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   2017| September-October  | Volume 27 | Issue 5  
    Online since August 31, 2017

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Role of gut-derived uremic toxins on oxidative stress and inflammation in patients with chronic kidney disease
S Gouroju, P. V. L. N. Srinivasa Rao, AR Bitla, KS Vinapamula, SM Manohar, S Vishnubhotla
September-October 2017, 27(5):359-364
DOI:10.4103/ijn.IJN_71_17  PMID:28904431
Several cardiovascular disease (CVD) risk factors have been identified among patients with chronic kidney disease (CKD). Gut-derived uremic toxins (GDUT) are important modifiable contributors in this respect. There are very few Indian studies on GDUT changes in CKD. One hundred and twenty patients older than 18 years diagnosed with CKD were enrolled along with forty healthy subjects. The patients were classified into three groups of forty patients based on stage of CKD. Indoxyl sulfate (IS), para cresyl sulfate (p-CS), indole acetic acid (IAA), and phenol were estimated along with the assessment of oxidative stress (OS), inflammatory state, and bone mineral disturbance. All the GDUT increased across the three groups of CKD. All patients had higher levels of malondialdehyde (MDA), ferric reducing ability of plasma (FRAP), high-sensitivity C-reactive protein (hsCRP), and interleukin-6 (IL-6) as compared to controls. IS and IAA showed positive association with MDA/FRAP corrected for uric acid, whereas IS and p-CS showed positive association with IL-6. IS, IAA, and phenol showed a positive association with calcium × phosphorus product. GDUT increase OS and inflammatory state in CKD and may contribute to CVD risk.
  2,272 120 -
MicroRNAs involvement in renal pathophysiology: A bird's eye view
P Jaswani, S Prakash, A Dhar, RK Sharma, N Prasad, S Agrawal
September-October 2017, 27(5):337-341
DOI:10.4103/ijn.IJN_264_16  PMID:28904427
MicroRNAs (miRNAs) are known to suppress gene expression by binding to messenger RNAs and in turn regulate different pathophysiological processes. Transforming growth factor-β, mitogen-activated protein kinase signaling, and Wnt signaling-like major pathways associated with miRNAs are involved with kidney diseases. The discovery of miRNAs has provided new insights into kidney pathologies and may provide effective therapeutic strategies. Research has demonstrated the role of miRNAs in a variety of kidney diseases including diabetic nephropathy, lupus nephritis, hypertension, nephritic syndrome, acute kidney injury, renal cell carcinoma, and renal fibrosis. miRNAs are implicated as playing a role in these diseases due to their role in apoptosis, cell proliferation, differentiation, and development. As miRNAs have been detected in a stable condition in different biological fluids, they have the potential to be tools to study the pathogenesis of human diseases with a great potential to be used in disease diagnosis and prognosis. The purpose of this review is to examine the role of miRNA in kidney disease.
  1,194 279 -
Recurrent crescentic immunoglobulin a nephropathy in the graft kidney
V Bhargava
September-October 2017, 27(5):335-336
DOI:10.4103/0971-4065.175982  PMID:28904426
  1,083 134 -
Correlation of pretransplant donor-specific antibody assay using luminex crossmatch with graft outcome in renal transplant patients
M Vimal, MP Chacko, G Basu, D Daniel
September-October 2017, 27(5):347-352
DOI:10.4103/ijn.IJN_132_16  PMID:28904429
The significance of pretransplant anti-human leukocyte antigen antibody levels that are detectable by more sensitive platforms (including the Luminex platform) yet undetected by complement-dependent cytotoxicity (CDC) assay remains unclear. The aim of this study was to determine the clinical significance of the donor-specific antibody (DSA) assay Luminex crossmatch and its impact on short-term renal graft outcome such as acute rejections, graft survival, and graft function. The results of pretransplant DSA-lymphocyte crossmatching (LCXM) assay in 126 renal allograft recipients whose CDCs crossmatches were negative were retrospectively analyzed for correlation with posttransplant outcomes. Of the 126 recipients, 32 (25.4%) had pretransplant DSA positive. Statistically significant association was found between DSA-LCXM positivity with 14th day estimated glomerular filtration rate (eGFR) (P = 0.05), DSA Class I with 3rd (P = 0.014) and 6th month (P = 0.02) eGFR, DSA Class II with 14th day (P = 0.06) and 1st month (P = 0.10) eGFR, mean fluorescent intensity (MFI) DSA with 7th day (P = 0.08) and 14th day (P = 0.09) eGFR, and maximum MFI DSA with 7th day eGFR (P = 0.09). The posttransplant eGFR was higher at various time intervals in DSA-LCXM-negative patients as compared to DSA-positive patients. However, pretransplant DSA-LCXM results did not predict the rejection episodes, graft loss, and 1-year posttransplant 24 h urine protein. Pretransplant DSA detected by LCXM in patients with a negative CDC does not predict adverse short-term outcomes. However, the difference in posttransplant eGFR supports further investigation in long-term effects.
