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   Poster Presentat...
   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 ...
   21. Evaluation o...
   22. Tuberculosis...
   23. Infection Pr...
   24. Rituximab Th...
   25. Assessment o...
   26. Volume Asses...
   27. Unrecognised...
   28. Laparoscopic...
   29. Metformin As...
   30. Analysis of ...
   31. Outcomes and...
   32. Spectrum of ...
   33. Tuberculosis...
   34. Identifying ...
   35. Big Data Giv...
   36. Mirdeep: Pot...
   37. Wolfram Synd...
   38. Post Renal- ...
   39. Histological...
   40. Tunneled Cat...
   41. Study of Hea...
   42. Stimulation ...
   43. Performance ...
   44. Long Term Re...
   45. Unrecognized...
   46. Study of Cog...
   47. A Rare Funga...
   48. A Study on A...
   49. Is Once Dail...
   50. Rituximab Th...
   51. Dialysis Ade...
   52. Etiology; Cl...
   53. Non Diabetic...
   54. Clinicopatho...
   55. Do The anti-...
   56. Analytical A...
   57. An Audit of ...
   58. Relationship...
   59. Utilizing Dm...
   60. Preoperative...
   61. Clinico-Path...
   62. An Unusual C...
   63. Urine B2 Mic...
   64. Health Relat...
   65. Evolution of...
   66. Low Dose ATG...
   67. Evaluation o...
   68. Study on Oxi...
   69. Retrospectiv...
   70. Assessment o...
   71. Short-Dwell ...
   72. Rose Gardene...
   73. Death Censor...
   74. Comparison o...
   75. Pseudo Aneur...
   76. Infectious C...
   77. To Study The...
   78. Crescentic G...
   79. A Study Comp...
   80. To Assess Th...
   81. To Compare G...
   82. Acute Kidney...
   83. Home Visit b...
   84. Epidemiology...
   85. Fractures in...
   86. Genetic Muta...
   87. Complication...
   88. Peak Systoli...
   89. Clinicopatho...
   90. Pattern of N...
   91. Lupus Nephri...
   92. Histological...
   93. Big Data fro...
   94. The Response...
   95. Poisoning As...
   96. Open Labelle...
   97. Do All Chron...
   98. Crrt in Crit...
   99. To Evaluate ...
   100. Ambulatory ...
   101. The Spectru...
   102. Dengue in R...
   103. Clinico Pat...
   104. Unusual Cau...
   105. Incidence o...
   106. Clinicopath...
   107. Non Invasiv...
   108. Histopathol...
   109. Pattern of ...
   110. Case Series...
   111. Changing Pr...
   112. A Study of ...
   113. Bedside Lun...
   114. Study of Re...
   115. Rare Presen...
   116. Prevalence ...
   Poster Presentat...
   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 ...
   21. Evaluation o...
   22. Tuberculosis...
   23. Infection Pr...
   24. Rituximab Th...
   25. Assessment o...
   26. Volume Asses...
   27. Unrecognised...
   28. Laparoscopic...
   29. Metformin As...
   30. Analysis of ...
   31. Outcomes and...
   32. Spectrum of ...
   33. Tuberculosis...
   34. Identifying ...
   35. Big Data Giv...
   36. Mirdeep: Pot...
   37. Wolfram Synd...
   38. Post Renal- ...
   39. Histological...
   40. Tunneled Cat...
   41. Study of Hea...
   42. Stimulation ...
   43. Performance ...
   44. Long Term Re...
   45. Unrecognized...
   46. Study of Cog...
   47. A Rare Funga...
   48. A Study on A...
   49. Is Once Dail...
   50. Rituximab Th...
   51. Dialysis Ade...
   52. Etiology; Cl...
   53. Non Diabetic...
   54. Clinicopatho...
   55. Do The anti-...
   56. Analytical A...
   57. An Audit of ...
   58. Relationship...
   59. Utilizing Dm...
   60. Preoperative...
   61. Clinico-Path...
   62. An Unusual C...
   63. Urine B2 Mic...
   64. Health Relat...
   65. Evolution of...
   66. Low Dose ATG...
   67. Evaluation o...
   68. Study on Oxi...
   69. Retrospectiv...
   70. Assessment o...
   71. Short-Dwell ...
   72. Rose Gardene...
   73. Death Censor...
   74. Comparison o...
   75. Pseudo Aneur...
   76. Infectious C...
   77. To Study The...
   78. Crescentic G...
   79. A Study Comp...
   80. To Assess Th...
   81. To Compare G...
   82. Acute Kidney...
   83. Home Visit b...
   84. Epidemiology...
   85. Fractures in...
   86. Genetic Muta...
   87. Complication...
   88. Peak Systoli...
   89. Clinicopatho...
   90. Pattern of N...
   91. Lupus Nephri...
   92. Histological...
   93. Big Data fro...
   94. The Response...
   95. Poisoning As...
   96. Open Labelle...
   97. Do All Chron...
   98. Crrt in Crit...
   99. To Evaluate ...
   100. Ambulatory ...
   101. The Spectru...
   102. Dengue in R...
   103. Clinico Pat...
   104. Unusual Cau...
   105. Incidence o...
   106. Clinicopath...
   107. Non Invasiv...
   108. Histopathol...
   109. Pattern of ...
   110. Case Series...
   111. Changing Pr...
   112. A Study of ...
   113. Bedside Lun...
   114. Study of Re...
   115. Rare Presen...
   116. Prevalence ...
   Poster Presentat...
   1. Iron Deficien...
   2. Prospective D...
   3. Sociodemograp...
   4. Evaluation of...
   5. Hearing Abnor...
   6. Nocturnal Int...
   7. Clinic0 Patho...
   8. Spectrum of I...
   9. Non Alcoholic...
   10. Dialysis Nur...
   11. A Rare Case ...
   12. Use of Graft...
   13. Twice Weekly...
   14. Unusual Case...
   15. Profile of D...
   16. Correlation ...
   17. Cavitatory P...
   18. Infective En...
   19. C1Q Nephropa...
   20. Spectrum of ...
   21. Rare Present...
   22. A Study on P...
   23. Bilateral Pe...
   24. Renal Tuberc...
   25. Role of Seru...
   26. A Rare Assoc...
   27. Study of Non...
   28. Impact of Sc...
   29. An Observati...
   30. Rituximab in...
   31. Rare Fungal ...
   32. Histopatholo...
   33. Association ...
   34. A Prospectiv...
   35. Early Arteri...
   36. Retrospectiv...
   37. Comparison o...
   38. Risk Factors...
   39. New Onset Di...
   40. A Cross Sect...
   41. A Rare Case ...
   42. Hypercalcemi...
   43. Predictors o...
   44. Page Kidney ...
   45. Rituximab in...
   46. Evaluation o...
   47. Comparing Ou...
   48. Risk Factors...
   49. Anti-Biofilm...
   50. Differential...
   51. Prospective ...
   52. Nothing Goin...
   53. Strongyloid ...
   54. Granulomatou...
   55. Follow Up Cl...
   56. Prevalence o...
   57. WeaknessR...
   58. Double Whamm...
   59. Extradural M...
   60. Does Haemodi...
   61. Assessment o...
   62. Peritonitis ...
   63. Tricuspid Va...
   64. Impact of Go...
   65. Prevalence o...
   66. Prevalence C...
   67. Profile of P...
   68. Case Report-...
   69. Role of Plas...
   70. New Entrance...
   71. A Study of C...
   72. A Review on ...
   73. Evaluation o...
   74. Familial Mem...
   75. Diabetic Fib...
   76. Nocardia Inf...
   77. A Rare Case ...
   78. Clinicopatho...
   79. Oculocerebro...
   80. A Case Repor...
   81. An Extremely...
   82. Sofosbuvir B...
   83. Vascular Acc...
   84. Unusual Cuta...
   85. Clinico-Path...
   86. Diet Recall ...
   87. ADPKD with E...
   88. Congenital V...
   89. A Case of Ad...
   90. Perception o...
   91. Unusual Caus...
   92. Clinicopatho...
   93. Prostatic Cy...
   94. Evaluation o...
   95. Cyclophospha...
   96. Role of Cope...
   97. Clinicopatho...
   98. A Rare Prese...
   99. Clinical Pro...
   100. Proliferati...
   101. Dual Kidney...
   102. A Rare Case...
   103. High Preval...
   104. Rare Presen...
   105. An Rare Cas...
   106. Metformin A...
   107. Clinico Eti...
   108. Immediate R...
   109. Assessment ...
   110. Kidney Allo...
   111. Non-Simulta...
   112. The Inescap...
   113. Pediatric K...
   114. Kidney Tran...
   115. Longitudina...
   116. Long Term O...

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ABSTRACT
Year : 2018  |  Volume : 28  |  Issue : 7  |  Page : 28-122
 

Poster Presentations



Date of Web Publication12-Dec-2018

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How to cite this article:
. Poster Presentations. Indian J Nephrol 2018;28, Suppl S1:28-122

How to cite this URL:
. Poster Presentations. Indian J Nephrol [serial online] 2018 [cited 2019 Dec 10];28, Suppl S1:28-122. Available from: http://www.indianjnephrol.org/text.asp?2018/28/7/28/247337





  Poster Presentations – 21st December 2018 - 12.00-13.00 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 and Hospital; 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 Post Graduate 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; Gurugram; 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; Gurugram; 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, Vikas Agarwal, Narayan Prasad

Department of Nephrology and Immunology; 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 0.1-1µm); 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 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. 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 (1µM; 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.


  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; 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; ABCB1gene 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 AKI (PR-AKI) 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 CKD-MBD 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; Mumbai; Maharashtra; India

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; Lucknow; 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 48.7 Y 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 2Medical 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: 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.


  21. Evaluation of Urine Microscopy As A Tool For Prediction of Outcome of Acute Kidney Injury Top


Abhishek Chakrabarti, Dipankar Sircar, Arpita Raychaudhury, Sanjay Dasgupta, Debabrata Sen, Rajendra Pandey

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

BACKGROUND: Acute Kidney Injury (AKI) is common in hospitalized and critically ill patients and has an important modifying effecton mortality; kidney recovery and health resource utilization. Prompt diagnosis of AKI can be helpful in reducing the mortality and morbidity; but the available means are either poorly sensitive or cumbersome or costly. This study aims to evalutate urine microscopy score (UMS) as a marker for necessity for initiation of RRT in patients with AKI and observe the outcomes.

AIM OF THE STUDY: To find out any correlation between severity of AKI and urine microscopy findings in the patients with AKI and use these findings in prediction of the outcome of these patients including need of RRT.

METHODS: Starting from February 2017; 153 patients of AKI due to various non glomerular causes aged ≥18 years not started on RRT were examined and their non catheterised urine samples examined with phase contrast light microscope for granular casts & renal tubular epithelial cells. A urine microscopy score (UMS) ranging from 1 to 3 was formulated based on the findings. Rest of the management including providing RRT was according to standard practice guidelines. The patients were observed for a period of maximum 4 weeks for evidence of recovery or residual renal impairment; persistent RRT need or death.

RESULTS: Of the 153 patients studied; 6 patients (3.92%) expired. Among the rest; 99 patients (64.71%) did not require dialysis; 39 (25.49%) patients needed dialysis for <4 weeks; 9 patients (5.88%) needed dialysis for >4 weeks. However 102 patients (66.67%) had complete recovery; 36 (23.53%) had partial recovery; and 9 (5.88%) were dialysis dependent. The mean UMS of patients not requiring any RRT; those requiring RRT for short period and the dialysis dependent ones were 1.83; 2.36 and 3 respectively (p <0.001). The mean UMS of patients having complete recovery; partial recovery; dialysis dependence and death were 1.68; 2.83; 3 and 3 respectively (p <0.001).

CONCLUSIONS: Since UMS was found to be significantly associated with both dialysis requirement in short term as well as with long term outcomes of AKI it can be beneficial as a sensitive marker of AKI. Moreover the minimum equipment & time needed for this will put it ahead of more emphasised biomarkers.


  22. Tuberculosis in Renal Transplant Recipients: Clinical Profile and Response to Treatment Top


S Murugesh Anand, M Edwin Fernando, Anu, N D Srinivasaprasad, S Sujit, S Thirumalvalavan, Chandrasekar, Vivek Praveen

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

BACKGROUND: Renal transplant recipients have a higher risk for mycobacterial infection than the general population; as the immunosuppressive therapy impairs cytotoxic T-cell response; a key host defense against mycobacterial infection. Clinical diagnosis may be difficult and delayed since symptoms at presentation is often atypical. Simultaneous management with anti-tuberculous and immunosuppressive drugs remains a great challenge to the treating Nephrologist.

AIM OF THE STUDY: 1. To study the clinical profile of tuberculosis in renal transplant recipients 2. To study the response to anti tuberculous drugs.

METHODS: A single centre; prospective observational study was conducted to learn the clinical profile; management and outcome of tuberculosis in renal transplant recipients who underwent renal transplantation from January 2016 till November 2017.

RESULTS: 76 renal transplant recipients who underwent renal transplantation from January 2016 till November 2017 in our unit where included in this study. 7 of them were diagnosed with tuberculosis; the prevalence being 9.2%. Of the 7 patients; induction agents were used in 2. Fever (57.1%) was the most common symptom followed by significant loss of weight (42.8%). Pulmonary TB was seen in 57.14% of all patients; Disseminated TB in 14.28% and Extra- pulmonary TB was seen in about 28.57%. The diagnosis of tuberculosis was confirmed by demonstration of the organism in 57.14% of individuals and in the rest it was empirical. Gene Xpert was used in the demonstration of organism in 42.8% of cases. Two of them (28.57%) had concurrent CMV infection and 3 of them (42.85%) had Post transplant diabetes Mellitus. No association with rejection was evident. 3 of them (42.85%) completed treatment; 3 of them (42.85%) are on treatment and 1 (14.28%) expired.

CONCLUSIONS: In this study; the prevalence of tuberculosis in renal transplant recipient was 9.2%. Pulmonary form of tuberculosis dominated. Gene Xpert was useful in confirming the diagnosis in about 42.8% of cases. Prevalence of tuberculosis was more common within first 6 months of transplant.


  23. Infection Profile in North India Renal Transplant Population Receiving Induction- ATG Versus Basiliximab Top


Ankit Sharma, Irfan Ahmad, Rajesh Goel, Ravi Bansal, Sanjiv Saxena

Department of Nephrology; Pusphawati Singhania Hospital and Research Institute; New Delhi; India

BACKGROUND: With the use of Induction agents and potent immunosuppression drugs; Infection rates are increasing; which is also a major cause of morbidity and mortality in post renal transplant patients. Antithymocyte globulin and Basiliximab (IL2R) blocker is used as induction agents in high-risk transplants i.e. second transplant; deceased donor transplants; ABO incompatible transplants; etc. Infection increases the rate of graft rejection; new onset diabetes; Cardiovascular events; lymphoproliferative disorders.

AIM OF THE STUDY: To determine the rates of infections between ATG and Basiliximab induction groups and to determine the high incidences of infections in ATG group.

METHODS: This is a retrospective; observational study. All patients who underwent transplant between June 2013 and July 2017 & received induction either with ATG or Basiliximab were included in this study. All patients with criteria such as presence of fever and features of the systemic inflammatory response syndrome with a suspected source of infection and asymptomatic patients with microbiological evidence of infection either by culture or using serology were registered as infectious cases. Data was collected from medical records (discharge summary; patient's transplant dairy and hospital admission records). The data was analysed for the Induction agent used; Immunosuppression protocol; types of infection; time period from transplant and their relevance with each other. Patterns of infection were further categorized with regard to the time interval after transplantation; the causative organism; and the site of infection. Patients with drug toxicity; malignancy & non-infectious causes were excluded.

RESULTS: A total of 197 patients underwent renal transplant in this period; out of these 130 patients received induction. Follow up period after transplant was 1.7 ± 0.6 years. The majority of the study participants used basiliximab (58.4%) as part of induction therapy. 83 (63.84%) patients had infections out of those who received induction therapy. UTI was the most common post-transplant infection observed in 37 patients (19 in ATG group while 18 in Basiliximab) followed by respiratory tract infections in 17 (11 in ATG while 6 Basiliximab); CMV in 8 (4 patients in each group); Tuberculosis in 5 (All in ATG group). We also noticed Pneumocystis carinii; Nocardia; Mucormycosis; Tropical sprue and post-transplant lymphoproliferative disorder in 1 patient each; all in ATG group. Among UTI; E. coli was the most common causative organism. A total of 19 patients had multiple infections such as UTI; CMV; Lower respiratory tract infections. Majority of infections were within one year after transplant.

CONCLUSIONS: Infection rates and complication are common and severe in case of ATG as compared to Basiliximab. Incidence of infection were statically significant within 6 months. Early and aggressive workup of the patients and adequate optimization of immunosuppression reduces the rate of morbidity and mortality.


  24. Rituximab Therapy in Steroid and Calcineurin Inhibitor Dependent or Resistant Nephrotic Syndrome – A Single Centre Experience Top


Rohit Raj, M Sreelatha, T P Noushad, E P Jayakumar

Department of Nephrology; Government Medical College; Kozhikode; Kerala; India

BACKGROUND: Idiopathic nephrotic syndrome is one of the most common glomerular disease in children and adults with the central event being podocyte injury. The treatment of nephrotic syndrome remains a therapeutic challenge to nephrologists despite the availability of different drugs. The crucial role of B lymphocytes in the pathogenesis of nephrotic syndrome has made it a possible therapeutic target. Rituximab; a chimeric monoclonal antibody is found to be effective in nephrotic syndrome.

AIM OF THE STUDY: To study the efficacy and safety of Rituximab in steroid and calcineurin inhibitor dependent or resistant nephrotic syndrome.

METHODS: It was a prospective study which included a total of 41 patients with nephrotic syndrome who were either steroid dependent or resistant and calcineuirin inhibitor (CNI) dependent or resistant with symptomatic relapse of illness. These patients were given 4 doses of Rituximab 375 mg/m2 one week apart and the response to it was assessed along with its safety profile during follow up.

RESULTS: Out of 41 patients in the study 27 were males. 24 patients had biopsy proven minimal change disease and 17 had FSGS. 36 of them were steroid dependent and remaining 5 were steroid resistant. 34 were CNI dependent and 7 were resistant. After giving 4 doses of Rituximab; 32 went into remission and 9 were resistant to rituximab. Among the MCD group; 91% of them responded to Rituximab while 58% of patients with FSGS responded to rituximab. At the end of 1 year post –Rituximab; 27 patients out of 32 remained in remission while 5 developed relapse Mild infusion reaction was observed in 2 patients and two of them developed urinary tract infection.

CONCLUSIONS: Rituximab is safe and effective in patients with steroid and calcineurin inhibitor dependent or resistant nephritic syndromeSteroid dependent nephritic syndrome cases responded better to RituximabPatients with minimal change disease responded better to Rituximab than FSGS.


  25. Assessment of The Severity of Lumbar Aortic Calcifications in Patients on Continuous Ambulatory Peritoneal Dialysis and Its Use As A Prognostic Marker in Predicting Cardiovascular Disease and Mortality Top


P Kadhir Selvan, K Sampath Kumar

Department of Nephrology; Meenakshi Mission Hospital and Research Centre; Madurai; Tamil Nadu; India

BACKGROUND: The study is to analyze the severity of lumbar aortic calcifications in patients on continuous ambulatory peritoneal dialysis and correlate them with demographic; biochemical parameters and to define its prognostic role in predicting the cardiovascular outcome and mortality in these patients.

AIM OF THE STUDY: To assess severity (APSS) of abdominal aortic wall calcification in CAPD pts & correlate it with their demographics; biochemical parameters /ECHO findings. To analyze APSS validity as a prognostic marker.

METHODS: Lateral lumbar films; obtained in 45 patients on continuous ambulatory peritoneal dialysis; were analyzed for the presence of abdominal aortic wall calcification corresponding to the first till the fourth lumbar vertebrae. The severity of aortic calcification were graded as per anterior and posterior severity score. These APSS grades were correlated with the patients demographic; biochemical parameters and its association with the echocardiogram findings were also analyzed. As only less than 5 % of the study population were on drugs such as calcium supplements; phosphate binders; vitamin D supplements; these factors were not considered in our study. Our patients were followed up for the past one year and APSS grades were correlated with the mortality rate in our study population.

RESULTS: The prevalence of aortic calcification was 47% in both genders with a mean age and total duration of dialysis of 57 yrs and 34 months respectively. Other than age no other demographic factors had significant correlation. Association with APSS and biochemical parameters was not significant. Average APSS (scale 0–24) was 3 and it was 6.5 in patients who had calcification. In our study we inferred that L4 and L3 segment of the aorta were affected early compared to L2 and L1; probably explained by the bifurcation of aorta at the level of l4. Both left ventricular dysfunction and mitral valve calcification had significant positive correlation with aortic calcification & pts who had aortic calcification had high mortality rates (52 % patients) compared to 21 % Pts without calcification. Cumulative patient survival by apss grade showed pts with severe apss had poor survival of 37 mths compared to 76 & 102 mths in pts with moderate & no calcification respectively.

CONCLUSIONS: Lumbar aortic wall calcifications remains an simple; cost effective; easily accessible/valid tool. More research is needed to assess the progression of calcification using serial abdominal xray at particular interval is required in dialysis patients. Pts with apss ≥ 4 to be screened for cad.


  26. Volume Assessment in Maintenance Hemodialysis- A Comparison of Present Methods in Clinical Practice with Sonographic Lung Comets Top


A Ishwarya, M Edwin Fernando, Suhasini, N D Srinivasaprasad, S Sujith, K Thirumalvalavan, R Vivekpraveen, K Chandrasekaran

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

BACKGROUND: Dry weight assessment in dialysis patients remains a challenging endeavor owing to the limitations of the available methods for volume assessment. Lung ultrasound is emerging as an invaluable tool to assist in the appropriate assessment and assignment of dry weight.

AIM OF THE STUDY: (1) to determine the reliability of clinical signs and symptoms for volume assessment; (2) to compare lung ultrasound with HRCT chest- and with inferior vena cava diameter.

METHODS: The cross-sectional study involves 50 patients on maintenance hemodialysis. Lung ultrasound for B line estimation and ultrasonographic measurement of IVCD performed before and after hemodialysis by a nephrologist trained in ultrasonography. Limited HRCT was obtained just before hemodialysis.

RESULTS: Edema; crackles; and dyspnea had a poor sensitivity of 37.9%; 11.5%; and 52.6%; respectively; to detect clinically significant pulmonary congestion by lung ultrasound. A highly significant correlation was obtained between B-line score and HRCT signs of pulmonary congestion (P < 0.001) before dialysis. B lines showed statistically significant reduction with dialysis. The absolute reduction of B lines showed significant correlation with ultrafiltration volume and weight loss.

CONCLUSIONS: Bedside lung ultrasound appears a sensitive tool for evaluating real-time changes in extravascular lung water and would serve to optimize volume status in dialysis patients.


  27. Unrecognised Renal Dysfunction in Patients with Acute Coronary Syndrome Top


B Karthikeyan, M Edwin Fernando, Flaicy Varghese, S Sujit, S Thirumalvalavan, N D Srivasaprasad, Vivekpraveen, Chandrasekar

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

BACKGROUND: Unrecognized renal insufficiency is present in patients with acute coronary syndrome (ACS). Causes of Acute kidney Injury (AKI) in ACS are underlying renal dysfunction; negative impact of iodinated contrast; impaired cardiac output with arterial underfilling; and increased venous congestion with venous overfilling. AKI is an independent risk factor for late mortality in ACS patients.

AIM OF THE STUDY: 1. To determine the prevalence of unrecognized renal insufficiency in ACS patients. 2. To determine eGFR; 3 months after AKI and its effects on mortality.

METHODS: Ours was a Cross Sectional Study which included 100 ACS patients. Patients were selected from those who were admitted in Medical and Cardiology wards during the study period; after confirming the diagnosis via ECG; enzymatic and ECHO studies. On admission Sr.Creatinine was done and eGFR was calculated using MDRD (4 variable) formula. The study cohort was stratified into three groups according to renal function assessment (patients with normal renal function (eGFR >60 ml/min/1.73 m²); patients with unrecognized renal insufficiency (serum creatinine<1.2 mg/dl and eGFR <60 ml/min/1.73 m2) and patients with recognized renal insufficiency (serum creatinine >1.2 mg/dl and eGFR <60 ml/min/1.73 m²). Patients who were selected for the study were followed up for 3 months and Sr.Creatinine was done and eGFR were calculated.

RESULTS: Mean age of the study population 58.13 ± 9 years; 60% of them being male. Unrecognized renal insufficiency is present in 40% of patients with ACS. At 3 months follow up mortality rates were highest in patients with recognized renal insufficiency; followed by patients with unrecognized renal insufficiency; and were lowest in patients with normal renal function (27.3%; 9.9%; and 2%; respectively <.0001). There is no statistically significant relation existing between the diagnosis (anterior; anterolateral; anteroseptal; inferior; posterior; RVMI; atypical and typical chest pain; STEMI) or risk factors (systemic hypertension; diabetes mellitus; smoking; prior CAD; CHF; CVA) and renal function [p > 0.05]. We could not establish any statistically Significant relation existing between usage of aspirin; clopidogrel; β blocker; ACEI/ARB inhibitors intake and renal dysfunction in ACS patients.

CONCLUSIONS: This study showed that unrecognized renal dysfunction is common among patients with ACS. Mortality rates were highest in patients with recognized renal insufficiency; followed by patients with unrecognized renal insufficiency.


  28. Laparoscopic CAPD Insertion by Nephrologist: Outcome Analysis Top


Pavitra Manu Dogra, Parikshit Singh Chauhan

Military Hospital; Jalandhar; Punjab; India

BACKGROUND: Peritoneal dialysis (PD) is a good option of renal replacement therapy for significant number of end-stage kidney disease patients. There are various techniques for CAPD catheter insertion. Majority nephrologists prefer percutaneous method; while some do surgical insertions and very few do laparoscopic insertion. Laparoscopic insertions have their limitations; requiring fitness for anaesthesia; laparoscopy set with monitors and operation room; along with skill in laparoscopy.

AIM OF THE STUDY: To analyse the feasibility; technical outcomes and complications of laparoscopically inserted CAPD catheters by Nephrologist.

METHODS: We prospectively analysed the outcomes of laparoscopic assisted 2-cuffed CAPD catheter insertion by nephrologist at a tertiary care hospital in north India. Catheter insertions were done in presence of surgeon over 6 months period (July 2017 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 were also included. Data was analysed for operational feasibility; technical survival of catheter; patient survival; procedure related complications; anaesthetic complications; infective and mechanical complications and technique success.

RESULTS: 20 CAPD catheters were inserted by nephrologist by laparoscopic method. Procedure involved general anaesthesia; inflation of peritoneal cavity; insertion of laparoscopy ports and 5 mm camera; followed by insertion of 42 cm two-cuffed straight CAPD catheter (Quinton CAPD catheter insertion kit) via left paramedian insertion; suturing of deep cuff into anterior rectus sheath and thensubcutaneous tunnel. The break-in period was 5 days. Primary catheter failure occurred in nil cases. There was no catheter migration; bowel injury or pericatheter leak. One patient each developed refractory primary peritonitis leading to PDC removal and port injury to mesenteric artery branch; causing profuse peritoneal hemorrhage; and managed by emergency laparotomy. Two patients developed cardiac arrhythmias and hypotension following peritoneal insufflation. The catheter survival censored to death and patient survival at 6 months was 95% and 85% respectively.

CONCLUSIONS: Laparoscopic CAPD insertion by nephrologist is in infancy. Our experience has been good. There were no mechanical or flow related complications. We had one port related mesenteric artery injury requiring emergency laparotomy and one refractory peritonitis. This method should be encouraged.


  29. Metformin As Potential Regulator of P-gp Expression in SLE Top


Mohit Kumar Rai, Sandeep Kansurkar, Durga Prasanna Misra, Vikas Agarwal, Narayan Prasad

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

BACKGROUND: P-glycoprotein expression is linked to drug resistance and has been shown to be associated with higher disease activity in SLE. Metformin inhibits expression of P- Glycoprotein (P-gp) in cancer cells. There is scarce data on effect of metformin on P-gp expression and cytokine secretion on immune cells in autoimmune diseases like lupus.

AIM OF THE STUDY: To study the effect of Metformin on P-gp expression.

METHODS: PBMCs of nine lupus patients (Mean age 30 yrs; all females) were cultured using RPMI medium and then stimulated with PMA/ ionomycin; with or without increasing dose of metformin (0.01; 0.1; 1; 10 mMol/L) for 24 h. P-gp expression was measured in same samples by flow-cytometry.

RESULTS: In MTT assay viability of cells was maintained across all concentrations of metformin used in this study. Metformin decreased expression of P-gp in PBMCs in dose dependent manner (p=0.003).

CONCLUSIONS: Merformin has immunomodulatory activity by reducing expression of P glycoprotein. Hence it is has a therapeutic potential in SLE. Also due to its effect on P glycoprotein; it can be especially useful in drug resistant disease. Further studies are required in this direction.


  30. Analysis of Peritoneal Equilibration Test in PD Patients in A Tertiary Care Centre Top


D Keerthi Reddy, T Gangadhar, G Swarnalatha, Uttara Das, R Karthik, Ramchander, Praveen

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

BACKGROUND: PD is a modality of renal replacement therapy which uses the peritoneal membrane as a filter. Peritoneal Equilibration Test is the most widely used test to evaluate the peritoneal transport characteristics.

AIM OF THE STUDY: To study the characteristics of Peritoneal Equilibration Tests of the patients on CAPD in NIMS and compare the peritonitis rates and outcome of patients among the high and low transporter patients.

METHODS: An analysis of the demographics of 80 PD patients at NIMS was made. An analysis of the PET of 34 of these patients; and the relation between the PET characteristics on demography; biochemical parameters; adequacy; ultrafiltration and outcome were analysed. Statistical tools like mean; median mode were used.

RESULTS: Average age of the 80 patients on PD was 53 years with a M:F ratio 1.5:1. The average duration of the patients on CAPD was 20 months. The residual renal function was 376 ml. 35.2% - high transporters; 11.7% - high average transporters; 20.5% - low average transporters; 32.3% - low transporters. The UF was high – 1118 ml; 1300 ml – high average; 1350 ml – low average; 1250 ml – low). The mean creatinine was 6 mg/dl in the high transporter group and 8.3 mg/dl in the low transporters. The presence of diabetes was high in the high transporter group. Overall there was 1 episode of peritonitis per 51.4 patient months. The incidence of peritonitis was least in the low transporter group (1 episode per 50.8 patient months) and highest in the high and high average transporter group (1 episode per 20 patient months). Overall mortality was 25%. Mortality in the high transporter group (16%) and 9% in the low transporter group.

CONCLUSIONS: Incidence of peritonitis and mortality are highest in the high transporter group.


  31. Outcomes and Follow Up of Living Kidney Donors Top


Arun Kumar Ponna, Manisha Sahay, Kiran Mai, P S Vali

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

BACKGROUND: The increase of live kidney donation (LKD) demands that we scrutinize its long-term consequences. Long-term effects of uninephrectomy for kidney donation are of particular interest in the currently increasing practice of living-donor transplantation.

AIM OF THE STUDY: We have retrospectively analyzed the general health status and renal consequences of living-related kidney donation. Maintain.

METHODS: Living-related kidney donors were called for follow up; who had donated their kidneys from 1990 to 2017. Data on age; sex; relation to recipient; weight; blood pressure; serum creatinine and creatinine estmation; level of proteinuria; uric acid levels; renal length by ultrasonography and new onset diabetes mellitus were analyzed. Donors with co-morbidities not related to nephrectomy were excluded from the analysis.

RESULTS: 210 cases of living kidney donation were noted. 80 cases attended the follow up center. The mean age at donation was 41.26 ± 8.12 years. There was a mean rise of 9.96 mm Hg in SBP and 7.18 mm Hg in DBP. Hypertension was noted in 13 (16%). 20 donors (25%) developed microalbuminuria post nephrectomy and 10 (12%) developed overt proteinuria (>300 mg/day). Incidence of proteinuria was seen mostly in age group 40-49 years. New onset Diabetes was seen in five (6 %) patients; mostly in age group of 50-59 years. Hyperurecimia was observed in three (4%) donorMean GFR pre and post nephrectomy was 96.4 ± 6.91 ml/min and 73.54 ± 14.64 ml/min with a mean reduction of 24.2 ± 13.57 ml/min. There was no significant change in serum creatinine after donation (0.97 ± 0.09 mg/dl vs 1.22 ± 0.82 mg/dl) (p >0.01). There was an increase in renal length of 1.14 ± 0.73 cm.

CONCLUSIONS: A significant number of donors demonstrated proteinuria and elevated blood pressure levels and inadequate antihypertensive treatment due to poor follow up. No case of end-stage renal disease was identified.. Both of these issues demonstrate the need for a better-structured lifelong follow-up.


  32. Spectrum of Glomerular Diseases in Patient with Chronic Liver Disease in North India: A Single Centre Study Top


Dibyajyoti Kalita, Suman Lata1, Amar Mukund2, Archana Rastogi2, R P Mathur2, Shreepriya Mangalgi, Anuradha2, Rajesh Jaiswal2, Anand Jain2

2Institute of Liver and Biliary Sciences; 1Dharamshila Narayana Superspeciality Hospital; New Delhi; India

BACKGROUND: Renal dysfunction is frequently associated with chronic liver diseases. Renal involvement has a significant impact in the morbidity and mortality of patient with chronic liver diseases. However; due to associated coagulopathy; percutaneous renal biopsy is often not feasible. Hence; data regarding pattern of glomerular involvement in chronic liver disease is limited. Histological diagnosis of glomerular involvement may impact decision regarding liver transplant and management of such cases.

AIM OF THE STUDY: This study was undertaken with the following aims: 1) to find the types of glomerular involvement in CLD patients.) to look into the adequacy and safety of transjugular Kidney biopsy in CLD patient.

METHODS: A total of 30 patients of chronic Liver Disease in who underwent transjugular Kidney biopsy in the Institute of Liver and biliary Sciences between 2013 and 2018 were included in the study. The baseline characteristics of the study subjects included a mean age of 44.7 yrs; mean INR 1.86 and mean platelet count of 120/cu mm The biopsy specimen had a mean 6.7 glomeruli; 3.6 needle pass per core and an average length of 1.2 cm. Light Microscopy and immunoflorescence was done in all the cases; whereas electron Microscopy was done in selected cases.

RESULTS: The most common Glomerular disease was found to be MPGN (16 %) followed by IgA nephropathy and Mesangioproliferative GN (10 % each); Membranous nephropathy and renal amyloidosis (6 % each) and Hypertensive; Diabetic and C 3 glomerulopathy (4 % each). 24 % Biopsy specimen were inadequate. 13 % Biopsy showed acute tubular necrosis (ATN).

CONCLUSIONS: Glomerular diseases are common and varied in patients with chronic liver disease. Transjugular kidney biopsy may be a safe and effective approach for definitive diagnosis of glomerular disease in chronic liver disease patients.


  33. Tuberculosis: Clinical Profile& Response to Treatment in Patients with Chronic Kidney Disease Top


S Murugesh Anand, M Edwin Fernando, S Anu, N D Srinivasaprasad, S Sujit, S Thirumalvalavan, K Chandrasekaran, Vivek Praveen

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

BACKGROUND: Chronic Kidney Disease (CKD) is a state of chronic inflammation; resulting in a weak immune system and as a result; the prevalence of tuberculosis is higher in patients with CKD than in general population.

AIM OF THE STUDY: 1. To study the clinical profile of tuberculosis in chronic kidney disease patients 2. To study the response to anti tubercular treatment including adverse effects.

METHODS: A Single centre; prospective observational study which was conducted to learn the clinical profile; management and outcome of tuberculosis in patients with CKD; who were diagnosed with the same during the study period of 14 months from October 2016 till November 2017.

RESULTS: During this study period; over 1052 CKD patients were evaluated in our unit and 55 of them were found to have tuberculosis; the prevalence being 5.22%. Tuberculosis was predominantly found in CKD V / VD patients (61.8%). Cough (45.5%); weight loss (30.9%) & fever (23.6%) were the commonest symptoms observed at the time of presentation. Pulmonary TB was seen in 63.6% of all patients and Extra- pulmonary TB was seen in about 36.4%. The diagnosis of tuberculosis was confirmed by demonstration of the organism or non caseating granuloma in 22 patients (40%) and in the rest it was empirical based on clinical picture; pleural/ ascitic fluid analysis and radiological investigations. Gene Xpert was used in demonstrating organism in 23.6% of cases. The mean duration of anti tuberculous therapy was 7 months- 18 were declared cured; 23 cases completed treatment; 5 are on ATT; 8 lost follow up & 1 expired (Pulmonary TB) during the study period. One patient had worsening of peripheral neuropathy.

CONCLUSIONS: In our study; the prevalence of TB in CKD was 5.22%. Pulmonary for of TB dominated. Diagnostic confirmation was possible in 7.3% of patients and in the rest it was based on clinical suspicion. Cure from tuberculosis was observed in 32.7% of patients with anti-tuberculous therapy.


  34. Identifying Dysfunctional Cross-Talks in Neuro-Inflammatory Axis During Acute Kidney Injury Using Systems Biology Approach Top


Aprajita Gupta, Veena Puri, Sanjeev Puri1

Centre for Systems Biology and Bioinformatics; UIET; Panjab University; 1Department of Biotechnology; UIET; Panjab University; Chandigarh; India

BACKGROUND: The neuro-inflammation & pain perception are upcoming therapeutic targets in AKI. TNF-α & CGRP which are modulated in kidney & brain during AKI represent ideal candidates for understanding their role in reno-neuro axis. Bioinformatics provides a system of networks to identify how TNF-α and CGRP interplay is linked to AKI predisposition. The interplay of signals common on reno-neuroaxis in acute kidney injury could pave way for better understanding of the disease and therapeutics interventions.

AIM OF THE STUDY: To establish the role Reno-neural axis in the pathogenesis of AKI through systems biology approach with specific targeting of CGRP and TNF alpha.

METHODS: The in-silico approach was used to find the neuro-inflammatory molecules of AKI. The neuro-inflammatory genes of AKI and their respective signalling pathways were searched byPANTHER; GENOMATIX and Target Explorer. Further; common interactors between TNF and CGRP were expedited by STRING and CYTOSCAPE to find their common partners. The in-vitro study was performed on male Balb/c mice by inducing acute kidney injury through the intraperitoneal injection of folic acid (250 mg/kg). The expression level analysis of CGRP and TNF-alpha; as well as their common interactors i.e TRPV1 and PTGER4 genes was performed by quantitative real-time PCR analysis in kidney and brain were tissues. The immune-histological changes for TNF and CGRP were observed in both kidney as well as brain.

RESULTS: The in-silico analysis retrieved a list of 49 genes participating in pain process of AKI. The STRING-CYTOSCAPE combined with PANTHER hunt pointed towards the role of TRPV1 and PTGER4 in TNF-a and CGRP mediated AKI pathways. The mRNA expression by qPCR suggested modulatory expressions of CGRP; TNF; TRPV1 and PTGER4; with progression of injury in kidney and brain tissues.

CONCLUSIONS: This study reveals the modulation of inflammatory and pain molecules in kidney and brain tissues and unveils the route of the communication between CGRP and TNF on neuro-immune axis.


  35. Big Data Given by The Hemodialysis Machine – Can We Forecast Vascular Access Problems? Top


Pranit Kakde, Viswanath Billa, Deepa Usulumarty, Shrirang Bichu, Parag Tilve, Ganesh Sanap, Komal Nagori, Jatin Kothari, Rajesh Kumar

Department of Nephrology; Bombay Hospital and Medical Research Centre; 1APEX Kidney Care; Mumbai; Maharashtra; India

BACKGROUND: Extremely large data sets analysed computationally reveal patterns; trends; and associations termed as big data analysis. Machine learning builds algorithms that can receive input data and use statistical analysis to predict an output value within an acceptable range. A conventional hemodialysis machine typically generates data pertaining to 34 variables. Except for a handful the rest of the numbers are ignored to oblivion.

AIM OF THE STUDY: To compare the 1 second machine big data variables in a patient with healthy vs a sick AV fistula.

METHODS: Machine data from Nipro surdial dialysis machines (model SURDIAL 55) was collected and 1 second data was collated with the help of an engineering student. As a pilot model 2 prototype hemodialysis patients were chosen. One with a normal AV fistula doppler and another with severe stenosis. The machine data for venous pressure; blood pressure; blood flow and Kt/V was collected every one second during a dialysis session was recorded over 3 sessions. The results were then analysed.

RESULTS: The graphical patterns for venous pressures; systolic blood pressure; diastolic blood pressures; flow rates and serial Kt/V were strikingly different for the patient with healthy AVF as compared to the patient with the severely stenotic AV Fistula on doppler ultrasound.

CONCLUSIONS: Analysing Big Dialysis Data can help to identify early those AV Fistulas that are beginning to become dysfunctional. Early identification of dysfunctional fistula can help potentially salvage them and prevent underdialysis.


  36. Mirdeep: Potential Regulation of Deep Coding Region of TGF-B1 and VEGFA Genes by miR-663a and miR-23a and in End Stage Renal Disease Recipients Top


Pradeep Jaswani, R K Sharma1, Narayan Prasad1, Suraksha Agrawal2

Departments of 1Nephrology and 2Hematology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India

BACKGROUND: miR-663a and miR-23a are potent regulators of TGF-β11 and VEGFA genes by binding to the coding region of the respective genes; thus determines their expression pattern. TGF-β1 is cytokine implicated in the pathogenesis of fibrosis; while VEGF stimulates development of glomerular endothelial cells. Quantification of miRNAs with corresponding target gene has been functional relevance in renal diseases and they might represent a new class of biomarkers for frequent evaluation of renal failure.

AIM OF THE STUDY: To analyze the potential role of miR663a and miR23a in regulating coding region of TGF-β1 and VEGFA genes; and to correlate this with the incidence of ESRD.

METHODS: miRWalk database revealed that miR663a compliment with deep coding region of TGF-β1 and miR23a regulate coding region of VEGFA gene. Total RNA was isolated from whole blood followed by cDNA preparation by reverse transcription. Sybergreen based Real-time-PCR was performed for candidate miRNA with their corresponding target gene in 528 ESRD patients and ethnically matched 528 healthy controls. Patients were differentiated in four primary basic causes are DN; HTN; CIN and CGN. GAPDH and U6 RNA were used as internal controls. The relative expression level of mRNA was analyzed by 2-ΔΔCt method. Statistical analysis was performed using SPSS v. 21.

RESULTS: Expression data evident that miR-663a positively regulate TGF-β1 while miR-23a establish inverse relationship with VEGFA. in blood of renal failure patients when compared with normal healthy controls. It was observed that upregualtion of miR-663a (8 fold) would enhance TGF-β1 expression up to 30 fold which might leads to increase in renal fibrosis. While downregualtion of miR23a significantly downregulate VEGFA expression. Decrease in VEGF expression might inhibit VEGF induced renal damage repair system. Patients with DN and CGN shown significant decrease in GFR and retention of uremic toxins. Similarly increased expression of miRNA663a and miR23a established same relationship with TGF-β1 and VEGFA in other basic diseases.

CONCLUSIONS: Individuals are susceptible to ESRD in presence of higher miR663a; miR23a and TGF-β1 expression and lowered VEGFA expression. The combined quantification of miR-663a with TGF-β1 and miR-23a with VEGFA may help to better predict ESRD in early stages in a precise and clinically applicable way.


  37. Wolfram Syndrome: A Case Report Top


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

Apex Kidney Care - The Apex Database; Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

BACKGROUND: Wolfram syndrome is an autosomal recessive neurodegenerative disorder. It manifests as early onset; insulin dependent diabetes mellitus (DM) and progressive optic atrophy in all patients with added diabetes insipidus and sensory neural deafness in 70% of patients; where it is referred to as DIDMOAD. There can be atony of the urinary tract; which leads to dilatation of the upper urinary tract and bladder dysfunction. Parental consanguinity is noted and 1 in 350 people carry the genes of WFS.

METHODS: A 24 year male; was diagnosed to have DM 1 at age 7 years. At 17 years he had visual impairment due to optic atrophy with some changes of diabetic retinopathy; treated with laser. After 4 years; he developed hearing difficulty due to high tone hearing loss. He presented with a Se.Creatinine of 2.1; with symptoms of difficulty in initiating micturition since long. Sonography of kidney and bladder was suggestive of bilateral enlarged kidney (12.5 x 5.9 cm) with moderate dilation of bilateral pelvi-calyceal system and ureters. The bladder was over distended bladder with pre void of 670 cc & post void of 470 cc. MCU did not show any vesicoureteric reflux. 24 hour urine protein was 70 mg/day. He was started on tamsulosin; to which he showed an immediate and dramatic rsponse. The Se.Cr on next followup after 3 weeks reduced to 1.67. Repeat USG showed no significant interval change. Genetic testing with sequencing of 30 Monogenic genes showed (c.2643_2644delCT) WFS1 gene mutation.

RESULTS: The presence of renal failure and diminished vision in a diabetic patient rcan be due to DM or non DM etiologies. Absence of proteinuria and diabetic retinopathy favour the latter. Presence of optic atriophy; and ultrasound changes of obstructive uropathy should raise the suspicion of Wolfram syndrome. A large atonic bladder; a low-capacity; high-pressure bladder with sphincteric dyssynergia; and hydroureteronephrosis are common manifestations; arising from central and peripheral neurologic dysfunction. Therapy for bladder dysfunction include anticholinergic drugs; clean intermittent catheterization; electrical stimulation and physiotherapy. Recurrent urinary tract infection arising out of this bladder dysfunction is one of the common clinical challenges in patients with Wolfram syndrome.

CONCLUSIONS: Wolfram Syndrome is rare genetic disorder with very few cases reported from India. From a Nephrology perspective its important to identify this condition when the related comorbidities coexist in a diabetic patient.


  38. Post Renal- Transplant Malignacy in India: Single Centre Experience Top


Nishita Mohan Philip, D Bhowmik, S Mahajan, S Bagchi, R K Yadav, Arun Kumar, S K Agarwal

Department of Nephrology; All India Institute of Medical Sciences; New Delhi; India

BACKGROUND: Post renal transplantation malignancies (PRTM) are an important cause affecting long-term patient survival after renal transplant (RT). There is impression that incidence of PRTM in India is lower than western counterpart. In absence of RT national registry; there is no national data on PRTM. Most available data from India is single center experience. Present study is a retrospective study of prospectively collected data out of ongoing Department RT registry on PRTM.

AIM OF THE STUDY: To study the incidence and pattern of de novo PRTM; its management and impact on allograft and patient's survival of renal allograft recipients who underwent RT between 1983-2017 in our hospital.

METHODS: All patients who received RT at our hospital between 1983 till 2017 were taken as subjects for the study. Out of total RT done during this period; patients diagnosed to have some type of malignancy formed the subject for analysis. In addition to nature and site of malignancy; other factors analyzed included first or subsequent RT; patient gender; patient age at time of RT; induction; type of baseline immunosupression (IS); any acute rejection (AR) before malignancy; time since RT; clinical presentation; management and graft and patient outcome.

RESULTS: Of the 2634 RT; between 1983 to 2017; 32 (1.2%) patients developed PRTM. The mean age of patients at RT was 30 +/- 8 years; 27 (84%) male. Mean interval since RT was 112+/-54 (32-300) months. 22 had HCV infection; (2 treated). Induction (Daclizumab) was given in 3. Cyclosporin was used in 25 patients and Tacrolimus in 7. In anti-proliferative agents; Azathioprine was used in 25 and MMF in 6. Ten had AR before diagnosis of PRTM. Of 32 patients; 16 (50%) had PTLD. Rest were carcinoma (CA) skin[2]; CA tongue[1]; CA colon[1]; renal cell CA[1]; CA bladder[1]; Kaposi's Sarcoma[1]; CA Thyroid[1]; plasma cell leukemia[1]; Malignant leiomyoma[1]; CA penis[1]; Papilloma breast[1]; CA duodenum[1]; bowel malignancy[1]; and unclassified malignancy[1]. IS was decreased in all; switch to mTORi was done in 10; surgery required in 12 and chemotherapy in 8 (Rituximab in 3). Overall; 6 with PTLD and 5 with other PRTM died.

CONCLUSIONS: Incidence of PRTM in India is 1.2% of which 50% are PTLD. Management includes decreasing IS with other modalities depending upon type of PRTM. Significant number of patients does survive with PRTM.


  39. Histological Spectrum of The Clinical Kidney Disease in Type 2 Diabetes Mellitus Patients: A Biopsy Based Study Top


Prem Shankar Patel, Jai Prakash, Shiv Shankar Sharma, Suraj Prakash, Harish Saini, Partha Pratim Mandal, Usha

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

BACKGROUND: Diabetic nephropathy (DN) is most common and devastating complication of diabetes mellitus. However; diabetic nephropathy (DN) is not the sole renal disease in diabetes mellitus. Kidney disease in diabetes patients may have heterogeneity in histology on renal biopsy including diabetic kidney disease (DKD) and non-diabetic kidney disease (NDKD) alone or superimposed on diabetic nephropathy. DN is difficult to reverse. However; NDKD are often treatable and even remittable.

AIM OF THE STUDY: The aim of this study was to analyze the histological spectrum of the clinical kidney disease in patients with type 2 diabetes mellitus; based on kidney biopsy.

METHODS: This prospective study was carried in the Department of Nephrology; Sir Sunderlal Hospital; Institute of Medical Sciences; Banaras Hindu University; Varanasi; from October 2016 to August 2018. Diabetes was diagnosed as per WHO criteria. Forty seven (47) type 2 diabetes mellitus patients with clinical kidney disease; of both gender and age >18 years; were enrolled for study. The indications of renal biopsy were nephrotic syndrome; active urinary sediments; rapid decline in renal function; absence of diabetic retinopathy and varying grade of proteinuria. All patients underwent kidney biopsy under ultrasound guidance. Biopsy sample was studied under light microscope; using Hematoxylin and Eosin; periodic acid Schiff; and acid Fuchsin orange G stains. Methyl violet and Congo red staining were done as and when required.

RESULTS: A total 47 (male 39; female 8) patients were included in the study. The clinical presentation in these patients were; nephrotic syndrome 23 (48.9 %); chronic kidney disease 11 (23.4%); asymptomatic proteinuria and hematuria 6 (12.7%); acute kidney injury 4 (8.5%) and acute nephritic syndrome 3 (6.3%). DR was observed in 17 (36.17%) cases and 30 (63.82%) cases had no DR. Kidney biopsy revealed isolated DN; isolated NDKD and NDKD superimposed on DN in 24 (51.0%); 14 (29.7%); and 9 (19.1%) cases respectively. Idiopathic MN (4) and Amyloidosis (2) were commonest cause of NDKD; whereas DPGN were main cause of NDKD superimposed on DN. Immune complex MPGN; lupus nephritis (class V+III); DPGN; mesangioproliferative glomerulonephritis; hypertensive nephropathy; xanthogranulamatous pyelonephritis; CTIN and TMA were present in one case each. DN was observed in 82.3% cases in presence of DR; and it was also noted in 33.3% cases in absence of DR. Biopsy showed DN in ¾ patients with microalbuminuria.

CONCLUSIONS: 49% patients had NDKD either alone or coexisted with DN. DN was noted in absence of DR and in patient with low level of proteinuria. Level of proteinuria and presence of DR is not helpful in distinguishing DN Vs NDKD. Hence; renal biopsy is recommended in patients with type 2 DM with kidney disease.


  40. Tunneled Catheter Insertion by Nephrologist in A Tertiary Care Centre Top


L Mahendra Varman, S Vel Arvind

Department of Nephrology; Apollo Hospitals; Tiruchirappalli; Tamil Nadu; India

BACKGROUND: Tunneled catheter as an access for maintenance hemodialysis is a pretty costly affair; and is usually done at a tertiary care centre; with help of either vascular surgeon or an interventional radiologist. Usually; fluoroscpic guidance is necessary for it. Thus to bring down the cost; tunneled catheter insertion was done by us in a tertiary care hospital in absence of fluoroscopy.

AIM OF THE STUDY: To assess the success rate; complications of tunneled catheter insertion by a nephrologist in a tertiary care centre without fluoroscopic guidance.

METHODS: 10 patients underwent tunneled catheter insertion in our hospital. Catheter was inserted under USG guidance without fluorosopic assistance. The length of the catheter was chosen depending upon the stature of the patient. The length of the tunnel and the placement of tip was chosen with the help of surface marking of superior vena cava and atrial junction. The position of catheter was confirmed by chest X ray and echocardiography. The patients were followed up for 1 month and blood flow rate that was achieved and complication during or after procedure and incidence of catheter associated blood stream infections were noted.

RESULTS: 10 patients underwent tunneled central venous catheter insertion by us at our centre. 9 patients underwent catheterisation of right internal jugular vein and one patient of left internal jugular vein. Correct position was achieved in all of them. Blood flow rate of more than 300 ml/min was achieved in the 10 patients. No catheter associated blood stream infections were seen until 1 month of follow up. Only one patient had thrombus of the catheter and catheter was removed. At end of one month all except one patient had good flow through the tunneled central venous catheter.

CONCLUSIONS: Thus; tunneled catheter can be inserted by nephrologists without fluoroscopic guidance and achieve good blood flow and correct position inside right atrium and fewer complications at low cost with out radiation exposure.


  41. Study of Health Related Quality of Life in Chronic Kidney Disease Stage 5 Patients Top


Patel Neel, Rajapurkar Mohan, Gang Sishir, Hegde Umapati, Konnur Abhijit, Patel Hardik

Department of Nephrologist; Muljibhai Patel Urological Hospital; Nadiad; Gujarat; India

BACKGROUND: ESRD is one of the chronic diseases causing high level of disability in different domains of patient's lives leading to poor quality of life. Augmentation of Quality of life may perhaps be a challenge and observable fact of specific interest for renal health care teams. The concept of QOL and quality adjusted life years in chronic diseases are still emerging topics in India.

AIM OF THE STUDY: To assess and compare Quality of Life (QOL) and their association with clinical and laboratory parameters in CKD-5 patients:CKD-5 not on dialysis; CKD-5 on hemodialysis and post renal transplant (RTX).

METHODS: Kidney disease Quality of Life-36 (KDQOL-36) questionnaire was applied to CKD 5 patients at baseline; 6 and 12 months. Physical; mental and kidney disease component summary (PCS; MCS and KDCS) scores were calculated. Clinical; demographic data and nutritional parameters were collected and their association with QOL was assessed.

RESULTS: Total 195 CKD-5 patients:50 not on dialysis; 70 MHD and 75 RTX patients were enrolled from April 2016 to March 2018. Average age was 44.3; 47.8 and 37.16 years; respectively. The prevalence of diabetes mellitus; hypertension and ischemic heart disease was lower in RTX group (p<0.05).KDQOL-36 score was significantly better in RTX group as compare to other two groups (p<0.01). The variables: Age (p<0.05); Sex (p-0.02); employment (p-0.04); HD access (P<0.05); frequency of HD (p<0.05); adequacy of HD (p<0.05); hemoglobin (p<0.01); S albumin level (p<0.01); graft dysfunction (p<0.05); weight change (p<0.05) and SGA score (p<0.05) affects KDQOL-36 score. Poor baseline KDQOL-36 score associated with early initiation of RRT and mortality (p<0.05).

CONCLUSIONS: QOL was better in RTX patients at base lime and further improved at 12 months. There were socio-demographic; clinical and nutritional risk factors that can affect QOL in CKD-5 patients. QOL strongly predicts mortality and early initiation of RRT in CKD 5 on conservative treatment.


  42. Stimulation Index of Peripheral Mononuclear Cells in Patients on CAPD Top


Arshi Rizwan, Sandeep Mahajan, Bimal Kumar Das

Department of Nephrology; All India Institute of Medical Sciences; New Delhi; India

BACKGROUND: Infections remain important complication in CKD and peritoneal dialysis (PD) patients. Peripheral blood mononuclear cells (PBMCs); an initial component of innate immunity are first line of defense against invading pathogens. Though few studies have demonstrated reduced activation of PBMCs in hemodialysis patients; no study has systematically looked at their function among CKD stage 5 and PD patients.

AIM OF THE STUDY: We hypothesized that PD dialysate effluent can cause activation of PBMCs by its bio-incompatible nature further worsening their immune responsiveness.

METHODS: Stimulation index (SI) of PBMCs to various external stimuli including PD effluent were studied in 20 consenting patients each on PD; CKD stage 5 not on dialysis & healthy controls. PBMCs were isolated as per standard procedures and were seeded in tissue culture plates in a concentration of 1 × 106 cells/well. They were stimulated with phytohaemagglutinin (PHA; a potent T- and B-cell mitogen); peritoneal dialysate effluent (DE) and fresh peritoneal dialysis fluid (PDF; Baxter; India). The SIs for different stimuli was estimated by counting uptake of 3H-thymidine using scintillation counter analyzer.

RESULTS: Mean SIs values of PBMCs proliferation with PHA; DE and PDF were 2.14±0.89; 1.8±0.89 and 0.29±0.21 for PD patients; 4.06±1.19; 3.26±1.04; and 0.84±0.42 for CKD patients and 6.39±2.37; 3.41±1.67 and 1.15±0.28 respectively in controls. SIs values were significantly depressed in patients with CKD as compared controls; with PD patients doing the worst. SIs values were significantly more with PHA followed by DE and PDF respectively in each group.

CONCLUSIONS: PBMCs from CKD & PD patients are less immunoresponsive to T-& B-cells mitogen. PD effluent by chronically activating PBMCs may contribute further to this hyporesponsiveness.


  43. Performance of Estimated GFR Equations in Patients with Chronic Liver Disease Top


Dhanin Puthiyottil, Biju Pottakkat, Satish Haridasan, Sreejith Parameswaran, P S Priyamvada

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

BACKGROUND: Accurate measurement of glomerular filtration rate (GFR) is needed in patients with chronic liver disease (CLD). Serum creatinine measurements are unreliable due to lower muscle mass and reduced hepatic production of creatine. The accuracy of eGFR equations in Indian patients with CLD is not known. Here we measured the eGFR in liver transplant awaited patients using CKD-EPI; MDRD 4 and MDRD 6 and compared it with GFR measured by DTPA renogram (mGFR).

