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  ~ Table of Contents - Current issue
July-August 2021
Volume 31 | Issue 4
Page Nos. 331-424

Online since Friday, August 20, 2021

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Acquired pure red cell aplasia and recombinant erythropoietin p. 331
Somanath Padhi, Sandip K Panda
Recombinant erythropoietin (rEPO)-associated immunologically driven acquired pure red cell aplasia (PRCA) is an underreported, potentially worsening clinical syndrome in the setting of treatment of anemia of chronic kidney disease. Most cases reported in world literature are related to different formulations of erythropoiesis-stimulating agents with an implication in diagnosis and management. This brief review highlights the clinical guidelines of rEPO usage in nephrology practice, the pathophysiologic mechanism of PRCA, clinical features, diagnosis, and suggested management protocols.
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Grafalon® vs. Thymoglobulin® as an induction agent in renal transplantation – A retrospective study Highly accessed article p. 336
Pranaw Kumar Jha, Abhyudaysingh Rana, Ajay Kher, Shyam Bihari Bansal, Sidharth Sethi, Ashish Nandwani, Manish Jain, Dinesh Bansal, Dinesh Kumar Yadav, Ashwini Gadde, Amit Kumar Mahapatra, Puneet Sodhi, Vijay Kher
Introduction: Antihuman thymocyte immunoglobulin, used as an induction agent in renal transplantation, is of two types – thymoglobulin and grafalon (formerly ATG-Fresenius). In this study, we compared outcomes with these two agents. Methods: This was a single-center retrospective study of patients transplanted from January 2017 to October 2019, who received either grafalon or thymoglobulin induction. Grafalon or thymoglobulin was given at 6 and 3 mg/kg, respectively, followed by standard triple immunosuppression of tacrolimus, MMF, and prednisolone. Results: Median follow up was 22 (3–36) months. Thymoglobulin was given to 255 patients, whereas 78 patients received grafalon. Baseline demographics were similar between the two groups although significantly more patients in the grafalon group received ABO incompatible transplant (15% vs. 4.3%; P = 0.002). Patient survival was similar between the two groups (99% in grafalon vs. 98.8% in thymoglobulin; P = 1.0). Death censored graft survival was also similar (99% in grafalon vs. 100% in thymoglobulin; P = 0.23). Biopsy proven acute rejection (BPAR) was significantly higher in the grafalon group (12.8% vs. 5.1%, P = 0.04). The significance persisted after multivariable regression analysis (P = 0.02). Other outcomes such as infection rate and estimated glomerular filtration rate on last follow up were comparable between the two groups. Conclusions: Grafalon (6 mg/kg dose) when used as an induction agent was associated with significantly higher rate of BPARs as compared to thymoglobulin (3 mg/kg dose) although with comparable short-term patient and death censored graft survival, graft function, and infection rates.
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Effect of vitamin D on urinary angiotensinogen level in early diabetic nephropathy p. 341
Himansu Sekhar Mahapatra, Adarsh Kumar, Bindu Kulshreshtha, Anubhuti Chitkara, Anamika Kumari
Background: Urinary angiotensinogen (UAGT) is supposed to be a marker of activation of the intrarenal renin– angiotensin system (RAS) system in early diabetic nnephropathy (EDN). Vitamin D has been studied as a negative regulator of the circulating and tissue RAS activity, so its supplementation may prevent the progression of diabetic nephropathy (DN). This study was planned to assess the RAS activation and effect of vitamin D supplementation in EDN progression by estimating the UAGT level. Methods: A total of 103 EDN subjects were randomized in two groups to receive either cholecalciferol (54) or matching placebo (49) in a double-blind manner. All were subjected to routine investigations, urinary albumin-to-creatinine ratio (UACR), UAGT, vitamin D, and intact parathyroid hormone (iPTH) at the 0 and 6 months. A total 40 healthy controls were also included for assessment of the same investigations at 0 month. Results: Significant reduction of UACR, UAGT, and iPTH level were corroborated with an increase in 25(OH) vitamin D level from 0 to 6 months (all four P < 0.001). After 6 months, the median [interquartile range (IQR)] of UAGT and UACR levels was significantly lower in the cholecalciferol group as compared to placebo group (p < 0.001 and P = 0.04, respectively). The median UAGT level was significantly higher in patients with EDN (cholecalciferol & placebo Group) than control group at 0 month (p = 0.001). Conclusion: Significantly higher UAGT levels in EDN supports the role of intrarenal RAS activation. A significant decrease in UAGT level in the cholecalciferol group supports the beneficial role of vitamin D supplementation in the progression of EDN.
