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   1. Study of Risk...
   2. Clinical Safe...
   3. Heat Stress I...
   4. Case Control ...
   5. Does Platelet...
   6. The Role of C...
   7. Novel Urinary...
   8. New-Onset Dia...
   9. Simplified Ri...
   10. Clinical and...
   11. Combination ...
   12. Biomarkers i...
   13. Anti Complem...
   14. Is Automated...
   15. A Prospectiv...
   16. A Prospectiv...
   Rekha-1 Pattern ...
   17. Setting Up a...
   18. Role of Dono...
   19. Co-Inheritan...
   20. Role of Iron...
   21. Podocyte Inf...
   22. Technical Su...
   23. Epigenetic R...
   24. Tacrolimus C...
   25. Genome Wide ...
   26. Direct Antiv...
   27. Tacrolimus M...
   28. The Linkage ...
   29. Weight Gain ...
   30. Strategies o...
   31. Measurement ...
   ORO – Post...
   1. Carnosine Pre...
   2. Tuberculosis ...
   3. An Observatio...
   4. Renal Deposit...
   5. Contast Induc...
   6. Ultrasound As...
   7. Phosphodieste...
   8. Utility of Fl...
   9. Circulating E...
   10. 5-HT2 and 5-...
   11. Influence of...
   12. Clinical Spe...
   13. Maintaining ...
   14. Molecular Pr...
   15. Post Renal T...
   16. Targeting Mi...
   17. A Study on I...
   18. Study of Car...
   19. Vascular End...
   20. Association ...

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  Table of Contents  
Year : 2018  |  Volume : 28  |  Issue : 7  |  Page : 1-27

Oral Presentations

Date of Web Publication12-Dec-2018

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How to cite this article:
. Oral Presentations. Indian J Nephrol 2018;28, Suppl S1:1-27

How to cite this URL:
. Oral Presentations. Indian J Nephrol [serial online] 2018 [cited 2019 Dec 11];28, Suppl S1:1-27. Available from:

Oral Paper Presentations 21 December 2018 (10.20 am to 11.40 am) Hall A

  1. Study of Risk Factors for Early-Onset Peritonitis in Peritoneal Dialysis Patients Top

Naveen Koppara, R Ram

Department of Nephrology; SVIMS; Tirupathi; Andhra Pradesh; India

BACKGROUND: Early peritonitis was confirmed to be associated with a higher risk of early technique failure. However; literature concerning peritonitis within the first 3 months of peritoneal dialysis (PD) initiation is scarce. The present study was to investigate risk factors associated with early-onset peritonitis in PD patients.

AIM OF THE STUDY: Study of risk factors for early peritonitis.

METHODS: In this retrospective observational cohort study; all incident PD patients from January 1; 2013; to January 31; 2018; were recruited and followed up until June 31; 2018. According to time-to-first episode of peritonitis; patients were divided into early-onset (≤ 3 months) peritonitis and late-onset (> 3 months) peritonitis. Baseline demographic; clinical; and laboratory data; as well as episodes of peritonitis; were collected. Risk factors associated with early-onset peritonitis were evaluated using logistic regression model.

RESULTS: Of 321 patients on PD; 241 (75%) developed at least 1 episode of peritonitis and 29 (9.0) patients presented the first episodes of peritonitis within the first 3 months. A multivariate logistic analysis showed that higher body mass index (BMI) (odds ratio [OR] 1.08; 95% confidence interval [CI] 1.01 – 1.15; p = 0.034); hypoalbuminemia (OR 1.75; 95% CI 1.11 – 2.78; p = 0.017); and catheter exit-site infection (OR 4.14; 95% CI 2.45 – 7.00; p < 0.001) were risk factors independently associated with early onset peritonitis. Compared to those with late-onset; patients with early-onset peritonitis had a higher overall peritonitis rate (0.76 vs 0.38 per patient-year; p < 0.001) and worse technique survival (p < 0.001); while patient survival did not differ significantly between the 2 groups during the long-term follow-up (p > 0.05).

CONCLUSIONS: Higher BMI; hypoalbuminemia; and catheter exit site infection were the risk factors associated with early-onset peritonitis in PD patients.

  2. Clinical Safety and Efficacy Testing of The First Indian Hemodialysis Device Top

K K Kiran, M S Shetty, A Sharma1, P Keshaviah2, S V Rao1, L Vincent3

Department of Nephrology; JSS Medical College Hospital; Mysore; 1Renalyx Health Systems Pvt. Ltd; 3Department of Nephrology; Narayana Hrudayalaya; Bengaluru; Karnataka; 2Himalayan Institute Hospital Trust; Dehradun; India

BACKGROUND: Haemodialysis (HD) improves the survival and quality of life in patients with chronic kidney disease stage-5 (CKD-5). However; high quality; cost effective hemodialysis devices are not manufactured in India. New means of manufacturing and delivering haemodialysis are therefore needed for local populations.

AIM OF THE STUDY: Our aim was to assess the safety and efficiency of a HD device Renalyx RxT17 for the first time in India at the nephrology department; JSS Medical College Hospital; India.

METHODS: An open label; crossover; observational study was conducted. Five stable male patients (mean age 38± 8 years) with CKD-V due hypertensive nephropathy were studied. The Fresenius 4008S machine was used for a single control dialysis session. Subsequently; three consecutive sessions were conducted on the RxT17 HD device to determine safety; efficacy and variations within or between dialysis. A total of 20 sessions were carried out (5 sessions on the Fresenius 4008S machine and 15 sessions on RxT17 HD device). Patient characteristics (vitals; adverse events) and machine (conductivity; TMP; temperature; UF volume; alarms) and were documented. Biochemical; microbiological and haematological samples were collected and analysed. Any adverse events and device deficiencies were noted. A validated patient satisfaction questionnaire (RTSQ) was used to understand morbid and therapy.

RESULTS: All patients had stable vital signs with no serious adverse events during the dialysis sessions. The machine operated within the acceptable range of conductivity (Na equivalent of less than 3 mEq/L); temperature (less than 0.5°C); and set ultrafiltration (UF) volume (within 10%) of target value; comparable to the Fresenius machine. The mean ± SD of clearance; KT/V (Urea) RxT-17 HD was 1.15±0.3 Vs 0.96±0.5 for Fresenius 4008S. The mean Urea reduction Ratio (%) was 56.7±12.3 for RxT17 HD Vs 49.0±19.1 for Fresenius 4008S. No haemolysis in any of the dialysis sessions. The RTSQ evaluation revealed good treatment satisfaction scores.

CONCLUSIONS: This preliminary report suggests that the Renalyx RxT17 haemodialysis machine is comparable to Fresenius 4008S in efficacy and safety of delivering normal dialysis to patients with CKD-V.

  3. Heat Stress Implications on Renal Health of Steel Industry Workers Top

Johnson Priscilla, Venugopal Vidhya, P K Latha, S Rekha, K Manikandan, S Krishnan

Department of Nephrology; Sri Ramachandra Institute of Higher Education and Research (Deemed to be University); Chennai; Tamil Nadu; India

BACKGROUND: Rising global temperatures coupled with inadequate water intake may worsen the effects of occupational heat exposure among workers in tropical countries. Studies have shown that populations exposed to recurrent dehydration due to high ambient temperatures; inadequate fluid intake and intense physical activity have a higher incidence of kidney stones. Recent research has shown that subjects who develop kidney stones were twice as likely to develop end-stage kidney disease in subsequent decade.

AIM OF THE STUDY: This study was conducted to evaluate the effects of chronic indoor occupational heat stress on the kidney health of workers exposed to high temperatures.

METHODS: This study was conducted among 340 workers in a steel industry in South India. Indoor heat stress in various workplace locations were assessed via measurements of the Wet Bulb Globe Temperature (WBGT) using a portable heat stress monitor. Details regarding the workers’ perception on heat exposure and any self-reported heat-related health issues were obtained using a standardized questionnaire. Heat strain indicators such as core body temperature (CBT); sweat rate and urinary specific gravity were measured. Ultra-sonogram abdomen and pelvis was done for individuals who reported heat stress related illness and who had higher CBT; urine specific gravity and sweat rate.

RESULTS: 65% (n=220) of the workers had WBGT exposures higher than the recommended TLV (Avg. WBGT-33.2°C±3.8°C) as per ACGIH guidelines. 74% of the study participants reported symptoms of heat stress such as heat rash; headache; heat exhaustion; heat cramps etc. Significant association was noticed between heat exposure and heat strain indicators such as CBT and urinary specific gravity (X-squared = 5.0142; df = 1; p-value = 0.02514). A significant association existed between the workers’ heat exposure and presence of renal calculi (X-squared = 5.65; df = 1; p-value = 0.017). Duration of exposure to heat source also had a significant association with the occurrence of kidney related issues (X-squared = 4.651; df = 1; p-value = 0.031).

CONCLUSIONS: Occurrence of heat-related renal illnesses among a group of workers in hot environment has to be flagged as this indicates inadequacy of heat control measures and medical screening. This stresses the need for early diagnosis of heat-stress nephropathy and to design prevention strategies.

  4. Case Control Study of Rituximab (Active) Versus Modified Ponticelli Regimen (Control) in Primary Membranous Nephropathy Top

Abhinaba Debnath, Sanjay Dasgupta, Arpita Roy, Dipankar Sircar, Debabrata Sen, Rajendra Pandey

Department of Nephrology; Institute of Post Graduate Medical Education and Research; Kolkata; West Bengal; India

BACKGROUND: Primary MN is one of the commonest causes of adult onset nephrotic syndrome and also a common glomerular cause of ESRD. It is B cell mediated disease and rituximab; an anti CD20 monoclonal Ab has emerged as promising treatment option. Current treatment options corticosteroid; alkylating agent and CNIs; all of them are associated with significant adverse effects. So we have designed this case control study to compare the efficacy of rituximab with historical control of modified ponticelli regimen.

AIM OF THE STUDY: To compare the safety and efficacy of rituximab in the management of primary membranous nephropathy and to compare with historical control group treated with modified ponticelli regimen.

METHODS: Since February 2017; we treated 14 biopsy proven primary MN with 4 weekly doses of i.v. rituximab (375 mg/m2).100 mg i.v. methyl prednisolone was given prior to first dose.24 hour urine protein; serum creatinine; albumin and lipid profile was performed at baseline; 6th and 12th month. Patients who completed 12 months of follow-up were compared to a historical control group of 15 primary MN treated with modified ponticelli regimen. The primary outcome of this study was cumulative number of patients who experienced both partial or complete remission (PR/CR). The secondary outcome was change in 24 hour urine protein; serum albumin; eGFR and adverse effects. Definition of PR/CR; relapse; treatment failure and inclusion criteria was followed according to KDIGO guideline. Exclusion criteria were: patients with active infection/TB; DM; HBV/HCV/HIV; neoplasia; pregnancy; membranous lupus nephritis; previous therapy with prednisolone; MMF; CNIs within 4 months and alkylating agents within 6 months.

RESULTS: 14 biopsy proven primary MN treated since February 2017. Among them 8 completed 12 months of follow-up. We compared them with 15 historical control treated with modified ponticelli regimen. Their baseline variables were comparable to each other. At 12th month 5 patients (62.5%; 30.57-86.32) achieved primary end point [complete remission 1 and partial remission 4] in rituximab group and 7 patients (46.7%; 24.81-69.89 [complete remission 2 and partial remission 5]) in ponticelli group (p=0.66). At 12th month 24 hour urine protein reduced from 6.30 (5.11-13.9) to 1.37 (0.83-3.38) [p=0.034]in rituximab group and 6.8 (5.35-7.83) to 4.5 (0.53-8.91) [p=0.005] in ponticelli group and mean reduction of proteinuria was 66.36% and 28.44% respectively. At the end when compared both group; there was no significant difference in change in 24 hour urine protein[p=0.22]; serum albumin[p=0.09] or eGFR[p=0.22]. In ponticelli group serious adverse event occurred in 1 patient; whereas it was none in rituximab group.

CONCLUSIONS: In conclusion; rituximab appears to be effective in achieving CR/PR of proteinuria in 62% without any adverse event; but there was no significant change in GFR. When we compared with modified ponticelli regimen; there was no significant difference in remission rate; proteinuria reduction or GFR changes.

  5. Does Platelet Function; As Measured by Platelet Function Analyser-200 Predict Risk of Post Renal Biopsy Bleed in Chronic Kidney Disease Stage G 4 and 5 Patients? - A Prospective; Observational Cohort Study Top

Anjali Mohapatra, AT Valson, S Kakde, T Geevar, R G Dave, M S Bindra, N Duhli, D Korula, V Moses, N K Shyamkumar, V G David, S Alexander, S Jacob, G Rajan, P M Koshy, E E John, S Varghese, G T John

Department of Nephrology; Transfusion Medicine and Immunohaematology; Department Pathology and Radiodiagnosis; Christian Medical College; Vellore; Tamil Nadu; India; Department of Renal Medicine; Royal Brisbane and Women's Hospital; Brisbane; Queensland; Australia

BACKGROUND: In a recently published study; our group showed that bleeding time is normal in the majority of CKD stage G 4 and 5 patients; yet an audit of our biopsy data showed that 60% of symptomatic post renal biopsy bleeds occurred in this group. We wanted to determine if this increased bleeding risk could be attributed to platelet dysfunction; and if so; whether the use of a sensitive platelet function test such as PFA-200 could predict the risk of bleeding after kidney biopsy.

AIM OF THE STUDY: To assess whether abnormal platelet function as assessed by the Platelet function analyzer 200 (PFA 200) predicts a higher risk of bleeding in CKD stage G4-5 patients who undergo a renal biopsy.

METHODS: Between May and August 2018; after taking written; informed consent; we recruited consecutive adult CKD Stage G4-5 patients who were to undergo an ultrasound guided native kidney biopsy. We excluded patients who had received dialysis in the two weeks prior to the study; patients with acute kidney injury; chronic liver disease; haemoglobin <8 g/dL despite blood transfusion and platelets < 1 lakh/mm3. After an overnight fast; 4.5 ml of whole venous blood was collected on the morning of the renal biopsy and used to measure collagen adenosine diphosphate closure time (CADPCT) by PFA 200 and perform platelet counts and morphology. At 30 minutes and 24 hours after biopsy; patients were screened by ultrasound to look for any evidence of a haematoma. A minor bleed was defined as haematoma or gross haematuria not requiring blood transfusion. A major bleed was defined as bleeding requiring blood transfusion; angioembolization or nephrectomy or causing hypotension; septicemia or death.

RESULTS: A total of 52 patients (mean age 44.4 ± 12.3 years; CKD EPI eGFR 17.3 ± 6.3 ml/min/1.73 m2; 69% male; 38% diabetic) were included in the study. Only 3 patients had a prolonged (≥ 142 seconds) CADPCT and the median CADPCT was 88 seconds. Sixteen patients (30.8%) had a bleed; all minor. There was no difference in bleed rate between patients with normal and abnormal CADPCT (14/49 vs. 2/3; p = 0.221); CADPCT above or below the median value (32% vs. 29.6%; p = 1.00) or lowest and highest quartiles of CADPCT (30.8% vs. 41.7%; p = 0.545). Bleeding was associated with younger age (p = 0.015; 95% CI 0.88 – 0.98); lower BMI (p = 0.043; 95% CI 0.69-0.99) and biopsy diagnosis of diabetic nephropathy (p = 0.003; 95% CI 2.7-145.6) but not eGFR; blood pressure; platelet count; renal cortical thickness or parenchymal grade; biopsy gun passes; experience of the person performing biopsy; biopsy core length; degree of glomerulosclerosis; interstitial fibrosis; or arteriosclerosis in the biopsy specimen.

CONCLUSIONS: CADPCT as measured by PFA-200 is normal in most patients with CKD 4-5 and does not predict the risk of post renal biopsy bleed. Young age; low BMI and biopsy proven diabetic nephropathy are risk factors for post biopsy bleed.

  6. The Role of Catalytic Iron in Experimental Contrast-Induced Acute Kidney Injury Top

Chandrashekar Annamalai1,2, Badrinathan Sridharan1, Gokula Kannan1, Baniprata Mukhopadhyay3, Mohan Rajapurkar3, Pragasam Viswanathan1

1Renal Research Lab; School of Biosciences and Technology; VIT; Vellore; Tamil Nadu; 2Department of Nephrology; Apollo Hospitals; Bilaspur; Chhattisgarh; 3Department of Nephrology; Muljibhai Patel Urological Hospital; Nadiad; Gujarat; India

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is an important cause of hospital-acquired AKI. Though studied extensively; the complete pathogenesis is not clear. Kidneys express many proteins that are involved in iron metabolism and transport. And iron is being increasingly implicated in the pathogenesis of nephrotoxicity both in in vitro and in vivo models.

AIM OF THE STUDY: To induce contrast-induced AKI in experimental animal by using Iohexol; an iodinated radiocontrast agent and to elucidate the role of catalytic iron in inducing oxidative stress and nephrotoxicity.