  886 130 -
Collapsing glomerulopathy- A troublemaker for the renal allograft: Lessons learnt
KV Kanodia, AV Vanikar, LK Nigam, RD Patel, KS Suthar, HV Patel, HL Trivedi
September-October 2017, 27(5):342-346
DOI:10.4103/ijn.IJN_287_16  PMID:28904428
Collapsing glomerulopathy (CG) is a well-recognized distinct morphological pattern of proliferative parenchymal injury leading to rapid graft failure. We conducted a single-center retrospective study to evaluate the prevalence, clinicopathological features, and prognosis of CG in renal transplant recepient. We analyzed 2518 renal allograft biopsies performed from 2007 to 2015 and correlated their clinicopathological features. The prevalence of CG was 0.83% (21 out of 2518) of allograft biopsies with a higher prevalence of 1.4% during the period from 2012 to 2015. Out of 21 patients, 18 (85.71%) patients had undergone live donor and 3 (14.28%) patients had undergone deceased donor renal transplant. Hypertension was observed in 3 (14.28%) patients. The mean duration of diagnosis for CG was 1.85 ± 1.91 years. Urinalysis revealed microhematuria in 5 (23.8%) patients. The mean 24 h urinary protein excretion was 4.77 ± 5.3 g and serum creatinine was 2.12 ± 1.5 mg/dl. The predominant native kidney diseases in recipients were chronic glomerulonephritis of unknown etiology in 12 (57.14%) patients and hypertensive nephropathy in 3 (14.28%) patients. CG was associated with rejection in 9 (42.85%), calcineurin-inhibitor toxicity in 2 (9.5%), and BK virus nephropathy in 1 patient. All patients received standard triple immunosuppression. Eleven (52.38%) patients developed graft failure over a mean period of 2.2 ± 1.7 years and 6 (28.57%) patients recovered with stable graft function. CG can coexist with viral infection, drug toxicity, rejection, microvascular injury, etc. CG usually presents with moderate to severe proteinuria and may lead to rapid graft dysfunction and subsequent graft failure in most of the patients.
