship of urine protein excretion with hypothyroidism has not been systematically investigated.

Aim of the Study: We investigated the changes in estimated GFR (eGFR) by CKD-EPI eGFR equation and urine protein excretion over 3 months in subjects with severe hypothyroidism.

Methods: In this prospective cohort study; all subjects with clinical diagnosis of hypothyroidism and attending the outpatient clinic were eligible for screening. The inclusion criteria were age between 18-60 years and severe hypothyroidism (defined as TSH >45 uIU/mL). The main exclusion criteria were pregnancy or lactation in case of females; pre-existing CKD; history of renal stone disease or AKI in the past; organ transplant recipient or poor functional status. The primary endpoint was difference in eGFR by CKD-EPI at 3 months after treatment. The secondary endpoint was difference in 24-hour urine protein excretion at 3 months. Acute kidney disease (AKD) was defined as baseline eGFR ≤60 ml/min/1.73 m2 which improved to >60 ml/min/1.73 m2 by 3 months. The study was approved by Institute Ethics Committee.

Results: Out of 1680 screened subjects; 45 subjects were finally enrolled. 44 subjects completed follow up visit at 3 months and were included for analyses. The mean age of the study population was 38.1±12.4 years and majority were females (M/F:12/32). The median serum TSH at presentation was 138 uIU/mL (IQ range: 100-194.8). Serum creatinine decreased significantly at 3 months [mean difference between follow up and baseline: -0.19 mg/dL (95% CI: -0.27 to -0.12); p<0.001]. eGFR significantly increased at 3 months [mean difference between follow up and baseline: 17.6 mL/min/1.73 m2 (95% CI: 11.5 to 23.6); p<0.001]. 24-hour urinary protein also significantly decreased at follow-up [mean difference between follow up and baseline: -68.1 mg/24 hours (95% CI: -105.9 to -30.3); p<0.001]. 18.6% of subjects had AKD as per above definition.

Conclusions: Severe hypothyroidism is significantly associated with increase in circulating creatinine levels; decrease in eGFR; and increase in urine protein excretion.

4. BK Virus Nephropathy in Live Renal Allograft Recipients: Experience from a Large Transplant Centre in India

Pallav Gupta, D S Rana, A K Bhalla, Ashwini Gupta, Manish Malik, Anurag Gupta, Vinant Bhargava

Sir Ganga Ram Hospital; New Delhi; India

Background: BK virus is a polyoma virus which remains in latent phase in urinary tract particularly renal tubular epithelial cells. In immunosuppressed individuals it is activated and manifests as tubulointerstitial nephritis causing renal allograft dysfunction.

Aim of the Study: To study the spectrum of pathologic changes in patients with BK virus nephropathy.

Methods: Retrospective study was done on 402 patients undergoing renal allograft biopsy from 2013 to 2016.

Results: 6 cases were diagnosed as BK virus nephropathy. Mean serum creatinine at the time of biopsy was 2.13±0.45 mg/dl. Review of the histopathology slides showed acute tubular injury and interstitial lympho-plasmacytic infiltrate along with presence of ground glass intranuclear inclusion (type I) within the tubular epithelial cells in all the cases. Type III inclusion were seen in two cases whereas type IV inclusion was seen in only a single case. In all but one case; interstitial fibrosis and tubular atrophy was seen (<50% of the cortex) suggestive of stage 2 disease. In case 5; no interstitial fibrosis and tubular atrophy was seen (stage 1 disease). There was accompanying mild tubulitis in four cases. Parietal epithelial cell proliferations along with intranuclear inclusions in these cells were seen in one case (case 4).

Conclusions: BK virus is reactivated in the renal tubular epithelial cells. Clinically it mimics acute rejection and therefore histopathology along with immunohistochemistry is essential in making a correct diagnosis. The prevalence of BK virus associated nephropathy at our centre is 1.49%.

5. Histopathological Spectrum of Renal Diseases in a Tertiary Care Health Centre in India: A Ten-Year Retrospective Study

Sanjiv Jasuja, Vijay Kumar Sinha, Gaurav Sagar, Anupam Bahl, Sonika Puri

Department of Nephrology; Indraprastha Apollo Hospital; New Delhi; India

Background: Prevalence of renal diseases varies as per the geography and the ethnicity of the population. The prevalence of different glomerular diseases in our country is not known due to lack of a central biopsy registry and large multicentric studies. This study analysed the prevalence of various Glomerular diseases in a large tertiary care centre in India.

Aim of the Study: To study the clinical characteristics of various histological diagnosis of renal biopsies over a 10 year period.

Methods: A retrospective analysis of all renal biopsies performed at our centre from 1st January; 2003 to 31st December 2012 was done. All biopsies were done under ultra sound guidance using automated biopsy gun. Two core biopsies were taken. Clinical and laboratory data along with Light and Immunoflorescence (IF) microscopy findings were analysed. Electron Microscopy was not performed. Biopsies were divided into Native and allograft kidney biopsies. Native kidney biopsies were primarily classified into Glomerular (GD) and Non-Glomerular diseases and then sub-classified into primary and secondary glomerular diseases (PGD and SGD respectively) and further into different glomerular diseases as per histopathologic findings on light and Immunoflorescence microscopy and other relevant data.

Results: A total of 708 (60.5%) native kidney biopsies were performed of which 75.5% showed glomerular diseases (GD). Twenty percent of patients were in the age group of 31-40 years; followed by 41-50 years (19%) at the time of biopsy. Among patients with GD male: female ratio was 1.59:1 and mean age was 38.62 years. The most clinical presentation was nephrotic syndrome (NS; 42.9%); followed by chronic glomerulonephritis (31%). Among the PGDs; minimal change disease (MCD) was the most common (15.5%) with average age at presentation as 39 years; followed by Ig A nephropathy (12.3%; average age 33.6 years) and membranous nephropathy (12.1%; average age 42 years). NS and CGN was the most common presentation of MCD and IgAN respectively. Of the secondary GDs; lupus nephritis was the most common SGD (6.9%; average age 27.8 years with female preponderance) followed by Diabetic nephropathy (4.2%; average age 55 years). The most common histological presentation of both was chronic GN.

Conclusions: NS constitutes a major histological diagnosis in our series. MCD is the most common primary GD while LN is the most common secondary GD. Overall a male preponderance was observed.

6. Profile of Acute Kidney Injury at the time of Nephrology Referral and its Correlation with the Outcomes in Intensive Care Unit Patients

Vidya Nand, Manju Aggarwal, Jeetendra Sharma

Artemis Hospital; Gurgaon; Haryana; India

Background: AKI is a common and devastating medical condition in critically ill patients. Many epidemiological studies have demonstrated wide variation in causation and risk factors associated with AKI in ICU and its outcome. Nephrologists are usually involved when severe AKI has already settled; requiring dialysis. There are very few studies from north India.

Aim of the Study: To assess the clinical and etiological profile of patients with AKI at the time of nephrology referral. We also assessed the outcome of AKI patients and its association with early and late referral.

Methods: This was a prospective observational study of 18 months duration in a multidisciplinary ICU of a tertiary care centre in north India. AKI patients seen by nephrologists from October 2015 to February 2017 were included. AKI was defined as per AKIN diagnostic criteria. Early nephrology consultation was defined when it was performed within 48 hour of diagnosis of AKI. All patients were designated according to AKIN staging system at the time of first nephrology consultation. Primary outcome of patients in this study was mortality within first 28 days of inclusion and secondary outcome was dialysis dependence at the time of discharge. Recovery from AKI was defined as returning of Serum creatinine to within 25% of baseline. Partial recovery was defined as dialysis independence with serum creatinine higher than 25% of baseline. All patients were followed up until discharge. They were called every two weeks for follow up after discharge for 3 months.

Results: Total 201 patients were included. Mean age was 59.4±16.6. Eighty percent were medical; 17% surgical and 2.5% were obstetric. 83% patients were in early referral group and 17% in late referral group. Sepsis was the commonest cause (91%) of AKI. Dialysis was required in 57% in early Vs 51% in late referral group. Metabolic acidosis (51%) was the commonest dialytic indication. Complete recovery was seen in 21% patients of early and 28% of late referral group. Early and late referral group had 8% and 6% dialysis dependence at discharge. In-hospital mortality was similar in both groups (41 and 40%). In patients of AKIN stages 1; 2 and 3 complete recovery was seen in 29; 23 and 20%; dialysis dependence was 0; 7 and 11% and mortality was noted in 32; 35 and 46% respectively. AKIN stage 3 had the highest mortality in both early and late group (44 & 53%). Mortality in patients requiring dialysis was 61% whereas 69% died in ventilated group. Total number of deaths at 28 and 90 days was 47 and 51%.

Conclusions: Sepsis is still the predominant cause of AKI in ICU of tertiary care setting. In hospital mortality was noted in 41% of patients. Presence of sepsis; vasopressor requirement; ventilator requirement and higher AKIN stage at time of consultation were significantly associated with higher mortality.

7. Bioelectrical Impedance Analysis for Assessing Dry Weight of Dialysis Patients Using Inbody S10

Jitendra Khandge, Sana Humdulay, Zaheer Virani, Prashant Rajput, Bharat Shah

Global Hospital; Mumbai; Maharashtra; India

Background: Achieving dry weight (DW) is of prime importance in hemodialysis (HD) patients. The conventional clinical method of DW assessment may fail to account for ongoing changes in nutritional status affecting lean body mass. There is emerging evidence that Bioelectrical impedance analysis (BIA) is a reliable non invasive method to determine body composition and DW in HD patients.

Aim of the Study: To determine DW by BIA in patients with ESRD undergoing HD and compare this with DW estimated by conventional (clinical) method.

Methods: Sixty-three stable ESRD patients on HD were included. Patients who had pacemaker were excluded from the study. DW measurement was done by the BIA technology using InBodyS10 (InBoday Co. LTD.; Seoul; Korea). To standardize the procedure; BIA measurements were taken in the supine position with the limbs spread apart. DW was also determined clinically by the nephrologist who was blinded to the DW reading obtained by BIA. This was considered as the weight at which patient had no symptoms or abnormal findings suggestive of volume overload.

Results: Of 63 cases in this study; 39 were males and 24 were females. Average age of patients was 57.01+21.06 years (Males: 56.56+15.29 years; Females 54.75+ 16.99 years). The etiology of CKD was diabetic kidney disease in 31 patients and non-diabetic kidney disease in 32 patients. The Mean +1SD DW calculated by BIA method was 62.32 +14.28 kg. The Mean + 1SD DW calculated by conventional clinical method was 62.12 +13.92 kg. (P>0.05). There was good correlation of dry weight measured by BIA and clinical method.

Conclusions: Our study shows that there is no significant difference in DW estimated by the BIA and conventional method.

8. Sensitization History: Good and Cheap but not Perfect Discriminator of Sensitization

Ajay Kher, Pranav Dorwal, Ashwini Gadde, Ashish Nandwani, Shyam B Bansal, Pranaw Jha, Dinesh Bansal, Manish Jain, Reetesh Sharma, Vijay Kher

Flow Cytometry; Waikato Hospital; Hamilton; New Zealand; Fortis Escorts Kidney and Urology Institute; New Delhi; Medanta Kidney and Urology Institute; Gurugram; Haryana; India

Background: Immunological evaluation is a critical part of pre-transplant evaluation. The tests available include complement dependent cytotoxic crossmatch (CDC XM); Flow cytometric crossmatch (Flow XM); Flow panel reactive antibody (Flow PRA); single antigen bead (SAB). Cost constraints mean that all tests cannot be done on all in India. This study was conducted to assess if sensitization history would discriminate between sensitized and unsensitized recipients.

Aim of the Study: Evaluate whether sensitisation history identifies transplant recipients who are sensitised.

Methods: All potential transplant recipients undergoing transplant evaluation at our center from May 2015 to August 2016 underwent evaluation by sensitization history; CDC XM; Flow XM and Flow PRA. Those with any positive tests were recommended to undergo SAB testing. Sensitization history was present if patients had any history of transfusion; transplant or pregnancy. 241 patients underwent this evaluation and 206 (85%) underwent transplantation.

Results: The patients who had a history of sensitization were more likely to be positive for CDC XM; Flow XM and Flow PRA compared to those with no sensitization history. However; there were some recipients who did not have any sensitization history but still were positive for Flow XM or Flow PRA. Sens H/o (241) CDC XM Flow XM Flow PRA TransplantsPresent (118) 7 (6%) 26 (22%) 26 (22%) 94 (80%) Absent (123) 0 (0%) 6 (4.9%) 3 (2.4%) 112 (91%).

Conclusions: Sensitization history is a cheap and good discriminator for sensitization but not a perfect discriminator. Sensitization history may be utilized to develop algorithms to make judicious use of immunological tests in cost constrained conditions.

9. Clinical and Histopathological Profile of Multiple Myeloma Patients with Kidney Involvement- A Single Centre Retrospective Study

Arunima Mahanta, M Sharma, A K Barman, P J Mahanta, S Kakati, B D Medhi, P Doley, P Bordoloi, G Pegu, H Das, B Agarwalla, M Parry, H Jeelani

Gauhati Medical College and Hospital; Guwahati; Assam; India

Background: Multiple myeloma (MM) is a clonal B-cell disease of proliferating plasma cells. Kidney disease is a common and a potentially serious complication of MM that occurs in 20%–25% patients and in up to 50% patients during the course of their disease. Kidney dysfunction is potentially reversible in approximately 50% patients; but the remaining patients will have some degree of persistent chronic kidney disease (CKD); and of these; 2%–12% will require renal replacement therapy (RRT).

Aim of the Study: To investigate the distinctive clinical and histopathological profile of Multiple Myeloma patients with kidney involvement.

Methods: This study was hospital based retrospective analysis of clinicopathological data of MM patients with kidney involvement. The study was conducted at Department of Nephrology and Haematology; GMCH; Assam; from the period of March 2016 to February 2017. A total of 50 patients who met the inclusion/exclusion criteria were included in the study. Patient data (clinical/demographic and laboratory data including renal biopsy) was collected. Diagnosis of MM was made by the Revised International Myeloma Working Group Diagnostic Criteria.

Results: Clinical presentation of MM patients with kidney involvement were fatigue (98%); anaemia (95%); bone pain (67%); hypercalcemia (91%) and lytic bone lesions (86%). Acute kidney injury was the most common renal syndrome (54%) in MM patients followed by chronic kidney disease (29%); subnephrotic proteinuria (14%) and nephrotic syndrome (3%). The histopathological findings in patients with AKI were acute tubular necrosis; acute tubulointerstitial nephropathy and myeloma cast nephropathy; CKD were amyloidosis; myeloma cast nephropathy; monoclonal immunoglobulin deposition disease and tubulointerstitial nephropathy; subnephrotic proteinuria/nephrotic syndrome were amyloidosis and monoclonal immunoglobulin deposition disease. The various precipitating factors for renal failure in MM patients were hypercalcemia (45%); infection (24%) and non-steroidal anti-inflammatory drugs (NSAIDs) (38%).

Conclusions: Majority of MM patients with kidney involvement present with fatigue and anaemia. AKI is the most common renal syndrome followed by CKD. Myeloma cast nephropathy was the most common histopathological lesion. Hypercalcemia is the most common precipitating factor for renal failure in MM patients.

10. An Unusual Cause of Myoglobinuria

Abhishek Dixit, Deepa Usulumarty, Shrirang Bichu, Parag Tilve, Viswanath Billa

Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

Background: Rhabdomyolysis is characterized by acute breakdown of skeletal muscle; which can lead to AKI in severe cases. Number of etiologies have been identified in rhabdomyolysis with drugs and trauma accounting for the majority. Rhabdomyolysis following a massage session is rare. We report unique case of rhabdomyolysis with AKI following aggressive massage session.

Aim of the Study: To report an unusual case of myoglobinuria and to create awareness regarding rare causes of myoglobinuria.

Methods: Case: A 57 year old gentleman with Diabetes and Hypertension presented with fever; breathlessness and decreased urine output. On investigations it was found that his serum creatinine was 6.4 mg%. Further investigations revealed Hb of 12.7 gm% and TLC was 21400/cumm. His other blood tests showed: LDH 1095U/l; CPK 58928U/l; potassium 6.7 mEq/l and BUN 76 mg/dl. In view of the hyperkalemia & fluid overload he was dialyzed. The qualitative test of urine for myoglobin was positive. The time–concentration curve of CPK and LDH was similar to that of WBC & CRP level indicating that extent of inflammation was closely related to rhabdomyolysis process. Downward trend of creatinine also associated with fall in CPK; LDH; CRP and WBC levels. After 2 weeks; patient was discharged with a stable creatinine of 1.2 mg/dl.

Results: To determine etiology of raised CPK; detailed history was taken & he confessed to regularly receive body massage for 1 hour. However a day prior; he received prolonged body massage session for 2h served by two masseurs simultaneously with higher intensity.

Conclusions: Compression-induced rhabdomyolysis has been reported in coma or immobilized patients; but it has rarely been associated with body massage. The people receiving body massage should drink adequate amount of water to prevent rhabdomyolysis-associated AKI; which is exacerbated by volume depletion.

11. Practices and Patterns of Hemodialysis in South Asia: A Survey of Nephrologists

Sanjiv Jasuja, Sonika Puri, Anupam Bahl, Gaurav Sagar

Indraprastha Apollo Hospital; New Delhi; India

Background: South Asian (SA) region faces a high burden of end stage renal disease (ESRD) and has a large gap between demand and supply for renal replacement therapy (RRT). We present the assimilated findings of a survey of nephrologists of the SA region on prevalent hemodialysis (HD) and vascular access (VA) practices in their respective units.

Aim of the Study: To obtain data on current HD practices in South Asia and to determine their regional variation.

Methods: Nephrologists or Internal Medicine specialists running HD centers in the SA region were sent an online questionnaire. Literature was reviewed to fill gaps for missing data. Responses obtained were then converted into graphs using google survey automated software.

Results: 1700 physicians were contacted. 90 doctors responded (India: 70; Pakistan: 10 with 0 responses from Afghanistan; Maldives and Bhutan). The total health expenditure (% of Gross Domestic Product) ranges from 13.7% in Maldives to 2.6% in Pakistan. The prevalent dialysis population ranges from 101 ppm in Pakistan to 35 ppm in Nepal. The number of nephrologists in each country is as follows: India: 1; 400; Pakistan: 143; Nepal: 40 and Sri Lanka: 20. The number of dialysis units and machines range from 6081 and 23; 900 respectively in India to 20 and 200 respectively in Sri Lanka. Majority of patients undergo HD twice a week (45%:Myanmar to 80%: Sri Lanka). AV access trend is as follows: Prevalent AV fistula use: 80 (India) to 30% (Myanmar) Prevalent Temporary catheter: 30% (Pakistan) to 10% (Sri Lanka). Incident AVF use: 30% (Sri Lanka) to 3% (Bangladesh). The figures mentioned above are estimates and may not represent the actual number.

Conclusions: There is regional disparity between availability of nephrologists and HD units within this region. Few patients utilize AVF for incident HD or undergo HD three times a week. Greater public private partnership is needed. Limitations of the survey included recall bias and very low response rate.

12. Spectrum of Renal Biopsy in Children: A Single-Center Experience from Tertiary Hospital

Bhaskara Rao Beesetty, G Prasad, V Ramesh Chandra, S K Chaitanya, R Ranga Rao, Praveen S. Srinivasa Rao Sirisa, Praveen, Sam Rao

Aandhra Medical College; Visakhapatnam; Andhra Pradesh; India

Background: Renal biopsy has limited indications in children. However; whenever necessary the procedure should be promptly carried out. Indications of renal biopsy are RPGN; SRNS; non recovering AKI and following transplantation etc. Renal biopsy is usually performed percutanously. Biopsy performed by using 23 G needle. The risk of complications is increased with bleeding diathesis; uncontrolled hypertension and renal failure.

Aim of the Study: This study was conducted retrospectively to know the indications for renal biopsy in native kidneys and to analyze pathological findings in the last 2 years in a single tertiary teaching hospital.

Methods: All patients under 18 years who underwent renal biopsy at our hospital between 2015 and 2017 were included in the present study. Renal biopsy was performed under ultrasound guidance with a biopsy gun. All renal biopsies were studied under light and immunofluorescent microscopy.

Results: A total of 34 renal biopsies were done in patients under 18 yrs of age with minimum age being 3 yrs. Female to male ratio among 34 patients were 1.125:1. Most common presentation was anasarca. Anasarca is presenting symptoms in 32 out of 34 patients either as isolated symptom or in combination. Most common indication for renal biopsy was nephrotic syndrome (38.2%) followed by steroid resistant nephrotic syndrome (35.3%) and nephritic syndrome (20.6%). Most common renal biopsy finding was FSGS (26.5%) followed by MCD (23.4%); MEMBRANOUS NEPHROPATHY (11.8%) and C3 glomerulopathy (11.8%). Among steroid resistanant nephritic syndrome patients common lesion was FSGS (41.6%) followed by MCD (33.3%). C3 glomerulopathy; FSGS and SLE are more common among female patients; whereas MCD was found to be common among male patients. C3 glomerulopathy; FSGS; MCD and membranous nephropathy were more common in children more than 10 yrs age.

Conclusions: Most common indication for renal biopsy was nephrotic syndrome followed by steroid resistant nephritic syndrome and nephritic syndrome. Most common histopathological finding was FSGS followed by MCD.

13. Renal Replacement Therapy in Intensive Care Unit: A Novel Beginning at a Tertiary Care Center in Nepal

Krishna K Agrawaal, Pramod K Chhetri, Dhiraj N Manandhar, Prakash Poudel, Sameer K Baidya

Department of NephrologyNepal Medical College and Teaching Hospital; Kathmandu; Nepal

Background: Acute Kidney Injury is a major complication in ICU patients. It is associated with increased in-hospital mortality; length of stay and is a risk factor for CKD including the need for long-term dialysis. Majority of these patients are on Mechanical Ventillator and transferring them for RRT is time consuming and risky. The provision of RRT in ICU is not available in resource poor countries like Nepal. We started this service at Nepal Medical College in outskirts of Kathmandu.

Aim of the Study: The study aims look into the clinical; biochemical profile and outcomes of the patients during hospital stay who received RRT in the ICU.

Methods: It was a Prospective observational study from July 2016 till July 2017 which included all the patients receiving Renal Replacement Therapy in the general ICU at Nepal Medical College. The patient's demographic data; Indications; biochemical tests; Outcomes; modality of RRT and no. of sessions were recorded and entered into Microsoft Excel format. Mean and percentage was calculated for descriptive data and Chi Square test was applied for inferential statistics. SPSS version 17 was used for statistical analysis and P value ≤ 0.05 was used for statistical significance.

Results: There were total of 649 admission in ICU of which 148 had Kidney related complications. Of 148 patients; 69 (47%) received RRT. Of 69 patient 36 (52%) were females. Mean age; admitting urea and creatinine were 50.17±18.42; 174.54±63.46 mg/dL and 8.05±3.49 mg/dl respectively. Around 32 (47%) had DM; 42 (61%) had Hypertension. They underwent 4.32±3.09 sessions and 12.86±12.06 hours of RRT. Around 22 (32%) had AKI. Around 41 (60%) had septic shock. SLED was done in 42 (61%) of patients among which 31 (72%) were on two or more ionotropes. About half of the patients were on ventilator. In hospital mortality was 19 (28%); 36 (56%) were switched to MHD and 9 (14%) recovered. The In Hospital mortality was statistically significant with Presence of Septic Shock (p 0.02) and Mechanical Ventillation (P 0.05). Nearly 50% of the cause of Sepsis was Pneumonia and Urosepsis combined together.

Conclusions: Nearly half of the patients in ICU with Renal complications require Renal Replacement Therapy. Septic Shock is a major predictor of Mortality in these patients. Sustained Low Efficient Dialysis can be done in patients on ionotropes and patients can be switched over to Maintenance hemodialysis.

14. Bedside Peritoneal Dialysis Catheter Repositioning - Case Series of a Novel Technique

Santosh Varughese, Suceena Alexander, Anna T Valson, Shibu Jacob, Kakde Shailesh Thulsidas, Anjali Mohapatra, Vinoi George David, Veerasami Tamilarasi

Christian Medical College; Vellore; Tamil Nadu; India

Background: Malfunction of peritoneal dialysis (PD) catheters usually need surgical repositioning; requiring anaesthesia; operating time; longer hospital stay and surgical expertise.

Aim of the Study: This novel technique obviates need for surgical intervention where successful.

Methods: A novel technique of percutaneous PD catheter repositioning was done.

Results: In the 20 patients so far; we have had an immediate technical success of 100% and a month later 14 catheters were functioning well (70%). Six months later; 12 catheters remained functional except in the one patient who died four months later due to cardiac disease and one that required surgical repositioning.

Conclusions: In a significant proportion of cases; this novel procedure will help to obviate surgical repositioning; saving money; lowering hospital stay and not necessitating personnel with surgical expertise and is exceptionally useful in resource-poor settings of South Asia.

15. Effect of Dietary Habits on Dietary Phosphorous Intake in Chronic Kidney Disease Patients from Different Religious Communities On Their First Visit To Nephrologists

Trisha Sachan, Anita saxena, Amit Gupta, Eesh Bhatia

Sanjai Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

Background: Hyperphosphatemia is a major concern in chronic kidney disease patients (CKD). Phosphorus intake is restricted in order to prevent hyperphosphatemia. Animal protein has higher organic phosphorus; 80% of which is absorbed compared to inorganic phosphates of vegetable origin; absorption of which is 50-60% only.

Aim of the Study: To evaluate if dietary habits based on religion influence phosphorous intake of CKD patients.

Methods: A total 97 patients were screened from outpatient Department of Nephrology and Endocrinology; among which 13 were Muslims (Group 1) and 85 were Hindu (Group 2). 5 patients were in stage 1; 18 in stage 2; 27 in stage 3; 26 in stage 4 and 31 in stage 5 CKD. Patients in CKD stages 4 and 5 were on phosphate binders. Three days dietary recall of the patients was taken to evaluate energy; protein; calcium and phosphorous intake with the help of standard nutrition tables of National Institute of Nutrition (NIN) published by ICMR. Patient's anthropometric measurements and biochemical parameters were tested.

Results: No significant difference observed in weight; height; BMI; serum creatinine; anthropometric parameters; GFR and systolic and diastolic blood pressure in the two groups. Serum creatinine significantly correlated with serum phosphorus (0.001) and serum calcium (0.000). In both the groups; energy; protein; calcium intake was less than that recommended for CKD patients (35 kcal/kg/d energy; 0.6 g/kg/d protein and 1000-1500 mg calcium) respectively. There was significant difference in dietary phosphorous (p 0.040); protein (p 0.000); calcium (p 0.038); serum creatinine (p 0.017) in the groups. Correlation analysis showed significant association between serum creatinine and dietary energy; protein; phosphorus and serum phosphorus. Dietary energy was significantly associated with serum albumin (p 0.002); dietary protein calcium and phosphorus (p 0.000) and GFR (p 0.000). Dietary protein was associated with dietary calcium (p 0.000); phosphorus (p 0.000); serum albumin (p 0.003) and GFR (p 0.000).

Conclusions: High dietary phosphorous intake was observed in Group 2 (Hindu Community) with normal serum phosphorus levels showing low absorption of phosphorus from plant based diet. So; we recommend vegetarian diet for CKD patients for the prevention of hyperphosphatemia and associated cardiovascular outcomes.

16. Cognizance About Chronic Kidney Disease Diet- Patients Preview

Nancy Sahni, K L Gupta, Manish Rathi>

Department of Nephrology, PGIMER; Chandigarh; India

Background: Data shows that CKD diet are one of the most complicated and confusing diets; hence wrong cognizance for the same is but natural. What we eat defines our health and vica versa but failing kidneys and wrong dietary perceptions can be a lethal combination for further disease progression and mortality.

Aim of the Study: Know how of barriers in healthy eating by CKD patients due to wrong food perceptions & misconceptions.

Methods: Pre-dialysis patients (N=245) were enrolled from nephrology OPD; PGIMER. Misconceptions about cognizance of CKD diet was recorded via 24 hour recall method of food intake and food frequency questionnaire. SGA was used to score nutrition status.

Results: 51.6%were under the misconception that milk and milk products are bad for failing kidneys. Fact is HBV protein has to be 50 percent in CKD diet and the only source is milk& milk products in a vegetarian Indian diet. 75.4% had “sour” food fear while 44.3% patients did not include green leafy vegetables in diet. All sour foods like curd; pineapple etc; all GLV's are not potassium rich & can be added in a calculated amount. 46.7% patients considered rice to be bad for kidneys. Rice is richer in carbohydrates (energy source); has less phytate; less protein but more net protein utilisation as compared to wheat. 49% patients considered fat/oil to be taken in less amount due to misconception that failing kidneys cannot digest fat. If a low protein CKD diet is energy (fat) deficit; it will lead to muscle wasting and disease progression. Lower intake per day of was recorded (energy- 1492.80±409.93 kcal; protein-40.36±12.40 g; Vit. C-30.63±10.4; Vit. A-263.129±61.61 μg retinol). SGA scoring was lower.

Conclusions: Nutrition surveys to gauge awareness about wrong food perceptions and misconceptions are a must in CKD patients to guide them through healthy low protein CKD diet plans for delaying disease progression and optimum nutritional parameters.

17. Clinical Profile of IgA Nephropathy at a Tertiary Care Hospital in North India

Ajay Jaryalassistant, Sanjay Vikrant

Indra Gandhi Medical; Shimla; Himaachal Pradesh; India

Background: IgA nephropathy (IgAN) is one of the commonest glomerulonephritis worldwide; with variable prevalence across different races and geographic regions. It has varied prevalence; prognosis and clinical features. We did retrospective analysis of data of patients with biopsy diagnosis of IgAN at our centre to elucidate its clinical features.

Aim of the Study: To report the clinical profile of IgA Nephropathy seen at our centre.

Methods: A retrospective analysis of all the patients who underwent kidney biopsy at Indira Gandhi Medical College Shimla; Himachal Pradesh from June 2014 to May 2017 and had a biopsy diagnosis of IgA Nephropathy was done. The record was retrieved for presenting complaints; clinical diagnosis; urine analysis; serum creatinine; serum albumin; 24 hour urine protein; viral markers and biopsy findings on light microscopy and immunofluorescence.

Results: A total of 376 native kidney biopsies were done over a period three years (June 2014 to May 2017). Among these 44 (11.7%) had a diagnosis of IgA Nephropathy. Among 44 patients with IgA Nephropathy; 23 (52.3%) had clinical diagnosis of rapidly progressive glomerulonephritis (RPGN); 8 (18.2%) CKD; 5 (11.4%) nephrotic syndrome; 3 (6.8%) gross haematuria; 3 (6.8%) asymptomatic urinary abnormalities and 2 (4.5%) malignant hypertension. Among 23 patients of RPGN; majority (52.2%) presented with hypertensive crisis. Overall 38 (86.4%) of 44 patients had blood pressure >140/90 mm of Hg; 14 (31.8%) patients presenting as hypertensive crisis; 2 of them had malignant hypertension. Among patients with hypertensive crisis; 10 (71.4%) had biopsy evidence of thrombotic microangiopathy (TMA) whereas none had TMA on kidney biopsy among those without hypertensive crisis (p<0.05). 2 of 44 patients had preceding history of Henoch Schonlein purpura.

