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  ~ Table of Contents - Current issue
Coverpage
January-February 2020
Volume 30 | Issue 1
Page Nos. 1-58

Online since Wednesday, January 8, 2020

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COMMENTARY  

Atheroembolic renal disease p. 1
Narinder P Singh, Anish K Gupta, Gurleen Kaur
DOI:10.4103/ijn.IJN_382_18  
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ORIGINAL ARTICLES Top

Effects of individualized dialysate sodium prescription in hemodialysis – Results from a prospective interventional trial p. 3
Radhika C Radhakrishnan, Santosh Varughese, Abitha Chandran, Shibu Jacob, Vinoi G David, Suceena Alexander, Anjali Mohapatra, Anna T Valson, Basu Gopal, C Palani, Arun Jose, B Antonisamy, V Tamilarasi
DOI:10.4103/ijn.IJN_391_18  
Introduction: Individualized dialysate sodium prescription does affect weight gain, blood pressure (BP), and intradialytic complications. A prospective interventional trial (Dialysate Individualised Sodium (DISO) trial) was conducted to study this issue in Indian patients. Methods: Forty patients on thrice-weekly maintenance hemodialysis (HD) for at least 6 weeks were enrolled. The study was performed in two different phases. In the first phase, 12 consecutive HD sessions were done with a standard dialysate sodium concentration of 140 mEq/L. In the second phase, 12 consecutive HD sessions were done with dialysate sodium concentration set to individualized value (mean of pre-HD sodium concentration multiplied by Donnan coefficient of 0.95). Differences in pre- and post-HD sodium, interdialytic weight gain (IDWG), pre- and post-HD BP, thirst scores, and intradialytic adverse events during both phases were assessed. Results: The mean age of patients was 45.65 years (24 males, 16 females). The mean serum pre-HD sodium level was 138.7 ± 1.7 meq/L in the standard phase and 138.2 ± 2.6meq/L in the individualized phase (P = 0.229). In the standard phase, the mean IDWG was 2.64 ± 1.56 kg and 2.13 ± 0.99 kg in the individualized phase (P = 0.008). The mean pre-HD systolic BP was 138 ± 18 mmHg and 134 ± 17 mmHg in the standard and individualized phases (P = 0.008). There was no difference in intradialytic symptoms, hypotensive episodes or requirement of interventions. Hypertension episodes occurred at a mean value of 2.2 and 1.2 in the standard and individualized phases, respectively (P = 0.010). Conclusion: The use of individualized dialysate sodium level is safe and results in lower IDWG, pre-HD systolic BP, and intradialytic hypertension in patients on HD.
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Immunoperoxidase and immunofluorescence on formalin-fixed, paraffin-embedded tissue sections versus immunofluorescence on frozen sections in the assessment of renal biopsies p. 8
Nasar Yousuf Alwahaibi, Rajaa Mohammed Alsidiri, Thuraiya Amer Alsinawi, Wafa Hamed Almalki, Shadia Said Alsinawi, Marwa Abdullah Alriyami
DOI:10.4103/ijn.IJN_356_18  
Introduction: There are few published studies comparing immunofluorescence on formalin-fixed, paraffin-embedded (FFPE) tissue sections (IF-P) and immunoperoxidase on FFPE tissue sections (IP-P) with immunofluorescence on frozen sections (IF-F) for evaluation of renal diseases. Also, the accuracy for each method differs greatly. The aim of this study was to evaluate IF-P and IP-P as an alternative to IF-F (gold standard method) in the diagnosis of renal biopsies specimens. Methods: In all, 101 renal biopsies were subjected to IF-P, IP-P, and IF-F staining to demonstrate immunoglobulin IgA, IgG, and IgM immune deposits. Sensitivity, specificity, false-positive, and false-negative values were calculated. Results: IP-P showed sensitivity of 61.8%, 74.2%, and 64.2%, and specificity of 84.8%, 69.2%, and 66.7% for IgA, IgG, and IgM, respectively. IF-P showed a sensitivity of 45.6%, 69.4% and 52.8%, and specificity of 87.9%, 87.2% and 77.1% for IgA, IgG and IgM, respectively. False-positive cases of IF-P and IP-P were 4, 5, and 11 and 5, 12, and 16 for IgA, IgG, and IgM, respectively. Conclusion: Where IF-F lacks glomeruli or fresh renal biopsies are not available, IP-P is a sensitive method, whereas IF-P is a specific method for the evaluation of immune deposits in the renal tissue biopsies. The presence of false-positive cases in both methods deserves further research.
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mtDNA analysis: A valuable tool to establish relationships in live related organ transplants p. 14
Vikash C Mishra, Kirti A Gautam, Richa Chaudhary, Hina Solanki, Saurabh Pokhariyal, Vishal Saxena, Pranav Dorwal, Trupti Deshpande, Parvind Singh, Archana Anthwal, Nikki Dey, Dinesh Chandra, Vimarsh Raina
DOI:10.4103/ijn.IJN_346_18  
Introduction: In India, 90% kidneys for transplantation are obtained from living donor while only 10% come from deceased donors. Since the rate of living organ donors is high, it therefore leads to the problem of organ trafficking.To minimize the chances of organ trafficking, the Transplantation of Human Organ Act (THOA) 2014 was enacted in India that makes it mandatory to prove the relationship between patient and donor by DNA testing. The present study was undertaken to evaluate the degree of matching between maternally related patients and donors, performed using mitochondrial DNA (mtDNA).Methods: After taking an informed consent, a total of 84 subjects were recruited in the study, 42 kidney transplant recipients and 42 their corresponding donors. An attempt was made to establish and confirm the claimed relationship betweenrecipient and donor using mtDNA analysis. Results: Out of the total 42 cases, mtDNA analysis supported the claimed relationship in 33 (78.57%) cases, whereas in 9 (21.42%) cases claimed relationship could not be supported. Conclusion: mtDNA can be used as valuable tool to support the claimed relationships of maternal lineage. It is important that more and more organ transplant physicians, surgeons and committees are made aware of this diagnostic modality.
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MicroRNA-21 as an early marker of nephropathy in patients with type 1 diabetes p. 21
Mohamed Fouad, Ibrahim Salem, Khaled Elhefnawy, Nermin Raafat, Amal Faisal
DOI:10.4103/ijn.IJN_80_19  
Introduction: Diabetic nephropathy (DN) is the most common cause of chronic kidney disease worldwide. A major challenge is to identify early diabetic nephropathy. microRNAs (miRNAs) are short noncoding RNA sequences and regulate a wide range of biological processes as cell differentiation, proliferation, cell metabolism and apoptosis. miRNAs may have a role in molecular mechanisms linked to cellular pathways of DN. The aim of this study was to investigate the level of microRNA-21 as a potential marker of early nephropathy in type 1 diabetes mellitus (T1DM). Methods: A total number of 340 participants were included and classified into 3 groups; Group I included 100 healthy participants, Group II included 120 patients with T1DM with <5 years duration, and Group III included 120 patients with T1DM with >5 years duration. All participants were submitted to detail clinical examination, laboratory investigations, urinary albumin/creatinine ratio (ACR), estimated glomerular filtration rate (eGFR) as well as plasma microRNA-21 assays. Results: Blood pressure and ACR were significantly higher in group III than groups I and II. Further, microRNA-21 was significantly higher in group III than groups I and II, and more in group II than group I. microRNA-21 starts to rise in group II before microalbuminuria. miRNA-21 at a level of 0.01 had a greater sensitivity 94.1% and specificity 100% for identifying DN than ACR at level 45 mg/gm with sensitivity 88.2% and specificity 89%. Conclusion: Plasma microRNA-21 can serve as an early marker for diagnosis and identifying diabetic nephropathy in T1DM.
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CASE SERIES Top

