15TH DECEMBER 2023
ABSTRACT NO. 1
ORAL HEALTH ASSESSMENT IN CHRONIC KIDNEY DISEASE (CKD) PATIENTS ON MAINTENANCE HAEMODIALYSIS
Akash Rana, Gurvanit Kaur Lehl, Palak Dudeja, Gurasis Sodhi
Department of Nephrology; Government Medical College and Hospital; Chandigarh; India
E-mail: sanjaydcruz@gmail.com
BACKGROUND: CKD is disease of global health concern causing significant morbidity and mortality in patients worldwide. CKD causes multisystem manifestations which have been extensively studied but one lesser talked about aspect is the oral health issues which arises from the disease activity and therapy as well. This might stem from the uremic milieu imbalances in calcium and mineral metabolism endocrine and immune dysfunction all of which can contribute to inadequate oral health. CKD can lead to reduced salivary production due to restrictions on fluid intake retrograde parotitis breathing through the mouth and acidosis. These factors lead to dry mouth and alterations in the sense of taste. Elevated levels of salivary phosphorus and decreased magnesium encourage the formation of dental calculus a marker of suboptimal oral health. Additionally gingivitis occurs more frequently resulting in gum bleeding and increased vulnerability. This can be attributed to insufficient oral hygiene compromised overall health a weakened immune system and the presence of inflammation. CKD patients also exhibit a higher prevalence of periodontal pockets and greater tooth mobility. This is attributed to CKD-mineral bone disease (MBD) causing loss of mandible and maxillary alveolar bone and weakening of the periodontal ligament responsible for tooth loss which in turn leads to alterations in body image. Cardiovascular disease is the leading cause of mortality in CKD patients due accelerated atherosclerosis in CKD patients resulting from chronic inflammation. Periodontitis has been found to be associated with increased cardiovascular mortality in these patients and it has been shown that periodontitis if managed effectively this can decrease cardiovascular mortality in these patients. Oral health problems also lead to masticatory problems contributing to malnutrition which further aggravates the morbidity in CKD patients. There have been studies conducted in CKD patients to determine oral health problems associated with CKD and its effect on overall outcome in these patients in western population but data about Indian subcontinent population is scarce. Furthermore even fewer studies have been done to assess oral health in CKD patients on maintenance hemodialysis in Indian population. So we conducted this study to better understand the effects CKD and hemodialysis therapy on oral health of patients in the context of Indian population.
AIMS OF THE STUDY: This study is to assess the oral health status of CKD patients on maintenance hemodialysis.
METHODS: It was a cross-sectional prospective observational study spanning 12 months conducted at a single center with patients enrolled from in and out-patient department. Inclusion criteria: Adults diagnosed with CKD on maintenance hemodialysis (CKD-5D). Exclusion: Age less than 18 years CKD patients not on hemodialysis (CKD-ND). Sample Size of 80 was decided based on prevalence of Oral health problems among CKD patients as reported in earlier studies assuming 95% Confidence level and 10% absolute precision. Based on above criteria 80 patients were enrolled for the study after taking informed consent. The selected patients were administered to a questionnaire and were also subjected to oral health examination by qualified dental surgeon in department of dentistry by using following tools- 1. WHO oral health questionnaire. Available at https://apps.who.int/iris/rest/bitstreams/453131/retrieve pages 111 to 114 2. WHO oral health assessment form 2013 to look at various aspects of oral health such as dentition status periodontal status loss of attachment gingival bleeding dental erosion and oral mucosal lesions. Available at https://apps.who.int/iris/rest/bitstreams/453131/retrieve pages 83 and 84 The oral health symptoms were judged in four categories of tooth/mouth pain dry mouth mastication problems and body image issues based on the answers given to WHO oral health questionnaire. The oral health examination was used to assess four parameters: (1) Total number of sound teeth (2) DMFT score (decayed missing due to caries fixed tooth) which was used to assess the burden of caries. (3) Gingival bleeding score was used as marker of gingival health (4) Periodontitis was assessed based on clinical loss of attachment at site of greatest loss radiographic bone loss tooth loss due to periodontitis and probing depth. The results obtained from above study were then compared with data from similar study conducted previously at our center on CKD patients not on dialysis to determine the differences between two groups.
CONCLUSION: (1) A comparison of results with a previous study conducted in our center which assessed oral health in CKD patients not on dialysis reveals an association between disease progression and increase in oral health problems with all parameters of oral health symptoms namely tooth/mouth pain, dry mouth, masticatory problems, and body image issues having statistically higher prevalence among CKD-5D group, (2) In the oral health examination, the DMFT score and Gingival bleeding score in CKD-5D group was higher than the CKD-ND group with p < 0.05 indicating statistically significant difference between dialysis and non-dialysis patients, (3) This data reveals increased burden of oral health problems in CKD-5D patients compared to CKD-ND patients indicating that oral disease burden increases with initiation of dialysis in CKD patients, (4) We suggest including oral health assessment on a periodic basis to look at this neglected aspect of poor oral health in CKD-5D which leads to poor nutrition, inflammation and body image issues, (5) Timely oral health assessment and management of dental issues will improve nutrition, reduce inflammation and provide a better quality of life to these patients.
15TH DECEMBER 2023
ABSTRACT NO. 2
GENETIC ASSOCIATION IN PATIENTS WITH CHRONIC KIDNEY DISEASE OF UNKNOWN ETIOLOGY: AN OBSERVATIONAL STUDY
Tarun Kumar, A K Bhalla, Ratna Dua Puri, Vaibhav Tiwari
Department of Nephrology; Sir Ganga Ram Hospital; New Delhi; India
E-mail: tarun.shikarwar@gmail.com
BACKGROUND: Chronic kidney disease of unknown etiology is common and poses a substantial problem for patients in final management. We aim to utilize next generation sequencing in a single center to discover the genetic association in patients with Chronic Kidney Disease of unknown etiology.
AIMS OF THE STUDY: To determine the diagnostic yield of whole exome sequencing in patients with Chronic Kidney Disease of unknown etiology.
METHODS: In this observational cross-sectional study all the patients with chronic kidney disease of unknown etiology irrespective of age and gender were included. Clinical indications for genetic testing were categorized as glomerular diseases nephrolithiasis tubulopathies cystic kidney diseases chronic kidney disease of unknown etiology and others. Next genration sequencing was used for genetic analysis. The pathogenicity of the genetic variant was interpreted as per the American College of Medical genetics classification.
CONCLUSION: Nearly one third (26.78%) of the patients with chronic kidney disease of unknown etiology underwent gene study and were tested positive for a genetic disease. Genetic testing confirmed the clinical diagnosis, changed the clinical diagnosis or made a new diagnosis, which helped in making better treatment strategies for the patients.
15TH DECEMBER 2023
ABSTRACT NO. 3
TO STUDY THE PATTERN OF USE AND TOLERABILITY TO USE OF ACE INHIBITORS AND ARBS IN CKD PATIENTS WITH PROTEINURIC ILLNESS AND/OR CARDIAC FAILURE
Mahak Joshi, Gaurav Singla, Vikas Makkar
Department of Nephrology; DMCH; Ludhiana; Punjab; India
E-mail: mahakg21@gmail.com
BACKGROUND: Angiotensin converting enzyme inhibitors (ACE Inhibitors) and Angiotensin receptor blockers (ARB) are the best-studied antihypertensive agents that provide significant renal and cardiovascular protection for chronic kidney disease (CKD) patients. Recent studies suggest lack of evidence regarding the risk-benefit balance of ACE inhibitors/ARBs in patients with advanced CKD leading to their underutilization. There is need to assess the gap in the prescription and tolerability to use of these agents.
AIMS OF THE STUDY: To study the Pattern of use and tolerability to use of ACE inhibitors and ARBs in CKD Patients with proteinuric illness and/or cardiac failure.
METHODS: We conducted a prospective observational study on CKD Stage 3 & 4 patients. The study screening involved the eligible population. Out of eligible population only 33% patients were taking either ACE inhibitors or ARBs at the time of enrolment and remaining 67% patients were the new patients those who were started on ACE inhibitors or ARBs as a part of their treatment at the time of their enrolment into the study. Pattern for use of these drugs was studied and both these group of patients were followed for a period of 6 months to evaluate the tolerability to these drugs and to study the factors causing discontinuation among these patients.
CONCLUSION: Our study reveals the underutilization of ACE inhibitors/ARBs in CKD patients with proteinuric illness and heart failure. Percentages of patients tolerating these medications were greater as compared to prevalence for their use for intended benefit. Tolerability of patients can be improved by a system of care that ensures regular checks of renal and cardiovascular function.
15TH DECEMBER 2023
ABSTRACT NO. 4
SPECTRUM OF CLINICAL AND BIOCHEMICAL PROFILE OF TUBERCULOSIS IN PATIENTS WITH CHRONIC KIDNEY DISEASE AT TERTIARY CARE CENTER OF SOUTH INDIA-SINGLE CENTRE CROSS SECTIONAL OBSERVATIONAL STUDY
H A Karthik Urala, Avinash Thakur, Shweta S Phadke, Lalit Kumar Dasale, Ravitej Madipalli, Sree Bhushan Raju
Department of Nephrology; Nizam’s Institute of Medical Sciences; Hyderabad; Telangana; India
E-mail: karthikurala@outlook.com
BACKGROUND: Tuberculosis (TB) is among the most common causes of death from infectious disease worldwide. It is a s is major health illness in developing countries especially India. Immunodeficiency in CKD may make people moe vulnerable for TB. This study will focus on spectrum of clinical profile various organ involvement and outcome in Chronic Kidney Disease patients affected with Tuberculosis.
AIMS OF THE STUDY: To study clinical profile of patients with chronic kidney disease diagnosed with Tuberculosis.
METHODS: In the present study entitled Spectrum of clinical and biochemical profile of tuberculosis in patients with chronic kidney disease at tertiary care center of south India-single centre cross sectional observational study Study design-Cross sectional descriptive observational study Study setting: Department of Nephrology in a Tertiary Care Hospital in South India Study duration: 3 months after IEC approval Sample size:100 Study procedure The study was conducted after approval of the NIMS institutional ethics committee (NIEC). This study was a cross sectional observational study designed to be conducted Chronic Kidney Disease patients at NIMS hospital Hyderabad. Patients baseline medical records of CKD noted and data was collected from those who satisfy inclusion and exclusion criteria. Details like age sex demography presenting symptoms examination findings necessary investigations treatment details and other necessary information pertaining to the study was be collected. After inclusion routine investigations included complete blood picture and anemia workup blood chemistry analysis liver function tests ESR CRP TST and viral markers biochemical and microbiological fluid analysis reports were collected and Radiological imaging (Radiograph CT imaging) findings including nuclear scan reports such as FDG PET CT were noted. In selected patients histopathological examination reports were also noted Cases were defined 1. Sputum smear/CB NAAT /culture positive for M tuberculosis 2. Specimens positive for culture or CB NAAT for M tuberculosis 3. Radiologically proven Tuberculosis 4. Histopathological specimen showing necrotizing caseating granuloma All cases were treated for tuberculosis with ATT adjusted for weight and eGFR Duration of therapy is left to discretion of Physician or Nephrologist All patients were followed up for complications of ATT and at the end outcomes were noted.
CONCLUSION: (1) Relative frequency of Tuberculosis in ESKD patients was high in our population, (2) Patients na ve to Renal Replacement Therapy (within 12 months) are at high risk of acquiring tuberculosis, (3) There is a high frequency of extra pulmonary TB. Therefore, a high index of suspicion for early diagnosis and treatment is required, (4) Microbiological diagnosis is seldom possible thus have to rely on clinical and radiological diagnosis.
15TH DECEMBER 2023
ABSTRACT NO. 5
COMPARATIVE STUDY ON OUTCOME IN LIVING DONOR ABO INCOMPATIBLE AND PAIRED KIDNEY TRANSPLANTATION
Neethu Varghese, Benil Hafeeq 1 , Jyothis Gopinathan 2
Departments of Nephrology and 2 IQRAA International Hospital and Research Centre; Kozhikode; Kerala; India
E-mail: neethu7v@gmail.com
BACKGROUND: The main obstacles for living donor transplantation are immunological incompatibility due to the presence of antibodies directed against the human leukocyte antigen system of the donor or due to the incompatibility of the ABO blood group system. Desensitization of recipient to remove the antibodies in order to prevent their rebound after transplantation and the exchange of organs between two or more donor recipient pairs are methods usually adopted to overcome the aforementioned problems. We aimed to compare the outcomes of paired exchange kidney transplantation with ABO incompatible kidney transplantation in our setting.
AIMS OF THE STUDY: To compare the outcomes of paired exchange kidney transplantation with ABO incompatible kidney transplantation in our setting.
METHODS: A review of medical records of 90 patients who underwent ABO incompatible transplantation and 46 patients who underwent paired kidney exchange from July 2016 to January 2023 was done. The patient’s demographics native kidney disease graft function at 6 months biopsy proven acute rejection incidence of delayed graft function need for dialysis following transplantation and patient survival were compared.
CONCLUSION: The outcomes of paired kidney donation and ABO incompatible transplantations were comparable in terms of graft function at 6 months, biopsy proven acute rejections, delayed graft function and graft survival. Therefore, paired kidney donation and ABO incompatible donations should be encouraged in patients who has immunological incompatibility due to the presence of donor specific antigens.
15TH DECEMBER 2023
ABSTRACT NO. 6
RIGHT VENTRICULAR DYSFUNCTION IN DIALYSIS PATIENTS
Rajinder Parshad, Jasmine Dass
Department of Nephrology; Government Medical College; Tanda; Himachal Pradesh; India
E-mail: abhinavrana2729@gmail.com
Cardiovascular disease is leading cause of mortality in patients undergoing dialysis accounting 50% of deaths. Most of the available studies have focused on LV function in dialysis patients. In recent years the assessment of right ventricular function by tissue Doppler imaging (TDI) has been established as a common approach to detect preclinical abnormalities of cardiac function and has also been proposed as a reliable predictor of prognosis. Data on the prevalence of RVD in patients undergoing chronic dialysis are still lacking. A few studies that have investigated the impact of haemodialysis (HD) on RV functions have reported deterioration of RV systolic and diastolic functions in HD patients and very few have studied the impact on peritoneal dialysis patients. Importantly RVD may also affect left ventricular filling via interventricular interaction.
The aim of the study was to study the prevalence of right ventricular dysfunction in dialysis patients and to compare the impact of haemodialysis and peritoneal dialysis on right ventricular dysfunction.
This prospective observational study was conducted in CKD - 5D patients in a tertiary care hospital in North India. Patients on haemodialysis and peritoneal dialysis were included in the study. HD patients were further divided into two categories dialysis through radio-cephalic and through brachiocephalic fistula. All patients aged ≥ 18 years on haemodialysis or peritoneal dialysis for at least 3 months were included. Haemodialysis patients receiving at least two sessions of dialysis/week and peritoneal dialysis patients with minimum 3 exchanges /day. Dialysis data regarding vascular access volume status and adequacy of dialysis was recorded. ECHO was done post dialysis (within one day of dialysis) by a trained technician or a doctor. In all patients evaluation of both RV and LV function was done by M -mode 2D and Doppler echocardiography by using ECHO machine SIEMENS ACUSON SC2000 with 4V1c transducer with a frequency of 3.5 MH in the left lateral and supine position. All measurements were performed according to the recommendations of the American Society of Echocardiography Recommendations 2015. Sample size was 52 quantitative variables were expressed as mean or median with standard deviation or interquartile range. Qualitative variables were expressed as frequency of occurrence with percentages. Appropriate statistical test such as Mann Whitney U test ‘U’ test and “chi square test” was used whenever required. A value < 0.05 was considered statistically significant. Right ventricular dysfunction was assessed using four ECHO parameters Tricuspid annular plane systolic excursion (TAPSE). Values lower than 17 mm are highly suggestive of RV systolic dysfunction. Right ventricular index of myocardial performance (RIMP). A RIMP greater than 0.54 by TDI is indicative of RV dysfunction. Tricuspid annular motion was evaluated by tissue Doppler to measure the longitudinal velocity of the tricuspid annulus. Velocity has been named the RV S’ or systolic excursion velocity. Normal values for pulsed tissue Doppler S wave is 14.1 ± 2.3 or >9.5 cm/s. The RV fractional area change (FAC) provides an estimate of global RV systolic function. Normal RV FAC is greater than 35%.
Of 56 patients included in the study 38 (67.9%) were male and 18 (32.1%) were female. Among 56 patients 44 (78.6%) patients had RVDD with any of the four factors positive while 12 (21.4%) had no dysfunction. TAPSE <17 mm was seen 19 (33.9%) patients while 37 (66.1%) patients had no RVDD suggested by TAPSE >17mm. RV FAC <35% was seen in 5 (8.9%) patients while 51 (91.1%) patients had RV FAC > 35% suggestive of no dysfunction. 29 (51.8%) patients had RVDD characterised by RIMP >0.54 while 27 (48.2%) patients had RIMP < 0.54 suggestive of no dysfunction. S PRIME < 9.5cm/s was seen in 10 (17.9%) patients which was suggestive of RVDD and 46 (82.1%) patients had S PRIME > 9.5cm/s suggestive of no RVDD dysfunction. On comparing ECHO parameters between HD and PD group the average LV Ejection fraction in Haemodialysis group was 44.34 ± 10.82% and Peritoneal dialysis group was 53.07 ± 8.11% and the difference was statistically significant (p<0.05). Among the four parameters for Right ventricular dysfunction TAPSE, RVFAC, RIMP and S-Prime, TAPSE <17 mm was found in 17 (41.5%) HD patients and only 2 (13.3%) peritoneal dialysis patient and was statistically significant (p < 0.05) rest all other ECHO parameters of RV dysfunction showed no significant statistical difference.
RVD assessment is of paramount significance in patients undergoing dialysis as RVD is present in large number of patients undergoing dialysis. The prevalence of RVD was 78.6%. The prevalence is higher in HD group compared to PD group (87.8 vs 53.3%, p < 0.05). Moreover, while assessing RVD all the four parameters for measuring RVD TAPSE, RIMP, RVFAC, should be measured as this increases the sensitivity of detecting RVD. Further we can conclude that PD can be considered as a better dialysis modality as far as RVD is concerned but whether it relates to morbidity or mortality is not evaluated in this study.
15TH DECEMBER 2023
ABSTRACT NO. 7
IS GENETIC ANALYSIS ACTUALLY NECESSARY IN A DEVELOPING COUNTRY? - “ ANALYSIS OF SPECTRUM OF MUTATIONS IN PATIENTS WITH NEPHROTIC SYNDROME
Harrini Devi Palani Baskar, Prathiba Parthasarathy, Gopikumar Sekar, Dinesh Kumar Thanigachalam, Jayalakshmi Seshadri, Natarajan Gopalakrishnan
Department of Nephrology; Madras Medical College; Chennai; Tamil Nadu; India
E-mail: harrinidevi@gmail.com
BACKGROUND: Genetic screening as a part of nephrotic syndrome work-up is well established in developed countries. In developing countries like India the role of genetic screening is not clearly established because of financial constraints. There is no clear guidelines for weaning of immunosuppression in SRNS patients without genetic analyses.
AIMS OF THE STUDY: To study the prevalence of genetic mutations among challenging nephrotic syndrome patients and its usefulness in weaning of immunosuppressive therapy.
METHODS: We have retrospectively analysed 34 nephrotic syndrome patients, genetic analyses done from Jan 2022 to July 2023 at Institute of Nephrology Madras Medical College. Genetic analyses were done using Next-Generation Sequencing (NGS) and patients were analysed for targeted nephrotic syndrome panel and some were supplemented with whole exome sequencing. Patients demographic data pattern of nephrotic syndrome reason for genetic analyses clinical presentation association of syndromic features presence or absence of mutation associated with nephrotic syndrome and renal biopsy findings were analysed. Statistical analyses were done using SPSS version 23.
CONCLUSION: An unequivocal molecular diagnosis could allow us for framing a personalised treatment approach with reduction or stopping of immunosuppressive therapy, avoidance of renal biopsy and provision of genetic counselling and recurrence risk assessment post renal transplant. Identification of new causative mutations will help us to discover new pathogenic mechanisms of glomerular disease and provide new insights into podocyte biology, glomerular function and mode of treatment for nephrotic syndrome.
15TH DECEMBER 2023
ABSTRACT NO. 8
COMPARATIVE STUDY ON DIETARY PATTERN AND KNOWLEDGE ATTITUDE PRACTICE (KAP) DURING PRE AND POST DIETARY INTERVENTION AMONG DIFFERENT STAGES OF CKD PATIENTS
Deepshikha Khattar, Lakshman, Muthu Kumar, Himansu Sekhar Mahapatra
Department of Nephrology; Atal Bihari Vajpayee Institute of Medical Sciences and Dr. RML Hospital; New Delhi; India
E-mail: deepshikhakhattar@gmail.com
BACKGROUND: KAP assessment on dietary habits and patterns have emerged as a practical approach to evaluate qualitative as well as quantitative management aspects of CKD. However scanty data is available on the KAP of dietary habits and effect of change in dietary pattern after counselling.
AIMS OF THE STUDY: Comparison of dietary pattern and knowledge attitude practice (KAP) and effect of dietary habits after dietary counselling among different stages of CKD patients.
METHODS: In this one-year study patients of CKD 3 to 5 (ND) of age 18 to 60 years were enrolled from nephrology OPD. Basic demographic profile socio- economic status dietary habits and physical activity details are being recorded. Normal subjects were also taken for comparison and their dietary nutrient analysis (calories protein sodium potassium calcium phosphorus liquid) was done by Diet Cal version 10.0 software using a 4-day dietary record. Dietary nutrients and nutritional status were measured at baseline and every 6 months for only CKD patients. Patients were categorised into Normal protein (0.8-1.0 gm/kg/day) low protein (0.6 gm/kg/day) and very low protein (0.3 gm/kg/day) categories. Knowledge Attitude and practice was also recorded at baseline and after 6 months. All patients underwent dietary intervention with a home-based PS diet. Dietary re-enforcement and counselling for clinical as well as diet-related patient concerns were done by exclusive renal dieticians with weekly telephone calls. All the parameters were analysed by using the Chi-Square test paired/unpaired t-tests and one-way ANOVA to assess Effect of PS.
CONCLUSION: Study showed a significant increase in knowledge, attitude and practice at one year after dietary counselling. Further, there were significant changes in intake of energy, protein, fats, carbohydrates, potassium, phosphorus and progression in all stages of CKD.
15TH DECEMBER 2023
ABSTRACT NO. 9
THROMBOTIC MICROANGIOPATHIES POST RENAL TRANSPLANTATION
Ajey Indrajeet Jha, Umapati Hegde, Sishir Gang, Mohan Rajapurkar, Abhijit Konnur, Hardik Patel
Department of Nephrology; Muljibhai Patel Society for Research in Nephro-Urology; Nadiad; Gujarat; India
E-mail: ajeyjha@gmail.com
BACKGROUND: Thrombotic microangiopathy (TMA) is a life-threatening disease characterized by endothelial dysfunction and presence of platelet thrombi in small blood vessels causing thrombocytopenia and causing microangiopathic hemolytic anemia. TMA is a serious complication affecting kidney transplant recipients in 0.8–14% of patients leading to poor graft and patient survival. It can either occur in a systemic form or renal limited TMA either occur as a recurrent disease or de Novo with later being more common. Post Transplant TMA can be caused by complement protein mutations drug induced Antibody mediated rejection infections. Patients improved with treatment of the etiological agent plasma exchange which usually improve the hematological abnormality or complement blockade with eculizumab.
AIMS OF THE STUDY: Our aim was to study the graft outcomes after TMA in Renal transplant recipients.
METHODS: This was a single centre Retrospective cohort study where 64 renal transplant recipients who developed biopsy proven TMA out of the 766 renal transplant done at our centre from Jan 2017 to Dec 2022. Data collected included demographic parameter creatinine Complete blood count and histopathology. Graft outcomes were defined based on the serum creatinine at last follow up.
CONCLUSION: TMA in the post transplant period is commonly associated with drug toxicities, ABMR, or recurrent HUS. There is no correlation between drug levels and extent or prognosis of TMA. Change of CNI, Plasma exchange however remains the mainstay of the treatment.
15TH DECEMBER 2023
ABSTRACT NO. 10
INSIGHT INTO CLINICAL AND PATHOLOGICAL PERSPECTIVES OF RENAL ALLOGRAFT DYSFUNCTION: A 10-YEAR EXPERIENCE
V R Krishnakumar, T P Noushad 1 , R Sajeevkumar 1 , Noble Gracious 1 , Vineetha 1
Departments of Nephrology and 1 Government Medical College; Thiruvananthapuram, Kerala; India
E-mail: krishnakumarvylapally@gmail.com
BACKGROUND: Renal allograft dysfunction remains a significant challenge in kidney transplantation as highlighted by a decade-long single-center experience. The complexity and impact of this issue stem from a diverse range of native kidney diseases and donor characteristics emphasizing the need for personalized management strategies. Detecting problems early and implementing targeted interventions are vital for improving graft survival and patient well-being. To enhance transplant protocols and patient care further research and collaboration are essential with the aim of achieving better graft outcomes in the future. Additionally exploring the potential of NLR and Banff scores in multicenter studies can provide deeper insights into their role in understanding and managing renal allograft dysfunction.
AIMS OF THE STUDY: Characterize Clinicopathological Profiles of kidney transplant recipients experiencing allograft dysfunction including demographic data transplantation history and clinical presentations. Correlate Clinical Data with Biopsy Findings: Analyze renal biopsy results and correlate them with clinical data including immunosuppressive regimens donor information Identify Underlying Causes: Determine the underlying causes of renal allograft dysfunction in the study population distinguishing between rejection infection drug toxicity and other factors.
METHODS: This retrospective single-center study was conducted at Government Medical College Thiruvananthapuram focusing on renal allograft biopsies spanning from 2012 to 2023 as documented in the department records. To ensure the completeness of our dataset missing data from these biopsies were meticulously collected through a combination of telephone inquiries and patient visits to the Transplant Outpatient Department (OPD). This comprehensive approach allowed us to compile a robust and detailed dataset providing a solid foundation for our analysis of renal allograft dysfunction over the specified timeframe.
CONCLUSION: Renal allograft dysfunction remains a significant challenge in kidney transplantation, as highlighted by a decade-long single-center experience. The complexity and impact of this issue stem from a diverse range of native kidney diseases and donor characteristics, emphasizing the need for personalized management strategies. Detecting problems early and implementing targeted interventions are vital for improving graft survival and patient well-being. To enhance transplant protocols and patient care, further research and collaboration are essential, with the aim of achieving better graft outcomes in the future. Additionally, exploring the potential of NLR and Banff scores in multicenter studies can provide deeper insights into their role in understanding and managing renal allograft dysfunction.
15TH DECEMBER 2023
ABSTRACT NO. 11
CLINICOPATHOLOGICAL PROFILE AND HEMATO-RENAL OUTCOMES OF LARGEST BIOPSY COHORT OF RENAL AMYLOIDOSIS FROM SOUTH ASIA
Rizwan Alam, Elenjickal Elias John, Sanjeet Roy, Selvin Sundar Raj, Joseph Johny, Manish Lalwani, Nisha Jose, Sabina Yusuf, Jeethu Joseph Eapen, Athul Thomas, Vinoi George David, Santosh Varughese, Suceena Alexander
Department of Nephrology; CMC; Vellore; Tamil Nadu; India
E-mail: rizwangb0557@gmail.com
Kidney is the most common organ involved in systemic amyloidosis. This study reports the clinicopathological outcomes of the largest series of renal amyloidosis from South Asia.
To study the Clinicopathological Profile and Hemato-renal Outcomes of renal amyloidosis in a tertiary care centre from South Asia.
This retrospective biopsy registry cohort included 260 consecutive patients of renal amyloidosis who underwent kidney biopsy between January 2005 to December 2022 at our tertiary care hospital in South India.
The mean age of the cohort was 52.5 ± 11.3 years and 175/260 (67.3%) were males. The type of amyloid was immunoglobulin (Ig) amyloidosis in 190 (73.1%), AA amyloidosis in 40 (15.4%) and unclassified in 30 (11.5%) patients. AL was the predominant type of Ig amyloidosis (186/190, 97.9%). Extrarenal involvement was seen in 59 (22.7%) patients. The most involved extrarenal organs were cardiovascular (42/260, 16.1%) and gastrointestinal (14/260, 5.4%) system. Rheumatological diseases constituted the commonest etiology of AA amyloidosis (20/40, 50%). Patients of Ig amyloidosis had more proteinuria [5.1 (IQR, 3.2-7.2) versus 3.7 (IQR, 1.9-8.1) g/day] but higher eGFR [68.2 (IQR, 35.9-100.3) versus. 28.4 (IQ R, 17.3-59.8) ml/min/1.73 m] than patients with AA amyloidosis at presentation. Among the patients of Ig amyloidosis, M band on electrophoresis was seen in 78/90 (86.7%), abnormal IFE in 93/165 (56.4%), abnormal kappa: lambda ratio in 99/165 (60%) and 24.2 % (46/190) patients met the criteria of multiple myeloma. Amyloid deposits were seen universally within the glomeruli; 206/260 (79.2%) and 88/260 (33.8%) had additional vascular and interstitial deposits. Forty-one percent (104/290) received RAAS inhibitors and 73% of patients with Ig amyloidosis received CyBorD chemotherapy regimen. Of the 116 patients with follow-up details more than 3 months, 21(18.1%) progressed to kidney failure, 86/98 (87.7%) had persistent proteinuria and 32/43 (74.4%) patients of Ig amyloidosis attained a hematologic response VGPR. Only 1/32 (3.1%) patients who attained hematological response VGPR progressed to kidney failure. Sixteen patients (13.7%) died during the follow-up period due to infections and cardiovascular disease.
Majority of cases of renal amyloidosis are Ig derived. Attainment of VGPR is associated with better renal response.
15TH DECEMBER 2023
ABSTRACT NO. 12
EXPANDING THE DONOR POOL IN RENAL TRANSPLANTATION: COMPARISON OF OUTCOME BETWEEN DECEASED DONOR PAIRED KIDNEY EXCHANGE AND ABO INCOMPATIBLE TRANSPLANTATION - SINGLE CENTER EXPERIENCE
Aparna Balachandran, Sajith Narayanan, N A Ismail, Feroz Aziz, B Sreejesh, A Thushara
Department of Nephrology; Aster MIMS Hospital; Kozhikode; Kerala; India
E-mail: aparnabhay@gmail.com
BACKGROUND: Transplant programs are forced to pursue ABO-incompatible (ABOiTX) and Paired kidney exchange (PKE) as the deceased donor program (DDKT) has been unpredictable. Immunological and logistic challenges of ABOiTX and PKE make it difficult to be done as routine.
AIMS OF THE STUDY: We aim to compare the outcome of DDKT ABOiTX and PKE with respect to renal function incidence of acute rejections (AR) death censored graft survival (DCGS) and patient loss (PL).
METHODS: Retrospective observational study from 2012 to 2022. We have reviewed the data of ABOiTX or PKE or DDKT from our institute during the study period. Incidence of AR Graft Loss (GL) or PL were compared.
CONCLUSION: The long-term results show the feasibility of expanding donor options. PKE and ABOiTx have better graft survival compared to DDKT. PKE has better death censored graft survival compared to ABOiTx. PKE helps to transplant sensitized patients without increased risk of allograft AR. Better allocation criteria may help in improving DDKT outcomes.
15TH DECEMBER 2023
ABSTRACT NO. 13
PROFILE OF RENAL RE-TRANSPLANTATION IN A TERTIARY CARE CENTER IN SOUTH INDIA: A SINGLE CENTRE EXPERIENCE.
Kiran Ravi, Kartik Ganesh, Jitin S Kumar, Sunita Simon, M Abi Abraham
VPS Lakeshore Hospital and Research Center; Kochi; Kerala; India
E-mail: kiransark26@gmail.com
BACKGROUND: Advances in immunosuppression have prolonged the life of renal allografts although not indefinitely. Acute organ shortage has lead to increasing demand for renal re-transplantation all over the world. Many studies report inferior outcomes compared to primary transplantation. The cause for inferior outcomes reported to be due to increased duration of dialysis after graft failure to retransplantation acute rejections vascular thrombosis infections smoking recipient age and comorbidities. We report our experience with renal retransplants at our centre.
AIMS OF THE STUDY: To study the clinical profile of renal re-retransplantation done atVPS Lakeshore hospital and Research Centre Kochi from 2008 to 2022. To analyse graft survival and patient survival after renal retransplantation. To analyse post transplant infections. To analysethe desensitization protocols followed To compare the graft survival and patient survival of retransplant recipients with the primary transplant recipients in the same time period.
METHODS: A Retrospective analysis of all patients who underwent renal retransplantation from January 1 2008 to August 31 2022 at VPS Lakeshore Hospital and Research Centre Kochi was carried out. All patients were monitored for their graft function at 1 year 3rd year and fifth year. All biopsy proven rejection episodes opportunistic infections were also studied. Graft survival was defined as the time from transplantation until dialysis requirement. Patient survival was defined as the time from transplantation to death of the patient with or without a functional graft.
CONCLUSION: Kidney re-transplantation has comparable long-term outcomes to primary transplantation. Due to the good long-term outcome, patients with transplant failure should be offered re-transplantation at the earliest.
15TH DECEMBER 2023
ABSTRACT NO. 14
OUTCOMES OF T-CELL MEDIATED REJECTION-SINGLE CENTRE STUDY
S Vishnu Shankar, R Balasubramaniyam, Balaji Kirushnan
Department of Nephrology; Kauvery Hospital Alwarpet; Chennai; Tamil Nadu; India
E-mail: shankar.vishnu2011@gmail.com
BACKGROUND: Rejection of the transplanted kidney remains the most important cause of graft loss. T-cell mediated or cellular and antibody mediated or humoral. T-cell mediated rejection (TCMR) is most common can be EARLY or LATE cellular rejection. Tubulo-interstitial infiltration with lymphocytes/monocytes and macrophages commonly. IFTA is seen in chronic rejection. Low immunosuppressant Non-compliance or viral infections. Hence we aimed at studying the different patterns precipitating factors and outcomes of TCMR in our institution.
AIMS OF THE STUDY: (1) To study the pattern of Cell mediated rejection in renal allografts (2) To assess the short term and long term outcomes in these patients and its correlation with induction agent.
METHODS: Retrospective analysis Clinical characteristics laboratory data renal biopsy reports precipitating factors treatment modalities and follow up data. The study period was between March 2015-July 2023 Inclusion criteria: Biopsy proven T-cell mediated rejection. Exclusion criteria: Combined ABMR and T-cell mediated rejection. Pearson chi-square test.
CONCLUSION: All patients with Cell mediated rejection was treated with Methylprednisolone pulse therapy for 3 days at the dose of 500/day. Serial monitoring of Serum Creatinine was done Patients in whom serum creatinine did not show improvement with pulsing steroids and BANFF 2A were treated with ATG S. Creatinine reached pre-rejection levels in 60% who showed improvement. TCMR is most common cause of rejection. Responsible for graft loss. In our study we analysed various factors like live/deceased donor, induction agent use, precipitating factors and grades of TCMR. Low tacrolimus level were seen in 5 (30%) pts.
15TH DECEMBER 2023
ABSTRACT NO. 15
RIGHT EXTERNAL JUGULAR VEIN AND LEFT INTERNAL JUGULAR VEIN AS ALTERNATIVE ACCESS FOR RIGHT INTERNAL JUGULAR VEIN FOR TUNNELED DIALYSIS CATHETER: A PROSPECTIVE COMPARATIVE STUDY
Vineet Behera, K P Rohith, P Chauhan, R Sivasankar, R Ananthakrishnan
INHS Asvini; Mumbai; Maharashtra; India
E-mail: beheravineet@gmail.com
BACKGROUND: Right internal jugular vein (RIJV) is the commonest site for tunneled dialysis catheter (TDC). After exhaustion of RIJV left internal jugular vein (LIJV) right external jugular vein (REJV) or other veins may be used. This prospective study compared the clinical profile and outcomes of TDC in REJV vs LIJV.
AIMS OF THE STUDY: To Compare the Right External Jugular Vein and Left Internal Jugular vein as Alternative Access for Right Internal Jugular vein for Tunneled Dialysis Catheter.
METHODS: A prospective non-randomized single centre study included ESRD patients on with TDC with exhausted RIJV while patients with SVC occlusion or unwilling were excluded. Patients with patent REJV/right BCV underwent REJV TDC. Patients with occluded REJV/right BCV underwent LIJV TDC. Primary outcome was cumulative catheter patency (insertion to removal of TDC) while secondary outcomes was primary catheter patency (insertion to TDC catheter dysfunction) and CRBSI. Appropriate IEC approval and patient consent was obtained. Patients were followed up for minimum 1 year.
CONCLUSION: Rt EJV access is superior to left IJV as an alternate insertion route for TDC in patients on hemodialysis with exhausted RIJV.
15TH DECEMBER 2023
ABSTRACT NO. 16
URINARY EXOSOMAL MIRNA SIGNATURE OF IGA NEPHROPATHY: A CASE-CONTROL STUDY
Mythri Shankar, Aditya Shetty, N S Madhura, C G Sreedara, A Kishan, Girish Reddy
Department of Nephrology; Institute of Nephrourology; Bengaluru; Karnataka; India
E-mail: mythri.nish@gmail.com
BACKGROUND: IgA nephropathy is the most common primary glomerulonephritis worldwide and can progress to end-stage kidney disease (ESKD). The current gold standard for diagnosis is kidney biopsy which is invasive and associated with morbidity. miRNAs are small non-coding endogenous RNA that may serve as non-invasive biomarkers and that are found in urinary exosomes. Thus far there are a paucity of studies of the miRNA profile for the diagnosis of IgA nephropathy.
AIMS OF THE STUDY: Hence we aimed to study the urinary exosomal miRNA signature of Indian patients with IgA nephropathy.
METHODS: Fifty biopsy-proven IgA nephropathy patients 50 healthy controls and 25 patients with ESKD (due to IgA) were recruited over 2 years (2020-2022). Urinary exosomes were isolated from which miRNA was extracted. Analysis of urinary exosomal miRNA was done using the digital multiplexed nCounter® human v3 miRNA Expression Assay which contains 799 unique miRNA barcodes. Candidate miRNAs were identified using Lasso regression and consensus clustering.
CONCLUSION: This study of indian patients identified that there was a significant difference in the urinary exosomal miRNA profile between patients with IgA nephropathy and healthy controls, suggesting that miRNAs may be valuable in the non-invasive diagnosis of IgA nephropathy.
15TH DECEMBER 2023
ABSTRACT NO. 17
CHANGES IN PLASMA PROTEOMIC PROFILING AFTER LIVING KIDNEY DONATION: A PILOT STUDY
Kajal Kamboj, Manshi Rana, Jaskiran Kaur, Sachin Naik, Vivek Kumar, Ashok Kumar Yadav
Department of Nephrology; PGIMER; Chandigarh; India
E-mail: nadhakajal@gmail.com
BACKGROUND: The adaptive changes after nephrectomy may play an important role in predicting long-term kidney function in living kidney donors however the exact adaptive process and factors affecting the process still remain obscure. It has been hypothesized that changes in the plasma protein after nephrectomy is often associated with kidney adaptation and as well as kidney function. There is a critical need for the development of biomarkers to assess kidney function after nephrectomy. Plasma proteomics has become a powerful tool for novel biomarker discovery in kidney disease. This is a pilot study focused on the individual integrative large-scale approach that may generate significant additional insight into renal adaptation after living kidney donation.
AIMS OF THE STUDY: To study the changes in plasma proteomic profiling six months after living kidney donation.
METHODS: This was a prospective observational cohort study conducted at PGIMER Chandigarh. In this study we analysed plasma proteome of 12 healthy kidney donors before as well as after 6 months of living kidney donation. Participants were followed up at 6 months after surgery. Clinical and biochemical characteristics were recorded at baseline and at 6 months follow up. Plasma proteomics was studied using high resolution Liquid Chromatography Mass spectrometry/Mass spectrometry (LC-MS/MS) analysis using Thermo Scientific™ Orbitrap Fusion™ Tribrid™ mass spectrometer to identify differentially expressed proteins (DEPs). GeneOntology database was used for involvement of DEPs either in normal kidney metabolic pathway or in kidney related diseases.
CONCLUSION: The data from this pilot study indicates that there are some proteins which may have an important role in compensatory kidney growth post nephrectomy in living kidney donors. However, this is the pilot study and finding of this study needs validation in larger cohort of living renal donors.
15TH DECEMBER 2023
ABSTRACT NO. 18
A STUDY OF THE ASSESSMENT OF VOLUME STATUS IN CKD PATIENTS ON HEMODIALYSIS BY LUNG ULTRASONOGRAPHY
Beningwar Jimmy Hulang, Abhiit Taraphder
Department of Nephrology; Apollo Multispecialty Hospital; Kolkata; West Bengal; India
E-mail: manish_dr_jain@yahoo.in
BACKGROUND: Assessing extracellular fluid volume is one of the most difficult tasks for physicians caring for hemodialysis (HD) patients. The study explores the feasibility and utility of Lung ultrasonography (USG) for evaluation of volume status in Chronic Kidney Disease (CKD) Patients on hemodialysis (HD).
AIMS OF THE STUDY: To assess the feasibility of using Lung USG as a method to evaluate the volume status of hemodialysis dependent CKD patients and its correlation with IVC diameter and clinical parameters.
METHODS: A cross-sectional study was performed on all consenting adult CKD patients on maintenance hemodialysis (MHD). Lung USG evaluation of B-Lines was the primary study and its relevance with respect to assessment of volume status was compared with Inferior Vena Cava (IVC) diameter Weight Blood Pressure (BP) and clinical parameters.
CONCLUSION: Lung USG B-lines can be used to evaluate volume status of CKD patients on MHD with the additional possibility of using it as a method of determining a person’s dry weight.
15TH DECEMBER 2023
ABSTRACT NO. 19
INFECTION RELATED GLOMERULONEPHRITIS CO-EXISTING WITH DIABETIC NEPHROPATHY ON RENAL BIOPSY: SGPGI LUCKNOW EXPERIENCE
Sonal Tripathi, Sumeet Narain, Dharmendra Bhadauria, Narayan Prasad, Manoj Jain
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: mnjjain@yahoo.com
BACKGROUND: Infection-related glomerulonephritis (IRGN) is a condition where the immune response triggered by infection damages the glomerulus. Elderly individuals especially those with compromised immune systems like diabetics have an elevated risk of IRGN following infections. However few cases of IRGN coexisting with diabetes have been reported in medical literature.
AIMS OF THE STUDY: This study aims to investigate the incidence and clinical-pathological characteristics of patients with both IRGN and diabetic nephropathy identified through renal biopsies at a tertiary care center in north India.
METHODS: Retrospective analysis of native kidney biopsies between January 2018 and May 2023 revealed seven cases of IRGN with diabetic nephropathy. Clinical data were obtained from hospital records and renal biopsy slides immunofluorescence and electron microscopy findings were reviewed.
CONCLUSION: Elderly patients with diabetes and history of infection, presenting with acute kidney injury, should raise a suspicion of IRGN. Timely kidney biopsy and histological characterization are crucial to provide immediate treatment and mitigate further complications.
15TH DECEMBER 2023
ABSTRACT NO. 20
A PROSPECTIVE OBSERVATIONAL STUDY TO ASSESS THE OUTCOMES OF TUNNELLED DIALYSIS CATHETERS INSERTED BY NEPHROLOGISTS IN PATIENTS ON HEMODIALYSIS
Pooja P Lokkur, Manish Jain, Dinesh Kumar Yadav, Shyam Bansal, Amit Mahapatra, Dinesh Bansal, Abhyuday Singh Rana, Ankur Mittal
Department of Nephrology; Medanta - The Medicity; Gurgaon; Haryana; India
E-mail: pooja.lokkur@gmail.com
BACKGROUND: Majority of patients with kidney disease present to nephrologists as Chronic Kidney disease (CKD) stage 5-requiring dialysis thereby making planned dialysis initiation difficult. Tunnelled dialysis catheters (TDCs) though not ideal are a “necessary evil” as they form a bridge before AV Fistula (AVF) or transplant. There are several advantages of tunnelled dialysis catheter insertion by Nephrologists like rapid access better understanding of vascular access needs and streamlined care process. This study was conducted to determine the outcomes of tunnelled dialysis catheter (TDC) insertion by nephrologists.
AIMS OF THE STUDY: To determine catheter survival rates number of days on catheter complications and infection rates in tunnelled hemodialysis catheters inserted by nephrologists. To assess factors involved in elective/emergency removal of tunnelled hemodialysis catheters.
METHODS: This was a single-centre prospective observational study of patients with end-stage renal disease who underwent a tunnelled dialysis catheter insertion by nephrologists between August 2021 and August 2022 at our institution. Analysed data included clinical background demographics functioning of catheter complications if any reason for removal and catheter survival.
CONCLUSION: There are several advantages of TDC insertion by nephrologists. With an active role and responsibility of vascular access creation, nephrologists get better idea about the vascular access needs of their patients. Care will not compartmentalised across various disciplines. Tunnelled dialysis catheter insertion by nephrologists has a good success rate and safety profile with lesser cost. Our study thereby shows that TDC insertion by nephrologists is safe and effective with outcomes comparing favourably to those reported in the literature.
15TH DECEMBER 2023
ABSTRACT NO. 21
INCIDENCE PREDICTORS AND OUTCOME OF ACUTE KIDNEY INJURY IN POST CARDIAC SURGERY AT TERTIARY CARE HOSPITAL
Gaurav B Modi, Aakash A Upadhyay, Manoj R Gumber
Department of Nephrology; Apollo Hospitals International Limited; Ahmedabad; Gujarat; India
E-mail: gauravmodi912@gmail.com
BACKGROUND: Acute kidney injury (AKI) is a common complication after cardiac surgery incidence of which varies from 7% to 40%. This prospective observational study was conducted in the Department of Nephrology Apollo Hospital International Limited Gandhinagar.
AIMS OF THE STUDY: To assess the incidence predictors and outcome of acute kidney injury in the patients undergoing cardiac surgery in the post operative period.
METHODS: Prospective Observational Study included 100 adult patients who underwent emergency or elective cardiac surgical procedure including those with pre-existing chronic kidney disease not requiring haemodialysis.
CONCLUSION: Incidence of AKI is 30% in post cardiac surgery patients with no preponderance of specific age group or gender. Significant association of comorbidities like diabetes mellitus, hypertension, COPD, dyslipidemia was seen. Statistically significant factors in development of AKI in post cardiac surgery patients are emergency surgeries, duration <7 days from previous CAG, H/O contrast induced nephropathy, On pump surgery, High CPB time and aortic cross clamping time. Patients with AKI had longer hospital stay and higher 30-day mortality rate than non-AKI group.
15TH DECEMBER 2023
ABSTRACT NO. 22
CLINIC-EPIDEMIOLOGICAL SPECTRUM OF ACUTE KIDNEY INJURY IN PATIENTS WITH CIRRHOSIS
Himanish Goswami, T Das, M Bora, D J Choudhury, P Medhi
Department of Nephrology; Apollo Hospitals; Guwahati; Assam; India
E-mail: himanish19@gmail.com
BACKGROUND: Acute Kidney Injury (AKI) is a critical complication that frequently occurs in cirrhotic patients and significantly impacts their prognosis. Cirrhosis is often accompanied by hemodynamic alterations splanchnic vasodilation and increased susceptibility to infections all of which can contribute to AKI development. Understanding the risk factors mechanisms and outcomes of AKI in cirrhotic patients is essential for guiding clinical management and improving patient outcomes.
AIMS OF THE STUDY: Our study aims to look at the prevalence risk factors etiology clinical outcomes and predictive factors of Acute Kidney Injury in patients with cirrhosis. The study also seeks to identify the impact of AKI on the overall prognosis and survival of cirrhotic patients.
METHODS: The study was a retrospective study over a period of 6 months. It included patients with cirrhosis over the age of 18 years with or without AKI at admission but with no known background chronic kidney disease. AKI was defined according to the KDIGO criteria. Clinical records laboratory results imaging reports and patient demographics were collected and analysed using appropriate statistical tests.
CONCLUSION: AKI following advanced liver cirrhosis is a critical condition. Our study sheds light on the common causes and risk factors associated with AKI development which can help us prevent and mitigate these factors. Patients with AKI had worse clinical outcomes and increased mortality rates. Early recognition and management of risk factors may help mitigate the burden of AKI in cirrhotic patients and improve overall prognosis.
15TH DECEMBER 2023
ABSTRACT NO. 23
PRE AND EARLY POSTOPERATIVE ULTRASOUND IN PREDICTING FISTULA FAILURE IN CHRONIC KIDNEY DISEASE PATIENTS
Shikhar Gupta, Mehtab Ahmed 1 , Sayema 1 , Azam Haseen 2 , Saif Quaiser 3
Departments of Radiology, 1 Radiodiagnosis and 2 CTVS; Jawaharlal Nehru Medical College; 3 Nephrology Unit; Department of Medicine; Jawaharlal Nehru Medical College; Aligarh; Uttar Pradesh; India
E-mail: drssaif@gmail.com
BACKGROUND: The increasing prevalence of chronic kidney disease (CKD) coupled with advancements in the diagnosis and treatment of renal diseases and improvements in life expectancy has led to a greater number of patients requiring hemodialysis. The preferred method of vascular access for hemodialysis is arteriovenous fistula (AVF) formation; however it is associated with a high rate of failure.
AIMS OF THE STUDY: In our prospective study we focused on ultrasound Doppler-based AVF blood flow assessment using various standard assessment parameters preoperatively in 40 CKD patients. planned for initiation of maintenance hemodialysis. The primary objectives of our study were: (1) To measure the AVF blood flow during early postoperative period (7”14 days) (2) To evaluate the performance of AVF blood flow during early postoperative periods for predicting fistula failure and determine optimal cutoff value.
METHODS: We employed preoperative ultrasound mapping to assess cephalic vein diameter compressibility and colour flow as well as radial and brachial artery diameter peak systolic velocity and intimal wall calcification. Postoperatively ultrasound examinations were conducted on day 7 and at 6 weeks to evaluate fistula blood volume and detect any complications.
CONCLUSION: Preoperative vessel mapping and early postoperative ultrasonography are indispensable for patients who require AVF formation for hemodialysis and provide valuable information for selecting suitable vessels for successful fistula creation and enable early intervention to salvage a failing fistula after the surgery. By utilizing this, necessary steps can be taken to optimize the outcomes of AVF formation.
15TH DECEMBER 2023
ABSTRACT NO. 24
ATYPICAL HEMOLYTIC UREMIC SYNDROME - A CASE SERIES FROM A TERTIARY CARE HOSPITAL FROM NORTH INDIA
Shailendra Kumar Tiwari, Abhilash Chandra, S Namrata Rao, Shakeb Ahmad, Pratyush Kumar
Department of Nephrology; Dr. Ram Maohar Lohiya Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: drsktiwarikgmu@gmail.com
BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is primarily caused by dysregulation of the complement alternative pathway due to genetic mutations mainly in complement factor H genes or due to anti-factor H autoantibodies (anti-FH) leading to uncontrolled overactivation of the complement system. Anti FH associated aHUS is a/w better prognosis in the short-term with renal recovery seen in a 60% of patients even in settings where eculizumab is unavailable for use. However the intermediate and long-term follow-up of this disease are presently unclear.
AIMS OF THE STUDY: The aim of the study was to study the follow-up of patients diagnosed with aHUS at one year after the index presentation. The primary outcome of the study was to determine the clinical outcomes at 1 year in patients managed for aHUS. The outcomes studied included: death dialysis-dependence recurrence of aHUS and serum creatinine at 1 year post-discharge. The baseline characteristics and clinical outcomes were then compared in the groups with and without anti-FH Abs. Statistical analysis was carried by SPSS software version 26 IBM corporation.
METHODS: This is a single-centre retrospective observational study of aHUS treated between August 2021 to August 2022 at a tertiary care public sector hospital in Northern India. It was a retrospective study based on hospital records. Patients were diagnosed as aHUS based on clinical and biochemical parameter and standard initial treatment followed included PE steroids. In case of anti FH aHUS additional therapy with cyclophosphamide or rituximab was added in follow-up with 3-monthly monitoring of anti FH Abs until 1 year.
CONCLUSION: While short-term results of PE, steroid based therapies are satisfactory in aHUS patients, the subset of anti FH Abs positive aHUS in the present study was a/w poorer intermediate and long-term prognosis. This requires careful prospective evaluation in future studies.
15TH DECEMBER 2023
ABSTRACT NO. 25
THE CHANGING LANDSCAPE OF POSTPARTUM AKI IN THE CONTEMPORARY SETTING
Rachana Shenoy, A Kaul
Department of Nephrology; SGPGIMS; Lucknow; Uttar Pradesh; India
E-mail: rachanashenoy.k@gmail.com
BACKGROUND: Acute kidney injury (AKI) occurring in the postpartum period is fairly prevalent and may be associated with significant morbidity and mortality in young and often otherwise healthy women. With increasing age during pregnancy higher non-communicable disease prevalence like DM HTN and obesity use of artifical reproductive technology and multifetal gestations there is a tendency for more severe AKI in this cohort.
AIMS OF THE STUDY: To assess prognostic factors determining renal recovery and factors associated with dialysis-dependency in PPAKI in a single centre at a tertiary care hospital in North India.
METHODS: Retrospective single centre study including all patients with Postpartum AKI admitted to Nephrology services at our centre during 10 years- 2013-2022. Demographic clinical and laboratory data of the patients were collected from electronic medical records and telephonically. Outcome variables including maternal and fetal mortality with renal outcomes at discharge were analysed.
CONCLUSION: There is a changing spectrum with shift from septic abortions and puerperal sepsis to TMA and glomerular diseases causing PPAKI highlighting improvement in obstetric practices. In our study, presence of oligoanuria, high LDH, schistocytes on smear, low C3 and C4, ANCA positivity, dialysis dependency at presentation with advanced renal failure (eGFR <30) and cortical necrosis were found to be associated with poor renal recovery and dialysis-dependency. Postpartum AKI was associated with overall mortality of 13% and poor renal recovery.
15TH DECEMBER 2023
ABSTRACT NO. 26
SAFETY AND OUTCOME OF PERCUTANEOUS KIDNEY BIOPSIES IN MECHANICALLY VENTILATED PATIENT
Prabhav Bhansaly, Arun Prabhakar, Vivek Kumar
Department of Nephrology; Post Graduate Institute of Medical Education and Research; Chandigarh; India
E-mail: prabhavbhansaly@gmail.com
BACKGROUND: The most common cause of Hospital acquired AKI in a ICU setup is Acute Tubular necrosis which requires only supportive care. But often ICU patients can also be affected by other forms of AKI requiring specific interventions like pulmonary renal syndromes thrombotic microangiopathies and glomerulonephritis. Pulmonary renal syndromes may sometimes present with diffuse alveolar hemorrhage acute respiratory failure or hemorrhagic shock require mechanical ventilation. There is low correlation between clinical diagnosis and histopathological diagnosis and thus renal biopsy becomes a tool for definitive diagnosis to instill definitive therapy. Safety and outcome data for biopsies in ventilated patients are almost a decade old. New data on safety and outcomes are necessary with sophisticated ventilators and better portable ultrasounds makes biopsies much less cumbersome and safe then previously.
AIMS OF THE STUDY: To evaluate safety and outcome of bedside percutaneous kidney biopsies in critically ill mechanically ventilated patients.
METHODS: Retrospect data from all bedside biopsies done in PGIMER under department of Nephrology were collected. Demographic data weight clinical syndromic diagnosis pre biopsy treatment given pre and post biopsy histopathological diagnosis ventilatory support inotropic requirements fractional oxygen requirements vitals during biopsy as well as post biopsy post biopsy ultrasound for hematoma blood transfusion requirements and other complication were recorded. Outcome post biopsy and at 90 days were also recorded. Data were analyzed for safety treatment change and outcome.
CONCLUSION: Bedside biopsy using prone position, using inspiratory maneuvers in ICU are safe procedure and can add significantly value to management of critically ill.
15TH DECEMBER 2023
ABSTRACT NO. 27
IMPACT OF DEMOGRAPHIC PROFILE AND SOCIO-ECONOMIC STATUS ON INFECTIVE COMPLICATIONS AND OUTCOMES IN LUPUS NEPHRITIS
Nikhil Ingle, Arunkumar Subbiah, R K Yadav, S Bagchi, Geetika Singh, Adarsh Barwad, S Mahajan, D Bhowmik, S K Agarwal
Departmnt of Nephrology; All India Institute of Medical Sciences; New Delhi; India
E-mail: nikhilingle46@gmail.com
BACKGROUND: Lupus Nephritis involves all spectrum of patients from all the age groups and different socioeconomic strata. Data on correlation between the socioeconomic status with outcome and infective complications is sparse.
AIMS OF THE STUDY: To study the demographic and socioeconomic distribution amongst patients of Lupus Nephritis and to assess their correlation with outcome and infective complications.
METHODS: This ambispective study included patients of lupus nephritis diagnosed between 2018 and 2023 and on regular follow-up at AIIMS New Delhi. The demographic data including the socioeconomic status data (as per Modified Kuppuswamy scale 2018) was collected along with laboratory parameters infectious complications and disease outcomes on follow-up. The primary objective of this study was to assess the correlation of the demographic profile and socioeconomic status with patient outcomes.
CONCLUSION: Socioeconomic status of the patient affected patient outcomes with respect to remission as well as the infective complications. The study also showed significant correlation between the gender and the outcome of the patients with Lupus Nephritis.
15TH DECEMBER 2023
ABSTRACT NO. 28
CONSERVATIVE VERSUS MINIMALLY INVASIVE UROLOGICAL INTERVENTION FOR TREATMENT OF ACUTE NON OBSTRUCTIVE PYELONEPHRITIS - A COMPARATIVE STUDY
R S Vishnuvarthan, Raniya, Ramprabahar, Jayanivash, Sathaiyan
Nephrology; SIMS Hospital; Chennai; Tamil Nadu; India
E-mail: drjayanivash@yahoo.in
BACKGROUND: There has been a paradigm shift in clinical manifestations/renal outcomes of patients with acute bacterial pyelonephritis with Acute Kidney Injury (AKI) being a common manifestation. The standard of care is a conservative one with parenteral antibiotics for duration of 2-3 weeks. However there is a school of thought that minimally invasive urological intervention - (Cystoscopy guided DJ stenting) together with antibiotics is of added benefit. The literature supporting the above is scarce.
AIMS OF THE STUDY: (1)To compare the renal outcomes in patients with acute non obstructive pyelonephritis who underwent CONSERVATIVE management vs MINIMALLY INVASIVE UROLOGICAL intervention for the same. (2) To assess the incidence of AKI secondary to Acute non obstructive pyelonephritis in a Tertiary care hospital.
METHODS: (1) A retrospective observational analysis of the acute non obstructive pyelonephritis patients admitted in SIMS Hospital between Jan 2021 and Dec 2022 was done. (2) A subgroup head on comparison was done between KDIGO stage III AKI patients who underwent conservative vs minimally invasive urological intervention.
CONCLUSION: The incidence of AKI is significantly high even in acute non obstructive pyelonephritis in our study indicating paradigm shift in severity/renal manifestations over decades. Parenteral antibiotics continue to be the treatment of choice with this study revealing no added benefit of minimally invasive urological intervention.
15TH DECEMBER 2023
ABSTRACT NO. 29
STUDY OF RED CELL DISTRIBUTION WIDTH AND MEAN PLATELET VOLUME IN ACUTE KIDNEY INJURY
Sayantan Mukherjee, Anita Tahlan, Dinesh Walia
Department of General Medicine; Pathology-Hematology and Community Medicine; Government Medical College and Hospital; Chandigarh; India
E-mail: sanjaydcruz@gmail.com
BACKGROUND: Acute kidney injury (AKI) is one of the most frequently seen clinical syndromes in hospital settings and it is related to increased morbidity and mortality. AKI complicates 5-7% of acute care hospital admissions and up to 30% of admissions to the ICU. AKI carries not only high mortality but also is now recognized as an important risk factor for non-recovery of kidney function increasing incident chronic kidney disease (CKD) burden. Mean platelet volume (MPV) is the average platelet size with a value ranging from 7.2-11.2fL. It stands apart from platelet count as whatever the pathology high platelet turnover secondary to inflammation leads to increased MPV. However there is considerable variability in studies on MPV as a predictor of AKI with higher MPV associated with increased 28-day all-cause mortality and lower MPV associated with poorer outcomes and high dialysis requirements. Red Cell Distribution width - coefficient of variation (RDW-CV) measures the variability of red cell size and volume used to determine the causes of anemia. It has a normal value ranging from 11.6-14.6% in our laboratory. RDW also increases in inflammatory states and independently predicts mortality in AKI patients admitted in ICU and CCU. Serum creatinine and urine output are forerunners of the prognostic significance in AKI have been traditionally incorporated in the parameters defining and staging AKI. Apart from these validated tools in defining the severity and outcome of AKI estimation of RDW and MPV both individually and in combination might open new avenues in early detection and predictability of AKI and its prognostication.
AIMS OF THE STUDY: (1) To study red cell distribution width and mean platelet volume in patients with acute kidney injury in tertiary care hospital setting (2) To correlate RDW and MPV in predicting outcomes in patients of AKI. Predetermined outcome measures were requirement of dialysis death or discharge from hospital.
METHODS: The study was a prospective observational study spanning 18 months. Inclusion criteria: (1) Adult population (age more than 18 years) (2) All patients having AKI as per KDIGO guidelines. Exclusion criteria: (1) Patients diagnosed with CKD and those CKD patients on dialysis. (2) Patients with hematological disorders. (3) Patients with terminal malignancy. (4) Patients on chemotherapeutic agents or drugs causing bone marrow suppression. (5) Patients with a history of platelet transfusion within the last 24 hours. (6) Patients who were chronic smokers. (7) Patients who suffer from Crohns disease Systemic Lupus Erythematosus. Patients who meet the inclusion criteria and are willing were enrolled as study subjects. Complete data for 102 patients were available for evaluation. They were explained regarding the study and its purpose through patient information proforma and were enrolled after their written informed consent form. After enrolment the demographic data comprehensive history perform a complete physical examination were entered. Blood samples were collected from the subjects who met the inclusion criteria on days 0 1 3 5 and 7 and MPV and RDW were analyzed using the XN1000- Hematology Analyzer.
CONCLUSION: (1). Both RDW CV and MPV were significantly higher in patients with AKI as compared to normal lab values. (2) It was also observed that MPV was a more accurate predictor of AKI than RDW in people over the median age group of 45 years. (3) There was no correlation between RDW and MPV values insofar as need for dialysis was concerned. (4) There was a trend towards increased MPV in those patients who died, however the difference did not reach statistical significance. This result is similar to another study from India which looked at this aspect. (5) Further studies with higher sample size is needed to draw proper conclusions regarding the usefulness of RDW and MPV in prognosticating the outcomes in patients of AKI.
15TH DECEMBER 2023
ABSTRACT NO. 30
PREVALENCE OF DEPRESSION IN HEMODIALYSIS PATIENTS: PROSPECTIVE AND FOLLOW UP STUDY IN TERTIARY CARE HOSPITAL
Giribabu, Manisha Sahay, Kiranmai Ismail
Department of Nephrology; Osmania Medical College; Hyderabad; Telangana; India
E-mail: giribabugorakala@gmail.com
BACKGROUND: Even though depression is one of the most common psychiatric disorders it is under-recognized in hemodialysis (HD) patients. Existing literature does not provide enough information on evaluation of predictors of depression among HD patients. The objective of the current study was to determine the prevalence and predictors of depression among HD patients.
AIMS OF THE STUDY: To evaluate prevalence and predictors of Depression in hemodialysis patients.
METHODS: HADS questionnaire was used to assess the depression level among study participants. 200 maintenance hemodialysis patients were included in this study. Patients with physical and/or cognitive limitations that prevent them from being able to answer questions were excluded.
CONCLUSION: Depression was prevalent in the current study participants. Negative association observed between depression and hemodialysis patients. Patients timely intervention is necessary to enhance quality of life.
15TH DECEMBER 2023
ABSTRACT NO. 31
SPECTRUM OF BIOPSY PROVEN RENAL DISEASE IN CENTRAL INDIA : A TWO CENTRE STUDY
A V Vinay Kumar, Vinay Rathore, Prawash Choudhary, Saurabh Nayak
All India Institute of Medical Sciences; Raipur; Chhattisgarh; India
E-mail: vinaykumarav91@gmail.com
BACKGROUND: Renal Biopsy plays an indispensable role in diagnosis of glomerular tubulointerstitial and vascular disorders of kidney. Prevalence of various biopsy proven renal disorders varies with different geographical regions. Since there is a lack of renal registry at national and regional level the exact prevalence of various kidney disorders in India and regional variation of various kidney disorders is not clear yet. Lack of renal registry also makes it difficult to observe nationwide trends in renal disease over time. Renal biopsy is an indispensable tool for diagnosis of various renal disorders and also plays a role in assessment of disease activity responsiveness to various immunosuppressants and prognosis. In view of paucity of data from central India we have conducted a study on prevalence of biopsy proven renal disease over last 5 years (2017-2022) from 2 centres in Raipur Chhattisgarh India. AIIMS Raipur is a tertiary care centre in Chhattisgarh but also provides service to various regions from Maharashtra Odisha Andhra Pradesh Madhya Pradesh in Central India and renal biopsies data from Ramakrishna care hospitals from Raipur Chhattisgarh is also included in the study.
AIMS OF THE STUDY: To study the histopathological spectrum of primary and secondary renal diseases in Central India.
METHODS: A retrospective study of all the biopsies conducted in AllMS Raipur and Ramakrishna Care Hospital in Raipur Chhattisgarh was done for past 4 years (may 2017- June 2022). Relevant patient data was obtained from inpatient medical records. Patient data including like Age Sex presenting clinical syndrome serum creatinine 24-hour urinary protein at presentation and histological biopsy diagnosis was recorded. Histological Biopsy diagnosis was made by light microscopy and immunofluorescence in most of the patients and were correlated with clinical syndromic presentation. Light microscopy and Immunoflorescence was done on all samples and electron microscopy was done in few selected patients. A total of 920 renal biopsies were analysed in the study period. 120 Biopsies were discarded due to incomplete reports and allograft biopsies. 800 native kidney biopsies were included for final analysis. All the biopsies were done with real time ultrasound guidance using a 16 G automatic trucut biopsy gun with standard precautions. 2 cores were taken for each patient one for light microscopy in formalin and the other for immunofluorescence in michel’s transport media.