METHODS: 30 Albino Wistar rats each weighing 200 grams (Group 1) were injected with Iohexol at 3 grams iodine/kg dose. 6 control rats (Group 2) were given saline. From group 1; six animals were sacrificed each at 2; 4; 6; 12 and 24 hours following contrast use. Serum iron; total iron binding capacity; serum ferritin (Cat: MBS564109) and haptoglobin (Cat: MBS564114; MyBiosource; USA) were measured by ELISA. Serum and urine catalytic iron were measured by bleomycin-detectable iron assay after suitable modification. Urinary NGAL was assayed using ELISA (Cat: sc-80561; Santa Cruz Biotechnology Inc; USA). Renal histology was done using H&E and Perl Prussian blue stains along with transmission electron microscopy. Gene expression of transferrin receptors 1 and 2; ferritin; hepcidin and ferroportin by qPCR were carried out along with Western blot and immunohistochemical analysis of transferrin. Lipid peroxidation and antioxidant (total thiol; catalase; superoxide dismutase) levels were determined.

RESULTS: A significant raise in serum creatinine and urinary NGAL levels and proteinuria occurred following Iohexol injection. Acute tubular necrosis was seen on light and electron microscopy. Hemosiderin deposits were visible on Perl Prussian Blue staining. Altered iron-regulating gene expression was evident. Serum and urine catalytic iron levels were significantly increased (p = 0.0001 and p = 0.0012; respectively). No significant correlation noted between serum catalytic iron and serum creatinine and urinary NGAL. However; a significant positive correlation occurred between urinary catalytic iron and urinary NGAL (r = 0.7573; CI 0.4492 to 0.9044; p = 0.0003). Serum creatinine negatively correlated with serum iron and haptoglobin. Urinary NGAL was directly associated with serum iron and serum ferritin. Both serum and urinary catalytic iron positively correlated with tissue peroxidation. On multivariate linear regression; superoxide dismutase negatively predicted serum creatinine (p = 0.034).

CONCLUSIONS: Intrarenal presence of iron and elevated catalytic iron together with altered gene expression of iron-regulating proteins and increased oxidative stress implicate iron in nephrotoxicity. AKI is likely to be a renal sideropathy with iron being a potential nephrotoxin and a key therapeutic target.

  7. Novel Urinary Biomarkers in Non Hypertensive Early Diabetic Nephropathy Top

Himansu Sekhar Mahapatra, Bindu Kulshreshtha, Anubhuti, Parul Goel, Muthu Kumar, Adarsh, Anamika Kumari, Bibhash Dutta, Arpita Arora, Yadunandan Prasad Gupta, Venkateshan Sekhar

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

BACKGROUND: Although conventional urine microalbumin testing is the gold standard for detecting early Diabetic nephropathy (DN); novel Urinary Biomarkers (UBM) which include Angiotensinogen (AGT); Cystatin C (CysC); Interleukin -18 (IL-18) and Neutrophil gelatinase associated lipocalin (NGAL) estimation may detect nephropathy even in hyper-filtration stage; thereby preventing progression. Available literature shows varied ranges of these UBM levels across different studies.

AIM OF THE STUDY: To study the comparison of urinary biomarkers in early diabetic nephropathy with healthy individuals’ biomarker levels available in the existing literature.

METHODS: All patients attending OPD were screened as per their past history; clinical records to define pre-diabetic and diabetic state. They underwent detailed clinical examination such as measurement of blood pressure; body weight; height and investigations which include fasting and post prandial Blood sugar; HbA1C; routine urine examination by Multi-stix; Albumin creatinine ration (ACR) and serum creatinine for calculation of estimated Glomerular Filtration Rate (e-GFR). Considering inclusion and exclusion criteria; the same investigations has been repeated after three months’. Thereafter study subjects were included. The ACR and e -GFR were repeated at 6th and 12th month to see the progression. At 6th month all the UBM's (NGAL; AGT; IL-18; Cys C) were estimated and compared with the control group of the available literature.

RESULTS: A total of 952 patients were screened. Of them; 46 (4.8%) were Pre-diabetic; 641 (67.3%) wewe Diabetes; 310 (32.5%) were hypertensives and 114 (11.9%) were hypothyroid. After exclusion; 161 met our inclusion criteria; have early DN and were enrolled in the study. At the 6th month; all the UBM values were elevated significantly{(mean difference; standard error; p value) of NGAL; ATN; IL-18 & CysC were (-23.9; 7.52; 0.0007); (-193.55; 27.35; 0.0000); (-16.69; 4.53; 0.0002) & (-18.82; 1.832; 0.000) respectively} when compared with controls (healthy individuals available in the existing literature). At one year; average GFR value has decreased to normal from hyperfiltration stage (GFR120 ml) and ACR have been in rising trend.

CONCLUSIONS: This is a unique study where four novel UBM's were estimated; which appears to detect early DN. Our ongoing longitudinal study shall clarify the range of different UBM in progressing phases of DN.

  8. New-Onset Diabetes After Transplantation and Glucose Metabolism in At Risk Patients Receiving Cyclosporine Versus Tacrolimus: A Randomised Controlled Trial Top

Neeraj Jain, Manish Rathi

Department of Nephrology; PGIMER; Chandigarh; India

BACKGROUND: NODAT is an immunosuppressive agent-induced metabolic complication after renal transplantation. Incidence varies from 4% to 29% in various studies. The United States Renal Data System demonstrated NODAT to be associated with a 63% increased risk of graft failure (P<.0001) and 87% increased risk of death (P<.0001). No study has evaluated the incidence and outcome in transplant recipients at risk for the NODAT. Effect of modification of immunosuppressive regimen is not clear from present studies.

AIM OF THE STUDY: The incidence of NODAT in at-risk patients who had received Tac versus CsA. Compare Insulin resistance (HOMA-IR) and beta cell function (HOMA- %B) in two groups and graft outcome between groups.

METHODS: This Pilot study was a randomized controlled trial; carried out at the Department of Nephrology; PGIMER; Chandigarh between 1st January 2017 and 30th June 2018. Patients who underwent renal transplant at PGIMER; Chandigarh were evaluated for risk factors For NODAT by recording family history of diabetes; FPG; OGTT; HbA1c. Patients who were at risk for NODAT were selected and randomised into two groups. One group was given cyclosporine and the other tacrolimus. Randomisation was done by random number allocation. All study participants were followed up at 1; 3 and 6 months and were enquired about major or minor side effects of medications. Their renal function and glucose metabolism parameters were also recorded. Primary endpoint was Percentage of patients with fasting plasma glucose (FPG) > 126 mg% or 2-hours OGTT > 200 mg% at 1; 3 and 6 months in both groups. Other Study variables were changed glucose metabolism parameters and graft outcome between two groups.

RESULTS: Out of 231 patients screened; 26 patients fulfilling the inclusion and exclusion criteria were selected and randomised to receive tacrolimus and cyclosporine. 5/13 (38.4%) patients in tacrolimus group and 4/13 (30.7%) patients in cyclosporine group developed NODAT (p=0.68). Recipients with Normal glucose tolerance were 53.8% in the cyclosporine group and 30.8% in the tacrolimus group (p=0.37). Resolution of NODAT was 50% in cyclosporine group and 20% in tacrolimus group (p=1.0). The mechanism of development of NODAT was insulin resistance (p=0.04) and relative B cell dysfunction (p=0.02) at 06 months. Age (p=0.02) and waist hip ratio (p=0.01) of recipients who developed NODAT was more than the recipients who didn’t develop NODAT. Incidence of delayed graft function; graft rejection and infections were similar in tacrolimus and cyclosporine groups; and other drug adverse effects were not different in the two groups. eGFR was also not significantly different between the groups.

CONCLUSIONS: Cyclosporine; as compared to tacrolimus; didn’t prevent the occurrence of NODAT in patients who were at high risk. However; Cyclosporine was shown to have relatively better β cell function and less insulin resistance. Rejection rates were similar. Further studies with larger sample size are needed.

Oral Paper Presentations 21 December 2018 (10.20 am to 11.40 am) Hall B

  9. Simplified Risk Score to Predict The Probability of Developing Contrast Induced Nephropathy After Parenteral Contrast Exposure Top

Chaitanya Kulkarni, Jatin Kothari, A F Almeida

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

BACKGROUND: Contrast induced nephropathy (CIN) is a well-known complication after parenteral contrast medium (CM) exposure. Scores are available to predict probability of CIN after cardiac interventions but not many for non-cardiac interventions and intravenous exposure to CM. This study has been designed to determine the probability of developing CIN by utilizing a score derived from identified risk factors in patients exposed to parenteral contrast medium.

AIM OF THE STUDY: To develop a simplified risk score to predict the probability of developing contrast induced nephropathy in patients receiving parenteral contrast medium (arterial or venous).

METHODS: This prospective; single centre; study on 1347 consecutive patients who received parenteral CM exposure was carried out between April 2017 and March 2018. Of 1300 patients available for analysis; the initial 1000 comprised the derivation cohort and 300; the validation cohort for the equation. CIN was defined as increase of ≥25% and/or ≥0.5 mg/dl in serum creatinine at 48-72 hours after CM exposure. Univariate and multivariate regression was applied to twelve variables to identify significant risk factors. ‘p’ <0.05 was considered statistically significant. Risk factors with the strongest prediction of CIN were used to build the risk score. This was validated in the validation cohort. Area under curve (AUC) of Receiver Operating Characteristic (ROC) was used to evaluate the model discrimination between patients with and without CIN. Conditional probability of occurrence of CIN is given by the equation based on significant variables.

RESULTS: The characteristics of the study population were as follows (Values expressed as (Mean ± SD): age 58±14.4; Hb 11.8±2.1 gm/dL; Hct 11.8±6.6%; e-GFR 79.8±27.9 ml/min/1.73 m2. The volume of CM used was 81.7 ± 35.4 ml. 67.6% were males and 32.4%; females. There were 39.1% diabetics and 54.8% hypertensives. CIN incidence (3.8%) was higher among the patients who received intra-arterial CM (6.0%) than in patients who received intra venous CM (1.6%). Age; volume of CM; route of CM; diabetes mellitus (DM); e-GFR were significant variables with relation to CIN. Gender; hypertension; Hb; Hct were not significant variables. The developed risk score had a sensitivity of 90.4 % and specificity of 98.78%. The risk score overall accuracy was 97.8%. The observed high values of AUC of ROC in development data set (AUC=0.9467) and validation data set (AUC=0.9878) indicate that the predicted CIN risk score correlated well on its calibration and discriminative characteristics.

CONCLUSIONS: Incidence of CIN is higher in patients exposed to intra-arterial CM as compared to intra-venous CM exposure. Route and volume of CM administered; low e-GFR; DM are the significant risk factors. The developed Risk Score has excellent sensitivity and accuracy in predicting probability of CIN.

  10. Clinical and Microbiological Profile of Patients with Urinary Tract Infection During The First 3 Months After Renal Top

Priti Meena, D S Rana, Anil Kumar Bhalla, Ashwini Gupta, Manish Malik, Anurag Gupta, Vinant Bhargava

Department of Nephrology; Sir Ganga Ram Hospital; New Delhi; India

BACKGROUND: Urinary tract infection (UTI); especially recurrent UTI; is a common problem; occurring in 36 - 75 % of kidney transplant recipients; in different series. UTI degrades the health-related quality of life and can impair graft function; potentially reducing graft and patient survival. Our objective was to elucidate the underlying causes; risk factors and microbiological profile of UTI in renal transplant recipients in our center.

AIM OF THE STUDY: To study clinical and microbiological profile of patients with UTI during 3 months Post renal transplantation.

METHODS: This was a prospective observational study; conducted at the Department of Nephrology; Sir Gangaram Hospital; New Delhi; India. Two hundred and seventy renal transplant recipients were studied over a period of one year.

RESULTS: Out of 270 transplant recipients; 99 (36.7%) had UTI. 16 /99 (16.2%) UTI patients were undergone ABO-incompatible transplantation. The mean age of patients with UTI was 36.63 ± 10 years. Female transplant recipients had a higher incidence of UTI than males (31/54; 57.4% in females vs 68/216; 31.5% in males; p-value <0.001). 37 (40.35%) patient with UTI had diabetes. Escherichia coli (62.5%) was the most common causative agent. The majority (90.2%) of cases were attributed by Gram-ve bacilli while Gram+ve cocci accounted for 9.8%. Klebsiella pneumoniae was found to be MDR in most of the cases (95.6%). Underlying urinary tract abnormalities were detected in 20% of patients. In 55 patients (55.6%) episode of UTI was associated with acute graft dysfunction. Older age (p=0.02); urinary tract abnormality (P <0.001); Female sex (P < 0.001); prolonged Foley's catheterization (P <0.01); DM (P=0.02); were statistically significant predisposing factors for UTI; upon multivariate analysis.

CONCLUSIONS: Older age; female sex; prolonged foley's catheterization; diabetes; and abnormalities of the urinary tract were the strongest predictors of UTI in post-transplant patients.

  11. Combination of *1/*1 Wild Variant of CYP3A5 and TT/AA Mutant Variant of MDR G2677T/A Gene Polymorphism Requires Higher Tacrolimus Dose to Achieve Target Trough Level Top

Akhilesh Jaiswal, Narayan Prasad, Vikas Agarwal, Mantabya Singh

Department of Nephrology and Immunology , Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

BACKGROUND: Tacrolimus (Tac) is the most common drug used in transplantation. TAC shows wide inter-individual variability. Significant inter-individual variations in Tac concentration may be due to expression of P-gp varying between individuals and/or differential metabolizing capacity of CYP450.

AIM OF THE STUDY: To evaluate the expression of P-glycoprotein along with MDR-1 and CYP3A5 gene polymorphisms in renal transplant recipient patients and correlate their effect on Tac dose requirement.

METHODS: We recruited 155 renal transplant recipients out of 27 were ABO incompatible renal transplantation on Tac; MMF and prednisone. The mean age was 34.29±10.96 and 131 (84.5%) were males. Of the 155 patients; 68 had CGN; 40 had CIN; 4 had ADPKD; 13 had DKD; 5 had CKDu; 5 had DGGS; 2 had Alport's syndrome and 18 had other native kidney diseases. The mean creatinine level at the time of discharge was 1.11±0.28. P-gp expression was analyzed by flowcytometry and polymorphism was performed by PCR-RFLP. Of 155; 50.3% were CYP3A5*3/*3 (non-expressers homozygous); 38.0% were CYP3A5*1/*3 and 11.6% were CYP3A5*1/*1 (expressers). Out of 155; 40.6% were GG (wild type homozygous); 41.3% were GT/GA (heterozygous) and 18% were TT/AA (mutant homozygous) of MDR G2677T/A gene.

RESULTS: Tac level was high in *3/*3 as compare to *1*1 (p=0.001) and *1*3 (p=0.022) respectively. CYP3A5*1/*1 patients had lower levels of dose-adjusted TAC (54.73±27.33ng/mL/mg/kg/day) to achieve target blood level and required higher daily dose per weight (0.138±0.023 mg/kg/day) than CYP3A5*1/*3 patients; 109.73±70.84 ng/mL/mg/kg/day and 0.122±0.036 mg/kg/day (p=0.022) and CYP3A5*3/*3 patients; 141.9±85.02 ng/mL/mg/kg/day and 0.11±0.04 mg/kg/day (p<0.001). Tac Co was low in TT/AA as compare to GG (p<0.001) and GT/GA (p<0.001) respectively. Daily Tac dose requirement was high in TT/AA as compare to GG (p<0.001) and GT/GA (p=0.027) genotype to achieve target blood concentration. The P-gp expression was also high in TT/AA as compare to GG (p<0.001) and GT/GA (p<0.001). Genotype C1236T and C3435T of MDR-1 gene had no significant effect on Tac dose requirement. Patients with CYP3A5*1/*1 and TT/AA of MDRG2677T/A gene had highest Tac daily dose requirement to achieve target Tac tough concentration.

CONCLUSIONS: Daily Tac dose requirement is higher in patients with CYP3A5 expresser and MDR G2677T/A homozygous mutant gene. Genetic variants may predicts the optimal dose of Tac in renal transplant recipients.

  12. Biomarkers in Contrast-Induced Acute Kidney Injury in Adult Intensive Care Unit Patients Top

Ravi Mishra, Harshit Singh, Saurabh Chaturvedi, Kritika Singh, Vikas Agarwal1, Mohan Gurjar1

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

BACKGROUND: NGAL (Neutrophil Gelatinase-Associated Lipocalin); KIM-1 (Kidney Injury Molecule 1) and Cystatin C have been found early and sensitive marker of acute kidney injury (AKI). In adult ICU patients; both plasma (P) and urine (U) NGAL; KIM-1 and Cystatin C levels after intravenous contrast have not been evaluated simultaneously in earlier studies.

AIM OF THE STUDY: To evaluate biomarkers in plasma (P) and urine (U) after intravenous contrast in adult ICU patients.

METHODS: Single centre study; where all ICU patients who were >18 years and having normal renal function; requiring radiographic contrast for diagnostic or interventional computed tomography (CT scan); were considered for inclusion. Exclusion criteria includes: presence of AKI or CKD; recent exposure to contrast within 3 days; and pregnancy. After ethical approval; samples of 5 ml blood and 5 ml urine were collected before contrast exposure and at 4 h; 24 h and 48 h after contrast exposure. In patients having CI-AKI; mean values changes from pre-contrast to at 4 h; 24 h and 48 h after contrast NGAL; KIM-1 and CystatinC assay were done by ELISA; and urinary levels were normalized as per urine creatinine (UCr) values for each sample. In present study; CI-AKI is defined as a rise in SCr of ≥0.3 mg/dl within 48 hrs. Data presented in mean or median; and ANOVA analysis performed.