AIM OF THE STUDY: To evaluate the performance of CKD-EPI; MDRD 4 and MDRD-6 equations in estimating GFR in patients with CLD.

METHODS: 45 adult patients with CLD waitlisted in the cadaveric liver transplantation program in JIPMER were included. Patients with AKI in the preceding 3 months were excluded. All the patients underwent DTPA renogram to measure the GFR (mGFR). Three GFR values were calculated using MDRD-6; MDRD- 4 and CKD-EPI equations. Relative bias was defined as the median percentage of overestimation by eGFR equations compared to mGFR. Relative precision was defined as the interquartile range of the relative bias. Accuracy was defined as the proportion of patients with eGFR values not exceeding 30 % of the mGFR.

RESULTS: Out of 45 participants 40 (88.9%) were males. The mean age and BMI were 47.4 (CI 44.5-50.3) and 24.1 (CI 22.2-26) respectively. 60% were ethanol related CLD. The mean serum creatinine was 1.04 (CI 0.98-1.1). Mean eGFR with DTPA; MDRD6; MDRD 4 and CKD-EPI were 65.64 (CI 59.6 -71.6); 77.6 (CI 70.9-84.4); 84.3 (CI 77.7-90.9) and 85.7 (CI 79.4-92.0) respectively. All e GFR equations overestimated the GFR. The relative bias of MDRD6; MDRD 4 and CKD EPI were 19.3%; 32.8% and 34.04% respectively with DTPA as the reference. Relative precision by MDRD6; MDRD 4 and CKD EPI were 34.8%; 48.7% and 37.2 % respectively. The accuracy of MDRD6; MDRD 4 and CKD EPI were 68.9 %; 48.9 % and 44.4% respectively.

CONCLUSIONS: In patients with chronic liver disease MDR4; MDRD6 and CKD-EPI overestimates the GFR.


  44. Long Term Renal Outcomes After Kidney Donation - A Single Center Observational Study Top


Avinash Rao, Hardik Patel, Umapathi Hegde

Department of Nephrology; Muljibhai Patel Urological Hospital; Nadiad; Gujarat; India

BACKGROUND: In the era of growing number of live donor kidney transplants in India; the query on consequences of kidney donation over long term has limited answers. We hereby share our decade's experience in the present paper.

AIM OF THE STUDY: To study the long term renal outcomes in kidney donors.

METHODS: It is a retrospective observational study in 204 kidney donors who donated their kidneys in the year 2009 and 2010. The eGFR measured by CKD-EPI method and the blood pressure status over 1; 3; 5 and 8 years were noted. The population was divided into 2 groups based on age at donation (group 1 - <50 yrs and group 2 - ≥50 yrs) and were compared for outcomes.

RESULTS: Mean eGFR of the study population was 81.18 ± 19.99 ml/min/1.73 m² in group 1 (n=73) and 60.08 ± 18.84 ml/min/1.73 m² in group 2 (n=40) 8 years post donation. There was statistically significant difference (p<0.001) in eGFR between the two groups. The group 1 patients with pre donation hypertension had better eGFR as compared to group 2 patients with pre donation hypertension (p<0.001). There was no difference in the urine protein creatinine ratio between groups over the period of study.

CONCLUSIONS: The presented data has practical relevance highlighting the need for careful selection of kidney donors with respect to the age group. Donors with age ≥50 years with hypertension have poor long term renal outcomes as compared to younger patients.


  45. Unrecognized Renal Dysfunction in Patients with Acute Stroke Top


G Gowthaman, P Kalavathi, M Edwin Fernando, S Sujith, N D Srinivasa Prasad, K Thirumalvalavan, R Vivekpraveen, K Chandrasekaran

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

BACKGROUND: Unrecognized Renal insufficiency defined as an (eGFR) estimated glomerular filtration rate <60 ml/min/1.73 m2 in the presence of normal serum creatinine levels; is common among patients with acute stroke and contributes to mortality. This issue has not been sufficiently addressed.

AIM OF THE STUDY: To determine the prevalence of the unrecognized renal insufficiency in patients admitted with acute stroke and its clinical significance.

METHODS: This cross sectional study consisted of patients with acute stroke admitted in medical wards at Stanley Medical College from March 2017 to August 2017. eGFR was estimated using MDRD4 formula. Study population was divided into three groups (normal renal function; unrecognized and recognized renal dysfunction) as per eGFR. The two primary outcomes such as severe disability at hospital discharge and in-hospital mortality were compared in each group.

RESULTS: Of the 100 patients with stroke included in the study; 62% had normal renal function; 31% had rocognized renal insufficiency and 7% had unrecognized renal insufficiency. Mortality rates were higher in patients with recognized and unrecognized renal insufficiency compared with patients with normal renal function (29% and 28.5% and 9.6%) respectively; P<0.05). Similarly; severe disability rates at discharge were also higher in patients with recognized and unrecognized renal insufficiency compared with patients with normal renal function (72.27%; 80%; and 32.14%) respectively; P<0.05.

CONCLUSIONS: Unrecognized renal insufficiency is common among patients with acute stroke and is associated with adverse short-term outcomes.


  46. Study of Cognitive Function in Patients with Chronic Kidney Disease and The Effect of Renal Transplantation Top


Kishore Kumar Ariga, K P Kochhar1, Ashima Nehra2, K K Deepak1, S K Agarwal, Gurdeep Kaur3, Dipankar Bhowmik

Departments of Nephrology; 1Physiology; 2Neuropsychology and 3Dietetics; All India Institute of Medical Sciences; New Delhi; India

BACKGROUND: Moderate to severe cognitive impairment is prevalent in end stage renal disease (ESRD) patients. The most common cognitive defects in ESRD patients include decreased mental efficiency; impaired attention; decreased psychomotor speed and memory. Renal transplantation may improve cognitive function and studies assessing the effect of renal transplantation on cognitive function have shown varied results with the majority showing improvement in cognition. There is no data in Indian patients.

AIM OF THE STUDY: We planned to study the effect of renal transplantation on cognitive function and prefrontal motor cortex activity in patients with chronic kidney disease.

METHODS: A total of thirty-three ESRD patients on maintenance haemodialysis and thirty-four healthy controls were studied with neuropsychological testing and functional near infrared spectroscopy (fNIRS) during cognitive tasks. Montreal cognitive assessment (MoCA); Neuropsychological Evaluation Screening Tool (NEST); auditory verbal learning test (AVLT); color trails A and B; digit symbol substitution test (DSST) were used for cognitive testing. WHOQOL-BREF; depression anxiety stress scale (DASS); Robson self-concept and Pittsburgh sleep quality index (PSQI) were used to assess quality of life; mood; self-concept; and sleep quality respectively. Baseline testing of patients was done before transplantation and repeat testing was done after transplantation at 3 months (in 33 patients) and 6 months (17 patients). Single point testing of cognitive function was done in controls. fNIRS during tasks (1 back; 2 back; and Stroop) was done before transplant; at 3 months and 6 months after transplantation.

RESULTS: Mean age of patients was 30.5±7.6 years with only one diabetic patient included. In comparison with controls; ESRD patients had reduced cognitive function pre-transplant as assessed by MoCA; NEST; color trails A and B; AVLT and DSST. As compared to the findings pre-transplant; at 3 and 6 months post-transplant there was improvement in all the tests. At 6 months; there was further improvement in colour trails B; DSST; AVLT 5th trail; total learning and immediate recall in comparison to results at 3 months. There was no difference in cognitive function with MoCA and NEST between patients post-transplant and controls. There was improvement in tests like color trails A and B; AVLT trail 1 and 5; total learning; Hits and DSST post-transplant and were comparable to controls. With fNIRS; there was significant change in the ΔHBO in channel 2 between baseline and 3 months post-transplant during 2 back test. During Stroop task; there was significant decrease of ΔHBO in channel 1 post-transplant.

CONCLUSIONS: ESRD patients have significantly reduced cognitive function. There is an improvement in cognitive domains like focussed attention; psychomotor speed; verbal learning and memory after renal transplantation with further improvement as time after the transplant increases.


  47. A Rare Fungal Infection in Early Post Transplant Period Top


Pallavi Prasad, Dinesh Khullar, Nimish Gupta

Department of Nephrology; Max Superspeciality Hospital; New Delhi; India

BACKGROUND: Systemic fungal infections; although uncommon in the normal population; are relatively common in the late post transplant period in renal allograft recipients. Fungal infections are difficult to diagnose and drug interaction of antifungals with calcineurin inhibitors makes treatment challenging.

AIM OF THE STUDY: We describe here the case of a 59 year old post transplant patient who developed a rare fungal infection (Scedosporium) within second week after transplant and was treated with oral antifungals.

METHODS: A 59 year old male patient underwent renal transplant surgery with live related donor in view of ESRD due to diabetic nephropathy. Induction was with 3 mg/kg of rabbit-ATG and maintenance immunosuppression was with tacrolimus; mycophenolate sodium and prednisolone. He was discharged on post-op day 7 with a nadir creatinine of 1.1 mg/dl. He presented to us on post op day 13 with fever; dry cough and shortness of breath since 2 days. Examination revealed coarse crepitations in right infrascapular area and a chest X ray was suggestive of bilateral lower zone inhomogenous opacities. Treatment with oral antibiotics was started but patient continued to have high grade fever. An HRCT chest was done which revealed a large necrotic lymph node in subcarinal region 4.6 x 3.2 cm. with pretracheal and paratracheal lymphadenopathy and patchy consolidation in right lower lobe. On basis of the CT chest; he was suspected to tuberculosis and planned for EBUS-TBNA from lymphnode.

RESULTS: EBUS-TBNA sample from lymph node was purulent and culture showed negative Gram's stain; AFB stain; nucleic acid based test for tuberculosis but fungal stain showed filamentous branched septate hyphae and culture showed growth of Scedosporium species. Patient was started on oral antifungals (voriconazole) as per culture sensitivity. Tacrolimus dose was decreased in view of drug interaction and eventually shifted to once a day sustained release tacrolimus to maintain a tacrolimus trough concentration between 8-10 ng/ml and mycophenolate dose was reduced. Patient became afebrile within one week of starting antifungals and dyspnea improved. He was discharged and followed up in OPD. CT scan done one month later showed regression of size of lymph nodes and resolution of consolidation. He is maintaining stable graft function and tacrolimus levels around 7-8 ng/ml on once daily long acting tacrolimus; low dose mycophenolate and steroid. We plan to give him a minimum of 3 months of antifungals.

CONCLUSIONS: Rare fungal infections should be kept in differentials of necrotizing lymph nodes in renal transplant recipients and may present in early post transplant period; contrary to popular belief. Early treatment with antifungals may help improve outcomes as mortality rate with fungal infections is high.


  48. A Study on Assessment of Health Status by SF-12 in CAPD Patients At Teritary Care Hospital Top


R Sujith Reddy, Manisha Sahay

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

BACKGROUND: The quality of life in chronic diseases like ESRD on CAPD is to be determined by health surveys; this study has used SF -12; which is a one page; two minute questionnaire module and a multipurpose short form measure of health status; it is rapidly becoming an instrument for purposes of monitoring health. SF-12 measures both physical and mental health; and has 12 questions with eight components; 2 divisions which are physcial component summary (PCS) and mental component summary (MCS).

AIM OF THE STUDY: To access the physical and mental health status by SF-12 (SHORT FORM HEALTH SURVEY) in patients with ESRD treated with continuous ambulatory peritoneal dialysis (CAPD).

METHODS: This is a cross sectional observational study; 50 patients diagnosed to have CKD (ESRD) on CAPD admitted in Osmania General Hospital were evaluated for health status by using health survey SF-12.

RESULTS: Overall health related quality of life was poor compared to general population; age; sex; comorbities; level of social support and emotional support; duration of treatment were significant predictors of health status. Older age group had lesser PCS and MCS scores and education status also had a role in PCS and MCS scores; self treated patients had less PCS and MCS scores Compared to Assisted patients. More the number of peritonitis episodes lesser were the PCS and MCS scores. Adults 60.09%; pediatric 30.9% Male: female - 38:12 Diabetes: 9 Hypertension: 33 members.

CONCLUSIONS: CKD patients especially ESRD will have poor quality of life; so to improve quality of life; not only objective parameters but subjective parameters should be taken into account; SF 12 is quick method to know the mental and physical health status of particular individual and follow up later.


  49. Is Once Daily Oral Iron Supplementation As Good As Twice Daily Oral Iron Supplementation For Correction of Iron Deficiency in Subjects with Stage G3-4 Chronic Kidney Disease? Top


Vivek Sood, Vivek Kumar, Krishan Lal Gupta, Prateek Bhatia, Samir Malhotra, Ashok Kumar Yadav, Sanjay Singh, Thakur Sen

Department of Nephrology; PGIMER; Chandigarh; India

BACKGROUND: RCT is a first ever attempt to the best of knowledge comparing OD oral iron supplementation with conventional BD dosing in CKD stage G3-4 patients with iron deficiency. The study provides the strongest evidence so far that iron availability & consequent incorporation in Hb may have been better in OD group suggesting that OD dosage might be equally effective if not better than BD; thereby setting a platform for future study to validate our hypothesis over an extended cohort and period of time.

AIM OF THE STUDY: To assess change in % Transferrin Saturation; serum ferritin; hemoglobin and hepcidin levels at 12 weeks with OD vs. BD oral iron supplementation in patients with stage G3-4 CKD and iron deficiency.

METHODS: 30% ≤Study was a single center; parallel arm; randomized; open label; active controlled; interventional CTRI registered trial. A total of 328 CKD G3-4 patients satisfied inclusion criteria of age between 18–70 years; iron deficiency (TSAT & 500 mg/L). However 248 got excluded≤ferritin & 80 patients were enrolled & randomized (1:1 allocation) to receive oral iron supplementation with ferrous ascorbate (100 mg elemental iron/tablet) either in OD or BD dosage. Patients were reevaluated during follow up visits at 2; 6 & 12 wks. All enrolled patients with non-missing outcome data were analyzed. Continuous variables were compared with independent samples paired t test/Mann–Whitney U test as appropriate. Categorical variables were analyzed with chi-squared test/Fisher exact test as appropriate. Paired t test & Wilcoxon signed-rank test were used for within-group comparisons. Repeated measure ANOVA was used to assess change in % TSAT & ferritin over 2; 6 & 12 wks in either dosage group.

RESULTS: There were no differences between groups (OD vs. BD) wrt demographic details & co-morbidities. Baseline hematological & biochemical parameters did not differ between groups except for Hb [12.59 ± 1.67 (OD) vs.11.91 ± 1.25 g/dl (BD); p=0.04] & eGFR [39.51 ± 12.35 (OD) vs. 33.80 ± 11.10 mL/min/1.73 m2 (BD); p=0.03]. Increase in ferritin & iron was significant in BD group [between-group difference in mean change at 12 wks (OD-BD): -54.60 ug/L; p=0.05 (ferritin) and -21.6 ug/L; p=0.01 (iron)]. However; increase in MCHC was significant in OD group: 0.95 g/dL; p=0.001. Effect on % TSAT of both OD dosage; p=0.043 & BD dosage; p=<0.001 was significant. Effect on ferritin of both OD dosage; p=0.034 & BD dosage; p=0.001 was also significant. Though Hb differed in two groups at baseline; values did not change significantly in either group. There was significant interaction of dosage group with change in MCHC with significant rise in OD group as compared to drop in the BD group (p < 0.001).

CONCLUSIONS: Despite no difference in %TSAT & Hb with significant increase in ferritin & iron in BD group; results suggest iron availability & incorporation in Hb to be better in OD group; indirectly supporting that OD dosage may be better to BD (double dose; cost & pill burden; more A/Es & lesser adherence).


  50. Rituximab Therapy in The Treatment of Refractory Lupus Nephritis: A Retrospective Analysis from Western India Top


Amar Kulkarni, Mayuri Trivedi, Jatin Kothari, C Balakrishnan, Girish Kakade, Divya Bajpai, Tukaram Jamale, N K Hase

Department of Nephrology; P.D. Hinduja Hospital and Medical Research Centre; Seth G.S. Medical and K.E.M. Hospital; Mumbai; Maharashtra; India

BACKGROUND: Corticosteroids; in conjunction with mycophenolate mofetil or cyclophosphamide; is the standard treatment given for proliferative lupus nephritis. Rituximab; a monoclonal antibody targeting the B lymphocytes; has been used with patients with refractory disease even though the available literature on this agent still continues to remain controversial.in this retrospective study we describe our experience with Rituximab in treatment of refractory lupus nephritis.

AIM OF THE STUDY: To study the outcomes of refractory lupus nephritis after treatment with Rituximab.

METHODS: This retrospective study includes the analysis of patients who presented in the Lupus clinics in the last 15 years (January 2003-January 2018) of a corporate tertiary care hospital and a public hospital in Mumbai and had renal disease which was refractory to conventional immunosuppressive therapy including IV cyclophosphamide or Mycophenolate or both agents and had been offered Rituximab as salvage therapy. Rituximab was administered as an infusion of 375 mg/m2 every week for 4 weeks followed by additional doses every 6 monthly if required in some patients. Complete remission (CR) of lupus nephritis was defined as normal serum creatinine and serum albumin levels; inactive urine sediment; and proteinuria<0.5g/day; partial remission (PR) was defined as a ≥50% improvement in all renal parameters that were abnormal at baseline. Follow up data was collected at 6 months and at last follow up.

RESULTS: 26 patients received Rituximab for refractory disease in the two institutes. The median follow up after diagnosis of Lupus nephritis was 96 (Range 24-276) months and median follow up after receiving the first dose of rituximab was 30 (Range 6-84) months.2 patients were male. A total of 1/26 patients (3.84%) reached Renal CR and 14/26 patients (53.84%) reached Renal PR at the end of 6 months and 3/26 (11.53%) and 15/26 (57.69%) had CR and PR by the last follow -up respectively.3 patients showed infective complications. 8 patients failed to show any response to therapy.8 patients had progressive CKD out of which 4 patients progressed to ESRD. In these 8 patients who showed progressive disease; five patients had achieved partial remission at six months and three had showed no response to therapy.6 of these patients had severe proliferative histopathology features; of whom three had Class IV-G and three had Class III-A. Two patients died while on long-term haemodialysis.

CONCLUSIONS: Rituximab showed some response in 18/26 patients. However in patients with severe renal impairment; it did not prevent progression to ESRD. It may be considered as an option in treatment of refractory Lupus nephritis.


  51. Dialysis Adequacy and Quality of Life of Diabetic and Nondiabetic Bangladeshi Patients on Maintenance Haemodialysis Top


Shudhanshu K Saha, Rafi N Islam, Muhammad A Rahim, Mehruba A Ananna, Tabassum Samad, Mohammad A Mansur, Wasim M M Haque, Sarwar Iqbal

BIRDEM; Dhaka; Bangladesh

BACKGROUND: Quality of life (QOL) is one of the chief areas required to be addressed when caring for people with end stage renal disease (ESRD). The continual function of the native kidneys to excrete uraemic toxins are replaced in such patients by few sessions of few hours of rapid and enforced urea clearance in an entire week.

AIM OF THE STUDY: To explore whether increasing weekly hemodialysis sessions and hemodialysis adequacy do improve patients’ QOL and whether being diabetic influences QOL was also investigated.

METHODS: This cross-sectional study recruited 135 adults (60% males) who were on maintenance haemodialysis (MHD) for 3 months or more from dialysis centers of three tertiary care hospitals in Dhaka from January to December; 2013. Patients with advanced malignancy; dementia and psychosis were excluded. Patients were interviewed once by the investigators to fill a validated Bangla version of the kidney disease quality of life short form questionnaire (KDQOL-SF-36 version 1.3) and calculate a score for QOL. Several clinical parameters were recorded for each patient and a few laboratory tests were run (including those necessary to calculate dialysis adequacy). The data was analyzed with SPSS 11.5.0 using Student's t-tests and ANOVA where applicable. Statistical significance was set at p<0.05.

RESULTS: QOL score for the study sample was 50±17. Only 43 (31.9%) patients received adequate haemodialysis (mean Kt/V of 1.3). Numbers of months on MHD and hemoglobin; total protein; albumin; ferritin and transferin saturation were not significantly different for those who received adequate dialysis compared to the rest. Those with 3 dialysis sessions/week had lower “effect of kidney disease” scores (p=0.021); higher “quality of social interaction” scores (p=0.031) and lower “role emotion” scores (p=0.002) than those on 2 sessions/week. When quality of life parameters were compared between diabetic patients (n=82; mean age 54±8 years; MHD duration 18.5±9.5 months) and non-diabetic subjects (n=53; aged 42±13 years; MHD duration of 25±16 months); “effects of kidney disease”; “cognitive function” and “quality of social interaction” scales were significantly higher in those having diabetes (p<0.045; p<0.024 and p<0.022 respectively).

CONCLUSIONS: Achieving a hemodialysis adequacy (Kt/V>1.2) was not found to improve QOL scores in the study subjects and therefore bearing the extra cost of an additional dialysis session per week may not be advisable for those not so well off.


  52. Etiology; Clinical Features and Outcomes of Treatment of Hyponatremia: A Prospective Study Top


Prawash Kumar Chowdhary, Sanjeev Anant Kale, Abbas Naqvi, Ganesh Duryodhan Murkut

Department of Nephrology; Ramkrishna Care Hospital; Raipur; Chhattisgarh; India

BACKGROUND: Hyponatraemia is one of the common causes of electrolyte imbalance occurring in 22% of hospitalized patients. Nonspecific symptoms lead to delay in diagnosis and treatment of this electrolyte imbalance.

AIM OF THE STUDY: To evaluate the etiology; clinical feature and outcome of treatment of hyponatremia in hospitalized patients.

METHODS: This prospective study was conducted on 100 hospitalized patients admitted in Ramkrishna Care Hospital; Raipur of age group 25-75 years with low sodium level (below 135 meq/L) during the period; Sep 2016 to Nov 2017. Patients with severe renal dysfunction (CCr<30/ml/min/1.73 m2) and deep coma (GCS<3/15) were excluded. After detailed history and clinical examination necessary investigation were done. In some patients when required special investigation were done. Depending on volume status patients were divided into three groups (Hypovolemic; Euvolemic; Hypervolemic). On the basis of serum sodium (134-130; 129-120; <120) meq/L patients were divided into three groups (Mild; Moderate; Severe) respectively. Clinical symptoms of Hyponatraemia were studied. Depending on severity and etiology correction of serum sodium was done. Outcome was assessed by duration of clinical stability; duration of hospital stay; residual defect and mortality of hyponatraemic patients.

RESULTS: In present study 53% Male and 47% Female; with Mean age 57.±2.6 yrs. 16% patients had mild; 44%moderate and 40% had severe hyponatraemia. Overall most common cause was diuretic and salt restriction (53%). In Hypovolemic hyponatraemia (74%); Diuretics was most common etiology in all group. In Euvolemic Hyponatraemia (7%) etiology was Hypopituitarism (100%) mild; Hypothyroidism (50%) moderate and SIADH (50%) severe group. In Hypervolemic hyponatraemia (19%) etiology in mild group was CHF (100%) and CLD (50%) in moderate group. In severe group equal number of patients were found in CHF; CLD and NS. Commonest presentation was Nausea (53%) and Vomiting (40%). Duration of clinical stability 1.57±1.87 days Mild; 2.53±1.5 days moderate and 4.66±1.83 days severe hyponatraemic patients. Duration of hospital stay was 5.13±4.78; 6.57±4.36 and 7.78±2.48 days in mild; moderate and severe hyponatraemia group respectively. 2 cases had residual defect in severe hyponatraenia group. Total mortality in this study was 2%.

CONCLUSIONS: Elderly hypertensive patient on diuretics and salt restriction are prone to developed hyponatremia. Early identification of hyponatremia is required to prevent serious complication like seizures. Closed monitoring during treatment will prevent morbidity and mortality and helps in full recovery.


  53. Non Diabetic Renal Disease in Type 2DM - A Single Center Retrospective Study Top


Prawash Kumar Chowdhary, Sanjeev Anant Kale

Department of Nephrology; Ramkrishna Care Hospital; Raipur; Chhattisgarh; India

BACKGROUND: Diabetic Nephropathy is one of thee most frequent and clinically important complications of diabetes. Among patients with Type 2Diabetes the prevalence of NDRD varies widely depending on the selection criteria and the population being studied. Early diagnosis of treatable non diabetic disease in diabetic patients is important to improve renal outcomes.

AIM OF THE STUDY: The aim of this study was to evaluate the renal biopsies performed on Type 2Diabetic patients for suspicion of NDRD and to correlate pathological with the clinical and laboratory findings.

METHODS: From June 2011 to Dec 2017; a total of 57 patients with Type 2 Diabetes with clinically suspected NDRD underwent renal biopsy; reported by a single pathologist. The case records of these patients were retrospectively analyzed. Patient were grouped as group I (NDRD isolated or superimposed on underlying diabetes glomerulosclerosis) and group II (Diabetic glomerulosclerosis) based on renal biopsy. Clinical and laboratory data were also analyzed and compared with the histopathology findings.

RESULTS: 57 patient were studied; 34 (59.6%) male; 23 (40.3%) female with mean age 55.4± 11.07 years. Clinical diagnosis was Nephrotic syndrome 26 (45.6%); AKI 17 (29.8%); RPRF 08 (14.03%) and Acute on CKD 06 (10.5%). Duration of diabetes was significantly less in group I then group II (5.21± 2.37 and 7.26± 2.47 respectively; P<0.0026). There was no significant difference between two group in age; gender; HTN; GFR or 24 hour urine protein estimation. Significant difference were found for presence of haematuria (P<0.023); and Retinopathy (P<0.0023). Most common NDRD were Cresentric GN 08 (29.6%). AIN 06 (22.23%); DPGN 04 (14.81%); Membranous Nephropathy 03 (11.12%); TMA 02 (7.4%); IgA Nephropathy 2 (7.4%); Primary FSGS 01 (3.7%) and Renal Amyloidosis 01 (3.7%).

CONCLUSIONS: The prevalence of NDRD (either isolated or superimposed on underlying Diabetic glomerulosclerosis) was very high in appropriate clinical settings. Shorter the duration of diabetes; presence of haematuria; absence of Retinopathy and Nephrotic proteinuria strongly predict NDRD.


  54. Clinicopathological Profile and Outcome of Acute Antibody Mediated Rejection in Renal Transplant Recipients: A Single-Center Experience Top


M Myvizhiselvi, R Sakthirajan, T Dineshkumar, J Dhanapriya, V Murugesan, N Malathy, T Balasubramaniyan, N Gopalakrishnan

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

BACKGROUND: Acute antibody-mediated rejection (AMR) is a major cause of renal allograft dysfunction. Therapeutic strategies include plasmapheresis; Intravenous immunoglobulin; rituximab; and optimisation of immunosupressants. We studied the clinicopathologic profile and outcome of AMR in our renal transplant recipients.

AIM OF THE STUDY: To study the clinicopathological profile and outcome of AMR in our renal transplant recipients.

METHODS: We retrospectively analysed the renal transplant recipients who underwent transplant between January 2008 and July 2018 and developed acute antibody mediated rejection any time post transplant irrespective of treatment received. They were treated with plasmapheresis (PP) with or without Intravenous immunoglobulin (IVIG) unless contraindicated. Any infection during treatment were documented and patients were followed up regularly.

RESULTS: Thirty one patients were included in our study. Of them 24 (77.4%) were Males. Mean age of our patients was 31 years. Out of 31 recipients 23 (74%) of them had undergone LRRT and 8 (26%) DDRT. Eight of them (25.8%) had Basiliximab induction; 6 (19.3%) had ATG induction and 17 (54.8%) had no induction. Mean Baseline serum creatinine was 1.2 mg/dl. Twenty out of 31 (64.5%) recipients had Cd4 positivity. Twenty three (74%) out of 31 recipients with AMR were treated with plasmapheresis. Of the 23 patients 13 were treated only with plasmapheresis and 10 recipients received PP with IVIG. Median numberof PP was 4. Six recipients (26%) developed infections during plasmapheresis. Ten (43.5%) out of 23 patients treated with PP achieved baseline serum creatinine. Seven recipients (30.4%) had decline in GFR and remained with stable graft function. Six recipients (26.1%) needed haemodialysis. Seven out of 8 patients who were not treated with PP became dialysis dependant.

CONCLUSIONS: Antibody mediated rejection is a serious complication after renal transplantation. Early detection and intensive treatment is mandatory for salvaging the graft.


  55. Do The anti-PLA2R Negative Idiopathic Membranous Nephropathy Patients Have Better Response than anti-PLA2R Positive Patients? Top


Mantabya Singh, Narayan Prasad, Akhilesh Jaiswal, Harshit Singh, Vikas Agarwal, Dharmendra Bhadauria, Anupama Kaul, Manas Ranjan Patel, Manas Bahera

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

BACKGROUND: Idiopathic membranous nephropathy (IMN); an autoimmune associated nephrotic syndrome of adults is mainly associated with PLA2R antibody expressed on podocytes.

AIM OF THE STUDY: To decipher the efficacy of tacrolimus (Tac) plus prednisolone and associated changes in anti-PLA2R in adult IMN.

METHODS: Total 101 IMN patients were treated with combination of prednisolone 1 mg/kg alt-day) and Tac 0.1 mg/kg/day (trough 6-10 ng/ml first 6M and 4-6 ng/ml for next 3M) then both taper by 1/3 every month up to 12M. Out of 101 patients; 15 diabetic; 7 lupus; 1 HBV and 1 ankylosing spondylitis patients were excluded. Finally 77; (51 (66.3%) anti-PLA2R +ve and 26 (33.7%) anti-PLA2R -ve by ELISA) patients were followed. The follow-up duration was 41 (14 to 57) months. CR; PR; relapse and side-effects were compared between anti-PLA2R +ve and anti-PLA2R -ve patients.

RESULTS: Of the 77; at 3M 60 (77.92%; CR-37; PR-23); at 6M 61 (79.22%;CR-53; PR-8); at 12M 53 (68.86%; CR-47; PR-6) achieved remission. Eight (10.38%) relapsed and 16 (20.77%) showed no response at 12M. At end of follow-up; out of 54 responsive patients 37 (68.51%; CR-36; PR-1) remained in remission and 17 (31.48%) patients relapsed. Remission rate was low in PLA2R+ve than PLA2R-ve (36/51 vs 24/26; p=0.03) at 3M; (36/51 vs 25/26; p=0.009) at 6M and (31/51 vs 22/26; p=0.03) at 12M.PLA2R level was decreased by 60.38% and 77.56% at 3M and 6M respectively. During therapy 4 patients develop cutaneous tenia; 1 osteonecrosis of femur head; 1 corpus tunnel syndrome; 4 new onset diabetes; 3 tremor and 14 patients experienced GI symptoms. The eGFR was decreased significantly (p=0.003) by 26.5% at the end of therapy and was normalized after stopping Tac and 5 non-responsive patients had doubling of serum creatinine and progressively deterioted eGFR. To note; 4 females had pregnancy and successful delivery in our cohort of patients.

CONCLUSIONS: PLA2R+ve patients showed poor response compare to PLA2R-ve patients. Remission with Tacrolimus and prednisolone therapy is comparable to historical Ponticelli (Pred plus CYP) regimen. Successfull pregnency was ovserved on Tac based regimen.


  56. Analytical Approach to Modify SF 36 Health Related Quality of Life Questionnaires For Easy Use in Nephrology Out Door Patients Top


Himansu Sekhar Mahapatra, Lalit Pursunani, Himanshu Verma, Muthu Kumar, Renju, Arpita Arora, Y P Gupta, V Sekhar

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

BACKGROUND: Quality of life in Kidney disease patients are less in priority due to disproportionate rise in Chronic Kidney Disease burden compared to the available Nephrologist in India. Standard HRQOL questionnaires are time consuming to use in out door patients so not used routinely.

AIM OF THE STUDY: To analyze standardized SF 36 questionnaire by doing factor analysis and to develop an easy usable questionnaire for out patient Kidney Disease patients.

METHODS: In a cross-sectional study standardized SF 36 questionnaire were applied in all CKD stage IV; hemodialysis; peritoneal dialysis (CAPD) and Transplant recipient patients attending to out door. Principal component analysis of questionnaire was carried out to obtain independent factors and questions that were highly loaded on each of the factors were considered as a final set of questions which would be used to obtain quality of life. The purpose of Principal Component Analysis is to reduce the number of questions while retaining most of the variation in the data obtained. While doing the analysis; only those questions were considered which were in scale data and whose communality was greater than 0.5. Communality represents the extent of variance explained in each questions by the number of factors obtained. The varimax rotated solution was used to arrive at the results. Rotation is done so that each questions are properly aligned with one factor compared to other factors.

RESULTS: Of 1019 patients 66% were males. Among the four groups there were CKD stage 4 (36.3%); CAPD (2.75%); hemodialysis (40.45%) and transplant recipients (20.5%). Six independent factors which together could explain 69.3% of response (factor 1- 25.82%; factor 2- 15.57%; factor 3- 8.47%; factor 4-7.43%; factor 5- 7.16%; and factor 6- 4.87%) were identified. Rotated factor solution obtained which indicated a total of 10 items. Thus the number of items in each factor is as follows: physical (factor 1) – 3 items; mental (factor 2) – 3 items; bodily pain (factor 3) – 2 items; vitality (factor 4) one item; resigned to fate (factor 5) – 2 items; vulnerability (factor 6) – one item. These factors were named as physical; mental; bodily pain; vitality; resigned to fate; and vulnerability. Thus a total of 12 items will be used to collect information of quality of life.

CONCLUSIONS: Less time consumable a set of 12 questions were considered as adequate to measure the quality of life instead of standard 36 questions. However; it needs validation in future study.


  57. An Audit of Renal Allograft Biopsies Performed in A Single Centre Top


C Rakesh Durai, N Gopalakrishnan

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

BACKGROUND: Analysis of allograft biopsies is essential to identify trend changes in diseases afflicting the allograft. It informs scientific decision making. Many revisions to Banff classification was made after histologic analysis of allograft biopsies.

AIM OF THE STUDY: To audit allograft biopsy data of 6 years at Institute of Nephrology; Madras Medical College.

METHODS: We did a retrospective study of allograft biopsies performed in Institute of Nephrology; Madras Medical College between October 2011 and June 2018. Data was collected from transplant records which are meticulously maintained for all our transplant recipients.

RESULTS: A total of 427 biopsies were performed on 315 patients. Of the total number of patients 258 were men and 57 were women. The patients were between 14 years to 59 years of age and 11 patients were less than 18 years of age. 67.2% of the biopsies were performed less than 1 year post transplant with 33.3% being less than 1 month post transplant. Acute cellular rejection accounted for 24% of cases. Antibody mediated rejection accounted for 6.8% of the cases. 2.8% of specimens were suspected to be c4d negative AMR but we could not confirm it by doing DSA. Acute tubular injury contributed to 33.5% of cases out of which 8.4% were suspected to be due to CNI toxicity. TMA was present in 3.9% of biopsy specimens. Glomerular diseases (recurrent/de novo) was found in 9.1% of cases. On analysing IFTA in the biopsies 13.6% had mild IFTA; 9.4% had moderate IFTA and 4.2% had severe IFTA.

CONCLUSIONS: Majority of biopsies are performed within 1 year posttransplant. Acute tubular injury is the commonest finding followed by acute cellular rejection.


  58. Relationship Between TSH; Serum Proteins; Serum Albumin and Lipid Profile Among Patients Undergoing CAPD Top


S Aashish, G Swarnalatha, Uttara Das, Raja Karthik, Gangadhar Taduri

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

BACKGROUND: Subclinical hypothyroidism is common in CAPD patients. The reason for the elevated TSH levels in CAPD patients was not clear. Iodide excess due to reduced renal excretion may contribute to the increased frequency of hypothyroidism in ESRD patients. Hypothyroidism has been found to be associated with adverse cardiovascular outcomes and mortality in CAPD patients in some studies. This study assessed relationship of hypothyroidism with malnutrition and dyslipidemia.

AIM OF THE STUDY: To assess the relationship between TSH; serum protein; serum albumin and levels of total cholesterol; HDL; LDL and triglycerides among patients undergoing CAPD.

METHODS: The patients undergoing peritoneal dialysis who were attending CAPD OPD at Nizam's Institute of Medical Sciences were recruited in this study. Retrospective cross-sectional analysis of these patients was conducted. The correlation between TSH and HDL; LDL; Total cholesterol; Total serum proteins and albumin were assessed. Hypothyroidism was defined if TSH levels were >5 U/ml. Hypoproteinemia was defined if TSP <6 g/dl; Hypoalbuminemia was defined if serum albumin <3.5 g/dl. Low HDL was defined if HDL was <40 mg/dl. Hypertriglyceridemia was defined if TG levels >150 mg/dl. High LDL levels were defined if LDL >100 mg/dl. Hypercholesterolemia was defined if total cholesterol levels >170 mg/dl.

RESULTS: A total of 80 patients were studied. Hypothyroidism was present in 13.75 % of patients. Mean age of hypothyroid patients was 52.9 years. Average duration of CAPD of hypothyroid patients was 17 months. The prevalence of hypoproteinemia in hypothyroid and euthyroid patients was 36.3% and 47% respectively. Hypoalbuminemia in hypothyroid and euthyroid patients was 100% and 79.4%. Hypercholesterolemia in hypothyroid and euthyroid patients was 36.3% and 38.2% respectively. Low HDL levels among hypothyroid and euthyroid patients was 36.3% and 29.4%. Elevated LDL levels among hypothyroid and euthyroid patients was 18.2% and 0.1%. Hypertriglyceridemia was present in 54.5% of hypothyroid and 58.8% of euthyroid patients. TSH levels were negatively correlated with HDL levels and serum proteins and were positively correlated with Triglyceride; LDL and total cholesterol levels. TSH levels were not correlating significantly with these variables among euthyroid patients.

CONCLUSIONS: CAPD patients with hypothyroidism had higher rates of hypoalbuminemia; low HDL levels and high LDL levels. Higher TSH levels were associated with lower levels of HDL and total serum proteins. Higher TSH levels were associated with higher levels of total cholesterol; LDL and triglycerides.


  59. Utilizing Dmsa Scan to Detect Silent Vascular Insults in Renal Transplants: A Prospective Observational Study Top


Vijay Joshi, Manju Aggarwal, Fayaz Ahmed, Vidyanand Jha

Department of Nephrology; Artemis Hospital; Gurugram; Haryana; India

BACKGROUND: Silent vascular insults in renal allografts; detected on radionuclide scans have been poorly studied. Tc-99 DMSA scan was undertaken to study the occurrence of silent vascular insults and correlate it with the presence of accessory artery. The effect of silent vascular insults on the serum creatinine was studied.

AIM OF THE STUDY: To study the incidence of silent vascular insults in renal transplants; as detected on DMSA scanning of the allograft kidney and correlate it with serum creatinine.

METHODS: We prospectively studied all living donor renal transplant recipients who underwent transplant between July 2016 and February 2018. They underwent Tc-99 DMSA scan on day 6 post-transplant. Serum creatinine in the post-transplant period were recorded at discharge and one month. The scans were studied for presence of photopenic defects and correlated to the presence of accessory artery in graft and its effect on renal function. Impact of other factors including ischemia time and graft dysfunction that could affect the occurrence of defects was studied.

RESULTS: Eighty-nine renal transplant recipients underwent DMSA scans of which 16 (18%) patients had defects. 10 of 89 patients (11.2 %) received a graft with accessory artery. 5 of the 16 cases with defects had accessory artery in graft kidney. There was a significant association of presence of accessory artery with the occurrence of DMSA defect with odds ratio of 6.18. The presence of defect on DMSA scan; correlated significantly to discharge creatinine. There was no difference of serum creatinine at 1 month among the two groups.

CONCLUSIONS: Silent vascular insults are common in renal transplant recipients. DMSA scan is a good diagnostic modality to detect such insults in the post-transplant period. Graft kidney accessory artery has significant association with vascular insults; but it did not affect the short-term graft outcome.


  60. Preoperative Blood Transfusion is Strong Determinant of Postoperative Graft Outcome in Renal Transplant-Role of Single Antigen Bead Assay Top


Rakesh Chauhan, Ashish Sharma, Deepesh B Kenwar, Sarbpreet Singh

Postgraduate Institute of Medical Education and Research; Chandigarh; India

BACKGROUND: Blood transfusion has a strong potential to induce sensitization. CKD patients with ESRD are at a risk of anaemia and need some measures to treat it. In the present era when other options like erythropoietin analogues are available blood transfusion should be avoided as it exposes the patients to allosensitization leading to graft rejection and loss or long waiting time in the list.

AIM OF THE STUDY: To study the role of pre-op blood transfusion on renal graft outcone.

METHODS: The authors have conducted a study in PGIMER Chandigarh in 46 patients between March 2018 to July 2018. ESRD patients on dialysis with the history of transfusion; who were potential candidates for transplantation; were worked up in the pre-op transplant OPD and were included in the study. Mean blood transfusion was 2.7 units/ patient. Those with history of previous transplantation or pregnancy were excluded from the study. Selected patients were cross matched with their live donors with CDC; FCXM and Single antigen bead assay (SAB). Any MFI >1000 on SAB with luminex method was taken as positive result as a predictor of sensitization. The patients were tested against HLA-A; HLA-B and HLA-DR loci. The patients underwent transplantation with standard immunosuppression with ATG induction if DSA was present; tacrolimus; mycophenolate and prednisolone. Postop graft biopsy was done if any time creatinine value increased by 15% on two respective occasions.

RESULTS: Out of 46 patients included in study 36 were males and 10 were females with mean age of 33.7 years. 37 of the donors were females in different relations; mothers being highest in number. 9 donors were males. 23 (50%) patients were of B blood group; 10 (21%) of AB; 9 (19%) of A and 4 (8%) of O group. 19 (41%) patients were pre-transplant SAB positive. Out of these 19 patients; 7 had antibodies against the HLA of the respective donors and 12 had antibodies against non donor HLA. There was rejection in 8 (17%) patients with positive SAB which is 42.1% of the SAB positive cases. Whereas in patients with negative SAB; only 2 (7.4%) had acute rejection. The mean creatinine of DSA positive patients was 1.3 mg% and 1.27 mg% at discharge and follow-up; whereas creatinine of DSA negative patients was 1.2 mg% and 1.05 mg% at discharge and 6 follow-up respectively. The mean creatinine of the DSA positive patients who had rejection was 1.5 mg% and 1.2 mg% at discharge and at follow-up.

CONCLUSIONS: This study proves that blood transfusion strongly exposes the kidney transplant patients to the allosensitization and rejection. Intensification of immunosuppression with avoidance of blood transfusion may improve the graft outcome.


  61. Clinico-Pathological Study of C3 Glomerulonephritis At A Tertiary Care Centre Top


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

Institute of Nephro Urology; Bengaluru; Karnataka; India

BACKGROUND: Complement dyregulation has become an important etiology for glomerular diseases. C3 glomerulonephritis has emerged as a new entity with heterogenous presentation.

AIM OF THE STUDY: To study the clinico-pathological profile of patients with C3 glomerulonephritis at a tertiary care centre.

METHODS: A prospective observational study of all cases of C3 glomerulonephritis was done between August 2016 and December 2017. C3 glomerulopathy was defined by predominant glomerular C3 fragment deposition defined as C3c intensity ≥2 orders of magnitude more than any other immune reactant on a scale of 0 to 3.

RESULTS: C3 glomerulonephritis was present in 32 cases (2.68%). The mean age was 35±2 years 56.25% males. 72% patients presented with RPGN. 56.25% had low serum C3 levels. Anti CFH antibodywas elevated in 2 patients (33.3%). On LM the dominant lesion was crescentic GN (43.75%). On IF; all patients had dominant C3 staining. EM study was done in two patients and was suggestive of DDD in one patient. All patients were managed with pulse steroids followed by oral steroids. IV Cyclophosphamide was used monthly for 6 doses in 14 patients (43.7%) while oral cyclophosphamide was used in 2 patients (6.25%). Plasmapharesis was done in patients with elevated anti CHF antibody and in patients with diffuse crescents (11 patients -34.37%). Also 11 patients required haemodialysis (34.37%) of which 4 have recovered completely and are in complete remission.

CONCLUSIONS: C3 glomerulonephritis has emerged as a new entity with most of our patients presenting with RPGN; One third of our patients required haemodialysis. Plasmapharesis was done in one third of patients. Patients with anti CFH antibody were successfully treated with IV cyclophosmamide.


  62. An Unusual Cause of Paraplegia in A Renal Transplant Recipient Top


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

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

BACKGROUND: Introduction: Post-transplant lymphoproliferative disorders (PTLD) are lymphoid or plasmacytic proliferations occuring in solid organ transplant recipients as a result of immunosuppression. Majority of these tumors are B cell lymphomas. There are very few case reports of T cell PTLD presenting as acute compressive myelopathy. Case report: A 35 year old woman who underwent living related renal transplant (LRRT); 7 years ago; presented with backpain and acute onset weakness of both lower limbs.

AIM OF THE STUDY: Her renal allograft had an angiomyolipoma which never increased in size nor affected the graft function. She was on triple immunosuppressant therapy (CSa/MMF/PDN) and had normal graft function.

METHODS: Her motor power was 0/5 in both lower limbs with hypotonia and absent reflexes. All modalities of sensation were lost below the inguinal region with no bladder or bowel involvement. MRI spine revealed an extraosseous soft tissue lesion extending into epidural space causing severe canal stenosis and cord compression at D12-L1 level. A similar soft tissue lesion was seen in D5 and L4 vertebrae level without spinal cord compression. CT guided biopsy of the lesion revealed diffuse sheets of intermediate sized lymphoid cells with irregular nucleus which were CD3 and CD4 positive and CD20 negative on immunohistochemistry (IHC) study. There was no dissemination of the disease in PET (Positron Emission Tomography) scan nor marrow involvement in bone marrow study. Her Ebstein Barr Virus (EBV) DNA serology was negative.

RESULTS: She was treated with reduction of immunosupressants; radiotherapy and chemotherapy (CHOP regimen). Repeat imaging revealed significant resolution of the lesion and her muscle power improved to 3/5 in both lower limbs. Discussion: Unique features in our case: The graft angiomyolipoma never increased in size nor affected the graft function during 7 years of follow up. T cell and EBV negative PTLD are quite rare. They generally present late similar to our case and are very virulent; but our patient is surviving for 8 months since the diagnosis of PTLD with stable graft function. Similarly; involvement of the spine is extremely unusual. To the best of our knowledge this is the first case report of T cell lymphoma presenting as extradural mass with cord compression in renal transplant recipients.

CONCLUSIONS: PTLD can present late; especially EBV negative T cell lymphomas and though spinal involvement is rare; PTLD should be considered in the differential diagnosis of acute compression myelopathy in renal transplant recipients.


  63. Urine B2 Microglobulin As A Marker of Persistent Tubular Injury in Patients with Acute Kidney Injury Due to Hemotoxic Snake Envenomation Top


Challa Jaswanth, P S Priyamvada

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

BACKGROUND: Snake envenomation is a common cause of acute kidney injury (AKI) in the tropics. The victims are often young individuals without the conventional risk factors or comorbidities. It is estimated that 25 to 40% of patients who sustain AKI following snake envenomation develop chronic kidney disease (CKD). There is only limited data on the utility of tubular injury markers to identify patients who are at risk for progression to CKD; following an episode of AKI.

AIM OF THE STUDY: To identify the utility of urinary beta 2 microglobulin as a marker of subclinical tubular damage following AKI from hemotoxic snakebite.

METHODS: All patients admitted to medical wards with AKI due to hemotoxic envenomation were screened. Hemotoxic envenomation was defined as the presence of whole blood clotting time > 20 minutes in patients who sustained a snake bite. AKI was defined as per KDIGO 2012 work group criteria. Patients with previous history of CKD were excluded. An ultrasound examination of abdomen to assess kidney size was performed. Patients with bipolar length of kidneys less than 9 cm; cysts; stones or any other structural abnormalities of kidneys were also excluded. A total of 42 patients who developed AKI following hemotoxic envenomation were followed up for a period of 6 months. Urine albumin excretion (UAE); estimated glomerular filtration rate (e GFR) using CKD-EPI 2009 equation and urine β 2 microglobulin levels (β2m) were measured at 15 days; 3 months and six months following discharge from the hospital. The statistical analysis was done with IBM SPSS Statistics; V 19.0 (IBM Corp: Armonk; NY).

RESULTS: At the end of six months follow up; 06 patients (14.28%) progressed to CKD (e GFR < 60 ml/UAE >30 mg/day). One patient did not recover from AKI and remained dialysis dependent. Among the remaining 41 patients with recovery of kidney function; the urine β2m levels were 1590 µg/L (IQR 425-5260); 610 µg/L (IQR 210-1850); 850 µg/L (IQR 270-2780) (P=0.020) at 2 weeks; 3 months and 6 months respectively. The levels of urinary β2m in the study population at the end of 6 months remained significantly higher compared to the levels in healthy control population (850 µg/L {IQR 270-2780} vs 210 µg/L {IQR 150-480}; p = 0.001). The proportion of patients with of patients with urine β2m levels exceeding the 95 th percentile of control population (> 644 mg/L) during the follow up visits were 70.7% (n=29); 48.7% (n=21) and 51.2% (n=22). The patients with urine β2m> 644 mg/L at 6 months had marginally lower GFR through out the follow up period.

CONCLUSIONS: Urinary β2m levels remained elevated in about half of the individuals who recover from snake bite related AKI. Urinary β2m can be used as a potential marker to monitor renal tubular recovery following an episode of AKI. Long term studies are required to correlate elevated β2m with development of CKD.


  64. Health Related Quality of Life Among Different Categories of Chronic Kidney Disease Patients Top


Himansu Sekhar Mahapatra, Lalit Pursunani, Himanshu Verma, B Muthukumar, D P Kushal, Anamika Kumari, Bibhash Dutta, Y P Gupta, V Sekhar

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

BACKGROUND: Health related Quality of Life (HRQoL) depends on physical; psychological and social aspects of life. Its measurement in CKD is important for evaluation of patient survival and to make public health policy. In India; it is not used in routine nephrology practice and benefit of its assessment is unknown.

AIM OF THE STUDY: To measure HRQoL among CKD stage IV and stage V not on Dialysis; Dialysis (both Hemo and Peritoneal) and renal transplant recipient patients.

METHODS: In a period of eight months’ quality of life of all Nephrology OPD patients (CKD stage IV and V not on dialysis; both Hemo and Peritoneal Dialysis and renal transplant recipient) were assessed by using standard SF-36 Performa diffusing to eight major subdomains of QoL. The data have been analyzed to obtain composite measures of physical health comprising measures of Physical Functioning; Role-Play; Bodily-Pain and General Health; Mental Health; comprising Vitality; Social functioning and Role-Emotional activity. These scores ranged between 21 and 73 for Physical Health and 15-76 for Mental Health. Further; ANOVA has been used to demonstrate if group-differences existed.

RESULTS: A total 1019 patients were analyzed. The median age was 46 years and 738 (72.4%) were males. There were 441 (43.3%) on Dialysis (415 Hemodialysis and 26 Peritoneal Dialysis); 374 (36.7%) on Stage 4 & stage 5 CKD but not on Dialysis; and 204 (20.0%) had their Renal Transplant. The composite scores in respect of all three categories were obtained. Physical health score of dialysis; not on dialysis and Renal Transplant patients were 42.9 ±10.33; 45.6 ± 10.33 and 56.1 ± 10.96 respectively. Mental health scores of dialysis; not on dialysis and Renal Transplant patients were 40.2±9.26; 43.62±8.98 and 53.0±10.46 respectively. Comparison of means among three categories; using ANOVA; revealed that the mean differences were statistically significant (p-value=0.000). Post Hoc comparisons revealed significant differences among all categories (p-value 0.000).

CONCLUSIONS: The quality of life as measured by SF-36 and interpreted indicated that though all the patients were in the upper half of the QoL scores. Renal Transplant scored higher values than those not on Dialysis but CKD stage IV and V not on dialysis have a higher score compared with those on Dialysis.


  65. Evolution of Multi- and Extremely-Drug Resistant Bacterial Infections in Patients with Renal Diseases Top


Ashutosh Pathak, Sushma Singh, Narayan Prasad, Kashi N Prasad

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

BACKGROUND: Infectious diseases are common cause of morbidity and the second cause of mortality among chronic kidney disease (CKD) patients. Antibiotic resistant bacterial infections are potentially life-threatening in renal transplant recipients. With increase in antibiotic resistance in bacteria; there are either limited or sometimes no options available for treatment; especially in renal transplant recipients who are often more vulnerable.

AIM OF THE STUDY: To screen the bacterial pathogens and their antimicrobial drug resistance profiling in patients suffering from renal diseases admitted in nephrology ward of a tertiary care referral hospital.

METHODS: A total of 100 urine samples from patients suffering from renal diseases admitted in the nephrology ward and kidney transplant unit of SGPGIMS were screened. The patients selected were suffering from chronic kidney disease; mostly diabetic nephropathy and some with incompatible renal transplantation. The bacterial cultures were isolated using the standard microbiological techniques. The antibiotic sensitivity screening was performed by disc diffusion method. The minimum inhibitory concentrations of antibiotics were determined by E-test strips.

RESULTS: Out of the total 100 urine samples that were screened; 20 (20%; 20/100) were culture positive. Out of these culture positive samples; 5 samples (25%; 5/20) were found to be infected with gram positive bacteria while 14 samples (70%; 14/20) with gram negative bacteria. One sample (5%; 1/20) had both gram positive and negative bacterial infection. Among the gram positive; Enterococcus sp. and coagulase-negative Staphylococcus were dominant while among the gram negative the dominant species were Enterobacter cloacae; Escherichia coli; Klebsiella pneumoniae; Providencia rettgeri; Morganella morganii and Pseudomonas aeruginosa. The antibiotic sensitivity screening revealed that all the above bacteria were multi-drug resistant. Variable resistance to polymyxins; carbapenems; cephalosporins and aminoglycosides were observed among Gram-negative bacterial isolates. Two isolates were pan-drug resistant; while one isolate was extremely-drug resistant.

CONCLUSIONS: The emergence of pan-drug and extremely drug resistant bacteria in patients suffering from renal diseases; especially the renal transplant recipients indicates towards a grim situation where no therapeutic options will be available for treatment of infections caused by deadly bacterial pathogens.


  66. Low Dose ATG (Single Dose of 1.5 Mg/Kg) Versus High Dose ATG (Three Doses of 1 mg/kg/day) As Induction Prophylaxis in Renal Transplant Patients: Does It Matter? Top


Abhinav Seth, Ashish Sharma, Sarbpreet Singh, Deepesh Benjamine Kenwar, Gaurav Shankar Pandey, Vidyasagar Kallepalli

Department of Renal Transplant; Postgraduate Institute of Medical Education and Research; Chandigarh; India

BACKGROUND: ATG is an infusion of horse or rabbit-derived antibodies which causes a significant depletion of CD3+; CD4+; CD8+ and natural killer cells leading to lower incidence of acute rejection. However; this is counterbalanced by increase in serious infections. Currently; induction prophylaxis with 3-7 mg/kg/day ATG is the recommended dose. However; many Indian centers use a single dose (1-1.5 mg/kg) because of fear of life threatening infections. The efficacy of this dose has never been studied.

AIM OF THE STUDY: To evaluate whether a low dose ATG regime of 1.5 mg/kg is as efficacious as the standard regime of 3 mg/kg in terms of occurrence of graft dysfunction and infections.

METHODS: This was a prospective randomized study in patients of renal transplant; divided into two groups: Group I: Induction prophylaxis with a single dose of 1.5 mg/kg ATG on day 0Group II: Induction prophylaxis with 3 doses of 1 mg/kg/day ATG on day 0; day 1; day 2. Patients with age > 18 years undergoing; living donor transplant with more than 3/6; HLA mismatch or deceased donor transplant were included. All patients underwent triple drug immunosuppression with tacrolimus; mycophenolate and prednisolone. Patients underwent protocol biopsy at 1 and 3 months post transplantation and when clinically indicated. Outcome was studied in terms of incidence of acute rejection; incidence of various infections; CD3+ counts; incidence of delayed graft function; biopsy findings and graft dysfunction between the two groups over a period of 6 months.

RESULTS: There were 21 patients in Group 1 and 25 patients in Group 2 with mean age of 39.10 ±8.71 and 41.48 ±8.94 years respectively. There was predominance of males in both groups ((M:F- 13:8 in Group I and 18:7 in Group II). 12/21 patients in Group I and 10/25 patients in Group II received a deceased donor kidney. The cause of end stage renal disease was unknown in majority of patients in both groups (76.19% and 72% respectively). The mean creatinine values for Group I and Group II at 1 month were 1.26 ±0.53 mg% and 1.33 ±0.37 mg% respectively and at 6 months were 1.21 ±0.41 mg% and 1.20 ±0.26 mg% respectively. Biopsy proven acute rejection was seen in 5 (23%) patients in Group I vs 4 (16%) patients in Group II. Serious life threatening infection was seen in 2 patients in Group I and in 1 patient in Group II. There was 1 death in Group I. The absolute CD3+ count in Group I measured on next day of ATG dose was 510. The CD3+ count in Group II measured on next day of last dose of ATG was 471

CONCLUSIONS: Three doses of ATG (1 mg/kg/day) results in a lesser incidence of acute rejection as compared to a single dose ATG (1.5 mg/kg) in preventing rejection with no increase in infectious complications.


  67. Evaluation of Risk Factors for Acute Kidney Injury Among Patients with Chikungunya: Experience from A Tertiary Care Hospital of A Developing Country Top


Muhammad A Rahim, Shahana Zaman, Wasim M M Haque, Sarwar Iqbal, Khwaja N Uddin

BIRDEM; Dhaka; Bangladesh

BACKGROUND: Chikungunya is one of the most rapidly spreading mosquito-borne viral infections of global concern including Bangladesh; where it is an emerging infection. Generally chikungunya is a self-limiting febrile illness; it may have protracted rheumatological courses and life-threating features including cardiomyopathy and encephalitis. Acute kidney injury (AKI) and nephritis are less well described complications of chikungunya.