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Analgesia for pediatric arteriovenous fistula cannulation in hemodialytic patients: A comparison of lidocaine gel, lidocaine spray, and needle plate p. 349
Yalda Ravanshad, Mohaddeseh Golsorkhi, Sahar Ravanshad, Anoush Azarfar, Mohammad Esmaeeli, Alireza Ghodsi
Background: Children undergoing hemodialysis (HD) via arteriovenous fistula (AVF) experience approximately 300 painful punctures per year which may lead to non-compliance with HD. This study was conducted to show the effect of local anesthetics on pain perception in AVF cannulation. Methods: This randomized clinical trial included 20 children under HD via AVF in Sheikh Children's Hospital Hemodialysis Center in February 2014. The first intervention was conducted as the baseline pain assessment (control), then every patient randomly received all three other interventions: Lidocaine gel, lidocaine spray, and needle plate, before venipuncture. Pain perception was expressed and recorded by patients using the visual analogue scale (VAS). VAS scores were compared, and a P value of <0.05 was considered significant. Results: The VAS mean in lidocaine spray state, lidocaine gel state, and needle plate state was respectively 47.87, 51.31, and 49.43, which were significantly less than the control state with the VAS mean of 60.06 (lidocaine spray vs. control P value = 0.001, lidocaine gel vs. control P value = 0.001, and needle plate vs. control P value = 0.003). Conclusion: Our study showed that the use of needle plate, lidocaine spray, and lidocaine gel are all equally effective ways in controlling the degree of pain in AVF needling in children undergoing HD.
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Comparative analysis between urinary calprotectin and serum creatinine for early detection of intrinsic acute kidney injury p. 353
Marjan Vakili, Daryoush Fahimi, Seyed-Taher Esfahani, Meysam Sharifzadeh, Mastaneh Moghtaderi
Background: Acute kidney injury (AKI) is a common and important clinical condition that may lead to chronic kidney disease if it is not diagnosed and treated in its early stages. Urinary calprotectin is a valuable recognized biomarker that can be used to differentiate prerenal and intrinsic AKI. However, till date only a few reports on urine calprotectin measurement in early diagnosis of intrinsic AKI are available. In this study, we compared the sensitivity and specificity of urinary calprotectin with those of serum creatinine in detecting early intrinsic AKI. Methods: Over 6 months period (April to October 2018), 81 of 408 patients admitted to the pediatric intensive care unit met the criteria of this cross-sectional study. Their serum creatinine and urinary calprotectin were measured on the first and third day of admission using Jaffe and Elisa radioimmunoassay methods, respectively. The AKI was defined according to the pRIFLE criteria. Results: Of the total 81 patients, 67 had the criteria of intrinsic AKI. Of these 62% were female and 38% were male. The mean age of the patients was 22 months. According to data analysis, the area under the curve of ROC of urinary calprotectin on day-1 to detect renal failure is 0.93 with the best cutoff point obtained at 530 ng/mL. The sensitivity, specificity, positive, and negative predictive values of urinary calprotectin levels in diagnosing AKI at this cutoff point are 92.5%, 92.8%, 98.4, and 72.2%, respectively. Besides, urinary calprotectin changes occur much earlier than the rising of serum creatinine. Conclusion: Urinary level of calprotectin is a very sensitive biomarker for early diagnosis of intrinsic AKI in children and it can be used in intensive care units or anywhere critically ill children admitted to detect intrinsic AKI. Besides, this study shows that urine calprotectin may be a more sensitive and specific biomarker than serum creatinine in the early phases of intrinsic AKI.