RESULT : During the 5-year study period 920 biopsies were conducted among which for 800 biopsies were native kidney biopsies and had adequate sample in both light microscopy and immunofluorescence for analysis. Among 800 biopsies 300 biopsies were conducted in Ramakrishna Care Hospital and 500 biopsies were conducted in AIIMS, Raipur. 45.6% (365) samples were from females and 54.4%(435) samples were from males. Majority of the patients 42.4%(339) belonged to 20-39 years age group. Mean Age of the study population is 33.89 ± 16.09 years ranging from 1-78 years. Mean size of the tissue core taken for biopsy is 0.89 ± 0.39 cm. 720 (90%) of patients presented with pedal edema. 360 (45%) of patients presented with Hypertension. 398 (49.9%) patients were clinically categorized to Nephrotic syndrome, 247 (30.9%) to Nephritic syndrome and 65 (8.1%) with Acute kidney injury (AKI). 724 (90.5%) of the patients had glomerular disorders and 53 (6.6%) patients had tubulointerstitial disorders and 23(2.9%) had vascular pathology. Among Primary glomerular diseases MGN is the most common pathology accounting for 124(26.8%) cases followed closely by MCD 110(23.8%) cases, IgAN 106(22.9%) cases and FSGS 98(21.2%) cases. Among secondary glomerular diseases Lupus Nephritis is the most common disease accounting for 139(54.5%) cases followed by idiopathic immune complex DPGN 41(16.1%) cases and DN (15.7%) cases. Amyloidosis accounted for 14(5.5%) cases. Nephrotic Syndrome is the most common clinical syndrome (around 50%) of presentation in all age groups followed by Nephritic syndrome. Most common biopsy diagnosis in <20 years is Lupus Nephritis, 20-39 years is Lupus Nephritis, 40-59 years and >60 years age group is Membranous Nephropathy
CONCLUSION: The histopathological spectrum of biopsy proven renal disorders varies with different races, geographical regions and within India, as India is a culturally and geographically diverse nation. We found MGN as the most common primary glomerular disease in the renal biopsies in Central India. Lupus Nephritis is the most common secondary glomerular disorder followed by Diabetic Nephropathy. A central registry for Kidney biopsy is needed to circumvent the heterogeneity in the biopsy data.
15TH DECEMBER 2023
ABSTRACT NO. 32
ROLE OF PLASMA EXCHANGE IN MULTIPLE MYELOMA - A RETROSPECTIVE STUDY FROM SINGLE CENTER
Shivani Kanwal, S Namrata Rao, Abhilash Chandra, Manoj Dhanorkar, Vinay Sagar
Dr. Ram Manohar Lohia Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: kanwalshivani2017@gmail.com
BACKGROUND: Renal failure in multiple myeloma is a frequent complication and has a significant impact on overall survival. Severe degree of renal failure and dialysis dependency are associated with poor outcomes despite adequate chemotherapy. The role of plasmapheresis is still undefined in the era of bortezomib-based anti-myeloma therapies and therefore this study was undertaken.
AIMS OF THE STUDY: The aim of the present study was to examine the efficacy of plasma exchange in the management of multiple myeloma with dialysis-requiring renal failure on cyclophosphamide bortezomib and dexamethasone (CyBorD) therapy. The primary outcome studied was to determine the proportion of patients still requiring renal replacement therapies at one year after the institution of plasma exchange. Secondary outcomes studied were: death re-hospitalization and serum creatinine at one year in this cohort of patients.
METHODS: This is a single-centre retrospective observational study of multiple myeloma treated between January 2022 to August 2022 at a tertiary care public sector hospital. It was a retrospective study based on hospital records. Multiple myeloma was diagnosed on the basis of International Myeloma Working Group Diagnostic Criteria for Multiple Myeloma criteria. Plasma exchange (PE) was carried out if serum involved FLC > 1500 mg/L or if renal biopsy revealed cast nephropathy at a dose of 40 ml/kg/ sessions over 5-7 sessions.
CONCLUSION: Based on this small, retrospective study, PE seems to be safe and beneficial in this cohort of patients with multiple myeloma and dialysis-dependent renal failure.
15TH DECEMBER 2023
ABSTRACT NO. 33
CLINICOPATHOLOGICAL PROFILE AND OUTCOME OF PATIENTS UNDERGOING PLASMAPHERESIS FOR VARIOUS RENAL INDICATIONS A SINGLE CENTRE EXPERIENCE FROM TERTIARY LEVEL HOSPITAL IN SOUTH INDIA
Desale Lalitkumar Dipakrao, Shwetha Phadke, Karthik Urala, Sree Bhushan Raju, Rahul R Nair
Department of Nephrology; Nizam’s Institute of Medical Sciences; Hyderabad; Telangana; India
E-mail: desalelalitkumar@gmail.com
BACKGROUND: Plasmapheresis is a therapeutic intervention that involves extracorporeal removal return or exchange of blood plasma or components. The underlying mechanism this procedure is accomplished by either centrifugation or filtration using semipermeable membranes.
AIMS OF THE STUDY: To study the clinicopathological profile and clinical response to plasma therapy for various renal indications & various complications of plasmapheresis.
METHODS: The present study is observational retrospective study - A single centre experience from tertiary level hospital from Dept of Nephrology in South India. In this study 60 patients who underwent plasmapheresis for various indications were enrolled and evaluated.
CONCLUSION: Plasmapheresis can be considered as a standard therapy or adjunctive therapy in various immunologically mediated renal diseases Plasmapheresis is useful in severe organ threatening Paucimmune glomeruionephritis and systemic Lupus erythematosus as an adjunctive therapy. The combination of clinical presenation, histopathological profile and biochemical values can be used to make clinical utilty of plasmapheresis on a case to case basis.
15TH DECEMBER 2023
ABSTRACT NO. 34
HISTOPATHOLOGICAL AND CLINICAL FEATURES IN PATIENTS WITH TYPE 2 DIABETES MELLITUS AND KIDNEY DISEASE IN A TERTIARY CARE HOSPITAL- SINGLE CENTRE STUDY
Lohitha Mallipeddi, Manisha Sahay, Kiranmai Ismal, K Anuradha, E Rama, Yogesh Jadav
Department of Nephrology; Osmania General Hospital; Hyderabad; Telangana; India
E-mail: lohithamallipeddi3@gmail.com
BACKGROUND: Diabetes mellitus is a major cause of kidney disease associated with morbidity and mortality throughout the world. DKD accounts for 30.7% of the total CKD patients. The presence of diabetic retinopathy along with proteinuria is usually suggestive of diabetic glomerular disease and these patients are treated for DN on clinical background without histopathological diagnosis. Importance of renal biopsy to exclude non-diabetic renal disease lies in the management as these patients may need disease specific therapies in addition to ACEI/ARB treatment given for diabetic nephropathy.
AIMS OF THE STUDY: Our aim was to study the spectrum of DN and NDRD in atypical presentations of renal disease in Type 2 Diabetes mellitus.
METHODS: This is a Retrospective study conducted in the Department of Nephrology Osmania General Hospital Hyderabad Telangana. Renal Biopsy data of 134 patients having Type 2 Diabetes mellitus and Renal disease who visited Osmania General Hospital from the period of May 2019 to May 2022 were collected and analyzed. Renal biopsies were performed by using an automated biopsy gun. Tissue was processed for Light microscopy-LM and immunofluorescence-IF study. Clinical information such as presence or absence of retinopathy and hypertension Type II Diabetes duration of diabetes and clinical presentations on admission were acquired from records. Laboratory data and demographic information was also collected from records. Presence of abnormal serology such as positive anti-nuclear antibody (ANA) anti-neutrophil cytoplasmic antibody (ANCA) anti-glomerular basement membrane antibody (anti-GBM) or low complement levels were also mentioned. Pathologic diagnosis and histological findings were manually extracted from pathology reports. The patients were grouped into three categories based on the biopsy results: Isolated NDRD combination of NDRD plus DN and isolated DN.
CONCLUSION: Even though many studies have shown statistical significance of presence of atypical features for diagnosis NDRD, our study did not show similar results for few atypical features (RPRF, Isolated RBC casts) which is comparable to few other study who failed to show similar results. Even in absence of atypical clinical features patient had significant NDRD prevalence suggesting use of renal biopsy should be increased to diagnose NDRD. Out of all NDRD cases 33% patients required additional treatment in addition to ACE and ARBS for diabetic patients. Our study we found that 10 cases out of 43 (23.25%) from NDRD group had features of diabetic retinopathy, which concludes that presence of DR on fundus does not rule out possibility of NDRD on renal biopsy. Our results were comparable to our old study done at Osmania General Hospital in 2013, it showed similar results in terms of DR correlating with high class of DN and but it did not correlate with duration of diabetes. One more thing which was high lighted that presence of diabetic retinopathy does no exclude NDRD.
15TH DECEMBER 2023
ABSTRACT NO. 35
ANTIHYPERTENSIVE DRUGS USAGE PATTERN IN HEMODIALYSIS POPULATION
Abhilash Chandra, Namrata Rao
Department of Nephrology; Dr. RMLIMS; Lucknow; Uttar Pradesh; India
E-mail: acn393@gmail.com
BACKGROUND: The prevalence of hypertension in patients on maintenance dialysis is quite high (>70%). Most of the patients on hemodialysis eventually require pharmacological therapy for the management of hypertension. Blood pressure (BP) lowering medications are known to reduce cardiovascular mortality. Understanding BP medication patterns will improve overall BP control preserve residual renal function and prevent cardiovascular mortality.
AIMS OF THE STUDY: To study the pattern of use of antihypertensive agents in maintenance hemodialysis population.
METHODS: A retrospective observational cross-sectional study of all prevalent end-stage renal disease (ESRD) patients aged 18 years who were receiving hemodialysis for at least 3 months visiting the outpatient department (OPD) of Nephrology at this North Indian tertiary care hospital from April 2021 to May 2023 was conducted. BP medication patterns were recorded including the class dose and frequency. We used descriptive statistics (mean ± standard deviation [SD]) for continuous variables. Independent t-test was used to compare continuous variables. Chi-square was used to compare categorical variables between the two groups.
CONCLUSION: Out of a total of 461 patients screened, after the application of inclusion and exclusion criteria, 278 hemodialysis patients were included in our study. The patient population was young (mean age: 45.76 ± 13.73 years) and comprised a higher number of males (176 [63.3%]). The mean BMI was 21.35 ± 3.5 kg/m 2 . Mean blood pressure was 144.5 ± 14.56 mmHg systolic and 87.34 ± 7.52 mmHg diastolic respectively. Hypertension was the most common comorbidity followed by diabetes mellitus. Calcium channel blockers (CCBs) were the most commonly used antihypertensive agents. Among CCBs, amlodipine was the most commonly used one. Metoprolol was the most common beta blocker to be used. Nifedipine in the slow-release preparation and succinate formulation of metoprolol were used in the subjects. Torsemide was the only loop diuretic used in the study population. The only prevalent combination used was that of CCBs and BBs. Eight (3.2%) patients were not on any antihypertensive agent. 47% of subjects required at least 2 drugs, 28% required 3 drugs, 15% required 4 drugs and 7% required 5 drugs to control the blood pressure. Clonidine contributed the maximum to the pill burden. ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin receptor blockers) were used only in 4.6% of subjects.
15TH DECEMBER 2023
ABSTRACT NO. 36
IGA NEPHROPATHY WITH THROMBOTIC MICROANGIOPATHY A CASE SERIES
Nayana Melath Babu, Manjusha Yadla, B Vikram, B Srikanth
Department of Nephrology; Gandhi Medical College; Secunderabad; Telangana; India
E-mail: nayanababu67@gmail.com
BACKGROUND: Thrombotic microangiopathy (TMA) is a pathological entity caused by heterogenous group of disorders. But its association with glomerular diseases has rarely been reported. Among them cases of IgAN and TMA had been most described. Historically it was thought that IgAN was only associated with TMA in cases of severe hypertension or advanced chronic kidney disease. But recent studies have shown TMA as a common histological feature of IgAN and can occur even in normotensive patients or with near normal renal histology. TMA is associated with worse renal prognosis even after adjusting for the hypertension severity as seen in few studies.
AIMS OF THE STUDY: To analyse the clinical features and outcome of patients diagnosed with IgA nephropathy with Thrombotic microangiopathy.
METHODS: Study Design - Observational study. Setting: Department of Nephrology Gandhi medical college Inclusion criteria: All patients with biopsy proven IgAN with TMA admitted in Nephrology department from May 2022 May 2023 Methodology: Casesheets were collected from medical records and analysed. Demographic details comorbidities laboratory parameters and outcome status noted.
CONCLUSION: Thrombotic microangiopathy lesions are severe in IgAN, and have poor prognosis Accelerated Hypertension, microscopic hematuria, subnephrotic proteinuria with worsening renal function are present in most cases.
15TH DECEMBER 2023
ABSTRACT NO. 37
NAVIGATING STEROID-RESISTANT NEPHROTIC SYNDROME IN CHILDREN: INSIGHTS FROM A SINGLE-CENTER STUDY
Modugula Bhava Pragna, Manisha Sahay, Kiranmayi Ismal
Department of Nephrology; Osmania Medical College; Hyderabad; Telangana; India
E-mail: bhavapragna94@gmail.com
BACKGROUND: Nephrotic syndrome (NS) represents a prevalent glomerular disorder in children predominantly responsive to steroid therapy. Nevertheless a notable proportion of pediatric patients approximately 10-20% exhibit resistance to steroids presenting a therapeutic challenge. This study seeks to comprehensively assess the clinical profile and treatment outcomes of children with steroid-resistant nephrotic syndrome (SRNS).
AIMS OF THE STUDY: To look at the clinical profile biopsy findings and treatment outcomes in children with SRNS.
METHODS: A total of 44 pediatric patients (56% female 44% male) diagnosed with NS during a period of 2 years January 2021-January 2023 characterized by edema massive proteinuria hypoalbuminemia and hyperlipidemia were enrolled. International treatment protocols were followed for NS management. SRNS was identified in patients with idiopathic NS who failed to achieve complete remission with steroid therapy after 4 weeks. Renal biopsies were performed on 38 SRNS patients at Osmania General Hospital. Nonsteroidal immunosuppressive agents were administered to SRNS patients post-biopsy. Genetic analysis were sent for 22 patients.
CONCLUSION: Although some children with SRNS can achieve sustained remission with second or third-line immunosuppressive agents, a significant proportion experience progression to ESRD despite treatment efforts. Tacrolimus resulted in prolonged clinical remission compared to Cyclophosphamide. The burgeoning field of molecular genetics holds promise for shedding light on the pathogenesis and advancing the therapeutic landscape for this challenging disease. This study underscores the need for continued research and innovative approaches to enhance the management of steroid-resistant nephrotic syndrome.
15TH DECEMBER 2023
ABSTRACT NO. 38
COMPARISION OF EXTRACORPOREAL THERAPIES IN PARAQUAT POISIONING WITH ACUTE KIDNEY INJURY
Bonthu Srinitha, Manjusha Yadla, B Vikram Kumar, B Sreekanth
Nephrology; Gandhi Medical College; Hyderabad; Telangana; India
E-mail: srinitha6.reddy@gmail.com
BACKGROUND: Paraquat (1, 1’-dimethyl-4, 4’-bipyridinium dichloride) is a fast-acting and non-selective contact herbicide with a high mortality rate in acute poisoning. Exposure occurs accidentally or intentionally as a suicide attempt. Paraquat poisoning is becoming a serious public health concern especially in developing countries due to its easy access and lack of awareness of potential harms. Multiple organ failure including lung kidney and liver failure occurs in severe poisoning. The most common cause of death is respiratory failure. There is still no standard and effective treatment. Decreased absorption by gastric lavage and oral activated charcoal; elimination through different techniques conventional hemodialysis hemoperfusion continuous venovenous hemofiltration [CVVH] and continuous renal replacement therapy [CRRT]); decreased inflammatory response by the immunosuppressants (corticosteroids and cyclophosphamide); antioxidants (N-acetyl cysteine Vitamin C and Vitamin E); and a combination of different therapies have been used to treat patients with PQ intoxication with different outcomes for survival.
AIMS OF THE STUDY: To compare renal replacement modalities CRRT and conventional HD in patients of paraquat poisoning with acute kidney injury.
METHODS: Study Design - Prospective observational study, Study Population: 244 patients Duration of Study - 2 years, Study Setting: Tertiary care centre. Inclusion Criteria: Patients aged between 10-60 years who consumed paraquat of any quantity were included in the study. Demographic details latency of referral lab parameters mode of renal replacement therapy outcomes of kidney injury and factors affecting mortality were assessed.
CONCLUSION: Paraquat poisoning is still a concern in developing countries. It may be useful to educate public health professionals and the general population about the serious consequences of exposure to this toxic agent. Paraquat poisoning is still no cure.
15TH DECEMBER 2023
ABSTRACT NO. 39
PERITONEAL MEMBRANE CHARACTERISTICS AND ITS IMPACT ON MORTALITY AND TECHNIQUE SURVIVAL: A SINGLE CENTRE EXPERIENCE FROM NORTH EAST.
Akash Singh, N Sharatkumar Singh, T Brojen Singh, L K Saratchandra Singh, Jimmy Hulang, Swati Bhagat, Ng Archana, Pankaj Puri
Department of Nephrology; Regional Institute of Medical Sciences, Imphal; Manipur; India
E-mail: ahsingh7000@gmail.com
BACKGROUND: Continuous Ambulatory Peritoneal Dialysis (CAPD) is now established form of renal replacement therapy (RRT) in management of end stage renal disease (ESRD). Several studies have concluded that in the short-medium term CAPD assures similar patient survival in comparison to hemodialysis (HD). Studies have suggested that increased peritoneal permeability is associated with mortality and morbidity. In our study we compared the clinical outcome in CAPD patients with Fast Slow and Average transporter.
AIMS OF THE STUDY: To determine baseline peritoneal transport characteristics and its impact on Patient survival.
METHODS: It is a prospective single-center study with a long term follow-up a total of 672 patients were implanted with CAPD between September 2001 and July 2021. Out of 672 patients 276 patients had done their Standard peritoneal equilibration test (PET) at baseline within 6 months who were included in the study. Standard PET was done Dialysate / Plasma Creatinine ratio (D/P Creatinine ratio) was used to classify patient as Fast Slow and Average transporter. Patient was followed up and clinical outcomes were evaluated.
CONCLUSION: Our study suggests that fast peritoneal transport at initial PET is associated with high risk of mortality. Mean systolic BP was found to be higher in fast transporter and serum albumin was found to be low in fast transporter, these findings can have a impact on lower survival in fast transporter in comparison to other transporter type.
15TH DECEMBER 2023
ABSTRACT NO. 40
OUTCOME OF CUFFED TUNNELED DIALYSIS CATHETERS AS ACCESS FOR HEMODIALYSIS PATIENTS: A SINGLE CENTRE EXPERIENCE IN A TERTIARY CARE CENTRE
Y Dharanidhar Reddy, E Indhumathi
Department of Nephrology; Saveetha Medical College and Hospital; Chennai; Tamil Nadu; India
E-mail: dharanidharreddy.reddy91gmail.com
BACKGROUND: Arteriovenous fistula is the most common vascular access for patients requiring hemodialysis but tunneled cuffed catheters (TCC) are increasingly being used as an access in certain clinical situations such as in AVF failure or lack of suitable vessels for AVF creation or bridge to living donor transplant.
AIMS OF THE STUDY: To study the clinical characteristics of the patients with tunneled cuffed catheters (TCC) indications for TCC complications and to determine the infection and survival rate of catheter and patient with various factors influencing the outcome.
METHODS: A retrospective observational study was done in a tertiary care centre. Twenty-seven TCC placement were done by nephrologists with fluoroscopy in a percutaneous fashion between June 2022 to July 2023. Minimum follow up period was 9 months. Patient demographics laboratory data including microbiological profile infection rate were collected and analyzed. Catheter dysfunction is defined as failure to attain and maintain an extracorporeal blood flow of 300ml/min or grater at a prepump arterial pressure more negative than -250 mmhg. Statistical analysis was done using Kaplan-Meier analysis was used for survival determination. All patients included in the study consented for the procedure.
CONCLUSION: Catheter related infection rate (CRBSI) was 11 (40.7%), Catheter dysfunction was noted in 5 patients (18.5%). Predominant organism isolated was Klebsiella and E. coli. Catheter survival at 6 months was 88.8% and mortality directly related to TCC due to infection occurred in 1 patient.
15TH DECEMBER 2023
ABSTRACT NO. 41
STUDY OF CLINICAL PROFILE AND PREDICTORS OF OUTCOME IN CMV INFECTION IN POST-RENAL TRANSPLANT PATIENTS
Sanket Patel, T Gangadhar, Raja Karthik, Niranjan Ganesh, Lalitkumar Desale
Department of Nephrology; Nizam’s Institute of Medical Sciences; Hyderabad; Telangana; India
E-mail: sanketrpatel1995@gmail.com
BACKGROUND: Cytomegalovirus (CMV) is a common opportunistic infection following renal transplantation (RTx). It responds promptly to antiviral therapy if detected early. Identification of risk factors helps in the early diagnosis of CMV.
AIMS OF THE STUDY: (1) to study demographic features risk factor clinical presentation and outcomes associated with CMV infection in Rtx recipients despites valganciclovir prophylaxis. (2) To study predictors of outcome in CMV infection.
METHODS: Study design - cross section observational study study period - 01-06-2022 to 31-05-2023 study population - 26 post renal transplant patients admitted with CMV infection in NIMS hospital.
CONCLUSION: Indentification of risk factors, early diagnosis and treatment of CMV infection is paramount important in Rtx recipients.
15TH DECEMBER 2023
ABSTRACT NO. 42
A CROSS-SECTIONAL OBSERVATIONAL STUDY TO LOOK FOR PREVALENCE AND PROGNOSIS OF ACUTE KIDNEY INJURY PATIENTS IN PREGNANT WOMEN
Saptadipa Das, Geeta Seth
Departments of Nephrology; Grant Government Medical College and JJH; Mumbai; Maharasthra; India
E-mail: write2sapta@gmail.com
BACKGROUND: Pregnancy related acute kidney injury is a common occurrence causing significant maternal mortality and morbidity in developing countries. Acute kidney injury in pregnancy bears a high risk of bilateral cortical necrosis and consequently chronic renal failure and also fetal demise. Study aimed to evaluate the risk factors responsible for pregnancy related acute kidney injury and to assess the outcome and prognostic factors of patients with pregnancy related acute kidney injury during pregnancy.
AIMS OF THE STUDY: This study is initiated to look into the causes risk factors and outcome and prognostic markers of pregnancy-related acute kidney injury (PRAKI) in a tertiary care hospital in western India.
METHODS: Patients are analyzed on the basis of demographic data detailed history clinical presentation and laboratory investigations including urine analysis blood biochemistry and hemogram with peripheral smear. Sepsis screening including bacterial culture sensitivity on blood urine and vaginal swabs workups for disseminated intravascular coagulation serum complements anti-nuclear and anti-cytoplasmic antibodies is to be done whenever required. The indications for renal biopsy are persistent renal failure more than three weeks and features suggestive of underlying renal disease. Each patient will undergo complete obstetric examination. Specific inquiries are conducted regarding the mode of delivery need for blood transfusion and surgical intervention. The results presented as percentage and/or mean + SD. Chi-square is used to compare categorical variable and student t test will be used for continuous variable (two groups). p value <0.05 will be considered significant. The socio demographic profile clinical profile and lab profile (haematological biochemical and radiological) of the eligible consenting participants recorded in the proforma.
CONCLUSION: Promt and timely intervention in cases of PR-AKI can prevent significant mortality and morbidity. Sepsis, a largely preventable entity, continues to be a major cause of AKI despite increase in the number of institutional deliveries and is associated with poor outcome. Early referral to higher center for patients developing compro-mised renal function, improvement of nutritional status and anemia correction through better antenatal care, and increasing sepsis prevention awareness in peripheral health-care facilities may help reduce burden of PRAKI.
15TH DECEMBER 2023
ABSTRACT NO. 43
UTILIZATION OF A NOVEL TUNNELLED NON-CUFFED CATHETER AS A VASCULAR ACCESS FOR HAEMODIALYSIS
B Sairam, Gireesh Reddy, C G Sridhara, A Kishan, S Mythri, Leelavathi, L Umesha, Haritha, Aditya Shetty, S Ranjitha, S Gowri, Viswas, M N Atthish, Prasanna Bhat, Ankita Raisinghani, Anusha, Keerthi, Kallappa, Varalakshmi
Nephrology; Institute of Nephro Urology; Bengaluru; Karnataka; India
E-mail: sairam.b1992@gmail.com
BACKGROUND: A tunnelled cuffed catheter (TCC) is one of the most commonly used vascular access devices in dialysis patients. Apart from the need to provide adequate blood flows an ideal TCC should prevent thrombosis and CVS by reducing trauma at the vein site have a low risk of formation of a fibrous sheath and prevent the migration of bacteria from the exit site and subsequent formation of biofilm inside the lumen of the catheter. In general technical problems associated with late catheter dysfunction in TCC is due to thrombosis or fibrous sheath formation. It has recently been postulated that the fibrin sheath originates and extends from the cuff. So we attempted to resolve the issue by utilising a tunnelled catheter devoid of the cuff.
AIMS OF THE STUDY: To study the possibility of using a tunnelled non-cuffed catheter as a vascular access device in hemodialysis and monitor its outcomes.
METHODS: Design - The design includes a dual-lumen straight catheter with a hub-to-tip length of 24 cm designed for over-the-wire placement. The set includes a tunneler and a peel-away sheath. The technique of insertion is the same as for any TCC. Method - We undertook a pilot project in which patients underwent our catheter insertion after the novelty of the catheter was explained and consent was obtained. This is an observational study where these patients were observed until catheter removal for any cause or death. Complications including infective and technical complications were recorded. Catheter performance during dialysis was observed and recorded. The primary outcome of this study was catheter removal of any cause which was recorded as: catheter removal after successful fistula; catheter removal due to infection; catheter removal due to flow dysfunction.
CONCLUSION: We hereby introduce a novel design of a tunnelled, non-cuffed catheter as a vascular access for hemodialysis. The longevity of the catheter and the complications need to be analysed in a larger cohort. The expertise of the nephrologist performing the insertion procedure and the non-uniformity of the dialysis centres are major confounding factors in accessing the complications.
15TH DECEMBER 2023
ABSTRACT NO. 44
CLEARING THE FOG OF MISSING HLA TYPING: DONOR HLA TYPING FROM KIDNEY BIOPSY
Ajay Kher, Yoginder Pal Singh 1 , Saurabh Shukla, Vijay Kher
Department of Nephrology and HLA Lab; Epitome Kidney Urology Institute and Lions Hospital; 1 Agilus Diagnostics; Delhi; India
E-mail: ajay@epitomehospitals.com
BACKGROUND: It has been increasingly recognized that Antibody mediated rejection (AMR) in the form of Acute AMR and more importantly as Chronic AMR are significant causes of graft dysfunction and graft loss. Evaluating and managing them requires recipient evaluation for HLA antibodies and donor HLA typing to assess which of the HLA antibodies are donor specific. However in many conditions the HLA typing may not be available (deceased donor) or may be incomplete (old transplants). In such situations donor DNA extraction from kidney biopsy can be performed it may be useful to do HLA typing from the donor tissue not only to assess current status of donor specific antibodies but also for future risk assessment.
AIMS OF THE STUDY: Use Kidney Biopsy tissue to identify HLA typing of donors.
METHODS: We present two transplant recipients in whom kidney biopsy was being done for cause (increased creatinine) but donor typing was not available. In both these patients a sample was taken in normal saline and sent for HLA typing. The laboratory obtained DNA from donor tissue by using Qiagen QIAamp DNA Mini Kit and performed Molecular HLA typing to deduce donor HLA haplotypes.
CONCLUSION: Donor HLA typing from kidney biopsy is feasible and may be a helpful adjunct in cases where HLA typing is not available or incomplete. However, due to presence of recipient HLA in kidney biopsy, simultaneous HLA typing of the recipient should also be performed or full HLA typing of the recipient should be available for HLA lab to make the best evaluation of donor HLA typing. Despite these efforts some possible HLA typing combinations may remain impossible to conclusively resolve. However, the knowledge of ethnicity, haplotype and linkage disequilibrium and inheritance pattern of HLA and population-based HLA prediction software can help in the precise assignment of the alleles. The additional information obtained is likely to be useful for better risk assessment, future evaluation and better graft outcomes. Hence, kidney biopsy for HLA typing should be considered in these settings.
15TH DECEMBER 2023
ABSTRACT NO. 45
ASSOCIATION OF FRAILTY WITH QUALITY OF LIFE IN ADVANCED CHRONIC KIDNEY DISEASE PATIENTS
Tanvi Thakker, B Muthukumar, Lalit Pursnani, H S Mahapatra
Nephrology; Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital; New Delhi; India
E-mail: tanvithakker92@gmail.com
BACKGROUND: Frailty assessment was originally devised by gerontologists to evaluate the overall decline that occurs with ageing. Frailty is associated with increased vulnerability to stressors and poor clinical outcomes. Chronic kidney disease is a state of accelerated metabolic ageing and thus maybe associated with frailty even in younger patients and may significantly affect their quality of life.
AIMS OF THE STUDY: To assess the association of frailty with quality of life in advanced chronic kidney disease patients.
METHODS: This observational study included advanced chronic kidney disease patients more than 18 years of age. Patients on maintenance dialysis were excluded. Patients were assessed for frailty using the Fried frailty phenotype and Quality of life was assessed using the KDQOL-SF questionnaire. Biochemistry lab parameters were done and data was collected for all patients. Descriptive analyses were used to study the association of frailty with various factors like age gender comorbidities biochemical parameters and quality of life. p-value of < 0.05 was considered as significant.
CONCLUSION: Chronic kidney disease is associated with a high prevalence of Frailty. Frailty in these patients is associated with significant worsening of quality of life in physical as well as mental domains. Interventional studies improving frailty are need of the hour in chronic kidney disease patients.
15TH DECEMBER 2023
ABSTRACT NO. 46
CLINICAL AND HISTOLOGICAL MANIFESTATIONS OF IGA NEPHROPATHY IN RENAL ALLOGRAFTS
Sumeet Narain, Sonal Tripathi, Narayan Prasad, Manoj Jain, Vinita Agrawal
Department of Nephrology and Pathology; Sanjay Gandhi Postgraduate Institute of Medical Science; Lucknow; Uttar Pradesh; India
E-mail: vinita.agrawal15@gmail.com
BACKGROUND: IgAN is the most frequent glomerulonephritis in kidney allografts. Early recognition and prompt management can help in reducing long term graft loss.
AIMS OF THE STUDY: To evaluate the laboratory and histological features of post-transplant recurrent/de-novo IgA nephropathy.
METHODS: The study included eighteen patients diagnosed as IgA Nephropathy on post-transplant for-cause renal allograft biopsies from August 2022 to August 2023. Clinical details were retrieved from hospital records. The histological features and immunofluorescence findings were reviewed.
CONCLUSION: Post-transplant IgAN is often an incidental finding in renal allograft biopsies. Renal allografts show lower Oxford scores as compared to IgAN in native biopsies, due to high dose of immunosuppression. High index of suspicion and full immunofluorescence panel is essential for early diagnosis.
15TH DECEMBER 2023
ABSTRACT NO. 47
PUTTING INTO PRACTICE THE NEXT GENERATION OF EVIDENCE BASED PATIENT CARE: IT’S ABOUT TIME!
Sayali Kondkar, Deepa Usulumarty, Parag Tilve, Jatin Kothari, Shrirang Bichu, Viswanath Billa
Apex Kidney Care; IIT Bombay; Bombay Hospital; Mumbai; Maharashtra; India
E-mail: drsaayali@gmail.com
BACKGROUND: The current clinical management of patients is progressively veering towards the use of Electronic Health Records (EHR) which will soon become the standard of care. In addition to improving data capture storage transmission and data retrieval for research such electronic platforms also make themselves amenable to seamlessly integrate with upcoming technologies in the healthcare domain to improve patient outcomes and minimize errors.
AIMS OF THE STUDY: Putting into practice the next generation of evidence based patient care. It about time!
METHODS: At Apex Kidney Care we use a proprietary Nephrology EHR application called Axis. During the patient consultation it captures all the clinical data of a patient from history to investigations to drug prescriptions to dialysis planning and many other parameters. While this data capture is an active user driven process of punching in data Axis has developed a Decision Support system (DSS) which operates seamlessly at the back end and helps make the patient medical management more personalized and evidence based. In order to deliver such precision therapy Axis identifies the most appropriate treatment protocol for a patient with a specified diagnosis. As the user sequentially punches a patient clinical data Axis selects certain key demographic diagnostic and clinical variables of the patient and at the back end correlates this information against an embedded library of diagnosis-specific clinical trials and protocols. By doing so it identifies in parallel that treatment protocol which matches closest to the current patient attributes for the specified diagnosis. This protocol is then suggested by Axis to the user by the time he reaches the treatment page. This library is continuously upgraded and appended by another proprietary AI tool which crawls the web and updates itself each time it is used.
CONCLUSION: The practice of medicine in the current day needs the Nephrologist to be abreast with voluminous literature in order to deliver the expected standard of care. The status quo model that we use today in clearly unsustainable. We have an overarching goal to improve health outcomes. Delivering such a personalized and pragmatic patient care is the need of the hour and contemporary technology needs to be leveraged to achieve this sustainable goal. Integration of AI is perceived as a friction with human intelligence. However, it can well be used to augment human intelligence, to achieve the desired patient outcomes.
15TH DECEMBER 2023
ABSTRACT NO. 48
A RANDOMIZED CONTROL STUDY TO ASSESS DECLINE OF RESIDUAL URINE OUTPUT IN PATIENTS INITIATED ON INCREMENTAL VERSUS CONVENTIONAL THRICE PER WEEKLY HEMODIALYSIS REGIMEN
Renju Binoy 1 , Himanshu Sekhar Mahapatra 1 , Lalit Pursnani 1 , B Muthukumar 1 , Himanshu Verma 2
1 ABVIMS and Dr. RML Hospital; 2 VMMC and Safdarjung Hospital; New Delhi; India
E-mail: rbnephro@gmail.com
BACKGROUND: Patients starting on hemodialysis are prescribed an empirical thrice per week regimen despite the guidelines advising some leeway in reducing dialysis dose in those with adequate residual renal function. But the evidence for this is miniscule and prospective studies examining the impact of incremental HD in preserving residual urine output is sparse. We hypothesized that patients starting on incremental HD will have better preservation of residual urine output at the end of one year.
AIMS OF THE STUDY: To determine whether incremental initiation of hemodialysis in those with adequate residual renal function is associated with better outcomes in terms of one year survival or residual renal function as measured in terms of urine output.
METHODS: In this open label-parallel arm randomized study 81 incidental ESKD patients with a urine output >600 ml were randomized to incremental initiation of HD or conventional regimen. Urine output and other parameters were measured every 3 months. Those patients who got randomized to twice per week schedule and was deemed to require thrice per week HD by the treating nephrologists were shifted to thrice per week HD during the course of the study.
CONCLUSION: Our study shows that initiation of HD in an incremental fashion in incidental ESKD patients with adequate residual urine output is feasible and is associated with better preservation of residual urine output at the end of 1 year. However, much larger studies with long follow ups are required for assessing whether this will be translated to improvements in quality of life, number of hospitalizations, health care expenditure and more importantly patient survival.
15TH DECEMBER 2023
ABSTRACT NO. 49
CLINICO-BIOCHEMICAL PROFILE OF PATIENTS WITH HYPOCALCEMIA IN A TERTIARY CARE CENTRE
L N Anusha, E Mahesh, Gurudev, M S Gireesh, Rajashekar, Yousuff, Pooja, Hamsa
Department of Nephrology; M. S. Ramaiah Medical College; Bengaluru; Karnataka; India
E-mail: anusha.natraju@gmail.com
BACKGROUND: Hypocalcemia is a common biochemical abnormality presenting with a wide range of clinical manifestations. As the symptoms are varied from asymptomatic presentation to life threatening arrhythmias measurement of serum calcium becomes crucial. Data concerning clinical laboratory features and management of patients with hypocalcemia is limited. This study was undertaken to with an objective to study the clinico-biochemical profile of patients with hypocalcemia.
AIMS OF THE STUDY: To study the clinico-biochemical profile of patients with hypocalcemia.
METHODS: This is a retrospective chart review including patients age 18 years from 2018 to 2023. Data regarding presenting features biochemical findings and hormonal assays were obtained from the medical digital records of the patients visiting Ramaiah hospitals. Details of treatment and complications were recorded and analyzed. For the purpose of the study hypocalcemia was defined as total serum corrected calcium levels less than 8.0 mg/dl.
CONCLUSION: Vitamin D deficiency and chronic kidney disease are the most frequent causes of hypocalcemia in our clinical setup.
15TH DECEMBER 2023
ABSTRACT NO. 50
ASSOCIATION OF SERUM CALCIUM AND PHOSPHORUS AFTER RENAL TRANSPLANT WITH GRAFT SURVIVAL AND PATIENT OUTCOMES
L N Anusha, E Mahesh, Gurudev, M S Gireesh, Hamas, Rajashekar, Pooja, Yousuf
Department of Nephrology; M. S. Ramaiah Medical College; Bengaluru; Karnataka; India
E-mail: Anusha.natraju@gmail.com
BACKGROUND: Kidney transplantation has increased the survival of chronic kidney disease (CKD) patients who are on dialysis. Immunosuppressive agents have increased graft survival rates. There are immunological and non immunological factors which affect the graft survival. There is little attention towards the abnormalities in calcium and phosphorus metabolism in post renal transplant recipients and allograft outcomes where as there is a strong association between serum calcium and phosphorus abnormalities with increased mortality in dialysis patients.
AIMS OF THE STUDY: Our aim is to assess the impact of calcium and phosphorus derangements in post transplant on allograft and recipient outcomes.
METHODS: We conducted retrospective chart review of all adult first renal transplant in Ramiah medical college hospital from 2012 to 2022. Data regarding demographic features biochemical findings were obtained from the medical digital records. Patients were categorised into tertiles based on the serum calcium and phosphorus levels in post transplant. We used multivariate proportional hazard regression to assess the independent association between serum calcium and phosphorus levels in post renal transplant allograft and recipient long term outcome.
CONCLUSION: Hypophosphatemia and hypercalcemia are common derangements in post transplant recipients. High concentrations of serum phosphate was associated with an increased risk for allograft loss in these renal transplant recipients, whereas high serum calcium concentrations seemed to lower the risk.
15TH DECEMBER 2023
ABSTRACT NO. 51
FIVE-YEAR CLINICAL OUTCOMES OF THE FIRST SOUTH-ASIAN PROSPECTIVE LONGITUDINAL OBSERVATIONAL IGA NEPHROPATHY COHORT (GRACE-IGANI)
Sabina Yusuf, Sanjeet Roy, Joseph Johny, Nisha Jose, Selvin Sundar Raj Mani, Sabina Yusuf, Jeethu Joseph, Athul Thomas, Vinoi George David, Santosh Varughese, Jonathan Barratt, George T John, Suceena Alexander
Christian Medical College; Vellore; Tamil Nadu; India; University of Leicester; Leicester; UK
E-mail: suceena@gmail.com
BACKGROUND: Glomerular Research And Clinical Experiments - IgA Nephropathy in Indians (GRACE-IgANI) is the first prospective single centre South Asian IgAN cohort with prespecified objectives protocolized longitudinal follow-up and extensive biosample collection.
AIMS OF THE STUDY: To report the actual five-year longitudinal clinical outcomes of the GRACE-IgANI cohort.
METHODS: 201 incident adults with kidney biopsy proven primary IgAN were recruited into GRACE-IgANI cohort between March 2015 and September 2017. All patients with a 24-hour urinary protein (24UP) >1 g/day or an eGFR <60ml/min/1.73 m2 with any proteinuria received oral prednisolone at 2 mg/kg A/D for 3 months along with optimized supportive care which was then tapered and stopped at 6 months along with RASB. In-centre scheduled follow-up visits were at 6 months one two and three years with additional visits dictated by the clinical needs. Patients were contacted at least once every 3-6 months to determine medication adherence and monitor for medication side effects ensure optimisation of BP medications using self-reported/clinic BPs and review local blood test results.
CONCLUSION: There is significant morbidity and mortality associated with IgAN patients in South Asia.
15TH DECEMBER 2023
ABSTRACT NO. 52
UNVEILING NOVEL MIRNA SIGNATURES FOR EARLY DETECTION AND MANAGEMENT OF IGA NEPHROPATHY: EXPLORING INSIGHTS FROM THE INDIAN POPULATION
Muralinath Vukkadala, Poornachandra Yedla, Sai Ram Keithi Reddy
Nephrology; AIG Hospital; Hyderabad; Telangana; India
E-mail: dr.muralinath@gmail.com
BACKGROUND: IgA nephropathy (IgAN) is a globally prevalent glomerular disease exhibiting immune-mediated pathology with diverse clinical manifestations. Over two decades 30-40% of those afflicted could develop end-stage renal disease. Given varying diversity and limited Indian studies predicting IgAN renal progression is vital. To detect IgAN early and enable timely management novel biomarkers are required. MicroRNAs (miRNAs) play a pivotal role in post-transcriptional gene regulation influencing the expression of target proteins. Previous studies have identified few miRNAs directly associated with immunological and pathological changes of IgAN. In addition genome-wide studies have indicated geographical disparities in genetic susceptibility to IgAN and its disease progression.
AIMS OF THE STUDY: Our study aims to identify potential miRNAs in kidney tissues thereby providing novel biomarkers for the diagnosis and therapy of IgAN potentially preventing its progression to end-stage renal failure.
METHODS: We isolated miRNAs from kidney biopsies of IgAN patients (n = 6) and healthy control tissues from renal cell carcinoma patients (n = 6). Small RNA libraries were prepared followed by NGS on the ION S5 Torrent. Differential expression analysis was conducted using DeSeq2. The KEGG database and Cluster Profiler were used to further process the data for GO enrichment analysis and KEGG pathway analysis. The predicted transcription factors and key hub genes involved in the disease progression were identified using FunRich and cytoHubba respectively.
CONCLUSION: This study has uncovered a set of four novel miRNAs associated with IgAN in the Indian population. These miRNAs possess the capacity to impact vital signalling pathways crucial to the development of IgAN. However, the potential application of these miRNAs as targets for diagnostic and therapeutic purposes in managing IgAN within the Indian community warrants exploration. The findings open up new avenues for understanding IgAN pathogenesis and devising personalized approaches for its management.
15TH DECEMBER 2023
ABSTRACT NO. 53
QUALITATIVE NUTRITIONAL HABIT SURVEY IN MAINTENANCE HD PATIENTS AND CORRELATION WITH GI SYMPTOMS
Shreshta Tripathi, Jill Parekh, Deepa Usulumarty, Parag Tilve, Shrirang Bichu, Jatin Kothari, Viswanath Billa
Apex Kidney Care; Bombay Hospital; Mumbai; Maharashtra; India
E-mail: Shreshtatripathi@yahoo.in
BACKGROUND: This is a cross-sectional survey of 3000 hemodialysis (HD) patients from 160 dialysis centers across India were surveyed for gastrointestinal (GI) symptoms using the Gastrointestinal Symptom Rating Scale (GSRS) questionnaire with special consideration of socioeconomic class urban setting and dietary habits.
AIMS OF THE STUDY: To identify HD patients exhibiting GI symptoms and its correlation with the socioeconomic class/urbanization and dietary patterns.
METHODS: We surveyed HD patients from private centers (higher socioeconomic status) and public centers (lower socioeconomic status) across cities in India. The GSRS questionnaire was employed to assess GI symptoms. Qualitative analysis of dietary habits including: carbohydrate protein fiber junk food and fluid intake was considered.
CONCLUSION: The nutritional habits of Indian hemodialysis patients irrespective of their socioeconomic status is carbohydrate predominant with no fibre deficit. The protein intake is satisfactory. The Patients with severe GI symptoms had significant correlation with increased fluid consumption.
15TH DECEMBER 2023
ABSTRACT NO. 54
HIGH P-GLYCOPROTEIN EXPRESSION WITH INCREASED IL-12 AND IL-23 CYTOKINES ARE POTENTIALLY ENHANCE THE TRANSITION OF TH17 CELLS INTO IFN-³ POSITIVE TH17.1 CELLS IN REFRACTORY NEPHROTIC SYNDROME
Akhilesh Jaiswal, Narayan Prasad, Vikas Agarwal
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: akhileshjaiswal@hotmail.com
BACKGROUND: Th17 cells are critical effectors mediating autoimmunity in organ specific diseases like nephrotic syndrome (NS). Elevated IFN-³ has also been involved in NS; however it remains unclear to what extent Th17 and IFN-³ expressing Th17.1 cells contribute to glucocorticoid resistance in NS. P-glycoprotein (P-gp) effluxes glucocorticoids outside the cells and is selectively expressed differentially on T cell subtypes.
AIMS OF THE STUDY: In this study we investigated the role of P-gp and the cellular source of IFN-³ producing T cells and assessed its contribution to glucocorticoid resistance in NS.
METHODS: We analyzed the frequency of pathogenic IL-17A + IFN-³ + Th17/1 lymphocytes and P-gp expression on their surface by flow cytometry in SSNS (n = 32; mean age: 9.06 ± 5.84) and SRNS (n = 28; mean age: 11.29 ± 3.73) patients. All patients were recruited as per the criteria of ISKDC. We also included 15 age- and sex-matched healthy controls. All patients were of biopsy-proven minimal change disease and all patients were treated with steroids.
CONCLUSION: The above findings clearly show that higher expression of P-gp on IFN-³+ Th17.1 cells is associated with steroid resistance in nephrotic syndrome through both IL-17A and IFN-³.
15TH DECEMBER 2023
ABSTRACT NO. 55
HOW LARGE IS THE MENTAL HEALTH CHALLENGE IN OUR HEMODIALYSIS PATIENTS AND WHAT ARE THE FACTORS AFFECTING THIS?
Ajay Raghavan, Varun Billa
Apex Kidney Care; Mumbai; Maharashtra; India
E-mail: billav@gmail.com
BACKGROUND: Chronic kidney disease is increasing in prevalence globally contributing to the ever increasing number of patients requiring hemodialysis. In India nearly 2 lakh new patients are being diagnosed with ESRD every year. In addition to the morbidity posed by the disease itself these patients are also exposed to stressors on the financial occupational and social front that CKD imposes. This makes them vulnerable to mental health problems. While every attempt is made by the existing systems and processes to address the physical comorbidities arising out of CKD there is limited focus on their mental health.
AIMS OF THE STUDY: To study the prevalence of depression in CKD patients on maintenance hemodialysis and evaluate the factors affecting it.
METHODS: This was a cross-sectional survey of 282 patients on maintenance hemodialysis from 4 dialysis centres of Apex Kidney Care at Mumbai. Their mental health assessment was done using the PHQ-9 survey which is a validated questionnaire for assessing depression. The PHQ-9 module scores each of the 9 DSM-IV criteria as “0” (not at all) to “3” (nearly every day). Data was collected on a google form and analysed. A logistics regression for multivariate analysis for hypothesis test Z test for proportionality and Mann-Whitney U test comparing two medians was used in the statistical analysis.
CONCLUSION: The prevalence of depression in the maintenance hemodialysis patients is substantial. This indicates the need to have a mental health redressal mechanism in place for all patients on MHD. Since employment status seems to be the only controllable factor to address this challenge, every attempt should be made to accommodate dialysis shift timings and periodic counselling of these patients to help them become gainfully employed. However whether mental health problem is the cause or the result of unemployment needs to studied separately.
15TH DECEMBER 2023
ABSTRACT NO. 56
CRYPTOCOCCAL INFECTIONS IN RENAL TRANSPLANTATION: A SINGLE CENTRE EXPERIENCE
G S Aneesh Kumar, Kartik Ganesh, Jithin S Kumar, M Abi Abraham, Sunita Simon
VPS Lakeshore Hospital and Research Centre; Kochi; Kerala; India
E-mail: aneeshkumargs008@gmail.com
BACKGROUND: One among the opportunistic infections in solid organ transplant recipients is Cryptococcosis. This particular invasive basidiomycete has 3 distinctive varieties (vargattii grubii and neoformans) and ranks as the third most common cause of fungal infection among solid organ transplant recipients with a prevelance rate of 0.5-2.8%. [1] Cryptococcal meningitis has a high mortality and often subtle presenting features. In addition disseminated and pulmonary forms also contribute to morbidity. We hereby present our analysis of our experience with cryptococcal infections presenting to the department of Nephrology VPS Lakeshore Hospital and Research Centre Kochi during the period 2018 to 2022.
AIMS OF THE STUDY: To describe the clinical presentation management and prognosis of cryptococcal infections that presented to the Nephrology department in various clinical settings.
METHODS: Retrospective analysis of 7 patients who presented with Cryptoccocal infections to the Nephrology Department at VPS Lakeshore Hospital and Research Center Kochi was done. The presenting features management strategies and prognosis have been were analyzed.
CONCLUSION: Cryptococcal infection may affect major organ system. Since this infection is having high mortality rate, early diagnosis and prolonged treatment is crucial in survival.
15TH DECEMBER 2023
ABSTRACT NO. 57
STUDY OF CLINICAL PROFILE AND OUTCOMES OF PREGNANCY RELATED ACUTE KIDNEY INJURY AT A TERTIARY CARE CENTER IN EASTERN UTTAR PRADESH
Uttam Kumar Singh, Shivendra Singh
Department of Nephrology; IMS; BHU; Varanasi; Uttar Pradesh; India
E-mail: Iamuttamsingh@gmail.com
BACKGROUND: In developing countries pregnancy-related complications still account for 15% “25% of all cases of acute kidney injury (AKI) and septic abortion accounts for the most cases of pregnancy-related AKI (PRAKI). PRAKI occurs commonly due to preeclampsia and puerperal sepsis etiologies seen in non-pregnant state can also be encountered in the setting of AKI during pregnancy. We studied clinical profile of PRAKI patients at our center and their outcomes and compared with previous studies of last decade and look for paradigm shift.
AIMS OF THE STUDY: To study clinical profile and compare their outcomes in patients with pregnancy related AKI.
METHODS: We retrospectively analyzed patients with pregnancy related acute kidney injury over past three years. We analyzed from our IMS BHU nephrology records patient clinical profile including demography etiology of AKI and their outcomes over 3 months post AKI.
CONCLUSION: Unlike previous reports in our study sepsis was most common cause of PRAKI, explanation maybe we have selected patients in which nephrology intervention was required. Most of them recovered completely (71%). We encountered 2 patients with IRGN which is rare in this subset of patients.
15TH DECEMBER 2023
ABSTRACT NO. 58
EFFICACY OF ACUTE PERITONEAL DIALYSIS (PD) OVER SUSTAINED LOW EFFICIENCY DIALYSIS (SLED) IN CRITICALLY ILL CHRONIC LIVER DISEASE PATIENTS WITH AKI
Himanish Goswami, Mitul Bora
Department of Nephrology; Apollo Hospitals; Guwahati; Assam; India
E-mail: himanish19@gmail.com
BACKGROUND: Acute peritoneal dialysis (PD) has largely been replaced by Continuous Renal Replacement Therapy (CRRT) and Sustained Low Efficiency Dialysis (SLED) in critically ill patients with liver disease requiring Renal Replacement Therapy (RRT). Choosing one modality over the other largely depends on the clinical status of the patient and judgement of the physician. Providing the best RRT with the least use of resources can greatly help our patients and reduce the burden on them and the healthcare system overall.
AIMS OF THE STUDY: Our study aims to look at Acute Peritoneal Dialysis (PD) and Sustained Low Efficiency Dialysis (SLED) done in critically ill patients with liver disease needing renal replacement therapy and to measure the differences (if any) in their efficacy clinical laboratory and other outcome parameters between the two.
METHODS: Patients admitted in the ICU with Acute Kidney Injury and Chronic Liver Disease were included in the study irrespective of the aetiology of renal failure. Patients were randomly divided in to two groups. Group A patients received acute peritoneal dialysis and Group B patients received SLED. Primary outcomes were correction of uremia metabolic acidosis fluid overload dyselectrolytemia and mortality. Secondary outcomes were improvement in sensorium hemodynamic stability ICU length of stay cost of treatment and duration of mechanical ventilation (where applied).
CONCLUSION: Acute PD still remains a viable alternative to SLED in critically ill patients in low cost setting. Advantages are its low cost, ease of administration, needs less expertise and its metabolic and clinical outcomes are not inferior to SLED.
15TH DECEMBER 2023
ABSTRACT NO. 59
IS PREEMPTIVE KIDNEY TRANSPLANTATION ASSOCIATED WITH IMPROVED OUTCOMES WHEN COMPARED TO NON-PREEMPTIVE KIDNEY TRANSPLANTATION? A RETROSPECTIVE OBSERVATIONAL STUDY FROM A TERTIARY CENTRE
M Vaseem, N Sajith, N Ismail, A Feroz, B Sreejesh, A Thushara
Aster MIMS; Kozhikode; Kerala; India
E-mail: vaseem.mithilag@asterhospital.com
BACKGROUND: Optimisation of uremic milieu and cardiovascular status is critical for successful outcome in kidney transplantation (K-Tx). Theoretically pre-emptive transplant group (PTx-Gr) has many advantages over non-pre-emptive transplant group (NPTx-Gr) but there is scarcity of data from India with long term follow-up.
AIMS OF THE STUDY: To analyse and compare outcomes between PTx-Gr and NPTx-Gr groups with respect to uremic complications acute rejections (AR) graft loss (GL) and patient loss (PL).
METHODS: Retrospective observational study of our centre from 2006 to 2022. PTx-Gr included patients who were transplanted without dialysis or just needed HD 4 weeks. NPTx-Gr included patients on dialysis for 3 months but 12 months. Incidence of pre transplant admissions with uremic/cardiovascular complications AR GL or PL were assessed in both groups.
CONCLUSION: The incidence of pre transplant admissions with uremic complications, AR, GL and PL were comparatively higher in the dialysis group when compared with pre-emptive group. Meticulous preparations of patients with CKD with proper counselling can facilitate preemptive transplant which can result in less complications and better allograft/patient outcomes.
15TH DECEMBER 2023
ABSTRACT NO. 60
CLINICOPATHOLOGICAL PROFILE AND OUTCOMES OF PATIENTS WITH BIOPSY PROVEN INFECTION-RELATED GLOMERULONEPHRITIS AT A TERTIARY CARE CENTRE IN EASTERN INDIA
Sanjana Sharma, Koushik Bhattacharjee, Abhishek Vashisth, Sanjay Dasgupta, Keya Basu, Arunansu Bandyopadhyay
Nephrology; IPGMER and SSKM Hospital; Kolkata; West Bengal; India
E-mail: sanjanasharma006@hotmail.com
BACKGROUND: Infection-Related Glomerulonephritis (IRGN) is an immune-complex mediated disease usually preceded by an infection followed by renal dysfunction and subsequent recovery and resolution.
AIMS OF THE STUDY: The aim of the study was to analyse the clinical histopathological profile and the short term outcomes both patient and renal survival in biopsy proven IRGN cohort.
METHODS: A 6 month prospective observational study was undertaken in patients with biopsy proven IRGN at IPGMER Kolkata from January to June 2023. A detailed clinical examination was performed to identify any focus of infection along with routine investigations. Blood cultures urine cultures immunological profile including complement levels were undertaken. Radiological investigations included chest X-ray abdominal ultrasound and echocardiography as per clinical suspicion. Patients were thereafter subjected to renal biopsy. Light microscopy and immunofluorescence were performed in all cases. The histopathological profile and outcomes in terms of renal and patient survival were evaluated along with treatment modalities.
CONCLUSION: IRGN is not a benign disease and can have adverse outcomes, both in terms of renal and patient survival. Complement levels and early renal biopsy can have major prognostic significance and should be routinely employed in patients suspected to have IRGN. Regular follow-up is mandated.
15TH DECEMBER 2023
ABSTRACT NO. 61
DEMYSTIFYING FUNGAL PYELONEPHRITIS: A CASE SERIES
Husain Abbas, M. Aslam, Amir Husain, Sheikh Ashraf, Amir Husain Farooqui
Department of Medicine; Jawaharlal Nehru Medical College; AMU; Aligarh; Uttar Pradesh; India
E-mail: dochusain675@gmail.com
BACKGROUND: Fungal Pyelonephritis is an emerging health concern with grave prognostic implications. In diabetics and immunocompromised patients it accounts for 40% - 60% mortality rate. Various species of Genus Candida particularly Albicans Glabrata and Tropicalis account for majority of cases. The anti-fungal spectrum is variable with rising trend of resistance to traditional anti-fungal drugs such as Fluconazole and Voriconazole. It is therefore imperative to understand the trends and patterns of Fungal Pyelonephritis especially in the developing world.
AIMS OF THE STUDY: To assess the clinico-radiological profile of Fungal Pyelonephritis. To assess the determinants and anti-fungal spectrum of these patients.
METHODS: A Case Series of 25 diagnosed cases of Fungal Pyelonephritis was conducted in the medicine department of a tertiary care hospital in North India.
CONCLUSION: Diabetics are significantly predisposed to developing fungal pyelonephritis. Majority of patients do not present with typical Lower urinary tract symptoms. CT scan is superior to USG in radiologically diagnosing pyelonephritis. The predominant causative agent is Candida Albicans. The rise of antifungal resistance is alarming. Patients have a significant likelihood of worsening into Sepsis and its sequelae and complicating into CKD. Prompt initiation of broad spectrum anti-fungal drugs, proper intensive care and optimizing treatment of co-morbidities is likely to improve outcomes.
15TH DECEMBER 2023
ABSTRACT NO. 62
FREQUENCY AND CLINICAL PROFILE OF PATIENTS WITH INTRADIALYTIC HYPERTENSION ON MAINTENANCE HEMODIALYSIS IN A TERTIARY CARE CENTER
Uday Kiran Raju Kallepalli
Nephrology, Father Muller Medical College Hospital; Mangalore; Karnataka; India
E-mail: udaykiranrajukallepalli@gmail.com
BACKGROUND: The prevalence of Intradialytic Hypertension (IDH) is estimated to be around 5 to 15% in the Hemodialysis (HD) population (1). Intradialytic hypertension has been associated with increased risk for short-term (6 months) and long-term (2 years) morbidity and mortality (1). Indian data on Intradialytic hypertension is sparse (3). We plan to estimate the frequency of IDH in Maintenance Hemodialysis Patients and describe the clinical profile of Maintenance Hemodialysis Patients with intradialytic hypertension.
AIMS OF THE STUDY: To estimate frequency of Intradialytic Hypertension in Maintenance Hemodialysis Patients. To describe the clinical profile of patients with intradialytic hypertension.
METHODS: Definitions intradialytic-hypertension - Intradialytic-Hypertension is defined as the increase in Systolic Blood Pressure greater than 10mmHg from Pre- Hemodialysis to Post- hemodialysis in hypertensive maintenance hemodialysis patients in at least four of out six consecutive hemodialysis treatments. Dry weight - Dry weight is defined as the level below which further fluid removal would produce hypotension muscle cramps nausea and vomiting. This weight will be decided by the treating nephrologist. Hypertension in dialysis - Hypertension in dialysis patients is defined as a midweek median intradialytic blood pressure greater than 140/80 mmhg. Source of data and study setting - Patients on Maintenance Hemodialysis in Dialysis Unit Father Muller Medical College Hospital Mangaluru Karnataka State India. Sample size calculation - The sample size for estimation of prevalence is calculated using z2 n 1 2 p (1’ p) d Z 1-alpha/2 = 1.96 with 95% confidence Interval P = Prevalence from Reference Study (2) = 5% d = margin of error = 5% n = 73 A minimum of 73 patients will be included in the study. Inclusion criteria - Age 18 - 85 years Patients on dialysis for more than 3 months Previously diagnosed with Hypertension - Pre-Dialysis Blood Pressure >140/90 mmHg or Post-Dialysis Blood Pressure >130/80 Patients at target dry weight. Exclusion criteria - Oral or intravenous antibiotic treatment within the past one month. Active Malignancy Not willing to participate. Study design and duration - Cross-sectional Observational Study of Hypertensive Maintenance Hemodialysis patients fulfilling the inclusion criteria undergoing Hemodialysis for 6 consecutive treatment sessions in the hemodialysis unit. A minimum of 73 patients will be enrolled in our study from august 1 2022 to July 31 2023. Method and procedure - Patients satisfying the inclusion criteria on arrival to the Hemodialysis Unit will be seated comfortably in a chair and questioned about the pertinent clinical history and the same will be recorded. Latest available laboratory parameters and 2 D ECHO findings will be entered in the data sheet. The weight of the patient is then recorded using an electronic weighing scale. The blood pressure will be measured by staff nurse/dialysis technician or a doctor. The patient is then made to lie down supine in bed. Manual BP will be measured and recorded using a mercury sphygmomanometer before insertion of dialysis access needles on patients on dialysis through.
CONCLUSION: The study is nearing completion by September 2023.
15TH DECEMBER 2023
ABSTRACT NO. 63
SILDENAFIL AND 5HT2B RECEPTOR COMBINATION ABROGATE PROGRESSION OF PERITONEAL MEMBRANE FIBROSIS IN PD PATIENTS
Saurabh Chaturvedi, Harshit Singh 1 , Narayan Prasad 2
School of Allied Health Sciences; Delhi Pharmaceutical Sciences and Research University; New Delhi; 1 Translational Health Science and Technology Institute; Faridabad; Haryana; 2 Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: saurabhchaturvedi267@gmail.com
BACKGROUND: Peritoneal fibrosis (PF) results in ultrafiltration failure in peritoneal dialysis (PD) patients. 5-hydroxytryptamine (5-HT; serotonin) induces extracellular matrix (ECM) proteins synthesis in fibroblasts in a transforming growth factor beta 1 (TGF-²1) dependent manner. TGF-²1 activates resident fibroblasts trans-differentiate into peritoneal myofibroblasts. Peritoneal myofibroblasts characterized by increased alpha-smooth muscle actin (± -SMA) expression ECM proteins production is key in the pathogenesis of PF. PDE5 selective competitive inhibitor sildenafil has documented anti-fibrotic potential in systemic sclerosis.
AIMS OF THE STUDY: We evaluate anti-fibrotic efficacy of phosphodiesterase-5 (PDE-5) inhibitor Sildenafil and 5-HT2B inhibitor SB204741 in combination on human peritoneal fibroblasts (HPFBs) isolated from parietal peritoneum biopsy (PB) of PD patients.
METHODS: Human peritoneal fibroblasts (HPFBs) isolated from PD patients (n = 8) and controls (n = 8) were incubated with TGF-²1 (10 ng/ml) for 1 hour and later with TGF-²1 (10 ng/ml)/[Sildenafil (10µM) or SB204741 (1 µM)] and their combination for 24 hours (post-treatment strategy). In the pre-treatment strategy HPFBs were pre-treated with [Sildenafil (10µM) or SB204741 (1µM) and a combination of the two for 1 hour and later with only TGF-²1 (10ng/ml) for 24 hours. Real time PCR for pro-fibrotic (COL1A1 COL1A2 ACTA2 CTGF FN1 TGF’1) and anti-fibrotic genes (MMP2/TIMP1) expression was performed. Levels of cytokines IFN-gamma IL-4 IL-17 IL-1² IL-6 TNF-alpha (proinflammatory) and IL-10 (anti-inflammatory) in the culture supernatant of HPFBs were determined by ELISA. Type-1 collagen/ ± -SMA were examined by immunoblotting.
CONCLUSION: This study suggests that the combination of Sildenafil and SB204741 may be efficacious in treating peritoneal fibrosis in its active phase during chronic peritoneal dialysis.
15TH DECEMBER 2023
ABSTRACT NO. 64
VITAMIN D RECEPTOR (VDR) AND OPIOID RECEPTORS (OR) EXPRESSION IN CKD-AP PATIENTS
Mohinder Kaur, Arun Prabhahar, B Narayanan, Anuradha Bishnoi, Sanjeev Handa, HS Kohli, Raja Ramachandran 1 , Vinod Kumar
Department of Dermatology; Venereology and Leprology and Nephrology; Postgraduate Institute of Medical Education and Research; Chandigarh; India
E-mail: Kaurmohinder885@gmail.com
BACKGROUND: Itching or pruritus is an annoying sensation that makes you scratch. The itch-scratch reflex is an evolutionarily conserved mechanism that allows mammals to quickly identify harmful environmental stimuli (e.g. toxic plants parasites) and mechanically remove them from the skin. Approximately 13% of CKD (stage 1-5) and 35% of haemodialysis patients experience episodes of chronic itch (CKD-aP). Till date only central opioid receptor (OR) location was thought to cause itch. However the current investigations indicate a larger peripheral distribution of the OR and found alterations in the expression of OPRK1/-opioid receptor (KOR) and OPRM1/¼-opioid receptor (MOR) in epidermal keratinocytes in atopic dermatitis (AD) patients. The lack of reports of OR expression in CKD-aP we decided to conduct a study to evaluate the expression and distribution of OR and Vitamin D receptor (VDR) in the skin of CKD patients.
AIMS OF THE STUDY: To evaluate the expression and distribution of Opioid receptors (OR) and Vitamin D receptor (VDR) in the skin of CKD-aP patients.
METHODS: 15 CKD patients were recruited for the study. A skin biopsy punch of 2 mm was obtained and formalin fixed till experimental analysis. A portion of the same biopsy was processed for total cellular RNA isolation. The expression of VDR and OR receptors (KOR and MOR) were assessed using confocal microscopy. The change in mRNA levels was quantified using qRT-PCR.
CONCLUSION: The present study indicates that VDR expression might contribute to the change in the expression of ORs. This modulation further can be explored to control pruritus sensation among CKD-aP patients.