AIM OF THE STUDY: This study was designed to evaluate the frequency of AKI among patients with chikungunya and to evaluate possible risk factors.

METHODS: This case-control study was done in a tertiary care hospital in Dhaka; Bangladesh from May to October 2017. Adult patients (>18 years) with confirmed diagnosis of chikungunya were included in this study. Patients were followed up clinically and by laboratory tests. AKI was diagnosed as per Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for Acute Kidney Injury. Patients suffering from chikungunya complicated by AKI were cases and those without AKI were controls. Age; presence of diabetes mellitus (DM); chronic kidney disease (CKD); gastrointestinal (GI) symptoms including diarrhea and/or vomiting; requirement of hospitalization; concomitant use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) and non-steroidal anti-inflammatory drugs (NSAIDs) were evaluated as possible risk factors for AKI.

RESULTS: Total patients were 107 with a mean age of 35.6 years. Common comorbidities were DM (22; 20.6%); hypertension (19; 17.8%) and CKD (13; 12.1%). Presentation included fever (93; 86.9%) or recent history of fever (14; 13.1%); joint pain (95; 88.8%); rash (25; 23.4%); pruritus (17; 15.9%); diarrhea and/or vomiting (30; 28%); lymphadenopathy (13; 12.1%); gum swelling/oral ulcer (5; 4.1%) and oedema (9; 8.4%). Fourteen (13.1%) patients required hospitalization. Eleven (10.3%) cases were complicated by AKI. Risk factors for AKI included increasing age (>55 years; OR 2.55; 95% CI 0.70-9.33; p 0.1550); presence of DM (OR 28.73; 95% CI 5.57-148.10; p 0.0001); CKD (OR 31.0; 95% CI 2.94-326.7; p <0.0001); diarrhea and/or vomiting (OR 16.07; 95% CI 3.22-80.14; p 0.0007); hospitalization (OR 23.10; 95% CI 2.37-226.31; p <0.0001); use of ACEIs/ARBs (OR 6.65; 95% CI 1.77-24.98; p 0.005) and NSAIDs (OR 2.88; 95% CI 0.52-16.04; p 0.2251).

CONCLUSIONS: One-tenth of adult patients suffering from chikungunya were complicated by AKI in this study. DM; CKD; diarrhea and/or vomiting; hospitalization and use of ACEIs/ARBs appeared as significant risk factors for AKI.


  68. Study on Oxidative Stress in Maintenance Haemodialysis Patients Top


K Sai Sundeep, Ch. Nageswara Rao, Bhaskar Beesetty, R Praveen, A Sam, Sireesha, P R Akhil, K Sai Harisha, V Rameshchandra, G Prasad

Department of Nephrology; Andhra Medical College; Visakhapatnam; Andhra Pradesh; India

BACKGROUND: Chronic kidney disease itself an inflammatory state and in haemodialysis the blood is in contact with artificial membranes which generates reactive oxygen species; so further predispose patients to oxidative stress. Apart from traditional risk factors; inflammation and oxidative stress are also risk factors for cardiovascular disease which accelerates the atherosclerotic process and increases cardiovascular morbidity and mortality.

AIM OF THE STUDY: To estimate the oxidative stress in maintenance haemodialysis patients by measuring the ferric reducing ability of plasma and its correlations with blood urea; serum creatinine and C-reactive protein.

METHODS: This is a case control prospective study done at a tertiary care centre in India during the period August 2015 to October 2016. Group 1 (G1) consists of 50 patients who are randomly selected from 113 patients who met the eligibility criteria out of 207 maintenance haemodialysis patients in our centre and 50 age; sex matched healthy subjects selected from our blood bank taken as control group (G2). The following blood parameters serum creatinine; blood urea; C-reactive protein (CRP); ferric reducing ability of plasma (FRAP) are estimated. Serum creatinine is estimated by jaffes method; blood urea by modified berthelot method; C-reactive protein by turbidimetric immunoassay mindray semi autoanalyzer and ferric reducing ability of plasma by ferric reducing ability of plasma assay. The correlation of FRAP with remaining parameters are calculated using Karls pearsons coefficient and chi square test applied for comparing means between 2 groups.

RESULTS: The mean ages and male to female ratios in group 1 and group 2 are 49.9±8.8 yrs; 48.86±6.8 yrs and 2.3:1; 2.1:1 respectively. The mean blood urea; serum creatinine; C-reactive protein in group 1 is 94.08±20.47 mg%; 7.27±2.21 mg%; 3.01±1.84 respectively. The mean ferric reducing ability of plasma (FRAP) in group 1 and group 2 are 633.9±145.1 µmol/L and 135.67±49.12 µmol/L. Ferric reducing ability of plasma (FRAP) is correlated well with urea (r=0.81; p<0.001); serum creatinine (r= 0.765; p<0.001) in group 1 and it is negatively correlated with urea (r= -0.063; p=0.663) in control group (G2).

CONCLUSIONS: Oxidative stress is high in haemodialysis patients and correlated well with urea compared to healthy subjects which has a negative correlation.


  69. Retrospective Analyses of Acute Obstructive Uropathy with Special Reference to Clinical Profile; Prognosis and Outcomes in Acute Pyelonephritis with Renal Papillary Necrosis Top


Prakash Prabhu, G K Prakash

Manipal Hospitals; Bengaluru; Karnataka; India

BACKGROUND: UTI are more common; more severe; and carry worse outcomes in patients with diabetes. CT KUB is sensitve in diagnosing pyelonephritis and any anatomical abnormalities of urinary tract. Acute pyelonephritis is the most common cause for renal papillary necrosis which can cause obstructive uropathy; and if undiagnosed can lead to poor renal and patient outcomes.

AIM OF THE STUDY: To study the presentation of the illness; course in the hospital and outcomes of patients who were diagnosed as acute pyelonephritis with renal papillary necrosis during the year 2017.

METHODS: Study Design: Retrospective study. Study place: Manipal Hospital. The list of all patients who underwent DJ stenting from Jan- Dec 2017 were obtained from the OT records. The etiology and final diagnosis of obstructive uropathy was obtained from the medical records. The data of patients who were diagnosed with Acute pyelonephritis with renal papillary necrosis was analysed in detail. The various ways of presentation of the illness; underlying comorbidities and past history was noted. Course in the hospital; the investigations including radiological imagings were recorded. Finally; the treatment received by the patient including the ICU stay; ventilator support; dialysis; renal outcomes and patient outcomes at discharge were documented and analysed.

RESULTS: 118 underwent DJ stenting. Most common cause was uretric calculus (88). 15 had acute pyelonephritis and renal papillary necrosis. On analyses: 11 had fever with pain abdomen. 2 were in altered sensorium. Diabetes+.7 CKD -3 diabetic nephropathy plus BPH & 4 solitary kidney. 6 had past history of UTI. Course in hospital: 7 had AKI; 7 had AKI on CKD; and 1 had normal creatinine. 10 had culture positive (blood/urine/both) E. Coli-most common.1 had Brucella IgM positive. Pyelonephritis was diagnosed in 7 by USG; all 15 had CT evidence (8-RPN; 1-emphysematous pyelonephritis). 9 were critically ill; 4 required ventilation and dialysis. URS revealed RPN in all.5 out of 12 patients with unilateral RPN on CT; underwent bilateral stenting (purulent urine from both ureters). Outcome- 7 had partial recovery & 4 had complete recovery of renal functions with conservative management. All patients who had CKD; had further worsening of renal functions. 3 died and 1 had partial recovery of renal function despite RRT.

CONCLUSIONS: Keep a high index of suspicion in diagnosing pyelonephritis in diabetics as it has poor prognosis. CT-KUB- investigation of choice; is sensitive in diagnosing RPN. Worsening of sepsis and renal functions despite conservative management; warrants URS and DJ stenting as RPN may be diagnosed on table.


  70. Assessment of Adequacy of Peritoneal Dialysis Dose at A Tertiary Care Hospital from South India Top


Ramchander Thorrem, G Swarnalatha

Department of Nephrology; NIMS; Hyderabad; Telangana; India

BACKGROUND: Adequacy of peritoneal dialysis improves patient survival; quality of life and biochemical outcomes and minimizes disease complications and hospitalizations.

AIM OF THE STUDY: To study the adequacy of peritoneal dialysis and to correlate with clinical and biochemical parameters of patients.

METHODS: This study was an observational cross-sectional study that was conducted in April; 2018. Baseline characteristics of all patients are noted and assessed the adequacy of peritoneal dialysis by measuring the weekly Kt/v. According to ISPD Guidelines (2006); the total (renal + peritoneal) Kt/v urea should not be < 1.7 at any time.

RESULTS: Of the 24 patients; 17 (70.83%) were males. The mean age of the patients was 59.9 years. The mean body mass index (BMI); mean weekly Kt/v; mean haemoglobin (Hb); mean total serum proteins (TSP); mean serum albumin (SA); mean systolic boold pressure and mean diastolic blood pressure were 23.4 kg/m²; 1.51; 10.6 gm/dl; 6.31; 3.02; 151.2 mm of Hg and 85.5 mm of Hg. For average weekly Kt/v; there was no significant difference between men and women (1.6 versus 1.3). Only 7 (29.16%) patients achieved the Kt/V goal. Fifty percent of patients with Kt/v of more than or equal to 1.7 have peritoneal membrane of high transporter activity. Patients with residual urine volume (RUV) of less than 100 ml/day and more than 100 ml/day have Kt/v of 1.2 and 1.5 respectively and those with RRV of more 100 ml per day with adequate Kt/v have mean haemoglobin; mean total serum proteins; serum albumin and mean HDL are 10.7 gm/dl; 6.5; 3.2 and 100 respectively and these variables are well maintained than inadequately dialysed patients.

CONCLUSIONS: Around 30% of patients were adequately dialyzed. It is very important to calculate Kt/v periodically; preserve RUV and individualize the dialysis doses for each patient and attempts to achieve the desired goals are necessary.


  71. Short-Dwell Daily Ethanol-Lock Therapy in Management of Hemodialysis Tunneled Cuffed Catheter Related Blood Stream Infection Top


Jigar Patel, Sishir Gang, Mohan Rajapurkar, Umapati Hegde, Abhijit Konnur, Hardik Patel

Department of Nephrology; Muljibhai Patel Urological Hospital; Nadiad; Gujarat; India

BACKGROUND: The standard therapy of hemodialysis catheter related blood-stream infection (CRBSI) involves systemic antibiotics with catheter replacement/ removal. As majority of CRBSI are often associayed with development of biofilm; antibiotics alone is rarely effective therapy for catheter salvage. Hence eradication of biofilm using Antimicrobial locking solutions is a promising modality for CRBSI treatment; hence catheter salvage.

AIM OF THE STUDY: To evaluate efficacy and safety of short-dwell daily Ethanol-lock therapy (ELT) in combination with systemic antibiotics for management of CRBSI associated with hemodialysis TCC.

METHODS: We enrolled 56 patients with suspected TCC related bacteremia and treated with 70% ELT for 1 hour daily for 5 days along with broad-spectrum systemic antibiotics which were changed according to blood culture reports. 17 patients with CRBSI who didn’t consent for ELT were treated with antibiotics alone. Effect of ELT was evaluated as clinical cure (fever resolution and negative surveillance cultures); infection-free TCC survival duration and adverse event of ELT among patients with CRBSI. The parameters were compared with 17 patients treated with antibiotics alone.

RESULTS: Ethanol-lock therapy was successful in 50 out of 56 patients (89.28%). Among 17 patients with CRBSI who were treated with antibiotics alone; only 7 patients (41.17%) responded (p <0.001). Mean TCC survival was also significantly higher with Ethanol-Lock therapy combined with systemic antibiotics (126.23±18.67 days) compared to antibiotics alone (38.76±9.91) (p = 0.006). No systemic adverse effects were noted with ELT; 2 patients receiving ELT had catheter breakage during study period.

CONCLUSIONS: We conclude that short-dwell daily Ethanol-lock therapy with systemic antibiotics is effective therapy for CRBSI in hemodialysis patients with TCC.


  72. Rose Gardener's Disease (Sporotrichosis)- Rare Fungal Infection Post Renal Transplant Top


Amandeep Singh, Vikas Makkar, Suman Sethi, P M Sohal, Simran Kaur

Dayanand Medical College; Ludhiana; Punjab; India

BACKGROUND: Fungal infections; including candidiasis; cryptococcosis and aspergil- losis; occur in 9% to 14% of patients following a renal transplant and vary according to geographic areas. Sporotrichosis; also known as rose gardener's disease is rare in renal transplant recipients. We report a case of renal transplant recipient presenting with sporotrichosis.

AIM OF THE STUDY: To report case of rare fungal infection post renal transplant – Sporotrichosis.

METHODS: Patient; 40 years male recieved renal allograft from his wife in March 2017. After about one year he presented with skin lesions below his left knee in form of violaceous papules coelescing to form plaques since one month. His skin biopsy was done which revealed spirotrichosis.

RESULTS: He was treated with itraconazole for 6 weeks and responed to treatment.

CONCLUSIONS: Fungal infections including candidiasis; cryptococcosis and aspergillosis are common in post renal transplant patients. Spirotrichosis is rare and easily treatable entity which should be considered in differential diagnosis of fungal infections in transplant patients.


  73. Death Censored Kidney Outcomes in Communityacquired Acute Kidney Injury vs Hospital Acquiredacute Kidney Injury Top


Sam Athota, Praveen, Sireesha, Akhil, Sndeep, Harisha, Ramesh Chandra, G Prasad

Department of Nephrology; Andhra Medical College; Visakhapatnam; Andhra Pradesh; India

BACKGROUND: Acute Kidney Injury (AKI) is estimated to occur in up to 15% of hospitalized patients and up to 60% of critically ill patients. In developing countries AKI is commonly caused by community-acquired diseases in contrast developed countries it occurs in ICU of Hospitals. Very few studies have described the risk factors and outcomes for patients developing AKI during hospitalization compared to AKI that has developed in the community.

AIM OF THE STUDY: To study death censored kidney outcomes and the clinical characteristics associated with the Community acquired Acute Kidney Injury in comparison with Hospital acquired Acute Kidney Injury.

METHODS: A Prospective; Observational study was carried out in the department of Nephrology; KGH; Visakhapatnam. The study was conducted from January 2016 to April 2017 and those with AKI (HAAKI and CAAKI) were followed up for period of 3 months. Patients who fulfilled KDIGO criteria for AKI (community and hospital) and those with age ≥18 years were included in the study. Patients; who died; lost to follow up and those having pregnancy with AKI were excluded from the study.

RESULTS: The mean age in the Hospital acquired acute kidney injury (HAAKI) group was 43.82 ± 11.53 years and in the Community acquired acute kidney injury (CAAKI) group was 42.17± 13.08 years. Majority i.e.; 53 (66.25%) cases were males and 27 (33.75%) cases were females. In HAAKI; males constituted 62.5% and in CAAKI it was 70%. Presence of Hypertension; DM; usage of NSAIDs; malaria; diarrhoea; usage of ACEI/ARB; doubling of S.Cr and ESRD were more common in CAAKI than compared to HAAKI. But this difference was not found to be statistically significant except for diarrhoea. Higher serum creatinine values were observed in CAAKI group than compared to HAAKI group at baseline and during admission and it was found to be statistically significant. Doubling of the serum creatinine values were more in CAAKI group than compared to HAAKI group and it was also found to be statistically significant.

CONCLUSIONS: Higher serum creatinine values at admission; baseline and more doubling of serum creatinine values more End Stage Renal Disease was observed in CAAKI than HAAKI.


  74. Comparison of Inflammatory Markers in Culture Positive Versus Culture Negative CAPD Peritonitis Top


Rohan Dwivedi, B N R Ramesh, Sree Bhushan Raju, G Anvesh, D Krishna Prasad, N Vamsi Krishna

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

BACKGROUND: Peritonitis is the most important complication leading to increased morbidity and technique dropout in a peritoneal dialysis (PD) program. Despite efforts to improve methods for culturing dialysate; culture-negative peritonitis; is seen in significant proportion of patients. Monitoring of systemic inflammation provides valuable insights for clinical management of PD-related peritonitis; it is thus of importance to identify inflammatory markers in PD-related peritonitis patients.

AIM OF THE STUDY: To study association of inflammatory markers with culture positivity in CAPD patients.

METHODS: A retrospective study in which total 100 patient were included During August 20 - August 2017 at Department of Nephrology NIMS Hyderabad. Diagnosis of peritonitis was made according to the guidelines of International Society for Peritoneal Dialysis. Blood samples were collected before administration of antibiotics and two weeks after antibiotic treatment. Levels of total WBC count; effluent WBC count; serum procalcitonin; Hs-CRP; Ferritin and serum albumin were measured according to standard protocol.

RESULTS: Total 50 patient had PD related peritonitis of which 22 patients (44% of PD peritonitis patients) had growth in the PD effluent cultures; 28 patients (56% of PD peritonitis patients) had no growth. The most common age group among PD peritonitis patients was 46 to 60 years. At baseline There was no significant difference in the mean serum procalcitonin level between culture positive patients (6.77±5.26 ng/mL) and culture negative patients (5.53±4.8 ng/mL) with a p value of 0.580. however; there was significant difference in the mean Hs-CRP and ferritin level between culture positive patients and culture negative patients with a p value of 0.01 and 0.04 respectively. serum procalcitonin levels were significantly higher in patients who required catheter removal (9.44±6.36) compared to those who did not require catheter removal (5.34±4.35) with a p value of <0.05.

CONCLUSIONS: In present study serum HSCRP and ferritin level was significantly high in culture positive peritonitis. Although serum procalcitonin is known to be significantly raised in sepsis but the present study had showed no difference between the two group.


  75. Pseudo Aneurysm of Thyrocervical Branch from Subclavian Artery – A Rare Complication of Internal Jugular Vein Catheterisation Top


Muzamil Latief, Mnajusha Yadla

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

BACKGROUND: Pseudoaneurysm occur usually following angiographic procedures; canulations and trauma. The commonest site of such Pseudoanerysms is Femoral. The rare sites of occurrence of Pseudoanerysm following Cental Venous cannulation include vertebral artery; subclavian artery; thyrocervical trunk; transverse cervical; inferior thyroid artery.

AIM OF THE STUDY: To highlight the complications of blind Central Venous Craterization done.

METHODS: A 50 year old male patient Hypertensive since 5 years; non diabetic; diagnosed CKD 1 year back elsewhere and was initiated on HD by placing right internal jugular vein double lumen catheter. After 3 sessions of hemodialysis; got the catheter removed; left hospital against medical advice. Now one year later patient presented to us with complaints of painless diffuse swelling over the right lower lateral part of the neck. Local examination of neck revealed a diffuse swelling of approximately 6 × 6 cms in the right lower lateral part of the neck Other evaluation revealed raised renal parameters and patient was initiated on hemodialysis through left femoral double lumen catheterization. Doppler and C T Angiography of neck vessels revealed large pseudo aneurysm partially filled with thrombus arising from a branch of thyrocervical trunk of right subclavian artery. Patient was not ready for further management.

RESULTS: Patient was found to have developed pseudoaneurysm of thyrocervical branch of Subclavian artery with thrombus and was advised further management to which he did not agree.

CONCLUSIONS: It should be noted that rare complications develop during CVC placement with or without ultrasonographic guidance.


  76. Infectious Complications After Rituximab Therapy in Kidney Transplant Recipients Top


Prashant Rajput, Pavan Deore, Zaheer Virani, Hepal Vora, Hitesh Gulhane, Ishan Pariekh, Bharat Shah

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

BACKGROUND: Off-label use of rituximab is increasing in kidney transplantation. We reviewed the occurrence of infectious complications and its outcome after rituximab therapy.

AIM OF THE STUDY: To compare the infectious complications in kidney transplant recipients who received rituximab and those who didn’t.

METHODS: We included all patients who underwent kidney transplant between Feb 2012 and June 2018 who received rituximab (200-500 mg; 1 or 2 divided doses) as an induction agent. We reviewed the occurrence of infectious complications and its outcome in those who received rituximab and compared with a control group who didn’t receive rituximab.

RESULTS: The study included 351 patients between Jan’12 to Jun’18; 140 (39.8%) were in rituximab group and 211 (60.2%) in control group who didn’t receive rituximab. The median follow-up was 37.4 months for rituximab group and 28 months for control group. The incidence of infections was significantly higher in rituximab group (78.5% vs 40.9%; p=0.00005). The incidence of bacterial infection (p=0.004) and tuberculosis (p=0.048) were significantly high in rituximab group. Eighteen out of 140 patients (12.8%) died in rituximab group; of which 10 deaths (7.1%) were due to an infectious cause; compared to 4.7% in the control group (p=0.005). The independent predictive factors for infection induced death were the combined use of rituximab and antithymocyte-globulin; diabetes mellitus; age>60 years and bacterial and fungal infections.

CONCLUSIONS: Use of rituximab is associated with a higher risk of infectious complications and death in kidney transplant recipients.


  77. To Study The Safety and Efficacy of Dalteparin in Patients with Chronic Kidney Disease Stage 3B; Stage 4 and Stage 5 Predialysis Top


Mohammed Moinuddin Nawazi, Ram Mohan Sripad Bhat

Narayana Hrudayalaya Institute of Medical Sciences; Bengaluru; Karnataka; India

BACKGROUND: Low-molecular-weight heparins (LMWH) have better bioavailability and a more predictable anticoagulant effect than unfractionated heparin in patients with normal renal function. We intend to analyze the pharmacokinetic data of Dalteparin; the LMWH commonly used for VTE (Venous Thromboembolism) prophylaxis at our center; for up to 3 weeks in patients with various degrees of renal impairment and compare it within different stages of renal failure.

AIM OF THE STUDY: To evaluate safety and efficacy of Dalteparin for up to 3 weeks in patients with CKD stage 3B; stage 4 and stage 5 pre dialysis and to asses for bio-accumulation of Dalteparin with time.

METHODS: We performed a prospective clinical observational study in 31 patients with advanced renal failure in stages of CKD 3B; stage 4 and stage 5. All patients received subcutaneous Dalteparin for prophylactic and therapeutic indications. Anti-Xa measurement was done 4 h after the third dose. This is the ideal time for an assay; as opposed to the trough; since it provides the best reflection of the pharmacokinetic exposure to low molecular weight heparins. Follow up measurements was made every third day for up to three weeks where possible.

RESULTS: We studied 31 patients with CKD stage 3B/4/5 not requiring dialysis. No significant bleeding was noted during followup for 6 days after the last dose. Only 3 patients (9.7%) were in stage 3B CKD; 15 patients (48.4%) were stage 4 CKD and 13 patients (41.9%) were in stage 5 CKD who were not requiring dialysis. 23 patients (74.2%) had their anti Xa levels in prescribed therapeutic range. 5 patients (16.1%) had their anti Xa levels in subtherapeutic range. Second Anti Xa levels done on day 6 of dalteparin in 5 pts did not show significant bioaccumulation. 1 patient with a third Anti Xa level done on day 9; with no significant bioaccumulation. Supra-therapeutic levels of anti Xa was seen in only 3 patients (9.7%) and all three patients were in medical management group and all of them belong to stage 4 CKD; however none of them had any significant bleeding. Incidence of patients with subtherapeutic Anti X a level was slightly higher as compared to those who had supratherapeutic anti Xa levels.

CONCLUSIONS: LMWH's were found to be safe in our study without significant bioaccumulation even in advanced renal failure. There was no significant correlation between adjusted anti-Xa levels and GFR in our population. Most of our study population achieved therapeutic levels of anti Xa levels by day 3.


  78. Crescentic Glomerulonephritis Associated with Polycythemia Vera: A Rare Occurrence Top


Rohan Dwivedi, D Krishna Prasad, Sree Bhushan Raju

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

BACKGROUND: Polycythemia vera is chronic myeloproliferative disorder characterized byaccumalation of phenotypically normal red cells; granulocytes and platelet. Glomerular crescents are dramatic lesion and more than often associated with severe and devastating clinical presentation in the form of Rapidly progressive Glomerulonephritis. However; its association with PV has rarely been described. We report here a rare case of Pauci-immune crescentic Glomerulonephritis in a patient of Polycythemia vera.

AIM OF THE STUDY: To report a rare case of crescentic GN associated with Polycythemia vera,

METHODS: A 50-year-old female presented with complaints of Anorexia and Abdominal fullness for 4 months. She has 3-4 episodes of bleeding from gums during this period for which she was evaluated at primary health care facility and found to have splenomegaly; polycythemia; and deranged renal parameters. She was referred to this hospital.

RESULTS: Her Peripheral smear and BM bx were s/o polycythemia vera with secondary Myelofibrosis which was further confirmed by positive JAK2 V617F mutation. She underwent renal Bx which revealed Pauci-immune crescentic glomerulonephritis although her Autoimmune work up including Anti-GBM abs; ANA; Anti-dsDNA; ANCA were negative. During further course of hospitalization her clinical condition and renal parameters worsened; she developed Pulmonary hemorrhage. Despite IV Methyle prednisolone; IV Cyclophosphamide; plasmapheresis and ventilatory support she succumbed to her illness.

CONCLUSIONS: The present study reports a rare occurrence of crescentic glomerulonephritis in Polycythemia vera. Although variety of pathological renal disease has been described; crescentic glomerulonephritis should always be considered as deferential diagnosis in Polycythemia vera.


  79. A Study Comparing Arteriovenous Fistula and Arteriovenous Grafts; Its Patency Rates; Survival and Outcomes Among Hemodialysis Patients in A Tertiary Centre in South India Top


A Srivatsa, E Indhumathi, M Jayakumar

Department of Nephrology; Sri Ramachandra Medical College and Research Institute; Chennai; Tamil Nadu; India

BACKGROUND: Among vascular access (VA) in hemodialysis (HD) patients; Arteriovenous fistula (AVF) is considered superior to Arteriovenous grafts (AVG) and AVG are preferred in elderly owing to the poor vessel quality and limited life expectency.

AIM OF THE STUDY: To compare the patencies; failures and salvageability of Vascular access among AVF vs AVG and to study the factors that may influence its survival.

METHODS: Vascular accesses (VA) of randomly selected 95 Hemodialysis patients from a tertiary centre in South India where about 300 patients undergo maintenance HD over the last 5 years were analysed. Baseline characteristics of the AVF and the AVG groups were tabulated. Patencies were compared between the two groups using Kaplan Meier survival curves and Log Rank tests. Hazard Ratios (HR) for fistula failure relative to grafts and 95% confidence interval (C.I) were analysed. VA thrombosis; salvageability; infections and mortality among the two groups were compared. Diabetes Mellitus (DM); coronary artery disease (CAD); Left ventricular dysfunction (LVD) were studied for their effect on the survivability of VA. Cox regression analysis among the entire population was charted and analysed.

RESULTS: There were 63 (66.3%) AVF and 32 (33.7%) AVG. The mean age was 57.1 years for AVF (47.6% males) and 57.2 years for AVG (37.5% males) with majority being <65 years (78.1% in AVG vs 81% in AVF). The primary survival were longer for AVF than AVG (40.2 vs 25.1 months) [HR-3.85; 95% CI: 1.696-8.752;p=0.001]. The total cumulative patency after intervention did not show significant difference between AVF & AVG (23.2 vs 28.5 months) [HR-1.508; 95% CI:0.8- 2.6;p=0.152]. VA thrombosis was more in AVG than AVF (59.4% vs 28.6%; p=0.007); hence requiring more interventions (40.6% vs 12.7%; p=0.003) of which AVG interventions were more salvageable (34.4% vs 11.1%; p=0.01). VA infections was seen only in AVG in our study (15.6% vs Nil; p=0.003). AVG group had more mortality compared to AVF (18.8% vs 4.8%; p=0.05). No significant difference were noted among the two groups with respect to VA survival among DM; CAD; or elderly (65 yr & more) subgroups. In entire population; Male (HR-3.7; p=0.03) and CAD (HR-5.7; p=0.026) had more thrombosis.

CONCLUSIONS: AVF had longer primary patency; less thrombosis; however; AVG required more interventions with better salvageability. But after interventions; the cumulative patency didn’t differ much between the two groups. More infection & mortality were seen in AVG. In overall population; males & CAD had more VA failures.


  80. To Assess The Treatment and Outcome of HCV Infection Treated with Direct Antiviral Agents Prior to Renal Transplantation Top


Manoj Gupta, Pratik Das, Deepak Shankar Ray

Rabindranath Tagore International Institute of Cardiac Sciences; Kolkata; West Bengal; India

BACKGROUND: Hepatitis C virus (HCV) infection is a major health problem in worldwide in patient undergoing renal transplant.persons with chronic HCV infection who are renal transplantation candidates should receive treatment of HCV prior to renal transplantation.

AIM OF THE STUDY: To assess the treatment and outcome of HCV infection treated direct antiviral agents prior to renal transplantation.

METHODS: This was a retrospective real-life study conducted among HCV Infected ESRD patients on haemodialysis awaiting renal transplant. Patients aged more than 18 years with HCV and CRF undergoing hemodialysis and being treated with sofosbuvir 400 mg in combination with daclatasvir 60 mg (Group A) or ledipasvir 90 mg (Group B) were included in the study. Viral load and genotyping were done before treatment and HCV RNA was assessed at 4 weeks and at 12 weeks. After 12 weeks of treatment patients underwent renal tranplantion and HCV RNA was re assesed at 1 month and 3 month post transplantation.

RESULTS: A total of 58 patients were enrolled in the study and 49 (Group A; n=32; Group B; n=17) were eligible for final analysis. The baseline viral load was 2; 619; 203 IU/L and 1; 525; 943 IU/L for Group A and B; respectively. The most common genotype in Group A and B were 3 (n=29) and 1 (n=16); respectively. At week 4; 29 (90.6%) patients from Group A and all 17 (100%) patients from Group B had sustained viral response (SVR). At week 4 two patients were positive. One patient who did not visit at week 4 was found positive at week 8. At week 12; 29 patients from Group A; who completed the visit; were negative (including three patients who were positive at week 4 or 8); however; 14 patients from Group B completed the visit and found negative. AT 1 month and 3 months post transplantation HCV RNA was found to be negative in all.

CONCLUSIONS: Results showed that pre transplantation treatment of HCV infection with sofosbuvir in combination with daclatasvir or ledipasvir is safe; simple and effective.


  81. To Compare Graft Outcome and Survival Rates of Renal Transplant Patients Who Receive Induction Therapy with Those Who Do Not Receive Induction Therapy Top


Irfan Ahmad, Sanjiv Saxena, Ravi Bansal

Pushpawati Singhania Research Institute; New Delhi; India

BACKGROUND: Renal transplantation is the treatment of choice for patients with ESRD. Short term outcome of renal transplant have dramatically improved over the past decades; in large part due to improvement in immunosuppression and medical care. Choice of induction agent varies from country to country; center to center and patient to patient. ATG and basiliximab are the most commonly used induction agent. Use of induction agent is now routine but benefit should be balanced against it's risk.

AIM OF THE STUDY: To compare graft outcome and survival rates of renal transplant patients who receive induction therapy with those who do not receive induction therapy.

METHODS: This was a retrospective observational study. We included 200 renal transplant recipients; 100 in induction and 100 in non induction group. Induction therapy was given to comparatively high immunological risk patients. All data and lab reports were collected from medical records and OPD visit records from time of transplant until 24 months post transplant. All patients were maintained on triple immunosuppression. Transplant outcome were calculated as number of clinically suspected or biopsy proven rejection; serum creatinine; clinically significant infection; graft and patient survival at 1; 6; 12 and 24 months after transplant. Treatment response and efficacy of drugs were noted. Statistical analysis were performed using SPSS software.

RESULTS: Mean age of recipients in non induction and induction group was 36.14 and 41.93 years respectively. Male to female ratio was 3.65:1. Mean duration on hemodialysis was 6.6 months in both group. Chronic tubulointerstitial nephritis was the most common cause of CKD followed by Diabetes and CGN. Incidence of acute graft rejection at 3 months was 9% overall; 13% in non induction and 5% in induction group which was statistically significant (P value-0.048). Biopsy proven acute rejection occurred in 9% in non induction and 3% in induction group. Incidence of late graft rejection (between 3 months to 2 years) was 8% overall; 10% in non induction and 6% in induction group which was statistically non significant. Incidence of UTI; respiratory tract infection; CMV and BKV were higher in induction group but it was statistically not significant. Difference in Sr Cr was significant at 1 month. Graft outcome and patient survival at 2 years were comparable between non induction and induction group.

CONCLUSIONS: Although induction therapy prevented episodes of acute graft rejection at 3 months; this benefit was not seen on long term follow up. Graft and patient survival rate at 2 years was comparable in non induction and induction groups. So induction therapy may be avoided in low risk patients.


  82. Acute Kidney Injury After Liver Transplant: Incidence; Risk Factors and Clinical Outcome Top


Hitesh Harish Gulhane, Zaheer Amin Virani, Prashant Rajput, Vaishali Salao, Pawan Deore, Hepal Vora, Bharat Shah

Global Hospital; Mumbai; Maharashtra; India

BACKGROUND: Acute kidney injury (AKI) is a common postoperative complication after liver transplantation (LT). Post-LT AKI is multifactorial in origin.

AIM OF THE STUDY: To assess incidence; risk factors; and outcome of AKI after liver transplant (LT).

METHODS: This is a retrospective study; which included all post LT patients between Mar’15 and Jan’18. Patients with pre-transplant AKI and CKD were excluded. Patients were divided in two groups; Group I with AKI [as per KDIGO definition] and Group II without AKI. Demographic profile; presentation of liver failure; co-morbidities; complications; graft dysfunction; hospital stay and 30 days mortality were compared.

RESULTS: Out of 154 studied patients; 92 developed AKI. Aetiology of liver failure undergoing liver transplant were Acute liver failure (ALF) (14 out of 30) and Chronic liver disease (78 out of 124). Intra operative blood transfusion and high Tacrolimus trough level post transplant were significantly associated with AKI. Notably; age of patients; preoperative Meld Score; comorbiditiesand preoperative serum creatinine was not associated a significant predisposing factor for AKI. Patients with AKI had prolonged ICU; hospital stay (p<0.05); and 30 days mortality as compared to non-AKI group (4% vs. 3%).

CONCLUSIONS: AKI is an important complication after LT and has a high incidence. AKI post LT was associated with prolonged hospital stay; however majority of patients recovered from AKI post liver transplant.


  83. Home Visit by A Nephrologist: A Promising Step to Abate Peritonitis in Peritoneal Dialysis Patients Top


Naveen Kumar Koppara, R Ram

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

BACKGROUND: End-stage renal disease leading to renal replacement therapies imposes strict regulations on the lifestyle of our patients. Peritoneal dialysis (PD) is a treatment option that enables patients to perform dialysis in their own homes without being separated from social life. Peritonitis is common complication during PD therapy. Home visits and education may improve patient compliance with dietary restrictions and maintains good hygiene technique which will lead to decreased rates of peritonitis.

AIM OF THE STUDY: To decrease the peritonitis rate in peritoneal dialysis patients. To asses the knowledge of patients on peritoneal dialysis.

METHODS: In this prospective observational cohort study; all incident PD patients from May 1; 2018; to May 31; 2018; were recruited and followed up until august 31; 2018. According to home visits; patients were divided into two groups. During the visits; a training assessment form comprising 31 questions based on the routine PD education of our unit organized in 8 groups (nutrition; constipation; exchange room; peritonitis; infections; medications; personal hygiene; and dialysis materials) was filled in based on answers supplied by the patients. And education about nutrition and retraining of PD procedure done according to requirement. patients followed up to 3 months. Baseline demographic; clinical; and laboratory data; as well as episodes of peritonitis; were collected.

RESULTS: Of 132 patients on PD; 17 (12%) developed 1 episode of peritonitis in 3 months. 2 episodes developed in home visit group and 15 episodes in another group. According to chi-square analysis showed that patient peritonitis rate showed significant difference between the 2 groups during the long-term follow-up (p ≤ 0.05).

CONCLUSIONS: Home visits by a nephrologist; with regular training and education of patient and relatives had significant role in peritoneal dialysis patients.


  84. Epidemiology of Glomerular Disorders in Elderly Population at Tertiary Hospital Top


Praveen Revu, Ranga Rao, Sireesha, Akhil, Sundeep, Harisha, Sam Rao, Ramesh Chandra, G Prasad

Department of Nephrology; Andhra Medical College; Visakhapatnam; Andhra Pradesh; India

BACKGROUND: Renal disease related to infection; urinary tract obstruction; atherosclerosis and malignancy are becoming increasingly common with ageing. One of the most common forms of renal diseases is glomerular disease (GD) and can have many different clinical presentations. Certain types of GD may have different incidence; clinical presentation and prognosis among the elderly in comparison with younger adults.

AIM OF THE STUDY: To study the prevalence; clinical characteristics and outcomes of glomerular disorders in elderly population.

METHODS: A Prospective; Observational study was conducted in the department of Nephrology; King George Hospital; Visakhapatnam. All elderly patients (age >60 years) who attended from March 2016 to November 2017; who fulfilled standard clinical criteria (edema; Hematuria; proteinuria) for evidence of glomerular disease were studied.20 patients with biopsy proven glomerular disorders were included in the study. Analysis of Variance (ANOVA) test is used for the difference in the mean laboratory values whether significant or not.

RESULTS: In the present study majority of the cases (15/20) were in the age group of 60 to 69 years. Male to female ratio 3:1. Nephritic syndrome cases were 5 (25%) (c1q nephropathy- 1; diffuse proliferative glomerulonephritis- 2; Ig A nephropathy- 1; Membrano proliferative glomerulonephritis-1); rapidly progressive glomerulonephritis patients were 3 (15%)(Anti GBM disease-1; Pauci Immune Crescentic GN- 2) and nephrotic syndrome patients constituted the majority that is 12 (60%). (Idiopathic membranous Nephropathy-5; diffuseproliferativeglomerulonephritis- 1; Amyloidosis (multiple myeloma related)- 2; FSGS-2; Minimal Change Disease - 2). Membranous nephropathy is major biopsy finding (25%). Next common finding is DPGN (15%) Primary GN in 10 patients and secondary GN in 10 patients. After follow up for 3 months; deaths were more common in Pauci immune GN group. Nephrotic syndrome patients had more stable renal function.

CONCLUSIONS: Primary glomerular disease is not uncommon in elderly population with most common presentation in this study being Idiopathic Membranous nephropathy. Outcome was poor in RPGN group.


  85. Fractures in Patients on Dialysis Top


S Ramakrishnan, Dilip Rangarajan, Kiran Chandra Patro, Anitha, R Ramprasad

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

BACKGROUND: Patients with CKD on maintenance dialysis are at higher risk for falls and fractures in view of several factors and changes in bone and mineral metabolism Incidence of fractures is higher in all stages of CKD. Fractures in this population is associated with higher morbidity and mortality in comparison with general population There is paucity of data on the incidence of fractures in this population and its outcomes.

AIM OF THE STUDY: To study the clinical and biochemical profile of CKD stage 5 D patients who had sustained fractures and to calculate the incidence rate of fractures in our population.

METHODS: Study population: a) patients undergoing maintenance hemodialysis (HD) and b) patients on continuous ambulatory peritoneal dialysis (CAPD) on follow up in NU Hospitals; Padmanabha Nagar who had sustained peripheral fractures after January 1; 2015 Materials: Medical records and discharge summaries of the study population Methods: Retrospective data collection for demography; precipitating factors; prescription (for calcium and vitamin D supplements and phosphorus lowering drugs) and laboratory parameters of mineral metabolism in the study population Laboratory parameters analyzed - serum calcium; phosphorus; albumin; alkaline phosphatase; sodium and bicarbonate within 3 months preceding fracture; mean of two values of each of these parameters calculated.

RESULTS: Clinical profileNumber of patients 9; Patients on HD 8; mean age at the time of event 65.4; males 7; DM 7; Hypertension 7 - 2 not on medications in view of postural hypotension; IHD 3; CVA 2; peripheral neuropathy 2; Mean duration of CKD preceding dialysis 90 months; Mean duration on dialysis prior to fracture 37 months; Site of fracture femur in 7; acetabulum in 1 and radius in 1 Location of fall 8 at home; 1 on roadOutcome Mortality in 1 within 3 months of fallBiochemical profile (mean values) Serum calcium 8.1 mg/dL Serum phosphorus 4.32 mg/dL Serum albumin 3.26 g/L Serum alkaline phosphatase 148 U/L Serum sodium 136 mEq/L Serum bicarbonate 20.2 mEq/LIt was observed that only one patient had undergone estimation of vitamin D and parathyroid hormone in the year preceding the eventOn a prospective analysis for the year 2018; among 193 patients with CKD 5HD; one had hip fracture; incidence rate was 22.16 fractures per 1000 patient years.

CONCLUSIONS: 1. Fractures among dialysis patients are common but often overlooked with an incidence comparable to 2004 data from USRDS. 2. There was a gap between guideline recommendation and clinical practice on biochemical evaluation of mineral metabolism in this population.


  86. Genetic Mutations in Alternate Complement Pathway and Its Varied Renal Manifestations - Case Series Top


Rohit Raj, M Sreelatha, T P Noushad, E K Jayakumar

Department of Nephrology; Government Medical College; Kozhikode; Kerala; India

BACKGROUND: Alternate complement pathway (ACP) dysregulation and its varied clinical manifestations are an area of intense interest in contemporary nephrology research. Diagnoses such as atypical hemolytic uremic syndrome (aHUS); atypical infection related glomerulonephritis (IRGN) and the relatively new entity C3 glomerulopathy; have been linked to aberrancies in alternate complement pathway activation.

AIM OF THE STUDY: 1) To study the clinical profile of patients with abnormal alternate complement pathway. 2) To identify the genetic mutations in alternate complement pathway in our population.

METHODS: STUDY DESIGN: Retrospective studySTUDY PERIOD - January 2017 – May 2018. STUDY POPULATION: 3 groups 1) Patients with oligoanuric renal failure; anemia; thrombocytopenia; MAHA; low C3 complement levels suggestive of atypical HUS 2) Patients with renal biopsy showing MPGN pattern with predominant C3 deposits on IF suggestive of C3 Glomerulonephritis 3) Patient with renal biopsy showing DPGN pattern with persistent microhematuria and low C3 levels suggestive of Atypical IRGN METHODOLOGY: Details regarding clinical presentation; relevant lab investigations and treatment given were collected. Renal biopsy findings and response to treatment were included. Genetic study to identify mutation in alternate complement pathway regulatory proteins (CFH; CFI; CFHR1; CFHR3; CFB; CD46; C3; THBD) was send in affordable patients.

RESULTS: We had total of 15 patients in our case series.9 of them presented with oligoanuric renal failure. They had low complement levels and their investigatons were consistent with hemolytic uremic syndrome. genetic analysis was done in them and 3 of them showed Homozygous partial gene deletion of CFHR1 and CFHR3 gene.4 patients in our case series presented with edema; hypertension; deranged renal function. Renal biopsy in them showed MPGN pattern with predominant coarse granular deposits of C3 on immunofluorescence consistent with C3 glomerulonephritis. One had Frame shift mutation in CFHR5 gene; 2 had Partial deletion in CFHR1 - CFHR3 gene and the other had Mutation in CRB2 gene on genetic study.2 patients in case series presented with acute glomerulonephritis with low C3. Biopsy showed DPGN pattern. Follow up after 3 months showed persistently low C3 complement levels. Possibility of atypical IRGN considered; genetic study showed deletion in CFHR1-CFHR3 gene and Mutation in C3 gene in other.

CONCLUSIONS: Alternate complement pathway dysregulation may lead to a variety of histopathologic patterns and different clinical expression of renal injury in affected patients. Partial deletion of CFHR1 and CFHR3 gene is the most common genetic abnormality seen in alternate complement pathway in our population.


  87. Complications and Outcomes of Critically Ill Adult Patients with Acute Kidney Injury or End Stage Renal Disease Requiring Continuous Renal Replacement Therapy Top


K B Shashikiran, N Vamsi Krishna, D Sree Bhushan Raju, G Anvesh, D Krishna Prasad, B N R Ramesh

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

BACKGROUND: Continuous Renal Replacement Therapy (CRRT) has evolved as renal replacement therapy of choice in critically ill patients. Though CRRT offers several theoretical advantages; complication rates and mortality has remained high over the last several years. This study enumerates the complications; short term outcome and in hospital mortality predictors associated with CRRT.

AIM OF THE STUDY: 1. To study the electrolyte disturbances and other complications associated with CRRT. 2. To study the short term outcomes and predictors of in hospital mortality in patients receiving CRRT.

METHODS: Single center retrospective observational study over a 2 year study period. All patients > 18 yrs of age receiving CRRT from various intensive care units of Nizam's institute of medical sciences were included. Patients who received CRRT for less than 12 hours were excluded. Demographic and clinical data were recorded and analyzed by using SPSS 19.0 v. Recovery of renal function was defined as the absence of ongoing renal replacement therapy at the time of discharge. In predictive models; continuous variables were dichotomized based on the median value to improve interpretability. For values that were available in both AKI and ESRD populations; medians for the entire population were used for dichotomization to allow for comparison between groups. One hundred and twenty patients who received CRRT were included in the final analysis.

RESULTS: Mean age of patients was 54.7±13.9 yrs. Male to female ratio was 1.7:1. Mode of renal injury was AKI in 64 (53.3%) AKI on CKD in 36 (30%) and ESRD in 20 (16.7%). Most common indication for initiation of CRRT was septic shock accounting to 61.6%. Electrolyte disturbances associated with CRRT in our study were hypokalemia (61.6%); hypophosphatemia (30.38%) and hypomagnesemia (15%). Hypotension during CRRT was noted in 57 (47.5%) and Bleeding episodes in 9 (7.5%) patients which include GI bleed (5); hematuria (2); epistaxis (1) and cerebellar hemorrhage (1). Overall in-hospital mortality was 78.3% and it was 78% and 80% respectively in AKI and ESRD groups respectively. Renal recovery was seen in 20 out of 22 patients in AKI group. The factors found to have significant association with in-hospital mortality in AKI group include admission to MICU; lactate >3 mmol/L; s. albumin <3 g/dl; need of mechanical ventilation and ≥2 ionotropic support. S.alb <3 was the only association in ESRD group.

CONCLUSIONS: Electrolyte disturbances like hypokalemia and hypophosphatemia are commonly seen in patients undergoing CRRT. Predictors of mortality differ between AKI and ESRD groups; likely reflecting differences in the clinical processes that lead to initiation of CRRT.


  88. Peak Systolic Velocity in Doppler Ultrasound-A Sensitive Predictor of AV Fistula Dysfunction Top


Pranit Kakde, Deepa Usulumarty, Ganesh Sanap, Komal Nagori, Shrirang Bichu, Parag Tilve, Kothari, Rajesh Kumar, Viswanath Billa

The Apex Database - Apex Kidney Care; Sushrut Hospital and Research Centre; Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

BACKGROUND: The AV fistula is the preferred vascular access in the hemodialysis population. For long term MHD patients; the development of complications within them can lead to AVF dysfunction and failure. Since there is a limitation on the number of options at creating new AVFs; safeguarding the health of the active accesses is a necessity for all MHD patients.

AIM OF THE STUDY: To compare the accuracy of clinical examination & Doppler ultrasound to assess patency of AV Fistulae and evaluate the role of peak systolic velocity readings to predict steno-thrombosis in the AVF.

METHODS: We performed a multicentre; observational and a cross sectional study enrolling 47 patients in a hemodialysis unit; for AV fistula surveillance using Doppler ultrasound. The peak systolic velocity (PSV); internal diameters and blood flow rates were recorded at specific sites such as inflow artery proximal to the fistula; the anastomotic site; puncture sites; the proximal; mid; and distal outflow veins; the axillary and subclavian veins. We used a clinical score of 0-3 based upon ‘look. listen and hear’ clinical findings; for each AV fistula and compared these findings with fistula age and doppler results on anatomical abnormality; and PSV.

RESULTS: On clinical examination; there is a significant difference in the clinical score between normal and steno-thrombotic fistulae (p =0.02). On Doppler examination; a PSV2/PSV1 ratio >2; was significantly different between patients with normal and steno-thrombotic fistulae (p =0.043) and is a sensitive marker of stenosis/thrombosis in the fistula. However clinical examination alone is a poor predictor of fistula patency. 63% of clinically normal fistulae had varying degrees of steno-thrombosis.

CONCLUSIONS: Clinical examination is a screening tool for AVF monitoring but can miss steno/thrombotic lesions. The PSV2/PSV1 > 2; on Doppler is suggestive of stenosis/thrombosis in the AVF. Clinical examination with Doppler evaluation may help identify fistula lesions early and extend the life of AV fistulae.


  89. Clinicopathological Association and Predictors of Outcome in C3 Glomerulopathy Top


Priti Meena, Vinant Bharghava, A K Bhalla, Ashwini Gupta, Manish Malik, Anurag Gupta, D S Rana

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

BACKGROUND: The term C3 glomerulopathy is characterized by the presence of glomerular deposits of C3 in the absence of significant amounts of other immunoglobulins. The full spectrum of histologic change observed in C3 glomerulopathy is yet to be clearly defined and the pathological predictors of it's renal outcome(s) remains largely unknown.

AIM OF THE STUDY: This study included a cohort of patients with C3 glomerulopathy and aimed to identify the clinicopathological predictors of renal outcome.

METHODS: We retrospectively analyzed all the kidney biopsies done in the Department of Nephrology at Sir Ganga Ram Hospital; New Delhi from 1st May 2013 to 31st May 2018 (period of 6 years). Patients fulfilling the pathological criteria for a diagnosis of C3 glomerulopathy were included in the study. We recorded the histological; demographic; and clinical data of these patients and determined the predictors of end stage renal disease (ESRD) using the multivariate analysis.

RESULTS: Amongst 2462 patients; 34 (1.34%) were identified fulfilling the criteria for C3 glomerulopathy. The mean age at diagnosis was 35 (±17.5) year. Nephritic syndrome was the most common presentation 13 (38.2%); followed by AKI 12 (35.3%) and nephrotic syndrome 9 (26.5%). 15 patients (44.1%) were hypertensive. In 8 patients; the disease was triggered by an episode of URTI whereas skin rashes was seen in 8 patients. 25 (73%) patients had hematuria including both microscopic 17 (50%) and macroscopic 8 (23%). Membranoproliferative glomerulonephritis (GN) (11 (32.3%)) was the most common pattern of biopsy finding followed by diffuse endocapillary proliferative GN 10 (29.4%). Mesangial proliferative pattern of injury was present in 7 (20.6%) patients. Six biopsies (17.6%) showed glomeruli with greater than 50% crescents. Presence of crescents was associated with poor outcomes. Immunosupressive therapy appeared to improve renal survival in our subset of patients.

CONCLUSIONS: This study identifies important clinicopathological features of patients with C3 GP. These predictors of renal outcome could be used to stratify patients; enabling application of emerging mechanism-based therapies to patients at high risk for poor renal outcome.


  90. Pattern of Non-Diabetic Renal Diseases in Patients with Diabetes Mellitus at State Run Tertiary Care Center Top


Megha Pai, L Umesha, S M Shivaprasad, C G Sreedhar, V Leelavathi, V Kishan

Institute of Nephro Urology; Bengaluru; Karnataka; India

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

AIM OF THE STUDY: To study the profile of Non diabetic renal disease in patients with diabetes mellitus who underwent renal biopsy.

METHODS: The demographic; clinical; and biochemical data of patients with DM (defined by ADA) who underwent renal biopsy in this institute for a duration of from 2012 August to September 2018 were analyzed prospectively. 280 patients were included in the study. Data were collected from inpatient file; monitor sheets; histopathological reports.

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

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


  91. Lupus Nephritis: Our Experience at Tertiary Care Centre Top


Gajanan Pilgulwar, R Swami, P Saruk, Shakir Ahmad, Kalpana Mehta

Department of Nephrology; T. N. Medical College and B. Y. L. Nair Ch. Hospital; Mumbai; Maharashtra; India

BACKGROUND: The clinical outcome & therapeutic response vary among patients with lupus nephritis [LN]. We evaluated the clinical outcomes of the established immunosuppressive regimens in LN.

AIM OF THE STUDY: To assess the efficacy of various immunosuppressive regimens in achieving & maintaining remission in LN.

METHODS: A cohort of 70 Lupus Nephritis [LN] patients treated with various immunosuppressive therapies was analyzed retrospectively. Kidney biopsies were evaluated with LM; IF & EM & classified according to ISN/RPS class. Class I and II received steroids. Class II with occasional subendothelial deposits were treated as classIII/IV LN. ClassIII/IV received NIH regimen/MMF/CSA; Class V received steroids & MMF/CSA. Time to achieve complete/partial remission of proteinuria; improvement in GFR; disappearance of serologic activity was noted.

RESULTS: Class I/II N=9 [3 received NIH regimen] showed complete remission [CR]. Class III/IV [N=55] 47 received NIH regimen; 6 MMF & 2 CSA as induction. Of 47 with NIH regimen; 31 showed complete CR of proteinuria within 3 to 24 months; 7 partial remission [PR]; 4 non-responders & 5 were lost to FU. Of 7 with PR; 3 are completing NIH regimen; 3 changed over to CSA; while 1 went off treatment. 4 non responders; when changed over to MMF; CSA & RTX [2; 1; 1 respectively] showed CR. Of 6 cases with MMF induction; 4 showed CR and 1PR & 1 drug defaulter. Both cases with CSA induction showed CR. Class V [N=6] 4 received MMF while 2 received CSA. Of 4 with MMF; 2 showed CR; 1 was lost to FU; 1 was changed to CSA with CR. Of 2 treated with CSA; CR was noted in 1. Mean Serum creatinine pre & post treatment in cohort was 1.27 & 1.07 mg%. Complications included hemorrhagic cystitis in 1; diarrhea 1; mortality 4.

CONCLUSIONS: Diffuse proliferative LN was commonest [42.86%] followed by focal proliferative LN [35.71%]. CR was seen in 68.57%. NIH was mainstay therapy in 71.42%. CR was seen in 68% who received NIH regimen.


  92. Histological Spectrum of Nephropathy in Diabetic Patients Top


Sonu Manuel, Faizan Ansari, Vamsi Nagalla, G Anvesh, D Krishnaprasad, Sree Bhushan Raju

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

BACKGROUND: Diabetes mellitus (DM) represents one of the most important health problems worldwide. by 2030; no of patients with diabetes will rise to 552 million. The prevalence of diabetic nephropathy (DN) was 3.3% in diabetic adults. According to ISN registry DN is the leading cause of end-stage renal disease (ESRD). Yet majority of diabetic patients with renal involvement are not biopsied; hence we try to evaluate the histological spectrum of nephropathy in diabetic patients.

AIM OF THE STUDY: To classify renal histopathologic lesions in diabetic nephropathy as per the renal pathology society classification systemTo evaluate incidence and causes for nondiabetic renal disease.

METHODS: All patients with Diabetics as per American Diabetes Association classification criteria; who underwent renal biopsy for various indications from august 2013 to august 2015 were included in the study. Demographic; clinical and biochemical profile of patients was collected. eGFR was calculated using the Modification of Diet in Renal Disease formula. DN on histology was classified according to Tervaert classification.

RESULTS: Total of 267 Diabetic patients who underwent renal biopsy for various reasons were included in this study. Among them 218 (81%) patients were male and 49 (19%) were female. The mean age was 51.53±10.29 years. Mean age of female patients was 49.53±10.83 years. Mean age of male patients was 51.98±10.13 years. Among them type 1 diabetic were 15 (5.62%) and 252 (94.38%) were type 2 diabetics. 65 (24.34%) patients had pure non-diabetic renal (NDR) lesions. 41 (15.35%) patients had NDR in addition to DN. Pure DN was seen in 161 (60.29%) patients. DN was seen in total of 202 (75.65%) patients. The most common non-diabetic renal lesion noted was acute interstitial nephritis in 54 (20.22%) patients. The most common glomerular class of diabetic nephropathy is class III. Symptomatic hematoma occurred in 8 (2.9%) of our patients.

CONCLUSIONS: The prevalence of NDRD is remarkably frequent in DM. differential diagnosis of NDRD and DN in diabetic patients is of considerable importance since therapy and prognosis are quite different. Therefore renal biopsy is essential for precise diagnosis of nephropathy in patients with T2DM.


  93. Big Data from The Hemodialysis Machine – Can We Predict Vascular Access Problemss? Top


Pranit Kakde, Mihir Wagle, Jatin Desai, Sameer Kothari, Deepa Usulumarty, Ganesh Sanap, Vinayak Ukirde, Pankaj Jawandiya, Jatin Kothari, Rajesh Kumar, Shrirang Bichu, Parag Tilve, Viswanath Billa

The Apex Database - Apex Kidney Care; Raikar Dialysis Centre; Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

BACKGROUND: Extremely large data sets analysed computationally reveal patterns; trends; and associations termed as big data analysis. Machine learning builds algorithms that can receive input data and use statistical analysis to predict an output value within an acceptable range. A conventional hemodialysis session typically generates 500000 data points data relating to 34 variables. Typically just a few of these are utilised. A large part of this data can be potentially useful.

AIM OF THE STUDY: To use big data generated by the machine during the dialysis session to differentiate between a healthy versus an unhealthy AV Fistula.

METHODS: One second data generated from a Nipro Surdial dialysis 55 machine during the dialysis session was collected and this data was collated and analysed. As a pilot; 2 prototype hemodialysis patients were chosen - one with a normal AV fistula on Doppler and another with severe stenosis. The machine data for venous pressure; blood pressure; blood flow and Kt/V was collected every second during a dialysis session and this was repeated over 3 such sessions. The results were then analysed.

RESULTS: The graphical patterns for venous pressures; systolic blood pressure; diastolic blood pressures; flow rates and serial Kt/V were strikingly different for the patient with healthy AVF as compared to the patient with the severely stenotic AV Fistula on Doppler ultrasound.

CONCLUSIONS: Analysing Big Dialysis Data can help identify early those AV Fistulas that are beginning to become dysfunctional. Early identification of dysfunctional fistula can help potentially salvage these fistulae.