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Kidney transplantation with ABO-incompatible donors: A comparison with matched ABO compatible donor transplants p. 358
Aniketh Prabhakar, Sishir Gang, Umapathi Hegde, Abhijit Konnur, Hardik Patel, Mohan Rajapurkar
Introduction: ABO-incompatible kidney transplantation (ABOiKTx) expands the living donor pool. There is limited long-term outcome data from India especially in comparison with ABO-compatible kidney transplantation (ABOcKTx). Here we report outcomes of the first 100 ABOiKTx compared to ABOcKTx from our center. Methods: Between August 2013 and December 2019, 100 consecutive ABOiKTx were compared with 100 ABOcKTx done during the same period.Controls were matched for age, donor characteristics, HLA mismatches, and date of transplantation. Results: Mean (SD) follow up period was 25.9 ± 20.5 and 27.2 ± 20.6 months in ABOi and ABOcKTx respectively. Patient survival at 1 and 5 years post-transplant was 93.3 and 73.5% vs. 95.4 and 93% (P = 0.03), while graft survival rates were 85 and 60% vs. 93.1 and 83% in ABOi and ABOcKTx respectively (P = 0.03). The incidence of antibody-mediated rejections was 15% vs. 4%, and that of T-cell-mediated rejections was 10 vs. 12% respectively. Infections, malignancies, and surgical complications were similar. Level of anti ABO titers, HLA mismatches, recipient age, donor age, and presence of diabetes did not impact graft survival amongst ABOiKTx. The predicted survival and incidence of acute rejections and infections in the later 50 ABOiKTx transplants were better than the first 50 ABOiKTx when compared to their respective controls. Conclusion: Outcomes of ABOiKTx were inferior to ABOcKTx but tends to improve as more experience is gained. Incidence of ABMR was higher but infections and surgical complications were comparable.This data provides evidence that ABOiKTx is viable option for those without a ABO compatible donor.
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Clinical Utility of 24-h Ambulatory Blood Pressure Monitoring in Hospitalized Patients with Chronic Kidney Disease p. 365
Santosh B Salagre, Nigarbi N. A. Ansari, Vandana S Mali
Introduction: Hypertension leads to rapid progression of kidney disease. Hypertension (HTN) is the second most common cause for CKD after diabetes. Ambulatory blood pressure monitoring (ABPM) helps in accurate and early diagnosis of HTN along with measurements of other variables, namely nondippers, reverse dippers, hyperbaric index (HBI), percentage time elevation (PTE), and early morning surge. Methodology: After obtaining the institution ethics committee approval total 192 cases, of 12–80 years age group, who were diagnosed with CKD were included in the study. ABPM was done for patients using Meditech ABPM-05 machine. Results: Study showed male predominance. Maximum patients were in the age group of 41–60 years. Prevalence of Hypertension in patients with CKD was 88.02%. The systolic BP, diastolic BP, and mean arterial pressure (MAP) were significantly higher by clinic BP measurement than ABPM in all stages of patients with CKD especially in stage IV than stage V CKD. Systolic, diastolic, MAP, HBI and PTE at nighttime were significantly higher than daytime in all patients with CKD, especially in patients with resistant hypertension. Prevalence of whitecoat HTN (4.1%), whitecoat effect (16.1%), resistant hypertension (39.6%), masked HTN (1%), and masked uncontrolled HTN (10.4%) was noted. Systolic and diastolic HBI was lower in patients on hemodialysis as compared to those not on hemodialysis. Non-dippers were more than dippers. Conclusion: Apart from mean systolic and diastolic BP, ABPM gives the extent of end-organ damage and insights into the need for control of 24 h BP in patients of CKD.