Conclusions: RPGN is commonest clinical diagnosis and hypertension commonest clinical finding in IgAN with about 1/3 presenting in hypertensive crisis. The presence of TMA on kidney biopsy was more common in patients of IgAN with hypertensive crisis than those without it.

18. To Study Pattern of Salivary Gland Involvement using Radionuclide Scan in Patients with Sjogren's Syndrome Presenting with Distal RTA

Shriganesh R Barnela, Sachin S Soni

United Ciigma Hospital; Aurangabad; Maharashtra; India

Background: Sjogren's syndrome due to its varied presentations and multisystem involvement remains a diagnostic dilemma to confirm the diagnosis. Salivary gland scintigraphy with 15 mCi of Tc pertechnetate is a non-invasive test with advantage of objective and functional assessment of salivary glands. It can be used to assess the involvement and severity of glands involvement and to assess progression of disease activity as well. Renal involvement in SS is reported variably with prevalence between 2-67%.

Aim of the Study: To study pattern of salivary gland involvement using radionuclide scan in patients with Sjogren's syndrome presenting with distal RTA.

Methods: A prospective study of patients of SS was done to analyze salivary gland involvement using radionuclide scan. These patients were referred for evaluation of renal tubular acidosis/electrolyte imbalance in Nephrology clinic. The patients were evaluated in details for confirmation of diagnosis of SS; distal RTA and pattern of salivary gland involvement. All documented and confirmed cases of SS with dRTA were included in present study.

Results: Total 11 cases of SS with dRTA were included in present study. All are female patient with mean age of 44.35±9.22 years. Major presenting symptom were; dryness of eyes (8/11); dryness of mouth (7/11); generalized weakness (5/11) and polyuria (4/11). Anti Ro/Anti La antibody was positive in all patients. RA factor was positive in 2/11 cases and ANA in 9/11 cases respectively. All patients had metabolic acidosis (Mean pH – 7.22 ± 0.05); hypokalemia (Potassium; 3.085±0.44 Meq/L) and low HCO3 (11.75±1.69). Mean presenting Urine pH 6.34±0.27; urine potassium (7.91±2.24 Meq/L). Pattern of salivary gland involvement on radionuclide scan showed moderate reduction of activity in bilateral submandibular glands in 10/11 patients. Similarly reduction of tracer uptake and activity was seen in Right parotid gland (6/11) and Left parotid gland (2/11). All patients with predominant complaint of dryness of mouth had both submandibular and parotid gland involvement on scan.

Conclusions: Salivary scintigraphy is non invasive diagnostic tool to assess salivary gland involvement in SS which also obviates the need of invasive biopsy. Parotid and submandibular gland involvement presents with dryness in mouth. Submandibular gland is almost always involved in patients with SS with RTA.

19. A Retrospective Study of Pres in MHD Patients

Krishna Prasad, Vijay Kiran, Sreebhushan Raju

Nizam's Institute of Medical Sciences; Hyderabad; Telangana; India

Background: PRES is a clinico-radiologic entity characterized by headache; altered level of consciousness; seizures and visual disturbances and reversible vasogenic edema. HTN and renal failure are well known risk factors for the development of PRES. However risk factors and outcome of PRES in dialysis patients has not been studied systematically. The aim of this study is to characterize the factors predisposing to development of PRES in patients on MHD.

Aim of the Study: To analyze the clinical details; course and laboratory data and One year follow up for recurrence of PRES and mortality.

Methods: We performed a retrospective analysis in patients of MHD who were diagnosed with PRES between 1st August 2013 and 31st July 2015. PRES was diagnosed when patients presented with symptoms of headache; visual disturbances; seizures; altered sensorium and suggestive radiologic findings. We analyzed the clinical details; course and laboratory data. One year follow up data was noted for recurrence of PRES and mortality.

Results: A total of 18 patients were included for the final analysis. Of total; 13 (72%) patients were males and mean age was 21.1 years (6-50 years). Most of the episodes developed shortly after initiation of MHD with mean duration of 2 months after initiation of MHD (1 month – 3 years). Of the 18 patients; 8 (45%) patients were diagnosed with infection. Overall 4 (22%) patients developed recurrence of PRES and all these episodes developed within 2 months of index event. no mortality was reported at the end of one year. Overall 7 (39%) patients underwent renal transplantation and none of these patients developed PRES after transplantation.

Conclusions: PRES is not uncommon in patients on MHD. Uncontrolled HTN is essential but not sufficient to cause PRES. Infection is one of the very common predisposing factors. Renal transplantation is safe in this group of patients. One year outcome of PRES is excellent and survival is not influenced by PRES.

20. Clinical and Histopathological Spectrum of Rapidly Progressive Glomerulonephritis – A Single Center Experience

M Sreedhar Sharma, K Praveen Kumar, K Varaprasada Rao, B Bhargav

Narayan Medical College and Hospital; Nellore, Andhra Pradesh; India

Background: Rapidly progressive glomerulonephritis (RPGN) is a clinical syndrome charecterised by active urinary sediment suggestive of glomerular disease and by progressive loss of renal function over a comparatively short period of time (days; weeks or months). It is most commonly characterized morphologically by extensive crescent formation. This is an analysis of age; gender; renal histopathological features and their outcomes in patients presenting with RPGN at our center.

Aim of the Study: This is an analysis of age; gender; renal histopathological features and their outcomes in patients presenting with RPGN at our center.

Methods: All adult patients admitted with clinical features suggestive of RPGN from May 2015 to May 2017 were included. Renal biopsy was done and subjected to light (LM) and immunofluorescence microscopy (IF) studies. They were treated according to standard treatment protocols. Patients were followed up with monthly serum creatinine; urine protein to creatinine ratio; urine microscopy and blood counts. Primary outcomes were analyzed at the end of 3 months. All the patients received standard protocol based immunosuppression in addition to supportive care.

Results: Immune-complex glomerulonephritis (ICGN) (78%; n=25) was the most common etiology followed by pauci-immune glomerulonephritis (12.5%; n=4). Anti-glomerular basement membrane disease was seen in 1 (3.12%) case. The most common etiology of ICGN was IgA nephropathy (37.5%; n= 12) followed by post-infectious glomerulonephritis (PIGN) (21.8%; n=7); lupus nephritis (6.24%; n=2); MPGN II (3.12%; n=1) .Membranous nephropathy with crescents were seen in 2 (6.24%) cases.

Conclusions: The Patients with Pauci immune GN were older compared to those with ICGN. 41% of the patients reached ESRD at the end of three months requiring dialysis. 51% of the patients had CKD. Complete remission was seen in 8% of the patients.

21. Late Onset De-novo Focal Crescentric IgA Nephropathy in a Renal Allograft Recipient

Ashok Ramasamy, Ravindra Prabhu, Shankar Prasad, Dharshan Rangasamy, Indu Rao, Mahesha Vankalakunti

Kasturba Medical College and Hospitals; Manipal; Karnataka; India

Background: IgA nephropathy (IgAN); the most common type of GN can recurin up to 60% of patients and can lead to allograft loss in upto 16% of cases. Recurrent crescentic IgAN is a rare entity and account for approximately 3–5%. De-novo IgANwith focal or diffuse crescents in transplanted kidneys are extremely uncommon.

Aim of the Study: Case report.

Methods: A 46 yr old hypertensive male; recipient of a live renal allograft six and half years back; presented with acute onset of fever and swelling and pain of left lower limb following a trauma. Pre-transplant patient was diagnosed as a case of chronic tubulointerstitial nephritis and underwent renal transplant with wife as donor. He had received anti-thymocyte globulin induction and his current immunosuppressivedrugs were prednisolone (5 mg/day); Tacrolimus and mycophenolate mofetil (1 gm/day). He had a stable allograft function with a serum creatinine (SrCr) of 1.1 mg/dl with no acute rise in Sr. Cr or any previous renal allograft biopsy. On evaluation at admission patient had an leukocytosis; acute graft dysfunction (SrCr 1.6 mg/dl) and was diagnosed with left lower limb cellulitis. His urine examination displayed microscopic hematuria and patient had 2.8 gm proteinuria on 24 hr urine quantification. His renal ultrasound and serum complement levels were normal. His blood and urine culturewas sterile.

Results: Over the next three days his renal function worsened (SrCr 2.7 mg/dl) for which patient underwent a renal allograft biopsy. A single core was sent for LM and IHC for C4d suspecting rejection. Biopsy was reported to have focal (2 out of 7 glomeruli) crescents with mild mesangial expansion and non-proliferative glomeruli with single contoured basement membrane and no evidence of rejection. On IHC; C4d was negative. Patient serum was negative for ANCA and Anti-GBMtiters and patient was given a dose of pulse MP 500 mg and the maintainence dose of steroids was increased to 0.5 mg/kg/day. Patient renal function improved over the next one week. Patient underwent a repeat renal allograft biopsy after one week. His repeat biopsy showed reduced number of crescents and immunofluorescence showed diffuse and global granular deposits of IgA (3+) and C3 (1+) in the mesangium. Patient steroid dose was gradually tapered to 10 mg/day over 1 month and his 2nd month follow-up serum creatinine was 1.2 mg/dl.

Conclusions: De-novo IgA nephropathy can occur following systemic infection in renal allograft recipients. Physicians should have a low threshold for allograft biopsyand tissue should always be processed for complete immunofluorescence studyespecially in the presence of proteinuria and an active urine.

22. Acute Kidney Injury in Intensive Care Unit: A Clinical and Outcome Study

Danish Kathuria, N P Singh, N P Agarwal, Anish Kumar

Max Super Speciality Hospital; Vaishali; Ghaziabad; Uttar Pradesh; India

Background: Acute kidney injury (AKI) has both short term as well as long term consequences in critically ill patients. Our study reviews etiological profile and outcome of AKI in critically ill patients which has been only scarcely done in India.

Aim of the Study: To study the etiological profile of AKI among patients admitted in ICU and assess the clinical outcome at the time of discharge and at 3 months.

Methods: 120 patients admitted with or developing AKI during their ICU stay were included in this prospective study and were defined as well as staged according to the KDIGO guidelines. Then patients were followed up at discharge and at 3 months to determine the outcome as either favourable (renal recovery) or adverse (residual renal dysfunction; dialysis dependence or death). Various known risk factors; as laid down by KDIGO; were identified and analyzed with respect to their association with the outcome.

Results: Out of total 120 subjects; almost half of the subjects (47.5%) had stage I AKI; 27.5% had stage II AKI and remaining quarter of subjects had stage III AKI. Anemia and sepsis were the most prevalent risk factors. The highest rate of renal recovery was demonstrated in stage I AKI. Overall mortality was 28%; highest in stage III AKI. Almost 50% of the stage I AKI showed complete renal recovery at 3 months as compared to only 25% and 29.6% for stage II and III respectively. Different stages of AKI also showed a graded increase in mortality at 3 months - 19.2% for stage I compared to 35.7% for stage II and 37% for stage III.

Conclusions: This study demonstrated increasing prevalence of adverse outcome in a linear fashion with increase in the severity of AKI. Sepsis was not only the most prevalent risk factor but was also strongly associated with an adverse outcome.

23. Central Venous Stenosis in Hemodialysis Patients and Efficacy of PCI (Percutaneous Intervention) in a Tertiary Care Hospital

Gaurav Sagar, N N Khanna, A Bhal, S Puri, R Ranganadha Rao, S Jasuja

Indraprastha Apollo Hospital; New Delhi; India

Background: Chronic kidney disease (CKD) is one of the leading causes of death and morbidity. Patients on MHD frequently develop venous obstruction in the central veins. Multiple central venous catheter placements have been associated with a greater risk of central venous stenosis and obstruction. Venous catheters placed by a subclavian access have a particularly high risk. The present study was conducted to investigate the pattern of CVO (Central Venous Stenosis) in ESRD patients.

Aim of the Study: (1) The profile of central venous stenosis in hemodialysis patients (2) Efficacy of percutaneous catheter intervention (PCI) in the management of CVO in immediate; 3 months and 6 months follow up.

Methods: Prospective; observational; hospital based study in the Department of Interventional Cardiology and Nephrology at Indraprashta Apollo Hospitals; SaritaVihar; New Delhi. 14 Patients of ESRD receiving maintenance hemodialysis who presented with abnormalities related to vascular access and underwent percutaneous catheter intervention (PCI) from June 2015 to December 2016 were included for the present study. Central venous stenosis diagnosed based on clinical presentation; examination; non invasive studies like Doppler and CT angiography and invasive studies like angiography. Interventions like angioplasty and stenting done in critical stenotic lesions. Patients were followed up clinically for symptoms and adequacy of dialysis and non-invasive Doppler studies were performed as required. Three- and 6-month assessment was performed in our studied patients.

Results: Among the 14 patients evaluated most common site of stenosis is Left Subclavian vein in 6 patients (43%) followed by Left Innominate in 5; SVC in 2; Right Subclavian in 1 patient. Main risk factor for CVO is previous catheterization (IJV 12; femoral 2) 4/14 underwent only PTA and 8/14 underwent PTA with Stenting; in one patient AVF closure done and one patient no intervention done as patient denied consent Patency rates of vessel were satisfactory; at 3 months 80% with PTA and 100% with PTA with stenting. At 6 months 60% with PTA and 83% with PTA with stenting. No major complications occurred with these procedures.

Conclusions: This study concluded that PTA and stenting are effective procedure for management of CVO with good patency rates and minimal complications.

24. A Study to Evaluate Efficacy of Hepatitis B Vaccination in Hemodialysis Patients

Manjunath J Kulkarni, Nikhil Dsouza

Father Muller Medical College; Mangalore; Karnataka; India

Background: Hepatitis B is one of the vaccine preventable disease in dialysis patients. Availability of safe vaccine for hepatitis B has made this vaccination a standard of care in ESRD patients. However; data suggests that the response to vaccination may be poor in dialysis population. Hence; we undertook a study to look into the efficacy of hepatitis B vaccination in dialysis patients as compared with those with normal renal functions.

Aim of the Study: To look into the efficacy of hepatitis B vaccination in dialysis patients as compared with those with normal renal functions.

Methods: This study was done on CKD stage 5 patients who were initiated on maintenance hemodialysis in a medical college hospital in Mangalore from January 2016 to June 2016. Patients less than 18 years of age; active hepatitis infection and those who completed or started on vaccination before initiation of dialysis were excluded. The patients were given hepatitis B vaccination 40 ug intramuscular on months 0; 1; 2 and 6 months. The antibody titres were measured 1 month after the completion of the schedule. Anti HBs levels by measuring the antibody titres using HEPALIZA microwell ELIZA test kit by J. Mitra & co. Pvt. ltd. Adequate response was defined as antibody titres >10 IU/ml and excellent response as titres >100 IU/ml.

Results: Response rates to vaccination was less in dialysis patients as compared to those with normal renal functions. 40% of our patients did not seroconvert after vaccination.

Conclusions: 40% of our patients did not seroconvert after vaccination. Further studies are required to see if good responders maintain protective titres longer than weak responders. There is also need to identify factors which are responsible for no response to vaccination.

25. An Analysis of Acute on Chronic Kidney Disease in a Sub-Urban Tertiary Care Centre

Venugopal Lakshminarayanan, Yuvaraja, S. Krishna Kumar, S. Sreedhar, R. Padmanabhan

SRM Medical College Hospital and Research Centre; Chennai; Tamil Nadu; India

Background: Acute kidney injury is very common in patients admitted in the ICU. We set to find the precipitating causes of AKI in CKD patients and their outcomes. Being aware of causative factors will decrease the morbidity and mortality.

Aim of the Study: To assess the prevalence of acute on CKD and to analyse the various precipitating cause of acute kidney injury in patients with CKD.

Methods: We have done a retrospective study in our Nephrology ICU and Ward for a period of 6 months from January to June 2017. Patients with CKD as proven by contracted kidneys by ultrasound or documented elevation of serum creatinine over 3 months with discharge diagnosis of AKI or elevation of plasma creatinine by 0.3 mg/dL and above or basic disease causing CKD ascertained from case records. Patients with plasma creatinine more than 5 mg/dL are excluded from the study.

Results: Patients between the ages 27 and 87 years are studied. Among 142 patients with Acute on CKD; 90 were male and 52 were female. Baseline creatinine of the subjects ranged from 1.6 to 5 mg/dL. We studied that increase in level of serum creatinine was from 0.3 to 9.0 mg/dL above the baseline. 72 patients were diabetic. The precipitating causes of AKI are as follows; Urosepsis (27); Sepsis (50); Cardio Renal Syndrome (60); GI Causes (11); Accelerated Hypertension (7); Hypokalemia/RTA (1); Malignancies (7); Obstruction (13); Snake bite (2) and Hyperurecemia (4). Prognosis: Among 142 patients 30 were needing hemodialysis; 5 patients expired; 9 patients went Against Medical Advice; 98 patients improved.

Conclusions: Acute on CKD forms 30% of total AKI admissions. Sepsis remains the leading cause of AKI in patients with CKD followed by medications and toxins. AKI reversed with treatment in a majority. The mortality is around 10% (if against medical advice is included as death).

26. Rituximab Treatment of Adult Patients with Resistant Primary Focal Segmental Glomerulosclerosis

Vineet Behera, Soumita Bagchi, Raj Kanwar Yadav, Sandeep Mahajan, Dipankar Bhowmik, Sanjay Kumar Agarwal

Department of Nephrology; All India Institute of Medical Sciences; New Delhi; India

Background: Primary Focal Segmental Glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome (NS) in adults with one third having an aggressive clinical course. Achieving remission of proteinuria is essential for renal survival. The treatment of steroid resistant FSGS in adults continues to be challenging. Rituximab (RTX) has been effective in steroid dependent FSGS to achieve steroid free remission. There is paucity of data about its efficacy in steroid resistant primary FSGS in adults.

Aim of the Study: To study the outcomes of rituximab as a treatment of adult patients with steroid resistant primary focal segmental glomerulosclerosis.

Methods: All adult patients with primary FSGS resistant to steroids who had received RTX therapy between June 2013 to May 2017 were included in the study. Steroid resistance (SR) was defined as no reduction in proteinuria after 16 weeks of adequate oral steroid therapy (1 mg/kg/day). Their clinical; laboratory and prior immunosuppression treatment details and outcome following RTX therapy were recorded.

Results: Twelve patients of steroid resistant-FSGS had received RTX during the study period. Mean age was 34.8±15.9 years [median-33.5 (19-81)] and 41.7% were males. The mean serum creatinine was 1.6±0.9 mg/dL; serum albumin was 2.2±0.8 mg/dl and proteinuria was 6.8±3.5 g/day before giving RTX. Other immunosuppression used in these patients without any response were: tacrolimus-11 (91.7%); mycophenolate mofetil-7 (58.4%) and cyclophosphamide-5 (41.7%). Eight patients received 2 doses of RTX (500 mg each); 3 patients received 3 doses and 1 patient received 1 dose. Three (25%) patients achieved partial remission and no response was seen in the remaining 8 (75%) patients. One patient developed chest infection and one developed mediastinal tuberculosis after RTX therapy.

Conclusions: Response to rituximab therapy in immunosuppression resistant FSGS is suboptimal. More studies are necessary to characterize further the dose; efficacy and long term effects of rituximab in FSGS.

27. Clinical Value of Indicated Repeat Biopsy in Lupus Nephritis

Joyita Bharati, Hari Prasad, A Raja Ramachandran, Manish Rathi, Aman Sharma, Ritambhra Nada, Kishan Lal Gupta

Postgraduate Institute of Medical Education and Research; Chandigarh; India

Background: Lupus nephritis presents with varied clinical and pathological manifestations. It is characterised by disease quiescence and flares. Although repeat biopsy in a flare/resistant disease is suggested in almost all guidelines; few conclusive studies have investigated its clinical value. We analysed the contribution of repeat biopsy in treatment decision and assessed various predictors of renal outcome.

Aim of the Study: To compare clinical and histopathological parameters of patients with lupus nephritis at initial and repeat renal biopsy. We also aim to determine factors affecting long term renal outcome.

Methods: Sixty-four patients who underwent repeat biopsy for clinical indications in between January 2012 to December 2016 were included. Various clinical and histological parameters at initial biopsy and repeat biopsy were compared. Logistic regression analysis was carried out to determine factors affecting long-term renal response (response at last/recent visit). Survival analysis was also done for renal and relapse-free survival. Renal relapse and response were defined based on KDIGO (Kidney Disease: Improving Global Outcomes) guideline. Renal survival was defined as the interval from the time of enrolment to end-point i.e. doubling of serum creatinine; end-stage renal disease (ESRD) or death.

Results: Repeat biopsy was done for relapse in 56% and for resistant disease in 44% of patients. Nine (17%) out of 52 patients with baseline proliferative histology converted to non-proliferative disease while 2/11 (18.2%) with non-proliferative lesion converted to proliferative disease. On repeat biopsy; endocapillary proliferation and fibrinoid necrosis decreased whereas glomerulosclerosis and interstitial fibrosis/tubular atrophy (IFTA) increased (P<0.001). After second biopsy; 84% of patients had their therapy changed. With a median follow-up of 38.6 months (IQR 22-76) from the initial biopsy; 75% patients were in remission and 6.5% needed renal replacement therapy at the last visit. The median renal survival of patients was 108 months with the probability of renal survival at 1; 2 and 5-year being 95%; 86% and 78%; respectively. Response to induction therapy; the presence of IFTA ≥25% and acute tubular necrosis (ATN) on first biopsy were independent predictors of long-term outcome.

Conclusions: Chronicity parameters increase on repeat biopsy irrespective of prior clinical response. Repeat biopsy determines the extent of histological chronicity. Clinical response to therapy after each biopsy and presence of IFTA ≥25% on the first biopsy are independent predictors of long-term outcome.

28. Assessment of Dietary Intake in a Group of Patients with Chronic Renal Failure on Haemodialysis

Eranga Harshani Silva, C M Wickramatilake, S Lekamwasam, L K B Mudduwa, R Ubayasiri

Faculty of Medicine; University of Ruhuna; Matara; Sri Lanka

Background: Malnutrition is common among patients with chronic renal failure (CRF) on regular haemodialysis (HD) and it leads to increased mortality and morbidity. Assessment of nutritional status plays a vital role in the long term management of dialysis patients. This; however; can be a daunting task since the indices of nutritional status are influenced by CRF related factors other than diet. Hence dietary assessment is vital in patients with CRF.

Aim of the Study: Aim of this study was to assess the adequacy of dietary intake in a group of patients with CRF on HD.

Methods: Forty two patients with CRF attending a Tertiary Care Centre in Southern Sri Lanka for routine haemodialysis were interviewed using a food frequency questionnaire which had been validated to Sri Lankans. Dietary intake during the last 30 days was assessed and analyzed using the Nutri - Survey software. Their height and post dialysis weight were measured and body mass index (BMI) was calculated. Since nearly all patients were supplemented with Ca; vitamin D and iron we confined our assessment only for nutrients which are not routinely supplemented. Data were analysed using descriptive statistics. Informed written consent was obtained from all the participants.

Results: Mean (SD) age of the group (total 42 and 31 men) was 46.2 (12.9) Ys. Mean (SD) BMI of the group was 21.6 (4.0) kgm-2. Twenty seven patients (64.3%) had BMI below 23 kgm-2 and 8 had BMI higher than 25 kgm2 (19.1%). Average (SD) energy intake was 1650.2 (591.8) kcal/day and 28 (66.7%) were consuming less than the recommended energy (35 kcal/kg/day) calculated for their ideal body weight according to the National kidney Foundation Kidney Disease Outcomes Quality; Clinical practice guidelines. Protein intake was below the recommended daily intake (RDI) (≥ 1.1 g/kg/day) in 35 (83%). Carbohydrate consumption was higher than the RDI (50 - 60%) in 41 patients (97.6%) and fat consumption was lower than RDI (25 - 35%) in 40 patients (97. 6%). Mean (SD) daily intake of dietary sodium; potassium; phosphorus and zinc were 1479.7 (877.5) mg; 1488.2 (581.8) mg; 943.5 (323) mg and 7.3 (2.8) mg respectively and 78.6%; 76.2%; 38.1% and 71.4% of them consumed the respective mineral lesser than RDI.

Conclusions: Dietary intake of energy; protein; fat; sodium; potassium; phosphorus and zinc are low in this group of CRF and well below RDIs. Significant amount of patients are underweight. It is important to address this aspect in the long term management of CRF patients.

29. Body Composition Monitoring and its Impact on Cardiovascular Morbidity in Dialysis Patients

Ashutosh Ojha, Arnab Chaudhary, Col. Muthukrishnan

Internal Medicine; Armed Forces Medical College; Pune; Maharashtra; India

Background: Water is an essential regulator in its internal environment and causes many physiologic derangement including fluid overload. In CKD it can also increase TNF-a; leading to inflammation; fibrosis; and cardiac dilation. By contrast; too much fluid removal can result in intra dialytic injury leading to a reduction in residual renal function; which aggravates fluid accumulation.

Aim of the Study: To find out the impact of the body composition on cardiovascular system on dialysis patients by using Bio Impedance Analysis (BIA).

Methods: This was a randomized case control study in which 50 case and 50 control patients were studied in 18 months. The Body water was assessed with Bio Impendence Assay with Body Composition Monitoring machine while in control group the same was assessed on weight gain; edema; history of breathlessness; Jugular Venous height and echocardiography.

Results: In our study; 65 males and 35 female patients were studied. Pre-dialysis Systolic Blood pressure was significantly higher in control group with P value<. 001. Post dialysis Diastolic Blood Pressure was significantly lower in cases compared to controls.

Conclusions: BCM by Body Impendence Analysis is a good tool to monitor fluid overload state and planning Ultra-filtration in ESRD patients.

30. Unemployment and Low Self-Esteem: Threat to the Quality of Life (QOL) of Dialysis Patients

Mohd Shah Alam, Rachana Jasani, Paras Dedhia, Virendra Gupta, Jatin Kothari, Shrirang Bichu, Viswanath Billa, Rajesh Kumar

Apex Kidney Foundation; Mumbai; Maharashtra; India

Background: Significant numbers of patients either lose or quit their jobs due to either comorbidities or physical; social and psychological stress. This not only makes them dependent for their medical expenditure but is also associated with low self-esteem and poor quality of life.

Aim of the Study: The primary aim was to assess% of patients quitting their jobs after the initiation of dialysis and correlate it with overall QOL. The secondary aim was to assess the reasons for quitting jobs.

Methods: This was a cross-sectional; multicenter study conducted on 275 dialysis patients. Patients were interviewed for their employment status and their quality of life (QOL) was assessed using Short form –36 questionnaires.

Results: Of the 275 subjects; 165 were males and 110 were females. Their average age was 50.9 ± 14.8 years. Average no of family members were 5.8 and no of earning members were 1.4. The average medical expense per month was Rs. 17630.8 ± 15024. Out of 275 patients; 79 were retired; 42 were employed and working after the initiation of dialysis and 26 were employed and left the working after initiation of dialysis and 128 were unemployed. The overall quality of life score of patients who were retired was 60.9; those who were employed after the initiation of dialysis was 74.4; that of patients who left the job after initiation of dialysis was 68.8 and that of patients who were unemployed was 62.8. The major reasons for quitting jobs were depression; illness; low self-confidence and esteem.

Conclusions: There is high prevalence of unemployment in dialysis population. QOL of patients with employment and the ones who continue working is superior as compared to that of the ones who quit working after the initiation of dialysis. Counselling sessions may play a key role in retaining employment.

31. Combined Fluoroscopy and Ultrasound Guided Transjugular Kidney Biopsy in Cirrhotic Patients

Suman Nayak, Amar Mukund, Shahnawaz Bashir

ILBS D1; New Delhi; India

Background: There is paucity of data on TJKB on safety and diagnostic yield from this part of world.

Aim of the Study: The purpose of this study is to describe the combined fluoroscopy and ultrasound guided technique for TJKB in cirrhotic patients and evaluate the safety and diagnostic yield of this method.

Methods: A retrospective review of 30 patients was done who underwent TJKB from June 2013 to June 2016 in our hospital. All the procedures were performed using fluoroscopy and simultaneous trans-abdominal ultrasound guidance. The data was analysed for number of pass taken; number of glomeruli in the tissue cores; adequacy of tissue core for histopathologic diagnosis; and incidence and severity of complications.

Results: The average number of pass per case was 3.6 (range 2 to 6). The total length of tissue cores ranged from 0.4 to 2.5 cm. The mean numbers of glomeruli per procedure on light microscopy were 6.7 (range 0 to 17). Diagnostic biopsy specimens were obtained in 26 (85%) out of 30 patients. Eleven patients had minor complications. One patient had haemoglobin drop of 2.1 mg/dl and required angio-embolisation and blood transfusion. No other major complications were recorded.

Conclusions: Fluoroscopy and ultrasound guided TJKB yield adequate tissue samples with lesser number of pass; reduced rates of complications in high risk patients having cirrhosis with coagulopathy.

32. Thrombotic Microangiopathy -Clinical Profiles and Outcomes

A T Maasila, T Dineshkumar, J Dhanapriya, R Sakthirajan, V Murugesan, N Malathy, T Balasubramaniyan, N Gopalakrishnan

Institute of Nephrology; Madras Medical College; Rajiv Gandhi Govt General Hospital; Chennai; Tamil Nadu; India

Background: Thrombotic microangiopathy is a clinicopathological condition characterized by thrombocytopenia; microangiopathic hemolytic anemia and renal failure. It is associated with intra luminal platelet thrombosis and a partial or a complete obstruction of the vessel lumina. Thrombosis involves the brain; kidney; heart and other vital organs. It can affect any age and both sexes. It is associated with severe renal failure if it is not diagnosed earlier.

Aim of the Study: To study the Clinico Pathological features and outcomes of Thrombotic microangiopathy.

Methods: Retrospective study conducted at Institute of Nephrology; RGGH; Chennai from June 2013 –August 2017. History; clinical features and relevant investigations were obtained from medical records. Patients with biopsy proven thrombotic microangiopathy with atleast three months of follow up were included in the study. Post transplant TMA were excluded.

