Justification: In 2001, the Indian Pediatric Nephrology Group formulated guidelines for management of patients with steroid-sensitive nephrotic syndrome. In view of emerging scientific evidence, it was felt necessary to review the existing recommendations. Process: Following a preliminary meeting in March 2007, a draft statement was prepared and circulated among pediatric nephrologists in the country to arrive at a consensus on the evaluation and management of these patients. Objectives: To revise and formulate recommendations for management of steroid-sensitive nephrotic syndrome. Recommendations: The need for adequate corticosteroid therapy at the initial episode is emphasized. Guidelines regarding the initial evaluation, indications for renal biopsy and referral to a pediatric nephrologist are updated. It is proposed that patients with frequently relapsing nephrotic syndrome should, at the first instance, be treated with longterm, alternate-day prednisolone. The indications for use of alternative immunosuppressive agents, including levamisole, cyclophosphamide, mycophenolate mofetil, and cyclosporin are outlined. The principles of dietary therapy, management of edema, and prevention and management of complications related to nephrotic syndrome are described. These guidelines, formulated on the basis of current best practice, are aimed to familiarize physicians regarding principles of management of children with steroid-sensitive nephrotic syndrome.

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Peritoneal dialysis catheter (PDC) for continuous ambulatory peritoneal dialysis is inserted into the abdominal cavity either by a surgeon, interventional radiologist or nephrologist. Various innovations have been made in the methodology adopted in the placement of the PDC. We compared the percutaneous approach for PDC insertion with the open surgical technique. From January 2006 to May 2007, 25 of the 46 catheters were successfully inserted using the percutaneous Seldinger technique. The incision size (2.6 ± 0.7 vs 7.3 ± 0.6 cm) and the length of hospital stay (11.9 ± 5.9 vs 17.3 ± 6.8 d) were considerably less in the percutaneously placed group compared to the surgically placed group. Early initiation of exchanges and reduction in the expenses were other important advantages of this method.

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This article aims to bring to the fore, issues regarding the interface of psychiatry and renal failure. Depression, anxiety, suicide and delirium are common complications observed in patients with renal failure. Pharmacological management of these problems need stringent monitoring on part of the psychiatrist. This article examines the various complications that may be observed in patients with renal failure while discussing treatment approaches and also emphasizing the need for interdisciplinary team work in improving the quality of life of patients with renal failure and those on dialysis.

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Chronic kidney disease (CKD) is being increasingly recognized in children, especially prevalent in those who recover from serious illness. The ability to recognize the pathophysiological conditions that predispose to renal parenchymal damage or disorders and the application of preventive measures or institution of ameliorating therapy may lessen the burden of the parenchymal damage leading to CKD. These measures include antenatal immunization, antenatal diagnosis, fetal surgical interventions and postnatal screening procedures for proteinuria, hypertension, dyslipidemia and prevention of obesity - all of which could play a significant role in the prevention of CKD or its progression to end stage renal disease.

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Renal osteodystrophy is a common complication of chronic kidney disease (CKD). It is the part of a broad spectrum of disorders of mineral and bone metabolism that develop in this clinical setting and result in both skeletal and extraskeletal consequences. Insights into the mechanisms of bone remodeling, mineral metabolism and vascular calcification have shed light on the systemic nature of the disorder. Central to the assessment of disturbances in the bone and mineral metabolism is the ability to assess the bone disease accurately by noninvasive means. Recent emphasis is on the requirement to begin the therapy early in the course of CKD. Guidelines on a 'step care' approach to the detection and management of alterations in calcium, phosphorus and parathyroid hormone metabolism in various stages of CKD are now available. Although constant improvements in the technicalities of the parathyroid hormone assays have improved the diagnostic capability, controversies regarding this aspect still exist. Noncalcium, nonaluminum-based phosphate binders hold promise for the future developments in the management of calcium-phosphate metabolism. Further research and progress in this area continue to evaluate the appropriate interventions to address both the skeletal and extraskeletal consequences targeted toward improving patient outcomes.