  94. The Response to Treatment with Direct Antiviral Agents on Patients with Hepatitis C on Maintenance Hemodialysis Top


Vinayak Ukirde, Geeta Malkan-Billa, Komal Nagori, Ganesh Sanap, Deepa Usulumarty, Pranit Kakde, Pankaj Jawandhiya, Jatin Kothari, Rajesh Kumar, Shrirang Bichu, Parag Tilve, Viswanath Billa

The Apex Database - Apex Kidney Care; Sushrut Hospital and Research Centre; Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

BACKGROUND: HCV infection is the commonest hepatotropic infection in patients on MHD. Its prevalence in MHD patients ranges from from 4.3% - 45% in India. Nosocomial transmission and via blood and its components are 2 important factors that affect HCV incidence. Chronic liver disease is an important cause of mortality and morbidity in MHD patients. DAAs have revolutionised the management of these patients. However there is emerging but limited data to support the use of these drugs in the MHD population.

AIM OF THE STUDY: To study the response to treatment with direct acting antivirals on patients with Hepatitis C on maintenance hemodialysis. To monitor the clinical safety of these drugs in this patient population.

METHODS: HCV + MHD patients were treated with DAAs by a Hepatologist and the response was assessed.

RESULTS: 25 MHD patients were included. Mean age was 50.2±12.1; there were 15 males and 10 females; Median duration on HD was 32±26 months. 12/25 (48%) received transfusion in last 1-3 yrs; 6/25 (24%) had cirrhosis. 22/25 had genotype 1 (88%). Mean baseline viral load was 5.4±1.37 logs. Mean ALT was 65.5±52.58 at baseline and 18.86±6.16 at 12 weeks of treatment. Majority of patients (16) were on Sofosbuvir + Ledipasvir; 5 pts were on Sofosbuvir + Velpatasvir and 4 patients were on Sofosbuvir + Daclatazavir. Treatment duration was 12 weeks for 22 patients and 24 weeks for 3 patients. All patients were given daily treatment post HD after initial 1 week of alternate day therapy. All patients became HCV-RNA negative after 4 weeks of therapy. 4 patients have not yet completed 3 months post treatment. 21 patients who are 3 months post therapy are all negative at 3 months. 5 patients died; 2 elderly patients with cirrhosis persisted with decompensated liver disease and died. 3 died to unrelated causes.

CONCLUSIONS: DAAs are safe and effective in achieving sustained viral remission in MHD patients. Treatment prevents HCV transmission in HD units when used along with other infection control measures. Caution needs to be exercised when using this therapy in elderly patients with established cirrhosis.


  95. Poisoning Associated Acute Kidney Injury: Spectrum and Outcome Top


Parikshit Singh Chauhan, Manish Rathi

Department of Nephrology; PGIMER; Chandigarh; India

BACKGROUND: There have been only a few studies from any centre ascertaining the AKI associated with all poisons whether animal; chemical or plant related.

AIM OF THE STUDY: To ascertain incidence; mode of treatment and outcomes of Acute Kiney Injury (AKI) associated with various chemical poisonings; drugs overdoses and envenomation at a single centre.

METHODS: This was a prospective observational study of all patients (n= 49) presenting with AKI following animal or chemical poison between January 1st 2016 and 28 Feb 2017 at Post Graduate Institute of Medical Education and Research; Chandigarh. Demographic characteristics; clinical and laboratory parameters; treatment methods and outcomes were noted. All surviving patients were followed for 3 months.

RESULTS: Incidence of AKI was 19.91% (49 cases out of 246 cases of poisoning); Animal poisons were almost twice as common than chemical poisons in causing AKI; Snakebite was the commonest cause of poisoning associated AKI; Mean age of patients was 37.59 +/-16.29 years and was significantly more in animal than chemical poisons; Males were 67.2% and females were 32.8%; Geographical distribution was not related to outcome or type of poisonings; Most of of the cases (61.22%) occurred in monsoon season; there was no affect on mortality by duration between exposure and presentation. 79.59% of poisoning associated AKI required RRT; SLED was more common in patients who expired than survivors; Duration of stay was more for survivors; Improvement in renal functions predicted better outcome; Animal poison associated AKI had better prognosis than chemical poison associated AKI. On follow up; 29% had abnormal urine findings at 12 weeks on routine and microscopic examination.

CONCLUSIONS: Our study demonstrates than Animal poisoning is more common cause of AKI than chemical poisons; SOFA score being more in expired patients; use of SLED commoner in expired patients and more duration of stay for survivors than expired patients.


  96. Open Labelled Prospective Randomized Controlled Trial of Calcium and Vitamin D on Bone Health in Kidney Transplant Recepient Top


Sudhanshu Sekhar Bhoi, Rajendra Pandey, D Sen, Arpita Roy Chowdhury, Dipankar Sircar, Sanjay Dasgupta

Department of Nephrology; IPGMER and SSKM Hospital; Kolkata; West Bengal; India

BACKGROUND: Bone loss occurs during the first 6 months after renal transplantation; and corticosteroid therapy plays an important role. Although calcium plus vitamin D administration prevents corticosteroid-induced osteoporosis; its use in kidney transplant recipients is limited by the risk of hypercalcemia.

AIM OF THE STUDY: To study the effect of calcium and vitamin D on bone health in renal transplant recipient.

METHODS: This is open labelled; prospective; randomized controlled intervention trial examining the effect of daily calcitriol (0.25 microgram/day) and calcium supplementation (0.6 gm/day) in the first 6 months after renal transplantation (case); with only calcium supplementation (0.6 g/day) in control arm. The primary outcome measure was the change in bone mineral density (BMD) at 6 months after transplant. 21 recipients were randomized to calcitriol and 20 were randomized to calcium only. All the patients were on triple immunosuppressant (tacrolimus/MMF/Steroids).

RESULTS: Both groups had a similar degree of pre-existing hyperparathyroidism (187±229 vs. 191±183 pg/mL); but a more pronounced decrease of parathyroid hormone (PTH) levels after renal transplant was observed in patients on calcitrol (at 6 months: 60.4 ± 42.2 vs. 85.7 ± 53.1 pg/mL; P = 0.02). Patients on calcitriol preserved their BMD at neck of femur significantly better than those on only on calcium (6 months: 0.04 ± 3.3 vs. −1.93 ± 3.2%; P = 0.01); Differences did not reach significance at the lumbar spine and radial bone. 2 patients on calcitriol (9.52%) and 1 patient on calcium only (5%) developed a hypercalcemia during the first 6 months after renal transplant.

CONCLUSIONS: Therapy with low-dose calcium supplements and calcitriol for 6 months after kidney transplant; is safe; decreases PTH levels more rapidly; and prevents bone loss in neck of femur.


  97. Do All Chronic Kidney Disease Patients Need Ambulatory BP Monitoring?? Top


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

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

BACKGROUND: The diagnosis and management of hypertension are still predominantly on the basis of office BP. Patients with CKD are prone to abnormal BP patterns when BP is measured outside of the office at home and with ambulatory BP monitoring. Although there are some studies that have evaluated the role of ABPM in patients with CKD; there is still limited data in this population from India. This study was; therefore; undertaken to look for various “invisible” BP patterns in CKD patients.

AIM OF THE STUDY: To determine whether abnormal blood pressure patterns on 24 hr ABPM are predominant only in select subgroups of CKD patients.

METHODS: 100 CKD outpatients (excluding those on dialysis) with uncontrolled BP (office and/or home); underwent 24 hr ABPM (Spacelabs medical DPI:1200/Oscar-2; Suntech Medical). Basic epidemiological and laboratory parameters were noted.

RESULTS: Mean age - 50± 14 years; M:F -54:46. Diabetic=35%. In our study; the prevalence of patterns “invisible” to office measurements such as white coat hypertension (WCH) was 21%; Masked uncontrolled hypertension (MUCH)=45%; nocturnal hypertension (NH)=79 % &early morning surge (EMS)-25%. Only 11 % had no” invisible” patterns. Subgroup analysis (i.e Age < 50 years vs > 50; Male vs Female; Diabetics vs Non diabetics) showed no significant difference in prevalance of above BP patterns; except that younger CKD patients had more NH (p=0.04). Diabetics had higher Mean 24 hr SBP (p=0.04); awake SBP (p=0.03) & more EMS (p=0.03). Comparison between patients of CKD stage 1; 2 and 3A (GFR> 45 ml/min) with those of Stage 3B; 4 and 5 ND (GFR <45 ml/min) similarly showed no significant difference in prevalance of WCH; MUCH; NH and ES.

CONCLUSIONS: In CKD; the prevalance of abnormal BP patterns (WCH; MUCH; NH and ES) is not influenced by age; sex; diabetes and Stages of CKD. Therefore we advocate wider usage of 24 hour ABPM in all CKD patients for better definition of BP patterns and appropriate adjustment of antihypertensive treatment.


  98. Crrt in Critically Ill Patients with AKI Top


C Shakthi Kumar, K Sampath Kumar, Andrew Deepak, Anandhan, Kadir Selvan

Department of Nephrology; Meenakshi Mission Hospital and Research Centre; Madurai; Tamil Nadu; India

BACKGROUND: CRRT remains an important treatment modality in critically ill patients; especially haemodynamically unstable ones. Mortality remains high despite theoretical advances in methods and delivery over the last several years 14. Identifying patients who would most achieve positive outcomes from this costly intervention is a particular challenGE.

AIM OF THE STUDY: 1) Survival rate among critically ill patients WITH AKI initiated on CRRT 2) Predictive factors associated with clinical outcomes 3)To identify clinical profile of patients requiring CRRT.

METHODS: This is a prospective study which included 57 Patients who are critically ill patients with acute renal failure of multifactorial causes admitted in ICU setup in our hospital; initiated on CRRT. Patients with Age more than or equal to 18 years and AKI (defined by KDIGO Stage 3) in Critically ill patients requiring renal replacement therapy for classic indications were included. Patients whose age is less than 18 or more than 80 years of age; CKD/ESRD were excluded from the study. Exclusive use of CVVHDF as renal support in the patient satisfying inclusion criteria was followed. All patient s demographic and clinical data were recorded; including age; gender; type of ICU; clinical diagnosis; any pre-existing diagnosis of ESRD; details of initial clinical presentation and biochemical Patients were followed during there hospitalization for assessment of recovery of renal function; survival and death during the study period.

RESULTS: We observed most of the patients who are initiated on CRRT was admitted under medical ICU (39%) vs (18%) in surgical ICU. Also septicemic shock was the most common etiological cause of AKI (56.1%); followed by that cardiogenic shock (19.2%). Among infectious causes most common source of sepsis is urosepsis (31.2%) followed by tropical fever with MODS (25%). We found that the survival rate was 42% at hospital discharge; and In hospital mortality was 57.4%. Factors such as age; serum creatinine levels; various cause of AKI was not correlated with the outcome (P value =0.168; not significant). but the univariate statistical analysis among the factors showed that the higher the Mean blood urea; serum lactate levels; APACHE II Score and lower the Mean serum bicarbonate and mean arterial pressure at the initiation of CRRT are predictive of poor outcome (mortality) when compared to survivors.

CONCLUSIONS: High mortality of patients initiated on CRRT reflects the fact that they frequently constitute the most severely ill patients. Septicemic shock is the commonest cause of AKI.


  99. To Evaluate and Compare Urinary Protein in Fractional Urine Collection Versus Traditional 24- Hour Urine Collection As A Step Towards Improvising Urine Collection Method Top


Sowrabha Rajanna, Limesh Marisiddappa, Anitha Devanath, Girish Konasagara Shanthaveeranna, Ravi Prakash Deshpande, S Renuka

Department of Nephrology; St John's Medical College and Hospital; Bengaluru; Karnataka; India

BACKGROUND: 24 hours traditional urine collection method is cumbersome and tedious process with less patient compliance. Our study proposes a novel urine collection method for protein estimation that would entail fractional urine collection every time patient voids. This study was done to compare measured urine protein from the proposed urine collectionmethod to that of traditional 24 hour sampling method.

AIM OF THE STUDY: This study was done to compare measured urine protein from the proposed urine collectionmethod to that of traditional 24 hour sampling method.

METHODS: Volunteers (48 subjects) and Chronic Kidney disease (52 subjects) were recruited. Out of which; 76 subjects were selected for the study. The subjects were grouped based on protein excretion per day. Group 1 with < 0.3 g/day; 0.3 g/day to 1 g/day in group 2 and group 3 > 1.0 g/day. Fractional urine collection method was compared with conventional method in each of these groups. Interclass correlation coefficient (ICC) and Bland Altman analysis was used.

RESULTS: All the values were combined without categorization into groups; comparison of fractional urine collection method without preservative (F1) and with preservative (F2) versus conventional method. ICC before centrifugation was 0.93 (C.I; 0.9 to 0.95) and 0.96 (C.I; 0.94 to 0.97) respectively; which is indicative of good correlation. Also; fractional urine collection method without preservative (F1) and with preservative (F2) versus conventional method; ICC before centrifugation was 0.95 (C.I; 0.92 to 0.97) and 0.91 (C.I; 0.86 to 0.94) respectively; which is indicative of good correlation.

CONCLUSIONS: The novel collection method is as reliable as traditional 24-hour method. The use of thymol as preservative leads to negative interference and centrifugation is mandatory to have better comparable values.


  100. Ambulatory Blood Pressure Monitoring in Potential Renal Donors Top


Parikh Mital, Hegde Umapti, Rajapurkar Mohan, Gang Sishir, Konnur Abhijit, Patel Hardik

Department of Nephrology; Muljibhai Patel Urological Hospital; Nadiad; Gujarat; India

BACKGROUND: Blood pressure measurement techniques have always been an issue of controversy. ABPM helps to identify truly hypertensives and also those with masked hypertension as compared to standard mercury/aneroid BP apparatus. Hence we undertook this research to correctly identify hypertension among potential kidney donors by using ambulatory blood pressure monitoring technique which is more sensitive in detection of masked hypertension and non dippers.

AIM OF THE STUDY: To identify hypertension prevalence in kidney donors by ABPM and to study effect of unilateral nephrectomy on BP in them.

METHODS: We recruited 80 potential renal donors and followed them serially at pre-donation; 6 & 12 months. BP was measured in clinic by sphygmomanometer and by ABPM meditechABPM05. 2D-echocardiography; Ophthalmological examination and 24 hours urine protein measurement & eGFR were done at each visit.

RESULTS: There was significant difference (P<0.001) in pre-donation systolic blood pressure by clinic and ABPM suggestive of white coat (WC) effect of 40% which decreased at 6 and 12 months; 3.75% were masked hypertensive (MH) & only 12.5% donors were sustained hypertensive (SH). Blood pressure was stable by ABPM till 1 year. Obese and elderly (>50 years) donors had higher observed BP by OBPM and ABPM and significantly low eGFR (105.03 & 99.28 mg/dl respectively). Mean (diastolic clinic) BP; systolic-diastolic BP and its day-night component by ABPM was significantly higher in SH and MH groups as compared to WC and SN. 78.5% of normal dippers were normotensive by ABPM while 21.5% had hypertension. eGFR decreased at 6 months (-24%); by 12 months it showed an increase of 2% reaching to 76% of baseline value. Hypertension by ABPM at baseline was associated with more decrease in eGFR at 1 year of follow up with age >50 years and higher BMI contributing as risk factors.

CONCLUSIONS: For prospective donors; ABPM provides a more accurate and reproducible estimate of BP compared to clinic BP.


  101. The Spectrum and Outcome of Tuberculosis Post Renal Transplant: A 10-Year Single Centre Experience Top


Mayuri Trivedi, Amar Kulkarni, Jatin Kothari, Rasika Sirsat

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

BACKGROUND: Kidney transplant recipients; especially in developing countries; are at a greater risk of opportunistic infections like tuberculosis (TB). The overall spectrum of tuberculosis has seen a change in recent years with greater number of drug resistant cases; even in the general population. The aim of this study was to describe the epidemiology; clinical features and treatment outcomes of post renal transplantation tuberculosis from a tertiary care facility in Mumbai.

AIM OF THE STUDY: To study the spectrum and outcome of treatment of tuberculosis in post renal transplant.

METHODS: This retrospective; observational study included transplant recipients who had undergone renal transplantation at our centre between 1st January 2005 and 31st December 2015 and had been diagnosed and treated for tuberculosis at any stage during their follow-up.

RESULTS: Out of the 402 renal transplants; 35 patients developed post-transplant TB (8.7%). The median time period for manifestation of TB was 37 months (Range: 2-148 months post- transplant) with a median follow up of 96 months (3-151 months). The most common presentation was extrapulmonary TB (n=18; 51.4%). Majority of the cases were drug sensitive (n=30; 85.71%) with drug resistant TB in 5 cases (14.29%). The overall mortality was 28.57% (n=10) with TB related mortality in 11.4% (n=4. Graft loss was observed in 14.29% (n=5). 2 cases had relapse of tuberculosis after completing prescribed treatment and 1 patient who defaulted after 3 months; was reinitiated on therapy on subsequent follow-up. We used rifampicin sparing; fluoroquinolone based therapy in 82.85% of cases (n=29) with treatment success seen in 65.5% of these cases (n=19). The rest of the drug sensitive TB patients received conventional four drug regimens and the drug resistant cases were treated with individualised therapy.

CONCLUSIONS: Transplantation increases the risk of developing tuberculosis with higher rates of extra-pulmonary and drug resistant disease which needs to be identified and treated promptly. Rifampicin sparing treatment regimens using fluoroquinolone based therapy appear to be safe and effective in treatment.


  102. Dengue in Renal Allograft Transplant Recipients and The Effect of Dengue Screening in Both Donor and Recipient and Its Outcome in Recipients Top


Vidyasagar Kallepalli, Abhinav

PGIMER; Chandigarh; India

BACKGROUND: India is an endemic zone for dengue which is caused by an Arbovirus transmitted by the mosquitoes Aedes aegypti. Renal transplant recipients who live or travel in endemic zones of dengue are at risk of contracting this infection. A few case reports have described dengue infection in renal transplant recipients with the transmission of dengue from donor to recipient but no study in literature described the effect of dengue screening of both donor and recipient before undergoing transplant.

AIM OF THE STUDY: To study dengue infection in renal allograft transplant recipients and to describe the results of pretransplant dengue screening in both donor and recipient.

METHODS: Between June 2107- November 2017; renal transplant recipients with dengue were identified based on either NS 1 or Ig M positivity with typical clinical syndrome of fever; myalgia; arthralgia; headache; facial flushing; leucopenia; thrombocytopenia and transaminitis. Baseline haemogram; renal and liver function tests were done and subsequently followed up. Mycophenolate (MMF) was withheld or reduced when leukocytes <4000 or platelet count < 50; 000. Platelet transfusions were given when platelets were <10; 000 or bleeding manifested. MMF was restarted once the platelets were >75000 or were showing steady improving trend. Granulocyte colony stimulating factor was given to the patients with absolute neutrophil count <1000. Screening for dengue was initiated in both donor and recipient prior to transplantation after the first case of dengue infection was detected in the perioperative period. These patients were followed up and evaluated for dengue if post operative fever occurred.

RESULTS: Renal allograft recipients with dengue infection were 36 (M:F-31:5) with mean age 37.13 years and mean transplant duration 36.2 months. NS-1 was positive in 35 whereas dengue IgM was positive in 19 patients. Fever was present in all patients; myalgia-18; arthralgia-12; vomiting-10; hedache-7; diarrhoea-9; leucopenia-24 and thrombocytopenia in 34 cases. MMF stopped in 29; reduced to half in 3 cases. Creatinine raise (>25% from baseline) in 21 patients of whom 16 were achieved their base line where as 3 were not. There were 2 mortalities with dengue shock syndrome; 3 cases of dengue opthalmopathy and 1 case of dengue encephalopathy. Two patients received G-CSF and 2 received single donor platelets. Out of 44 donor recipient pairs screened for dengue using NS-1 antigen and IgM antibody; 8 were positive. After a mean waiting period of 7.16 weeks; NS-1 was negative in all pairs in which one recipient developed and recovered from dengue during post operative period.

CONCLUSIONS: Renal allograft recipients with dengue will have reversible graft dysfunction and should have a high index of suspicion for complications in early post transplant period. Screening of donor and recipient for dengue should be done before transplant in endemic areas during the dengue season.


  103. Clinico Pathological Study of Incidence of Scrub Typhus in Acute Kidney Injury Top


Purna Chandra Kar, C R Kar, M R Ranjit

SCB Medical College and Hospital; Cuttack; Odisha; India

BACKGROUND: Scrub typhus is described as re-emerging infectious disease in India owing to frequent outbreaks. It is one of the important causes of acute undifferentiated febrile illness in India. In most cases it is under diagnosed and under reported. Renal involvement ranges from simple proteinuria to AKI and ESRD. This study investigated clinical; pathological and renal involvements in all patients diagnosed as scrub typhus.

AIM OF THE STUDY: To study the incidence of scrub typhus in acute kidney injury patients and to investigate the clinical; pathological and renal involvement in all patients diagnosed as scrub typhus.

METHODS: A prospective observational study was conducted in SCBMCH; Cuttack; Odisha between June 2017-June 2018. All patients with unexplained acute febrile illness were included in this study. Diagnosis of scrub typhus was made by a quantitative ELISA based IgM serology. AKI was defined as per KDIGO definition.

RESULTS: Out of 140 patients 39 patients (27.80%) were scrub typhus positive. 69.20% were male and 30.80% were female. Mean age group was 40-59 Years (43.50%). Clustering of cases were seen between Aug-Nov. Patients presented with AKI were divided into stage 1 (7.70%); stage 2 (23.00%); stage 3 (69.30%) respectively according to KDIGO criteria. Urinalysis was abnormal in 36.00% patients with Albuminuria (20.50%) & microscopic hematuria (5%) being common. 24 out of 39 patients (62.00%) undergone hemodialysis with an average dialysis session of 4. All patients had recovered except 3 patients (7.60%) who were expired presented with jaundice; oliguria; encephalopathy & MODS. Dramatic response to treatment with doxycycline or azithromycin was noted in all patients except 3 patients who had fatal outcomes. Fever < 7 days (100.00%); headache (56.40%); hepatomegaly (33.33%); splenomegaly (28.00%); lymphadenopathy (33.00%); Anemia (75.00%) were predominant clinical features.

CONCLUSIONS: Scrub typhus was diagnosed in 27.8% of patients presenting with acute febrile illness. 62% of patients need Hemodialysis at presentations & 7.6% of patients expired. So; we suggest all patients with unexplained fever to be investigated for scrub typhus.


  104. Unusual Cause of Hypertensive Emergency in Haemodialysis Patients-Case Series Top


Pankaj Jawandhiya, Shrirang Bichu, Vishwanath Billa, Parag Tilve, U Deepa, Pranit Kakde

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

BACKGROUND: Patients on dialysis have an increased incidence of tuberculosis due to their waning immunity. Rifampicin; a firstline antitubercular therapy drug is a potent inducer of hepatic cytochrome P450 (CYP)3. There is potential for pharmacokinetic interaction between rifampicin and antihypertensives that are CYP substrates. In dialysis patient such interaction between antihypertensive drugs and rifampicin is overlooked thing; we hereby presents 4 such cases to highlight this important interaction.

METHODS AND RESULTS: 4 End stage renal disease patients on maintenance haemodialysis with controlled blood pressure on antihypertensive medicines; started on AKT for ankle; pulmonary; mediastenal lymphadenopathy and pericardial effusion tuberculosis. Patients presented after 1-2 weeks (ranging from 1-5 weeks) with different forms of hypertensive emergency including hypertensive left ventricular failure; pulmonary edema; macular edema and malignant hypertensive retinopathy; seizure and altered sensorium due to PRES. Blood pressure was sky rocketingly high despite adding 4-5 antihypertensive at their at their maximum doses. Blood pressure came under control only after readjusting OR changing rifampicin to levofloxacin. Rifampicin causes decrease in blood level of commonly used antihypertensive drug such as amlodipine; cilnidipine; Nifedipine; nimodipine; Bisoprolol; Losartan; diltiazem; verapamil. Many other interaction with anti-hypertensive medicines not known till date.

CONCLUSIONS: Rifampicin & anti hypertensive medicines interaction is of significant clinical importance in hypertensive CKD 5D patients. It would be prudent to monitor patients closely for worsening of hypertension after initiation of rifampicin. Or use an alternative antitubercular drug in place of rifampicin.


  105. Incidence of Post Transplant Diabetes Mellitus in Non Diabetic CKD Transpalnt Recipients at Six Months Post Transplant Top


Krithika D Muralidhara, Rammohan S Bhat, Subramanian Kannan

Narayana Hrudayalaya Hospitals; Bengaluru; Karnataka; India

BACKGROUND: Occurence of de novo diabetes mellitus post transplant has been implicated in reduced graft survival and increased cardiovascular morbidity and mortality. Consensus meeting in 2010 defined PTDM as an entity and formulated guidelines for diagnosis; prevention and treatment. Most available data on PTDM comes from retrospective studies. Reported incidence of PTDM varies from 4-25%. This study was designed to prospectively analyse the incidence of PTDM and associated risk factors for PTDM.

AIM OF THE STUDY: To study the incidence of Post Transplant Diabetes Mellitus (PTDM) at 6 months post renal transplantation and identify the risk factors at a tertiary care centre.

METHODS: Patients with Non diabetic CKD who underwent renal transplant were included after obtaining informed consent. Demographic details; Pre and post-transplant risk factors associated with PTDM were obtained. Pre-transplant inflammatory status with serum CRP as marker and Trace element (Aluminium; Copper; Selenium and Zinc) deficiency were noted. In the post operative period; patients were monitored for trough levels of Serum Tacrolimus and Blood glucose levels at specified time points (Fasting; Post-lunch; Post dinner) by glucometer based estimation. At the time of discharge; patients were advised on Glucometer based Home Self monitoring of blood glucose levels at specified time points (Fasting; Post-breakfast; Post-lunch and Post-dinner glucose levels). Oral glucose tolerance test (OGTT) was done at months 1; 3 and 6 post transplant in patients not diagnosed with PTDM by Home monitoring of blood glucose. The various time points of diagnosis of PTDM was recorded.

RESULTS: The incidence of PTDM in our study was 36.6%. The cumulative incidence was 20% at month 1; 30% at month 3 and 36.6% at month 6 of follow-up post transplant. The mean age was 36 years. The cause of ESRD was CGN. The rejection episodes in our cohort was 22%. CRP levels was not found to be higher in those developing PTDM. Pre-transplant Zinc levels were found to be significantly low in those who developed PTDM. The presence of Post Transplant Transient Hyperglycemia was found to have association with development of PTDM. During the follow up; we used gluometer based home monitoring to detect hyperglycemia early. We found a pattern of post prandial hyperglycemia with fasting euglycemia in those who developed PTDM. The glycemic excursions were found to happen at post-lunch and post- dinner time points. A diagnosis of PTDM in two thirds of our patients was made by home monitored glucose values meeting the ADA criteria. In the rest one third; PTDM was diagnosed by OGTT at clinic visits.

CONCLUSIONS: The incidence of PTDM in our study was 36.6%. Zinc deficiency emerged as risk factor for PTDM. All the patients who developed PTDM had Post Transplant Transient Hyperglycemia. Of the patients with PTDM; two thirds were diagnosed by Home monitoring and rest by OGGT at clinic visit.


  106. Clinicopathological Profile of Renal Disease in Paraproteinemia and Monoclonal Gammopathy of Renal Significance Top


K Sathyasagar, T Balasubramaniyan, N Gopalakrishnan, J Dhanapriya, T Dineshkumar, R Shakthirajan, N Malathy

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

BACKGROUND: The spectrum of plasma cell dyscrasias associated renal diseases include light chain deposition disease; cast nephropathy; AL amyloidosis; cryoglobulinemic glomerulonephritis; fibrillary and immuotactoid glomerulonephritis. Monoclonal gammopathy of renal significance (MGRS) is diagnosed by demonstration of monoclonal deposits in the kidney. Patients with MGRS do not meet the criteria for overt multiple myeloma.

AIM OF THE STUDY: To study the clinical and pathologic presentations of renal disease in paraproteinemia and monoclonal gammopathy of renal significance.

METHODS: We did a retrospective cum prospective observational study between March 2013 to July 2018 on the clinical profile; hematological characteristics; renal biopsy findings and outcome among 46 patients. Patients with monoclonal immunoglobulin deposits in kidney were included in the study. Patients had either multiple myeloma or MGRS. Multiple Myeloma was diagnosed by presence of marrow plasmacytosis (>10 %); a serum and urine M component and end organ damage. Monoclonal gammopathy of renal significance (MGRS) in the absence of hematological malignancy or other myeloma defining events.

RESULTS: Among 46 patients mean age was 59 years. Number of male patients were 30 and the number of female patients were 16. Male female ratio was 2:1. Rapidly progressing renal failure (RPRF) was the most common presentation (48 %) followed by nephrotic syndrome (26%); unexplained renal failure (14%); acute kidney injury (4%); chronic kidney disease (4%). Monoclonality in serum was found in 58 %; Monoclonality in bone marrow was found in 45 % and in 34% there was no monoclonality either in serum or bone marrow. Sixty percent had MM and forty percent had MGRS. Most common renal pathology seen was cast nephropathy (36%). Light chain deposit disease (6%); amyloidosis (10%); Cryoglobulinemic glomerulonephritis (2%); Proliferative glomerulonephritis with monoclonal immunoglobulin deposit disease (2%); Light chain proximal tubulopathy with amyloidosis (4%). Seventeen patients (36%) were treated with bortezomib. Mortality was 26%.

CONCLUSIONS: Most common presentation was rapidly progressive renal failure. Most common pathology seen was cast nephropathy. Patients with cast nephropathy had poor outcome.


  107. Non Invasive Continuous Monitoring of Arterio-Venous Fistula Using Bio-Sensors in Chronic Kidney Disease Patients: A Novel Device Top


R Sowrabha, Raviprakash Deshpande, M Limesh, T Prashanth

Department of Nephrology; St. Johns Medical College and Hospital; Bengaluru; Karnataka; India

BACKGROUND: Primary AVf failure is around 20-30%. Early recognition and timely revision of AVF failure is needed. Hence; we have come out with a novel devise to monitor early AVF failure.

AIM OF THE STUDY: Aim of the study: To develop a novel sensor (wearable device) for continuous monitoring of the Patency; rupture and optimal functioning of the AV fistulas in patients on hemo dialysis.

METHODS: The data (temperature; thrill; Bruit) will be collected from the wearable sensor and also ultrasound study will be carried to characterise the fistula and correlate with the data measured by the sensor tag. Validation will be carried out both in lab experiments and by ultrasound imaging.

RESULTS: Description: The physiological nature of the Av-fistula in terms of surface temperature above the fistula; thrill and bruit in a patient will be measured. From these; three data sources obtained; a composite patient specific index on the health of the fistula will be calculated. This index will be regularly compared with routine data that will be sampled on an hourly basis and any deviation (+-2SD) from this will be considered as abnormal and a visible indication will be provided on the wearable device. On observing the visible indication of adverse change; the patient has to meet his nephrologist for early management of avfistula failure and prevent complete occlusion of the avfistula.

CONCLUSIONS: The electronics will be housed in silicon skin friendly jacket and applied just above the avfistula. The wearable device will be 45 mm sq in area and will have a thickness of 6 mm.


  108. Histopathological Spectrum of Renal Biopsies in Patients with Chronic Liver Disease Presenting with Renal Dysfunction Top


K B Shashikiran, Rajesh Goli, D Sree Bhushan Raju, G Anvesh, D Krishna Prasad, N Vamsi Krishna

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

BACKGROUND: Renal failure in patients with Chronic Liver Disease (CLD) can be multifactorial. Studies describing the pathological features of renal biopsy in these patients are sparse. This study describes the histopathological spectrum of renal involvement in patients with chronic liver disease.

AIM OF THE STUDY: To study the histopathological pattern of renal biopsies in patients with chronic liver disease and renal dysfunction.

METHODS: In this retrospective study patients with compensated chronic liver disease and renal dysfunction were included. Proteinuria >0.5 g/day and/or hematuria and/or unexplained high serum creatinine levels >1.5 mg/dl were the indications for renal biopsy. All biopsy specimens were examined by the same pathologist with light and immunofluorescence microscopy. Demographical; Clinical and histopathological data were recorded. Descriptive statistics was used and results were expressed as frequencies; percentages; and mean ± SD. Statistical analysis was carried out using SPSS ver. 20.

RESULTS: Over a study period of 2 years; 40 patients of CLD with renal involvement underwent renal biopsy. Male to Female ratio was 7:1. The mean age of patients included was 48.12 ± 1.5 years. Co-morbidities associated were hypertension in 57.5%; Diabetes Mellitus in 37.5% and both in 32.5%. Predominant etiologies of CLD in our patients were Alcoholic liver disease in 45% followed by Hepatitis B virus associated CLD in 22.5% and Hepatitis C virus associated CLD in 7.5%. Twenty eight (70%) them had associated glomerular disease; of which Ig A nephropathy (22.5%) was the commonest follow by Diabetic glomerulopathy (20%). Nonglomerular lesions like chronic injury of renal vessels and/or the tubulointerstitial system was found in > 70 % of cases. Complications noted were gross hematuria in 15% of patients and peri-nephric hematoma in 7.5%; none required blood transfusion or surgical drainage.

CONCLUSIONS: Renal biopsy is safe and can yield important diagnostic and prognostic information in patients with chronic liver disease presenting with renal dysfunction.


  109. Pattern of Direct Immunofluroscence Study in Idiopathic Primary Glomerular Diseases; Lupus Nephritis and Diabetic Nephropathy in A Single Centre of South India: 20 Years Experience Top


Uttara Das, K V Dakhinamurty, T Gangadhar, Aruna Prayaga

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

BACKGROUND: Direct Immunofluroscence (IF) study in renal biopsy plays a critical role in the diagnosis of glomerular diseases. It is a powerful adjunctive modality for adequate pathologic evaluation of renal biopsy and guide to differential diagnosis. Some of them are diagnosed exclusively on the basis of IF findings. Routinely used antibodies includes antibodies specific for IgG; IgA; IgM; kappa and lamda light chain; C3; C4; C1q; fibrin/fibrinogen.

AIM OF THE STUDY: This study was undertaken to analyze the pattern of IF deposits in different Primary glomerular diseases (PGD); Lupus nephritis (LN) and diabetic nephropathy (DN) in a single centre of south India.

METHODS: This cross sectional analytical study was conducted in Nizam's Institute of Medical Sciences during the period from January 1997 to December 2017 (20 years). All kidney biopsies with light microscopy (LM) and IF reports along with details of demographic; clinical and biochemical data were collected. All renal biopsy specimens obtained were prepared as per the standard protocol and examined by the same group of pathologists and technicians of our institute. Analysis included light microscopy (LM) and immunofluorescence (IF). For LM; three sections were stained with Hematoxylin and Eosin; one with periodic acid Schiff; one with Masson's trichrome; and one with Jones silver methanamine. Special stains were used when warranted. IF study was done by using polyclonal antisera (FITCconjugated Rabbit Antihuman Antisera manufactured by DAKO from Denmark) against human IgG; IgM; IgA; C3; C1q; and kappa and lambda light chains. Standard definitions of the clinical syndrome were used

RESULTS: Total no. of patients with complete data was 1946. Male:Female was 1.22:1. The mean age of patients was 32.37± 14.9 years. Frequency of predominant IF deposition in glomerular diseases are shown in percentage as follows: MCD (310): IgM 7 and IgG 2. FSGS (214): IgM 44; IgG 11; C3C 19; kappa in 3; lamda 3. MGN (188): IgG 100; IgM 44; C3C 34; C1q 5; kappa 53 lambda 48. IgAN (255): IgA 100; C3c 61; IgM 33; IgG 20; C1q 4; Kappa 29; lamda 42. DPGN (91): C3c 66; IgG in 60; IgM 34; C1q 10; kappa 19; lamda 14. FPGN (22): C3c 32; IgM 28; IgG 14; IgA 5; Cq1 5. MesPGN (79): IgM 50; C3c 33; IgG in 23; IgA 5; C1q 6 kappa 5; lamda 3. MPGN (52): C3c 77; IgG 54; IgM 44; c1q 29; IgA 23; kappa 13; lamda 6. CreasGN (70) : C3c 46; IgM 26; IgG 10; IgA 6; C1q 3; kappa 14; lambda 12. PIGN (107): C3c 71; IgG 69; C1q 17; IgA 10; kappa 13; lamda 12. LN (334): IgG 81; C3c 80; C1q 75; IgM 66; IgA 56; kappa 39; lamda 43. DN (56): IgM in 16; IgG 11; C3c 9; IgA 3; C1q nil; kappa 7; lamda 6.

CONCLUSIONS: IgM is mostly observed in FSGS; MesPGN and MGN. IgA is predominant in IgAN and LN; IgG in MGN; LN; DPGN; MPGN and PIGN; C3c in PIGN; MPGN; LN; and IgAN; C1q is predominant only in LN. Kappa and lambda are predominant in MGN; LN and IgAN. There are no predominant IF deposition in DN.


  110. Case Series on Hemolytic Uremic Syndrome in Patients with Snake Bite Top


Maria Bethsaida Manual, Ram R

Department of Nephrology; Sri Venkateshwara Institute of Medical Sciences; Tirupathi; Andhra Pradesh; India

BACKGROUND: Snake bite is an important health problem in tropical countries like India. Acute Kidney Injury occurs in around 5-30% of the cases with snake bite. Various causes include Acute tubular necrosis; Cortical necrosis; Interstitial nephritis; AGN and HUS. Hemolytic Uremic Syndrome (HUS) is one of the rare cause of AKI and includes triad of ARF; Hemolytic anemia with schistocytes and thrombocytopenia.

AIM OF THE STUDY: Study of the case series of 6 patients who presented to SVIMS; Tirupathi with features of HUS due to snake bite.

METHODS: The above mentioned patients were admitted in the nephrology department and analysed in terms of (Inclusion criteria)-1. history of snake biteExclusion criteria-1. Age of the patient 2. Gender 3. Socio-economic status 4. prior history of diabetes and hypertension 5. Preexisting renal problemsMethods-each patient was evaluated clinically and investigations like CBC; peripheral smaer; urine routine; Blood Urea; Serum Creatinine; liver function tests were sent. Patient were clinically monitored for the general condition; urine output and the records were maintained about the patients who underwent plasmapheresis and haemodialysis. Finally renal biopsy was done on the patients to look into the pathology at the microscopic level and the cause of the renal failure were analysed.

RESULTS: Laboratory parameters were showed to be abnormal with elevated LDH; schistocytes and thrombocytopenia in peripheral smear. All patients were initially managed with plasmapheresis. Renal biopsy was done; which showed fibrin thrombin in glomerulus with intense edema; suggestive of Thrombotic microangiopathy; interstitial nephritis and cortical necrosis. Patient presenting with abnormal elevated levels of Se. Creatinine levels took a longer duration to recover and had progressed to chronic kidney disease.

CONCLUSIONS: Patients presenting with snake bite and AKI with thrombocytopenia and hemolytic anemia; HUS should be considered; prompt diagnosis and early plasmapheresis to improve the renal outcome.


  111. Changing Profile in UTI Among Post Renal Transplant Recipients-A Single Centre Experience Top


A Poongodi, T Dinesh Kumar, R Shakthirajan, J Dhanapriya, N Malathy, T Balasubramaniyan, N Gopalakrishnan

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

BACKGROUND: Urinary tract is one of the known cause of morbidity in renal transplant recipients. This study was done to study the changing profile; among renal transplant recipients in Madras Medical College and Hospital.

AIM OF THE STUDY: To analyse the changing profile in risk factors in occurence of UTI; will help in formulation of preventive stratergies; in decreasing episodes of UTI.

METHODS: Retrospective analysis of recipients from 2008 to 2012; was compared with recipients from 2013 to 2017.

RESULTS: 2008-2012 No of patients with UTI is 46. No of episodes of UTI is 68.23% is DDRT.74% is LRRT.ATG was used as induction agent in 10%. Basiliximab in 6%. No induction in 84%. DGF was 21%. Commonest organism was klebsiella. 17% of UTI presented with urosepsis. Complicated UTI in 39%. Recurrent UTI was seen in 34%. 2013-2017 No of patients with is 62. No of episodes of UTI is 83. DDRT in 38%. LRRT in 62%. ATG as induction agent in 37%. Basiliximab in 31%. No induction in 32%. DGF in 54% of patients. Commonest organism is ECOLI. 16% of UTI; presented with urosepsis. Complicated UTI in 30%. Recurrent UTI was seen in 22%.

CONCLUSIONS: UTI is known; as one of the hospitalized reasons in renal transplant recipients. Defining the changing clinical profile will help in decreasing the episodes of UTI.


  112. A Study of Acute Kidney Injury Secondary to Rhabdomyolysis Top


Varun Mamidi, S Manikandhan, E Ramprasad, M Jayakumar

Department of Nephrology; Sri Ramachandra Medical College and Research Institute; Chennai; Tamil Nadu; India

BACKGROUND: Rhabdomyolysis is caused by injury to skeletal muscle and involves leakage of large quantities of nephrotoxic intracellular contents into systemic circulation. It is a type of pigment nephropathy. Acute kidney injury (AKI) is one of the serious complications of rhabdomyolysis. Here we report nine cases of rhabdomyolysis induced AKI secondary to various causes and their outcome from a single centre in south India.

AIM OF THE STUDY: To study and identify cases of acute kidney injury secondary to rhabdomyolysis and the clinical manifestations; laboratory profile and outcome.

METHODS: A retrospective observational study was performed on nine patients who presented with rhabdomyolysis induced AKI during January 2018 and February 2018. Their aetiology; clinical manifestations; laboratory profile and outcome were analysed. History; clinical examination findings; laboratory investigations and outcome were recorded.

RESULTS: 8 days. No deaths recorded in our study. Four patients (44.4%) progressed to CKD at a 3 months follow up.± 5.2 sessions. The most common metabolic abnormality was hyperuricemia. Mean duration of hospital stay was 12.8 ± 2.82 mg/dl respectively. Aetiology of rhabdomyolysis include infection/sepsis (2); poisoning (1); drug induced (2); illicit drugs (1); trauma (1); strenuous exercise (1); genetic disorder (1). Most common presenting complaint was myalgia (77.8%) followed by nausea/vomiting (66.7%). Six patients required haemodialysis (66.6%) during hospital stay and the mean number of HD sessions were 3.89 ± 3.0 mg/dl and 5.3 ± 27.7 years; 55% were males and 33.3% presented with oliguria. Mean serum creatinine at presentation and peak creatinine were 3.9 ± A total of nine patients were included with a mean age 50.

CONCLUSIONS: Rhabdomyolysis is an important cause of renal failure requiring HD. 33% of patients presented with oliguria and 66% required HD. Most common aetiology is drugs; followed by infection/sepsis. Four patients progressed to CKD; all of them belonged to elderly age group.


  113. Bedside Lung Ultrasound in The Assessment of Volume Status in Chronic Hemodialysis Patients Top


Asheesh Malhotra, Rajan Isaac’s, Timothy Rajamanickam, Subhash Singla1

Department of Nephrology; Christian Medical College; 1Department of Radiology; Christian Medical College and Hospital; Ludhiana; Punjab; India

BACKGROUND: Dry weight of patient with chronic kidney disease on hemodialysis is usually assessed by using clinical parameters (BP; edema etc); Biochemical parameters (BNP; ANP); Bioimpedance Spectroscopy and IVC diameter - collapsibility on ultrasound. Sonographic B-lines; also known as lung comets; have been shown to correlate with the presence of extravascular lung water. Our study aims to assess the usefulness of ultrasound chest for assessment of volume status in patients on maintenance hemodialysis.

AIM OF THE STUDY: To compare the efficacy of body fluid volume status and lung water assessment by clinical methods; Ultrasound chest and Bioimpedance Spectroscopy in chronic kidney disease patients on hemodialysis.

METHODS: A cross-sectional study was conducted at hemodialysis center in Department of Nephrology at Christian Medical College and Hospital; Ludhiana over a period of 6 months. Lung ultrasound using MicroMaxx Ultrasound System with a 6 Mhz vascular probe and Bioimpedance spectroscopy using Bodystat QuadScan 4000 was performed for each patient. A longitudinal ultrasound scan with patient in supine position; from second to the fourth intercostal space of the left hemi-thorax and second to fifth intercostal space of the right hemi-thorax in parasternal; midclavicular; anterior axillary and midaxillary lines of each side making a total of 28 sectors was performed before and after dialysis. The comet score was determined by calculating the total B-lines found in each examined site. Bioimpedance spectroscopy was also performed and total body water (TBW); intracellular water (ICW); extracellular water (ECW); residual fluid overload (ECW pre HD- ECW post HD) was recorded for each patient.

RESULTS: We conducted 100 assessments on 34 patients presenting to the hospital for maintenance hemodialysis. The mean age of the study population was 54.3 + 11 years with a sex ratio (M/F) of 6:1. Mean systolic blood pressure was 141.1 + 19 mmHg and diastolic blood pressure was 83 + 9.3 mmHg with 3 episodes of intradialytic hypotension. The mean dry weight was 59.8 + 10 Kg and weight gain by clinical assessment was 2.1 + 1.5 Kg. Residual fluid overload on Bio impedance spectroscopy was 1.11 ± 0.85 litre. Comet score assessed by chest ultrasound had a mean of 4.54 + 2.53 before dialysis and 1.73 ± 1.36 after dialysis. The residual fluid overload on Bio impedance spectroscopy and lung ultrasound comet score after dialysis had a significant correlation (p value <0.0001). Of the 100 assessments; 40% had fluid overload after dialysis with Bio impedance and 35% had lung congestion on ultrasound chest even after achieving euvolemia according to the dry weight assessed clinically.

CONCLUSIONS: Our observations strongly support the use of bedside lung ultrasound in estimating volume overload and monitoring the response to therapy in patients on dialysis. It can therefore help in decreasing the subjective errors of volume status assessment by clinical methods.


  114. Study of Recipient and Donor Profile of Renal Transplant Unit in SCB Medical College; Cuttack; Odisha from 2012 – 2016 Top


Bapu Nayak, C R Kar, S B Rout

Department of Nephrology; SCB Medical College; Cuttack; Odisha; India

BACKGROUND: Over 2 million people with CKD-ESKD worldwide currently receive treatment with dialysis or transplant. In India more than 500000 people die every year due to non-availability of organ. SCB Medical College is Govt. Hospital where live related kidney transplant programme has started from March 2012. Yearly in an average 30 transplants are done.

AIM OF THE STUDY: To study recipient & donor profile of patients who had undergone renal transplantion in SCB medical College; Cuttack from March 2012 to March 2016.

METHODS: The present study was undertaken with objective to study recipient & donor profile of patients who had undergone renal transplantion in SCB medical College; Cuttack from March 2012 to March 2016. The clinical profile of recipients and donors of 94 cases were studied retrospectively.

RESULTS: Recipient profile: Mean age - 35 years; Male – 92.5%; Married – 63.3%; Type 2 DM present in 21.3%; Hypertension in all patients; History of blood transfusion present in 30.8%; AV Fistula created in 80% of patients. Mean Hb – 8.75 gm; Blood group A+ve – 20.2%; B+ve – 27.6%; O+ve – 42.5%; AB+ve – 9.6%; mean duration for Tx-12.8 months; HCV and CMV positive in 5.3% and 3.2% respectively; crossmatch +ve in 4.25% Donor Profile: Mean age – 44.9 years; Female – 85.2%; Related donor – 85.1%; Unrelated donor – 14.9%; Mean Hb – 11.7 gm; Blood group A+ve – 20%; B+ve – 26.6%; O+ve – 46%; 38.3% HLA mismatch 3/6; mean length of right and left kidneys-94.6 mm; 96.3 mm by usg and 96.2 mm; 98.2 mm by CT angiogram; mean GFR of rt and lt kidney-40.2 and 39.8 ml/min respectively.

CONCLUSIONS: Most of the renal transplant recipient are male (92.5%) whereas most of the donors are female (85.2%) with mother (43.3%) & wife (26.6%) being the donor. Majority of recipient & donor have blood group O+ve.


  115. Rare Presentation of Anti-GBM Disease Top


Amandeep Singh, Vikas Makkar, P M Sohal, Suman Sethi, Simran Kaur

Department of Nephrology; Dayanand Medical College; Ludhiana; Punjab; India

BACKGROUND: Anti-GBM disease is rare with an incidence of approximately 1/1; 000; 000. It is an autoimmune disease with circulating antibodies against GBM epitopes in α3 chain of type IV collagen. It is characterized by a linear immunoglobulin G deposition along GBM on immunofluorescence microscopy along with cresents on light microscopy. We present here a rare case of Anti-GBM disease with no immunoglobulin deposition on IF.

AIM OF THE STUDY: To report rare presentation of Anti-GBM disease - Pauci immune cresentric glomerulonephritis.

METHODS: Patient; 42 year female presented to us with history of macroscopic hematuria and rapidly rising serum creatinine since 5 days. On diagnostic evaluation her Anti-GBM antibody came out to be positive with Anti-GBM titres of 1033. Her renal biopsy showed 11 glomeruli with 100% cresents (10 cellular; 1 fibrocellular); but IF does not revealed any immune deposits. She was treated with steroid and cyclophosphamide pulse along with plasmapherisis.

RESULTS: Patient does not recovered completely and was discharged with s.creatinine of 3.

CONCLUSIONS: Anti-GBM disease is rare. It presents with cresentric glomerulonephritis along with Ig deposits on GBM. Rarely Ig deposits can be missed due to severe destruction of GBM. This entity should be kept in mind to avoid misdiagnosis of pauci-immune cresentric glomerulonephritis in ant-GBM disease.


  116. Prevalence of Malnutrition and Inflammation in Nondialyzed Patients with Chronic Kidney Disease: A Clinical Study Top


Hamad Jeelnai, Manjuri Sharma, P J Mahanta, P K Doley, B Medhi, Manzoor Parry, Arunima Mahanta, Bishal Aggarwala, M Mastakim, A Shahzad

Department of Nephrology; Guahati Medical College and Hospital; Guahati; Assam; India

BACKGROUND: The prevalence of chronic kidney disease (CKD) in India varies from 0.16–0.78%. The reported incidence of malnutrition in CKD patients is 37–84%. The prevalence of inflammation is very high (30–50%) in end stage kidney disease (ESKD) patients. Inflammatory state in these patients is assessed by analyzing various markers. There is a paucity of data on the quantification of malnutrition and inflammation in undialyzed patients of CKD from north east of India.

AIM OF THE STUDY: This study analyzed the prevalence and causes of malnutrition and inflammation in patients with CKD; before the Initiation of dialysis treatment.

METHODS: This prospective study was conducted from May 2017 to May 2018 in the department of nephrology Guwahati medical college hospital (a tertiary care hospital); assessment of nutritional and inflammatory status were carried out in patients with CKD before initiation of Dialysis. Serum albumin; body mass index (BMI); triceps skin fold thickness (TST); mid-arm muscle circumference (MAMC); and subjective global assessment (SGA) scoring were used for assessment of nutritional parameters. Serum C-reactive protein; serum albumin and serum ferritin level were used to assess the inflammatory status in these patient.

RESULTS: A total of 528 (male/female 359/169) patients with CKD participated in this study. Diabetic Nephropathy (35%) was the most common; followed by; HTN (23%) Chronic glomerulonephritis (20 %). The evidence of malnutrition was noted in 344 (65%). The mean age of patients with malnutrition was 52.8±12.45 years; with a male predominance (68%). On the basis of SGA score; malnutrition was noted in 344 patients (mild moderate [36%]; severe; [30%]); remaining (34%) were well nourished. Thus; evidence of Malnutrition was noted in 65% of patients with CKD.). Serum total protein & albumin were higher in the non-malnourished patients in comparison to malnourished (5.83±1.0 vs 5.31±1.12 p<0.05; 3.65±0.7 vs 2.62±0.74) The inflammatory markers ser.ferritin & C reactive protein were elevated significantly in patients with malnutrition in comparison to those without malnutrition (308.15±60.18 mg/dL vs. 251.64±63.14 mg/dL; p < 0.001; 77% vs. 50%; p < 0.01).

CONCLUSIONS: Malnutrition and inflammation are common in patients with CKD before the commencement of dialysis. This indicates that an emphasis should be placed on the assessment and prevention or correction of malnutrition and inflammatory burden in these patients with CKD.


  Poster Presentations – 22.12.2018 – 12.35- 13.35 HR Top



  1. Iron Deficiency to Iron Excess: Has The Pendulum Swung? Top


Print Kakde, Deepa Usulumarty, Komal Nagori, Geeta Billa, Ganesh Sanap, Shrirang Bichu, Parag Tilve, Vinayak Ukirde, Pankaj Jawandiya, Jatin Kothari, Rajesh Kumar, Viswanath Billa

The Apex Database; Apex Kidney Care; Sushrut Hospital and Research Centre; Bombay Hospital Institute of Health Sciences; Mumbai; Maharashtra; India

BACKGROUND: Anaemia management with parenteral iron and erythropoesis stimulating agents has become effortless; with the availability of inexpensive formulations. This has led to a largely unmonitored use of these agents in hemodialysis patients. The potential risk of over treatment by this approach can have serious consequences of iron overload.

AIM OF THE STUDY: To identify patients with iron overload in CKD population on MHD with contemporary iron supplementation protocols.

METHODS: We performed a multicentre; observational; cross sectional study enrolling a total of 70 patients. Inclusion criteria were age >18 yrs; exclusion criteria were: patients with catheters; patients with HIV/Hepatitis B/C. All patients underwent CBC; iron studies; lipid profile and liver profiles. Patients with serum Ferritin levels > 2000 ng/ml were suggested liver MRI to measure liver iron content.

RESULTS: Ten of 70 patients (14.28%) had serum ferritin levels > 2000 ng/ml suggestive of iron overload. Five of 10 patients (50%) had a haemoglobin concentration < 11 gm% despite very high ferritin levels. All 10 patients had ALT values more than 21 U/l (lower limit of normal in patients on MHD) with mean ALT value being 31.9 U/l. Three of 4 patients who underwent Liver MRI showed signs of iron overload while one showed splenic overload. No strong correlation was seen between haemoglobin vs TSAT (R=0.01) & haemoglobin vs ferritin (R=0.0028).

CONCLUSIONS: Unmonitored iron therapy can be counterproductive. Periodic surveillance of iron status is imperative. Elevated ALT in the absence of hepatitis can provide a clue towards iron overload. Normal values of ALT in hemodialysis patients are approximately half of that in the non hemodialysis population.


  2. Prospective Data on Changes in Cardiac Structure and Functional Parameters in Renal Allograft Recepients Top


Manpreet Kaur Jhingar, Vikas Makkar, P M Sohal, Suman Sethi, Simran

Dayanand Medical College; Ludhiana; Punjab; India

BACKGROUND: Prospective data on changes in cardiac structure and functional parameters in renal allograft recepients is scanty. Our hypothesis is that there should be improvement in cardiac function after renal transplantation. Thirty renal allograft recepients will be included. Patients with valvular heart disease and coronary artery disease will be excluded. Echocardiography will be done before renal transplant surgery and repeated at 3 months and if possible 6 months after renal transplantation.

AIM OF THE STUDY: To document any improvement in the cardiac function after renal transplant.

METHODS: Thirty renal transplant recepients had mean age of 38.52 (range 16-69) that 54.7% were men and the mean duration of dialysis was 3.74 years. There were significant differences after 3 and 6 months compared with before kidney transplantation. The results of this study appeared that kidney transplantation had a positive effect on the cardiovascular status of patients with ESRD and improved the cardiac function of these patients.

RESULTS: Mean left ventricle ejection fraction before and after renal transplantation was 53.83+- 10.14% and 57.33+-4.49% respectively (p=0.09). Left ventricular hypertrophy; LAH existed in 46.7% patients which was improved in 30% after renal transplantation. It is suggested that renal transplantation could improve left ventricle parameters in patients with ESRD.

CONCLUSIONS: Transplantation. It is suggested that renal transplantation could improve left ventricle parameters in patients with ESRD.


  3. Sociodemographic and Clinical Profile of Post-Transplant Erythrocytosis Top


Chinmaye Sapre, K Praveen Kumar, Varaprasad Rao, Raghavendra

Narayana Medical College; Nellore; Andhra Pradesh; India

BACKGROUND: Post-transplant erythrocytosis (PTE) is defined as a hematocrit persistently above 51% after a renal transplant. The incidence of post-transplant erythrocytosis is 10-15%. It is most commonly seen after 8-24 months after transplant.

AIM OF THE STUDY: To find the clinic demographic profile and ore transplant factors affecting development of post transplant erythrocytosis.

METHODS: This is a retrospective descriptive study. Patients undergoing transplant had their baseline characteristics evaluated at the time of the transplant. These patients were screened and patients fitting the inclusion criteria were included in the study. These cases were matched with controls with similar baseline characteristics. Univariate regression analysis was used to find correlation of different factors associated with PTE.

RESULTS: Total 84 transplants were done of which 7 patients developed PTE (incidence=8.3%). Out of the 7 transplants 5 were live related transplants and 2 were deceased donor transplant. The statistically significant pre transplant factors associated with PTE were presence of smoking; pre-transplant iron and erythropoietin supplementation (p value <0.05). Presence of HTN; male gender; native kidney in situ and pre transplant duration of HD were all found to be associated with PTE but were not statistically significant. Testosterone levels in patients with PTE showed no elevation. No patient in the PTE was found to have renal artery stenosis. Two patients PTE reverted spontaneously and two patients PTE subsided after starting angiotensin converting enzyme inhibitor. Three patients needed phelobotomy as they did not respond to pharmacological treatment.

CONCLUSIONS: PTE is an uncommon complication seen post renal transplant. Factors predictive of PTE are pre-transplant presence of smoking; erythropoietin supplementation and iron supplementation.


  4. Evaluation of Safety and Effectiveness of Tunneled Hemodialysis Catheters: A Prospective Observational Study Top


Rohan Dwivedi, G Anvesh, Sree Bhushan Raju

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

BACKGROUND: The tunneled hemodialysis catheters are indicated in cases requiring long term catheterization (3 weeks or more). The catheterization which is not guided by a fluoroscopy is quite challenging to a nephrologist.

AIM OF THE STUDY: To study association of inflammatory markers with culture positivity in CAPD patients.