Results: Fifty four patients were included in the study. 34 were females (63%) with male:female ratio 1:1.7. Mean age: 34.4 yrs (age group 13 yrs–63 yrs). Etiology: Obstetrics AKI 15 (28%); Malignant Hypertension-10 (18.52%); lupus nephritis-6 (11.1%); others -23 (42.6%). Clinical Presentation: 53 (98.15%) AKIN 3; 1 (1.85%) were AKIN 2. Among them 38 (70.37%) patients had thrombocytopenia at presentation; 21 (38.89%) patients had fragmented RBC seen in peripheral smear. All patients had elevated LDH. 18 (33.33%) patients had low C3; anti-CFH antibodies were positive in one patient. Associated biopsy features were cortical necrosis-21 (38.89%); collapsing glomerulopathy 1 (1.85%); lupus nephritis – 6 (11.115%); malignant hypertension-9 (16.67%). 50 (92.59%) required HD. 32 (59.26%) patients underwent plasmapheresis. Those patients who received plasmapheresis had better survival (31.25%) when compared to patients who do not underwent plasmapheresis (9.09%). Mortality in our study 8 (14.82%).

Conclusions: TMA is an important cause of pregnancy related AKI. Early initiation of plasmapheresis were associated with better survival. There was 14.82% mortality associated with TMA in our study.

33. A Rare Case Report of Acute Kidney Injury Due to Ciprofloxacin Crystal Nephropathy

Hardik Gajera, Tarun kumar Saha

Apollo Hospital; Jubille Hills; Hyderabad; Telangana; India

Background: Crystal induced acute kidney injury (AKI) is caused by the intratubular precipitation of crystals leads to obstruction and AKI. The cause is being drugs and one of them are fluroquinolones. Ciprofloxacin is a widely used fluoroquinolone for the treatment of infections. Ciprofloxacin is known to immune mediated interstitial nephritis and crystalluria; rhabdomyolysis; and granulomatous interstitial nephritis in Chronic kidney diseases; advance age; alkaline urine and high dose of drug.

Aim of the Study: Judicious use of ciprofloxacin (I.V/oral) in high risk patient.

Methods: Case report.

Results: 44 years male patient without any co morbidities; presented to us with history of Oligo-anuria and anasarca. He had received oral ciprofloxacin (500 mg BID) for seven days with cumulative dose was 7 gms for 2 weeks prior. His detail evalation are Hemoglobin-14.2 g/dl; total leukocyte count 9500 cells/mm3; platelets 2.2 lakhs/L; S. creatinine 7.6 mg/dl on admission which was 1.1 mg/dl ten days ago; blood urea 122 mg/dl; serum electrolytes were normal; calcium 9.2 mg/dl; uric acid 8.0 mg/dl; phosphorus 5.9 mg/dl; total proteins 6.6 g/dl; albumin 3.8 g/dl; and other liver parameters are normal. His urine analysis showed pH of 5.9 and bland sediment. Autoimmune workup was normal. He has been initiated on hemodialysis and later renal biopsy was done which shows needle-shaped crystals occupying the entire tubular luminal circumference which were birefringent under polarized light. He was improved after 10 days with supportive medication without steroid; proper hydration; regular dialysis.

Conclusions: Treatment is conservative and includes hydration with isotonic or hypotonic solutions and prevention of alkalinization of the urine.

34. Antibiotic Lock Therapy for Vascular Access Salvage: A Single Centre Experience

Amar Kulkarni, Mayuri Trivedi, Rajeev Soman, Jatin Kothari, Rasika Sirsat, Alan Almeida

P.D. Hinduja Hospital and Medical Research Center; Mumbai; Maharashtra; India

Background: Vascular access related infections are the major cause of mortality and morbidity for patients on hemodialysis and often the catheter needs to be salvaged due to lack of other available vascular sites. Antibiotic lock therapy [ALT] is an alternative for management of 'highly needed' infected haemodialysis catheters In this study; we describe our single centre experience of the spectrum of vascular access infections and catheter salvage with use of ALT.

Aim of the Study: To assess the efficacy of Antibiotic lock therapy (ALT) for HD catheter salvage in cases of Catheter related infections.

Methods: Prospective; observational study between 1st January 2016 to 31st March 2017. Consecutive Haemodialysis requiring patients with catheters as the vascular access clinically suspected to have catheter associated infections; were identified. Two sets of blood cultures were sent along with DTP and emperic i.v antibiotics and report specific ALT were used. Successful outcome was defined as ability to salvage the catheter for at least 30 days. Failure was defined as Inability to resolve the bacteraemia needing catheter removal during therapy (as confirmed by repeat Blood cultures after 72 hours of therapy) or persistence of colonization of the catheter tipor if the patient expired within 8 days of starting ALT.

Results: Of the 110 episodes of suspected CRBSI in a 13 month period (1st March 2016 to 31st March 2017); 41 were culture positive proven infections. Fungal infections were seen in 6 and gram-negative organisms in 28 episodes. Catheter salvage with ALT attempted in 24 cases; was successful in 14 instances.

Conclusions: In patients who have CRBSI with GN organisms; use of ALT along with systemic antibiotics; has a good catheter salvage rate. Further research is warranted to establish ALT as a standard of care for CRBSI/symptomatic colonisers.

35. Step by Step Video Demonstration of Basilic Vein Transposition

Himanshu Verma and DK Sinha Nephrologist

Varenyam Vascular - Day Care Vascular Service Providers; New Delhi; India

Background: Basilic vein (BV) is an under-utilised conduit for autogenous AV fistula in ESRD. Deep and medial location of basilic vein makes it inaccessible for dialysis puncture. Basilic vein transposition is a well known technique where basilic vein is harvested and transposed superficially and medially; connecting to brachial artery. We describe step by step technique of basilic vein transposition.

Aim of the Study: Step by step video demonstration of basilic vein transposition.

Methods: Technique: (1) Incision: Incision extends from the antecubital crease to the axilla. The dissection begins in the middle of the upper arm and proceeds distally. (2) Basilic vein harvest: Mobilization of the vein is carried proximally to its junction with the axillary vein. Venous tributaries are transfixed with fine silk suture and divided. Care is taken to avoid injury to the medial antebrachial cutaneous nerve; a sensory nerve that is draped over the BV. (3) Brachial artery exposure: The brachial artery is exposed proximally to its entry into the antecubital fossa. Exposure of the artery can usually be accomplished through the same incision used to mobilize the vein (4) Tunelling: A gently curving subcutaneous tunnel is created over the anterior upper arm. The basilic vein is brought through this tunnel to brachial artery. Care is taken to avoid twisting or kinking the vein during tunneling.

Results: Follow up: Sutures are removed in two weeks time. Follow up Doppler is must to evaluate swing point turbulence.

Conclusions: Basilic vein transposition is a valuable tool for patients with exhausted native AV access options. A step by step video demonstration will help trainees to understand the technique better.

36. Nutritional Status of Hemodialysis Patients at Lalitpur Unit of National Kidney Centre

Ruju Khadka, Nabin Basnet, Rishi Kumar Kafle

Sumeru Kidney Hospital; Lalitpur; Nepal

Background: Malnutrition is an predictor of mortality in hemodialysis patients. Nutritional status of each patient is adversely affected by various factors. The patients are often put on vigorous dietary restriction and are prone to under-dialysis. Nutritional assessment and monitoring is vital in such scenario. The tools for nutritional assessment are tedious to apply and often do not produce reproducible results. So; majority of the patients are exposed to malnutrition without proper monitoring.

Aim of the Study: This study aims to assess the nutritional status of chronic hemodialysis patients at a single centre and factors affecting it with various nutirional assessment tools.

Methods: Nutritional evaluation was done in a cross-sectional observational study. Patients who gave voluntary consent to interview; examination; blood tests; and body composition monitoring were included in the study. They were assessed using dietary recall; anthropometric measurement; biochemical parameters; subjective global assessment; and body composition monitoring. With the tools; these patients were categorized as normal nutrition; mild to moderate malnutrition; and severe malnutrition.

Results: Seventy-five patients were enrolled in the study and nutritional tools applied to assess and categorize the patients. They were of 50.2 ± 1.9 years of age with male outnumbering the female. Most of the patients claimed to follow the prescribed dietary advice. 9.7% however admitted deviation from the advice. Only 12.5% were vegetarian in the study sample. Malnutrition was found to be prevalent in 52.78% of the sample. Age and sex significantly predicted risk of malnutrition. Female were more prone to malnutrition with 62.1% of the female patients falling into category of malnutrition. Elderly patients though served higher number of meals per day compared to younger patients had higher prevalence of malnutrition.

Conclusions: Hemodialysis patients are at risk of malnutrition and overseen because of easy to apply nutritional assessment tools. Subjective Global Assessment and Body Composition Monitor are good tools for clinical purpose. Malnutirion was prevalent and female and elderly population are at higher risk.

37. Clinical Profile of Children Presenting with Bed Wetting to a Tertiary Care Centre

R Dev, K Anand, K Pai, R Mazahir, P K Pruthi

Department of Pediatrics; Division of Pediatric Nephrology; Institute of Child Health; Sir Ganga Ram Hospital; New Delhi; India

Background: Enuresis is defined as nearly complete evacuation of the bladder at a wrong place; time at least twice a month after 5 years of age. It can be divided into primary or secondary and monosymptomatic or nonmonosymptomatic. The evaluation of bed wetting requires a detailed history; physical examination and investigations. Treatment includes counseling; alarm therapy and drugs. The aim of the study is to identify the clinical profile of children presenting with bed wetting at a tertiary care centre.

Aim of the Study: To identify the clinical profile of children presenting with complains of bed wetting to a tertiary care center.

Methods: All patients presenting with complains of bed wetting in the pediatric OPD or IPD of Sir Ganga Ram Hospital; New Delhi between the age group of 5 years- 18 years were included in the study. Data regarding symptoms; signs; evaluation and response to therapy was collected. The study was conducted between January 2016 to July 2017.

Results: Total patients enrolled were 150.58% were males. 90% had primary and 10% had secondary enuresis. 21% had MSE; 79% had NMSE. In MSE; 50% were males.68% had a positive family history of bed wetting. There was no history of urinary tract infection (UTI) in any patient. Conservative management was offered to all. Desmopressin was used in 93% patients (response rate was 89%; recurrence rate was 10%). Alarm therapy was used in 20% patients. In NMSE; 61% were male.40% had urgency; 33% had hesitancy; 67% patients had dribbling. 66% patients had history of UTI.5% had a tuft of hair over lumbosacral area; 16% had a surgical scar of meningomyelocele repair/tethered cord release; 11% had lower limb weakness and a patulous anus. 7% patients had a history of renal calculi. 69.5% patients had neurogenic bladder; 2.5% had nonneurogenic neurogenic bladder and 28% had overactive bladder. 14% had vesicoureteric reflux. Anticholinergics; alpha blockers and desmopressin were used in 88%; 12% and 8% patients respectively.

Conclusions: (1) NMSE was more common than MSE (2) Bed wetting was more common in males than females especially NMSE (3) Neurogenic bladder was the most common cause of NMSE (4) Desmopressin was found to be highly effective in treatment of MSE with a low relapse rate.

38. Acute Kidney Injury: Experience from a State Run Tertiary Care Centre in Southern India

S R Patil, Umesha L

Institute of Nephro-Urology; Victoria Hospital Campus; Bengaluru; Kernataka; India

Background: AKI (Acute Kidney Injury) constitutes approximately 5-7% of hospital admissions and up to 30% of admissions to intensive care units. Large referrals to dialysis units suggest that the condition is more common in India.

Aim of the Study: To study clinical profile of AKI patients presenting to tertiary care hospital in Southern India.

Methods: We conducted a prospective longitudinal observational study between July 2012 and July 2017. AKI was diagnosed as per Acute Kidney Injury Network (AKIN) criterion. Renal biopsy was performed if a patient was oliguric or dialysis dependent at the end of 3 weeks.

Results: The total of 712 patients were studied. The mean age of AKI study group was 39.8 ± 14.48 years and male to female ratio 0.9:1. Among the medical causes of AKI; the sepsis related AKI (30%); obstetric AKI (22.5%); acute gastroenteritis (15.5%); drugs and toxin induced AKI (11.03%); parasitic infections (7.6%) and unknown AKI (13.37%).

Conclusions: Sepsis related AKI followed by pregnancy-related AKI was the the most frequent etiological factors for AKI. Multi-organ failure; puerperal sepsis were accounted for the majority of mortality in AKI. AKI among these instances are largely preventable.

39. Exercise-Induced Acute Kidney Injury Due to Type 2 Renal Hypouricemia

Nithyashree Nandagopal, Mayur Kapuria, Saravanan Margabandhu

Apollo Hospitals; Chennai; Tamil Nadu; India

Background: Hereditary renal hypouricemia is a genetic disorder characterized by defective renal handling of uric acid that predisposes the affected individual to exercise-induced acute kidney injury and is classified into 2 types depending on the genetic mutation. However; renal hypouricemia with exercise-induced acute kidney injury (AKI) is uncommon.

Aim of the Study: We report a case of a 23-year-old previously healthy male with exercise induced AKI due to type 2 renal hypouricemia.

Methods: He presented with vomiting; bilateral flank pain and low-grade fever following unaccustomed physical exertion (Climbing mountain carrying 20 kg weight). He was non-oliguric and his serum creatinine was 7.2 mg/dl); Urine routine showed trace protein and active sediments. Ultrasound abdomen showed normal sized kidneys. CPK level was normal. His serum uric acid was 1.2 mg/dl. The fractional excretion of uric acid was increased (FEUA of 150%).

Results: He was managed conservatively with intravenous hydration. He had complete recovery of renal function. He had persistent uricosuria and hypouricemia even after resolution of AKI. Genetic testing revealed a homozygous mutation in SLC2A9 gene that encodes for the GLUT9 transporter. He was commenced on Pyrazinamide. His sibling was screened for hypouricemia. He had normal serum uric acid level and normal fractional excretion of uric acid.

Conclusions: Exercise induced AKI is not always due to rhabdomyolysis. Hereditary renal hypouricemia should be suspected in the presence of AKI with hypouricemia. Also; prompt screening of family members of the affected individuals will lead to early diagnosis and may help prevent AKI episodes.

40. An Unusual Presentation of Filarial Nephropathy

Arvind Krishnakumar, Anna T Valson, Neelaveni Duhli, Anjali Mohapatra, Shailesh Kakde, Vinoi George David, Suceena Alexander, Shibu Jacob, Santosh Varughese

Christian Medical College; Vellore; Tamil Nadu; India

Background: Filarial organisms are known to cause immune complex mediated glomerular disease. Here we present a case of glomerulopathy; possibly due to direct mechanical damage.

Aim of the Study: To describe an unusual presentation of filarial infection.

Methods: A 55 year old gentleman with no comorbidities; presented with fever and renal dysfunction. Evaluation showed active urinary sediments; subnephrotic proteinuria and renal dysfunction with a serum creatinine of 1.6 mg%. He was also detected to have microfilariae in the blood; and was initiated on diethylcarbamazine. A renal biopsy was performed to evaluate for the cause of renal dysfunction.

Results: Renal biopsy was reported as a proliferative glomerulonephritis with intracapillary microfilarial organisms. His proteinuria and renal dysfunction improved with treatment with diethylcarbamezine.

Conclusions: The unusual feature in the patient was that he had circulating intracapillary microfilariae; suggesting the possibility of both direct damage as well as immune mediated damage of the glomeruli.

41. The Impact of Early BK Viruria Surveillance on Renal Allograft Outcome at 1-Year

M Vijay, R A Annigeri

Apollo Hospitals; Chennai; Tamil Nadu; India

Background: BK virus nephropathy (BKVN) is an important cause of graft dysfunction during the early period after renal transplantation. BKVN is generally preceded by BK viruria and intervention based on the surveillance of BK viruria may prevent BKVN.

Aim of the Study: To study the impact of early BK viruruia surveillance on 1 year renal allograft outcome.

Methods: We monitored BK viruria at 8 to 12 weeks after renal transplantation in 33 renal allograft recipients. BK viruria was determined by polymerase chain reaction (PCR) method. When significant BK viruria was detected de-escalation of immunosuppression was done. The data on age; gender; ischemia time; HLA match; delayed graft function; induction immunosuppression; type of immunosuppression; acute rejection episodes; serial serum creatinine and estimated GFR (eGFR) using 4 variable MDRD equation over a period of 12 months was collected. The end point was eGFR and allograft survival at 12 months.

Results: Mean age of study population was 41.24 ±11.8 years and 26 (79%) were male. Twelve (36%) transplant recipients had BK viruria within 3 months after transplant. There was no significant difference in age and sex distribution; type of donor; acute rejection episodes; serum creatinine and eGFR at 1 month and 12 month; and change in eGFR (ml/min/1.73 m2). The eGFR at 1 month was 67.2 ± 18.5 and 73.6 ± 14.8 in BK viruria and non-BK viruria groups respectively (p=0.29). The eGFR at 12 months was; 60.04 ± 25.7 and; 67 ± 15.2 in BK viruria and non-BK viruria groups respectively (p=0.36). The change in eGFR in BK viruria and non-BK viruria groups was -3.53 ± 19.1 and -4.7 ±11.8 respectively (p=0.84). There was no graft loss and death in both groups.

Conclusions: BK viruria was observed in 36% of renal transplant recipients within first 3 months. There was no difference in graft survival or eGFR at 12 months in patients with and without BK viruria. Thus; surveillance for BK viruria after renal transplantation results in similar allograft outcomes.

42. Outcomes of Radiocephalic Arteriovenous Fistula by Nephrologists at a Tertiary Care Center from North India

T Venkatesh, Manas Ranjan Patel, Dharmendra Bhadauria, Amit Gupta, Anupama Kaul, Narayan Prasad

Department of Nephrology; SGPGIMS; Lucknow; Uttar Pradesh; India

Background: Arteriovenous fistula (AVF) is considered as gold standard access for maintenance hemodialysis. Due to increasing burden of ESRD and late referral to nephrologists; it's important for nephrologists to be involved in creation of AV fistulas.

Aim of the Study: This study was done to assess the outcomes of AV fistula surgeries done by nephrologists at a tertiary care institute from North India.

Methods: This was a retrospective study that included all radio-cephalic arteriovenous fistulae; which were performed by nephrologists between November 2015 and January 2017. AVFs were performed in patients whose duplex ultrasonography revealed both arterial and venous diameter of at least 2 mm. Information was obtained regarding age; sex; dialysis status; basic disease; comorbidities; lipid profiles; mineral bone disease parameters and were correlated with the various outcomes. We have also collected information regarding long term outcomes like survival; thormbosis; stenosis and the need for interventional procedures.

Results: We had included 500 patients; out of whom 412 (82.4%) were males; 108 (21.6%) were diabetics and 477 (95.4%) were hypertensive. Mean age of patients was 39 years (14-84 years). Left RCF was done in 469 (93.8%) patients. Only 63 (12.6%) fistulas could be performed prior to initiation of renal replacement therapy. Eighty three (16.6%) patients had primary failure. Among the remaining 417 patients without primary failure; 31 (7%) had secondary failure. Among the remaining 386 patients; 83 (21.5%) had undergone renal transplant with a functioning fistula; while 84 (22%) patients expired with a functioning fistula. Mean survival among the patients without primary failure was 11 months (1-21 months). Out of 417 patients; 17 patients (3.4%) underwent angioplasty due to stenosis or thrombosis. On univariate analysis; presence of diabetes predisposed to primary failure; which was statistically significant.

Conclusions: None of the factors determined the occurrence of secondary failure; occurrence of stenosis or thrombosis.

43. Pulmonary Phaeohyphomycosis in Renal Transplant Recepient – A Rare Occurrence

Rohit Patil, K C Prakash, V Ramasubramanian

Apollo Hospitals; Chennai; Tamil Nadu; India

Background: Renal transplant recipients are at a high risk for developing invasive fungal infections. Phaeohyphomycos is a collective term for cutaneous; subcutaneous; and systemic disease caused by dematiaceous fungi. Here we present a case report of a patient infected with cladophialophora species of pigmented fungi.

Aim of the Study: Case report of pulmonary phaeohyphomycosis in renal transplant.

Methods: Case Report.

Results: We report a case of pulmonary phaeohyphomycosis after 2 years of deceased donor renal transplantation. He presented to us with fever; dry cough. CXR PA; HRCT thorax; bronchoscopy and bronchoalveolar fluid were inclusive for diagnosis. Initially he improved with intravenous antibiotics but readmitted with persistent fever and breathlessness. He was intubated and lung biopsy was done which showed fungal granuloma and increased CMV quantitative PCR. Fungal culture grew cladophialophora species of pigmented fungi. All immunosuppressant were stopped and started on voriconazole and ganciclovir. He responded significantly to antifungal and antiviral treatment. He was extubated and discharged with antifungal; antiviral and tablet prednisolone. He was having normal renal function at discharge.

Conclusions: Here we present a rare fungal infection with cladophialophora species of pigmented fungi confection with CMV. Withholding the immunosuppression and prompt anti fungal treatment form the cornerstone of treatment.

44. Day Care Renal Biopsy – A Single Centre Experience

S Jasuja, A Bahl, SPuri, G Sagar

Indraprastha Apollo Hospital; New Delhi; India

Background: Renal biopsy forms the corner stone for diagnosis; prognostic assessment and guidance of therapy of renal diseases affecting native and transplant kidneys. Our post procedure observation period has been on an average for 3-4 hours with low complication rate. Various articles have been published over time about the optimum period of observation post biopsy.

Aim of the Study: We attempted this study as we have a large footfall with over 100 biopsies being performed annually. A short in hospital stay period was studiedc at no additional risk to the patient.

Methods: Prior to the procedure CBC; RFT; BT/CT; PT/INR were measured using standard methods in all patients. Antiplatelets were stopped 3-5 days prior to the procedure and LMWH was prescribed if indicated. Target BP was <140/90. A prior USG confirmed biopsiable kidneys. With pt in prone position automated spring loaded biopsy gun with 10 cm or 15 cm with 18 G needle were used in real time USG guided kidney biopsy performed from lower pole of left kidney. The procedure local pressure was applied with gauze and elastic bandage. The patients were made to lie strictly supine for next 2 hours with timed monitoring of vitals. Once the patient passed clear urine 2 times; he was discharged with advice for avoidance of strenuous physical activity and bending at least for next couple of days. Check ultrasound was performed in case of hematuria or pain abdomen only.

Results: A total of 511 biopsies were done-OPD 263 & IPD 248. Minor bleeding in patients post biopsy occurred in 0.9% (5/511) and major bleeding requiring blood transfusion occurred in 0.3% (2/511) both were ipd pts. We did not have any episode of late bleed. Perirenal hematoma was confirmed in 1.3% (7/511) pts of which 0.7% (2/263) were opd pts & 2% (5/248) ipd pts which were all graft biopsies. 2 of the ipd pts required evacuation of hematoma. We had one case of AVF formation 0.001% (1/511) in a native kidney ipd biopsy which was managed conservatively with multiple blood transfusions due to severe hematuria. We performed biopsy on 2 horsehoe kidneys as OPD procedures with no complications.

Conclusions: Kidney Bx is safe as a daycare procedure. Complication rates are comparable to available data. Short staysaves offworkhours & is economicallybeneficial. Pts are less anxious & a repeat biopsy is not deterring. Performing biopsy under real time ultrasound ensures less pain as fewer passes are required.

45. Outcome of Primary Focal Segmental Glomerular Sclerosis (FSGS) After Renal Transplantation in Adult

R K Yadav, SK Agarwal; D Bhowmik; S Mahajan; S Bagchi

All India Institute of Medical Sciences; New Delhi; India

Background: FSGS is a common cause of nephrotic syndrome leading to ESRD in adults. It has been reported as having relatively poorer transplant outcomes largely because of disease recurrence. The FSGS recurrence in allograft is in range of 20 to 52%; frequently followed by graft loss in up to 60% patients. There is paucity of data about outcome of FSGS after renal transplantation in India.

Aim of the Study: To assess transplant outcome in patients with primary FSGS.

Methods: Retrospective Analysis of medical records of all allograft recipients of the institute were done from May; 1984 to July; 2017. Patients with primary FSGS as basic disease were included in the study. The patients were followed as per department protocol and characteristics including patient age; gender; HLA matching; donor age; donor source; renal function test; proteinuria level; infection episode; rejection events; progression; recurrence of FSGS; graft loss and patient death were recorded.

Results: 2564 patients received renal transplant in the study period; of which 33 (1.23%) patients had primary FSGS. The median follow was 45 (01-198) months after transplantation. The patient survival was 96% (95 CI: 77.9-99.1) and 65% (95 CI: 41.8-81.2); death- censored graft survival was 100% and 90% (95 CI: 50.8-98.6) and graft survival (non- censored for death) was 96.5% (95 CI: 77.9-99.5) and 84% (95 CI: 63.3-93.9) at one and five years respectively. The five (13%) patients developed significant proteinuria (2030 to 8400 mg/day); of which only two (6%) had recurrent FSGS after 34 months of transplantation (partially responded to plasmapheresis and rituximab); rest have transplant glomerulopathy. There was no association between graft and patient survival with age; gender of patient; donor age; donor source; HLA mismatching; induction; tacrolimus vs cyclosporine; post-operative ATN; acute rejection; tubercular; CMV; HCV and urinary tract infection and recurrent GN.

Conclusions: FSGS recurrence and resulting graft loss after kidney transplantation was not so common in the present cohort.

46. A Complicated Case of Central Diabetes Insipidus

Prakash Sharbidre, Girish Hiregaudar, Vaheed Shikalgar, Shriya Gadve, Madhura Joshi, Sampat Chougule

Apple Saraswati Multispeciality Hospital; Kolhapur; Maharashtra; India

Background: We present a case of a patient with diabetes insipidus who landed up with dangerous hypernatremia due to fluid deprivation in the perioperative period. Managed with hypotonic fluids and desmopressin. Imaging studies suggestive of central DI.

Aim of the Study: This study highlights the approach to a patient with polyuria. Also the hazards of water deprivation in a patient with DI & the challenges faced while managing such patients is discussed.

Methods: The story lies in two parts. A 55 yr female hypertensive who presented with polyuria with creatinine 0.9 mg/dl; sodium 149 mEq/L; potassium 3.7 mEq/L. Serum osmolarity 305 mOsm/L & urine osmolarity 66 mOsm/L. Emperically started on desmopressin nasal spray 10 mcg nasal puff twice a day. To which she responded & was kept on one puff at night. Pt lost to follow up & landed with a surgeon & underwent a cystoscopy. The perioperative fluid restriction lead to dangerous raise in sodium levels to 197 mEq/L. Pt was referred back to us. This was managed by hypotonic fluids & desmopressin spray. The fluid therapy was guided by the water deficit formula & the formula developed by Adrogue & Madias. The high sensitivity of patient to desmopressin by significant drop in urine output lead to wide intraday fluctuations in sodium levels was managed with small aliquot infusions of 3% saline. Pituitary MRI revealed hypointensity signals in posterior pituitary. Pt remained drowsy & quadriparetic.

Results: During the second presentation the patient presented to us with severe hypernatremia after more than 48 hrs and hence was chronic hypernatremia. This necessitates to reduce sodium by no more then 10-12 mEq/L/day. The sodium was gradually reduced from 197 mEq/L on day 1 of admission to 137 on day 6. Despite all the precautions while correcting hypernatremia the sodium levels often fail to obey the currently available rules of correction. The urine output of thee patient reduced to approx 1.6 L/day by day 7. Patients sensorium improved to some extent but was having flaccid quadriparetic. MRI revealed extrapontine myelinolysis. The hypointensity signals in posterior pituitary and the response to desmopressin confirmed the diagnosis of central DI. The patient was shifted to higher institute after correcting hypernatremia. Despite correction of hypernatremia within permissible limits patient developed flaccid quadriparesis.

Conclusions: This is a case of Central diabetes insipidus presenting in adulthood probably idiopathic. Perioperative fluid restriction can lead to life threatening hypernatremia. Managing such severely chronic hypernatremic is a challanging task. Osmotic demyelination can develop even after gradual correction.

47. Analysis of Graft Biopsies in Aboi Renal Transplant

Pranaw K R Jha, Ashish Nandwani, Rajan Duggal, Shyam Bansal, Ajay Kher, Sidharth Sethi, Reetesh Sharma, Manish Jain, Dinesh Bansal, Dinesh Yadav, Vijay Kher

Fortis Escorts Hospital; Medanta - The Medicity; Gurgaon; Haryana; India

Background: ABO incompatible (ABOi) transplant is the only option left for patients with blood group incompatible donors who do not have suitable pair available for paired kidney exchange. The reports on graft biopsy experience in ABOi renal transplants are far and few. Present study looks at the biopsy findings in ABOi renal transplants.

Aim of the Study: To retrospectively analyze renal biopsies in ABO incompatible renal transplantation.

Methods: A retrospective analysis of all the biopsies performed in ABOi renal transplant patients at the center was done. Biopsy reports were accessed through hospital database. Initially at our center protocol biopsies were done in ABOi patients at 3 months. After first seven transplants we stopped doing protocol biopsies. Subsequently graft biopsies were done only for indication such as graft dysfunction (acute or chronic); worsening proteinuria with or without active sediment.

Results: From November 2011 to August 2017; 63 ABOi renal transplants were done. Median follow up period was 30 (1-68) months. Total 34 biopsies were done in 30 patients. There were 7 protocol biopsies of which 6 were normal and one showed borderline cellular rejection (BCR). There were 26 indication biopsies. 20 biopsies were done for acute graft dysfunction; of which 6 showed acute cellular rejection (ACR); 1 showed BCR; 4 showed antibody mediated rejection (AMR); 5 showed acute tubular necrosis (ATN); one CNI toxicity and cortical necrosis each and 2 showed thrombotic microangiopathy (TMA). One TMA was CNI induced and other one was idiopathic. Five biopsies were done for chronic graft dysfunction of which 2 showed IFTA; 2 showed chronic AMR while one showed TMA. One patient biopsied for nephrotic range proteinuria and active sediment had C3 glomerulopathy on biopsy. C4d was positive in 65% (n=22) of the biopsies. Of these; AMR was seen in 5 biopsies (4 acute and one chronic).

Conclusions: TMA was one of the most common histopathological findings. All the AMRs were associated with TMA. C4d positivity was seen in majority of the patients even in the absence of antibody-mediated rejection suggesting accommodation.

48. A Retrospective Analysis of the Clinicopathological Attributes and Outcome of the Spectrum of Monoclonal Gammopathy of Renal Significance (MGRS) in the Department of

R V Deepthi, Vinoi George David, Shibu Jacob, Anjali Mahopatra, Suceena Alexander, Anna T Valson, Kakde Shailesh Tulsidas, Santhosh Varughese, V Tamilarasi

Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India

Background: The term monoclonal gammopathy of renal significance groups patients who have renal disease secondary to monoclonal immunoglobulin secreted by a nonmalignant B-cell clone. As per the new classification of MGRS; the two major groups are based on renal biopsy findings; depending on whether the fibrils are organized or non- organized. This spectrum of renal diseases clinically presents with proteinuria; hypertension and renal failure.