15TH DECEMBER 2023
ABSTRACT NO. 65
CROSS SECTIONAL STUDY OF OUTCOMES OF TUNNELED CUFFED CATHETERS IN HEMODIALYSIS PATIENTS IN TERTIARY CARE HOSPITAL
Giribabu, Manisha Sahay, Kiranmai Ismail
Nephrology; Osmania Medical College; Hyderabad; Telangana; India
E-mail: giribabugorakala@gmail.com
BACKGROUND: Arteriovenous fistula is the most common vascular access for patients requiring hemodialysis but it is not always possible or practical hence cuffed tunneled dialysis catheter comes into play. The aim of the study was to determine the outcome of cuffed tunneled dialysis catheter used for hemodialysis at a teaching hospital.
AIMS OF THE STUDY: To assess outcomes associated with tunneled cuffed catheters as an access for hemodialysis patients.
METHODS: A descriptive cross-sectional study was conducted between January 2022 and June 2023 on 105 chronic dialysis patients with end-stage renal disease presenting to a tertiary care hospital. Whole sampling was done. Data entry and analysis were done in Microsoft Excel 10 and used SPSS software respectively.
CONCLUSION: Cuffed tunneled dialysis catheter is effective for maintenance hemodialysis in patients with the end-stage renal disease if used with proper care during dialysis even in our setup. The results and outcomes of the procedure are at par with standards.
15TH DECEMBER 2023
ABSTRACT NO. 66
CLINICAL EXPERIENCE AFTER ONE YEAR OF TREATMENT WITH TOLVAPTAN IN PATIENTS WITH AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE - A SINGLE CENTRE STUDY
Deep Mukhopadhyay, Pinaki Mukhopadhyay, Architaben Ramanbhai Patel
Nephrology; Nil Ratan Sircar Medical College and Hospital; Kolkata; West Bengal; India
E-mail: drdeepnephrology@gmail.com
BACKGROUND: Tolvaptan is the first vasopressin-receptor antagonist approved for the treatment of autosomal dominant polycystic kidney disease (ADPKD). No publications report Tolvaptan experience in real clinical practice during the first year of treatment.
AIMS OF THE STUDY: To asses the effect of Tolvaptan on eGFR decline in ADPKD effect on urine osmolality Blood pressure & serum electrolytes and also to asses its side effect profile & Tolerability over the period of 1 year.
METHODS: A prospective study of an initial cohort of 55 rapidly progressing patients treated with Tolvaptan for 12 months. The tolerability of Tolvaptan the evolution of the estimated glomerular filtration rate (eGFR) analytical parameters and blood pressure were analyzed.
CONCLUSION: Tolvaptan treatment is well tolerated by most patients. Liver toxicity is very rare and self-limited. Tolvaptan reduces eGFR in the first month without showing further changes during the first year of treatment. Patients with a higher starting eGFR will suffer a greater initial drop, with a longer recovery. We suggest using the eGFR observed after a month of treatment as the reference for future comparisons and calculating the rate of eGFR decline in patients undergoing Tolvaptan treatment.
15TH DECEMBER 2023
ABSTRACT NO. 67
DIAGNOSTIC UTILITY AND CLINICAL IMPACT OF GENOMIC TESTING IN ADOLESCENT AND ADULT KIDNEY DISEASE PATIENTS WITH SUSPECTED MONOGENIC ETIOLOGY BY ESTABLISHING AN INTEGRATED KIDNEY GENETICS SERVICE
Suceena Alexander, Phaneedra, Rajanbabu Franklin, R V Shaji, Joseph Johny, Nisha Jose, Selvin Sundar Raj Mani, Sabina Yusuf, Jeethu Joseph, Athul Thomas, Vinoi George David, Santosh Varughese
Nephrology; Christian Medical College; Vellore; Tamil Nadu; India
E-mail: suceena@gmail.com
BACKGROUND: Though studies have shown positive impact of genomic testing in pediatric population the diagnostic utility and the clinical impact in real world situations faced by nephrologists when managing adolescent and adult patients with suspected monogenic kidney disease is not known.
AIMS OF THE STUDY: Impact of genomic testing in adult and adolescent kidney disease patients.
METHODS: It is a prospective observational pragmatic cohort study. Consecutive patients satisfying the inclusion and exclusion criteria was recruited after written informed consent and pre-test genetic counselling. Genetic testing was by exome sequencing and results returned with post- test genetic counselling. The whole exome sequencing was done for all probands and the bio-informatics was performed using in-house and commercial (VarSeq Golden Helix) pipeline to identify diagnostic variants for patients renal disease by data scientist and nephrologist trained in genetics. Segregation testing was done on parents of probands to confirm inheritance pattern if required. The diagnostic utility and the clinical impact was assessed at 3 months of patient follow-up following detailed phenotype-genotype correlations.
CONCLUSION: In-house generation of database and bio-informatics performed together nephrologist in the team, helps to correlate the phenotype and genotype tightly and identify disease causing variants by ACMG criteria.
15TH DECEMBER 2023
ABSTRACT NO. 68
POISONING AND ENVENOMATION INDUCED ACUTE KIDNEY INJURY: A HOSPITAL-BASED STUDY
Arham Khan, Saif Quaiser, Ruhi Khan
Jawaharlal Nehru Medical College; Aligarh Muslim University; Aligarh; Uttar Pradesh; India
E-mail: drssaif@gmail.com
BACKGROUND: Most of the cases of acute kidney injury (AKI) in the Indian subcontinent are community-acquired as seen in previous studies and are sepsis or dehydration-related. However some causes of AKI like poisonings (plant/animal toxin) and envenomation/insect stings are unique to the demographics of tropical countries like India.
AIMS OF THE STUDY: This study examined the clinical features spectrum and outcomes of AKI in patients with intoxication/envenomation/insect bites and evaluated the predictors of mortality in the study cohort.
METHODS: This was a prospective observational study conducted between July 2021 to June 2023. Data was collected from patients admitted to the emergency of Jawaharlal Nehru Medical College Aligarh with an alleged history of poisoning/snake bite or insect sting. Relevant medical/medicolegal history on presentation vitals routine laboratory tests on admission mode of treatment and outcome were recorded from all patients who gave informed consent. These patients were followed up for 3 months since their date of admission to our hospital with relevant investigations.
CONCLUSION: This study which is probably the first from North India highlights the fact that most cases of poisoning/envenomation-related AKI are preventable and contribute to a sizeable amount of morbidity/mortality which needs to be addressed seriously.
15TH DECEMBER 2023
ABSTRACT NO. 69
A COMPARATIVE STUDY OF RENAL LIMITED AND SYSTEMIC PAUCI-IMMUNE CRESCENTIC GLOMERULONEPHRITIS: ADVANCED PRESENTATION BUT FAVOURABLE OUTCOMES
J Meyyappan, N Prasad, V Vamsidhar, M R Behera, R S Kushwaha, M R Patel, A Kaul, D S Bhadauria, M Yachha
Department of Nephrology; SGPGI; Lucknow; Uttar Pradesh; India
E-mail: jeyakumarmeyyappam@gmail.com
BACKGROUND: Most of the cases of acute kidney injury (AKI) in the Indian subcontinent are community-acquired as seen in previous studies and are sepsis or dehydration-related. However some causes of AKI like poisonings (plant/animal toxin) and envenomation/insect stings are unique to the demographics of tropical countries like India.
AIMS OF THE STUDY: This study examined the clinical features spectrum and outcomes of AKI in patients with intoxication/envenomation/insect bites and evaluated the predictors of mortality in the study cohort.
METHODS: This was a prospective observational study conducted between July 2021 to June 2023. Data was collected from patients admitted to the emergency of Jawaharlal Nehru Medical College Aligarh with an alleged history of poisoning/snake bite or insect sting. Relevant medical/medicolegal history on presentation vitals routine laboratory tests on admission mode of treatment and outcome were recorded from all patients who gave informed consent. These patients were followed up for 3 months since their date of admission to our hospital with relevant investigations.
CONCLUSION: This study which is probably the first from North India highlights the fact that most cases of poisoning/envenomation-related AKI are preventable and contribute to a sizeable amount of morbidity/mortality which needs to be addressed seriously.
15TH DECEMBER 2023
ABSTRACT NO. 70
POST TRANSPLANT OUTCOME OF PATEINTS WITH IGA NEPHROPATHY WITH CRESCENTS
Atharva Chintawar, P Paul Joy, Rajesh Nair, George Kurian, Anil Mathew, Zachariah Paul
Department of Nephrology; Amrita Institute of Medical Sciences; Kochi; Kerala; India
E-mail: atharva.chintawar@gmail.com
BACKGROUND: After renal transplantation IgA nephropathy (IgAN) is one of the most common recurrent glomerulonephritis. The incidence of IgAN recurrence in grafts is around 9 to 53%. Previous studies have reported that crescentic IgA nephropathy in native kidneys is associated with recurrence in allograft. However the studies are inconclusive.
AIMS OF THE STUDY: This study was done to analyze the outcome of IgAN with more than 25% crescents after transplantation.
METHODS: Patients with IgA nephropathy of age more than 18 years who underwent renal transplant at Amrita Hospital Kochi from 2006 to 2020 were included in the study. Data of patients with more than 25% crescents was collected from the medical records. Clinical outcome in terms of graft function hematuria and proteinuria was analyzed. In this study we followed up the patients till 3 years of transplant. We looked at eGFR at 6 months 1 year and 3 years post-transplant.
CONCLUSION: Our study showed 1 (5.55%) patient had recurrence at 2 ½ years and 1 (5.55%) had hematuria at the end of 3 years, probably related to IgA. Mean eGFR at 6 months post-transplantation was 71.5 mL/min/1.73 m 2 , mean eGFR at 1-year post-transplantation was 68.28 mL/min/1.73 m2 and Mean eGFR at 3 years post-transplantation was 61.42 mL/min/1.73 m2.
15TH DECEMBER 2023
ABSTRACT NO. 71
EVALUATION OF EARLY COMPLICATIONS IN URGENT START PERITONEAL DIALYSIS: SINGLE-CENTER EXPERIENCE
D Arjun, T Jayaprakash, Jeethu Joseph Eapen, Santosh Varughese
Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India
E-mail: arjundinesan1992@gmail.com
BACKGROUND: Peritoneal dialysis is an excellent but underutilized technique. The main barrier in urgent start peritoneal dialysis is the fear of early mechanical complications followed by the risk of early peritonitis.
AIMS OF THE STUDY: The objective of the study is to investigate the early complications within 3 months in patients who received urgent start peritoneal dialysis (PD).
METHODS: In this retrospective study we enrolled all patients who were initiated on urgent start PD at our institution between 1 January 2013 and 31 December 2021. Urgent PD was defined as initiation of PD exchanges within 2 weeks of catheter insertion. Details regarding early complications both mechanical and infectious occurring within 90 days following catheter insertion were recorded.
CONCLUSION: Improvements in peritoneal dialysis catheter insertion techniques and reduction in infection rates may result in long-term PD catheter survival.
15TH DECEMBER 2023
ABSTRACT NO. 72
A STUDY ON CLINICAL CHARACTERISTICS AND SHORT TERM DIVERSE OUTCOMES OF ACUTE KIDNEY INJURY DUE TO TROPICAL INFECTIOUS DISEASES IN A TERTIARY CARE CENTRE FROM SOUTH INDIA
Rohan J Desai, Bhushan C Shetty, Mayoor V Prabhu, Sushanth Kumar B, M Ashok Bhat, V Darshan, B Karina, Raunak Sharma
Kasturba Medical College; Manipal Academy of Higher Education; Mangalore; Karnataka; India
E-mail: batista2966@gmail.com
BACKGROUND: Tropics are a region surrounding the equator between the Tropic of Cancer and Tropic of Capricorn and India is one of them. Acute kidney injury (AKI) associated with tropical infectious diseases like malaria dengue leptospirosis scrub typhus Meliodosis typhoid etc. AKI in tropical countries is heavily influenced by local climatic and economic conditions and is different from that seen in affluent countries. The prevalence of AKI due to tropical infections in different parts of India varies. This is a first of its kind study encompassing a large population with special emphasis on the diverse renal outcome of AKI in tropical infectious disease in a tertiary care centre from South India.
AIMS OF THE STUDY: (1) To find the incidence of acute kidney injury in tropical infectious diseases. (2) To study the clinical characteristics of patients with AKI due to tropical infections. (3) To study the renal outcome in these patients at the end of 2 weeks from admission.
METHODS: It was a prospective study conducted at Kasturba Medical College Mangalore Hospitals from 1st May 2019 to 30th August 2023. Inclusion criteria: (1) Age > 18 years with AKI admitted in Medicine or Nephrology wards including intensive care units due to tropical infectious diseases. (2) Criteria for diagnosing tropical infectious diseases adopted were: Malaria : MP card test positive QBC peripheral smear showing malarial parasite Dengue : NS1 or IgM dengue card test positive Leptospirosis: Lepto IgM positive (>15 Panbio units) Salmonella: Blood culture positive for salmonella Melidiosis: Blood culture positive for burkholderia Scrub typhus: IgM scrub typhus positivity Exclusion criteria: Obstretric Post-surgical drug induced snake bite underlying chronic kidney disease and patients lost to follow up within 8 weeks of discharge were excluded. All patients were evaluated clinically and with laboratory investigations. Acute kidney injury was defined based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Underlying chronic kidney disease was defined as documented high serum creatinine above baseline four weeks prior to onset of symptoms or persistence of renal dysfunction beyond 8 weeks of discharge from the hospital or bilateral small kidneys in ultrasound on admission Patients were treated as per standard of care and renal replacement therapy (RRT) whenever indicated. All were followed up serially and their renal outcome at the end of 2 weeks was noted and documented. Renal outcomes at the end of two weeks is defined as one of the following (1) normalization of renal function tests (2) persistent renal dysfunction without the need of dialysis (3) dialysis dependency (4) death within 2 weeks of admission All data were analysed in suitable statistical tool by latest SPSS software.
CONCLUSION: AKI is a challenging problem in the tropics in view of the changing burden of the disease, the late presentation of patients to health care facilities and the lack of resources to support patients with established AKI in many regions. The overall prevalence of AKI in tropical infectious disease at out centre was 7.09%. AKI due to tropical infections can lead to increased mortality and morbidity rates. Severity of AKI and requirement of dialysis were more in patients with leptospirosis, malaria, and least with enteric fever. The current research is the first of its kind study comprising a large population, with special emphasis on the diverse renal outcome of AKI in tropical infectious disease in a tertiary care centre from South India.
15TH DECEMBER 2023
ABSTRACT NO. 73
RENAL FUNCTIONAL RESERVE IN AKI PATIENTS REQUIRING DIALYSIS
Kapil Sejpal, P S Priyamvada, Sreejith Parameswaran, Madhusudanan Ponnusamy
Jawaharlal Institute of Postgraduate Medical Education and Research; Puducherry; India
E-mail: kapilsejpal@gmail.com
BACKGROUND: Acute kidney injury (AKI) affects one quarter of all hospitalized patients worldwide. Although normalization of serum creatinine after AKI might indicate complete recovery kidneys might lose the renal functional reserve (RFR). RFR represents the extent to which kidneys can increase the glomerular filtration rate (GFR) when they are exposed to various physiological or pathological conditions. RFR is usually assessed clinically by exposing the kidneys to an oral protein load or intravenous amino acid infusion once the baseline GFR is determined. A reduced RFR may signify subclinical damage or an increased susceptibility to further insults.
AIMS OF THE STUDY: To assess the renal reserve among AKI patients requiring dialysis with complete recovery of AKI at 3 months after the onset of AKI.
METHODS: A prospective observational study was conducted at the Department of Nephrology JIPMER from December 2019 to March 2021. All dialysis requiring patients with AKI where included in the study. Patients with CKD (eGFR<60 ml/min) and patients with obstructive uropathy where excluded from the study. At 3 months from the onset of AKI for patients who show complete recovery (eGFR >60 ml/min and uACR <30) renal reserve was assessed with amino acid infusion. On day 0 of follow up a baseline GFR was measured by DTPA plasma clearance method. On the following day 1 of follow up GFR was measured after infusion of 10% amino acid solution at 4 ml/kg for 3 hours. Renal functional reserve was calculated as percentage increase in GFR relative to baseline measurement.
CONCLUSION: Median RFR at 3 months was 10.06% (IQR 5.60-20.15) in patients who showed complete recovery of AKI. Measured GFR was significantly lower at 3 months of follow up as compared to estimated GFR in patients who showed complete recovery of AKI.
15TH DECEMBER 2023
ABSTRACT NO. 74
BUDESONIDE IN IGA NEPHROPATHY: ASSESSING RENAL PROTECTION - AN INITIAL EXPERIENCE
K P Jayakumar, Tharun Lorenz 1 , Gautham Rajan 1 , Ajeesh 1 , Christine 1 , G A Suresh 1
Department of Nephrology; Government Medical College; 1 Caritas Hospital and Insitute of Health Science; Kottayam; Kerala; India
E-mail: drkpjk@gmail.com
BACKGROUND: IgA nephropathy is a chronic kidney disease characterized by the deposition of galactose-deficient IgA from the gut-associated immune system in the glomeruli. Budesonide a locally acting drug has shown potential in modulating the dysregulation of gut-related immune responses making it an attractive therapeutic option for IgA nephropathy.
AIMS OF THE STUDY: Determine the effectiveness of Budesonide in reducing hematuria proteinuria and stabilizing renal function in IgA nephropathy patients.
METHODS: Over the course of a six-month study spanning from December 2022 to August 2023 a cohort of 15 patients diagnosed with biopsy-proven primary IgA Nephropathy was closely examined. Certain exclusion criteria were applied leading to the exclusion of patients below 18 years of age those experiencing rapidly progressive renal failure or having an eGFR below 30 ml and individuals with comorbidities such as Diabetes Mellitus and Autoimmune diseases. This study featured two distinct groups: Group 1 designated as the Control group and Group 2 identified as the Intervention group. The Control group received prednisolone as part of their designated treatment regimen while the Intervention group was administered budesonide at a dosage of 9mg. In addition to these primary treatment approaches both groups also received supportive therapy in the form of telmisartan. To assess the efficacy of these treatments researchers compared the results obtained during the study to the baseline data collected prior to the initiation of treatment. Additionally the data collected at the six-month mark was thoroughly evaluated to monitor any changes or improvements in the participants’ conditions. The patients were diligently monitored for various critical parameters including the presence of hematuria proteinuria eGFR and Mean Blood Pressure.
CONCLUSION: Budesonide may be an effective treatment option for IgA nephropathy, as evidenced by a reduction in proteinuria and stabilization of renal function. Budesonide demonstrated a favourable safety profile in the study, with a low incidence of adverse events or side effects in treated patients.
15TH DECEMBER 2023
ABSTRACT NO. 75
BEHAVIOURAL HEALTH RISK PROFILE OF INDIVIDUALS FROM GENERAL POPULATION IN NORTH INDIA
Rupinder Kaur, Jaskiran Kaur, J S Thakur, Vivek Kumar, Ashok Yadav, Vivekanand Jha
Postgraduate Institute of Medical Education and Research; Chandigarh; George Institute for Global Health India; New Delhi; India
E-mail: kaur_rupin83@yahoo.com
BACKGROUND: Behavioural health risk factors and their co-occurrence resulting in co-morbidities is a major concern in noncommunicable diseases. The risk profiles change with time and it is important to trace and study them in order to mitigate the disease burden. Identifying the magnitude of risk profile may help in reducing the burden of NCDs like Chronic Kidney Disease.
AIMS OF THE STUDY: We estimated the behavioural risk profile in general population in ongoing research being undertaken to measure the glomerular filtration rate in Indian population. We investigated the behavioural health risk factors and their co-occurrence. We also explored the differences by gender and age (younger age group (18-35 years) middle age group (36-49 years) and older age group (>50 years).
METHODS: The study has a cross-sectional design and is enrolling healthy subjects from the communities in Chandigarh. Systemic stratified sampling is used for selecting households and the KISH grid method for selecting individuals from houses. Adults 18 years of age with stable clinical state and no chronic illness are being enrolled. We are presenting the data describing the behavioural health risk factors (HRF) profile including alcohol and tobacco use patterns physical activity related behaviour and overweight. HRFs were defined as- alcohol consumption; current users of any type of alcohol beverage tobacco consumption; current users of tobacco in any form such as smoking or chewing physical activity; moderate to high intensity workout for >30 min/day for 4-5 days a week and overweight; subjects with BMI 25 kg/m2.
CONCLUSION: The evidence so far suggests that the behavioural risk factors are prevalent in the study population. The marked co-occurrence of behavioural risk factors in the populations needs to be understood and addressed through specific interventions.
15TH DECEMBER 2023
ABSTRACT NO. 76
KLOTHO IN CKD
Akash Pandya, Abhijit Konnur, Umapati Hegde, Sishir Gang, Hardik Patel
Department of Nephrology; MPUH; Nadiad; Gujarat; India
E-mail: akumar.pandya@gmail.com
BACKGROUND: Current methods to diagnose and monitor CKD are not perfect. Our objectives were to observe association of Klotho with fall in GFR MBD Atherosclerosis. We also looked for 40% or more fall in GFR requirement of initiation of RRT death with different Grades and tertiles of Klotho deficiency.
AIMS OF THE STUDY: To investigate association of Klotho and Ckd progression- GFR fall MBD Vascular calcification inflamation Death Requirement of RRT.
METHODS: We included 107 patients and recorded their BP Ankle Brachial Pressure Index (ABPI) Carotid Intima Media Thickness (CIMT) and laboratory data for relevant parameters. We did ELIZA for klotho for healthy individuals (n = 25) and patients at 6 (n = 107) and 12 (n = 102) months.
CONCLUSION: Klotho levels correlated well with renal function. Klotho was found to decrease in patients with advanced kidney failure. Klotho correlated significantly with Inflammation, Atherosclerosis, and vascular calcification. Death, significant reduction in renal function and initiation of RRT were seen more in patients with more severe Klotho deficiency.
15TH DECEMBER 2023
ABSTRACT NO. 77
FASCIOTOMY IN SNAKE BITE VICTIMS AND RENAL OUTCOME IN A TERTIARY CARE HOSPITAL
T Chakravarthi, M Seenivasan, P Nagarajan, S A K Noor Mohammed, S Manokaran, C Archana, R Aravinth Kumar
Department of Nephrology; Government Mohan Kumaramangalam Medical College; Salem; Tamil Nadu; India
E-mail: drtchakravarthi@gmail.com
BACKGROUND: Snake bite is an occupational hazard of rural Indian population. In India about 0.5% of death is due to snake envenomation each year mostly in young individuals. Russel viper is the most common cause of mortality due to snake bite in south India. The presenting symptoms of Russel viper bite are cellulitis (96.7%) regional lymphadenopathy (89.5%) and bleeding manifestations (23.8%). Local manifestations are more severe in Russel viper bite including swelling bleeding blistering necrosis and sometimes severe swelling and pain leading to compartment syndrome. The development of cellulitis is one of the risk factors for Acute kidney injury. Fasciotomy may be needed to reduce tissue pressure in some cases of Viper bite. There is risk of fasciotomy for the victim due to the combination of consumption coagulopathy thrombocytopenia and enhanced fibrinolysis. We aimed to study the renal outcome of viper bite victim who had undergone fasciotomy to reduce intra compartmental pressure. Snake bite is a neglected tropical disease. More than 50% of death due to snake bite in the world occurs in India. Acute kidney injury (AKI) is the cause of morbidity and mortality in viper bite. The compartment syndrome is a rare manifestation of snake bite. There is paucity of data on the role of fasciotomy in viper bite.
AIMS OF THE STUDY: To study about the renal outcome of early fasciotomy in case of snake bite with AKI with compartmental syndrome.
METHODS: This is a prospective observational study done in a tertiary care hospital from June 2022 to May 2023. The study was approved by the Institute ethics committee. We included all snake bite patients in the age group of 15 to 75 years developing acute kidney injury (AKI) by elevation in serum creatinine of at least by 0.3 mg/dl within 48 hours or 1.5 times the reference creatinine by Kidney Disease Improving Global Outcome (KDIGO) criteria. The snake bite patients with pre-existing chronic kidney disease with no cellulitis and with pure neurotoxic envenomation were excluded. All patients underwent the following investigations: 20 minutes whole blood clotting time complete blood count blood urea serum creatinine urine analysis and prothrombin time. The creatinine phosphokinase and lactate dehydrogenase estimation were done in selected patients. The patients who developed AKI underwent ultrasound abdomen. The patients were treated with intra venous (IV) fluids and IV antibiotics. Anti-snake venom (ASV) was given according to local symptoms or systemic envenomation in the form of coagulopathy or neurotoxicity. Some patients with features of clinical compartment syndrome in the form of pain on passive movement pallor pulseless limb hypoesthesia over the territory of sensory nerve passing through the compartment underwent fasciotomy after adequate antivenin administration and correction of coagulopathy according to the surgeon clinical decision. Intra-compartmental pressure was not measured. Early fasciotomy was defined as those who had undergone fasciotomy within 36 hours of the bite and late fasciotomy between 36 to 72 hours of the bite. The snake bite AKI patients managed conservatively without dialysis were excluded from the final analysis. Patients who had undergone fasciotomy less than 72 hours after snake bite and developed renal failure were compared to those patients with similar age and who had similar bite-to-ASV time and developed AKI for renal outcome in the form of peak creatinine and duration of dialysis requirement. The continuous variables were described as Mean ± Standard deviation and categorical variables were described in percentage. Fisher’s exact test was used for categorical variables. The statistical analysis was done using one-way ANOVA test (SPSS software). The P value < 0.05 was considered statistically significant.
CONCLUSION: Fasciotomy was needed in 16.1% of viper bite victims. The requirement of anti-snake venom was more in those who needed fasciotomy following snake bite. The peak serum creatinine and duration of dialysis dependency were less, in those who underwent fasciotomy following snake bite. In view of favorable renal outcome, early fasciotomy should be judiciously considered in viper bite victims with compartment syndrome, after adequate ASV administration.
15TH DECEMBER 2023
ABSTRACT NO. 78
NOVEL ABPM PARAMETERS AND BLOOD PRESSURE PHENOTYPES IN CKD
Bahaar Athavale, Hardik Shah, Akshay Ramteke, Dilip Kirpalani, Ashok Kirpalani
Department of Nephrology; Bombay Hospital Institute of Medical Sciences; Mumbai; Maharashtra; India
E-mail: duchess229@gmail.com
BACKGROUND: Uncontrolled blood pressure is associated with target organ damage and unfavorable cardiovascular outcomes especially in CKD. The standard BP phenotypes: White Coat Effect (WCE) Masked Hypertension Nocturnal Hypertension and Early Morning BP Surge (EMBS) by traditional sleep trough method are known to be more prevalent in the CKD population. However the novel BP parameters as detected only by ABPM such as BP variability morning masked hypertension Double Risers and EMBS by moving average sleep trough method have helped in managing hypertension of CKD better. Recently several studies have demonstrated association of these novel BP phenotypes with higher incidence of arterial stiffness proteinuria and progression of kidney disease.
AIMS OF THE STUDY: Our study aims to compare novel ABPM parameters between CKD and non-CKD patients and also within various subgroups of CKD.
METHODS: 100 consecutive hypertensive patients-{Group A with CKD Stage 1 to 4 (n=50) and Group B - without CKD (n=50)}; underwent measurement of single clinic BP (SOBP by Omron 7113) averaged automated clinic BP (AOBP by Omron HEM 907) and 24 hours ABPM (by SunTech Oscar 2).
CONCLUSION: As compared to the non-CKD population, the CKD patients have higher prevalence of ABPM phenotypes such as masked hypertension, nocturnal hypertension, EMBS and BP variability irrespective of age, stage of CKD and level of control of office BP. Utilization of novel ABPM parameters can guide towards holistic management of hypertension in CKD.
15TH DECEMBER 2023
ABSTRACT NO. 79
SECONDARY HYPERPARATHYROIDISM IN MAINTENANCE HEMODIALYSIS PATIENTS AND RESPONSE TO THERAPY
Sayali Dalvi, Satarupa Deb, Deepa Usulumarty, Parag Tilve, Sachin Bodke, Narayan Rangaraj, Santosh Noronha, Jatin Kothari, Shrirang Bichu, Viswanath Billa
Apex Kidney Care; IIT Bombay; Bombay Hospital; Mumbai; Maharashtra; India
E-mail: dalavi.sayali@gmail.com
BACKGROUND: Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a complication of CKD characterized by disturbances in the levels of calcium phosphorus parathyroid hormone (PTH) and vitamin D; abnormal bone formation affecting the mineralization and linear growth of bone; and vascular and soft tissue calcification. Secondary hyperparathyroidism is defined as adaptive parathyroid gland hyperplasia with increased production of PTH. Secondary hyperparathyroidism generally encompasses the biochemical abnormalities associated with CKD MBD. Studies have shown that Secondary hyperparathyroidism in CKD is associated with increased morbidity and mortality.
AIMS OF THE STUDY: The aim of the study was to identify factors associated with increased incidence of refractory hyperparathyroidism (RHPTH) and to assess survival benefit in patients who responded well to therapy (SHPTH).
METHODS: 552 dialysis patients were screened. 107 patients with PTH >700 pg/ml and under active treatment for hyperparathyroidism were included in this retrospective observational study. Follow-up data for 3 years was collected from our database. At the end of 3 years of treatment if serum PTH kept rising despite optimum treatment then such patients were labelled as refractory (RHPTH); rest were secondary (SHPTH). Various factors including demographic parameters serial PTH phosphorus and alkaline phosphatase (AlkP) value were analyzed in both groups. Compliance was assessed at the time of data collection by MMAS-4 score (Morisky Medication Adherence Scale). Along with the clinical outcome (RHPTH/SHPTH) mortality and hospitalization rates were the other outcome parameters analyzed.
CONCLUSION: Baseline PTH and phosphorus had no impact on treatment response, however higher pre-treatment AlkP increased the risk of RHPTH. Older age, diabetes and non-compliance were the other risk factors identified on multivariate analysis. While survival benefit was not proven, SHPTH group had lesser symptom burden. Parathyroidectomy surgery was not associated with increased mortality risk in refractory group.
15TH DECEMBER 2023
ABSTRACT NO. 80
A STUDY ON THE PREVALENCE OF PULMONARYHYPERTENSION INPATIENTS WITH CHRONIC KIDNEY DISEASE ON MAINTENANCE HEMODIALYSIS AND ASSESSMENT OF THE VARIOUS FACTORS AND RESPONDS TO VARIOUS TREATMENT MODALITES
Karthikeyan, V Ramasubramaian, P Sankar, V Kannan Bhaba, P K Senthikumar, S Murugesh Anand, A Shivakumar
Department of Nephrology; Tirunelveli Goverment Medical College; Tirunelveli; Tamil Nadu; India
E-mail: drkarthikeyan111@gmail.com
BACKGROUND: Pulmonary hypertension (PH) is a chronic progressive disease characterized by an elevated pulmonary arterial pressure and a mean pulmonary arterial pressure (mPAP) greater than 20 mmHg at rest is considered as elevated. PH in patients with end-stage kidney disease (ESKD) is a serious condition that is associated with an elevated risk of cardiovascular events and mortality. Prevalence of PH in patients on any mode of dialysis on hemodialysis and on peritoneal dialysis was 38% 40% and 19% respectively. PH is an independent predictor of increased mortality in patients with chronic kidney disease CKD. Identifying PH can be challenging but is important as management strategies differ for ESKD patients with PH and without PH. Identifying the presence of PH and the factors associated with it can help in planning appropriate interventions at an earlier stage to reduce mortality among them.
AIMS OF THE STUDY: (1). To estimate the prevalence of pulmonary hypertension among CKD patients undergoing hemodialysis. (2) To assess the various factors associated with pulmonary hypertension. (3) To assess the benefit of extended hemodialysis and other interventions.
METHODS: This was a hospital based analytical cross sectional study conducted among 150 adult patients aged more than 18 years of both gender diagnosed with CKD stage 5 as per KDIGO guidelines and on Hemodialysis in Nephrology department of Tirunelveli Medical College Hospital Tamilnadu. Known cases of primary PH known valvular and congenital heart diseases chronic obstructive lung diseases obstructive sleep apnea were excluded. Consecutive sampling was followed for recruiting participants into the study. Socio demographic details of participants causes of CKD presence of co morbidities (DM HTN CAD) type of fistula smoking history dialysis-related factors AVF flow rates dialysis vintage and laboratory investigation values (hemoglobin albumin calcium phosphorus) were collected. Echo cardiogram was done for all patients and the findings were recorded and Pulmonary artery systolic pressure was calculated with the Bernoulli equation. Data were entered in Microsoft excel sheet 2016 and were analyzed using IBM SPSS software version 23. Categorical variables were expressed in frequency percentages and continuous variables were expressed in Mean ± SD. Chi square test was used to test the association between categorical variables and independent sample t test or Mann whitney U test was used to test the significant difference in means and p value <0.05 was considered to be statistically significant.
CONCLUSION: The present study showed a high prevalence of PH among CKD patients undergoing hemodialysis. Variables like duration of dialysis, presence of severe anemia, PEM, underweight, brachio cephalic fistula access, Left ventricular hypertrophy, pericardial effusion, RV dysfunction, had statistically significant association with pulmonary hypertension. Patients who were treated with the combination drugs Isolazine/extended HD and Isolazine/sildanefil had showed significant improvement when compared with other modalities of treatment. Though patients with under weight, brachiocephalic fistula and pericardial effusion had higher mortality in our study, larger studies are needed to validate our findings.
15TH DECEMBER 2023
ABSTRACT NO. 81
ROLE OF ASYMMETRICAL DIMETHYL ARGININE AS A NOVEL BIOMARKER IN TYPE II DIABETES MELLITUS IN RELATION TO CORONARY ARTERY DISEASE AND DIABETIC KIDNEY DISEASE
Satyendra Kumar Sonkar, Jyoti Verma, Akash Gupta, Gyanendra Kumar Sonkar 1 , Abhishek Singh 2 , Pravesh Vishwakarma 2 , Vivek Bhosle 3 , Sharad Sharma 4
Departments of Medicine; 1 Biochemistry and 2 Cardiology; King George’s Medical University; 3 Pharmacology Clinical and Experimental Medicine Central Drug Research Institute; 4 Pathology Clinical and Experimental Medicine Central Drug Research Institute; Lucknow; Uttar Pradesh; India
E-mail: satyendra.sonkar@gmail.com ; satyendrakrsonkar@kgmcindia.edu
BACKGROUND: Type 2 Diabetes Mellitus (T2DM) patients are at high risk of developing micro and macroangiopathic complications. Endothelial dysfunction is an early event in atherosclerotic cardiovascular disease (ASCVD). Nitric oxide (NO) a vasodilatory and anti-inflammatory molecule is necessary for endothelial function and is competitively inhibited by asymmetric dimethylarginine (ADMA).
AIMS OF THE STUDY: In this study we assessed the role of ADMA as a novel biomarker for increased cardiovascular risk in T2DM patients.
METHODS: The study was a cross-sectional case-control study conducted at a tertiary hospital in Northern India over a period of one year. Patients with T2DM between age group of 18-65 years were included in the study. A total of 136 participants were included and divided into four groups. Group 1 was the normal healthy control group Group 2 was the DM group Group 3 was the DCAD group and Group 4 was the DKD group. The clinical and laboratory findings were compared among the four groups.
CONCLUSION: The majority of the diabetic patients (67%) had raised HbA1c (7%) suggesting uncontrolled diabetes. ADMA was significantly increased in diabetic patients compared to controls (p < 0.001). ADMA was highest in the DCAD group.
15TH DECEMBER 2023
ABSTRACT NO. 82
THE SPECTRUM OF KIDNEY DISEASE IN TYPE TWO DIABETIC PATIENTS: A SINGLE-CENTER STUDY
Ankita Raisinghani, C G Sreedhara, A Kishan, Gireesh Reddy, S Mythri
Department of Nephrology; Institute of Nephrourology; Bengaluru; Karnataka; India
E-mail: raisinghaninank@gmail.com
BACKGROUND: Diabetic nephropathy (DN) is the dominant reason for end-stage kidney disease linked with a rise in cardiovascular mortality rate. However besides DN type 2 diabetic patients may also suffer from various non-diabetic renal diseases (NDRD).
AIMS OF THE STUDY: e objective of the current research was to assess the occurrence and type of NDRD diagnosed by kidney biopsy in type 2 diabetic subjects evaluate the association of various clinical and laboratory characteristics with histopathology findings and identify essential predictors of NDRD.
METHODS: Retrospective analysis has been performed through medical record revision of 101 patients with type 2 diabetes undergoing percutaneous renal biopsy AT institute of nephrourology bengaluru. Single centre between January 2020 to August 2023.
CONCLUSION: Clinical parameters such as short duration of diabetes, older age, higher hemoglobin level, and lower proteinuria or massive proteinuria might be associated with NDRD in type 2 diabetic patients. Multiple myeloma was also not uncommon.
15TH DECEMBER 2023
ABSTRACT NO. 83
CLINICAL PROFILE DIAGNOSIS THERAPEUTIC INTERVENTION AND COMPLICATION INBIOPSIED CKD PATIENTS - AN OBSERVATIONAL STUDY
Sourya Sourabh Mohakuda, Dharmendra S Bhadauria, Anupma Kaul, Narayan Prasad
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: souryasourabh@gmail.com
BACKGROUND: Clinicians avoid biopsy in Chronic kidney disease (CKD) as there is high risk of bleed. However there are conditions where benefits outweigh risks like ascertaining cause of CKD in patients going for transplant and in those where reversibility is expected. There is paucity of data on the outcomes of renal biopsy in CKD patients.
AIMS OF THE STUDY: This study aims to study the clinical profile diagnosis therapeutic intervention and complications in biopsied CKD patients.
METHODS: All CKD patients who underwent biopsy from Mar 2003 to Mar 2023 were included in the study.
CONCLUSION: Despite a high risk procedure, renal biopsy may bring an opportunity to modify the treatment of the disease which showed positive results in more than one third patients with minimal chances of grave complications associated with the procedure.
15TH DECEMBER 2023
ABSTRACT NO. 84
SPECTRUM OF KIDNEY INVOLVEMENT IN PATIENTS WITH CANCER
Gauri Kulkarni, Niwrutti Hase, Aniket Hase
Department of Nephrology; Jupiter Hospital; Thane West; Maharashtra; India
E-mail: anikethase@gmail.com
BACKGROUND: Almost all compartments of kidney can be affected by cancer directly or by indirect mechanisms. Presentation of kidney involvement is wide and diverse also is sparsely reported. We aimed to study the clinical profile and type of kidney disease in patients with cancer.
AIMS OF THE STUDY: To study the clinical profile and type of kidney disease in patients with cancer To assess the etiological factors associated with kidney involvement in patients with cancer. To study the complications of kidney involvement in patients with cancer. To identify predictors of outcome for kidney involvement in cancer.
METHODS: We prospectively studied 79 cancer patients presenting to us as kidney involvement. Demographic data history Clinical examination clinical course and laboratory Parameters were noted. Patients clinical presentation was identified according to clinical syndrome such as AKI AKI on CKD Obstructive nephropathy Electrolyte disturbances. Patients were followed to to 90 days for measuring the outcome in terms mortality and renal function.
CONCLUSION: Kidney involvement in patients with malignancy is common in elderly with male preponderance, having 41% mortality with hematologic malignancies being most common involving kidney.
15TH DECEMBER 2023
ABSTRACT NO. 85
LONG-TERM RENAL OUTCOMES OF A COHORT OF UNRELATED KIDNEY DONORS
Sumathi Govindaraju, Tanuj Lamech, Venkatesh Arumugam, V S Jibia, Guhan Senthilkumaran; Vaishanavi Devi Rajarathinam, Premkumar Devaraju, Vinoj Murugesan, Chelvamalai Muthukumaran, Praveenkumar Natarajan, Srinidhi Viswanathan, Gopikumar Sekar, Prathiba Parthasarathy, Harrini Devi Palani Baskar, Natarajan Gopalakrishnan
Department of Nephrology; Madras Medical College; Chennai; Tamil Nadu; India
E-mail: sumathi.krenos@gmail.com
BACKGROUND: Kidney transplantation is the ideal form of renal replacement therapy for patients with end-stage kidney disease (ESKD). As live-donor kidney transplantation is on the rise donor health assessment and follow-up should be prioritised to evaluate the long-term risks of kidney donation.
AIMS OF THE STUDY: We present long-term renal outcomes from a cohort of commercial kidney donors who underwent nephrectomy and recently presented to our Institution for assessment.
METHODS: We conducted a cross-sectional study at the out-patient department of the Institute of Nephrology at Rajiv Gandhi Government General Hospital in the year 2022. Our study included fifty-four patients from a single geographical area who had undergone donor nephrectomy for transplantation to unrelated recipients. These cluster of donors living in the same locality had purportedly received financial compensation for kidney donation and had now been brought to our institution by a social activist interested in the welfare of these patients. At presentation over 10 years had elapsed since donor nephrectomy had been performed. Clinical data relating to age gender pre-donation comorbidities surgical technique duration of hospitalisation and post-operative complications were collected (via patient history or by available documentation). Their current renal function was also assessed.
CONCLUSION: Individuals undergoing donor nephrectomies must be made aware of the small but significant long-term risk of hypertension and chronic kidney disease. Although this should not preclude live-related transplantation, donors should be appraised of potential risk, as this would aid shared decision-making and also encourage more regular long-term follow-up.
15TH DECEMBER 2023
ABSTRACT NO. 86
RISK FACTORS FOR DEVELOPING NEW ONSET DIABETES AFTER TRANSPLANTATION (NODAT)
Virendra Kumar Chauhan, D Madhavi, V Krishnapriya, G Chaitrali, V Hepal, V Zaheer, R Prashant, T Shruti, S Mita, S Bharat
Department of Nephrology; Global Hospitals, Mumbai; Maharashtra; India
E-mail: imcool.vrc@gmail.com
BACKGROUND: NODAT is considered an important complication affecting long term outcome of kidney transplant.
AIM OF THE STUDY: To study risk factors for developing NODAT.
METHODS: This study included 332 non diabetic renal transplant recipients from 1st August 2013 till 31st August 2022. NODAT was defined as presence diabetes (as per ADA) post-transplant at 6 months.
CONCLUSION: NODAT is an important complication which develops in almost 25% of recipients after kidney transplant. Family history, old age, a high or low BMI, pre-transplant HbA1C, fasting hyperglycemia and a higher mean tacrolimus levels at 3rd month post-transplant increased the risk of development of NODAT.
15TH DECEMBER 2023
ABSTRACT NO. 87
A COMPARATIVE STUDY OF EARLY VERSUS LATE INITIATION OF HEMODIALYSIS IN PATIENTS WITH SNAKE BITE INDUCED ACUTE KIDNEY INJURY AND ITS IMPACT ON THE SHORT-TERM AND LONG-TERM OUTCOMES
Kaushik Mondal 1 , Abhishek Mukherjee 1 , Pinaki Mukherjee 1 , Tanima Bhattacharya 1 , Avishek Maity 1,2
1 Department of Nephrology; NRS Medical College; 2 Nil Ratan Sircar Medical College; Kolkata; West Bengal; India
E-mail: kaushik.medicine1990@gmail.com
BACKGROUND: Being one of the commonest causes of acute kidney injury (AKI) in India with variable outcomes comprising of death complete or partial or non-recovery snake bite deserves utmost importance for timely intervention. Though life-threatening complications (volume overload refractory hyperkalaemia refractory metabolic acidosis) warrant immediate starting of hemodialysis but in absence of such symptoms timing to start hemodialysis remains unclear.
AIM OF THE STUDY: Our study aims to observe the short-term outcome (at 30 days) and long-term changes in kidney function (at 90 days) in snake envenomation induced AKI who are subjected to either an early strategy or a delayed strategy of initiation of renal replacement therapy (RRT).
METHODS: We are assessing data of 53 patients in a prospective open label interventional randomized controlled study excluding stage 3 AKI (KDIGO) or pre-existing kidney disease. Early RRT initiation strategy includesRRT initiated within 12 hours of documentation of KDIGO stage 2 AKI and delayed RRT includes RRT initiated 48 hours after documentation of KDIGO stage 2 AKI. Patients were monitored monthly basis with renal function tests and urinalysis reports. USG of whole abdomen and 24-hour urine protein estimation were done at the end of the 3-month study period.
CONCLUSION: There was increased mortality in patients assigned to the early initiation strategy of RRT compared to delayed initiation strategy with no significant difference in terms of progression from AKI to chronic kidney disease at the end of 90 days in the two groups of patients in snake-bite induced AKI.
15TH DECEMBER 2023
ABSTRACT NO. 88
PROSPECTIVE STUDY COMPARING EFFICACY AND COST EFFECTIVENESS OF HEMODIAFILTRATION VS CONVENTIONAL HEMODIALYSIS IN A TERTIARY CARE CENTER
B Dushyanth, C D Prashant
Department of Nephrology; Apollo Hospitals; Bengaluru; Karnataka; India
E-mail: dushyanth492@gmail.com
BACKGROUND: Study was conducted comparing efficacy in terms of solute clearance between hemodiafiltration and conventional hemodialysis in a tertiary care center. Study compared frequency of hospitalization and cost effectiveness between hemodiafiltration and conventional hemodialysis. In addition study also assessed the overall quality of life index in patients on hemodiafiltration and conventional hemodialysis. Lack of Indian data comparing the efficacy of dialysis quality of life between hemodiafiltration and conventional hemodialysis patients.
AIM OF THE STUDY: Primary Objective - To compare efficacy in terms of solute clearance between hemodiafiltration and conventional hemodialysis in a tertiary care center Secondary Objective - To assess overall quality of life index in patients on conventional hemodialysis vs hemodiafiltration To compare frequency of hospitalization and cost effectiveness between conventional hemodialysis vs hemodiafiltration.
METHODS: Study was conducted in Department of Nephrology Apollo Hospitals Bangalore 1 year hospital based prospective observational study Sample Size - 32 participants 20 in the HD group and 12 in the HDF group.
CONCLUSION: (1) Patients in HDF had better solute clearance, lesser rates of hospitalization as compared to conventional hemodialysis (2) HDF patients had more monthly expenditure as compared to patients on conventional hemodialysis.
15TH DECEMBER 2023
ABSTRACT NO. 89
CLINICO-BIOCHEMICAL PROFILE OF PATIENTS WITH HYPERCALCEMIA IN A TERITIARY CARE CENTRE
Pulipati Akshaya Chowdary, E Mahesh, K C Gurudev, M S Gireesh, Rajashekar, V Hamsa, Pooja Prabhu, Yousuff
Department of Nephrology; M. S. Ramaiah Medical College; Bengaluru; Karnataka; India
E-mail: akshaya.pulipati@gmail.com
BACKGROUND: The etiology of hypercalcemia varies according to the clinical setting. There is a dearth of information on the prevalence and characteristics of hypercalcemia among hospitalized South-Indian patients.
AIM OF THE STUDY: The aim of this observational study to determine the clinico-biochemical profile of patients with hypercalcemia admitted in a teritiary care hospital in south India.
METHODS: A retrospective study was performed at the Ramaiah group of Hospitals among individuals aged above 18 years admitted from 2018 with corrected calcium levels of more than 10.2mg/dL. The details of patients admitted with disorders of calcium metabolism were collected from the medical records department and the data of patients with hypercalcemia is recorded.
CONCLUSION: Hyperparathyroidism and malignancy are the most common cause of hypercalcemia although the etiology of hypercalcemia is very variable in different regions. With increased use of over the counter vitamin d supplements, incidence of vitamin d toxicity is increasing and judicial use of vitamin d supplements should be practised.
15TH DECEMBER 2023
ABSTRACT NO. 90
CLINICAL PROFILE AND LONG-TERM OUTCOME IN RENAL TRANSPLANT RECIPIENTS WITH COVID 19 INFECTION
Elsa George, N Sajith, N A Ismail, A Feroz, B Sreejesh, A Thushara, P Jithu, B Aparna, M Vaseem, N Sumesh
Aster MIMS; Kozhikode; Kerala; India
E-mail: elsageorge.cmc@gmail.com
BACKGROUND: This study investigated the 6-month outcomes of COVID-19-infected renal transplant recipients focusing on mortality and kidney function. The study aimed to identify factors contributing to severe infections and the link between kidney dysfunction and lung injury in these patients.
AIM OF THE STUDY: (a) To assess the allograft function and patient survival status at 6 months. (b) To determine the additional risk factors contributing to severe COVID-19 infection. (c) To study the association between acute allograft dysfunction and lung injury.
METHODS: This hospital-based study observed renal transplant recipients who contracted COVID-19 and were followed for at least 6 months at Aster MIMS Calicut. Participants aged 18 and above were included while those with irregular follow-up prior allograft failure or back on dialysis were excluded.
CONCLUSION: Our study highlights higher COVID-19 mortality among renal transplant recipients than the general population. AKI risk rises during acute illness, especially with poor baseline allograft function. Around one-third of the study group had a decline in allograft function necessitating vigilant follow-up and immunosuppressive monitoring. There was a significant association between risk for lung injury in patients with AKI. Even though vaccination didn’t notably alter disease severity, COVID-specific antibody cocktail was found to be beneficial.
15TH DECEMBER 2023
ABSTRACT NO. 91
CLINICAL PROFILE AND OUTCOME OF PATIENTS WITH ACUTE PARAQUAT POISONING MANAGED WITH HEMOPERFUSION
Sruthi Haridas, Nidila Mohan, Avin Alex, V Unnikrishnan Ramachandran, Binoj Panekkatil, Krishna Suresh, Sebastian Abraham, M K Mohandas
Department of Nephrology; Government Medical College; Kottayam; Kerala; India
E-mail: shruthyh543@gmail.com
BACKGROUND: Acute paraquat (PQ) poisoning is associated with high toxicity and mortality rates necessitating effective treatment strategies.
AIM OF THE STUDY: This study aims to analyze clinical profiles outcomes of acute paraquat poisoning and to identify outcome predictors for patients with PQ intoxication treated with hemoperfusion.
METHODS: A prospective analytical study was conducted on 21 adult patients admitted with acute paraquat intoxication at Government Medical College Kottayam India between July 2022 and July 2023. Clinical and laboratory data were collected and primary outcome measures were 60-day survival and time to death. Appropriate statistical tests were used to derive outcome predictors.
CONCLUSION: Early hemoperfusion (15.50 hours) correlated with improved survival outcomes. Higher toxin ingestion volume and hypoxia were identified as predictors of mortality in acute PQ poisoning.
15TH DECEMBER 2023
ABSTRACT NO. 92
COGNITIVE IMPAIRMENT AMONG END STAGE STAGE RENAL FAILURE ON HEMODIALYSIS
Anurag Thakur, Rajeev Bhatia, Ajay Marwaha, Marwaha Sanchita, Thakur Shevata
Department of Nephrology; Shrimann Superspeciality Hospital; Jalandhar; Punjab; India
E-mail: rajivjbhatia1961@gmail.com
BACKGROUND: Patients with end stage renal failure requiring hemodialysis undergo important changes in living habits and frequently need caregiving. These patients are risk groups for the development of physical and psychological symptoms. This study aimed to evaluate the prevalence of anxiety depression stress fatigue social support cognition and quality of life in patients with CKD and are on hemodialysis.
AIM OF THE STUDY: To study cognitive impairement among End Stage Renal Failure patients on hemodialysis. Cognitive impairment is relatively common in end-stage renal disease patients on chronic hemodialysis but the course of cognitive function deterioration in hemodialysis patients is essentially unknown. The present study aimed to evaluate if changes in Mini Mental State Examination (MMSE) over time in hemodialysis patients differ significantly and determine the variables associated with such possible changes.
METHODS: In this study a sample of 72 patients with end stage renal failure and are on hemodialysis were randomly taken from ShrimannSuperspeciality Hospital Jalandhar city. We included patients aged over 18 years on dialysis treatment. The participants social demographic clinical laboratory and psychological variables were evaluated using Modified Mini-Mental Status examinationModified Mini-Mental Status examination to check their cognition. The data was analysed with the help of SPSS.
CONCLUSION: Cognitive ability was decreased in renal patients in the early stages of disease. Patients having high level of creatinine showed more cognitive impairment. It was possible to establish sociodemographic, clinical and laboratory risk factors for a worse cognitive ability in this population.
15TH DECEMBER 2023
ABSTRACT NO. 93
ASSOCIATION OF URINARY MTDNA WITH RENAL OUTCOME FROM COMMUNITY ACQUIRED-ACUTE KIDNEY INJURY
Jaskiran Kaur, Jasmine Sethi, Vivek Kumar, Ashok Kumar Yadav
Postgraduate Institute of Medical Education and Research; Chandigarh; India
E-mail: jaskiran265@gmail.com
BACKGROUND: Acute kidney injury (AKI) is characterized by a rapid decline of kidney function which may progress to chronic kidney disease (CKD) and end-stage renal disease (ESRD). In tropical nations like India dehydration diarrhoea infections venomous snakebite and other factors can induce AKI which is typically community acquired (CA-AKI). Recent research highlights the role of mitochondrial dysfunction in AKI. Urinary mitochondrial DNA was elevated in AKI patients and associated with AKI severity. However, there is no studies showing the link between urinary mtDNA with renal outcome of AKI.
AIM OF THE STUDY: To find the association of urinary mtDNA with renal recovery from CA-AKI.
METHODS: In this prospective observational study stable patients of either sex aged between 18-70 years with no underlying CKD and diagnosed with CA-AKI were enrolled at the time of hospital discharge. The patients were followed at 4th months after hospital discharge to assess the outcome (recovery and non-recovery). Total urinary DNA was isolated from urine pellet collected at the time of hospital discharge. Levels of urinary mtDNA genes ND-1 and COX-3 were analysed by qRT-PCR method. mtDNA genes were normalised with-actin gene.
CONCLUSION: The expression of urinary mtDNA genes, ND-1 and COX-3 were significantly higher in patients who were failed to recover from CA-AKI after 4 month of hospital discharge. However, normalised gene expression was similar in both the group. Finding from this study needs further evaluation for the potential role of urinary mtDNA in renal recovery after AKI in with adequate sample size.
15TH DECEMBER 2023
ABSTRACT NO. 94
CLINICAL MANIFESTATIONS OF MULTIPLE MYELOMA WITH RENAL INVOLVEMENT: A SINGLE CENTRE OBSERVATIONAL STUDY
Mugdha Sathe, Deep Gala, Narayan Prasad
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: sathe.mugdha94@gmail.com
BACKGROUND: Renal impairment (RI) is one of the most common complications of multiple myeloma (MM). The incidence of RI at diagnosis ranges from 20% to 50%.1 Toxic effects of the monoclonal light chains on basement membranes of the glomeruli and/or the renal tubule is the primary cause for renal impairment in multiple myeloma. The clinical manifestations of renal involvement in plasma cell disorders are heterogeneous and range from acute cast nephropathy in multiple myeloma to rare forms of glomerulonephritis. Cast nephropathy the most common etiology of renal involvement is a myeloma defining lesion. 2 There are several renal disorders than are caused by monoclonal proteins besides myeloma cast nephropathy such as amyloidosis monoclonal deposition diseases as well as uncommon disorders such as immunotactoid glomerulopathy proliferative GN with monoclonal immunoglobulin deposits light-chain proximal tubulopathy and the rare entities of crystal-storing histiocytosis and crystalglobulinemia. 3 Kidney biopsy is the gold standard for differentiating them. 4 In a review of 190 renal biopsies of patients with MM MIDD and amyloidosis accounted for 22% and 21% of the total pathology respectively.
AIM OF THE STUDY: To study clinical manifestations and kidney biopsy findings in multiple myeloma with renal involvement.
METHODS: A prospective analysis of all kidney biopsies in patients with the clinical diagnosis of newly diagnosed multiple myeloma with renal involvement defined as serum creatinine > 2 mg/dL or as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2. (as per CKD EPI 2021 equation) was performed from May 1 2023 to August 31 2023 from single tertiary care hospital in North India.
CONCLUSION: Patients with multiple myeloma and kidney involvement have myriad of findings on histopathology which may influence prognosis and treatment decisions.
15TH DECEMBER 2023
ABSTRACT NO. 95
EVALUATION OF CHANGES IN ECHOCARDIOGRAPHY MARKERS OF BONE MINERAL METABOLISM AND CAROTID INTIMAL MEDIAL THICKNESS (CIMT) AFTER RENAL DONATION
Sachin Srivastava, Sandeep Mahajan 1 , Arun Kumar 1
Department of Nephrology; Command Hospital; Udhampur; Jammu and Kashmir; 1 Department of Nephrology; AIIMS; New Delhi; India
E-mail: sachinsrivastava.id@gmail.com
BACKGROUND: Renal transplantation particularly from a living donor is the treatment of choice for most patients with end-stage renal disease (ESRD) The life expectancy of kidney donors appears to be similar to that of nondonors (2). Living kidney donors (LKDs) experience an immediate decline in glomerular filtration rate (GFR) followed by a gradual improvement to 60% to 70% of baseline as a result of hypertrophy and hyperfiltration in the remaining kidney (3). Mineral metabolism adaptations in early CKD are still debated and not well studied in LKDs (4). It is however believed that increased phosphate retention is the primary event leading to parathyroid hormone (PTH) elevation mainly via complexation of calcium (5). It is also observed that FGF23 increase is an early event in CKD decreasing 1 25 hydroxylation and enhancing phosphaturia(6). Kidney donation provides a good opportunity to study the effect of a mild reduction in GFR on mineral metabolism. The question of mineral bone metabolism alteration after living kidney donation is a matter of controversy (7). In this situation as the patients are their own control we can study the effect of the loss of renal function without other confounding factors usually found in CKD such as associated glomerular or tubular diseases. Traditionally donor candidates were advised that donating a kidney did not alter the lifetime risk of developing kidney disease if the remaining kidney was healthy at the time of donation. Recent data have led to a reconsideration of this traditional advice. Although there are many outcomes to consider after kidney donation KDIGO considered the long-term risk of developing kidney failure as central and proposed a quantitative framework for medical evaluation and acceptance of donor candidates according to the donor candidate estimated post-donation risk in relation to the transplant center threshold for acceptable risk. In one of the study with 201 donors has recently demonstrated 23% higher PTH and 5.4% lower phosphate serum levels 6 months after donation (8). Conversely Young et al . in a non-prospective study of 198 donors found higher FGF23 and increased PTH levels five years after donation compared to control subjects (9). Fibroblast growth factor-23 is a phosphaturic hormone secreted from osteoblasts in response to high phosphate levels in the body. FGF-23 also suppresses 1 25 OH Vitamin D formation along with an increase in its degradation.
AIM OF THE STUDY: To evaluate changes in eGFR Echocardiography markers of bone mineral metabolism and carotid intimal medial thickness (CIMT) after renal donation. Objective: To assess any change in clinical parameters eGFR and proteinuria from baseline and subsequently at 3 rd and 6 th .
METHODS: This study is a single-center prospective study of apparently healthy kidney donors. It was conducted in the Department of Nephrology All India Institute of Medical Sciences New Delhi from Dec 2018 with a patient follow-up period of 06 months. Study Population 1. Heathy kidney donors. sample size 50. Exclusion criteria Patients already diagnosed with osteopetrosis or on treatment with Vitamin D supplements and bisphosphonates. Baseline lab investigations (1). Renal function tests 24 hrs urinary protein Albuminuria Blood sugar fasting and Postprandial HbA1c Serum uric acid levels Lipid profile Serum calcium/phosphate/alkaline phosphatase Serum 25-hydroxy Vitamin-D levels Serum intact- parathyroid hormone 2 D echo CIMT Ambulatory BP monitoring. All biochemical parameters were obtained in study donors prospectively before surgery and on the 3rd 6th month post kidney donation. A comparison between groups was performed using a T-test for normally distributed variables. Spearman’s rank correlations was used to determine correlations between variables.
CONCLUSION: The mean measured DTPA GFR in our cohort of 67 kidney donors was 93.7 ± 14.74 ml/min/1.73m2 before nephrectomy. On follow up the mean DTPA GFR on 59.3 ± 10.13 ml/min/1.73 m2. We evaluated for percentage change in GFR on basis of differential function and further compared with follow up DTPA GFR at 1 yr to look for the compensatory increase in values. This increase in measured GFR correlated with baseline 24 hrs ambulatory diastolic blood pressure, renal function at 6th month, baseline renal resistive index, and baseline measured DTPA GFR. However, there was no association with age, body mass index, and albuminuria. There was significant increase in blood urea, serum creatinine, proteinuria, triglyceride, HbA1c and serum iPTH values from baseline. Serum calcium, serum phosphate levels were lower than the baseline values.
15TH DECEMBER 2023
ABSTRACT NO. 96
COMPARISON OF LIPID PROFILE IN PATIENTS UNDERGOING LONG-TERM CONTINUOUS AMBULATORY PERITONEAL DIALYSIS AND HEMODIALYSIS IN A TERTIARY CARE HOSPITAL
Madhurima Dutta, Tonmoy Das, Pranab Kumar Medhi, Mitul Bora, Dhrubajyoti Choudhury
Department of Nephrology; Apollo (Unit International) Hospital; Guwahati; Assam; India
E-mail: madhurimadutta12@gmail.com
BACKGROUND: Dyslipidemia is a primary risk factor of cardiovascular disease in patients with End-Stage Renal Disease (ESRD). Dyslipidemia among patients in dialysis negatively impacts cardiovascular profile which in turn influence the frequency and/or duration of hospitalizations. Patients with Chronic Kidney Disease (CKD) usually have an elevated ratio of Low-Density Lipoprotein (LDL) cholesterol to High-Density Lipoprotein (HDL) cholesterol. Lipoprotein (a) has been identified as an independent risk factor for atherosclerotic vascular disease. The cardiovascular mortality is not only increased 10-20 fold when compared with the general population but cardiovascular disease (CVD) develops very prematurely. Besides hypertension diabetes mellitus hyperhomocystenuria left ventricular hypertrophy smoking increased oxidative stress inflammation and malnutrition dyslipidaemia factors also contribute to this high risk.
AIM OF THE STUDY: To compare lipid parameters including Lip(a) between healthy individuals and long-term Continuous Ambulatory Peritoneal Dialysis (CAPD) and Hemodialysis (HD) patients.
METHODS: Design - Case Control Study Setting - A tertiary care hospital in North-East India Participants 43 CAPD and 43 HD patients were carefully matched for age sex BMI smoking habit and duration of dialysis were studied. A group of 43 healthy individuals matched for age sex BMI smoking habit were used as control. Duration - 6 months (February 2023 to July 2023) Exclusion Criteria Patients with pre-existing atherosclerotic diseases cerebral infarction or peripheral vascular disease at the start of dialysis. The study included 86 ESRD patients of which CAPD (n = 43) HD (n = 43) who has been on their initial modality for more then 2 years. In both the groups mean values of the lipid profile during 1st and last 6th month were calculated and is compared with age sex matched healthy control group (n = 43). Lipid profiles included Total Cholesterol (TC) Triglyceride (TG) Low Density Lipoprotein Cholesterol (LDLC) High Density Lipoprotein Cholesterol (HDLC) TC/HDLC ratio & LDLC/HDLC ratio and Lip(a). TC & TG were determined by enzymatic colorimetric assay; LDLC was determined by Friedwald Formula if Fasting TG <400mg/dl and by ultracentrifugation if TG >400 mg/dl; HDLC was determined enzymatically in the supernatant fluid after precipitation of other lipoproteins with Dextran-sulphate magnesium & Lp(a) determined by monoclonal anti-Lp(a) antibody technique by enzyme immunoassay. Comparison of continuous or discrete variable was performed using Students t-test or Chi-Square test; a p value < 0.05 was considered statistically significant.
CONCLUSION: CAPD patients exhibit a more atherogenic lipid profile than HD patients. The low levels of HDLC and increased levels of the atherogenic ratios TC/HDLC and LDLC/HDLC have been found to significantly increase cardiovascular morbidity and mortality. Increased lipid synthesis contributes to hyperlipid.
CLINICAL PROFILE AND OUTCOME OF AA AMYLOIDOSIS IN INDIAN PATIENTS: Aemia in CAPD patients, which may result from the glucose load as well as from the continued loss of albumin from the peritoneal membrane, leading to a non-specific stimulation of hepatic protein synthesis, causing increased lipoprotein levels.
15TH DECEMBER 2023
ABSTRACT NO. 97
SPECTRUM OF PULMONARY INFECTIONS IN CHRONIC KIDNEY DISEASE PATIENTS AND THE ROLE OF VARIOUS DIAGNOSTIC MODALITIES: A SINGLE CENTRE OBSERVATIONAL STUDY
Humam Siddiqui, Sanjeev Saxena, Ravi Bansal, Gopi Chand Khilnani 1
Departments of Nephrology and Kidney Transplant Medicine and 1 Pulmonology and Critical Care; Pushpawati Singhania Hospital and Research Institute; New Delhi; India
E-mail: drhumamsiddiqui@gmail.com
BACKGROUND: Respiratory infections are a severe risk to CKD patients and can be fatal if not promptly addressed. Understanding the microorganisms involved aids in initiating empirical treatment while awaiting confirmatory tests. Due to similarities in symptoms and imaging a more accurate explanation of dyspnea in CKD patients is crucial. Diagnostic methods include sputum testing chest X-rays HRCT scans bronchoscopy and thoracic biopsies.
AIM OF THE STUDY: To study the clinical features microbiological spectrum and the role of various diagnostic modalities and outcome of pulmonary infections in renal patients.
METHODS: A cross-sectional study was conducted at Pushpawati Singhania Hospital and Research Institute’s Department of Nephrology. It included CKD and post-renal transplant patients with respiratory infections attending the outpatient department over two years from April 2021 to April 2023. Patients with end-stage renal disease who were bedridden or in poor general condition were excluded. Comprehensive clinical evaluations were conducted including physical examinations and detailed patient histories. In addition various laboratory tests radiographic evaluations and specialized examinations were performed to identify the causative organisms. Sputum specimens were examined for bacterial and fungal elements using Gram stain and Ziehl-Nielsen stain for acid-fast bacilli. Additional procedures such as bronchoalveolar lavage high-resolution CT scans and culture sensitivity tests were also carried out.
CONCLUSION: The predominant symptoms reported in this study were cough, fever, and generalized weakness. The CT scans revealed common findings such as cavitations, nodules, lymph node involvement, and pleural effusion.. Bacterial infections were the most prevalent among the reported cases. The most frequently identified organisms in the study were Klebsiella, Mycobacterium tuberculosis, SARSCoV-2 virus. Mortality rate was 9.78%.