METHODS: A prospective observational study was conducted in 120 patients of chronic renal failure with AVF failure or awaiting AVF from May 2015 to Jan 2018. Tunneled hemodialysis catheters were placed without fluoroscopy guidance by a skilled nephrologist after ensuring the stable hemodynamic status of the patient and adequate dialysis 24 hours prior to the procedure. The patency of the cervical veins is checked with the help of ultrasonography.

RESULTS: 120 catheters were placed in 73 males and 47 females with a success rate of 97.5%. The patency of catheter ranged from 15 days to 18 months. There was no mortality during the procedure. The catheter was removed in 70 patients (58.3%) and 37 (30.8%) are on catheter till date. The indications of removal were AVF maturation in 48 (40%); underwent transplant in 15 (12.5%); absent flow in 5 (4.1%); refractory sepsis in 4 (3.3%) and deep venous thrombosis in 1 (0.8%) patient. 10 patients were expired during the course of the treatment. Various indications for the TCC were multi-access failure in 10 patients (8.3%); low caliber vein in 60 patients (50%); poor access to dialysis Centre in 5 patients; old age in 20 patients (16.6%); diabetes in 15 patients (12.5%); CAPD failure in 10 patients (8.3%). Catheterization was done through Right internal jugular vein 113 (94.1%); left Internal Jugular Vein in 4 (3.3%); Right subclavian in 2 (1.6%) and 1 left femoral (0.8%).

CONCLUSIONS: The success rate of the procedure is 97.5%. The TCC were in situ for 3 to 6 months in 58.3% and for 6 months in 10 % cases. Although there were few complications (16.6%); the procedure can be considered safe by a skilled nephrologist in the absence of Fluoroscopy.


  5. Hearing Abnormalities in Patients with End Stage Renal Disease in Correlation with Audiometry Findings Top


B Rajasekhar, Vikram Kumar, Manjusha Yadla

Gandhi Medical College; Hyderabad; Telangana; India

BACKGROUND: Hearing loss among patients with ckd has been a common finding in multiple studies. In patients with CKD; multiple risk factors have been hypothesized to cause hearing loss including too toxic medications; hypertension; diabetes mellitus. Vitamin D deficiency might be contributing factor to cause hearing loss in renal failure. The objective of the study is to assess the hearing abnormalities in patients with ESRD on MHD and to correlate vitamin D levels with hearing loss.

AIM OF THE STUDY: To asses the hearing abnormalities in patients with ESRD on maintenance he o dialysis and to correlate the serum vitamin D levels with hearing loss.

METHODS: This was a hospital based crosssectional observational study conducted in a teritiary care teaching hospital. Cases were evaluated in nephrology unit and ENT ops. The study comprised of 200 patients with CKD on maintenance hemodialysis. Patients are examined clinically including the systems of the body followed by bedside hearing abnormality evaluation by rinses and Weber's test. Blood parameters including hemoglobin; sodium; pottaisum chloride were also analysed.

RESULTS: In the present study of 200 CKD patients on MHD 124 patients had mild SNHL; 28 patients had moderate SNHL. Mean duration of CKD was 12.2 months in the mild SNHL group and 13.1 in moderate SNHL group. Mean vintage of dialysis was 10.3 months in mild SNHL group and 10.0 months in moderate SNHL group. In the present study 100 patients vitamin D levels were assessed out of which 23 were vitamin D deficient; 30 Were vitamin D insufficient; 47 Patients had sufficient vitamin D levels. In the present study in the vitamin D deficient group 6 patients had normal hearing; 15 patients had mild SNHL; 2 patients had moderate SNHL. In the Vitamin D insufficient group 4 had normal hearing; 15 had mild SNHL; 7 had moderate SNHL; 4 had severe SNHL.

CONCLUSIONS: The present study showed that SNHL is present in 82.5% of the patients on MHD. Mild SNHL was common. Hearing loss is of high frequency range (2000-8000 hz). Diabetes mellitus and SNHL are found to have statistically a significant correlation.


  6. Nocturnal Intermittent Peritoneal Dialysis: A Preliminary Report from A Tertiary Care Centre in North Kerala Top


Amrutha Prabhakaran, M Sreelatha, T P Noushad, E K Jayakumar

Department of Nephrology; Government Medical College; Kozhikode; Kerala; India

BACKGROUND: The mode of RRT usually have great impact on the health and social well being of CKD patients. Automated methods of peritoneal dialysis have developed as alternative methods of treatment to CAPD. We review our experience of 12 patients treated with nocturnal intermittent peritoneal dialysis (NIPD) as mode of RRT.

AIM OF THE STUDY: Between August 2017 and July 2018 we treated 12 patients with NIPD. Patients undergo dialysis every alternate night with exchanges performed by an automated CYCLER machine (BAXTER).

METHODS: We use two 5 litredilaysate bags per session and perform 2 hour cycles. At the end of 3 months after enrollment we analysed the adequacy of PD. Solute clearance was calcultedPeritoneal KT = Daily drain vol* dialysate urea nitrogen BUN (midnight) *volumeRenal KT = 24 hour urine urea N2 BUN *VWeekly KT/V = (peritoneal kt/v *3)+ (renal kt/v * 7) Indications for NIPDMajority of these patients were suggested CAPD due to their co morbid illnesses. But they had no caregivers to do CAPD at home. Remaining patients were initiated on NIPD as bridge.

RESULTS: Most of the patients were relatively asymptomatic. 2 of them had persistent GI symptoms. With respect to volume status 9 of them were euvolemic and normotensive. 3 of them had symptoms of volume overload requiring frequent admissionsBiochemistry The mean hemoglobin was 7.7 g/dl and mean potassium was 4.3 meq/l. The phosphorus mean was 5.4 mg/dl and bicarbonate mean was 21. The mean weekly Kt/V was 2.47. Those with residual reanl function had good total Kt/V values. Only one patient developed peritonitis and was treated with culture sensitive intra peritoneal antibiotics. NIPD was well accepted by the patients with 9 out of 12 being very satisfied with it. The three patients dissatisfied were switched over to MHD. NIPD is a promising mode of RRT in our resource limited scenario. Its preferred for those with significant residual renal function. Compared to MHD less man power and water usage needed.

CONCLUSIONS: The two major problems of CAPD: relatively high incidence of peritonitis and the inconvenience of performing several manual exchanges a day is not there with NIPD. NIPD may be effective in cases where fluid removal by CAPD is ineffective due to increased peritoneal membrane permeability.


  7. Clinic0 Pathological Profile of Chronic Kidney Disease of Unknown Origin in Odisha Top


Rudrashis Samal, S B Rout, C R Kar

Department of Nephrology; SCB Medical College; Cuttack; Odisha; India

BACKGROUND: CKDU was defined as a chronic kidney disease without an identifiable etiology in those living in an area recognized to be endemic for CKDU for a minimum period of 5 years. This disease is characterized by it's disassociation with the well-known risk factors such as diabetes; hypertension or chronic glomerulonephritis. The disease remains asymptomatic; and usually presents as end stage kidney disease.

AIM OF THE STUDY: To identify clinicopathological features of CKDu in state of odisha by clinical evaluation and renal biopsy in all cases.

METHODS: A cross-sectional study was conducted; to determine the clinicopathological features of CKDu in state of odisha by clinical evaluation and renal biopsy in all cases.

RESULTS: The mean age of those affected by endemic CKDU was 42.5 ± 12.5 years and the male to female ratio was 3:1. The total number of renal biopsies done during the study period is 12. The predominant biopsy finding was presence of interstital fibrosis and tubular atrophy invoving more than 30 to 50% glomeruli in 10 patient (83.33%) and involving less than 30% glomeruli in 2 patient (16.77%). All patient presented with some degree of glomerular sclerosis. Severe degree of involement was seen in male patient (75%). About 80% of male patient had some degree of anaemia during time of biopsy. All female patient were asymptomatic at time of biopsy.

CONCLUSIONS: The study revealed that the overall pathology of CKDU was characterized by consistent presence of interstitial fibrosis with or without interstitial inflammation; tubular atrophy and glomerular sclerosis; viable glomeruli were unremarkable.


  8. Spectrum of Infections in Kidney Transplant Recipients with rATG Induction Top


Narinder Sharma, Manoj Kumar Singhal, Dushyant Nadar, Anuja Porwal

Department of Nephrology; Fortis Hospital; Noida; Uttar Pradesh; India

BACKGROUND: Infections account for significant morbidity and mortality after kidney transplant. There is an increase in the use of rATG induction in kidney transplant recipients worldwide; as well as in India. This study aims to look at the spectrum of infections in kidney transplant recipients with rATG induction.

AIM OF THE STUDY: To study the spectrum of infections in kidney transplant recipients with rATG induction.

METHODS: 109 consecutive kidney transplant recipients enrolled between 01/06/15 to 31/05/17 and followed till 31/5/18. 102 (94%) patients received rATG. Patients with high risk were given high dose rATG (> 4.5 mg/kg/day). Rest all patients were offered low dose rATG (<4.5 mg/kg; usually 3 mg/kg). All patients received CNI; MMF and steroids. CNI were started on dose of 0.1 mg/kg/day and titrated as per trough blood levels. MMF was started on initial dose of 1 gm twice a day; tapered to 500 mg thrice a day by post op day 8. Steroids were started at dose of 40 mg once a day and was reduced to 5 mg once a day by post op 2 month. Trimethoprim/Sulfamethoxazole (80 mg/400 mg) was given for Pneumocystis carinii pneumonia prophylaxis for minimum of 6 months. CMV Prophylaxis was given to patients with high risk (high dose rATG ie >4.5 mg/kg/day; D+R). Detailed assessment for infections and clinical profile was done during each follow up visit. Data was tabulated and statistically evaluated.

RESULTS: Mean follow up period was 1.2±0.8 year. Forty-two episodes of infections were recorded in thirty-five patients (32%). Mean period to first infectious episode was 7.25 ± 6.56 months. Of all infectious episodes; 21% were in initial 1st month; 38% were in 2nd-6th month and 41% were after 6 months. 9% of all patients had urinary tract infections. Gastrointestinal infections were recorded in 7% patients; lung infection in 5% patients; soft tissue infections in 5% and sepsis in 3% patients. 5% patients had herpes zoster; 3% patients had CMV infection. Other infections were recorded in 3% patients. Bacterial infections constituted 62% of all infectious episodes. 24% of all infectious episodes were virus related and 9% of all infections were fungal. A total of three deaths were recorded in study; all deaths were due to infections. Death censored graft survival was 97.6% at end of one year. Patient survival was 97.78% at one year.

CONCLUSIONS: We found that despite using rATG in most of our patients; the overall rate of infection in our study was low and is comparable to other studies. Hence we concluded that the overall net immune-suppression rather than the use of specific induction agent is the harbinger of infection.


  9. Non Alcoholic Fatty Liver Disease and Chronic Kidney Disease….Any Crosstalk? Top


Adelene Teena Manuel, Noble Gracious

Government Medical College; Thiruvananthapuram; Kerala; India

BACKGROUND: Evidence linking NAFLD to the development and progression of CKD isemerging as a popular area of scientific interest. The liver-kidney crosstalk in NAFLDincludes altered RAS system and 5'AMP activated protein kinase activation and its regulation of fetuin A and adiponectin andexcessive dietary fructose intake; which affects renal injury. In turn; the kidney reacts promoting further RAS activation; increased angiotensin II and uric acid production in a vicious cycle leading to fibrosis.

AIM OF THE STUDY: To study the prevalence of NAFLD among chronic kidney disease patients of all causes and theirassociation.

METHODS: A cross-sectional analysis of 500 patients with chronic kidney disease (CKD) attending theNephrology OPD; Govt. medical College; TVM was done and prevalence of non alcoholicfatty liver disease (NAFLD) assessed. A control group of 482 patients from MedicalGastroenterology department without CKD was also assessed. Age; sex; BMI; presence ofdiabetes mellitus; hypertension and dyslipidemia were matched. NAFLD was definedultrasonographically in the absence of ethanol intake; viral; autoimmune or other liverdiseases. CKD was defined as an estimated GFR of ≤60 ml/min/1.73 m2 or the presence ofalbuminuria in patients with eGFR>60 ml/min/1.73 m2 for more than three months. Data was analysed using SPSS program and Odd's ratio calculated and p value assessed.

RESULTS: Prevalence of NAFLD was 13.2% (66 out of 500) among CKD patients whereas it was 19.1% (92 out of 482) in those without CKD (odds ratio 0.6301; 95% confidence interval0.4466 - 0.8890; p=0.0085).

CONCLUSIONS: In our study; after adjusting for features of metabolic syndrome; ultrasound-diagnosed NAFLDis not significantly associated with prevalent CKD. Aggressive public health efforts areneeded to prevent and treat metabolic syndrome.


  10. Dialysis Nurse Driven Bedside Assessment of Peripheral Vascular Disease in Dialysis Patients: A Quality Improvement Project Top


Rajesh Kumar, G Virendra, A Mohd Shah, J Rachana, K Jatin, B Shrirang, B Viswanath, D Paras

Apex Kidney Foundation; Mumbai; Maharashtra; India

BACKGROUND: Peripheral vascular disease (PVD) is highly prevalent in dialysis patients and associated with increased mortality and morbidity. Early identification and intervention may help to decrease morbidity and amputation in prevalent dialysis patients.

AIM OF THE STUDY: The main aim of the study was to evaluate prevalence of PVD in dialysis patients by ABI method by dialysis technicians.

METHODS: Peripheral vascular disease was screened by bedside ankle brachial index (ABI) using handheld Doppler by trained dialysis nurse. The ABI was calculated by the ratio of ankle systolic BP divided by arm systolic BP. Subjects were divided into 3 categories according to their ABI values; low (ABI < 0.9); normal (ABI 0.9-1.3); incompressible (ABI >1.4). Systolic BP in upper extremity was measured on brachial artery of the arm contralateral to vascular access and in lower extremities on posterior tibialis artery.

RESULTS: Of the 281 subjects; 62 % were males. The average age was 53.5± 13.4 years. The average dialysis vintage was 3.3± 2.5 years. 31% had diabetes; 66 % had hypertension and 30 % had history of ischemic heart disease. 12 % reported history of smoking or tobacco use. Low ABI (<0.9; suggestive of atherosclerosis) was found in 12.5% subjects; normal ABI was found in 67.1% and incompressible ABI (suggestive of calcified vessels) was found in 20.3% subjects.

CONCLUSIONS: PVD is fairly common in dialysis patients. Among dialysis patients; 1-in-3 had either low ABI or incompressible ABI. This calls for quality improvement initiative in each dialysis unit to screen and monitor for PVD by dialysis nurses and facilitate early referral for timely intervention.


  11. A Rare Case Report of Acute Kidney Injury Due to Levofloxacin Induced Crystal Nephropathy Top


A Faizan, G Anvesh, Sree Bhushan Raju

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

BACKGROUND: Crystal induced acute kidney injury (AKI) is caused by the intratubular precipitation of crystals; which results in obstruction and AKI. Drugs are one of the frequent causes; which include fluoroquinolones. Levofloxacin is frequently used fluoroquinolone for the treatment of infections.

AIM OF THE STUDY: Judicious use of levofloxacin (IV/oral) in high risk patients.

METHODS: Case report.

RESULTS: 37 year old male with no comorbidities; presented to our hospital with oligo-anuria. He had received IV levofloxacin (500 mg OD) for 5 days with cumulative dose of 2.5 g. At admission routine investigations revealed haemoglobin 10 mg%; WBC 10400/mm3; platelete count 1.8 lakhs/mm3; serum creatinine 6.1 mg%; serum electrolytes were normal; calcium 9.1 mg%; phosphorus 4.1; Urine examination showed ph of 6.1 with trace proteins and no active sediments; 24 hour urine proteins was 100 mg/day. Ultrasound abdomen was unremarkable with bilateral normal size kidneys. His autoimmune workup was normal. Serum creatinine increased to 7.5 mg% during the ward course. So renal biopsy was performed; and light microscopy showed polygonal to needle shaped circumferential; luminal; refractive crystals in tubules; which showed reddish white polarization. He improved after 10 days with adequate hydration and supportive treatment without steroids and dialysis.

CONCLUSIONS: Levofloxacin rarely can cause crystal induced AKI in at risk individuals. Treatment is conservative with adequate IV hydration and prevention of alkalinisation of urine.


  12. Use of Graft Vessel for Dual Kidney Transplantation: A Novel Technique Top


Abhinav Seth, Ashish Sharma, Deepesh Benjamine Kenwar, Sarbpreet Singh, Gaurav Shankar Pandey, Vidyasagar Kallepalli

Department of Renal Transplant Surgery; Postgraduate Institute of Medical Education and Research; Chandigarh; India

BACKGROUND: There are three different surgical techniques for dual kidney transplantation (DKT) reported in literature. These are bilateral placement; unilateral placement with separate anastomoses and unilateral placement with patch anastomoses. However there are few disadvantages of these techniques. Bilateral placement leads to both sides being scarred and access for re-operation becomes more difficult. Unilateral placement with separate anastomoses and bilateral placement has a long operative period.

AIM OF THE STUDY: To discuss a novel technique of Dual Kidney Transplantation using donor graft vessel that has not been described in literature.

METHODS: In our technique the common iliac with external and internal iliac was harvested from the donor. During back table preparation of the graft the renal artery of right graft kidney was anastomosed with external iliac and left graft kidney renal artery was anastomosed to internal iliac. The common iliac artery was anastomosed to recipient's right external iliac artery. The renal veins were separately anastomosed to external iliac vein. This technique was used in two cases. The ureters were implanted in urinary bladder separately in one recipient and together in another recipient.

RESULTS: Case 1. A 56 year old female received DKT from a 60 year old diabetic male. The frozen section of the graft kidney revealed 20-30% interstitial fibrosis and tubular atrophy. The cold ischemia time was 275 minutes and operative time was 187 minutes. Patient required two sessions of hemodialysis in post operative period. Patient urine output picked up on post day (POD) 5 and reached creatinine of 1 mg/dl on POD 14. Patient was discharged on POD 23. Case 2. A 49 year old male received DKT from a 63 year old hypertensive male. The cold ischemia time was 765 minutes and operative time was 192 minutes. Patient had adequate urine output and reached creatinine of 1.2 mg/dl on POD 7. Patient was discharged on POD 25. Both patients underwent computerized tomography angiography which did not reveal any thrombosis. Both patients have stable graft function at 5 month and 4 month follow up respectively.

CONCLUSIONS: With the help of this technique there is shorter operative time and easier placement of dual kidneys in right iliac fossa.


  13. Twice Weekly Versus Thrice Weekly Hemodialysis Top


Kapuriya Mayur Kumar, K C Praksh

Apollo Main Hospital; Chennai; Tamil Nadu; India

BACKGROUND: Chronic kidney disease is an emerging health problem in India; with an incidence of end stage renal disease (ESRD) reported to be 160–232 per million population. Few observational studies analyzed HD outcomes in India; particularly of the variance in practice compared to set norms of the developed world. However; there is a gap of knowledge of the clinical aspects of patients; mortay and morbidity in patients dialyzed twice weekly in India.

AIM OF THE STUDY: To compare the differences between the patients in twice weekly HD and thriceweekly HD.

METHODS: Study population included all patients aged more than 18 years on either thrice weekly or twice weekly regular maintenance HD. All the prevalent patients receiving dialysis for more than 3 months from Apollo dialysis centre were categorized into twice weekly hemodialysis and thrice-weekly hemodialysis. Following details were collected at the time of enrollment; at 6 months and at 12 months. Laboratory parameters; frequency of dialysis; duration in hours per week; SpKt/V and Standard Kt/v; hypotension episodes; modified SGA score; triceps skin fold thickness; mid arm circumference; pill burden and EPO use per week.

RESULTS: Out of total 200 patients who were satisfying inclusion and exclusion criteria; 83 patients were receiving twice weekly HD and 117 patients were receiving thrice weekly HD. The mean age of study population was 55.54 ±15.11 years. The mean dialysis vintage was 35.87 ± 27.53 months. The mean single pool Kt/v was high in twice weekly HD group compared to thrice weekly HD group. However; the mean standard Kt/v was high in thrice weekly HD group. There was high average interdialytic weight gain in twice weekly HD group. We found more episodes of hypotension in twice weekly HD group. The mean total pill burden as well as mean pill burden for hypertension was more in twice weekly HD group. We found more mean erythropoietin use per week in twice weekly dialysis. The mean number of admissions was more in twice weekly HD group compare to thrice weekly HD. There was no statistically significant deference in mortality in both groups.

CONCLUSIONS: Our study demonstrates that twice weekly HD is not superior mode for dialysis compared to thrice weekly.


  14. Unusual Case of Car Polish Poisoning Manifesting as AKI Top


Rajasekhar, Manjusha Yadla, Muzamil Latief

Gandhi Medical College; Hyderabad; Telangana; India

BACKGROUND: Acute kidney injury secondary to the ingestion of agrochemical poisoning is a known entity. AKI as a manifestation of carpolish poisoning is uncommon. Naphtha is a key ingredient of carpolish that is toxic. Exposure to naphtha occurs by inhalation or ingestion and predominantly have respiratory and CNS manifestations. Here we present a case of car polish (naphtha) poisoning with AKI as the predominant manifestation.

AIM OF THE STUDY: A 21 years old male with no previous comorbidities; came to the hospital with chief complaints of alleged history of ingestion of carpolish 48 hours before getting admitted in our hospital.

METHODS: Following the ingestion of carpolish the patient was given gastric lavage and later the patient had three to four episodes of vomiting. The patient had no history of oliguria; hematuria; dyspnea. On routine evaluation the patient was found to have elevated renal parameters; with mild hyperkalemia. In view of elevated renal parameters with acidosis he was initiated on hemodialysis.

RESULTS: The patient was supported by 4 sessions of hemodialysis was given; following which the patients renal parameters improved; acidosis settled and the patient was discharged in a stable condition.

CONCLUSIONS: Car polish manifesting as AKI is rare and there are very few case reports of the same. The exact pathophysiologic mechanism by which car polish (naphtha) causes AKI is unknown.


  15. Profile of Delayed Graft Function in Renal Allograft Recipients at A Tertiary Centre; South India Top


Neeharika, Swarnalatha, Uttara Das, Raja Karthik, T Gangadhar

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

BACKGROUND: Renal transplant is the best treatment for end stage renal disease. Immediate post transplant period patients may have either immediate; slow or Delayed graft function. Whether this difference in graft function has any effect on long term outcomes not known.

AIM OF THE STUDY: To evaluate profile of Delayed Graft Function (DGF) among renal allograft recipients at a tertiary center in South India.

METHODS: Retrospective analysis of renal allograft recipients who underwent renal transplantation either live or deceased; from 2015-18 and assessed for graft function during immediate post-transplant period. Accordingly patients categorized into immediate; slow and delayed graft function. Patients were managed with Renal Replacement Therapy (RRT) either Hemodialysis (HD) or Peritoneal Dialysis (PD) till the adequate graft function achieved. All the patients were kept on maintenance triple immunosuppression. All the patients were followed up at regular intervals. Patients with DGF were included in this study. At each visit; renal function was assessed with clinical history; urine output monitoring and biochemical investigations. Patient outcomes were analysed in terms of stable graft function; graft dysfunction & its etiology; graft loss and patient loss.

RESULTS: Total number of patients who underwent transplant during study period-145; 14.5% (21) patients had DGF during immediate post-transplant period. Among these patients; males were 76%; females were 24%. CIN (23.8%); CGN (19%); DN (19%) were the most common etiologies for CKD. Average duration of cold ischemic time was 7.6 hours. For 95% of patients; induction agent being Basiliximab; for the rest ATG was given. Average serum tacrolimus level on day 4 was 8.5 mg/dl. Average number of HD sessions during DGF period was 5. Most common cause for DGF being ATN; AMR presented as DGF was seen in 10% of patients. Average duration of followup was 18.6 months. Infectious complications were common among these patients. Respiratory and urinary tract infections are most common among them. At the end of study; 76% patients had stable graft function; 10% had mortality; 5% had graft dysfunction. 5% had lost followup.

CONCLUSIONS: Though most common cause of DGF being ATN; Rejection should also be considered as one of the etiologies for DGF. Though DGF patients required RRT during immediate post-transplant period; short term outcomes were encouraging and requires further studies to assess the long term outcomes.


  16. Correlation of Kidney Dimensions at Ultrasonography with Demographic and Anthropometric Measurements in Healthy North Indian Adults Top


Shweta Bhardwaj, Ravinder Kaur, Sanjay D’Cruz

Department of Nephrology; Government Medical College and Hospital; Chandigarh; India

BACKGROUND: Sonography offers excellent anatomical details; and is the standard preliminary imaging modality to assess kidney size. Renal length; volume and cortical thickness measurements serve as surrogates for renal functional reserve. The nomograms available in the West cannot be extrapolated to our population. We aim to determine the ultrasonographic renal size in a group of healthy individuals with no known renal disease and correlate it with age; sex; height; body mass index and body surface area.

AIM OF THE STUDY: 1. To determine the ultrasonographic renal size in a group of healthy individuals with no known renal disease 2. To correlate it with age; sex; height; body mass index and body surface area.

METHODS: After baseline history and investigations to rule out hypertension; diabetes and chronic kidney disease; healthy adults were evaluated. Ultrasound images of both the kidneys were obtained in 511 subjects who took part in this cross sectional observational study at Government medical college and hospital Chandigarh; India. There were 202 female subjects and 309 male subjects. Length; width; and thickness of the kidney and of its central echogenic area were measured. Renal length was measured as the maximum bipolar dimension in longitudinal plane and in same plane the length of central echogenic area was measured. Width and thickness of the kidney and the central echogenic area was measured in section perpendicular to the longitudinal section. Cortical thickness was measured at upper pole; mid pole and the lower poleMean of the three readings was taken for each measurement. Volume of the kidneys was measured by appropriate formula; Volume = 0.5233 × (length × width × thickness).

RESULTS: Our study group (511 North Indian volunteers) showed a mean kidney length of the whole cohort irrespective of gender to be 9.6 ±0.7 cm of right kidney and 9.9±0.7 cm of left kidney. In our study; right renal length in males was 9.64±0.7 cm and in females was 9.51±0.7 cm; left renal length in males was 10.0±0.72 cm and in females 9.8±0.8 cm. In females renal length best correlated with BSA followed by weight and showed negative correlation with age and no correlation with height and BMI. RPV in female's best correlated with BSA followed by weight followed by BMI and negative correlation with age and no correlation with height. In males renal length best correlated with height followed by BSA followed by weight and negative correlation with age and no correlation with BMI. RPV best correlated with height followed by BSA followed by weight and negative correlation with age and no correlation with BMI.

CONCLUSIONS: Renal volume showed strongest correlation with BSA; weight and height. Renal length is more practical and showed strong correlation with BSA; weight. Renal size in our study population is different to commonly quoted normal values in literature and needs to be validated by population based studies.


  17. Cavitatory Pneumonia in A Renal Transplant Recipient- A Case Report Top


Niranjana Joy, M Jayakumar

Department of Nephrology; Sri Ramachandra Medical College and Research Institute; Chennai; Tamil Nadu; India

BACKGROUND: Invasive zygomycosis or mucormycosis is an extremely rare but potentially fatal infection following renal transplantation. Mucormycosis represents a small amount of IFIs in kidney transplants with incidence of 0.2–1.2%. The overall mortality rate of mucormycosis ranges from 38% to 56.5%. Mortality has been reported from 33% to 60% for isolated pulmonary infection; 10% to 17% for cutaneous infection; and 31% to 93.3% for rhinosinus infection (98% when disseminated to the central nervous system).

AIM OF THE STUDY: Diabetes mellitus; Immunosuppression status; renal failiure; CMV infection are risk factors for mucormycosis.

METHODS: A 59 yr Male with ESRD on dialysis; Diabetic nephropathy; underwent renal transplantation (Spouse donor). ATG induction given; on Triple Immunosupression. Discharge Creat -0.8 mg/dl. After 5 months patient presented with Cough with expectoration for 5 days; no hemoptysis. Vitals:normal. Systemic examination:RS:-B/L crepts+.other systems normal. Investigations: Basic investigations revealed anemia with normal total counts. RBS 384 mg/dl; HBA1c 8.1. Creat-1.2 mg/dl. USG Abdomen-normal. Urine culture; Blood culture-No growth. CMV PCR- 24; 500 copies/ml. CT- Thorax - Thick walled cavity 5*5.7 cm in posterior basal segments of left lower lobe. BAL fluid:Gram stain; AFB stain-Negative. KOH stain-negative. Fungal culture-No growth. Galactomannan index-<0.5. Β-D-Glucan-23 pg/ml. CT guided lung biopsy -Acute &chronic inflammatory infiltrate with lymphocytes and eosinophiles. Foci of broad aseptate fungal hyphae with irregular branching- MUCOR Special stains and PAS-Positive. IHC for CMV-Negative.

RESULTS: The incidence of mucormycosis in renal transplant recipients ranges from 0.2%-1.2%. The above patient had many risk factors such as use of induction agent; immunosuppression status; renal failure; CMV infection; uncontrolled diabetes mellitus. Pulmonary involvement in Solid organ transplant recipients accounts for 39% of cases. CT features of pulmonary mucormycosis in SOT recipients includes consolidation or mass-like lesions; nodules; or cavities. Initially BAL done was inconclusive and diagnosis was made after tissue biopsy which is gold standard for diagnosis. Amphotericin B (AmB) is considered the drug of choice. Patient was started on inj. amphotericin; inj ganciclovir and immunosuppressants were reduced. Mortality associated with mucormycosis may be in part due to delays in diagnosis and initiation of appropriate therapy. Surgical resection is associated with improved outcomes. Patient. S. creat 0.9 mg/dl on discharge.

CONCLUSIONS: Early diagnosis; aggressive surgical debridement; in conjunction with an intravenous antifungal therapy and immunosuppression reduction or withdrawal have favourable outcome.


  18. Infective Endocarditis in Hemodialysis Population- Experience from Center in India Top


Amit Kumar, Sunil Parkash, Ashwini Goel, Ganesh Dhenuka, Satynder

Department of Nephrology; BLK Super Speciality Hospital; New Delhi; India

BACKGROUND: Hemodialysis (HD) population is at increased risk for infective endocarditis (IE) due to impaired nutrition and vascular access; with its associated morbidity and mortality.

AIM OF THE STUDY: Aim of present study is to analyze incidence of Infective endocarditis in hemodialysis population in India.

METHODS: This was retrospective analysis from BLK Hospital. Data was collected from May 2015 to April 2018. All patient who underwent maintenance dialysis with a diagnosis of CKD were included. Patients diagnosed with Infective endocarditis based on clinical as well as echocardiographic (trans thoracic (TTE) or trans esophageal (TEE) criteria were identified. There demographic parameters; clinical presentation; and clinical outcome was recorded.

RESULTS: Total 457 patient with CKD underwent maintenance dialysis in this period. Of which 6 patient (1.31%) developed infective endocarditis. Mean age was 41.3 years. 4 were male and 2 patients were female. 3 patients had temporary dialysis catheter; one had permacath and 2 had Arterio-venous fistula as vascular access. Average duration on dialysis was 10.3 months. Duration of fever before diagnosis was 18.3 days (range 7 to 45 days). A pre-existing heart disease was present in 1/3rd of patients. Staph Auerus was identified in 2 and both were on dialysis catheter. Staph epidermiditis was identified in 1 patient and blood cultures were sterile in three. Only 1 patient was diagnosed with trans thoracic echocardiography while trans esophageal echocardiography was required in 5. Aortic valve was involved in 3; mitral valve in 2 and tricuspid valve was involved in one patient. One patient expired; rest survived.

CONCLUSIONS: Infective endocarditis in not uncommon in Indian population and diagnosis is often delayed. Resulting in high morbidity and mortality. High Index of suspicion is required for early diagnosis. When suspected trans esophageal echocardiography should always be considered.


  19. C1Q Nephropathy in A Case of Heroin Addict Top


Pinaki Mukhopadhyay, P Banerjee

NRS Medical College and Hospital; Kolkata; West Bengal; India

BACKGROUND: Heroin induced glomerulopathy is not well studied and c1q nephropathy is rare.

AIM OF THE STUDY: To study the effect of Heroin in kidney.

METHODS: 28 year old male was presented with progressive generalized anasarca for the first time. He was addicted to heroin for 6 months. There were no H/O hypertension; Diabetes; hypothyroidism. On clinical examination BP was 130/70 mmhg and bilateral pedal pitting edema. There was no anaemia or jaundice. On Blood examination Hb-13.5 gm/dl; TLC-7800; Creatinine-1.3 mg/dl. Serum total protein and albumin was 5.2 gm/dl and 2.1 gm /dl respectively. Among lipid profile total cholesterol was 256 mg/dl; Triglyceride was 350 mg/dl. Other parameter was Serum antinuclear and anti-DNA antibodies; antineutrophil cytoplasmic antibodies (ANCA); HIV; Hepatitis B and C serology; were negative. liver enzymes an complement were all normal. Urine RBC was 4-6 /hpf otherwise normal. urine culture was negative. 24 hour urine protein was 9 gm/day. Renal and abdominal ultrasonography was normal.

RESULTS: The histopathological study revealed DPGN; with moderate increase of mesangial matrix; The IF was positive (dominant) for Clq (+++) and IgA; IgG; IgM; C3++; all of them with a granular mesangial distribution. Ultrastructural findings were pedicelar effacement and paramesangial electron-dense deposits. Tubular reticular inclusions (TRI) were not found. He was treated with steroid; telmisartan and oral cyclophosphamide in some center but after 3 months though creatinine was 0.9 mg/dl; 24 hour urine protein was 5.8 gm/day. No remission was achieved. Then he was evaluated again and tacrolimus was started (0.05 mg/kg/day); keeping TAC Co level between 3-7 ng/dl. The patient remains with normal renal function and achieved complete remission by 4 months of therapy and continued for another 4 month with tapering dose. He was continued with telmisartan and followed up.

CONCLUSIONS: Even after one year of stoppage of cytotoxic drug there was no relapse. Patient is still in remission phase. He was psychologically evaluated and not taking any abusal drug and completely well. C1q nephropathy though rare can be managed if diagnosed correctly.


  20. Spectrum of Biopsy-Proven Renal Disease in The Pediatric Age Group Top


K B Shashikiran, Rohan Dwivedi, D Sree Bhushan Raju, D Krishna Prasad, G Anvesh, N Vamsi Krishna

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

BACKGROUND: Kidney biopsy is a very important tool in the armamentarium of a Nephrologist. It has important implications on early diagnosis; therapeutic interventions and prognostication of renal diseases. This study describes the histopathological spectrum of renal diseases in children.

AIM OF THE STUDY: To study the distribution pattern of glomerular diseases in children.

METHODS: This is a retrospective review of medical records of all children who underwent renal biopsy between January 2017 to August 2018 in Nizam's Institute of Medical Sciences. Patients from department of Nephrology and Rheumatology were included. The clinical; laboratory and hisopathological data were recorded. All biopsy specimens were examined by the same pathologist with light and immunofluorescence microscopy. Electron microscopic analysis was performed only in selected cases. Descriptive statistics was used and results were expressed as frequencies; percentages; and mean ± SD. Statistical analysis was carried out using SPSS ver. 20.

RESULTS: A total of 189 biopsies were done in children aged below 18 years. The biopsy was inadequate in 16 (8.4%). 173 of them were included in the final analysis. The mean age of children who underwent renal biopsy was 13.6 years (Youngest being 3 years 2 months). Seventy nine percent of our patients were adolescents and females outnumbered with; M: F ratio of 1:1.2. Nephrotic syndrome (39.6%) was the most frequent indication for kidney biopsy in children. The most common secondary renal disease was Lupus Nephritis seen in 22.2 % followed by Henoch Schoenlein Purpura nephritis in 3.1% of the cases. Primary glomerulopathy was noted in 74.5 % of patients. The most common primary glomerular disease noted in our study was Minimal change disease occurring in 21% followed by Ig A nephropathy in 13.1%. The kidney biopsy was normal in 4.1% of our patients; 1 patient had acute cortical necrosis and 1 patient with features of CNI toxicity.

CONCLUSIONS: The importance of renal biopsy in management of glomerular diseases cannot be over emphasized. Nephrotic Syndrome still continues to be the most common indication for renal biopsy in children and Minimal Change Disease being the most common primary glomerular pathology.


  21. Rare Presentations of Hypertension in Infants Top


Sonia Sharma, A P Mehta, P Sidana, A Chitakara

Max Hospital and PSRI Hospital; New Delhi; India

BACKGROUND: Hypertension in newborn & infants is a rare phenomenon with incidence of 0.3 to 2 % and most often results due to renovascular and intrinsic renal diseases.

AIM OF THE STUDY: Highlighting infantile presentation of hypertension.

METHODS: Case1:. A- 35-week – late preterm newborn-boy weighing appropriate for gestational age from non-consanguineous marriage was diagnosed with hypertension after an initial life-threatening event on day 3 of life. Hemodynamic instability due to cardiogenic shock event was managed & showed early reversal with gradual increase in blood pressure in subsequent days. Contrast angiogram revealed upper segmental infarct of left kidney with bilateral renal artery stenosis. Antihypertensive therapies were weaned gradually with spontaneous resolution in later infancy. Baby is thriving well post one - year after initial event.

RESULTS: Case 2:3 months–female-term /B.W 3.5 kg/ consanguineous marriage /presented with prior diagnosis of neonatal cholestasis & hypothyroidism for concern of polyuria; polydipsia; AKI & hyperkalemia. Her weight: 4.1 kg (25th centile); length 54 cm (75th centile). PR: 154/min; RR: 36/min; BP: 138/ 70 mmHg (>99th centiles). Investigations: Urea: 92 mg/dl; Creatinine: 1.42 mg/dl; Sodium: 134; potassium: 6.2 albumin: 3.9 gm/dl; urine r/m: nil protein & RBC; Normal AG metabolic acidosis (pH: 7.25; Bicarbonate: 14.3; lactate: 1.2). Focused exom sequencing revealed the diagnosis. NPHP3 (Renal-hepatic –pancreatic dysplasia) mutation; exon13; c. 1985+5G>A homozygous mutation.

CONCLUSIONS: Early recognition and intervention for hypertension in infancy improve long term outcome.


  22. A Study on Prevalence of Sleep Disturbance and Factors Affecting it in CKD-5 Patients on Maintenance Hemodialysis Top


Avinash Ignatius, Shubhangi Jagtap-Karmakar, Avinash Ignatius, Suresh Sankar

Department of Nephrology; DaVita Care Pvt Ltd.; Bengaluru; Karnataka; India

BACKGROUND: Sleep disturbance has a significant impact on quality of life of chronic kidney disease (CKD) patients on regular hemodialysis.

AIM OF THE STUDY: To measure the prevalence of sleep disturbance in CKD patients on maintenance hemodialysis and to examine the factors associated with sleep disturbance.

METHODS: Prevalent Dialysis patients at two DaVita Dialysis units with dialysis vintage of more than 90 days who consented to participate were included in the study. Demographic data; co-morbidities; access type; dialysis frequency; dialysis vintage and adequacy of dialysis (by Kt/v) were recorded. Quality of sleep was measured using the Pittsburgh Sleep Quality Index (PSQI). Poor Quality of sleep was defined as PSQI index>5. The quality of sleep was correlated with above factors.

RESULTS: 118 maintenance dialysis patients were included in the study. male-female ratio was 75:43. All patients were from two units of DaVita Pune region. Mean age of the patients was 59.47 years. Mean vantage of dialysis is 3 years. Fifty-four patients (45.76%) had ‘poor sleep’ defined as a global PSQI score>5. Nine factors were statistically measured to find out significant relationship with poor sleep. Eight out of these; namely; gender (P = 0.07); age (P = 0.89); diabetes (P = 0.35); hypertension (P = 0.74); comorbidity (P = 0.25); dialysis access (P = 0.21); dialysis frequency (P = 0.79); dialysis vintage (P = 0.75) showed no significant relationship with quality of sleep. However; there was a statistically significant relationship between the global PSQI score of >5; which was dialysis adequacy (kt/v) (P = 0.012).

CONCLUSIONS: In this study low adequacy of dialysis is shown as major factor relating to poor Quality of sleep in CKD patients on hemodialysis. However this study is limited by the number of patients and absence of long term follow up to completely exclude other factors.


  23. Bilateral Perinephric Collection in A Young Female: Is It A Vasculitic Masquerader? Top


Renju Binoy, Himansu Sekhar Mahapatra, Lalit Pursunani, Himanshu Verma, Muthu Kumar

Department of Nephrology; Dr. RML Hospital; New Delhi; India

BACKGROUND: Bilateral perinephric collections which is very unusual presentations of Polyarteritis Nodosa (PAN); Bilateral renal lymphangiectasia and Tuberculosis. Here we present such type of a case which was a diagnostic difficulty but improved on conservative management.

AIM OF THE STUDY: A case report of bilateral perinephric collection; which was thoroughly investigated to find out the diagnosis.

METHODS: A case report.

RESULTS: We were able to establish the perinephric collection as benign renal lymphangiectasia after ruling out all the other possible diagnosis.

CONCLUSIONS: This is a rare case of bilateral renal lymphangiectasia; improved on conservative management but necessitate thorough investigation to rule out other treatable causes.


  24. Renal Tuberculosis in Adult Polycystic Kidney Disease - A Case Report Top


C Shakthikumar, K Sampath Kumar, Andrew Deepak, Anandhan, Kadir Selvan

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

BACKGROUND: The association between ADPKD and tuberculosis has rarely been reported and is related to a more unfavorable course since the infection becomes refractory to specific treatment. Transplantation may also pose a problem in these patients because quiescent foci may get reactivated.

AIM OF THE STUDY: TB of ADPKD kidneys is rare and diagnosis and treatment is difficult because numerous cysts are infected and antibiotics do not easily penetrate the cysts. Only very few case reports are available.

METHODS: 41 year old male patient k/c/o ADPKD/ESRD on hemodialysis was admitted with chief complaints of abdominal distension for the past 1 month duration associated with fever and chills + rigors. USG and CT abdomen showed enlarged liver of size 25 cm with multiple cysts of varying sizes replacing the liver parenchyma. Right kidney was 14.1 x 6.7 cm with multiple cysts. Left kidney was 21 x 7.7 cm with multiple cortical cysts of varying sizes and few cysts showing calcifications/hemorrhage within. Moderate ascites was present and few enlarged lymph nodes were present in the paraaortic region. Nephrectomy was planned as patient had worsening abdominal distension and abdominal pain. Left nephrectomy was done as left kidney was larger than the right.

RESULTS: Entire kidney showed cysts filled with serous fluid; few of the cysts filled with hemorrhagic material and others showed purulent and necrotic material. Sections show renal parenchyma with glomeruli and tubules with multiple cysts lined by flattened epithelial cells and filled with eosinophilic fluid. Multiple caseating granulomas with epithelioid cells and langerhan type of giant cells seen. Extensive areas of haemorrhage into cysts and fibrosis were seen. Sections from renal artery and ureter show no significant pathology. Special stain - AFB was Positive. Patient was diagnosed to have Tuberculosis of polycystic kidney and was started on 4 drugs ATT (Isoniazid; Rifampicin; Pyrazinamide and Ofloxacin). Post operative course was uneventful and fever settled. He was discharged in a stable condition. Right nephrectomy was planned at a later date.

CONCLUSIONS: Renal TB should be recognized as a cause of renal infection in ADPKD; and surgical treatment should be instituted without delay.


  25. Role of Serum Uromodulin As A Noninvasive Biomarker for Intact Tubular Mass in Immuglobulin A Nephropathy Top


K Krishnakumar, M Sreelatha, T P Noushad, E K Jayakumar

Department of Nephrology; Government Medical College; Kozhikode; Kerela; India

BACKGROUND: Uromodulin; released from tubular cells of the ascending limb and early distal tubule into the blood; might represent a promising biomarker for the number of intact nephrons.

AIM OF THE STUDY: We estimated serum uromodulin levels in normal subjects and patients with IgAN. We also correlated Uromodulin levels with degree of IFTA in IgAN and with conventional biomarkers of renal function.

METHODS: The study group comprised a total of 75 patients divided into 3 arms-25 normal controls; 25 patients with moderate (T1) IFTA and 25 patients with severe IFTA (T2) in biopsy proven IgAN. Serum uromodulin levels were assessed using a ELISA kit.

RESULTS: Among 75 cases enrolled 58.7% were males. Mean uromodulin levels in the control; T1 and T2 arms were 295.11; 213.90 and 97.98 ng/ml respectively. The cumulative average serum uromodulin levels in females was higher compared to males. Most of the analysed variables had statistically significant correlation with uromodulin levels in univariate analysis. Significant negative correlation was noticed between S. uromodulin levels and blood urea; S uric acid; S. cholesterol and S potassium values. significant positive correlation was noticed between S. uromodulin levels and hemoglobin level. Multiple linear regression modeling was applied to establish the association between uromodulin and other variables. All the predictors analysed in the regression model were found to statistically significantly predict S uromodulin values among which total cholesterol; eGFR and control of BP added significantly to the prediction at a p value of less than 0.05. [R square change 0.503].

CONCLUSIONS: We conclude that serum uromodulin is a novel non invasive kidney-specific biomarker to assess the structural integrity of the nephron; chronicity of the disease and renal function.


  26. A Rare Association of Pathological Variant of Alport Syndrome Caused by Hemizygous 5’ Splice Mutation in Intron 10 of COL4A5 Gene with Metachondromatosis Due to Heterozygous Missense Variation in PTPN Top


Sudhir Mehta, Suman Sethi, Vikas Makkar, Simran Kaur, P M Sohal

Department of Nephrology; Dayanand Medical College and Hospital; Ludhiana; Punjab; India

BACKGROUND: Metachondromatosis is a rare genetic disease of osteochondroma and enchondroma formation; caused by loss of function of the PTPN11 gene [1-7]. Loss of function of the protein tyrosine phosphatase non-receptor type 11 (PTPN11) tumour suppressor gene has been identified as a cause and the condition is inherited in an autosomal dominant pattern with incomplete penetrance.

AIM OF THE STUDY: To study the genetic mutation in a patient of Alport syndrome with dialysis dependent CKD with metachondromatosis.

METHODS: This study was done in deptt. Of NephrologyDayanand Medical college and hospital; Ludhiana; Punjab; India.

RESULTS: The genetic analysis was done; which was suggestive of hemizygous 5’ splice mutation in intron 10 of COL4A5 gene that affects invariant GT donor splice site exon 10. This was reported as patological variant. There was another indel variation in exon 45 of COL4A3 gene that results in stop codon and premature truncation of the protein at codon 1331; but this variant was of uncertain significance. This was confirmed with sanger sequencing. The genetic analysis also revealed heterozygous missense variation in PTPN11 gene.

CONCLUSIONS: The presence of multiple bony swelling near epiphysis of long bones with characteristics distribution pattern with history of regression should prompt the possibility of metachondromatosis.


  27. Study of Non Diabetic Kidney Disease in Type 2 Diabetic Patients with Renal Involvement Top


Manzoor Ahmad Parry, Manjuri Sharma, P J Mahanta, B D Medhi, P K Doley, Gayatari Pegu, Hamad Jeelani, Arunima Mahanta, Bishal Aggarwala, M Masatkim, A Shahzad

Department of Nephrology; Gauhati Medical College and Hospital; Gauhati; Assam; India

BACKGROUND: Diabetes mellitus is the most common cause of chronic kidney disease (CKD) worldwide. 20-40% patients with diabetes develop renal disease of which Diabetic Nephropathy (DN) is the most common. The prevalence of non diabetic kidney disease (NDKD) among patients with type 2 diabetes mellitus varies widely depending on the selection criteria and the populations being studied.

AIM OF THE STUDY: To evaluate the renal biopsies performed on type 2 diabetic patients for suspicion of NDKD and to correlate the pathological findings with the clinical and laboratory findings.

METHODS: This study was done in in the department of Nephrology; Gauhati Medical College and Hospital; Guwahati; Assam. It was a cross sectional study. All type 2 diabetes mellitus patients aged more than 18 years were included in this study who had biopsy done for following reasons; Unexplained rapid deterioration of renal function (decrease in glomerular filtration rate (GFR) more than 1 ml/min/1.73 m2/month); proteinuria not accompanied by retinopathy; unexplained haematuria (3 or more red blood cells per high-power field in centrifuged urine sample). Basic clinical details; blood; urine investigation and USG abdomen was done. Renal biopsy was analyzed by light microscopy and immunofluorescence. Optic fundae examination was done in the Dept of Ophthalmology. Based on biopsy patients were grouped into three (i) Isolated NDKD (ii) NDKD with; underlying DN and (iii) Isolated DN.

RESULTS: A total of 31 patients underwent kidney biopsy and were enrolled in this study. Recent onset nephrotic syndrome (13) was the most common indication of biopsy followed by active urine sediment (8). 45% patients on renal biopsy had isolated DN; while as NDKD was seen in 32% and DN plus NDKD in 26%. Focal segmental glomerulosclerosis (FSGS) and IgA nephropathy (IgAN) were the most common causes of isolated NDKD; while as chronic tubulointerstitial nephritis was common in NDKD plus DN. Female gender; short duration of diabetes (<5 yrs) and active urine sediment were independent predictors of NDKD according to multiple logistic regression analysis.

CONCLUSIONS: NDKD was seen in 55% of patients with atypical presentation. FSGS and IgAN were common in NDKD diseases. Judicious use of biopsy atypical presentation may help in diagnosis of NDKD especially in females with short duration of diabetes.


  28. Impact of Screening For BK Virus At 3 Months Post Renal Transplant on Graft Function and Survival At 1 Year Top


Patil Rohit Ramesh, Rajeev A Annigeri

Department of Nephrology; Apollo Hospitals; Chennai; Tamil Nadu; India

BACKGROUND: Polyoma BK virus (BKV) remains a commoncause of post-transplantation viral infections in renal transplant recipients. BK virus nephropathy (BKVN) caused by BKV is an important and dreaded complication ofrenal transplantation. The prevalence of BKVN has increased since 1995 and now ranges between 1% and 10%. BK viruria; BK viremia; and tubulointerstitial nephritis (possible; presumptive; and definitive BKVN) are observed in 35-40%; 11-13%; and 0-8% of renal transplant recipients; respectively.

AIM OF THE STUDY: To study the impact of policy of BK virus screening in renal transplantrecipients on the allograft function and survival.

METHODS: All patients admitted for both live donors as well as deceased donor transplantation were included in study. Baseline biochemical investigations like serum creatinine; serum urea of recipients were done according to standard methods in the routine clinical laboratory at 1 weekPost transplantation and were repeated at 1 month; 3 month and 1 year posttransplantation. Real time quantitative PCR for BKV in urine was done once for all recipients at 3 months after renal transplantation and noted down. The patients were grouped in to BKV positive (Real time quantitative PCRfor BKV more than 140 copies/ml) and BKV negative (Real time quantitative PCR for BKV less than 140 copies/ml) based on the test performed at 3 months according to our center's laboratory. We evaluated several variables for the risk of development of BK viruria at 3 months after renal transplantation; by univariate as well as multivariate analysis.

RESULTS: Our study included 65 kidney transplant recipients; out of which 1 recipient died and 1 patient was lost for follow up at one year. Mean age for recipients (±SD) was 41.88 (±13.66) years and males predominated (78.46%) compared to females (21.53%). Most common basic disease for recipients were diabetic nephropathy (21.5%) and IgA nephropathy (21.5%). 15 (23.06%) recipients were detected positive for BK viruria. 12 (18.46%) recipients had BK viruria load > 107 copies/ml. The multivariate analysis showed that recipient age; donor age; HLA mismatches; use of DJ stent were independently associated with the development of BK viruria at 3 months after renal transplantation which is a strong risk factor for development of BK virus nephropathy. The mean eGFR is lower in BK viruria positive patients as compared to BK viruria negative patients at 3 months and 1 year after renal transplantation which is statistically significant with P value of 0.001 and 0.04 respectively.

CONCLUSIONS: Monitoring for BK viruria early in renal transplantation may be useful to prevent the development of BKVN and preserve renal function. High level BK viruria can be a good screening tool for BKVN in renaltransplant patients.


  29. An Observational Study to Determine The Hemodynamic Tolerability; Efficacy and Clinical Outcomes of Critically Ill Patients with Acute Kidney Injury on Sustained Low Efficiency Dialysis Top


Midhun Ramesh, Satish Balan, Praveen Muraleedharan

Department of Nephrology; S K Hospital; KIMS Hospital; Thiruvananthapuram; Kerela; India

BACKGROUND: AKI is a common complication of critical illness. In patients with severe AKI requiring renal replacement therapy (RRT); mortality is in tune of 50% to 70% Management of AKI may require initiation of RRT to correct metabolic and fluid derangements. SLED is basically a hybrid technique between CRRT and IHD

AIM OF THE STUDY: To determine the hemodynamic tolerability& efficacy of Sustained Low Efficiency Dialysis (SLED) in critically ill patients with AKI.

METHODS: This study was conducted at a tertiary level multispecialty hospital in South India. SLED was administered by trained dialysis staff. Dialysate composition; frequency of sessions; blood flow and ialysis flow rates was individualized to patient requirements and the desired ultrafiltration volume will be prescribed by Nephrologists. Hemodynamic monitoring and decision regarding vasopressor dosing was at the discretion of critical care team. Data on Demographic information; pre-dialysis serum Biochemical & Hematological parameters including serum electrolyte and Renal function tests was collected and recorded in standard proforma. Clinical outcomes in terms of mortality and survivorship and survival predictors was described using a SOFA (Sequential Organ Failure Assessment) scoring system done at the time of initiation of first SLED. All data was entered in to MS Excel and analyzed using the statistical software SPSS version 16.0.

RESULTS: 427 SLED sessions were analyzed. Mean age of the study group was 52.09 + 13.424 years; comprising of 103 males and 45 females with a mean SOFA score of 8.79. The mean BP at time of initiation of SLED was 101/67 mm of Hg. Only two patients suffered cardiac arrest during SLED in this study group. The hemodynamically unstable sessions were higher in those age groups with mean SOFA score was 9 or above. There was increased requirement of ionotropic support in 56 sessions which was has been labeled as hemodynamically unstable SLED sessions. Hypotension refractory to ionotropic medication; requiring SLED discontinuation occurred only in 14 sessions. Excluding these 72 (16.9%) sessions; SLED was successfully completed in the majority of critically ill patients with AKI.

CONCLUSIONS: SLED is a well-tolerated and feasible RRT modality in the majority of critically ill patients of patients with AKI; who would be typical candidates for CRRT.• SLED has comparable hemodynamic tolerability to CRRT. SLED is a feasible alternative to CRRT in resource limited settings.


  30. Rituximab in The Treatment of Chronic Allograft Dysfunction: A Single Center Experience Top


Amar Kulkarni, Alan Almeida, Rasika Sirsat, Mayuri Trivedi, Jatin Kothari

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

BACKGROUND: Chronic allograft dysfunction is a leading cause of graft loss in patients undergoing renal transplantation and has no defined treatment regimens. Rituximab has been used in the treatment of this entity to stabilise and halt the further decline of renal function. In this retrospective study; we describe our centre's experience of the use of Rituximab in Post renal transplantation patients with chronic graft dysfunction.

AIM OF THE STUDY: To study the role of Rituximab in chronic allograft dysfunction.

METHODS: We analysed post kidney transplantation recipients over the last 10 years (January 2008-2018) with renal dysfunction; underwent an allograft biopsy and were offered Rituximab for chronic graft dysfunction. Rituximab was administered at a dose of 375 mg/m2 once a week for four doses followed by 6 monthly doses; wherever indicated. The patients were followed up at monthly intervals for 3 months followed by 6 months and annually till the last follow up or graft loss. Renal functions; graft and patient survival were recorded.

RESULTS: Seven patients with chronic allograft dysfunction were offered Rituximab during the study period. The median follow-up after transplantation was 40 months (Range: 33-115 months) and median follow up after rituximab therapy was 17 months (Range:6-40 months). Donor specific antibodies (DSA) was positive in one case. Three patients had Chronic antibody mediated rejection; two patients had interstitial fibrosis and tubular atrophy (IFTA); one patient had chronic calcineurin inhibitor (CNI) toxicity and one patient had recurrence of IgA nephropathy on allograft biopsy. Five patients had graft loss within 6 months of Rituximab therapy and were initiated on Renal replacement therapy (RRT). Two patients have stable kidney functions at the end of 36 months and 17 months respectively. One patient has undergone a second transplant and is doing well 3 years post transplant. Two patients expired at 4 and 28 months post Rituximab therapy with cardiovascular events.

CONCLUSIONS: Rituximab therapy may be used in stabilising of renal function and delaying graft loss in patients with chronic allograft dysfunction.


  31. Rare Fungal Infection in A Renal Transplant Recipient- Scedosporium Apiospermum Top


Moturu Venkata Viswanath, K Praveen Kumar, Raghavendra Sadineni, Varaprasad Rao

Narayana Medical College and Hospital; Nellore; Andhra Pradesh; India

BACKGROUND: Organ transplantation has always been considered to be the standard therapeutic intervention in patients with end-stage organ failure. After transplant; the extent of the immune response is influenced by the amount of IL-2 being produced by the T-helper cells. Transplant immunosuppressive therapy primarily targets T cell-mediated graft rejection. Calcineurin inhibitors impair calcineurin-induced up-regulation of IL-2 expression; resulting in increased susceptibility to invasive fungal diseases.

AIM OF THE STUDY: Transplant recipients are prone for opportunistic fungal infections commonly by Candida and Aspergillus. We are reporting a rare case of cutaneous fungal infection caused by Scedosporium apiospermum.

METHODS: A 45 yrs old male patient; case of end stage renal disease underwent live related renal transplantation.

RESULTS: Patient was on triple immunosuppressive medication (tacrolimus; mycophenolate and steroid) and was doing well. After 20 months post transplant period he presented with lesions over ankle; thigh and penis. Biopsy of the same initially was suggestive of Aspergillus infection. He was started on voriconazole and immunosuppressive medications were optimised. Despite the organism being sensitive to voriconazole there was worsening of lesion. Repeat biopsy was performed and culture showed Scedosporium apiospermum; which was sensitive to voriconazole and echinocandin. Patient was started on echinocandin following which he improved and lesions gradually subsided.