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Outcomes of kidney transplantation in the elderly recipients p. 370
Vinant Bhargava, Priti Meena, Krishna Agrawaal, Lovy Gaur, Devinder Rana, Anil Bhalla, Ashwani Gupta, Manish Malik, Anurag Gupta, Digvijay Kumar
Introduction: In a developing country with a predominantly young population, the valid assumption is directed toward medical care toward the young. However, as medical technology has advanced, quality care has ensured better survival for the elderly population also. The aim of this study was to determine the clinical outcomes in elderly patients undergoing kidney transplantation. Materials and Methods: A retrospective analysis of 1150 patients who had undergone live related renal transplantation was done from January 2006 to December 2014. These patients were divided into two groups; Group 1: age >60 years (N = 150), Group 2: age 18–60 years (N = 1000). The clinical outcomes were compared. Results: The mean age in Group 1 was 69 ± 7.5 years (SD ± 7.5), and group 2 was 41 ± 8 years. In groups 1 and 2, males were 80% and 82%; death censored graft survival at 5 years was 82% and 87%; patient survival at 5 years was 86% and 94%, respectively. The incidence of biopsy-proven acute rejection was similar in both groups (11.3 vs. 10.2%, P = 0.12). Urinary tract infection was the most common infectious complication. Sepsis was the primary cause of death in both groups. Conclusion: In the elderly patients who underwent kidney transplantation, satisfactory graft function, and patient survival were maintained over a period of 60 months. Urinary tract infections were common, and sepsis was the most common cause of death with a surviving allograft. The acute rejection and mortality rates were comparable to the literature published from India so far.
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Spot urine albumin creatinine ratio can be a predictor of cognitive function in type 2 diabetes mellitus p. 377
Deepak Kumar Panigrahi, Debasish Chaudhury
Introduction: In diabetes mellitus (DM), the underlying pathophysiology of albuminuria and cognitive dysfunction is similar. So, we hypothesized that urinary albumin excretion (UAE) could be linked to cognitive dysfunction in type 2 diabetes mellitus. Methods and Materials: It was a hospital-based observational study. Patient aged 40–60 years with type 2 DM were included in this study. Complete assessment with detailed history, physical examination, and necessary biochemical investigations including spot urine albumin creatinine ratio (uACR) was done. Cognitive status was determined in all the individuals with the application of Hindi translated version of the mini-mental status examination (MMSE) questionnaire. Results: In 80 patients, the mean MMSE score was 25.37 ± 3.34. Cognitive dysfunction (score <26) was present in 45% of individuals. Spot uACR, estimated glomerular filtration rate (eGFR), glycated hemoglobin (HbA1c), presence of retinopathy and dyslipidemia were significantly different between the normal and subnormal scoring groups. On multivariate analysis spot uACR was found to be independently predicting odds of developing cognitive dysfunction (OR 1.01, CI 1.004–1.022; P = 0.001).The mean MMSE scores in normo-albuminuric (n = 15), moderately increased albuminuric (n = 48) and severely albuminuric (n = 17) patients were 28.00 ± 1.60, 25.54 ± 3.33 and 22.58 ± 2.31, respectively, which were significantly different among the three groups (P < 0.001). Conclusions: Spot uACR could be helpful in predicting cognitive decline in people with type 2 DM.
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Renal microvascular ischemia secondary to nonsteroidal anti-inflammatory drugs p. 383
Sagar Kulkarni, Vipul Chakurkar, Valentine Lobo
Nonsteroidal anti-inflammatory drugs (NSAIDs), widely prescribed for pain, can affect kidneys in various ways. We present a case of a 37-year-old woman with multiple NSAIDs intake over a short period for dysmenorrhea followed by the development of new-onset bilateral flank pain. Computed tomography revealed bilateral multiple renal infarcts. Renal function was normal. Investigations showed no cardiac or renal artery lesion and vasculitis work-up was negative. She was treated conservatively and further NSAID intake was avoided. Follow-up scan showed complete restoration of the blood flow in previously affected areas. Thus, microvascular ischemia secondary to NSAIDs was thought to be responsible.
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Papillary renal cell carcinoma with sarcomatoid differentiation in a native kidney of transplant recipient: A case report and review of literature p. 386
Satish K Ranjan, Ankur Mittal, Sunil Kumar, Sanjeev Kishore, Tushar A Narain, Kim J Mammen
Renal cell carcinoma (RCC) developing in a transplant recipient is about 5–20 times higher than the general population. It is more common in native kidneys than graft kidney, and incidence varies between 0.3% and 4.8%. Clear cell and papillary types are more frequently reported. Most RCC of allograft recipient is usually low-grade with favorable prognosis. We present a case of papillary RCC with sarcomatoid differentiation (SD) in a native kidney of renal transplant (RT) recipient. The coexistence of sarcomatoid variant with papillary RCC, as in our case, makes it a high grade (WHO/ISUP grade 4) and portends a poor prognosis. Relative aggressiveness and rarity of this variant histology in transplant recipients prompted us to report this case and carry out an extensive search of the available literature.