RESULTS: In patients having CI-AKI; mean values changes respectively plasma (P); NGAL (ng/ml) before (708.5±201.76); After 04 h (851.5±332.05; p=0.07); After 24 h (1093.25±225.03; p=0.02) after 48 h (788±323.4; p= 0.21)(with contrast); Urine (U) NGAL (ng/mg of UCr); before (67.63±48.09); After 04 h (39.69±19.79; p= 0.07); After 24 h; (101.97±90; p= 0.12); After 48 h; (59.87±56.85; p=0.73) (with contrast)(P) KIM-1 (ng/ml); before (0.98±0.58); After 04 h 0.94±0.58; p=0.39); After 24 h (1.54±0.43; p=0.006); after 48 h (1.36±0.46; p=0.012) (with contrast); (U) KIM-1 (ng/mg of UCr); Before (0.38±0.22); After 04 h (0.25±0.09; p= 0.73); After 24 h (0.24±0.01; p=0.003). After 48 h (0.31±0.15; p=0.49); (with contrast) (P) CystatinC (ng/ml); Before (4698.85±574.71) After 04 h (4704.57±1144.87; p= 0.02); After 24 h (4428.85±1135.73; p= 0.03); After 48 h (4288.85±435.8; p=0.17) (U) CystatinC (ng/mg of UCr) (with contrast) Before (346.06±224.7) After 04 h (219.66±72.18; p= 0.91); After 24 h (470.21±536.28; p= 0.99); After 48 h (633.61±811.77; p= 0.23) (with contrast) was found.

CONCLUSIONS: In critically ill adult patients; earliest (4 h) significantly increased was in plasma Cystatin C. At 24 h; plasma NGAL and KIM-1 were found significantly increased; while plasma KIM-1 increased till 48 h. In urine; there was no significant increase in any biomarker after intravenous contrast.

  13. Anti Complement Factor H Mediated Glomerulonephritis At A Tertiary Care Centre Top

V Akila, L Umesha, S M Shivaprasad, V Leelavathi, Sreedhara, Kishan, V Mahesha

Institute of Nephrourology; Bengaluru; Karnataka; India

BACKGROUND: Complement dyregulation has become an important etiology for glomerular diseases. Anti body against complement factor H which regulates the alternate complement pathway can cause atypicical HUS and C3 glomerulopathy.

AIM OF THE STUDY: To study the clinical profile and outcome of patients with anti complement factor H mediated glomerulonephritis at a tertiary care centre.

METHODS: We studied the clinical profile and outcome of patients with anti complement factor h mediated disease at a tertiary care centre over 18 months. 8 patients were studied and followed up to assess their response to therapy.

RESULTS: Mean age was 20.5 yrs. All patients presented with hypertension with RPGN. Mean serum creatinine at presentation was 6.8+/- 1.2. Serum c3 was low in all patients. 100% patients were dialysis dependent at presentation. Renal biopsy showed TMA in 4 patients and C3 glomerulopathy in 4 patients. Anti CFH H antibody was elevated in all patients with a mean of 161 AU/ml. All patients were managed with pulse steroids followed by oral steroids with IV cyclophosphamide. Plasmapharesis was done in all patients. All of them showed improvement in renal function after plasmapharesis and were free from dialyisis. Among the 8 patients; one was post transplant thrombotic microangiopathy. Patient responded well to our treatment and had normal renal function by the 3rd week post transplant. 5 paediatric patients are in complete remission. One of the adult patient expired due to sepsis. Post transplant patient expired due to intracerebral bleed. Last patient has a stable creatinine of 2.2.

CONCLUSIONS: Our case series shows that anti complement factor H mediated disease shows good response to immunosuppression and plasmapharesis without the need for eculizumab.

  14. Is Automated and Resting Blood Presurre Measurement in Chronic Kidney Disease Stage The Need of The Hour? Top

Nikhil Bhasin, Hardik Shah, Dilip Kirpalani, A L Kirpalani

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

BACKGROUND: Automated office BP (AOBP) is now being recommended as the preferred method for office BP measurement by various international guidelines. It has been shown to correlate with 24 hr ABPM and reducing the white coat effect. In India; there are very few studies which have evaluated the use AOBP in CKD; hence this study was undertaken to look to for its role in office BP measurement in CKD patients.

AIM OF THE STUDY: To compare averaged and unobserved automated office oscillometric BP [AOBP] measurement; sphymgomanometric (SPBP) and single observed oscillometric measurement (SOBP) with 24 hour ABPM in CKD.

METHODS: 160 consecutive CKD stage I –V (Excluding those on dialysis) outpatients who needed 24 hour Ambulatory BP monitoring (ABPM) underwent prior office BP measurement with 3 methods: Spyghmomanometric (Mercury apparatus-by doctor); Single oscillometric (Omron HEM 742- by paramedic) and multiple unobserved oscillometric (averaged) in resting state (OMRON HEM 907/ BpTRU- by paramedic). These readings were compared with average day time ABPM.

RESULTS: The mean systolic and diastolic AOBP correlated significantly to the mean awake ambulatory pressure (SBP 129±18 mmHg vs 135± 17 mmHg; r=0.59 p= 0.006) and (DBP 78±10 mmHg vs 84±9 mmHg; r=0.62 p=0.0001). Correlation between mean SPBP and awake ABPM (r=0.26/r=0.45) and between SOBP and awake ABPM (r=0.35/r=0.55) were statistically much weaker as compared to AOBP. The mean difference between SPBP and AOBP 19±14 mmHg SOBP and AOBP was 11±12 mmHg; suggesting significant prevalence of White Coat Hypertension (WCH); condition which confounds the management of BP in CKD.

CONCLUSIONS: ABPM is the best modality for detecting WCH and targeting antihypertensive therapy; but cannot be offered to all patients. In comparison with SPBP and SOBP; the recent innovation AOBP; is a better surrogate of the average daytime ABPM and reveals hidden WCH in CKD.

  15. A Prospective Study to Determine Significance of Arfi Values on Transient Elastography for Detection of Both Acute and Chronic Renal Allograft Dysfunction Top

Amit Satendra Jain, M M Bahadur, Rushi Deshpande

Jaslok Hospital and Research Centre; Mumbai; Maharashtra; India

BACKGROUND: Prospective study to access the use of ARFI for detection of allograft dysfunction in bothacute and chronic cases. Strong positive correlation between the ARFI scores and percentageof fibrosis in both acute and chronic cases. Cut off value of ARFI scores ≤2 m/s correctlydifferentiated 23.3% acute cases from chronic cases with high sensitivity (71.4%) andspecificity (79.3%) whereas there was no significant difference in the RI values between twocases.

AIM OF THE STUDY: To study co-relation of ARFI values with serum creatinine; RI values and percentage offibrosis. To determine usefulness of ARFI values to differentiate between acute and chronicgraft dysfunction.

METHODS: Forty three consecutive patients satisfying inclusion criteria of acute and chronic graftdysfunction were enrolled and demographic; clinical; biopsy report including percentage offibrosis and ARFI (acoustic radiaiton force impulse) values on transient elastography andRI (resistance index) values on doppler ultrasonography recorded. Correlations of ARFI valueswith serum creatinine; estimated GFR; time since transplantation; resistance index onDoppler ultrasonography and percentage of fibrosis on renal biopsy was made in both acuteand chronic cases. Receiver operating curve (ROC) with sensitivity and specificity of ARFIvalues in differentiating acute and chronic cases was made.

RESULTS: No significant differences in demographic characteristics between the two groups exceptdonor status making them comparable. Percentage of fibrosis was significantly different in thetwo groups however RI values had no statistical difference in acute and chronic graftdysfunction. Fibrosis significantly positively correlated with ARFI scores in both acute (r=0.95; p=0.0001) and chronic graft dysfunction patients (r=0.79; p=0.0001). RI alsosignificantly positively correlated with ARFI scores in both acute (r=0.53; p=0.04) andchronic graft dysfunction patients (r=0.62; p=0.0001). However there was no positive ornegative correlation between the ARFI scores and time since transplantation; serum creatininevalues or eGFR. Cut off value of ARFI scores ≤2 m/s correctly differentiated 23.3% acutecases from chronic cases with high sensitivity (71.4%) and specificity (79.3%).

CONCLUSIONS: Cut off value of ARFI scores ≤2 m/s can correctly differentiate 232.3% of acute cases fromchronic cases with high sensitivity (71.4%) and specificity (79.3%). Hence ARFI values canbe used to differentaite between acute and chronic graft dysfunction whereas RI values areonly diagnostic.

  16. A Prospective Randomized Controlled Trial Comparing Efficacy of Different Lock Solutions in Preventing Catheter Related Blood Stream Infection in Hemodialysis Patients Top

Prasun Roy, Debabrata Sen, Sanjay Dasgupta, Dipankar Sircar, Arpita Roy Choudhury, Rajendra Pandey

Department of Nephrology; IPGMER; Kolkata; West Bengal; India

BACKGROUND: Hemodialysis (HD) is the most common form of renal replacement therapy available to end stage renal disease in India. To start with; non-cuffed catheter is mostly used vascular access. However; it has significant infective and non-infective complications. Most common infective complication is catheter related blood stream infections (CRBSI).

AIM OF THE STUDY: We planned this study to compare effect of two different catheter lock solution viz. Heparin vs gentamicin lock on catheter lifespan and incidence of CRBSI in a tertiary care referral center.

METHODS: This is a prospective randomized controlled study conducted in a single centre tertiary care referral hospital in eastern India from February 2017 to august 2018. 47 Consecutive ESRD patients of any etiology on maintenance HD via non-cuffed venous catheter were included and divided in 2 equal groups. One group received heparin only catheter lock and another gentamicin-heparin lock. Catheter was removed if fever persists for 2 days inspite of empirical antibiotic therapy or blood flow during dialysis is persistently less than 200 ml/min. Catheter lifespan and CRBSI rate was compared. Further removed catheter tip was cultured and pattern of organism and drug sensitivity was observed.

RESULTS: 109 patients were screened. 47 participants satisfied the eligibility criteria and were included in the study. The average catheter duration was 40.62 ± 7.89 days. The cumulative incidences of CRBSI at the end of the study period were 5.76 events per 1000 catheter-days. 11 (23.4%) patients developed catheter related infection during the study. Incidence of CRBSI in control arm is 7.97 events per 1000 catheter-days vs 3.88 events per 1000 catheter-days in test arm. Catheter lifespan in control and test arm is 38.17 ± 7.15 days and 42.96 ± 7.99 days in test and control arm respectively. (p= .036). Infection due to Gram +ve organism occurred in 54.55% of cases and gram –ve organism in 45.45% cases. Most commonly isolated organism being MRSA followed by E. coli.

CONCLUSIONS: Routine use of antibiotic lock solution in uncuffed catheter decrease the rate of catheter related blood stream infection and a modest but statistically significant increase in catheter lifespan.

Oral Paper Presentations 22 December 2018 (11.20 am to 12.25 pm) Hall A

  Rekha-1 Pattern of Urinary Sodium Excretion in Healthy Volunteers and Chronic Kidney Disease Patients Top

Shidram Kamate, Ilangovan Veerappan, Ramaswami Sethuraman

Department of Nephrology; KG Hospital and Post Graduate Institute; Coimbatore; Tamil Nadu; India

BACKGROUND: The gold standard for assessing dietary sodium (Na) is by timed urine collection; but is cumbersome. Spot sample with/ without creatinine correction have been used in various studies and given conflicting results. Despite the usefulness of assessing urinary Na excretion it is not widely followed.

AIM OF THE STUDY: To determine the pattern of urine sodium excretion in normal healthy volunteers and chronic kidney disease patients in relation to food.

METHODS: Prospective single centre interventional study conducted in healthy and CKD patients stages 1 to 4. The consenting subjects were instructed to discard the 1st morning urine. After a fixed standard meal at 8 AM spot urine samples were checked at 0; 1; 2 and 4 hrs. 2 ml of the sample was taken for testing and the remainder collated with the 24 hours collection. Fixed lunch at 1 PM and dinner at 8 PM was followed through the day with restrictions for Na intake. Subjects were allowed to have extra food and documentation of Na was done. Na content in the food was not measured. 24 hours urine collection was educated to the subjects. In all the samples; spot and 24 hours; Na; Chloride (Cl); Creatinine (Cr) was measured. Demographics of the subjects were noted. Pattern of urinary Na excretion; correlation between spot and 24 hour collection; variation with eGFR; relationship between Na and Cl excretion were noted in both groups.

RESULTS: 58 patients (32 males) of which 28 healthy volunteers and 30 CKD were included in the study. Demographics did not statistically affect the urinary Na/Cr excretion in both groups. Urinary spot Na excretion was maximum at 2nd hour post breakfast (Na= 2.1 meq/L ± 1.2) in healthy subjects but without peak in CKD. Pattern of excretion of Na; Cl were similar in both groups. All spot ratios correlated well with 24 hour Na; Cl as evidenced by Cronbach's alpha value of 0.78 and 0.67 respectively. The 1st hour spot Na/Cr best predicted the 24 hr urine Na in healthy and CKD patients and a formula for extrapolating the same was deducted. 24 hr Na (meq/day) = [71.63+138.2*1sthrNa/Cr-68.41*1sthrNa/Cr^2+15.56*1sthr Na/Cr^3] (R2of 57.5% and p value<0.001; 0.067; 0.092 for linear; quadrantic and cubic equations respectively). Difference of 10.98 meq/day between observed and predicted 24 hr Na was shown in Bland Altman plot which indicated good correlation between Na and Cl excretion (R2 0.913).

CONCLUSIONS: Salt load excretion is prompt for healthy patients and delayed for CKD patients. In our study 1st hour spot Na/Cr best predicted the 24 hour Na excretion in both the groups with statistically significant correlation. The formula may be useful in making salt excretion studies more acceptable.

Oral Papers 22 December 2018 (11.20 am to 12.35 pm) Hall A

  17. Setting Up and Operating A Large Standalone Haemodialysis Centre Under A Unique Public - Private Partnership Model - The Jipmer Experience Top

Sreejith Parameswaran, Dhanin Puthiyottil, A K Saravanan, Ashok Shankar Badhe, Sunil Jadhav, Satish Haridasan, P S Priymavada, Sakthivel

Department of Nephrology; Jawaharlal Institute of Postgraduate Medical Education and Research; Puducherry; India

BACKGROUND: With increasing incidence of ESRD & its economical burden on patients; the government of India launched a National Dialysis Program to ensure access to dialysis. A PPP model was adopted; where govt institution provides space; water; electricity whereas private partner brings in capital investment establishing the service & takes care of day to day operation. Information on the quality of care; patient outcome & expenses; for the public exchequer & the pts are not widely available

AIM OF THE STUDY: To describe the unique PPP model implemented by JIPMER; with the clinical outcomes & expenditure for the institution & out of pocket expenditure for patients availing treatment at the dialysis centre.

METHODS: The Expression of Interest (EOI) and Request for Proposal (RFP) documents along with all addenda and other relevant tender related documents with the department of Nephrology; JIPMER was reviewed to describe the PPP model. The capital investment (Capex) for setting up the centre and the operational expenses (Opex) were calculated from information obtained from the tender documents as well as from cost estimates provided by the private partner. Out of pocket expenditure for patients was calculated by interviewing 30 patients undergoing dialysis at the centre. The patient outcomes and quality of performance data was extracted from the TDMSSoftware at the centre as well as from medical records available at the dialysis centre.

RESULTS: The standalone dialysis centre has 25 HD machines (Fresenius 4008S); Fresenius AquaBplus water treatment plant; Therapy Data Monitoring System (TDMS) etc. 4 stations are provided for isolation dialysis. Water quality monitored every month. Staff: Machine ratio 1:3. The centre has completed 21 months. A total of 183 patients were added between December 2016 & August 2018. Access was AVF in 153 (83.6%) patients. 82 (44.8%) patients were covered under insurance scheme; 27 BPL; 67 APL; 7 were JIPMER staff. 38 pts underwent transplantation; 9 lost to follow up (4.9%); 21 pts (11.4%) expired. Average Kt/V was 1.3 & average blood flow was 244 ml/m. Mean Hb & albumin were 9.2 g/dl & 3.7 g/dl respectively. JIPMER provided 5000 sqft area; free water; electricity & doctors in the centre. The Capex was sourced from a local MP's Local Area Development Fund. The Capex was ₹59; 899; 333/. Average cost/session of HD was ₹812/-. The average out of pocket expenditure was ₹58; 800/- per yr.

CONCLUSIONS: PPP model for HD with Capex borne by the govt; Comprehensive terms & conditions for quality & performance parameters; realistic cost estimates for establishment & operations & utilization of state health insurance schemes can ensure access to good quality dialysis with good clinical outcomes.

