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  ~ Table of Contents - Current issue
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March-April 2020
Volume 30 | Issue 2
Page Nos. 63-140

Online since Wednesday, March 4, 2020

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SPECIAL ARTICLE  

Kidney health for everyone everywhere - From prevention to detection and equitable access to care p. 63
Philip Kam-Tao Li, Guillermo Garcia-Garcia, Siu-Fai Lui, Sharon Andreoli, Winston Wing-Shing Fung, Anne Hradsky, Latha Kumaraswami, Vassilios Liakopoulos, Ziyoda Rakhimova, Gamal Saadi, Luisa Strani, Ifeoma Ulasi, Kamyar Kalantar-Zadeh, for the World
DOI:10.4103/ijn.IJN_50_20  
The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions – be it primary, secondary or tertiary. This complementing article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management and treatment are often lacking. Hence, there is an urgent need to increase the awareness of the importance of preventive measures throughout populations, professionals and policy makers.
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ORIGINAL ARTICLES Top

Vitamin D receptor activity, vitamin D status, and development of de-novo donor-specific antibody after renal transplantation p. 72
Sonia Mehrotra, Raj K Sharma, Mahabaleshwar Mayya
DOI:10.4103/ijn.IJN_353_18  
Introduction: Vitamin D has immunomodulatory properties and could have a role in allograft outcome. Methods: Fifty-two chronic kidney disease patients going for transplantation were studied for vitamin-D receptor (VDR) activity, 25(OH)D, estimated glomerular filtration rate (e-GFR), and de-novo donor-specific antibody (d-DSA). Results: Vitamin D deficiency was seen in 25% of recipients before transplant (26.09 ± 12.19 ng/ml), in 48.1% at 6 months posttransplant (23.36 ± 15.11 ng/ml). VDR activity before the transplant was 15.41 ± 31.41 ng/ml, which was similar to control group (13.24 ± 9.78 ng/ml), and after transplantation showed an increase at 3 months to 21.91 ± 38.80 ng/ml and at 6 months to 26.03 ± 53.90 ng/ml. d-DSA developed in 27.3% and 6.7% patients of vitamin D-deficient patients (levels <31 ng/ml) and non-deficient (levels ≥20 ng/ml) patients respectively (P < 0.042). Low VDR activity at 3 months posttransplant was associated with significantly higher d-DSA positivity (33.3%) as compared to the group with normal VDR activity where d-DSA developed only in 5.9% of patients (P < 0.009). Patients with vitamin D levels <20 ng/ml and the group with low VDR activity at 3 months had significantly less e-GFR at 1 year after transplant. Conclusion: d-DSA was associated with vitamin D deficiency and low VDR activity with decreased graft GFR at 12 months posttransplant.
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Link between ACE I/D gene polymorphism and dyslipidemia in diabetic nephropathy: A case-control study from Hyderabad, India p. 77
Umme Najiya Mahwish, Kamakshi Chaithri Ponnaluri, Babi Heera, Satish Reddy Alavala, K Rudrama Devi, Sree Bhushan Raju, G Suman Latha, Parveen Jahan
DOI:10.4103/ijn.IJN_244_18  
Introduction: Diabetic nephropathy (DN) is the commonest single cause of end-stage renal failure, and dyslipidemia is a critical risk factor in the occurrence of DN. In the light of recent reports emphasizing the importance of angiotensin I-converting enzyme (ACE) in the modulation of plasma lipids, we sought to evaluate the influence of ACE I/D gene polymorphism with dyslipidemia status among type 2 diabetic (T2D) patients with and without nephropathy in the genetic predisposition and the progression to DN. Method: This study comprised of 600 subjects, which include patients with DN, T2D, and healthy controls (HC). Polymerase chain reaction based genotyping of ACE I/D polymorphism was performed and appropriate statistical analysis was done.Results: Out of the 600 subjects, 20 (10%) of the HC, 73 (36.5%) of the T2D group, and 125 (62.5%) of the DN subjects had dyslipidemia. The D allele (0.62) and DD (42.5) genotype frequencies were higher in the DN group in comparison with T2D and HC (P < 0.05). The genotypes also varied among patients with dyslipidemia (χ2 5.04; P < 0.05) but not in the non-dyslipidemia group. Under the co-dominant model, DD genotype conferred a risk of 1.26 (P < 0.001) toward DN, whereas the ID genotype offered protection from DN among the dyslipidemic subjects (OR = 0.05; P < 0.01). In addition, genotype-dependent difference was seen in the plasma lipid levels among study groups. A multiple logistic regression analysis revealed male gender, BMI, HbA1c, TG, HDL, and ACE DD genotype as independent risk factors for the development of DN. Conclusion: The study showed a significant predisposing association of ACE DD genotype with DN and protective effect of ID genotype on DN in the dyslipidemia subgroup.