Aim of the Study: To describe the clinical spectrum; biochemical abnormalities and renal pathological lesions in patients with MGRS and to analyze the outcome of the different spectrum of disorder between 2010 to April 2017. The spectrum of disorders included were Primary amyloidosis Membranoproliferative GN with immunoglobulin or light chain deposition; Fibrillary GN; Cryoglobulinemic GN; C3 glomerulopathy; Immunotactoid GN; Monoclonal immunoglobulin deposition disease and proliferative GN with immunoglobulin deposition.

Methods: Patients in whom MGRS was diagnosed was identified from the departmental histopathology database. Retrospective data was collected on the renal and extra renal clinical manifestations; biochemical parameters; complications; treatment received and response to treatment. The extent of renal deposition of immunoglobulins and light chains was done by immunoflorescent analysis of renal biopsy specimens. The details of evaluation for a plasma cell dyscrasia and lymphoproliferative disorder was collected with respect to bone marrow examination; skeletal survey; serum electrophoresis; immunoglobulin assay; serum free light chain assay and kappa lamba ratio. Organ involvement was classified according to the international amyloid consensus criteria in those patients with AL amyloidosis; light chain or heavy chain deposition disease. Different modalities of treatment received for the varied conditions were reviewed and response to the same assessed.

Results: To describe the clinical spectrum; biochemical abnormalities and renal pathological lesions in patients with MGRS and to analyze the outcome of the different spectrum of disorder between 2010 to April 2017. The spectrum of disorders included were Primary amyloidosis Membranoproliferative GN with immunoglobulin or light chain deposition; Fibrillary GN; Cryoglobulinemic GN; C3 glomerulopathy; Immunotactoid GN; Monoclonal immunoglobulin deposition disease and proliferative GN with immunoglobulin deposition.

Conclusions: Diagnosis of MGRS relies on renal biopsy that demonstrates the effect of the monoclonal gammopathy on the kidney. The heterogeneity of the MGRS spectrum is evident in the varied clinical presentation; management and outcome of this group of disorders.

49. Clinicopathological Features and Risk Factors Analysis of IgA Nephropathy Associated with Acute Kidney Injury: A Single Centre Retrospective Study

Bishal Agarwalla, M Sharma, Bishal Agarawalla, A K Barman, P J Mahanta, S Kakati, B D Medhi, P Doley, P Bordoloi, G Pegu, H Das, A Mahanta, M Parry, H Jeelani

Guwahati Medical College and Hospital; Guwahati; Assam; India

Background: The prevalence of AKI in IgAN varies widely because of underreporting; regional disparities; and differences in definition. Understanding the epidemiological features and the associated risk factors would help greatly in identification of AKI in IgAN. Previous studies focused more on macroscopic hematuria related AKI rather than clinical and pathological risk factors.

Aim of the Study: The aim of this study is to investigate the distinctive clinico-pathological characteristics of AKI in IgAN and identify the possible risk factors for AKI in IgAN.

Methods: This study was hospital based retrospective analysis of clinico pthological data of IgAN. The study was conducted at department of nephrology; GMCH; Assam; from the period of January 2012 to December 2015. A total of 169 patients who met the inclusion/exclusion criteria were included in the study. Patient data (clinical/demographic and laboratory data including renal biopsy) was collected and was analysed to assess the risk factors for AKI in IgAN. For the purpose of analyses the patients were divided into two groups; AKI (n=28) and non-AKI group (n=141).

Results: 28 patients out of 169 developed AKI. The prevalence of AKI in IgAN patients in our centre was 16.5% (28/169). Most AKI patients were older aged; male (19/28); hypertensive; hyperlipidemic; had pre-existing impaired kidney function; and higher serum creatinine; serum uric acid and proteinuria; with lower serum albumin and hemoglobin (p<0.05). Use of herbal medication was also significantly more common in AKI group (p<0.05). Pathological features; like crescents (both cellular and fibrocellular) and interstitial fibrosis/tubular atrophy were also more severe in AKI group (p<0.05). In multivariate logistic regression analysis; we found that older age; male gender; malignant hypertension; proteinuria; cellular and fibrocellular crescent; glomerular sclerosis were possible risk factors for AKI.

Conclusions: Prevalence of AKI in IgAN is not as uncommon in North-Eastern India as previously thought and knowledge of risk factors for AKI can help in early identification of at risk individuals.

50. Systemic Fungal Infections in Renal Transplant Recipients

Mamidi Varun, E Indumathi, S Manikantan, E Ram Prasad, M Jayakumar

Sri Ramachandra University; Chennai; Tamil Nadu; India

Background: Invasive fungal infections (IFI) are a significant and often lethal problem in transplant patients. The high rates of mortality owing to fungal infections render prevention; early diagnosis and treatment imperative in immunosuppressed patients.

Aim of the Study: To estimate the incidence; outcome of systemic fungal infections in renal transplant recipients in a single centre from South India and to identify the main fungal agents.

Methods: This was a retrospective study of invasive fungal infections in renal transplant recipient reported in our hospital over a period of four years on 280 renal transplant patients.

Results: IFI was diagnosed in 26 (9.2%) patients on immunosuppression; with males 18 (69.2%) with mean age 36.57±11.9 years. 17 (65.3%) received induction therapy. 11 (64.7%) basiliximab; 6 (35.2%) anti thymocyte globulin. All patients received triple immunosuppression. Candida was the commenst pathogen seen in 15 (57.6%) cases. Mucormycosis (4 cases; 15.3%); Aspergillosis (1 case; 3.8%); Histoplasmosis (1 case; 3.8%); Fusarium solani (1 case; 3.8%); Cladophialophora carrionii (1 case; 3.8%); Cryptococcus (1 case; 3.8%); Fungal ball (2 cases; 7.6%). Sites of infection were GI tract (10 cases; 38.4%); urinary tract (4 cases; 15.3%); respiratory tract (4 cases; 15.3%); CNS (1 case; 3.8%); leg ulcer/abcesses (3 cases; 11.5%); others (3 cases; 11.5%). In all cases incidence was seen after 6 months. 6 out of 26 patients died (23% mortality). Eight patients were diabetic; 7 had superadded cytomegalovirus infection; 9 had bacterial infections.

Conclusions: In our centre; IFI incidence more in patients who received induction. Candida was the most commen pathogen. GI tract being the commenst site of infection. Diabetes and infections were added risk factors. Most of the patients recovered. Hence; prevention; early diagnosis and management is necessary.

51. Study of Prevalence of MICA Antibodies in Patient with CKD Stage V During Pretransplant Evaluation

R Ritesh, G Sagar, A Bahl, S Puri, M Chaudhry, S N Mehta, S Guleria, V Rajkumari, S Jasuja

Departments of Nephrology; Immunology and Transplant Surgery; Indraprastha Apollo Hospital; New Delhi; India

Background: Renal transplantation is the treatment of choice for patients with end-stage renal disease. The rejection being strongly associated with HLA antibodies; some 11–20% rejections are without HLA antibodies. Furthermore; hyperacute rejection can occur in the absence of HLA antibodies; thus implicating other non-HLA alloantigens [5; 6] including the MHC class I–related chain A (MICA) may have role in both acute and chronic antibody mediated graft dysfuction.

Aim of the Study: We studied the prevalance of MICA antibodies during prestransplant evaluation.

Methods: The study included 45 patient with CKD stage V which were planned for live related renal transplant. During their pre transplant evaluation we performed LUMINEX based MICA antibody testing in addition to CDC cross match and DSA antibody test.

Results: In our study we found the prevalance of MICA antibody of 15.5 percent (7/45). 3 out of 7 patient had history of blood transfusion in past (42.8 percent). Out of 7 mica positive 6 patient underwent renal transplant at our centre after pretransplant desensitisation which included injection rituximab and plasmapheresis (2 session). There was not a single event of antibody mediated rejection in any of the six patient in mean follow up period of six month.

Conclusions: There is significant prevalance of Mica antibodies in Ckd patient; presence of which may hamper the short and long term graft survival. Pretransplant desensitisation anti CD antibody (rituximab) and plasmapheresis may be good strategy in such patients which me improve graft survival.

52. Maintenance Hemodialysis for HIV Positive Patients: Experience from A Dedicated HIV Hemodialysis Centre

Pankaj Jawandhiya, Deepa Usulumarty, Ganesh Sanap, Jatin Kothari, Rajesh Kumar, Shrirang Bichu, Parag Tilve, Viswanath Billa

Apex Kidney Care – Sunshine Dialysis Centre; Mumbai; Maharashtra; India

Background: Kidney disease is a frequent complication in HIV patients; also blood related HIV transmission can occur in ESRD patients on dialysis. Transmission rate of HIV by needle stick injury is only 0.3% as compared to HbsAg patients; which is quite high at 6%-30%. There is significant social stigma regarding dialysis of HIV patient and hence maintenance hemodialysis options for HIV positive patients are limited.

Aim of the Study: The experience of providing maintenance hemodialysis services to HIV positive patients.

Methods: We studied 38 HIV positive patients; who have been on maintenance hemodialysis at a dedicated HIV positive hemodialysis centre. All patients are dialyzed with single use disposables. The staff at this centre works with personal protective equipment. We studied their infection rates; hospitalisation rates; biochemical and clinical outcomes; CD4 count; HIV RNA viral load since initiating treatment at this centre.

Results: Total number of patients were 38 (30 males & 8 females). Twelve patients expired over 18 months; 1 lost to follow-up & 2 recovered from AKI on CKD. Mean age was 50+9.6 years. 17 patients (44%) continued to be on employment while on dialysis; 5 had retired & the rest were unemployed.82% patients were taking ART;Mean duration was 87±62 months. The dialysis frequency was 3/week for 55% patients & 2/week for rest. Out of the 26 alive ones; 12 needed hospitalisation over the past 18 months;mean days of stay being 4.04+7.28. There were nine episodes of infection in 7 patients; 4 were line related; 2 tuberculosis and one viral fever. The change in key variables from the time the patients initiated on HD at this centre to current values was a mean rise in Serum Albumin of 0.3+0.7; Haemoglobin drop of -1+1.8; and the dry weight decrease of -0.6+ 4.4 kg. For 13 patients whose data was available; the viral load was undetectable; others had mean load of 1610 copies/ml.

Conclusions: Managing HIV positive patients on hemodialysis is a clinical and financial challenge. However with a focused approach it is possible to keep these patients alive; well and employed. Transmission of virus to the staff can be avoided by strict adherence to standard infection-control procedures.

53. Study of S. Hepcidin and Iron Indices in CKD Anemia with Refrence to Bone Marrow Iron Reserves

Anupam Agarwal, Shivendra Singh, Mohd Iqbal Bhatt, Shiv Shanker Sharma, Prem Shanker Patel

IMS BHU; Varanasi; Uttar Pradesh; India

Background: Chronic kidney disease (CKD) has emerged as a global public health burden. Anemia is a common feature of CKD; it is difficult to differentiate anemia in CKD on usual iron indices S. ferritin and tranferrin saturation. Still in present era bone marrow iron estimation remains gold standard for iron reserves. Hepcidin a peptide synthesize in liver is principal regualtor of iron homeostasis.

Aim of the Study: The aim of the study was to study different parameters of iron indices and S. Hepcidin in CKD stage 3 to CKD 5 with using bone marrow iron estimation as gold standard.

Methods: Hospital based cross-sectional was study done in IMS BHU Varanasi. Study included 74 patients of CKD stage 3 to 5 (CKD define on NKF/KDOQI 2002 guidelines and staging done by MDRD equation); anemia was diagnosed as per KDIGO 2012 guidelines. Study included adults of both sex and age ranges from 18 years to 78 years. All nonrenal cause of anemia were excluded like occult bleeding; malignancy; end-stage liver disease; and collagen vascular disease; blood transfusion within the past 3 months; infection requiring antibiotics within the past 4 weeks; patient receiving oral iron or parentral iron or on EPO. Informed consent; detailed history; physical examination and relevant investigation included CBC with peripheral smear; reticulocyte count; serum iron profile; serum B12 and folic acid; C-reactive protein; USG Abdomen; RFT; LFT; plasma glucose; and bone marrow iron estimation was done by Perls' Prussian blue stain. Quantitative measurement of hepcidin was done by ELISA method.

Results: Mean age of patients was 42.36 ± 16.52 years with slight male preponderance 54% (n = 40) and 46% (n=34) were female. Mean haemoglobin was 8.01±1.53 gm%; Median serum hepcidin levels were significantly high in patients 114 ng/ml as compared to age- and sex-matched healthy adults 16 ng/ml in controls (P < 0.05). Hepcidin level depicted rising trend successively with CKD stages 3–5. In univariate model showed log normalized hepcidin positively correlated with log normalized ferritin values (P < 0.001). Bone marrow iron pattern suggestive of Iron deficiency in 52%; 33% had anemia of chronic inflammation; normal iron distribution was found in 12%; and iron overload in 03% cases. Only 28% patient had iron indices suggested of iron deficiency as per KDIGO 2012 that is S. Ferritin<100 ng/ml and TSAT<20% does'nt correlate well with bone marrow finding.

Conclusions: Hepcidin values were significantly high in CKD patients; Hepcidin correlate positively with ferritin. Median hepcidin levels were significantly higher in patients with anemia of chronic inflammation; followed by normal iron status as compared to absolute iron deficiency.

54. Clinical Characteristics and Outcomes in Elderly Peritoneal Dialysis Patients- A Single Centre Experience

B Karthikeyan, R K Sharma, Amit Gupta, Narayan Prasad, Anupama Kaul, Dharmendra Bhadauria

SGPGIMS; Lucknow; Uttar Pradesh; India

Background: The number of elderly patients initiated on renal replacement therapy is increasing all around the world. The optimal form of renal replacement therapy in elderly is still not clear. Many of the elderly populations has AV access related issues and hypotension during hemodialysis. The outcomes of the elderly PD population in developing countries is less known. Previous studies mention that older age and diabetes were associated with poor survival in PD.

Aim of the Study: The aim of this present study is to analyse the characteristics and outcomes in elderly patients on PD and to compare survival rates between diabetics and non-diabetics.

Methods: In this study; data of 148 elderly ESRD patients who initiated CAPD between January 2001 to December 2015 were collected. Of these; 28 patients were excluded. Baseline characteristics; clinical data and events during the study period were recorded. Infectious complications and outcomes of these patients were collected. Overall technique and patient survival rates were analysed and compared between diabetic and non-diabetic elderly group.

Results: One hundred and twenty patients who were initiated PD during the study period were included for final analysis. Mean age was 70.3±5.1 and 94 (80%) were males. Among these patients 79 (65.8%) had diabetes. Peritonitis and exit site/tunnel infection incidence were 1 episode in 41.2 patient-months and 37.2 patient-year respectively. At the end of the study period only 20 (16.6%) patients were remained on PD.84 (70%) patients were died during PD and 15 (12.5%) patient were transferred to HD during the study period. The main reasons for death were cardiovascular (56.6%) and sepsis due to peritonitis (18.8%) and other causes (12.2%). The mean patient survival time was 38.2±2.6 months. The patient survival rates were 88.3%; 54.1%; 39.1% at 1; 3 and 5 yr respectively. The mean technique survival time was 92.0±5.1 months. Technique survival rates at 1; 3; and 5 yr were 95.8%; 90.8%; and 87.5%. No significant difference between diabetic and non-diabetic patients in terms of technique and patient survival.

Conclusions: Patient and technique survival rates were comparable between diabetic and non-diabetic elderly PD patients. PD may be good option of renal replacement therapy in elderly patients. Diabetes in elderly should not deter nephrologists from starting peritoneal dialysis.

55. Unusual Cause of Thrombocytopenia in Renal Transplant Recipient (Across Blood Groups) – Tacrolimus!

Kiran Chandra Patro, F Mataf Md, Shakuntala Modi, S Padmanabhan

Department of Nephrology; NU Hospitals; Bengaluru; Karnataka; India

Background: Various drugs have been implicated as cause for leucopenia in renal transplantation; however; Tacrolimus causing leucopenia is rare.

Aim of the Study: To report an unusual cause of leucopenia in across blood group renal transplant recipient.

Methods: A case report - across blood group renal transplant recipient.

Results: This gentleman; across blood group renal transplant recipient; wife donor (donor blood group A positive; recipient blood group O positive; basic renal disease – arteriosclerosis with secondary focal segmental glomerulosclerosis); underwent renal transplantation after antibody depletion protocol (one dose of Rituximab; 4 sessions of immunoadsorption and 4 sessions of plasmapheresis; following which Anti A antibody titres decreased from 1:125 IgG and 1:64 IgM to 1:4 IgG and 1:2 IgM); induction by interleukin 2 receptor antagonist Basiliximab and under triple immunosuppression (Tacrolimus; Mycophenolate Mofetil and Prednisolone). Nadir creatinine reached was 1.05 mg/dl. He developed leukopenia which was not improving following stopping of routine offending agents such as Mycophenolate Mofetil; Valganciclovir or Co-trimoxazole. Vitamin B12 and folate levels were normal; CMV DNA PCR was negative and bone marrow biopsy revealed hypocellular marrow.

Conclusions: Following Tacrolimus withdrawl and introduction of Cyclosporine; the leucocyte count improved to the normal range. Tacrolimus is a rare cause of leucopenia in renal transplant recipients.

56. A Leap Towards Brighter Future - Deceased Donor Renal Transplantation: 2.5 Years of Experience in SMS Hospital; Jaipur

Harshal Joshi, Dhananjai Agarwal

SMS Medical College; Jaipur; Rajasthan; India

Background: Every year about 1.75 lac people are diagnosed to have ESRD requiring RRT. Resources for RRT are very scarce and available only in urban areas. Renal transplantation is the best modality of RRT but it is costly and available in only few centers. Prime hurdles are lack of transplant facility; high cost of transplant in private facility and shortage of donors. With improvement in public education and awareness; Cadaveric renal transplantation programme is increasing in popularity.

Aim of the Study: (1) To know clinical profile of deceased donor renal transplant recipients. (2) To know renal and patient outcome of deceased donor renal transplant recipients.

Methods: We analyzed 20 deceased donor renal transplant recipients retrospectively; transplanted in last 2.5 years. After evaluating fitness; patients who were willing for registration are selected and registered through RNOS. Deceased donor kidney was allocated after confirming negative CDC crossmatch for T cell. Patients received induction immunosuppressive therapy with methylprednisolone with either r-ATG or Basiliximab. Maintenance immunosuppression consisted of prednisolone; tacrolimus and mycophenolate sodium. The doses of MMF and CNI were adjusted according to complete blood counts and trough level of tacrolimus. Tac dosing was adjusted to achieve target T0 concentrations of 4-7 ng/mL. All patients received prophylaxis against CMV; fungal and pneumocystis jiroveci pneumonia infection. All recipients were followed up and investigated till death. Post transplant renal allograft function was measured using Serum creatinine and eGFR.

Results: Total 20 deceased donor renal transplants were done from Feb 2015 to August 2017 out of which 15 were male. Mean post transplant follow up was 357 ± 287 days. Patient survival was 80% (16/20) and death adjusted graft survival was 85% (17/20). 2 grafts were lost due to death with functioning graft. Mean post transplant creatinine on last follow up was 1.96 ± 1.9 mg/dl. 3 patients (15%) developed DGF and 2 (10%) developed SGF. Most common post transplant medical complication was Early sepsis (6/20; 30%). Late sepsis was seen in 2 patients (10%). Other complications included NODAT (4/20; 20%); ABMR (2/20; 10%); Chronic graft dysfunction leading to ESRD (1/20; 5%) and post transplant erythrocytosis (1/20; 5%). Most common surgical complication was wound infection (2/20; 10%). Other surgical complications included Arterial thrombosis requiring graft nephrectomy (1); Urinoma (1); Hematoma (1); Urinary leak (1); DVT (1); and strangulated incisional hernia (1).

Conclusions: Renal transplantation is one the best modalities of RRT. Deceased donor renal transplantation (DDRT) is a boon for ESRD patients who do not have live donors. With increasing public education; awareness and with the help of public private partnership; DDRT is increasing in popularity.

57. Study of Prevalence of Metformin Associated Lactic Acidosis in Patients with Creatinine Clearance More than 20 ml/min/Per 1.73 m2

Pradeep , K A Arun, Arpitha Chouksey, Usha Samuel, S Gomathy

Government T.D. Medical College; Alappuzha; Kerala; India

Background: A common clinical challenge facing all practitioners treating patients with type 2 diabetes mellitus today are the guidelines for metformin contraindicating its use in men and women with serum creatnine concentrations ≥1.5 and ≥ 1.4 mg/dl (≥132 and ≥123 mmol/L); respectively. Despite the proven benefits; metformin remains contraindicated in a large segment of the type 2 diabetic population; largely because of concerns over the rare adverse effect of lactic acidosis.

Aim of the Study: To study the prevalence of lactic acidosis in patient taking metformin with creatnine clearance more than 20 ml/minute/per 1.73 m2.

Methods: The study was conducted under the Department of nephrology; Government T D Medical college; Alappuzha which is a teritiary care hospital in central Kerala; South India. Patients attending the department of General Medicine and Nephrology who satisfied the inclusion criteria were enrolled in the study during the study period of one year (March 2014 to February 2015). Study was conducted in the cross sectional design. All Type 2 DM patients with creatnine clearance above 20 ml/minute in the age group of 13 years and above were included after taking informed written consent.

Results: Out of the 102 patients studied; 65 were males and 37 were females.8 of them were <40 years; 62 were between 40-60 years age group and 32 were more than 60 years age group. The data analysed showed four cases of metabolic acidosis. The bicarbonate levels were low 21.8; 21.0; 21.4; 21.5 mmol/L and the eGFR values were 22.50; 28.56; 23.33 and 31.27 ml/min per m2 respectively. A chi-square test was done to determine the association between the two categorical variables (eGFR and bicarbonate level) in the sample and therefore it is likely to reflect a real association between these 2 variables in the population. Pearson chi-square value was 75.727 with an associated p value less than 0.001.

Conclusions: Metformin can be continued or initiated when the eGFR<60 ml/min per 1.73 m2 but the renal function should be closely monitored (every 3-6 months). Metformin is not recommended or to be stopped when eGFR falls to <20 ml/min per 1.73 m2.

58. Assessment the Utility of Finger-Nail Creatinine to Differentiate Between Acute Kidney Injury and Chronic Kidney Disease

Nilesh Shinde, Atul Sajgure, Atul Mulay, Charan B Bale, Ashwini Sharma, Abhishek Goel, Vajed Mogal, Pratik Shete, Shirin Telang, Tushar A Dighe

Dr. D Y Patil Medical College; Pimpri; Pune; Maharashtra; India

Background: It is necessary to establish if azotemia is acute or chronic as it plays vital role in initiating treatment and in preventing its progression. When a patient presents with renal failure; it is often difficult to ascertain whether the individual is suffering from acute or chronic renal failure. Efforts were made to use fingernail creatinine to differentiate between the two. While some studies found this useful; there are studies which were inconclusive.

Aim of the Study: To determine usefulness of finger-nail creatinine to differentiate between Acute Kidney Injury and Chronic Kidney Disease.

Methods: In this prospective observational cohort study conducted at tertiary health care centre; 20 patientswere selected for the study. Out of which 10 patients were diagnosed as Acute Kidney Disease (AKI) and 10 patients were diagnosed as chronic Kidney disease (CKD) with 30 days of dialysis vintage. Ten healthy volunteers were also included in the study as controls. For estimating finger-nail creatinine concentrations; fingernails of all participating subjects were clipped and collected separately in plain tubes. The nails were cleaned under tap water; dried & the weight was recorded. The Nail creatinine was extracted in water first by pulverization; followed by mechanical powdering. Sample powder incubated at 45°C for 2 hrs; centrifuged and then assayed by Alkaline Picrate-method on semi Auto Biochemistry Analyzer (Robonik).

Results: We found that when nail creatinine level in AKI (30.41 +/- 4.32 micrograms/g of nails) was significantly low compared with nail creatinine in CKD (91.59 +/- 47.76 micrograms/g of nails) [p-value (Two-tailed unpaired T test) 0.0013]. However; when nail creatinine level in AKI compared with nail creatinine in healthy volunteer (33.99 +/- 4.54 micrograms/g of nails); there was no significant difference [p-value (Two-tailed unpaired T test) 0.088].

Conclusions: The finger-nail creatinine levelin AKI was significantly low than finger-nail creatinine in CKD. Hence nail creatinine can be used as a one of the diagnostic tool to differentiate between AKI & CKD in patients presenting with renal failure.

59. Profile of High Sensitivity C Reactive Protein in Acute Kidney Injury and Chronic Kidney Disease

Abhishek Goel, Tushar Dighe, Atul Mulay, Charan Bale, Ashwini Sharma, Jayraj Korpe, Nilesh Shinde, Vajed Mogal, Pratik Shete, Atul Sajgure

Department of Nephrology; Dr D Y Patil Medical College; Pune; Maharashtra; India

Background: Prevalence of chronic kidney disease (CKD) is around 10% worldwide; while that of acute kidney injury (AKI) has not been systematically examined. Inflammation has been identified as an important factor of co morbidities in AKI and CKD. High sensitivity C reactive protein (hsCRP) assay is useful for detection of inflammatory state.

Aim of the Study: (1) To study the profile of serum hsCRP in patients of AKI and CKD on hemodialysis (CKD5D). (2) To study the correlation of hsCRP with other inflammatory markers.

Methods: A prospective observational single tertiary care centre study from western India. Serum hsCRP; serum ferritin and serum albumin levels were checked on initiation of hemodialysis for both AKI and CKD subjects. All were dialyzed with a low flux dialyzer. Sample was collected for hsCRP; pre and post hemodialysis. All subjects were divided into AKI; CKD and Acute on CKD groups. HsCRP was analyzed using the Immuno Turbidimetry method with Cobas Integra 400 plus fully automatic analyzer. Unpaired t test was used to denote the statistical significance. Correlation between different inflammatory markers was calculated using the Pearson's correlation coefficient.

Results: A total of 106 subjects were enrolled; which included 78 (73.6%) males. The mean age of participants was 49.90±15.22 years. 74 (69.8%) were CKD; 17 (16%) in Acute on CKD and 15 (14.2%) subjects in AKI group. Serum hsCRP in AKI group (65.23±47.25 mg/l) was significantly higher (p=0.023) compared to CKD (31.93±52.60 mg/l). On comparing AKI with Acute on CKD (39.87±37.11 mg/l; p=0.106) and Acute on CKD with CKD (p=0.47); were not statistically significant. Serum hsCRP was not found to correlate with serum ferritin level in AKI (R=0.43; p=0.11); Acute on CKD (R=0.23; p=0.37) and CKD groups (R= -0.04; p=0.73). Correlation was also not found with serum albumin levels in AKI (R= -0.9; p=0.73); Acute on CKD (R= -0.33; p=0.198) and CKD (R= -0.13; p=0.26). A two tailed paired samples t test on Pre and Post hemodialysis values of hsCRP revealed that the hsCRP levels does not change with hemodialysis (p=0.128).

Conclusions: Serum hsCRP is higher in subjects with AKI as compared to CKD; while no difference was found on comparing both the groups with acute on CKD. Serum hsCRP does not correlate with other inflammatory markers and is not dialyzable.

60. Pill Burden and Pill Adherence in Dialysis Patients

Virendra Gupta, Rachana Jasani, Rajesh Kumar, Viswanath Billa, Shrirang Bichu, Jatin Kothari, Mohd Shah Alam, Paras Dedhia

Apex Kidney Foundation; Mumbai; Maharashtra; India

Background: End stage renal disease is associated with multiple comorbidities and poor health related quality of life. Due to multiple comorbidities; dialysis patients have high pill burden and hence impact on medication adherence.

Aim of the Study: The primary aim was to study pill burden and pill adherence in dialysis patients. The secondary aim was to assess the reasons for non-compliance.

Methods: 188 subjects undergoing thrice a week hemodialysis; underwent a cross sectional; multicenter assessment of total daily pill burden. Medical prescription by the Consultant Nephrologist was used to identify the number of pills prescribed. These pills were divided into following categories-pills for hypertension; ischemic heart disease (IHD); diabetes; calcium supplements and phosphate binder and vitamin supplements. Percentage adherence of all classes of medicines and reasons of non-adherence were recorded in 80 patients.

Results: The average age of patients was 55.2 ± 13.9 years. Out of 188 patients; 115 were males and 73 were females. The total numbers of pills prescribed were 10.5 ± 3.2 and the total number of pills adhered were 9.8 ± 2.1. Percentage compliance was 88% for hypertension; 96% for IHD; 80% for diabetes; 70% for calcium supplements; 61% for phosphate binders and 70% for vitamin D/secondary hyperparathyroidism related medications. Reasons for non-compliance were - 65% were tired of taking pills; 45% were forgetting to take pills; 39% were refraining due to high cost and 14% reported that they stopped taking due to its side effects.

Conclusions: Overall due to multiple medical comorbidities; dialysis patients have a high pill burden. High pill burden has an adverse impact on adherence/compliance of phosphate binder.

61. Prevalence of Major CKD Risk Factors and Estimation of Low Glomerular Filtration Rate Among Subjects Referred for Health Check-up in a Tertiary Care Hospital from North India

Anish Kumar, N P Singh, Ruby Bansal, Taposh Sarkar

Max Super Speciality Hospital; Vaishali; Ghaziabad; Uttar Pradesh; India

Background: Chronic kidney disease (CKD) is increasingly being recognized as an emerging public health problem in India. Major risk factors for CKD include diabetes; hypertension; and obesity. According to the WHO estimates; the prevalence of raised BP in Indians was 32.5%. The global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014. In our previous study the prevalence of low eGFR has increased to 4.2% which was higher than previous estimates.

Aim of the Study: To study the prevalence of major CKD risk factors such as hypertension; Diabetes; obesity and find-out prevalence of low eGFR among subjects referred for health check-up in tertiary care hospital.

Methods: The study was conducted among 3500 subjects referred for health check-up. Hypertension was defined as per JNC-7 guidelines. Systolic blood pressure (SBP) ≥ 140 mmHg and diastolic blood pressure (DBP) ≥ 90 mmHg were used as cut-offs. Patients taking anti-hypertensive drugs were also included; even if they had blood pressure values lower than cut-off. As per ADA guideline; Known diabetics on treatment were considered diabetic regardless of their glycemic control. For others; a 12-hour fasting blood sugar level of ≥ 126 mg/dl was used as cutoff. As per KDIGO guideline low GFR defined as eGFR <60 ml/min/1.73 m2 (calculated by MDRD equation). Twelve hour fasting blood sampling was done.