15TH DECEMBER 2023
ABSTRACT NO. 98
HISTOPATHOLOGICAL SPECTRUM OF NATIVE KIDNEY BIOPSY FROM A TERTIARY CARE HOSPITAL IN EASTERN PART OF INDIA: AN OBSERVATIONAL STUDY
Shalini Sinha, Om Kumar, Amresh Krishna, Prit Pal Singh, Harsh Vardhan
Department of Nephrology; Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India
E-mail: drshalinisinha17@gmail.com
BACKGROUND: Kidney biopsy is the GoldStandard for the diagnosis of renal diseases. In our country there is no national registry for kidney biopsy and data from the eastern part of India is sparse.
AIM OF THE STUDY: To study the clinic-histopathological spectrum of native kidney biopsy conducted at IGIMS Patna.
METHODS: It is a retrospective observational study conducted at IGIMS Patna where all native kidney biopsies performed between 1st January 2013 to 31st December 2019 were reviewed. For all patients demographics clinicopathological data and relevant laboratory investigations were noted. Age and gender-appropriate workups were also conducted. Kidney biopsy was done under real-time USG guidance with an automated 18-gauge biopsy gun. Two cores were obtained and were sent for light microscopy and immunofluorescence studies. Electron microscopy was also sent as needed.
CONCLUSION: In our study, Nephrotic Syndrome was the most common indication to perform kidney biopsy. FSGS remained the most common lesion across different age groups and genders. MCD and MN are the second and third most common lesions. However in the age group <18 years MCD is the most common lesion and in older individuals, MN is more common.
15TH DECEMBER 2023
ABSTRACT NO. 99
CLINICOPATHOLOGICAL PROFILE AND OUTCOME PREDICTORS OF CRESCENTIC GLOMERULONEPHRITIS: A SINGLE CENTRE EXPERIENCE
Nidila Mohan, M K Mohandas, Sebastian Abraham
Department of Nephrology; Government Medical College; Kottayam; Kerala; India
E-mail: nidilamohan@gmail.com
BACKGROUND: Crescentic glomerulonephritis is a rapidly progressive glomerulonephritis characterized by crescents in more than or equal to 50% of glomeruli. There is significant heterogeneity in the etiology and outcomes of crescentic glomerulonephritis. Indian experience is different from rest of the world and there is limited data from our population.
AIM OF THE STUDY: This study aimed to study the clinical and pathological profile and predictors of outcome of crescentic glomerulonephritis in our population.
METHODS: This is a retrospective cohort study performed at Department of Nephrology Government Medical College Kottayam which included all patients with biopsy proven crescentic glomerulonephritis between January 2017 to January 2022. Their clinical and histopathological features were analyzed. Follow up data including laboratory parameters and dialysis requirement were collected during follow up visit till August 2023. Appropriate statistical tests were applied for analysis and determination of outcome predictors of crescentic glomerulonephritis in our population.
CONCLUSION: In our cohort, the most common type of crescentic glomerulonephritis is the immune complex mediated glomerulonephritis. Patients with type I and III have worst prognosis compared to type II crescentic glomerulonephritis. ANCA negative and double positive cases were identified. Oliguria at presentation, need for dialysis at presentation, arteriolar fibrinoid necrosis and lymphocytic infiltration in histopathology were significant predictors of end stage renal disease.
15TH DECEMBER 2023
ABSTRACT NO. 100
SURVIVAL OF HEMODIALYSIS PATIENTS AT 5 YEARS AND ITS DETERMINANTS IN AN OUTPATIENT HEMODIALYSIS CENTRE IN THE PUBLIC SECTOR SOUTH INDIA-A RETROSPECTIVE STUDY
Syeda Hurmath, Anandababu, N Ramachandran, Vidhya K Zachariah, Piyush Ravindra Panchalwar, Rama Venkatesh, P S Priyamvada
Department of Nephrology; Jawaharlal Institute of Postgraduate Medical Education and Research; Puducherry; India
E-mail: sparameswaran@outlook.com
BACKGROUND: Haemodialysis (HD) is the commonest renal replacement therapy for patients with kidney failure in India. Survival of HD patients are determined by multiple factors including socio-economic background. Outcome data on HD patients is limited from India and there are reports of poor outcomes in HD program in the public sector. Our institute a public sector hospital established a standalone HD centre offering subsidized or free HD for the underprivileged 7 years back. We report the patient outcome at our HD centre.
AIM OF THE STUDY: (1) To determine the survival of HD patients at 3 years and 5 years (2) To assess the factors affecting patient survival.
METHODS: We retrieved medical records of patients enrolled at our dialysis centre between 1st December 2016 and 31st December 2018. Demographic & dialysis treatment related data was extracted from records lab data was retrieved from electronic medical records (HIS). Frequencies with proportions or percentages were used to summarize the categorical variables. Mean ± SD or Median ± IQR was used to summarize the continuous variables based on normality of distribution. Chi-square test and Logistic regression was used to identify the factors associated with survival at 3 and 5 years.
CONCLUSION: Survival of HD patients at our centre offering subsidized/free HD services in the public sector was comparable or better than similar centres in India, with minimal drop out of patients.
15TH DECEMBER 2023
ABSTRACT NO. 101
PREVALENCE AND ETIOLOGY OF HYPONATREMIA IN POST RENAL TRANSPLANT PATIENTS
Gulab Jha, Dharmendra Bhadauria, Narayan Prasad, Anupama Kaul
Department of Nephrology; SGPGIMS; Lucknow; Uttar Pradesh; India
E-mail: imgulab.jha@gmail.com
BACKGROUND: Hyponatremia is a common electrolyte disturbance in post renal transplant patients with significant clinical implications. However the prevalence and etiology of hyponatremia in this population remain poorly defined with varying estimates reported in the literature.
AIM OF THE STUDY: This study aims to investigate the prevalence and etiology of hyponatremia in post renal transplant patients through a comprehensive review of existing literature and a well-designed research protocol.
METHODS: Data was collected from a cohort of n = 954/1000 post renal transplant patients. Various clinical and biological variables associated with hyponatremia were analyzed. The study excluded patients with hypernatremia graft failure within 3 months unstable sodium status in the early period of transplantation graft dysfunction and multiple organ transplantation. The stability of sodium levels over a period of 3 months was considered for inclusion in the study. Clinical parameters such as age sex comorbidities previous transplantation donor type and use of medications were recorded. Laboratory data including serum sodium urinary sodium TSH serum cortisol HbA1c uACR potassium hepatitis B virus surface antigen and anti-hepatitis C antibody were also analyzed.
CONCLUSION: The findings of this study provide valuable insights into the prevalence and etiology of hyponatremia in post renal transplant patients. Understanding these factors can aid in clinical decision-making, improve patient care, and lead to targeted interventions aimed at mitigating the impact of hyponatremia on post renal transplant outcomes. However, further research is needed to validate and expand upon.
15TH DECEMBER 2023
ABSTRACT NO. 102
CORRELATION BETWEEN CHRONIC KIDNEY DISEASE-MINERAL BONE DISORDER PARAMETERS AND CAROTID INTIMA MEDIA THICKNESS IN CHRONIC KINDEY DISEASE PATIENTS
Mohit Gupta, Reetesh Sharma, B K Upadhyay
Nephrology; Asian Institute of Medical Sciences; Faridabad; Haryana; India
E-mail: mohit201088@yahoo.co.in
BACKGROUND: Chronic kidney disease (CKD) is a global health problem. Mineral and bone disorders are common in CKD and are now collectively referred to as chronic kidney disease - mineral bone disorder (CKD - MBD). There is a very high cardiovascular morbidity and mortality in CKD patients and atherosclerotic changes are a major contributor to it. Carotid intima media thickness (CIMT) can be measured to assess atherosclerosis and can predict the onset and progression of cardiovascular disease with reasonable accuracy. Although deranged CKD - MBD biochemical parameters are significant risk factors for vascular calcification which is an advanced form of atherosclerosis it is unclear whether there is any correlation between these parameters with increase in CIMT in CKD patients which is an early form of atherosclerosis. This correlation if present will enable CKD-MBD parameters to be used as surrogate marker for early detection of atherosclerosis and cardiovascular risk in chronic kidney disease patients.
AIM OF THE STUDY: To study the correlation between chronic kidney disease - mineral bone disorder parameters and carotid intima media thickness in chronic kidney disease patients
METHODS: A hospital based cross-sectional study was conducted on 140 adult patients of CKD stage 3 4 5ND (not on dialysis) and 5D (on hemodialysis). Laboratory parameters for CKD-MBD (Calcium Phosphorus Vitamin D and PTH) and spot urine protein creatinine ratio were evaluated. Carotid intima media thickness was measured on ultrasound machine. Intima media thickness was taken as distance between leading edge of first echogenic line (lumen intimal interface) and second echogenic line (medial adventitia interface). These measurements were recorded at 0.5 1 and 2 cm below bifurcation of common carotid artery on both sides (left and right) and mean average value was taken. CKD-MBD parameters (Calcium Phosphorus Vitamin D and PTH) and spot urine protein creatinine ratio were correlated with mean average value of CIMT of total study CKD patients.
CONCLUSION: In conclusion, CKD-MBD parameters (calcium, phosphorus and PTH) and spot urine protein creatinine ratio may be used as surrogate marker of atherosclerosis and cardiovascular risk in chronic kidney disease patients. Since there is paucity of good quality ultrasound machine and trained ultrasonologists in India (especially remote areas), it may not be always possible to assess carotid intima media thickness. Early assessment and correction of deranged values of CKD- MBD parameters (calcium, phosphorus and PTH) and spot urine protein creatinine ratio can prevent progression of atherosclerosis and thus decrease cardiovascular morbidity and mortality in CKD.
15TH DECEMBER 2023
ABSTRACT NO. 103
CLINICAL PROFILE OF NONPROTEINURIC KIDNEY DISEASE IN TYPE 2 DIABETIC PATIENTS
Sukhwinder Singh Sangha, R K Yadav, A Subbiah, S Bagchi, S Mahajan, D Bhowmik, S K Agarwal
Department of Nephrology; Command Hospital Lucknow; Uttar Pradesh; India
E-mail: drsukhi_sangha@yahoo.co.in
BACKGROUND: Diabetic kidney disease (DKD) is the commonest cause of end stage renal disease (ESRD) across the world. Development of microalbuminuria is regarded as the earliest marker of DKD and is a predictor of progressive decline in estimated glomerular filtration rate (eGFR). However recent evidence has suggested that a significant proportion of diabetic patients have chronic kidney disease (CKD) without proteinuria.
AIM OF THE STUDY: This study aims to evaluate the demographic and clinical characteristics of non-proteinuric kidney disease in type 2 diabetic Indian patients.
METHODS: In this single center prospective observational study 400 consecutive type 2 diabetic patients with either overt proteinuria (> 500 mg/day) and/or renal dysfunction (eGFR < 60 ml/min/1.73 m2) were recruited from nephrology OPD. Those requiring renal replacement therapy were excluded from the study. Baseline demographic and clinical data were recorded. eGFR and proteinuria were recorded at six months and one year. Patients with proteinuric (proteinuria >0.5 g/day) and non-proteinuric (proteinuria <0.5 g/day) phenotypes were compared for progression of renal dysfunction in terms of doubling of serum creatinine and need for dialysis.
CONCLUSION: Non-proteinuric diabetic kidney disease is common. Patients with non-proteinuric DKD tend to be older with a slower decline in eGFR.
15TH DECEMBER 2023
ABSTRACT NO. 104
SPECTRUM OF GLOMERULAR DISEASES IN EASTERN INDIA: EXPERIENCE FROM A TERTIARY CARE CENTER
Paromita Das, Priti Meena, M Karthikeyan, Anish Garg, Sandip Kumar Panda, Suvendu Purkait
Department of Nephrology; All India Institute of Medical Sciences; Bhubaneswar; Odisha; India
E-mail: paromita.05.das@gmail.com
BACKGROUND: Glomerular diseases account for a significant burden of renal disorders worldwide. Renal biopsy is indispensible for the diagnosis of glomerular diseases and often plays an integral role in their prognosis and management. Comprehensive clinico-pathological data regarding the varied spectrum of glomerular disease is lacking. We report our findings from a retrospective observational study conducted at All India Institute of Medical Sciences (AIIMS) Bhubaneswar where we studied the clinical presentation and the histo-pathological diagnosis of glomerular diseases.
AIM OF THE STUDY: To study the clinico-pathological spectrum of glomerular disease from a tertiary care hospital in eastern India.
METHODS: We retrospectively analysed the data of all patients undergoing renal biopsy in department of nephrology at our institute from April 2018 to September 2022. The epidemiological data and clinical presentation of the patients and the subsequent histo-pathological diagnosis on renal biopsy were noted.
CONCLUSION: The most common indication for patients undergoing renal biopsy at our institute was nephrotic syndrome. Membranous nephropathy was the most common histo-pathological diagnosis in adults with nephrotic syndrome.
15TH DECEMBER 2023
ABSTRACT NO. 105
CLINICAL MANIFESTATIONS, MORPHOLOGICAL PATTERN AND TREATMENT OUTCOMES OF COMPLEMENT 3 GLOMERULOPATHY ON LONG TERM
Nidhi Gupta, Narayan Prasad, Anupama Kaul, Dharmendra Bhadauria, Manas Patel, Ravi Kushwaha, Manoj Jain, Manas Behera, Monica Yaccha, Pallavi Prasad, Vinita Agrawal
Department of Nephrology and Pathology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: drnidhigupta0625@gmail.com
BACKGROUND: C3 glomerulonephritis (C3GN) is a clinicopathologic entity defined by the presence of isolated or dominant deposits of C3 on immunofluorescence.
AIM OF THE STUDY: We aimed to study the impact of immunosuppression on C3GN outcomes on follow-up.
METHODS: The study included 111 patients of C3GN with a median follow up of 33 months (maximum 156 months) who reported to the institute between January 2010 to July 2022. Patients satisfying pathological criteria for a diagnosis of C3GN were identified. All patients were treated with Steroids with and without mycophenolate mofetil (MMF). We have compared the outcomes of the patients with and without MMF.
CONCLUSION: Out of 103 patients who were treated, 75 patients were grouped into two category, 45 patients received steroid and MMF and thirty received steroid without MMF. Clinical remission was observed in 56 patients (74.6%) in total. Patients achieving remission (complete and partial) was more in steroid with MMF (n = 39, CR = 15, 33.3%and PR = 24, 53.3%) as compared to steroid without MMF (n 17, CR = 8, 26.6% and PR = 9, 30%). The doubling of serum creatinine on follow-up was significantly high without MMF as compared to with MMF. On Kaplan-Meier survival analysis, the renal survival was almost similar at 6 months but significantly better in MMF group as compared to non-MMF group, at 12month, 24-month, 48 month and 60 months was 93.3%, 84.4%, 64.4%, 39.9% and 22.4% patient who received steroid plus MMF and compared to steroid without MMF was 96.6%, 70%, 53.6%, 28% and 7% respectively. Overall remission rate and renal survival was significantly better in group with steroid and MMF as compared to patients without MMF. Thus, immunosuppressive treatments, particularly steroid plus MMF, can be beneficial in C3 glomerulonephritis.
15TH DECEMBER 2023
ABSTRACT NO. 106
EFFICACY AND SAFETY OF IMMUNOSUPPRESSIVE THERAPY IN PRIMARY FOCAL SEGMENTAL GLOMERULOSCLEROSIS IN ADULT PATIENTS: A PROSPECTIVE OBSERVATIONAL STUDY IN A TERTIARY CARE HOSPITAL IN EASTERN INDIA
Neeraj Saini, Nephrology, Taniya Bhuiya, Koushik Bhattacharjee
Department of Nephrology; IPGMER and SSKM Hospital; Kolkata; West Bengal; India
E-mail: neerajsaini2607@gmail.com
BACKGROUND: Focal segmental glomerulosclerosis (FSGS) is a rare condition that can affect patients of any age and has the potential to progress into chronic kidney disease (CKD). While the use of corticosteroids and other immunosuppressive agents in the treatment of primary FSGS is generally accepted in clinical practice the effectiveness and safety of these immunosuppressive therapies are not yet clearly established.
AIM OF THE STUDY: Objective of the study is to assess the clinical effectiveness and safety of immunosuppressants in the treatment of primary FSGS in adult patients.
METHODS: Adult patients with biopsy proven FSGS were enrolled. Managed with Renin angiotensin aldosterone system (RAAS) inhibitor immunosuppressants (steroid CNI rituximab) and other supportive measures as per Kidney Disease: Improving Global Outcome (KDIGO) guidelines. Proteinuric response (24 hour urinary protein) renal function (creatinine clearance as per CKD EPI formula) and adverse effects were observed on follow up for a period of 6-24 months.
CONCLUSION: Patients treated with immunosuppressants experienced significant decrease in proteinuria and improvement in renal functions. Even though use of immunosuppressants was associated with adverse effects but these were well tolerated in 98.7% of patients. As favorable treatment response was achieved in 82% of the patients, we should consider immunosuppressants in treatment of primary FSGS.
15TH DECEMBER 2023
ABSTRACT NO. 107
SPECTRUM OF KIDNEY INVOLVEMENT IN DIABETES MELLIYUS
Navin Jha, Niwrutti Hase, Aniket Hase
Department of Nephrology; Jupiter Hospital; Thane; Maharashtra; India
E-mail: navinjha190@gmail.com
BACKGROUND: Diabetic kidney disease is common complications of diabetes. Diabetes is leading cause of CKD and ESKD requiring dialysis. Traditionally it is thought diabetes proteinuria and then decrease glomerular filtration rate and finally ESKD. However this spectrum is changing. DKD/CKD in diabetes can be without proteinuria Aim of this study is to find out current spectrum of kidney involvement in diabetes.
AIM OF THE STUDY: To study the spectrum of kidney disease in Diabetes mellitus.
METHODS: Study was in tertiary care hospital. Diabetes was defined as per ADA criteria kidney involvement CKD proteinuria and non proteinuriawere defined as per KDIGO criteria. All patients with Diabetes and kidney involvement were included in study. They were evaluated for risk factors micro macrovascular complications and progression of CKD.
CONCLUSION: CKD in diabetes is common in elderly population Substantial number of patients are nonproteinuric suggesting changing spectrum. Proteinuric patients had similar decline in eGFR as nonproteinuria. CKD in diabetes will require multidisciplinary approach to improve outcome.
15TH DECEMBER 2023
ABSTRACT NO. 108
A CASE OF MYCOBACTERIUM CHELONAE COLD ABSCESS IN A RENAL TRANSPLANT RECIPIENT
Madhusudhan Manda, Vivek Sood, Jai Inder Singh, Pratik Thosani, P K Sharma
Department of Nephrology; Command Hospital Eastern Command; Kolkata; West Bengal; India
E-mail: viverit@gmail.com
BACKGROUND: Nontuberculous Mycobacteria (NTM) are omnipresent in the environment and there has been a renewed interest in them in view of increasing number of cases of NTM infections in immunocompromised patients. Last few decades have been witness to increasing number of solid organ as well as hematopoietic stem cell transplants. This has come with its own set of complications one of which is NTM infections. Here we present a case report of Mycobacterium chelonae suture site infection in a renal transplant recipient.
AIM OF THE STUDY: A Case of Mycobacterium Chelonae cold abscess in a Renal Transplant Recipient.
METHODS: 46yr old male known to be hypertensive on anti-hypertensives. He underwent deceased donor renal transplant Left graft kidney was healthy Patient was started on immunosuppression with ATG 100 mg IV x 3 days and maintenance Immunosuppression with MMF - 1000 mg BD Tacrolimus - 3 mg BD and Prednisolone. Post -Transplant patient had brisk diuresis with steady fall in creatinine to 1.2 mg/dL on D+ 9. During follow up patient was found to have sub therapeutic Tac levels even with 4 mg BD. His CYP 3A4*22-C/C genotype was s/o higher enzymatic activity hence he was switched to cyclosporine. His course was further complicated with persistent pancytopenia. CMV DNA PCR- Negative Bone marrow aspirate cellular reactive bone marrow. In view of persistent leukopenia - MMF Everolimus 0.25 mg (Everolimus level 5.73 ng/ml on 3 Mar 19). In Feb 2019 patient developed fever and swelling at suture site. USG was s/o heteroechoic collection (7.7 x 1.8 cm) with few punctate and linear echogenic areas s/o organised collection. 5 ml pus was drained microbiology revealed numerous AFB+ bacilli & culture (Sri Ganga Ram Hosp) isolated Mycobacteria chelonae. He was given Inj. Amikacin 500 mg iv OD x 7 days followed by Tab linezolid 600 mg BD and Tab Azithromycin 500 mg OD (wef 06 March 2019) for 12 weeks. After 8 weeks of therapy swelling had completely subsided with no collection in followup USG. Till May 2020 patient had uneventful course with persistent thrombocytopenia and stable graft function (baseline creatinine 1.6 mg/dl) on cyclosporin 100 mg BD Everolimus 0.25mg BD and Prednisolone 7.5 mg OD. In Jun 2020 patient developed nephrotic range proteinuria (4.3 g/day) presumably secondary to mTORi and renal dysfunction (serum creatinine-2.0 mg/dl). Renal biopsy was deferred in view of persistent thrombocytopenia and recovery of proteinuria as well as renal dysfunction following Everolimus withdrawal and re-initiation of MMF. Presently he maintains stable graft function with baseline creatinine of 1.7 mg/dl.
CONCLUSION: NTM infection in a renal transplant recipient at graft site presenting as suture abscess in early transplant period is rare and hence reported for its novelty.
15TH DECEMBER 2023
ABSTRACT NO. 109
CLINICAL PROFILE AND OUTCOME OF ACUTE KIDNEY INJURY RELATED TO PREGNANCY: A SINGLE CENTER STUDY FROM EASTERN PART OF INDIA
Archita Patel, Pinaki Mukhopadhyay
Department of Nephrology; Nil Ratan Sircar Medical College and Hospital; Kolkata; West Bengal; India
E-mail: archita.1994patel@gmail.com
BACKGROUND: Acute kidney injury (AKI) is a serious complication in pregnancy resulting in significant maternal morbidity/mortality and fetal loss. Although the incidence of pregnancy-related acute kidney injury (PRAKI) has decreased in developed countries it is still common in developing nations.
AIM OF THE STUDY: This study aimed to investigate the incidence clinical characteristics and outcomes of acute kidney injury (AKI) during pregnancy in Indian population.
METHODS: Prospective observational study was conducted in pregnant patients admitted to Nil Ratan Sircar Medical College And Hospital Kolkata India. Acute kidney injury was assessed using Risk Injury Failure Loss of function and End-stage renal disease (RIFLE) criteria. Patients were analyzed on the basis of demographic data detailed history clinical examination and laboratory investigations. The primary outcome was maternal renal outcome including return to normal renal function and progression to chronic kidney disease (CKD). The secondary outcomes included the mode of delivery complications of pregnancy intensive care unit (ICU) admission and maternal death.
CONCLUSION: AKI in pregnancy was common in postpartum period and sepsis being the commonest cause.
15TH DECEMBER 2023
ABSTRACT NO. 110
RARE CUTANEOUS PRESENTATION OF AN ODD TROPICAL INFECTION IN A POST RENAL TRANSPLANT PATIENT: A CASE REPORT
Beauty Suman, B Muthukumar, Lalit Pursnani, Himansu Sekhar Mahapatra
Nephrology; Atal Bihari Vajpayee Institute of Medical Sciences and Ram Manohar Lohia Hospital; New Delhi; India
E-mail: beautysuman.doc@gmail.com
BACKGROUND: Infection is frequently a cause of morbidity and mortality in solid organ transplant (SOT) recipients and it depends on immunosuppressive treatment. Leishmaniasis is one of those rare infections. It has various clinical presentation: cutaneous leishmaniasis visceral leishmaniasis Post Kala azar dermal leishmaniasis (PKDL). PKDL is rare cutaneous complication that develops after variable interval of apparent cure of Visceral Leishmaniasis. It is prevalent in East Africa (especially Sudan) and South Asia (Eastern India and Bangladesh). We report a rare cutaneous presentation in a post renal transplant patient already treated for Visceral leishmaniasis three years back.
AIM OF THE STUDY: To study PKDL presentation in a 10 year post renal transplant patient.
METHODS: 25 years old male resident of Bihar underwent live-related haploidentical blood group compatible renal transplant in 2013. He was on tacrolimus mycophenolate mofetil and prednisolone. Seven years post transplant he was evaluated for fever loss of appetite and weight loss for 4 months which showed pancytopenia with hepatosplenomegaly. He was investigated for chronic infections like tuberculosis cytomegalovirus infection and tropical infections (malaria). Initial investigations were negative. In view of persistent pancytopenia with hepatosplenomegaly and demographics his serology for rK 39 antigen was done which showed positivity. Bone marrow examination demonstrated Donovan’s bodies. A diagnosis of Visceral Leishmaniasis was made and was treated with Inj. Liposomal amphotericin B for 2 weeks. At the time of discharge the pancytopenia picture had improved and splenomegaly regressed 1 month later. MMF dose was stopped temporarily and was restarted at 1gm per day after the completion of antifungals. He lost to follow-up for the next 2 years. In June 2023 he presented with papulonodular lesions all over his body for 6 months and a fever associated with loss of appetite for 2 months. He was evaluated and results were recorded.
CONCLUSION: Visceral leishmaniasis, cutaneous leishmaniasis, PKDL are rare reported case in post renal transplant patient. RT-PCR can even miss the diagnosis. Culture remains gold standard for diagnosis. Clinical presentation with demographics, histopathology and good clinical acumen helps in early diagnosis.
15TH DECEMBER 2023
ABSTRACT NO. 111
RELEVANCE OF SERUM A PROLIFERATION-INDUCING LIGAND (APRIL) AS A BIOMARKER IN SOUTH ASIAN PROSPECTIVE LONGITUDINAL OBSERVATIONAL IGA NEPHROPATHY COHORT (GRACE-IGANI)
Suceena Alexander, Rajanbabu Franklin, Joseph Johny, Nisha Jose, Selvin Sundar Raj Mani, Sabina Yusuf, Jeethu Joseph, Athul Thomas, Vinoi George David, Santosh Varughese, Jonathan Barratt, George T John
Christian Medical College; Vellore; Tamil Nadu; India; University of Leicester; Leicester; UK
E-mail: suceena@gmail.com
BACKGROUND: The role of serum APRIL as a biomarker in a prospective longitudinal South Asian IgAN cohort (GRACE-IgANI) and the impact of immunosuppression (IS) is not known.
AIM OF THE STUDY: (1) Clinical relevance of s.APRIL as a diagnostic biomarker in the GRACE-IgANI cohort. (2) Impact of short course (6 months) oral steroids on longitudinal measurements of s.APRIL at 1 year 2 years and 3 years. (3) Clinical relevance of s.APRIL as a prognostic biomarker in the GRACE-IgANI cohort at three years for clinical outcomes.
METHODS: Serum APRIL levels were measured in baseline and longitudinal sera (1 year 2 year & 3 year) in IgAN patients and at baseline in disease controls and healthy controls by ELISA (R&D Systems; Catalog No: DY884B). Short course IS was given to patients with proteinuria 1g/day and/or renal impairment (73%). Composite outcome (CO) was defined as 50% fall in eGFR (CKD EPI) from baseline and/or eGFR <15 ml/min/1.73 m2 or RRT/death.
CONCLUSION: Serum APRIL levels were an indepenpendent risk factor for progressive kidney disease in this cohort.
15TH DECEMBER 2023
ABSTRACT NO. 112
LONG TERM CLINICAL OUTCOMES OF ASYMPTOMATIC BACTERIURIA IN POST RENAL TRANSPLANT - A RETROSPECTIVE STUDY
Anubhuti Bhardwaj, Narayan Prasad, Anupma Kaul, D S Bhadauria, Manas Ranjan Behera, Manas Ranjan Patel
Department of Nephrology; SGPGIMS; Lucknow; Uttar Pradesh; India
E-mail: dranubhutibhardwaj@gmail.com
BACKGROUND: Asymptomatic bacteriuria (ASB) in post renal transplant is a frequently encountered phenomenon. There is a controversy whether treatment affects graft outcome or simply adds to the load of antibiotic resistance and paves the way for MDR organisms.
AIM OF THE STUDY: The primary aim of this study was to study the 3 year graft outcome and development of pyelonephritis of patients with ASB.
METHODS: A retrospective observational study was conducted at SGPGIMS Hospital. Data of patients who uinderwent renal transplantation between 2016-2020 with ASB were collected. Patients were routinely commenced on prophylactic sulfamethoxazole-trimethoprim. The baseline characteristics and outcomes in terms of development of pyelonephritis and graft dysfunction were recorded.
CONCLUSION: The presence of ASB did not necessarily lead to development acute pyelonephritis and there was no significant graft dysfunction in the patients at 3 year follow up. The concept of treating ASB should be re-considered, specially in the era of antimicrobial stewardship.
15TH DECEMBER 2023
ABSTRACT NO. 113
VASCULAR ACCESS AND PATIENT SURVIVAL IN THE FIRST 90 DAYS OF HEMODIALYSIS INITIATION IN LOW-RESOURCE SETTINGS
Suresh Sankarasubbaiyan, Suresh Sankarasubbaiyan, Savitha Kasiviswanathan, P Rajesh, Devender Pandey, Venkatraman Ganapathy, Kamal D Shah
NephroPlus Dialysis Centers; Hyderabad; Telangana; India
E-mail: suresh150902@gmail.com
BACKGROUND: The growing public insurance system is improving hemodialysis access in India but the challenges at initiation including vascular access and patient survival are unknown.
AIM OF THE STUDY: The aim of the study is to understand the patient profile initiated on hemodialysis and to estimate the proportion of vascular access outcomes and patient survival in the first 90 days of hemodialysis.
METHODS: All patients who were initiated on hemodialysis within 30 days of shifting into a public-payer system in a single state in India from February to April 2023 were included in the study. We descriptively analyzed the demographic co-morbidity and dialysis-related factors.
CONCLUSION: In this study, only 43% got their AVF/AVG done within 90 days of start of hemodialysis. Among them, majority of them got it done within 30 days. The mortality was high among those on catheters. Hence, it is important to understand barriers to early creation of permanent access and design interventions to decrease the high mortality in the hemodialysis initiation phase.
15TH DECEMBER 2023
ABSTRACT NO. 114
CLINICAL PROFILE AND OUTCOME OF AA AMYLOIDOSIS IN INDIAN PATIENTS
Akash Sarkar, Bhavik Bansal, Geetika Singh, Adarsh Barwad, Arun Kumar Subbiah, Raj Kanwar Yadav, Sandeep Mahajan, Dipankar Bhowmik, Sanjay Kumar Agarwal, Soumita Bagchi
Department of Nephrology; All India Institute of Medical Sciences; New Delhi; India
E-mail: drasarkar.cmc@gmail.com
BACKGROUND: Inflammatory (AA) amyloidosis is characterized by deposition of excess insoluble serum amyloid A (SAA) proteins produced in chronic inflammatory conditions. There is paucity of data about this disease in the Indian population.
AIM OF THE STUDY: To delineate the clinical profile and outcome of AA amyloidosis in Indian patients.
METHODS: In a retrospective study we screened our kidney biopsy data from 2013 to 2021 to identify patients diagnosed with AA amyloidosis. Demographic and laboratory details were collected from medical records. Primary outcome was deterioration of renal function defined as sustained decline in estimated glomerular filtration rate (eGFR) by >50% documented during at-least 2 consecutive clinic visits or progression to end stage kidney disease (ESKD).
CONCLUSION: The prevalence of Inflammatory (AA) amyloidosis is low in Indian patients. Majority had a documented predisposing chronic inflammatory disease. In the absence of definitive treatment renal survival is poor.
15TH DECEMBER 2023
ABSTRACT NO. 115
POSTPARTUM RENAL CORTICAL NECROSIS: AN UNSOLVED CONUNDRUM. A CASE SERIES OF TEN PATIENTS
Abhilasha Soni, Nitin Kumar Bajpai, Manish Chaturvedy, Rajesh Jhorawat
All India Institute of Medical Sciences; Jodhpur; Rajasthan; India
E-mail: drnitinbajpai@gmail.com
BACKGROUND: Renal cortical necrosis (RCN) is the most catastrophic form of acute kidney injury (AKI) and is associated with increasing maternal morbidity and mortality. Whether sepsis related intense complement activation or a primary complement deficiency leads to RCN is still unanswered. The overlapping features of puerperal sepsis disseminated intravascular coagulation (DIC) and complement mediated thrombotic microangiopathy (CM-TMA) may complicate the clinical diagnosis; thus warranting early renal biopsy and guidance regarding definitive management and disease prognostication.
AIM OF THE STUDY: To evaluate the clinico-epidemiological profile and outcome of pregnancy related RCN and to highlight the likely contribution of CM-TMA in this condition with possible role of plasmapheresis in disease management.
METHODS: This is a prospective case series of 10 patients admitted under the department of Nephrology of AIIMS Jodhpur from February 2022 to August 2023. Acute kidney injury in postpartum patients was defined according to 2012 KDIGO definition of AKI. Patient clinico-epidemiological data including obstetric history risk factors and pregnancy related complications was collected. A diagnosis of sepsis was made when patient had fever leucocytosis and elevated procalcitonin; with diagnosis being definite if culture grew microorganism. Microangiopathic hemolyticanemia (MAHA) was defined as the simultaneous measure of LDH >500 IU/L and peripheral blood film showing >1% schistocytes with normal coagulation markers. DIC was diagnosed according to ISTH criteria.
CONCLUSION: The etiopathogenesis of RCN is highly complex with multiple variables contributing to it. CM-TMA is an important cause of obstetric AKI and should be considered as a differential so that initiation of procedures like plasmapheresis can help in improving residual renal reserve. Early biopsy and timely intervention can aid in future prognostication and should be the cornerstone in management of postpartum AKI patients.
15TH DECEMBER 2023
ABSTRACT NO. 116
A CLINICAL PROFILE OF PATIENTS WITH OBSTRUCTIVE SLEEP APNEA AND END STAGE RENAL DISEASE ON HAEMODIALYSIS
Arighna Mukherjee, Arghya Majumdar
Nephrology; Advanced Medicare and Research Institute; Dhakuria; West Bengal; India
E-mail: marighna42@gmail.com
BACKGROUND: Patients with end stage renal disease (ESRD) are affected with various sleep disorders like insomnia sleep-related breathing disorders like obstructive sleep apnoea (OSA) hypoventilation central sleep apnoea central disorders of hypersomnolence circadian rhythm sleepwake disorders parasomnias and sleep-related movement disorders like Restless legs syndrome. Amongst these OSA needs special mention as CKD is a comorbidity of OSA and contributes to the course of OSA.
AIM OF THE STUDY: The aim is to study the prevalence of obstructive sleep apnea (OSA) in ESRD patients on hemodialysis to analyse the association of comorbidities in this group of patients on OSA and to ascertain the impact of complications of HD on OSA.
METHODS: The study was an observational descriptive study with cross sectional design conducted on 75 patients more than 18 years with CKD stage 5 on MHD attending Haemodialysis centre of AMRI hospitals Dhakuria Kolkata. For selection of the study subjects stratified sampling was used and a pre-designed and pre-tested semi-structured schedule was used to collect data. The statistical software SPSS version 20 was used for the analysis.
CONCLUSION: This study emphasizes the need to routinely screen for sleep disordered breathing, do a diagnostic workup and take corrective measures by correcting causative factors and treatment with CPAP to improve the quality of life of these patients. Large multicentre trials are mandated in this regard.
15TH DECEMBER 2023
ABSTRACT NO. 117
COMPARTMENTALIZED GUT-INVASIVE CMV AN UNDER-RECOGNIZED SPECTRUM OF CMV DIARRHEA IN RENAL TRANSPLANT RECIPIENTS
S Sabarinath, Dharmendra Bhadauria, Narayan Prasad, Anupma Kaul, M R Patel, Ravi Kushwaha, M R Behera, Monika Yachha, Rajagopal
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: sabarivenus@gmail.com
BACKGROUND: CMV disease in post-renal transplant recipients presents as acute CMV syndrome chronic diarrhea and other organ invasive disease. Chronic diarrhea can be Blood CMV PCR positive chronic diarrhea and Gut-invasive (tissue PCR positive blood PCR-negative) compartmentalized CMV. The available literature on compartmentalized gut CMV is scarce.
AIM OF THE STUDY: The Aim is to determine the clinical pattern of CMV disease in post renal transplant recipients and their outcomes. The objectives are Survival analysis (Time to CMV disease from transplant Time to Death and graft loss from the disease onset among various CMV disease groups) and Adverse outcome analysis (relapse graft loss and death).
METHODS: This is a retrospective single-center follow-up study of patients with CMV disease who were transplanted between 2000 and 2020. Diagnostic variables like blood CMV PCR (polymerized chain reaction) positivity with constitutional symptoms presence or absence of chronic diarrhea tissue PCR positivity and site of tissue biopsy were given harmony codes and 6 syndromes were identified CMV diarrhea (Blood PCR positive presence of diarrhea) compartmentalized gut-invasive CMV (Blood PCR negative presence of diarrhea rectal tissue quantitative CMV PCR positive) Acute CMV syndrome CMV Esophagitis CMV nephropathy CMV cystitis. Out of which patients presenting with diarrhea were included for analysis. The baseline descriptive statistical measures were carried out using analysis of variance. The time to CMV disease from transplant and time to death and graft loss from CMV disease was computed using reliability models by identifying the pattern by parametric log-logistic distribution and log normal distribution respectively. Survival analysis was done by a parametric reliability model identifying location scale and threshold parameters from which month-wise prediction of probabilities was found for survival. The proportion of adverse outcomes (relapse death and graft loss) between the groups was analyzed by one-way ANOVA and Tukey pairwise comparison. (P < 0.05 significant). All the patients were followed up till death or last follow-up.
CONCLUSION: Compartmentalized gut invasive CMV represents a larger proportion of chronic diarrheal illness with a higher relapse rate, which needs invasive gut tissue PCR analysis, despite negative blood PCR, for early diagnosis and management.
15TH DECEMBER 2023
ABSTRACT NO. 118
STUDY OF CLINICAL PROFILE AND OUTCOMES OF C3 GLOMERULOPATHY AT TERTIARY CARE CENTRE IN EASTERN UTTAR PRADESH
Nikhil Chaudhary
Department of Nephrology; IMS; BHU; Varanasi; Uttar Pradesh; India
E-mail: nikhiljangala@gmail.com
BACKGROUND: C3 glomerulopathy is a rare disease. It encompasses dense deposit disease (DDD) and C3 glomerulonephritis (C3GN). It can have varied presentation from spontaneous recovery to advanced renal failure. As there is paucity of Indian data on treatment response in C3GN so we share our center experience on C3GN.
AIM OF THE STUDY: To study clinical profile and therapeutic outcomes in C3GN at 1 year with various treatment options.
METHODS: We retrospectively analyzed data from January 2019 to December 2022 on patients with biopsy proven C3GN at our centre. Distinction into dense deposit disease (DDD) and C3 glomerulonephritis (C3GN) was done on basis of electron microscopy. All patient received treatment according to institutional protocol based on KIDGO guidelines for glomerular disease. Treatment included standard care either alone or with Steroid and mycophenolate or with Steroid and cyclophosphamide. Patients outcomes were analysed at 1 year of follow up.
CONCLUSION: C3GN is important cause of chronic glomerulonephritis leading to end stage renal disease especially in young population. Though definitive therapy is controversial but when promptly diagnosed and treated there is definitive chance of recovery. With Newer therapy and genetic testing we are enhancing our understanding of disease. With targeted therapy like eculizumab we hope to improve disease outcomes in future.
15TH DECEMBER 2023
ABSTRACT NO. 119
FOLLOW UP STUDY OF KIDNEY DONORS FROM A TERTIARY CARE CENTRE
A Poongodi, N D Srinivasaprasasd, K Thirumal Valavan, V Murugesan, S Thirumavalavan, S Sujit, M Edwin Fernando, A M Veerakumar
Department of Nephrology; Government Stanley Medical College; The TN Dr. MGR Medical University; Chennai; Department of Community Medicine; Government Theni Medical College; The TN Dr. MGR Medical University, Theni; Tamil Nadu; India
E-mail: poongodr1981@gmail.com
BACKGROUND: Renal transplantation from living kidney donors is a major source of allografts that helps to overcome the organ shortage of cadaveric donors. Living-donor transplantations yield much better outcomes than deceased-donor transplantations. The benefits of live donor kidney transplantation must be balanced against the potential harm to the donor.
AIM OF THE STUDY: To study the immediate and long term consequences of kidney donation.
METHODS: 200 related kidney donors who underwent donor nephrectomy at our centre were contacted.160 of them responded. All the donors were evaluated clinically biochemically (urine analysis urine protein creatinine ratio (PCR) serum creatinine CBC random blood glucose uric acid) and radiologically. Pre donation parameters were collected from predonation records. We analysed the records of 140 donors who have completed all investigations as per protocol. Results were analysed with SPSS software continuous variables by descriptive statistics and students t test categorical variables by Fishers exact test.
CONCLUSION: In this study of follow up of renal donors: (1) Gender disparity still prevails in organ donation. (2) There was no increased incidence of hypertension (24.3%) and diabetes (17.1%), when compared to general population. (3) Perioperative complications were negligible. (4) Incidence of CKD post donation in donors without hypertension and diabetes, is 7.8%, which is comparable with general population 5.9% as in the SEEK INDIAN COHORT (2013). (5) Long term follow up of donors is mandatory. (6) When appropriately chosen, renal donation seems to be safe.
15TH DECEMBER 2023
ABSTRACT NO. 120
OUTCOME OF ACUTE PYELONEPHRITIS IN HOSPITALISED TYPE 2 DIABETES MELLITUS PATIENTS FROM A TERTIARY CARE CENTRE OF SOUTH INDIA
G. Prasanna Babu, R Vairakkani
Department of Nephrology; Stanley Medical College; Chennai; Tamil Nadu; India
E-mail: s.prasad77@yahoo.co.in
BACKGROUND: The studies on follow up of acute pyelonephritis (APN) inflammation of the kidney parenchyma due to infection is sparse.
AIM OF THE STUDY: We aimed to study the effect of acute pyelonephritis both emphysematous and non-emphysematous in type 2 diabetes mellitus (T2DM) patients on renal function on follow up and factors associated with it.
METHODS: This was a hospitalbased prospective study done over a period of 6 months on newly diagnosed consecutive 102 patients of APN with T2DM. Data on demography clinical laboratory radiological microbiological findings complications treatment modality renal replacement therapy and 90-days outcome were analysed. The outcome studied was a composite of de novo chronic kidney disease (CKD) (eGFR < 60 ml/min/1.73 m2) CKD progression (decline in eGFR category to any higher stage) in patients with baseline CKD or death at 90 days.
CONCLUSION: APN in T2DM was observed predominantly in females. Mortality was low owing to early and aggressive medical management. Baseline CKD status was found to predict the short-term renal outcome or death.
15TH DECEMBER 2023
ABSTRACT NO. 121
HEMODIALYSIS ADHERENCE-CONTRIBUTING FACTORS AND ROLE OF STRUCTURED TEACHING PROGRAMME ON SELF-CARE OF HAEMODIALYSIS PATIENTS
Himanshu Varma, Sourabh Sharma, Radhe Shyam, Anupam Aggarwal, Renju Binoy
Department of Nephrolog; Vardhman Mahavir Medical College and Safdarjung Hospital; New Delhi; India
E-mail: drsourabh05@gmail.com
BACKGROUND: End-stage renal disease is a long-term chronic illness that is often treated with either dialysis or kidney transplantation. Patients with end-stage renal disease (ESRD) are faced with complicated and demanding treatment regimens that include dietary and fluid restrictions and medication schedules.
AIM OF THE STUDY: To identify factors that affect adherence to haemodialysis among end stage renal disease (ESRD) patients and to assess role of structured teaching programme (STP) on self-care of haemodialysis patients in terms of knowledge and practice.
METHODS: This was pre-experimental one-group pre-test post-test design study involving 50 participants. Structured knowledge interview ESRD-AQ tool and structured 4-point Likert-practice rating scale were implied.
CONCLUSION: Most patients were non-adherent and were deficient in knowledge and practices regarding self-care. Patient education and self-care teaching is beneficial in improving adherence.
15TH DECEMBER 2023
ABSTRACT NO. 122
EFFECT OF TYPE 2 DIABETES MELLITUS AND CHRONIC KIDNEY DISEASE ON BONE MINERAL DENSITY
Debajyoti Roy 1 , Ng Chee Yong 1 , Koduri Sreekanth 1 , Vasudevan Vyjayanti 2 , Wenxiang Yeon, Rehena Sultana 3
1 Changi General Hospital; 2 SAS; 3 Duke-NUS; Singapore
E-mail: debajyotiroy@yahoo.com
BACKGROUND: Diabetes mellitus (DM) and chronic kidney disease (CKD) are common medical conditions among the elderly and have been shown to increase the risk of bone fractures due to their negative impact on bone quality. Recent data demonstrates the association of bone mineral density (BMD) with fragility fractures in patients with CKD. When DM and CKD occur in combination the negative impact on BMD may be greater due to the complex interplay between the two conditions. Given that T2DM is common in an Asian population it is important for healthcare providers to be aware of the potential impact of DM and CKD on bone health and to implement appropriate interventions to reduce the risk of bone fractures in this population.
AIM OF THE STUDY: This study aims to investigate potential differences in the impact of T2DM and CKD on BMD in a cohort of elderly patients with fragility hip fracture when these conditions occur alone versus when they occur in combination. We also investigate the relationship of worsening HBA1c to BMD in the groups with and without CKD.
METHODS: A cross-sectional study was conducted on 715 elderly patients (age > 65 years) with fragility hip fracture admitted to a tertiary care hospital between January 2018 and December 2020. The study population was divided into four groups: Group 1 - No CKD or Diabetes (n = 201) group 2 - No CKD with diabetes present (n = 188) group 3 - CKD present with no diabetes (n = 166) group 4 - Both CKD and diabetes present (n = 160). BMD was measured using dual-energy X-ray absorptiometry (DXA) at the femoral neck. The data were analyzed using analysis of variance (ANOVA) and post-hoc testing with Bonferroni correction.
CONCLUSION: The results of this study suggest that elderly patients with T2DM had higher BMD as compared to those without CKD or diabetes mellitus. The mean BMD was 0.30 higher in the diabetic group. The presence of T2DM and CKD in combination was not associated with a worse BMD as compared to those with either condition alone. There was a positive association between worse HBA1C and BMD, however this linear correlation is not strong. Limitations: This study has several limitations, including its cross-sectional design, which does not allow for causal inference. Additionally, the study population was limited to elderly patients with fragility hip fracture.
15TH DECEMBER 2023
ABSTRACT NO. 123
INCIDENCE AND CHARACTERISTICS OF NON ALBUMINURIC DIABETIC KIDNEY DISEASE IN TERITIARY CARE CENTRE
Veluru Rakesh, E Mahesh, K C Gurudev, M S Gireesh, Rajshekhar, Pooja Prakash Prabhu, Yousuf
Department of Nephrology; M. S. Ramaiah Medical College; Bengaluru; Karnataka; India
E-mail: vrr3488@gmail.com
BACKGROUND: Diabetes kidney disease is most common cause of ESRD in both developed and developing countries. Urine albumin Excretion is considered as early sign of DKD. Hence it is most commonly used as a screening tool for diagnosing DKD. Most recent studies have shown there is decrease in glomerular filtration rate in type 2 diabetes mellitus patients without significant albuminuria. This entity is known as non albuminuric diabetic kidney disease.
AIM OF THE STUDY: To assess the prevalence and clinical characteristics of patients with non albuminuric kidney disease.
METHODS: Study type - In this single centre ambispective observational study. From Jan 2022 to July 2023 1252 type 2 diabetic patients with eGFR < 60 ml/1.73 m2 were included. Patients with Renal dysfunction and proteinuria secondary to other causes apart from type 2 diabetes mellitus active urinary tract infections uncontrolled type 2 diabetes mellitus on haemodialysis excluded.
CONCLUSION: In our study we found that non albuminuric diabetic kidney diseases is seen older patients, and have higher eGFR when compared albuminuric DKD patients. Incidence of CAD and dyslipidaemia is more in non albuminuric diabetic kidney disease than non albuminuric kidney disease. No there no significant difference in retinopathy, sex, kidney size and duration of diabetes in both groups.
15TH DECEMBER 2023
ABSTRACT NO. 124
VENOUS EXCESS ULTRASOUND (VEXUS) GUIDING FLUID THERAPY IN COMPLEX PATIENTS WITH ACUTE KIDNEY INJURY: AN INSTRUCTIVE CASE SERIES
Kritika Soni, Shubhangi Kanitkar
Department of Nephrology; Dr. DY Patil Medical College; Pune; Maharashtra; India
E-mail: kritikasoni1@gmail.com
BACKGROUND: It is extremely important to recognize functional right ventricular failure and resultant splanchnic venous congestion in complex patients with acute kidney injury. The recent development of the venous excess ultrasound score (VExUS) and point-of-care ultrasound in the last decade has made for a potentially very useful clinical tool in addition to the traditional physical examination and standard diagnostic imaging which does not help in these complex cases. Venous Excess UltraSound (VExUS) grading system is based on the combination of alterations of hepatic vein portal vein or intra-renal venous flow on pulse-wave Doppler ultrasound with an IVC of > 2 cm of diameter at ICU admission. We hereby present classic instructive cases where VExUS helped in the fluid management of patients and added value to the standard physical and diagnostic imaging modalities.
AIM OF THE STUDY: To determine whether Venous Excess Ultrasound can help guide the fluid therapy in complex patients with acute kidney injury in addition to the standard physical examination and imaging.
METHODS: Study Design: Case Series - Inclusion Criteria: Critical patients admitted with suspected right ventricular pathology and deranged kidney function were selected for the study. Methodology: In addition to the standard physical examination and diagnostic imaging VExUS was performed in all patients. The Venous Excess UltraSound (VExUS) grading system combines inferior vena cava (IVC) diameter and venous Doppler waveform of the portal hepatic and interlobular renal veins. Based on the abnormalities in doppler parameters the venous congestion is classified in grade 0-3 where 0 is no congestion with a normal IVC diameter and grade 3 is severe venous congestion.
CONCLUSION: Venous Excess Ultrasound (VExUS) provides an excellent tool as a window to the venous pathophysiology and help in providing precise fluid delivery to critical, complex patients with acute kidney injury. We are currently in process of conducting a prospective study on the same.
15TH DECEMBER 2023
ABSTRACT NO. 125
RENAL FUNCTION AS A PREDICTOR OF CLINICAL OUTCOMES IN COVID-19 PATIENTS
Kamakshi Narula, Dinesh Khullar, Rahul Grover, Gagan Deep Chhabra, Sahil Bagai, Deepak Kumar Panigrahi, Jaya Kumar, Arun Dewan, Narinder Pal Singh, Anish Kumar Gupta
Department of Nephrology; Max Super Speciality Hospital; New Delhi; India
E-mail: drdineshkhullar@gmail.com
BACKGROUND: COVID-19 patients frequently exhibit kidney disease upon admission or develop acute kidney injury (AKI) during hospitalization linked to unfavorable clinical outcomes.
AIM OF THE STUDY: Our study aimed to assess how abnormal kidney function whether pre-existing or new-onset during admission or hospital stay is associated with COVID-19 outcomes.
METHODS: The retrospective study was conducted at a tertiary care hospital and encompassed non-pregnant patients aged 18 and above admitted with COVID-19 diagnosis confirmed by RT-PCR. We included those with renal dysfunction at admission or during hospitalization including renal allograft recipients with or without graft issues. Participants were categorized into dialysis-dependent and non-dialysis-dependent groups on admission. Among non-dialysis patients further subdivisions included AKI AKI on CKD and Renal Allograft Recipients. AKI and CKD staging followed KDIGO guidelines while estimated GFR was computed using the CKD-EPI Equation. COVID-19 severity was classified into Mid Moderate and Severe based on WHO criteria. We used Chi-square or Fisher exact tests to examine the link between the spectrum of renal failure and poor COVID-19 prognosis.
CONCLUSION: The dialysis-dependent group (CKD Stage 5D/Graft Loss) showed the highest proportion of discharged/recovered participants. Conversely, the AKI group exhibited the greatest proportion of fatalities, underscoring the detrimental prognostic implication of AKI in COVID-19 patients.
15TH DECEMBER 2023
ABSTRACT NO. 126
NATIVE KIDNEY RENAL CELL CARCINOMA IN POST RENAL TRANSPLANT RECIPIENTS AN OBSERVATIONAL STUDY
M Senthil Kumar, Vivek Pathak, Kandasamy Sadayandi, Madhav Venkatesan, Kuppurajan Narayansamy, Devdas Madhavan
Department of Nephrology; Kovai Medical Center and Hospital; Coimbatore; Tamil Nadu; India
E-mail: senthil1992@gmail.com
BACKGROUND: Kidney transplant recipients are at increased risk for developing cancers post transplantation. [1] The risk of developing renal cell carcinoma in kidney transplant recipients is 15-100 times compared to the general population. [2] Here we present our data on renal cell carcinoma in native kidneys post renal transplantation.
AIM OF THE STUDY: (1) To find out the incidience of renal cell carcinoma in native kidneys post renal transplantation (2) To analyse the types of renal cell carcinoma that developed.
METHODS: All Kidney transplant recipients since January 2006 were taken into consideration. Post renal transplantation patients who are on regular follow-up get their routine screening ultrasound abdomen during which time any abnormal lesion or mass lesion might be picked up. Those patients were followed up with CT scan to confirm the lesion and were subjected to bilateral nephrectomy. Both kidneys were sent for histopathological examination post nephrectomy and the type of neoplasm was documented.
CONCLUSION: All individuals were picked up only on followup imaging and they didn’t have any symptoms at the time of presentation. This reiterates the need for followup ultrasound imaging of the native kidneys during transplant followup. This series represents the largest one in India. The incidence is 0.29%. The incidence rates are comparable to other cohorts. [3 - 6]
REFERENCES
Au E, Wong G, Chapman JR. Cancer in kidney transplant recipients. Nat Rev Nephrol 2018;14:508-20.
Moris D, Kakavia K, Argyrou C, Garmpis N, Bokos J, Vernadakis S, et al . De novo renal cell carcinoma of native kidneys in renal transplant recipients: A single-center experience. Anticancer Res 2017;37:773-9.
Hoshida Y, Tsukuma H, Yasunaga Y, Xu N, Fujita MQ, Satoh T, et al . Cancer risk after renal transplantation in Japan. Int J Cancer 1997;71:517-20.
Moudouni SM, Lakmichi A, Tligui M, Rafii A, Tchala K, Haab F, et al . Renal cell carcinoma of native kidney in renal transplant recipients. BJU Int 2006;98:298-302.
Agraharkar ML, Cinclair RD, Kuo YF, Daller JA, Shahinian VB. Risk of malignancy with long-term immunosuppression in renal transplant recipients. Kidney Int 2004;66:383-9.
Ianhez LE, Lucon M, Nahas WC, Sabbaga E, Saldanha LB, Lucon AM, et al . Renal cell carcinoma in renal transplant patients. Urology 2007;69:462-4.
15TH DECEMBER 2023
ABSTRACT NO. 127
SHORT TERM OUTCOMES OF LOW RISK RENAL TRANSPLANT RECIPIENTS WITHOUT INDUCTION THERAPY
Ravina Rajdeo, Sishir Gang, Hardik Patel, Umapati Hegde, Abhijit Konnur
Nephrology; Muljibhai Patel Urological Hospital; Nadiad; Gujarat; India
E-mail: ravinarajdeo222@gmail.com
BACKGROUND: The benefit of using induction agent in low risk live related allograft recipients (LRAR) has been established by old RCT’s using cyclosporine based immunosuppression regimen.
AIM OF THE STUDY: This study aims to study the outcomes in this subgroup without induction therapy in first 12 months post-transplant.
METHODS: Single centre observational prospective study. Low risk LRAR included haplomatch or better ABO compatible D + R + CMV IgG status negative donor specific antiHLA antibodies and excluded those with prior transplant or those who had two or more pregnancies from the donor. These low risk LRAR receiving neither induction therapy nor CMV prophylaxis were recruited from April 2021 to March 2022 and followed up for one year post-transplant.
CONCLUSION: In the current prednisolone, MMF and tacrolimus era, low immunological risk patients can be transplanted without induction therapy with low risk of rejections. Incidence of CMV and BKV infection is considerably low in these set of patients despite not being on prophylactic therapy.
15TH DECEMBER 2023
ABSTRACT NO. 128
CLINICO-EPIDEMIOLOGICAL CHARACTERISTICS OF EARLY VERSUS LATE ONSET CYTOMEGALOVIRUS DISEASE AMONG RENAL TRANSPLANT RECIPIENTS: TWO DECADE EXPERIENCE FROM A SUPER SPECIALITY HOSPITAL IN INDIA
Shuvam Roy, Anupma Kaul, Dharmendra Bhadhuria, Narayan Prasad, Manas Ranjan Patel, Manas Behera, Ravi Shankar Kushwaha, Monica Yaccha
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: royshuvam90@gmail.com
BACKGROUND: Cytomegalovirus (CMV) can cause opportunistic infection in post transplant period. It is an immunomodulatory virus which can lead to rejection. It can present as viral syndrome or as tissue invasive disease with identifiable end organ involvement. CMV disease occurring early or late after transplantation can have different manifestations.
AIM OF THE STUDY: The study aimed to examine the difference between early versus late onset CMV disease among renal transplant recipients with respect to nature of immunosuppressive medications (induction agents maintenance agents and heightening of immunosuppression) nature of manifestation and occurrence of biopsy proven rejection after CMV disease.
METHODS: A retrospective observational study was conducted among the renal transplant recipients who underwent kidney transplant in the period between 1st January 2002 to 31st December 2021 in the Department of Nephrology Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow. Those patients who had any sign and symptoms of CMV infection and confirmed by laboratory investigations were further studied in details. CMV disease was classified as early or late depending on whether CMV infection was first detected before or after 90 days from date of transplant respectively Nature of induction and maintenance immunosuppression as well as profile of CMV infection were noted and analysed. All the renal transplant cases were followed up till December 2021. Considering the lost to follow cases and death of cases before December 2021 the CMV cases had variable length of follow up.
CONCLUSION: Compared to renal transplant recipients with early CMV infection, those with late CMV infection are more likely to have received ATG and CMV prophylaxis. Early CMV presents more frequently as CMV syndrome while late CMV usually manifests as tissue invasive disease. Diarrhoea and thrombocytopenia are more common in late CMV. Graft loss occurs more frequently after late CMV disease.
15TH DECEMBER 2023
ABSTRACT NO. 129
CLINICAL PROFILE AND OUTCOMES OF ATYPICAL HEMOLYTIC UREMIC SYNDROME: A RETROSPECTIVE, SINGLE-CENTER STUDY
V Vamsidhar, Narayan Prasad
Department of Nephrology; SGPGI; Lucknow; Uttar Pradesh; India
E-mail: vamsidharveeranki@gmail.com
BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA) that affects multiple organs and the kidneys in particular. Conventional immunosuppression and Plasma Exchange are widely available in tertiary centers in India and there is hardly any published literature on renal and patient outcomes of aHUS based on protocols using these modalities alone.
AIM OF THE STUDY: Here, we present our large single centre experience with long term follow-up.
METHODS: This was retrospective study from a large, single, tertiary care public sector hospital. All the consecutive patients admitted between January 2016 and December 2022 with the diagnosis of atypical Hemolytic Uremic syndrome were included. Patients with TTP, typical HUS, renal transplant recipients, secondary causes of HUS were excluded. The immediate (1-month), short-term (6-month) and the long-term (12-month) outcomes were analyzed.
CONCLUSION: This study provides valuable insights into the clinical profile and outcomes of aHUS in a single-center setting. Furthermore, the study underscores the need for early diagnosis, tailored treatment strategies, and a holistic approach to patient care.
15TH DECEMBER 2023
ABSTRACT NO. 130
PROTOCOL AND RATIONALE FOR A MULTI-CENTER MULTI-ARM AND MULTI-STAGE (MAMS) RANDOMIZED EMBEDDED ADAPTIVE PLATFORM CLINICAL TRIAL IN SOUTH ASIAN KIDNEY BIOPSY-PROVEN IGA NEPHROPATHY
Selvin Sundar Raj Mani, Santosh Varughese, Vinoi George David, Narayan Prasad, Natarajan Gopalakrishnan, Sishir Gang, Edwin Fernando, Binu Susan Mathew, Prasanna Samuel Premkumar, Babak Choodari-Oskooei, Nisha Jose, Joseph Johny, Jonathan Barratt, George T John, Suceena Alexander
Christian Medical College; Vellore; Tamil Nadu; India
E-mail: selvinsr@gmail.com
BACKGROUND: IgAN is the most common primary glomerular disease in adults. Our group has shown that South Asian ethnicity is associated with much severe phenotype rapid progression in the first prospective longitudinal IgAN(GRACE-IgANI) cohort. The KDIGO guidelines advocate enrolling patients prospectively in Clinical Trials who remain at high-risk despite on maximally tolerated RAASi. There is a dearth of funded academic pragmatic clinical trials looking at commonly available and approved generic drugs that can be effective long-term strategies for better clinical outcomes in the South Asian region. Platform trials with common concurrent control arm for multiple interventions within-trial adaptations pre- specified interim analyses and embedded nature ensures greater acceptability and more efficient use of resources.
AIM OF THE STUDY: Hypothesis: The study hypothesis is that drugs such as SGLT2 inhibitor hydroxychloroquine mycophenolate mofetil or oral prednisolonein addition to maximally tolerated RAASi can significantly improve the kidney outcomes at 2 years when compared to RAASi alone (SOC) in adult primary IgAN who on follow-up remain at high risk of progression. Primary Objective:1. To evaluate the change in UPCR at 1 and 2 years. Secondary Objectives:1. Efficacy Parameters include a) To evaluate the proportion of patients reaching the composite endpoint of 50% decline in eGFR onset of ESKD or death at 2 years b) To evaluate the mean change in total eGFR slope and time averaged proteinuria at 1 and 2 years.2. To enumerate the adverse events and medication adherence of interventions and evaluate the patient related outcome measures at baseline and 2 years. Exploratory objectives: a. To evaluate the pharmacokinetics of HCQ mycophenolate and steroid. b. To evaluate the longitudinal change in serum biomarker profile.
METHODS: Phase IV Randomized Embedded Adaptive MAMS Platform Trial with Concurrent Comparator arm and four Interventional arms in two stages.
CONCLUSION: We will be able to generate primary evidence of clinical efficacy and toxicity of anti-proteinuric and immunomodulatory therapies in primary glomerular diseases in South Asian population. Platform MAMS trial design, being used for the first time in proteinuric kidney diseases will help to establish GRACE- Clinical Trial Network for similar studies in glomerular diseases.
15TH DECEMBER 2023
ABSTRACT NO. 131
HEMODIALYSIS CATHETER: “BITE THE BULLET”
Apurwa Pratap Mall, Anupama Kaul, Narayan Prasad, Dharmendra Bhadauria, Manas Ranjan Behera, Harshita Saxena
Department of Nephrology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: apurwa35@gmail.com
BACKGROUND: Infections are common complications among patients who are on maintenance hemodialysis with Central venous catheters. Patients with a catheter have a 2- to 3-fold increased risk of hospitalization for infection and death compared with patients with an arteriovenous fistula or graft. Catheter-related infections (CRIs) further divided into Catheter-related bloodstream infections (CRBSIs) exit-site infections and tunnel infections. Catheter-related bloodstream infections (CRBSIs) alone have a reported incidence of 1.1 to 5.5 episodes per 1000 catheter days and are associated with increased morbidity hospitalization and death.
AIM OF THE STUDY: In the form of case series we tried emphasizing the different spectrum of a Catheter-related infections (CRIs) that can present to us with devastating outcomes with Clinical and microbiological evidences in complicated CVC-Related Blood Stream Infections (CRBSI).
METHODS: We collected our cases with a study design of retrospective observational study for study period extending from May 2022 to September 2023 admitted to wards and ICUs at our center.
CONCLUSION: We concluded that metastatic CRBSI is associated with higher rates of prolonged ICU stay, financial burden, morbidity and mortality. These complications can be avoided by timely access creation, early referral to tertiary care hospitals, training of health care professionals for proper handling of access, regular surveillance of OT complexes/ dialysis centers for cultures/antibiogram and providing patients with ESKD life plan.
15TH DECEMBER 2023
ABSTRACT NO. 132
HEPATITIS C INFECTION IN MAINTENANCE HEMODIALYSIS PATIENTS IN LOW RESOURCE SETTING: A PROVIDER-DRIVEN STRATEGY TO ADDRESS HEALTH SYSTEM GAP
Suresh Sankarasubbaiyan, Suresh Sankarasubbaiyan, Savitha Kasiviswanathan, Venkatraman Ganapathy, P Rajesh, Devender Pandey, Kamal D Shah
NephroPlus Dialysis Centers; Hyderabad; Telangana; India
E-mail: suresh150902@gmail.com
BACKGROUND: Hepatitis C is an indolent infection that occurs not uncommonly among maintenance hemodialysis patients. It is due to the clustering of risk factors within dialysis units. Implementation of effective prevention strategies must be combined with treatment but the latter is beyond the reach in low-resource settings.
AIM OF THE STUDY: The aim is to review the structure and clinical outcome of provider-driven Hepatitis C treatment program and to describe the benefits to patients and health care.
METHODS: NephroPlus India’s largest dialysis provider conducted a pilot program in 6 dialysis centres during May 2022 - April 2023 under a Public-Private Partnership (PPP) program to screen documented Hepatitis C-positive patients by HCV Ig M Elisa method using the quantitative RNA method. The compliant patients below 60 years without comorbidities with compliance to frequency of at least 2 dialysis sessions per week for 3 months were treated with a combination of Sofosbuvir and Velpatisivir for 12 weeks. HCV RNA was repeated after treatment to assess viral remission.
CONCLUSION: The provider-driven program has demonstrated proactive HCV RNA testing and treatment will address false positivity, decrease disease burden and infection risk in dialysis units, improve individual prognosis and be cost-effective to the health system. Hence there is a need to reexplore the present approach to HCV management in low-resource hemodialysis settings.