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Intradialytic hypertension increases non-access related hospitalization and mortality in maintenance hemodialysis patients p. 85
Gajanan Kale, Manish Mali, Amit Bhangale, Jaymin Somani, Tarun Jeloka
DOI:10.4103/ijn.IJN_153_19  
Background and Aims: Intradialytic hypertension, in patients on maintenance hemodialysis, is associated with increased morbidity and mortality. As there is no data available from India, this study was aimed to determine the prevalence and outcome of intradialytic hypertension (IDH) in a tertiary care dialysis centre in India. Methods: This was a prospective analytical study of 120 patients on hemodialysis. At screening phase, all patients were subjected to fluid optimization and adjustment in the antihypertensive medicines for appropriate control of blood pressure (BP). BP measurements during hemodialysis were recorded. The prevalence of IDH was noted. IDH was defined as increase in systolic BP of >10 mmHg from pre to post hemodialysis or after 2nd hour of dialysis when significant ultrafiltration had occurred, on 3 consecutive sessions. Factors associated with IDH were evaluated and compared with cohort without IDH. The outcome of these patients in terms of morbidity and mortality over a follow-up period of 12 months were recorded. Results: The prevalence of IDH was 21.9%. The baseline demographic parameters of patients in both the groups (with and without IDH) including age, sex, dialysis access, duration of dialysis, and comorbidities were similar. Laboratory parameters were similar except serum potassium and serum phosphorus, which were lower in patients with IDH. Out of all the variables studied, only low serum phosphorus was associated independently with IDH. During follow-up, at 6 months, 19/71 (26%) non-IDH and 12/20 (60%) IDH patients (P = 0.006) and at 12 month, 30/71 (42%) non-IDH patients and 12/20 (60%) IDH patients required admission (P = 0.05). Mortality at 6 months was similar, 5/71 (7%) in non-IDH and 4/20 (20%) in IDH (P = 0.10) patients, but was higher at 12 months, 11/71 (15.5%) in non-IDH and 8/20 (40%) in IDH (P = 0.028). Conclusion: Incidence of intradialytic hypertension is high (21.9%) with increased morbidity in terms of hospitalization and increased mortality over a period of one year.
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A study on effect of bicarbonate supplementation on the progression of chronic kidney disease p. 91
Suhan Alva, M Divyashree, Janardhana Kamath, PS Prakash, Shama Prakash K
DOI:10.4103/ijn.IJN_93_19  
Introduction: Chronic kidney disease (CKD) is a major health problem in India. Prevalence of CKD will continue to rise, reflecting the growing elderly population and increasing number of patients with diabetes and hypertension. Methods: A total of 67 patients with CKD participated in the study. Patients were randomized into two groups. Group 1 received oral bicarbonate and Group 2 was the control group. Their baseline, 6 and 9 months estimated glomerular filtration rate (eGFR), bicarbonate, muscle mass and serum albumin were estimated. We analysed the effect of bicarbonate supplementation on the progression of CKD. Results: Bicarbonate supplementation decreased the metabolic acidosis in CKD patients. After bicarbonate supplementation, the serum bicarbonate level increased time-dependently from 16.62 to 18.02 and 19.77 mEq/L after 6 and 9 months, respectively. It also restored the eGFR to its baseline value. The eGFR values of Group 1 at baseline, after 6 months and 9 months were 22.39, 22.66, and 22.65 mL/min/1.73 m2, respectively. In contrast, the eGFR value in Group 2 reduced significantly. Patients who received bicarbonate supplementation displayed increased serum albumin levels compared with the controls. The albumin level was significantly increased from 4.05 to 4.24 and 4.34 g/dL, respectively, after 6 and 9 months (P = 0.0001). Also, bicarbonate supplementation showed significant improvement in muscle mass. Conclusion: Study confirms the role of bicarbonate in relieving the metabolic acidosis and thereby its possible role in the management of CKD progression.