Granulomatous interstitial nephritis – A series of six cases p. 26
Subhrajyoti Karmakar, Keya Basu, Moumita Sengupta, Dipankar Sircar, Arpita Roychowdhury
DOI:10.4103/ijn.IJN_364_18  
Granulomatous interstitial nephritis is an uncommon variant accounting for about 6% of all tubulointerstitial nephritis. The etiology can be drugs such as antibiotics and nonsteroidal anti-inflammatory drugs and infections such as tuberculosis, sarcoidosis, and fungal infections. Renal biopsy remains the gold standard for establishing the diagnosis. Here, we present a series of six cases of granulomatous interstitial nephritis, of which two cases were associated with lupus nephritis and another two cases with crescentic glomerulonephritis. Focal segmental glomerulosclerosis and mesangiosclerosis with chronic tubulointerstitial nephritis were detected in the rest of the cases. Most of the patients presented with features of nephrotic syndrome. Urine analysis showed albuminuria in all cases. In renal biopsy, interstitial epithelioid cell granuloma was a constant feature along with which there were foci of necrosis and moderate fibrosis in few cases. But none of our cases had any relevant history of prolonged drug intake. Tuberculosis and fungal infections were also ruled out. Thereby in this case series, we subgroup all the cases into two category four cases associated with granulomatous nephritis and two cases with idiopathic granulomatous nephritis.
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CASE REPORTS Top