15TH DECEMBER 2023
ABSTRACT NO. 133
CHALLENGES AND LESSONS LEARNT FROM INDUSTRY DRIVEN MULTI-CENTRE GLOBAL CLINICAL TRIALS IN IGAN - A SITE INVESTIGATORS’ PERSPECTIVE
Selvin Sundar Raj Mani, Laisa Arul Gladys, P Gowrishankar, Premkumar Murugan, Rajanbabu Franklin, Priscilla, Sabina Yusuf, Jeethu Joseph Eapen, Athul Thomas, Elenjickal Elias John, Santosh Varughese, Vinoi George David, Suceena Alexander
Christian Medical College; Vellore; Tamil Nadu; India
E-mail: selvinsr@gmail.com
BACKGROUND: IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide. Over the last 5 years many promising bio-molecules are being studied in clinical trials. These trials are almost invariably industry sponsored multicentre and global. Uniform protocol is applied to all regions and sites.
AIM OF THE STUDY: Does this really reflect the regional practices or standard of care in a geographically varied disease like IgAN?
METHODS: This was the site investigators perspective after being involved in 5 completed/ongoing industry driven phase 2/3/OLE multi-centre clinical trials in IgAN. More than 20 eligible patients were enrolled from one of the largest not-for profit private quaternary medical centre in South India over a span of 3 years. We had a dedicated team of clinical trial co-ordinators nurses pharmacist and doctors for these trials. There has been no participant drop-out. We are highlighting some of the best practices and some of the regional challenges for participants.
CONCLUSION: Industry driven global clinical trials are indispensable but sponsors could consider some regional modifications in the entry criteria, follow-up protocol and post-trial access. This highlights the need for academic trials that repurpose molecules that are already widely available in these countries with well-known side-effect profile.
15TH DECEMBER 2023
ABSTRACT NO. 134
CLINICAL PROFILE AND PREVALENCE OF HYPONATRAEMIA IN CRITICALLY ILL PATIENTS
Jaish George, E Mahesh, Gireesh, Rajshekar, Pooja
Nephrology; M. S. Ramaiah Medical College; Bengaluru; Karnataka; India
E-mail: georgejaish@gmail.com
BACKGROUND: Hyponatremia is an important electrolyte disorder in critically ill patients. Hyponatraemia in critically ICU patients has frequently been overlooked and has rarely been studied in surgical or mixed ICUs. The aim of this study is to investigate the incidence of hyponatraemia in ICU and to ascertain the frequency aetiology and mortality in critically ill patients admitted to the ICU with hyponatremia.
AIM OF THE STUDY: The aim of this study is to investigate the incidence of hyponatraemia in ICU and to ascertain the frequency aetiology and mortality in critically ill patients admitted to the ICU with hyponatremia.
METHODS: This is a retrospective study conducted at ICU Ramaiah memorial hospital from from June 2021 to January 2023. Data was collected by accessing electronic medical records.
CONCLUSION: Donzze et al . found an incidence of 41.9% among 4,295 patients hospitalized with a diagnosis of congestive heart failure but in our study Increased volume in chronic kidney disease was the common cause for hyponatraemia BUT its mortaility is less (22%). Damanti et al showed use of anti-inflammatory drugs (NSAIDs) was associated with an increased risk of having hyponatremia at hospital admission similar to our study thus underlying the importance of considering rare but potentially reversible causes of hyponatremia, which can lead to serious consequences. Therefore evaluating for cause of hyponatremia is equally important as treating the underlying cause would prevent considerable morbidity and mortality associated with this enigmatic electrolyte disorder.
15TH DECEMBER 2023
ABSTRACT NO. 135
FIBROBLAST GROWTH FACTOR 23 (FGF23) HAD SIGNIFICANT CORRELATION WITH CARDIOVASCULAR DISEASE IN PATIENTS WITH CHRONIC KIDENY DISEASE (CKD) ON MAINTENANCE HEMODIALYSIS (MHD) IN INDIA
Iman Kalyan Sarkar, Arghya Majumdar
Department of Nephrology; AMRI Hospitals; Dhakuria; West Bengal; India
E-mail: drik.sarkar1993@gmail.com
BACKGROUND: Chronic kidney disease increases the risk of premature death mainly due to atherosclerotic cardiovascular diseases and congestive heart failure. This is also attributed to adjunctive hypertension and anemia. However aggressive control of the traditional risk factors like diabetes hypertension obesity smoking etc does not significantly improve heart failure outcomes in patients with CKD which suggests that there are additional mechanisms. The most important non-traditional risk factor is abnormal mineral metabolism also known as chronic kidney disease mineral bone disorder (CKD-MBD). One of the key players in CKD-MBD is fibroblast growth factor 23 (FGF23) a phosphaturic hormone and physiologic inhibitor of vitamin D secreted by the osteocytes. With declining kidney function serum phosphate level rises due to its decreased excretion. As a result FGF23 level also rises. Higher FGF23 levels have been shown to predispose to a higher risk of mortality. Multiple studies have demonstrated the independent association of higher levels of FGF23 with left ventricular hypertrophy. Arterial calcification an important mechanism of cardiovascular disease in CKD has inconsistent association with FGF23. Studies have shown that higher levels of FGF23 was associated with left ventricular hypertrophy reduced ejection fraction (EF) congestive heart failure events and cardiovascular mortality. An experimental study showed an inhibitory effect of FGF23 on erythropoiesis. However only a few human studies have suggested a possible association between FGF23 and anemia in CKD patients. Interestingly few animal and human studies showed that absolute and functional iron deficiencies stimulate FGF23 production. Studies are scarce in the Indian population. The only study on level of FGF23 in maintenance hemodialysis patients in India conducted in few hospitals in South India showed that FGF23 levels were significantly associated with serum phosphorus and parathyroid hormone levels and no significant association between FGF23 and cardiovascular comorbidities and mortality was shown.
AIM OF THE STUDY: The aim of the study was to correlate levels of FGF23 with cardiovascular events in CKD patients on MHD.
METHODS: This was a single-centre hospital based prospective study. It was conducted in the Dialysis unit of the Department of Nephrology in Advanced Medicare and Research Institute (AMRI) Dhakuria Kolkata. Adult patients (age >18 years) of either gender diagnosed to have end stage renal disease (ESRD) on maintenance haemodialysis (MHD) of duration at least 3 months attending Dialysis unit of AMRI Dhakuria were included. Patients below age of 18 years those with early CKD patients with history of cardiovascular disease prior to diagnosis of CKD and patients with history of any type of anemia prior to diagnosis of CKD were excluded. Eight patients were lost to follow up and 14 patients did not have all the necessary data for analysis. So the final analysis included 50 patients. From each of the patients 4 ml of blood was obtained in clot vial by nursing staff of the dialysis unit from their HD access just prior to the beginning of their hemodialysis. The samples were stored in -80 degree Celsius after centrifugation. After all the samples were collected the test for FGF23 level using a standard ELISA kit from Elabscience was conducted in the month of March 2020. Patients were then followed up for 16 months i.e till June 2021. They were interviewed and information regarding demographic data such as age and sex along with history of other comorbidities such as hypertension diabetes hypothyroidism ischemic heart disease cerebrovascular disease or neurological disorders were obtained. They were asked about their dialysis history- like duration of dialysis frequency of dialysis per week vascular access etc. A detailed medication history was also obtained. A thorough physical examination was conducted. All the data collected were analysed for correlation with FGF23 level.
CONCLUSION: In the present study, Higher levels of FGF23 were found to be associated with left ventricular hypertrophy (LVH) and evidence of left ventricular strain. FGF23 levels also correlated with LV dysfunction as evidenced by a positive correlation with NT-proBNP. In the patient population, 26% developed heart failure. Incidence of left heart failure correlated with rising levels of FGF23, from Quartile 1 to Quartile 4 (8.3%, 15.4%, 35.7% and 45.5% respectively) which is consistent with other studies. The prevalence of systolic dysfunction was more in higher quartiles, especially Quartile 4 in comparison to lesser quartiles. There was no correlation between FGF23 levels with serum iPTH or phosphate. There was a linear association of iron stores ie. ferritin with FGF23, which was direct and significant. However, there was no statistically significant association between hemoglobin levels and FGF23 quartiles.
15TH DECEMBER 2023
ABSTRACT NO. 136
A CROSS SECTIONAL SURVEY OF INDIAN PHYSICIANS TO ASSESS CURRENT PRACTICE OPINION AND ATTITUDES ON EARLY IDENTIFICATION AND INTERVENTION FOR CHRONIC KIDNEY DISEASE IN DIABETIC HYPERTENSIVE PATIENTS
Aafreen Naik, Jayesh Desai, Mukesh Shete, Jayant Panda, D K Singh, Kapil Dev Mehta
Shreeji Clinic; Navnath Healthcare; Mumbai; Maharashtra; Departmentof Medicine; SCB Medical College; Cuttack; Odisha; Medical Affairs JB Pharma; Ranchi; Jharkhand; India
E-mail: aafreen.naik@jbpharma.com
BACKGROUND: Diabetes (T2DM) and Hypertension two major causes of chronic kidney disease (CKD) are spreading like silent epidemic in India and other developing countries. In order to improve the implementation of CKD care it is important to know clinician underlying thoughts and beliefs about CKD and the implementation of the new guidelines. The present study therefore aims to explore the perspectives of clinician who were familiar with the guideline on CKD management in daily practice.
AIM OF THE STUDY: The objective of this nationwide survey on Indian physicians was to understand their clinical opinions on the significance and methods of diagnosis of kidney dysfunction early-on in the treatment journey of a hypertensive/diabetic patients.
METHODS: This was a questionnaire-based digital survey of 430 practicing Indian Physicians conducted over a period of 4 months across the country. The survey instrument (online survey questionnaire at survey monkey) was developed by researchers upon review of existing literature and detailed discussion with practicing clinicians. Face and content validity and reliability (test-retest method) was assessed through a focused panel of clinicians to determine if content was adequate to obtain the necessary data.
CONCLUSION: Our study provides insight into the perspectives of physicians concerning early-stage CKD management and could give input for future quality-improvement interventions. The BP targets for diabetic hypertensives should be maintained below 130/80 mm Hg, as per recent ESH 2023 guidelines. Physicians taking care of hypertensive and diabetic patients must screen for early kidney damage and to initiate early intervention to retard the progression of kidney disease.
15TH DECEMBER 2023
ABSTRACT NO. 137
PROLIFERATIVE GLOMERULONEPHRITIS WITH MONOCLONAL IMMUNOGLOBULIN DEPOSITS: A RARE BENIGN HEMATOLOGICAL DISEASE WITH UNFAVOURABLE RENAL OUTCOMES
Joseph Johny, Elenjickal Elias John, Sanjeet Roy, Rizwan Alam, M Selvin Sundar Raj, Nisha Jose, Manish Lalwani, Sabina Yusuf, Atul Thomas, Jeethu Joseph Eapen, Vinoi George David, Santosh Varughese, Suceena Alexander
Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India
E-mail: josephjohny1857@gmail.com
BACKGROUND: Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a rare entity classified under the umbrella of monoclonal gammopathy of renal significance. The clinical implications of circulating monoclonal immunoglobulin light chain restriction on immunofluorescence microscopy histopathological pattern and type of therapy on renal outcomes are not clearly defined.
AIM OF THE STUDY: To look into the baseline characteristics clinical features histopathological aspect treatment pattern and prognostic factors of biopsy proven Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID).
METHODS: In total 16 patients of PGNMID diagnosed between 2013 and 2020 were included from a biopsy registry of 11 459 patients at a single centre in South India and follow up data was collected from electronic medical records until June 2021.
CONCLUSION: One-third of PGNMID patients progress to kidney failure despite a benign hematological presentation. To the best of our knowledge, this is the largest case series of PGNMID from the Indian subcontinent.
15TH DECEMBER 2023
ABSTRACT NO. 138
A PROSPECTIVE OBSERVATIONAL STUDY OF THE ETIOLOGY AND OUTCOME OF CRITICAL CARE ADMISSIONS IN PATIENTS OF CHRONIC KIDNEY DISEASE ON MAINTENANCE HEMODIALYSIS
Oendrila Roy, Subhash Kumar Todi, Arghya Majumdar
AMRI Hospitals; Dhakuria; West Bengal; India
E-mail: royoendrila1991@gmail.com
BACKGROUND: The global prevalence of chronic kidney disease (CKD) is rising due to an ageing population and an exponential increase of predisposing factors such as hypertension and diabetes mellitus. According to the Global Kidney Health Atlas less than 1 in 4 low-income countries can estimate their incidence or prevalence of CKD owing to deficiencies in health information systems (HIS). The burden of kidney failure deaths in India is greater in comparison to other low- and middle-income economies with a similar sociodemographic index suggesting that an improvement in mortality rates in India is possible even with the existing resources. There is sparse data available for CKD patients on maintenance hemodialysis (MHD) who get admitted to critical care unit (CCU) in low and middle-income countries where both MHD and CCU-related costs impose a high economic burden on this population. Conducting a prospective observational study in such a cohort would reveal valuable information. Our study aimed to gather comprehensive information about the primary reasons of CCU admissions for patients on MHD along with insights into their outcomes associated comorbidities CKD related complications demographic characteristics and infection profiles. The collated data could serve as a crucial foundation for shaping future triage strategies treatment policies and optimal resource allocation in healthcare.
AIM OF THE STUDY: Identify major reasons for CCU admissions in CKD patients on MHD. Gather comprehensive clinical profiles of CKD patients on MHD admitted to CCU. Explore correlations between diagnosis outcomes and dialysis-related parameters. Establish connections between dialysis-related and patient-related factors with outcomes. Document associated co-morbidities and CKD complications assessing correlations. Enhance CKD patient care through evidence-based insights for prevention and intervention.
METHODS: The study was conducted at AMRI Hospital Kolkata. This observational study spanned 20 months (May 2021 to January 2023) after ethics committee approval. It was carried out in a 350-bed private tertiary care facility with 65 ICU beds. The study population comprised adult patients undergoing maintenance hemodialysis for over 3 months who needed admission to the CCU. Patient demographic data clinical profiles and outcomes were meticulously recorded. The study evaluated mortality (ICU and hospital) length of stay (ICU and hospital) and duration of mechanical ventilation. In addition we examined correlations between clinical profiles and outcome parameters.
CONCLUSION: Cardiovascular disease and sepsis are the leading causes of admissions to CCU for CKD patients on MHD. Cardiovascular emergencies are associated with prolonged ICU stays and higher mortality rates. Adequate frequency of hemodialysis and effective management of diabetes mellitus contribute to better clinical outcomes in critical situations. AV-Fistula is recommended as the preferred vascular access choice to reduce central line-associated bloodstream infections. Early assessment of NUTRIC, SOFA, and APACHE II scores can aid in prognosis and guide nutrition strategies for patients. Establishing comprehensive health record systems to track clinical, demographic, and infection profiles of CKD patients on MHD is crucial for future triage, treatment policies, resource utilization, and reducing the economic burden of these patients. Multi-center trials are needed to address the growing CKD population in CCUs, which will guide resource allocation decisions. Long-term outcome studies are necessary to validate treatment strategies in CCUs for this patient population.
15TH DECEMBER 2023
ABSTRACT NO. 139
ASSOCIATION BETWEEN KLOTHO AND CARDIAC ABNORMALITIES IN PRE-DIALYSIS CHRONIC KIDNEY DISEASE PATIENTS
Sourabh Sharma, Himanshu Varma, Manoj Kumar, Anupam Aggarwal, Renju Binoy
Vardhman Mahavir Medical College and Safdarjung Hospital; New Delhi; India
E-mail: drsourabh05@gmail.com
BACKGROUND: The onset and progression of CKD is strongly linked to a decrease in klotho which was once thought to have anti-aging effect. The specific mechanism of this enzyme connection with CKD and its related co-morbidities has to be investigated further.
AIM OF THE STUDY: Present study was aimed to test Klotho levels in various phases of CKD and to study their correlation with cardiac morbidity.
METHODS: Present study was single-center observational cross-sectional Study conducted in all genders with age 18 years who presented with CKD stages G1-G5 ND. All cases underwent battery of investigations including estimation of serum Klotho & FGF 23 levels along with 2D echocardiography.
CONCLUSION: With our study, we want to emphasize the prognostic value of Klotho and FGF 23 in routine evaluation of CKD patients. Low serum Klotho & high FGF 23 Levels were associated with Low Left ventricular Ejection fraction, left ventricular Hypertrophy and Left ventricular dysfunction among chronic kidney disease patients.
15TH DECEMBER 2023
ABSTRACT NO. 140
ACCELERATED NEUROPATHY OF RENAL FAILURE - A CASE CONTROL STUDY
S P S Subrahmanian 1 , M Subramani 2
1 Sundaram Hospital; 2 Government KAPV Medical College; Trichy; Tamil Nadu; India
E-mail: spssubrahmanian@yahoo.co.in
BACKGROUND: Accelerated neuropathy of renal failure is a syndrome of rapidly worsening peripheral neuropathy typically described in end stage kidney disease (ESKD) patients undergoing dialysis. Accelerated neuropathy is important as it rapidly progresses to crippling.
AIM OF THE STUDY: We aimed to assess the clinical presentation electrophysiologic characters risk factors and prognosis of accelerated neuropathy in a series of ESKD patients who presented with accelerated neuropathy after being initiated on hemodialysis.
METHODS: In this single center case-control study from India we present the clinical features electrophysiologic findings and outcome of a series of patients who developed accelerated neuropathy after commencing hemodialysis for ESKD. Those who initiated hemodialysis and did not develop accelerated neuropathy were included as controls. For every case four controls were included. We used logistic regression to identify predictors of accelerated neuropathy.
CONCLUSION: Accelerated neuropathy presented shortly after hemodialysis initiation implying a potential role for dialysis in its pathogenesis. Patients with diabetes mellitus and pre-existing neuropathy could be anticipated to develop accelerated neuropathy after hemodialysis initiation. Aceelerated neuropathy tends to resolve with continued dialysis and supportive care and patients with accelerated neuropathy could remain optimistic about recovery.
16TH DECEMBER 2023
ABSTRACT NO. 141
AN INTRIGUING CASE SERIES ON THE ENDEMIC OUTBREAK OF NELL1 MEMBRANOUS NEPHROPATHY ASSOCIATED WITH USE OF FAIRNESS CREAMS
Sajeesh Sivadas 1 , Ranjit Narayanan 2 , Thushara Appu 2 , Anila Abraham 3
1 Aster MIMS; Kottakkal; 2 Aster MIMS; Calicut; Kerala; 3 Renopath; Chennai; Tamil Nadu; India
E-mail: ranjitnarayanan@gmail.com
BACKGROUND: NELL-1 identified as a target antigen in cases of Membranous Nephropathy (MN) demonstrates notable co-localization with IgG within the glomerular basement membrane. There is a well documented obsession with fair skin in our society with marked popularity of fairness creams in the market. We noticed a disproportionate rise in the number of membranous nephropathy cases in our hospital who were turning out to be NELL1 positive of late.
AIM OF THE STUDY: Our case series sheds light on a disconcerting trend highlighting a correlation between the utilization of over-the-counter fairness creams known for their elevated heavy metal content and the manifestation of NELL-1 positive membranous nephropathy.
METHODS: This case series includes ten young patients who presented with nephrotic syndrome at our hospital till July 2023. Renal biopsy was performed in all the patients and those who were diagnosed to have membranous nephropathy pattern by light microscopy and immunofluorescence were worked up further with immunohistochemistry for PLA2R and NELL1. Screening for viral markers including HIV HBsAg and HCV. and analysis of complement proteins (C3 and C4 levels) ANA and APLA were performed where indicated. Individuals who tested positive for NELL1 underwent further scrutiny for uncommon etiological agents including history of intake of indigenous medications and use of skin creams. Heavy metal screening was carried out in blood and urine. The skin creams were sent for chemical analysis.
CONCLUSION: Use of over-the-counter whitening creams, has led to the development of NELL-1-associated membranous nephropathy in our patients likely as a result of high levels of heavy metals in these agents. The obsession with fair skin in our society leading to high utilization coupled with easy availability is leading to an endemic which needs to be addressed with proper legislation, regulation and enforcement. Public awareness measures need to be undertaken urgently to sensitize the general public of the health hazards associated with the indiscriminate use of such skin creams.
16TH DECEMBER 2023
ABSTRACT NO. 142
USE OF LOW DOSE RITUXIMAB FOR MEMBRANOUS NEPHROPATHY IN A TERTIARY CARE HOSPITAL: A CASE SERIES
Judhajit Maiti, Gerry George Mathew, V Jayaprakash, S Sreedhar
Nephrology; SRM Medical College Hospital and Research Centre; Kattankulathur; Tamil Nadu; India
E-mail: yuddhrocks@gmail.com
BACKGROUND: Membranous Nephropathy (MN) as a cause of adult Nephrotic Syndrome follows a non-uniform and varied course from natural history. Rituximab has emerged to be a relatively newer treatment modality but standard doses are associated with side-effects and secondary infections. Its high cost also stands as an hindrance in its use on a large scale in MN in developing nations. Trial of low dose Rituximab with serial monitoring of CD19 cell count is a promising alternative compared to standard treatment regimen.
AIM OF THE STUDY: To evaluate the efficacy and potential of low dose Rituximab in patients of Primary Membranous Nephropathy (Single centre experience).
METHODS: Biopsy proven Membranous Nephropathy (MN) patients were included in the study. They were evaluated first to rule out secondary causes of MN. Patients had serum creatinine values & 24 hr urinary protein levels ranging from 0.7 to 1.6 mg/dl & 5 to 12 gms respectively. Then 3 months of optimized conservative management was done with ACEI/ARBs. When patients failed to respond they were counselled about other treatment options. Some patients had chosen low dose Rituximab (100-200 mg) as a first line treatment and were followed up with CD19 count for atleast 6 months. Patients who had chosen other drugs were treated for 6-8 months if had treatment failure were again shifted to Rituximab and followed up with CD19count.
CONCLUSION: Low dose Rituximab has a potential role in treatment of Primary Membranous Nephropathy (MN) in developing countries. It requires CD19 count monitoring but still it is cost effective and has lesser chances of secondary infections. Keeping in mind the varied presentation of MN, treatment with low dose Rituximab requires large scale studies in our country to validate its efficacy to the fullest.
16TH DECEMBER 2023
ABSTRACT NO. 143
POST DIARRHEAL ACUTE KIDNEY INJURY DURING AN EPIDEMIC IN MONSOON - A RETROSPECTIVE STUDY FROM A TERTIARY CARE HOSPITAL
Nived Haridas, M Edwin Fernando, Vijaya Durairaj, A Poongodi
Department of Nephrology; Government Stanley Medical College; Chennai; Tamil Nadu; India
E-mail: nived.srk@gmail.com
BACKGROUND: One of the most serious consequences of acute diarrheal disease is acute kidney injury (AKI). Data regarding the epidemiology and outcomes of post-diarrheal acute kidney injury (PD-AKI) is sparse.
AIM OF THE STUDY: This study analyses the burden of post diarrheal acute kidney injury (PD-AKI) the clinical profile of patients the outcomes and prognosis of post diarrheal acute kidney injury (AKI) of the patients admitted during an epidemic during the monsoon of 2021 at our hospital
METHODS: We retrospectively analyzed the data of 93 patients admitted with PD-AKI during an epidemic of diarrheal illness. Patients were stratified according to the Kidney Disease: Improving Global Outcomes (KDIGO) AKI stage qSOFA score and the clinicodemographic data and outcomes were recorded and analyzed
CONCLUSION: This study provides valuable insights into the clinicodemographic characteristics and outcomes of PD-AKI. The high prevalence of severe AKI emphasizes the importance of early recognition and appropriate management strategies for these patients.
16TH DECEMBER 2023
ABSTRACT NO. 144
U SHAPED MORTALITY RELATION BETWEEN URIC ACID AND CONTINUOUS AMBULATORY PERITONEAL DIALYSIS PATIENTS
T Surya Prakash, Namesh Kamat, R Ram, V Siva Kumar
Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India
E-mail: suryaprakashnephro@gmail.com
BACKGROUND: Epidemiological studies have shown that hyperuricemia is associated with metabolic syndrome coronary artery disease and chronic kidney disease. In addition hyperuricemia is an independent predictor for all-cause and cardiovascular mortality in the hemodialysis population.
AIM OF THE STUDY: The aim of this research is to study the influence of serum uric acid (UA) levels on patient mortality in continuous ambulatory peritoneal dialysis (CAPD) patients.
METHODS: A retrospective observational cohort study was conducted over 3 years at a tertiary care Institute in South India. A total of 151 patients on CAPD comprised the study subjects which were divided into quintiles by serum UA levels. The patient demographics laboratory data comorbid conditions and medications were collected at baseline.
CONCLUSION: Our study shows a U-shaped relationship between UA levels and all-cause mortality in patients on CAPD with higher mortality rate in those of higher and lower UA groups. The role of UA-lowering agent in mortality was explained by several mechanisms, but warrants further investigation.
16TH DECEMBER 2023
ABSTRACT NO. 145
CLINICOPATHOLOGICAL PROFILE AND OUTCOMES OF BIOPSY PROVEN CRESCENTIC GLOMERULONEPHRITIS IN EASTERN INDIA - A ONE YEAR ANALYSIS
Abhishek Vashisth, Koushik Bhattacharjee, Sanjana Sharma, Sanjay Dasgupta, Keya Basu, Arunansu Bandyopadhyay
IPGMER and SSKM Hospital; Kolkata; West Bengal; India
E-mail: abhi.vashisth009@gmail.com
BACKGROUND: Crescentic Glomerulonephritis (CrGN) also called as Rapidly Progressive Glomerulonephritis (RPGN) is associated with rapidly declining renal functions and is histologically defined as presence of >50% glomerular crescents. It is not a disease by itself but is a pathological entity representing a spectrum of glomerular diseases with catastrophic outcomes. Scarcity of data in the Indian setting necessitates a thorough research in this area so that a prompt and streamlined management of this medical emergency can be undertaken.
AIM OF THE STUDY: The aim of the study was to estimate the incidence demography clinicopathological and immunological profile along with outcomes both patient and renal survival of biopsy proven CrGN cases.
METHODS: A prospective observational study was undertaken from August 2022 to July 2023 in biopsy proven patients of CrGN at IPGMER Kolkata. Clinical immunological haematological biochemical investigations along with histopathological features in terms of glomerular and extraglomerular patterns of injury were analysed. Two cores of renal tissue were taken at the time of real time ultrasound-guided biopsy and subjected to light microscopy and immunofluorescence. Therapeutic approach and clinical outcomes were evaluated.
CONCLUSION: CrGN has an overall poor prognosis and, therefore, warrants need for an urgent diagnosis and intervention. Progression to ESKD remains high in these patients despite aggressive therapy.
16TH DECEMBER 2023
ABSTRACT NO. 146
CLINICAL PROFILE OF RENAL FAILURE IN ONCOLOGY PATIENTS
M Sowmiya, T Balasubramanian
Department of Nephrology; Kilpauk Medical College; Chennai; Tamil Nadu; India
E-mail: sowmiyamohan22@gmail.com
BACKGROUND: Oncology patients now make up a significant number of the patients that nephrologists see for kidney-related problems in the outpatient clinic on the inpatient floors and in the medical intensive care unit (ICU). There is an increase in the number of patients with kidney disease in part related to high incidence rates for many malignancies as well as improvement in the cancer death rates due to more effective chemotherapeutic agents including biologics and stem cell therapies. However this has led to an increase in the number of cancer survivors that often develop acute and/or CKD due to their malignancy and/or its associated treatment. Care for oncology patients has become more specialized and complicated requiring collaboration between nephrologists oncologists intensivists and palliative care specialists. This is an evolving field in which only few studies has been published. So this study focusing the clinical profile of renal failure patients is need of the hour.
AIM OF THE STUDY: To study the clinical profile of renal failure in oncology patients
METHODS: After attaining informed consent from the patient detailed history and the following data will be collected from the medical records of 100 oncology patients who had renal failure. Age and sex, Renal function test. Urine output Histological type of the carcinoma Details of chemotherapy and radiotherapy got by the patient Details of renal replacement therapy by which the patient got treated.
CONCLUSION: This study helps in understanding the clinical profile of onconephrology patients and helps in deciding the best possible approach to deal with renal failure in these patients which would improve the morbidity and quality of life in these patients.
16TH DECEMBER 2023
ABSTRACT NO. 147
CRESCENTS FORMATION AND ITS RELATIONSHIP WITH CLINICAL-HISTOLOGICAL PARAMETERS IN LUPUS NEPHRITIS: A CROSS-SECTIONAL STUDY FROM WESTERN RAJASTHAN
Rajesh Jhorawat, Uttayan Chakrabarti, Manish Chaturvedy, Nitin Kumar Bajpai, Asma Nalwa, Vikarn Vishwajeet, Vikrant Verma, Rajesh Jhorawat
Department of Nephrology; All India Institute of Medical Sciences; Jodhpur; Rajasthan; India
E-mail: jhorawat2000@gmail.com
BACKGROUND: The formation of crescent in Lupus Nephritis has important clinical significance. Our study assesses the relationship of various clinical and histological parameters with crescent formation in LN patients.
AIM OF THE STUDY: Assesses the relationship of various clinical and histological parameters with crescent formation in LN patients.
METHODS: Thirty-three patients who have crescent in kidney biopsy in LN were included. The crescents were estimated in percentage. Activity index and chronicity index were measured
CONCLUSION: Crescent formations were frequently seen in Class IV LN. In our study, hypertension, proteinuria, and class of lupus nephritis strongly correlated with the crescent formation in Lupus Nephritis.
16TH DECEMBER 2023
ABSTRACT NO. 148
DIFFERENCES IN QUALITY OF LIFE PARAMETERS IN THE YOUNG VERSUS ELDERLY HEMODIALYSIS PATIENTS - A CROSS-SECTIONAL STUDY
Dayanath Mishra, Sushmita Goswami, Gopalakrishna Gandikota
Department of Nephrology; D.M. Hospitals Pvt. Ltd.; Kolkata; West Bengal; India
E-mail: dayanath@hotmail.com
BACKGROUND: The prevalence of Chronic Kidney Disease and ESRD increases with age so that increasing number of elderly patients are accepted into the hemodialysis programs. The quality of life of patients on hemodialysis in general is low however it is not known if there is a difference between the young and elderly. Studies in this area are conflicting and few.
AIMS OF THE STUDY: To find the differences in Quality of Life between the younger (31-59 years) with the elderly (60-82 years) in our incident dialysis patients at D.M. Hospital Kolkata.
METHODS: We had 135 incident dialysis patients as of March 2023. Patients having dialysis for less than 3 months (n = 9) and one with cancer were excluded from this study. Of these 66 patients belonged to younger age (Group 1) while 59 belonged to the elderly (Group 2). These patients were similar in all demographic characteristics studied. The characteristics studied were gender (Male - P 0.37 Female p - 0.57) total duration of dialysis ( for 3-30 months p - 0.43 31-60 months p - 65 61-90 months p - 0.57 91-126 months p - 0.65 ) frequency of dialysis /week (1/wk. - 0.41 2/wk. 0.64 3/wk. 0.58.) number of comorbidities (0- p - 0.2 1-p - 0.34 2- 0.64 3-p - 0.6 ) with diabetes mellitus p - 0.23 Hypertension p - 0.31 cardiovascular disease 0.76 anaemia p - 0.68 Patients energy deficit (0 deficit p - 0.086 mild 1-25% deficit 0.16 Intermediate 25-50% -p - 0.19. Severe >50% p - 1.0) patients protein deficit nil (0 deficit p - 1 mild 1-25% p - 0.667 intermediate 25-50% p - 0.52. severe p - 0.39 ) Subjective Global Assessment (SGA) scores mild 7-14 to Moderate 15-28 p - 0.4210 and Severe 29-35 p - 1). Socioeconomic Status scores were good 34-42 p - 0.65 intermediate 25-33 and p - 0.5287 and there were no patients of poor status (15-24) in both groups. The Quality of Life scores were obtained using Kidney disease and Quality of Life (KDQOL_36) form translated into Bengali and English and were compared between the two age groups. Individual scores obtained were classified into 3 components physical health with limitations due to physical health emotional health with limitations due to emotional health and those related to pain and general health. They were classified as Good (75-100) intermediate (50-75) low (25-50) and poor (0-25).
CONCLUSION: The decrease in quality of life is more related to physical well-being and limitations due to physical health in the younger while in the older, the quality of life is more affected in the emotional well-being and limitations due to emotional well-being and presence of pain.
16TH DECEMBER 2023
ABSTRACT NO. 149
SIMPLE OBJECTIVE ASSESSMENT - A SIMPLE TOOL FOR ASSESSMENT OF NUTRITIONAL STATUS IN HEMODIALYSIS PATIENTS
V Krishna Priya, Chaitrali Gawde, Virendra Chauhan, Madhvi Dadwe, Hepal Vora, Zamrudd Patel, Zaheer Virani, Prashant Rajput, Shruti Tapiawala, Bharat V Shah
Nephrology; Global Hospitals, Mumbai; Maharashtra; India
E-mail: drvadlapatla92@gmail.com
BACKGROUND: Nutrition among dialysis patients a common predictor of mortality is assessed comprehensively by Subjective Global Assessment (SGA) score which is time consuming and not practical to follow in routine clinical practice. We studied a more pragmatic tool - the Simple Objective Assessment (SOA) and have compared its performance with SGA.
AIM OF THE STUDY: To assess the nutritional status of haemodialysis patients by (1) Using Subjective Global Assessment (SGA) and Simple Objective Assessment (SOA) (2) To compare the performance of SOA with SGA.
METHODS: 54 adult patients who were on haemodialysis for at least 6 months with no active infection or malignancy were included and their nutritional status was assessed by SGA and SOA scoring systems. SGA score consists of 7 variables and the SOA score consists of change in weight and serum albumin over 6 months as parameters.
CONCLUSION: Periodic assessment of nutritional status is important in hemodialysis patients. Most widely accepted method is SGA. However, this is time consuming, needs dedicated personnel and not practical in routine clinical practice. Our study shows that SOA using delta weight and delta albumin over 6 months provides as good information as SGA (R 0.85) and is easy to implement in routine clinical practice.
16TH DECEMBER 2023
ABSTRACT NO. 150
SPECTRUM OF COMPLICATIONS IN PATIENTS ON MAINTAINENCE HEMODIALYSIS
Shweta Phadke, Karthik Urala; Lalit Desale; Sree Bhushan Raju
Department of Nephrology; Nizam’s Institute of Medical Sciences; Hyderabad; Telangana; India
E-mail: spsg.1987@gmail.com
BACKGROUND: Maintenance haemodialysis (MHD) is the lifesaving treatment modality in end-stage renal disease. Patients of CKD are prone to develop multiple complications during their course of disease which can lead to repeated hospitalisations resulting in significant morbidity and mortality.
AIM OF THE STUDY: To study the spectrum of complications in patients on MHD and the correlation between laboratory parameters and complications in patients on MHD and outcomes.
METHODS: The present study is a cross sectional observational study conducted in Department of Nephrology of a tertiary care hospital in South India. 299 patients MHD attending to nephrology outpatient/inpatient department or MHD unit were evaluated and enrolled.
CONCLUSION: Patients on MHD develop wide variety of complications, regular follow up, watchful screening for complications and compliance to treatment are the keys reduce morbidity and mortality.
16TH DECEMBER 2023
ABSTRACT NO. 151
SUPERIOR LONG-TERM OUTCOME OF ABO INCOMPATIBLE (ABOI) COMPARED TO ABO COMPATIBLE (ABOC) KIDNEY GRAFTS
Madhavi Anil Dadwe, Virendra Chauhan, Hepal Vora, Zaheer Virani, Prashant Rajput, Shruti Tapiawala, Bharat Shah
Nephrology; Global Hospitals, Mumbai; Maharashtra; India
E-mail: dadwe10@gmail.com
BACKGROUND: About 25-30% of living related donors are ABOi. Over the last few years outcome of transplants with ABOi donors have significantly improved.
AIM OF THE STUDY: To show improving and superior outcome of ABOi kidney transplants
METHODS: One hundred and three ABOi and 361 ABOc kidney transplants performed from March 2014 to February 2023 patients have been included. In ABOi transplants desensitization protocol included Rituximab and plasmapharesis or immunoadsorption. Induction immunosuppression was thymoglobulin in the early part and Basiliximab thereafter. In ABOc transplants no desensitization was used and induction immunosuppression was thymoglobulin in most cases. Standard triple immunosuppression was used for maintenance in both groups. One five and nine year actuarial patient and graft survival in these patients has been compared with that of ABOc transplant.
CONCLUSION: ABO incompatible living donor kidney transplantation yielded better long term graft survival that ABOc transplantation. We hypothesize that desensitization used in ABOi transplants reduces the risk of chronic antibody mediated rejection which is the leading cause of chronic allograft nephropathy.
16TH DECEMBER 2023
ABSTRACT NO. 152
RHABDOMYOLYSIS AND AKI - AN INTERESTING CASE SERIES FROM A TERTIARY CARE CENTER
K Sai Sindhu Singh, Dharanidhar Reddy, E Indhumathi
Department of Nephrology; Saveetha Medical College, Chennai; Tamil Nadu; India
E-mail: sindhusingh26@gmail.com
BACKGROUND: Rhabdomyolysis a clinical syndrome characterized by the breakdown of skeletal muscle cells and release of creatine kinase (CK) lactate dehydrogenase (LDH) and myoglobin into the plasma and interstitial space. The incidence of rhabdomyolysis associated AKI is 10-40% Rhabdomyolysis can occur due to various reasons such as traumatic injuries muscle compression genetic muscle disorders prolonged immobilization extreme exertion drug abuse or certain infections.
AIM OF THE STUDY: To study the etiology various clinical presentations and outcome of rhabdomyolysis causing AKI in our hospital.
METHODS: Here we present a case series of 11 adult patients who presented with AKI diagnosed as per KDIGO criteria and found to have increased creatine kinase more than five times normal value. Demographic data clinical presentation etiology laboratory investigations requirement of renal replacement therapy and outcome data were collected and analyzed. All patients were followed up for a minimum period of 90 days.
CONCLUSION: A high level of clinical suspicion is required for early diagnosis and effective management with fluid resuscitation, and/or initiation of renal replacement therapy. Elimination of causative agents can help prevent complications. Most of our patients had recovered the renal function although RRT was needed.
16TH DECEMBER 2023
ABSTRACT NO. 153
MYELOMA - THE DECEIVER: UNVEILING THE MYSTERY OF SPURIOUSLY ELEVATED PHOSPHORUS LEVELS IN PLASMA CELL DYSCRASIA
S Sudhaker, Vinoi George David, Athul Thomas, Selvin Sundar Raj
Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India
E-mail: sudhaker.91@gmsil.com
BACKGROUND: Patients with Multiple Myeloma commonly manifest a wide range of electrolyte abnormalities including hypercalcemia hyperkalemia hyponatremia and both hyper and hypophosphatemia. However unlike hypercalcemia hyperphosphatemia usually develops when the patient is in renal failure. The common causes of hyperphosphatemia in Multiple Myeloma include high-phosphorus diet Tumor Lysis syndrome.
AIM OF THE STUDY: To describe a rare entity causing hyperphosphatemia in multiple myeloma.
METHODS: Our patient was a diagnosed case of multiple myeloma who was treated with 8 cycles of CyBorD regimen from January 2022 to August 2022 followed by Autologous HSCT in September 2022 in Complete remission followed by Lenalidomide maintenance. He did not have renal dysfunction throughout the course of his illness. After 3 months of Autologous HSCT he had maintained his remission with the last Protein electrophoresis showing M-Band of 0.4 g%. He relapsed in Feb 2023 and during the admission for treatment of his disease relapse he was found to have severe hyperphosphatemia however it was not accompanied by other features of Tumor Lysis syndrome and he had normal renal functions at the time hence the hyperphosphatemia was inexplicable by myeloma or by other etiologies like dietary overload Vitamin D intoxication phosphate containing laxatives acidosis drugs or renal failure. There was no evidence of hypoparathyroidism or thyrotoxicosis which had the propensity to enhance the renal phosphate reabsorption resulting in hyperphosphatemia. Since the patient had isolated clinically significant Hyperphosphatemia without accompanying hyper or hypocalcemia renal dysfunction or hyperuricemia and no suggestive clinical symptoms the possibility of pseudo hyperphosphatemia was considered.
CONCLUSION: In conclusion, spurious hyperphosphatemia is a rare phenomenon that can occur in patients with gammopathy, especially during progression from SMM to MM, during relapse, due to paraprotein interference with phosphomolybdate assays. Recognition of this possible interaction is essential to ensure early detection of pseudohyperphosphatemia. Doing so could avoid unnecessary testing and inappropriate treatment with phosphate binders and even dialysis.
16TH DECEMBER 2023
ABSTRACT NO. 154
RARE PRESENTATION OF YOUNG LADY WITH CAMPHOR POISONING PRESENTING AS ACUTE INTERSTITIAL NEPHRITIS
Durga Prasad, Venkatesh, Shaik Shaheda Heera, R Ram, V Sivakumar
Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India
E-mail: sundurga3335@gmail.com
BACKGROUND: Introduction: Camphor is cyclic ketone of the group of hydroaromatic terpene compounds. It has been proven to be harmless when used in low concentrations (0.2 to 12%). The strong pleasant aroma of camphor has led to its use in many oils ointments and inhalants as a remedy for coryza and sore throat.
AIM OF THE STUDY: Case description: A 38 years lady non-diabetic non-hypertensive with alleged history of camphor ingestion for cold and sore throat 3 days after which she developed vomiting nausea and decreased urine out for 2 days. On examination her BP-130/70mmhg was PR- 80 bpm pedal oedema was present. Her systemic examination was uneventful
METHODS: On examination her BP-130/70 mmhg was PR- 80 bpm pedal oedema was present. Her systemic examination was uneventful. On evaluation she had serum creatinine of 6.35 mg/dl urea-70 mg/dl at admission. Her Hb was 9.3 mg/dl TLC-10800 PLT-1.56 lakhs Na-137 k+-3.6 meq/l. Her urine examination revealed specific gravity-1.015 albumin-1+ sugar-nil puscells-2-4 epithelialcells-6-8 RBC-occasional. Her ANA profile negative C3-170.15 mg/dl C4-33.85 mg/dl. She was initiated on Haemodialysis after few sessions her creatinine came down to 6 mg/dl. Later her creatinine started to increase despite of haemodialysis. Renal biopsy was done in view of non-resolving AKI. Biopsy report was suggestive of acute interstitial nephritis. She was started on 1mg/dl prednisolone. Her urine out put improved and serum creatinine stabilised to 2.8 mg/dl. She was discharged ask to follow at OPD. On examination her BP-130/70mmhg was PR- 80 bpm pedal oedema was present. Her systemic examination was uneventful. On evaluation she had serum creatinine of 6.35 mg/dl urea-70 mg/dl at admission. Her Hb was 9.3 mg/dl TLC-10800 PLT-1.56 lakhs Na-137 k+-3.6 meq/l. Her urine examination revealed specific gravity-1.015 albumin-1+ sugar-nil puscells-2-4 epithelialcells-6-8 RBC-occasional. Her ANA profile negative C3-170.15 mg/dl C4-33.85 mg/dl. She was initiated on Haemodialysis after few sessions her creatinine came down to 6 mg/dl. Later her creatinine started to increase despite of haemodialysis. Renal biopsy was done in view of non-resolving AKI. Biopsy report was suggestive of acute interstitial nephritis. She was started on 1 mg/dl prednisolone. Her urine out put improved and serum creatinine stabilised to 2.8 mg/dl. She was discharged ask to follow at OPD.
DISCUSSION: Camphor is a toxic substance that can be fatal on ingestion even in the doses of 30 to 50 mg/kg. Camphor forms an important constituent of religious events and prayers in India and is a content of many oils and liniments. Common clinical manifestations of camphor poisoning are Seizure. Other known central nervous system effects include agitation, confusion, myoclonus, hyperreflexia, lethargy and even coma. Our patient is rare manifestation of camphor poisoning presenting with renal failure. Biopsy revealed Acute interstitial nephritis.
CONCLUSION: Accidental exposure to camphor is a common phenomenon causing seizures in children. Few case of camphor induced seizures are reported in adults as well, but can rarely presented as acute renal failure secondary to acute interstitial nephritis
16TH DECEMBER 2023
ABSTRACT NO. 155
UNMASKING A MASKED GLOMERULOPATHY
Smita Patil, Tusti Kumari, Ajit Dash, Abhijeet Budhe, Sagar Sarda, Mayuka Gowda, Atim Pajai, Kalpana Mehta
Nephrology; TNMC and B.Y.L. Nair Hospital; Mumbai; Maharashtra; India
E-mail: ssppatil78.sp@gmail.com
BACKGROUND: Routine immunofluorescence is considered the gold standard for the detection of immune deposits but a peculiar form of glomerular immune complex deposition requires an antigen retrieval step to be visualized. IgG deposits which are not seen on renal biopsy by routine immunofluorescence but are unmasked by paraffin digestion are known as “masked” deposits. Membranous-like glomerulopathy with masked IgG kappa deposits is characterized by masked deposits that show IgG kappa restriction and are subepithelial and mesangial on electron microscopy.
AIM OF THE STUDY: To report a case of membranous-like glomerulopathy with masked IgG-kappa deposits (MGMID) and its clinical outcome.
METHODS: A 27-year-old male with no comorbidities presented with frothing of urine bilateral lower limb swelling puffiness of the face early satiety and abdominal fullness. There was no history of preceding infection joint pain rash photosensitivity oral ulcer oligouriahematuria or cola-colored urine. There was no history of NSAIDs drug abuse or over-the-counter medication intake. On clinical examination the patient had grade 2 pedal edema (pitting type) and periorbital puffiness. The blood pressure was 130/80 mmHg. The systemic examination was normal. Urine routine showed protein 2+ WBC 2-3/HPF and RBC 3-4/HPF. Baseline 24-hour urine protein was 2.7 g/day with serum creatinine of 0.9 mg/dl and serum albumin of 3.2 g/dl. HIV HBsAg and HCV were negative. C3 and C4 were normal.
CONCLUSION: Because C3 is only stained by routine immunofluorescence, membranous glomerulopathy with a masked IgG kappa deposit could be misdiagnosed as C3 glomerulonephritis. Hence, paraffin immunofluorescence evaluation should be considered in such cases. Despite the light chain restriction within these deposits, there was no evidence of a lymphoproliferative disorder. A study published by Christopher P. Larsen et al. showed only 3 out of 6 patients responded to RAS blockade alone, and out of 15 patients who were treated with immunosuppression, 3 achieved complete remission, 2 achieved partial remission, and disease persisted in 6 patients. The best type and duration of the treatment are still unclear. However, given the possibility of progression and the fact that most of the patients are young, we believe that immunosuppressant therapy should be considered in an effort to prevent disease progression.
16TH DECEMBER 2023
ABSTRACT NO. 156
MANTLE CELL LYMPHOMA PRESENTING AS IMMUNE-COMPLEX MEDIATED MPGN: A RARE CASE REPORT
Souvik Ghatak, Sanjay Dasgupta, Atanu Pal, Koushik Bhattacherjee, Pallavi Mahato
Department of Nephrology; Institute of Post Graduate Medical Education and Research; Kolkata; West Bengal; India
E-mail: ghataksouvik@gmail.com
BACKGROUND: A 48 year old male smoker for last 25 years and recent onset hypertension has come to IPGMER Nephrology Department with History of anasarca for last 3 months and reduced urineouput for last 2 weeks. On examination generalised lymphadenopathy was found. The lymphnodes biopsy was done and renal biopsy was also done. Renal biopsy came out mpgn immune complex mediated and ln biopsy came out mantle cell lymphoma. The patient was referred to hematology department. After receiving treatment he recovered completely with serum creatinine 1.2 and output maintained.
AIM OF THE STUDY: As this is a case report there is no aim of this abstract.
METHODS: The patent came to nephrology department with anasarca and oliguria. On examination B/L axillary lymphnodes of size 2*2 was found and also B/L epitrochlear LN were also found. His creatinine went rise to 6.2. Urine R/E came out to have 3+ protein and RBC plenty. ANA ANCA MPO/PR3 report came negative. C3 and C4 were both low. After 5 sessions of hd both renal and ln biosy were done.
CONCLUSION: A middle aged patient when present with renal dysfunction in terms of immune complex mediated MPGN we should look for any solid organ malignancy or hemtological malignancy. And we should not forget to look for lymphadenopathy in regions other than cervical regions as NHL can present with peripheral lymphadenopathy, organomegaly or bone marrow involvement or only with renal dysfunction.
16TH DECEMBER 2023
ABSTRACT NO. 157
VITAMIN C - INDUCED OXALATE NEPHROPATHY: A CASE REPORT
Archita Patel, Deep Mukhopadhyay, Pinaki Mukhopadhyay
Department of Nephrology; Nil Ratan Sircar Medical College and Hospital; Kolkata; West Bengal; India
E-mail: archita.1994patel@gmail.com
BACKGROUND: Acute renal failure can occur as a result of acute tubular necrosis secondary to acute oxalate nephropathy due to the deposition of calcium oxalate crystallization within the renal tubules. Oxalate nephropathy can occur in both primary and secondary hyperoxaluria. Secondary hyperoxaluria can occur due to increased dietary oxalate intake increased absorption of oxalate from the bowel increased production of oxalate. Here is the case report showing excessive vitamin C ingestion leading to oxalate nephropathy.
AIM OF THE STUDY: To address harmful effects of vitamin C in excessive dose which is considered “Good for health” by population.
METHODS: A 42 Year male non hypertensive and non diabetic Health care professional landed up at local emergency with decreased Urine Output following episode of GI Upset of 2 days after eating some outside food. Patient had volume overload and his creatinine was 12.38 mg/dl so patient started on hemodialysis. His CBC and autoimmune profile was normal. Urinr RE Suggestive of +2 protein with 6-7 RBC/HPF. His USG suggestive of normal sized kidney with increase cortical echogenicity. After 2 weeks of HD dependency patient was done renal biopsy in a view of unexplained renal failure which suggest oxalate crystals in biopsy sample. On repeated asking patient given history of daily ingestion of 2 g vitamin C tablets from 1.5 years. After 3 weeks of HD treatment patient gradually improved urine output & discharged with 2.1 mg/dl of creatinine which get normalized later in follow up after 3 months.
CONCLUSION: In spite the multiple potential benefits of vitamin C, we strongly recommend cautious use of large doses of vitamin C irrespective of baseline renal status. We believe that oxalate nephropathy secondary to vitamin C can be prevented by increasing the awareness between physicians as well as patients.
16TH DECEMBER 2023
ABSTRACT NO. 158
NON LUPUS FULL HOUSE NEPHROPATHY IN THE RENAL ALLOGRAFT RECIPIENT PRESENTING WITH GRAFT DYSFUNCTION: TWO RARE CASES
Varun Kulkarni, D K Agarwal, Ankit Data
Department of Nephrology; Indraprastha Apollo Hospital; New Delhi; India
E-mail: varun.kulkarni3@gmail.com
BACKGROUND: Post transplant glomerulopathy can be of various morphologies. Full house pattern of immunofluorescence with any morphological pattern first suggests the possibility of lupus nephritis. However when clinical and serological evidence of SLE are lacking it is termed Non lupus full house nephropathy (NLFHN). When C1q staining is dominant or co-dominant it is termed C1q nephropathy.
AIM OF THE STUDY: We present two cases of post-transplant NLFHN in a 53 yeor old lady who underwent renal transplant in 2015 (ABO compatible live related donor) and a 49 year old male patient who underwent renal transplant in 2017 (ABO compatible live related donor). Basic renal disease in both the patients was unknown. Both patients presented with gradually rising creatinine.
METHODS: After relevant investigations both patients underwent allograft biopsy.
CONCLUSION: Both patients have received 4 doses of Inj. Rituximab. Follow up is awaited. C1q nephropathy is a poorly understood disease with limited treatment options. The significance of non lupus full house nephropathy with proliferative glomerular lesions is not known. More studies are required to define management of such patients to improve graft survival.
16TH DECEMBER 2023
ABSTRACT NO. 159
RETROSPECTIVE ANALYSIS OF VARIABLE PRESENTATION OF RENAL DYSFUNCTION DUE TO MULTIPLE MYELOMA: A CASE SERIES
Gopambuj Singh Rathod, Atanu Pal, Koushik Bhattacharjee, Rajnarayan Mukherjee, Muzzamil Ahmad
Department of Nephrology; IPGMER and SSKMH; Kolkata; West Bengal; India
E-mail: gopambujnephro@gmail.com
BACKGROUND: In patients having multiple myeloma and other monoclonal gammopathies kidney disease is a common and known complication. A wide range of kidney manifestations and various pathologies involving different mechanisms have been described with these disorders. Kidney injury most often occurs in patients with a high tumor burden and can evolve as either an acute or chronic disorder. Myeloma can involve both the glomerular and extraglomerular structures in the kidneys and the presentations of the patients can vary accordingly.
AIM OF THE STUDY: To show that multiple myeloma is a cause of renal dysfunction in patients presenting with different spectrum of renal involvement.
METHODS: This case series comprises of 4 patients who were admitted in nephrology ward of IPGMER & SSKMH Kolkata over a period of 5 months. Blood and urine investigations renal biopsy (in 3 patients) and bone marrow study was done in these patients.
CONCLUSION: All the patients presented with varied features but renal involvement was common in them. With investigations all the 4 patients were ultimately diagnosed having multiple myeloma. None of the patients were dialysis (HD or PD) dependent and were managed conservatively from our side.they were subsequentially referred to the Department of Hematology, NRS Medical College Kolkata for the management of multiple myeloma.
16TH DECEMBER 2023
ABSTRACT NO. 160
HIGH DOSE INTRAVENOUS IMMUNOGLOBULIN (IVIG) IN BK VIRUS NEPHROPATHY: A CASE REPORT
Md. Mahboob Alam, B Muthu Kumar, Himansu Sekhar Mahapatra, Lalit Pursnani; Beauty Suman Singh
Department of Nephrology; Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital; New Delhi; India
E-mail: mahboob9761@gmail.com
BACKGROUND: With the advent of newer and potent immunosuppressants graft survival has improved but it has also led to increased post transplant viral infections. BKV nephropathy has emerged as a cause of graft dysfunction and graft loss. But the treatment of BKV Nephropathy remains challenging for transplant physician. Reduction of immunosuppression is accepted as the first line of treatment. Other therapies such as intravenous immunoglobulin (IVIg) cidofovir leflunomide and fluoroquinolones have been tried with varying degrees of success. We are here reporting a case of BKV Nephropathy treated with IVIg.
AIM OF THE STUDY: Role of IVIg in treatment of BKV Nephropathy.
METHODS: 60 years female known case of hypothyroidism Type 2 Diabetes Mellitus and Hypertension since 12 year and was diagnosed with Chronic kidney disease 5 year back. She underwent renal transplant on 16th July 2022 with live unrelated blood group matched donor HLA 5/6 mismatch induction-ATG 3 mg/kg discharged on triple drug immunosuppression (TDI)-Tacrolimus Mycophenolate mofetil and Prednisolone. Nine months later she presented with epigastric pain with nausea and vomiting no complaints of dysphagia. On evaluation there was deranged renal function with creatinine of 2 mg/dl urine routine-normal CBC-normal. She was managed conservatively for her symptoms. Graft biopsy was done for acute graft dysfunction which revealed findings of BKV associated Nephropathy. Plasma BKV DNA level done which was 9.7 lac (April 2023) CMV DNA PCR- 333copies/mL. She was managed with reduction in immunosuppressant (MMF was stopped) and was started on valgancyclovir. However her symptoms of loss of appetite and nausea did not improved. She presented to our hospital with same complaints.
CONCLUSION: Treatment of BKV Nephropathy remains challenging. Reduction in immunosuppressants being only established treatment. IVIg may be considered in non responding patient. Role of Intravenous immunoglobulin is variable, however to establish safety and efficacy of IVIg in BKV Nephropathy, a large scale study is needed.
16TH DECEMBER 2023
ABSTRACT NO. 161
PULSELESS DISEASE IN A FILTERLESS KIDNEY - A DOUBLE HIT - A RARE CAUSE OF NEPHROTIC SYNDROME IN TAKAYASU ARTERITIS
Hemalatha Saminathan, Vinoi George David, George Joseph, Sanjit Roy, Ragapriya
Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India
E-mail: drhemalatha.s@gmail.com
BACKGROUND: Takayasu arteritis (TA) is a chronic granulomatous inflammatory systemic vasculitis affecting large and medium-sized arteries like the aorta and its branches commonly & at times affecting coronary and pulmonary arteries. TA has varied symptoms and clinical manifestations. Amyloidosis is characterized by the accumulation of pathologic amyloid in different tissues by a process of cleavage misfolding and aggregation into a highly ordered abnormal-sheet conformation. The kidney is the most common organ involved in systemic amyloidosis. Renal involvement had been reported earlier but glomerular lesions causing nephrotic syndrome are very rare. Both TA & and AA are very rare conditions and the coexistence of both conditions is further uncommon. This is a rare instructive case report of Takayasu arteritis presenting with nephrotic syndrome due to secondary amyloidosis(AA) as a result of the underlying chronic inflammatory state. This deposition of amyloid fibrils is mediated by acute phase reactant serum amyloid protein (SAA).
AIM OF THE STUDY: Review of literature - Because of the rarity of both the TA & AA only a few cases have been reported in the literature. Review of the literature search in pubmed database had shown only a few reports of this association that too not even a single case from India. Review of literature in a US cohort showed no cases of AA amyloidosis from the Mayo clinic in 126 patients. In a Chinese report no cases of amyloidosis or nephrotic syndrome in a large cohort of 566 patients with Takayasu who were followed over a period of 5 ± 0.2 years. However in a Russian cohort of 128 patients with Takayasu arteritis prevalence of AA amyloidosis was too high 3.9%. All had proteinuria ± nephrotic syndrome and biopsy-proven diagnosis of AA amyloid. In this cohort study of Russian patients AA amyloidosis was found to be a poor prognostic factor in TA patients with five years survival was only 60% and in the whole cohort it reached around 98%. The cause of death in two of those patients was found to be infection and pulmonary embolism.
METHODS: Clinical history - A 47-year-old female presented with complaints of generalized weakness and tiredness fatiguability on exertion for the past 3 months with gradually increasing leg swelling frothy urine and weight loss of 2-3 kgs over the past 2 months. She was diagnosed to have TA at 15 years of age based on clinical and radiological parameters -absent pulses in hand differential BP in limbs and CT angiogram showing multiple diffuse arterial occlusions for which she was not on any treatment. On evaluation she was found to have features of nephrotic syndrome with raised inflammatory markers. The infectious and myeloma workup was negative. She turned out to be negative for an autoimmune disease profile. On Doppler imaging she did not have renal artery stenosis. Renal biopsy was done which showed features of secondary amyloidosis. She was treated with immunosuppressants and monoclonal antibodies. Followed by initiation of immunosuppression she was found to have suppressed inflammatory activity and resolution of proteinuria and improvement of serum albumin levels.
CONCLUSION: Membranoproliferative glomerulonephritis (GN), crescentic GN, ischemic and hypertensive nephronsclerosis, and infrequently amyloidosis, are the most frequent causes of nephrotic syndrome in TA. Nevertheless AA should be considered as a differential diagnosis in patients with TA presenting with nephrotic syndrome due to its poor prognostic consequences Renal biopsy is mandatory in such patients The prognosis and quality of life of people with this uncommon form of vasculitis may be improved with early diagnosis and effective treatment. Initiation of immunosuppressants and monoclonal antibodies helps to avoid organ impairment and considerable morbidity.
16TH DECEMBER 2023
ABSTRACT NO. 162
THE USE OF KDQOL-36 TO ASSESS HEALTH RELATED QUALITY OF LIFE AMONG PATINETS ON CONTINUOUS AMBULATORY PERITONEAL DIALYSIS AND ITS ASSOCIATION WITH DIALYSIS ADEQUACY IN A TERTIARY CARE CENTRE IN KERALA
V Akshay, V N Aravind, T P Noushad, Noble Gracious, Sajeev Kumar
Department of Nephrology; Government Medical College; Thiruvananthapuram; Kerala; India
E-mail: akshay10293@gmail.com
BACKGROUND: Chronic kidney disease (CKD) patients’ Health related quality of life (HRQoL) is an important predictor of morbidity and mortality in patients on dialysis and its evaluation is important the comprehensive care in this population however it is an often-neglected aspect of chronic kidney disease (CKD) care especially in resource poor settings. The Kidney Disease Quality of Life (KDQOL-36) is widely used for this assessment. Measurements of HRQoL would help the clinician to better understand the disease from patients’ perspective and would aid in optimal care. There are limited studies on HRQoL especially among continuous ambulatory peritoneal dialysis (CAPD) patients from India. This study intends to assess HRQoL and its association with dialysis adequacy in CAPD patients using a kidney disease specific tool (KDQOL-36).
AIM OF THE STUDY: To assess the quality of life in chronic kidney disease patients on continuous ambulatory peritoneal dialysis using Kidney Disease Quality of Life 36 (KDQOL-36) and its association with dialysis adequacy.
METHODS: Descriptive cross-sectional study. KDQOL 36 quality of life questionnaire was applied to 31 patients undergoing continuous ambulatory peritoneal dialysis for more than 3 months at Government Medical College Thiruvananthapuram Kerala.
CONCLUSION: In our study, we assessed the HRQoL among CAPD patients and it was found that patients with comorbidities especially diabetes mellitus and coronary artery disease had poor quality of life and the kidney disease specific domains were affected to a greater extent. As the duration of dialysis increased, patients performed poorly in the Mental Composite domain. Patients with adequate dialysis seemed to perform better and have better quality of life. HRQoL is often a blind spot in the comprehensive treatment of CKD patients with focus being mostly only on improvement of biochemical parameters especially in our country. Improvement of quality of life by providing better patient-centered health education, better control of comorbid conditions, increasing dialysis adequacy and providing psychosocial support measures when needed can help patients with CKD. This tool can also help evaluate the mental composite of these patients and improvement of mental health and emotional well-being should also be considered as a priority along with disease control to help improve quality of life. A better understanding of HRQoL and its determinants would help us to formulate patient-based treatment strategies and including quality of life using this simple tool in the treatment of CKD can help patients lead a more wholesome and fruitful life.
16TH DECEMBER 2023
ABSTRACT NO. 163
RENAL HISTOPATHOLOGICAL PREDICTORS OF END-STAGE KIDNEY DISEASE IN ANCA-ASSOCIATED VASCULITIS WITH GLOMERULONEPHRITIS: A SINGLE-CENTRE STUDY
S L Devika, T P Noushad, Sajeev, Vineetha
Department of Nephrology; Government Medical College; Thiruvananthapuram; Kerala; India
E-mail: ashikashukkoor@gmail.com
BACKGROUND: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a multisystem autoimmune disease characterised by necrotising vasculitis affecting primarily capillaries arterioles and venules and occasionally medium-sized arteries. Renal involvement is a common manifestation with a significant proportion progressing to ESKD (End Stage Kidney Disease). Several clinical and biochemical parameters have been previously used to prognosticate the stage of disease and predict outcome. But histopathology has evolved as a major determinant of prognosis. The primary goal of a kidney biopsy is to establish the diagnosis in many renal diseases. However in ANCA-associated glomerulonephritis (ANCA-GN) identification of disease progression and prognostic stage is the main role as typical clinical presentation and specific ANCA serology are usually sufficient to make the diagnosis. Unlike the conventional biopsy analysis stating a pauci-immune extracapillary glomerulonephritis with variable tubulointerstitial involvement there is increasing proof to show the value of detailed study of other structures seen. Initially standardized methods of histopathology reporting AAV-GN was proposed but this ended in vain due to poor reproducibility of the lesion and subjective variability. Later scoring systems used for other purposed like Lupus nephritis Banff classification of transplant pathology etc were used in AAV-GN. But since the clinical scenario had wide difference these were not widely accepted. In 2010 Berden et al. introduced the popular classification based on baseline glomerular involvement and its association with renal survival at 1 and 5 years. As it was confined to glomerular only -based classification it had its drawbacks. In 2018 a new clinico-pathologic score the Brix’s ANCA Renal Risk Score (RRS) was developed which took into consideration both clinical and histopathological factors. Similarly The Mayo Clinic Chronicity Score (MCCS) published in 2017 also takes into account glomerular tubular and vascular status for prognostication. Despite ongoing research in diagnostic and therapeutic management of ANCA-GN ESKD still occurs in up to 30% of affected patients within 5 years following diagnosis. Thus it is necessary to identify patients with higher stage for whom aggressive immunosuppressive therapy will be life saving.
AIM OF THE STUDY: This study investigated whether histopathological classification and histologic lesion scores could significantly and independently predict the progression to ESKD. An attempt was made at comparing various scoring systems using clinical and histopathological parameters in their effectiveness in predicting outcome.
METHODS: The study was conducted on 46 patients diagnosed with AAV-GN from 2018- 2021. Retrospectively their clinical biochemical and histopatholigical data at diagnosis was collected and their current status ie whether end stage kidney disease or not were assessed. ESKD was defined as initiation of dialysis due to kidney function indicated by eGFR < 15 mL/min/1.73 m2 and related uremic symptoms after excluding acute kidney injury requiring dialysis. For patients who progressed to ESKD the follow-up duration based on ESKD was defined as the period between AAV-GN diagnosis based on kidney biopsy and ESKD occurrence. Conversely for patients without ESKD the follow-up duration was defined as the period between AAV-GN diagnosis and the last visit. The clinical and biochemical variables collected include Age Sex Hb at diagnosis S. Cr at diagnosis eGFR at diagnosis and Urine PC ratio at diagnosis. The histopathological variables assessed include- The class according to Berdens classification the extent of glomerular involvement (global or segmental) type of crescent presence of acute tubular injury interstitial inflammation interstitial fibrosis tubular atrophy fibrinoid necrosis intimal fibrosis/ hyperplasia arterial medial sclerosis and antibody status (Ig G Ig A Ig M C3 C1q Kappa and Lambda). All statistical analyses were performed using IBM SPSS Statistics for Windows version 26.0. Continuous variables were expressed as medians with interquartile ranges whereas categorical variables were expressed as numbers (percentages). Significant differences between two categorical variables were analysed using the chi-square and Fisher’s exact tests. The Mann Whitney U test was used to identify significant differences between two continuous variables. Comparisons of the cumulative ESKD-free and patients survival rates between the two groups were analysed using the Kaplan Meier survival analysis with log-rank tests. Statistical significance was set as P<0.05.