  843 145 -
Risk factors for urinary tract infections in renal allograft recipients: Experience of a tertiary care center in Hyderabad, South India
M. V. N. L. R. Mohan, M Neeraja, S Sudhaharan, SB Raju, T Gangadhar, V Lakshmi
September-October 2017, 27(5):372-376
DOI:10.4103/ijn.IJN_331_16  PMID:28904433
Renal transplantation is an effective and commonly performed procedure for end-stage renal disease. Urinary tract infections are a major cause of morbidity and mortality in renal transplant patients. As data on postrenal transplant urinary tract infections from the Indian subcontinent are limited, the present study was conducted to estimate the burden of urinary tract infections in this vulnerable group of patients. This was a prospective study on patients undergoing renal transplantation in 2014 at our tertiary hospital in South India with a follow-up of 2 years to evaluate the risk factors for urinary tract infections. The prevalence of urinary tract infections was 41.9% with a male preponderance of 76.9%. Mean age of the 31 patients was 32.4 ± 10.2 years (range: 16–55 years). Gram-negative bacilli were the most common isolates with Escherichia coli being the predominant pathogen (53.3%). All the infections occurred within 1 year of transplantation with delayed graft function (P < 0.001; confidence interval [CI]: 29.0–96.3) and prolonged hospital stay (P = 0.0281; CI: 42.1–99.6) being the significant risk factors for acquiring urinary tract infections. Carbapenemase production was noted in 33.3% of isolates and all the Gram-negative organisms isolated in the 1st month of transplantation were carbapenem-resistant (CR) E. coli. The high rate of carbapenem-resistant organisms in the early posttransplant period is a point of concern, especially with cadaver transplants. Infection control practices and catheter care need to be strictly monitored to minimize the risk for UTI in the immediate posttransplant period.
  762 125 -
Effect of double filtration plasmapheresis on various plasma components and patient safety: A prospective observational cohort study
K Jagdish, S Jacob, S Varughese, VG David, A Mohapatra, A Valson, K Tulsidas, T Veerasami, S Alexander
September-October 2017, 27(5):377-383
DOI:10.4103/ijn.IJN_64_17  PMID:28904434
Double filtration plasmapheresis (DFPP) was historically used for blood group incompatible renal transplantation. Very few studies are available worldwide regarding its efficiency in removing specific plasma components, and safety. We conducted a prospective observational cohort study over 1 year on patients undergoing DFPP for various renal indications. There were 15 patients with 39 sessions. The pre- and post-procedure plasma samples of serum IgG, IgA, IgM, fibrinogen, calcium, phosphate, potassium, and magnesium were analyzed. The effluent albumin concentration was also measured, and complications during the hospital stay were recorded. Cumulative removal of serum IgG, IgA, IgM, fibrinogen, and albumin at the end of four sessions were 72%, 89%, 96%, 88.5%, and 21.3%, respectively and effluent albumin concentration was 1.75 – 2.0 times (range: 6.3 g/dl – 7.2 g/dl; mean ± standard deviation (SD) – 7 g/dl ± 0.3 g/dl) the preprocedural serum albumin (mean ± SD – 3.5 g/dl ± 0.5 g/dl). Removal of other plasma components were not statistically significant. Hypotensive episodes were observed only 16.6%, with the usage of effluent concentration albumin as replacement fluid despite an average 2.4 (mean ± SD – 2.4 ± 0.4 l) liters of plasma volume processing each session. DFPP removes IgG, IgA, IgM, fibrinogen, and albumin. The cumulative removal IgG (72%) is suboptimal, whereas IgA (89%) and IgM (96%) are comparable to historical controls. We observed lesser episodes (12.5%) of hypotension with effluent albumin concentration as replacement fluid, and all bleeding complications were observed when serum fibrinogen level was <50 mg/dl.
  798 86 -
Immunohistochemical analysis of anti-phospholipase A2 receptor antibody on renal biopsies: A single tertiary care center study
A Gudipati, MS Uppin, RK Kalidindi, G Swarnalatha, U Das, G Taduri, SB Raju, L Rajasekhar, Aruna K Prayaga
September-October 2017, 27(5):353-358
DOI:10.4103/ijn.IJN_79_17  PMID:28904430
Membranous nephropathy (MN) is one of the common cause of nephrotic syndrome. The discrimination between primary MN (iMN) and secondary MN is essential because of treatment implications. Immunohistochemical (IHC) evaluation with the help of anti-phospholipase A2 receptor (PLA2R) antibody helps in tissue evaluation of iMN, which is an easy, cost-effective, and pathologist-friendly technique. The study included 82 cases of MN over a period of 3 years. IHC using PLA2R antibody was performed on iMN and secondary cases with adequate tissue. Cases of minimal change disease (MCD) were included as control. Granular staining along the basement membrane in the absence of staining of podocytes was considered positive. Medical records were verified for clinical information, baseline biochemical parameters, details of viral markers, connective tissue disease profile, and basic imaging workup. Of the 82 cases of MN, 51 were iMN and 31 secondary MN (sMN). Thirteen MCD cases were included as control. IHC with PLA2R antibody showed a sensitivity of 91.8% and specificity of 95.1%, positive predictive value of 95.7%, and negative predictive value of 90.7% in the diagnosis of iMN. The other parameters, either clinical or laboratory, did not show significant differences between iMN and sMN groups. The results of PLA2R staining by IHC were comparable with other studies and showed a higher sensitivity (91.8%) and specificity (95.1%). IHC with anti-PLA2R antibody can be considered as the standard diagnostic approach to identify iMN and offer scope for individualized treatment.