  18. Role of Donor Related Factors in Short Term Graft Outcomes in Deceased Donor Renal Transplantation Top

Nabadwip Pathak, Sandeep Mishra, M. S. Gopalakrishnan, R. Manikandan, Pankaj Kundra, Anusha Cherian, Senthil, Pradeep Pankajakshan Nair, Prasanna Bidkar, M V S Satyaprakash, R Lenin Babu, Vaibhav, A S Ramesh, Sathiya Prabhu, K S Sreerag, L N Dorairajan, Satish Haridasan, Ashok Shankar Badhe, Sreejith Parameswaran

Departments of Nephrology; Anaesthesiology and critical care; Neurosurgery; Urology and Neurology; JIPMER; Puducherry; India

BACKGROUND: Brain dead donors at our centre; who are mostly victims of road traffic accidents; are often young and otherwise healthy. However; by the time brain death is confirmed and patients are referred to the deceased donor (DD) Transplantation team; their physiological status is quite deranged. DD related factors like age; AKI in the donor; vasopressin requirement are likely to influence graft outcomes; including DGF; SGF; Graft rejection and graft outcomes in the short term.

AIM OF THE STUDY: To study the role of donor related factors in short term Graft outcomes in deceased donor renal transplantation at JIPMER; Puducherry.

METHODS: Demographic and Clinical data of all deceased donors and clinical details of all recipients of deceased donor (DD) renal transplantation performed between Dec 2013 to Sep 2018 were collected from medical records. Donor data: demographic data; presence of DM; HT; vasopressor requirement; hypothermia; pre-operative serum creatinine (Scr); Cold ischemia time (CIT) & presence of AKI. Recipient data: delayed graft function (DGF); slow graft function (SGF); early acute cellular rejection (ACR); early antibody mediated rejection (AMR); CNI toxicity; nadir Scr in immediate post transplant; Scr at 1 month and 6 month. Logistic regression was performed to determine the association between ACR; AMR; DGF; SGF; CNI toxicity with the different covariates. Linear regression was performed to determine the association between Scr at baseline; at 1 month; at 6 month with the different covariates. All analysis was performed in SPSS (v18); p < 0.05 was considered as statistically significant.

RESULTS: Seventy two (72) patients underwent kidney Transplantation from 37 DD during the study period. Twenty eight (75.7%) of DD were males & mean age was 33.54 + 14.29 years. Among them; 13 (35%) had hypothermia; all had hypotension necessitating vasopressors (3 drugs in 24% & 2 drugs in 76%); & 14 (37%) had AKI. Mean CIT was 209 (± 124.7) min. Six (8.3%) recipients had DGF; 5 had SGF; 2 had ACR & 3 had AMR. Two kidneys (from the same donor) had primary nonfunction. Mean (+SD) Scr at discharge and 1 & 6 months after Transplantation were 1.71+1.109; 1.59+ 0.65 and 1.59+ 0.77 respectively. There was significant correlation of CIT with ACR (OR: -1.23; 95% CI: -3.89; -0.02; p< 0.05) and graft function (Scr) at 6 months (OR: 2.24; 95% CI: 0.03; 4.21; p < 0.05) but not at baseline and 1 month. AKI in the donor was significantly associated with Nadir Scr (OR: 3.7; 95% CI: 1.12; 5.28; p < 0.05) and Scr at 1 month (OR: 2.42; 95% CI: 1.02; 3.11; p < 0.05) but not at 6 months.

CONCLUSIONS: Cold ischemia time is associated with occurrence of ACR and graft function at 6 months in DD kidney transplantation. AKI in the DD is common and adversely impacts short term graft function. Earlier identification and better supportive care of DDs may translate into better short term graft outcome.

  19. Co-Inheritance of PKD1 and PKD2 Mutation Presenting As Severe Antenatal Phenotype Top

Vaibhav Tiwari, Veronica Arora, Sunita Bijarnia, Ratna Dua Puri, Ishwar Chander Verma

Department of Nephrology; Sir Ganga Ram Hospital; New Delhi; India

BACKGROUND: ADPKD occurs worldwide and in all races; with a prevalence estimated to be between 1 in 400 and 1 in 1000. Factors determining the disease severity in ADPKD are PKD1 mutations itself; truncating mutations; 5’ region mutations. Herein we describe report of severe antenatal presentation of ADPKD with bilineal mutation inherited from each parents.

AIM OF THE STUDY: To study the effect of co-inheritance of bi-lineal PKD1 and PKD2 mutations in a couple with two foetuses affected with polycystic kidney disease.

METHODS: Targeted exome sequence on the foetal sample revealed two mutations; one in PKD1 and one in PKD2. These were sanger validated and segregation was done which showed that mother was a carrier of PKD1 nad father of PKD2. The second foetus was also tested for the same 2 variations which were presented.

RESULTS: Genetic testing of the foetus revealed the following variants in a heterozygous state:PKD1- Exon 1 : c.3860T>C; PKD2: Exon 4; c.1000C>ASanger validation confirmed the above variants.

CONCLUSIONS: Co-inheritance of PKD1 and PKD2 mutations results in a synergistic effect; thus leading to a much more severe phenotype in the foetal life; presenting with polycystic kidneys and oligohydramnios. Further studies are required to establish a genotype phenotype co-relation.

  20. Role of Iron in Snake Venom Induced Acute Kidney Injury and It's Severity in Experimental Model Top

Rajdeb Banerjee, Pinaki Mukhopadhyay, Roshnara Mishra, Raghwendra Mishra

Department of Nephrology; NRS Medical College; Department of Physiology; University of Calcutta; Department of Physiology; Ananda Mohan College; Kolkata; West Bengal; India

BACKGROUND: Previous studies have reported that iron; an important micronutrient; have a major role in acute kidney injury (AKI) and chronic kidney disease. It acts by increasing oxidative stress and inflammation. Snake envenomation is one of the major responsible factors for producing AKI in rural area. So; in this study we have investigated whether the catalytic iron plays role in etiology and severity of snake venom induced AKI.

AIM OF THE STUDY: The focus of the study is to investigate the role of iron in SAKI pathogenesis and consequent deterioration of kidney function by using Deferoxamine; an iron chelator drug.

METHODS: To find out the role of iron in Russell Viper venom induced nephrotoxicity; male adult swiss albino mice were taken and RVV was injected intramucscularly at a dose of 30 µg/100 gm body weight. An iron chelator drug; Deferoxamine was used for iron chelation by which might indicate the role of catalytic iron. 72 hours after envenomation inflammatory and stress parameters e.g. TC; DC; NO; TBARS activity; OSI; free iron were measured in plasma and renal tissue. Severity of renal injury was denoted by plasma creatinine and urinary microprotein level. Renal histology was done by H-E and picrosirius red staining. Anti TGF-β; anti CTGF antibody were used for IHC study. Images were analyzed with imageJ image analysis software. Data were represented as mean ± standard error of mean.

RESULTS: The iron chelator significantly reduced the AKI markers; inflammation; oxidative stress levels and also reduced the level of plasma and tissue catalytic iron. These findings were supported by histological study. The severity of AKI was also significantly reduced by iron chelation as noted in fibrotic markers. Collagen deposition in renal tissue and level of TGF-β and CTGF were significantly increased after envenomation and were reduced by the Deferoxamine treatment.

CONCLUSIONS: The iron chelator ameliorates venom induced nephrotoxicity and reduces its severity by delaying the onset of fibrosis along with inflammation and oxidative damage. So it can be concluded that iron plays a role in SAKI and its severity.

  21. Podocyte Infolding Glomerulopathy: An Indian Case Series Top

A Faizan, G Anvesh, Sree Bhushan Raju

Department of Nephrology; Nizam Institute of Medical Sciences; Hyderabad; Telangana; India

BACKGROUND: Several cases of Podocytic infolding glomerulopathy (PIG) has been reported from Japan as a new disease entitysince 2008. It is a rare glomerular abnormality seen predominantly among women in associaciation with membranous nephropathy and autoimmune diseases involving glomerular basement membrane (GBM) bubbling visualised by light microscopy (LM); invagination of the podocyte membrane; and the presence of microspheres viewable by electron microscopy (EM).

AIM OF THE STUDY: To study demographic and clinical profile of patients with Podocyte infolding glomerulopathy.

METHODS: We retrospectively analysed cases of PIG as per the diagnostic criteria during preceding two years.

RESULTS: Eight cases of PIG have been diagnosed in our institute. The mean age of the patients was 48; (43-66) years; and all were men. Both hypertension and diabetes were seen in six; one each had hypertension and diabetes. Four patients had nephrotic range proteinuria and two had insignificant proteinuria. All had increased creatinine with a mean of 4.3 mg%. Autoimmune workup and viral markers were negative in all. LM showed diabetic nephropathy (DN) in 6 cases and hypertensive changes in 1 case and secondary FSGS in 1 case. Microspheres were present in all but podocyte infolding and cluster formation of microspheres were found in 1 & 4 cases respectively.

CONCLUSIONS: PIG in our case series differs from that of Japan in male preponderance and is associated with diabetic nephropathy. The clinical significance of PIG in South Indian population is yet to be elucidated.

  22. Technical Survival of Continuous Ambulatory Peritoneal Dialysis Catheters: Surgical Placement by Nephrologist Top

Pavitra Manu Dogra, Ranjith K Nair, Satish Mendonca, Bhaskar Datt, Parikshit Singh Chauhan

Department of Nephrology; Army Hospital (Research and Referral); Delhi; India

BACKGROUND: The incidence of end stage renal disease is on the increase in India. The majority of patients are from villages who have a limited access to hemodialysis due to distance and time factor. Peritoneal dialysis (PD) is the preferred available option for such significant number of end-stage kidney disease patients. Viability of a two-cuffs PD catheter (PDC) is always a concern and acts as the limiting factor. The success depends upon the experience and sensitivity of the physician to the disease.

AIM OF THE STUDY: The aim of the study is to analyse CAPD catheter technical survival; patient survival; procedure related complications; infective and mechanical complications and technique success.

METHODS: We prospectively analysed the outcomes of 2-cuffs PDC inserted by surgical minilaparotomy technique at a tertiary care hospital in north India. Catheter insertions were done over 23 months between March 2016 and January 2018 and patients were followed up till July 2018 (minimum 6 months) on outpatient and inpatient basis. Obese and post-abdominal surgery patients undergoing PDC insertion were also included. Data was analysed for catheter technical survival; patient survival; procedure related complications; infective and mechanical complications and technique success. The data was analysed by R core software.

RESULTS: 120 2-cuffs PDC were inserted by nephrologist using ‘30 degree exit’ technique at anterior rectus sheath. 75% of PDC inserted were 57 cm coiled PDC. The break-in period was 8.7 days. Primary catheter failure as defined by failure to function within 1 month of insertion occurred in 2.5% cases of which one patient underwent laparoscopic repositioning whereas PDC was removed in other 2 patients. There was no primary peritonitis or immediate exit site infections. Mean catheter survival was 13.2 months. Peritonitis rates were 1 episode per 46.4 catheter months. Refractory peritonitis occurred in 6.6% patients; thus PDC removal. There was no incidence of hemorrhagic complications; catheter migration; bowel injury or pericatheter leak. The catheter survival censored to death was 96.7% and 91.1% at 6 months and 12 months respectively. Patient survival was 90% and 75% at 6 months and 12 months respectively. Major cause of mortality was presumed cardiac event at home.

CONCLUSIONS: The surgically inserted 2-cuffs peritoneal dialysis catheters by nephrologist had good technical survival and safety profile and less mechanical complications. The practice of “30 degree exit” technique at anterior rectus sheath obviated the need of sling for maintaining curvature of catheter.

  23. Epigenetic Regulation: Does HDAC2 Plays Role in Drug Resistance Via Regulation of P-gp and MRP-1 Top

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

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 and MRP-1 expression.

METHODS: Total of 20 subjects were considered in the study out of which 10 were steroid sensitive nephrotic syndrome (SSNS); and 10 were steroid resistant nephrotic syndrome (SRNS) patients. mRNA expression was analyzed on peripheral blood mononuclear cells (PBMCs) in SRNS patients (mean age 8.43±3.8 years); SSNS patients (mean age 7.54±3.5 years). PBMCs were treated with 1 µM of Theophylline (HDAC2 stimulator) and 0.8 µM of Trichostatin A (HDAC2 inhibitor) for a period of 48 hours. 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).

RESULTS: Expression of P-gp (4.79±0.10 v/s 2.13±0.12; p<0.0001); MRP-1 (3.99 ±0.08 v/s 1.99 ±0.11; p<0.0001) on PBMCs was increased in SRNS compared to SSNS. HDAC2 mRNA levels were decreased in SRNS patients compared to SSNS (2.97 ± 0.15 v/s 6.02 ± 0.13; p<0.0001). Theophylline decreased mRNA levels of P-gp/MRP-1 in PBMCs of SRNS with maximal induction at 1 µM (fold change 2.65 and 2.21; *p<0.0001); however HDAC2 mRNA expression increased (fold change5.67; *p<0.0001). In SSNS patients; P-gp/MRP-1 mRNA expression decreased at 1 µM (fold change 1.25; 1.24; *p<0.0001); HDAC2 mRNA increased (fold change 6.93; *p<0.0001). Trichostatin A increased mRNA levels of P-gp/MRP-1 in PBMCs of SRNS with maximal induction at 0.8 µM (fold change 7.51; 7.31; *p<0.0001) but decreased HDAC2 levels (fold change1.50; *p<0.0001). In SSNS patients P-gp/MRP-1 mRNA expression increased at 0.8 µM (fold change 3.49; 3.35; *p<0.0001); HDAC2 decreased (fold change2.53; *p<0.0001) at 0.8 µM.

CONCLUSIONS: As we observed that HDAC2 regulates P-gp and MRP-1 efflux pumps; Inducer of HDAC2 (Theophylline) may be a probable strategy to reduce steroid toxicity for patients of Idiopathc Nephrotic Syndrome.

Oral Paper Presentations 22 December 2018 (11.20 am to 12.35 pm) Hall B

  24. Tacrolimus CYP3A5 Genotyping and Trough Levels in Renal Transplantation Top

S. P. S. Anandan, Sampath Kumar Krishnsamy

Meenakshi Mission Hospital and Research Centre; Madurai; Maharashtra; India

BACKGROUND: In kidney transplant patients the tacrolimus trough level recommended in the first month is 12-15 ng/ml. Tacrolimus is a substrate of cytochrome p450 CYP 3 A and much of variability is explained by a single nucleotide polymorphism in Intron 3 of CYP 3A5. The starting dose required to achieve therapeutic trough level was analyzed between three groups of patients (Poor; intermediate and extensive metabolizers).

AIM OF THE STUDY: To compare the mean trough levels attained between three groups Poor; Intermediate and Extensive metabolizers.

METHODS: 29 patients who underwent renal transplantation both live and deceased donors were selected for the study. Tacrolimus genotyping (CYP3A5) was performed by real time PCR (an in-house developed assay for research purposes by Dr Lal Pathlabs) in all of these patients and patients were divided into three groups based on the results to extensive metabolizers (CYP3A5 *1/*1); Intermediate metabolizers (CYP3A5 *1/*3) Poor metabolizers (CYP3A5 *3/*3). All these patients were given triple immunosuppression as per local protocol and starting dose of Tacrolimus was 0.1 mg/kg. The first trough level with initial starting dose was compared between the three groups using one way Anova test. Trough level per mg dose was compared between three groups and likely dose required was proposed. The incidence of early acute rejection rates was compared between the three groups.

RESULTS: Average initial dose of Tacrolimus was 0.0883 / per kg body weight per day in the extensive metabolizer group compared to 0.102 / per kg of body weight per day in the intermediate metabolizer group and 0.084 / per kg body weight per day in the poor metabolizer group. The average initial trough level after the above mentioned dose was 3.08 in the extensive metabolizer group; 3.88 in the intermediate metabolizer group and 11.14 in the poor metabolizer group. One way ANOVA analysis of trough levels between the three groups showed f-ratio value of 14.24 and p value was < 0.00001. Average trough level after 1 mg was 4.622 in poor metabolizer group; 1.774 in the intermediate metabolizer group and 1.19 in the extensive metabolizer group. Prevalence of acute rejection was 16% in extensive metabolizer group and 15% in intermediate metabolizer group compared to 10% in poor metabolizer group.

CONCLUSIONS: Recommended trough level was achieved only in patients of poor metabolizer group compared to ext and int metabolizer groups at 0.08 to 0.1/kg. The proposedstarting dose of Tacrolimus in poor metabolizer group should be 0.1 mg/kg and in both int and ext metabolizer group should be 0.3 mg/kg/day.

  25. Genome Wide Analysis Study to Evaluate Potential Genetic Risks and Immunological Pathways Associated with Chronic Kidney Disease of Unknown Etiology Top

Narayan Prasad, Swayam Prakash, Abdul Waheed Khan, Dharmendra Bhadauria

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

BACKGROUND: Chronic kidney disease of unknown etiology (CKDu) has been studied on the light of its etiology and pathogenesis; mostly on possible involvement of environmental factors. Earlier inconsistent data on involvement of different heavy metals has been suggested along with plausible roles of herbicides; mycotoxins; pesticides; and algal toxins with CKDu. The present study is proposed to identify exact cause(s) of CKDu and complex involvement of genetic and environmental factors.