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Managing active iupus nephritis during COVID-19 pandemic p. 390
Joyita Bharati, Manish Rathi, Raja Ramachandran, Aman Sharma, Ritambhra Nada, Harbir S Kohli
India is seeing a rapid rise in coronavirus disease-2019 (COVID-19). Immunosuppression is a possible risk factor for severe COVID-19, although their exact interaction is unclear. A total of 13 cases with active lupus nephritis (LN, with or without extra-renal manifestations) were managed with intense immunosuppression between January 2020 and June 2020 during the COVID-19 pandemic at our center. There were no other comorbidities in any patient. All patients received hydroxychloroquine as a part of standard of care. Vigorous precautionary measures were taken for preventing infection in all. One patient developed acute respiratory distress syndrome but was tested negative for COVID-19. None of the other 12 patients developed symptoms suggestive of COVID-19. We report safe management of patients with active LN with intense immunosuppression along with vigorous precautions amidst the COVID-19 pandemic. The role of hydroxychloroquine along with timely precautions needs to be further explored as protective measures against COVID-19 among systemic lupus erythematosus patients.
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Anti-nuclear antibody-negative lupus nephritis or post-infectious glomerulonephritis: Diagnostic dilemma in a young male p. 394
Joyita Bharati, Saif Quaiser, Ritambhra Nada, Raja Ramachandran, Harbir Singh Kohli, Manish Rathi
Proliferative lupus nephritis (LN) is histologically characterized by endocapillary hypercellularity and large immune deposits on light microscopy. Immunofluorescence shows almost all immunoglobulins and complement staining. The presence of antinuclear antibodies (ANA) is important for diagnosing systemic lupus erythematosus (SLE). Absence of ANA rules out the possibility of SLE according to the 2019 European League Against Rheumatism/American College of Rheumatology classification criteria for SLE. We report a young boy with fever, nephrotic-nephritic syndrome and pancytopenia consistent with hemophagocytic lymphohistiocytosis. Renal biopsy was consistent with LN; however, his initial ANA was negative. In view of pathological features of LN and persistent pancytopenia, high dose steroid therapy was started. Repeat ANA, done during the illness, turned positive. In this report, we describe the relevance of pathological patterns and the uncertainties of ANA positivity in making a diagnosis of SLE.
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Dialyzer first use reaction with polysulfone membrane: Moving beyond ethylene oxide p. 398
Abraham Tharakan
Acute anaphylactic/anaphylactoid reactions to dialyzers are uncommon. Indeed, they are thought to have decreased in incidence since the transition to more biocompatible dialyzer membranes and with the abandonment of ethylene oxide for sterilization of dialyzers. However, few recent Spanish studies suggest that the incidence actually remains the same. Here, we report two cases of dialyzer first use reactions that occurred with polysulfone dialyzers. These were not ethylene oxide sterilized dialyzers and the reactions were less intense/absent from the second reuse onwards. Both the patients were successfully dialyzed by switching to a cellulose triacetate dialyzer or by using a preprocessed dialyzer filled with renalin. Thus, the cause of the reaction could either be the primary polysulfone membrane or a leachable substance from the dialyzer.