  748 108 -
Everolimus-associated acute kidney injury in patients with metastatic breast cancer
A Chandra, NS Rao, KP Malhotra, M Rastogi, R Khurana
September-October 2017, 27(5):406-409
DOI:10.4103/ijn.IJN_304_16  PMID:28904441
Recently, everolimus (Evl) has been introduced in the management of hormone receptor-positive metastatic breast cancer, in combination with aromatase inhibitors. Evl-induced acute kidney injury has hitherto been described in other malignancies, especially renal cell cancer, but only once before in a patient with breast cancer. We describe two cases of Evl-associated nephrotoxicity in patients with breast cancer, one of whom underwent a renal biopsy showing acute tubular necrosis. Both our patients improved after withdrawal of the offending agent and have normal renal functions on follow-up.
  777 74 -
Renal cysts and nephrocalcinosis in 11 beta-hydroxylase deficiency
MC Abdulla, R Narayan, S Ahamed
September-October 2017, 27(5):410-411
DOI:10.4103/ijn.IJN_327_16  PMID:28904442
  743 63 -
Cryptococcal infection in transplant kidney manifesting as chronic allograft dysfunction
C Agrawal, V Sood, A Kumar, V Raghavan
September-October 2017, 27(5):392-394
DOI:10.4103/ijn.IJN_298_16  PMID:28904437
Invasive fungal infections (IFIs) are a significant cause of morbidity in solid organ transplant (SOT) recipients. Common causes among them are Aspergillus, Candida, and Cryptococcus. Antifungal prophylaxis has led to decrease in overall incidence of IFI; however, there is very little decline in the incidence of Cryptococcal infections of SOT recipients because effective prophylaxis is not available against this infectious agent. Spectrum of manifestation of Cryptococcal infection varies in immunocompetent and immunocompromised host with subclinical and self-limiting with lungs being the primary site in immunocompetent and central nervous system as the most common site in an immunocompromised host. Other preferred sites are cutaneous, pulmonary, urinary tract (prostate) and the bone. Herein, we describe a young adult renal transplant recipient male diagnosed as a rare case of biopsy proven Cryptococcal infection in transplant kidney manifesting as chronic allograft dysfunction.