AIM OF THE STUDY: This study has evaluated the potential candidate genes associated with CKDu through a genome wide analysis study (GWAS).

METHODS: A total of 96 participants; 56 cases and 40 controls and two covariates i.e. eGFR and Urine analysis protein were considered in this analysis. All samples were genotyped using the AXIOM PMRA (Affymetrix Inc.; CA; USA). SNP calls were carried out using the Best Practice Workflow of Affymetrix Axiom Analysis Suite. Genotype markers were excluded if they had a call rate < 97%; Fisher's linear discriminant Score (FLD) <3.6; Heterozygous cluster strength offset values (HetSO) < -0.1; Homozygote ratio offset (HomRO) <0.9; Hardy Weinberg equilibrium test score < 0.0001; and minor allele frequency < 0.05. Data was analyzed using: (1) standard PLINK based single-SNP analysis by the logistic model; (2) sequence kernel association test (SKAT) approach; which assesses the SNP effects using the linear kernel machine; (3) Adaptive Rank Truncated Product (ARTP) approach; and (4) functional mapping and annotation of genetic associations using FUMA.

RESULTS: Of the 9; 02; 560 SNP probes; 2; 83; 232 (31.38%) and 4; 25; 488 (47.14%) SNP probes were validated as polymorphic and monomorphic high-quality SNPs respectively. Only 0.1% (874) of probes had a call rate below the threshold. Finally; a total of 2; 42; 900 SNPs passed quality control and used for further analyses. Significantly high-risk association was found with rs61652410 (Gene:NLRP4; p-value=156.2; OR=0.014); rs992037 (Gene: PRKN; p-value=0.012; OR=105.9); and rs61774076 (KAZN; p-value=0.013; OR=326.4). Under SKAT approach; a total of 1355 and 1331 significant genes were identified using linear weighted kernel and IBS weighted kernel respectively; whereas 1084 significant genes (SNP-Set) identified (p<0.05) using performance of SNP-set analysis using ARTP approach. Pathway analysis revealed genes associated with insulin receptor signaling; PDGF signaling; chemokine; cytokine and interferon signaling; B-cell receptor; and NOTCH signaling pathways to be significantly associated with CKDu.

CONCLUSIONS: We found a significant association of CKDu with SNPs related to NLRP4; and PRKN genes. The study also reports an association of some major biological pathways with CKDu. This will further aid in a focused functional evaluation of the pathway specific genes with CKDu.

  26. Direct Antiviral Agents in The Treatment of Hepatitis C Virus Infection in Renal Transplant Recipients: A Single Centre Experience Top

T Sugan Gandhi, T Dinesh Kumar, R Shakthirajan, J Dhanapriya, V Murugesan, N Malathy, T Balasubramaniyan, N Gopalakrishnan

Department of Nephrology; Institute of Nephrology; Madras Medical College; Chennai; Tamil Nadu; India

BACKGROUND: Hepatitis C Virus (HCV) Infection among renal transplant recipients is associated with significant morbidity and mortality. Studies have shown that the Direct Antiviral Agents (DAA) achieve a sustained viral remission rate of >99% in renal transplant recipients; with a better safety profile. However there are only a few studies from India on the usage of DAA in renal transplant recipients.

AIM OF THE STUDY: To study the efficacy and safety of DAA in the therapy of HCV infection in renal transplant recipients.

METHODS: We did a retrospective observational study among the renal transplant recipients either from a deceased or a living donor with active HCV infection defined by detectable HCV RNA and treated with DAA; irrespective of prior treatment for HCV infection and estimated glomerular filtration rate (eGFR). We excluded patients who were less than 18 years of age at the time of transplant; those with primary non-functioning kidney; Decompensated liver disease; Co infection with HBV or HIV and those on irregular drug therapy with DAA. In our centre; DAAs are used in renal transplant recipients since 2015. Response to therapy was assessed by detecting the viral load at the end of therapy (ETR); sustained viral remission at the end of 4 weeks after the completion of therapy (SVR4) and at the end of 12 weeks after the completion of therapy (SVR12).

RESULTS: 31 renal transplant recipients received treatment for HCV infection. 16 recipients were treated with sofosbuvir and ledepasvir; 8 with sofosbuvir and ribavirin; and 7 with sofosbuvir and daclatasvir. 30 recipients were treatment naïve and 1 received interferon therapy prior to transplant. The most common genotype was genotype1 (90.32%; n=28). The median interval between transplant and treatment initiation was 7 yrs (Range 4 mths to 17 yrs). At the initiation of therapy; the estimated glomerular filtration rate (eGFR) was 31-60 ml/min/1.73 m2 in 15 recipients; 61-90 ml/min/1.73 m2 in 10 and >90 ml/min/1.73 m2 in 6. Therapy was stopped in 1 recipient in view of DAA induced severe anaemia. ETR; SVR4 and SVR12 rate was 100% in those who completed therapy (n=30). Occurrence of anaemia was 100% in sofosbuvir with ribavirin therapy (n=8); 14.2% in sofosbuvir with daclatasvir therapy (n= 1) and 12.5% in sofosbuvir with ledepasvir therapy (n=2).

CONCLUSIONS: DAAs are effective and safe in the therapy of HCV infection in renal transplant recipients. Ribavirin with sofosbuvir therapy is associated with a higher occurrence of anaemia than other combination therapies.

  27. Tacrolimus May Regulate The Pathogenic TH17 Cells in Lupus Nephritis Refractory Patients Top

Anamika Anuja, Mohit Kumar Rai, Vikas Gupta, Durga Prasanna Misra, Vikas Agarwal, Narayan Prasad

Department of Nephrology and Immunology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

BACKGROUND: About 15-30% of Lupus Nephritis (LN) patients do not respond to first-line immunosuppressive therapy. Increased pathogenic (CD4+IL-17+IFN-γ) Th-17 cell population has been reported in such patients. Pathogenic Th-17 cells are known to express P-glycoprotein (P-gp) that may efflux out glucocorticoids and thus contribute to resistance to treatment. In this in vitro study we evaluated the effect of Tacrolimus on pathogenic Th-17 population in refractory Lupus Nephritis patient’s.

AIM OF THE STUDY: To Study the effect of Tacrolimus on the Pathogenic Th17 cells in refractory Lupus nephritis patients.

METHODS: 10 Lupus Nephritis patients (mean age 34.06±10.84; all females) who were refractory to the cyclophosphamide treatment were recruited. Their Peripheral blood were collected in heparinized vial and stimulated with PMA & Ionomycin and co-cultured with or without Tacrolimus for 24 hour. Pathogenic Th-17 population was analyzed using flow-cytometer.

RESULTS: Tacrolimus significantly (p=0.006) reduced; 5.5±1.1% to 4.24±1.3%; the frequency of Th-17 cells in PMA/ionomycin stimulated PBMCs of these patients. Similarly; frequency of pathogenic Th17 cells was also significantly (p=0.004) reduced; 1.75±.14% to 0.53±0.16%; by Tacrolimus. Additionally; Tacrolimus significantly (p=0.001) reduced; 90.5±5.67% to 67.53±8.89%; the expression of P-gp on pathogenic Th-17 cells.

CONCLUSIONS: Tacrolimus not only significantly reduced the frequency of Pathogenic Th17 cell population but also expression of P-gp on Pathogenic Th-17. It may have potential to reverse treatment non-responsiveness in lupus nephritis.

  28. The Linkage between Rising Temperatures and Renal Health: Epidemiological Evidence from Indian Workplaces Top

Vidhya Venugopal, P K Latha, S Rekha, K Manikandan

Department of Environmental Health Engineering; Sri Ramachandra Medical College and Research Institute; Chennai; Tamil Nadu; India

BACKGROUND: High-heat exposures at workplaces; especially for workers with moderate or heavy work intensity and where protective workplace policies/optimal controls are not in place have particularly increasing adverse occupational health consequences across the globe; which will be an increasing problem as climate change progresses. Status of occupational heat stress; its general health implications and impacts on renal health are presented with an overview of the very important next steps.

AIM OF THE STUDY: To examine the potential implications of occupational heat exposures on general and renal health of workers.

METHODS: Epidemiological evidence from author's seasonal studies with workers engaged in moderate to heavy labor in ~35 Indian workplaces collected over a 8-year period on heat exposures (n=~3600); self-reported heat-related health symptoms and physiological data (n=~2100) were analyzed to understand the impacts of heat stress on occupational health.

RESULTS: A significant number of workers (~82%) had heat exposures higher than the recommended safe limits of exposure (Max. WBGT of 41.7°C±2.13°C). Workers exposed to chronic high-heat had significant higher odds of adverse-health outcomes (OR=2.43; 95% CI 1.88-3.13; p-value=<0.0001) and compromised renal health in select occupations (47%). Above normal sweat rates; urinary specific gravities; rise in Core Body Temperature and moderate dehydration were common among workers (33.4%). High heat exposures was significantly associated with a 9% prevalence of kidney stones in steel workers (X-squared = 5.650; df = 1; p-value = 0.017) and with about 13% workers having lower kidney function in salt-pans (X-squared = 4.872; df = 1; p-value = 0.027). Climate Projections show that future temperature rise to impose additional health risks for workers; especially in hot seasons.

CONCLUSIONS: In-depth research & epidemiological investigations on renal health impacts of heat stress is an urgent need which form the basis to drive protective labor policies and welfare measures for better occupational health for the workers.

  29. Weight Gain and Obesity After Transplant Top

Ishan Parekh, Pawan Deore, Zaheer Virani, Hitesh Gulhane, Prashant Rajput, Bharat Shah

Institute of Renal Sciences; Global Hospital; Mumbai; Maharashtra; India

BACKGROUND: Weight gain & obesity is reported to be a common complication after transplant. Is this true in Indian setting? There's no data available from India.

AIM OF THE STUDY: To determine change in weight after uneventful kidney transplant.

METHODS: 243 kidney transplants were performed between Sept’2013 & Aug’2017; of these 110 patients had an uneventful course; defined as absence of rejection or infection; malignancy or cardiovascular complications. Patients had completed at least 1 year follow up. We also looked at behavior of pre-transplant weight in 37 patients who had been followed for at least 1 year before transplant. Data of these patients was analyzed.

RESULTS: Amongst these with uneventful course & at least 1 year follow up (n=110); 29% were females & 71% males. The mean age was 42±12.5 years. These patients were followed for a mean duration of 36.5±13.6 months. Mean weight at the time of transplant was 63.1±16.4 kg; at 6 months; 12 months; 24 months; 36 months & 48 months was 68±15 kg; 71.1±15.2 kg; 72±16.2 kg; 73.9±18.1 kg; 71.1±14.7 kg; respectively. While there was definitely a weight gain in the first 12 months compared to weight at transplant; when we looked at behavior of weight before transplant it was mainly regain of weight which was lost in a year before transplant.

CONCLUSIONS: Our study shows that there's significant increase in weight after transplant. However this is by and large; a regain of weight lost in the period before transplant. Therefore it is not true weight gain.

  30. Strategies of Harnessing The Social Media to Improve The Impact and Reach of ISNCON 2017 Top

Arvind Conjeevaram, Manish Rathi1, Raja Ramachandran1, Sanjeev Nair2, Manisha Dassi3, Garima Aggarwal3, Amit Langote4, Mayuri Trivedi5, Umesh Khanna6, Sidharth Kumar Sethi7, Tejas Desai8

Sagar Hospitals; Bengaluru; Karnataka; 1Post-graduate Institute of Medical Education and Research; Chandigarh; 2Saveetha Medical College Hospital; Chennai; Tamil Nadu; 3Max Super Speciality Hospital; Ghaziabad, Uttar Pradesh; 4Apollo Hospitals; Navi Mumbai; 5PD Hinduja Hospital and Medical Research Centre; 6Lancelot Medical Centre; Mumbai; 7Medanta - The Medicity Hospital; Gurgaon; Haryana; India; 8NOD Analytics; Charlotte; USA

BACKGROUND: Social Media (#SoMe) have been used in and enriched Conferences all over the world. In the field of medicine; Nephrologists in many countries have quickly adopted Social Media strategies to disseminate the scientific content of conferences; worldwide. In India; it is only the Nephrology Community that is actively involved in Medical Conference tweeting. At ISNCON 2017; the organizers went one step ahead and formed a #SoMe team to help in the spread of knowledge to more than just the attendees.

AIM OF THE STUDY: To look at how adopting different Social Media strategies helps in increasing the reach of Conference scientific content worldwide.

METHODS: As part of the Social Media Team we led a campaign on Twitter; Facebook and Whatsapp using the hashtag #ISNCON starting 2 months prior to the conference date with tweets and posts about the content of the conference; the speakers and their topics. Data analysis on tweets was done using NOD Ananlytics. Manual counts of Facebook posts were done. While posts were made on Whatsapp about conference content and links provided to tweets and to the videos/live streams; it was difficult to obtain stats about whatsapp posts. Suffice it to say that the links provided on whatsapp helped increase live stream views and exposure to tweets from the conference. Poster Presentation is a unique area that does not get noticed outside the conference arena much and we were able to bring it to the world through #SoMe live streams; pictures and poster-round interviews.

RESULTS: Pre-conference tweets were 209 in number; there were 21 video enriched tweets as well; and we were able to engage 41 people on twitter on this subject; from 10 countries. The tweet count during the conference stood at 1297 tweets. Vibrant tweets; that is; tweets that contained pictures and videos (multimedia) made up 62% of the tweets sent out. We were able to engage 129 people from the nephrology community throughout the world from 21 countries. The no of videos streamed from the conference were 48 and these videos garnered 3926 unique views. On Facebook; during the conference and a 2 month period before it; a total of 89 posts were made. These posts were liked 2089 times. 15 videos were posted on Facebook about the conference and these videos procured 1567 views. Poster presenters were interviewed and live streamed directly to the world from the conference. A poster round was held where-in senior nephrologists discussed contents of the posters with the presenters.

CONCLUSIONS: Social Media help to a great extent in disseminating the scientific content of conferences We achieved this at the ISNCON 2017 by Live Tweeting as well as Live Streaming conference content. Facebook and Whatsapp posts were an important new avenue for distributing conference content.

  31. Measurement of Glomerular Filtration Rate by Plasma Clearance of Iohexol in Indian Subjects: Preliminary Data Top

Prabhjot Kaur, Kajal Kamboj, Ashok Yadav, Vivek Kumar, Nusrat Shafiq, Krishan Lal Gupta, Vivekanand Jha

Departments of Nephrology; Experimental Medicine and Biotechnology; and Clinical Pharmacology; PGIMER; Chandigarh; George Institute for Global Health; India

BACKGROUND: Accurate estimation of glomerular filtration rate (GFR) is critical for diagnosis and risk stratification in chronic kidney disease (CKD). We have recently shown poor performance of currently recommended estimating GFR (eGFR) equations in Indian population against gold standard of urinary inulin clearance.

AIM OF THE STUDY: As a first step towards study aiming to derive an eGFR equation for Indians; we present measured GFR by plasma iohexol clearance during pilot standardization phase and performance of eGFR equations.

METHODS: Clinically stable adults (18-70 years) who are being evaluated as prospective renal donors or have been diagnosed as CKD are eligible for recruitment. After overnight fasting and pre-procedure hydration; subjects receive intravenous injection of iohexol (3-5 ml) followed by venous plasma sampling at 60; 120; 180; 240 min after injection. Measurement of iohexol in plasma is being done by HPLC. mGFR was measured by plasma disappearance rate of iohexol and bias calculated for MDRD and CKD-EPI eGFR equations.

RESULTS: A total of 31 subjects (23 normal individuals and 8 with CKD) were studied. 58% subjects were female. 52% were vegetarians; and the remainder ate meat at average rate of 2.5 times every month. Mean mGFR in the study population was 56.3±19.5 ml/min/1.73 m2. Mean of eGFR by MDRD was 86.03±41.08 and by CKD-EPICr was 86.7±35.6; both of which overestimated mGFR (p<0.01). The mean bias for CKD-EPICr and MDRD were -30.5±29.8 ml/min/1.73 m2 (95% CI: -41.8 to -19.2) and -29.9±34.9 ml/min/1.73 m2 (95% CI: -43.2 to -16.6); respectively.

CONCLUSIONS: Existing creatinine-based GFR estimating equations significantly overestimate GFR in Indian subjects. The data stress upon the need of development of accurate eGFR equation for Indian population.

  ORO – Poster Presentations 22 December 2018 (12.35–13.35 h) Top

  1. Carnosine Prevents Viper Venom Induced Nephrotoxic and Fibrotic Development in Experimental Model Top

Sreyasi Das, Pinaki Mukhopadhyay, Raghwendra Mishra, Roshnara Mishra

Department of Nephrology; NRS Medical College; Department of Physiology; Ananda Mohan College; Department of Physiology; University of Calcutta; Kolkata; West Bengal; India

BACKGROUND: Snake envenomation is a serious medical burden in rural tropical countries which may lead to Acute Kidney Injury (AKI). The only existing treatment of envenomation - anti-snake venom (ASV); is not always effective against AKI. So; alternative strategies are needed to overcome this problem.

AIM OF THE STUDY: The aim of the study is to investigate whether carnosine; an already studied molecule against AKI of different etiologies; could provide protective effects on Russell's viper venom (RVV) induced AKI.