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Till the early 1990s there was no standardized international classification of renal allograft biopsies resulting in considerable heterogeneity in reporting among the various centers. A group of dedicated renal pathologists, nephrologists, and transplant surgeons developed a schema in Banff, Canada in 1991. Subsequently there have been updates at regular intervals. The following review presents the evolution of the Banff classification and its utility for clinicians.

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Bardet-Biedl syndrome (BBS) is a rare autosomal recessive condition characterized by retinitis pigmentosa, postaxial polydactyly, central obesity, and renal involvement. Renal failure is the commonest cause of death. We report the first case of BBS with documented end-stage kidney disease from India. The diagnosis had been missed until the patient presented at our hospital. The relevant literature has also been reviewed.

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Background: Pulmonary hypertension is said to be present when the systolic and mean pressures in the pulmonary artery exceeds 30 and 20 mmHg, respectively. There is a paucity of data on the incidence and prevalence of pulmonary hypertension in chronic kidney disease (CKD) in Indian patients. Materials and Methods: A total of 100 CKD patients (male 69, female 31), who were on conservative management, hemodialysis, or continuous ambulatory peritoneal dialysis at a tertiary care center, were studied for the presence of pulmonary hypertension. None of the patients were smokers. The variables studied were hypertension, diabetes, and duration of dialysis, and the hemoglobin, blood urea nitrogen (BUN), creatinine, and serum bicarbonate levels. Results: Forty-one percent of the patients had pulmonary hypertension, 96% had anemia (Hb<10 gm/dl), and 85% had metabolic acidosis. The dialysis vintage was less than 10 months in 29% of the patients. Conclusion: The prevalence of pulmonary hypertension was highest in the hemodialysis group (33%). Multivariate regression analysis showed that age, duration of renal failure, vintage of dialysis, hemoglobin, BUN, serum creatinine, and bicarbonate levels were all positively correlated with pulmonary hypertension; in all cases, the correlation was statistically significant.

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Patients on dialysis cannot independently regulate salt and water removal. Although hypokalemia has been reported to occur in 10-36% of peritoneal dialysis patients, hyponatremia is uncommon. We describe a rare case in whom hyponatremia and hypokalemia developed while on continuous ambulatory peritoneal dialysis and discuss the management.

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Studies in the Western literature show a linear relationship between degree of microalbuminuria and body mass index (BMI), blood pressure, and duration of diabetes. This study was aimed to determine the correlation of microalbuminuria with age, sex, duration of diabetes, BMI, and creatinine clearance in type-2 diabetics in Indian population. One hundred patients (59 males and 41 females) with type-2 diabetes mellitus of duration six months or more and negative for albumin in urine by albustic method were included in the study. Detailed clinical history was taken followed by a thorough physical examination that included neurological examination in the selected patients. Micral test was used for estimation of microalbuminuria. Overall prevalence of microalbuminuria in the present study was 37%. Among the patients with microalbuminuria, 20 were males and 17 were females. Pearson correlation of microalbuminuria with age showed statistically significant linear relationship. Gender-wise correlation analysis of microalbuminuria failed to show any statistical significance. Correlation of microalbuminuria with BMI was also not significant ( r = 0.063, P > 0.05). Creatinine clearance negatively correlated with microalbuminuria, but this was statistically insignificant. There was a statistically significant correlation of microalbuminuria with duration of diabetes. Prevalence of microalbuminuria is around 37% in type-2 diabetes mellitus. Incidence of microalbuminuria increases with age as well as with increased duration of diabetes mellitus. There is no effect of BMI and sex on the prevalence of microalbuminuria.

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A cross-sectional study was conducted to evaluate the quality of life (QOL) of hemodialysis patients. An attempt was made to compare the QOL of hemodialysis patients with the QOL of the general population, renal transplant patients, and patients with a chronic disease, in this case, asthma. The WHOQOL-BREF questionnaire was used to assess the quality of life. Hemodialysis patients who had completed three months of maintenance hemodialysis ( n = 75) were enrolled into the study. The quality of life of hemodialysis patients was found to be significantly impaired ( P < 0.05) in comparison to healthy individuals of the general population, particularly with respect to the physical, psychological, and social relationship domains. In comparison to the quality of life of renal transplant patients, the quality of life of hemodialysis patients was significantly ( P < 0.05) lower in all the four WHOQOL-BREF domains. Only in the environmental dimension was the quality of life of hemodialysis patients found to be significantly lower than that of the asthma patients. Female hemodialysis patients showed significantly ( P < 0.05) lower quality of life than did male patients in the psychological and environmental dimensions of WHOQOL-BREF. A positive association was seen between higher education and the psychological functioning and the environmental dimensions of WHOQOL-BREF. Thus, the quality of life of hemodialysis patients was found to be considerably impaired when compared to that of healthy individuals of the general population as well as of renal transplant patients.