Results: Sixty three percent were male with mean age of population was 46.07±12.76. Prevalence of hypertension; diabetes and low GFR found to 34% (male;female:24%;10%); 18% (male;female:12.5;5.5) and 2.3% (male;female:1.4;0.9) respectively. About 53% and 44% of treated patients had their BP and blood glucose under control. 19.14% and 5.5% had newly diagnosed hypertensive and new onset diabetic respectively. The prevalence of low eGFR in hypertensives was 1.5% as compared to 0.8% in non-hypertensives. Mean value of elevated SBP and DBP; high FBS (>126 mg/dl) and low eGFR were 127.5±13.9 mmHg; 81.63±9.29 mmHg; 173.91±56.3 mg/dl and 49.54±12.58 ml/min/172 m2 respectively. The prevalence of obesity (BMI ≥ 25 kg/m2) was 70.2% and was comparable across gender (male;female:42%;28%). There was association of hypertension and other risk factors (age; sex; obesity) on the prevalence of low eGFR.

Conclusions: Prevalence of hypertension and diabetes was high and low eGFR was associated with hypertension; age; sex; and obesity. There were significant numbers of newly diagnosed cases of CKD risk factors. Screening program is needed for primary prevention and management of targeted CKD risk factors.

62. Analysis of Renal Biopsies Over A 6 Month Period in a Tertiary Care Centre

D Keerthi Reddy, T Gangadhar, G Swarna Latha, Uttara Das, K Raja Karthik

Nizam's Institute of Medical Sciences; Hyderabad; Telangana; India

Background: The different presentations of renal pathologies are nephrotic syndrome; acute glomerulonephritis and rapidly progressive glomerulonephritis. The incidence of nephrotic syndrome is about 3 per 1; 00; 000 adults/year. The incidence of acute glomerulonephritis varies from 0.2/100 000/year and 2.5/100 000/year. This study was done to analyse the incidence of glomerular pathologies; the degree of proteinuria and renal dysfunction in the different diseases and the spectrum of biopsy findings.

Aim of the Study: To analyse the renal biopsies and know the incidence of nephritic syndrome; nephrotic syndrome; causes of graft dysfunction and the common diseases causing nephritic syndrome and nephrotic syndrome.

Methods: This is a cross-sectional observational study. The renal biopsies done over a 6 month period from January 2017 to July 2017 in the Department of Nephrology; NIMS were analyzed. Histopathology and immunofluorescence staining were done and reported by the pathologist of our institute. The degree of proteinuria; serum creatinine; and other clinical data was collected. Basic statistical tools like mean; median were used to interpret the data.

Results: Over a 6 month period; 170 renal biopsies were done. 48 biopsies were for nephrotic syndrome; 47 were acute nephritic syndrome; 40 were to know cause of chronic kidney disease; 3 of the biopsies were in acute kidney injury; 32 were post transplant biopsies. Most common cause of nephrotic syndrome in our centre was membranous nephropathy followed by FSGS. Most common cause of acute nephritic syndrome was lupus nephritis; followed by Ig A nephropathy and full house nephropathy. Crescentic glomerulonephritis was seen in 2 patients. Chronic glomerulonephritis accounted for majority of the chronic kidney disease. Diabetic nephropathy also contributed significantly to chronic kidney disease. Of the 32 post transplant biopsies; 10 were due to rejection. 3 were cellular rejection; 4 were antibody mediated rejection and 3 were due to combined cellular and antibody mediated rejection. 6 biopsies showed CNI toxicity.

Conclusions: Membranous nephropathy was the most common cause of nephrotic syndrome (33%). The most common cause acute nephritic syndrome was lupus nephritis (21%). Rejection accounted for 32% of the post transplant biopsies. CNI toxicity accounted for 19% of post transplant biopsies.

63. Hospital Admissions for Patients on Maintenance Dialysis

S Ramakrishnan, Kiran Chandra Patro, Anitha Ram Prasad, Dilip Rangarajan

NU Hospitals, Padmanabha Nagar; Bengaluru; Karnataka; India

Background: Hospital admissions among patients on maintenance dialysis are common; they contribute significantly to financial burden and morbidity of these patients. Some causes for admissions are modifiable; identification and correction may help to bring down admission and readmission rates. Readmission rate is an important quality improvement metric. We should be aware that there are penalties for hospitals with higher rates of readmission under Hospital Readmission Reduction Program in US.

Aim of the Study: To analyze indications and outcome for hospital admission of patients on OP dialysis (both HD and PD) from July 2016 to October 2016 in our Hospital; a tertiary care Nephrology Urology center.

Methods: Study population: Patients (a) on OP HD in our Hospital; (b) on PD under regular follow up with us and (c) immigrant dialysis patients consulting us for second opinion or management of intercurrent illness or some procedure who had undergone 2 consecutive sessions of HD or had visited at least twice while on PD after dischargeStudy period: July 2016 till October 2016 data collection - Retrospective from medical records of study population Definitions of calculations (BY means divided by):Patient years at risk (A) - total number of days of follow up as OP BY 365 Admission rates (B) - total number of admissions for the period BY total number of patient years at riskHospital days per patient year (C) - total number of hospital days for the period BY total number of patient years at risk 30 days readmission rate (D) - percentage of admitted patients getting hospitalized within 30 days of discharge from hospitalAverage length of stay (E) – (C) BY (B).

Results: Table Overall HD PD (A) 31.20 28.23 2.96. Mortality (%) 10.8 8.47 33 admissions 41 35 6 hospital days 239 205 34 (B) 1.31 1.23 2.02 (C) 7.66 7.26 11.48 (D) 15.3 16.6 0 (E) 5.84 5.90 5.68. Mortality (%) 19.3 7.6 80 indications for admission - PD - peritonitis in 2; sepsis of unknown focus in 2 and pneumonia and electrolyte abnormality in 1 each HD – access related mechanical problems 5; fluid overload in 5; sepsis in 4; CLABSI in 4; pneumonia in 3; reactive airways disease 2 and encephalopathy in 212 admissions in patients with HD within 3 months of initiation on dialysis; vascular access central vein catheter in 11 of these admissions 17% hospital admissions for management of dialysis related infection 9 patients (8 on HD and 1 on PD) were admitted more than once. Indications for admission same in 4 out of 9 50% deaths due to dialysis related infections.

Conclusions: (1) Infections contribute significantly to admission and mortality; focus on access care and retraining is likely to help in reduction in admission in study population (2) Readmission is for a similar indication in 44%; it is better to do root cause analysis for every admission.

64. Influence of Initial Mechanical Complications on Peritonitis and Other Clinical Outcome of Indian PD Patients

Archana Sinha, Narayan Prasad, Amit Gupta, Dharmendra Bhadauria, R K Sharma

Departments of Dietetics and Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; 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. The peritonitis rate (episodes/patient-year) in patients with complication was 1.1 as compared to 0.35 without complications.

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.

65. Spectrum of Biopsy Proven Renal Disease in Children

Anuradha Kavadi, Manisha Sahay, Kiran Mai Ismail, Sharmas Vali Osmania

Department of Nephrology; General Hospital; Hyderabad; Telangana; India

Background: Renal biopsy has adefinite role in confirmation of diagnosis in various renal diseases. Histopathological diagnosis is not only helpful in diagnosis but also usefull in treatment and prognostication.

Aim of the Study: To study the spectrum of clinical profile of BPRD in children Below 18 yrs. presented to the department of nephrology.

Methods: Retrospective analysis of the histopathlogical reports of all renal biopsiesPerformed from 2011-2016 To study the spectrum of clinical profile of BPRD in children. Below 18 yrs. Presented to the department of nephrologyin children below 18 yrs of age. All renal biopsies were studied by Light microscopy and IF microscopy.

Results: A total of 340 cases were analysed in the study age ranged from as early as 28 days to children less than 18 yrs. Male to female ratio was 1.3. The most common clinical indication for renal biopsy was nephrotic syndrome. Commnest BPRD was primary glomerulonephritis. MCD was commnest accounting for 42.3% followed by FSGS accounting for 12.35%. Among the SGN PIGN was seen in 12.6% followed by Lupus nephritis 2.9%. RPRF presentation was seen in 10% of cases among them among them ATIN was commonest 20%. Indication for renal biopsy in primary glomerulonephritis were FRNS (29%) Age below 1 & 10 yr (36%) SRNS (25)%; SDNS 8%. In 2 cases of HIV positive children MCD was seen. 2 cases of oxalosis were reported in infants.

Conclusions: Our study represents an important contribution to understanding renal diseases in children.

66. Clinical Profile and Short Term Outcome in a Patients with IgA Nephropathy in a Tertiary Hospital in South India

Anil Mudda, L Umesh, S. M. Shivprasad, Leelavathi, Sreedhar, Kishan , Vishwanath Patil

Institute of Nephrourology; Victoria Hospital Campus; Bengaluru; Karnataka; India

Background: The natural history of IgAN can range from clinically silent urinary abnormalities and preserved renal function over many decades to ESRD. Progression to ESRD occurs in 10%–50% of patients; usually developing slowly over 20 years. The modern approach to such proteinuric patients emphasizes rigorous BP control. The short-term outcome of patients with IgA nephropathy has to be studied including the clinical spectrum and outcome.

Aim of the Study: To study about the clinical profile and short term outcome and measures to prevent the decline in GFR and reduce the morbidity and mortality in IgA nephropathy.

Methods: The study has been conducted in Department of Nephrology; Institute of Nephro-Urology; Victoria Hospital Campus Bangalore; India between January 2016 and June 2017. The study will be conducted in patients with biopsy proven IgA nephropathy.

Results: Total of 126 patients were found to have biopsy proven IgA nephropathy . Among them 81 were males and 45 were females. At presentation; 96 cases found to have active urinary sediments. 24 patients presented with nephrotic range proteinuria. 123 patients were found to have hypertension 24 patients with RPGN picture showed crescentic GN 63 patients were in ckd stage 5; 18 patients in ckd stage 4; 39 patients in ckd stage 2/3.6 patients had normal renal function.

Conclusions: IgA is commonest primary glomerulonephritis. We can diagnose patients early by screening patients with hematuria and proteinuria. Control of blood pressure and judicious use of steroids and cytotoxic therapy may help to post pone dialysis and transplantation.

67. Common Symptoms but Uncommon Infections in Transplant Patients

Pankaj Jawandhiya, Hardik Shah, Dilip Kirpalani, Ameya Bedekar, Shweta Khurana, A L Kirpalani

Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

Background: Opportunistic infections still remain the most common factor for increased morbidity and mortality in kidney transplant patients. Apart from routine bacterial; fungal sitic infections; rarely uncommon infections may be encountered in these patients who may present with non specific and common complaints but may not manifest classical symptoms of the said infections. We report 2 such interesting cases.

Aim of the Study: Case report.

Methods: Case 1:52 years; male; farmer; live related transplant; 8 years ago; on triple immunosuppression with tacrolimus; wysolone and azathioprine. He presented with headache since 1 month with increased severity over 8 days; no other symptoms. On examination Terminal neck stiffnes present; rest is normal. Creatinine 1.2 mg/dl; all other biochemical and haematological investigations unremarkable. CT and MRI brain normal. CSF done (in view of persistent symptoms) suggestive of protein 102 mg/dl; WBC -70 cells/mm3 (N 65%; L 32%;). Gram and ZN stain negative; CSF ADA normal. CSF cryptococcal antigen - positive. Patient responded to 14 day course of amphotericin B; followed by oral fluconazole. On 1 month follow up; he was asymptomatic with no neurological deficit and normal renal function.

Results: Case 2:50 years; male; farmer; live related transplant; 4 years ago; on triple immunosuppression with azathioprine; tacrolimus and wysolone. He presented painless swelling (2.2* 2 cm) on right foot; non ulcerating and without draining sinus. He was afebrile and other clinical examination was unremarkable. Incision and drainage done in view of persistent swelling despite routine course of antibiotics. Pus sent for bacterial culture was negative; but silver stain showed fragmented septate hyphae consistent with aspergillosis. Patient treated with 14 days course of amphotericin B followed by oral voriconazole. Complete resolution of symptoms noted within a week of above.

Conclusions: In transplant patients; usual and nonspecific symptoms may be a harbinger of unusual and lifethreatening infections; hence due diligence and thorough evaluation is necessary.

68. Central Venous Stenosis in Chronic Hemodialysis Patients

Ismail Naduvileparambil Aboobacker1, Benil Hafeeque1&2, Sajith Narayanan1, Jyotish Gopinathan2, Asishkumar Mandalay3, Feroz Aziz1&2

1Department of Nephrology; Aster MIMS; 2Department of Nephrology; Iqraa Hospital; 3Department of Cardiology; Meitra Hospital; Kozhikode; Kerala; India

Background: Central vein Stenosis (CVS) is a common non-infectious complication of hemodialysis (HD) catheter. Occlusion of AVF; extremity and facial edema are common manifestation of CVS. Venogram is diagnostic.

Aim of the Study: To study the clinical and radiological characteristics; status of intervention and outcome of patients on long-term HD with significant CVS.

Methods: Our study is retrospective case-series from 2 tertiary-care centers in Calicut having dialysis service for > 10 years. Dialysis records of patients initiated in last 6 years were analyzed. Only symptomatic patients with venogram were included. Clinical features; site of obstruction; need for venoplasty; re-stenosis and outcome were studied.

Results: On average 120 -150 patients/year get initiated on HD from each center. Twenty-nine patients were diagnosed to have a venogram proven CVS. All patients had undergone a neck-line placement and had clinical features of CVS. Most common symptom was extremity edema and most common site CVS was at confluence of Rt-IJV-Subclavian-SVC. Twelve of 29 (41.3%) patients had undergone venoplasty. Eight of 12 (66.6%) patients had re-stenosis and had underwent repeated procedure. Of the 29 patients; 44% (13/29) patients could continue on HD; 38% (11/29) patients had to be switched to PD and 18% (5/29) patients underwent expedited kidney-transplantation. Of the 13 patients who continued on HD; 4 patients could utilize the vein that underwent venoplasty. Seven patients expired during the study period of which six were from group switched to PD. One patient on HD was lost with no mortality in transplant-group.

Conclusions: CVS develops in a sub-group of patients with central-venous catheter. Role of contributory factors like hypercoagulability and venous-lumen characteristics need further study. Even with venoplasty ± stenting re-stenosis rates are high (65%). Patients switched to PD showed high mortality (50%).

69. Burden of Vitamin D Inadequacy in Chronic Kidney Disease: A Systematic Review and Meta-Analysis of Observational Studies

Rajiv Ahlawat, Pramil Tiwari, Sanjay D'Cruz1

Department of Pharmacy Practice; National Institute of Pharmaceutical Education & Research; S.A.S. NAGAR; Punjab; 1Department of General Medicine; Government Medical College & Hospital; Chandigarh; India

Background: Vitamin D deficiency and insufficiency are one of the major emerging health problems globally. Chronic kidney disease (CKD) patients are at a higher risk because of impaired vitamin D metabolism.

Aim of the Study: To summarize evidence from observational studies to assess the prevalence of vitamin D deficiency in CKD patients.

Methods: A methodical search from inception to June 2017 was carried out using Pubmed; Cochrane library databases; Google scholar; and Elsevier-ScienceDirect. PRISMA Statement was followed. The patients were classified into vitamin D insufficient (15–30 ng/mL); deficient (<15 ng/ml) and severe deficient (<5 ng/mL). Kidney disease improving global outcomes (KDIGO) definition of CKD was used. Heterogeneity was reported using I2 statistics and Cochrane Q-statistics test. Publication bias was assessed by using funnel plot. Studies quality was accessed using Newcastle-Ottawa scale. Random effect model was used.

Results: These findings are based on the 22 observational; in 12622 CKD patients; globally. Most of the studies were cross-sectional followed by retrospective and prospective observational studies (13; 5; and 4; respectively). A number of study participant's varied from 27 to 6518. The average pooled prevalence of vitamin D insufficiency and deficiency in CKD I-V patients not on dialysis was 55.8% (95% confidence interval [CI]; 39.3-71.2) and 51.4% (95% CI; 36.7-66.0). In patients on hemodialysis the pooled prevalence of insufficiency and deficiency; was 49.3 (95% CI; 32.6-66.2) and 39.5 (95% CI; 23.6-58.0); respectively. Pooled prevalence of insufficiency and deficiency in patients on peritoneal dialysis was found to be 40.8% (95% CI; 27.6-55.6) and 37.7% (95% CI; 19.7-59.9); respectively. Lack of supplementations and diabetes are the major predictors of vitamin D deficiency.

Conclusions: Vitamin D deficiency is highly prevalent in patients with CKD and on hemodialysis or peritoneal dialysis. Vitamin D supplementation; in the dose recommended by KDIGO; is the treatment of choice.

70. Utility of Peritoneal Dialysis in Successful Management of Transient Hyperammonemia of Newborn

R Mazahir, K Anand, R Dev, K Pai, P K Pruthi

Department of Pediatrics; Division of Pediatric Nephrology; Institute of Child Health Sir Ganga Ram Hospital; New Delhi; India

Background: Transient hyperammonemia in a newborn (THAN) is a rare condition of unknown etiology; first described in 1978. Because of enormously elevated serum ammonia levels these babies become symptomatic and develop lethargy which rapidly progresses to somnolence; coma; respiratory distress and death. We report a neonate presenting within first 3 days of life with neonatal encephalopathy; secondary to THAN; who showed significant improvement following initiation of peritoneal dialysis (PD).

Aim of the Study: Utility of Peritoneal Dialysis in Successful Management of Transient Hyperammonemia of Newborn.

Methods: A term male neonate born of a third degree consanguineous marriage to a 27 years old third-gravida mother; appropriate for gestational age with birth weight of 3036 grams; developed refusal to feed; vomiting and lethargy on day 3 of life requiring admission in NICU. On the day of admission he developed 2 episodes of generalized seizures; CSF analysis was normal. On day 4; child developed respiratory failure; shock requiring mechanical ventilation and inotropic support. Investigations showed respiratory alkalosis; high anion gap; and high serum ammonia level (1683 umol/L). Sepsis work up was negative; renal function tests were normal; LFT showed total serum bilirubin - 9.9 mg/dl (direct-0.69 mg/dl); SGOT-108 IU/L; SGPT-24 IU/L. His tandem mass spectrometry and gas chromatography mass spectrometry was normal thus excluding urea cycle defect. On day 6 of life; bedside single cuff tenckhoff catheter insertion was done and peritoneal dialysis was initiated.

Results: PD initiation led to decrease in the blood levels of ammonia; along with neurological improvement; decreasing inotropic requirement and ventilatory support. PD was stopped after 7 days at an ammonia level of 54 umol/L. The child did not develop any complication either related to hyperammonemia or peritoneal dialysis procedure.

Conclusions: In children with transient hyperammonemia of newborn; peritoneal dialysis is a cheap and effective treatment modality. If initiated on time; can prevent serious neurological deficit and mortality.

71. Plasmapheresis in Hump-Nosed Pit Viper Induced Thrombotic Microangiopathy

K Vinod Kumar, V N Unni, P K Bipi, P Jojo, Rajappan Pillai1, P C Alexander1

Departments of Nephrology and 1Pediatrics Aster Medicity; Kochi; Kerala; India

Background: Hump-nosed pit viper (HNV) bites are common in Indian sub-continent. It causes only minor effects in most cases. Systemic effects including acute kidney injury is seen in only 3 to 10% of cases; out of which majority develop Thrombotic Microangiopathy (TMA). No specific or polyvalent anti-venom is available yet for human use in HNV envenoming.

Aim of the Study: A case report of a child bitten by Hump nose pit viper; who developed thrombotic microangiopathy and acute kidney injury. She was treated with plasmapheresis and she recovered.

Methods: A 13 year old girl was bitten by hump-nosed pit Viper on her right leg and was treated with multiple doses of polyvalent anti-snake venom before she presented to our hospital with anuria; generalized bleeding manifestations and drowsiness. Investigations showed severe renal failure; coagulopathy; thrombocytopenia and severe anemia. She was started on hemodialysis and supported with transfusion of blood products. She had persistent thrombocytopenia; evidence of hemolysis and falling hemoglobin levels; serum LDH levels of 2540 IU/L; elevated reticulocyte count and schistocytes on peripheral blood smear. Along with this; patient had fever and altered sensorium and hence a diagnosis of Thrombotic microangiopathy (TTP) was made. She was started on Plasmapheresis and steroids. Her sensorium improved after first session of plasmapheresis; facilitating extubation. Platelet count; coagulation parameters and LDH levels normalized with six sessions of plasmaphersis.

Results: The renal functions and other blood parameters became normal and she is doing well at one year after the recovery of acute kidney injury.

Conclusions: Venom induced consumptive coagulopathy and TMA often co-exist in patients with viper bites. In selected cases with a strong clinical suspicion of TMA; Plasmapheresis can be a lifesaving option when considered at early stages of envenomation.

72. Clinical Spectrum and Outcomes of Patients in Acute Renal Care Unit-A Tertiary Center Experience

Siva Parvathi, Swarna Latha, Uttara Das, Kaarthik Kaarthik

Nizams Institute of Medical Sciences; Hyderabad; Telangana; India

Background: Acute kidney injury and electrolyte disturbances constitute the most common causes of nephrologist referrals in critical care units. The clinical spectrum of patients with an underlying renal disease who are admitted to Acute Renal Care Unit (ARCU) is a less well studied and reported.

Aim of the Study: To study the clinical profile and causes of admission in to acute renal care unit; including the etiology of renal dysfunction and outcomes over 6 months period.

Methods: A retrospective study which includes data analysis of all the patients admitted to ARCU between February 15 2017 to August 15 2017. The baseline demographic data; causes and clinical presentation and etiology of renal dysfunction and their outcomes with respect to mortality was analyzed.

Results: A total of 173 patients got admitted to ARCU in 6 months; of them 57 percent were males and 43 percent were females. Majority are with in age group of 40 to 60 years constituting 39%. CKD (chronic kidney disease) and its associated complications is the major cause for admission to ARCU (43%); followed by AKI (40%); SLE (8%); post transplant (7%); and nephrotic syndrome (2%) respectively. Hemodialysis is the most common modality followed by PD for RRT accounting for 48% and 23% respectively. The overall mortality is 36% of which AKI has 18% contribution. We have sub analyzed the causes of admission in each category; and Urosepsis (29%) is the most common cause in AKI and internal jugular vein sepsis (19%) followed by pneumonia (12%) is the most common cause among CKD patients. Infections are presenting features in SLE patients and chronic allograft nephropathy with uremia and infections in POST TRANSPLANT patients.

Conclusions: The presence of a dedicated renal care unit could improve the outcomes of patients with an underlying renal disease by 64%. The advantages include tailoring the mode of renal replacement therapy to hemodynamic status of the patients.

73. Patient's Awareness and Knowledge about Dialysis Therapy – A Multicenter Survey

Rachana Jasani, Paras Dedhia, Vishwanath Billa, Shrirang Bichu, Jatin Kothari, Virendra Gupta, Mohd Shah Alam, Rajesh Kumar

Apex Kidney Foundation; Mumbai; Maharashtra; India

Background: Patient education plays a very important role in dialysis population. There is a clear gap between the demand and imparting of knowledge about the overall clinical and allied parameters and its impact on life on dialysis.

Aim of the Study: The aim of this study was to assess which category of patients performed better when interviewed for their overall health and their knowledge about dialysis therapy.

Methods: 1015 patients undergoing hemodialysis across 17 centers in Mumbai were interviewed. 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. Each question was scored and accordingly they were graded as (score 0 -10) poor; (10 - 20) fair and (20 - 30) good. Independent t-test was applied to compare the differences.

Results: Out of 1015 subjects; 634 were males and 381 females. Their average age was 53.0 ± 14.1 years. According to composite scoring; 14.4% of patients scored between 0 – 10; 58% of patients scored between 10 – 20 and 27.5% scored between 20 – 30. Based on age criteria; patients with < 55 years age had better scores (p-value <0.0001) compared to > 55 years old. When compared the scores of patients having education < SSC versus > SSC; patients with education > SSC had higher score (p-value<0.0001). On comparing the scores of patients undergoing dialysis < 2 years versus >2 years; patients with dialysis vintage > 2 years had higher score (p-value<0.0001).

Conclusions: The overall awareness is greatly influenced by education; dialysis vintage and younger age.

74. Tunneled Dialysis Catheter in an Atypical Position in a Patient with Central Venous Stenosis

Gaurav Sagar, Sanjiv Jasuja, N N Khanna, Anupam Bahl, Sonika Puri

Department of Nephrology and Cardiology; Indraprastha Apollo Hospitals; New Delhi; India

Background: 54 years old female patient on maintenance hemodialysis through a Right Internal Jugular tunnelled hemodialysis catheter (TCC); presented to the hospital with poor flow in the access. She had history of multiple failed AV Fistulae and was presently receiving dialysis through this access since last 13 months. She had clinical features of central venous occlusion on physical examination. She was taken up for an angiogram in the cath lab.

Aim of the Study: End of the road options for Hemodialysis access options.

Methods: Contrast instilled through the TCC revealed complete occlusion of the SVC with predominant flow into the Azygos vein. Attempts to negotiate a wire through the TCC into the SVC failed. Efforts to negotiate a wire into the SVC through a femoral sheath from below also failed [Figure 2]. The patient therefore had total complete occlusion of the SVC through which a wire could not be crossed. In addition the present catheter was in the Azygos vein with the tip at the curvature resulting in poor flows [Figure 3].

Results: Since the Azygos vein was of good caliber with adequate flows [Figure 4] we decided to push in a longer catheter (33 cm) to negotiate the curve. This is the final position of the catheter [Figure 5]. Oblique views revealed no kinks in the catheter and adequate flows could be achieved through this access. Anticipating problems in the future the patient has been counseled for transplant and CAPD in future.

Conclusions: In patients with central venous stenosis the Azygos vein becomes dominant and may be used as an access for hemodialysis.

75. Central Venous Stenosis in Patients on Hemodialysis

Venugopal Lakshminarayanan, Yuvaraja, S. Krishna Kumar, S. Sreedhar, R. Padmanaban

SRM Medical College Hospital and Research Center; Chennai; Tamil Nadu; India

Background: Studies in symptomatic patients have shown a prevalence of 9.2% for central venous stasis.

Aim of the Study: To study prospectively the prevalence and outcome of central venous stenosis in Hermodialysi (HD) patients.

Methods: Inclusion criteria: Patients undergoing HD for more than 3 months; unilateral edema of AV fistula arm with or without hemi-facial swelling; Angio graphic evaluation if edema of limb is presentExclusion criteria: Presence of local infection; and lymphatic edema.

Results: Total no. of patients on HD 171 Int. jugular catheters 28 Perm-cath 08 AV fistula 135 total no. of patients with edema of limb 6 all the 6 had ipsilateral jugular catheter prior duration of HD ranged from 3 to 9 years angio proven central venous stenosis 5 (one declined) Interventions: Baloon angioplasty 1 Closure of av fistula 3 Fistula rupture 1 Mortality: 2 died one due to Intracerbral hemorrhage due to warfarin and other due to sepsis following rupture of av fistula.

Conclusions: The prevalence of central venous stenosis is 3.5% in our centre. The presence of Central venous stenosis is associated with considerable morbidity oan mortality (2 out of 6 ie 35%).

76. Feasibility of Mortality Risk Predictor Scores for Elderly Dialysis Patients in Indian Population

Sriharsha Gurram, Krishna Kishore Chennu

Department of Nephrology, Narayana Hrudayalaya , Banglore, India

Background: An objective risk assessment of mortality and health-related quality of life of elderly patients to be initiated on dialysis; facilitates nephrologist in recommendation of dialysis or conservative care; as decision making is quite complex. It also helps patient in shared decision making. Risk predictor models have been developed and recommended for bedside use. Assessment of quality of life is also important in elderly ESRD patients. There is paucity of Indian studies for the same.

Aim of the Study: (1) To know utility of 6 months mortality risk predictor tools developed by Thamer et al. and Couchoud et al. and compare them. (2) To assess quality of life in elderly diaysis patients over 6-months.

Methods: It is a retrospective and prospective observational study. Patients >/= 65 yrs initiated on dialysis between January 1 2012 to February 31 2017 were included. Those getting renal transplant within first 6 months were excluded.7-item and 9-item mortality risk predictor tools developed by Thamer et al and Couchoud et al applied at initiation of dialysis and mortality if any observed. Health related quality of life assessed by 36-item short-form SF-36 employed at the start; at intervals of 3 months and 6 months of dialysis Age; gender; BMI; Socioeconomic status; duration and cause of CKD; modality of dialysis; symptoms at the start of dialysis; unplanned/planned dialysis start; first access; comorbidities; mobility status of the patient; haemoglobin; s. albumin; s. creatinine; eGFR (by CKD -EPI) Outcome: All cause mortality observed at 3 month or 6 months interval. student t-test; Chi-square/Fisher exact test applied for tests of significance. ROC analysis for comparative analysis.

Results: Total 111 patients enrolled. 98 pateints survived; 9 expired and 4 lost to follow-up. Mean age of population was 70.5 years. Mean Couchoud score in “survived” group of patients 3.27 and expired group was 5.33. Mean Thamer score in “survived” group of patients was 2.32 and “expired” group was 3.0. The difference was statistically significant in Couchoud score but not Thamer score. In ROC curve analysis AUC for Couchoud score was 0.72 and for thamer score it was 0.66. Sf- 36 score classified as Physical composite summary (PCS) score and Mental composite summary (MCS) score. Mean PCS score at baseline; 3 months; 6 months was 38.85 ± 22.3; 67.42 ±21.3; 68.0 ± 21.6 respectively. Mean MCS score at baseline; 3 months; 6 months was 41.9 ±19.9; 70.9±17.1; 73.1 ±18.1 respectively. The difference in score was statistically significant. There was no statistical significance observed when scores were compared between “survived” group and “expired” group at baseline and 3 months.

Conclusions: Couchoud score is better in predicting short term (6 months) mortality risk at higher score as compared to Thamer score. HRQOL improves after initiation of dialysis in elderly patients and should be assessed prior to dialysis initiation in elderly. There is need for further study with larger sample.

77. ABO Incompatible Living Donor Kidney Transplant in a HIV Positive Woman

Zaheer Virani, Prashant Rajput, Bharat Shah

Global Hospital; Mumbai; Maharashtra; India

Background: With recent advances in treatment of HIV; renal transplantation is no longer considered a contraindication in properly selected HIV positive patients. However; doing an ABO incompatible transplant could be a challenge due to higher immunosuppression that can result from the desensitization; exacerbating HIV-related immune dysfunction.

Aim of the Study: Present a case of living related donor ABO incompatible kidney transplant in an HIV positive patient.

Methods: A 27 years old HIV positive female (blood group A) underwent kidney transplant with father (blood group B) being the donor. Her Anti-B IgG and IgM titers were 1:64. Our standard desensitization protocol for ABO incompatible transplant includes rituximab 200 mg on day -7 and day 0 and plasmapheresis and/or immunoadsorption to achieve anti-blood group antibody titers (ABGAT) < 1:16 (2). This was modified in her case. She was given only single dose of rituximab 200 mg on day -7 to minimize the risk of intense immunosuppression. Further; no induction immunosuppression was used and maintenance immunosuppression comprised of tacrolimus; mycophenolate sodium and tapering doses of steroids. Antiretroviral therapy included lamivudine; abacavir and raltegravir which do not interact with tacrolimus and mycophenolate.