METHODS: Control group received normal saline intramuscularly (i.m). Venom group received RVV at a dose of 30 µgm/100 gm BW i.m. Treatment group received daily oral carnosine supplementation. After 72 hr; animals were sacrificed. Plasma and urinary creatinine and urinary microprotein concentration were measured. Plasma and renal oxidative stress parameters such as Total Oxidative stress (TOS); Total Antioxidant Status (TAS); Nitric Oxide (NO) and lipid peroxidation (MDA) were measured. Renal histology was done with Hematoxylin & eosin and picrosirius red staining. Immunohistochemistry was done with anti-CTGF; TGF-β; α-SMA antibody. Images were analyzed with imageJ image analysis software. Data were represented as mean ± standard error of mean.

RESULTS: Carnosine treatment significantly normalized venom induced alterations in plasma and urinary creatinine and urinary micro-protein concentration. It also significantly reduced plasma and renal TOS; MDA and NO concentration and increased TAS as compared to venom treated group. Picrosirius red stained slides revealed decreased collagen deposition with carnosine treatment. Venom treatment significantly increased renal fibrotic markers such as CTGF; TGF-β; α-SMA which is reduced after carnosine treatment.

CONCLUSIONS: From the present investigation it can be concluded that carnosine has role in ameliorating snake venom induced Inflammation; acute kidney injury and onset of fibrosis and therefore it can be considered as effective therapy. Further study is required for understanding its clinical potential.

  2. Tuberculosis in Renal Transplant Recipients - Is There A Role of Rituximab? Top

Praveen Chandrashekar, Anupama Kaul, Raj Kumar Sharma, Amit Gupta, Narayan Prasad, Dharmendra Singh Bhadauria

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

BACKGROUND: Rituximab is an anti CD 20 agent which acts by depleting B-lymphocytes and used widely in renal transplant recipients. Its use is associated with various infections; however; its association with tuberculosis (TB) is not well established. Some experimental evidence suggest a possible role of B lymphocytes in the immunity against TB. A few case reports in renal transplant recipients associate TB with the use of Rituximab but it is not confirmed by larger studies.

AIM OF THE STUDY: This study was undertaken to assess whether there is any increase in incidence of TB with the use of Rituximab in renal transplant recipients.

METHODS: This is a single centre; retrospective analysis of 56 renal transplant recipients who received single dose of 500 mg IV Rituximab infusion for various indications and 287 renal transplant recipients who never received rituximab; during the study period from January 2013 to June 2017. All the patients were aged more than 18 years and had a follow up of at least 6 months. The patients who were on treatment or treated for TB within one year prior to renal transplantation were not enrolled. None of the patients were screened for latent TB. TB was diagnosed based on microbiological evidence of acid fast bacilli or characteristic radiological features. The association between the use of rituximab and the incidence of TB was studied. Other factors associated with tuberculosis were also investigated.

RESULTS: Baseline characteristics were similar in both the groups. Mean time for occurrence of TB was 18.4 +/- 10.6 months after renal transplantation. Rituximab use was not significantly associated with tuberculosis or any other infection. Patients who had allograft rejection (60% vs 32.72%; p=0.029) had higher incidence of TB. However; no specific type of rejection was associated with tuberculosis. Use of plasmapheresis in post- transplant period for treatment of humoral rejections was associated with significantly higher incidence of TB (33.33% vs 13.41%; p=0.031); however when pre- transplant plasmapheresis was also considered; there was no significant difference found. The choice of induction agent was not associated with higher incidence of TB. Poor survival was associated with use of IV steroids (p=0.014) or plasmapheresis (p=0.023) for treating rejection and if no induction agents (p=0.007) were used; Rituximab use nor tuberculosis were associated with increase in mortality.

CONCLUSIONS: Use of rituximab is not associated with higher incidence of TB. Higher overall immunosuppression in patients experiencing rejection episodes may predispose to TB and other infections. Thus; sreening and prophylaxis of latent TB prior to Rituximab use is not justified in renal transplantation.

  3. An Observational Prospective Study to Evaluate The Effectiveness and Safety of Direct Acting Antivirals in Post-Renal Transplant Patients; For The Management of HCV Infections Top

Ashish Nandwani, Dhaval Khetia, Manish Jain, Neeraj Saraf, Vijay Kher, Shyam Bansal

Department of Nephrology; Medanta - The Medicity; Gurgaon; Haryana; India

BACKGROUND: Hepatitis C infection in post renal transplant patients is known to reduce the graft and patient survival and increases morbidity in renal transplant recipient. Direct acting antivirals have proven effectiveness and safety data in non-transplant population. They have been studied in renal transplant population for interaction with immunosuppression and tolerability.

AIM OF THE STUDY: To study effectiveness and safety of direct acting antivirals in renal transplant recipients with Hepatitis C infection.

METHODS: The study was carried out at a tertiary care institute in Dept. of Nephrology and Transplant Medicine; Medanta Kidney and Urology Institute; Medanta – The Medicity Study Population Consisted of all the patients above 18 years of age; both males and females; who received a renal transplant and has a functioning renal graft; and who received direct acting antivirals for treatment for hepatitis C infection. All patients were subjected to detail clinical and biochemical evaluation related to Hepatitis C infection; liver function; renal function and blood counts. They were evaluated for serious adverse events; need of drug discontinuation or interaction with immunosuppression therapy Outcomes were recorded during the therapy and 12 weeks after the end of therapy.

RESULTS: We studied 35 renal transplant recipients with follow up of 6 months (M:F – 27:8; mean age 39.2±14.4 years). Mean HCV RNA titer was 8485766 IU/ml. Baseline eGFR of patients was 78±21.8 ml/min/m2. All 35 patients were on Tac-MMF-steroid based immunosuppression. DAA based therapy was started after median 2 weeks of transplant (range -1 to 52 weeks). Genotype 1 patients (n=14) received Sofosbuvir + Ledipasvir; and genotype 3 patients (n=21) received Sofosbuvir + Daclatasvir daily for 12 weeks. SVR12 was seen in 97.1% patients (genotype 1 - 100%; genotype 3 - 95.2%). Age; gender; duration from renal transplant or HCV genotype doesn’t appear to have any impact on achieving SVR 12. During study; graft function remained stable. One patient had a borderline cellular rejection. Transaminase levels (SGPT & SGOT) improved significantly (p value- 0.016 & 0.037 respectively). 3 patients required change in immunosuppressive regimen. There was no serious adverse event or discontinuation of therapy.

CONCLUSIONS: Direct acting antiviral based therapy of hepatitis C in renal transplant recipient is having high efficacy; irrespective of age; gender; HCV genotype; or duration from renal transplant. Therapy is well tolerated; with no serious adverse event or drug discontinuation noted in any of the patients.

  4. Renal Deposits of Antibodies Against PLA2R in Membranous Nephropathy – Is It The Sine Qua Non of Idiopathic Membranous Nephropathy or There are Other Concerns Too? - A Prospective Intervent Top

Luvdeep Dogra, Kiranmai Ismail, P S Vali, Manisha Sahay

Department of Nephrology; Osmania Medical College; Hyderabad; Telangana; India

BACKGROUND: MN is the most common etiology of primary Nephrotic syndrome in adults; with upto 40% reaching ESRD over 15-20 years. Usual causes of MN including autoimmune diseases; infections; and malignancies. When one of these is present the disease is termed as ‘secondary MN’ (sMN). Cases with no cause identified are classified as iMN. The role of PLA2R Antibodies; have been a major discovery; and is considered a surrogate marker of iMN. However; PLA2R Antibodies in cases with sMN pose diagnostic dilemma.

AIM OF THE STUDY: Primary: To study the prevalence of renal deposits of antibodies against PLA2R in patients with MNSecondary: To study the response to immunosuppressive regimens in patients with iMN.

METHODS: 35 patients with MN were studied. Patients were eligible if the diagnosis of MN was confirmed by renal biopsy and if they had not received any prior immunosuppressive treatment and PLA2R-antibody staining done. Baseline serum biochemistry and urinary protein quantification obtained. All patients underwent a screening for secondary causes of MN; including a detailed medical history consisting of medication; physical examination; serological analysis (i.e.; for SLE; hep B; hep C and HIV); and the appropriate evaluation of malignant diseases. Patients were managed as per the KDIGO guidelines for MN and response to treatment was closely monitored. Progression to CKD was considered primary end point for study. IEC clearance was obtainedInclusion criteria for iMN included renal deposition of antibodies against PLA2R; negative serological testing for ANA; ANCA; HCV; HBV; HIV; as well as a negative clinical evaluation for any neoplasm.

RESULTS: Antibody deposition against PLA2R was positive in 32 cases (91.4%; n=35). Of these; two were seropositive for SLE; one each had Ca ovary; Rheumatic heart disease and pulmonary TB and were reclassified as sMN (5 cases ~16%; n=32). Of the three patients with PLA2R negativity; one had Pulmonary TB; remaining two were Screen negative for sMN. Of 32 cases with PLA2R positivity; 8 cases (25%; n=32) progressed to CKD; mean follow up 72 months; (range 10 mo –200 mo) All patients were initially started on ACE inhibitors; at follow up 14 patients were added on Modified Ponticelli regimen. 6 patients developed complete remission (CR) and 2 partial remission (PR) and 6 no response. Of the 6 patients with CR; two subsequently relapsed. Of the six patients (42%; n=14) with no response; 2 were managed with ACEi. Of remaining four; 3 recieved Tacrolimus and one MMF; with no improvement. 2 cases further subjected to Rituximab; however; none responded.

CONCLUSIONS: 5 cases with PLA2R staining had an underlying cause; and were falsely positive. Response to modified Ponticelli regimen was the most consistent predictor of remission; no case with failed Ponticelli regimen; responded to further therapy. Unknown target antigen may be the cause of PLA2R negative Smn.

  5. Contast Induced Nephropathy: A Hospital Based Study on Risk Factors and Outcomes Top

Shiv Shankar Sharma, Shivendra Singh, Dharmendra Jain, Amit Nandan Dhar Dwivedi, Prem Shankar Patel

Department of Nephrology; Institute of Medical Sciences; Banaras Hindu University; Varanasi; Uttar Pradesh; India

BACKGROUND: CIN is 3rd commonest cause of hospital acquired AKI. It usually carries a fair outcome but risk factors like renal dysfunction; diabetes; old age; dehydration; type & volume of contrast media etc can increase incidence and severity of CIN. Incidence of CIN reported in various studies differ widely (5- 60%) due to no consensus on diagnostic criteria & various study-populations. Indian studies on CIN targeting both CT and Cardiovascular procedures are scarce despite the procedures being very common.

AIM OF THE STUDY: To study incidence & outcome of CIN in diagnostic & interventional radiocontrast related procedures. Specially the contribution of various known risk factors; modifiable as well as non modifiable.

METHODS: In this observational study; 300 hospitalized patients undergoing contrast enhanced radiographic investigation or percutaneous coronary procedures were enrolled. Patients with significant existing renal disease (eGFR<30) and diseases prone to cause AKI like sepsis; ARDS; severe CCF; hypotension; poly-trauma etc. were excluded. Serum creatinine was measured prior to radiocontrast exposure & post procedure at 48 hours; at 1 week and SOS at 14th day (if creat found elevated at 1 week). GFR was estimated using CKD-EPI formula. Clinical profile; risk factors; volume & type of contrast used; and outcome of patient were recorded & analyzed. CIN was defined as an increase of s.creatinine >25% or absolute increase >0.5 mg/dl from pre-procedural values after contrast exposure. All patients with CIN defining rise of creatinine were re-evaluated for any other diseases and were excluded if any such disease diagnosed during study period. All CIN cases were monitored for outcome and need of dialysis.

RESULTS: A total of 266 patients completed the study; 138 undergoing contrast CT & peripheral angiography and 128 undergoing percutaneous coronary intervention (CAG/PTCA). The cumulative incidence of contrast induced nephropathy was 15.4% (n=41). The volume of contrast used (250-300 ml) and CIN incidence was highest in PTCA group (24%). Of the risk factors studied; moderate- pre-existing renal dysfunction (eGFR30-60) and diabetes were associated with maximum incidence of CIN (33.8 and 31% respectively) while no significant increase was noted in mild renal dysfunction (gfr 60-90) and anemic patients. The incidence increased with increasing number of risk factors and with increasing contrast volume. The patients exposed to low volume of contrast had significantly lower incidence even when significant pre-existing renal dysfunction was present. Most patients had benign disease with 97% having recovery of renal function by 14th day. Of the 41 CIN cases; 3 patients required temporary dialytic support.

CONCLUSIONS: CIN is common even with hydration and avoidance of high osmolar contrast in current era. Risk is more with PTCA due to shared risk factors. Incidence increases with increasing risk factors & repeat procedures. Life saving procedures shall not be delayed because of fear of CIN as it is mostly benign.

  6. Ultrasound Assessmentof Kidey Sizes in Different Age Groups Without Renal Disease Top

Moiduddin Azhar, Nazma, Manjusha Yadla

Department of Nephrology; Gandhi Medical College; Secunderabad; Telangana; India

BACKGROUND: Estimation of renal size by ultrasonography can be performed by measuring renal length; renal volume; cortical volume or thickness. Renal length as well as renal cortical thickness has been closely related to creatinine clearance in patients with chronic kidney disease.

AIM OF THE STUDY: Our primary aim was to establish a normal range of values for kidney length and volume in our adult population with normal renal function.

METHODS: This was a prospective observational study. Ultrasonographic assessment of 499 healthy normotensive (defined as systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) volunteers; both male and female; between 18 to 80 years of age; was done. Volunteers with known urinary calculi; renal cysts or having a past history of renal surgeries; volunteers with existence of acute or chronic disease capable of causing damage to renal function; pregnant females etc.; were excluded from the study population.

RESULTS: Out of 499 volunteers 327 (65%) were males and 172 (35%) were females. 17.8% volunteers were less than 30 years of age; 51.5% volunteers were in the age group of 30-60 years and 30.7% were above 60 years of age. Mean BMI in males was 25.20 +/- 3.96 whereas mean BMI in females was 24.08+/- 3.28. In males the mean cortical thickness in Right kidney was 13.68+/- 2.47 mm and in left kidney CT was 13.94+/- 2.6 mm. In females right kidney cortical thickness was 12.63+/- 1.91 mm and left kidney CT was 13.40+/-2.37 mm. In the present study the right mean renal length was 9.9± 40 and left renal length was 10.19±0.978 and had correlation with BMI.

CONCLUSIONS: Size of kidney has significant ethnic and geographic basis. We found correlation between BMI and kidney size in our study population.

  7. Phosphodiesterase 5 Inhibitors Alleviate Fibrotic Phenotype and Restore Anti-Fibrotic Responses of Peritoneal Fibroblasts Isolated from Patients Top

Kritika Singh, Narayan Prasad1, Saurabh Chaturvedi, Harshit Singh, Mohit Kumar Rai, Akhilesh Jaiswal, Ravi Mishra, Durga Prasanna Misra, Vikas Agarwal

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

BACKGROUND: Peritoneal fibrosis is a major cause of ultrafiltration failure in continuous ambulatory peritoneal dialysis (CAPD) patients. Transforming growth factor beta 1 (TGF-β1) is an essential factor in progressive changes in the peritoneal membrane leading to fibrosis. TGF- β1 activates resident fibroblasts which trans-differentiate into myofibroblasts (MFBs); characterized by increased expression of alpha-smooth muscle actin (α-SMA) and enhanced extracellular matrix (ECM) proteins production.

AIM OF THE STUDY: To evaluate anti-fibrotic role of Phosphodiesterase-5 inhibitors; sildenafil and zaprinast; respectively in human peritoneal fibroblasts (HPFB) isolated from peritoneum of CAPD patients.

METHODS: Parietal peritoneum biopsy (PB) of control patients (n=8; age-50±8 years; M/F-5:3) and CAPD patients (n=6; age-47±8 years; M/F-4:2)) excised during laparotomy was incubated overnight in dispase (2.4 U/mL)/37°C. HPFB appeared within 2 weeks. In post-treatment strategy; HPFB from PB were incubated with TGF-β1 (10 ng/ml) for 1 hr and later with TGF-β1 (10 ng/ml) and (Sildenafil; Zaprinast-10 µM; each) for 24 hr. In pre-treatment strategy; HPFB from PB were pretreated with (Sildenafil; Zaprinast-10 µM; each) for 1 hr and later with only TGF-β1 (10 ng/ml) for 24 hr. Real time qPCR for pro-fibrotic (Col1a1; Col1a2; ACTA2; CTGF and FN1) and anti-fibrotic genes (MMP2/TIMP1) expression was performed. Type I collagen and α-SMA was examined by western blotting.

RESULTS: In TGF-β1 stimulated HPFB; upregulated mRNA expression of pro-fibrotic genes (p<0.05) at 24 hr was observed. Pre-treatment of HPFB with Sildenafil and Zaprinast more effectively reduced expression of Col1a1; Col1a2; ACTA2; CTGF and FN1 respectively (fold change 4.31; 6.34; 3.28; 5.89; 2.12; 2.89; 6.56; 7.32; 3.12; 3.99; p<0.05) than disease mimicking strategie. Ratio of anti-fibrotic mRNA responses (MMP2/TIMP1) was restored with the pretreatment strategy more efficiently than disease imitating strategy respectively (fold change 1.25; 2.54; 1.99; 2.98; p<0.05). Also pre-treatment with Sildenafil and Zaprinast decreased type 1 collagen and α-SMA competently respectively (fold change 1.78; 2.13; 1.67; 2.01; p<0.05).