CONCLUSION: In conclusion, this study demonstrated the worst renal prognosis for the sclerotic class among the four histopathological classes. High histological lesion scores for interstitial fibrosis, tubular atrophy were significantly associated with the progression to ESKD. Therefore, more careful monitoring and shorter follow-ups are needed in patients with AAV-GN with high scores in the biopsy findings.
16TH DECEMBER 2023
ABSTRACT NO. 164
CLINICOPATHOLOGICAL SPECTRUM AND SHORT TERM OUTCOMES OF INDUCTION THERAPY IN PEDIATRIC LUPUS NEPHRITIS - A STUDY FROM TERTIARY CARE CENTRE IN SOUTH INDIA
Rohan J Desai, M Ashok Bhat, Bhushan C Shetty, Mayoor V Prabhu, B Sushanth Kumar, V Darshan, Brahma Jana Reddy
Department of Nephrology; Kasturba Medical College; Manipal Academy of Higher Education; Mangalore; Karnataka; India
E-mail: batista2966@gmail.com
BACKGROUND: Childhood-onset systemic lupus erythematosus (cSLE) is a rare but severe multisystem autoimmune with the incidence is 0.3-0.9/100000 children-per year with a prevalence of 3.3-8.8/100000 children. Majority of cSLE has renal involvement and is often fatal. Data on the clinical course short and long-term outcome predictors of disease progression in children with lupus nephritis (LN) are scant. So here we studied the clinicopathological spectrum and short term outcomes of induction therapy in pediatric lupus nephritis patients attending our hospital.
AIM OF THE STUDY: (1) To study the clinicopathological characteristics in pediatric lupus nephritis (2) To study the short term outcomes of induction therapy in pediatric lupus nephritis in a tertiary care centre from South India.
METHODS: Study design - A retrospective study conducted at KMC Hospitals Mangalore between 1st July 2019 and 30th July 2023 which included a total of 10 cases after fulfilling the inclusion criteria Inclusion criteria: (1) Age less than 18 years (2) Renal biopsy proven lupus nephritis with serological evidence of SLE in the form of positive ANA (indirect immunoflourescene) and anti dsDNA (3). Patients with a minimum follow up of atleast 3 months after initiating the induction therapy. Clinical features renal biopsy findings laboratory parameters being entered into the Microsoft excel sheet and tabulated. Treatment given: Induction therapy included methylprednisolone (15 mg/kg) intravenously for 3 days followed by prednisolone 1 mg/kg orally tapered to 10 mg once daily at the end of 6th month. Cyclophosphamide (as per modified NIH) or MMF (30-35 mg/kg/day) is given along with steroids. However immunosuppression is being prescribed on case to case basis. Hydroxychloroquine ACE inhibitors and other supportive care being provided. Treatment response is monitored every month in the form of renal function tests urine routine urine PCR/24 hour urine protein estimation C3 levels. In our study short term outcomes of induction therapy means assessment of patients clinical status renal function tests 24 hour urine protein and C3 levels at the end of 3 months. Complete remission is defined as normalisation of renal functions and proteinuria <500 mg/day whereas partial remission as proteinuria and renal functions improvement of at least >50% from the baseline at the end of 3 months.
CONCLUSION: Response to induction therapy in lupus nephritis reflects the long term renal outcome especially in pediatric population. There is region wide variation in the therapy and response with respect to lupus nephritis. Usually the response of therapy in the induction phase is assessed at the end of 6 months. Our study mainly focused on assessing the outcomes at the end of third month, so as to know the early treatment response trends and to act upon at the earliest in the form of additive immunosuppression if required along with standard of care since it is pediatric population.
16TH DECEMBER 2023
ABSTRACT NO. 165
RISK FACTORS AND MORTALITY OUTCOMES IN HEMODIALYSIS PATIENTS WITH COVID-19 AT A NORTH-INDIAN TERITARY CARE CENTRE
N Madhu Hasini, Mohd Aslam, Nafis Faizi, Sheikh Ashraf, Ahmad Raza, Mohd Irfan
Department of Medicine; Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University; Aligarh; Uttar Pradesh; India
E-mail: madhunarsingolu@gmail.com
BACKGROUND: The Corona virus pandemic disease caused severe acute pulmonary syndrome in most of the affected but COVID-19 associated kidney injury is a common complication with 45% of the affected in ICU requiring RRT. CKD is a well identified risk factor for AKI.
AIM OF THE STUDY: To identify the risk factors and determinants of mortality in patients with COVID-19 who underwent hemodialysis.
METHODS: This single center retrospective observational study collected data with baseline demographic clinical laboratory and radiological characteristics of 30 patients with COVID -19 who underwent hemodialysis. The main study outcome was in-hospital mortality and the determinants involved which were analysed by Mann-Whitney U test and Fischer exact test to compare the survival and non -survival groups.
CONCLUSION: SARS Co V -2 poses a greater risk of mortality in patients with kidney injury requiring RRT [Renal Replacement Therapy]. Our study identifies anemia, elevated D-dimer levels and higher CORADS score as potential risk factors associated with mortality in these patients and helps to mitigate burden of death in the same.
16TH DECEMBER 2023
ABSTRACT NO. 166
OUR EXPERIENCE WITH MEMBRANOUS NEPHROPATHY: RETROSPECTIVE STUDY FROM A TERTIARY CARE CENTER IN SOUTH INDIA
Jerry Joseph, Edwin Fernando, M Murugesan, S Thirumalavan, N D Srinivasaprasad, K Thirumalavan, S Sujith, A Poongodi, Anila Abraham
Department of Nephrology; Government Stanley Medical College and Hospital; Chennai; Tamil Nadu; India
E-mail: jerry16joseph@gmail.com
BACKGROUND: Membranous nephropathy (MN) is one of the most common causes of adult nephrotic syndrome. It is characterized by the deposition of immunoglobulin G and complement components in the glomerular capillary wall and attendant new basement membrane synthesis. Primary MN is a kidney-limited auto-immune disease and accounts for about 80% of cases. In 20% of patients the disease is secondary to a variety of disorders and is therefore termed secondary MN. MN patients with severe proteinuria and other complications are usually managed with immunosuppressive medications (modified Ponticelli regimen and Rituximab).
AIM OF THE STUDY: To study the clinical profile course and to assess the outcome of patients with membranous nephropathy.
METHODS: All patients with biopsy-confirmed membranous nephropathy between December 2017 and December 2021 are included in the study. Their details are collected from registers in the Department of Nephrology. Their presentation examination details laboratory investigations biopsy reports treatment course and outcome are all collected and analyzed. Patients who have defaulted treatment are excluded from the study.
CONCLUSION: Membranous nephropathy is a primary glomerular disease and is one of the most common causes of nephrotic syndrome in adults. In this retrospective study, we analyzed the clinical features, course, and outcome of membranous nephropathy patients who presented to us over the past four years. The most common cause of secondary membranous nephropathy was lupus nephritis. Most primary MN were male, and PLA2R-positive patients were significantly younger than negative patients. The most common presentation is anasarca. Spontaneous remission was less in our study, probably because most patients had massive proteinuria. Statistically significant factors associated with spontaneous remission were lower proteinuria and higher albuminemia at baseline and PLA2R negativity. Treatment response was associated with lower proteinuria at presentation.
16TH DECEMBER 2023
ABSTRACT NO. 167
STUDY OF CLINICAL AND LABORATORY PROFILE OF NORMO-ALBUMINURIC AND ALBUMINURIC PHENOTYPES OF RENAL DISEASE IN PATIENTS WITH TYPE 2 DIABETES MELLITUS
Malavika Mittal, S K Verma, Shahbaj Ahmad
Department of General Medicine; SRHU; Dehradun; Uttarakhand; India
E-mail: malavikamittal96@gmail.com
BACKGROUND: Diabetic kidney disease (DKD) is clinically defined by the presence of impaired renal function and/or elevated urinary albumin excretion, in a patient with type 2 diabetes mellitus (T2DM). A substantial proportion of T2DM patients with renal impairment are normo-albuminuric.
AIM OF THE STUDY: This phenotype suggests an alternate pathogenesis of nephropathy in such patients, and a review of our understanding and classification of diabetic nephropathy is thus needed.
METHODS: One hundred T2DM patients with eGFR <60 mL/min/1.73 m² were included in the study. Socio-demographic, clinical, laboratory, and radiological parameters were observed. Patients were divided based on UACR into 3 groups: normo-albuminuria (UACR<30 mg/g), micro-albuminuria (UACR 30-300 mg/g), and macro-albuminuria (UACR >300 mg/g). These were compared in terms of the afore-mentioned parameters.
CONCLUSION: This study highlights the need for a more comprehensive understanding of the pathological processes and implications of decline in kidney function not associated with proteinuria.
16TH DECEMBER 2023
ABSTRACT NO. 168
UNVEILING FEASIBILITY AND RISKS: EVALUATING THE REUSE OF PLASMA FILTERS IN RESOURCE-LIMITED SETTINGS
Anish Garg, Priti Meena, Paromita Das, Karthikeyan M
Department of Nephrology; AIIMS; Bhubaneswar; Odisha; India
E-mail: anishgarg30@gmail.com
16TH DECEMBER 2023
ABSTRACT NO. 169
IMPACT OF DONOR-SPECIFIC ANTIBODIES (DSAS) AND NON-DSAS DETECTED BY SINGLE ANTIGEN BEAD ASSAY ON BIOPSY-PROVEN ACUTE REJECTION (BPAR) AND GRAFT SURVIVAL IN RENAL TRANSPLANT RECIPIENTS AT A TERTIARY CA
K Rachana Shenoy, Narayan Prasad
Department of Nephrology; SGPGIMS; Lucknow; Uttar Pradesh; India
E-mail: rachanashenoy.k@gmail.com
BACKGROUND: Single antigen bead (SAB) assays allow for sensitive detection of recipient HLA antibodies and their specificities. The results can be interpreted in multiple ways application of which is complex and yet to be fully understood. More than 60% of chronic allograft injury is due to antibody-mediated rejection making antibody detection the central dogma of solid organ transplantation. Strong donor-specific antibodies are associated with hyperacute/acute rejection while weak DSAs have been shown to be associated with slow persistent injury to the graft. The role of non-DSAs and their outcomes on graft outcomes are not completely understood.
AIM OF THE STUDY: To study the impact of DSA and non-DSA detected by SAB assay on BPAR and graft survival.
METHODS: This retrospective single centre study was conducted at a tertiary care hospital in North India to analyse the risk factors for BPAR in living-related donor renal transplant recipients with DSAs and non-DSAs from 2019-2022. Data pertaining to demographics HLA sensitisation crossmatching histopathology were collected from electronic medical records. Each patient was followed up for at least 3 months post transplant. Virtual crossmatching reports were correlated with donor HLA typing for detection of DSAs and non-DSAs.
CONCLUSION: We did not find a statistically significant association between the type of DSA/ DSA vs non-DSA/DSA titre/presence of multiple DSAs and non-DSAs on graft survival. Those with preformed DSAs had an estimated survival of 50 months in comparison to 158 months in those without (p = 0.096). Similar effect was not seen with de novo DSAs.
16TH DECEMBER 2023
ABSTRACT NO. 170
AN INTERESTING CASE OF PSEUDOBARTTER SYNDROME:
S Rangavenamma, S Ananth, Venkata Pakki Reddy, Shridhar Sharma
Nephrology; Kurnool Medical College; Kurnool; Andhra Pradesh; India
E-mail: rangaveni2011@gmail.com
BACKGROUND: Cystic fibrosis (CF) an autosomal recessive disorder occurs due to mutations in CFTR gene resulting in impaired cystic fibrosis transmembrane conductance regulator (CFTR) chloride channel function in various epithelia. In addition to the well-known pulmonary and pancreatic morbidities CF is characterized by electrolyte and acid-base abnormalities- hypochloremia hyponatremia hypokalemia and metabolic alkalosis. These are collectively known as Pseudo-Bartter syndrome as similar abnormalities are seen in Bartter syndrome- an inherited tubulopathy affecting thick ascending limb of loop of Henle. There may be a significant clinical overlap between the Classic Bartter syndrome and CF presenting as Pseudo-Bartter syndrome especially in early childhood. This review focuses on Pseudo-Bartter syndrome in CF its pathogenesis and differentiation from Bartter syndrome. Other causes of metabolic abnormalities resembling Bartter syndrome are also highlighted.
AIM OF THE STUDY: To report and highlights the case of overlapping clinical symptoms electrolyte abnormalities and the diagnostic confusion between Bartter syndrome and Cystic fibrosis.
METHODS: A case of 2.5 year male patient presented with frequent admission for recurrent infection with history of failure to thrive with polyuria with svere acute malnutrition and electrolyte abnormalities hypokalemia hyponatremia and metabolic alkalosis. Weight of patient - 8.2 kg height - 72.1 cm head circumference - 42.1 cm mid upper arm circumference - 11.5 cm
CONCLUSION: The characteristic abnormalities of Pseudo-Bartter syndrome need to be considered in CF patients. CF should be kept in the list of differential diagnosis of an infant with unexplained hypokalemic metabolic alkalosis in addition to Bartter syndrome. Further, one should rule out common conditions like excessive GI losses and diuretics before making the rare diagnoses of CF and Bartter syndrome.
16TH DECEMBER 2023
ABSTRACT NO. 171
UNVEILING ATYPICAL HEMOLYTIC UREMIC SYNDROME: TWO CASES DIVERSE TRAJECTORIES
Pulkit Khosla, Megha Saigal, Chandan Kumar, Arghaya Chakraborty
Department of Nephrology; All India Institute of Medical Sciences; Patna; Bihar; India
E-mail: pulkitluv17@gmail.com
BACKGROUND: Atypical Hemolytic Uremic Syndrome (aHUS) is a rare form of thrombotic microangiopathy (TMA) that occurs due to dysregulation of alternate complement pathway affecting both children and adults. Traditionally it was only characterized by the triad of microangiopathic hemolyticanemia thrombocytopenia and acute kidney injury (AKI). HoweveraHUS is known to have a wide spectrum of clinical presentation and its outcomes differ in every patient depending upon the different mutations harbored by the patient. Currently available therapeutic options for aHUS are plasmapheresis and Eculizumab (a monoclonal antibody against complement C5). Here we report two cases of aHUS one with complete recovery after plasmapheresis and the other one with persistent renal dysfunction requiring hemodialysis.
AIM OF THE STUDY: The purpose of this case series is to highlight the variety of clinical characteristics and long-term outcomes of patients diagnosed with aHUS and explore in detail its two different etiologies and treatment modalities.
METHODS: This case series describes two cases who presented with varied signs of thrombotic microangiopathy. Both were subsequently diagnosed and managed for aHUS with varied outcomes in both the cases
CONCLUSION: The presented cases highlight the diverse clinical gamuts of aHUS. aHUSis due to sporadic or familial mutations in the genes encoding the complement regulators complement factor H, membrane cofactor protein, factor B, and factor I. This case series also emphasizes the influence of etiological factors like high antibody titers on prognosis and also signifies the impact of plasmapheresis in expediting hematological remission, AKI recovery, and positively impacting the overall prognosis of aHUS patients.
16TH DECEMBER 2023
ABSTRACT NO. 172
GLOMERULOCYSTIC KIDNEY DISEASE - AN ADULT CASE. A DISEASE THAT PROBABLY RUNS IN A FAMILY OF WESTERN RAJASTHAN
Abhilasha Soni, Manish Chaturvedy, Nitin Kumar Bajpai, Rajesh Jhorawat
Department of Nephrology; All India Institute of Medical Sciences; Jodhpur; Rajasthan; India
E-mail: abhilashasoni90@gmail.com
BACKGROUND: Glomerulocystic kidney (GCK) disease is a renal cortical cystic disorder which occurs due to uniform dilation of Bowman’s space to a size of 2 to 3 times greater than the normal. To our knowledge till date approximately twenty cases of GCKs have been diagnosed in adults worldwide; thus making it a rare entity. Out of these twenty cases two families were described; one family was having four cases and other family was having seven cases of GCK.
CONCLUSION: Glomerulocystic kidney disease is primarily a disease of newborns and infants; but, it should be considered in the differential diagnosis of renal dysfunction of unknown cause in adults. This could be aided by early kidney biopsy and genetic analysis including whole exome sequencing. Genetic counselling may increase the family understanding of a genetic condition; thus, mitigating the risk of further inheritance.
16TH DECEMBER 2023
ABSTRACT NO. 173
POST-RENAL TRANSPLANT INFECTIONS: ONE YEAR EXPERIENCE FROM EASTERN INDIA
M Kathirvel, Atanu Pal, Kaushik Bhattacharjee, Sanjay Das Gupta, Arunansu Bandyopadhyay
Department of Nephrology; IPGMER and SSKM Hospital; Kolkata; West Bengal; India
E-mail: kathir.kmp@gmail.com
BACKGROUND: Post transplant infections are the leading cause of morbidity and mortality in renal transplant patients.
AIM OF THE STUDY: To estimate the incidence and to assess the clinical profile of post-renal transplant infections.
METHODS: We analysed the data of 54 patients who underwent renal transplantation in our centre from April 2022 to April 2023. Patients received ATG or Basiliximab as induction agent followed by maintenance therapy with Tacrolimus MMF and steroids as per institutional protocol. Cytomegalovirus and cotrimoxazole prophylaxis were started in all patients. Post transplant infections are divided into: <1 month (phase I) 1-6 months (phase II) and >6 months (phase III).
CONCLUSION: (1) Incidence of post-transplant infections in our centre was 81.48%. (2) Urinary tract infection was the most common infection. (3) Lower respiratory tract infection was the significant cause of mortality. (4) There was no difference in the number of infections when ATG and Basiliximab was compared as induction agents. (5) Post transplant diabetes mellitus was the independent risk factor for the infections.
16TH DECEMBER 2023
ABSTRACT NO. 174
INTERIM ANALYSIS OF A PAN INDIA REGISTRY STUDY TO UNDERSTAND THE CLINICOEPIDEMIOLOGICAL PROFILE COMORBIDITIES AND MANAGEMENT PRACTICES ASSOCIATED WITH HYPERURICEMIA
Sanjiv Jasuja, Yogesh Sharma
Indraprastha Apollo Hospital; New Delhi; India
E-mail: sanjivjasuja@yahoo.com
BACKGROUND: In India there are no specific guidelines for the management of hyperuricemia and scarce clinical evidence is available to monitor the community natural use of hyperuricemia treatment that would guide clinicians in choosing optimal treatment course for lowering serum uric acid (SUA) levels in patients with hyperuricemia and other comorbid conditions.
AIM OF THE STUDY: To study the clinicoepidemiological profile comorbidities and prevailing management practices for hyperuricemia in patients with chronic kidney disease (CKD).
METHODS: In this 6-month interim analysis of a 24-month observational study (enrollment target: 255 patients with CKD stages 2-4) following were assessed: (1) percentage of patients with hyperuricemia by comorbidity type and baseline serum uric acid (SUA) levels (2) demographics/baseline characteristics of patients with hyperuricemia (3) percentage of patients on lifestyle modification (LSM [diet/exercise]) ± urate-lowering drugs (ULDs) and (4) impact of treatment on renal parameters in all patients and by comorbidity at 6 months. Statistically significant changes in continuous variables were determined using paired t test.
CONCLUSION: Patients on ULD + LSM showed significant improvement in renal parameters such as SUA and eGFR over 6 months. Nevertheless, final study results are awaited to validate these findings.
16TH DECEMBER 2023
ABSTRACT NO. 175
ASSESSING THE IMPACT OF NGAL AND KIM-1 LEVELS IN PLASMA AND URINE FOLLOWING ACUTE KIDNEY INJURY INDUCED BY INTRAVENOUS CONTRAST IN ADULT ICU PATIENTS
Ravi Mishra, Narayan Prasad, Saurabh Chaturvedi, Harshit Singh, Mohan Gurjar, Durga Prasanna Misra, Vikas Agarwal
Department of Nephrology, Immunology and Critical Care Medicine; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: mishraravi13@gmail.com
BACKGROUND: Despite advancements in medical care Acute Kidney Injury (AKI) remains a prevalent clinical concern. The quest to promptly detect AKI has driven the exploration of biomarkers. While the AKIN (Acute Kidney Injury Network) criteria relying on serum creatinine and urine output represented progress in AKI diagnosis there remains a noticeable absence of dependable biomarkers to effectively differentiate and apply in practical clinical settings.
AIM OF THE STUDY: NGAL and KIM-1 have emerged as early and responsive indicators of AKI. However these biomarkers have not been concurrently assessed in both plasma (P) and urine (U) following intravenous contrast administration among adult ICU patients.
METHODS: Inclusion criteria encompassed adult ICU patients with normal renal function who required radiographic contrast for CT scans. Exclusion criteria involved individuals with AKI/CKD recent contrast exposure within 3 days and pregnancy. Blood and urine samples (5 ml each) were collected prior to contrast exposure as well as at 4 hours 24 hours and 48 hours post exposure. NGAL and KIM-1 levels were quantified using ELISA with urinary levels normalized based on UCr values for each sample. CI-AKI was defined as a ≥ 0.3 mg/dl increase in SCr within 48 hours.
CONCLUSION: In critically ill adult patients, a notable rise in plasma KIM-1 levels was observed as early as 4 hours post-contrast exposure, persisting significantly even at the 48-hour mark. Conversely, plasma NGAL levels did not exhibit any increase at 4 hours, 24 hours, or 48 hours following contrast exposure.
16TH DECEMBER 2023
ABSTRACT NO. 176
A CASE OF DISSEMINATED STRONGYLOIDES INFECTION IN A PATIENT WITH IGA NEPHROPATHY ON IMMUNOSUPPRESSIVE TREATMENT
Manzoor Ahmad Parry, Rayees Yousuf
Department of Nephrology; Sher-i-Kashmir Institute of Medical Sciences; Srinagar; Jammu and Kashmir; India
E-mail: maparry33@gmail.com
BACKGROUND: Immunosuppressive medications such as high dose steroids and antimetabolites are frequently used in glomerulonephritis. However use of these medications is usually associated with various adverse effects.
AIM OF THE STUDY: Aim of this case report is to highlight that among the drawbacks of immunosuppressive therapy the risk of reactivation of latent infections including parasitic infestations is to be considered.
METHODS: Case report.
CONCLUSION: Our case signifies need of awareness among clinicians of the risk of disseminated strongyloidiasis as a complication of the treatment with immunosuppressive medications even in non-endemic areas.
16TH DECEMBER 2023
ABSTRACT NO. 177
CYTOMEGALOVIRUS INFECTION IN IMMUNOCOMPROMISED PATIENTS IN NON-TRANSPLANT SETTINGS - A GREAT MASQUERADER
K Ambily, Gayathri, Rahul, Jithu Kurien, Satheesh Balakrishnan, Subhash Pillai, Reena Thomas
Pushpagiri Institute of Medical Sciences and Research Centre; Thiruvalla; Kerala; India
E-mail: ambily.nephro@gmail.com
BACKGROUND: Cytomegalovirus (CMV) is a herpes virus with which a majority of the population is latently infected. In immunocompromised patients CMV reactivates and proliferates and results in viremia and sometimes infection. CMV reactivation is an expected complication in post-renal transplant settings considering the high immunosuppression these patients receive.
AIM OF THE STUDY: To describe three cases from different non -transplant settings which presented to us with CMV infection after receiving immunosuppression.
METHODS: We describe three cases from different non - transplant settings which presented to us with CMV infection after receiving immunosuppression. We describe their history examination findings lab findings differential diagnosis and management.
CONCLUSION: Clinicians should have a low threshold to test for CMV in patients on immunosuppression, even in non- transplant settings
16TH DECEMBER 2023
ABSTRACT NO. 178
KNOWING ABOUT WHITE COAT HYPERTENSION IN CHRONIC KIDNEY DISEASE
Anirban Singha, Abhijit Taraphder, Manish Kumar Jain
Nephrology; Apollo Hospital; Kolkata; West Bengal; India
E-mail: dr.anirbansmc2010@gmail.com
BACKGROUND: Hypertension is present from early stages of chronic kidney disease (CKD). CKD patients suffer from both masked hypertension (MH) and white coat hypertension (WCH). MH has cardiovascular prognosis close to that of sustained hypertension but limited data is available regarding the same in WCH groups especially in CKD patients. Ambulatory BP monitoring (ABPM) which is found to be superior to conventional (office) BP measurement not only helps to find out WCH but also helps to find out sustained hypertensives from a group of patients who have normal BP at home.
AIM OF THE STUDY: This study aims at determining cardiovascular involvement in form of Left Ventricular Hypertrophy (LVH) in both CKD patients with WCH and CKD patients with normal BP at home by Home Blood Pressure Monitoring (HBPM) but elevated BP in ABPM.
METHODS: This is one and half year duration hospital based observational study where 52 CKD patients with eGFR of ≤ 60 ml/min/1.73m² and age ≥ 18 years who claim to be normotensives at home but are found to be hypertensive at clinic were enrolled. They underwent 24-hour APBM and analysed the readings. BP at clinic is measured by oscillometric method. The interpreters of their HBPM are considered as skilled when they have basic knowledge of BP measurement and they are generally doctors nurses and paramedics. Otherwise the interpreters are considered as ‘unskilled’. Statistical analysis is done by SPSS and GraphPad Prism version 5. A p-value ≤ 0.05 is considered significant.
CONCLUSION: This study showed LVH is pretty common in CKD patients with WCH. There emerged a group of patients who are normotensives on HBPM but when subjected to ABPM they are found to be sustained hypertensive. We identified such a group as pseudo whitecoat hypertensive which emerged as a result of ‘faulty’ HBPM interpretation by unskilled persons. Such pseudo whitecoat hypertensive CKD patients, whose detection become possible with the help of ABPM, also showed evidence of additional end organ damage in the form of LVH and it is statistically significant.
16TH DECEMBER 2023
ABSTRACT NO. 179
A RANDOMIZED OPEN LABEL CLINICAL TRIAL TO EVALUATE THE EFFICACY OF DESIDUSTAT IN COMPARISON TO ERYTHROPOIETIN IN PATIENTS OF ANEMIA WITH DIALYSIS NAIVE CHRONIC KIDNEY DISEASE.
Hiramani Rabha, Syed Shariq Naeem, Saif Quaiser, Waseem Rizvi
Department of Nephrology; Jawaharlal Nehru Medical College; Aligarh Muslim University; Aligarh; Uttar Pradesh; India
E-mail: hiramanirabha279@gmail.com
BACKGROUND: Anemia is a prevalent and serious complication of chronic kidney disease (CKD) that worsens the quality of life and escalates the mortality risk in patients. The current standard of care for anemia of chronic kidney disease is erythropoiesis-stimulating agents (ESAs) synthetic forms of erythropoietin (EPO) that stimulate red blood cell production. However ESAs have several limitations such as high cost cardiovascular risks and potential immunogenicity. Desidustat is a novel oral hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI) that promotes the physiological response to hypoxia and enhances endogenous EPO synthesis and iron utilization.
AIM OF THE STUDY: In this study we aim to compare the efficacy and safety of desidustat compared to erythropoietin in dialysis naive CKD patients with anemia.
METHODS: This study was designed as open label randomized non inferiority clinical trial. 60 dialysis naive CKD patients with baseline hemoglobin of 9 g/dL with adequate iron store were randomized (1:1) to receive either desidustat 100 mg oral tablets thrice a week for 6 months or Erythropoietin subcutaneous injection 0.75 g/kg once in a week for 6 months.
CONCLUSION: Desidustat can be a safe and effective alternative to EPOs with better compliance due to oral dosage form.
16TH DECEMBER 2023
ABSTRACT NO. 180
EPIDEMIOLOGY AND CLINICAL PROFILE OF RENAL STONE DISEASE PATIENTS WITH RENAL INSUFFICIENCY-A STUDY FROM TERTIARY CARE HOSPITAL
Prathehas, Manjusha, Vikram, Sreekanth
Department of Nephrology; Gandhi Hospital; Hyderabad; Telangana; India
E-mail: prathehas@gmail.com
BACKGROUND: Renal calculi are common in the current population requiring interventions. Factors predisposing for the same are many like poor hydration diet urinary tract infections malabsorption anatomical abnormalities. Treatment includes medical and surgical. Recurrent stone former needs extensive evaluation to avoid progression of chronic kidney disease.
AIM OF THE STUDY: To study the clinical profile of patients with renal stone disease treatment they underwent.
METHODS: It is a prospective observational study conducted in Department of Nephrology. Study was conducted over the period of April 2022 to November 2022 Random sampling method was used.
CONCLUSION: (1) Most Common presentation among these patients is loin pain. (2) RRT was required in 73.9% of the patients. 3.67.1% of patients were having obstructive calculi. (4) Most common complication was Hematuria followed by sepsis. (5) Most common procedure performed was bilateral DJ stenting (60.8%) followed by unilateral DJ stenting. (6) Out of 146 Patients, 20.5% patients completely recovered. (7) Out of 146 Patients, 11.6% patients required maintenance hemodialysis. (8) Mortality constituted about 8.2%. 9. 54.7 % patient in the study population had CKD.
16TH DECEMBER 2023
ABSTRACT NO. 181
THYMOMA WITH MEMBRANOUS GLOMERULONEPHRITIS? A RARE CASE STUDY
Tejaswini Bhatlawande, J P Tiwari, Shital Lengade, Rohit Gaude
Goa Medical College; Bambolim; Goa; India
E-mail: tejaswini2840@gmail.com
BACKGROUND: Thymoma has been only showed to be associated with renal manifestations through isolated case reports. As such the association between thymic pathology and renal manifestations such as lupus nephritis and membranous glomerulonephritis has not been studied. The pathogenic mechanisms of the above three conditions may be associated with one another as suspected through the following case.
AIM OF THE STUDY: To study a rare case report of a patient of thymic mass with associated renal manifestations. To discuss the workup and management of the same.
METHODS: A patient with 10-day history of anasarca was evaluated for the possible etiology. Renal biopsy pointed towards lupus nephropathy and membranous glomerulonephritis. Cross sectional imaging and further tissue diagnosis showed the presence of thymoma as well. Through appropriate tests their correlation was studied so as to start treatment for the same.
CONCLUSION: Membranous glomerulonephropathy may be a rare manifestation of thymoma and their association should be studied further. Evaluation should also be done in future so as to find out whether thymectomy improves the clinical status in refractory cases.
16TH DECEMBER 2023
ABSTRACT NO. 182
COMPARATIVE STUDY OF PATIENT SATISFACTION BETWEEN SPECIALITY CLINIC AND GENERAL OPD OF NEPHROLOGY DEPARTMENT IN A CITY - BASED GOVERNMENT MEDICAL COLLEGE AND HOSPITAL
Pinaki Mukhopadhyay, Pratip Chakraborty, Arindham Kargupta, Amlan Kanti Biswas, Archita Patel
Department of Nephrology; Nil Ratan Sircar Medical College and Hospital; Kolkata; West Bengal; India
E-mail: drpinaki71@yahoo.com
BACKGROUND: In modern healthcare system patient satisfaction is a crucial measure for evaluating quality and effectiveness of medical services. It is not only an indicator of the overall service quality but also has impact on treatment adherence patient loyalty and ultimately determines the success of healthcare system.
AIM OF THE STUDY: To Assess patient satisfaction in patients visiting speciality OPD.
METHODS: This is a cross-sectional study conducted in Nephrology OPD of NRS Medical College Kolkata (Govt. of West Bengal ) on 50 patients (25 from General Nephrology OPD and 25 from Glomerular clinic). Data collected from patients doctors non-medical staffs through a structured questionnaire covering various aspects of patient satisfaction in scoring system according to level of patient satisfaction and were analysed with appropriate software and p-values were calculated.
CONCLUSION: The study highlights the importance of patients satisfaction in healthcare system and provides valuable insights to enhance the quality of service delivery and ultimately to optimize the clinic operation for better patients outcome.
16TH DECEMBER 2023
ABSTRACT NO. 183
AN UNCOMMON MANIFESTATION OF LUPUS NEPHROPATHY WITH DIALYSIS REQUIRING ACUTE KIDNEY INJURY (AKI) - A CASE REPORT
Md. Mahboob Alam, B Muthu Kumar, Himansu Sekhar Mahapatra, Lalit Pursnani, Beauty Suman Singh
Department of Nephrology; Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital; New Delhi; India
E-mail: mahboob9761@gmail.com
BACKGROUND: Lupus podocytopathy is distinct clinical entity of lupus nephritis with distinct clinical-morphological features. It is characterized by diffuse foot process process effacement without peripheral capillary wall immune deposits and glomerular proliferation. It presents with nephrotic syndrome and biopsy reports can show glomerular minimal change mesangial proliferation or FSGS pattern. These variants may differ in AKI incidence tubular injury and response of treatment.
AIM OF THE STUDY: To study a rare case of lupus podocytopathy presenting with nephrotic syndrome and dialysis requiring acute kidney injury (AKI).
METHODS: 37 years female known case of hypothyroidism presented with complaints of generalized body swelling and frothing of urine since 1 month. There was history of non-painful oral ulcers on and off and hair loss since 3 months. There was no history of fever joint pain rashes photosensitivity. There was no history of oliguria hematuria.
CONCLUSION: SLE patients presenting with nephrotic syndrome may have other variants apart from class IV/V LN. Lupus podocytopathy is to be considered in the absence of any immune-complex deposits on immunofluorescence studies. There are only few cases reported to have dialysis requiring AKI in nephrotic syndrome associated with lupus. Incidence of AKI occurring in such cases depends on the variant of lupus podocytopathy. Optimal supportive care and timely dialysis is key to successful management.
16TH DECEMBER 2023
ABSTRACT NO. 184
AN UNUSUAL COMPLICATION OF FAILED DEFLATION OF PTA BALLOON DURING VENOPLASTY ASSISTED FEMORAL TUNNELED CATHETER INSERTION
Vignesh Jagannathan, J Jayanivash, M Ramprabahar, S Sathiyan, Vishnuvarthan
Department of Nephrology; SRM Institute of Medical Science; Chennai; Tamil Nadu; India
E-mail: drjayanivash@yahoo.in
BACKGROUND: Despite a paradigm shift and improvement in dialysis modalities vascular access still remains an important prerequisite for Hemodialysis (HD). As the survival of patients in maintenance Hemodialysis contiues to improve the problems associated with vascular access have become a common issue. AV Fistula and AV graft still remains the vascular access for Hemodialysis as the infective and thrombotic complications are lower compared to Tunnelled Central Catheters (TCC). However TCC becomes a viable option who have ran out of other possible vascular accesses. Here we share a case of IVC angioplasty assisted Femoral Tunneled venous catheter insertion and the uncommon complication encountered during the procedure.
AIM OF THE STUDY: (1) To share experience of femoral - atrial TCC in hemodialysis. (2) To discuss the role of Venoplasty assistance in placement of TCC (3) To share unusual complication of Failed deflation of PTA balloon after inflation.
METHODS: Our patient with dialysis vintage of 8 years exhausted AVF/AVG options prior Right & Left IJV TCC catheter dysfunction chronic total occlusion of SVC on Hemodialysis through Femoral TCC presented with poor flow during dialysis. His 1st Femoral TCC catheter was 28 cm (45 cm) Palindrome with tip placed infra renal IVC (L2. L3 Vertebrae) with primary patency of 3 months cumulative patency of 6 following which it was removed for catheter dysfunction. The 2nd Femoral TCC was also 28 cm (45 cm) Palindrome catheter placed with a tip higher up in Sub-hepatic portion of IVC had a primary patency of 3 months and cumulative patency of 10 months. All the intraluminal thrombolytic therapy had been tried and went in vain hence Patient was admitted for further access care. The Femoral catheter was removed and replaced with a 12 Fr 40 cm Sheath in Right Femoral Vein. The venogram revealed chronic thrombus and stenosis of IVC at multiple levels. The IVC venoplasty/Balloon maceration of the thrombus/stenotic lesion was attempted with 20 mm*4 cm peripheral PTA balloon (ATLAS). The balloon after full inflation to nominal pressure failed to deflate and remained adherant to the venous walls. After failure of standard deflation manoeuvres the balloon was deflated by puncturing the same with a AMPLATZ stiff guide wire inserted through the same sheath and the busrt balloon was then removed. The venogram showed reasonable flow through IVC with residual stenotic/thrombotic lesion. A 55 cm (72 cm) palindrome catheter was inserted over the guidewire and tip was placed in IVC/Right atrial Junction. The primary and cumulative patency of this Femoral - Atrial TCC was 12 and 14months respectively and the catheter was functional when patient succumbed to unrelated sepsis event.
CONCLUSION: Femoral TCC are viable alternatives as vascular access in patients with exhausted options. They provide adequate blood flow rates, with comparable patency and infectivity rates. The role of Venoplasty assisted TCC insertions is on the rise and is a life saving option in dialysis patients with central vein occlusions. Failed deflation of balloon is a rare complication of Venoplasty.
16TH DECEMBER 2023
ABSTRACT NO. 185
AN OCCULT CENTRAL VEIN STENOSIS
R S Vishnuvarthan, Ram Prabhahar, S Sathiyan, J Jayanivash, Vignesh Jagan
Department of Nephrology; SRM Institute of Medical Sciences; Chennai; Tamil Nadu; India
E-mail: drjayanivash@yahoo.in
BACKGROUND: A detailed history taking and thorough clinical examination is a basic prerequisite in medical practice. In the era of modern medicine with advancement of technologies the art of history taking and clinical examination is more often lost. In Hemodialysis patients vascular access remains the achilles heel till date with the role of endovascular interventions increasing by day to improve longevity. We share an interesting case of AV fistula related complication fixed by endovascular intervention and the context of the case showing the importance of history and clinical examination in deciding the apropriate site / modality vascular access for hemodialysis patients.
AIM OF THE STUDY: (1) Importance of History and physical examination in creating vascular access (2) vascular access creation in CIED (Cardiac implantable electronic devices) patients.
METHODS: This 60 year old man a known case diabetes mellitus Complete heart block - s/p Permanent pacemaker insertion - CIED (2010) Chronic Kidney disease - ND progressed to ESRD and was advised pre emptive creation of Arterio Venous Fistula for the future needs of dialysis initiation. He underwent Left Radio Cephalic AVF creation following which he started developing diffuse edema of left forearm. Initially attributed to post surgical edema it progressed to entire left upper limb within 4 weeks of AVF creation and patient was referred to our centre. In our initial assessment we noticed extensive edema of left upper limb dilated subcutaneous veins in left upper arm and chest wall the surgical site scar of the subcutaneous pacemaker pocket. Labs revealed severe azotemia and patient was inducted on Hemodialysis. The possibility of venous hypertension secondary to central vein stenosis was considered and patient underwent a CT venogram which showed no evidence of central vein stenosis. Since the suspicion of Central vein stenosis was high we proceeded with Conventional Venogram. Venogram showed Subclavian vein stenosis and near total occlusion at the junction of SCV with left BCV. Patient underwent Percutaneous Central Venoplasty with 12 mm * 4 cm PTA Balloon ( Mustang). The stenotic segment opened up well with residual stenosis of less than 20% and patient had excellent clinical improvement within 48 hrs with complete resolution of Left upper limb edema. The access was put to use and patient remained symptom free for 8 months. The symptoms recurred with full blown Venous hypertension and extensive edema of left upper limb. The blood flow through Left RCF was more than 2000 ml/min. The patient was explained the need for repeat central venoplasty as well as flow reduction at fistula endovascularly (MILLER procedure). He underwent Central Venoplasty with 14 mm*4 cm PTA balloon (ATLAS) and had excellent radiological resolution of stenotic lesion. In view of extensive edema of left upper limb he was planned for MILLERS procedure after 1-2 weeks once edema subsides. However the venous hypertension did not resolve and started increasing over a period of 2-3 weeks and hence patient opted for Creation of newer AV fistula in right hand and ligation of the old left RC AVF.
CONCLUSION: A through history taking and clinical examination still remains a mandatory prerequiste for deciding the appropriate AV access for the Dialysis patients. Percutaneous Central Venoplasty is a go to approach for central vein stenosis, with stenting advocated for recurrent lesions, with flow reduction procedures being done in fistulas with high blood flow. In patients with CIED, the choice of vascular access and the side should me made carefully with contralateral side being the limb of choice.
16TH DECEMBER 2023
ABSTRACT NO. 186
ELEVATED INFLAMMATORY BIOMARKERS ARE RISK FACTORS FOR COMPOSITE OUTCOME IN SOUTH ASIAN IGA NEPHROPATHY (IGAN)
Suceena Alexander, Rajanbabu Franklin, Joseph Johny, Nisha Jose, Selvin Sundar Raj Mani, Sabina Yusuf, Jeethu Joseph, Athul Thomas, Vinoi George David, Santosh Varughese, Jonathan Barratt, George T John
Christian Medical College; Vellore; Tamil Nadu; India; University of Leicester; Leicester; UK
E-mail: suceena@gmail.com
BACKGROUND: The role of inflammatory biomarkers in high-risk South Asian IgAN the effect of IS on longitudinal biomarkers and its impact on CO is not known.
AIM OF THE STUDY: (1) Clinical relevance of inflammatory biomarkers in the GRACE-IgANI cohort. (2) Impact of short course (6 months) oral steroids on longitudinal measurements of these biomarkers at 1 year 2 years and 3 years. (3) Clinical relevance of these biomarkers as a prognostic biomarker in the GRACE-IgANI cohort at three years for clinical outcomes.
METHODS: Serum APRIL levels were measured in baseline and longitudinal sera (1 year 2 year) by ELISA. Serum Gd-IgA1 levels were measured in baseline and longitudinal sera (1 year 2 year) using KM55 ELISA. Serum levels of TNF-RI CD27 & BCMA were quantified with a Luminex multiplex assay. CO was defined as 50% fall in eGFR (CKD EPI) from baseline and/or eGFR (CKD EPI) <15 ml/min/1.73 m2 or RRT/death. Partial remission (PR) in proteinuria was defined as decrease of 24-hour urine protein by 50% from baseline and <3 g/day if nephrotic at baseline OR proteinuria <1.5 g/day if non-nephrotic at baseline for at-least three months.
CONCLUSION: There was significant association between baseline inflammatory markers and CO at 3 years.
16TH DECEMBER 2023
ABSTRACT NO. 187
MPGN DUE TO KINASE INHIBITOR LENVATINIB IN A CASE OF METASTATIC HCC
P J Gopika Menon, G Prasad, Jagadeesh Metta, D Kiran Kumar
Department of Nephrology; Andhra Medical College and King George Hospital; Visakhapatnam; Andhra Pradesh; India
E-mail: gopikamenon92@gmail.com
BACKGROUND: Lenvatinib is an oral VEGEF inhibitor which is used in malignancies like metastatic RCC HCC and thyroid cancer. One of the most common side effects of Lenvatinib is renal injury causing proteinuria. TMA and FSGS associated with Lenvatinib has been described. Nephrotic syndrome with biopsy proven MPGN in a case of metastatic HCC (non-HCV related) has not been reported previously.
AIM OF THE STUDY: To report a case of MPGN probably due to oral kinase inhibitor Lenvatinib.
METHODS: Patient was admitted and evaluated with routine blood and urine examination including 24 hour urine protein. Percutaneous renal biopsy was done for histopathological analysis of the proteinuria.
CONCLUSION: MPGN is a common pattern of injury associated with malignancies. This is a rare case of MPGN associated with metastatic HCC in a patient on oral kinase inhibitor- Lenvatinib.
16TH DECEMBER 2023
ABSTRACT NO. 188
CLINICO
Spoorthi Sreeram, E Mahesh, Gurudev, Gireesh, Rajashekar, Pooja, Yousuff
Department of Nephrology; M. S. Ramaiah Medical College; Bengaluru; Karnataka; India
E-mail: spoorthisraam@gmail.com
BACKGROUND: Hypernatremia is defined as serum sodium concentration >145 mEq/L. It has detrimental effects on various physiological functions. It is also an independent risk factor for mortality in ICU patients. Critically ill patients are at increased risk of hypernatremia due to their inability to control free water intake as a result of sedation altered mental status intubation fluid restriction and also due to administration of sodium containing fluids and medications.
AIM OF THE STUDY: The aim of this study is to ascertain the clinicobiochemical profile of hypernatremia with an emphasis on the risk factors prevalence development progress and clinical outcomes in critically ill patients.
METHODS: This is a retrospective study carried out at Ramaiah memorial hospital attached to medical college a tertiary care centre in south India from January 2019 to march 2023. It included 402 hospitalized patients in Multispecialty ICU who had hypernatremia at presentation or during the course of their management. Data is collected by accessing medical records.
CONCLUSION: Hypernatremia is a preventable complication in critically ill patients. Identification of at risk patients, adjustments in IV fluids and sodium containing medications, maintaining water balance helps not only in preventing hypernatremia and also reduce the mortality risk associated with severity of hypernatremia. Patients who develop hypernatremia have to be evaluated early and treated according to the cause.
16TH DECEMBER 2023
ABSTRACT NO. 189
SCRUB TYPHUS IN A KIDNEY TRANSPLANT RECIPIENT
Darshit Pansuriya, Ankur Mittal, Shyam Bihari Bansal
Kidney and Urology Institute; Medanta - The Medicity; Gurugram; Haryana; India
E-mail: meoff2k@gmail.om
BACKGROUND: Scrub typhus is a vector-borne Rickettsiaceal Infection. clinical presentation includes fever Myalgia headache and vomiting which may progress to end-organ dysfunction in the form of acute kidney injury meningitis or meningoencephalitis.
AIM OF THE STUDY: To discuss the clinical presentation and management of less reported infection of Scrub typhus in a kidney transplant recipient.
METHODS: We reviewed the case study of a kidney transplant patient presenting to us with an acute febrile illness with acute graft dysfunction and later detected to have an infection with scrub typhus.
CONCLUSION: Tropical infections like Tuberculosis, leptospirosis, Malaria, and dengue are reported to occur in transplant patients and cause significant morbidity and mortality in cases of delayed diagnosis. In a transplant patient presenting with acute febrile illness, the occurrence of scrub typhus is uncommon but is one of the definite possibilities after ruling out other possible causes of febrile illness.
16TH DECEMBER 2023
ABSTRACT NO. 190
5-HT2/5-HT2B RECEPTOR INHIBITION ABROGATE FIBROTIC POTENTIAL OF PERITONEAL FIBROBLASTS BY REDUCING THE PRODUCTION OF EXTRACELLULAR MATRIX PROTEINS IN PD PATIENTS
Harshit Singh, Saurabh Chaturvedi 1 , Narayan Prasad 2
1 Department of Nephrology; Sanjay Gandhi Post Graduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; 2 Department of Medical Laboratory Technology; School of Allied Health Sciences; Delhi Pharmaceutical Sciences and Research University, New Delhi, India
E-mail: rajatharsh@gmail.com
BACKGROUND: Peritoneal fibrosis results in ultrafiltration failure in peritoneal dialysis patients. 5-hydroxytryptamine (5-HT; Serotonin) strongly induces extracellular matrix synthesis in peritoneal fibroblasts in a Transforming growth factor beta 1 (TGF-²1) dependent manner. We aimed to evaluate anti-fibrotic role of inhibitors of 5-HT2 and 5-HT2B (Terguride and SB204741) respectively in human peritoneal fibroblasts (HPFBs) isolated from peritoneum of PD patients.
AIM OF THE STUDY: We aimed to evaluate anti-fibrotic role of inhibitors of 5-HT2 and 5-HT2B (Terguride and SB204741) respectively in human peritoneal fibroblasts (HPFBs) isolated from peritoneum of PD patients.
METHODS: Biopsy from parietal peritoneum (PB) of control patients (n = 8) and PD patients (n = 8) excised during laparotomy was incubated overnight in dispase (2.4 U/mL)/37 °C. In post-treatment strategy cells were incubated with 5-HT (1µM) for 1 hr and later with 5-HT (1 µM) and terguride or SB204741 (1 µM each) for 24 hr. In pre-treatment strategy cells were pre-treated with terguride or SB204741 (1 µM each) for 1 hr and later with only 5-HT (1 µM) for 24 hr. HPFBs were also incubated with TGF-²1 (10 ng/ml) and 5-HT inhibitors similar to the above strategies. Real time quantitative PCR for pro-fibrotic (TGF-’1 COL1A1 COL1A2 ACTA2 CTGF and FN1) and anti-fibrotic genes (MMP2/TIMP1) expression was performed. Type 1 collagen and alpha smooth muscle actin (± -SMA) was performed by immunoblotting.
CONCLUSION: 5-HT receptor antagonists attenuate 5-HT/TGF-²1 mediated pro-fibrotic potential of HPFBs by attenuating the production of ECM proteins and alpha smooth muscle actin in HPFBs.
16TH DECEMBER 2023
ABSTRACT NO. 191
IMPACT OF DIABETES MELLITUS ON THE CLINICAL PRESENTATION AND EXTENDED-TERM RESULTS IN ADULTS WITH INFECTION-RELATED GLOMERULONEPHRITIS: A COMPARATIVE INVESTIGATION
V Vamsidhar, Narayan Prasad
Department of Nephrology; SGPGI; Lucknow; Uttar Pradesh; India
E-mail: vamsidharveeranki@gmail.com
BACKGROUND: There has been a relative increase in frequency of the adult variant of IRGN compared to its childhood counterpart besides the poorer prognosis and renal outcomes of the former. The overall clinical presentation, immediate and long-term patient and renal outcomes of IRGN among diabetics in comparison to non-diabetics remain unknown.
AIM OF THE STUDY: Hence, we aimed to compare the clinical profile and outcomes of IRGN among diabetic population versus those without underlying diabetes mellitus.
METHODS: This is a single center, prospective study conducted at department of Nephrology and Renal Transplantation, SGPGIMS. Patients aged 18 years with clinical and histopathological proven IRGN were included. The renal and patient survival including short-term at 6 month and long-term outcomes at 48 months were compared and analyzed across the diabetic and non-diabetic cohorts.
CONCLUSION: The study highlights the importance of considering the diabetic status of patients with IRGN in clinical decision-making and emphasizes the need for close monitoring and early intervention, especially in diabetic patients, to improve long-term renal outcomes.
16TH DECEMBER 2023
ABSTRACT NO. 192
CAVEAT OF CAVITIES-POST RENAL TRANSPLANT CAVITARY LUNG DISEASE
Shweta Phadke, Karthik Urala, Lalit Desale, Sree Bhushan Raju
Department of Nephrology; Nizam’s Institute of Medical Sciences; Hyderabad; Telangana; India
E-mail: spsg.1987@gmail.com
BACKGROUND: Cavitary lung disease (CLD) in renal transplant recipients is an infrequent complication causing high morbidity and mortality. Risk factors contributing to CLD include old age smoking status comorbid diseases cadaveric renal transplantation heavy immunosuppression and treatment of graft rejection.
AIM OF THE STUDY: Here are 8 cases of CLD post renal transplant at our centre from January 2021 till September 2023. The aim is to study clinical spectrum predisposing factors and outcomes.
METHODS: Sr.no. Age Sex HDV (month) Mode ATG T/T of rejection QIS comorbidities smoking DFT (months) etiology Treatment Outcome 1 27 Male 7 LRRT NIL Yes Yes None No 3 Klebsiella Cefoperazonesulbactum Resolution 2 26 Male 10 LRRT YES YesYes HTN No 6 Staph aureus vancomycin Resolution 3 40 Male 12 LRRT NIL No No HTN No 6 Aspergillus AMP B f/b voriconazole Death 4 42 Male 36 DDRT YES No No HTN no 5 Mucor AMP B f/b posaconazole Resolution 5 42 Male 36 LRRT YES No No PTDM HTN No 10 Mucor AMP B f/b posaconazole Resolution 6 41 Male 48 DDRT YES No No HTN yes 2 Aspergillus and TB ATT AMP B f/b voriconazole death 7 50 Female 24 DDRT YES No No HTN PTDM No 2 Mucor AMP B f/b Posaconazole Death 8 40 Male 30 DDRT YES No no HTN DM No 6 Aspergillus AMP B f/b voriconazole Resolution.
CONCLUSION: Infectious CLD is more common in first year post transplant. Despite development in immunosuppression and antibiotic therapy, CLD carries high morbidity and mortality. Key words- DFT- duration from transplant, HTN- hypertension, PTDM- post transplant DM, QIS- quadruple immunosuppression.
16TH DECEMBER 2023
ABSTRACT NO. 193
MANY FACES OF CNI TOXICITY
Tapabrata Das, Manish Chaturvedy 1 , Nitin Kumar Bajpai 1 , Rajesh Jhorawat 1 , Aasma Nalwa 2 , Vikrant Verma 2
Departments of 1 Nephrology and 2 Pathology; AIIMS; Jodhpur; Rajasthan; India
E-mail: tapabrata.3.das@gmail.com
BACKGROUND: Calcineurin inhibitors (CNI) are both the saviour and Achilles heel of kidney transplantation. Though CNI have significantly reduced rates of acute rejection their numerous toxicities can plague kidney transplant recipients. Here we present 3 cases with varied presentation of CNI toxicity.
AIM OF THE STUDY: Case1 27 year old male transplanted on November 2022 donor being his father presented with polyuria and increased serum creatinine. He was previously shifted to cyclosporin due to tacrolimus toxicity (trough level 27). Biopsy showed borderline TCMR with chronic CNI toxicity. He was treated for rejection and responded well.
METHODS: Case 2 31 year old male transplanted on December 2022 donor being his mother presented with significant polyuria hyponatremia hypomagnesemia and increased serum creatinine. Tacrolimus trough level was 17. Urine electrolytes confirmed salt losing nephropathy. Biopsy showed chronic CNI toxicity with TMA. He was shifted to everolimus based therapy after which serum creatinine and electrolyte parameters improved.
CONCLUSION: CNI use can lead to a wide variety of toxicities that may cause both acute and chronic renal parenchymal injury, electrolyte derangements, and association with rejection is also not infrequent due to CNI dose tapering or conversion to everolimus based therapy.
16TH DECEMBER 2023
ABSTRACT NO. 194
A SINGLE CENTER INVESTIGATION OF THE INITIAL HEMODIALYSIS VASCULAR ACCESS AND ITS RELATED FACTORS IN A TERTIARY CARE HOSPITAL IN GUWAHATI
Tanu Rekha Hazarika, Tonmoy Das, Mitul Bora, Pranab Kumar Medhi, Dhrubajyoti Choudhury
Department of Nephrology; Apollo Hospitals; Guwahati; Assam; India
E-mail: dr.tanurekha@gmail.com
BACKGROUND: As the prevalence of chronic kidney disease (CKD) has been rising steadily the increased incidence of end-stage renal disease (ESRD) has been recognized as a major public health problem worldwide. Hemodialysis (HD) continues to be the most prevalent modality of kidney replacement therapy for patients with ESRD in India. Vascular access use is an integral and important aspect of hemodialysis treatment. Two types of vascular accesses are most commonly used in hemodialysis: (1) autologous arteriovenous fistulas (AVF) that are formed from a patient endogenous vasculature and (2) a central venous catheter (CVC) which placed into a large vein. It is reasonable to have an AVF in patients requiring HD when consistent with their ESRD Life-Plan and overall goals of care in KDOQI Clinical Practice Guideline for Vascular Access 2019 Update.
AIM OF THE STUDY: To investigate the initial hemodialysis vascular access in a tertiary care Hospital in Guwahati and provide evidence for improving the use of autologous arteriovenous fistula by identifying factors associated with the choice of initial vascular access.
METHODS: We retrospectively studied the initial hemodialysis vascular access of 773 patients in hemodialysis unit in Guwahati during a 12-month period (August 2022 to July 2023). A logistic regression was used to identify the risk factors of failing to use an arteriovenous fistula at the initiation of hemodialysis.
CONCLUSION: The proportion of patients using arteriovenous fistula as the initial hemodialysis vascular access in Guwahati was still very low. The choice of vascular access for the first hemodialysis was related to age, eGFR, and the primary etiology of end-stage renal disease. Increasing the proportion of planned vascular access and arteriovenous fistula at the initiation of hemodialysis is still our current goal.
16TH DECEMBER 2023
ABSTRACT NO. 195
Comparison of critical quality attributes of various commercial products of FCM in India impacting safety and bioavailability.
Abhishek.T
Department of Vaccine Division, Dr Reddys laboratories
AIMS OF THE STUDY: To compare various critical quality attributes or critical bioequivalence parameters of Dr Reddy’s indigenously manufactured FCM (IRNY) with various other commercialized FCM preparations available in India and US FDA Reference listed drug - Injectafer.
METHODS: Dr Reddy’s laboratories quality and control team performed various laboratory tests using validated methodology to assess various critical quality attributes of indigenously manufactured (own manufactured) FCM and few other commercialized FCM preparations available in Indian market, which may have a significant impact on patient safety and bioavailability of the Iron. These parameters include carbohydrate content, molecular weight, surface charge, degradation kinetics by alpha amylase. We have compared these important quality attributes with the standards set by the USFDA for the reference listed drug (Injectafer).
RESULTS: Carbohydrate content: As per literature carbohydrate content (mg/mL) for Ferric carboxymaltose injection in Innovator Product is 75mg/mL (7.5%) for 50mg Iron/mL. So, optimum carbohydrate content with respect to Iron is required for efficacy and safety. Carbohydrate content of Dr.Reddy’s product is similar to US-RLD (Injectafer). The molecular weight is critical parameter for Bio-equivalence with reference product. Rate of iron release from iron core inversely related to molecular weight. This means, lower the molecular weight higher the iron release and vice versa. A high molecular weight may potentially lead to lower bioavailability, while Lower the molecular weight will lead to faster iron release, which may lead to toxic effects. Surface charge (zeta potential) - The zeta potential of Iron-complex colloid is Related to opsonization, MPS uptake, PK, and tissue distribution. In general negative zeta potential of particles leads to more uptake by RES system and hence may lead to saturation of transferrin. Degradation kinetics by Amylase - It is known from the literature that in human plasma, Ferric carboxymaltose is partially degraded/digested by alpha-amylase enzyme, which is internalized by macrophages through phagocytosis and complete shell degradation. The T75 i.e. time to partially degrade 75% of the total FCM given. If T75 is high, more time may be required to process the complex by macrophages and may lead to reduced bioavailability.
Conclusion: The major critical quality attributes of Dr Reddy’s FCM (IRNY) are comparable to US RLD (Injectafer).
16TH DECEMBER 2023
ABSTRACT NO. 196
OUTCOME OF LIVING RELATED DONOR KIDNEY TRANSPLANTATION IN PATIENTS WITH NEGATIVE CDC AND FLOW CROSS MATCH BUT POSITIVE LUMINEX DONOR-SPECIFIC HLA ANTIBODIES
V Krishna Priya, Chaitrali Gawde, Virendra Chauhan, Madhvi Dadwe, Hepal Vora, Zaheer Virani, Prashant Rajput, Shruti Tapiawala, Bharat V Shah
Nephrology; Global Hospitals, Mumbai; Maharashtra; India
E-mail: drvadlapatla92@gmail.com
BACKGROUND: In clinical practice one does come across situation where CDC and flow cross match is negative but luminex donor specific antibodies (DSA) is positive.
AIM OF THE STUDY: To describe outcome of kidney transplant in cases where CDC and flow cross match is negative and luminex DSA positive
METHODS: For all living related donor transplants we do CDC cross match flow cross match and panel reactive antibody (PRA). If PRA is positive we do luminex single antigen bead assay to look for DSA.
CONCLUSION: Our study shows that results of LRD transplant are good even when luminex DSA is positive if CDC and flow cross match are negative.
16TH DECEMBER 2023
ABSTRACT NO. 197
A CASE OF PIGMENT NEPHROPATHY IN A SUSPECTED CASE OF COMPLICATED MALARIA
Md Aftab Ansari, Amresh Krishna
Nephrology; Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India
E-mail: ansariaftab007@gmail.com
BACKGROUND: Malaria is a major world health problem. It is an endemic in Asia Africa and Latin America. Severe malaria can cause disease in glomeruli tubules and in the interstitium. Hemolysis is the second most common cause of pigment nephropathy. Heme proteins can cause AKI through decreased renal perfusion direct cytotoxicity and intratubular cast formation.
AIM OF THE STUDY: Our aim is to present an interesting case of 17years old male with no prior comorbidity presented with the complain of high grade intermittent fever with rigor for ten days with anemia and AKI. Although malarial antigen test was negative but patient responded with anti-malarial therapy.
METHODS: Lab investigation showed Hb-8gm/dl serum creatinine-22.30 mg/dl serum LDH- 690IU/L. kidney biopsy showed non-proliferative glomerular morphology. Tubular atrophy and interstitial fibrosis involve about 8-10% of sampled cortex. Diffuse severe acute tubular injury with presence of several coarse granular/ pigmented casts (positive in hemoglobin by IHC) in tubular lumina.
CONCLUSION: In the endemic areas of malaria, it is important to early diagnose and treat malaria even if malaria antigen test is negative but clinical features are suggestive of malaria.
16TH DECEMBER 2023
ABSTRACT NO. 198
HEPATORENAL SYNDROME IN A TERTIARY CARE CENTRE – A RETROSPECTIVE
Sarbabhaum Tripathy, Narayan Prasad, Samir Mohindra
Department of Nephrology and Gastroenterology; SGPGIMS; Lucknow; Uttar Pradesh; India
E-mail: sarbagmc.tripathy@gmail.com
BACKGROUND: Acute kidney injury (AKI) is one of the most serious complications in end-stage liver disease. Hepatorenal syndrome is one of the phenotypes of AKI that occurs in patients with advanced cirrhosis. Early diagnosis is central in the management and recent changes in the definition of hepatorenal syndrome help identify patients at an earlier stage.
AIM OF THE STUDY: This study was done with the aim to study the clinical profile and functional outcome of hepatorenal syndrome in a tertiary care centre.
METHODS: This is a retrospective observational study, conducted on patients admitted to Department of Gastroenterology and Nephrology in a tertiary care centre where prospectively stored electronic Data, physically recorded follow up data, was retrieved and analysed, in cases of AKI presenting in patients of chronic liver disease(CLD)and acute on chronic liver failure(ACLF).
CONCLUSION: The present study was designed to improve our knowledge and understanding of hepatorenal syndrome. Thus, the current study concluded that early detection and prompt initiation of Injection Albumin, Injection Terlipressin, and Tablet Midodrine treatment are pivotal for positive renal and patient outcomes in hepatorenal syndrome (HRS).
16TH DECEMBER 2023
ABSTRACT NO. 199
TRANSPLANTING VERY SMALL PEDIATRIC KIDNEYS INTO ADULTS - FIRST INDIAN REPORT
V Krishna Priya, Chaitrali Gawde, Virendra Chauhan, Madhvi Dadwe, Hepal Vora, Zaheer Virani, Prashant Rajput, Shruti Tapiawala, Bharat V Shah
Global Hospitals, Mumbai; Maharashtra; India
E-mail: drvadlapatla92@gmail.com
BACKGROUND: There is a large gap between the demand and availability of organs. On the other hand kidneys from very small pediatric donors are underutilized.
AIM OF THE STUDY: Describe outcome of 2 kidney transplants performed with very small pediatric donors.
METHODS: Case 1 - Dual en-bloc kidney transplant was performed from an 18 months old female child with brain-stem death due to head injury into a 43 years old male with ESRD due to diabetic nephropathy. Case 2 - Single kidney from a 3 years old male child weighing 10 kg brain dead due to severe traumatic head injury was transplanted into a 22 years old male.
CONCLUSION: The results of transplant with very small pediatric kidneys are good. With widening gap between need and availability of kidneys, pediatric kidneys from very small donors should be accepted for transplant. This is the first Indian report of transplanting single kidney from a very small pediatric donor.
16TH DECEMBER 2023
ABSTRACT NO. 200
POST TRANSPLANT TMA SECONDARY TO IGAN
K Rachana Shenoy, D S Bhadauria, Monika Yachha
Department of Nephrology; SGPGIMS; Lucknow; Uttar Pradesh; India
E-mail: rachanashenoy.k@gmail.com
BACKGROUND: Thrombotic microangiopathy (TMA) in renal allograft recipients is most attributed to calcineurin inhibitor toxicity. Other possible etiologies include antibody-mediated rejection (ABMR) infections including viruses like CMV BKV Parvo B19 Hepatitis C; other drugs like mTOR inhibitors ischemia-reperfusion injury and pregnancy. Incidence is about 5-15% across studies. TMA in the post-transplant setting can be either recurrent or de novo. De novo TMA is more common and has worse prognosis. A retrospective study of TMA in 958 renal allograft biopsies where clinical and histopathological features were correlated showed that de novo TMA occurred in 6.1% of patients with C4d positivity in 55%. The most common cause of TMA was ABMR in this population with glomerulitis and peritubular capillaritis being significantly more prominent when compared to non-ABMR related TMA. A 5-year single centre study of 1520 renal allograft biopsies of TMA from South Asia revealed 61 graft-limited TMA (4.1%) with most common etiology being ABMR.
AIM OF THE STUDY: We report a case of post-transplant TMA secondary to recurrence of IgA nephropathy (IgAN).
METHODS: A 28-year old female diagnosed with IgA nephropathy in 2013 underwent ABO-compatible living donor kidney transplantation with her mother as donor in 2015. She received no induction and had excellent graft function. She was continued on triple immunosuppression with Tacrolimus Mycophenolate mofetil and Prednisolone; along with Amlodipine for hypertension. She had an uneventful period after renal transplantation surgery up until current event. Her antimetabolite drug was changed to Azathioprine in February 2021 for a planned pregnancy in the future. She had a natural conception in December 2021. She had a normal antenatal period with no evidence of proteinuria or worsening graft function. Therapeutic drug monitoring was done frequently and CNI dosages were optimized accordingly. She underwent emergency lower segment Caesarean section at 33+ weeks in view of fetal distress and worsening graft function. At discharge from the maternity ward her Creatinine was 1.6mg/dL with optimal Tacrolimus trough levels. 3 months following delivery she presented to Ophthalmology OPD with sudden onset blurring of vision and severe headache of 2 days duration. On examination she had blood pressure of 240/140mmHg bilateral papilledema and Grade IV hypertensive retinopathy on fundus examination. Work up revealed Creatinine- 5.3mg/dL thrombocytopenia (Platelet count- 40 000/mm3) anemia (Hemoglobin- 8.4g/dL) raised lactate dehydrogenase. In view of advanced graft dysfunction and oliguria she was started on intravenous Methyl Prednisolone 500mg daily for 3 doses. Her platelet count improved after 2 days. She underwent graft kidney biopsy which revealed changes of TMA with IgAN
CONCLUSION: TMA in the renal allograft is a challenging disease to treat, by virtue of its severity and various etiologies. Early syndromic recognition and necessary intervention may help to save the renal allograft.