  710 87 -
Employment status of patients receiving maintenance dialysis – peritoneal and hemodialysis: A cross-sectional study
BS Lakshmi, A. C. V. Kumar, HK Reddy, J Gopal, V Chaitanya, VS Chandra, P Sandeep, RD Nagaraju, R Ram, VS Kumar
September-October 2017, 27(5):384-388
DOI:10.4103/ijn.IJN_151_16  PMID:28904435
The long-term dialysis therapy for end-stage renal disease takes a heavy toll of quality of life of the patient. Several factors such as fatigue and decreased physical capability, impaired social and mental functioning, contribute to this forlorn state. To meld maintenance dialysis treatment with a regular employment can be a serious test. A cross-sectional study of employment of patients on hemodialysis and peritoneal dialysis in a state government tertiary institute in South India was performed between June 2015 and December 2015. Patients who completed 3 months of regular dialysis were only included in the study. The number of patients on hemodialysis was 157 and on peritoneal dialysis was 69. The employment status before the initiation of dialysis was 60% (93 out of 155) and 63.7% (44 out of 69) in hemodialysis and peritoneal dialysis, respectively. After initiation, the loss of employment was observed in 44% (41 out of 93) in hemodialysis and 51.2% (26 out of 44) in peritoneal dialysis (P = 0.2604). Even though there was fall of absolute number of job holders in both the blue and white collar jobs, the proportion of jobholders in the white collar job holders improved. On univariate analysis, the factors which influenced the loss of employment were males, age between 50 and 60 years, number of comorbidities >2, illiteracy and blue collar versus white collar job before the initiation of dialysis. The majority of patients had the scores above 80 on Karnofsky performance scale and the majority belonged upper and middle classes than lower classes on modified Kuppuswamy's socioeconomic status scale; however, the loss of employment was also disproportionately high. There appeared a substantial difference in the attitude of the patients toward the employment. There was no difference between hemodialysis and peritoneal dialysis in the loss of employment of our patients.
  704 84 -
Primary hyperoxaluria Type 1 with homozygosity for a double-mutated AGXT allele in a 2-year-old child
S Krishnamurthy, GB Kartha, VS Venkateswaran, M Prasannakumar, S Mahadevan, M Gowda, A Pelle, D Giachino
September-October 2017, 27(5):402-405
DOI:10.4103/ijn.IJN_261_16  PMID:28904440
Primary hyperoxaluria (PH) Type 1 is a rare, genetic disorder caused by deficiency of the liver enzyme alanine-glyoxylate aminotransferase, which is encoded by AGXT gene. We report a 2-year-old South Indian Tamil child with nephrocalcinosis due to PH Type 1, in whom a homozygous genotype for two missense mutations in the AGXT gene was found: first, a C to G transversion (c. 32C>G) in exon 1 resulting in the amino acid substitution p.Pro11Arg; second, a T to A transversion (c. 167T>A) in exon 2 resulting in p.Ile56Asn. A therapy based on potassium citrate and pyridoxine was started. This is the first report of molecular testing-proven childhood onset-PH Type 1 from South India and is notable for the co-occurrence of two missense mutations in one AGXT allele, which might lead to different and more severe phenotype than each mutation alone. To the best of our knowledge, AGXT allele carrying two already known mutations has not been previously reported.
  711 75 -
Impact of steroids on the inflammatory response after ischemic acute kidney injury in rats
J Fontana, A Vogt, A Hohenstein, U Vettermann, E Doroshenko, E Lammer, BA Yard, S Hoeger
September-October 2017, 27(5):365-371
DOI:10.4103/ijn.IJN_40_17  PMID:28904432
Inflammation plays a crucial role in acute kidney injury (AKI). The current study was designed to analyze the influence of prednisolone treatment on the inflammatory reaction during the first 96 h after AKI induction in a rat model. AKI was induced by unilateral clipping of the renal vessels. The treatment group received prednisolone 5 mg/kg s.c. daily. Infiltration rates of macrophages, leukocytes, and T-cells (24, 96 h) as well as plasma concentrations of the inflammatory markers intercellular adhesion molecule, interleukin-1 beta (IL-1β), IL-18, IL-6, and tumor necrosis factor-alpha (0, 6, 24, 96 h) were determined by fluorescence-activated cell sorting (FACS) analysis only. Ninety-six hours after AKI induction, the prednisolone group demonstrated significantly lower creatinine concentrations compared to the control group (P < 0.05). Twenty-four hours after induction of AKI, a significantly higher rate of infiltrating leukocytes was detectable with FACS analysis in the control group (P < 0.01) with a corresponding significantly higher rate of macrophages after 96 h (P < 0.01). IL-6 and IL-1β demonstrated a peak after 6 h with a significantly higher release in the control group (IL-6: P < 0.01; IL-1β: P < 0.05). In contrast to the control group, the prednisolone group demonstrated no further incline of IL-18 after 24 h. The results demonstrate the importance of stretching the observation period in an ischemia-reperfusion-induced AKI setting beyond the first 24 h. Despite the demonstrated protective effects of a continuous prednisolone application, it seems that this single anti-inflammatory agent will not be able to completely suppress the inflammatory response after an ischemia-reperfusion-induced AKI.