CONCLUSIONS: Phosphodiesterase-5 inhibitors reduce pro-fibrotic mRNA expression and restore anti-fibrotic mRNA responses in co-cultured human peritoneal fibroblasts with TGF-β1.

  8. Utility of Flowcrossmatch Testing in Prospective Renal Transplant Recipients Top

Smriti Sinha, Shyam Bansal, Pranaw Jha, Ashwini Gadde, Amit Tiwari, Vijay Kher

Department of Nephrology; Medanta - The Medicity; Gurgaon; Haryana; India

BACKGROUND: Rejection remains one of the major causes of graft failure today. A detailed pretransplant immunological workup is a prerequisite but due to lack of availability and cost constraints; many centres in India are still not doing routinely doing Flowcrossmatch and Luminex SAB testing. Doing only CDC crossmatch test can lead to missing of clinically significant Anti HLA antibodies and help in planning induction and immunosuppression.

AIM OF THE STUDY: To determine the prevalence of Flow crossmatch positivity in prospective renal transplant recipients and its co relation with CDC crossmatch and luminex SAB testing.

METHODS: All renal transplant patients undergoing renal transplant workup from October 2016 to October 2017 were enrolled. Information regarding their immunological tests; history of sensitizing events was collected. CDC and Flowcrossmatch was done in all patients. Luminex was done in immnulologically high risk patients like second transplant and positive crossmatch result. They were followed up for 6 month and history regarding graft outcomes i.e. creatinine at discharge; creatinine at 6 months and biopsy proven rejection was collected and analysed.

RESULTS: A total of 200 were enrolled in the study. 170 patients underwent renal transplantation. CDC crossmatch was positive in 5.5% and Flowcrossmatch positive in 19% (p=0.001). Luminex SAB was done in 36 patients. DSA was seen in 65.5% (n=19; p=0.027) of Flowcrossmatch positive patients. 14 (7%) patients had negative CDC but Positive Flowcrossmatch with DSA detected. 12 flowcrossmatch positive patients were transplanted of which 4 patients had DSA. They all underwent desensitization. Graft outcomes of Flowcrossmatch positive patients were similar to the negative group in terms Serum creatinine at 6 months (1.18 vs 1.29 mg/dl) and rate of rejection (8.3 vs 7.6%). ABMR was seen in 1.9% of patients; all were Flowcrossmatch Negative. None of the Flowcrossmatch Positive DSA positive patients had ABMR.

CONCLUSIONS: Flowcrossmatch tests is a more sensitive tests than CDC crossmatch in detecting Anti HLA antibodies and allows for better risk stratisfivcation and transplant planning in terms of desensitisation; induction and immunosuppression.

  9. Circulating Endothelial Microparticles in Endothelial Injury of Patients with IgA Nephropathy Top

Niharika Bharti, Mohit Kumar Rai, Vinita Agrawal, Rakesh Pandey, Vikas Agarwal, Narayan Prasad

Department of Pathology, Immunology and Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

BACKGROUND: IgA Nephropathy (IgAN) is most common cause of end-stage renal disease in Indian patients characterized by hematuria with proteinuria; suggesting role of endothelial injury in IgAN. Endothelial injury may generate small membranous vesicles (size 0.1-1 µm); called as Endothelial Microparticles (EMPs); which regulates inflammation; vascular function; apoptosis and cell proliferation or differentiation. In this study; we had evaluated the Endothelial microparticles as biomarkers in IgA Nephropathy.

AIM OF THE STUDY: To study the association between endothelial injury and the presence of endothelial microparticles in IgAN.

METHODS: 10 biopsy proven IgA nephropathy (Age=29.5±6.6 years) and 5 healthy control (Age=28.6±4.03 years) were recruited in this study. Platelet-Poor-Plasma from citrated blood were isolated and centrifuged at 20; 000 g (90 min) at 4°C. EMPs were analyzed by Flow cytometry using EMPs specific antibodies for antiCD31-FITC and AntiCD146-PE. All quantification related to size and no. was done by using cell count beads.

RESULTS: There is a significant increase in endothelial microparticles in patients with IgAN compared to healthy control (p=0.045). No. of EMPs strongly correlated with proteinuria. Thus this may be the simple and highly reproducible method useful for monitoring endothelial injury/ dysfunction in IgAN.

CONCLUSIONS: MPs may provide insights into their pathophysiologic; diagnostic and therapeutic roles in IgAN.

  10. 5-HT2 and 5-HT2B Receptor Antagonism Attenuate Peritoneal Fibrosis by Blocking Non-Canonical Signaling Pathways Including STAT3 Top

Saurabh Chaturvedi, Narayan Prasad1, Harshit Singh, Mohit Kumar Rai, Akhilesh Jaiswal1, Ravi Mishra, Kritika Singh, Durga Prasanna Misra, Vikas Agarwal

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

BACKGROUND: Peritoneal fibrosis is a major cause of ultrafiltration failure in continuous ambulatory peritoneal dialysis (CAPD) patients. 5-hydroxytryptamine (5-HT; Serotonin) strongly induces extracellular matrix synthesis in peritoneal fibroblasts in a Transforming growth factor beta 1 (TGF-β1) dependent manner.

AIM OF THE STUDY: To evaluate anti-fibrotic role of inhibitors of 5-HT2 and 5-HT2B (Terguride and SB204741); respectively in human peritoneal fibroblasts (HPFB) isolated from peritoneum of CAPD patients.

METHODS: Biopsy from parietal peritoneum (PB) of control patients (n=8; age-50±8 years; M/F-5:3) and CAPD patients (n=6; age-47±8 years; M/F-4:2) excised during laparotomy was incubated overnight in dispase (2.4 U/mL)/37°C. In post-treatment strategy; cells were incubated with 5-HT (1 µM) for 1 hr and later with 5-HT (1 µM) and terguride or SB204741 (1 µM; each) for 24 hr. In pre-treatment strategy; cells were pre-treated with terguride or SB204741 (1 µM; each) for 1 hr and later with only 5-HT (1 µM) for 24 hr. HPFB were also incubated with TGF-β1 (10 ng/ml) and 5-HT inhibitors similar to the above strategies. Real time quantitative PCR for pro-fibrotic (TGF-Β1; COL1A1; COL1A2; ACTA2; CTGF and FN1) and anti-fibrotic genes (MMP2/TIMP1) expression was performed. Type I collagen and α-SMA; phosphorylation status of Smad-3; ERK1/2 and STAT-3 was examined by immunoblotting.

RESULTS: In 5-HT and TGF-β1 stimulated HPFB; upregulated expression of COL1A1; COL1A2; ACTA2; CTGF and FN1 (p<0.05) mRNA at 24 hr was observed. Co-culture of HPFB with 5-HT2 and 5-HT2B receptor antagonists significantly reduced pro-fibrotic genes expression (p<0.05) in both the strategies. Effect on anti-fibrotic genes mRNA in both the strategies was not affected. Pre-treatment with both 5-HT inhibitors decreased the production of type 1 collagen and α-SMA significantly (p<0.05). 5-HT dose-dependently increased the mRNA levels of TGF-Β1. Terguride and SB204741 did not influence Smad-3 phosphorylation (canonical pathway) rather they significantly reduced STAT-3 and ERK1/2 phosphorylation (non-canonical pathway) (p<0.05).

CONCLUSIONS: TGF-β1 mediated non-canonical pathways; ERK1/2 and STAT3 have been implicated in regulation of pro-fibrotic genes and in the development of fibrosis. 5-HT receptor antagonists might reduce fibrosis via suppression of TGF-β1 mediated non-canonical pathways.

Oro Poster Presentation 22 December 2018 (12.35-13.35 h)

  11. Influence of CYP3A5 and ABCB1 Polymorphism on Tacrolimus Drug Dosing in South Indian Renal Allograft Recipients Top

S. Manokaran, Edwin Fernando, N D Srinivasaprasad, S. Sujit, Thirumalvalavan

Department of Nephrology and Immunology; Government Stanley Medical College Hospital; Chennai; Tamil Nadu; India

BACKGROUND: Tacrolimus blood levels are influenced by polymorphisms involving Cytochrome 3A subfamily (CYP3A5) and P-Glycoprotein (ABCB-1) genes. However their role in transplant outcomes were less studied in South Indian population. We studied the prevalence and impact of these polymorphisms in renal transplant recipients from south India.

AIM OF THE STUDY: to identify the prevalence of CYP3A5; ABCB1 polymorphisms in South Indian kidney transplant recipients and to determine the effect of CYP3A5; ABCB1 gene polymorphisms on serum tacrolimus concentration.

METHODS: An analysis of CYP3A5; ABCB1 genotype done in 101 renal transplant recipients by Polymerase Chain Reaction was correlated with Blood tacrolimus trough levels (CLIA method); weight; concentration/dose (L/D) ratio; incidence of biopsy proven early acute rejections and tacrolimus toxicity.

RESULTS: Prevalence of CYP3A5 *1/*1; *1/*3 and *3/*3 and ABCB1 (3435C>T) TT; CT; CC genotypes were 12 (11.9%); 48 (47.5%); 41 (40.6%) and 16 (15.8%); 45 (44.6%); 40 (39.6%) respectively. Mean Tacrolimus level; Median Concentration/Dose (L/D) ratio were significantly lower in homozygous (CYP3A5 *1/*1-6.54 ng/ml; 48.99 ng/ml/mg/kg/day) and heterozygous expresser group (CYP3A5*1/*3-5.08 ng/ml; 68.93 ng/ml/mg/kg/day) when compared to non-expresser group [CYP3A5*3/*3-6.52 ng/ml (P<0.001);181.3 ng/ml/mg/kg/day (P0.019)]. No significant differences observed between the ABCB1 genotypic groups. Incidence of early acute rejections (30% vs 9.76%; P 0.016) and Tacrolimus related toxicity (14.6% vs 5%; P 0.039) were significantly higher in CYP3A5 expressers and non-expressers respectively. No correlation observed between the ABCB1 polymorphisms between rejection episodes or tacrolimus renal toxicity.

CONCLUSIONS: Among 101 patients; 40.6% were non-expressers (poor metabolisers) (*3/*3). CYP3A5 Polymorphisms correlated with Tacrolimus dose requirements and blood levels; incidence of early acute rejection and Tacrolimus nephrotoxicity.

  12. Clinical Spectrum and Outcome of Pregnancy Related Acute Kidney Injury in A Tertiary Care Centre in South India Top

Muzamil Latief, Manjusha Yadla

Department of Nephrology; Gandhi Medical College; Secunderabad; Telangana; India

BACKGROUND: Spectrum of PR-AKI is quite broad and various conditions either lead or contribute to its development which not only affect the severity but also are to be considered to decide the management plan. The various conditions leading to PR-AKI are preeclampsia; Eclampsia; Puerpeural sepsis; acute fatty liver of pregnancy; Antepartum or postpartum haemorrhage HELLP (Hemolysis; Elevated Liver function tests; Low Platelets) syndrome; and the thrombotic microangiopathies (TMA).

AIM OF THE STUDY: To study the clinical spectrum and outcome of Pregnancy Related AKI in a tertiary care centre

METHODS: We conducted this prospective study among pregnant patients admitted in Gandhi Hospital who presented with Pregnancy Related AKI on admission or developed PR-AKI during the course of hospital stay. Over a period of 5 years a total of 250 patients with PR-AKI were studied.

RESULTS: During the study period a total of 55560 pregnant patients were admitted in our hospital 0.44% developed PR-AKI. PR-AKI constituted 4.12% of AKI patients. Mean age of the patient population was 24.8 +/- 4.13 years. Preeclampsia/ Eclampsia was observed in 41.6% of patient.48% patients had IUD. LSCS was done in 52.8% patients. Sepsis as a cause and contributor was seen in 76.4% patients. 11 patients were subjected to Renal Biopsy (3 had Diffuse cortical Necrosis; 2 had ATN and 6 had Patchy cortical necrosis). Mean serum Creatinine levels were 3.59+/- 1.97 mg/dl. Oliguria was seen in 62.4% patients where as 11.2% patients were anuric. 51.6% patients had thrombocytopenia and 21.6% patients had multi organ involvement. 23.6% patients were managed conservatively where as 65.5% patients received HD; 9.2% patients received PD and 2% patients received both HD and PD. Overall mortality among admitted pregnant patients was 1.07% where as it was 22.8% in pregnant patients with PR-AKI

CONCLUSIONS: In our study PR-AKI constituted 4.12% of total AKI patients during study period.. Among pregnant patients admitted during study period 0.44% patients develoed AKI. Overall mortality in admitted pregnant patients was 1.07% where as in patient with PR-AKI it was 22.8%.

  13. Maintaining A Balanced Bone Health by Optimum Management of Chronic Kidney Disease-Mineral and Bone Disorder in The Hemodialysis Population Top

Pankaj Jawandhiya, Deepa Usulumarty, Pranit Kakade, Vinayak Ukirde, Komal Nagori, Ganesh Sanap, Parag Tilve, Shrirang Bichu, Ritesh Agarwal, Jatin Kothari, Rajesh Kumar, Viswanath Billa

Department of Nephrology, Apex Kidney Care - The Apex Database; Bombay Hospital Institute of Medical Sciences; Sushrut Hospital and Medical Research Centre

BACKGROUND: Mineral bone disorders form an important and generally unrecognised problem in the dialysis population. The impact of this disorder on fracture risk and vascular calcification has been well documented. However this aspect of their medical care often gets overlooked despite the availability of powerful diagnostic and therapeutic interventions.

AIM OF THE STUDY: To evaluate the prevalence of CKD-MBD in the hemodialysis population and the effects of specific therapeutic interventions; both medical and surgical. and their outcomes.

METHODS: This was a retrospective; cross sectional study of patients at a single haemodialysis centre. Patients were divided into two groups based upon their iPTH levels - iPTH <100 pg/dl and >1000 pg/dl representing low turnover & high turnover bone disease respectively. Patient with low turnover bone disease were treated with either low calcium bath; or Injection Teriparatide or both. Bone mineral density (BMD) was evaluated with a densitometry scan (DEXA) done pre treatment and after 3 months to see the effect of treatment with Teriparatide. Patients with high turnover bone disease were treated with Cinacalcet; Injection Vitamin D3 or both. Parathyroid surgery was done in patients who were refractory to medical treatment for 3 months.

RESULTS: A total of 152 patients were evaluated. 21 patients had iPTH <100 pg/ml (13.8%). 31 patients had iPTH >1000 (20.4%). The extremes of the CKD MBD spectrum afflicted 34% patients. For the low PTH group; the mean values for iCa; PO4; iPTH and ALP pretreatment were 1.22±0.062; 4.88±2.058; 68.9±33.18; 162.4±72.74 respectively. The posttreatment values were 1.15±0.09 (p=0.12); 4.83±1.93 (p=0.95); 128.22±85.17 (p<0.0001) & 117.75±48.61 (p=0.031) respectively. Out of 31 patients with iPTH>1000; 6 were on vitamin D; 1 patient was on Cinacalcet only and 16 were on combination therapy. 4 underwent parathyroidectomy. Mean pretreatment value of iCa; PO4; iPTH & ALP in the medically treated group were 1.1±0.11; 5.48±0.83; 1327.023± 169.58 and 159.76±62.76 respectively. The values after treatment were 1.15 ± 0.23; 5.8± 0.89; 469.66 ± 366.9 (p<0.0001) and 131.22±44.47 (p=0.10) respectively. Out of 4 patients who underwent surgery; mean value of iPTH pre & post surgery 1384±433.97 & 666.25±308.73.

CONCLUSIONS: Significant CKD MBD exists in a third of the dialysis patients. Medical management is successful in the majority of patients. A small proportion are successfully treated with parathyroidectomy. Timely monitoring parameters of CKD MBD is essential to mitigate the morbidity of this condition.

  14. Molecular Profile of Exosomal Mirna in Human Kidney Proximal Tubular Cell Line Top

Nisha Sinha, Veena Puri1, Vivek Kumar2, Vivekanand Jha3, Sanjeev Puri4

Centre for Stem Cell and Tissue Engineering; Panjab University; 1Centre for Systems Biology and Bioinformatics; Panjab University; 2Department of Nephrology; Post Graduate Institute of Education and Medical Research; 4Department of Biotechnology; University Institute of Engineering and Technology; Panjab University; Chandigarh; 3The George Institute of Global Health; New Delhi; India

BACKGROUND: Type 2 diabetics often develop Diabetic Nephropathy along with Albuminuria that is caused primarily by impaired uptake of albumin by proximal tubular cells; rather than by increased leakiness of the glomerular filtration barrier. Proteins controlling these cellular processes are strictly regulated by miRNA. These miRNA are packaged into nanosized vesicles called exosomes. The exosomal miRNA profile of tubular cells might aid to unravel the molecular mechanism involved under diseased condition.