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Urinary tract infection (UTI) is the most common infection experienced by humans after respiratory and gastro-intestinal infections, and also the most common cause of both community-acquired and nosocomial infections for patients admitted to hospitals. For better management and prognosis, it is mandatory to know the possible site of infection, whether the infection is uncomplicated or complicated, re-infection or relapse, or treatment failure and its pathogenesis and risk factors. Asymptomatic bacteriuria is common in certain age groups and has different connotations. It needs to be treated and completely cured in pregnant women and preschool children. Reflux nephropathy in children could result in chronic kidney disease; otherwise, urinary tract infections do not play a major role in the pathogenesis of end-stage renal disease. Symptomatic urinary tract infections occur most commonly in women of child-bearing age. Cystitis predominates, but needs to be distinguished from acute urethral syndrome that affects both sexes and has a different management plan than UTIs. The prostatitis symptoms are much more common than bacterial prostatic infections. The treatment needs to be prolonged in bacterial prostatitis and as cure rates are not very high and relapses are common, the classification of prostatitis needs to be understood. The consensus conference convened by National Institute of Health added two more groups of patients, namely, chronic prostatitis/chronic pelvic pain syndrome and asymptomatic inflammatory prostatitis, in addition to acute and chronic bacterial prostatitis. Although white blood cells in urine signify inflammation, they do not always signify UTI. Quantitative cultures of urine provide definitive evidence of UTI. Imaging studies should be done 3-6 weeks after cure of acute infection to identify abnormalities predisposing to infection or renal damage or which may affect management. Treatment of cystitis in women should be a three-day course and if symptoms are prolonged, then a seven day course of antibiotics should be given. Selected group of patients benefits from low-dose prophylactic therapy. Upper urinary tract infection may need in-patient treatment. Treatment of acute prostatitis is 30-day therapy of appropriate antibiotics and for chronic bacterial prostatitis a low dose therapy for 6-12 months may be required. It should be noted that no attempt should be made to eradicate infection unless foreign bodies such as stones and catheters are removed and correctable urological abnormalities are taken care of. Treatment under such circumstances can result only in the emergence of resistant organisms and complicate therapy further.

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We present an 11-year-old girl with Senior-Loken syndrome, a rare familial syndrome of retinopathy and nephronophthisis. The patient presented to us with renal insufficiency. There was a strong family history of renal and ocular involvement. This is the first report of this syndrome from the Arabian peninsula.

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Various studies have demonstrated that treatment with methyl prednisolone and chlorambucil could increase the chance of remission of idiopathic nephrotic syndrome (INS) of varied histology in patients who do not respond to the conventional treatment. This study was done to assess the safety and efficacy of methyl prednisolone and chlorambucil regimen in patients with various types of glomerulonephritides which were resistant to the usual conventional immunosuppressive drugs. Thirty nine patients were treated between June 1998 and December 2003 with Ponticelli regimen for six months. Twenty three patients (58.98%) were men and 16 (41.02%) were women. Mean age at the onset of NS was 23.59 ± 1.28 (range 10-51) years. Four patients (10.2%) had minimal change disease (MCD), six patients (15.4%) had membranoproliferative glomerulonephritis (MPGN), two (5.1%) had IgA nephropathy, and 18 patients (46.1%) had focal segmental glomerulosclerosis (FSGS). Eleven patients were excluded from the final analysis. Of the remaining 28 patients, mean baseline proteinuria was 3.31 ± 3.09 g/day. Mean baseline plasma albumin was 2.84 ± 1.002 g/dl and mean baseline serum creatinine was 0.87 ± 0.42 mg/dl. At the end of six months of treatment, mean proteinuria was 1.02 ± 0.85 g/day. Mean plasma albumin was 3.69 ± 0.78 g/day, and mean serum creatinine was 0.85 ± 0.26 mg/dl. Mean followup was 13.21 ± 7.7 times in 18.92 ± 12.58 months. At the end of six months of treatment, seven patients (25%) achieved complete remission (CR), 10 patients (35.71%) partial remission (PR), and 11 patients (39.3%) did not show any response to the therapy. Most of the patients in responder group had FSGS (64.70%), whereas in nonresponder group patients had MPGN and mesangioproliferative glomerulonephritis (MesPGN). Out of 13 FSGS cases five (38.46%) achieved CR, six (46.15%) PR, and only two (15.38%) failed to respond. The incidence of side effects was 39.3%. Responders had more side effects than nonresponders (47 vs 27.3%). Methyl prednisolone and chlorambucil therapy (Ponticelli regimen) is safe and efficacious in achieving remission in significant number of INS patients other than membranous nephropathy, without any serious side effect on short term followup. However, a longer followup is required to demonstrate the sustained efficacy and long-term side effect of this regimen.