CONCLUSIONS: Since Scedosporium apiospermum is a rare cause of post transplant fungal infection; high index of suspicion is required to diagnose such cases.


  32. Histopathological Pattern of Renal Disease in Elderly Population Top


Rohan Dwivedi, K B Shashikiran, Sree Bhushan Raju

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

BACKGROUND: Primary glomerular diseases in the elderly population is challenging for both the diagnosis and decision making about treatment. With the improving health facility; life expectancy has increased worldwide. Similar to other comorbidities; renal diseases especially glomerulopathies are also seen in elderly henceforth it is important to recognize the spectrum of renal diseases in the elderly in order to understand the etiology; disease progression and management.

AIM OF THE STUDY: To study the histopathological spectrum of renal diseases in elderly patients (≥60 years) with especial emphasis on glomerular diseases.

METHODS: This retrospective study included all patients aged 60 years and above who underwent native renal biopsy at Department of Nephrology NIMS Hyderabad between January 2017 and July 2018. The following data were analyzed: age; sex; clinical syndrome at presentation; and histological diagnosis (light microscopy and immunofluorescence).

RESULTS: Total 236 biopsies were assessed out of which 23 biopsies were inadequate. The mean age of patients was 65.89 years; and the male sex prevailed with male: female; 3.06:1. The most common clinical presentation was Nephrotic syndrome (34.32%); Acute kidney injury (31.78%) followed by RPRF (12.78%). Glomerular diseases were as follows: Diabetic nephropathy (38.46%); Hypertensive nephrosclerosis (15.38%); MN (8.2%) and FSGS (7.7%). In patients with nephrotic syndrome; Diabetic nephropathy (61%) was the leading cause; followed by MN (13.58%); FSGS (11.12%) and Amyloidosis (4.9%). 

CONCLUSIONS: Nephrotic syndrome was most common clinical presentation in Indian elderly who underwent renal biopsy and among them Diabetic nephropathy followed by hypertensive nephrosclerosis and MN were most common histopathological pattern.


  33. Association of Protein Energy Wasting and Peritonitis with Socio-Economic Status in Peritoneal Dialysis Patients: Longitudinal Study Top


Anita Saxena, Suman Lata Dubey, Amit Gupta, Jai Kishun, Bimla Rani1

Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh and 1Mai Bhago College of Nursing; Amritsar; Punjab; India

BACKGROUND: Peritoneal dialysis is a well established treatment modality for end-stage-renal-disease. Major complication associated with PD is peritonitis which at times leads to removal of PD catheter.

AIM OF THE STUDY: To establish association between protein energy wasting; peritonitis rate; technique survival; and socio-economic status in patients on peritoneal dialysis patients.

METHODS: A total of 91 patients on peritoneal dialysis were recruited. Biochemical parameters included hemoglobin; TLC; platelets; serum creatinine; sodium; potassium; calcium; phosphorus; albumin; protein; lipid profile and CRP; vitamin D and iPTH levels. Anthropometry included skinfold thickness; and BMI. Three days dietary intake of the patients was taken. Nutritional status was assessed with SGA score and handgrip strength. Protein energy wasting was diagnosed based on ISRNM criteria and peritonitis was diagnosed based on ISPD guidelines. Patients were stratified according to socio-economic status (SES) according to ICMR criteria into four groups: group 1 high middle SES (N=46); group 2 middle middle SES (N=45).

RESULTS: On initiation of dialysis patients were anemic and hypoalbuminimic with significant difference between SES groups in serum albumin; BMI; energy (p 0.001) and protein (p 0.001) intake; were higher in SES group 1 compared to group 2; In SES group 1 s. albumin decreased to 3.04±0.43 and in SES group 2; it decreased to 2.6±0.65 at Visit 3. There was significant decline in energy and protein intake with time. Twenty two patients developed peritonitis. Catheter removal was negatively associated with HGS; SGA Score and SES. HGS was associated with MUAC; BMI serum albumin and SGA score (p 0.000). On visit 3 Peritonitis was negatively associated with dietary energy; protein; intake; skinfold; MUAC and SGA score (p -0.040).

CONCLUSIONS: SES affects serum albumin; BMI; dietary energy and protein intake; protein energy wasting; peritonitis; catheter removal; death; SGA score; biochemical profile and dietary intake. In order to maintain nutritional status; measures need to be taken to prevent peritonitis.


  34. A Prospective Study of Clinical Profile; Outcomes and Survival of Temporary Femoral Hemodialysis Catheters in A Tertiary Care Centre Top


Behera Vineet, R K Yadav, D Bhowmik, A Kapil, A Kumar, S Bagchi, S Mahajan, S K Agarwal

Department of Nephrology; All India Institute of Medical Sciences; New Delhi; India

BACKGROUND: Hemodialysis (HD) catheters can be temporary uncuffed catheters or tunnelled cuffed catheters. Temporary femoral catheters (DLFC); used for short duration HD needs or in emergency situations when jugular or permanent catheters cannot be used. DLFC are associated with serious complications including catheter related blood stream infection (CRBSI). There is increasing use of these catheters in resource limited settings. There is scarce data on prevalent use; complications and survival of DLFC.

AIM OF THE STUDY: To study the epidemiology; clinical profile; outcomes; complications and survival of temporary femoral HD catheters in a tertiary care centre.

METHODS: A prospective observational study was conducted over an one year period from 01 Jan 2017 to 31 Dec 2017 in AIIMS; New Delhi in which all patients with DLFC were included while those with single lumen femoral catheters were excluded. All DLFC were inserted under USG guidance; taking all necessary precautions and as per existing departmental protocol. The initial details of catheter insertion; patient and the underlying illness; clinical and biochemical parameters and any immediate complications were recorded. The catheter course or the period of the catheter was observed for any complications like CRBSI; thrombosis. Catheters were removed when no longer required or in case of complication. In case of catheter removal; duration of catheter stay; reasons for catheter removal; any catheter-related complications or other details related to HD catheter was recorded. Statistical analysis was performed using Strata 14.

RESULTS: A total 1118 HD catheters were inserted of which 656 (59%) were DLFC and commonest indication was pulmonary edema in 181 (27.5%). 411 (62.6%) catheters were removed out of which; elective removal for renal recovery was in 161 (24.5%); patient choice/ discharge from hospital in 78 (11.8%) and alternate catheter in 119 (18.1%). 233 (35.5%) catheters were lost due to patient death and 19 (1.8%) were lost to follow up. Complications occurred in 115 (20.69/ 1000 catheter days) with CRBSI being 18.89; thrombosis being 2.69 and other complications being 0.89/1000 catheter days respectively. GNB were seen in 43 (84.6%); GPB in 6 (10.2%) and fungi in 2 (4.2%); most common being Klebsiella in 14 (26.9%) and Acinetobacter in 13 (25%). Factors significantly associated with complications (on multivariate analysis) were hypertension; emergency catheterization and catheter stay duration. The median catheter survival was 7 days (1 – 40 days) with survival at 30 and 60 days being 3.9 and 1.3 respectively.

CONCLUSIONS: DLFC constituted 59% HD catheter use with median stay of 7 days; 3.9% catheters staying >30 days and 35% patients died with DLFC in situ. Complications were seen in 17.5% with CRBSI and thrombosis being most common with increasing prevalence of GNB (Klebsiella and Acinetobacter) causing CRBSI.


  35. Early Arteriovenous Fistula Creation – A Myth or Truth? Top


S Ramakrishnan, Dilip Rangarajan, Kiran Chandra Patro, Anitha, R Ramprasad

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

BACKGROUND: Use of arteriovenous fistula (AVF) at commencement of hemodialysis (HD) is not high despite guideline recommendations on its timely creation (18.4% in our center) Timing of AVF is always tricky; AVF created too early may develop complications. If created late; it may not be ready to use resulting in reliability on central vein catheters (CVC) as VA with attendant risks of morbidity; mortality and costFailure of AVF to mature enough may be a reason for suboptimal AVF use.

AIM OF THE STUDY: To assess the functional utility of AVF procedures done prior to initiation of dialysis and the need for CVC as VA at initiation of HD.

METHODS: Subjects: Patients with CKD who had undergone AVF procedures for HD prior to initiation on dialysis Center: NU Hospitals; Padmanabhanagar; Bengaluru; a tertiary care center for Nephrology and Urology services Study period: 1; January; 2017 till 31; August. 2018 AVF procedures were done by in center urologists who had been appropriately credentialed; Doppler study of upper limb veins was done routinely prior to AVF creationFollow up events: a) primary failure of AVF and/or abandonment prior to initiation of HD and b) initiation on HD Those who had undergone repeat procedures following failure and/or abandonment of the previous ones were also followed up for the functional status of the new ones if these procedures had been done prior to initiation on HD.

RESULTS: Study group: 37 (33.9%) had undergone their first procedure prior to initiation on HD. 28 (75.6%) of them were males. Mean age of the study group was 57.4 years (range 19 to 80 years). 40.5 % were older than 60 years. 29 (78%) had DMPrimary failure of AVF:Primary failure (failure prior to cannulation) of first procedure in 13 (five immediate; two each in <2 weeks and between 3rd and 6th week and four after 6 weeks); 11 of them underwent 12 procedures thereafter (3 salvage; 9 AVF at another site); all salvage procedures were in vain; 3 of the repeat procedures were primary failures All but two males; mean age 59.3 years; radiocephalic AVF in 9; brachiocephalic in 3 and brachiobasilic in one; DM in 10 and vascular ailments in 6AVF as initial VA Among 29 who were under regular follow up; 23 had been initiated on dialysis so farSuccessful cannulation at initiation was possible in 13 (56.5%) Mean time to initiation on HD since AVF creation was 133.2 days (range 14 – 528 days).

CONCLUSIONS: A third of patients undergoing AVF had got it done prior to initiation on HDPrimary failure rate was around 35% for the first procedure resulting in need for secondary procedures (mean additional procedure 0.32 per patient) Successful cannulation at initiation was possible in 56.5%.


  36. Retrospective Study of 367 Renal Biopsies Done Over A Four Year Period in South Bengaluru Top


Arvind Conjeevaram, Priyangani Lohia, G S Ravishankar, C Maitreyi, Jagadeeswar Reddy, Mahesha Vankalakunti, H M Mallikarjun, Sanjeev Kumar Hiremath, H R Jyothi

The Bangalore Hospital; Sagar Hospitals; Manipal Hospitals; Bengaluru; Karnataka; India

BACKGROUND: Renal biopsies help characterize and aid in the treatment of renal disease in pts with proteinuria and/or renal dysfunction. The pattern of renal disease affecting pts varies from one region to the other. In the same region; the pattern of renal disease may vary over time such as the decreasing incidence of post infectious GN. We looked at the biopsies done at our hospitals over a four year period to establish a pattern of renal disease in our area.

AIM OF THE STUDY: To assess the patterns of renal disease affecting pts in South Bangalore by analysing our data on renal biopsies done over the past 4 years. To correlate clinical presentation with renal histopath.

METHODS: We conducted a retrospective study of the renal biopsies conducted over a 4 year period between March 2014 and March 2018 at the Bangalore and Sagar Hospitals; in Bangalore. The renal biopsy reports as well as the case sheets of the pts were perused for demographic and clinical data. All biopsies were read by the same nephropathologist (MV). Correlations between the clinical presentation of renal disease and the histopathology on the renal biopsies were done. Of the 367 biopsies done during this period; 311 were native kidney biopsies and 56 transplant kidney biopsies.

RESULTS: There were 367 biopsies done during this period. The male to female ratio was 1.5:1; mean age 44 yrs. Of 367 pts biopsied; 143 (38%) presented with nephrotic syndrome. Of these; 39 pts (27%) had membranous nephropathy; 38 pts (26%) had FSGS; 17 pts - minimal change disease (11%); 16 pts had diabetic nephropathy (11%); 13 had IGA nephropathy (9%) and 12 had lupus Nephritis (8%). Of 54 pts who had FSGS; 33 had FSGS-nos. There were 72 (19.6%) diabetics among the 367 pts biopsied; of these 22 (30.6%) had Diabetic Nephropathy and 50 (69.4%) had NDRD. Out of these 50 patients; 13 had MPGN; 9 had FSGS; 5 had MGN; 2 had IgA nephropathy & 2 had AIN. Of the 60 pts who presented with clinical suspicion of RPGN; Crescentic GN was seen in only 8 pts; ATN In 10 pts; IgAN in 8 pts. 25 pts had crescentic GN - pauci immune -6 pts; IGA nephropathy- 4; anti GBM dis - 3; IRGN 2; Lupus Nephritis 2. Of the 55 Pts who had IgAN on Bx; 21 presented with nephritic syndrome; 17 with NS and 7 with clinical RPGN.

CONCLUSIONS: FSGS and MN were the main causes of NS. FSGS-nos was the commonest variant in FSGS pts. Among the diabetics biopsied; 70% had NDRD. Of 60 pts who presented clinically as RPGN; only 8 had crescentic GN. Of the 56 transplant biopsies done; 21 were useful in diagnosing AR. 3 pts had RPGN.


  37. Comparison of Various Predictive Equations for Glomerular Filtration Rate in Healthy Individuals and Chronic Kidney Disease Patients from North India Top


Seshi Vardhan Janjirala, Monica Gupta, Sanjay D’Cruz

Department of Nephrology; Government Medical College and Hospital; Chandigarh; India

BACKGROUND: The method of calculating GFR in practice by 24 hour urinary estimation of creatinine is time consuming and cumbersome. A non-invasive and accurate estimate of glomerular filtration rate (GFR) is an essential prerequisite for medical professionals. In the absence of 24-hour urinary creatinine clearance; various predictive equations are in use for estimating GFR. These equations may have some inherent bias and therefore their applicability in the Indian population needs to be further verified.

AIM OF THE STUDY: 1. To assess the GFR in healthy adults CKD patients by different methods of eGFR. 2. To validate presently available predictive equations for eGFR in the Indian population.

METHODS: Subjects meeting both inclusion and exclusion criteria were enrolled. This cross-sectional observational study was conducted on 600 subjects including healthy adults as well as adults of various stages of CKD. All participants underwent RFT and 24 hour urinary estimations for creatinine and protein. CKD staging was done after calculating measured GFR by using 24 hour urinary creatinine clearance. Based on GFR so obtained; participants were categorized into six subsets; as per guidelines of NKF. eGFR was calculated using predictive MDRD-4; MDRD-6; CKD-EPI and Cockcroft and Gault formula. Values of eGFR obtained; were compared for accuracy and precision against measured GFR obtained by 24-hour endogenous creatinine clearance which was taken as reference for the study population. Data analysis was done using SPSS version 21. Statistical analysis was done to see for any significant difference in performance by comparing it with the standard.

RESULTS: In normal males and females; MDRD-4 and CG were the best equations respectively; which showed best correlation and best precision In CKD stage 1 males and females; MDRD-4 and MDRD-6 were the best equations respectively In CKD stage 2 males and females; CKD-EPI was adjudged the best equation; which showed best correlation; best precision and least bias. In CKD stage 3 males and females; CG and CKD-EPI were the best equation respectively; with best correlation; best precision; least biased and most accuracy. In CKD stage 4 males and females; MDRD-6 and MDRD-4 showed the best correlation; best precision and most accuracy respectively. In CKD stage 5; CKD-EPI demonstrated best results in both sexes.

CONCLUSIONS: We observed that all the predictive equations were good estimates of GFR in one or other stage of CKD; but no single predictive equation showed consistent results when compared among normal subjects and CKD sub-groups.


  38. Risk Factors for Proteinuria Among Newly Detected Type 2 Diabetic Subjects: Experience from A Tertiary Care Hospital of Bangladesh Top


Muhammad A Rahim, Samira H Habib, Wasim M M Haque, Faria Afsana, Sarwar Iqbal

BIRDEM; Dhaka; Bangladesh

BACKGROUND: Diabetes mellitus (DM) is one of the most common causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in developed as well as in developing countries principally resulting from the increasing prevalence of type 2 diabetes mellitus (T2DM). Patients with T2DM passes through pre-diabetic stages and half of T2DM patients remain undiagnosed. During diagnosis up to one-third of T2DM patients may have nephropathy. 

AIM OF THE STUDY: This study was designed to evaluate risk factors for proteinuria among newly detected T2DM subjects.

METHODS: This case-control study was done at out-patient department of BIRDEM; Dhaka; Bangladesh from October 2016 to July 2017. Newly detected (<3 months) adult (18 years or above) T2DM patients of either sex; who underwent test for urine albumin to creatinine ratio (UACR) were included in this study. Patients with diagnosed renal disease; features of glomerulonephritis; systemic lupus erythematosus; vasculitis; history of recent fever and exercise; urinary tract infection and pregnancy were excluded. Patients with UACR 30 mg/g or more were cases and those with UACR <30 mg/g were controls.

RESULTS: Total patients were 100; including 35 cases [microalbuminuria (UACR 30-299 mg/g) 33 and overt proteinuria (UACR 300 mg/g or more) 2] and 65 controls. Regarding risk factors for proteinuria; hypertension (OR 4.93; p 0.001); family history of DM (OR 1.62; p 0.0001) and diabetic nephropathy (OR 25.13; p 0.003) and diabetic retinopathy (OR 14.18; p 0.046) were significant. On multiple logistic regression; hypertension (OR 4.31; p 0.003); family history of DM (OR 1.77; p 0.001) and diabetic nephropathy (OR 24.31; p 0.001); higher BMI (>25 kg/m2) (OR 2.11; p 0.013) and diabetic retinopathy (OR 14.09; p 0.021) were significant.

CONCLUSIONS: One-third of the study participants had microalbuminuria and overt proteinuria. Family history of DM and nephropathy; hypertension; higher BMI and diabetic retinopathy were significant risk factors for proteinuria.


  39. New Onset Diabetes After Kidney Transplantation: Our Experience Top


Shakir Ahmad, Pradip Saruk, Gajanan Pilgulwar, Rudramani Swami, Kalpana Mehta

Department of Nephrology; T. N. Medical College and BYL Nair Hospital; Mumbai; Maharashtra; India

BACKGROUND: Apart from the traditional risk factors common in the nontransplant setting; the use of diabetogenic immunosuppressants (calcineurin inhibitors [CNIs] and steroids); hepatitis C virus (HCV) infection; cytomegalovirus infection; human leukocyte antigen (HLA) matching characteristics; and perioperative hyperglycemia have been implicated to increase the risk of NODAT. Our study gives data experience from our tertiary care center.

AIM OF THE STUDY: To study epidemiology of NODAT in kidney transplant recipients [KTR] who are on regular follow up.

METHODS: Inclusion criteria: Regular Post transplant follow up of at least 6 months: NODAT as per WHO & ADA criteriaRetrospective analysis was done to study incidence; time of onset; immunosuppression at that time; duration of NODAT; co-morbid conditions; and present status of disease.

RESULTS: Number of KTRs as per inclusion criteria: 67. M:F=56:11. Mean age at transplant was 29.6 yrs. Mean follow up period: 11 years 2 months. Mean Serum creatinine at follow up- 1.77 mg % [excluding those with graft loss but including those with death but functioning graft]NODAT was observed in 40 KTRs (59.70%). [Live First Degree Related/spouse KT 37; Diseased Donor KT=3]70% [N=28/40] developed NODAT within 1 month; 22.5% [N=9/40] between 1 to 3 months & 7.5% [N=3/40] between 3 to 6 months. The cohort included one KTR with pre-transplant HCV positive status & two post transplant CMV disease. 60.31% [N=38/63] recipients on TAC based regimen & 50% [N=2/4] on CSA regimen developed NODAT. Induction was given to 12/40 KTRs. 33 KTRs received insulin and while 7 are on oral hypoglycaemic drugs. 8 out of 40 (20%) KTRs are off antidiabetic measures presently.

CONCLUSIONS: Incidence of NODAT is 59.70 % within 6 months; & 47.76% at follow up period [literature incidence of 2 to 53 %]. This reflects our intense triple immunosuppression as no regular induction is used in low risk KTRs.


  40. A Cross Sectional Study on The Effect of Residual Kidney Function on Maintenance Hemodialysis Patients Top


Marsook Ali, M Sreelatha, T P Noushad, E K Jayakumar

Department of Nephrology; Government Medical College; Kozhikode; Kerela; India

BACKGROUND: Residual kidney function (RKF) is an important predictor of survival in peritoneal dialysis patients; but its role in hemodialysis patients is less established. The present study was aimed to estimate RKF among CKD patients on maintenance dialysis; to study the potential benefits of RKF; factors influencing loss or maintenance of RKF and to compare the adequacy of urea removal of patients with RKF with those without RKF.

AIM OF THE STUDY: To estimate the KRF of patients on maintenance dialysis as KRU; the effect of various factors associated with loss/maintenance and the potential benefits of RKF.

METHODS: 126 patients undergoing maintenance HD at MCH Kozhikode were included. The baseline data and dialysis related data were obtained. KRU was estimated using standard formula from 24 hr urine collection and urinary urea estimation. spKt/v; EKt/v and STD Kt/v were calculated using web based calculators based on Daugirdas 2 formula. Renal Kt/v was calculated from KRU and added to weekly STD Kt/v to get total Kt/v per week. Patients were divided into 3 groups based on RKF; and no. of sessions of HD per week. The groups were compared for differences in parameters related to loss or maintenance of RKF and its influence on clinical outcomes.

RESULTS: Of the 126 patients; 93 were males. 35 patients were on weekly twice HD while the remaining 91 patients were getting 3 dialysis per week. 49 patients had urine output more than or equal to 200 ml. KRU was found to be 2 ml/min or more in 56 patients. Use of NSAIDs and aminoglycosides were associated with loss of RKF whereas a maintained RKF was associated with ARB use; good BP control; less intradialytic weight gain and low erythropoietin requirement. The study could not demonstrate any difference in cardiovascular events or AVF dysfunction. The mean total Kt/v was 2.12 in those with RKF on weekly twice HD while it was 2.07 in those without RKF on thrice weekly HD. Those patients with RKF and undergoing thrice weekly HD had a total Kt/v of 2.45. Estimation of KRU is a better method of assessing RKF than measuring urine output alone. Patients with maintained RKF had many benefits with regards to BP control; IDWG and EPO requirement.

CONCLUSIONS: Patients with on weekly twice HD and significant RKF had comparable total weekly Kt/v with those without RKF on weekly thrice HD. RKF contributes to overall clearance and an incremental HD from initiation with infrequent HD on the transition to dialysis may be sufficient andpreserve RKF longer.


  41. A Rare Case of Interstitial Nephritis Top


Amrutha Prabhakaran, M Sreelatha, T P Noushad, E K Jayakumar

Department of Nephrology; Government Medical College; Kozhikode; Kerala; India

BACKGROUND: Sarcoidosis is a rare diagnosis in our part of the world and it presenting as renal failure due to granulomoatous interstitial nephritis is unusual. Hence we report such a case of interstitial nephritis.

AIM OF THE STUDY: 38 yr old male with past history of maculopapular rash over both lowerlimbs prented with history of Right flank pain of 2 yr duration.

METHODS: On evaluation he was told to have renal calculi and had a s. creatinine of 2.7. He had history of lithuria and frothuria for past 3 months. No history of edema or gross hematuria. No history of hypertension or diabetes or other comorbidities in the past. On examination had depigmented maculopapaular rash over his both lower extremities. Blood pressure was 120/80 mmHg. Urine routine showed 2+proteinuria with microhematuria. Serum creatinine was 2.7 mg/dl; had normal serum C3 and serum albumin. Review of his skin biopsy report showed non caseating granuloma suggestive of sarcoidosis.

RESULTS: Further evaluation showed hypercalcemia; hypercalciuria and elevated serum ACE level. Ch USG abdomen revealed hepatosplenomagaly; normal sized kidneys with raised echoes and partially lost cmd with bilateral non obstructive renal calculi. Chest xray was normal. Hence HRCT thorax was done which showed fissural nodularity and thickening involving peribronchovascular interstitium and scaterred centrilobular nodules with mediastinal and right hilar LNE suggestive of early sarcoidosis. His viral markers were negative. Workup for TB was negative. Renal biopsy revealed multiple non caseating granulomas with inflammatory infiltrates in the interstitium. IF was Negative The histopathology report indicated granulomatous tubulointerstitial nephritis compatible with the diagnosis of sarcoidosis. He was started on steroids monotherapy in the form of oral prednisolone 1 mg/kg/day. and is on regular follow up at present. He has now serum creatinine of 1.3 with no proteinuria.

CONCLUSIONS: Granulomatous interstitial nephritis due to sarcoid is a treatable cause of renal failure and hence to be kept as differential diagnosis in any unexplained renal failure. Early diagnosis with renal biopsy is the key to treatment.


  42. Hypercalcemia -A Diagnostic Dilemma Top


Niranjana Joy, M Jayakumar, Manikantan

Sri Ramachandra Medical College and Research Institute; Chennai; Tamil Nadu; India

BACKGROUND: Sarcoidosis is a multisystem granulomatous disease; typically presenting as non-necrotizing epithelioid granuloma. The occurrence of non-infective necrotizing sarcoid granuloma (NSG) is infrequent; and the finding of NSG in the liver is rare. More common in the lung with extra-pulmonary involvement being very rare. The NSG appears to be more common in Caucasian females and sarcoidosis can present with hypercalcemia without pulmonary involvement.

AIM OF THE STUDY: NSG is a rare variant of sarcoidosis with features of necrosis and vasculitis. Hypercalcemia is the presenting feature in case of sarcoidosis which is rare in NSG when it primarily affects liver.

METHODS: A 36 year old female presented with: C/o giddiness; pain abdomen. Patient is a K/C/O of T2DM and hypertension for 8 months. Had elevated renal parameter creat 2.6 mg/dl for 3 months. On examination vitals normal. systemic examination normal. Investigations showed elevated renal parameters creat 2.1 mg/dl. urine routine normal. ALP 286; Calcium: 13.2; Uric acid: 11.1; Phosphorus: 4; Sr. IPTH: 5.5. Hence patient was evaluated for hypercalcemia. VITAMIN D (25OH): 9.9 ng/ml (20 – 100 ng/ml); VITAMIN D3: 37.6 ng/dl. Thyroid profile normal. Multiple myeloma was ruled out. SPEP:No M Band. Free light chain assay ratio-1.69. PET scan was done to rule out malignancy which showed multiple illdefined hypodense; fdg avid lesions in the liver. Liver biopsy was done which showed Necrotising granulomatous inflammation. biopsy AFB: negative. blood TB PCR: negative. blood TB quantiferon gold: negative. ACE levels: 119 microliter (8-53 miclit).ophthal examination: bilateral anterior uveitis. Hence a diagnosis of NSG was made.

RESULTS: This 38 yr old female initially presented with elevated renal parameters and hypercalcemia. Multiple myeloma and malignancy were ruled out. PTHrP not done. Thyroid profile was normal. After evaluation patient was found to have necrotizing granulomatous lesions in the liver which led to a dilemma whether it is of infectious or non infectious origin. TB workup was negative. patient was found to have elevated ACE levels and calcitriol with anterior uveitis which was suggestive of sarcoidosis. Necrotising lesion is rare in sarcoidosis and hypercalcemia is due to calcitriol synthesis from alveolar macrophages. But in this patient there was no pulmonary involvement. Renal manifestations in sarcoidosis is attributed to hypercalcemia. patient was treated with steroids which produced resolution of hypercalcemia and renal failure. Patient was treated with Tab. Wysolone 40 mg 1-0-0. After one month:Serum calcium: 10.1 ng/dl. Serum creatinine: 1 Mg/dL.

CONCLUSIONS: The NSG is a rare and poorly understood entity characterized by granuloma with caseous necrosis making it difficult to distinguish from infectious conditions like tuberculosis. Calcitriol and ACE levels can be used to monitor disease activity. There are no gold standard tests available.


  43. Predictors of Serum Hemoglobin in Hemodialysis Population; A Single Center Observational Study Top


Soumava Gupta, Deepak S Roy, Pratik Das

Department of Nephrology; Rabindranath Tagore International Institute of Cardiac Sciences; Kolkata; West Bengal; India

BACKGROUND: Serum Hemoglobin (Hb) is an important marker of dialysis adequacy. Hb level Variability in dialysis patients was described first by Lacson and Berns in 2003. Hemoglobin levels in individuals with chronic kidney disease fluctuate frequently above or below the recommended target levels within short periods of time. Several factors affect Hb variability. It is expected that both low and high hemoglobin levels would be associated with increased death risk.

AIM OF THE STUDY: To determine 1. The mean and range of Hb in the study population 2. Association of Hb with various variable determinants 3. Incidence of blood transfusion and its relationship with hemoglobin level.

METHODS: It is a longitudinal observational study; carried out at the hemodialysis unit of NHRTIICS. The study duration was between Jan 2016 to Deceember 2016 Anemia was defined as per KDIGO Guidelines; 2012 data was collected in a pretested questionnire. The co relation of hemoglobin with the various factor like age; sex; BMI; spKt/v; use of exogenous recombinant Human Erythropetin and Iron supplementation; Hospital admission were collected. The incidence of blood transfusion was noted. Patients who died or switched over to other modalities of RRT or were lost to follow up were excluded. Those who consented were ascertained a particular number and was randomized using the randomization table. First 100 patients were selected. The data was collected in a pre designed questionnire. The data thus collected were tabulated and analzed.

RESULTS: Total 16 patients got excluded and the sample size at the end of the study was 84. The mean Hemoglobin among the study population was 9.09 gm/dl with a range of 14.1-6.5 gm/dl. The co relationship between hemoglobin and various other variable is shown in the table-Variable OR 95% CIAge 0.6 0.1-1.2 Sex 1.1 0.8-1.05 BMI 1.2 1.1-1.07 Vintage 1.45 1.1-1.7 Epo Usage 0.5 0.2-0.8 Iron Supplementation 0.9 0.6-1.7 kt/V 1.8 1.5-2 Hospital Admissions 1.3 0.7-1.5 OR=Odd's RatioCI=95%Confidence IntervalEpo=Recombinant ErythropoetinTotal 41 units of Blood Transfusion were done.

CONCLUSIONS: 1. Serum Hemoglobin in the study population was much less than the mean recommended Hemoglobin level 2. Epo usage; BMI; spKt/V; usage of IV Iron are significant modifiable markers of Inter patient Hemoglobin variability 3. Iron markers however should be evaluated regularly to prevent overload.


  44. Page Kidney Secondary to Severe Ureterohydronephrosis and Perinephric Urinoma with Rupture of Renal Fornix Secondary to A Rare Complication of Ureteral Calculi Top


Jerne Kaz Niels B Paber, Michael Abutazil

Department of Internal Medicine; Zamboanga City Medical Center; Zamboanga; Philippines

BACKGROUND: Obstructive causes with perforation or rupture from an impacted urinary calculus is a rare condition.. The current recommendation is drainage of the obstruction either by tube drainage by nephrostomy or by stent placement for urine drainage. By relieving the obstruction; it solves both the hydronephrosis; the urinoma and Page kidney.

AIM OF THE STUDY: A case of 21-year-old male with a rare case of ureteral calculi causing severe hydronephrosis and urinoma eventually developing a rare cause of secondary hypertension called page kidney.

METHODS: A 21-year-old; Male; Single; Roman Catholic; Construction worker; from Zamboanga City; Philippines came to the Emergency room with a chief complaint of left flank pain. Eight days prior the patient had a sudden onset of left flank pain noted with gradual progression with radiation to the back. Enhanced CT scan revealed severe ureterohypronephrosis Left with secondary stricture at the ureterovescicular junction probably distal ureter secondary to stone passage with perinephric fluid collection secondary to ruptured fornix considering infected urinoma. The right kidney was 12.3 x 4.5 x 4.6 cm parenchymal thickness 2.1 cm and the left kidney 15.2 x 7.3 x 4.9 parenchymal thickness 2.2. There was dilatation in the collecting system down to the distal ureter with large perinephric fluid collection measuring 17 x 6.8 x 8.2 cm (492 ccs). The left parenchyma is compressed anteriorly by this collection with the consideration of page kidney.

RESULTS: The patient was then scheduled to nephrostomy tube insertion to divert urine production. Percutaneous ultrasound-guided nephrostomy tube drain was placed; an initial output 1000 cc bloody then eventual yellow tinged urine color. TB PCR of the urine was negative and culture of the nephrostomy drain had no growth. Metronidazole 500 mg TID and Ciprofloxacin 500 mg BID was continued for 2 weeks. The patient was discharged but was noted to have 500-800 cc daily output from the nephrostomy tube. There was also no episodes of elevated blood pressure. The patient then underwent ureterocystoscopy with ureteral tailoring and double J stent insertion for urine diversion. Upon follow up of the patient; there was decreasing drainage from the nephrostomy tube and there was a gradual reduction of the hydronephrosis and stent removal was done after 2 months. There was no presence of urinoma on repeated ultrasonography and no episodes of elevated blood pressure on frequent follow-ups.

CONCLUSIONS: Percutaneous diversion via nephrostomy tube insertion and stent placement may divert urine away from the site of the leak is often required to facilitate spontaneous healing within the genitourinary system and treat secondary hypertension.


  45. Rituximab in Glomerular Diseases – Is It Promising? Top


T Aswini Dutt, P S Vali, Kiranmai Ismail, Manisha Sahay

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

BACKGROUND: Rituximab is a chimeric anti CD20 antibody that results in depletion of B lymphocytes. It is currently used in the treatment of a variety of autoimmune diseases; in addition to CD 20 positive lymphomas. The use of rituximab in the treatment of glomerular diseases has emerged recently; although not yet established as a first line therapy in international guidelines.

AIM OF THE STUDY: The efficacy and safety of rituximab in patients with steroid resistant and steroid dependent nephrotic syndrome refractory to standard therapy.

METHODS: The treatment of nephrotic syndrome is often complicated by refractory and relapsing course with the risk of drug toxicity and progressive renal failure. We report the efficacy and safety of rituximab in patients with steroid resistant and steroid dependent nephrotic syndrome refractory to standard therapy.

RESULTS: Six pediatric patients with SDNS and 14 patients with SRNS (2 initial and 12 late resistance) with mean ages of 10.7 +/- 6.1 and 11.7 +/- 4.0 respectively; two adult patients with refractory lupus nephritis were included. Female: Male ratio was 1.2. 12 months after rituximab therapy; Out of 22; 7 patients (31.8 %) showed complete remission with SDNS (57.1 %); SRNS (28.5 %); Refractory lupus (14.2 %). Partial remission was achieved in 2 (40 %) SDNS; 2 (40%) SRNS; 1 (20%) in refractory lupus nephritis. Adverse effects like mild allergic reaction was noted in one patient.

CONCLUSIONS: Therapy with rituximab was safe and effective in inducing and maintaining remission in a significant proportion of patients with difficult SRNS; SDNS and refractory lupus nephritis.


  46. Evaluation of Erythropoiesis After Renal Transplantation; A Prospective Observational Study Top


Anand, Pratik Das

NH Rabindranath Tagore International Institute of Cardiac Sciences; Kolkata; West Bengal; India.

BACKGROUND: Renal transplantation is considered to be the treatment of choice for patients with ESRD. A successful renal allograft will not only correct the excretory functions of the kidney but also the endocrine functions. The extent to which renal endocrine function are restored is less well understood. Data regarding the factors involved in correction of post transplant anemia are scanty. So; we proposed a study on “Evaluation of Erythropoiesis after Renal Transplantation”.

AIM OF THE STUDY: 1. To detect the incidence of anemia post renal transplantation. 2. To evaluate the erythropoetic activity post transplant.

METHODS: This study was conducted in the Department of Nephrology; Rabindranath Tagore International Institute of Cardiac Sciences; Kolkata. Collectively 100 patients were included; who met the eligibility criteria and gave written consent during the study period of one year. Patients were investigated for hematopoietic &ferrokinetic parameters in the following schedule: Pre Renal Transplantation; 1 month; 3 months; 6 months & 12 months of post transplantation.

RESULTS: 1. Prevalence of Post Renal Transplant Anemia&Polycythemia were 7&15% respectively. 2. Haemoglobin showed slow &steady increase; and Serum Erythropoietin had biphasic peaks; one at 1 &other at 12 months respectively. 3. There was significant negative correlation between Hb& Serum Creatinine (S.Cr) at 12 months of RTx. 4. Patients with S.Cr>1.3 mg/dL were mostly anemic.

CONCLUSIONS: 1. Ferrokinetic parameters were corrected after RTx but the sequence & rate of correction were different. 2. Iron replacement is helpful in early post RTx period. 3. S. Epo may be helpful at the end of 1 year; when all ferrokinetics are normalized; especially in presence of graft dysfunction.


  47. Comparing Outcome of Kidney Transplant in Non-Diabetic; In Those Who Develop New Onset Diabetes After Transplant (NODAT) and in Diabetic Subjects Top


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

Department of Nephrology; Global Hospital; Mumbai; Maharashtra; India

BACKGROUND: Diabetes is an important risk factor determining outcome of transplant. Even NODAT increases the risk of complications after transplant. How do diabetic subjects and those who develop NODAT do after kidney transplant.

AIM OF THE STUDY: To assess the outcome of kidney transplant in non-diabetic; in those who develop NODAT and in diabetic subjects.

METHODS: All renal transplants performed from August 1; 2013 to June 30; 2018 at our centre were included. These patients were divided into 3 groups: non-diabetic; NODAT and diabetic. Induction and maintenance immunosuppression was similar in all 3 groups Prophylaxis against opportunistic infection included cotrimoxazole and valganciclovir. Patient survival and graft survival were the primary outcomes.

RESULTS: Out of 290 patients; 116 (40%) were non-diabetic; 85 (29%) were NODAT and 89 (31%) were diabetic. The 1; 3 and 5 year patient survival in non-diabetic subjects was 95%. It was 93%; 92% and 92% in NODAT and 92%; 81% and 81% in diabetic subjects (p<0.05). The 1; 3 and 5 year death censored graft survival in non-diabetic subjects was 97%; 96% and 96%. It was 93%; 92% and 87% in NODAT and 95%; 92% and 92% in diabetic subjects. Infections (particularly UTI and TB) and cardiovascular events were significantly higher in diabetic and NODAT.

CONCLUSIONS: Our study shows that diabetes is an important risk factor determining outcome of transplant. Even NODAT increases the risk of complications after transplant.


  48. Risk Factors for Urinary Tract Infection Due to Extended-Spectrum Beta-Lactamase Producing Uropathogens: Single-Center Experience from A Developing Country Top


Muhammad A Rahim, Wasim M M Haque, Sarwar Iqbal

BIRDEM; Dhaka; Bangladesh

BACKGROUND: Urinary tract infection (UTI) due to extended-spectrum beta-lactamase (ESBL) producing organisms are increasing through-out the world.

AIM OF THE STUDY: This study was designed to evaluate the frequency of ESBL-positive organisms causing UTI; their antibiotic sensitivity pattern and possible risk factors.

METHODS: This case-control study was done in BIRDEM; Dhaka; Bangladesh from January to March 2016. UTI due to ESBL-positive organisms were cases and non-ESBL organisms were controls.

RESULTS: Total patients were 136 including 99 females. Escherichia coli (84; 61.8%) was the commonest aetiological agent. Two-thirds of E. coli and two-fifths of Klebsiella ewere ESBL-positive. Overall 47.8% cases were due to ESBL-positive organisms. Imipenem (97.8%); amikacin (91.9%); gentamycin (80.1%) and nitrofurantoin (91.2%) were among the most sensitive antibiotics. Long duration (>5 years; OR=2.07; 95% CI=0.90-4.70; p=0.04) and poor control of diabetes (HbA1c >7%; OR=1.30; 95% CI=0.49-3.48; p=0.59); past history of UTI (OR=1.3; 95% CI=0.67-2.60; p=0.42); prior antibiotic use (OR=1.5; 95% CI=0.76-2.95; p=0.24) and prior hospitalization due to UTI (OR=2.8; 95% CI=1.32-5.81; p=0.006) were risk factors for UTI with ESBL-positive organisms. On multivariate logistic regression; longer diabetes duration (p=0.003); poor glycaemic control (p=0.007); past history of UTI (p=0.004) and history of hospitalization due to UTI (p=0.001) appeared as significant risk factors for ESBL-positivity.

CONCLUSIONS: Half of the UTI cases were due to ESBL-positive organisms in this study. Imipenem; amikacin; gentamycin and nitrofurantoin were most sensitive antibiotics. Long duration and poor control of diabetes and past history of UTI and hospitalization appeared as significant risk factors for ESBL-positivity.


  49. Anti-Biofilm and Antifouling Evaluation of Sol-Gel Coated Silicone Implants with Prolonged Release of Eugenol Against Pseudomonas Aeruginosa Top


Pragasam Viswanathan, R Prasanth, Bhasker Mohan Murari

Renal Research Lab; Centre for Bio-Medical Research; School of Bio-Sciences and Technology; Vellore Institute of Technology; Vellore; Tamil Nadu; India

BACKGROUND: The incidence of catheter-associated urinary tract infections (CAUTIs) is increasing worldwide. Biomaterial modifications like anti-microbial agent coated catheters intended to reduce the risk of bacterial colonization have not been supported by clinical evidence besides the risk of resistance development.

AIM OF THE STUDY: Aim of the study was for developing silicone segments coated with an anti-virulence agent (eugenol).

METHODS: Drug release profiles; efficacy analysis; neutrophil response studies and in vitro toxicity profiling proved the effective and safe performance of these eugenol coated sections.

RESULTS: Parameters for sol-gel preparation and coating were tailored to achieve a prolonged release of eugenol (at anti-virulence doses) from dip coated thin films for 35 days. In efficacy experiments; eugenol coated segments were able to prevent biofouling (p<0.001) and biofilm formation by Pseudomonas aeruginosa PAO1. Resistance development was minimized by choosing anti-virulence property over anti-microbial.

CONCLUSIONS: Therefore; for the first time; anti-virulence agent covered silicone segments offered a means of reducing CAUTIs.


  50. Differential Effects of SGLT2 Inhibitors on CV Risk Factors At Varying Degrees of Renal Function Top


Sagar Panchal, Sailesh Lodha1, Ajay Shah2, Anil Rajani

Janssen Medical Affairs; Mumbai; Maharashtra; 1Department of Diabetes and Endocrine Sciences; Eternal Hospital; 2Department of Endocrinology; SDM Hospital Cum Medical Research Institute; Jaipur; Rajasthan; India

BACKGROUND: Sodium glucose co-transporter 2 inhibitors owing to their glucosuric action significantly decreases HbA1c; FPG; PPG. As evident from their respective cardiovascular outcome trials. SGLT2i also reduces CV risk factors like body weight; blood pressure and albuminuria. Prior studies suggest that the HbA1c lowering effects of SGLT2i attenuate at lower estimated glomerular filtration rate (eGFR). However; effects on other CV risk factors at different eGFR levels are incompletely understood.

AIM OF THE STUDY: To evaluate effects of different SGLT2 inhibitors on CV risk factors at varying degrees of renal function.

METHODS: Data about differential effects SGLT2i on CV risk factors at varying degrees of renal function was obtained from online electronic databases like Pubmed and google scholar and analyzed.

RESULTS: Neuen et al. in analysis of CANVAS program- canagliflozin in reduced (eGFR <60) & preserved (eGFR >60) renal function; though there was moderate decrease in HbA1C lowering potential (- 0.43% vs -0.64%) at reduced renal function but similar reduction in CV risk factors like BW (-1.16 kg vs -1.43 kg); SBP (-3.89 mmHg vs -4.11 mmHg) & mean ΔUACR (-23% vs -17%). Petrykiv et al. in pooled analysis of 11 clinical trials assessed changes in HbA1c; body weight; BP etc. with placebo or dapagliflozin over 24 weeks in T2DM patients according to different baseline eGFR categories. HbA1c lowering effects of dapagliflozin were smaller at lower baseline eGFR levels. However; effects of dapagliflozin on BW and SBP were similar regardless of baseline eGFR. Cherney et al from five 24-week trials of 2286 T2DM patients randomized to empagliflozin or placebo showed significant reduction in HbA1C & BW only at higher eGFR levels but SBP reduction was maintained even at low eGFR levels.

CONCLUSIONS: SGLT2i have shown decreased potential of glycemic reduction at reduced renal function but effect on other CV risk factors is maintained. SGLT 2 i can be a promising therapeutic agent with additional cardiovascular benefits in T2DM with CKD; but this needs further evaluation at large scale.


  51. Prospective Study to Determine Correlation Between B Cell Count and Antibody Titre with Graft Function in Abo-Incompatible Kidney Transplantation Using Different Dosages of Rituximab Top


Nikhil Shinde, Deepak Shankar Ray, Pratik Das, Sharmila Thukral

Rabindranath Tagore International Institute of Cardiac Sciences; Kolkata; West Bengal; India

BACKGROUND: ABO incompatible Kidney Transplant was earlier considered to be contraindicated but nowadays it has been accepted as a alternative therapy for End stage renal disease and the outcomes of ABO incompatible are equivalent to ABO compatible kidney transplant. For desensitization; dose of Rituximab varies from centre to centre; ranging from 100 mg/m2 to 500 mg/m2. To avoid excessive immunosuppression and the concomitant risk of infection; tendancy has prevailed to reduce level of immunosuppression.

AIM OF THE STUDY: Correlation between rituximab dosage; B-cell level and antibody titer with graft function; to study the adverse outcome with different dosages of rituximab in ABO incompatible renal transplant.

METHODS: Prospective; randomized; interventional assessment of patients. INCLUSION CRITERIA -1) ABO incompatible kidney transplant recipients with antibody titer of ≤ 1: 5122) Age > 18 years of any gender. 3) Patients who are willing to give valid informed consent to take part in study. EXCLUSION CRITERIA –1) Patients undergoing re-transplant. 2) Patient with Hepatitis B; Hepatitis C; HIV positive. 3) ABO incompatible kidney transplant recipients with antibody titer of >1: 512 All ABO incompatible recipients received Rituximab (Group A = 100 mg; Group B = 200 mg) 14 days before the date of transplantation. Plasmapheresis and hemodialysis were given as per requirement. Each plasmapheresis was followed by 5 gram of Immunoglobulin slow Intravenous. Plasmapheresis was given to achieve the target anti-A/B antibody titer of ≤1:32 before transplant. Oral immuno suppressants; Tacrolimus (0.15 mg/kg) MMF (360 mg thrice daily) and Prednisolone (20 mg) were started 14 days before transplant.

RESULTS: Single dose of 100 mg rituximab had almost the same impact on B cells in the peripheral blood as 200 mg 14 days after administration. Incidence of infection though high in patient who received high dose (200 mg) as compare to low dose (100 mg) of rituximab but the difference in graft rejection and patient survival was not significant in both groups.

CONCLUSIONS: ABO-incompatible renal transplant with low dose rituximab atleast 2 weeks before transplant along with triple immunosuppresants has good outcome; low dose rituximab has ability to suppress absolute CD-20 sufficiently without having high incidence of rejection and low incidence of infection.


  52. Nothing Going Right - “Isolated PLSVC” - A Venous Access Issue Top


R Shafeeque, M Sreelatha, T P Noushad, E K Jayakumar

Department of Nephrology; Government Medical College; Kozhikode; Kerala; India

BACKGROUND: The congenital variations in the venous system are no exception in the gamut of anatomical malformations of various organs in the human body. The venous anomaly of a persistent left superior vena cava (PLSVC) is the most common congenital malformation of the thoracic venous system. It affects 0.3%–0.5% of the general population; and this incidence is up to 10% of those with congenital heart disease (CHD).”Isolated PLSVC” is an extremely rare venous anomaly.

AIM OF THE STUDY: Isolated PLSVC is usually innocuous; however; it can pose clinical difficulties with central venous access.

METHODS: Here we present a case of a 30 yr old male; ESRD with plans of initiating RRT Jugular dialysis catheter insertion tried on both sides in multiple attempts. Every time check x ray showed catheter lying in the left side of heart which forced us to remove. Further evaluation including venous doppler; contrast echo; CECT revealed the anatomic malformation of his venous system. He had persistent left superior vena cava (PLSVC) and that too an “Isolated PLSVC” draining into coronary sinus.

RESULTS: PLSVC with absent right superior vena cava; also termed as “isolated PLSVC;” is an extremely rare venous anomaly. He had no associated cardiac lesion and continued hemodialysis uneventfully with left jugular catheter before going for transplant.

CONCLUSIONS: Nephrologists always faces access issues of various forms. This case highlighten the need for suspecting venous anomalies in access failures and diagnosing early to avoid multiple attempts; to find associated cardiac lesions and to put a possible access at the earliest.


  53. Strongyloid Hyperinfection Syndrome (His) in IgA Nephropathy on Steroid: A Case Report Top


Dibyajyoti Kalita, R P Mathur, Suman Lata, Patibha Kale, Shreepriya Mangalgi, Anuradha, Rajesh Jaiswal, Anand Jain

Department of Nephrology; Institute of Liver and Biliary Sciences; New Delhi; India

BACKGROUND: Strongyloidiasis is caused by the female nematode Strongyloides stercoralis. It causes autoinfection leading to Hyperinfection syndrome and disseminated strongyloidiasis in patients with impaired cell-mediated immunity. Increased parasite turnaround and dissemination in patients with hyperinfection syndrome and disseminated disease often have catastrophic clinical manifestations. Diagnosis of Strongyloides hyperinfection syndrome can be very difficult.

AIM OF THE STUDY: Case report of Strongyloid hyperinfection in IgA nephropathy.

METHODS: A 54 years old farmer with well controlled type 2 diabetes mellitus and hypertension for 5 years; presented with frothy urine and pedal edema in January 2017. Renal biopsy done for nephrotic range protienuria showed IgA nephropathy (M1E0 S0 T0 C0). He was started on oral prednisolone in March 17; after 3 months of ARB showing no remission. In May 2018; he developed productive cough and worsening dyspneoa for 5 days. It was preceded by bulky diarrhea and abdominal cramps for a month. He was in Type 1 respiratory failure; blood sugar of 580 mg/dl with no urine ketones. Imaging was suggestive of atypical pneumonia.. He was treated IV pipericillin Tazobactum and clarithromycin. Blood; sputum and urine cultures were negative. Stool examination was unremarkable. Motile filariform larva of Strongyloid were seen in repeat stool microscopy; sputum microscopy and urine.. Blood culture had growth of Acenetobacter baumani and E. coli.

RESULTS: Strongyloid Hyperinfection was diagnosed and treated with oral ivermectin for 2 weeks. Day 5 sputum and stool microscopy showed larval clearance. EMR review showed eosinophilia (14 %) pre biopsy; that decreased to 3 % after 2 months of steroids. He was followed up on outpatient basis. Oral steroid was tapered and continued on ARB. His protienuria decreased to 2.4 g/g (UPCR) with serum albumin of 3.7 gm/dl during the next three (3) months of follow up and eosinophilia resolved.

CONCLUSIONS: There is a high prevalence of helmenthic infestation in India. Eosinophilia may be the only clue in an immunocompetent person. Microscopy of fresh stool samples for ova and cyst and anti helmenthic treatment prior to immunosuppressive therapy may prevent such complications.


  54. Granulomatous Interstitial Nephritis in Post Renal Transplant- Proton Pump Inhibitor The Culprit Top


Navin Pattanashetti, Ekta Paramjit, Raja Ramachandran, K L Gupta, Ritambhra Nada

Department of Nephrology; PGIMER; Chandigarh; India

BACKGROUND: Granulomatous interstitial nephritis (GIN) is a form of inflammation; characterised by formation of granuloma within the affected tissue with giant cells; macrophages and monocytes. It is seen in upto 0.9% of native renal biopsies. Considering initial innate nature; it has capacity to occur even in immune deficiency states and is rarely seen in renal allograft and proton pump inhibitor (PPI) induced GIN in renal allograft is rarest.

AIM OF THE STUDY: To present an unusual case of PPI induced post transplant GIN.

METHODS: A 36 years old male; underwent renal transplant in 2002 with wife as a donor; basic disease being chronic glomerulonephritis. Baseline creatinine was 0.9 mg/dl; on triple immunosuppression and amlodipine and atenolol. He was started on pantoprazole 40 mg OD when he presented with dyspeptic symptoms 1 month back. Now he presented with rise in serum creatinine (1.9 mg/dl); urine routine was normal; 24 hour urine protein was 220 mg/day; cyclosporine C0 levels were normal; renal biopsy showed 4 glomeruli all were normal; no evidence of rejection; multiple non necrotising granulomas with surrounding inflammation and giant cell reaction; ZN stain was negative so reported as GIN. Urine for AFB; TB PCR were negative; serum calcium and ACE levels were normal; computed tomography chest and abdomen was normal. So we kept possibility of PPI induced GIN and PPI was changed to H2 blocker (Ranitidine); over a period of 15 days his creatinine returned to baseline (1 mg/dl) without steroid therapy.

RESULTS: Interstitial inflammation in renal allograft is frequently seen with acute cellular rejection; however presence of granuloma with giant cell reaction has been reported most frequently with fungal and mycobacterial infection 2 and sarcoidosis 3. However Farris et al. 4; has reported drug induced GIN in 5/22 patients; out these 5 patients 2 due to bactrim; 1 dapsone; 1 foscarnet and 1 due to either omeprazole or acyclovir. In our case; he was receiving only triple immonosuppression and antihypertensive amlodepine and atenolol along with pantoprazole. Casual relationship has been established as serum creatinine increased following initiation with pantoprazole and returned to baseline once drug was stopped.

CONCLUSIONS: It warrants that PPI should be used cautiously even in transplant setting to avoid development of GIN and renal dysfunction; if necessary better to use H2 blockers.


  55. Follow Up Clinical Outcome of Patients with Nephrotic Syndrome and Experience As Newbie Pediatric Nephrologist Top


Sonia Sharma

Department of Nephrology; Max Super-Speciality Hospital and PSRI Hospital; New Delhi; India

BACKGROUND: Pediatric nephrology has wide scope and spectrum with lot of variability in diseases pattern and age group but have many challenges to survive in private sector. Nephrotic Syndrome in paediatric age is defined as edema; hypoalbumin; hypercholestrol and loss of protein in urine more than 1 gm /day or 40 mg/m2/h or a first-morning urine protein/creatinine of 2-3 mg/mg creatinine or greater.

AIM OF THE STUDY: Outcome of nephrotic syndrome patients who maintained follow up at-least for a period of 6 months. Also sharing initial challenges and experience as pediatric nephrologist at naïve center.

METHODS: Here presenting clinical data of nephrotic patients who followed [at-least for a period of 6 months. Children who came as first episode of nephrotic syndrome were treated with 6 weeks of 2 mg/kg daily steroids and then 1.5 mg/kg on alternate day. Children with frequent relapses or steroid dependent course were treated with alternative therapy other then steroids and in steroids resistant patients kidney biopsy was done.

RESULTS: 81/150 children followed for at-least 6 months over a period of 4 years. Loss to follow up was for patients with parents concerns for relapses and cost of treatment; no satisfaction & willingness to go for Gov. sector or to senior consultant. 81 patients with median age of 4.9 year were followed for a median time of 24 months. 47 patients were boys. 46.9% had FR/SD; 12.3% SRNS; 14.8% long term remission 23.4% CKD in 2 Alternative therapies were levamisole (n=13); Mycophenolate (n=18); calcineurin inhibitor therapy (n=6); IV cyclophosphamide (n=2) and rituximab (n=2). Kidney biopsy was done in 20 patients (FSGS (n=10); MCD (n=7); IgM nephropathy (n=1) and C1 q nephropathy (n=1); Monoclonal gammapathy (MGRS) (n=1). Severe infection (n=4); hypertension (n=5); Hypothyroidism (n=2) at nephrotic onset and none had thrombosis.

CONCLUSIONS: In between all challenges; shared clinical data of all nephrotic patients who followed for at-least a minimum period of 6 months. Social economy factor make it a challenge it to establish in private sector.


  56. Prevalence of Depression and Its Association with Non-Compliance Towards Diet Regime in Dialysis Patients Top


Mohd Shah Alam, J Rachana, D Paras, G Virendra, K Jatin, B Viswanath, B Shrirang, K Rajesh

Apex Kidney Foundation; Mumbai; Maharashtra; India

BACKGROUND: Depression significantly increases overall burden of illness in patients with chronic medical condition including dialysis therapy. Good nutrition status is a vital predictor of morbidity and mortality in dialysis patients. However; as dialysis patients are challenged with several triggers of stress; hence compliance towards diet regime is may be below optimal.

AIM OF THE STUDY: The main aim of this study was to assess the prevalence of depression in chronic dialysis patients and to study its association with dietary non-compliance.

METHODS: Patient Health Questionnaire (PHQ 9) was used to study prevalence of depression in 411 hemodialysis patients. PHQ9 has a scoring system from 0 to 27 where score of 0-4 refers to no depression; 5 -9-minimal depression; 10-14 –major depression with mild severity; 15-19-major depression with moderate severity and > 20 refers to major depression with severe severity. For assessing dietary compliance; a short questionnaire containing 9 questions was created and the level of depression leading to non-compliance was rated as – 0-25% - 0; 25-50% -1; 50-75%- 2; 75-100% -3.

RESULTS: Out of 411 patients; 238 were males and 173 were females. Each patient was personally interviewed on bedside. 50.3% patients did not have depression; 33.8% had minimal depressive symptoms; 11.6% had major depressive symptoms but with mild severity; 0.03% patients had major depression with moderate to high severity. When level of non-compliance was assessed amongst patients without depression; its prevalence was 35.3% and in patients with depression; it was 70.8%. The major triggers leading to depression were financial and social stress.

CONCLUSIONS: One third of the study population had minimal depression. The level of dietary non-compliance was greater in patients with depression. The major triggers leading to depression were financial and social stress.


  57. Weakness” in Hemodialysis Patients: Not Always “Under-Dialysis Top


Pritam Gade, Valentine Lobo, Vipul Chakurkar, Anil Godbole, Farrokh Wadia

Department of Nephrology; KEM Hospital; Pune; Maharashtra; India

BACKGROUND: Dialysis water quality is central to patient outcomes in hemodialysis. Improper maintenance of water purification system results in poor quality water; leading to complications.

AIM OF THE STUDY: We report series of cases from a peripheral dialysis centre; presenting to us with symptoms similar to inadequate dialysis but actually resulting from chemical contamination of dialysis water.

