Atherosclerotic renal artery stenosis (ARAS) is a common condition that causes hypertension and reduction in the glomerular filtration rate and is an independent risk factor for death. Despite high technical success, the clinical benefit of renal artery (RA) angioplasty with stenting in ARAS remains doubtful. The published randomized clinical trials provide no support for the notion that renal angioplasty with stenting significantly improves blood pressure, preserves renal function, or reduces episodes of congestive heart failure in patients with ARAS. RA stenting is associated with procedure-related morbidity and mortality. Agents to block the renin-angiotensin-aldosterone system improve outcome and should be a part of a multifaceted medical regimen in ARAS. Medical therapy effectively controls atherosclerotic renovascular disease at all levels of vasculature and hence is the best therapy for ARAS.

The purpose of this investigation was to assess the correlation of two biomarkers with the occurrence of renal flares in systemic lupus erythematosus (SLE). Urine levels of monocyte chemotactic protein-1 (MCP-1) and transforming growth factor beta (TGF-β) were measured at baseline, and at two and four months in five groups of patients: 25 lupus nephritis patients with active disease (active LN), 10 lupus nephritis patients with SLE in remission (remission LN), 25 patients with clinical active SLE and without nephritis (active NLN), 10 patients without nephritis with SLE in remission (remission NLN) and 10 healthy controls. We used repeated measurement and ANOVA with Duncan's post hoc to analyze the data; the urine level of the two proteins could distinguish the groups based on the existence of lupus nephritis and/or activity of SLE disease. Furthermore we performed receiver operating curve analysis to identify a cutoff point with a good sensitivity and specificity to diagnose lupus nephritis with either one of the urine proteins. Finally the samples from active LN were grouped according to whether they were Class IV or other classes. Baseline urinary MCP-1, but not TGF-β, was significantly different between the classes. Further investigation into the use of these cytokines in a prospective study is needed to determine their capacity as diagnostic tools for renal flares.

Multivessel coronary disease or peripheral arterial disease is the clinical clue to diagnosis of renal artery stenosis (RAS). RAS is considered equivalent to coronary artery disease in terms of cardiovascular risk. In this study, we evaluated the incidence of RAS in the patients who were proposed to undergo coronary artery bypass grafting (CABG). Diagnostic evaluations of coronary arteriography and renal artery angiography were performed during the same procedure; the patients who were proposed for CABG in terms of CAD anatomy and clinical manifestation were enrolled. RAS was evaluated and a diameter stenosis of ≥50% was considered as significant RAS; significant RAS patients were divided into five groups. The five groups of RAS were as follows: (1) unilateral RAS ≥50-70%, (2) unilateral RAS ≥70%, (3) bilateral RAS ≥50-70%, (4) one-renal-artery stenosis ≥50-70%, contralateral RAS ≥70%, and (5) bilateral renal artery stenosis ≥70%. A total of 151 patients were enrolled, and RAS (≥50% stenosis in either or both renal arteries) was identified in 47.02% (71/151) patients. Unilateral RAS ≥50-70% was identified in 16.6% (25/151) patients, unilateral RAS ≥70% in 4.6% (7/151) patients, bilateral RAS ≥50-70% in 7.9% (12/151) patients, one-renal-artery stenosis ≥50-70% and contralateral RAS ≥70% in 7.9% (12/151) patients, and bilateral RAS ≥70% was in 9.9%(15/151) patients. The incidence of RAS was 29.03% (18/62) in patients aged ≤60 years, 60% (36/60) in patients aged >60 and ≤70 years, and 58.62% (17/29) in patients aged >70 years. The incidence of RAS was significantly higher in patients aged >60 - ≤70, and >70 years than patients aged ≤60 years ( P = 0.001 and P = 0.007, respectively). There was a trend that the incidence of RAS in patients with hypertension [HTN, 50.40% (64/127)] was higher than those without HTN (29.17%, 7/24), with P = 0.056. The incidence of RAS was 47.02% in patients who were proposed for CABG; bilateral RAS of ≥70% was 9.9%. Older age and HTN were associated with RAS in patients who were referred for CABG. This study indicates that the incidence of RAS was high in the patients referred for CABG, and the renal function should be taken care of.