Pseudo-arterial Temporary Hemodialysis Catheter Placement in the Left Internal Jugular Vein Ipsilateral to a Preexisting Brachio-axillary Arteriovenous Graft p. 29
Macaulay Amechi Chukwukadibia Onuigbo, Nneoma Agbasi, Bibek Sarki, Sana Khan, Kramer Wahlberg
DOI:10.4103/ijn.IJN_389_18  
Internal jugular vein (IJV) cannulation was originally described by English et al. in 1969 as the safest approach. Carotid artery puncture had an incidence rate of 4–6% before ultrasound guidance. We encountered an unexpected sequence of events following the ultrasound-guided placement of a temporary HD catheter in the left IJV. The postprocedure chest radiograph was misinterpreted as an arterial misplacement, the blood return was correspondingly bright red, and simultaneous blood gas analyses from the left IJV catheter and a right radial artery were near mirror images. Subsequently, a transducer to the catheter showed a clearly venous waveform with a pressure of 40 mmHg. Thus, it was realized that the cacophony of missteps, misjudgments, and misinterpretations was due to the contiguous presence of a functional left brachio-axillary arteriovenous (AV) graft. To our knowledge, this is the first such report of this phenomenon of a pseudo-arterial central venous catheter placement in the IJV.
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Chylothorax in a child with nephrotic syndrome p. 32
Vinay Rathore, Deepanjan Bhattacharya, Jaya Pandey, Anmol Bhatia, Lesa Dawman, Karalanglin Tiewsoh
DOI:10.4103/ijn.IJN_24_19  
Chylothorax is an uncommon presentation of venous thrombosis in nephrotic syndrome. We present a case of an 8-year-old boy with nephrotic syndrome who presented with prolonged respiratory difficulty and dry cough. A detailed evaluation revealed left chylothorax secondary to thrombosis of the left brachiocephalic vein. He improved with conservative management including anticoagulation therapy, intercostal chest tube drainage, and dietary modification. This case highlights the need to consider venous thrombosis as a cause of chylothorax in patients with nephrotic syndrome to institute appropriate treatment.
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Successful treatment of anti-factor H antibody-associated atypical hemolytic uremic syndrome p. 35
Tomoo Kise, Shigeru Fukuyama, Masatsugu Uehara
DOI:10.4103/ijn.IJN_336_18  
Anti-complement factor H (CFH) autoantibody (Ab)-associated atypical hemolytic uremic syndrome (aHUS) has a poor prognosis in terms of frequent relapses. Although eculizumab is an effective treatment for this type of aHUS, the method of eculizumab discontinuation is not yet established. Herein, we report a case of anti-CFH Ab-associated aHUS in a 6-year-old boy. Eculizumab induction therapy following plasma exchange improved his condition. After 14 months, eculizumab was discontinued because of meningococcal bacteremia. After 6 months of eculizumab cessation, prednisolone (20 mg/alternate days) and mycophenolate mofetil (500 mg/day) were initiated. There were no relapses or increases in anti-CFH Ab titers for 26 months after treatment initiation. We believe that eculizumab induction therapy, following plasma exchange and maintenance therapy with immunosuppressants after eculizumab discontinuation are effective treatments for anti-CFH Ab-related aHUS.
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Acute interstitial nephritis in a patient with high aluminum blood levels: A case report p. 39
Urmila Anandh, Rakesh Kumar Ch., Vikas Aggarwal
DOI:10.4103/ijn.IJN_320_18  
A known case of hypertension and recent onset diabetes presented to our neurological clinic with symptoms of ataxia, rigidity, and tremors. His symptoms were of relatively recent onset. He gave no history of any renal disease in past. The magnetic resonance imaging of the brain done by the neurologist was suggestive of demyelinating pathology. His renal functions showed progressive deterioration (Cr 1.4 mg/dl about 3 months back to 2.2 mg/dl at present) along with the onset of his neurological illness. An extensive work up for autoimmune encephalitis and paraneoplastic syndrome was noncontributory. A toxicology screen revealed high levels of aluminum in the blood. A renal biopsy showed features of interstitial nephritis and predominant vacuolar injury of the proximal tubule (suggestive of toxic injury.) On further questioning, the patient gave history of using an over the counter native medication. The medication was stopped and weekly desferrioxime chelation advised. A short course of steroids (0.5 mg/kg/day tapering dose for 6 weeks) was also given. The creatinine stabilized to 1.3 mg/dl on follow-up after 3 months. The neurological symptoms also resolved completely.
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Acute kidney injury with neurological features: Beware of the star fruit and its caramboxin p. 42
Matheo A . M. Stumpf, Adriana F. M. Schuinski, Gilberto Baroni, Maikel Ramthun
DOI:10.4103/ijn.IJN_53_19  
Star fruit (Averrhoa carambola) is a well-known product in tropical countries. There are few reports published in literature with acute kidney injury due to oxalate induced nephropathy. However, none of them have an important neurological feature. We present a case of a 51-year-old male with paresis and altered mental status. Screening for neurological diseases such as stroke, Guillain-Barre, meningitis and encephalitis were negative. In the evolution, he developed acute kidney failure and was submitted to 4 dialysis sessions. After talking to the family, we discovered he had ingested over 50 star fruits prior to the acute neurologic deficits. He recovered renal function so a renal biopsy was not required. Physicians should actively look for star fruit ingestion history in patients presenting with unexplained acute kidney injury with or without neurological features. Besides, taking star fruit in a large amount, accompanied by an empty stomach and dehydrated state, is a risk factor for neurotoxicity.
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Membranous nephropathy with rapid progression p. 47
R Vairakkani, K Thirumal Valavan, M Edwin Fernando, T Yashwanth Raj
DOI:10.4103/ijn.IJN_85_19  
We report a 49-year-old man with microscopic hematuria, subnephrotic proteinuria, and rapidly progressive renal failure. His biopsy had features of PhosphoLipase A2 Receptor (PLA2R) positive membranous nephropathy with circumferential cellular crescents. Further work-up revealed IgG antiGlomerular Basement Membrane (anti-GBM) antibody titer of 188 U/mL (normal <7 U/mL). A final diagnosis of membranous nephropathy with anti-GBM disease was made. These two distinct pathological entities can occur together resulting in significant morbidity and mortality unless diagnosed early and treatment initiated promptly. Outcomes have been poor, given the nonspecific presentation and delay in diagnosis.
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LETTERS TO EDITOR Top