METHODS: We managed 7 maintenance hemodialysis patients dialyzing twice a week at a stand-alone; low-cost dialysis centre. All but one of them presented to us in a period of 3 months; with symptoms of generalized weakness; fatigue; difficulty walking or with altered sensorium. One patient had cardiac arrest during hemodialysis; revived and then was shifted to our centre. Their clinical and laboratory data is presented.

RESULTS: Investigations revealed high serum Magnesium levels in all patients (4.45±0.83 mg/dl). No patient was on Mg2+ containing drugs. Serum Mg2+ levels normalized after hemodialysis (mean 2 sessions each) at our centre (pre-discharge Mg2+ 2.21 ±0.19 mg/dl). One patient expired while all others improved symptomatically. Water system and hemodialysis machines at that centre were investigated. Machines delivered dialysate with Mg2+ level of 5.2 mg/dl. Feed and product water of RO had same Mg2+ levels (4.61 and 4.6 mg/dl; respectively); indicating non-functioning of RO membrane. The raw water; obtained from a well; also had high levels of Mg2+. After replacing the RO membranes; dialysate Mg2+ levels were within acceptable range and no further episodes of hypermagnesemia were reported from the centre.

CONCLUSIONS: Hypermagnesemia; an uncommon complication in hemodialysis; presented with symptoms similar to under-dialysis. In this case series; it was due to inadequate maintenance and quality control of dialysis water.


  58. Double Whammy - Pigment Nephropathy and Warfarin-Related Nephropathy as Aetiology for AKI in A Patient with Mechanical Heart Valves Top


Priyangani Lohia, G S Ravishankar, K Jagadeeswar Reddy, Mahesha Vankalakunti1, Arvind Conjeevaram

The Bangalore Hospital; 1Manipal Hospital; Bengaluru; Karnataka; India

BACKGROUND: It is well known that patients with mechanical heart valves may develop sheer stress related hemolysis and consequent pigment related nephropathy. Warfarin Related Nephropathy (WRN) is a relatively new entity and is defined as AKI in the setting of an INR of > 3.0; excluding other obvious etiologies. We describe a patient with mechanical heart valves on oral anticoagulation who developed both pigment nephropathy and WRN causing AKI.

AIM OF THE STUDY: A case report that delves into the aetiology of AKI in a patient with mechanical heart valves & a renal biopsy clinches the diagnosis of warfarin related nephropathy in addition to pigment nephropathy.

METHODS: A 33 year old male; known Hypothyroid on T4 supplementation; Bipolar disorder on Tab sodium valproate and Rheumatic heart disease with Mitral Valve and Aortic valve Replacement 8 years ago on anticoagulation (warfarin) therapy came to the OPD with complaints of abdominal pain; nausea and decreased urine output since 2 weeks. Patient had an episode of acute GE prior to these symptoms. Examination revealed BP 110/70 mmhg; HR – 160 bpm irregularly irregular pulse with prosthetic valve heart sound present. Pt had sub-cutaneous ecchymoses in right forearm and left arm.

RESULTS: Investigations showed elevated serum creatinine 4.37; Urea 57; Hb 11; Urine routine - plenty of RBCs; 1+ albuminuria. PT was 4.57 so warfarin was withheld & FFPs were given as needed. PS showed mild hemolysis with schiztocytes; Reticulocyte count 1.3%; LDH – 1003; Coomb's test was negative; Haptoglobin Low (<30). 2D Echo – unremarkable mitral valve prosthesis; LVH with variable function due to rapid ventricular rate; EF 72%. Coagulation profile was corrected with FFP and vitamin K; and Pt underwent a renal biopsy. This showed the tubules with moderate degree of ATN with numerous coarse brownish pigments in the cytoplasm of the proximal tubular epithelium. Additionally these pigments stain blue with prussian blue stain indicating the presence of heme content. Also in addition; the distal tubular lumina were blocked with fresh RBC casts at many places; lacking iron pigment. These findings confirmed the presence of pigment nephropathy and warfarin related nephropathy.

CONCLUSIONS: This patient with mechanical heart valves presented to us with AKI. A renal biopsy showed WRN and pigment nephropathy. WRN is defined as AKI in the setting of an INR of > 3.0; excluding other obvious etiologies and is now being increasingly recognized in pts on oral anticoagulation.


  59. Extradural Mass -Aspergilloma in Renal Transplant Recepient Top


Manpreet Kaur Jhingar, Vikas Makkar, Ravi Angral, P M Sohal, Suman Sethi, Simran

Dayanand Medical College; Ludhiana; Punjab; India

BACKGROUND: 55 years old Renal transplant recepient with date of transplantation 12- 12- 2017; basic disease hypertensive nephrosclerosis live related donor wife with no prior induction therapy. his procedure was uneventful. he was detected to have hep c infection for which he was started on DAA. He had on and off influenza symptoms which were managed conservatively. HRCT CHEST showed ground glass haze bilaterally and PCP/CMV pneumonitis possibility was kept. CMV Infection was excluded.

AIM OF THE STUDY: However he started to develop lumbar backache along with progressive lower limb weakness with duration of 1 month which was followed by acute onset of weakness of limb.

METHODS: He had also mild renal dysfunction associated with this episode with serum creatinine being 1.38 increased to 1.7. He was on tripple immunosupressants prednisolone/tacrolimus/Mycophenolate Mofetil. He was brought to casuality. On examination he was afebrile with normal vitals.

RESULTS: He underwent MRI spine which showed infiltrative mass lesion involving posterior elements of D11-D12 vertebrae with large posterior extradural component. Possibilities of infective Vs malignancy kept. USG guided trucut biopsy was taken and send for histopathological examination. Findings were suggestive of Aspergillosis.

CONCLUSIONS: He had 2d echo s/o fungal vegetation. advised surgery. So likely fungal metastasing to spine.


  60. Does Haemodialysis Prior to Renal Biopsy Reduce The Frequency and Severity of Bleeding in Patients with Severe Renal Failure? - A Retrospective; Observational Cohort Study Top


Vinod Babu Murakonda, A T Valson, A Mohapatra, S Kakde, V G David, S Alexander, S Jacob, G Rajan, P M Koshy, E E John, S Varughese

Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India

BACKGROUND: The risk of post renal biopsy bleed increases with declining GFR. This has been attributed to uraemic platelet dysfunction; and patients are often subjected to pre-biopsy haemodialysis (HD) to mitigate this risk; because of evidence that HD improves bleeding time and platelet function. Initiation of HD for optimizing platelet function prior to renal biopsy adds to the cost of treatment; yet its effect; if any; on reducing clinically significant post renal biopsy bleeds has not been studied.

AIM OF THE STUDY: To determine whether HD prior to renal biopsy reduced the frequency and severity of clinically significant bleeding in patients with severe renal failure (CKD EPI eGFR less than 10 ml/min/1.73 m2).

METHODS: We included all patients with CKD EPI eGFR less than 10 ml/min/1.73 m2 who underwent ultrasound-guided native renal biopsy at our centre for various indications between August 2016 and December 2017. The hospital information system and in-patient records were accessed for demographic and clinical details; including history of HD prior to biopsy; laboratory parameters and occurrence of clinically significant post biopsy bleed. Major bleeds were defined as bleeding requiring blood transfusion; angioembolization; nephrectomy; or causing septicaemia/death. Minor bleeds were defined as documented haemoglobin drop or haematoma with or without other symptoms (gross haematuria; flank pain) not requiring blood transfusion. Patients were deemed to have received HD if they had received even a single session of HD within the 1 week prior to a renal biopsy.

RESULTS: A total of 2118 patients underwent renal biopsy during the study period. Among them; 200 (9.44%) patients had a CKD EPI eGFR less than 10 ml/min/1.73 m2 and constituted the study population. Frequency of post biopsy bleeding was 11.5% (23 out of 200 patients); 12 patients (6%) had a major bleed and 11 patients (5.5%) had a minor bleed. The majority of patients (n = 136; 68%) were dialyzed before biopsy. Clinically significant bleeds (12.5% vs. 9.38%; p = 0.64) and major bleeds (7.35% vs. 3.13%%; p = 0.34) were more common in the dialyzed group; though this did not reach statistical significance. On multivariate analysis; the dialyzed group had a significantly greater proportion of patients with eGFR < 6 ml/min/1.73 m2 (p < 0.001; 95% CI 3.39-29.9) but did not differ from the non-dialyzed group in age; gender; diabetic status; pre-biopsy blood transfusion history; renal parenchymal grade; or degree of interstitial fibrosis and arteriosclerosis in the biopsy specimen.

CONCLUSIONS: 11.5% of patients with eGFR less than 10 ml/min/1.73 m2 develop a clinically significant post renal biopsy bleed. HD does not reduce; and; may even be associated with a higher risk of bleeding because patients with lower eGFR; and therefore greater platelet dysfunction are more likely to be dialyzed.


  61. Assessment of Sleep Quality in Dialysis Patients Top


Virendra Gupta, D Paras, K Rajesh, J Rachana, A Mohd Shah, K Jatin, B Vishwanath, B Shrirang

Apex Kidney Foundation; Mumbai; Maharashtra; India

BACKGROUND: Prevalence of insomnia has been reported to be 19 to 71% in patients with ESRD. The main contributors to sleep disorders in chronic hemodialysis are restless leg syndrome; sleep apnea; etc. apart of metabolic factors which include uremia; anemia; bone pain; poor sleep patter which includes frequent napping during daytime; etc.

AIM OF THE STUDY: The main aim of this study was to assess the sleep quality of patients on chronic hemodialysis.

METHODS: 432 patients were interviewed and to assess sleep quality a Pittsburg Sleep Quality Index (PSQI) score was used. According to the PSQI scale – score of 0 was indicative of good sleep quality and that of >5 was indicative of poor sleep quality.

RESULTS: Out of 432 patients; 252 were males and 180 were females. Their average age was 50.7 ± 13.7 years. The average number of sleeping hours was 7.0 ± 2 hours. As per the global PSQI score; it was found that 67.8% patients had poor sleep quality (PSQI score >5) and 32.2% patients had good sleep quality (PSQI score <5). 55.9% patients reported they had better sleep quality after dialysis session as compared to non-dialysis day. The major causes of sleep disorders were found to be psychological including anxiety (67.9%); followed by stress (26.8%) and rest were clinical causes like neuropathic pain (2.1%); restless leg syndrome (1.8%).

CONCLUSIONS: Approaches to alleviate psychological problems including anxiety and stress in hemodialysis patients should be addressed in order to achieve better quality of life in dialysis patients.


  62. Peritonitis Due to Unusual Fungal Infection in Patients on Continuos Ambutalory Peritoneal Dialysis Top


Nida Fatima, Kamini Singh, Ashutosh Pathak, Kashi Nath Prasad, Narayan Prasad, Amit Gupta

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

BACKGROUND: Fungal peritonitis is a serious problem in patients on peritoneal dialysis (PD). It leads to technique failure with high mortality and morbidity. Fungal peritonitis is increasingly being reported from the developing tropical countries. Here; we report peritonitis due to unusual fungi in patients on CAPD.

AIM OF THE STUDY: To report the unusual Fungal organism in peritonitis patients.

METHODS: We performed microbiological culture for bacterial and fungal pathogens using automated BACTEC culture system. Cell counts were routinely done on every dialysate. At least 100 ml PD fluid was centrifuged and cultured using appropriate culture medium. BACTEC medium with positive growth were sub-cultured and all the isolates were identified using standard biochemical tests. Antibiotic susceptibility was tested for bacterial isolates following Clinical Laboratory Standard Institute guidelines.

RESULTS: Thirty three patients on CAPD were included in the study. Total 14 samples had cell count > 100/µl; 11 of them were culture positive. Amongst the 11 culture positive cases; 7 were having bacterial infections such as S. aureus; P. vulgaris; Micrococcus; Staphcons; K. pneumoniae; P. mirabilis and Staphylococcus and the remaining 4 had from fungal infections such as Aspergillus; Hylohyphomycetes; Mucormycetes and Yeast.

CONCLUSIONS: There was a shift in fungal pathogens from yeast to mycelia. Hylohyphomycetes; a rare fungal organism is being reported for the first time in CAPD patients. Since mycelial infection is more difficult; patients training is utmost important to prevent such infections.


  63. Tricuspid Valve Endocarditis in Hemodialysis Patient- A Rare Infective Complication Top


Moiduddin Azhar, Manjusha Yadla

Department of Nephrology; Gandhi Medical College Musheerabad; Hyderabad; Telangana; India

BACKGROUND: About 2–6% of chronic hemodialysis patients develop IE. The left heart is the most frequent location of IE in Chronic HD and the different published series report a prevalence of left valve involvement varying from 80% to 100%. Right-sided IE is rare; with its incidence varying from 0% to 26%; and the tricuspid valve is the main location.

AIM OF THE STUDY: To Highlight a rare Infective Complication in Haemodialysis patient.

METHODS: A 50 years old male known case of CKD on MHD; wit Right IJV catheter as access; since 1 and 1/2 months presented with Hypotension and fever. Patient was evaluated and investigations revealed leucocytosis. Right IJV was removed. Blood culture showed growth of Enterococci. 2D-Echo was done which showed tricuspid valve vegetations. Patient was initiated on peritoneal Dialysis in view of persistent Hypotension.

RESULTS: Patient improved symptomatically after 4 weeks of Antibiotic therapy. Repeat blood culture was sterile and Patient was resumed on HD via Left IJV and advised AV fistula creation.

CONCLUSIONS: Tricuspid valve endocarditis is a rare infective complication in HD patients but should be considered during evaluation in febrile illness in such patients.


  64. Impact of Goods and Services Tax on Economics of Dialysis Top


Paras Dedhia, K Rajesh, G Virendra, A Mohd Shah, J Rachana, K Jatin, B Shrirang, B Viswanath

Apex Kidney Foundation; Mumbai; Maharashtra; India

BACKGROUND: With the rolling of the one nation; one tax system in the nation; its impact on the renal drugs and dialysis consumables cost needs urgent assessment and corrective measures.

AIM OF THE STUDY: To assess the differences in taxation of some common renal/dialysis drugs and consumables before and after implementation of GST.

METHODS: Renal/dialysis associated drugs and consumables were studied according to their classes and the differences were compared as pre-GST versus post GST tax percentages. Common dialysis consumables studied were dialyser; tubing; normal saline (NS); IV set; heparin; dialysis kit; dialysis fluid; AVF needle; syringe. Common drugs studied were antihypertensive agents; calcium supplements and phosphate binders.

RESULTS: Dialysers were into 0% bracket previously and now into 5% bracket under GST. Blood tubing; AVF needles; erythropoetin which were into 0% bracket and now are under 12%. Previously the tax on NS; IV set; syringes; heparin; dialysis fluid was 6% and GST on them is 12%. Similar inflation was seen in anti-hypertensive drugs; calcium supplements and phosphate binders.

CONCLUSIONS: This calls for an urgent need to appeal to government for revising GST rate on life saving treatment.


  65. Prevalence of Coronary Artery Disease in The Hemodialysis Population Top


Pranit Kakde, Deepa Usulumarty, Shrirang Bichu, Parag Tilve, Ganesh Sanap, Komal Nagori, Shrirang Bichu, Parag Tilve, Kothari, Rajesh Kumar, Viswanath Billa

The Apex Database; Apex Kidney Care; Sushrut Hospital and Research Centre; Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India

BACKGROUND: Chronic dialysis patients have a greatly increased age adjusted incidence and prevalence of coronary heart disease as well as increased mortality arising from coronary artery disease. The standard procedure is to evaluate patients with a 2D-Echo; ECG and stress test. The symptoms of renal failure often overlap with those of CAD and therefore CAD is often missed in such patients. Also these standard tests often underdiagnose and underestimate the burden of CAD.

AIM OF THE STUDY: To study the burden of coronary artery disease (CAD) in the hemodialysis population and identify predisposing factors to identify this risk.

METHODS: We performed a single centre; observational study enrolling 55 patients of age >50 years with symptoms of dyspnoea on exertion or rest; chest discomfort and recurrent episodes of fluid overload despite optimal dialysis therapy. Patients with established CAD were excluded. Patients underwent screening 2D echocardiography followed by coronary angiography. Based on coronary angiography findings; patients were classified into significant and insignificant coronary artery disease groups. Risk factors contributing to CAD were compared between these 2 groups.

RESULTS: Twenty six of 55 patients (47.27%) had significant coronary artery disease (>80% block) on angiography needing intervention with PTCA/CABG. Maximum blocks (80.76%) involved the left anterior descending artery and right coronary artery. There was no significant difference in the EF between the two groups (mean 50.44±15.81). While males; diabetics and smokers were at higher risk; dialysis vintage did not increase the risk for CAD in our patient population.

CONCLUSIONS: The prevalence of CAD in the MHD population is significant. Symptoms of dyspnoea; exertional breathlessness and chest discomfort have poor specificity in distinguishing renal from cardiac symptoms. 2D Echo is not a sensitive tool to identify coronary risk. An angiography is mandatory to diagnose CAD.


  66. Prevalence Clinical Profile and Outcome of Hypertension in Renal Transplant Recipients Top


A T Maasila, K Sathyasagar, T Balasubramaniyan, N Gopalakrishnan, J Dhanapriya, T Dineshkumar, R Sakthirajan, S Ganesh Aravind

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

BACKGROUND: Hypertension is a most commonly present in end-stage renal disease (ESRD) patients and its prevalence of 80%–85% among kidney transplant recipients. Various studies have shown the prevalence of 80% in immediate posttransplant and 50% in late posttransplant period. Hypertension is a major risk factor for atherosclerosis; increased cardiovascularmorbidity; mortality; and allograftdysfunction in transplant patients.

AIM OF THE STUDY: It is a retrospective study conducted to assess the prevalence; clinical profiles and outcome of hypertension in renal transplant recipients.

METHODS: t is a retrospective study conducted at Rajiv Gandhi Government General Hospital; Madras Medical College; Chennai; involving renal transplant recipients who are onfollow-up at nephrology outpatient department. Post-transplant hypertension was defined as systolic BP≥140 mmHg; diastolic BP ≥ 80 mmHg or the need of anti-hypertensive medication. Donor and recipient demographical details were obtained from medical records. Patients who underwent second renal transplant or graft nephrectomy were excluded.

RESULTS: Among 375 patients; 88% were male. Mean age of our study population was 35.82 ±9.37 years. 82.67% patients had post-transplant hypertension; of which 80.97% had pretransplant hypertension. 19.03% patients developed hypertension post transplant. Following transplantation hypertension resolved in 12.85%. Prevalence of well controlled; poorly controlled and resistant post-transplant hypertension were 49.68%; 50.32% and 7.42% respectively. Majority of them (90.97%) received calcium channel blockers.

CONCLUSIONS: Prevalence of hypertension in our renal transplant recipients was 82.67%. Early identification of risk factors; treatment and adequate blood pressure control will improve the long term patient; graft survival.


  67. Profile of Patients Attending Dialysis Unit in A Tertiary Care Centre in South India Top


Sarang Vijayan, G Swarnalatha, Uttara Das, Raja Karthik, T Gangadhar

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

BACKGROUND: Chronic Kidney disease (CKD) has shown increasing trends in recent years owing to increased prevalence of non-communicable diseases especially diabetes mellitus and systemic hypertension. Even though Kidney transplant is considered the best treatment option for CKD worldwide; most of the patients still depend on Hemodialysis (HD) mainly due to financial and social issues especially in developing countries like India.

AIM OF THE STUDY: 1. To assess the clinical and laboratory profile of patients attending dialysis unit in a tertiary care centre as well as to assess vascular access and related complications and transplant prospects.

METHODS: All patients attending the Dialysis unit undergoing maintenance hemodialysis during the year 2018 were taken into study. Baseline characteristics including demography; clinical and laboratory features; dialysis access and associated complications and transplant prospects were analyzed.

RESULTS: Our Dialysis centre caters to patients from entire Telangana state; but majority of patients belong to around 20 districts. Among the total 137 patients included in the study; 69% were males and 31% were females. Mean age of the study population was 39 years (SD-13.6). Mean systolic BP was 150 mm Hg (SD-20.5) and diastolic BP was 87 mm Hg (SD-11). Most common etiology identified was diabetes mellitus (20%); but most common native kidney disease was presumed chronic glomerulonephritis (biopsy not done). More than 75% of patients were having permanent vascular access including AV fistula (97%) and rest AV graft (3%). Those patients on temporary access were either having access failures (40%) or waiting for fistula maturation. Patients enlisted in Deceased donor kidney transplant programme were 60% and 15 % patients were undergoing workup for Live related kidney transplant.

CONCLUSIONS: Adequate Hemodialysis can maintain general wellbeing of CKD patients and stabilization of laboratory parameters. Diabetes mellitus single most risk factor for CKD. Because of active deceased donor transplant programme undergoing in Telangana; most of the patients are enlisted for DDKT.


  68. Case Report- Idiopathic Retroperitoneal Fibrosis-A Rare Cause of Obstructive Uropathy with Acute Kidney Injury Top


Anuradha, Suman Lata, R P Mathur, Shreepriya Mangalgi, Dibyajyoti Kalita, Rajesh Jaiswal, Anand Jain

Department of Nephrology; Institute of Liver and Biliary Sciences; New Delhi; India

BACKGROUND: Retroperitoneal fibrosis is a rare cause of acute renal failure (ARF) with very few cases reported in literature. We report a case of a 42 year-old female with an incidental diagnosis of retroperitoneal fibrosis.

AIM OF THE STUDY: A Case report of retro peritoneal fibrosis presenting as acute kidney injury.

METHODS: A 42-year-old female with no significant past medical history presented to us in March 2017 with a 6 months long history of intermittent low grade fever; low back pain; intermittent pain abdomen and associated nausea and vomiting. There was associated history of significant 8-10 kg weight loss over past 6 months. Physical examination was normal. On laboratory examination she was found to have Hb of 6.9 gm%; Blood Urea 135.5; Sr creat 7.55; Sr K- 7.5); USG W/A revealed RK 12 cms; LK 11.3 cms; with B/L increased echotexture. Soft tissue around IVC and aorta with bilateral HDUN? retroperitoneal fibrosis. CT Abdomen showed findings of retroperitoneal fibrosis with B/L hydronephrosis. CT guided biopsy was done which did not reveal any evidence of malignancy or granuloma. Her Sr CA-19.9; CEA; CA-125; CA-242-Neg; C3; C4-WNL; c-ANCA; p-ANCA; ANA; -neg; Montoux-neg; LDH- WNL; CRP-57.1; Sr IgG and IgG4 were raised; -25.6 g/l (6.3-13.4) and 3.25 g/l respectively.

RESULTS: She was given 3 sessions of hemodialysis and anemia was corrected using blood transfusion. B/L DJ stenting was done. Serum creatinine started decreasing and urine output improved. She was started on oral steroids; and was discharged 2 weeks later with a serum creat of 1.6 and daily urine output of 1.5 to 2 ltrs. As of Feb 2018 her serum creat hs normalised to 0.8 mg/dl with considerable reduction of retroperitoneal fibrosis on repeat CT Abdomen.

CONCLUSIONS: Retroperitoneal fibrosis is a rare entity and a rare cause of acute renal failure. It should be considered as a differential diagnosis in patients with acute renal failure and obstructive uropathy. Abdominal CT scan is the investigation of choice for diagnosis.


  69. Role of Plasmapheresis in Lupus Nephritis with Renal Limited TMA Top


Navin Pattanashetti, Manish Rathi, Raja Ramachandran, Ritambhra Nada, K L Gupta

Department of Nephrology and Pathology; PGIMER; Chandigarh; India

BACKGROUND: Thrombotic microangiopathy (TMA) in patients with lupus nephritis presents with severe manifestation and has high morbidity and mortality. There were no standardised guidelines for management of these patients.

AIM OF THE STUDY: Aim of the study was to assess the effectiveness of additional plasmapheresis (PLEX) over standard therapy in patients of lupus nephritis with renal limited TMA.

METHODS: Prospective observational study of two and half years; clinical and histopathological data of biopsy proven new onset lupus nephritis with TMA were included and they were actively followed up for 6 months. They were divided into 2 groups; one group who recieved PLEX another with no PLEX. The outcomes were noted as complete response; partial response; treatment failure and death.

RESULTS: In our study; 50 patients had TMA; Out of 50 patients 8 patients (16%) received PLEX. In PLEX group all the patients received at least 5 sessions of PLEX (40 ml/kg/session) in addition to cyclophosphamide or mycophenolate mofetil along with steroids. Patients who received PLEX had higher mean serum creatinine (5.13±3.75 vs 2.00±1.7; p-0.001); but comparable serum albumin (2.25±0.84 vs 2.86±0.84; p-0.70) and 24 hr urinary protein (4.13±2.10 vs 3.07±1.59; p-0.11) compared to group with no PLEX. PLEX group had higher deaths (25% vs. 9.5%) and failure to treatment (50% vs. 33.3%) and lower rates of complete response (0% vs 35.7%) but failed to show statistical significance (p-0.07). As the baseline data were significantly different between the 2 groups; the propensity score match was done. Even after matching; the group with PLEX had similar outcomes as that of group with no PLEX and there was no statistical significant difference between two groups with respect outcomes (p- 0.76).

CONCLUSIONS: Addition of plasmapheresis to standard therapy is not beneficial in management of new onset LN with renal limited TMA; since the sample size is small; warrants larger clinical trial.


  70. New Entrance Gate for Nephrotoxic AKI Top


Biswajit Mishra, E Ram Prasad, Indhumathi, Manikantan, M Jayakumar

Sri Ramachandra Institute of Higher Education and Research; Chennai; Tamil Nadu; India

BACKGROUND: Cresols are commonly used as household cleaners and disinfectants. They are a group of methyl phenol organic compounds. Exposure occuring at very low concentration is not harmful but if ingested; inhaled or skin contact at high concentration can lead to chemical burns and multiorgan damage. Modes of intoxication may be through accidental or self-induced.

AIM OF THE STUDY: Since there is a paucity of case reports with different routes of entry; we hereby report a case of cresol induced renal failure which had different course than previous reported literature.

METHODS: A 48-year-old woman with no known comorbidities presented with second degree chemical burns secondary to accidental contact along with inhalation of cresol solution. She complained of breathlessness and blackish discoloration on the burnt areas (flexor aspects of lower limbs; bilateral gluteal region; right hand and face). On examination vitals were stable; system examination were normal; with 40% BSA chemical burns. Laboratory investigations revealed leucocytosis; deranged renal parameters and metabolic acidosis. Hemodialysis was initiated in view of worsening renal functions USG abdomen & pelvis done was normal. Patient continued to be anuric and required total 10 sessions of dialysis. Patient subsequently became independent of dialysis. She was discharged with adequate urine output and normal renal function.

RESULTS: Cresol is a commonly available household agent which alters the structure and precipitates cellular proteins. It has high permeability properties comparable to phenol. Cresol can be excreted in two steps – initially biliary excretion post glucuronidation followed by urinary excretion. But clearance by conventional HD is restricted in view of protein binding and the extent of volume distribution. Inhaled or ingested or even direct skin contact with very high concentration can lead to chemical burns and organ damage. Cresol toxicity has been reported often through self induced or accidental injury. In the unconjugated phenol form it damages the renal tubules and glomeruli. It reduces glutathione levels; causes renal ischemia and leads to pigment nephropathy secondary to precipitation of haemoglobin. A detailed database search reveals an approximate of 38 case reports of cresol intoxication leading to multiple organ damage like liver; lung; skin etc.

CONCLUSIONS: Our case suggests that skin exposure is a new possible entrance gate for nephrotoxic agent. It has relatively low prevalence of hepatic dysfunction but higher prevalence for renal failure. Timely local decontamination and aggressive treatment could be a key to prevent systemic side effects.


  71. A Study of Comparison between Serum Cystatin C and Serum Creatinine in The Detection of Mild and Severe Diabetic Nephropathy Top


Prajit Mazumdar, Vidyapati, Malyaban Das, Divakar Kumar

Department of Nephrology; Rajendra Institute of Medical Sciences; Ranchi; Jharkhand; India

BACKGROUND: Measurement of serum creatinine is simple but the general view is that up to 50% of GFR can be lost before significant elevation of serum creatinine occurs. Therefore; in our study serum cystatin C; was compared to ceratinine as an accurate endogenous GFR marker in patients of mild and severe diabetic nephropathy.

AIM OF THE STUDY: To determine whether serum cystatin C is more accurate than serum creatinine in detection of mild and severe diabetic nephropathy.

METHODS: 25 patients with type 1 and 50 patients with type 2 diabetic nephropathy were evaluated with serum creatinine; and serum cystatin C clearance. Cystatin C was measured by a particle-enhanced turbidimetric method and creatinine by an enzymatic method. The cut-off levels for mild and severe nephropathy was set as glomerular filtration rate (GFR) less than 60 and 90 mL /min m2 respectively.

RESULTS: When comparing the diagnostic utilities for serum cystatin C versus serum creatinine in severe diabetic nephropathy (GFR < 60 mL min) 1 1.73 m) 2; there were no significant differences between the two markers whether age adjusted or not. However; for diagnosing mild nephropathy (GFR < 80 mL min); serum cystatin C was significantly more useful.

CONCLUSIONS: Serum cystatin C performed better compared with serum creatinine to detect mild diabetic nephropathy. Hence; Cystatin C could be used as a marker to detect diabetic nephropathy in early stages so that treatment could be initiated early so as to reduce morbidity and mortality.


  72. A Review on The Effect of SGLT2 Inhibitors on eGFR in Adults with T2DM With Chronic Kidney Disease Top


Biswajit Aich, Kalyan Gangopadhyay, Anil Rajani

Janssen Medical Affairs; Mumbai; Maharashtra; Department of Diabetes and Endocrinology; Peerless Hospital and B. K. Roy Research Center; Kolkata; West Bengal; India

BACKGROUND: Progression of chronic kidney disease (CKD); leading to end-stage renal failure; is a common complication in patients with type 2 diabetes mellitus (T2DM). Anti hyperglycaemic agent (AHA) treatment options are limited as many classes of agents may have decreased efficacy and may be associated with increased risk of adverse effects in patients with CKD.

AIM OF THE STUDY: We aimed to find the variation in eGFR while using a SGLT2 Inhibitor.

METHODS: A literature search in Pubmed was performed using key words (canagliflozin) OR (empagliflozin) OR (dapagliflozin) AND eGFR. 3 relevant articles are evaluated.

RESULTS: SGLT2 inhibitors have a favorable outcome on eGFR in patients with T2DM with CKD. With all the SGLT2 inhibitors a similar pattern of eGFR change is noticed. The reductions in eGFR with canagliflozin were largest at week 3 (the first postbaseline measurement) and then trended back towards baseline over week 26. In patients with T2DM and moderate renal impairment; mean change in eGFR from baseline at week 104 was -1.71; -3.5 and -2.38 ml/min/1.73 m2 with dapagliflozin 5 mg; 10 mg and placebo respectively. In patients with stage 2; 3; or 4 CKD; small decrease in eGFR were noted in the empagliflozin groups; which returned to baseline by the end of the 3 week follow-up after treatment completion. An initial decline followed by subsequently stable or improving eGFR values with all SGLT2i over the 26-52-week core treatment period is noticed.

CONCLUSIONS: The findings suggest that SGLT2 inhibitors may be an appropriate treatment option for patients with T2DM and Chronic Kidney Disease.


  73. Evaluation of Peritoneal Membrane Characteristics in CAPD Patients Using Standard Peritoneal Equilibration Test Versus Fast Peritoneal Equilibration Test Top


Aman Gupta, Pradeep Deshpande, Varun Vijay, Shashank Dhareshwar, G Sridhar, J Ramashankar

Global Hospital; Hyderabad; Telangana; India

BACKGROUND: Standard PET explained by Twardoski et al. in 1987 for peritoneal dialysis prescription proved to be laborious as a result various modifications in PET had been advised. One of the modifications is FAST PET; in which one dialysate and plasma sample for creatinine and glucose was taken at 4 th hour. The method seems to be less laborious and if results of FAST PET comes in concordance with STANDARD PET; Fast PET can be promoted as tool to measure membrane characteristics in our set up also.

AIM OF THE STUDY: To evaluate the peritoneal membrane characteristics of CAPD patientsuaing standard peritoneal equilibration test and fast peritoneal equilibration test and comparing the results of two tests.

METHODS: 50 CKD patients who are on CAPD; attending nephrology opd are taken for study. exclusion criteria was peritonitis in last 1 month. Patient came with overnight dwell which was removed. 2.5% solution was instilled and dialysate samples taken for creatinine and glucose in dialysate at 0th hour; 2nd hour; 4th hour. At 2nd hour blood sample for glucose and creatinine taken. And D/P creatinine ratio was calculated at each point of time and patient is categorised as High; high average; low average and low transporter depending upon D/P CREAT ratio. for fast Pey only 4 th hour blood and dialysate sample was taken and D/P creat ratio calculated and results of two tests compared by Pearson correlation coefficient and t test.

RESULTS: Out of 50 patients; 46 patients have comparable results with two types of PET and whatever difference was there was drastically insignificant. There was significant correlation between transport categories of standard PET and fast Pet.

CONCLUSIONS: Results of standard PET are comparable with fast Pet. Thus Fast Pet should be promoted as tool to assess the peritoneal membrane characteristics and is less time consuming thereby increasing the use of PET tests in CAPD units.


  74. Familial Membranous Nephropathy – A Rare Occurrence Top


Rohit Patil, Saravanan Margbandhu, Vadamalai Vivek, M K Mani, Rama Mani1, Anila Abraham2

Departments of Nephrology and 1Pathology; Apollo Hospitals; 2Renopath Laboratory; Chennai; Tamil Nadu; India

BACKGROUND: Membranous nephropathy (MN) is one of the most common causes of nephrotic syndrome in adults where as in children; it is a rare histological identity accounting <5% of cases[1]. In children; secondary membranous nephropathy is common[2]. Familial association in MN is reported very rarely in the literature [3].

AIM OF THE STUDY: Herewith we report a rare occurrence of familial membranous nephropathy in identical twins of age 8 years presented to our unit with nephrotic syndrome in a gap of three years.

METHODS: Recently 11 years old patient (case no. 1) presented to us with insidious onset of facial puffiness and leg swelling. Investigations revealed pure nephrotic syndrome with normal renal function. A renal biopsy was performed which showed features of membranous nephropathy. Tissue staining for both PLA2R antibody and IgG4 was positive suggestive of primary MN. But serum anti-PLA2R antibody was negative. We retrospectively looked in to the old records of his identical twin (case no. 2) who suffered from the same illness three years before. He was also diagnosed to have MN on renal biopsy and treated with the modified Ponticelli regimen for 6 months. He was in remission following that. Secondary causes for MN such as hepatitis B; hepatitis C; malaria & other infections; autoimmune diseases such as SLE; toxin or medicine intake were ruled out for these two patients.

RESULTS: After the diagnosis of second identical twin (case no. 1) with MN; we retrieved renal biopsy slide of the other old patient (case no. 2) and stained for PLA2R which showed positive and IgG4 staining showed negative. Serum anti-PLA2R antibody level was not done to the old patient (case no. 2) at the time of biopsy as it was not universally available at that time.. HLA DR3 is found to be associated with MN as per the literature;hence HLA typing was done for these identical twins. Their HLA typing wasHLA A11; A31; B15; B38; DRB1 10; DRB1 15. Second identical twin (case no. 1) was also treated with modified Ponticelli and he showed partial response after 3 months of treatment.

CONCLUSIONS: We report first case of familial MN in India. The exact cause for this association is not clear as there are contradictory findings in serology and histology. Further research is required to explore the genetic role in pathogenesis of MN.


  75. Diabetic Fibrillosis: Not an Uncommon Entity; A Case Series Top


Sonu Manuel, S B Raju, D Krishnaprasad, S Alok

Nizam Institute of Medical Sciences; Hyderabad; Telangana; Dr. Lal PathLabs Ltd.; National Reference Laboratory; Rohini; New Delhi; India

BACKGROUND: Diabetic Fibrillosis (DF) is a rare glomerular abnormality detected in electron microscopy as random nonbranching fibrillary deposits in mesangium. There are few case reports available related to this entity and we report a case series of this interesting association.

AIM OF THE STUDY: To study the clinical profile and electrone microscopy features of diabetic fibrillosis.

METHODS: We reviewed all the cases of type 2 diabetic patients who underwent renal biopsy for various indications in last one year (April 2017 to march 2018). Cases which were reported as DF in electron microscopy were collected. Clinical course; investigation reports and biopsy findings were analysed.

RESULTS: DF was reported in 5 (3.7 %) out of 134 cases of diabetic nephropathy. The mean age was 55.6±.6 years (46-65). All five had both hypertension and diabetes. Mean duration of diabetes was 12± 2.7 years. All five had increased serum creatinine with mean of 6.9±3.5 mg/dl. Three patients had nephrotic and two had subnephrotic range proteinuria (mean 3±1.3 g/day). Autoimmune and myeloma workup was negative. Light microscopy showed diabetic nephropathy class IV with arteriolar hyalinosis in all 5 cases. The Immunofluorescence and congo red stain was negative in all. GBM thickening is seen in all cases with mean thickness ranging from 426 to 714 nm. Random non branching fibrillary deposition is seen in mesangium of all cases. No spherular microparticles or tubuloreticular inclusions were seen.

CONCLUSIONS: Diabetic fibrillosis is not an uncommon entity with a prevalence of 3.7 % in our case series. The clinical significance of this entity is yet to be determined. The observations made in this series needs to be elicited with a larger series of cases to know the impact on long term kidney function.


  76. Nocardia Infection in Renal Transplant Patients; Report from Transplant Center in India Top


Amit Kumar, Sunil Parkash, Ashwini Goel, Ganesh Dhanuka, Bhanu Mishra

Department of Nephrology; BLK Super Speciality Hospital; New Delhi; India

BACKGROUND: Nocardosis is uncommon but important cause of Infection in immunosupressed population particularly transplant recipients. There is scarce data regarding Nocardisis from Indian Subcontinen.

AIM OF THE STUDY: To study spectrum of Nocardia Infection in transplant population from transplant center in India.

METHODS: A retrospective analysis of all transplant performed from July 2012 to June 2017 was performed. Patients with diagnosis of Nocardia infection were identified. Their immunosupressive regimen; clinical presentation and outcome was examined.

RESULTS: During the study period total 346 transplant were performed including Live; cadeveric; ABO-Incompatible. 3 patient (0.86%) developed Nocardia infection. Mean age at diagnosis was 58 years. 2 patients has Diabetes Mellitus and one has chronic Glomerulonephritis as native Kidney disease. All 3 received ATG as Induction and were on Tacrolimus; Mycophenolate and Prednisolone as maintenance immunosupression. Mean duration of presentation was 12 to 48 weeks after transplant. 1 patient was treated for acute cellular rejection in recent past with injection Methylprednisolone; one patient has recurrent infection including episode of CMV disease and tuberculosis in form of subcutaneous cold abscess and 3rd was largely asymptomatic prior to presentation.. One patient present with Pulmonary Nocardiosis; one with; epidural abscess at Dorsal Spine D3-D4 level and 3rd presented with Psoas abscess. All 3 were treated with combination antibiotic. 2 patients improved and one expired.

CONCLUSIONS: Pre transplant diabetes; treatment of rejection; ATG induction may be risk factor for Nocardia infection. High index of suspicion is essential for diagnosis as presentation is varied and patient may present late after transplant.


  77. A Rare Case of Pseudo-Aneurysm of Accessory Renal Artery After Percutaneous Biopsy of A Native Kidney Treated Successfully with an Emergency Selective Coil Embolization Top


Chinmaye Sapre, K Praveen Kumar, Varaprasad Rao, Raghavendra Rao

Narayana Medical College; Nellore; Andhra Pradesh; India

BACKGROUND: Percutaneous biopsy is an important tool for diagnosis of multiple renal diseases. Renal artery pseudo-aneurysm is a rare major complication of renal biopsy. Early detection of this pseudo-aneurysm is important as this can bleed and lead even to death. Here we describe a rare case of a pseudo-aneurysm of the accessory renal artery following an ultrasound guided percutaneous biopsy of the native kidney; treated successfully with an emergency selective coil embolization.

AIM OF THE STUDY: Post renal biopsy development of pseudo-aneurysm of the accessory renal artery treated successfully with an emergency selective coil embolization.

METHODS: Patient was transfused 2 Packed Cell Volumes and was immediately shifted to the catheterization lab. An emergency selective embolization of a 3 mm coil was done through fluoroscopic guidance into the intersegmental branch of the left accessory renal artery. A check renal angiogram revealed complete occlusion of the accessory renal artery with the absence of contrast opacification of the pseudo-aneurysm. There were no intra or post procedural complications.

RESULTS: Repeat Doppler ultrasonography showed complete absence of flow in the pseudo-aneurysm; with increased internal echogenicity suggesting thrombosis. The patient was then discharged after 5 days.

CONCLUSIONS: In the modern era where renal biopsy is a day care procedure we; through this case; wish to highlight the importance of admission for vigilant and strict monitoring.


  78. Clinicopathological Study and Short-Term Outcome of Pauci-Immune Glomerulonephritis Top


Ricken Mehta, L Umesh, Shivaprasad, C G Sreedhar, Leelavathi, Kishan, V Mahesha

Institute of Nephrourology; Bengaluru; Karnataka; India

BACKGROUND: Pauci-immune crescentic glomerulonephritis is the most common cause of crescentic glomerulonephritis (CrGN). Patients usually present with rapidly progressive glomerulonephritis (RPGN) with hematuria; proteinuria; andelevated serum creatinine levels. The characteristic feature of pauci-immune CrGN is focal necrotizing CrGN associatedwith little or no glomerular staining for immunoglobulin (Ig) by immunofluorescence microscopic examination.

AIM OF THE STUDY: To study the clinicopathological profile and short-term outcome of patients with pauci-immune glomerulonephritis.

METHODS: The study will be conducted in Department of Nephrology; Institute of Nephro-Urology; Victoria Hospital Campus Bangalore; India between February 2018 and February 2020. A total of 15 consecutive patients with pauci-immune glomerulonephritis will be included in the study.

RESULTS: At the end of follow-up; 23% were dependenton dialysis. Renal survival was significantly worse inpatients with WG compared with patients with MPAor RLV. A higher rate of end-stage renaldisease (ESRD) was noticed in PR3-ANCA- vs MPOANCA-positive patients. A total of 2 patientsdied. Predictors of patient mortality were developmentof ESRD; older age and the maximum creatinine inthe first month. Mortality was found to be higherin patients with WG and was significantly higher inPR3-ANCA-positive cases.

CONCLUSIONS: Our data underscore the pathogeneticpotential of ANCA by demonstrating a more aggressivedisease state and a poorer outcome in patientswith PR3-ANCA.


  79. Oculocerebrorenal Syndrome: Dianosis and Review of Literature Top


Sudhir Mehta, Suman Sethi, Vikas Makkar, Simran Kaur, P M Sohal

Department of Nephrology; Dayanand Medical College and Hospital; Ludhiana; Punjab; India

BACKGROUND: Oculocerebrorenal syndrome; also known as Lowe syndrome; is an X-linked recessive disorder that predominantly affects males and is characterized by growth and mental retardation; congenital cataract and renal Fanconi syndrome. OCRL1 is the gene responsible for Lowe syndrome and encodes an inositol polyphosphate-5-phosphatase.

AIM OF THE STUDY: To study the presentation of Oculocerebrorenal syndrome and its renal involvement.

METHODS: This study was done in Department of Nephrology; Dayanand Medical college and hospital; Ludhiana; Punjab; India.

RESULTS: Twelve years old boy presented with congenital bilateral cataract and delayed milestones. Later on he developed psychomotor retardation; dysmorphic facial features; behavior disturbances (irritability); which progressively worsened. Later on there is change in gait followed by frequent falls and multiple fractures at 3 years of age. Renal impairment was detected at the age of 4 years.

CONCLUSIONS: Diagnosis of oculocerebrorenal syndrome; is based on specific ophthalmologic; neurologic and renal abnormalities. Cataract is an important finding among all clinical features.


  80. A Case Report: Idiopathic Nodular Glomerulopathy Top


Aashay R Pandya, Niranjan Kulkarni, Sharad Sheth

Department of Nephrology; Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute; Mumbai; Maharashtra; India

BACKGROUND: Nodular glomerulosclerosis; a pathological finding characterized by areas of marked mesangial expansion with accentuated glomerular nodularity can be seen in a number. Idiopathic nodular glomerulosclerosis is a diagnosis of exclusion and is reported in patients with hypertension; smoking; chronic obstructive pulmonary disease; obesity; metabolic syndrome; etc. We report a case of idiopathic nodular glomerulosclerosis in an elderly hypertensive female patient.

AIM OF THE STUDY: A case report of a relatively rare clinical entity of idiopathic nodular glomerulopathy.

METHODS: An elderly hypertensive non diabetic female was admitted with complaints of breathlessness; anasarca and decreased urine output. On evaluation she was found to have nephrotic range proteinuria and hematuria. She underwent a renal biospy after ruling out possible causes of nephrotic nephritic syndrome.

RESULTS: Urine analysis: Protein +++ RBC 12-15 Pus cells 2-3 24 hour urinary proteins: 4.3 grams RFT: Creat 1.7 mg/dl BUN 25 Albumin 2.7 g/dl HBA1C: 5.1% ANA by IF: Negative C-ANCA; P-ANCA: Negative Complements C3 C4: Normal Anti GBM: Negative Cryoglobulins: Negative Serum Protein Electrophoresis: Negative Serum Free Light chain Assay: Normal Immunofixation electrophoresis: Negative Renal biospy: LM 13 glomeruli seen of which 2 are globally sclerosed. Others showed increase in mesangial matrix (PAS +) at places forming nodules. Thickening of basement membrane seen. Silver stain showed lamellation at peripheral portion of mesangial nodules. IF:Negative Congo red: Negative Electron microscopy which revealed diffuse flattening of foot processes with marked widening and ill-defined lobularity of the mesangium without any electron dense deposits. She was started on dietary modifications and Angiotensin Receptor Blocker for Proteinuria.

CONCLUSIONS: Idiopathic nodular glomerulosclerosis should be suspected in any nondiabetic with a histopathological description of diabetic nodular glomerulosclerosis after ruling out other causes of nodular glomerulosclerosis and EM is a must in these cases.


  81. An Extremely Rare Complication of Laparoscopic Donor Nephrectomy: Chyle Ascites Top


Abhinav Seth, Ashish Sharma, Sarbpreet Singh, Deepesh Benjamine Kenwar, Gaurav Shankar Pandey, Vidya Kallepalli

Department of Renal Transplant Surgery; Postgraduate Institute of Medical Education and Research; Chandigarh; India

BACKGROUND: Chylous ascites (CA) is an extremely rare complication after laparoscopic donor nephrectomy (LDN). It can increase the hospital stay; morbidity in postoperative period and thus negating the benefits of laparoscopic surgery. Most of the cases were managed conservatively; but surgical intervention may be occasionally required. This report describes importance of accurate localization of the leaking chyle duct and its repair by endosuturing in a renal donor not responding to conservative treatment.

AIM OF THE STUDY: To discuss the management of chylous ascites; which is a rare but significant complication of laparoscopic donor nephrectomy.

METHODS: A comprehensive review of literature regarding this rare complication after LDN was performed with Pubmed/Medline and Google Scholar using “chyle; complications; laparoscopic donor nephrectomy” as keywords. The demographic profile and management of patients is discussed in detail. The various surgical modalities used to manage these patients are described.

RESULTS: Fifty-five cases of Chyle leak/ascites have been reported after LDN in literature till date. Around 77% donors with CA could be successfully managed conservatively with dietary measures and total parentral nutrition. Surgical intervention was required in nearly 23% donors ranging from clip application; use of argon coagulation; endosuturing with application of glue after 36.1±19.07 days of failed conservative treatment. Donors with massive ascites or requiring frequent large volume paracentesis on conservative treatment are likely to require surgical therapy. The present case was successfully managed with laparoscopic endosuturing and has no recurrence at 6 month follow-up.

CONCLUSIONS: Chylous ascites is a rare complication after donor nephrectomy in experienced centres. While conservative management remains the first line of treatment; early surgical treatment shall be undertaken in cases of massive ascites.


  82. Sofosbuvir Based Anti Viral Therapy in Maintenance Hemodialysis Patients with Hepatitis C Infection - A Single Center Experience Top


M Myvizhiselvi, R Sakthirajan, T Dineshkumar, J Dhanapriya, V Murugesan, N Malathy, T Balasubramaniyan, N Gopalakrishnan

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

BACKGROUND: There is paucity of data on sofosbuvir based direct acting antiviral (DAA) therapy in patients on maintenance hemodialysis with hepatitis C infection. The objective of this study is to describe our experience using Sofosbuvir based direct antiviral agent (DAA) therapy in maintenance hemodialysis patients in our population.

AIM OF THE STUDY: To study the effectiveness of Sofosbuvir based directly acting antiviral (DAA) therapy in patients on maintenance hemodialysis with hepatitis C infection.

METHODS: Patients with hepatitis C infection on maintenance hemodialysis treated with sofosbuvir based regimen were studied. Before starting treatment; HCV genotype; viral load (quantitative PCR); fibroscan of liver and liver function tests were done on all patients. Sofosbuvir 400 mg on alternate day with either daclatasvir 60 mg daily or ledipasvir 90 mg daily were given for all patients. In few patients; sofosbuvir was given with velpatasvir 100 mg daily. The duration of therapy was 12 weeks. In patients with decompensated liver disease the treatment duration was extended to 24 weeks. HCV viral load was assessed at the end of treatment (ETR at 12 weeks/24 weeks) and 12 weeks after completion of therapy (sustained viral response-SVR).

RESULTS: A total of 32 patients were included in our study. Mean age was 37.7 (±9.7) years. Of the 32 patients studied 24 (75%) were men. Median number of HCV viral copies were 1; 400; 000 copies/dl. Five patients had clinical evidence of cirrhosis (mean fibroscan 20.1 (±8.7) kPa. The most common genotype was genotype 1 (78%) followed by genotype 3 (12.5%); then genotype 2 (6.25%) and genotype 4 (3.1%). Twenty nine out of 32 patients (90.6%) achieved sustained viral response (SVR). Out of 24 patients who took sofosbuvir and daclastasvir; 21 (87.5%) achieved SVR. Of 7 patients who took sofosbuvir and ledipasvir; all 7 (100%) achieved SVR. Only one patient took sofosbuvir and velpatasvir. SVR was achieved in this patient (100%). SVR was achieved in 24 patients (96%) with genotype 1; 2 patients (50%) with genotype 3. All patients in genotype 2 (2 patients) and in genotype 4 (1 patient) achieved remission. There were no significant adverse effects except dyspepsia in 4 patients (12.5%).

CONCLUSIONS: Sofosbuvir based DAA s were well tolerated and efficacious in maintenance hemodialysis patients and experienced fewer side effects.


  83. Vascular Access Assessment and Clinical Outcomes in Maintainance Hemodialysis Top


G S Karthik, P S Vali, Kiran Mai, Manisha Sahay

Department of Nephrology; Osmania General Hospital; Hyderabad; Telangana; India

BACKGROUND: Hemodialysis has become an increasingly safe and well-tolerated therapy for patients (ESRD). Arterio-venous fistula (AVF) is the preferred access for patients who require regular Hemodialysis (HD) and the preferred site is the wrist; preferably in the non-dependant arm. Tunneled dialysis catheters are used for temporary vascular access in patients awaiting placement or maturation of a permanent vascular access (AVF or AV graft). non-tunnelled cathers are more prone to infections.

AIM OF THE STUDY: AIM: To assess complications associated with various vasular access used in maintainence hemodialysis patients and comparision of outcomes by clinic-radiological methods.

METHODS: Single centre; Prospective observational studies. All patients in maintaince hemodialysis unit labeled as CKD stage 5; Patients having arterio-venous fistula; tunneled cathete; non-tunneled catheter. Patient being dialysed for AKI; RPRF are excluded from study. av fistular are studied by clinical examination; ultrasound imaging; cultures when necessary and outcomes are measured.

RESULTS: 127 patients were studied; Among vascular access 82 (64%) has AV fistula; 26 (20%) has non-tunnelled catheter; 9 (7.1%) has tunneled catheter while none had AV grafts; Among AV fistula 19 (21%) left BCF; 45 (54%) left distal RCF; 4 (3%) has left proximal RCF; 3 (3%) has right BCF; 11 (10%) has right RCF. 22 (26%) had BCF; 60 (74%) had RCF. 66 (80%); Among non-tunnelled catheter 6 (23%) right femoral; 14 (53%) right IJV; 4 (15%) left femoral; 2 (7%) left internal jugular; Among AV fistula failures 1 patient had right and left RCF; right and left BCF failure; 14 (10%) distal RCF failure; 8 (6%) left BCF failure; 2 (1%) had both distal right and left RCF; 51 (62%) patients. complications seen in AV fistula group 22 (70%) patients had thrombosis; infections in none. fistula pseudoanerurysm 28 (34%); scar present 11 (13%); thinning of skin seen in 14 (82%); arm swelling present in 9 (10%); visible collaterals seen in 24 (29%). On palpation pulsation in 70 (85%); thrill 80 (99%). Doppler measured findings such as flow rate.

CONCLUSIONS: AVF has lesser complications rate versus catheter. routine vascular access surveillance including clinical examination may help in early identification of complications and may help in early intervention which may improve AVF access outcomes.


  84. Unusual Cutaneous Fungal Infections in Renal Transplant Recipients Top


R Shafeeque, M Sreelatha, T P Noushad, E K Jayakumar

Department of Nephrology; Government Medical College; Kozhikode; Kerala; India

BACKGROUND: Fungal infections are an important cause of morbidity and mortality in renal transplant recipients. The causative agent and the risk factors differ depending on the period after the kidney transplant.

AIM OF THE STUDY: Also the incidence varies according to the geographical area. The symptoms and signs of fungal infections are nonspecific; particularly in their early stages.

METHODS: We are reporting few cases of rare cutaneous fungal infections in renal transplant recipients from a centre in north kerala. These include phaeohyphomycosis and cutaneous cryptococcosis.

RESULTS: Early diagnosis and treatment prevented dissemination and cured the lesions. We also tried potassium iodide drops aparts from other antifungal drugs.

CONCLUSIONS: These cases highlight how a high index of clinical suspicion and prompt diagnosis is very much essential for better outcome. The present case series highlights the unusual fungal infections and their manifestations in the renal transplant population.


  85. Clinico-Pathological Study of Lupus Nephritis in SCB Medical College; Cuttack; Odisha; From 2015- 2017 Top


Amalendu Jena, C R Kar, S B Rout

Department of Nephrology; SCB Medical College; Cuttack; Odisha; India

BACKGROUND: Lupus nephritis (LN) is the most common & serious manifestation of systemic lupus erythematous (SLE) and an important cause of morbidity and mortality. renal biopsies are required at diagnosis to enable classification of nephritis severity; to provide prognostic information; and to guide treatment. So objective of this study is to determine the frequency of distribution of different classes of LN based on renal biopsy reports and to correlate it with various laboratory findings.

AIM OF THE STUDY: Objective of this study is to determine the frequency of distribution of different classes of LN based on renal biopsy reports and to correlate it with various laboratory findings.

METHODS: Retrospective study was done in all patients with LN who had at least one representative renal biopsy and evaluated in nephrology dept of SCB Medical College; Cuttack in 2 years duration. Various laboratory values were recorded and correlated with histopathological lupus classifications.

RESULTS: Out of 52 patients enrolled 48 (92.31%) were females and 4 (7.69%) were males. Mean age was 27.61±9.63 yrs. Majority of cases belong to class IV (40.38%) followed by class III+V & IV+V (31.76%). Patients of class IV LN has a significantly low Hemoglobin (Hb) level. Similarly serum urea and creatinine are higher in class IV than other classes and serum creatinine was found to have significant correlation. 24 hr urinary protein excretion has significant correlation with the classes of LN. In our study NIH group had remission in 57.89% cases and MMF group had 53.84% remission 6 month after treatment.

CONCLUSIONS: This study suggests some meaningful correlation between laboratory findings & histopathological Lupus classification. This study also suggests that renal biopsies are still beneficial for better evaluation of renal status & determination of LN classes.


  86. Diet Recall for Nutrition Assessment – 24 Hour Versus 3 Day Versus 7 Day Recall in Dialysis Patients Top


Rachana Jasani, D Paras, A Mohd Shah, G Virendra, K Jatin, B Viswanath, B Shrirang, K Rajesh

Apex Kidney Foundation; Mumbai; Maharashtra; India

BACKGROUND: One of the most significant methods of nutrition assessment in dialysis patients is diet recall. Poor nutritional intake is an immediate predictor of depleting nutrition status; hence taking a diet recall forms the basis of a good nutrition assessment program.

AIM OF THE STUDY: To compare 24 hour versus 3 day versus 7 day diet recall of dialysis patients.

METHODS: We conducted a 7 day diet recall in 82 dialysis subjects. Average of dietary protein; calories; sodium; potassium; calcium and phosphorus were compared across 3 study groups. Repeated measures one-way ANOVA was used to test the level of significance.

RESULTS: The mean protein intake obtained was comparable across 3 groups (43.2 ± 13.7 g-24 hour; 51.6 ± 60.4 g-3 day; 43.6 ± 11.4 g- 7 day; p-value:0.23). The mean calorie intake was similar (1456.9 ± 408.8 kcal; 1494.0 ± 347.3 kcal; 1442.8 ± 350.5 kcal; p-value:0.40). The mean phosphorus intake was 1089 ±369 mg; 1053 ± 313 mg and 1027 ± 305 mg (p-value:0.92) while total phosphorus to protein ratio was 25.6 ±6.7; 29.3± 47.4 and 24.1 ± 4.9 (p-value:0.40).

CONCLUSIONS: Average dietary intake obtained through 24 hour; 3 day or 7 day diet recall does not show significant variations. Regardless of the number of days; dietary recall remains one of the instrumental methods of nutrition assessment in dialysis population.