Results: She had an uneventful post-transplant course and she was discharged with a serum creatinine of 0.78 mg%. On discharge; she was also started on valganciclovir and cotrimoxazole prophylaxis. A few days after discharge she developed diarrhea for which mycophenolate was changed to azathioprine (2 mg/kg once a day) which also does not interact with the HIV drugs she was on. A month after transplant; she developed leucopenia and her azathioprine was stopped She is now >12 months post-transplant with stable graft function.

Conclusions: A successful ABOi kidney transplant was performed in an HIV positive woman. To our knowledge; this is only second report in the world and first in India of ABOi kidney transplant in an HIV positive patient.

78. P- ANCA Vasculitis Presenting as Pyrexia of Unknown Origin with Renal Limited Diffuse Uptake of FDG on PET CT

Walter Anthony, Krishna Kishore, Rammohan Bhat

Narayana Hrudayalaya Hospital; Bengaluru; Karnataka; India

Background: ANCA vasculitis is a multisystem disease due to involvement of small vessel necrotising vasculitis. Renal involvement presents as glomerulonephritis; mainly as rapidly progressive glomerulonephritis. Inflammatory diseases constitute about 33% of cases of pyrexia of unknown origin. We present two patients who were evaluated for pyrexia of unknown origin and on evaluation were diagnosed to have pauci-immune cresentic glomerulonephritis.

Aim of the Study: Case series of two patients presenting with PUO and diagnosed to have P-ANCA vasculitis.

Methods: Patient 1: Patient 1 is a 54 years old female patient with no co morbidities presented with history of fever and chills with no localising symptoms of about 3 weeks duration. Her past history was significant for tubercular empyema about 25 years back. She was evaluated in an outside hospital and treated with empirical antibiotics but continued to have fever. Laboratory investigations revealed anemia; high ESR; mild leucocytosis; negative blood and urine culture. Chest X-ray was essentially normal. Urine analysis showed proteinuria with active urine sediments. She was progressive non-oliguric renal failure. As patient did not respond to empirical antibiotics; PET CT was done which showed bilateral bulky kidneys with renal limited diffuse FDG uptake; likely of infective/inflammatory etiology. Renal biopsy was done which was suggestive of pauci-immune crescentic glomerulonephritis.

Results: Patient 2: Patient 2 is a 74 years old elderly female patient with history of hypothyroidism and hypertension; now presented with history of fever; arthralgias; loss of appetite and generalised weakness of 2 months duration. She was extensively evaluated in an outside hospital and referred to us for further evaluation. Laboratory investigations were suggestive of anemia; leucytosis; high ESR; non-oliguric progressive renal failure; proteinuria and active urine sediments. Myeloma evaluation was negative. Blood and urine culture was sterile. Chest X-ray was normal. Despite empirical antibiotics patient continued to have fever. PET CT findings were similar to the description as in the above case. Both the patients were positive for MPO-ANCA. Renal biopsy was suggestive of pauci-immune crescentic glomerulonephritis.

Conclusions: Patient 1 is being treated with cyclophosphamide and oral steroids and has improving renal functions. Patient 2 received 2 doses of cyclophosphamide and is on maintenance oral steroid therapy. She has also received 2 doses of Rituximab and has improving renal functions.

79. Anti A/B Antibody Titer Rebound: Be Aware of your Intravenous Immunolglobulin

Ajay Kher, Amit Agarwal, Pranaw Jha, Vijay Kher

Fortis Escorts Kidney Urology Institute; New Delhi; India

Background: Rebound of anti blood group antibodies (Anti-A or Anti B) during ABO incompatible (ABO-I) transplant is a common problem. IVIG contains anti blood group antibodies. Impact of these antibodies in IVIG on rebound of anti-blood group titers; the variability of these antibodies in IVIG products by company and batch is unknown.

Aim of the Study: Assess anti-A and anti-B titer of IVIG from different companies and different batches from same company.

Methods: 26 year old female with mother as ABO-I donor (blood group B to O) had titer 1:256. She was desensitized with Rituximab; tacrolimus & Mycophenolate sodium. She received five double filtration plasmapheresis (DFPP). During DFPP; rebound of anti-B titer was noted. Anti-B titer pre & post DFPP; post IVIG & in IVIG administered was measured. On 9/9/16 when IVIG with titer of 1:8 was used the post IVIG titer did not increase. On 11/9/16 when IVIG with titer of 1:32 was used the titer increased from 1:16 to 1:32 post IVIG; increased to 1:64 on 13/9/16. Last DFPP was done without any IVIG & transplant performed. The transplant was successful; 6 months post transplant creatinine is 1.0. IVIG was tested for anti-A and anti-B titer from 3 companies (Reliance; Intas and Plasmagen) with multiple lots.

Results: There is large variation in anti-A and anti- B titers from the 3 companies and between different lots from the same company (as below). 97030009: A(8); B(8); 97030005: A(64); B(32)97030010: A(4); B(4). ID05G16001: A(16); B(16); ID05G16006: A(32); B(8)3C3000264: A(16); B(8) IGA400117: A(512); B(512).

Conclusions: Anti- A & anti-B titer in IVIG is very variable between companies and between different batches of the same company. Programs with ABO-i transplants should be aware of titer in their IVIG products and use lots/products with low titers to limit rebound during desensitisation.

80. Evaluation of Serum Lipoprotein (A) Levels and Novel Lipid Indices in Patients with Chronic Kidney Disease

S Manokaran, R Kalaivani, S A K Noor Mohammad, N D Srinivasaprasad, K Thirumal Valavan, S Sujit, S Thirumavalavan, M Edwin Fernando

Stanley Medical College; Chennai; Tamil Nadu; India

Background: Cardiovascular diseases are the most common cause of morbidity and mortality in non-dialytic CKD patients. In countries like India owing to the cost factors; measuring the lipoprotein levels are undermined. Studies have shown that novel lipid indices can be used to assess the CVD risks in CKD patients.

Aim of the Study: To evaluate Serum Lipoprotein (a) levels and assess the significance of novel Lipid Indices in patients with chronic kidney disease.

Methods: The study was conducted in Nephrology Clinic. 70 CKD patients from stage 1 to 5 were enrolled. Age and sex matched 70 healthy controls were studied. Patients with history of smoking; lipid lowering therapy; drugs causing dyslipidemia; and cardio vascular diseases were excluded. Serum urea; creatinine and the eGFR (MDRD formula); Serum total cholesterol; triglyceride; HDL and lipoprotein (a) levels were estimated. Serum LDL; non-HDL; VLDL and lipid indices were calculated from above. The results were compared by using excel software. Student unpaired “t” test; and Pearson coefficient of correlation were used for statistical analysis.

Results: Mean calculated eGFR was 34.72 (+16.7) ml/1.73 m2 and 105.8 (+17.08) ml/1.73 m2 in cases and controls respectively. Elevated triglyceride levels and lipoprotein levels noted in 74.3%; 48.6% of cases and 61.4%; 35.7% of controls. Statistically significant difference noted in triglyceride levels (227.41 vs 156.31); VLDL levels (45.48 vs 31.66) and lipoprotein (a) levels (53.26 vs 17.88) between cases and controls. Among the lipid indices; significant statistical difference was observed in Atherogenic Index of Plasma (AIP) (0.35 vs 0.21) and Lipid Tetrad Index (LTI) (73532.92 vs 12712.65) between cases and controls. No statistically significant difference observed in the other lipid indices. Significant positive Pearson correlation noted between the lipoprotein (a) and Atherogenic Index of Plasma (0.388) & Lipid Tetrad Index (0.799). While using lipid indices for risk stratification; early CKD stages (II; III) had highest CVD risk scores.

Conclusions: Lipid indices; especially atherogenic index of plasma and lipid tetrad index can be used to measure the burden of dyslipidemia especially when individual parameters are normal. Using lipid indices can complement to the routine lipid profiles to identify high risk of CVD in early CKD.

81. Barriers to Ambulatory Blood Pressure Monitoring (ABPM)

Rachana Jasani, Paras Dedhia, Virendra Gupta, Mohd Shah Alam, Viswanath Billa, Shrirang Bichu, Jatin Kothari, Rajesh Kumar

Apex Kidney Foundation; Mumbai; Maharashtra; India

Background: ABPM is considered as a gold standard method to assess hypertension in dialysis population; however; practical challenges preclude from obtaining meaningful information.

Aim of the Study: The main aim of this study was to assess the barriers or practical challenges faced while conducting 44 hours ABPM in dialysis patients.

Methods: Patients undergoing thrice a week hemodialysis were approached for conducting 44 hour ABPM. Willing patients were given ABPM machine in between 2 dialysis sessions beginning immediately post-dialysis. ABPM was recorded every 20 min during the day (7 am to 11 pm) and every 30 min during night (11 pm to 7 am) in non-fistula arm. ABPM readings of < 70% were considered unsuccessful. Reasons for unsuccessful measurements were obtained from the ABPM machine data.

Results: Out of 117 patients; 42 were unwilling to do the procedure. 11 patients denied due to job; 5 patients could not perform it due to presence of arterio-venous fistula on both hands; 3 were dropped from the study due to sickness and/amputation. 56 patients performed 44 hour ABPM; amongst them only 40 patients had ≥ 70% readings. The major reasons for the readings failures were movement in the arm; removal of the cuff at night time; loose connection between cuff and machine.

Conclusions: Although ABPM is an important tool to make clinical decisions; however; there are several practical barriers hindering its successful completion. Only 1-in-3 patient's readings had complete interdialytic information.

82. The Varied Renal Manifestations in Antiphospholipid Antibody Syndrome

Nithyashree Nandagopal, Saravanan Margabandhu, Chitra Sundharamoorthy, Rama Mani, Anila Abraham

Apollo Hospitals; Chennai; Tamil Nadu; India

Background: Anti-phospholipid syndrome (APS) is an auto-immune pro-thrombotic disorder characterized by vascular thrombi and presence of circulating anti-phospholipid antibodies. It is classified into primary or secondary APS if associated with other autoimmune states. Renal involvement although uncommon; is well recognized in secondary than in primary APS. Large vessel involvement in the form of thrombosis/stenosis and thrombotic microangiopathy (TMA) are commonly described renal finding.

Aim of the Study: We report a series of two cases of renal involvement in APS with distinct morphological lesions on renal biopsy.

Methods: 1. Primary APS causing secondary membranous nephropathy: 16 year old boy presented to our clinic with features of nephrotic syndrome had severe abdominal pain and breathing difficulty. He was found to have left renal vein thrombosis and bilateral pulmonary artery thrombosis. Investigations revealed persistently positive anti-phospholipid antibodies without an underlying systemic autoimmune disorder or malignancy. Renal biopsy revealed features of membranous nephropathy. Tissue staining for IgG4 and PLA2R antibody were negative; also serum anti-PLA2R antibody was not detected suggestive of secondary membranous nephropathy. Other causes of secondary membranous nephropathy were ruled out. Thus he was inferred to have Primary APS with secondary membranous nephropathy. He responded favorably to anticoagulation along with oral steroids and anti-proteinuric therapy. He had complete resolution of the pulmonary and renal vein thrombi and also achieved remission of proteinuria.

Results: In contrast we report another case of TMA in a 14-year-old girl with secondary APS associated with SLE. She presented with abdominal pain; swelling and rash over of the legs with uncontrolled hypertension. Investigations revealed micro-angiopathic hemolytic anemia (MAHA) with thrombocytopenia and elevated LDH. She had active urinary sediments with nephrotic range proteinuria and azotemia. Further work up detected the presence of antiphospholipid antibodies; anti-ds DNA antibody and low complement level. Renal biopsy revealed features of TMA and class III/IV lupus nephritis. She was treated with pulse steroids followed by oral steroids; 5 sessions of plasma exchange and 2 doses of Rituximab. On 1 month follow-up; she responded well with normalization of hemoglobin; platelet counts; serum creatinine and complement levels along with a reduction in anti-dsDNA titers but persists to have proteinuria and is on steroid/MMF.

Conclusions: The renal manifestations of APS are protean and have evolved as a distinct clinical entity. The above renal findings are albeit extremely infrequent is being increasingly recognized on renal biopsies.

83. A Controlled Study of the Effect of Cholecalciferol for Lowering Albuminuria in Chronic Kidney Disease

Kapiljit Chakravarty, Arpita Roychaudhury, Sanjoy Dasgupta, D Sen, R Pandey

IPGME & R & SSKM Hospital; Kolkata; West Bengal; India

Background: Vitamin D deficiency is highly prevalent in patients with CKD. Growing evidence supports a potential role for vitamin D receptor (VDR) activation in reducing proteinuria. Hence; the proposed work is intended to evaluate whether vitamin D supplementation with daily cholecalciferol could reduce albuminuria in CKD patients.

Aim of the Study: To study the effect of cholecalciferol for lowering albuminuria in chronic kidney disease patients admitted or referred to Department of Nephrology IPGME&R and SSKM Hospital; Kolkata.

Methods: STUDY DESIGN:single centre; controlled; open label prospective intervention study testing the hypothesis that vit D supplementation with daily Cholecalciferol (1000 IU/d) may have antiproteinuric effect in patients with CKD Stage 3-4. Study population: Patients diagnosed with CKD admitted and/or attending OPD and/or referred to Department of Nephrology; IPGME&R and SSKM Hospital; Kolkata. Inclusion criteria: Patients diagnosed with CKD (1) Age> 18 yrs (2) CKD Stage 3-4 according to MDRD formula (3) Albuminuria- defined as spot uACR >30 mg/g. EXCLUSION CRITERIA: (1) CKD Stage 1-2 or 52. uACR <30 mg/g (3) Significant Liver Disease (4) MalabsorptionSTUDY DESIGN: It is a hospital based prospective controlled study. Patients >18 yrs who have been diagnosed as CKD Stage 3-4 (based on MDRD Formula) with albuminuria (uACR >30 mcg/g); excluding those with the above mentioned exclusion criteria will be enrolled in the study. Primary Endpoints Changes in 25(OH) Vit D Changes in uACR Secondary Endpoints: Changes in PTH.

Results: 50 patients were included in the final analysis. 25 received cholecalciferol and 25 were assigned to the control group. At baseline, patients in the cholecalciferol group had significantly higher PTH and lower 25(OH)D levels. No other significant differences were observed at baseline. At the end of the study, there was a significant difference in the 25 (OH) vit D levels between the control and test group( p=0.000, using Independent sample T test).However, there is no significant difference in the uACR between the two groups at the end of the study(uACR median (IQR)-308(140 to 522.2) vs 440(31.2 to 60.2), p=0.258).Also, there is no significant difference in favorable outcome of eGFR between the two groups( p=0.742 using chi square test). Again using the chi square test, there is no significant difference in the favourable uACR outcome between the two groups( p=0.258).

Conclusions: The supplementation of cholecalceferol in patients of CKD 3-4 did not show significant decrease in uACR. Also,it did not reveal any significant favorable outcome in the form of improvement in eGFR of > 10%. As this study is conducted on a sample of only 50 patients, so a larger group study is required to interpolate the results.

84. Peritonitis in Patients of Peritoneal Dialysis; A Retrospective Study

N K Hase, Rahul Deshpande

KEMH; Mumbai; Maharashtra; India

Background: To identify epidemiological; clinical; microbiological factors affecting outcome of peritoneal dialysis (PD) associated peritonitis.

Aim of the Study: 37 patients of peritoneal dialysis (PD) at our institute were studied retrospectively.

Methods: 37 patients of peritoneal dialysis (PD) at our institute were studied retrospectively. A total of 38 episodes of PD associated peritonitis occurring in 37 patients were evaluated. The median age of patients 53 years (7-76). 23 (62.16%) males. Pain in abdomen only in 14 (36.84%); turbid effluent only in 9 (23. 68%) and pain in abdomen with turbid effluent in 9 (23.68%) were the measure clinical presentation. Most common episodes were gram positive 17 (52.63%); of these 29 (76%) were culture positive.

Results: Most common organism were coagulase negative staphylococcus (CONS) 8 (21%) followed by staphylococcus aureus; Pseudomonas aeruginosa; Klebsiella pneumoniae Scientific Name Search  5 each (13.15%) followed by others. Most episodes were treated successfully with medical management 33 (83.84%); 5 (13.15%) required catheter removal; there were no deaths. In our CAPD patients most common clinical presentation was only pain in abdomen followed by only cloudy effluent; so there should be high index of suspicion while diagnosing peritonitis. Most episodes of peritonitis were due to Gram positive organisms; the reason for which may be due to breach in sterile technique.

Conclusions: Most common organisms were CONS followed by staphylococcus aureus; Pseudomonas aeruginosa; Klebsiella pneumoniae in equal numbers. Most of infections were treated successfully with medical management and few required catheter removal.

85. Chyluria; with a Rare Etiology and Grave Prognosis: A Case Report

Manas Ranjan Behera, Dharmendra Singh Bhaduaria, Anupma Kaul, Narayan Prasad, Amit Gupta, Raj Kumar Sharma

Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

Background: Chyluria is often considered as benign disease. It is attributed to urinary leakage of lymph; rich in chylomicrons; results from abnormal pyelolympatic fistulas. Etiology can be parasitic or non-parasitic; predominant in tropical and western countries; respectively. Here we are describing a case chyluria with a rare etiology; unusual presentation and grave prognosis.

Aim of the Study: We are describing a case chyluria with a rare etiology; unusual presentation and grave prognosis.

Methods: Case Report: 35 years old male with history of chyluria for 1 year; admitted with complain of decreased appetite; generalized weakness for 1 month and sudden decreased urine output 4-5 hours. On evaluation; found to be in shock; edema; ascites with urinary retentions. Labs shows moderate renal failure deranged LFT; hypoprotinemia; hypoalbuminemia. 24 hour urine protein was >13 gm/day. But triglyceride and cholesterol was normal. CT scan abdomen shows hepato-spleenomegaly; bilateral necrotic adrenal with multiple retroperitoneal lymphadenopathies. After death postmortem biopsy was taken from liver; kidney; spleen and adrenal to confirm diagnosis.

Results: Postmortem biopsy from liver; kidney; spleen and adrenal shows numerous small oval fungal yeast forms displaying perinuclear halo s/o disseminated histoplsmosis.

Conclusions: Chyluria is not always a benign condition. It can be life threatening as describe above. Though filariasis is most common cause of chyluria in tropical country; other secondary causes to be rule out by X-ray chest and USG abdomen.

86. ABO – Incompatible Renal Transplantation – Searching for the Best Immunosuppression Protocol

Gagan Deep Chhabra, D Khullar, R Grover, K Gandhi, S Gupta, A Kumar

Department of Nephrology and Renal Transplanation; Max Super Specialty Hospital Saket; New Delhi; India

Background: ABO incompatible has been considered as an important immunological barrier for renal transplant. ABO incompatible transplant has been there for long but is relatively new in this part of world. We here by present a single centre experience of ABO incompatible renal transplants performed from April 2014 to February 2017.

Aim of the Study: Searching for best immunosuppression protocol for ABO-i Renal Transplant. Retrospective comparison of high dose Rituximab (500 mg or more) with low dose Rituximab (200 mg or low).

Methods: We analyzed 37 ABO incompatible Live Donor Renal Transplants that were performed during the period from April 2014 to Feb 2017. Our immunosuppressive protocol included Rituximab; Plasmapheresis; IVIg; Immunoadsorption; immunosuppressive medications and induction with Thymoglobulin in majority of cases (n = 34 out of 37). We regularly monitored ABO titers and targeted titer of 1:64 vs 9 patients with titers 1:8 to 1:64 and 2 patients > 1:64). ATG induction were given in 20 patients in group A and all patient in group B. IA and PE were used in combination in pre and post transplant period.

Results: In group A 5 patients required plasma/Immunoadsorption post transplant and group B 1 patient required post transplant Immunoadsorption/Plasmapheresis. Group A 4 patients had biopsy proven ATN one had chronic TMA (? CNI induced) and 6 patient had rejection (4 AMR + 2 mixed). In group B 3 patients had ATN and none had rejection (P value = 0.0645). On further analysis of patients with rejection it was observed than one had high DSA values prior to transplant (though adequately desensitized) and other had h/o drug default. Infections were comparable in both the groups.4 deaths were observed in group A vs 1 in group B (p value = 0.6).

Conclusions: Rituximab dose of (500 mg or above) may not give added advantage as compared to lower doses. Total immunological risk analysis of patient should be done and immunosupression planned accordingly. Studies should be planned for better assessment of immunosupressive status of these patients.

87. Deceased Donor Kidney Transplant Versus Live Related Kidney Transplant- A Single Centre Experience of 20 Years

Sayali Bhalchandra Thakare, R Deshpande, D Bajpai, S Lakhani, T E Jamale, N K Hase

Seth G.S. Medical College and K.E.M. Hospital; Mumbai; Maharashtra; India

Background: Renal transplantation is the treatment of choice for End Stage Renal Disease (ESRD). More than 95% transplants in India are live related donor transplants (LRDT). Deceased donor kidney transplant (DDTx) program is still in its infancy and is an underutilised modality. There are supposed concerns regarding the efficacy and survival in DDTx. We hereby share our experience of 31 patients of DDTx who were transplanted at our centre; KEM Hospital; Mumbai in a span of 20 years from 1997 to 2017.

Aim of the Study: To study demographic features; transplant outcomes; complications and survival in the two groups of patients who received Deceased donor versus Live related kidney transplant.

Methods: A retrospective study of total 62 patients of DDTx and LRDT was done by accessing records of patients who were currently or formerly following up at the Transplant clinic of KEM Hospital. The demographical data; immuno-suppresion protocols; surgical techniques and complications and immediate transplant outcomes were studied. Their subsequent follow ups/admissions were recorded further and graft function; complications; both infectious and non infectious; and graft survival and patient survival was compared in the two groups. Statistical analysis was performed with standard statistical tests using the SPSS software.

Results: In 20 years; 31 patients who received kidneys from Deceased donors were analysed (Males: 20; Females: 11). The mean ages were 38.5 years (DDTx) and 33.73 years (LRDT). Mean waiting time prior to availability of organ for DDTx was 5.3 years. DDTx patients had an average graft survival of 6.08 years (Range: 1.5 months to 20 years); LRDT had survival of 5.91 years ('p' values <0.05). All patient received triple immunosuppressants- Steroid; Calcineurin inhibitors and Mycophenolate or Azathioprine. 3 received induction with IL2 antagonist; rest with ATG. Delayed graft function was seen in 9 (29%) DDTx patients and in 2 (6.4%) LRDT patients. Graft functioned immediately in 22 (70.9%) in DDTx group. Primary non function was seen in 2 (6.4%) patients in DDTx. Biopsy proven rejections were seen in 3/31 (9.6%) in DDTx group and 2/31 (6.4%) in LRDT. Infectious complications were observed more frequently in the LRDT group in our study. The main cause of death was infections in both groups.

Conclusions: Deceased Donor Kidney Transplant provides acceptable outcomes and similar graft survival when compared to Live Related Donor Transplant and thus should be encouraged. In India; this will help us bridge the ever expanding gap between high demand and limited organ availability.

88. Rare Case of Medullary Nephrocalcinosis Associated with Conn's Syndrome – A Case Report

Ajay Goyal, Tarun Mittal1, Alok Sharma2

Department of Nephrology; Ivy Hospital; Panchkula; Haryana; 1Department of Nephrology; Rainbow Hospital; Agra; Uttar Pradesh; Deparment of Radiodiagnosis and Imaging Studies; Ivy Hospital; Mohali; Punjab; India

Background: Medullary nephrocalcinosis (MNC) is characterized by diffuse calcific deposits in renal medulla (usually renal pyramids). Cortical nephrocalcinosis is relatively less commonly seen. Number of causes of MNC has been described in available literature for e.g. – Medullary sponge kidney; distal renal tubular acidosis; primary hyperparathyroidism; neonatal nephrocalcinosis etc. Association of MNC with Conn's syndrome (primary hyperaldosteronism) has been reported very rarely.

Aim of the Study: To report association of medullary nephrocalcinosis with Conn's syndrome and review the relevant literature.

Methods: CaseA 43 year old woman presented to our hospital for evaluation of long standing resistant hypertension and persistent hypokalemia despite continuation of oral potassium supplementation. On evaluation she was detected to be having primary hyperaldosteronism with raised aldosterone levels and suppressed plasma rennin activity. Her ultrasonography examination revealed diffuse bilateral medullary nephrocalcinosis. MRI scan of upper abdomen was suggestive of a nodular lesion in medial limb/body of right adrenal gland. She was taken up for right sided adrenalectomy following which her blood pressure became normal without antihypertensive medications and serum potassium rose to high normal values.

Results: USG KUB – both kidneys were normal in size and outline. Diffuse medullary calcification noted in bilateral kidneys. Serum aldosterone – 373.0 ng/dL; Plasma Renin Activity (PRA) – 0.04 ng/ml/hr; serum potassium – 2.58 mmol/L; 24-Hour urine VMA – 0.11 mg/24 hrs; Serum urea – 19 mg/dl; serum creatinine – 0.70 mg/dl histopathological examination of surgical specimen following adrenalectomy was consistent with diagnosis of Adrenocortical adenoma.

Conclusions: Primary hyperaldosteronism is a rare cause of medullary nephrocalcinosis. Patients presenting with MNC should also be evaluated for primary hyperaldosteronism in appropriate clinical setting.

89. Urinoma as a Presentation with Ureteric Stone

Manpreet Kaur Jhinger, J S Sandhu

Dayanand Medical College; Ludhiana; Punjab; India

Background: To study perinephric collections.

Aim of the Study: to study perinephric collections.

Methods: 62 years old diabetic patient admitted with right sided flank pain with fever carrying an ultrasound and CECT abdomen showing urinoma formation in perinephric space extending up to right iliac fossa.

Results: Urinoma resolves after radilogical guided PCN was inserted. Fluid culture was sterile and he responded to intravenous carbapenems including the intervention so done.

Conclusions: Urinoma most commonly forms with traumatic etiolgy; however they can be seen with ureteric calculi which was rare entity; but nowadays becoming common.

90. Clinical Profile and Outcome of Rapidly Progressive Glomerulonephritis at a Tertiary Centre in North India

Jai Inder Singh, Indranil Ghosh, Ritambhara Nada

Command Hospital - Western Command Chandimandir; Panchkula; Haryana; India

Background: Rapidly progressive glomerulonephritis (RPGN) is a relatively uncommon but important cause of acute renal dysfunction. The presentation is usually with non specific symptoms which may be neglected by the patient or physician leading to delay in diagnosis. There is paucity of data regarding the incidence and outcome of RPGN from India. We present a series of sixteen cases of RPGN seen at our centre over past 24 months.

Aim of the Study: To analyse the incidence; clinical and histopathologic profile; and outcome of patients presenting with a clinical diagnosis of RPGN.

Methods: We retrospectively screened the clinical and biopsy data of patients who underwent kidney biopsy at our centre from Jul 2015 to Jul 2017 with a diagnosis of RPRF/RPGN.

Results: A total of 82 native kidney biopsies were done from July 2015 to Jul 2017 out of which 16 (19.5%) patients had clinical and biopsy profile of RPGN. Males were overall younger than females. 11 of the patients had crescentric glomerulonephritis (Cr GN). In the 11 case with CrGN; 7 (64%) were type II CrGN (Immune complex mediated); 2 (13%) were type III (pauci immune) and 2 (13%) were type I (anti GBM disease). Early kidney biopsy and management as per KDIGO guidelines was done. Majority developed CKD stage 3 or 4. Two patients became dialysis dependant and two died.

Conclusions: Immune complex mediated GN is the commonest cause of RPGN in our study. Crescentric IgA nephropathy was common in young males. Response to immunosuppression was good and dialysis dependant anti GBM disease also recovered. Risk of infection is the greatest challenge.

91. An Unsual Cause of Anuria in a Young Patient with Hypertension

Pradeep Khandavalli, Manjusha Yadla

Gandhi Medical College; Hyderabad; Telangana; India

Background: Renal infarct or renal papillary necrosis is rare in takayasu arteritis. Takayasu arteritis; being a large vessel vascultis would not involve small vessels. Literature search showed a review by Maritati etal stating that intra renal vasculitis with hemorrhage can occur in large vessel vasculitis.30 years aged woman detected hypertensive 3 month prior to admission in our hospital presented with anuria; breathlessness and vomitings of 3 days duration.

Aim of the Study: There was no history of fever; acute gastroenteritis; pedal edema; ingestion of herbal medicine or nephrotoxic drugs. At admission; she had tachypnea and tachycardia.

Methods: There was no pallor; pedal edema. Regarding pulse and BP; discrepancy was noted between upper and lower limbs. Her upperlimb pulses were felt normally. But in lower limbs; pulse was absent in popliteal posterior tibial and dorsalis pedis. BP was 190/110 mm of Hg in right upper limb; 190/100 mm of Hg in left upper limb; 200/100 in right lower limb and 220/110 in left lower limb. Fundus examination showed bilateral papilledema; cottonwool spots suggestive of hypertensive neuroretinopathy. Her hemoglobin was 10 gm/dl; total leucocyte count was 10; 800/mm3; platelets were 1.5 lakhs/cumm. Blood urea was 126 mg/dl and serum creatinine was 7.5 mg/dl. Serum sodium was 137 meq/L and serum potassium was 4.5 meq/L. Complete urine analysis was unremarkable. Ultrasound abdomen showed right kidney of 9.4 cm and left kidney of 11 cm in size. Doppler of renal vessels showed dieased aorta and renal vessels could not be appreciated.

Results: A CT angiogram was done after explaining the risk of contrast nephropathy. This revealed narrowing of aorta below the origin of inferior mesenteric artery till the bifurcation. Renal arteries could not be visualized. Features are suggestive of Takayasu arteritis type 4. Presence of hypertension and pulselesness disease is thought to be secondary to Takayasu arteritis. But the presence of anuria could not be explained with the above radiology findings. Hence; renal biopsy was done. This showed unremarkable glomeruli with loss of medullary architecture along with areas of necrosis suggestive of medullary infarct [Figure 1]. A differential diagnosis of medullary infarct and papillary necrosis were considered. Evaluation for the possible co existence of small vessel vasculitis was done. Serum for ANA; anti ds DNA; ANCA; APLA were negative. Her ESR was 120 mm. A diagnosis of Takayasu arteritis type 4 with Acute kidney injury due to renal medullary infarct was considered.

Conclusions: (1) Intra renal vasculitis needs to be considered as one of the causes of anuria in patients with Takayasu arteritis. (2) Renal papillary necrosis can be one of the clinical presenting manifestations of Takayasu arteritis.