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Effect of distal cephalic vein ligation on primary patency rates and proximal flow rates in distal radiocephalic fistula p. 98
Reuben F De Sousa
DOI:10.4103/ijn.IJN_104_19  
Introduction: The Brescia-Cimino radiocephalic fistula, originally devised as a side-to-side anastomosis, is simple to perform and provides a smooth vein–artery interface but requires greater mobilization for vein–artery approximation than does the end-to-side approach. Distal cephalic vein ligation is performed to prevent venous hypertension. The study aims to assess primary patency at one month following distal side-to-side radiocephalic fistula creation with and without distal cephalic vein ligation, to assess the effect of distal cephalic vein ligation on flow rates at one month, and to document the occurrence of venous hypertension over one year follow up. Method: A total of 100 patients requiring vascular access for hemodialysis were assigned to side-to-side anastomosis with and without distal cephalic vein ligation. Follow up Doppler exam was performed at one month for assessment of patency and flow rates and after one year clinical exam to document venous hypertension and the need for revision surgery. The quantitative and qualitative variables were evaluated using student t test and chi square test, respectively. Results: The patency rates of distal ligation and no ligation groups were 86.4% and 85.4%, respectively. The proximal flow rates of distal ligation and no ligation groups were 1192+/−812 ml/min and 1217+/−796 ml/min, respectively. The difference was not statistically significant (P > 0.05). Only two cases (5%) with no ligation required revision ligation within one year of surgery.Conclusion: Distal cephalic vein ligation does not increase the proximal cephalic flow rates and primary patency rates after one month. However, venous hypertension was associated in 5% of nonligated cases at one year follow up.
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A clinicopathological study of 267 patients with diabetic kidney disease based on the renal pathology society – 2010 classification system p. 104
Susmitha Chandragiri, Sree Bhushan Raju, Surendra Babu Mandarapu, Rajesh Goli, Sridhar Nimmagadda, Megha Uppin
DOI:10.4103/ijn.IJN_424_17  
Introduction: Renal biopsy is primarily indicated in patients with diabetes mellitus (DM) with proteinuria, to diagnose non-diabetic renal disease (NDRD). However, Renal Pathology Society classification (RPSc) – 2010 has classified diabetic nephropathy (DN) into four classes of glomerular lesions with a separate scoring for tubulointerstitial and vascular lesions. Paucity of data from Indian subcontinent prompted us to plan this study to classify DN on biopsy as per the RPSc and correlate the clinical profile with histology. Materials and Methods: Patients with DM who underwent renal biopsy for various indications (between Aug 2013 and Nov 2015) were included in the study. DN on histology was classified according to RPSc. Histopathology lesions of DN were correlated with clinical and biochemical profiles. Results: Of the 267 patients studied, 252 (94.3%) were type 2 DM. NDRD alone was seen in 65 (24.34%), DN in 161 (60.3%), and NDRD with DN in 41 (15.3%). The most common indications for biopsy were rapidly progressive renal failure (76.7%) and nephrotic syndrome (16.4%). The most common glomerular class was class IV (43.5%), followed class III (41%), class II (13.3%), and class I (1.9%). The most common NDRD seen was acute interstitial nephritis (AIN) in 20.2% and is frequently associated with class III. Tubulointerstitial chronicity and not the arteriolar chronicity, was correlated with low estimated glomerular filtration rate (eGFR). Conclusions: Most patients with DN subjected to renal biopsy were in class IV, and AIN was the most common NDRD. Only tubulointerstitial chronicity correlated with low eGFR.
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CASE REPORTS Top

A rare cause of coagulopathy in a patient with rapidly progressive renal failure p. 110
Rudreshwar Prabakaran, Jasmine Sethi, Manish Rathi, Harbir Singh Kohli, Pankaj Malhotra, Krishan Lal Gupta
DOI:10.4103/ijn.IJN_213_18  
Deranged coagulogram is a common problem, which a nephrologist faces before doing a renal biopsy. We describe a rare cause of coagulopathy in a patient with rapidly progressive renal failure due to acquired factor X deficiency caused by systemic light chain amyloidosis (AL). The patient had prolonged prothrombin and activated partial thromboplastin time, which got corrected on mixing with normal plasma, and factor X activity was markedly reduced at 5%. Rectal biopsy and immunofixation electrophoresis established the diagnosis of AL and the patient was started on bortezomib-based chemotherapy. Hence, appropriate coagulation work-up should be conducted in patients with renal dysfunction with prolonged coagulation times, as it can sometimes reveal the underlying diagnosis in situations where renal biopsy could not be done due to high risk of bleeding.
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Acquired pure red cell aplasia following recombinant erythropoietin (darbepoetin-alfa) therapy p. 113
Somanath Padhi, Gayatri Behera, Sandeep Abhijit Pattnaik, Prabodh Kumar Das, Amit Kumar Adhya, Susama Patra
DOI:10.4103/ijn.IJN_129_19  
Acquired pure red cell aplasia (PRCA) following use of recombinant erythropoietin (rEPO) is distinctly rare and sporadically reported in the literature. We discuss a case of PRCA following the usage of rEPO (darbepoetin-α) during the management of anemia of chronic kidney disease in an elderly male subject with review of literature and a brief insight into proposed pathophysiologic mechanism, diagnosis, and management.