AIM OF THE STUDY: To identify the differential expressed miRNA in exosomes of human kidney proximal tubular cell line (HK-2).

METHODS: HK-2 cells were cultured under low and high glucose conditions. Exosomes were isolated from these cells by combining filtration and ultracentrifugation method. They were further characterized by electron microscopy and flow cytometry. Total RNA was isolated by miRVana miRNA isolation kit and subjected to real time based miRNA expression profiling by Exiqon. miRNA with p-values < 0.05 based on the fold change were considered statistically significant and further validated by Real Time PCR. Targets of these miRNA were identified by at least three bioinformatics tools viz. MIRDIP; mirWalk; miRTarbase and/or Tarbase. DAVID and KOBAS bioinformatics resources were used for enrichment analysis. Protein- protein interaction (PPI) networks were identified by using STRING software and visualized in Cytoscape. Sub-networks were extracted from the PPI network to further elucidate the most significant functional modules of the differential expressed genes; using the MCODE Cytoscape plug-in.

RESULTS: Flow cytometry analyses showed about 95% positive CD81 (exosomal marker) vesicles and electron microscopy confirmed the size of the exosomes to be 30-100 nm. Eight miRNAs were found to be differentially expressed under type 2 diabetic conditions. We have validated four miRNAs with a p value < 0.05 by Real Time PCR in the same expression profile as in expression profiling by Exiqon. Overall we identified about 197 targets of these miRNAs. These targets were from various pathways viz FoxO Signalling pathway; Renal Cell carcinoma; Signalling by VEGF etc. The protein-protein interaction network analysis of these targets showed 195 nodes with enrichment p value as 1.33e-15. MCODE generated 5 clusters of these targets with different nodes and interactions.

CONCLUSIONS: Eight miRNAs were found to be differentially expressed under the diseased condition. These miRNA targets were used to build a network of pathway and Protein –Protein Interactions (PPI)/ for identifying novel molecular mechanisms for disease afflication and in therapeutic intervention.

  15. Post Renal Transplant Metabolic Acidosis: A Neglected Entity Top

Jayanivash Jayam, N D Srinivasaprasad, S Sujit, M Edwin Fernando

Department of Nephrology; Government Stanley Medical College Hospital; Chennai; Tamil Nadu; India

BACKGROUND: Metabolic Acidosis is a prevalent yet overlooked entity among renal transplant recipients (RTRs) with adverse effects on graft function. The prevalence is a difficult figure to establish as very few papers have assessed the issue and ranges from 11% to 50%. Although graft dysfunction and calcineurin inhibitor usage have been linked with Renal tubular acidosis; there is no Indian data on prevalence or risk factors

AIM OF THE STUDY: To assess the prevalence; severity; type and risk factors associated with acidosis in RTRs.

METHODS: A cross-sectional study was conducted on 106 adult renal transplant recipients; with a transplant duration of more than 6 months and an estimated GFR > 40 ml/min/1.73 m2. Patients with acute graft rejection within last 6 months; unstable graft function; active infection and diarrhoea were excluded. Metabolic acidosis was diagnosed on basis of plasma bicarbonate and pH. Additional measurements of serum & urine anion gap and electrolytes were made in acidotic patients to diagnose and type Renal tubular acidosis (RTA).

RESULTS: Acidosis was diagnosed in 44 of 106 patients (41. 5%) with 23 (52.27%) of these patients having severe acidosis. Type I RTA was the most common subtype (52.5%) followed by type IV (30.9%) and type II RTA (7. 5%). Despite low eGFR [OR-0.92; P=0.01] in the acidosis group; the correlation between eGFR and acidosis was minimally linear (r=0.1088) implying role of other pathogenic factors for acidosis. Multivariate analysis revealed previous acute rejection episodes; current serum tacrolimus (c0) levels; use of Cotrimoxazole and intake of animal proteins to be independent risk factors for acidosis. There was moderate and nil association between ACEi/ARB and metformin usage respectively with acidosis. The serum albumin levels were low in the acidosis group and showed a linear correlation with declining bicarbonate levels (r=0.298).

CONCLUSIONS: There is a high prevalence of metabolic acidosis in RTRs with type I and type IV RTA being most common subtypes. Multivariate analysis revealed previous acute rejection episodes; current serum tacrolimus levels; Cotrimoxazole and animal protein intake to be independent risk factors for acidosis.

  16. Targeting Micro-Rnas Expressed in Peripheral Blood of Patients with Chronic Antibody Mediated Rejection of Renal Transplant: A Next Generation Molecule Top

Sushma Singh, Mantabya Singh, Harshit Singh1, Vikas Agrawal1, Narayan Prasad

Departments of Nephrology and 1Clinical Immunology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Uttar Pradesh; India

BACKGROUND: MicroRNAs (miRNAs) are non-coding RNA that play pivotal role in modulating expression of multiple target genes at post-transcriptional level and have potential to modulate physiological & pathological processes thus can be used as potential therapeutic targets. In kidney; role of miR have been involved in renal fibrosis; organogenesis and in pathogenesis of many diseases including diabetic; IgA nephropathies; glomerulopathies etc thus opening the possibility of their use as biomarkers in CABMR.

AIM OF THE STUDY: The impact of miRNA regulation involved in allograft function and immunity has not been investigated thoroughly thus we studied the miRNAs expression involved in CABMR.

METHODS: Patients with CABMR (Banff's classification- 2017) were included. 11 blood donors (M=10) with a mean age of 48.7Y were served as controls. Samples were processed for RNA isolation. RNA integrity was checked by running over 1% agarose gel and quantity and qualities were checked using nanodrop with 260/230 and 260/280 ≥ 1.8. The miRNAs expressions; miR-21; miR-155; miR-210; miR-146a; miR-126; miR-34a; miR-150 and RNU6B (control) were detected by quantitative miRNA stem loop RT-PCR technology (TaqMan MicroRNA Assays; Applied Biosystems; CA) as per manufactures protocol. Briefly; we used highly target-specific stem loop structure and reverse transcription primer; and after reverse transcription; used specific TaqMan hybridization probes for miRNA amplification. This allowed for a high specificity only for the mature miRNA; and formation of a reverse transcription primer/mature miRNA chimera extending to the 5’ end of the miRNA. Expression was measured by calculating fold change.

RESULTS: Total 24 patients (Male=22 with mean age of 42.63 Y) were enrolled for the study with post transplant duration of 32.25 months. The demographic details with mean values were: S Creatinine = 1.75 mg/dl; BUN = 27.97 mg/dl; Tac level = 6.56 ng/ml; S Uric Acid = 6.778 mg/dl; S Albumin = 3.68 g/dl; Na+/K+ = 135.9/4.21 mmol/L; S Phosphorus = 3.250 mg/dl; S Alkaline phosphate = 81.65 u/L. Induction regimen (Basiliximab=20; ATG= 4) Baseline Immunosuppression MMF+Pred (Tacrolimus/Cyclosporin) = 22/2. C4d were positive in 22 and DSA+ in 2 patients. The expression of different microRNAs; miR-21 (p≤0.0001); miR-155 (p=0.0212); miR-210 (p=0.0001); miR-146a (p=0.0055); miR-126 (p=0.0001) were increased in CABMR patients compared to healthy controls whereas expression of miR-150 (p=0.0006) was shown to be reduced. Expression of miR-34a did not show any significant change.

CONCLUSIONS: Altered miRNA expression profiling was found in CABMR compared to healthy controls. MicroRNAs are crucial regulators of cell function. They are easy to detect and represent potentially good targets for novel therapies

  17. A Study on Incidence and Severity of Acute Renal Failure and Its Association with Parasite Density in Hospitalised Patients with Falciparum Malaria Top

Pinaki Mukhopadhyay, B. K. Das

Department of Nephrology, NRS Medical College and Hospital; Kolkata; West Bengal; India

BACKGROUND: Malaria is one of the most widespred tropical diseases with lot of morbidity and mortality. Parasite Density is an important marker of degree of infection. Various studies show the strong correlation between the parasite density and severity of both falciparum and vivax malaria but not well studied in eastern India.

AIM OF THE STUDY: (1) To find out the incidence of acute renal failure in falciparum malaria. (2) To correlate between the degree of parasitism at presentation with acute renal failure and its outcome

METHODS: This is an Observational and prospective study. A total of 50 cases of acute renal failure were selected from 174 patients diagnosed case of falciparum malaria. Selected patients were grouped according to the clinical features; laboratory parameters and were followed up for the outcome. All complicated malaria cases were treated with Quinine or artisunate as per protocol. They are followed till discharge or death.

RESULTS: Out of the 174 patients with falciparum malaria 50 patients (28.7%) had acute renal failure in falciparum malaria.36 (72%) cases were males and 14 (28%) were females. Mean age 32 ± 11.6 years. Out of the 50 cases of ARF; 29 cases were found to have severe ARF and 21 cases had milder form of ARF based on the GFR.21 had Parasite Density <5% (42%); 13 had 5-10% (26%) and 16 had >10% (32%). Out of 21 cases of mild ARF 12 patients had parasite density<5% and 9 had >5%. Out of 29 cases of severe ARF 9 patients had parasite density<5% and 20 had >5%.24 patients (48%) out of 50 patients got injection Quinine and 26 patients (52%) got injection Artesunate. Dialysis was done in a total of 31 cases (62%). Out of the 36 cases with oliguric ARF; 23 (63.88%) survived; while 13 cases expired.

CONCLUSIONS: Parasite Density has significant impact to predict the severity of renal failure; duration of hospital stay as well as the number of dialysis required.

  18. Study of Cardiac Arrhythmias in Hemodialysis Patients At A Tertiary Care Hospital Top

Jaymin Somani, Tarun Jeloka, Rajesh Badani, Manish Mali

Department of Nephrology; Aditya Birla Memorial Hospital; Pune; Maharashtra; India

BACKGROUND: Patients on hemodialysis have wide fluctuations in volume status; sodium; potassium; ionized calcium; magnesium and other divalent ions; during and between dialysis treatments; contributing to a potentially “arrhythmogenic milieu.” Two-thirds of cardiac deaths in hemodialysis patients are attributed to arrhythmia. These observations led us to study the incidence of cardiac arrhythmias and its correlation with factors that may contribute to the development of cardiac arrhythmias.

AIM OF THE STUDY: To study the incidence and outcome of cardiac arrhythmias in hemodialysis patients.

METHODS: A total 25 patients on hemodialysis without history or evidence of arrhythmias were enrolled. Holter monitoring was done for 24 hours: 4 hours hemodialysis and 20 hours post dialysis period; on two occasions: long interdialytic (LIDP) and short interdialytic period (SIDP). Incidence and types of arrhythmias; factors associated with and effect of interdialytic period on arrhythmia were studied. All patients were followed for 6 months to study the relationship of arrhythmias to adverse cardiovascular outcomes.

RESULTS: Incidence of arrhythmia was 68%. Sinus bradycardia being the commonest; in 60%; followed by supraventricular tachycardia; atrial tachycardia; premature ventricular complex; atrial fibrillation; premature atrial complex and ventricular tachycardia. Baseline demographic and laboratory parameters of patients with or without arrhythmias were similar; except serum creatinine and ultrafiltration after LIDP; which was higher in arrhythmia group. Incidence of arrhythmia was higher after LIDP as compared to SIDP (64% vs. 52%; p=0.004). There was a trend towards higher incidence of arrhythmias post dialysis period (60% vs. 36%; p=0.07). Two patients died in non-arrhythmia group and one developed heart failure in arrhythmia group over 6 months of observational period.

CONCLUSIONS: Asymptomatic arrhythmia is a common complication in hemodialysis (68%) with bradycardia being the commonest (60%). Incidence is higher after long interdialytic period with higher ultrafiltration and more common post hemodialysis.

  19. Vascular Endothelial Growth Factor Gene Polymorphisms Influence Acute Rejection in Renal Transplant Recipients Top

Ranjeet Singh, Narayan Prasad, Swayam Prakash1 Harshit Singh, Saurabh Chaturvedi, Ashok Pandey

Departments of Nephrology and 1Medical Genetics; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

BACKGROUND: Acute rejection is the single most important risk factor for the subsequent development of chronic allograft nephropathy; which is still the primary reason for late allograft loss in kidneytransplantation. Vascular endothelial growth factor (VEGF) is a pro-angiogenic factor that has animportant role in the development and maintenance of physiological endothelium. However its role in the development of acute and chronic allograft rejection remains unclear and warrant further investigation.

AIM OF THE STUDY: To study the association of VEGF polymorphisms with renal allograft rejection risk among the north Indian patients.

METHODS: Amplification of the four VEGF polymorphisms -1154 G>A; -2578 C>A; +936 C>T and -2549 Ins/Del were carried out in a thermal cycler (Mastercycler gradient; Eppendorf; Hamburg; Germany). Genotyping was done for -1154 G>A and -2578 C>A polymorphisms using ARMS PCR and for +936 C>T polymorphism using PCR-RFLP. PCR product of VEGF +936 C>T; was digested overnight with NlaIII restriction enzyme (New England Bio Labs; Beverly; MA; USA). In case of the VEGF +936 C>T SNP; T allele was cut into two fragments of 122 bp and 86 bp; whereas the C allele remained uncut with a length of 208 bp. The -2549 Ins/Del polymorphism was genotyped by PCR; using a common set of primers. PCR and RFLP products were run by gel electrophoresis on 2% agarose gel and visualized using ethidium bromide. Patients were categorized into acute allograft rejection (N=26) and non acute (N=48) categories.

RESULTS: The genotype and allele frequencies were found to be in Hardy Weinberg Equilibrium in normal healthy controls. The occurrence of mutant homozygous genotype (AA) of the -1154G/A polymorphism was significantly higher in AR cases compared to that of controls (OR=3.38; 95% CI=1.70-6.68; P=0.0009). Then variant (AA) genotype of - 2578C/A polymorphism was significantly more common in the AR cases as compared to controls and revealed fourfold risk (OR=4.19; 95% CI=2.12-8.28; P=0.0001). Prominently; for the +936 C/T polymorphism; the homozygous TT (OR=31.78; 95% CI=13.59-74.30; P=0.0001) and heterozygous CT (OR=14.33; 95% CI=7.43-27.63; P=0.0001) genotypes revealed statistically significant and staggering risk associations with AR. T-A-A-I; T-A-A-D and T-G-A-I were three 4 haplotypes found in AR and non-AR alleles. In-silico analysis showed involvement of +936T allele in the transcription regulation.

CONCLUSIONS: The present study signifies genetic associations of all the mutant genotypes and alleles of VEGF -1154G/A; -2578C/A; +936C/T and -2549Ins/Del SNPs to be at increased risk for renal allograft rejection.

  20. Association of Cardiovascular Disease with Biomarkers in Chronic Kidney Disease: Baseline Data from The ICKD Study Top

Kajal Kamboj, Prabhjot Kaur, Ashok Yadav, Vivek Kumar, Vivekanand Jha, ICKD Study Investigators Group

Departments of Nephrology and Experimental Medicine and Biotechnology; PGIMER; Chandigarh; George Institute for Global Health; New Delhi; India

BACKGROUND: Cardiovascular disease (CVD) is the most common cause of mortality in CKD. CVD risk assessment and management are important therapeutic goals in CKD. The state of CKD confers unique non-traditional CVD risk factors in additional to traditional ones. Circulating biomarkers associated with kidney or vascular function hold promise for development of predictive models for CVD in CKD.

AIM OF THE STUDY: We investigated the association of serum biomarkers (ADMA; NT-proBNP; Cystatin C; hsCRP; FGF-23; IL-6) with prevalent CVD at baseline in subjects enrolled in the ICKD study at PGIMER; Chandigarh.

METHODS: Subjects enrolled in the ICKD study at PGIMER; Chandigarh center were eligible for the purpose of this study. Demographic; history and biochemical data at baseline were obtained from the ICKD database. Biomarkers (ADMA; NT-proBNP; Cystatin C; hsCRP; FGF-23; IL-6) were measured by ELISA in baseline serum samples stored in the ICKD study biobank.

RESULTS: 667 subjects with CKD were included. Mean age of the study population was 47.9 ± 12.3 years with majority (65%) being male. Hypertension; diabetes mellitus and manifest CVD were present in 84%; 28% and 10% of subjects; respectively. The median eGFR by CKD-EPI was 38.34 (29.8 – 48.6) ml/min/1.73 m2. The serum level of different biomarkers were 73.9 ng/ml (52.9 – 109.2) for ADMA; 3.5 ng/ml (1.3 – 10.4) for NT-proBNP; 1.5 µg/ml (0.7 – 2.5) for Cystatin C; 6.0 mg/l (3.1 – 9.5) for hsCRP; 111.7 pg/ml (77.6 – 161.4) for FGF-23; and 3.7 pg/ml (2.8 – 3.03) for IL-6. There were no association of levels of any biomarker with CVD. However; serum levels of IL-6 significantly correlated with ADMA (r= 0.123; p=0.003) and NT-proBNP (r= 0.118; p=0.004).

CONCLUSIONS: Conclusion: None of the biomarkers were associated with CVD in the study population. However; association of biomarkers with incident CVD events during prospective follow up will become clear only in future.


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Indian Journal of Nephrology
Published by Wolters Kluwer - Medknow
Online since 20th Sept '07