92. Efficacy of Hepatitis B Vaccination in Dialysis Patients

Manjunath J Kulkarni, Nikhil Dsouza

Department of Nephrology; Father Muller Medical College; Mangalore; Karnataka; India

Background: Hepatitis B is one of the vaccine preventable disease in dialysis patients. Though not as effective as in people with normal renal functions; most of the dialysis patients are vaccinated. We undertook a study to look into the efficacy of hepatitis B vaccination as compared with those with normal renal functions.

Aim of the Study: To study the efficacy of hepatitis B vaccination as compared with those with normal renal functions.

Methods: This study was done on CKD stage 5 patients who were initiated on maintenance hemodialysis in a medical college hospital in Mangalore from January 2016 to June 2016. Patients less than 18 years of age; active hepatitis infection and those who completed or started on vaccination before initiation of dialysis were excluded. The patients were given hepatitis B vaccination 40 ug intramuscular on months 0; 1; 2 and 6 months. The antibody titres were measured 1 month after the completion of the schedule. Anti HBs levels by measuring the antibody titres.

Results: There were 67 incident dialysis patients. The antibody titres and response rates in these group will be compared with a control data of 67 patients with normal renal function. Seroconversion was observed in 60% of the study population. Whereas almost everyone in control group had seroconverted. Of the study group who had response; excellent response was seen only in 39%. In comparison; almost all patients with normal renal functions had protective titres with good response in 86%.

Conclusions: Response rates to vaccination was less in dialysis patients as compared to those with normal renal functions. 40% of our patients did not seroconvert after vaccination. Furthermore re-sponse was not as robust as in general population.

93. Minimal Change Disease as a Presenting Symptom of Leiomyosarcoma

Sriharsha Gurram, Rammohan Sripad Bhat

Narayana Nrudayalaya; Bengaluru; Karnataka; India

Background: Glomerular diseases are rarely seen in association with malignancy. Membranous nephropathy (MN) is most common pathology seen with solid tumors. Minimal change disease (MCD) is second most common pathology associated with tumors especially Hodgkin's lymphoma. We report a rare occurrence of MCD with a high grade Inferior Vena Caval sarcoma. MCD here is most probably a paraneoplastic presentation of IVC sarcoma. The association of MCD with sarcoma has not been described in the literature.

Aim of the Study: (1) To report a rare cause of secondary glomerular pathology (2) To emphasise the need of thorough evaluation in cases of steroid resistant adult onset nephrotic syndrome to rule out malignancies.

Methods: We report a case of a 45-year-old; female presenting as nephrotic syndrome (biopsy proven MCD) which was the presenting symptom of a leiomyosarcoma arising from inferior vena cava (IVC). MCD was steroid resistant and calcineurin inhibitors were required for partial response. The tumor was diagnosed 6 months after initial diagnosis when patient complained of right flank pain; which on imaging revealed right adrenal mass with extension to IVC and right atrium (RA). However; biopsy of the lesion after surgical resection was suggestive of a high-grade sarcoma arising from IVC. Unfortunately; patient died in immediate post-operative period due to uncontrolled bleeding and disseminated intravascular cagulation (DIC).

Results: Definitive diagnosis of secondary nephrotic syndrome is made when there is complete reolution of proteinuria after treatment of primary malignancy. Unfortunately; the patient expired in immediate post-operative period due to uncontrolled bleeding and disseminated intravascular coagulation (DIC) and hence resolution of nephrotic syndrome after tumor removal could not be assessed.

Conclusions: The lack of typical response to steroids and necessitating use of calcenurin inhibitors in an adult patient with MCD should prompt a search for a secondary cause. To our knowledge this is the first reported case of MCD as a presenting feature of a high grade sarcoma arising from the IVC.

94. Early Diagnosis of Mucormycosis in Transplant Recipient –Key to Successful Outcome

Mohit Madken, Vijay Kher, Vivekanand Jha, A S Narula, Ajay Kher, Pranaw Jha, Dinesh Bansal

Fortis Escorts Kidney and Urology Institute; New Delhi; India

Background: Mucormycosis is a devastating invasive fungal infection seen in immunocompromised patients and is associated with high mortality. Mucormycosis comprises 2-6% of invasive fungal infection seen in solid organ and allogenic stem cell transplant recepients. Direct examination of fluid or tissue and prompt treatment with amphoterecin B is crucial for successful management of this life threatening infection.

Aim of the Study: We describe a case of kidney allograft recipient who developed pulmonary mucormycosis and was successfully treated with medical management alone.

Methods: 32 year male post renal transplant 2013 with mother as donor presented with history of fever; cough and weight loss since 1 month. He was on tacrolimus; azathioprine and prednisolone and had received basiliximab induction at the time of transplantation. At presentation his vital signs were stable. Clinical examination revealed bilateral basal crepititions. Lab investigations normal counts and stable graft function. CECT Chest was suggestive of bilateral multiple nodular shadows with tree in bud appearance. CT guided biopsy of the lesion was suggestive of mucormycosis. Azathioprine was stopped and tacrolimus and prednisolone continued. He was managed with liposomal amphoterecin B followed by oral posaconazole to which he responded well. Radiographic clearance of disease within three months of treatment was apparent with no evidence of recurrence at six-month follow-up.

Results: We present a case of pulmonary mucormycosis in a transplant recipient that could be successfully managed due to early diagnosis and prompt initiation of therapy.

Conclusions: We emphasize considering a high index of suspicion of mucormycosis in transplant recipients. Early recognition along with aggressive diagnostic evaluation is critical to effective therapy and patient survival.

95. Case Series of Nephrotic Syndrome with Autosomal Dominant Kidney Polycystic Kidney Diseases

Gajera Hardik, Sanjay Maitra, Ashwini Panigrahi, Denis Savalia, Satyanarayana Garre, Somasekhar Mudigonda

Apollo Hospital; Hyderabad; Telangana; India

Background: Autosomal dominant polycystic kidney disease (ADPKD) is an inherited disorder characterized by the development and growth of corticomedullary cysts in the kidneys and other organs. Non-nephritic-range proteinuria is a common presentation in ADPKD but however nephrotic range proteinuria is unusual and needs to be investigated further to exclude coexisting glomerular disease.

Aim of the Study: It is mandatory to do either open renal biopsy or ultrasound guided biopsy in ADPKD patient with nephrotic range proteinuria with or without declining of glomerular filtration rate (GFR).

Methods: Our centre is tertiary care centre and we are performing 150 to 170 renal biopsies in a year. This is retrospective study of three case series of ADPKD and concomitant nephrotic syndrome with renal failure from March 2015 to July 2017; in which renal biopsy showed a mesangioproliferative glomerulonephritis with crescents; IgA (Immunoglobulin A) nephropathy & Primary membranous nephropathy.

Results: Of total three cases of ADPKD and concomitant nephrotic syndrome with renal failure of 27 months follow up; all the three cases were males (100%) in our study. Mean age of these patients were 44.33 years. Out of three cases; two cases (n=2; 66.66%) were diabetes type 2. Mean baseline serum creatinine was 2.03 mg/dl. Average 24 hours' proteinuria were 10.3 gms/day. One patient's baseline GFR was 20.39 ml/min; another two patients baseline GFR were 75 ml/min and 53 ml/min respectively. Out of three patients; two cases (n=2; 66.66%) posted for laparoscopic renal biopsy and one patient underwent bilateral nephrectomy in view of low GFR & Hugh kidney; renal biopsy showed Membranous; Immunoglobulin A nephropathy and MPGN type 1 respectively. Patients with IgA nephropathy and membranous nephropathy received course of steroid and immunosuppressant and at the end of 10 months; average serum creatinine was 1.6 mg/dl. One patient (MPGN) underwent renal transplant with stable graft function at one year.

Conclusions: In the era of evidence based medicine; in ADPKD who show massive proteinuria should be investigated in terms of concomitant glomerular disease not only for accurate diagnosis; treatment and prevention of deterioration of renal function but also to know about basic diseases.

96. Donor Blood Group Plasma Sans Plasmapharesis in ABO Incompatible Transplant- An in vitro and in vivo Study

Prashant Rajput, Rajeev Nikte, Zaheer Virani, Hepal Vora, Pavan Deore, Hitesh Gulhane, Ashwinee Hotkar, Bharat Shah

Department of Transfusion Medicine; Institute of Renal Sciences; Global Hospital; Mumbai; Maharashtra; India

Background: ABO incompatible (ABOi) kidney transplant was previously considered to be an absolute contraindication to transplantation are now being performed with increasing frequency. For a successful ABOi transplant outcomes it is important to achieve a low anti blood group antibody titers (ABGAT) by various desensitization techniques. Although ABO blood group antigens are regarded as RBC antigens they are actually secreted and are soluble in plasma.

Aim of the Study: To study the efficacy of donor blood group plasma infusions in-vitro and in-vivo to reduce ABGAT post PEX.

Methods: In vitro study- A set of 3 samples of 5 ml each of blood group O was taken and baseline ABGAT titers were measured. Corresponding 0.5 ml; 1 ml and 2 ml of Blood group O (Control group); saline (Control group) and donor (B) blood group (Test Group) plasma was added after removing equimolar quantity to keep volume constant at 5 ml. These were incubated at 37 degree Celsius for 2 hours and the ABGAT measured. (Column agglutination technique-semi automated Ortho-Bio Vue system) In Vivo study- This is retrospective study of 10 ABOi kidney transplant recipient transplanted at our center from March 2014-July 2017. Those with titers >1:64 were included. Group A (Historical Controls n=5) received PEX as a part of ABO desensitization (Plasmalyte A; Albumin and Fresh frozen plasma of AB Blood group). Group B (Test group n=5) included patients who received PEX (plasmalyte-A; Albumin and 500 ml of donor blood group plasma).

Results: In vitro study-The baseline titre of O blood group was 1:512; on addition of 0.5 ml; 1 ml and 2 ml plasma of blood group O and saline after removing same quantity to keep volume at 5 ml was incubated at 37 degree Celsius the Anti B titers remained 1:256 at all levels of volume replaced. On addition of donor blood group (Blood group B) the ABGAT titers dropped to 1:256; 1:128 & 1:64 respectively which was significant as compared to the control group. In Vivo study-Both the groups were matched for age; sex and etiology of chronic kidney disease. In group A the mean baseline ABGAT (IgG) titre was 1:320 (1:64-1:512) and the mean pre transplant titers were 1:11.2 (1:4-1:16). The mean number of PEX was 5.4 (4-9 sessions). In group B the mean baseline ABGAT (IgG) titers was 1:435 (1:128-1:1024) and the mean pre transplant titers was 1:10 (1:14-1:16). The mean sessions of PEX was 4.2 (2-6).

Conclusions: In our study both in-vitro and in-vivo use of donor blood group plasma significantly reduce ABGAT titers with lesser sessions of PEX in patients even with higher baseline ABGAT.

97. Spectrum and Outcome of Acute Kidney Injury: A Tertiary Care Centre Experience from North India

H K Aggarwal, Deepak Jain, Ajit Lathar

Pt B D Sharma University of Health Sciences; Rohtak; Haryana; India

Background: Acute kidney injury (AKI) is usually marked by a rise in serum creatinine concentration and/or decrease in urine output. Prerenal AKI represents the most common form of kidney injury and often leads to intrinsic AKI; if it not promptly corrected. Approximately 95% of consultations with nephrologists are related to AKI. Only few small studies are available from Indian population; hence; there was a need for a large cohort prospective study.

Aim of the Study: The present study was designed to find the spectrum and outcomes of acute kidney injury requiring hemodialysis in a tertiary care hospital.

Methods: A total 2777 indoor patient admitted in medical; surgical and obstetrical wards of PGIMS Rohtak from April 2015 to December 2016 were screened for AKI as per KDIGO guidelines. 112 patients fulfilling the criteria were included in this prospective study. All these patients were followed for 3 months after discharge from hospital and their spectrum and various outcomes were analysed.

Results: The mean age of patients was 35.21±16.85 years with female preponderance (51.78%). Out of these 94 had community acquired AKI while 18 had hospital acquired AKI. Mortality in hospital-acquired AKI was 16.6% while in community-acquired AKI it was 22.34%. Prerenal causes were found in 62.50% of patients; renal in 34%; and post renal in 3.5% of patients. Majority of patients were from medical specialty 53.33%; in which sepsis and gastroenteritis with hypovolemia were main causes. Obstetrical and gynecological cases were 26.66%. Surgical cause was found in 13.33% patients. Of the total AKI patients; 59.82% patients recovered with normal renal function; 21.42% patients died and 18.75 patients developed CKD. 60 patient required hemodialysis and out of these; 21 patients recovered with normal renal function; 20 patients died within 3 months and 19 patient developed CKD. Out of 60 patient requiring hemodialysis 50 were oliguric and 10 were nonoliguric.

Conclusions: Sepsis and Hypovolumia were the commonest cause of AKI in the present study. There should be low threshold for early diagnosis and management of AKI in critically ill patients. Renal replacement therapy like hemodialysis should be started early once indicated.

98. Peritoneal Membrane Transport Characteristics in Uni-Pet with Preceding Icodextrin Dwell as Compared to Classic PET with Preceding Glucose Dwell: A Pilot Study

G Vohra, V Kumar, V Sivatez, R Ramachandran, M Rathi, K L Gupta, H S Kohli

PGIMER; Chandigarh; India

Background: In subjects on CAPD who use icodextrin for long night dwell; it has been recommended that nocturnal exchange be replaced by dextrose dwell whenever PET is to be performed as preceding exchange with icodextrin temporarily increases peritoneal membrane permeability and therefore; gives high D/PCr and low D/D0 glucose values. Whether this temporary change is also seen with use of Uni-PET (which involves one hour dwell of 1.5% dextrose followed by 4-hour dwell of 4.25% dextrose) is not known.

Aim of the Study: To assess the effect of 7.5% icodextrin dialysate solution night dwell on peritoneal membrane permeability assessment by Uni-PET.

Methods: In this self; controlled study; subjects on CAPD; who were using icodextrin for long nocturnal dwell for at least 3 months; were screened for enrolment. Pregnancy or lactation; history of any PD related infectious complication in the past one month; present or past malignancy; and poor functional status were exclusion criteria. Enrolled subjects underwent classic PET with preceding 2.5% dextrose long nocturnal dwell on day 1 followed by Uni-PET with preceding 7.5% icodextrin long nocturnal dwell on day 2. Difference in D/PCr and D/D0 glucose between the two PETs were primary objectives. The study was approved by Institute Ethics Committee.

Results: 9.1 years. Majority were males and diabetes was the most common cause of CKD. Mean D/PCr were 0.68 ± 0.11 and 0.64 ± 0.08 in classic PET and Uni-PET; respectively. The difference between the two values was not significant [mean difference between D/PCr (classic PET-Uni-PET): 0.040 ± 0.86; 95% CI (-0.007 to 0.088); p=0.09]. Similarly; D/D0 glucose between classic PET and Uni-PET were also similar [mean difference between D/D0 glucose (classic PET-Uni-PET): -0.02 ± 0.09; 95% CI (-0.06 to 0.03); p = 0.448].±SD) age of study population was 60.8±15 out of 26 screened subjects were enrolled over a period of 18 months (July 2015-December 2016).

Conclusions: Peritoneal membrane small solute transport characteristics in Uni-PET with preceding icodextrin dwell are similar to classic PET with preceding glucose dwell. If Uni-PET is used; it may not be necessary to replace preceding nocturnal exchange of icodextrin with that of dextrose.

99. Microalbuminuria and Serum Cystatin C Correlation as an Early Predictor of Renal Impairment in Patients with Type 1 Diabetes

S Manokaran, K Anuja, S A K Noor Mohammad, N D Srinivasaprasad, K Thirumal Valavan, S Sujit, S Thirumavalavan, M Edwin Fernando

Stanley Medical College; Chennai; Tamil Nadu; India

Background: Early detection of renal impairment is important in type 1 diabetes to retard the progression to ESRD. Even though the microalbuminuria is an important indicator; some patients have renal impairment without microalbuminuria. Hence use of other earlier markers like Cystatin C levels which increases in serum earlier than creatinine.

Aim of the Study: To study the correlation of serum cystatin C with micro-albuminuria levels as an early predictor of renal impairment in patients with type 1 diabetes in our tertiary care hospital.

Methods: 72 subjects with type 1 diabetes were evaluated. They were divided into two groups depends on the duration of diabetes. In both groups the patients are sub-categorised into cases (30 to 300 mg/g) and controls (<30 mg/g) based on the urine albumin creatinine ratio. Micro-albuminuria tested with dipstick and latex turbidometry; modified Jaffe's method used for creatinine measurements. Colloidal gold enhanced turbidometry used for cystatin C measurement. In both cases and controls; serum cystatin C; creatinine levels were estimated and correlated with urine albumin levels.

Results: Pearson correlation showed significant positive correlation between duration of diabetes and ACR (0.1); cystatin C (0.4); HbA1c (0.4). Significant positive Pearson correlation of ACR with serum creatinine; cystatin C; and HbA1c levels; only in group II patients. Unpaired “t” tests between ACR and serum creatinine; cystatin C; and HbA1c levels in group II patients showed statically significant difference (7.65; 7.98; and 7.29). The cystatin C is increased in microalbuminuric group of diabetic patients with >5 yrs duration. Serum creatinine in these patients was not significantly increased. This refers that serum cystatin C is an early marker of diabetic nephropathy in comparison to serum creatinine.

Conclusions: Microalbuminuria is correlated with cystatin C in patients with more than 5 yrs of type 1 diabetes mellitus. Hence cystatin C can be used for early detection of renal impairment in patients with >5 yrs of type 1 diabetes.

100. A Case of Hemodialysis Permcath-Associated Superior Vena Cava Syndrome: Case Report and Review of the Literature

Sukanto Kishore Das

AMRI Hospital; Bhubaneswar; Odisha; India

Background: Superior vena cava syndrome (SVC syndrome) can arise due to obstruction of blood flow in the superior vena cava (SVC). Hemodialysis (HD) catheter is very commonly inserted into the superior vena cava (SVC); and can lead to thrombotic complications; thereby resulting in signs and symptoms of SVC syndrome.

Aim of the Study: A case of hemodialysis permcath-associated superior vena cava syndrome: case report and review of the literature.

Methods: Case presentation -We hereby report a case of a 59 year old male patient from Western Orissa who was diagnosed with end stage renal disease and was maintained on regular hemodiaysis via right jugular vein dual lumen cuffed tunnelled (permacath) catheter for five months and presented with with signs and symptoms suggestive of SVC obstruction. Chest and neck imaging and angiography was suggestive of right brachiocephalic vein thrombus extending up to SVC. Despite prompt intravenous anti coagulation his symptoms worsened; for which; he was taken for percutaneous transluminal angioplasty to svc followed by stenting to right brachiocephalic vein and svc.

Results: In view of this and siginificant clinical condition deterioration of the patient he was taken for percutaneous transluminal angioplasty of right brachiocephalic vein and SVC followed by stenting. Post procedure; the flow was good with patency restored to and there was marked improvement in clinical condition of the patient.

Conclusions: In view of frequency of HD catheter placement; nephrologists should be aware of these potential complications in any patient with HD catheter-related thrombosis and appropriate therapeutic intervention including stenting when required.

101. Rare Association of Two Autoimmune Disorders

A T Maasila, M Nagarajan, T Dineshkumar, J Dhanapriya, R Sakthirajan, V Murugesan, N Malathy, T Balasubramaniyan, N Gopalakrishnan

Institute of Nephrology; Madras Medical College; Chennai; Tamil Nadu; India

Background: Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are autoimmune disorders in which genetic; environmental and hormonal as well as immunological factors have been implicated. SLE can precede or follow the development of MG. Prevalence of SLE in MG is 2.2% - 8.3%.Prevalence of MG in SLE is 1.3%. Myasthenia occurred in younger age in SLE group than general population; with lower incidence of cutaneous; renal and neurological manifestations of SLE and higher frequency of APLA and LAC.

Aim of the Study: To evaluate the association of Myasthenia gravis with SLE/Lupus nephritis.

Methods: Mrs m; 38 years old female with bad obstetrical history (2nd pregnancy molar pregnancy; 3rd pregnancy IUD) presented with volume overload symptoms during peripartum (3rd preganacy) was diagnosed as case of SLE/peripartum cardiomyopathy. Treated with ACE inhibitors; carvidilol. Seven months later she had complaints of breathlesness; diminished urine output; bilateral leg swelling. On evalution found to have renal failure with nephrotic range proteinuria and active urine deposits. Renal biopsy suggestive of diffuse proliferative lupus nephritis SLE/LN IV A (early cellular crescents in two out eight glomeruli and IF with full house pattern). She was initiated on NIH protocol. Patient was still dialysis dependent at the end of two doses of injection cyclophosphamide. AVF created and initiated on MHD. Secondary AVF failure. Left BCF created. On follow up she presented with gradual onset of difficulty in opening both eyes.

Results: On examination she had bilateral ptosis; pallor. BP 150/100 mm of Hg. CVS; RS examination normal. No motor/sensory deficit. Cranial nerves examination was normal. lab parameters Hb = 11.8 gm/dl; OT/PT=10/16 U/L; Calcium = 10.1 mg/dl; Phosphorus=3.5 mg/dl; i PTH = 250 pg/ml; Creatinine kinase=140 u/l. Anti cardiolipin antibody; lupus anticoagulant negative. Nerve conduction studies showed decremental response 15-25% over fascial muscles with no decremental response over limb muscles suggestive of neuromuscular junction disorder. AchR antibody was negative. She was treated with tab pyridostigmine 60 mg. Clinical improvement was seen within 48 hours.

Conclusions: Peculiarities (1) MG developedin lupus nephritis patient (only 18% in published case report). (2) Onset of MG after patient developed CKD (usually autoimmune process quiescent after developing CKD). (3) No case report-MG onset after CKD. Thus any weakness and fatigue in SLE patients; MG should be considered.

102. Use of Twitter to Democratize Nephrology Education-An Indian Experience

Mayuri Trivedi, Amit Langote, Sanjeev Nair, Manisha Dassi, Garima Agarwal, Arvind Conjeevaram, Hemal Shah, Umesh Khanna

P.D. Hinduja Hospital and MRC; Mumbai; Maharashtra; India

Background: Social media holds great value as a novel teaching and learning tool. The penetration of this method of teaching within the educational realms has proven to be innovative; timely and above all improves the spread of Evidence based medicine In this study we examine the role of social media in the form of Twitter in synthesizing information and sharing knowledge regarding Interventional Nephrology from the conference AVATAR 2017 (Association of Vascular Access & InTerventionAl Renal Physicians).

Aim of the Study: To examine the role of Twitter in synthesizing information and sharing knowledge regarding Interventional Nephrology from the conference AVATAR 2017.

Methods: A dedicated social media team consisting of eight members covered the entire conference of AVATAR 2017 over a two day period (July 21st-22nd 2017) including live tweets and live streaming of individual lectures and workshops which was shared over individual twitter accounts under the hashtag #NephAVATAR. The Twitter analytics was done using the software Symplur (copyright ©2017 Symplur LLC) and 2017 NOD Analytics.

Results: In the preceding 2 weeks of the conference; there were approximately 710 lakh impressions with 921 total tweets by 105 participants from all over the world. Over the two day period of the conference; there were a total of 1.347 million impressions with 2885 total tweets by 154 participants from 24 countries all over the world.

Conclusions: We believe Twitter encourages active engagement & a dynamic process of learning and knowledge sharing which would ultimately encourage the spread of EBM & greater accountability amongst medical professionals. And to the best of our knowledge this is the first study of its kind in Indian Nephrology.

103. Use of Continuous Renal Replacement Therapy in Successful Management of a Child with Hepatic Encephalopathy and Acute Kidney Injury

R Dev, K Anand, R Mazahir, K Pai, P K Pruthi

Department of Pediatrics; Division of Pediatric Nephrology; Institute of Child Health; Sir Ganga Ram Hospital; New Delhi; India

Background: Pediatric acute liver failure (ALF) is a rare complex clinical syndrome leading to a fatal outcome; if not diagnosed and managed early. Hepatic encephalopathy (HE) refers to serious but often reversible neurologic abnormality that arises when the liver cannot detoxify the portal venous blood. We report a child presenting with Stage III HE; acute kidney injury; raised intracranial pressure and high serum ammonia levels; improving following continuous renal replacement therapy (CRRT).

Aim of the Study: Use of continuous renal replacement therapy in successful management of a child with hepatic encephalopathy and acute kidney injury.

Methods: A 3 year old child developmentally normal for age presented with fever for 7 days; hematemesis for 2 days and seizure for 1 day. She was admitted in PICU of Sir Ganga Ram Hospital with clinical diagnosis of Stage III hepatic encephalopathy and raised intracranial pressure (ICP). Investigations revealed deranged liver function tests – serum bilirubin (Total/Direct) - 3.7 mg/dl/2.23 mg/dl; SGOT 15269 IU/L; SGPT 8255 IU/L; serum ammonia 346 umol/L; deranged coagulation profile and deranged kidney function tests – BUN 27 mg/dl; Creatinine 2.12 mg/dl. Septic screen was positive (Procalcitonin - 11.67 ng/ml); viral markers and autoimmune workup negative. CRRT was started (left femoral access; CVVHDF mode; prismaflex M60 filter; heparin free) in view of impaired renal function (pRIFLE-stage III); raised ICP and Stage III hepatic encephalopathy.

Results: Upon initiation of CRRT there was significant improvement in neurological status with normalization of liver and renal function parameters. CRRT was discontinued at 74 hours without any complications.

Conclusions: CRRT is the most efficacious therapy for rapid clearance of ammonia without causing large variations in cerebral perfusion pressure and intracranial pressure. Early CRRT helps to prevent deterioration and to buy time for potential spontaneous recovery or as a bridge to liver transplantation.

104. Interesting Cases of Post Transplant Anemia

S P S Anandan, K Sampath Kumar, Andrew Deepak Rajiv, Sakthi Kumar, Kadhir Selvan

Meenakshi Mission Hospitals and Research Centre; Madurai; Tamil Nadu; India

Background: Prevalence of post transplant anemia is 30 to 40%. Majority of recipients have eGFR <60 and hence anemia is very common. CV disease is leading cause of death in Transplant patients Excellent 1 year graft and patient survival secondary to advances in immunosuppression however long term graft survival has not improved due to infection; malignancy and CV risk factors. PTA may be a marker for CVD and chronic allograft nephropathy. Parvovirus induced PRCA is one of the rare but treatable causes.

Aim of the Study: To delineate the common causes of PTA. To discuss about parvovirus induced PRCA as it is a rare but treatable cause of PTA.

Methods: 2 cases of post transplant anemia who were proved to be due to parvovirus induced PRCA by means of BMA and Parvovirus serology.

Results: Parvovirus induced PRCA is diagnosed by paucity of erythroblasts in bone marrow and positive parvovirus serology. Treated with IVIG 0.4 g/kg for a total of 5 doses. Very common within a year following transplant.

Conclusions: Parvovirus B19 induced PRCA is easily treatable. Hence high index of suspicion is needed BMA and Antibody/PCR demonstration is essential. Reduction in immunosuppression is often needed.

105. A Rare Presentation of Granulomatosis with Polyangiitis in Pregnancy and Successful Completion of Pregnancy

M K Hemanth Kumar, J S Sandhu, Vikas Makkar

Dayanand Medical College and Hospital; Ludhiana; Punjab; India

Background: Granulomatosis with polyangiitis is a relatively rare condition with incidence of 2.5 in 100000 population with a slight male preponderance mainly seen in the 5-7th decade. GPA presenting in pregnancy is extremely rare.

Aim of the Study: To report a case of gpa in a primi with 18 weeks gestation presenting with oliguric dialysis dependent renal failure & successful continuation of pregnancy to deliver a healthy female baby.

Methods: A 33-yr old female Mrs. RK; resident of delhi with 1 year 4 months into married life; primigravida with 18 weeks gestation presented to us with a history of 1 week of loose stools and vomiting; 4 day history of decreased urine output and pedal edema since 2 days. She had got her regular antenalal checkups and had no history of pre-eclampsia. Vague constitutional symptoms of joint pains were present since 1 month. At presentation her investigations revealed hb-6.8 gm%; s. creatinine-12.8 mg/dl; urine routine revealed 2+ proteinuria with 90-100 rbc's/hpf; normal sized kidneys on usg with no urological abnormalities. Her anca profile revealed strong positive anti-pr3 anca and c-anca titres were > 100. She was managed with almost daily hemodialysis as she remained oligo-anuric. She was given 3 days of pulse methyl prednisolone 500 mg* 3 doses and was given cycles of cyclophosphamide 500 mg. during her hospital admission she had developed hemoptysis.

Results: Her family was given the option of plasmapharesis but were unwilling. After 3 cycles; cyclophosphamide was stopped as she developed neutropenia. But till this time she was oligo-anuric and was on almost daily hemodialysis. Her fetal growth was well maintained. She was started on maintenance with azathioprine 100 mg/day and prednisolone. Her pregnancy was prolonged upto 34 weeks and due to her frequent cardiac decompensation; her pregnancy could not be prolonged further and lscs was done to deliver a healthy female baby of weight 1.8 kg. Presently she is still dialysis dependent and oliguric. She also has a low cardiac ejection fraction of 34%. Her baby is 3 months old and presently 2.8 kgs.

Conclusions: There were limitations in this report that plasmapharesis could not be given; renal biopsy could not be done; induction could not be completed. But nevertheless we could continue pregnancy of an oliguric dialysis dependent primi till 34 weeks and deliver a healthy baby.

106. An Unusual Case of “Sweet Hydrothorax” on Peritoneal Dialysis

Gajera Hardik, Satyanarayana Garre, Somasekhar Mudigonda, Ashwini Panigrahi

Apollo Hospital; Hyderabad; Telangana; India

Background: Sweet hydrothorax is an uncommon but well recognized complication of peritoneal dialysis and appears as a complication of continuous ambulatory peritoneal dialysis (CAPD) in approximately 2%-6% of all CAPD patients. It is a potentially serious condition that frequently requires cessation of CAPD and permanant transition to hemodialysis. It is due to movement of dialysate through pleuroperitoneal fistulas and identify by contrast imaging reveals tracer uptake transgressing the diaphragm.

Aim of the Study: To diagnose early; a case of recurrent hydrothorax due to pleuroperitoneal fistulas in case of peritoneal dialysis.

Methods: Single case report.

Results: We describe the case of a 62 years old male on peritoneal dialysis for end stage renal failure who developed a recurrent hydrothorax after one year of CAPD. On examination; he had decreased breath sounds on the right side. A chest radiograph showed a right-sided pleural effusion with a mediastinal shift. Pleural fluid was clear; yellowish and high glucose level of 289 mg/dl; a protein <3 gm/dl and lactate dehydrogenase (LDH) level of 10 U/L which were consistent with a transudate. There was high pleural fluid glucose than serum glucose so considered as pleuroperitoneal communication. After rule out other causes of transudative effusion; he underwent Tc-99 peritoneal scintigraphy which demonstrated pleuroperitoneal communication. We stopped the PD and started temporary hemodialysis. He underwent video-assisted thoracoscopy and multiple defects of the right diaphragm were identified which has sutured and subsequent chemical pleurodesis done & he resumed CAPD two weeks later.