Little is known about the quality of life and survival in the patients on maintenance hemodialysis (HD) in India. Poor nutrition and dialysis noncompliance is common. This study investigates the factors that affect the quality of life (QoL) in HD patients in India. This cross-sectional study included 78 patients on HD for ≥ two months. Demographic, nutritional, functional subjective global assessment and Kidney Disease Quality of Life (KDQOL-36) assessments were done. Predictors of QoL were assessed by regression analysis. The mean calorie and protein intake were 1245 ± 116.9 kcal and 0.86 ± 0.19 g/kg/day respectively. Male gender (OR = 9.68), serum parathyroid hormone PTH <150 pg/ml (OR = 0.03), age ≤65 years (OR = 1.25), no catheter use (OR = 1.9) and hospitalizations (OR = 0.11), were independent predictors of total score ≥50. Independent predictors of physical component summary (PCS) >25 were male gender (OR = 5.06) and urine output at start of dialysis (OR = 1.05). Independent predictors of mental component summary (MCS) ≥25 were male gender (OR = 11.02), serum PTH > 150 pg/ml (OR = 0.15), daily protein intake of >0.8 g/kg and caloric intake >20 K.cal/kg (OR = 10.8). Patients with urine output >1 liter per day had more hypotensive episodes during dialysis (r = 0.56, P = 0.045), more headaches (r = 0.63, P = 0.006) but that did not affect the PCS significantly. Low PTH (<150 pg/ml) (OR = 1.29), multiple access failures (OR = 3.36) and total score ≤50 (OR = 0.09) were independently associated with increased hospitalization. Males, patients with serum PTH >150 pg/ml and those not on catheter had better total score. Though patients with higher urine output had better PCS, those with output >1 liter had higher incidence of hypotension and dialysis-related headache. Protein-energy malnutrition affected the MCS significantly. Dialysis noncompliance seen in one-fourth of the population did not affect the scores significantly.

Acute pyelonephritis (APN) is an inflammatory disease that leads to kidney malfunction. The objective of this investigation was to evaluate the impact of gentamicin (GEN) and ceftriaxone (CEF) alone and in combination with mycophenolate mofetil (MMF) on experimentally induced APN. Forty two Wistar male rats were assigned into seven groups +APN, APN +GEN, APN+CEF, APN+MMF, APN+GEN+MMF and APN+CEF+MMF. APN was induced by injecting E. coli in the left kidney. The control and +APN groups were treated with normal saline while the other APN groups received GEN, CEF, or MMF alone and/or in combination for 2 weeks. The elevated total white blood cells count and increased level of creatinine and blood urea nitrogen (BUN) in +APN groups returned to normal levels following 14 days treatment with GEN and CEF. Co-administration of GEN with MMF could not recover the APN-induced changes and resulted in a significant (P < 0.05) elevation of creatinine and BUN levels. Histopathological studies supported the biochemical findings as GEN and CEF alone could partly restore the APN-induced degeneration and leukocytic infiltration; however, the combination therapy of GEN plus MMF failed to reduce the APN-induced damages. The antibacterial susceptibility test demonstrated that the strain of E. coli used in this study was susceptible to GEN and CEF and the combination therapy did not change the antibacterial potency. These findings suggest that co-administration of GEN with MMF in APN may enhance kidney damage and the adverse effects of combination therapeutic regimen could be related partly to incompatibility of these compounds.

Acute kidney injury (AKI) is one of the most dreaded complications of severe malaria. We carried out prospective study in 2010, to describe clinical characteristics, laboratory parameters, prognostic factors, and outcome in 59 (44 males, 15 females) smear-positive malaria patients with AKI. The severity of illness was assessed using Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA) score, Multiple Organ Dysfunction Score (MODS), and Glasgow Coma Scale (GCS) scores. All patients received artesunate and hemodialysis (HD). Mean age of patients was 33.63 ± 14 years. Plasmodium falciparum malaria was seen in 76.3% (n = 45), Plasmodium vivax in 16.9% (n = 10), and mixed infection in 6.8% (n = 4) patients. Presenting clinical features were fever (100%), nausea-vomiting (85%), oliguria (61%), abdominal pain/tenderness (50.8%), and jaundice (74.5%). Mean APACHE II, SOFA, MODS, and GCS scores were 18.1 ± 3, 10.16 ± 3.09, 9.71 ± 2.69, and 14.15 ± 1.67, respectively, all were higher among patients who died than among those who survived. APACHE II ≥20, SOFA and MODS scores ≥12 were associated with higher mortality (P < 0.05). 34% patients received blood component transfusion and exchange transfusion was done in 15%. Mean number of HD sessions required was 4.59 ± 3.03. Renal biopsies were performed in five patients (three with patchy cortical necrosis and two with acute tubular necrosis). 81.3% of patients had complete renal recovery and 11.8% succumbed to malaria. Prompt diagnosis, timely HD, and supportive therapy were associated with improved survival and recovery of kidney functions in malarial with AKI. Mortality was associated with higher APACHE II, SOFA, MODS, GCS scores, requirement of inotrope, and ventilator support.