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Rare occurrence of PLA2R-positive membranous nephropathy in a patient with Sjogren's syndrome and CIDP p. 117
Nimish Gupta, Dinesh Khullar, Pallavi Prasad, Rahul Grover, Gagandeep Chabbra, Kunal Raj Gandhi, Sahil Bagai
DOI:10.4103/ijn.IJN_152_19  
Membranous nephropathy is known to be associated with number of autoimmune diseases. Occurrence of PLA2R positive membranous nephropathy with sjogren's syndrome and chronic inflammatory demyelinating neuropathy (CIDP) is quite rare. Role of PLA2R antigen in autoimmune diseases like sjogren's syndrome and CIDP is largely unknown. Choice and initiation of immunosuppression if required may also be governed by the presence of other autoimmune diseases along with PLA2R positive membranous nephropathy
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Post-Renal Transplant Miliary Mottling: Not Always Tuberculosis p. 121
T Yashwanth Raj, R Vairakkani, TS Harshavardhan, ND Srinivasaprasad, V Dilli Rani, M Edwin Fernando
DOI:10.4103/ijn.IJN_141_19  
A 28-year-old male, 3 years post renal transplant with stable graft function, presented with vomiting for 2 days. He had graft dysfunction and graft biopsy done revealed acute cell - mediated rejection BANFF-IA. After receiving glucocorticoids for rejection, he developed severe enterocolitis and impending respiratory failure. Chest X-ray and computed tomography of the chest revealed miliary mottling. Evaluation showed presence of filariform larvae of Strongyloides stercoralis in the stool and sputum. A diagnosis of Strongyloides Hyperinfection Syndrome (SHS) was made. After a prolonged course of treatment with noninvasive ventilation, broad-spectrum antimicrobials, parenteral ivermectin and oral albendazole therapy, he eventually recovered. This case report is to highlight that Strongyloides Hyperinfection Syndrome should also be considered in the differential in any immunocompromised patient presenting with miliary mottling in imaging.
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Amyloid goiter in a patient with rheumatoid arthritis and end-stage renal disease p. 125
Ayşe Şeker, Taşkin Erkinüresin, Hakan Demirci
DOI:10.4103/ijn.IJN_271_18  
The association between amyloidosis and collagen vascular diseases, such as rheumatoid arthritis (RA) is well-documented. Amyloid goiter is an extremely rare pathologic condition caused by a massive amyloid infiltration of the thyroid tissue. Our patient had been diagnosed with RA 20 years ago and was on hemodialysis for 7 years. He was assessed for decreased appetite, dysphagia, and nausea during the hemodialysis. On physical examination, the thyroid was diffusely enlarged with multiple nodules. He was biochemically euthyroid. Ultrasound of the thyroid gland showed multinodular goiter. A total thyroidectomy was performed. Histopathological examination showed dilated follicles surrounded by abundant homogeneous substance that stained positive with Congo red. The patient was reported as amyloid goiter. Complaints of the patient improved after the surgery. In the literature, amyloid goiter with RA in a hemodialysis patient is very rare. Amyloid goiter should be considered if there is a rapid thyromegaly causing pressure symptoms in the background of any disease with chronic inflammation.
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Alport's syndrome: A rare clinical presentation with crescents p. 129
Ishani Haldar, Tarun Jeloka
DOI:10.4103/ijn.IJN_177_19  
Alport's syndrome (hereditary nephritis) is a familial disorder, which usually affects young males with clinical presentation of hematuric and glomerular disease. We report a rare case of Alport's syndrome in a 16-year-old male with typical extrarenal manifestations and renal biopsy findings with crescents.
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LETTERS TO EDITOR Top

Incidence and etiology of hemodialysis catheter related blood stream infections at a tertiary care hospital in Mumbai: A 5 year review p. 132
Sweta Shah, Tanu Singhal, Reshma Naik, Pooja Thakkar
DOI:10.4103/ijn.IJN_127_19  
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A rare case of hypertension in a young (fe)male p. 133
Anvesh Golla, Sreebhushan Raju, Krishna Prasad
DOI:10.4103/ijn.IJN_446_17  
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Hyperkalemia unveiled: A case of Barakat syndrome p. 135
Kulwant Singh, Jasmine Sethi, Vinant Bhargava
DOI:10.4103/ijn.IJN_132_19  
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AL amyloidosis in a patient with IgD myeloma p. 137
Hicham Rafik, Kawtar Hassani, Taoufiq Aatif, Driss El Kabbaj, Samira E Idrissi, Zohra Ouzzif
DOI:10.4103/ijn.IJN_78_19  
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Penile calciphylaxis: A rare case of penile lesion p. 138
Akil Adrian Sherif, Kamal Kant Sahu, Yan Li, Houman Javadi
DOI:10.4103/ijn.IJN_135_19  
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Indian Journal of Nephrology
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Online since 20th Sept '07