Conclusions: This case describes a classical presentation of hydrothorax in the context of peritoneal dialysis. All clinicians prescribing peritoneal dialysis should be aware of this complication.

107. Should Marginal Deceased Donor and Small Paediatric Donor can be taken up for Cadaveric Kidney Transplantation Program?

Gajera Hardik, Tarun Kumar Shaha, Ravi Andrews, Somasekhar Mudigonda

Apollo Hospital; Hyderabad; Telangana; India

Background: The organ shortage has resulted in increased use of kidneys from expanded criteria donors (ECD) and donors of extremes of age. These donors are unsuitable for single use; dual kidney transplants (DKT) may be possible.

Aim of the Study: Our purpose was to increase awareness of dual kidney transplant from expanded deceased donor; en bloc KT (EBKT) from small paediatric donors and it is an approach to expanding the organ donor pool.

Methods: Our centre is tertiary care centre and we are performing of 90 to 100 renal transplants in a year (deceased donor and live donor). From 2012 to 2016; retrospective study of total 8 DKT from donors who belongs to expanded criteria and enbloc KT (EBKT) from small paediatric of weight of less than 15 kg. Low risk and high risk recipients (Second transplant) instances were chosen for ABO compatible renal transplant with negative lymphocyte cross match by luminex method. Allograft survival was the primary outcome of our study along with recipient; transplant characteristics; outcome (Short and long term) were examined.

Results: Of a total of 93 deceased donor KTs during the 48-months study period; 8 (8.6%) recipients underwent DKT. Out of 8 dual kidney transplant 6 (6.5%) underwent DKT from expanded criteria donors (ECD) and 2 (2.1%) en bloc KT (EBKT) from small paediatric donor. Mean donor age was 65.4 years and 60.4 months in the DKT and EBKT groups; respectively. Patient and graft survival 100% at 6 months. One recipient was expired after 10 months of due to haemolytic uremic syndrome (HUS) from ECD group. The combined incidence of delayed graft function was 12.6% (1/8). Mean 12-months average glomerular filtration rates were 46 mL/min and 59 mL/min by DTPA renogram in the DKT and EBKT groups respectively. All 8 had received induction and triple immunosuppressant. Average serum creatinine at 2 years (n=3) and at 5 years (n=2) were 1.5 mg/dl. One year graft survival 83.3% for ECD and 100% for EBKT. One had chronic allograft injury and recurrence after 2 years. One had acute cellular rejection which was treated.

Conclusions: DKT using kidneys from marginal elderly donors and EBKT from small paediatric donors appear to offer a viable option to counteract the shortage of acceptable kidney donors.

108. Non Lupus Full House Nephropathy- A Clinical and Pathological Correlation Study

K A Arun, S Gomathy, Usha Samuel, B Pradeep

Government TD Medical College; Alappuzha; Kerala; India

Background: SLE is an autoimmune disorder characterised by auto antibodies targeted against various cytoplasmic and nuclear antigens. These antibodies are used in the diagnosis of SLE. According to some case series there is a subgroup of patients with typical lupus nephritis proven by biopsy without any other evidence of SLE and there is no consensus of opinion regarding the treatment or prognosis. In this scenario this study was planned to gather more information about this rare spectrum of disease.

Aim of the Study: (1) To study the clinical profile; histology and outcome of patients with non lupus full house nephropathy. (2) To correlate the clinical and histological features with the final outcome.

Methods: The study was done in the Dept. of Nephrology; Govt. T D Medical college; Alappuzha; Kerala. All patient with a renal biopsy proven non lupus full house from 2012 to 2017 were enrolled. Patients with any known risk factor for CKD; did not take proper treatment or follow up or evidence of SLE at presentation were excluded. After history and examination; RFT; LFT; Urinalysis; 24 hr urine protein assay; HIV; HBsAg; HCV; serum C3; ANA; ANA profile; USG abdomen was done. Renl biopsy was done in all patients (LM&IF). In patients with low C3; values repeated at 6-8 weeks. Patients received treatment based on clinical and lab parameters. They had regular follow up in the OPD every 8 weeks with monitoring of renal function during each visit. ANA profile and C3 repeated yearly. Data analysis was done using SPSS software.

Results: 18 patients were included in the study. Age of the participants ranged from 10 to 62 years with a mean of 39.8. There were 6 males and 12 females. This ratio (M:F=1:2) is different from SLE. Most common presentation was acute glomerulonephritis with transient renal failure followed by 4 cases of RPGN; 3 nephotic syndrome and 1 nephritic nephrotic syndrome. The outcomes measured were progression to ESRD & development of autoantibodies. The mean duration of follow up was 2.3 years. Two patients reached ESRD & another 2 became antibody positive on follow up. On analyzing the risk factors male sex was found to be associated with poor renal outcome. Persistently low C3 indicates high risk of progression to ESRD and antibody positive lupus just as degree of GSG; TIA; number of cresents whereas initial creatinine; proteinuria or HTN did not have any impact on final outcome.

Conclusions: Commonest presentation - AGN Female to male ratio 2:1 Male sex -poor outcome Low C3 – risk of progression to ESRD and SLE. GSG; crescents; TIA in biopsy associated with faster progression. Initial proteinuria or creatinine; HTN did not show any impact on outcome.

109. Vitamin D Deficiency as a Risk Factor for Development of Post Transplant Diabetes Mellitus

M Patil, V Kute, H Patel, P Shah, D Gera, H Trivedi

Institute of Kidney Disease and Research Center - Institute of Transplantation Sciences; Ahmedabad; Gujarat; India

Background: Many studies have shown a relationship between vitamin D deficiency and insulin resistance in general population but the results remains controversial especially in renal transplant patients. Post-transplant diabetes mellitus (PTDM) is a frequent metabolic complication following solid organ transplantation; affecting 10–45% of kidney transplant recipients. It leads to impaired patient and graft survival and an increased rate of cardiovascular events.

Aim of the Study: The study aims to provide preliminary information about the levels of 25-hydroxy Vitamin D in renal transplant patients and find any correlation between its deficiency and development of PTDM.

Methods: A retrospective analysis of 468 patients transplanted between 2014 and 2016 was done. Pre and post transplant vitamin D levels; fasting blood sugar (FBS); post prandial blood sugar (PPBS); HbA1c levels were noted down. Vitamin D levels were classified into three groups <10 ng/ml; 11-30 ng/ml and > 31 ng/ml. PTDM was considered as patients developing diabetes mellitus (FBS > 126 mg/dl; PPBS > 200 mg/dl and HbA1c > 6.5) after transplant. All patients with pre transplant diabetes mellitus were excluded from study.

Results: The study showed that incidence of PTDM was 12.6%. Vitamin D levels <10 ng/dl were found in 16.2%; 11-30 ng/dl in 59.8% and >31 ng/dl in 24.1% of patients. We found a positive correlation between vitamin D levels <10 ng/dl and occurrence of PTDM (p<0.001).

Conclusions: In this single centre observational study; we identified vitamin D deficiency at the time of transplantation as an independent risk factor of PTDM.

110. A Study of Comparison of Efficacy between Erythropoietin Alfa and Darbepoietin Alfa for Mainataining Hemoglobin Levels in Hemodialysis Patients

Sidhant Bansal, Manoj Kumar Singhal, Anuja Porwal

Fortis Hospital; Noida; Uttar Pradesh; India

Background: Anemia in patients with CKD is managed with erythropoiesis-stimulating agents (ESAs). Epoetin alfa (EPO) with shorter half-lives (1 to 3 times/week) and Darbepoetin alfa (DBO) having longer half life (once per week) are similar in maintain hemoglobin concentrations. Recent availability of DBO in India and also the increasing prevalence of CKD on MHD in Indian population motivated us to conduct the study.

Aim of the Study: To compare the effectivity of EPO and DBO alpha for maintaining hemoglobin levels in hemodialysis patients.

Methods: A prospective; observational; nonrandomized; open label comparative study of 24 weeks included patients with CKD on HD for 3 months; older than 18 years; categorized into 2 groups: Group 1 (DBO-25 patients):HD patients on EPO were converted to DBO Q weekly; using the conversion factor of 200:1; Group B (EPO-26 patients):patients continued on EPO treatment. Primary endpoints were percentage of patients achieving target Hb; Hb variability and closeness to target. Number of dose changes in each group; cost of therapy and morbidity and mortality in each study group were compared as secondary end points. Hb levels; CBC; BUN; serum creatinine; calcium; phosphorous; ALP; SGOT; SGPT; iron profile; iPTH were done at prescribed intervals. Total blood volume processed; ultrafilterate removed were noted. Study drug dose was adjusted by increments or decrements of 25% to achieve a Hb increase of 1.0 g/dL every 2 weekly interval and to maintain Hb levels within a range (11.0 to 13.0 g/dL).

Results: The mean (SD) age was 59.04±14.52 years and 53.69±15.61; 18 and 19 were men in each group respectively. 47% were diabetic. All expect 1 patient in each group reached target levels with overall 57% DBO and 62% EPO (p = 0.297) readings in the target range. There was no significant difference among the groups in relation to hemoglobin levels at any point of time during the study period. There was no significant difference of hemoglobin variability or closeness; mean number of dose changes or direct cost of therapy between the groups. There was higher number of hospitalizations in the DBO group but no difference in the number of deaths between the groups.

Conclusions: DBO with similar efficacy in intravenous or subcutaneous administration with ease of once weekly administration may result into better quality of life for patients and indirect cost savings by saving the time spent by health care personnel.

111. Profile of Urinary Tract Obstruction

Girish P Vakrani, Nambakam Tanuja Subramanyam, Hareesha Babu, Ranjanee M

Vydehi Institute of Medical Sciences and Research Center; Bengaluru; Karnataka; India

Background: Urinary tract obstruction can lead to irreversible renal damage. The etiology mainly determined by patient age can be benign or malignant.

Aim of the Study: Retrospective analysis of urinary tract obstruction cases.

Methods: Total of 78 urinary tract obstruction cases were included. Variables like age; gender details; time duration of obstruction; etiology of obstruction; co-morbities; presence of renal failure; associated complications; need of dialysis; treatment were analyzed.

Results: Among 78 patients; average age of patients was 48.5 yrs; 28 were found to be female; main cause of urinary tract obstruction was urolithiasis (71%); commonest site of obstruction was ureter (81%); commonest symptom was pain abdomen (91%); Urosepsis was present in 80%; Renal failure was seen in (78%); dialysis requirement was seen in 31%; renal recovery was seen in 56%; mortality was seen in 5%.

Conclusions: Most common cause of urinary obstruction was urolithiasis. Past UTI/Chronic renal damage; bilateral obstruction influenced the renal recovery.

112. An Unusual Presentation and Histological Correlation of Myeloma Related Interstitial Nephritis

Nitin Kumar, Girish Narayen

Maxcure (Formerly Mediciti) Hospital; Hyderabad; Telangana; India

Background: Multiple myeloma (MM) is a plasma cell dyscrasia that is most often seen in old age.1 Lytic bone lesion; anemia; kidney failure; and recurrent infection are usually common. 2; 3. Diagnosis of MM is based on the presence of at least 10% plasma cell in bone marrow; presence of monoclonal protein in serum or urine; and end organ damage.4-6 Kidney failure and infection are the major causes of death in these patients.

Aim of the Study: Unusal presentation and Histological correlation of Myeloma related Interstitial Nephritis.

Methods: We have case of > 60 years of age with long standing history 8 months; weight loss; uremic symptoms; progressive increase of creatnine we have evaluated this case with biochemical investigation; kidney biopsy; bone marrow; serum free light chain assay.

Results: Based on evaluation kidney biopsy reported as Acute interstitial nephritis; further evaluation bone marrow examination; free light chain assay proved a case of multiple myeloma.

Conclusions: To conclude we have reported an unusual presentation of case which is not correlated with kidney biopsy in terms of chronicity.

113. Hepatopulmonary Abscess with Bilateral Pyelonephritis in a Patient with AKI

P Srinivas, Manjusha Yadla

Gandhi Medical College; Secunderabad; Telangana; India

Background: A 26 years old male; painter by occupation; non diabetic; non hypertensive; chronic smoker; occasional alcoholic presented with complaints of fever with chills since 1 week; anuria since 4 days; shortness of breath and right sided chest pain since 3 days; vomittings since 2 days. INVESTIGATIONS: HB: 12.8 gm%; WBC count: 14500/cumm; platelet count 1.9 lakhs/cmm; LFT: S. bilirubin – 1.2 (0.3/0.9); Malaria PF/PV: negative; CUE: albumin +; pus cells 10-12/hpf; Rbc nil.

Aim of the Study: Chest x ray (P/A) – WNL Usg abdomen: Mild hepatomegaly; grade 1 fatty liver; Cholelithiasis; RK: 9.5 × 3.6 cms CMD – normal. LK: 9.8 × 3.8 cms PCS – normal.

Methods: At admission Hb: 10.2 g% TLC: 30000/Cumm TPC: 2.47 lakhs/Cumm LFT: S. bilirubin 3.2 (1.1/2.1) mg/dl; SGOT/PT 110/63 IU; Alk Po4 596 IU S. protein 6.7 (3.2/3.5); PT: 22 sec (INR – 1.9); ApTT: 68 sec; S. creatinine: 10.4 mg/dl; B. Urea: 124 mg/dl; S/Electrolytes: Na – 140 mEq/L; K – 3.7 mEq/L Serum CPK: 140 CUE: albumin +++; pus cells 10-15/hpf; Rbc 2-4/hpf. Hospital course: Patient was started on Inj Piperacillin + Tazobactam (2.25 gm TID) and Inj Metronidazole (500 mg TID). Initiated on Hemodialysis support through right IJV. Later patient developed epistaxis and hemoptysis.

Results: Chest x ray: Right side haziness with minimal CP angle blunting. ECG: WNL. USG abdomen: Liver – normal Cholelithiasis. RK: 13.8 × 6.3 cms. LK: 13.9 × 7.4 cms. CT Abdomen: Liver: 10.2 × 10.4 × 9.8 cms well defined hypodense lesion in right lobe of liver s/o liver abscess. Kidneys: RK: 11 × 6.7 cms LK: 11.3 × 7.7 cms Peri nephric fat stranding s/o B/L Pyelonephriris. Right Gross Pleural effusion. Further Management & investigations Pig tail catheterisation done and liver abscess (anchovy sauce coloured & blood stained) drained. Blood and urine culture/sensitivity revealed no growth. Pus culture sensitivit Staphylococcus aureus sensitive to Linezolid. Anti Amoeba Antibodies IgG lectin (ELISA)– positive. Patient was dialysis dependent and started on antibiotics. Patient was transfused FFPs in view of DIC. Renal biopsy deferred in view of DIC. Patients creatinine continued to be high (serum creatinine 8 mg) is oliguric and dialysis dependent.

Conclusions: FINAL DIAGNOSIS: Mixed Pyogenic and Amoebic Liver abscess with right sided empyema; sepsis and multi organ failure with AKI.

114. A Case Report of Acute Pancreatitis in a Peritoneal Dialysis Patient

Gajera Hardik, Satyanarayana Garre, Denis Savalia, Ravi Andrews, Ashwini Panigrahi

Apollo Hospital; Hyderabad; Telangana; India

Background: Pain abdomen on peritoneal dialysis (PD) is usually suggestive of infective pathology but however acute pancreatitis (AP) is one of the important cause of pain abdomen on PD. We report a case of idiopathic AP in a 52 years old female on PD who presented with abdominal pain; fever; vomiting and a clear dark dialysate. In more than a quarter; no cause for AP was found. Serum amylase was normal in 12%-15% of episodes.

Aim of the Study: Acute pancreatitis (AP) can be a rare; but serious complication of PD with a high mortality and must be considered in the differential diagnosis of abdominal pain in a PD patient.

Methods: Single case report.

Results: We describe a case of idiopathic AP in a 52 years old female on PD who presented with abdominal pain; fever; hypotension; vomiting and a clear dark dialysate. She was on four cycles of CAPD which includes long night dwell of icodextrin and other three cycles of 4.25%. Initial diagnosis of PD-associated infective peritonitis was made but dialysate cultures proved negative. There was no response with intra peritoneal antibiotics and her serum amylase showed a mild rise of 335 U/L. USG abdomen showing peri-pancreatic collection followed with computed tomography revealed necrotising pancreatitis. Her serum and peritonel fluid lipase level was 1430 U/L and 67 U/L respectively. There was no common risk factors for AP were identified (gall stone; dyslipidemia). She was treated in ICU with antibiotics and anti fungal intra parental but couldn't revived.

Conclusions: Acute pancreatitis (AP) can be a rare; but serious complication of PD which carries high mortality and poor prognosis and it must be considered in the differential diagnosis of abdominal pain in a PD patient.

115. Efficacy and Complications of Tunneled Hemodialysis Catheters Placed by Nephrologists; without Fluoroscopy Guidance

Gajanan S Pilgulwar, K S Mehta, R Swami, S Jadhav, V Kokate, P Saruk, N Pawani, S Lande

T.N. Medical College and B.Y.L. Nair Ch. Hospital; Mumbai; Maharashtra; India

Background: Guideline 5 of the K/DOQI recommends that TCC be inserted under ultrasound and fluoroscopic guidance to limit insertion complications and maximize blood flow. As fluoroscopy is not always available in most of the hospitals; so the participation of Nephrology Department can be substantial.

Aim of the Study: To assess efficacy & complications of tunnelled hemodialysis catheters; without fluoroscopy guidance.

Methods: This is an observational prospective study in CKD patients performed during study period of Aug 2014 to May 2017. Inclusion criteria being CKD (VD) patients (1) waiting for AVF (2) with AVF failure. Primary end points of the study were removal of catheter as AVF matured; no flow or refractory infection. Till date we have inserted 175 catheters without fluoroscopy and since Jan 2017 we are using USG for guided insertion. We assessed technical success rate and early complications. Being public health institute we do not have MHD policy; after catheter placement patients were asked for follow up regularly.

Results: Total 175 Tunnel catheters were placed. Etiology being CGN in 36% followed by DKD in 26% & HTN in 23%. Technical success rate was 98.28%; 2 of failure patients had block and one catheter insertion into azygous vein. Patency duration was of longest 385 and shortest 15 days. Indications of catheter removal being AVF maturity in 62% and CRBSI 6%. Infection requiring catheter removal and catheter dysfunction occurred at very low rate. No life threatening complications were seen.

Conclusions: Placement of tunnelled hemodialysis catheters placed by nephrologists; without fluoroscopy guidance be a viable choice that is not only safe but also inexpensive; representing a good alternative when no other choice is available; or when cost is an important factor.

116. Septic Pulmonary Emboli Secondary to Dialysis Catheter in the Absence of Endocarditis or Right Atrial Thrombus Managed with Cytosorb Filter

Satyanarayana Garre, Hardik Gajera

Apollo Health City; Hyderabad; Telangana; India

Background: Catheter-related bloodstream infection; although a major cause of morbidity and mortality in hemodialysis population; is rarely associated with septic pulmonary emboli (SPE). SPE is generally associated with endocarditis or right atrial thrombus. We describe a case of a young man on hemodialysis with fever; who was subsequently diagnosed to have SPE in the absence of endocarditis or right atrial thrombus.

Aim of the Study: Reprting a rare complication of IJ dialysis cathter.

Methods: Case report.

Results: A 58 yrs old lady CKD on HD with IJ cathter in place for 4 wks developed severe sepsis with shock on evaluation found to hav a thrombus on TEE and multiple septic emboli in lungs.

Conclusions: Rare of IJ dilaysis cathter realted septic embolus.

117. A Rare Case of Pgnmid in a Young Male Patient

Satyanarayana Garre, Hardik Gajera

Apollo Health City; Hyderabad; Telangana; India

Background: Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) is a newly described entity that belongs to the class ofdisorders known as monoclonal gammopathy of renal significance (MGRS). The renal deposit in PGNMID is composed of monoclonalimmunoglobulin (Ig). This entity affects adults and most patients presentwith nephrotic-range proteinuria and haematuria with or withoutrenal failure.

Aim of the Study: A rare case of PGNMID in a 8 yrs old young male child.

Methods: Case report.

Results: A rare case of PGNMID in a 8 yrs old young male child.

Conclusions: A rare case of PGNMID in a 8 yrs old young male child.

118. First Successful Simultaneous Pancreas Kidney Transplant in IKDRC-ITS

Deepak Kumar, H V Patel, J Rijvi, V B Kute, P R Shah, H I Trivedi

IKDRC-ITS; Ahmedabad; Gujarat; India

Background: A 36 year old male patient diagnosed case of type 1 DM since 12 yrs of age; CKD and HTN since last 6 yrs. Came to IKDRC-ITS with increasing B/L pedal edema and frequent episode of hypoglycemia since last 4 month; after admission underwent 4 cycle of HD and finally after explaning the risk & benefit of pancreas transplant with consent pt was enrolled in cadaveric simultaneous pancreas kidney transplant registry

Aim of the Study: Explaning the role of simultaneous pancreas kidney transplantation in long term management of diabetes mellitus.

Methods: Patient underwent spk transplant (with enteric drainage & systemic anastomosis) on 10/04/2017 from cadaver donor (age-22 yrs; male; declared brain dead due to RTA with SDH). Induction agent- ratg (1.5 mg/kg) triple immunosuprresive regimenprednisolone (20 mg) tac-(0.05 mg/kg) mmf -360 mg tds later on bd3 month post transplant follow up of patient is uneventful. patient achieved euglymia without insulin and serum creat was 0.70 mg/dl on last follow up.

Results: The major benefits of combined kidney-pancreas transplantation are decreased mortality and improved quality of life. The improved quality of life is due to freedom from frequent blood sugar monitoring; insulin therapy; hypoglycemia; and dialysis. SPK Transplantation also have favourable outcome in Glucose metabolism Lipid metabolism and atherosclerosis Nephropathy & Neuropathy Retinopathy Fertility Fracture risk.

Conclusions: Successful pancreas transplantation restores glucose-regulated endogenous insulin secretion; arrest the progression of the complications of diabetes; and improve quality & quantity of life.

119. Unusual Presentation of a Not so Rare Disease!!!

Neha Singh, P Soundararajan

Saveetha Medical College; Chennai; Tamil Nadu; India

Background: Meningoencephalitis is the most common clinical manifestation of cryptococcal infection. We report a unusual presentation of cryptococcal infection in a post renal transplant patient. 37 Yr/male; known case of deceased donor renal transplantation done in 2015; with stable graft function presented with history of recurrent symptomatic hyponatremia. CSF analysis was done which was suggestive of cryptoccocal Meningitis. Hyponatremia improved after appropriate anti fungal therapy.

Aim of the Study: Not applicable.

Methods: Not applicable.

Results: Not applicable.

Conclusions: Symptomatic Hyponatremia secondary to SIADH remains a rare complication of crypotococcal meningitis.

120. Role of Neutrophil Gelatinase-Associated Lipocalin (NGAL) in Plasma and Urine After Intravenous Contrast Induced Acute Kidney Injury in Adult ICU Patients

Sushma Singh, Saurabh Chaturvedi1, Harshit Singh, Ravi Mishra1, Mohan Gurjar2, Vikas Agarwal1, Pralay Ghosh2, Narayan Prasad

Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India.

Background: Acute Kidney Injury (AKI) is a common clinical condition despite progress in medical care. The goal of early identification of AKI has been the primary impetus for biomarker research. Although Acute Kidney Injury Network (AKIN) 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: NGAL has been found early and sensitive marker of AKI. This biomarker has 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 h after contrast exposure. NGAL assay done by ELISA; and urinary levels normalized as per UCr values for each sample. Contrast induced acute kidney injury (CI-AKI) is defined as a rise in SCr of ≥0.3 mg/dl within 48 hrs.

Results: 40 medical patients with 30 CT scans included. Median age was 36 yrs and 54% male. On the day of inclusion; median SOFA score was 3; 16% were on mechanical ventilation; and 10% on vasopressin. 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): 718.5±204.76; 854.5±330.05 (0.04); 1099.25±229.03 (0.03) and 790±321.4 (0.22); U NGAL (ng/mg of UCr): 67.63±48.09; 39.69±19.79 (0.07); 101.97±90 (0.12) and 59.87±56.85 (0.73). After contrast; P NGAL levels was significantly raised at 24 h (p=0.03) while U NGAL was not significantly raised at any point of time.

Conclusions: In critically ill adult patients; at 24 h there is significant increase in P NGAL levels while U NGAL is not increased either at 4 h; 24 h or at 48 h after contrast exposure.

121. Higher P-Glycoprotein Expression on Pbmcs Associated with High Tacrolimus Blood Level in Renal Transplant Recipient

Akhilesh Jaiswal, Mantabya Singh, Mohit Rai1, Harsit Singh, Saurabh Chaturvedi1, Vikas Agrawal1, Narayan Prasad

Departments of Nephrology and Renal Transplantation and 1Clinical Immunology; Lucknow; Uttar Pradesh; India

Background: Renal transplantation is the best modality of RRT and adequate immunosuppression is the cornerstone of the success of transplant. is adequate immunosuppression. Tacrolimus (Tac) is one of the most widely used immunosuppressant but there is marked inter individual variations with small therapeutic range of blood Tacrolimus level. This inter-individual variations in Tac level may be because off differential expression of P-glycoprotein (P-gp); which is efflux pump expressed on lymphocytes.

Aim of the Study: This study aimed to evaluate the P-gp expression on PBMCs; CD4 and CD8 cells and correlate with Tacrolimus trough concentration in renal allograft recipients.

Methods: We recruited 54 renal transplant recipients; of them 37 were high Tac level to dose ratio (4.04 ng/ml/mg) and 17 were low Tac level to dose ratio (1.04 ng/ml/mg) with stable renal function. Demographic and biochemical parameters were collected from OPD and kidney transplant unit. Of the 54 patients; 29 had glomerulonephritis; 19 had interstitial nephropathy; 5 had diabetic nephropathy and 1 had polycystic kidney disease. All patients were on triple immunosuppressive Tac; MMF and prednisolone. Heparinized blood sample were taken for P-gp expression analysis. P-gp expression and functionality were analyzed on flowcytometer.

Results: Tac dose was significantly low in high Tac trough level patients compare to low Tac trough level (2.26±1.52 vs 3.86±1.74; p=0.046); however Tac level was significantly high in patients with high Tac trough level compare to low Tac trough level (9.14±4.95 vs 4.05±1.64; p=0.001). P-gp positive cell and RFI were significantly high in high Tac level group (p<0.001; 0.001 respectively) compare to low Tac level group. When we analyze absolute P-gp expression w found significantly high expression in high Tac level group than low Tac level group. The functionality of P-gp was also high in high Tac level group than that of low Tac level group in lymphocyte population. CD4+; CD8+ and CD4+/CD8+ ratio were slightly low in low Tac level group but there were not any significant difference in the groups (p 0.486; 0.087; 0.358 respectively). However; P-gp positivity on CD4+ and CD8+ cell were significantly high (p 0.043; 0.001 respectively) in high Tac level group than that of low Tac level group.

Conclusions: P-gp monitoring predicts the optimal dose of tacrolimus in renal transplant recipients and may predict the initial daily dose needed by individual patients to obtain adequate immunosuppression.

122. The Indian Chronic Kidney Disease Cohort Study: Baseline Characteristics

Ashok Kumar Yadav, S Bhansali, V Kumar, S Gang1, G K Modi2, S Parameswaran3, N Prasad4, M Sahay5, S Varughese6, Shivendra Singh7, Dipankar Sircar8, J P Ojha7, R Pandey8, K L Gupta, V Jha9

Postgraduate Institute of Medical Education and Research; Chandigarh; 1Muljibhai Patel Urological Hospital; Nadiad; Gujarat; 2Samarpan Kidney Institute and Research Center; Bhopal; Madhya Pradesh; 3Jawaharlal Institute of Postgraduate Medical Education and Research; Puducherry; 4Sanjay Gandhi Postgraduate Institute of Medical Science; Lucknow; 7Institute of Medical Science; Banaras Hindu University; Varanasi; Uttar Pradesh; 5Osmania Medical College; Osmania General Hospital; Hyderabad; Telangana; 6Christian Medical College; Vellore; Tamil Nadu; 8Institute of Post Graduate Medical Education & Research; Kolkata; West Bengal, 9George Institute for Global Health; New Delhi; India

Background: Chronic kidney disease (CKD) has emerged as an important public health problem in India. The burden of disease; and its risk factors are expected to rise exponentially. Defining the correct epidemiology of disease is the first step in approach to address disease outcomes.

Aim of the Study: The Indian Chronic Kidney Disease (ICKD) study aims to define the course; progression and risk factors for disease complications in patients with CKD in India.

Methods: The ICKD study is an ongoing; nationwide; multi-centric prospective observational cohort study of CKD subjects; currently enrolling patients across nine centers in India. Inclusion criteria include age between 18-70 years and diagnosis of stage 1-3 CKD with stable clinical course for at least 3 months. Organ transplant recipients; those with malignancy for last 2 years; non-Indian ethnicity; pregnancy in case of females; on immunosuppressive therapy; life expectancy <1 year and with poor functional status are excluded. Demographic details; history related to kidney diseases and their risk factors; CVD and other co-morbidities are recorded periodically. Blood and urine samples are being collected at baseline and at follow up. The study is approved at each center by appropriate Institute Ethics Committees.

Results: We analyzed Data from the first 1551 subjects. The causes of CKD are diabetic nephropathy; chronic glomerulonephritis and chronic interstitial nephritis in 19%; 19% and 17% of subjects; respectively. An exact etiological diagnosis could not be made in 27%. A total of 10%; 53.8%; 26.7% and 9.5% subjects had baseline eGFR ≤30; >30-45; >45-60 and >60 ml/min/1.73 m2 respectively. The mean age was 50.3 ± 12.0 years. 69% were males; 58% hailed from rural areas and 40% were vegetarian. A total of 28% had education below high school. Medical insurance was available to 27%. Occupational exposure to sand; dust; chemicals; animals etc. was noted in 48%. Approximately 25% reported history of use of alternative medicines. About 7%; 51% and 42% subjects had BMI <18; 18-25 and >25 respectively. BMI was higher in females (p<0.001). About 69% subjects were hypertensive; 32% had diabetes and 16% had cardiovascular disease. The hemoglobin was <8; 8-11 and >11 mg/dl in 1.8%; 27.9% and 70.3%.

Conclusions: The study is the first comprehensive description of early stage CKD in India; and provides a platform to study clinical; laboratory as well as socioeconomic determinants of prognostic factors.


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Indian Journal of Nephrology
Published by Wolters Kluwer - Medknow
Online since 20th Sept '07