Successful retrieval of oocytes from renal transplant recipient followed by surrogacy p. 50
Kaberi Banerjee, Bhavana Singla
DOI:10.4103/ijn.IJN_37_19  
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Membranous nephropathy with collapse: Poor prognosis p. 51
Joyita Bharati, Archana Sundaram, Navin Pattanashetti, Ritambhra Nada, Vinod Nagesh, Krishan Lal Gupta, Raja Ramachandran
DOI:10.4103/ijn.IJN_36_19  
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Therapy with the combination of tolvaptan and furosemide for refractory edema in nephrotic syndrome p. 53
Jitendra Meena, Aditi Sinha, Pankaj Hari, Arvind Bagga
DOI:10.4103/ijn.IJN_358_18  
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Discordance between Flow-Cytometry Crossmatch and single antigen bead (SAB) assay: An uncommon finding and its resolution p. 55
Simmi Mehra, Aseem Kumar Tiwari, Geet Aggarwal, Dinesh Arora, Abhishek Saini, Chhavi Rajvanshi, Poonam Kumari, Pranav Dorwal
DOI:10.4103/ijn.IJN_61_19  
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Pre-transplant compatibility tests in kidney transplants: Case report on significance of epitope-based analysis in donor selection p. 57
Chhavi Rajvanshi, Aseem Kumar Tiwari, Jui Choudhuri, Simmi Mehra, Rajni Chauhan
DOI:10.4103/ijn.IJN_30_19  
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Indian Journal of Nephrology
Published by Wolters Kluwer - Medknow
Online since 20th Sept '07