In India, majority of patients on dialysis are 'self paying' because of limited health insurance coverage available from government as well as private insurance providers. Hence, cost of treatment becomes one deciding factor to choose between the two modalities of dialysis - hemodialysis (HD) and peritoneal dialysis (PD). Aim is to compare the monthly cost of maintenance hemodialysis and peritoneal dialysis at our center. Majority of patients at our center are on thrice a week hemodialysis and three times a day peritoneal dialysis. These patients were asked to submit their total direct cost of treatment of last three months. It included cost of dialysis, erythropoietin, other medicines, monthly laboratory tests, hospitalization cost, travel cost, and any other directly involved in the treatment. Monthly cost (Indian Rupees, Rs.) was then calculated by averaging the three month cost for each patient. The monthly cost of hemodialysis and peritoneal dialysis was then compared using 'independent sample t-test'. Thirty five patients were finally included in the analysis (21 on HD and 14 on PD). Demographic profile between the two groups was similar in terms of age, sex ratio, period on dialysis, hemoglobin, blood urea nitrogen, and creatinine. Total monthly cost of dialysis was similar in both the groups (Rs. 29,252 ± 6859 vs. Rs. 28,763 ± 5486, P = 0.85). The lower cost of hemodialysis procedure per se as compared to peritoneal dialysis procedure cost (Rs. 14,669 ± 1376 vs. Rs. 19,528 ± 4072, P = 0.000) was compensated by higher cost of erythropoietin (Rs. 7160 ± 3353 vs. Rs. 3093 ± 1889, P = 0.002) and travel cost (Rs. 1654 ± 1085 vs. Rs. 76 ± 66, P < 0.0001) to equalize the monthly cost between the two groups. Our analysis showed no difference in the monthly cost of hemodialysis and peritoneal dialysis and hence, for self-paying patient in India, cost of treatment should not be a deciding factor while choosing between the two modalities.

The association between hypertensive encephalopathy and cortical blindness in children with acute glomerulonephritis is extremely rare. We report the case of a 9-year old girl who presented with headache, seizures, altered sensorium, hematuria, and transient cortical blindness as a complication of hypertensive encephalopathy which showed complete reversal following normalization of blood pressure and an underlying post-infectious acute glomerulonephritis was revealed.

Although penicillamine has been used effectively in the management of a variety of diseases, several adverse reactions have been observed with prolonged administration of this agent. We report a case of Goodpasture's syndrome, as a result of induction of anti-myeloperoxidase antineutrophil cytoplasmic antibodies in a 51 year old man who was being treated with this drug for rheumatoid arthritis. This pulmonary-renal syndrome has been described on rare occasions in patients receiving penicillamine. Treatment with steroids and cyclophosphamide resulted in pulmonary and renal functional recovery.

Renal cortical necrosis (RCN) is a rare cause of acute renal failure (ARF). There is no clinical case report of RCN in a live kidney donor. A 48-year-old female kidney donor developed sudden anuria five hours postnephrectomy and remained anuric for more than three months on maintenance hemodialysis. Laboratory investigations revealed the features of hemolytic uremic syndrome. Contrast-enhanced computed tomography scan of abdomen showed hypoattenuated subcapsular rim of renal cortex favoring diagnosis of RCN. To the best of our knowledge, this is the first clinical case report of RCN in a live kidney donor in world literature.

Extra-pulmonary tuberculosis (TB) is more common in renal allograft recipients and may present with dissemination or an atypical features. We report a renal allograft recipient with intestinal TB presenting 3 years after transplantation with persistent fever, weight loss, diarrhea, abdominal pain and mass in the abdomen with intestinal obstruction. He was diagnosed to be having an ileocolic intussusception which on resection showed a granulomatous inflammation with presence of acid-fast bacilli (AFB) typical of Mycobacterium tuberculosis. In addition, AFB was detected in the tracheal aspirate, indicating dissemination. He received anti-TB therapy (ATT) from the fourth postoperative day. However, he developed a probable immune reconstitution inflammatory syndrome (IRIS) with multiorgan failure and died on 11 ^th postoperative day. This is the first report of intestinal TB presenting as intussusception in a renal allograft recipient. The development of IRIS after starting ATT is rare in renal allograft recipients. This report highlights the need for a high index of suspicion for diagnosing TB early among renal transplant recipients and the therapeutic dilemma with overwhelming infection and development of IRIS upon reduction of immunosuppression and starting ATT.

The occurrence of nephrotic syndrome following a bee sting is rarely reported in the literature. Hypersensitivity is believed to be the precipitating factor for the renal disease. We report a two-year-old boy, who developed generalized edema and decreased urine output, seven days after a bee sting. Physical examination and laboratory findings were consistent with nephrotic syndrome; and corticosteroid treatment induced prompt remission with resolution of clinical symptoms and normalization of laboratory findings. There was no relapse of the disease during a one-year follow up.

A 56-year-old man with diabetes, hypertension, and chronic kidney disease presented to the emergency room with a complaint of pain in his right foot. He was found to have tremors. Gabapentin toxicity was suspected and the patient was found to have high gabapentin level (6.3 mcg/ml). Patient was commenced on continuous venovenous hemodiafiltration (CVVHD) and the pharmacokinetics of gabapentin was studied. The patient improved symptomatically and his tremors subsided. In this case report, we describe the successful management of gabapentin toxicity with continuous renal replacement therapy and calculate the clearance of gabapentin which will enable future treatment of gabapentin toxicity by CVVHD.