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Objective: Chronic ambulatory peritoneal dialysis (CAPD) has been an established form of therapy in adult patients with end-stage renal failure in India for more than a decade and has emerged as accepted form of renal replacement therapy in urban areas. The objective of this paper is to report the experience with CAPD as a modality of renal replacement therapy from a tertiary care hospital in a hilly state of India with predominant rural population. Design: Retrospective study. Setting: A government-owned tertiary care hospital in Himachal Pradesh, a state with a population of 6 million. Materials and Methods: This study involved the patients who were initiated on CAPD between October 2002 and December 2006 and who survived and/or had more than 6 months follow up on this treatment with last follow up till June 30, 2007. Results: A total of 25 patients were included in the analysis. The mean age of the patients was 61 ± 10.2 years. 13 (52%) patients were female. 18 (72%) patients out of these lived in rural areas. The total follow up was 553.1 patient-months with a mean follow up of 22.1 ± 12.4 months. The total duration on peritoneal dialysis treatment was 541.1 patient-months with a mean duration of 21.6 ± 12.2 months and median duration of 19 patient-months (range: 6-56.3 patient-months). No patient had exit-site infection. There were 26 episodes of peritonitis. The rate of peritonitis was 1 episode per 21 patient-months or 0.6 per patient-year during the treatment period. The main cause of death was cardiovascular complications. Patient and technique survival at 1, 2 and 3 years was 80, 36 and 12%, respectively. Conclusion: Chronic ambulatory peritoneal dialysis (CAPD) is a safe and viable mode of renal replacement in remote and rural places. It can emerge as a revolutionized procedure for ESRD patients dwelling in remote and geographically difficult regions in developing countries such as India.

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Pregnancy-related acute renal failure (ARF) is a common occurrence and is associated with substantial maternal and fetal mortality. It also bears a high risk of bilateral renal cortical necrosis. We conducted this study to evaluate the contributing factors and to assess the frequency of cortical necrosis. In this prospective study, of the 772 patients with ARF admitted at our institute between January 2004 and May 2006, 70 had ARF associated with pregnancy complications. ARF was diagnosed by documenting oliguria (urine output <400 ml/d) or mounting azotemia in the presence of normal urine output. (serum creatinine >2 mg%). Renal biopsy was performed if a patient was found to be oliguric or required dialysis support at the end of three weeks. The incidence of pregnancy-related ARF was 9.06%. Approximately 20% cases occurred due to postabortal complications in early pregnancy and 80% following complications in late pregnancy. Puerperal sepsis was the most common etiological factor in 61.42% of the patients. Preeclampsia accounted for 28.57% of ARF. Two-thirds of patients recovered with dialysis and supportive care. The incidence of biopsy proven renal cortical necrosis was 14.8% (10 of the 70 patients). The incidence of renal cortical necrosis was 28.57% in the early pregnancy group and 10.71% in the late pregnancy group. Postabortal sepsis was the most common precipitating event for renal cortical necrosis. Maternal mortality was 18.57%. Sepsis accounted for a majority of deaths (61.53%). Pregnancy-related ARF is common in western India. Puerperal sepsis is the most frequent etiological factor. Renal cortical necrosis is common and postabortal sepsis was the most common precipitating event. Sepsis accounted for a majority of maternal mortality.