  87. ADPKD with Emphysematous Pyelonephritis Top


Raja Amarendra Muthina, K Naveen, A Sunnesh Reddy, N Sai Sameera, N Praveen, V Siva Kumar, R Ram

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

BACKGROUND: A 32 yrs gentle lady; presented with c.o swelling of feet; puffiness of face; decreased urine output; breathlessness for 1 month and on evaluation found to have ADPKD with chronic kidney disease and started on hemodialysis. She presented to our institute with pain abdomen; fever with chills and rigors; hematuria and right loin tense swelling. on CT scan abdomen she had features of emphysematous pyelonephritis with cyst rupture and subcutabeous abscess. she treated for the same and improved.

AIM OF THE STUDY: A very rare presentation of autosomal dominant polysystic kidney disease associated with emphysematous pyelonephritis.

CONCLUSIONS: A very rare combination of emphysematous pyelonephritis with ADPKD


  88. Congenital VII Factor Deficiency Presenting First Time As Isolated Recurrent Hematuria At Late Age: A Rare Presentation Top


Sudhir Mehta, Suman Sethi, Nitin Sethi, Vikas Makkar, Simran Kaur, P M Sohal

Department of Nephrology; Dayanand Medical College and Hospital; Ludhiana; Punjab; India

BACKGROUND: Hematological conditions can present as hematuria; although their incidence is rare. Isolated presentation of hematuria is even rarer as these bleeding disorders are accompanied by bleeding at other sites.

AIM OF THE STUDY: To studt the effect of Congenital VII factor deficiency presenting first time as isolated recurrent hematuria at late age.

METHODS: This study was done at DMCH; Ludhiana.

RESULTS: Patient had recurrent episodes of painless hematuria since last 3 months off and on. Clotting factor assay (i.e. factor VII activity) was done; which was suggestive of factor VII deficiency with levels of 8.3% (normal range 70-120).

CONCLUSIONS: In conclusion the presentation of congenital factor VII factor deficiency first time as isolated recurrent hematuria at the later age is one of the rare presentation. For the definitive diagnosis; the specific factor VII level should be investigated.


  89. A Case of Adult Onset Bartter's Syndrome Associtated with Pulmonary TB Top


D P Kushal, H S Mahapatra

Department of Nephrology; Dr. RMLH; New Delhi; India

BACKGROUND: Introduction: Bartter syndrome is a rare autosomal recessive disorder associated salt wasting and hypokalemic metabolic alkalosis. Adult-onset Bartter syndrome is very rare. Here we report a case of Adult-onset Bartter syndrome associated with tuberculosis.

AIM OF THE STUDY: Adult-onset Bartter syndrome is very rare. Here we report a case of Adult-onset Bartter syndrome associated with tuberculosis.

METHODS: Case report: A 24 year old female was admitted in RMLH on 3/3/2018; with complaints of increased frequency and volume of urine since 4 months; increased thirst since 4 months; tiredness since 3 months; weakness of both lower limbs since 2 months; generalised swelling since 6 weeks. Investigations revealed persistent hypokalemia; hypocalcemia and hypomagnesemia and ABG revealed alkalosis. CECT chest and abdomen revealed consolidation with air bronchogram in both upper and right middle lobe and Peribronchovascular nodular infitrates giving tree in bud appearence in both lung fields with upper lobe predominance s/o pulmonary TB. An increased serum renin aldosterone levels was also detected. A diagnosis of Hypothyroidism; Pulmonary Tuberculosis; Adult onset Bartter syndrome phenotype was made. Treatment in form of potassium and calcium supplementation; liberal salt intake; spironolactone; ATT and thyroxine given. Patient symptomatically better at discharge.

RESULTS: Discussion: Adult-onset Bartter syndrome is very rare. Few cases reported showed its association with chronic sialoadenitis; pulmonary tuberculosis and exposure to aminoglycosides like gentamycin. In this case patient had intractable dyselectrolytemia; metabolic alkalosis and increased serum renin aldosterone levels; all these above features are seen in Bartter syndrome. This case report reiterates that adult onset Bartter syndrome can occur in association with TB.

CONCLUSIONS: This case report reiterates that adult onset Bartter syndrome can occur in association with TB.


  90. Perception of Renal Replacement Therapy among Hemodialysis Technicians Top


G Virendra, D Paras, A Mohd Shah, J Rachana, K Jatin, K Rajesh, B Shrirang, B Viswanath

Apex Kidney Foundation; Mumbai; Maharashtra; India

BACKGROUND: Although renal transplant remains the best option for Renal Replacement Therapy (RRT); it is of interest to study the options that dialysis professionals would prefer if they were to select for themselves. In India; RRT decisions are largely guided by economic considerations.

AIM OF THE STUDY: To study the perception of RRT options among hemodialysis technicians.

METHODS: We interviewed dialysis technicians using a short questionnaire containing multiple choice questions. They were asked about the form of RRT which they would prefer for themselves.

RESULTS: We interviewed 114 dialysis technicians out of which 59 were males and 55 were females. The average age of technicians was 23.1± 5.7 years. 66% technicians reported that they would prefer incenter HD; 17.5% technicians reported they would prefer home HD while only 15.7% technicians reported that they would prefer PD as an option for RRT. The major reasons for less preference to PD were cost constraints and more chances of infection as compared to HD. Similarly; the main reasons for more preference towards HD is the availability of help in emergency situations and less frequency as compared to daily PD.

CONCLUSIONS: In our country; dialysis technicians themselves prefer HD than PD. The perception of dialysis technicians towards RRT options needs to be addressed through continuous dialysis education programs.


  91. Unusual Cause of Pyrexia in an End Stage Renal Disease Patient – Fracture Embolism of Uncuffed Catheter Guidewire! Top


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

Department of Nephrology; PGIMER; Chandigarh; India

BACKGROUND: Guidewire embolism is a rare iatrogenic complication that can be avoided with adherence to safe standardized insertion techniques. Complications of in-situ guidewire include thrombosis; infections; post-phlebitic syndrome; pulmonary embolism; arrhythmias; cardiac and vascular damage. Management involves extraction via percutaneous endovascular techniques; surgery being reserved for failed percutaneous measures; besides long-term anticoagulation and prophylactic antibiotics.

AIM OF THE STUDY: To report fracture embolism of guidewire (uncuffed catheter) as an unusual cause of fever in ESRD patient; awaiting transplant & to discuss complications of in-situ guidewire & retrieval techniques.

METHODS: 22 years male ESRD patient; presented with complaints of fever X 4 weeks. He denied any history suggesting localisation. Left radio-cephalic AVF was made 6 weeks back & MHD was initiated through an uncuffed right IJV catheter; which was removed 2 weeks prior to current admission; suspecting CRBSI. Blood or catheter tip culture was not done; however; he received empirical antibiotics X 2 weeks; besides MHD through AVF. He didn’t respond to a month of empirical ATT; had sepsis with leucocytosis and raised procalcitonin with sterile blood culture; normal Xray chest & negative sputum examination (gram/AFB stain/GeneXpert-MTB). TEE didn’t suggest infective endocarditis. CECT of thorax and abdomen; to look for alternative aetiology surprised us with linear hyperdense (982 HU) opacity extending from right internal iliac vein till IVC suggesting fractured guidewire embolism; which was retrieved under fluoroscopy guidance through Gooseneck snare device with disappearance of fever.

RESULTS: Signs that suggest an embolised guidewire are poor venous backflow & resistance to injection from distal lumen of the catheter; guidewire visible on a radiograph; and absence of guidewire when inspecting the catheter set. An excessive length of guidewire inserted has been associated with embolic complications with thrombosis; infections; post-phlebitic syndrome; pulmonary embolism; arrhythmias; cardiac & vascular damage. Factors contributing to guidewire loss into circulation include operator inexperience; lack of supervision and inattention. We suggest that in the case of a superficial guidewire embolus {guidewire can be palpated in the vessel (internal jugular vein/femoral)}; a venous cutdown can be performed to extract the guidewire. If the guidewire has embolised systemically; percutaneous extraction {interventional techniques: Dormia basket; gooseneck snare; endovascular forceps} is the most useful method in retrieving the guidewire; with surgery being the last rescue method.

CONCLUSIONS: Guidewire embolism is a preventable complication if simple measures are routinely practiced using the Seldinger technique. Usually asymptomatic; but rarely can be a nidus for complications. Most cases of guidewire embolism can be safely managed using percutaneous endovascular technique.


  92. Clinicopathological Study and Short Term Outcome of Membranoproliferative Glomerulonephritis Based on Recent Classification Top


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

Institute of Nephro Urology; Bengaluru; Karnataka; India

BACKGROUND: Membranoproliferative includes GN represents a pattern of injury that is seen on light microscopy. After reclassification; two types of MPGN are recognized which immune complex mediated MPGN and complement mediated MPGN. This study will give insight on the clinical and the pathological profile of patients with MPGN at our centre based on the new classification. Patients were followed up over a period of 18 months to assess the response to treatment.

AIM OF THE STUDY: To study the clinicopathological profile and short term outcome of patients with membranoproliferative glomerulonephritis based on the recent classification.

METHODS: Biopsy proven cases of MPGN were included in the study. Patients were classified as immune complex mediated and complement mediated based on the recent classification. Patients were treated based on the recent guidelines. Patients were followed up over a period of 18 months to characterize the response to treatment.

RESULTS: MPGN was present in 32 cases (2.68%) during study period of 18 months. The mean age was 32.5±2 years of which there was slight male preponderance. Creatine at presentation was 3.8 mg/dl. The mean serum C3 and C4 were normal. 4 patients had positive ANA. 2 patients were found to have hepatitis B infection with high viral load and were started on entecavir. One patient had positive immunofixation. On IF; 22 (68.75%) were immune complex type; 8 (25%) were c3 glomerulopathy while 2 (6.25 %) were null immune/complement. EM study was done in 2 patients and was suggestive of DDD in one patient. All patients were managed with pulse steroids followed by oral steroids. IV Cyclophosphamide was used monthly for 6 doses in 14 patients (43.7%) while oral cyclophosphamide was used in 2 patients (6.25%). Also 19 patients required haemodialysis (59%). Among the 19 patients who were dialysis dependent; 4 have recovered completely and are in complete remission with normal renal function.

CONCLUSIONS: MPGN has a heterogenous presentation and response to treatment.


  93. Prostatic Cyst: Association with Autosomal Dominant Polycystic Kidney Disease Top


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

Department of Nephrology; PGIMER; Chandigarh; India

BACKGROUND: Prostatic cyst is a rare disease of the prostate with prevalence ranging from 0.5% to 7.9%. Cystic lesions in the prostate could be either congenital or acquired. Though asymptomatic in most cases; it may be associated with recurrent urinary tract infection and outflow obstruction. Prostate cyst occurring as an extrarenal manifestation of Autosomal Dominant Polycystic Kidney Disease (ADPKD) is unusual.

AIM OF THE STUDY: To report a case of asymptomatic prostatic cyst in a patient of ADPKD; detected incidentally on transabdominal ultrasonography.

METHODS: A 28 years old male during evaluation for hypertension was detected to have bilateral ballottable kidneys. He had no history of flank pain; dysuria; haematuria or gravelluria. His father had recently been diagnosed with endstage renal disease secondary to ADPKD and initiated on maintenance hemodialysis. His two elder brothers also have polycystic kidneys with secondary hypertension. Digital rectal examination showed normal prostate with no tenderness. Laboratory investigations showed haemoglobin of 13 gm%; blood urea 38 mg%; creatinine 1.0 mg% and normal levels of prostate specific antigen (PSA). Urine examination showed no proteinuria and no cells or casts. Urine culture was sterile. His chest radiograph and ECG were normal. Transabdominal ultrasound showed bilateral enlarged kidneys with multiple cysts. Prostate measured 39 X 23 X 22 mm and there was a paramedian cyst measuring 12 X 10 mm within the rostate on right side. There were no cysts in any other organs.

RESULTS: ADPKD is an inherited disorder; usually manifests in adulthood with renal involvement in form of pain; bleeding; infection; calculus; hypertension and renal failure while extra-renal manifestations include cysts in other organs; cardiac valvular lesions; intra cranial aneurysms and hernias. Liver cysts are the most frequent extra-renal manifestation and are usually asymptomatic. 10% of the patients have cysts in pancreas; 5% have arachnoid cysts and fewer than 5% have cysts in spleen. Cysts of seminal vesicle and epididymis are even less common while prostate and testicular cysts are definitely rare. Till date; only two cases of prostatic cyst in ADPKD has been reported from India. Mostly asymptomatic; however some may have irritating or obstructive voiding symptoms and rarely haematospermia. Large benign prostatic cysts with elevated PSA; include Mullerian duct cysts; bladder diverticulum; teratoma; seminal vesicle cyst; epididymal cyst; Wolffian duct cyst as possible differentials.

CONCLUSIONS: Although prostatic cyst in ADPKD is rare; it is easily detectable on ultrasound. Patients with prostatic cyst of small size and no symptom should have routine follow-up. Although progressive symptoms; large size (2.5 cm or larger) or high serum PSA should be timely referred to urosurgeons.


  94. Evaluation of Bacterial Capture Efficiency of Functionalized Magnetic Iron Oxide Nanoparticles in Biological Fluids Top


Sowrabha Rajanna, Regan Charles1, P G Bharath1, Aishwarya Sudharsan1, Tarun Yadav1, Chandrani Hazra1, Madhukar2, Srikanth2, Cecil Ross2, M Limesh2, S Renuka2, Subhasis Sarangi1

1Department of Nephrology; St. John's Research Institute; 2St. John's Medical College Hospital; Bengaluru; Karnataka; India

BACKGROUND: The standard culture-based diagnosis of UTI has a typical delay of up to 2-3 days. In this study we report the application of amine-functionalized magnetic nanoparticles (AF-MNPs) for rapid; effective capture and removal of bacterial pathogens in urine.

AIM OF THE STUDY: To study the application of amine-functionalized magnetic nanoparticles (AF-MNPs) for rapid; effective capture and removal of bacterial pathogens in urine.

METHODS: The Magnetic Iron Oxide Nanoparticles (Fe3O4) of core size 12 nm were synthesized by modified co-precipitation method under nitrogen controlled environment. Thirty milliliter of midstream urine samples was incubated with 50 ug/mL of PEI and PEG functionalized magnetic iron oxide nanoparticles. The mixture was placed on a rocker for 30 minutes at room temperature.

RESULTS: The Magnetic Iron Oxide Nanoparticles (Fe3O4) of core size 12 nm were synthesized by modified co-precipitation method under nitrogen controlled environment. Thirty milliliter of midstream urine samples was incubated with 50 ug/mL of PEI and PEG functionalized magnetic iron oxide nanoparticles. The mixture was placed on a rocker for 30 minutes at room temperature.

CONCLUSIONS: The AF-MNPs allow rapid removal of bacteria from urine samples with efficiency from 95% to 98%. Though amino group offers less specificity/selectivity than biomolecules such as antibodies; AF-MNPs are efficient for capturing a wide range of bacteria.


  95. Cyclophosphamide Induced Melanonychia in A Patient with Steroid Dependent Nephrotic Syndrome Top


Sudhir Mehta, Vikas Makkar, P M Sohal, Suman Sethi, Simran Kaur

Department of Nephrology; Dayanand Medical College and Hospital; Ludhiana; Punjab; India

BACKGROUND: A number of chemotherapeutic agents are associated with melanonychia like; bleomycin sulfate; cyclophosphamide; methotrexate. The cases of cyclophosphamide-induced melanonychia are not frequent. Only few cases have been reported in the literature.

AIM OF THE STUDY: To studt the effect of Cyclophosphamide Induced Melanonychia.

METHODS: This was done on patient with steroid dependent nephrotic syndrome.

RESULTS: A known case of steroid dependent nephrotic syndrome; who developed melanonychia on starting treatment with cyclophosphamide.

CONCLUSIONS: Cyclophosphamide induced nail discoloration is a rare adverse event that is under-reported. It is not associated with any deleterious effect to patient health and only affects the physical appearance of the nails.


  96. Role of Copeptin Assay As An Improved Diagnostic Tool of Hypotonic Polyuria Top


Sameer S Deshmukh, Kaustubh S Chaudhari, Sameer S Deshmukh, Nishant R Tiwari, Rohan S Sharma

Department of Nephrology; University of Oklahoma Health Sciences Center; Oklahoma; USA

BACKGROUND: Indirect water deprivation test (WDT); the current diagnostic standard for differentiating various hypotonic polyuria etiologies like primary polydipsia; central and nephrogenic diabetes insipidus (DI); is inconvenient to administer and intrinsically inaccurate. Assaying osmotically stimulated copeptin; an arginine vasopressin prohormone can circumvent challenges faced in measuring antidiuretic hormone (ADH) owing to the former's ex vivo stability.

AIM OF THE STUDY: To evaluate the role of copeptin assay as a less cumbersome and more accurate alternative to WDT in differentiating primary polydipsia from diabetes insipidus.

METHODS: WDT monitors the renal concentrating capacity in response to prolonged fluid restriction (3-4 hours) or hypertonic saline infusion (3% saline at 0.05 ml/kg/min for <2 hrs) followed by exogenous desmopressin administration given 2 µg i.v. or 4 µg s.c. or 10 µg intranasally. Urinary osmolality increases up to 500 mOsm/kg post water-deprivation with no response to ADH indicating primary polydipsia; while there is a mild (nephrogenic DI); 15-50% (partial central DI) and 100% (complete central DI) increase after ADH administration. When WDT is the osmotic stimulant; ratio of copeptin before desmopressin administration to plasma sodium at end of test of <0.02 pmol/L suggests partial central DI while >0.02 pmol/L indicates primary polydipsia and basal copeptin of 2.6 pmol/L obtained after 8-hour water deprivation suggests complete central DI. When hypertonic saline infusion is the osmotic stimulant; basal copeptin <4.9 pmol/L suggests central DI while >4.9 pmol/L is seen in primary polydipsia.

RESULTS: Significant variability of treatment profiles of primary polydipsia and DI necessitates accurate diagnosis. However; water diuresis in WDT washes out the medullary gradient thus downregulating Aquaporin-2 channels (diminishing ADH response); while partial central DI upregulates ADH receptors (increasing ADH response) both affecting diagnostic value of WDT. Copeptin; a C-terminal segment of arginine vasopressin preprohormone is biologically inactive; has longer plasma half-life; doesn’t bind to platelets and has higher ex vivo stability and hence serves as a more effective surrogate marker of vasopressin. Further literature review revealed that copeptin assay after hypertonic saline infusion showed greater accuracy than WDT done alone; albeit copeptin post-WDT failed to show similar promise. The undoubted diagnostic efficacy of copeptin post-hypertonic saline is overshadowed by the risk of heart failure.

CONCLUSIONS: Copeptin assay after hypertonic saline infusion is definitely superior diagnostic test to differentiate hypotonic polyuria types esp. partial central diabetes insipidus and primary polydipsia when compared to WDT; thus prompting revision of the diagnostic guidelines of polyuria.


  97. Clinicopathological Spectrum and Outcomes of Crescentic Glomerulonephritis Top


Megha Pai, L Umesh, Shivaprasad, C G Sreedhar, V Leelavathi, A Kishan, V Mahesha

Institute of Nephro Urology; Victoria Hospital; Bengaluru; Karnataka; India

BACKGROUND: CrescenticGN represents the extreme end on the spectrum of glomerular injury and is characterised morphologically by extensive crescent formation. The clinical hallmark of CrescenticGN is RPGN. It can result from a wide range of disease conditions and clinically is marked by a rapid deterioration in renal function over days; weeks or months. Although rare; Crescentic Glomerulonephritis is an important entity to recognize because prompt treatment can improve patient outcomes significantly.

AIM OF THE STUDY: To determine the incidence; etiology; clinical features and outcome of crescentic glomerulonephritis.

METHODS: Biopsy proven cases of crescentic glomerulonephritis in which light microscopy containing minimum of 10 glomeruli will be included in the study after written and informed consent. Based on the percentage of glomeruli showing crescents; patients will be divided into three groups. • C1: 1-25% of glomeruli showing crescents• C2: >25% to <50% of glomeruli showing crescents• C3: >50% glomeruli showing crescents. The above score was proposed in The Oxford classification of IgA nephropathy 2016. It will be extrapolated in our studyPatients will be treated based on the etiology of Crescentic Glomerulonephritis as per protocol. Patients will be followed up over a period for 6 months to characterize the response to treatment and assess the outcome.

RESULTS: Mean age at presentation was 42 years. 40% were females. 20% had C1; 60% had C2 and 20% had C3 crescents. Most common eitiology was IgA nephropathy followed by lupus nephritis and immune complex mediated GN; while Anti GBM disease and Vasculitis were less common cause. 50 percent were dialysis dependent at presentation. 4 patients died due to sepsis while 20 patients had complete renal recovery.

CONCLUSIONS: Treatment of crescentic GN requires individualized approach and its necessary to consider the risk vs benefit before starting immunosuppressive therapy.


  98. A Rare Presentation of Takayasu Arteritis with Lupus with Secondary Nephrotic Syndrome Top


Raja Amarendra Muthina, K Naveen, A Sunnesh Reddy, N Sai Sameera, N Praveen, Sarat Chandra, V Siva Kumar, R Ram

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

BACKGROUND: A 36 years gentle nulliparous lady; short stature with kyphosis presented with c/o swelling of feet; puffiness of face with abdominal distention form 1 month. it was associated with both lower limb pain and gangrene of toes. she has no peripheral pulse. doppler and ct angiogram showed b/l subclavian arteries stenosis; abdominal aorta aortitis. anti dsDNA elevated; ANA positive; 24 hrs urine protein 2210 mg; s.albumin 2.2 gm.

AIM OF THE STUDY: A rare combination of vasculitis with lupus asociated with secondary nephrotic syndrome.

METHODS: For case report.

RESULTS: For rare case report.

CONCLUSIONS: A very rare combination of multiple diseases.


  99. Clinical Profile and Outcome of Hospital Acquired Acute Kidney Injury Top


Amandeep Singh, Vikas Makkar, P M Sohal, Suman Sethi, Simran Kaur

Dayanand Medical College; Ludhiana; Punjab; India

BACKGROUND: Acute kidney injury (AKI) is a common complication in hospitalized patients. There are few comparative studies on hospital-acquired AKI (HAAKI) in medical; surgical; and ICU patients.

AIM OF THE STUDY: To study epidemiology; aetiology and outcome of patients with hospital acquired acute kidney injury.

METHODS: This study was conducted to compare the epidemiological characteristics; clinical profiles; and outcomes of HAAKI among these three units. All adult patients (>18 years) of either gender from March 2017 to February 2018 who developed AKI based on AKIN criteria (using serum creatinine); 48 h after hospitalization were included in the study. Patients of chronic kidney disease; community acquired AKI and renal transplant recipients were excluded.

RESULTS: Incidence of HAAKI in medical; surgical; and ICU wards were 0.60%; 0.69%; and 2.7% respectively Most common etiology of HAAKI in medical unit was drug induced (40.1%); whereas in surgical and ICU; it was sepsis (36% and 37.1% respectively).

CONCLUSIONS: The clinical and epidemiological characters of HAAKI in medical; surgical; and ICU are different from each other in certain aspects. This is mainly contributory to the unit-specific factors and disease characters of the underlying primary disease.


  100. Proliferative Glomerulonephritis with Monoclonal Immunoglobulin Deposition Disease- Our Experience At Tertiary Care Centre Top


Megha Pai, L Umesh, S M Shivaprrasad, C G Sreedar, V Leelavathi, A Kishan, V Mahesha

Institute of Nephro Urology; Victoria Hospital; Bengaluru; Karnataka; India

BACKGROUND: Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a condition where monoclonal immunoglobulins are deposited in the glomerulus. Usually presents with nephrotic range proteinuria; hematuria with renal impairment. less than 30 percent patients have monoclonal circulation protein detectable at presentation. PGNMID may recur in the kidney transplant; despite lack of detectable circulating monoclonal protein.

AIM OF THE STUDY: To study the clinicopathological profile of biopsy proven PGNMID.

METHODS: Patients with biopsy proven PGNMID were included in the study. They were subjected to additional investigations (SPEP; UPEP. immunofixation electrophoresis; free light chain assay; bone marrow biopsy). Response to therapy was noted at follow up.

RESULTS: 2 patients had biopsy proven PGNMID. one was 26 year old female with normal renal functions presenting with adult onset nephrotic syndrome. biopsy showed mesangioproliferative glomerulonephritis with focal crescents with kappa light chain restriction. she is being treated with bortezomib with dexamethasone and thalidomide. second patient is a 20 year old male with normal renal function who presented with adult onset nephrotic syndrome. his biopsy showed PGNMID with MPGN pattern and focal crescent. planned to treat him with same regimen after consulting medical oncologist.

CONCLUSIONS: PGNMID is a heterogenous disease disease with variable response to treatment. High index of suspicion is required to diagnose this condition since it recurs in transplant kidneys.


  101. Dual Kidney Transplant Top


Menal Wali, Pawan Deore, Hepal Vora, Zaheer Virani, Prashant Rajput, Bharat Shah

Department of Nephrology; Global Hospital; Mumbai; Maharashtra; India

BACKGROUND: There is a large gap between the demand and availability of organs. Therefore; one must optimize the use of organs from all consenting donors including “expanded criteria donor”. Kidneys from ECD have 70% greater likelihood of graft loss. However by transplanting both kidneys (providing sufficient nephron mass) in a single recipient (dual kidney transplant); outcomes are just as good as a single-kidney transplant with standard criteria donor (SCD).

AIM OF THE STUDY: Describe our experience of dual kidney transplants performed with expanded criteria donors (ECD).

METHODS: In 4 recipients (3 males; 1 female; age 34 to 63 years) with end stage renal disease; both kidneys from ECDs (three over the age of 60 with death resulting from a stroke; and one from an 18 month old child) were transplanted. In all 4 cases; lymphocyte depleting agent was used for induction and standard triple immunosuppression (CNI; AZA/MMF and PSN) for maintenance. All patients received SMX-TMP prophylaxis.

RESULTS: In one patient there was delayed graft function while in other 3 cases there was an immediate graft function. The graft function was excellent (serum creatinine < 1.2 mg/dl) in all 4 cases. In the recipient of kidneys from pediatric donor; kidneys grew to adult size in 6 months. In none of the 4 cases there was any episode of rejection.

CONCLUSIONS: Our experience suggests that kidneys from ECDs should not be rejected. Rather; dual kidney transplant should be performed. This provides adequate nephron mass with excellent renal function. Provision of high renal mass probably reduces the risk of rejection.


  102. A Rare Case Report of Renal Limited ANCA Vasculitis in HIV Disease Top


B Muruganantham, T Dinesh Kumar, J Dhanapriya, R Sakthirajan, N Malathy, T Balasubramainyan, N Gopalakrishnan

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

BACKGROUND: INTRODUCTION: Anti neutrophil cytoplasmic antibody (ANCA) genesis was reported in variety of infections; inflammatory and malignant diseases; but only few patients will present with vasculitis. Similarly in HIV disease several studies show false positive auto antibodies including ANCA. But only few case reports show occurrence of vasculitis. We are presenting one such patient who presented with renal limited ANCA vasculitis in HIV disease; successfully treated and achieved renal remission.

AIM OF THE STUDY: CASE REPORT: A 37 yr woman who was diagnosed with retroviral disease in 2009; subsequently in NOV 2017; found low CD4 count (200) and started on ART –TLE regimen. After 7 days developed renal failure.

METHODS: Her s. creatinine progressively increased to 3 mg/dl and Further investigations showed 3+proteinuria; field full of rbcs; urine pcr-8.6. CBC was normal. S. creatinine 3 mg/dl; other viral markers were negative; sr. LDH-172IU/L; sr. CPK-26IU/L; LFT was normal. Ultrasound showed enlarged kidneys with increased echos. Based on clinical findings and investigations a syndromic diagnosis of rapidly progressive renal failure was made. We proceeded with renal biopsy for further evaluation; which showed necrotising glomerulonephritis with cellular crescents. IF was negative for all stains. Serological investigations revealed C ANCA positivity. She was treated with pulse methyl prednisone followed by oral prednisone 1 mg/kg bodyweight for 4 weeks then tapered and maintained at 5 mg od; along with azathioprine 50 mg od. Now patient is in remission with normal renal function. ART was restarted.

RESULTS: DISCUSSION: Machanism of ANCA vasculitis IN HIV: ANCA false positivity is 13-45% in HIV disease; but only few case reports showed disease activity like vasculitis. In HIV there is high level of TNF –alpha which stimulates neutrophils which brings the ANCA antigens to cell surface. Another possible mechanism is immune reconstitution inflammatory syndrome resulting in enhanced autoimmune activity during early phases of ART UNIQUE FEATURES IN OUR CASE: 1) In our case both serology and histopathology was consistent with renal limited ANCA vasculitis 2) Possibly in our case IRIS could be mechanism of ANCA vasculitis.

CONCLUSIONS: Any retroviral disease patient who presents with RPRF after initiation of ART; ANCA vasculitis should be considered as a differential diagnosis. Whether such patients should be treated with immunosupression and if so what drugs to be used are areas which need further research.


  103. High Prevalence of CKD From CKDU in A Tamil Nadu Village - Findings from A Community-Based CKD Screening Program Top


Nabadwip Pathak, Venkatachalam, Kandadamy, A K Saravanan, Stina Manjila, R Prakash, V Arjun, Nirmala, Sunil Jadhav, Satish Haridasan, P S Priyamvada, Soundaravalli, Sreejith Parameswaran

Department of Nephrology; JIPMER; Puducherry; India

BACKGROUND: Even though the CKD registry of India reported Diabetic Kidney Disease (DKD) as the most common cause of CKD in India; CKDu accounts for 70% of CKD at our centre. Since most of our patients belong to Villupuram district of Tamil Nadu; we have initiated a community-based screening program for CKD in rural areas of the district; to investigate whether CKDu is endemic in this region.

AIM OF THE STUDY: To estimate the prevalence of chronic kidney disease in Nainakuppam village in Villipuram.

METHODS: A voluntary CKD screening program was organised at the Nainakuppam village; 80 kms from Pondicherry; on 26th May 2018 by JIPMER; in collaboration with Sri Sharada Ashram located near the village. All adults who volunteered for the screening program underwent measurement of Height; Weight; Blood Pressure (BP); information was collected using a pre-designed form on age; sex; occupation; monthly family income; history of known diabetes mellitus (DM); Hypertension (HT); addictions; use of NSAIDs; Renal stone disease and any specific symptoms. Urine was tested for albumin using dipstick and blood samples were collected for Random Blood Glucose (RBG); Serum Creatinine (S Cr) and Haemoglobin (Hb). Blood samples were stored and transported to JIPMER for assays and SCr was used to calculate eGFR using CKDEPI equation.

RESULTS: There were 240 house holds in the village; with a total of 1200 inhabitants; among whom 938 attended the screening. Out of this; 508 were below 18 years of age and hence were excluded from screening. Among 430 screened; demographic data was available for 305; mean age (+SD) was 42.43+15 years; 152 (40.83%) were females; 159 (52.13%) were illiterate; 191 (62%) had income between ₹5000 - 10000 per month with predominant occupation being farming (63.6%). 25 (8%) were diabetic and 21 (6.8%) were hypertensive. Mean height (+ SD) was 155.46+9.5; Mean weight (+ SD) was 54.31+ 11.54; mean BMI (+SD) was 23.46+ 12.8. Mean (+ SD) SCr of study population was 1.57+ 0.63 with eGFR estimated by CKD-EPI was 78.93+ 28.5. 85 (19.7%) participant >18 years had eGFR less than 60 ml/min. Urine albumin was detected in 11 participant with 3 of them having eGFR less than 60. In the CKD population 2 were diabetic and 3 had HT.

CONCLUSIONS: The Nainakuppam village in Villupuram district of Tamil Nadu have a high CKD prevalence of 19.7%; with most of them attributable to CKDu. More extensive community-based screening is necessary to determine whether there are areas where CKDu is endemic among farming communities in Tamil Nadu.


  104. Rare Presentations of Leptospirosis with RPGN Top


B Naga Alekhya, Sangeeta Lakshmi

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

BACKGROUND: Renal manifestation of leptospirosis includes acute tubular necrosis; tubular dysfunction and acute interstitial nephritis. Crescentic glomerulonephritis due to leptospirosis has so far not been described.

AIM OF THE STUDY: Here with present three patients with leptospirosis who on renal biopsy eventually showed crescentic glomerulonephritis.

Methods and Results: 1st pateint is 35 year female who presented with fever of one month duration with cola coloured urine. her creatinine is 4.2 mg/dl; leptospira IgM positive. Renal biopsy revealed fibrinoid necrosis with crescents. Vasculitic work up is negative. She improved with immunosupression. 2nd patient is 41 year female who presented with fever of 15 days and leptospira IgM positive. renal biopsy revealed endocapillary hypercellularity with crescents. She improve with immunosupression 3rd patient is 48 year male with fever of 20 days; leptospira IgM positive. His creatinine-15.92 mg/dl and renal biopsy revealed endocapillary proliferation with crescents he did not improve with immunosuppression.

CONCLUSIONS: This is rare presentation of leptospirosis with crescents which has not been reported so far.


  105. An Rare Case of Late Onset Sheehans Syndrome Top


Prawash Kumar Chowdhary, S A Kale, Anuradha Tibrewal

Department of Nephrology; Ramkrishna Care Hospital; Raipur; Chhattisgarh; India

BACKGROUND: Sheehans syndrome occurs as a result of ischemic necrosis of the pituitary gland caused by severe PPH. The rapidity of onset and degree of pituitary insufficiency depends on the extent of the damage. Although a small percentage of patients remains undiagnosed. The pituitary failure is only recognised and treated after many years when their symptoms become acutely exacerbated during stress (e.g. Infection; surgery etc).

AIM OF THE STUDY: To present very rare case so that docter community will be aware of it.

METHODS: A 58 Yrs Postmenopausal women with Type 2DM; since 10 yrs was referred to us for management of UTI and deranged renal parameter. She had other complain of Myalgia; Lethargy; and Tiredness after doing household works. she has cold intolerance. she had episode of recurrent hypoglycaemia since 3 months for which her antidiabetic medicine were stopped. She has history of excessive vaginal bleeding requiring blood transfusion after second pregnancy. She had irregular menstruation after 3 yrs of second pregnancy; She attained menopause at 42 yrs of age.

RESULTS: On physical examination; heart rate 66/min; Blood pressure 100/60 mmhg; pallor; wrinkles around mouth and eyes; dry skin; pubic and axillary hair absent. Investigation revealed Hb 6.6 gm/dl; TLC was 3180/cmm; Platelet Count was 91000/cmms; S. Creatinine - 2.2 g/dl; S. Sodium 112 meq/L; Serumpotassium 3.9 meq/L; S. Uric Acid 3.6 mg/dl; serum osmolality 260 mosm/kgH20; urine osmolality 462 mosm/kgH2o; SpotUrinarySodium 61 meq/l. Other investigation showed free T3 1.22 pg/ml; free T4 0.62 ng/dl; TSH 0.843 uIu/ml;; FSH 2.2 miu/ml; LH 1.4 miu/ml; Prolactin was <1.0 miu/ml. Short ACTH simulation test; 250 mcg by intravenously was administered; basal cortisol level was 4.2 mcg/dl; 30 min cortisol was 8.8 mcg/dl; and 60 min cortisol was 12.4 mcg/dl. ECG suggestive of sinus bradycardia. Upper GI endoscopy and colonoscopy was normal. Bone marrow was suggestive of hypocellular marrow. USG showed B/L normal size kidney. Urine c/s showed growth of E-coli (>105 CFU). MRI of pituitary gland showed Empty Sella.

CONCLUSIONS: She was Managed with Antibiotics; Hydrocortisone; thyroid medication; Calcium and vitamin D3. Fluid intake and urinary out put were measured; Discharge blood pressure; sodium and renal parameter improved. 6 wks blood parameter improved. She need life time steroid replacement medication.


  106. Metformin As Potential Immunomodulator in Lupus Nephritis Top


Mohit Kumar Rai, Sandeep Kansurkar, Durga Prasanna Misra, Vikas Agarwal, Narayan Prasad

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

BACKGROUND: Metformin activates AMP kinase and reduces mitochondrial energy output. This has wide consequences on immune response as it is an active metabolic process. Activation of AMP kinase has been shown to alter transcription of multiple proteins including cytokines. In this study; we decied to study effect of metformin on secretion of cytokines IL-1beta; IFN gamma; TNF alpha; IL-6; IL-10 and TGF beta by PBMCs which are key effector cells in Lupus.

AIM OF THE STUDY: To study the immunomodulatory property of Metformin.

METHODS: PBMCs of nine lupus patients (Mean age 30 yrs; all females) were cultured using RPMI medium and then stimulated with PMA/ ionomycin; with or without increasing dose of metformin (0.01; 0.1; 1; 10 mMol/L) for 24 h. Cytokines IL-1b; IL-6; IFN-g and IL-10 were analyzed by ELISA in culture supernatant.

RESULTS: In the PBMC cultures with PMA and increasing concentration of metformin; there was decrease in production of pro-inflammatory cytokines: IL-1b (p=0.001); IL-6 (p=0.007) and IFNg (p<0.001) at even the lowest concentration of metformin. There was increase in production of anti-inflammatory cytokine IL-10 (p=0.014) and TGF beta (p=0.005). The suppression of IL-1; IL-6; IFNg and increase in IL10 and TGF beta production was dose dependent.

CONCLUSIONS: Merformin has immunomodulatory activity by reducing expression of pro-inflammatory cytokines.


  107. Clinico Etiological Profile of Snake Bite Patients with Acute Renal Failure Top


J Mukund, J Manjunath

Father Muller Medical College; Mangalore; Karnataka; India

BACKGROUND: There are many patients who suffer from renal failure after snake bite. The renal failure may resolve completely or there may be a permanent residual renal illness for which the patient may require treatment for lifetime.

AIM OF THE STUDY: To study the outcome of snake bite patients with renal failure.

METHODS: Retrospective study in which clinical data of snake bite patients admitted to father muller hospital who developed renal failure is studied.

RESULTS: The result of the study will be updated at the conference.

CONCLUSIONS: Patients with snake bite have a high chance of developing renal failure.


  108. Immediate Redo and Cannulation of AVF Following Secondary Failure Due to Acute Thrombosis- A Single Center Experience Top


Anjaney Yadur

Department of Nephrology; MIMS Hospital; Kozhikode; Kerala; India

BACKGROUND AND OBJECTIVES: Acute thrombotic occlusion is a major cause for late failure of AV fistula. Unlike for central venous catheter and AV grafts, thrombectomy is not an easy salvage option for AVF due to varying thrombotic load and abnormal vascular anatomy. Immediate Redo (IR-AVF) creation of a new proximal AVF within 48 hours of thrombosis utilizing the arterialized vein of prior AVF is a viable but less cited salvage procedure. Immediate cannulation and avoidance of a central venous catheter are the most important advantages of IR- AVF.

AIMS AND OBJECTIVES: To analyze our experience with IR-AVF for secondary AVF failures with respect to risk factors and outcome.

MATERIALS AND METHODS: Our study is a retrospective analysis of 124 redo AVF surgeries during the eight years from January 2009 to June 2016 in a single center by the same vascular surgeon. Background and clinical details were retrieved from Hospital Information System (HIS) – Medical records –Dialysis records & OT notes. Follow up details were updated from HIS and telephonic interviews. Only patients who had successful IR-AVF with updated follow up were included in the final analysis.

RESULTS: During the study period of eight years 959 AVF surgeries were done of which 153 (16%) were IR-AVF. Successful redo with follow up was available on 124 patients. Thirty-one out of 124 (25%) were female and 49 of 124 (40%) patients had diabetic nephropathy. Only 25 of 124 (20 %) patients were on anti-platelets prior to failure. All the AVFs attempted for redo were radio-cephalic and average life of AVF prior to failure was 566 ± 595 (12 to 3971) days. The IR-AVF was created proximally in same forearm itself in 90 %(111/124) of instances and remaining 10 %(13/124) in the elbow. All the 124 patients could undergo cannulation of AVF on the same day and could avoid a bridge with central venous catheter. Cost of IR-AVF is less than 12,000 INR compared to Cuffed catheter plus new AVF creation which can amount upto 35,000 INR. Eighty three of 124 (66%) patient continue on HD, 24 of 124 (20%) patients have died on HD and 17 of 124 (14%) are surviving after transplantation after a mean follow up of 1156 ± 533 days since date of IR-AVF.

CONCLUSION: IR-AVF Utilizing Arterialized Veins Is A Good Therapeutic Option With Good Long-Term Patency Rates For Avfs Which Developed Acute Thrombosis. Redo Avfs Can Be Cannulated Immediately And Patients Could Be Rescued From The Anguish And Cost Of A Central Venous Catheter.


  109. Assessment of Knowledge Regarding Prevention of Hepatitis B Infection Among African Undergraduate Students of Health Sciences in Davangere, Karnataka Top


Hussaini Muhammad Aikawa

Department of Sciences (Nursing); School of Continuing Education; Bayero University Kano, Kano, Nigeria

BACKGROUND: Hepatitis B is an inflammatory disease of the liver which is caused by Hepatitis B Virus. It is a global problem, with 66% of all the population living in areas where there are high levels of infections. Hepatitis B infection may be due to lapses in the sterilization of instruments as well as improper waste management. Knowledge regarding Hepatitis B and safety precautions is needed to minimize the health care setting's acquired infections among health personnel and students of health Sciences.

OBJECTIVES: (a) To assess the knowledge regarding Hepatitis B among African Students of Health Sciences (b) To associate the knowledge of the students regarding Hepatitis B with their selected demographic variables.

MATERIALS AND METHODS: A descriptive cross sectional design was used for the study were 50 students were selected using purposive sampling. A validated structured questionnaire was used for data collection. The data collected were organized, tabulated and analysed using descriptive and inferential statistics.

RESULTS: The results indicated that majority (52%) of the respondents are 22-24 years of age. The students of B. Pharm were 25 (50%) 38% MBBS and 12% B. Sc. Nursing and 60% of them all are in their 3rd year of study. The overall mean score on knowledge regarding hepatitis B Prevention was 15.74 with maximum score of 29. The association between the knowledge of hepatitis B prevention with some selected variables shows that the program and the year of study were very Significant.

CONCLUSION: The study was conducted among African Students of Health Sciences in order to assess their knowledge regarding Hepatitis B infection. After the completion of the study it is revealed that the knowledge of Hepatitis B prevention among the students was inadequate hence, recommends a similar study on a larger scale.


  110. Kidney Allocation Based Upon Virtual Cross Match in Deceased Donor Program Top


Abhinav Seth, Ashish Sharma, Deepesh Benjamine Kenwar, Sarbpreet Singh, Vidyasagar Kallepalli, Gaurav Shankar Pandey

Department of Renal Transplant Surgery; Postgraduate Institute of Medical Education and Research; Chandigarh; India

BACKGROUND: A negative complement dependent cytotoxicity cross match (CDC) has been the essential requirement in cadaver renal transplants. In this context, patients with high anti-HLA titers are often not listed in the active transplant list due to a high probability of a positive CDC cross match and poorer outcomes on non screened transplantation. The Luminex Single-Antigen Beads assay to detect donor specific anti-HLA antibodies (DSA) can improve short and long term outcomes by fine tuning the CDC cross match in such high risk transplants.

AIM: To discuss role of virtual cross match for allocating kidney from deceased donor.

METHODS: All sensitized recipients listed for deceased donor renal transplant were screened by Luminex assay for anti-HLA antibodies (n=63). Pretransplant HLA genotyping for A, B, and DR loci was performed using Luminex/sequence specific primers (SSP) at the time of donor identification. Only those patients with negative virtual crossmatch (DSA MFI <1000) were called for CDC X match before organ allocation. This method was used in eight previously sensitized cadaver kidney recipients (history of blood transfusion, previous transplant, multiple pregnancies or previous cross match positive and with antibody MFI more than 5000 on Luminex with peak MFI of 21444).

RESULTS: The mean age of recipients and donor was 39.38±9.43 years and 38.13±8.31 years respectively while M:F ratio was 2:6. The causes of end stage renal disease were diabetic nephropathy (n=2), focal segmental glomerulosclerosis (n=1), IgA nephropathy (n=1), membranoproliferative glomerulonephritis type I (n=1) or unknown (n=3). The mean cold ischemia time was 473.86 minutes. None of these patients had hyperacute rejection or suffered from infection. The average follow up was 2.1±1.89 months (median 1 month). The patient mean creatinine at discharge was 1.27±0.24 mg/dl and at one month was 1.13±0.3 mg/dl. Biopsy proven acute rejection was seen in one patient and treated with methyl prednisolone pulse.

CONCLUSION: Kidney allocation for sensitized patients from deceased donor based on virtual cross match may help in achieving better outcome in terms of improved graft function and preventing hyperacute rejection in patients who would otherwise not be eligible for a cadaver transplant.


  111. Non-Simultaneous Kidney Exchange Cycles in Resource Restricted Countries Top


Subho Banerjee, V B Kute, H V Patel, P R Shah, H P Singh, D P Engineer, P R Modi, V R Shah, S J Rizvi, B C Pal, B P Butala, M P Modi, S Gandhi, M A Rees, H L Trivedi

Department of Nephrology; IKDRC-ITS; Ahmedabad; Gujarat; India E-mail: drsubhobanerjee@gmail.com

INTRODUCTION: Recent reports suggest that the donor renege is rare (1.5%) as part of non-simultaneous kidney exchange chains. In developing countries, surgical space and resources limit the number of simultaneous kidney exchange transplant surgeries. The present study evaluated bridge donor renege during non-simultaneous kidney exchange cycles in a prospective single center cohort study (n=33).

METHODS: This was a single-center cohort study of non-simultaneous kidney exchange cycles in 33 donor-recipient pairs (DRPs) from August 2015 to January 2018. There were two 2-way (n=4), four 3-way (n=12), one 4-way (n=4) and one 6- way (n=6) exchange. Careful planning and selection of DRPs, non-anonymity, good matching, extensive evaluation, both physical and psychological was done to limit donor and recipient factor related renege. We insured that bridge donors didn’t wait long to donate. Donors of sensitized patients were not allowed to serve as bridge donors. The chains were kept short to restrict donor wait times.

RESULTS: The mean age of recipients (21 males, 5 females) and donors (6 males, 20 females) were 39.3±10 (range: 17-58) years and 43±8.9 (range: 27-60) years. DRPs were spousal [wife (n=15), husband (n=3)], parents [mother (n=4), father (n=3)] and sister (n=1). Reasons for kidney exchange were ABO incompatibility (n=16), sensitization (n=11, 6 recipients having PRA of 80%) and compatible pairs to get better HLA/age matching (n=2). Donor wait time was managed to maximum of 21 days. All DRPs were discharged with normal renal function and stay was uncomplicated. Donor renege was zero. Mean serum creatinine at last follow up was 1.2 ± 0.5 mg/dl. Biopsy proven acute rejection rates were 15%.

CONCLUSION: Non-simultaneous kidney exchange is a viable method to increase the rates of living donor kidney transplant in resource poor countries like India. With careful DRP selection and short chains of non-anonymous exchange, donor renege is not critical.


  112. The Inescapable Tunneled Cuffed Dialysis Catheters. A Single Center Experience Over One Year Top


Subho Banerjee, D P Engineer, Jaydeep Patel, Nilav Shah, Rutul Dave, V B Kute, H V Patel, P R Shah, H L Trivedi

Department of Nephrology; IKDRC-ITS; Ahmedabad; Gujarat; India

INTRODUCTION: Vascular access remains the Achilles heel of dialysis. Tunneled cuffed catheters (Permcaths) are the only option available to a large number of patients. Here we present a retrospective cohort of 161 patients with 170 permcaths, to study their longevity and overall outcomes.

METHODS: 161 patients with chronic kidney disease (CKD) on dialysis who underwent permcath insertion were followed for a duration of 1 year (23684 catheter-days). The site of permcath insertion was right internal jugular (135), left internal jugular (22) and left femoral (13). Three catheter designs- staggered tip, split tip and over-the-guidewire were used. All procedures were done under ultrasound guidance by nephrologists.

RESULTS: The mean age was 41.3 ± 17.8 years with 86 males and 74 females. Sixty-six (40.1%) patients were diabetic. 93 (57.76%) patients had previous fistula failure, 65 (39.16%) patients were ineligible for a fistula, due to thin veins (N=33) (50.77%), severe thrombophlebitis (N= 24) (35.38%) or poor overall health or severe upper limb edema (N=9)(13.85%). Two had failed CAPD. One was put on permcath after allograft failure. There were no catheter kinking while insertion. There was one procedure related death (sudden cardiovascular collapse) and one misplaced catheter tip requiring subsequent removal. One catheter with a split tip design developed a kink at the catheter tip. The 30 day, 90 day and 180 day survival of the permcaths were 84.11%, 65.8% and 45.9% respectively. The most common cause of catheter loss was death with a functioning catheter. Flow problems occurred in 45.18% patients while catheter infection occurred in 37.05% patients. Accidental removal of permcath occurred in 3 patients, two of them femoral catheters.

CONCLUSION: Overall permcaths provide a fairly effective fall back option for vascular access in dialysis patients. It is relatively safe but long term outcomes are less than excellent.


  113. Pediatric Kidney Donor with Weight less than 15 kg As Donor for Adult Recipient: A Report of 2 Cases Top


Gaurav Pandey

Department of Nephrology; PGIMER; Chandigarh; India

INTRODUCTION: There has been an increase in organ donation in recent times which still couldn’t meet the demand. Hence there is need to increase the donor pool by accepting the marginal donor. Many studies suggest the feasibility of pediatric kidney transplant to an adult recipients but no such literature have been published form India. We present two such case of pediatric donor weighing less than 15 kg operated at our center where kidney was transplanted to adult recipients with excellent graft function.

METHODS AND RESULTS: A 3 yr old female (weight 12 kg) was declared brain dead following a history of head trauma. Her kidneys were harvested and transplanted to 2 adult recipients, a 23 year old female (weight 50 kg) and 29 year old male (weight 55 kg). Both recipients were induced with ATG and were put on heparin infusion during post operative period. Both, male and female recipient have adequate urine output in post operative period and were discharged with a creatinine of 2.6 mg/dl and 1.2 mg/dl respectively at discharge. At 6 month follow up their creatinine are 0.59 mg/dl and 1.02 mg/dl respectively. In another case kidneys from an 11 month old male (weight 8 kg) were transplanted to a 38 year old female en bloc. She was induced with ATG and was kept on heparin infusion during post operative period. She had uneventful post operative course and was discharged with a creatinine of 0.8 mg/dl.

CONCLUSION: Pediatric kidney can be used in suitable adult recipient to increase donor pool. Complications like risk of thrombosis can be avoided by using meticulous surgical technique and anticoagulant therapy during post operative period.


  114. Kidney Transplantation from Donation After Circulatory Death: A Novel Method to Increase Donor Pool Top


Gaurav Pandey

Department of Nephrology; PGIMER; Chandigarh; India

INTRODUCTION: Donation after circulatory death (DCD) although, a well-accepted source of organs worldwide is not practiced in India so far due to lack of proper guidelines for the same. The present report describes a single-center experience with DCD organs in India, its advantages, outcome and associated challenges.

METHODS: During the 7 year period from February 2011 to February 2018, 126 deceased donor were harvested for renal transplant out of which 11 (8.73%) were DCD donors. Five had cardiac arrest after first brain death certifying committee evaluation whereas two had cardiac arrest after brain death certification. Brain death certification was not given to two donors. One patient with terminal lung disease and one patient with head injury had cardiac arrest in ICU. Donors received 25000 units of heparin after being declared brain dead. Nine donors were started with Chest compressions maintain circulation and ventilation which was continued till the organs were retrieved. In the remaining two donors, CPR was discontinued before donor was shifted to Operation Theater. Rapid cannulation was done in all donors with infusion of cold preservative solution during organ retrieval surgery. All except one recipient received ATG induction. All recipients received Tacrolimus, Mycophenolate and steroids.

RESULTS: 22 kidneys retrieved from 11 DCD donors out of which 19 (86.36%) were transplanted and three discarded (13.37%). One recipient underwent dual kidney transplant but graft nephrectomy was done in view of persistent intra-op hypotension after declamping. Due to high resistance during perfusion, kidneys retrieved from one donor were discarded. Cause of death was head injury in all but one patient. Recipient's mean age was 40.58 + 8.97 yrs with male female ratio being 13:5. All recipients except two had graft dysfunction and required dialysis in post-operatively. Mean day one urine output was 2269.41 ml. The best baseline creatinine achieved was 1.35 +0.398 mg% after mean duration of 24 days. The kidneys from donors where CPR was performed after death fared better with early recovery and less time to achieve normal renal function.

CONCLUSIONS: DCD donation present as a viable option to increase the donor pool in deceased donor program especially with already constraint organ supply for a large population of patient awaiting transplant. CPR seems to help improve the outcome following Circulatory death in a DCD donor.


  115. Longitudinal Study of Nutritional, Hydration and Biochemical Parameters among Hemodialysis Patients with or without Diabetes Mellitus Top


M K Verus, Abhishekan Davidar, Karthik Bala, Milly Mathew, Georgi Abraham

Department of Nephrology; Madras Medical Mission; Chennai; Tamil Nadu; India

BACKGROUND: The aim of the study is to analyze the nutritional, hydration and biochemical parameters and the effect of Diabetes Mellitus in haemodialysis (HD) patients. Body composition monitoring (BCM) by multifrequency bioimpedance spectroscopy (MFBS) is considered a superior modality of fluid assessment in hemodialysis patients. There is paucity of data on nutrition, hydration and biochemical parameters prevalent among hemodialysis patients from India. Diabetic nephropathy is a major cause of end stage renal disease with higher mortality in India. This study was undertaken to look at nutrition, hydration and biochemical parameters with longitudinal follow up to know the outcomes prevalent.

OBJECTIVE: Analyze nutritional, hydration and biochemical parameters between diabetic and non diabetic patients undergoing hemodialysis.

METHODOLOGY: Study included 100 prevalent hemodialysis patients (M:61, F:39, mean age: 54 years, Non DM: 51, DM:49). Prevalent patients for hemodialysis less than six months were recruited for the study and followed up for a period of 12 months. The hydration, nutrition and biochemical parameters were compared between the two sets of population at baseline and 12 months of dialysis treatment using student's two tail t test with a 95% confidence interval.

RESULTS: Mean BMI for non diabetic patients was 22.28 ±5.64 kg/m2 while mean BMI among diabetic patients was 24.63 ±4.17 kg/m2 and student t test revealed a significant p value of 0.019439. Baseline albumin level for Diabetic patients was 3.59 ±0.55 g/dL and non diabetic patients was 3.54 ±0.39 g/dL. After 12 months of dialysis treatment, the parameters were compared between the two populations which revealed mean albumin level of 3.51 ±0.39 g/dL among diabetics which was lesser than the average albumin level of 3.72 ±0.38 g/dL among non diabetics with a significant p value of 0.007617. Post 12 months dialysis mean serum iron value was 51.14 ±37.16 µg/dL among diabetics which was lesser than the mean serum iron value of 68.73 ±18.83 µg/dL with a p value of 0.004565.

CONCLUSION: Our study found BMI is higher among diabetic compared to non diabetic population at baseline. Post 12 months of dialysis treatment, there was statistical significance between the populations for serum albumin, serum iron and total iron binding capacity. Serum iron was found to be decreased among diabetics as well. There was no statistical difference found in extracellular water, intracellular water and total body water between Diabetic and non diabetic population. This is an ongoing study to analyze the effect of diabetes in Hemodialysis patients.


  116. Long Term Outcome of Lupus Nephritis: A Single Centre Study Top


G R Pramod, S Renuka, G K Prashanth, M Limesh, M Ravindra

Department of Nephrology; St. John's Medical College; Bengaluru; Karnataka; India

BACKGROUND: Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease, which affects kidney in up to 60% of patients with SLE. Renal injury is the main cause of mortality and morbidity of patients with SLE. LN may present from mild asymptomatic proteinuria to rapidly progressive glomerulonephritis, which may progress to CKD. Diagnosis and treatment aimed at halting disease progression, achievement of complete remission and there by improvement in the long term outcome of kidney.

PRIMARY: To assess the long term outcomes: Response to therapy, flare,mortality, treatment related complications, outcome post flare.

SECONDARY: To analyse the predictors of the outcome.

MATERIALS AND METHODS: This was a prospective observational study conducted from 2005 to 2015 at our hospital.

INCLUSION CRITERIA: Age above 18 years, regular for follow up, Complaint with medication.

EXCLUSION CRITERIA: Age below 18 years and biopsied elsewhere and referred for our centre. Routine clinical details were recorded from 61 patients who were studied between 2005 to 2015, which included age of onset, delay to onset of nephritis, clinical features at onset and renal symptoms at onset of kidney disease, and co morbidities. Routine blood test, serology and biopsy were done, all patients were classified based on ISN/RPS classification by renal pathologist. The patients were followed as per protocol for 7 years, treated as per National Institute of Health (NIH) protocol was followed and Maintenance therapy used was either Azothioprine, Mycophenolate mofetil, 3 monthly IV cyclophosphamide and other supportive treatment like antihypertensives and anti proteinuric and hydroxychloroquine was given.

RESULTS: 61 patients completed our study. Average duration of follow up was 84±6 months and mean age was 32±6 years and majority were females 83.3%(n=51). Most of the patients in our study group belonged to class IV (64%), at the onset most of them presented with arthritis (74%). On treatment at the end of 1 year 40 patients achieved CR among which 6 patients experienced renal flare and 19 patients had PR out of which 9 had renal flare. Among the flares 3 had refractory flare, Overall outcome at the end of our study 84+ 6 months - CR was seen in 38, PR in 6, CKD in 3, ESRD in 2 and death in 10 patient. With respect to pregnancy 7 patients conceived out of which only 2 had complicated pregnancies. Poor predictors which were studied were S creatinine > 1.8 mg, hypertension at onset, class IV lupus nephritis, failure to achieve remission at 1 year, occurrence of high number of infections all which were statistically significant.

CONCLUSION: Outcome if treated aggressively based on the class of lupus with standard immunosuppressive regimens is reasonable with a 7 year survival percentage of 84% in our study, but immunosuppression is associated with a high rate of infection. Patients need to be educated about predictors of poor outcome.






 

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