  670 70 -
Strongyloid hyperinfection in a patient with immunocompromised chronic kidney disease
S Hedau, VP Reddy, SD Mondhe, JV Devana
September-October 2017, 27(5):389-391
DOI:10.4103/ijn.IJN_290_16  PMID:28904436
Strongyloid hyperinfection is seen in immunocompromised individuals with underlying lung disease. The use of immunosuppressive drugs is an important risk factor. We report a case of IgA nephropathy with crescent, started on glucocorticoid and mycophenolate mofetil. He presented with bilateral lung opacities with breathlessness. As the breathlessness was not improving, despite adequate ultrafiltration, bronchoscopy was done. Bronchoalveolar lavage fluid examination showed the presence of strongyloid larvae, which was later demonstrated in stool also. He responded to antihelminthic treatment with disappearance of larvae from stool but later developed secondary bacterial infections.
  633 79 -
Utility of determining autoantibodies to M-type phospholipase A2 receptor in diagnosing primary membranous nephropathy: An ideal setting
R Ramachandran, V Kumar, N Singh, M Kataruka, M Rathi, HS Kohli, V Jha, KL Gupta
September-October 2017, 27(5):413-415
DOI:10.4103/ijn.IJN_165_16  PMID:28904444
  630 68 -
To compare acute peritoneal dialysis with sustained low-efficiency dialysis in critically Ill patients requiring renal replacement therapy
B Datt, R Ramachandran, N Sharma, V Kumar, M Rathi, HS Kohli, V Jha, KL Gupta
September-October 2017, 27(5):412-413
DOI:10.4103/ijn.IJN_167_16  PMID:28904443
  605 77 -
Association of amelogenesis imperfecta and Bartter's syndrome
A. C. V. Kumar, V Alekya, M. S. V. V. Krishna, K Alekya, M Aruna, M. H. K. Reddy, B Sangeetha, R Ram, VS Kumar
September-October 2017, 27(5):399-401
DOI:10.4103/ijn.IJN_203_16  PMID:28904439
Bartter's syndrome is an autosomal recessive renal tubular disorder characterized by hypokalemia, hypochloremia, metabolic alkalosis, and hyperreninemia with normal blood pressure. Bartter's syndrome is associated with hypercalciuria and nephrocalcinosis. Amelogenesis imperfecta (AI) is a group of hereditary disorders that affect dental enamel. AI could be part of several syndromes. The enamel renal syndrome is the association of AI and nephrocalcinosis. We report two patients of AI with Bartter's syndrome.
  580 73 -
Plasma cell infiltration of the kidney as a manifestation of myeloma: A report of three cases
T Kaur, S Krishnaprasad, R Shankar, R Kumar, S Gowrishankar, MD Padua
September-October 2017, 27(5):395-398
DOI:10.4103/ijn.IJN_215_16  PMID:28904438
Infiltration of renal parenchyma by neoplastic plasma cells in myeloma patients is an unusual finding. We report 3 cases of myeloma, with renal biopsy being the first clue to the diagnosis in one. The plasma cell infiltrate in other two cases was not so evident but immunofluorescence (IF) and immunohistochemical (IHC) stains for light chains helped establish the monoclonal nature of the infiltrate. We surmise that plasma cell infiltration in the kidney can be an important clue to the diagnosis of an underlying myeloma and could in future be regarded as a myeloma-defining event (MDE) if monoclonality is confirmed. This finding could directly affect the prognosis and be a direct indicator of the tumor burden. Further studies are however required to determine the exact prognostic value and precise relationship of such a finding with deranged renal functions in myeloma.
  580 67 -
Indian Journal of Nephrology
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