16TH DECEMBER 2023
ABSTRACT NO. 201
PYREXIA OF UNKNOWN ORIGIN (PUO) DUE TO MYCOBACTERIUM ABSCESSUS IN A PATIENT OF END STAGE RENAL DISEASE (ESRD) ON DIALYSIS
Parineeta Singhal, Vivek Goel, Anurag Gupta, Vaibhav Tiwari, Vinant Bhargava, Manish Malik, Ashwani Gupta, Anil Kumar Bhalla, D S Rana
Apollo Multispeciality Hospitals; Kolkata; West Bengal; and Sir Gangaram Hospital; New Delhi; India
E-mail: parineeta.singhal@gmail.com
BACKGROUND: Mycobacterium abscessus. fortuitumand. chelonae are considered clinically the most relevant rapidly growing nontuberculous mycobacteria (RGM). They ubiquitously exist in the environment including water soil and dust and can sustain and extreme conditions. M. abscessus is the most pathogenic of the RGM group and commonly causes pulmonary infection primarily in patients with underlying lung disease. 1 Blood stream infections are commonly caused by M. fortuitum and M. chelonae and rarely by M. abscessus. 2 M. abscessus strains may be responsible for infecting other sites like lymph node skin and soft tissue surgical site and prosthetic device in immunocompetent and immunocompromised hosts. 3 We report a case of PUO caused by M. abscessus in an ESRD patient on maintenance hemodialysis.
AIM OF THE STUDY: This report the first observation of a cavitary pulmonary infection with M. abscessus diagnosed through blood culture in a hemodialysis patient and highlight the importance of species identification in case of Mycobacterium infections.
METHODS: A 33-year-old female patient was a known case of hypertension chronic kidney disease on maintenance hemodialysis via tunnelled catheter for 5 months. She presented with complaints of low-grade intermittent fever for 2 months and cough with mucoid expectoration for 25 days. Sputum was positive for acid-fast bacilli (AFB) and she was started on Anti-tubercular therapy (ATT). Despite the therapy she remained febrile and had a bout of hemoptysis around 10 ml a few days later. Routine investigations revealed anemia and raised ESR. Echocardiogram demonstrated no evidence of vegetation. Repeat sputum smear for AFB was again positive but GeneXpert was negative. Blood cultures were sent from both peripheral and central sites and cultured using BacT/Alert Virtuo automated blood culture system. Blood Culture from both the sites signaled positive in 3.6 and 3.8 days respectively. Gram-stained smear of blood culture broth revealed Gram positive beaded bacilli so Ziehl Neelsen was also done which showed the presence of acid-fast bacilli (AFB) [Figure 2]. Growth of AFB was also obtained on sub-culture on Blood agar Mc Conkey agar and Lowenstein Jensen medium (LJ medium).
CONCLUSION: A 33-year-old female patient was a known case of hypertension chronic kidney disease on maintenance hemodialysis via tunnelled catheter for 5 months. She presented with complaints of low-grade intermittent fever for 2 months and cough with mucoid expectoration for 25 days. Sputum was positive for acid-fast bacilli (AFB) and she was started on Anti-tubercular therapy (ATT). Despite the therapy she remained febrile and had a bout of hemoptysis around 10 ml a few days later. Routine investigations revealed anemia and raised ESR. Echocardiogram demonstrated no evidence of vegetation. CT chest [Figure 1] showed thick-walled cavitating lesion with some surrounding areas of atelectasis and consolidation in the right lower lobe along with a few subcentimeter sized mediastinal nodes. Repeat sputum smear for AFB was again positive but GeneXpert was negative. Blood cultures were sent from both peripheral and central sites and cultured using BacT/Alert Virtuo automated blood culture system. Blood Culture from both the sites signaled positive in 3.6 and 3.8 days respectively. Gram-stained smear of blood culture broth revealed Gram positive beaded bacilli so Ziehl Neelsen was also done which showed the presence of acid-fast bacilli (AFB) - Fig 2. Growth of AFB was also obtained on sub-culture on Blood agar Mc Conkey agar and Lowenstein Jensen medium (LJ medium).
16TH DECEMBER 2023
ABSTRACT NO. 202
TRIPLE A SYNDROME AND THE SILENT BATTLE WITHIN: A RARE CASE REPORT OF END-STAGE RENAL DISEASE
Parineeta Singhal, Vivek Goel, Veronica Arora
Department of Nephrology; Apollo Multispeciality Hospitals; Kolkata; West Bengal; India
E-mail: parineeta.singhal@gmail.com
BACKGROUND: Allgrove syndrome or triple A (3A) syndrome is a multisystem disorder which classically involves the triad of esophageal achalasia alacrima and adrenal insufficiency due to adrenocorticotropin hormone insensitivity. Triple-A is an inherited condition caused by mutations in the gene and is inherited in an autosomal recessive pattern. While the complete triad is present in approximately 70% of patients 2 dysfunction of the autonomic nervous system is also seen in about one-third of the patients 3 leading some authors to use the term 4A syndrome (achalasia alacrima adrenal insufficiency and autonomic abnormalities).4. Since its first description in 1978 the knowledge on clinical and genetic characteristics has been expanding; however the current literature is limited to case reports and case reviews. Early recognition of the syndrome is challenging given the rarity of the condition and high phenotypic heterogeneity even among members of kin. Aside from the classic features of the syndrome several abnormalities including mainly neurological abnormalities have been reported in the syndrome. Herein we presented a case of Allgrove syndrome associated with end stage renal disease. To the best of our knowledge and extensive review of literature renal abnormality specifically end stage renal disease in Allgrove syndrome has not been reported until now.
AIM OF THE STUDY: We aim to report a rare association between Triple A syndrome and end stage renal disease which has not been described in literature until now and highlight the need for a high index of suspicion and early genetic testing even when one out the 3 classical features of triple A Syndrome are present.
METHODS: A detailed history was taken followed by a thorough physical examination laboratory investigations and genetic testing. This study presents the case of a 26-year-old male patient with chronic interstitial nephritis (CIN) who was admitted for prospective renal transplant surgery with his mother as the donor. The patient had a previous diagnosis of Addison’s disease which was initiated when he was 2½ years old and he was started on prednisolone 5 mg once a day. Â He then had normal blood pressure and renal function. The patient’s elder brother also deceased at a young age due to Addison’s disease. Recent symptoms of anorexia nausea and generalized weakness led to further investigations. The patient denied any history of swelling hematuria frothy urine or decreased urine output. Examination revealed; intact higher mental function but slurred speech (velopharyngeal insufficiency). He also had bilateral arachnodactyly camptodactyly pes cavus and generalized muscle wasting. Investigations revealed hemoglobin 5.5 g/dl creatinine 6.7 mg/dl and bilateral small kidneys on USG.
CONCLUSION: Triple-A syndrome is a rare autosomal recessive disorder characterized by alacrimia, achalasia, and adrenal failure. A high degree of suspicion enables all the components of this syndrome to be searched for, as early diagnosis can reduce morbidity and mortality. It occurs due to a mutation in the AAAS gene on chromosome 12q13 which codes for ALADIN protein. This mutated product protein fails to localize nuclear pore complexes which form a selective channel between cytoplasm and nucleus and so it remains mostly in cytoplasm. Its exact prevalence is unknown as case reports are a rarity. It usually manifests in the first decade of life. Alacrimia is the earliest and most consistent finding. Adrenal failure due to ACTH resistance is the second component. It occurs owing to progressive adrenal destruction at a variable time after birth, but usually in the first decade of life and may produce hypoglycaemic seizures and shock. Mineralocorticoid deficiency occurs in only 15% of cases. Our case reported a young male with a past and family history of Addison disease. While achalasia and adrenal insufficiency appear later during childhood or adulthood, some patients may also present with the so-called Double-A syndrome (i.e., alacrimia and achalasia, or alacrimia and adrenal insufficiency). Our patient did not have symptoms of alacrimia and dysphagia, nor could he be tested for the same. The patient’s genetic testing was done on a high degree of suspicion which was positive for the triple-A syndrome. Cases with the triple-A syndrome were reviewed based upon their presenting symptoms. No literature to the best of our knowledge could be found showing association of triple-A syndrome with end-stage renal disease or renal transplant. Triple-A syndrome should be considered in patients who exhibit only one or two of the main symptoms (i.e., alacrimia, achalasia, or adrenal insufficiency) as early diagnosis is important since Triple-A is a progressive disease.
16TH DECEMBER 2023
ABSTRACT NO. 203
UNILATERAL DIFFUSE ALVEOLAR HEMORRHAGE AS THE INITIAL PRESENTATION WITH MICROSCOPIC POLYANGITIS AND RPGN: A RARE CASE REPORT
Prabhat Kumar Mallick, Tapas Ranjan Behera, Biswajit Mishra, Bishwaranjan Mohanty
Department of Nephrology; Institute of Medical Sciences and SUM Hospital; Bhubaneswar; Odisha; India
E-mail: mallick.prabhat79@gmail.com
BACKGROUND: ANCA-associated vasculitis is an inflammatory disease of small blood vessels. Patients with vasculitis in the kidney may have normal function or mild-moderately reduced renal function or complete renal failure. Early diagnosis and initiation of effective treatment will lead to a better outcome. We report here on patient with RPGN with unilateral diffuse alveolar hemorrhage (UDAH). She was successfully managed with plasmapheresis and hemodialysis along with immunosuppressant.
AIM OF THE STUDY: REPORTING OF A RARE CASE - A 23 year girl presented to outpatient department with complains of cough with hemoptysisdyspnea and increasing paleness of body for 5 days. The patient is not a case of hypertension/diabetes mellitus/asthma/hypothyroidism or with no significant past medical history. On initial evaluation blood pressure was -160/100 mmhg respiratory rate-24/min temperature-36.50C and saturation was 96%. Initial laboratory findings were as follows: low hemoglobin (8.2 gm%) leukocyte count -16 570 (neutrophil-85%) creatinine-7.95 mg/dl. The urine dipstick showed proteinuria 3+ hematuria-2+ microscopy shows RBC 119/Hpf. chest radiography shows unilateral infiltration [Figure 1] and computed tomography (CT) shows unilateral diffuse opacities in entire lungs field [Figure 2]. Radiography of paranasal sinuses excluded sinusitis. After 1 day of hospitalization patient developed respiratory distress with falling Spo2 (84%) and shifted to intensive care and started with NIV oxygen@ 5L/min then intubated as oxygen requirement increases. Bronchoalveolar lavage was done. BAL fluid analysis shows hemosiderin laiden macrophages in a fibrino-hemorrhagic background with many pus cells & moderate no of gram negative bacilli and negative for malignant cells and fungal elements. BAL fluid culture shows no growth. Antineutrophilic cytoplasmic antibody (ANCA) examination revealed P-ANCA (MPO)-positive with titer 63.91 RU/ml and C-ANCA is negative with titer 4.87 RU/ml. Antiglomerular basement membrane antibody (Anti-GBM) and antineutrophilic antibody (ANA) profile is negative. Renal sonogram reveals both side kidneys normal size mildly increased parenchyma echogenicity with well maintained CMD. Renal biopsy planned to rule out glomerulonephritis. As urine output further decreased plasmapheresis started alternating with hemodialysis. Methyl prednisolone 1gram/day IV was given for 3 days and tapered. After 7 days of intensive care patient transferred to wara and renal biopsy done which showed burnt out cresenticglomerulonephritis.out of 16 glomeruli 12 are globally sclerosed and 4 showed partial sclerosis with fibrocellularcresents. IFTA 40-50% Immunofluorescence is inconclusive. Europian Union Vasculitis Protocol (EUVAS) started Left brachioradial atriovenous fistula done and patient advised to do regular twice weekly hemodialysis. The patient provided written informed consent taken and ethical approval was not necessary for this case.
METHODS: It is a case report prepared for poster presentation.
CONCLUSION: As illustrated by this case diffuse alveolar hemorrhage is a life threatening condition that requires rapid evaluation and management. Early diagnosis and initiation of effective treatment will lead to better outcome.
16TH DECEMBER 2023
ABSTRACT NO. 204
RENAL HYPOURICEMIA WITH EXERCISE INDUCED ACUTE KIDNEY INJURY-A CASE REPORT
Yogesh Kumar Gaur, Mulpuru Venkateshwar Rao, Srikanth Gundlapalli, Sujeeth Bande Reddy
Asian Institute of Nephrology and Urology; Hyderabad; Telangana; India
E-mail: dryogeshnephro@gmail.com
BACKGROUND: Exercise induced AKI.
AIM OF THE STUDY: Renal Hypouricemia with Exercise Induced Acute Kidney Injury-A Case Report.
METHODS: CASE REPORT.
CONCLUSION: Although liver transplantation is the definitive treatment, this case has shown that plasmapheresis can be a therapeutic option or has a promising role as a bridge to recovery in acute liver failure due to rat killer poisoning (yellow phosphorous). This is supported by the fact that there is a significant improvement in liver function and coagulation parameters post plasmapheresis.
16TH DECEMBER 2023
ABSTRACT NO. 205
FIBRILLARY GLOMERULONEPHRITIS - A CASE REPORT ON RARE KIDNEY DISEASE
Md Aftab Ansari, Amresh Krishna
Department of Nephrology; Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India
E-mail: ansariaftab007@gmail.com
BACKGROUND: Fibrillary glomerulonephritis is a rare disease characterized by presence of deposits of randomly oriented microfiber (16-24 nm size) in the glomeruli.
AIM OF THE STUDY: Our aim is to report a case of 32 years old female with no prior comorbidity presented with nephrotic syndrome with renal dysfunction.
METHODS: Lab investigation showed - s.creatinine-3.31mg/dl s.albumin-1 g/dl U PCR-6.9 g/g ANA-Negative Complement C3 & C4 - 24 hour urinary protein - 3.65 g/day Ultrasonography showed normal size kidney. Renal biopsy was performed.
CONCLUSION: Fibrillary GN is rare disease diagnosed with help of electron microscope.
16TH DECEMBER 2023
ABSTRACT NO. 206
PLASMAPHERESIS IN YELLOW PHOSPHORUS POISONING: A SCOPE FOR RECOVERY
Nidila Mohan, M K Mohandas, Sebastian Abraham, Krishna Suresh, R Unnikrishnan, Binoj Panekkattil
Department of Nephrology; Government Medical College; Kottayam; Kerala; India
E-mail: nidilamohan@gmail.com
BACKGROUND: Rodenticide poisoning is being increasingly recognized as a cause of acute liver failure in Indian subcontinent especially southern parts. The only definitive management in a patient who develops ALF due to rodenticide poisoning is urgent liver transplantation. In a resource limited setting focus is to maximize patient survival with non transplant modalities. Here we describe a case of 22 years old male with acute liver failure following consumption of rodenticide containing yellow phosphorous who was treated with plasmapheresis sequence of clinical recovery and trends in biochemical parameters.
AIM OF THE STUDY: Case report.
METHODS: Case report.
CONCLUSION: Although liver transplantation is the definitive treatment, this case has shown that plasmapheresis can be a therapeutic option or has a promising role as a bridge to recovery in acute liver failure due to rat killer poisoning (yellow phosphorous). This is supported by the fact that there is a significant improvement in liver function and coagulation parameters post plasmapheresis.
16TH DECEMBER 2023
ABSTRACT NO. 207
ACID TEST FOR THE EYE
Nikhil Elenjickal, Dilip Rangarajan, S Ramakrishnan, Ramprasad Ramalingam
Department of Nephrology; NU Hospitals; Bengaluru; Karnataka; India
E-mail: drnikhiljohn@gmail.com
BACKGROUND: Severe metabolic acidosis secondary to metformin use portends a poor prognosis. It carries a mortality rate of 25-30%. Sudden onset vision loss as a complication of severe metabolic acidosis has been rarely reported. Such patients may benefit with early initiation of renal replacement therapy to correct the acid base disturbances and improve the vision. We report such a case wherein a 68 year old gentleman diabetic on metformin presented to us with renal failure and severe metabolic acidosis. He was initiated on renal replacement therapy; however he had sudden onset bilateral painless vision loss. He was given additional sessions of dialysis with which his metabolic acidosis corrected and his vision improved.
AIM OF THE STUDY: To report a rare symptom of metformin associated lactic acidosis- sudden onset painless vision loss.
METHODS: A 68 year old male known diabetic on metformin glibenclamide and sitagliptin non hypertensive had recent history of travel to Tanzania. Had done trekking there followed by severe pain along the lower limbs. No history insect bite. Came back to India. Subsequently developed worsening of lower limb pain vomiting and anuria. He had taken Diclofenac for the pain. He was hospitalized at our centre. Found to have severe renal dysfunction serum creatinine -13.3 mg/dl (0.84 mg/dl in July 2022). And low serum bicarbonate 7.5 mmol/l. He was initiated on dialysis via temporary Right internal jugular hemodialysis catheter. On 2nd day after dialysis he had sudden onset complete painless loss of vision in both the eyes. Pupils were sluggishly reacting to light and visual acuity reduced to counting fingers at ½ metre. His fundus was examined and it was normal with no signs of diabetic retinopathy nor hemorrhage. His ABG was done showed severe metabolic acidosis- pH 6.72 HCO3-1.9 mmol/l PCO2 14.3 and lactate 18.12. He did not have any focal neurological deficit. An ophthalmologist opinion was taken and he was advised for MRI brain +Orbit. He was shifted to the ICU required temporary vasopressor support and was dialysed. His vision showed recovery by evening of the same day. He showed gradual and steady recovery. Vasopressors were tapered off. Echocardiography showed EF 62% with no RWMA. Urine Myoglobin was positive. CPK was raised- 2485 U/l. Urinanalysis showed protein ++ wbcs 4-6 rbcs 6-8/hpf. USG abdomen was normal with no obstruction.
CONCLUSION: Severe metabolic acidosis causing vision loss is rare. A high index of suspicion should be kept for patients presenting with this constellation of signs. Such patients, wherein blindness is not attributable to any other obvious cause, should be initiated on early dialysis to correct the acidosis.
16TH DECEMBER 2023
ABSTRACT NO. 208
CLINICAL SIGNIFICANCE OF PRESENCE OF IGM DEPOSITS IN PATIENTS WITH IGA NEPHROPATHY
J J Jeeja, R Ram, V Siva Kumar, Lakshmi Aishwarya, Surya Prakash, Namesh Kamat, Prasanna Kumar, Mathini, Saktivel
Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India
E-mail: jeeja87here@gmail.com
BACKGROUND: IgA nephropathy is one of the most common causes of primary glomerulonephritis. 50% of the patients with IgA nephropathy slowly progress to ESRD over 30 years. The presence of IgM in IgA nephropathy is associated with poor renal outcome - progression of serum creatinine increased proteinuria and ultimately ESRD.
AIM OF THE STUDY: To study the clinical significance of IgM deposition in IgA nephropathy.
METHODS: This is a retrospective study of patients with IgA nephropathy. Patients with IgA nephropathy diagnosed from 2014 to 2021 were enrolled. There were 62 patients. They were divided into two groups based on the IgM deposition in the biopsy. Both the groups were comparable in terms of demographic clinical and pathological variables at baseline and follow-up. They were followed up for 2 to 6 years.
CONCLUSION: In our patients of IgA nephropathy, the presence of IgM in biopsy was associated with increased serum creatinine and poor prognosis.
16TH DECEMBER 2023
ABSTRACT NO. 209
A STUDY ON THE FACTORS AFFECTING OUTCOMES OF FOCAL SEGMENTAL GLOMERULOSCLEROSIS AND THE IMPORTANCE OF GENETIC DIAGNOSTICS IN PREDICTING OUTCOMES
Kajaree Giri, Manisha Sahay, Kiranmai Ismal
Department of Nephrology; Osmania Medical College and Hospital; Hyderabad; Telangana; India
E-mail: kajaree.giri92@gmail.com
BACKGROUND: Focal segmental glomerulosclerosis (FSGS) is a histologic lesion rather than a specific disease entity primarily affecting podocytes. It manifests clinically by persistent nephrotic syndrome non-selective proteinuria microscopic hematuria hypertension and renal insufficiency at presentation. FSGS is commonly termed primary or secondary. Primary FSGS is caused by a primary podocytopathy while secondary FSGS denotes the development of FSGS lesion as an adaptive phenomenon secondary to reduction in nephron mass due to genetic cause drug toxicity or viral infections. The clinical course of primary FSGS varies and factors such as age of onset proteinuria at onset plasma creatinine at biopsy duration of treatment of corticosteroids genetics histopathologic subtype extent of TGF-B1 expression in biopsy are important prognostic factors in determining the outcome of the disease. Furthermore genetic analysis in FSGS patients have far reaching consequences. It is an increasingly important diagnostic tool in nephrology with advances in genetic testing methods. Genetic causes of FSGS are often overlooked in India due to financial constraints. Yet diagnosing genetic FSGS not only have implications for prognostication therapy transplantation but also for family and family planning. There are very few studies in India on factors affecting FSGS and the importance of genetic screening. There are no clinical or histopathological findings to distinguish genetic FSGS from other types. However there are several hallmarks of genetic disease a positive family history early age at disease onset severe/ steroid resistant disease. Over 50 genes responsible for FSGS have been identified. Few of them are 1. Slit diaphragm proteins- NPHS1 NPHS2 2. Cell membrane associated proteins - TRPC6 LAMB2 LMX1B 3. Cytosolic or cytoskeletal proteins- ACTN4 PLCE1 4. Nuclear proteins- WT1 5. Mitochondrial components- COQ2 COQ6 6. Lysosomal proteins- SCARB 2 Genetic FSGS usually does not respond to immunosuppression treatment. ACE inhibition is beneficial in COL4A related disease. Furthermore in case of a living related transplantation it is safest to have a genetically unaffected family member as donor. At risk family members should be advised pre-symptomatic evaluation of renal function. Likewise advanced techniques such as pre-implantation genetic diagnosis can be used to prevent the inheritance of the disease to the future children of a genetic FSGS patient.
AIM OF THE STUDY: Focal segmental glomerulosclerosis (FSGS) is a histologic lesion rather than a specific disease entity primarily affecting podocytes. It manifests clinically by persistent nephrotic syndrome non-selective proteinuria microscopic hematuria hypertension and renal insufficiency at presentation. FSGS is commonly termed primary or secondary. Primary FSGS is caused by a primary podocytopathy while secondary FSGS denotes the development of FSGS lesion as an adaptive phenomenon secondary to reduction in nephron mass due to genetic cause drug toxicity or viral infections. The clinical course of primary FSGS varies and factors such as age of onset proteinuria at onset plasma creatinine at biopsy duration of treatment of corticosteroids genetics histopathologic subtype extent of TGF-B1 expression in biopsy are important prognostic factors in determining the outcome of the disease. Furthermore genetic analysis in FSGS patients have far reaching consequences. It is an increasingly important diagnostic tool in nephrology with advances in genetic testing methods. Genetic causes of FSGS are often overlooked in India due to financial constraints. Yet diagnosing genetic FSGS not only have implications for prognostication therapy transplantation but also for family and family planning. There are very few studies in India on factors affecting FSGS and the importance of genetic screening. There are no clinical or histopathological findings to distinguish genetic FSGS from other types. However there are several hallmarks of genetic disease a positive family history early age at disease onset severe/ steroid resistant disease. Over 50 genes responsible for FSGS have been identified. Few of them are 1. Slit diaphragm proteins- NPHS1 NPHS2 2. Cell membrane associated proteins- TRPC6 LAMB2 LMX1B 3. Cytosolic or cytoskeletal proteins- ACTN4 PLCE1 4. Nuclear proteins- WT1 5. Mitochondrial components- COQ2 COQ6 6. Lysosomal proteins- SCARB 2 Genetic FSGS usually does not respond to immunosuppression treatment. ACE inhibition is beneficial in COL4A related disease. Furthermore in case of a living related transplantation it is safest to have a genetically unaffected family member as donor. At risk family members should be advised pre-symptomatic evaluation of renal function. Likewise advanced techniques such as pre-implantation genetic diagnosis can be used to prevent the inheritance of the disease to the future children of a genetic FSGS patient.
METHODS: Study Design: Hospital based investigator initiated observational longitudinal study Study Subjects: 50 patients with biopsy proven FSGS Period of Study: From January 2021 till December 2022; patients having minimum follow up of 3 months were included Study Area: Tertiary care hospital Telangana Ethical clearance: Study was approved by Institutional Ethics committee (Regd No. 20602001002D) Inclusion Criteria: All patients with biopsy proven FSGS Exclusion Criteria: Patients not willing to give informed consent secondary FSGS Patient selection: This was a prospective analysis of patients who had presented to our center from January 2021 to December 2022 and had FSGS on kidney biopsy. A review of the medical records identified 87 patients who were diagnosed with primary FSGS secondary causes like reflux nephropathy human immunodeficiency virus (HIV) infection solitary kidney were excluded. 37 patients were excluded due to the following causes - follow-up duration < 6 months (n = 24) inadequate number of glomeruli < 5 (n = 5) not giving consent (n = 4) and secondary FSGS (n = 4). A structured questionnaire was used for data collection. It included details of socio demography clinical investigations histopathology treatment and course of the disease. Patients having any of the following indications were advised for genetic testing: presence of congenital/infantile onset of nephrotic syndrome presence of syndromic or extra renal features steroid resistant nephrotic syndrome or presence of positive family history. Next generation sequencing of nephrotic syndrome gene panel was done and the variants were classified as per American College of Medical Genetics (ACMG) classification. Study end points: All patients were treated as per KDIGO 2021 guidelines and followed up two weekly till attainment of remission thereafter monthly. Outcome was assessed at the end of one year. Primary outcomes were: attainment of remission (complete remission CR/partial remission PR) relapses doubling of baseline serum creatinine concentration (D-sCr) or onset of ESRD. Statistical analysis: STATA MP/16.1 (College Station Tx) was used for all statistical analysis. The patient consent was taken for participation in the study and for publication of clinical details.
CONCLUSION: In conclusion, this study showed that prolonged treatment with corticosteroids increases the chances of a remission and preserves renal function in nephrotic patients with FSGS. The chance of remission may be increased with the addition of cyclophosphamide and, particularly, with the prolonged use of low dose tacrolimus. Persistent nephrotic syndrome and advanced renal insufficiency at presentation are associated with poor prognosis. Treatment should be initiated as early as possible since active lesions on renal biopsy are more likely to be associated with a favorable response to treatment. None of the histological features on renal biopsy were independently significant as predictors of ESRD. The severity of interstitial fibrosis is the only predictor of response to the therapy. The present study might help illuminate common clinical features of FSGS with a rare frequency of cellular and collapsing variants in the South Indian population. However, since present study included small number of patients, further studies with a larger sample size are required to delineate long-term outcome and response to treatment of the pathologic variants. The present study also identified the spectrum of genetic mutations in the FSGS patients from India, as 62% of patients in our study cohort had positive mutations (VUS 80%, pathogenic 16%, likely pathogenic 4%). Further studies with long term follow up are required to follow these patients to know the course of their diseases. Strength: This was the only study from India to assess both renal outcomes and next generation sequencing of FSGS patients to the best of my knowledge. All patients included in the study underwent genetic screening. Limitations: A small number of patients with cellular and collapsing variants could not render statistically significant data. Electron microscopy reports were unavailable due to economic constraints which would have helped us to interpret the histological variants better. Finally, segregation analysis of the parents of the patients affected with VUS mutations could not be done, which could have helped us to better analyse their genetic profiles.
16TH DECEMBER 2023
ABSTRACT NO. 210
INFECTIOUS COMPLICATIONS AMONG RENAL TRANSPLANT RECIPIENTS RECEIVING EARLY OR LATE PULSE STEROID THERAPY: EXPERIENCE FROM A SUPER SPECIALITY CARE CENTRE IN INDIA
Shuvam Roy, Anupma Kaul, Narayan Prasad, Dharmendra Bhadhuria, Manas Patel, Manas Behera, Ravi Shankar Kushwaha, Monica Yaccha
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: royshuvam90@gmail.com
BACKGROUND: Renal transplant recipients are at risk for infectious complications with opportunistic infections predominating early after transplant and community acquired infections occurring in late transplant period. Pulse steroid is a form of heightened immunosuppression given to a transplant recipient usually for treatment of rejection.
AIM OF THE STUDY: This study aimed to investigate the effects of early and late pulse steroid therapy on the development of infectious complications in renal transplant recipients.
METHODS: Study population was drawn from patients undergoing kidney transplantation in the period between 1st January 2016 and 31st December 2020 in the study centre. Early and late pulse steroid therapy was defined based on whether pulse steroid was received within or after 90 days from date of transplant respectively. Patients receiving either early or late (but not both) pulse steroids who were more than or equal to 18 years of age and had at least 90 days of follow up were included in the study. Patients were followed up till 31st December 2021 or till their death (whichever came earlier).
CONCLUSION: Late pulse steroid therapy is associated with more episodes of sepsis and viral infections compared to early pulse steroid therapy, although rate of overall infections do not significantly differ between the two groups. This study highlights the importance of surveillance for infections after pulse steroid therapy in renal allograft recipients.
16TH DECEMBER 2023
ABSTRACT NO. 211
MYCOBACTERIUM LEPRAE AS A CAUSE OF INFECTION-RELATED GLOMERULONEPHRITIS
V Sakthivel, S Mathini, N Prasanna Kumar, N Krishna Priya, T Navya, G Srilakshmi, P Aishwarya Lakshmi, R Ram, V Siva Kumar
Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India
E-mail: drsakthivelvenu@gmail.com
BACKGROUND: Adult infection-related glomerulonephritis (IRGN) is associated with a wider spectrum of non-streptococcal agents. Hansen’s disease with lepra reaction presenting with IgA dominant infection- glomerulonephritis was reported but not Mycobacterium leprae as a cause of IRGN. There are no similar reports of mycobacterium lepra resulting in Infection related glomerulonephritis. Hence this case is being reported.
AIM OF THE STUDY: To report a case of Mycobacterium Leprae As a Cause Of Infection-Related Glomerulonephritis.
METHODS: A 61-year-old man with no diabetes or hypertension presented with 10 days of breathlessness and anasarca. He also complained of abdominal distension nausea and anorexia. He also complained of oliguria for one-week duration. There were no complaints of dysuria haematuria and pyuria. He complained of a non-healing ulcer on the sole of his right foot for a one-year duration. The patient had admitted on probing paraesthesia of both lower limbs and slippage of footwear of one-year duration. No history of epistaxis. On examination blood pressure was 140/90 mm Hg oedematous with a trophic ulcer of 1x1 cm on the plantar aspect of the right foot and reduced touch and pain in the lower one-third of both lower limbs. The bilateral ulnar nerves lateral popliteal nerves and posterior tibial nerves were thickened and tender. Blood investigations renal biopsy skin biopsy were done which were suggestive of mycobacterium leprae causing infection related glomerulonephritis.
CONCLUSION: Adult infection-related glomerulonephritis (IRGN) is associated with a wider spectrum of non-streptococcal agents. The organisms reported include staphylococcus and Gram-negative organisms like Klebseilla pneumonia, Pseudomonas and Acinetobacter. The list could never be exhaustive. However, Hansen’s disease with lepra reaction presenting with IgA dominant infection- glomerulonephritis was reported, but not Mycobacterium leprae as a cause of IRGN. There are no similar reports of mycobacterium lepra resulting in Infection related glomerulonephritis.
16TH DECEMBER 2023
ABSTRACT NO. 212
ANALYSIS OF REVISITS TO THE EMERGENCY ROOM WITHIN 72 HOURS- A RETROSPECTIVE OBSERVATIONAL STUDY
Nikhil Elenjickal, Dilip Rangarajan, S Ramakrishnan, Ramprasad Ramalingam, Basil C Unni
Department of Nephrology; NU Hospitals; Bengaluru; Karnataka; India
E-mail: drnikhiljohn@gmail.com
BACKGROUND: Emergency room revisits are a cause for concern as it reflects the quality of treatment provided and the adequacy of care provided. Analyzing the root cause for revisits can help mitigate patient morbidity help deliver better medical care to the patient reduce financial burden on the patient and improve patient safety. This study helps to identify the causes for revisit of patients improve upon the lacunae and improve the quality of health care.
AIM OF THE STUDY: To analyze the causes for revisits to the emergency room of NU Hospital Bengaluru within 72 hours of primary visit.
METHODS: Details of patients who had an unplanned revisit to the emergency room (ER) from Jan 2021 - July 2023 were recorded and accessed via scanned MRD records on the hospital’s electronic database (HMIS). Demographic characteristics such as age gender comorbid conditions reason for primary visit and subsequent revisits to ER were noted. Patients brought dead or admitted after the 1st ER visit (with no possibility of revisit) planned revisits of patients to the ER urology patients were excluded from the study. Causes for Revisits were analysed and grouped under 3 categories: Patient related- non-compliance Physician related- assessment investigations diagnosis discharge plan - Illness related- progression of disease failure of standard treatment treatment related side effects Descriptive statistics were used for analysis.
CONCLUSION: In this study, patient related factors accounted for majority of the revisits to the ER. This was followed by illness and physician related factors. The most common complaints were fever and breathlessness. These symptoms should be considered as high risk for risk for revisits. Physician misdiagnosis/under diagnosis should be minimized by incorporating thorough evaluation of the patient at the primary visit itself. This will not only help to reduce the morbidity, but also reduce the financial burden on the patient and thereby avoiding a revisit to the ER.
16TH DECEMBER 2023
ABSTRACT NO. 213
A CASE REPORT ON CHRONIC KIDNEY DISEASE- SOLITARY KIDNEY WITH OBSTRUCTIVE UROPATHY DUE TO MULLERIAN AGENESIS
J J Jeeja, R Ram, V Siva Kumar, Lakshmi Aishwarya, Surya Prakash, Namesh Kamat, Saktivel
Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India
E-mail: jeeja87here@gmail.com
BACKGROUND: Mayer-Rokitansky-Kuster-Hauser syndrome is a rare congenital disorder of sex development which is characterized by agenesis of uterus cervix and upper part of vagina with or without associated renal skeletal ear or cardiac malformations. MRKH syndrome is of two types. Type 1 is uterovaginal aplasia. Type 2 is uterovaginal aplasia with extragenital malformations. Here we discuss a rare type of MRKH syndrome.
AIM OF THE STUDY: To present a case report on chronic kidney disease with solitary kidney and obstructive uropathy due to a rare cause.
METHODS: This report describes a case of 17 year old girl presenting with decreased urine output and leg swelling with history of primary amenorrhea. On general examination she had normal secondary sexual characteristics. Her hormonal profile were normal. Her renal parameters were deranged. Imaging studies revealed left renal agenesis with uterine aplasia and right moderate hydroureteronephrosis. Following stenting her urinary output and renal parameters improved.
CONCLUSION: MRKHS has autosomal dominant inheritance with incomplete penetrance. The prevalence of type 1 is 56-72% and type 2 is 28- 44%. Our patient presented with chronic kidney disease with right solitary kidney and obstructive uropathy due to Mullerian agenesis with associated bilateral sensorineural hearing loss consistent with type 2 MRKH syndrome.
16TH DECEMBER 2023
ABSTRACT NO. 214
RAPIDLY PROGRESSIVE RENAL DYSFUNCTION IN SYSTEMIC SCLEROSIS: SCLERODERMA RENAL CRISIS OR?
Pallavi Mahato, Atanu Pal, Koushik Bhattacharjee, Souvik Ghatak, Sourav Sarkar
Department of Nephrology; IPGMER and SSKM Hospital; Kolkata; West Bengal; India
E-mail: mahato.pallavi@gmail.com
BACKGROUND: Systemic sclerosis (SS) is an autoimmune disease of unknown etiology and characterized by fibrosis and thickening of skin and systemic involvement including gastrointestinal tract lungs kidneys and heart. It is more commonly seen in females. SS has an overall female to male ratio of 3:1 or greater. Diffuse systemic sclerosis and limited cutaneous systemic sclerosis are the two subsets of SS based on the extent of skin and systemic involvement. Oesophageal dysmotility pulmonary fibrosis arterial hypertension and hypertensive heart failure are some of the systemic manifestations of SS. Around 10% of the patients develop scleroderma renal crisis (SRC) a rapidly progressive oliguric renal failure due to immune mediated vascular endothelial injury. But some patients rarely may have alternative pathology leading to SRC like presentat ion. Here we present a similar challenging case of mimicking SRC and the role of renal biopsy in the diagnosis.
AIM OF THE STUDY: Rapidly progressive renal dysfunction and accelerated hypertension remains the hallmark for scleroderma renal crisis in patients of Systemic sclerosis. Here we present a case of 38 year old male patient who presented with clinical signs of systemic sclerosis and unexplained renal dysfunction associated with hypertension. A provisional of Scleroderma renal crisis was expected but renal biopsy surprisingly revealed features suggestive of Crescentric Glomerulonephritis.
METHODS: Relevant blood investigation like CBC Ur Cr Lipid profile Ca Phosphate uric acid CRP Procalcitonin ANA profile ANCA-MPO/PR3 C3 C4. Imaging like USG KUB HRCT Thorax. Renal biopsy was performed and sent for LM & IF.
CONCLUSION: It is not necessary that RPRF associated with hypertension in a patient of SS indicates SRC, other pathologies may exist and mimic a similar presentation. So every case of unexplained renal dysfunction should be subjected to renal biopsy expecting alternative pathologies because the treatment and prognosis differs hugely depending on the underlying pathology.
16TH DECEMBER 2023
ABSTRACT NO. 215
RARE ENTITIES CAN EASILY BE MISSED BUT THEY RETURN BACK TO HAUNT: UNUSUAL PRESENTATION OF NAIL PATELLA SYNDROME
Shalini Sinha, Prit Pal Singh, Amresh Krishna, Om Kumar
Department of Nephrology; Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India
E-mail: drshalinisinha17@gmail.com
BACKGROUND: Nail patella syndrome (NPS) is a rare (1 in 50,000) autosomal dominant pleiotropic condition. It is caused by a mutation in the LMX1B gene located on chromosome 9q34.1 encoding the LIM-homeodomain protein. In 88% of cases either of the parents is affected. It functions as a transcription factor in the development of the glomerular basement membrane as well as normal dorsoventral patterning of limbs. It is characterized by a diagnostic tetrad of 1. Fingernail dysplasia - (96-98%) 2. Absent or hypoplastic patellae - (74% cases) 3. Elbow involvement - (70% cases) - with hypoplasia of the radial heads. 4. Presence of posterior conical iliac horns on radiograph (70-76%) Other significant findings include renal involvement (30-50%) proteinuria with or without hematuria rarely leading to End-stage kidney disease (ESRD) and ophthalmologic involvement (10-25%). The clinical manifestations are variable in both frequency and severity with inter and intrafamilial differences. The most serious complication associated with NPS is nephropathy. In this case report we are describing a case of novel mutation of the LMX1B gene presenting as ESRD and severe upper limb deformity in a 30 years old female and upper limb deformity without any evidence of renal involvement yet in her three-year-old son but having the same mutation. Her mother has a similar mutation but an absence of diagnostic tetrad and renal involvement.
METHODS: Case Report A 30 year female presented to us in March 2022 with end-stage kidney disease. She was born with bilateral fixed flexion deformity with limitations of extension at elbow joints and dysplastic nails in all 4 limbs. She was seen by doctors in childhood but due to financial constraints it was not followed up. She got married at 22 years of age and has 2 children- a girl aged 6 years and a boy 3 years. All pregnancies were uneventful. Her physical examination revealed a pale thin built female with anasarca and hypertension. She had antecubital pterygium bilateral patellae nonpalpable and dysplastic nails in the form of longitudinal ridging and small in size in all 4 limbs. Systemic examination was largely unremarkable. Biochemical examinations showed advanced renal failure and ultrasound revealed bilaterally small kidneys. Radiological findings show small dysplastic patellae and B/L iliac horns. Ophthalmic examination suggested of early primary open-angle glaucoma (POAG). Upon enquiry none of her parents or siblings had similar deformities or renal derangements however her 3-year-old son was born with a similar elbow deformity. On examination he also had b/l fixed elbow deformity and small dysplastic patellae. The radiological features of her male child were suggestive of iliac horns and absent patellae. Gene Sequencing by Next generation sequencing (NGS) reported a heterozygous indel variation in intron 4/ exon 5 boundry of the LMX1 (chr9: g.126693516_126693523delinsAGT; Depth: 174x) that affects the acceptor splice site of exon 5 (c.742-8_742-1delinsAGT; ENST00000355497.10). This variant was not present in known 1000 genomes of LMX1B mutation and hence is of uncertain significance. NGS of her son also reported the same mutation. Parental study was also done patient mother also had similar mutation but she had no phenotypic or radiologic evidence of Nail Patella Syndrome. She was initiated on renal replacement therapy (RRT) in the form of hemodialysis with gradual improvement in her general condition. Her father came forward as a prospective donor and transplant work-up was initiated. Unfortunately the patient developed sepsis following a catheter-related bloodstream infection and succumbed to the illness four months after the first visit to our OPD. The son has undergone corrective surgery for elbow deformity and is under our followup.
CONCLUSION: Conclusion to summarize we learned the following lessons from this unusual case: 1. Proband had novel mutation not reported till date. 2. The patient first presented with ESRD which is seen in only 5% of cases of NPS 3. With the diagnosis of NPS and good prognosis post renal transplant she started workup for the same, 4. But due to late presentation and complications of CKD we lost the patient 5. The son of the proband has been diagnosed early and with regular follow-ups his prospect of holistic well-being seems plausible.
16TH DECEMBER 2023
ABSTRACT NO. 216
CROSS-SECTIONAL STUDY IN CLINICAL PROFILE OF LIVING KIDNEY DONORS
R J Sakthi Venkatesh, Manisha Sahay
Department of Nephrology; Osmania Medical College and Hospital; Hyderabad; Telangana; India
E-mail: drrjsakthi@gmail.com
BACKGROUND: The number of living kidney donors is increasing worldwide. The necessity of follow-up is still a debate. In this study we have gathered data from living kidney donors and their clinical profiles.
AIM OF THE STUDY: To make a cross-sectional study on the clinical profile of living kidney donors.
METHODS: 35 kidney donors underwent nephrectomy at Osmania General Hospital from 2014 to the end of 2022. All kidney donors were localized and evaluated for kidney function Haemoglobin Blood Sugar Blood Pressure microalbuminuria (UPCR) and time period since kidney transplant.
CONCLUSION: Living donors have on the average very good renal function with GFR 65 ml/min and only 20% microalbuminuria. Thus, all donors do not develop hyper filtration damages. The preservation of renal function seems very satisfactory even in high risk cases. Living donor nephrectomy seems a safe procedure when studying long-term data.
16TH DECEMBER 2023
ABSTRACT NO. 217
FIBRILLARY GLOMERULONEPHRITIS - RARE CAUSE OF NEPHROTIC SYNDROME IN YOUNG MALE WITH ASYMMETRIC KIDNEYS
Subhro Jyoti Mukherjee, Vivek Sood, Jai Inder Singh, K V Padmaprakash, Prasanta Sengupta
Departments of Nephrology; Internal Medicine and Pathology; Command Hospital (Eastern Command); Kolkata; West Bengal; India
E-mail: viverit@gmail.com
BACKGROUND: Fibrillary glomerulonephritis (FGN) is characterised by glomerular fibrillary deposition usually in subendothelial and mesangial areas composed of nonbranching haphazardly arranged fibrils (approx. 20 nm diameter). It is found in 0.5-1% kidney biopsies more commonly in elderly females. The fibrils are usually Congo red negative and consist of IgG (polytypic) complement and DNAJB9 the latter being pathognomonic for the disease. Most patients present with proteinuria haematuria and hypertension. FGN tends to be progressive and develops end stage renal disease (ESRD) by 2-5 years in over 50% patients especially in males or patients with superimposed crescentic disease or reduced GFR at presentation. These patients usually show poor response to immunosuppression; however Rituximab has shown some response by means of stabilisation of GFR.
AIM OF THE STUDY: In this context we report a middle-aged male who presented with nephrotic syndrome and evaluation revealed poorly functioning scarred right kidney and consequent biopsy from normal kidney revealed FGN. Patient was managed with oral steroids and rituximab besides non-immunosuppressive anti-proteinuric treatment (NIAT).
METHODS: Case Report - 40 years old male presented with facial puffiness pedal edema& passage of frothy urine X 3 months. Clinical evaluation revealed hypertension & obesity (BMI - 31 kg/m2). Investigations revealed nephrotic syndrome (24 hours urine protein of 9 g/day serum albumin of 1.9 g/dL) with normal renal function. NCCT KUB revealed scarred & shrunken Rt kidney (USG KUB- LK 13 cm normal echotexture; RK 7.7 cm scar in posterior & superior pole). Non-invasive work up for etiology of nephrotic syndrome including ANA/dsDNA/viral markers/C3/C4/TSH/serum PLA2R/Myeloma panel/HbA1c/fat pad biopsy was essentially unremarkable. As his nephrotic syndrome was not explained by hyperfiltration secondary to compensatory enlarged Lt kidney or obesity renal biopsy from normal kidney was contemplated. Biopsy suggested glomerulonephritis with organized deposits. [LM- 22 glomeruli - 1 globally sclerosed rest glom enlarged with proliferative pattern with wide mesangium & capillary walls with PAS + deposition (fuschinophilia with MT stain but negative for Silver & Congo red stain) IFTA - 10%; IF -7 glom - IgG/IgM/C3 - 2+ along capillary walls; IgA/C1q - Neg; Kappa/lambda - 1+/2+ capillary walls; EM suggested FGN [effaced foot processes of visceral epithelial cell -70% GBM thickening mesangial interposition accumulation of randomly oriented non-branching fibrillary structures 19.4 - 28.6 nm in mesangial & focal subendothelial regions]. FGN was confirmed later by DNAJB9 stain (Dr Lal Path Lab - diffuse granular to confluent staining/positivity in glomeruli.) In view of persistent proteinuria (6.5 g/day) despite NIAT patient was managed with oral steroid @ 0.5 mg/kg body weight followed by gradual tapering & Inj Rituximab (dosing titrated to CD 19 repletion/proteinuria) besides NIAT.
CONCLUSION: Fibrillary glomerulonephritis is very rare in a middle-aged male and portends poor prognosis. A regimen of renin-angiotensin blockade and immunosuppression is commonly employed; however, it is not particularly effective and progression to end stage renal disease is inevitable.
16TH DECEMBER 2023
ABSTRACT NO. 218
SUCCESSFUL TREATMENT OF SAPOVIRUS-ASSOCIATED DIARRHOEA IN A RENAL TRANSPLANT PATIENT WITHOUT ALTERING IMMUNOSUPPRESSION
Mohammed Sajid Abdul Samad, Ravi Andrews
Department of Nephrology; Apollo Hospital; Hyderabad; Telangana; India
E-mail: sajidameen9@gmail.com
BACKGROUND: Chronic immunosuppression puts solid organ transplant (SOT) recipients at increased risks of infectious diarrhoea. Viral diarrhoea among transplant patients is often due to cytomegalovirus (CMV) and norovirus. [1] As more sensitive diagnostic tools become available emerging causes of viral enteritis are being identified. Here we discuss a renal transplant recipient with sapovirus-associated diarrhoea treated successfully using nitazoxanide.
AIM OF THE STUDY: Rare case of Sapovirus + Enterotoxigenic E Coli in a patient post trasnplantation. First of its kind with mixed infection in India.
METHODS: A 26-year-old woman with history of chronic kidney disease stage 5 secondary to biopsy-proven chronic tubulo-interstitial nephritis received a live related renal transplant in September 2014. She was on triple drug immunosuppression and on regular follow up. Her baseline serum creatinine was maintained at 1.2 mg/dL. She presented to our outpatient department in April 2023 with two weeks history of diarrhoea. She was passing 6-8 stools daily and said it had started after consumption of around 100 mL of palm wine called kallu or toddy locally. Stools were watery whitish to yellowish and of medium volume. There was no fever nausea or anorexia but she occasionally had abdominal cramping. She was managed with loperamide and racedotril without much relief. Probiotics were not given due to fear of superadded infections by Lactobacilli Bifidobacterium Peptostreptococci etc. In May 2023 she was admitted for closer monitoring and intravenous fluid management. At admission her vitals were normal with no pallor icterus cyanosis lymphadenopathy or oedema. She was clinically volume depleted. The serum creatinine had risen to 1.9 mg/dL from the baseline of 1.2 mg/dL. Stool routine microscopy was negative for any parasitic ova or cysts and stool culture showed no pathogenic bacterial growth. The BioFireFilmArrayTM gastrointestinal panel of polymerase chain reaction (PCR) tests was positive for sapovirus and Shiga toxin producing E. coli (STEC)/ E. coli O157. Supportive care with intravenous fluids was continued and tablet nitazoxanide 500 mg twice a day was started. Within two days the stool frequency reduced and serum creatinine level fell to 1.2 mg/dL. Nitazoxanide was continued for a total of seven days. Immunosuppression therapy was not altered.
CONCLUSION: Due to lack of specific therapies, management of viral diarrhoea focuses on hydration and antimotility agents. In SOT patients, dose of immunosuppressants is often reduced on diagnosis of norovirus or sapovirus, in order to increase immunity, overcome the infection and prevent superadded infections. A fine balance is needed between managing the infection and preventing graft rejection. There are suggestions for an alternative management plan with use of oral nitazoxanide.
16TH DECEMBER 2023
ABSTRACT NO. 219
A RARE CASE OF SEVERE CMV DISEASE IN A PEDIATRIC EN-BLOC ALLOGRAFT RECIPIENT - HOW EARLY IS TOO EARLY?
Akshaya Jayachandran, Vinoi George David, Athul Thomas, Selvin Sundar Raj
Department of Nephrology; Christian Medical College; Vellore; Tamil Nadu; India
E-mail: aks.251192@gmail.com
BACKGROUND: Cytomegalovirus (CMV) has always been an important opportunistic pathogen due to its frequency in kidney transplant patients causing both organ dysfunction and graft related complications. In a review of over 5000 kidney transplants the incidence of CMV infection in the first 30 days after renal transplant was found to be just 0.2% most of whom were considered high-risk including previously immunosuppressed patients. The risk of CMV infection in the first month after transplantation is generally felt to be minimal despite the high intensity immunosuppression used at the time of transplant. This is considered to be due to a lack of prolonged immunosuppressive exposure. Widespread literature exists describing increased risk of negative patient and allograft outcomes when CMV infection or disease occurs in the first 3 months after transplant. Here we present a rare case of very-early CMV disease which manifested less than a month post-transplant.
AIM OF THE STUDY: To highlight the importance of having a high suspicion of CMV even in the early pre-transplant period as identification and prompt treatment will help in preventing graft related complications and poor outcomes.
METHODS: Our patient was a 15-year-old male child who received a deceased donor renal transplant (en-bloc) from a 3-year-old donor and had no major post-operative complications but developed CMV disease (CMV PCR positive Gastritis/Enteritis) within 20 days of transplant with Viral copies of 1.5 lakhs
CONCLUSION: In the setting of fever accompanying leukopenia, we always test for CMV infection regardless of time from transplant, especially in high-risk patients. However, this case report establishes the significance of having a high clinical suspicion for CMV, even in the absence of fever, if leukopenia is present with other unexplainable symptoms or organ involvement, even in very early post-transplant period, as it will significantly reduce complications like graft loss and severe infection.
16TH DECEMBER 2023
ABSTRACT NO. 220
A RARE CASE OF CALCINEURIN INHIBITOR INDUCED NEURO-LUNG TOXICITY: A CASE REPORT
P Vamshi Dharan, Manjunath S Shetty, K K Kiran, C Manoj, R Sowrabha
Department of Nephrology JSS Medical College and Hospital; Mysore; Karnataka; India
E-mail: dharanvamshi@gmail.com
BACKGROUND: For several decades calcineurin inhibitors (CNIs) have served as the cornerstone of immunosuppression in solid organ transplantation. The FDA granted approval for the use of CNIs specifically cyclosporin A and tacrolimus as immunosuppressive treatments in 1983 and 1999 respectively. CNI agents are now being investigated and employed in the management of several immune-mediated glomerular disorders. While calcineurin inhibitors (CNIs) have demonstrated efficacy in mitigating acute kidney transplant rejection and significantly aiding in the long-term management of anti-allograft immunity their therapeutic range is limited and they are associated with various adverse effects such as nephrotoxicity neurotoxicity hypertension tremors and metabolic disturbances.
AIM OF THE STUDY: A 20 yr old lady with Native Kidney Disease of Chronic Interstitial Nephritis with dialysis vintage of ~1 yr underwent ABO compatible live-related renal transplantation with donor being her mother. She was on triple immunosuppression with tacrolimus prednisolone and MMF and had normal graft function. Four months post transplantation she presented with seizures MRI brain showed features of PRES. As she did not have any accelerated HTN at the time of seizures she was diagnosed to have tacrolimus induced PRES and her immunosuppression was changed to cyclosporine.
METHODS: She presented a week later with complaints of breathlessness grade 2-3 NYHA requiring oxygen support with crepitations heard in bilateral infrascapular and infra-axillary areas of lung. Chest x-ray done showed fluffy cotton opacities in right middle and lower zone and in left lower zone of the lung. HRCT thorax done showed features of active infective etiology but as the patient was not producing any sputum she underwent bronchoscopy and BAL sample sent for analysis was negative for malignant/atypical cells AFB/ZN stain Modified acid-fast stain Toluidine blue stain KOH stain. Bal sample sent for CBNAAT was negative and cultures did not show any growth. After ruling out active infective etiology under antibiotic coverage she was pulsed with 3 doses of methylprednisolone following which her clinical condition improved and she was gradually weaned off oxygen support.
CONCLUSION: The utilisation of calcineurin inhibitors (CNIs) has brought about a significant transformation in the field of kidney transplantation, and their application remains extensive in current medical practise. The neurotoxicity caused by calcineurin inhibitors (CNIs) has been extensively described in academic literature. However, the occurrence of lung damage as a result of CNIs is infrequently observed. To far, there have been rare incidences of severe lung injury caused by CNI. Given the potential for respiratory failure and the reversible nature of this complication, it is advisable to investigate CNI as a potential cause in cases of Unexplained Pneumonitis after doing a thorough investigation to rule out infections.
16TH DECEMBER 2023
ABSTRACT NO. 221
WHEN FLUID OVERLOAD IN A DIALYSIS PATIENT TOOK AN UNEXPECTED TURN – A RARE CASE OF AORTOCAVAL FISTULA
Gayathri R Pillai, K Ambily, Rahul Rajan, Jithu Kurien, Satheesh Balakrishnan, Subhash B Pillai, Reena Thomas
Department of Nephrology; Pushpagiri Institute of Medical Sciences and Research Centre; Thiruvalla; Kerala; India
E-mail: gayathrirpillai@gmail.com
BACKGROUND: Aortic aneurysms (AA) are defined as segmental full-thickness dilations of the aorta resulting in a 50% increase in diameter when compared with the normal aortic diameter. Rupture is the most severe complication of larger aneurysms. In patients with thoracic AA the rate of rupture ranged from about 30 to 70% with a mortality risk of 50%. The mortality risk after abdominal AA rupture is reported in up to 85% of cases. Chronic kidney disease (CKD) patients are at increased risk for the development of AAs and their complications. eGFR and proteinuria have been independently associated with an increased risk for incident abdominal AA and an increase in diameter of the abdominal aorta. Aortocaval fistula is a rare and devastating complication of abdominal aortic aneurysm (AAA) in which the aneurysm erodes into the inferior venacava. Spontaneous rupture of an abdominal aortic aneurysm into the adjacent inferior vena cava occurs in <1% of all aneurysms and in ~3% of ruptured aortic aneurysms.
AIM OF THE STUDY: The features can be very atypical leading to a delay in diagnosis. The various factors that influence the clinical presentations are the origin size location and duration of the fistula. We present a case of aortic aneurysm who had presented as a case of resistant fluid overload.
METHODS: A 61 year old male a known case of CKD on MHD presented to us with complaints of bilateral lower limb and scrotal edema. He was admitted and daily dialysis was done for 5- 6 sessions and he was discharged. He again presented with similar complaints and the patient had abdominal bruit on examination. Emergency CT angiography was done which showed aortocaval fistula and was referred to vascular surgeon for management of aortic aneurysm which had eroded into abdominal aorta causing the fistula.
CONCLUSION: Thus, we conclude that aortic aneurysm and its complications needs to be kept as the differential diagnosis in CKD patients even when patients dont present with the classical description of pain. Symptoms maybe variable and we need to have a high index of suspicion.
16TH DECEMBER 2023
ABSTRACT NO. 222
A UNIQUE CASE REPORT OF MANAGING FLUID BALANCE AND DECIDING DOSE OF HEMODIALYSIS IN A PATIENT WITH END STAGE RENAL DISEASE ON MAINTENANCE HEMODIALYSIS WHO PRESENTED WITH INDUSTRIAL BURNS
Niral Patel, Manoj R Gumber
Department of Nephrology; Apollo Hospitals International Limited; Ahmedabad; Gujarat; India
E-mail: niralrpatel50@gmail.com
BACKGROUND: Managing burns with fluid is a long established practice especially those with acute kidney injury. In our case we have examined the role and ways of assessment of fluid balance and need for hemodialysis in a patient with end stage renal disease already on hemodialysis who presented with industrial burns. We were faced with inability to assess daily fluctuations in weight and the need of administering intravenous fluids as required by the nature and extent of burns. We achieved this by assessing inferior vena cava diameter and collapsibility as well as hematocrit.
AIM OF THE STUDY: To demonstrate challenges in managing fluid balance in a patient already on maintenance hemodialysis presenting with electrical burns.
METHODS: A single case study observed during April to June 2023 at our institution.
CONCLUSION: Indirect markers of hydration such as hematocrit and IVC diameter are important ways to assess, monitor and decide about administration of intravenous fluids as well as deciding hemodialysis dose and frequency in a patient on preexisting need of maintenance hemodialysis.
16TH DECEMBER 2023
ABSTRACT NO. 223
A RARE AND LETHAL FUNGAL COMPLICATION IN A YOUNG IV DRUG ABUSER WITH HEPATITIS C: A CASE REPORT
Shrinath Mashale, Jasmine Sethi
Department of Nephrology; PGIMER; Chandigarh; India
E-mail: shrinathmashale10@gmail.com
BACKGROUND: We present a comprehensive case report detailing the clinical course diagnosis and management of a 16-year-old male with a history of intravenous drug abuse prior Hepatitis C infection successfully treated with Direct-Acting Antivirals (DAA) and a rare and ultimately fatal fungal complicationIntravenous (IV) drug abuse remains a significant public health concern with associated complications ranging from infectious diseases to vascular and systemic complications. Hepatitis C is one such infectious consequence of IV drug abuse which can lead to chronic liver disease and cirrhosis. In this report we describe the unique case of a young IV drug abuser with a history of Hepatitis C who presented with a sudden onset of abdominal pain fever anuria and a complex multi-organ fungal infection.
CONCLUSION: This case report illustrates the formidable challenges posed by fungal infections in young IV drug abusers, particularly those with a history of Hepatitis C. Even with prompt and aggressive medical and surgical interventions, the rapid progression of the disease and the involvement of multiple organs led to a tragic and unfortunate outcome. The case underscores the vital importance of early recognition, immediate treatment, and vigilant monitoring in managing such complex clinical scenarios.
16TH DECEMBER 2023
ABSTRACT NO. 224
AN INTERESTING CASE OF PSEUDOBARTTER SYNDROME
S Rangavenamma, S Ananth, Venkata Pakki Reddy; Shridhar Sharma
Department of Nephrology; Kurnool Medical College; Kurnool; Andhra Pradesh; India
E-mail: rangaveni2011@gmail.com
BACKGROUND: Cystic fibrosis (CF) an autosomal recessive disorder occurs due to mutations in CFTR gene resulting in impaired cystic fibrosis transmembrane conductance regulator (CFTR) chloride channel function in various epithelia. In addition to the well-known pulmonary and pancreatic morbidities CF is characterized by electrolyte and acid-base abnormalities- hypochloremia hyponatremia hypokalemia and metabolic alkalosis. These are collectively known as Pseudo-Bartter syndrome as similar abnormalities are seen in Bartter syndrome- an inherited tubulopathy affecting thick ascending limb of loop of Henle. There may be a significant clinical overlap between the Classic Bartter syndrome and CF presenting as Pseudo-Bartter syndrome especially in early childhood. This review focuses on Pseudo-Bartter syndrome in CF its pathogenesis and differentiation from Bartter syndrome. Other causes of metabolic abnormalities resembling Bartter syndrome are also highlighted.
AIM OF THE STUDY: To report and highlights the case of overlapping clinical symptoms electrolyte abnormalities and the diagnostic confusion between Bartter syndrome and Cystic fibrosis.
METHODS: A case of 2.5 year male patient presented with frequent admission for recurrent infection with history of failure to thrive with plyuria with severe acute malnutrition and hypokalemia hyponatremia and metabolic alkalosis.
CONCLUSION: The characteristic abnormalities of Pseudo-Bartter syndrome need to be considered in CF patients. CF should be kept in the list of differential diagnosis of an infant with unexplained hypokalemic metabolic alkalosis in addition to Bartter syndrome. Further, one should rule out common conditions like excessive GI losses and diuretics before making the rare diagnoses of CF and Bartter syndrome.
16TH DECEMBER 2023
ABSTRACT NO. 225
A CASE OF IGA DOMINANT IRGN IN A DIABETIC PATIENT TREATED WITH IMMUNOSUPPRESSION
Abhishek Bhardwaj, Prit Pal Singh, Om Kumar, Amresh Krishna, Prem Shankar Patel
Department of Nephrology; Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India
E-mail: abhishekbhardwaj1709@gmail.com
BACKGROUND: IgA dominant IRGN is an immune complex mediated lesion typically associated with Staphylococcus aureus infections in adult patients with underlying comorbidities. It is suggested that pathogenesis involves staphylococcal enterotoxins functioning as superantigens leading to a B cell polyclonal IgG and IgA response. Active disease often presents with acute or rapidly progressive renal failure with nephrotic range proteinuria in 50% cases. Active infection is treated with appropriate antibiotics and this may lead to renal functional recovery. Progressive disease reported to be treated with corticosteroids have shown variable results.
AIM OF THE STUDY: To assess the role of immunosuppression in IGA dominant IRGN.
METHODS: A 57 year old male patient known case of diabetes mellitus since 8 months presented with right lower limb cellulitis followed by decreasing urine output. Patient was anuric at the time of admission. Hemodialysis was started and antibiotics were administered. Fundoscopic examination did not reveal changes of diabetic retinopathy. A kidney biopsy was performed which showed a mesangial and focal proliferative glomerulonephritis with cellular crescents over 5/13 glomeruli. IF revealed IgA with significant c3 deposits.
CONCLUSION: IgA dominant IRGN presenting as RPGN is at high risk for developing ESRD. The risks of immunosuppressive drugs together with antibiotics in these cases should be balanced against benefits and can be considered in selected cases.
16TH DECEMBER 2023
ABSTRACT NO. 226
A RARE DEMATICIOUS FUNGI MASQUERADING AS MASS LESION.
Gowri Shankar, Raja Ramachandran, Harsimran Kaur, Shivaprakash M Rudramurthy, Haseen Ahmad
Department of Nephrology; PGIMER; Chandigarh; India
E-mail: s.gowri.shank@gmail.com
BACKGROUND: Fungal diversity is highly uncertain; the current estimated numbers are between 1.5 to 12 million of which about 150 000 species have been named and classified. Fungi are important organisms in terrestrial and aquatic ecosystems that are involved in the decomposition and nutrient cycling of dead plant material. Also saprobic fungi play vital roles in soil food chains decomposition of plant and animal materials and solubilization of phosphorus. Nigrograna was introduced by de Gruyter. In 2022 Nigrograna represents 20 epithets listed in Index Fungorum and the members have been reported as saprobic human pathogenic and endophytic worldwide showing a wide range of hosts (marine and terrestrial habitats).
AIM OF THE STUDY: A 68 year old female known case of Immune complex glomerulonephritis induced in 2018 with pulse methyl prednisone and EUVAS Endoxan followed by azathioprine maintenance presented with chronic right knee swelling for 2 years duration. She had pain while walking because of the swelling. On examination there was a swelling in the anterior aspect of right knee around 2.5—2 cm exhibiting horizontal mobility. The mass didnt have any signs of inflammation. MRI knee was done which revealed cystic lesion in the anterior part of leg away from the right knee joint. In view of recent onset of pain and patient on immunosuppressive therapy single time aspiration was done which revealed purulent material around 30 ml. Pus was sent for microbiological investigation which revealed presence of septate hyphae. She developed intermittent fever for which blood and urine cultures were sent which were sterile. She was subjected to FDG PET SCAN which revealed no evidence of disseminated infection. The fungal strain was identified to belong to Nigrograna species. She was started on oral Itraconazole and the drug levels were within normal range. She is afebrile currently and is having normal renal function.
CONCLUSION: (1) Dematicious fungi are opportunistic pathogens known to cause skin and soft tissue infection in immunocompromised patients (2) Nigrograna species are one of the rare species known to be pathogenic to humans and can cause mycetoma (3) Prompt intiation of antifungal therapy and source eradication are important aspects of treatment.
16TH DECEMBER 2023
ABSTRACT NO. 227
UNUSUAL PRESENTATION OF DISSEMINATED HISTOPLASMOSIS IN A KIDNEY TRANSPLANT RECIPIENT WITH IGA NEPHROPATHY RECURRENCE
A V Niranjan, Jasmine Sethi, Nishant Nadda
Department of Nephrology; PGIMER; Chandigarh; India
E-mail: niranjanav7@gmail.com
BACKGROUND: Kidney transplant recipients are at risk for various infections due to immunosuppressive therapy. Histoplasmosis caused by the dimorphic fungus Histoplasma capsulatum is a rare but potentially life-threatening infection in this population. We report a case of disseminated histoplasmosis in a kidney transplant recipient with recurrent IgA nephropathy.