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About one in five people with multiple myeloma produce only light chains. Patients with lambda light chain disease have a three times worse prognosis than kappa light chain disease. We report a case of lambda light chain deposition disease in a 35-year-old female who presented with acute renal failure requiring hemodialysis. She had complete recovery and is now in complete remission following treatment with bortezomib and steroids.

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Obesity is fast becoming a bane for the present civilization, as a result of sedentary lifestyle, atherogenic diet, and a susceptible thrifty genotype. The concept of metabolic syndrome, which is a constellation of metabolic disturbances, has crystallized over the last 80 years with the aim of identifying those at greater risk of developing type 2 diabetes and cardiovascular disease. These patients have visceral obesity and insulin resistance characterized by hypertyriglyceridemia. Recently, it has been realized that they are also at an increased risk of chronic renal disease. Release of adipocytokines leads to endothelial dysfunction. There is also activation of systemic and local renin-angiotensin-aldosterone system, oxidative stress, and impaired fibrinolysis. This leads to glomerular hyperfiltration, proteinuria, focal segmental glomerulosclerosis (FSGS), and ultimately end-stage renal disease (ESRD). Treatment consists of lifestyle modifications along with optimal control of blood pressure, blood sugar and lipids. Metformin and thiazolidenidiones reduce insulin resistance; while angiotensin converting enzyme inhibitors and angiotensin receptor blockers reduce proteinuria and have a renoprotective effect. Exciting new medical therapies on the horizon include rimonabant a cannabinoid receptor type 1 antagonist, soy proteins, and peroxisome proliferator-activated receptor (PPAR) agonist. Bariatric surgery for morbid obesity has also been shown to be effective in treating metabolic syndrome.

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Hepatitis A runs a benign course in children, but may have atypical presentations in adults. Very rarely acute renal failure complicates nonfulminant hepatitis A. We report a patient with nonfulminant acute viral hepatitis A with multiorgan involvement. Patient had biopsy proven acute interstitial nephritis, acute pancreatitis, acute myocarditis and required hemodialysis for 6 weeks.

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The ability of Wormwood ( Artemisia absinthium L.) extract (A.Ab) to restore membrane-bound enzymes like Na⁺-K⁺-ATPase, Ca⁺⁺-ATPase, Mg⁺⁺-ATPase, and oxidative damage induced by lead were investigated. Rats were exposed to lead acetate (750 ppm) for 11-weeks and treated during 4-weeks with A.Ab. Lipid levels, ATPase activity, thiobarbituric acid reactive substances (TBARS), and proteins carbonyl were estimated. In liver and kidney, lead acetate inhibited membrane-bound enzymes and increased ( P < 0.05) the levels of cholesterol, triglycerides, free fatty acids, phospholipids, TBARS, and carbonyl proteins. After 4 weeks, the intoxicated group who received A.Ab showed a significant reduction in TBARS and carbonyl levels in liver and kidney compared to group exposed to lead. A.Ab restored the levels of membrane-bound enzymes and lipid levels to near normal. These results indicate that aqueous Wormwood extract had a significant antioxidant activity and protect liver and kidney from the lead-induced toxicity.

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Iron is an essential transitional metal required by the body for various biological functions. Iron is securely stored in ferritin and other biomolecules, either in ferrous or ferric state, and there are safe mechanisms for its storage or release from proteins to catalyze biological reactions. Under stress or some pathological conditions, there occurs the release of free iron or non-transferrin bound iron, which is free from its protein bound form, and it undergoes Fenton and Heiber-Weiss reactions to generate powerful reactive oxygen species. The reactive oxygen species generated will damage the biological macromolecules. It has been proved that in uremia or chronic renal failure patients, on conservative management or on hemodialysis program or under many other disease conditions, free iron or non-transferrin bound iron does exist; it induces damage to the biomolecules, thereby enhancing the disease process. In this review I have discussed the role of free iron or non-transferrin iron in general in biology and medicine, particulary in chronic renal failure.

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