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Complete Remission of Lupus Nephritis Following Chemoradiotherapy of Carcinoma Cervix: An Association p. 402
Niveditha Girimaji, Ritambhra Nada, Aman Sharma, Joyita Bharati, Manish Rathi
Systemic lupus erythematosus (SLE) is associated with a higher incidence of solid organ malignancies, including cervical carcinoma, creating a paradox in their management in the context of autoimmunity. We present a case of 45-year-old female presented with mucocutaneous, musculoskeletal symptoms of SLE. Renal biopsy showed class IV lupus nephritis (LN); modified NIH activity score: 8/24, chronicity score: 6/12. Post NIH regimen induction, she achieved partial remission; further developed proteinuric relapse which was re-induced with mycophenolate mofetil (MMF) to which she failed to respond. Subsequently diagnosed with carcinoma cervix stage IIB, she received four cycles of concurrent cisplatin-based chemoradiotherapy. MMF was stopped; low dose steroids continued. Following this, the patient achieved complete remission (CR) of LN and is in remission for 5 years. This is an unexpected association between chemoradiotherapy of cervical carcinoma and CR of class IV LN, allowing long-term discontinuation of immunosuppression.
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Granulomatosis with polyangiitis masquerading as renal mass: Case report and literature review p. 406
Vaibhav Tiwari, Abhishek Raman, Anurag Gupta, Pallav Gupta, Abhijeet Joshi, Vinant Bhargava, Manish Malik, Ashwani Gupta, Anil Kumar Bhalla, DS Rana
Wegener's granulomatosis or granulomatosis with polyangiitis (GPA) is multisystemic vasculitis. Kidney involvement in GPA often presents with rapidly progressive renal failure and requires urgent treatment. A 60-year-old female presented with prolonged history of fever, generalized weakness, decreased appetite, and weight loss over 4 months. Her renal function was normal; urine culture was sterile. On further evaluation, she was found to have large, hypodense solid lesion in mid pole of the right kidney on CECT. CT guided renal biopsy was done, which showed granulomatous interstitial nephritis with focal crescents. On further evaluation, she was found to have high titers of anti-MPO antibody. She was started on steroid and methotrexate with subsidence of fever. Follow-up after 12 months showed resolution of the lesion. GPA solely presenting as solid mass like lesion in the kidney is extremely rare presentation. Early diagnosis and prompt initiation of the treatment can prevent the progression of the disease.
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Ofloxacin Induced Hemolysis in G6PD-deficient Patient: A Rare Cause of Pigment Nephropathy p. 410
Mital Parikh, Maulin Shah, Jekishan Hirapara, Shailesh Soni, Bhalendu Vaishnav, Labani Ghosh
Thrombotic microangiopathy (TMA) commonly presents as a triad of acute kidney injury (AKI), jaundice, and hemolysis; however, tropical infections such as malaria, dengue, leptospira, and drugs like antimalarials can also have a similar presentation. They can cause AKI for many reasons including pre-renal causes but an important yet not relatively uncommon genetic cause of hemolytic anemia, that is, glucose 6-phosphate deficiency (G6PD) manifesting as jaundice, hemolysis, and AKI secondary to pigment nephropathy after receiving offending drugs needs to be worked up while evaluating such patients. Ofloxacin is not usually included in the lists of unsafe drugs in G6PD deficiency. Herein, we report a patient developing intravascular hemolysis secondary to G6PD deficiency associated with ofloxacin administration presenting as a rare cause for pigment nephropathy.
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Bilateral renal infarcts in a patient with COVID-19 pneumonia p. 414
Vishal V Ramteke, Ashwini Tayade, Virendra Belekar, Rajan Barokar, Vikram Rathi
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Increasing proportion of extensively drug-resistant gram-negative uropathogens among renal transplant recipients in Northern India p. 416
Sameer Bhuwania, Rajesh Goel, Ravi Bansal, Sanjiv Saxena
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COVID-19 and acute kidney injury: Point-of-care ultrasound in the assessment of volume status p. 418
Subhrashis Guha Niyogi, Krishna Prasad Gourav, Sunder Negi, Vikas Suri, Goverdhan Dutt Puri
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Chronic kidney disease among diabetes and hypertensive patients in a remote rural area of south India: A population-based cross-sectional study p. 420
Ariarathinam Newtonraj, Stephen Tovia, Ganesan Girija, Mani Manikandan, Antony Vincent
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RAAS-Blockade in COVID-19: The Ace of Spades? p. 423
Krishna A Agarwal, Periklis P Kyriazis, Stewart H Lecker
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Indian Journal of Nephrology
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