CONCLUSION: Gastro intestinal invlovment mimicking inflammatory bowel disease is a rare presentation of histoplasmosis. This case highlights the challenges in diagnosing and managing disseminated histoplasmosis in kidney transplant recipients, especially in the presence of concurrent infections and immunosuppression. A high index of suspicion is necessary for timely diagnosis and appropriate treatment in such cases to improve outcomes.
16TH DECEMBER 2023
ABSTRACT NO. 228
CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME IN A MALE PATIENT MIMICKING PULMO-RENAL SYNDROME AND VARIABLE PRESENTATIONS OF ANTI PHOSPHOLIPID NEPHROPATHY (APL-N) BEYOND THROMBOSIS: A CASE SERIES
Jyoti Aggarwal, Vinay Rathore, Rohit Paras Badge, Vinay R Pandit, Alok Sharma 1
Department of Nephrology; All India Institute of Medical Sciences; Raipur; Chhattisgarh 1 National Reference Lab of Lal Path Labs; New Delhi; India
E-mail: aggarwalsja.1990@gmail.com
BACKGROUND: Renal involvement in antiphospholipid syndrome (APS) has been poorly recognized. APS is usually diagnosed in young females and secondary APS (SAPS) is much more common than primary APS (PAPS). Catastrophic APS (CAPS) a potentially lethal complication occurs in less than 1% of these patients. We present a challenging case of a 50 year old male presenting as pulmonary renal syndrome later turning out to be CAPS with aPL-N on kidney biopsy. With the insight from new 2023 Eular/ACR APS Classification criteria we have elaborated histopathology features of three other aPL-N cases each with a mind boggling initial clinical presentation posing both diagnostic and therapeutic challenges.
AIM OF THE STUDY: To study the clinical presentation histopathology findings and treatment outcomes of renal biopsy proven aPL-N patients.
METHODS: CASE 1 - A 50 year old male smoker with hypertension and psoriasis vulgaris presented with high grade fever cough with expectoration moderate hemoptysis and progressive dyspnea worsening from MMRC grade II to IV over seven days. He had rapidly progressive renal failure with bland urine examination (24 hour urine protein 720 mg/day) and non-oliguria. Imaging and bronchoscopic lavage suggestive of diffuse alveolar hemorrhage (DAH). ANA MPO PR3 Anti GBM Anti CCP Complements Autoimmune and Myeloma workup was negative. Patient worsened rapidly and developed necrotising pancreatitis bilateral knee ankle joint swelling and maculopapular rash over trunk. In view of DAH and multi organ involvement APLA workup was done Lupus anticoagulant turned out to be strong positive. Kidney size was borderline with partially maintained cortico-medullary differentiation. Renal biopsy showed widespread arterial/arteriolar fibrotic intimal hyperplasia and luminal thrombotic occlusion thrombotic microangiopathy (TMA). Glomeruli revealed severe ischemic alterations concluding acute on chronic Anti Phospholipid nephropathy. Plasma exchange Pulse steroids Rituximab and IVIG were used in treatment however patient succumbed to sepsis after 25 days of hospital stay. CASE 2- A 39 year old diabetic female with severe NPDR presented with hypertensive emergency with rapidly worsening serum creatinine had grade 3 diabetic glomerulosclerosis and TMA in biopsy. Anti Phospholipid antibodies were high. History revealed young onset hypertension bad obstetric history with three first trimester abortions mitral valve calcification and transient ischemic attacks.
CONCLUSION: High index of suspicion is required to diagnose Anti Phospholipid nephropathy as it can be a great masquerader. Our case series emphasizes that one of the important causes of TMA is aPL-N even in males. Little is known about treatment of aPL-N, especially about the role of steroids; anticoagulation type, dose and duration in patients presenting with only TMA as the first presentation without other site thrombosis warranting more studies and trials.
16TH DECEMBER 2023
ABSTRACT NO. 229
CARDINAL SIN OF SOFT TISSUE SARCOMA IN A RENAL TRANSPLANT PATIENT
Sumiran Mahajan, M S Khanpet (Karishetti)
Department of Nephrology; Jawaharlal Nehru Medical College and KLES Dr. Prabhakar Kore Hospital; Belagavi; Karnataka; India
E-mail: sumiroks@gmail.com
BACKGROUND: Cancer is now the third leading cause of death in kidney transplant recipients. Recent evidence suggests that in the next 2 decades it will surpass cardiovascular disease as the most-common cause of death. van de Wetering demonstrated a shorter median for patient survival after the diagnosis of cancer. Solid organ transplant recipients have elevated cancer risk owing to immunosuppression and oncogenic viral infections. Among kidney recipients kidney cancer risk was elevated and bimodal in onset time. This increased risk of cancer was confirmed by a large Canadian study as well; however in this study sarcoma was not mentioned. The incidence of malignancy has been estimated at 20% after 20 years of chronic immunosuppression. Soft tissue sarcomas (STS) are rare neoplasms comprising less than 1% of all adult malignancies. To the examiner an STS typically presents as a painless mass that may not appear potentially malignant. Unfortunately sarcomas are highly malignant and improper management can prove devastating. Hereby We present a patient who is post deceased donor renal allograft transplant with bilateral symmetrical biopsy proven sts of thigh.
AIM OF THE STUDY: The purpose of this case report is to sensitize about high index of suspicion which is needed to make a diagnosis and discuss about diagnosing and managing an STS in the transplant patient and prompt need for intervention.
METHODS: The patient is a 37-year-old male who presented to us with bilateral symmetrical painless swelling of lower thighs. A review of his medical history did not reveal any history of trauma. His family history was negative for any malignancy. The results of the patient’s geneXpert and chest radiograph were negative and clinically there was no evidence of Mycobacterium tuberculosis infection. He underwent deceased donor renal allograft transplant in 2019. He received thymoglobulin induction. Intraoperative period was heralded with severe hypotension with requirement of haemodialysis on day 1st post operative. However patient was discharged after 10 days with nadir serum creatinine of 1.2 mg/dl. He was on maintenance immunotherapy regimen of prednisone tacrolimus and mycophenolate mofetil. Patient was subjected to renal allograft biopsy in 2021 in view of derangement of renal function test which showed acute cell mediated rejection. In the background of mild COVID 19 infection and persistent progressive derangement of renal function test in 2022 patient underwent 2nd renal allograft biopsy which showed borderline acute cell mediated rejection. Subsequently patient received three doses of pulse steroid. In the context of persistent progressive derangement of renal function test and on routine evaluation patient was diagnosed with BK Polyomavirus nephropathy. After reduction of immunosuppression doses renal function test stabilised at serum creatinine of 3 mg/dl. The patient returned to the hospital 2 months later with history of bilateral symmetrical painless swelling. Physical examination including palpation of inguinal lymph nodes and chest xray were unremarkable. A magnetic resonance image of his lower upper extremity showed intra and intermuscular soft tissue mass lesions (largest 6.1 x 1.4 cm on right side) of medial compartment of distal portion of bilateral thigh. Biopsy (LM and immunohistochemically) from left soft tissue was suggestive of pleomorphic sarcoma.
CONCLUSION: To the best of our knowledge, this is the first report of an undifferentiated pleomorphic sarcoma arising symmetrically from bilateral thigh post renal transplant. A thorough search of the literature was done using PubMed and Medscape databases looking for similar case presentations. Using the terms carcinoma and transplantation, carcinoma and transplantation, carcinoma and thigh, carcinoma and renal failure, no similar case could be found in the literature. If immunosuppression or oncogenicity of BK polyoma, covid-19 were the culprit is still unresolved and further research is warranted. However, as with all malignancies, early diagnosis is key to patient survival.
16TH DECEMBER 2023
ABSTRACT NO. 230
A RARE CASE OF COMBINED INFLAMMATORY AND INFECTIVE DISEASE IN A PATIENT
Sohil Sharda, Ravi Sarvi
Department of Nephrology; JNMC; Belagavi; Karnataka; India
E-mail: sohilsharda@gmail.com
BACKGROUND: The co-existence of Human Immunodeficiency Virus (HIV) infection and Systemic Lupus Erythematosus (SLE) is an unusual yet interesting phenomenon. The pathogenesis regarding how HIV infection a state of immunodeficiency triggers SLE is appealing. Diagnosing these two conditions as separate entities poses a great difficulty due to overlapping clinical features and initiating immunosuppressive therapy in such patients requires in depth knowledge regarding the interaction between HIV and SLE. We present a rare concomitant case of SLE and HIV infection.
AIM OF THE STUDY: To emphasize on coexistence of HIV and SLE its diagnosis and the challenges in its management.
METHODS: A 28 year old female patient known case of retroviral disease on ART since 4 years with no comorbidities presented with puffiness of face pedal edema reduced appetite and frothy urine since 1 week. On evaluation she was found to have pancytopenia along with renal dysfunction(creatinine 5.16mg/dl) massive proteinuria (urine protein 4+) with hematuria (urine RBC 100+) low complement levels (C3-31 C4-3) and ANA profile was strongly positive for anti DsDNA and anti-smith. Patient did not give history of fever rashes joint pain or joint stiffness and presented to us with Nephrotic syndrome. Patient underwent emergency hemodialysis in view of severe acidosis and anuria. To confirm the diagnosis of lupus nephritis renal biopsy was done which showed lupus nephritis CLASS III + CLASS V.
CONCLUSION: This case highlights the presence of concurrent SLE and HIV infection. Clinicians should be cautious on diagnosis, management and specific attention should be paid to the dose of immunosuppressants and the anti-retroviral therapy. While reporting this case, we would also like to stress on the importance of doing a serological screening to rule out HIV infection in cases of suspected auto immune disease.
16TH DECEMBER 2023
ABSTRACT NO. 231
ACUTE TUBULOINTERSTITIAL NEPHRITIS- A RARE MANIFESTATION OF ACUTE INTERMITTENT PORPHYRIA
Rohan Desai, Bhushan C Shetty, Mayoor V Prabhu, B Sushanth Kumar, M Ashok Bhat, V Darshan, Vivek Hari
Kasturba Medical College Hospitals; Manipal Academy of Higher Education; Mangalore; Karnataka; India
E-mail: batista2966@gmail.com
BACKGROUND: Acute porphyria is a group of rare metabolic disorders characterized by deficiencies in enzymes involved in heme biosynthesis. Acute porphyria primarily affects the nervous system renal involvement is uncommon. Porphyrins are highly reactive to ultraviolet rays in urine they cause it to turn to a reddish hue upon exposure to sunlight. [2] There are various causes of renal failure in acute porphyrias with acute interstitial nephritis (AIN) as a rare manifestation characterized by interstitial inflammation and tubular injury. Herein we present a case of acute intermittent porphyria manifesting as AIN probably the first report from India.
AIM OF THE STUDY: To report the first case of acute tubulointerstitial nephritis secondary to acute intermittent porphyria from India.
METHODS: Case report.
CONCLUSION: This case highlights a unique presentation of acute intermittent porphyria as acute tubulointerstitial nephritis, emphasizing the clinicians to consider AIN as a possibility in patients with acute porphyria presenting with unexplained renal dysfunction. Through this report, we can add acute intermittent porphyria as one of the cause of acute tubulointerstitial nephritis to literature.
16TH DECEMBER 2023
ABSTRACT NO. 232
THE CHALLENGES OF ASSESSMENT OF A HIGHLY SENSITIZED RECIPIENT
Mahendra Narain Mishra
Pathkind Diagnostics Pvt. Ltd. Reference Laboratory; Gurugram; Haryana; India
E-mail: mahendra.narain@pathkindlabs.com
BACKGROUND: HLA incompatible renal transplant require careful evaluation and post-transplant follow up to optimise graft survival and ameliorate the associated risks.
AIM OF THE STUDY: We intend to present a highly sensitized patient with Pyelonephritis aged 39 years being worked up for 2nd renal transplant and had received ten units of blood and present the challenges associated with highly sensitized cases.
METHODS: HLA typing was done at both low and high resolution; both flow crossmatch and single antigen bead assay were performed during the evaluation of two potential cadaver donors.
CONCLUSION: The complex antibody profile of the patient highlights the use of additional HLA typing for HLA- DPA1 and careful evaluation. It prevented a successful deceased donor offer and it was recommended to perform as transplant after use of Inflimidase.
16TH DECEMBER 2023
ABSTRACT NO. 233
PUJ OBSTRUCTION IN A TRANSPLANT KIDNEY: RECONSTRUCTION BY BOARI FLAP
Ankit Grover, D K Aggarwal, Ankit Data, Anshuman Aggarwal
Department of Nephrology; Indraprastha Apollo Hospital; New Delhi; India
E-mail: angrover@gmail.com
BACKGROUND: The success of renal transplantation depends on the preservation of renal graft function and despite many advances in the surgical techniques immune-suppressive regimens and supportive therapies many challenges remain including post-operative ureteral obstruction. This complication can pose a risk to graft and occasionally to the patient survival.
AIM OF THE STUDY: To propose BOARI flap as a curative treatment option for cases with short length ureter and obstruction in a transplant kidney that cannot be re-anastomosed.
METHODS: Here we present a case of 52 year old male Renal Allograft recipient who had an acute antibody mediated rejection post-operatively and was treated with Plasma Exchange and IVIG. On 15th post operative day he had discharge from the suture site and was re-explored. The leak was sutured and Double J stent was re-positioned however he continued to have high grade fever with chills. The urine sample sent for culture showed significant microbial growth and therefore a nephrostomy tube was placed in view of UTI.
CONCLUSION: We conclude that Obstruction of the renal transplant should be promptly diagnosed and treated. Percutaneous nephrostomy is a safe and effective method for immediate relief of ureteric obstruction. However for definitive curative treatment in cases of short length ureter with obstruction which cannot be re-anastomosed, BOARI flap remains cornerstone for treatment in the transplant kidney.
16TH DECEMBER 2023
ABSTRACT NO. 234
IMMUNOLOGICAL COMPLEXITY OF ANTI-HLA-C DONOR SPECIFIC ANTIBODIES
Lovy Gaur, Ajay Kher, Manoj Singhal
Department of Nephrology; Max Super Speciality Hospital; Ghaziabad; Uttar Pradesh; India
E-mail: drlovygaur@gmail.com
BACKGROUND: Anti-HLA donor-specific antibodies (DSAs) are associated with antibody-mediated rejection and chronic allograft nephropathy in kidney transplantation. The interpretation of immunological assays for DSAs can be challenging due to discordant results. A careful consideration of results along with overall clinical context can help in guiding decisions for kidney transplantation.
AIM OF THE STUDY: In this report we present two cases of kidney transplantation involving patients with anti-HLA-C DSAs. We discuss the interpretation of their immunological tests including complement-dependent cytotoxicity (CDC) crossmatches flowcytometry crossmatches and donor specific antigen using single antigen bead assays which influenced therapeutic decisions.
METHODS: A 41-year-old woman with end-stage kidney disease underwent work-up for transplant. Immunologically she was considered a high-risk candidate due to multiple pregnancies and several blood transfusions. During her work-up she was detected to have Hepatitis C infection. Subsequent investigations did not reveal any evidence of chronic liver disease and she was initiated on Sofosbuvir and Velpatasvir. Her 42-year-old sister volunteered as a donor and HLA typing revealed a 5/6 mismatch. While the CDC crossmatch showed no cell lysis the flow cross match revealed a positive B cell crossmatch against both autologous and donor B-cells. This suggested the possibility of autoantibodies directed against an antigen expressed on both autologous and allogenic B cells. To rule out any donor specific antibodies (DSAs) a single antigen bead assay for HLA-antibodies was conducted which detected only one DSA directed against HLA- C 03:03:01 (mean fluorescence intensity (MFI)- 27127). After careful consideration of these discordant immunological results and confirmation of a negative CDC on repeat testing we proceeded with the transplantation. She continues to have good graft function even after a follow-up of 20 months. The second case is about a 35-year-old man who sought his second kidney transplant after his first graft failed due to chronic antibody mediated rejection. For his second transplant his sister underwent evaluation as a potential donor. HLA typing revealed a 2/6 mismatch. The CDC crossmatch showed no cell lysis but but the flow cytometry-based T-cell cross match was positive. As expected anti-Class I HLA- DSAs were detected- against HLA C*07:01 (MFI-7133) and HLA C*07:02 (MFI- 5380). The CDC crossmatch was repeated again and the transplantation proceeded after confirming the negative report. The induction therapy involved the administration of 4.5 mg/kg ATG followed by standard triple-drug immunosuppression. The patient had an uncomplicated graft recovery. More than 30 months after transplantation he continues to have good graft function with serum creatinine level around 0.9 mg/dl.
CONCLUSION: The presence of HLA-C DSAs poses challenges in transplantation decision-making. Despite conflicting studies, the pathological nature of these antibodies has been demonstrated. Careful interpretation of immunological tests and consideration of the overall clinical context is essential in making therapeutic decisions. Further research is needed to understand the clinical significance of HLA-C DSAs and their impact on graft outcomes.
16TH DECEMBER 2023
ABSTRACT NO. 235
AMAUROSIS FUGAX IN A MHD PATIENT DUE TO A RARE CAUSE
J J Jeeja, R Ram, V Siva Kumar, Lakshmi Aishwarya, Surya Prakash, Namesh Kamat, Prasanna Kumar, S Mathini, Saktivel
Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India
E-mail: jeeja87here@gmail.com
BACKGROUND: Central venous obstruction (stenosis or occlusion) is common in patients with renal failure on hemodialysis and may be associated with intracranial hypertension (IH). Combination of high venous flow and central venous obstruction can lead to intracranial venous hypertension due to impaired CSF resorption. Here we discuss a case of 62 year old lady CKD on maintenance hemodialysis who developed headache decreased vision and unilateral facial edema.
AIM OF THE STUDY: To present a case of vision loss in patient on maintenance hemodialysis.
METHODS: A 62 year old lady with hypertension and chronic kidney disease on maintenance hemodialysis since 1 year via right brachiocephalic arteriovenous fistula presented with decreased vision for 6 months. It was gradually progressing along with right facial and right upper limb edema. CT upper limb angiogram reported short segment thrombosis in right brachiocephalic vein before forming superior venacava. Recanalisation with stenting was done. Following procedure her facial and right upper limb edema decreased. Her vision also improved.
CONCLUSION: Central venous stenosis is common in hemodialysis patients, affecting approximately 16-42%. The prevalence of papilledema in hemodialysis patients is low. Hemodialysis patients with intracranial hypertension should be screened with CT venography of the chest. Optimal treatment with vascular intervention will help to prevent vision loss from papilledema or nervous system damage.
16TH DECEMBER 2023
ABSTRACT NO. 236
A RARE CASE OF MAYER-ROKITANSKY-KUSTER-HAUSER SYNDROME
J J Jeeja, R Ram, V Siva Kumar, Lakshmi Aishwarya, Surya Prakash, Namesh Kamat, Prasanna Kumar, S Mathini, Saktivel
Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India
E-mail: jeeja87here@gmail.com
BACKGROUND: Mayer-Rokitansky-Kuster-Hauser syndrome is a rare congenital disorder of sex development which is characterized by agenesis of uterus cervix and upper part of vagina with or without associated renal skeletal ear or cardiac malformations. MRKH syndrome is of two types. Type 1 is uterovaginal aplasia. Type 2 is uterovaginal aplasia with extragenital malformations. Here we discuss a rare type of MRKH syndrome.
AIM OF THE STUDY: To present a rare type of Mayer-Rokitansky-Kuster-Hauser syndrome.
METHODS: This report describes a case of 17 year old girl with primary amenorrhea. On general examination she had normal secondary sexual characteristics and a vaginal dimple. Her hormonal profile were normal. Her renal parameters were deranged. Ultrasound abdomen and CT abdomen plain revealed left renal agenesis with uterine aplasia and right moderate hydroureteronephrosis. Audiometry was also performed.
CONCLUSION: MRKHS has autosomal dominant inheritance with incomplete penetrance. The prevalence of type 1 is 56-72% and type 2 is 28- 44%. Type 2 is characterized by uterovaginal aplasia and extragenital malformations.
16TH DECEMBER 2023
ABSTRACT NO. 237
RARE CASE OF CUTANEOUS HISTOPLAMSOSIS IN A RENAL TRANSPLANT RECIPIENT
Nidila Mohan, M K Mohandas, Sebastian Abraham, Krishna Suresh, R Unnikrishnan, Binoj Panekkattil
Department of Nephrology; Government Medical College; Kottayam; Kerala; India
E-mail: nidilamohan@gmail.com
BACKGROUND: Histoplasmosis is a very rare granulomatous disease caused by a dimorphic fungus Histoplasma Capsulatum. Solid organ transplant recipients on immunosuppression are at an increased risk of development of potentially fatal disseminated infections. Clinical features of histoplasmosis are non specific and often misdiagnosed as tuberculosis leading to high mortality. Isolated cutaneous presentation of histoplasmosis is uncommon. Here we report a case of mucocutaneous histoplasmosis in a 24 years old renal allograft recipient 5 years post transplantation.
AIM OF THE STUDY: Case report.
METHODS: Case report.
CONCLUSION: Although histoplasmosis can be seen in a substantial population of transplant recipients, isolated cutaneous histoplasmosis is a rare entity. Varied morphological features suggest that high degree of suspicion and tissue biopsy is required for early diagnosis and initiation of treatment.
16TH DECEMBER 2023
ABSTRACT NO. 238
PGNMID AND ITS VARIED PRESENTATION AND CLINICAL COURSE
Uttayan Chakrabarti, Rajesh Jhorawat, Nitin Kumar Bajpai, Vikarn Vishwajeet, Vikarant Verma, Aasma Nalwa, Manish Chaturvedy
Department of Nephrology; All India Institute of Medical Sciences; Jodhpur; Rajasthan; India
E-mail: jhorawat2000@gmail.com
BACKGROUND: Proliferative glomerulonephritis with monoclonal immunoglobulin deposit (PGNMID) is an entity among the spectrum of monoclonal gammopathy of renal significance (MGRS) which can manifest as altered renal function nephrotic or nephritic syndrome characterized histologically by membranoproliferative glomerulonephritis(MPGN) diffuse endocapillary mesangioproliferative or membranous nephropathy(MN) with immunofluorescence remaining the cornerstone of diagnosis differentiating it from immune complex GN. We are reporting four unusual presentations of PGNMID with different outcomes.
AIM OF THE STUDY: It is a case series.
METHODS: It is a case series.
CONCLUSION: Renal prognosis is poor, with progression to end-stage renal disease in 25% of patients within 30 months. PGNMID is a very heterogeneous pattern of renal injury with different renal and patient outcomes.
16TH DECEMBER 2023
ABSTRACT NO. 239
MONTHLY DARBEPOETIN ALFA: A SAFE AND EFFECTIVE ALTERNATIVE FOR ANEMIA CORRECTION IN CKD PATIENTS
Arjun Agarwal, Kanupriya Agarwal, Dhananjai Agarwal, Rakesh Gupta
Department of Nephrology; S.M.S. Medical College; Jaipur; Rajasthan; India
E-mail: arjunagarwal4jun@gmail.com
BACKGROUND: Nephrology SR second year.
AIM OF THE STUDY: The primary aim of this study is to evaluate the efficacy and safety of monthly darbepoetin alfa administration in the management of anemia in chronic kidney disease (CKD) patients.
METHODS: Study Design: This study will employ a prospective randomized controlled trial (RCT) design. Patient Selection: Inclusion Criteria: Adult patients diagnosed with chronic kidney disease (CKD) and anemia. Patients willing to participate in the study and provide informed consent. Exclusion Criteria: Patients with contraindications to darbepoetin alfa therapy. Patients currently receiving other treatments for anemia. Patients with uncontrolled hypertension or other comorbidities that may affect the study outcomes. Randomization: Eligible patients will be randomly assigned to one of two treatment arms: darbepoetin alfa group and erythropoietin group. Intervention: Darbepoetin Alfa Group: Patients in this group will receive monthly darbepoetin alfa injections as per the prescribed dosage. Erythropoietin Group: Patients in this group will receive erythropoietin injections following the standard dosing schedule recommended for CKD anemia.
CONCLUSION: In conclusion, our study demonstrates that monthly administration of high-dose darbepoetin alfa is a highly effective and safe approach for correcting anemia in chronic kidney disease patients. This regimen offers a substantial increase in hemoglobin levels, leading to improved overall health and quality of life for CKD patients without the burden of frequent dosing. The exceptional compliance seen in our study suggests that this treatment schedule is not only efficacious but also convenient for both patients and healthcare providers. High-dose darbepoetin alfa emerges as a promising option in the arsenal of therapies for managing anemia in CKD, offering the potential for enhanced patient outcomes.
16TH DECEMBER 2023
ABSTRACT NO. 240
THE CURIOUS CASE OF GAS IN THE GRAFT KIDNEY
K Rachana Shenoy, D S Bhadauria
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: rachanashenoy.k@gmail.com
BACKGROUND: Emphysematous pyelonephritis (EPN) denotes a severe infection of renal parenchyma resulting in necrosis and gas accumulation in the renal and perirenal tissue. Risk factors for urinary tract infections in renal transplant recipients include advanced age female gender reflux nephropathy prior to transplantation diabetes mellitus deceased donor kidney kidney pancreas transplant retransplantation antibody induction for immunosuppression urinary bladder catheterisation history of allograft rejection with subsequent escalation of immunosuppressive therapy and use of ureteral stents. There are no definite guidelines for management of EPN in renal allografts. If unstable and deteriorating graft nephrectomy should be undertaken as soon as possible. Any delay in surgical intervention be it percutaneous drainage or nephrectomy may result in death.
AIM OF THE STUDY: Case report of Acute Emphysematous Pyelonephritis in a renal transplant recipient with no traditional risk factors for urinary tract infection.
METHODS: A 25-year old male diagnosed with IgA Nephropathy (IgAN) received a living donor renal transplant from his mother in 2013 after a dialysis vintage of 3 years. He received Basiliximab induction followed by maintenance immunosuppression with Tacrolimus Mycophenolate mofetil and Prednisolone. He had no history of UTI in the immediate post-transplant period. His blood glucose levels were within normal limits and he had not had any urological intervention. In 2019 patient was diagnosed with IgAN recurrence as a cause of chronic renal allograft injury. His Creatinine at last follow up in July 2022 was 4.1mg/dL. He presented in September 2022 with fever chills vomiting pain in the right iliac fossa and inability to extend his right leg. At presentation his BP was 86/60 mmHg with pyrexia and tachycardia. Ultrasonography revealed an ill-defined collection superomedial to the graft kidney with doubtful posterior extension and air foci. Non-contrast CT study revealed a large subcapsular collection extending posteriorly into the right iliac fossa involving the right psoas major and inferiorly into the pelvis with air foci and no evidence of any urinary tract obstruction suggestive of Acute Emphysematous pyelonephritis with ruptured abscess. He was started on broad-spectrum iv antibiotics - Meropenem and Levofloxacin. Immunosuppression was reduced. Laboratory investigations revealed total leucocyte count of 37 000 cells/mm3 Creatinine of 11 mg/dL urine routine microscopy revealed field full of pus cells. Blood and urine cultures grew ESBL Escherichia coli. He was taken up for urgent urological intervention in the form of percutaneous drain insertion. Frank pus was aspirated and 200 mL drained instantaneously cultures of which demonstrated the same organism. Within 24 hours of pus drainage patient became afebrile and had pain relief. He was given 3 weeks of culture-appropriate iv antibiotics to continue another 3 weeks of oral Carbapenem. However his graft dysfunction persisted with no recovery and he became dialysis-dependent.
CONCLUSION: The complete pathogenesis of renal allograft EPN, especially in patients with no apparent traditionally described risk factors remains yet to be understood. A high degree of suspicion and early intervention may help to save the allograft.
16TH DECEMBER 2023
ABSTRACT NO. 241
THE TACTFUL BALANCE OF TACROLIMUS AND POTASSIUM
K Rachana Shenoy, Anupma Kaul
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: rachanashenoy.k@gmail.com
BACKGROUND: Calcineurin inhibitors (CNIs) Tacrolimus and Cyclosporine are the mainstay of immunosuppressive therapy regimen for solid organ transplants. Hyperkalemia is a common complication in solid organ transplant recipients seen in up to 30-70% of recipients. Type IV RTA is a rare form of acute nephrotoxicity associated with CNI use silently raising Potassium with normal Creatinine and urine output. Only <15% of such patients show high Tacrolimus trough levels. When graft function is excellent the culprit is usually pharmacotherapy. Majority of patients are usually on multiple drugs that contribute to hyperkalemia like diuretics Trimethoprim and beta blockers.
AIM OF THE STUDY: Here we report a case of difficult-to-treat hyperkalemia in a recent renal allograft recipient with high Tac levels.
METHODS: A 60-year-old male with end-stage renal disease due to diabetic kidney disease and on maintenance hemodialysis underwent a living related donor ABO compatible renal transplantation with his wife being the donor. He received Basiliximab induction and was managed on triple drug immunosuppressive therapy (Prednisolone 20 mg/day Mycophenolate mofetil 2 g/day and Tacrolimus 9.5 mg/day (0.16 mg/kg/day in divided doses). The serum creatinine reached a nadir value of 0.8 mg/dL on the ninth post-ope-rative day. On the 14th post-operative day the patient developed hyperkalemia (6.4 mEq/L). Tacrolimus trough level was 10.4 ng/mL. Blood gas analysis revealed normal anion gap metabolic acidosis suggesting a distal type IV RTA. He was started on medical correction of hyperkalemia despite which the patient had persistently high Potassium levels. Cotrimoxazole was withheld. He was started on oral bicarbonate supplements as well as a low dose thiazide diuretic (Tab CTD 12.5 mg OD). Serum Potassium levels did not subside even after 72 hours of diuretic therapy. As a last resort Fludrocortisone was added at 0.1 mg/day. Within 24 hours of starting therapy Potassium levels started declining steadily. He was given a total of 10 days of aldosterone agonist therapy and at discharge his Potassium was 4.8 mEq/L after 2 days of withholding the drug.
CONCLUSION: Life-threatening hyperkalemia can occur with Tacrolimus therapy. A high index of suspicion must therefore be maintained for type IV RTA in the presence of normal anion gap metabolic acidosis with associated hyperkalemia and hyperchloremia. Thiazide diuretics and Fludrocortisone appear to be effective therapies in countering this Potassium imbalance caused by an indispensable drug in solid organ transplant recipients.
16TH DECEMBER 2023
ABSTRACT NO. 242
AUTOSOMAL RECESSIVE ALPORT SYNDROME PRESENTING AS STEROID RESISTANT NEPHROTIC SYNDROME
M Kathirvel, Tathagata Mukherjee, Kaushik Bhattacharjee, Atanu Pal, Sanjay Das Gupta, Arunansu Bandyopadhyay
Department of Nephrology; IPGMER and SSKM Hospital; Kolkata; West Bengal; India
E-mail: kathir.kmp@gmail.com
BACKGROUND: Alport syndrome is a heterogeneous disease affecting the glomeruli cochlea and ocular basement membrane caused by mutations in collagen IV genes COL4A3 COL4A4 COL4A5 which leads to hematuria proteinuria and chronic progressive renal dysfunction. It may also be associated with extra renal manifestations such as sensorineural hearing loss retinopathy etc.
AIM OF THE STUDY: To study the alport syndrome presenting as primary steroid resistant nephrotic syndrome.
METHODS: A 9 years old male child born out of consanguineous marriage with a family history of focal segmental glomerulosclerosis developed anasarca and bilateral hearing loss at 8 years of age and he was diagnosed to have childhood onset nephrotic syndrome. He was started on full dose oral prednisolone at 2 mg/kg/day but he failed to achieve complete remission even after 6 weeks of therapy and hence diagnosed as primary steroid resistant nephrotic syndrome. He was started on Tacrolimus as a steroid sparing agent. Meanwhile his audiometry showed bilateral sensorineural hearing loss. His renal biopsy revealed focal segmental glomerulosclerosis and electron microscopy showed criss cross arrays and basket wave like patterns. Genetic study of him showed COL4A4NM_000002.5 homozygous autosomal recessive mutation.
CONCLUSION: This case report reiterates the need for renal biopsy and genetic testing in patients with steroid resistant nephrotic syndrome, nephrotic syndrome with systemic features and extra renal involvement, and those patient with family history of focal segmental glomerulosclerosis.
16TH DECEMBER 2023
ABSTRACT NO. 243
OSMOTIC NEPHROPATHY PRESENTING AS RPRF- A SURPRISING POSSIBILITY?
Zenila Bordoloi, Dhrubajyoti Choudhury, Tonmoy Das
Department of Nephrology; Apollo Hospital; Unit International; Guwahati; Assam; India
E-mail: zenila90@gmail.com
BACKGROUND: Osmotic nephropathy is seen due to use of iv hypertonic fluids like mannitol iv immunoglobulins low molecular weight dextran hydroxy ethyl starch iv radiocontrast agents drugs like sglt2 inhibitors etc. There is accumulation of proximal tubular lysosomes due to administration of exogenous solutes. The functional and structural changes due to osmotic nephrosis are mild and reversible however some cases progress to severe acute kidney injury and even end stage renal disease. Here we present a case of osmotic nephropathy presenting as rapidly progressive renal failure.
AIM OF THE STUDY: A 29year old male non- diabetic non-hypertensive presented with the complaints of palpitations and abdominal discomfort with no prior history of any significant medical illnes. Initial evaluation revealed deranged renal parameter with creatinine of 22 severe left ventricular dysfunction with ejection fraction of 20% normal hemogram and elevated liver enzymes. Urine analysis suggested active urine sediment and ultrasound abdomen showed normal sized kidneys with increased echotexture. Immunological markers evaluation ANA was negative but C-ANCA came positive.
METHODS: Patient stabilised with urgent hemodialysis and supportive treatment. He developed tachyarrhtymia and managed with amiodarone infusion. Further he underwent 7 sessions of hemodialysis and after stabilisation renal biopsy was done. Based on clinical presentation as rapidly progressive renal failure and consideing ANCA positivity iv methylprednisolone pulse therapy was given followed by iv cyclophosphamide.
CONCLUSION: Hence here we would like to discuss is there anything we missed out? Can osmotic nephropathy present as rapidly progressive renal failure? What else do we need to know about osmotic nephropathy?
16TH DECEMBER 2023
ABSTRACT NO. 244
EFFECT OF BLOOD FLOW RATE ON PHOSPHATE REMOVAL AND ITS IMPACT ON ADEQUATE DIALYSIS
Namesh Kamat, R Ram, V Sivakumar
Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India
E-mail: nameshkamat217@gmail.com
BACKGROUND: Patients with end stage renal disease are unable to sustain life without dialysis support. Dialysis delivery should be adequate not only to improve the quality of life but also to prolong survival. Thus the aims of dialysis are to decrease morbidity increase quality of life and prolong life span. Inadequacy of dialysis and its resultant effects like hyperphosphatemia and hyperurecemia are one of the determinants of morbidity and mortality in patients on maintenance hemodialysis. Hyperphosphatemia in chronic kidney disease is associated with increased vascular calcification and poor cardiovascular outcome. The blood flow rate is directly proportional to clearance of solutes and hence blood flow rate during dialysis is an important determinant of dialysis adequacy and phosphate removal.
AIM OF THE STUDY: The aim of this study was to assess the effect of increasing blood flow rate on dialysis adequacy and phosphate removal in patients on hemodialysis at tertiary care setting SVIMS Tirupati.
METHODS: The study was conducted in out-patient hemodialysis unit of SVIMS Tirupati.100 patients were included in this cross-sectional study. Each patient received six consecutive dialysis sessions as follows: three consecutive sessions with a blood flow rate at 250 ml/min followed by three consecutive sessions with a blood flow rate at 300 ml/min without changing other parameters of dialysis. Patient body weight was recorded and blood samples (blood urea and serum phosphate) were collected at the beginning and end of third session of dialysis at 250 ml/min and 300 ml/min blood flow rate. For assessing efficacy of dialysis urea reduction ratio (URR) URR = ((predialysis urea-post dialysis urea)—100)/(predialysis urea) and Kt/V Daugridas Kt/V = -log((PosthdBUN/prehdBUN)-0.03)+(4-3.5*(posthdBUN/prehdBUN) )*(UF/weight) and phosphate reduction ratio (PRR) PRR = ((prehd phosphate-post hd phosphate)*100)/(pre hd phosphate) were used.
CONCLUSION: Increasing blood flow rate by 60% i.e. from 250ml/min to 300ml/min, is effective in increasing dialysis dose and phosphate reduction ratio during haemodialysis hence helps to improve the morbidity, increase quality of life and improve cardiovascular outcomes. Future prospective studies are needed to evaluate the impact of increasing blood flow rate on phosphate removal and its impact on cardiovascular system.
16TH DECEMBER 2023
ABSTRACT NO. 245
THE HERPES CHRONICLES- AN UNUSUAL PRESENTATION IN A KIDNEY TRANSPLANT RECIPIENT
Lovy Gaur, Sandeep Kumar, Rajan Duggal, Manoj Singhal
Department of Nephrology; Max Super Speciality Hospital; Ghaziabad; Uttar Pradesh; India
E-mail: drlovygaur@gmail.com
BACKGROUND: Infection remains an important cause of morbidity in kidney transplant recipients. The immediate post-transplant period is fraught with the threat of both infections and rejection; biopsy is crucial in ascertaining the cause of graft dysfunction. Herpes simplex infections are not uncommon in solid organ transplant recipients but only two instances of histopathologically confirmed HSV-related graft interstitial nephritis have been described in the existing literature.
AIM OF THE STUDY: This case report intends to highlight the clinical trajectory of a kidney transplant recipient complicated by HSV-related interstitial nephritis and his subsequent recovery following appropriate treatment.
METHODS: A 32-year-old gentleman underwent second kidney transplantation the donor being his mother. He received induction therapy with anti-thymocyte globulin (ATG) followed by standard triple-drug immunosuppression. Graft recovery was good however within a week of the transplant he developed HSV-related esophageal ulcers following which he was initiated on oral valganciclovir. His symptoms abated and he was discharged with a serum creatinine of 0.9 mg/dl. On his subsequent follow-up visit he was noted to have creatinine of 2.1 mg/dl prompting a kidney biopsy on POD-15. On histopathology diffuse acute tubular injury was noted with cytopathic changes in tubular cells with positivity for HSV-2 on immunohistochemistry. He was initiated on intravenous acyclovir which was continued for 2 weeks. Graft function improved with serum creatinine declining to 1.0 mg/dl after 2 days.
CONCLUSION: HSV-related interstitial nephritis is an unusual presentation of herpes infection but may be organ-threatening or even life-threatening. A high degree of clinical suspicion and biopsy may be necessary to differentiate it from acute rejection. Prompt diagnosis and treatment are crucial to ensure good graft and patient outcomes.
16TH DECEMBER 2023
ABSTRACT NO. 246
POST TRANSPLANT TMA SECONDARY TO IGAN
K Rachana Shenoy, D S Bhadauria
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: rachanashenoy.k@gmail.com
BACKGROUND: Thrombotic microangiopathy (TMA) in renal allograft recipients is most attributed to calcineurin inhibitor toxicity. Other possible etiologies include antibody-mediated rejection (ABMR) infections including viruses like CMV BKV Parvo B19 Hepatitis C; other drugs like mTOR inhibitors ischemia-reperfusion injury and pregnancy. Incidence is about 5-15% across studies. TMA in the post-transplant setting can be either recurrent or de novo. De novo TMA is more common and has worse prognosis. A retrospective study of TMA in 958 renal allograft biopsies where clinical and histopathological features were correlated showed that de novo TMA occurred in 6.1% of patients with C4d positivity in 55%. The most common cause of TMA was ABMR in this population with glomerulitis and peritubular capillaritis being significantly more prominent when compared to non-ABMR related TMA. A 5-year single centre study of 1520 renal allograft biopsies of TMA from South Asia revealed 61 graft-limited TMA (4.1%) with most common etiology being ABMR.
AIM OF THE STUDY: We report a case of post-transplant TMA secondary to recurrence of IgA nephropathy (IgAN).
METHODS: A 28-year old female diagnosed with IgA nephropathy in 2013 underwent ABO-compatible living donor kidney transplantation with her mother as donor in 2015. She received no induction and had excellent graft function. She was continued on triple immunosuppression with Tacrolimus Mycophenolate mofetil and Prednisolone; along with Amlodipine for hypertension. She had an uneventful period after renal transplantation surgery up until current event. Her antimetabolite drug was changed to Azathioprine in February 2021 for a planned pregnancy in the future. She had a natural conception in December 2021. She had a normal antenatal period with no evidence of proteinuria or worsening graft function. Therapeutic drug monitoring was done frequently and CNI dosages were optimized accordingly. She underwent emergency lower segment Caesarean section at 33+ weeks in view of fetal distress and worsening graft function. At discharge from the maternity ward her Creatinine was 1.6mg/dL with optimal Tacrolimus trough levels. 3 months following delivery she presented to Ophthalmology OPD with sudden onset blurring of vision and severe headache of 2 days duration. On examination she had blood pressure of 240/140mmHg bilateral papilledema and Grade IV hypertensive retinopathy on fundus examination. Work up revealed Creatinine- 5.3mg/dL thrombocytopenia (Platelet count- 40 000/mm3) anemia (Hemoglobin- 8.4g/dL) raised lactate dehydrogenase. In view of advanced graft dysfunction and oliguria she was started on intravenous Methyl Prednisolone 500mg daily for 3 doses. Her platelet count improved after 2 days. She underwent graft kidney biopsy which revealed changes of TMA with IgAN.
CONCLUSION: TMA in the renal allograft is a challenging disease to treat, by virtue of its severity and various etiologies. Early syndromic recognition and necessary intervention may help to save the renal allograft.
16TH DECEMBER 2023
ABSTRACT NO. 247
AN EAGLE’S EYE FOUND AN ODD INFECTION IN A MALE PATIENT WITH ACTIVE LUPUS NEPHRITIS - A RARE EVENT
Abhishek Jha, Himanshu Sekhar Mahapatra, Muthukumar B, Beauty Suman
Nephrology; ABVIMS and Dr. RML Hospital; New Delhi; India
E-mail: abhishekjha099@gmail.com
BACKGROUND: Lupus nephritis (LN) is often severe and diagnosed late in affected male patients. Infections are common in lupus patients and are often associated with high morbidity and mortality. Kidney biopsy is the gold standard for diagnosing and staging LN. We report an odd unusual finding in the kidney in a male patient with active LN.
AIM OF THE STUDY: To report an uncommon infectious event hiding in the body was revealed by its smaller presence in the kidney in a case of male Lupus Nephritis.
METHODS: A 36-year-old male with no other co-morbidities had generalised anasarca hematuria and frothuria. He was diagnosed as SLE with LN supported by laboratory investigations which revealed anaemia leucopenia microscopic hematuria and sub nephrotic range proteinuria immunological examination showed positive for ANA hypocomplementemia was suggested renal biopsy but the patient was unwilling for it. He was started on MMF induction with steroids which he continued till December 2022 with irregular follow-up. His symptoms improved and he stopped all medication in January 2023. Four months later in April 2023 he again presented with anasarca frothuria breathlessness and episodes of fever on and off. The patient was examined and investigated and results were recorded.
CONCLUSION: Infections are common in lupus patients. Finding cryptococcus in renal tissue in the background of active systemic and renal lupus. It could be easily missed. It also documents the challenge of therapy in patients with severe fungal infection and high disease activity.
16TH DECEMBER 2023
ABSTRACT NO. 248
THE SPECTRUM OF RENAL BIOPSY FINDINGS IN PATIENTS WITH DIABETES
T Chakravarthy 1 , S Dheepa 2
1 Department of Nephrology; KG Hospital; Coimbatore; 2 Department of Pathology; SRM Instuite; Chennai; Tamil Nadu; India
E-mail: chakravarthy608@gmail.com
BACKGROUND: Diabetes mellitus is one of the most important health problems worldwide. As the prevalence of DM has reached epidemic proportions the number of renal biopsies performed is increasing. Patients with diabetes subjected to renal biopsy may manifest Diabetic Nephropathy (DN) alone DN with superimposed nondiabetic renal disease (NDRD) or NDRD alone.
AIM OF THE STUDY: (1) To assess the frequency of diabetic and non-diabetic renal disease in diabetic patients who undergo renal biopsy. (2) To correlate the various clinical parameters and laboratory data with occurrence of Diabetic Nephropathy and Non Diabeteic Renal Diseaase.
METHODS: This is a combined retrospective and prospective study for a period of 5 years January 2015 to December 2019. Relevant clinical and other details were collected from patent’s clinical records slides were retrieved from the archives of the Department of Nephrology and were studied.
CONCLUSION: This was a comprehensive study of renal biopsies in diabetic patients. With the help of detailed laboratory data with clinical history and histopathological features, the study was correlated with other literatures and studies. It is frequent to discover more than one disease process in a diabetic renal biopsy, hence renal biopsy is an invaluable tool in detecting non-diabetic renal changes in patients with Diabetic Nephropathy and also helps in assessing the prognosis and guiding management decision in these patients.
16TH DECEMBER 2023
ABSTRACT NO. 249
NEUROLOGICAL MANIFESTATIONS IN POST RENAL TRANSPLANT RECEPIENTS
S L Devika, T P Noushad, Sajeev, Vineetha, Basil Thambi
Department of Nephrology; Government Medical College; Thiruvananthapuram; Kerala; India
E-mail: sldevika1992@gmail.com
BACKGROUND: Neurological manifestations post renal transplant.
AIM OF THE STUDY: Clinical varied neurological presentations post renal transplant.
METHODS: Observational study.
CONCLUSION: Being immunosuppressed patients may not present with typicalnsymptoms of infection. But being post renal transplant high index of suspicion of infection and drug related toxicity should be there to avoid delay in diagnosis.
16TH DECEMBER 2023
ABSTRACT NO. 250
RARE PRESENTATION OF YOUNG MALE WITH MULTIPLE MYELOMA PRESENTING AS PROXIMAL TUBULOPATHY WITH LIGHT CHAIN CAST NEPHROPATHY
T Surya Prakash, Namesh Kamat, R Ram, V Siva Kumar
Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India
E-mail: suryaprakashnephro@gmail.com
BACKGROUND: Multiple Myeloma (Mm) Is Described As a Hematologic Malignancy Characterized By The Neoplastic Proliferation Of a Single Clone Of Plasma Cells Producing a Monoclonal Immunoglobulin. It Has Been Known To Be a Disease Of Older Adults Where The Median Age At Diagnosis Is 66 Years. Only 10 Percent Are Younger Than 50 Years a Mere 2 Percent Of Patients Are Younger Than 40 Years and 0.3% in less than 30 years. Our patient being 26 years aged falls in this 0.3% category. Generally younger males have good prognoses but our patient directly presented with high creatinine around 10.4 mg/dl which was a poor prognostic sign.
AIMS OF THE STUDY: To report rare presentation of multiple myeloma in young male with proximal tubulopathy abd light chain cast nephropathy.
METHODS: Case Description: 26-year-old male non-diabetic hypertensive for the past three months presented with history of fever and vomiting for one week.on examination he had blood pressure of 170/90 mm of hg pulse rate-88/min pedal edema +ve.his ABG showed ph-7.33 pco2-29 hco3-15.31.on investigation he had a serum creatinine of 10.46 mg/dl.hishb was 11.4 tlc-13200 plt-2.89 lakhs na-137 k+-5.6. His urine examination revealed albumin-1+ sugar-nil pus cells-3-4 epithelial cells-1-2 rbc-occasional. His 24 hr urine protein was 3699 mg/24 hours.he was initiated on hemodialysis. After a few sessions his creatinine came down to 6 mg/dl. Later his creatinine started to increase despite of hemodialysis. Renal biopsy was done because of non-resolving aki. Biopsy report was showing lambda light chain cast nephropathy and lambda light chain proximal tubulopathy. Bone marrow biopsy was done which revealed 48% plasma cells-plasma cell myeloma. Serum electrophoresis revealed M BAND and diagnosis of multiple myeloma was made and initiated on bortezomib cyclophosphamide and dexamethasone.
CONCLUSION: Multiple myeloma is a disease of the elderly, but rarely it may affect younger patients. When tumour burden is high, they present with cast nephropathy or other forms of the disease with precipitating factors being dehydration, NSAIDs, hypercalcemia, hyperuricemia, and contrast administration. Patients with severe renal failure and creatinine >2 have poor outcomes.
16TH DECEMBER 2023
ABSTRACT NO. 251
FRAILTY IN PATIENTS WITH CHRONIC KIDNEY DISEASE STAGE 5
Jerry Joseph, Edwin Fernando, V Murugesan, S Thirumavalavan, K Thirumal Valavan, N D Srinivasa Prasad, S Sujit, A Poongodi
Department of Nephrology; Government Stanley Medical College and Hospital; Chennai; Tamil Nadu; India
E-mail: jerry16joseph@gmail.com
BACKGROUND: Frailty is a construct developed to characterise a state of reduced functional capacity in older adults. However there are limited data describing the prevalence or predisposing factors of frailty in chronic kidney disease patients particularly those of CKD 5.
AIMS OF THE STUDY: To study the prevalence of frailty in patients with CKD stage 5 and to assess co-existing factors associated with frailty in chronic kidney disease.
METHODS: Prevalence of frailty was studied in CKD 5 patients from November 2021 to November 2022. CKD 5 patients of age more than 18 years were included. Patients on maintenance hemodialysis and CKD 5 patients on pre-dialysis care were included. Patients with active infection and significant morbidity were excluded. History and clinical examination were done; laboratory data recorded. Frailty assessment was done using modified Frieds criteria. Frailty was defined based on previously validated Frieds criteria which included 1. Slowness 2. Weakness 3. Unintentional weight loss 4. Exhaustion 5 Low physical activity. Patient is considered frail if three or more components are present. Prevalence of frailty in participants on pre-dialysis care and on dialysis care was evaluated along with association of frailty with coexisting factors.
CONCLUSION: Frailty is a marker of increased vulnerability to adverse outcomes. Significant proportion, 41% of CKD 5 patients are frail. Dialysis does not affect the prevalence of frailty in stage 5 CKD patients. Old age, comorbidities (diabetes, heart failure, coronary artery disease, cerebro-vascular accident), native kidney disease, edema and presence of intradialytic hypotension are significantly associated with frailty. CKD patients with above mentioned conditions should receive special care to reduce development of frailty.
16TH DECEMBER 2023
ABSTRACT NO. 252
NON-RENAL CAUSES OF ANEMIA IN CHRONIC RENAL DISEASE PATIENTS BEYOND CONVENTIONAL THINKING!
Nidhi Gupta, Anupama Kaul, Manas Behera, Narayan Prasad, Dharmendra Bhadauria, Manas Patel, Ravi Kushwaha, Monica Yaccha
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: drnidhigupta0625@gmail.com
BACKGROUND: Anemia a basic disease which seems simple but difficult to diagnose. Anemia is a frequent complication of chronic kidney disease (CKD) and it is associated with a decrease in the quality of life of patients causing in increase morbidity and mortality. Anemia defined as a haemoglobin (Hgb) concentration of <13 g/dl in men and <12 g/dl in women is an important complication of CKD. The prevalence of anemia increases across the advancing stages of CKD with estimates anywhere from 7%-50% in the more advanced stages of the disease. Not all anemias in CKD are of renal origin.
AIMS OF THE STUDY: Here we are presenting ten interesting cases where refractory anaemia in the setting of CKD was the clue that led us to think beyond anaemia of chronic disease.
METHODS: A detailed history and intense diagnostic work-up is required for ascertaining the causes of anaemia in CKD settings as we present different causes of anaemia beyond the conventional causes. One must look for systemic causes in association with CKD to arrive at a differential.
CONCLUSION: Anaemia in renal disease patients should not be underestimated. While approaching the patient for anaemia, differentials should always be kept. Patients who are not responding to the therapeutic dose of erythropoietin stimulating agents and hematinic need further evaluation.
16TH DECEMBER 2023
ABSTRACT NO. 253
RARE ASSOCIATION OF DONOR SPECIFIC ANTIBODY NEGATIVE ANTIBODY MEDIATED REJECTION WITH SEGMENTAL THROMBOSIS AND INFARCTION.
Aneesh Nanda, Jitendra Kumar
Department of Nephrology, Accord Superspeciality Hospital; Faridabad; Haryana; India
E-mail: aneeshnanda@hotmail.com
BACKGROUND: Transplant Renal artery thrombosis (RAT) is uncommon vascular complication following kidney transplant. It may be responsible for 2-7 % of early graft loss in adult and upto 35% in children. Most cases occur early in post-operative period following technical problems like intimal dissection kinking or torsion of the vessels. However thrombus formation can be delayed until after first week. Although acute rejection may cause renal artery thrombosis but association of acute rejection with segmental thrombosis is very rare. In this article we are presenting a case of Donor specific antibody negative antibody mediated rejection associated with segmental thrombosis and importance of ultrasound Renal Doppler besides graft biopsy in patients with acute graft dysfunction.
AIMS OF THE STUDY : A 36-year-old male k/c/o hypertension with chronic kidney disease stage 5 on maintenance haemodialysis underwent a living ABO compatible emotionally related donor transplantation on 22/11/2022. After an initial induction with anti thymocyte globulin the patient received triple immunosuppression which include prednisolone mycophenolate mofetil and tacrolimus. Type of anastomosis done was end to side (allograft renal artery to recipient external iliac artery and there was no intra operative complications. A clinical improvement with good diuresis was achieved and was discharged with nadir creatinine of 1.3 mg/dl.
METHODS: After 1 week patient was re-admitted with complaints of decrease urine output for 1 day associated with nausea and vomiting. Laboratory investigation showed rising creatinine trend (1.3 to 5.0) with arterial blood gas showing metabolic acidosis. Other laboratory investigation showed raised LDH (1432) tacrolimus level was 9.0 mg/dl. Peripheral smear showed no evidence of hemolysis in the form of schistocytes or drop in hemoglobin and patient coagulation studies were normal. With a clinical suspicion of acute rejection/ ABMR serum DSA and graft biopsy was done and was initiated on antirejection therapy (steroid pulse and plasmapheresis with IvIg) along with haemodialysis support. The donor specific antibody (Luminex method) was negative.
CONCLUSION: In contrast to total graft thrombosis, segmental thrombosis is uncommonly recognised. Although some reports suggest acute rejection as cause of graft thrombosis, but segmental thrombosis with infarction secondary to rejection has not been reported so far.
16TH DECEMBER 2023
ABSTRACT NO. 254
STUDY OF PROFILE OF CHRONIC KIDNEY DISEASE RELATED MINERAL BONE DISORDERS IN HEMODIALYSIS PATIENTS- A STUDY FROM RESOURCE LIMITED TERTIARY CARE SETUP
Snigdha Bachalakuri, Manjusha Yadla, B Vikram Kumar, Sreekanth Burri
Department of Nephrology; Gandhi Hospital; Hyderabad; Telangana; India
E-mail: snigzzz@gmail.com
BACKGROUND: Majority of Chronic kidney disease (CKD) patients are at an increased risk of developing disturbances of bone and mineral metabolism. These disturbances lead to a constellation of bone lesions which was previously referred to as renal osteodystrophy (ROD) manifesting as bone pain muscle-tendon rupture pruritus and high incidence of fractures. Patients with ROD are also predisposed to cardiovascular calcification with associated high morbidity and mortality rates. The term ROD does not encompass this important extraskeletal manifestation. Therefore to address these drawbacks and accommodate the extra skeletal manifestations The KDIGO workgroup recommended a broader term CKD mineral and bone disorder (CKD-MBD) for the systemic disorder of mineral and bone metabolism due to CKD and that the term renal osteodystrophy should exclusively be used to describe disorders in bone morphology associated with CKD CKD-MBD should be defined as: A systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: (i) abnormalities of calcium phosphorus PTH or vitamin D metabolism; (ii) abnormalities in bone turnover mineralization volume linear growth or strength; or (iii) vascular or other soft tissue calcification Several observational studies have shown an association between deranged markers of CKD-MBD and poor clinical outcomes in both predialysis and dialysis patients. For example elevated levels of phosphate calcium and PTH have been shown to be associated with cardiovascular-specific mortality in patients with CKD.
AIMS OF THE STUDY: To study the profile of mineral bone disorders in maintenance hemodialysis patients.
METHODS: Deatiled history onset of symptoms demographic profile biochemical profile- CBP/RFT/SE/ALP/CA/PO4/UA VIT D3 i PTH ASSAY USG NECK, skeletal survey Categories definition Hypocalcemia (corrected Ca< 8.5 mg/dL) Hypercalcemia (corrected Ca>10.5 mg/dL) Hyperphosphatemia (PO4 >4.5 mg/dL) Hypophosphatemia (PO4 <2.5 mg/dL) Vitamin D -Deficiency (<10 ng/mL) Insufficiency (10- 20 ng/mL) and Sufficiency (>20 ng/mL) Hyperparathyroidism was defined as iPTH levels of > 300 pg/ml. Adynamic bone disease in CKD 4 and 5 was defined as iPTH<100 pg/Ml National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003;42(4 Suppl 3): S1-201.
CONCLUSION: iPTH correlates significantly with Calcium, Phosphorous, Uric Acid, Alkaline phosphatase. Ultrasonography abnormalities of parathyroid gland are noted in 29.6%of the study group. Renal osteodystrophy was noted in 73.3% of the study population, of which Brown tumor was observed in 0.7%.
16TH DECEMBER 2023
ABSTRACT NO. 255
EFFECTIVENESS OF PROBIOTICS (PROCITE®) SUPPLEMENTATION ON UREMIC TOXINS AMONG STAGE 3-5 NON-DIALYSIS CHRONIC KIDNEY DISEASE PATIENTS: A REAL-WORLD OBSERVATIONAL STUDY
Yashpal Jadeja, Umapati Hegde, Monika Prasad
Biocon Biologics Limited Biocon House Electronics City Phase II; Bengaluru; Karnataka; India
E-mail: yashpal.jadeja@biocon.com
BACKGROUND: Gut dysbiosis is linked to CKD and cardiovascular disease progression. Probiotics have the potential to slow progression. A small number of studies have suggested that supplementation of probiotics may decrease CKD progression.
AIMS OF THE STUDY: Aim of this study was to determine the effectiveness of Procite (probiotics) supplementation in lowering uremic toxins in CKD patients.
METHODS: Real-world observational study in a tertiary care hospital and included patients aged 18-75 years with CKD stages 3-5 not on dialysis. Patients were given one capsule of Procite® containing 70 billion cfu of probiotic strains for 90 days in addition to the standard of care. Serum creatinine and blood urea were assessed on day 0 1 month and 3 months.
CONCLUSION: Supplementation of Probiotics in CKD was associated with lowering urea, creatinine and stabilising the condition. Probiotics can be helpful to adjuvant therapy in the management of CKD.
16TH DECEMBER 2023
ABSTRACT NO. 256
RENAL MALACOPLAKIA: A RARE CAUSE OF EARLY GRAFT DYSFUNCTION IN POST TRANSPLANT PATIENT
Teja Chimtalapudi, Aswini Panigrahi, Aswini Panigrahi
Department of Nephrology; Apollo Hospital; Hyderabad; Telangana; India
E-mail: dr.thejasaiprasad@gmail.com
BACKGROUND: Malakoplakia is a rare inflammatory disorder that affects predominantly the urinary tract and kidneys. An immunodeficient state favours the development of malakoplakia since 40% of patients who have developed this condition had immunosuppressive drugs. E. coli was detected in 80% of cases. Michaelis-Gutmann bodies are pathognomonic for malakoplakia. Given the potential for significant morbidity if missed malakoplakia should be included in the differential diagnosis of renal transplant recipients who present with recurrent urinary tract infections or acute kidney injury with an associated mass in the urinary tract.
AIMS OF THE STUDY: 47 years female CKD 5T (NKD CTIN) underwent deceased renal transplant in oct 22 with good graft function at the time of discharge diagnosed to have NODAT in follow up Had h/o recurrent UTI and pyelonephritis with culture positive E coli thrice in the span of 7 months with progressive worsening of renal parameters despite treating infection.
METHODS: BIOPSY REVEALED TYPICAL Michaelis-Gutman bodies features suggestive of renal malakoplakia and one of the rare case of malakoplakia in early post transplant.
CONCLUSION: Given the potential for significant morbidity if missed, malakoplakia should be included in the differential diagnosis of renal transplant recipients who present with recurrent urinary tract infections or acute kidney injury with an associated mass in the urinary tract.
16TH DECEMBER 2023
ABSTRACT NO. 257
POST RENAL TRANSPALNT CHRONIC DIARRHOEA AND FUNGAL COLITIS
Giribabu Gorakala, Manisha Sahay, Kiranmai Ismail
Department of Nephrology; Osmania Medical College and Hospital; Hyderabad; Telangana; India
E-mail: giribabugorakala@gmail.com
BACKGROUND: 28/F known case of CKD5D -CIN underwent cadaveric renal transplant in 2019 presented with chronjc diarrhoea and weight loss for one year.
AIMS OF THE STUDY: Evaluation and management of chronic diarrhoea in post renal transplant patients.
METHODS: Patient underwent routine stool examination multiplex PCR upper GI and lower GI endoscopy. Colonoscopic biopsy revealed fungal growthand culture revealed sporothrixschenkii
CONCLUSION: Proper evaluation and timely management of diarrhoea in post renal transplant patients is very crucial as it preserves quality of life, graft survival and overall well being.
16TH DECEMBER 2023
ABSTRACT NO. 258
A RARE CASE OF DIABETIC GLOMERULOSCLEROSIS WITH CRESCENTS : A CASE REPORT
Adityakumar Venkata Mullapudi, S Ananth, P L Venkata Pakki Reddy, M Sreedhar Sharma
Department of Nephrology; Kurnool Medical College; Kurnool; Andhra Pradesh; India
E-mail: mvadityakumar@rediffmail.com
BACKGROUND: Glomerular crescents which arise from the accumulation of cells in Bowman’s space that encircle and compress the glomerulus are predominantly linked to rapidly progressive crescentic glomerulonephritis (RPGN). However they also emerge in response to a broad spectrum of primary and secondary glomerular injuries such as lupus nephritis purpura nephritis IgA nephropathy post-infectious glomerulonephritis and membranoproliferative glomerulonephritis (MPGN). It is not surprising that these glomerulopathies occasionally overlap with diabetic glomerular injuries. Consequently the presence of crescents in renal biopsy specimens of diabetics may have prompted an investigation into etiologies other than diabetes. In this report we present an exceptional case of diabetic glomerulosclerosis with distinctive extracapillary proliferation.
AIMS OF THE STUDY: In this study we present an atypical case of diabetic glomerulosclerosis featuring distinctive extracapillary proliferation. Although the etiological connection between diabetic glomerulosclerosis and crescent development has been largely overlooked in the literature it may not be an uncommon occurrence. We have conducted a comprehensive review of previous literature and herein discuss the pathological implications of crescent formation in patients with diabetic glomerulosclerosis.
METHODS: In December 2022 a female patient aged 39 years was admitted to our hospital with complaints of progressive swelling of the legs and shortness of breath. Over the past five months she had gained approximately 10 kg. Seven years prior to admission the patient was diagnosed with type 2 diabetes with a fasting blood glucose (FBS) of 231 mg/dl and HbA1c of 9.6 for which insulin therapy was recommended. However the patient’s compliance with medication was poor resulting in poor glycemic control. The patient denied smoking alcohol consumption or drug use and no apparent history of renal disease was noted. Upon physical examination the patient exhibited facial swelling and edema in the upper and lower extremities with a blood pressure reading of 164/106 mmHg. There was no rash or lymphadenopathy and no petechiae were found. The patient’s heart sounds were normal. Renal sonography revealed that the size of both kidneys and each renal cortex echogenicity were normal while a cardiac echogram indicated mild concentric LVH with normal left ventricular ejection fraction. Her serum Creatinine was 1.1 mg/dl. Her 24 hour urinary protein excretion was 8 grams. Her fundoscopy showed non-proliferative diabetic retinopathy in both eyes. She underwent renal biopsy on 19th December 2022.
CONCLUSION: The present study reports an atypical case of diabetic glomerulosclerosis characterized by distinctive extracapillary proliferation. While the association between diabetic glomerulosclerosis and crescent formation has received limited attention in prior literature, it is possible that such a correlation is not uncommon. Additional research and a greater accumulation of renal biopsy data are necessary to more accurately ascertain the diagnostic and clinical significance of glomerular crescents in individuals with diabetic glomerulosclerosis.
16TH DECEMBER 2023
ABSTRACT NO. 259
THROMBOTIC MICROANGIOPATHY AND ACUTE KIDNEY INJURY ASSOCIATED WITH RECURRENT PANCREATITIS: A CASE REPORT
Niranjan AV, Nishant Nadda
Department of Nephrology; PGIMER; Chandigarh; India
E-mail: niranjanav7@gmail.com
BACKGROUND: A 28-year-old male with a history of recurrent pancreatitis presented with abdominal pain reduced urine output and yellowish discoloration of the skin. His initial evaluation revealed severe anemiathrombocytopenia and rapidly rising serum creatinine. Peripheral blood film demonstrated 11% schistocytes and LDH levels were elevated. The patient was suspected to have TMA and plasmapheresis (PLEX) was initiated on the first day of admission. Over five PLEX sessions his platelet count LDH levels and creatinine gradually improved. A CT abdomen revealed acute necrotizing pancreatitis without organized collections. Despite normal ADAMTS13 activity and negative anti-complement factor H (CFH) antibody genetic testing for aHUS was not pursued due to financial constraints. The patient was discharged with a creatinine level of 1.56 mg/dl.
CONCLUSION: TMA, including aHUS, should be considered in the differential diagnosis of AKI with characteristic peripheral blood film findings, even in the absence of ADAMTS13 deficiency or anti-CFH antibodies. Recurrent pancreatitis may act as a trigger for TMA in susceptible individuals. Timely initiation of PLEX can lead to significant clinical improvement. Further investigation, including genetic testing, is essential for a comprehensive understanding of the underlying etiology and to guide long-term management strategies.
16TH DECEMBER 2023
ABSTRACT NO. 260
CRESCENTIC GLOMERULONEPHRITIS IN HIV - A CASE BASED LITERATURE REVIEW
A V Niranjan, Prabhav, Jasmine Sethi
Department of Nephrology; PGIMER; Chandigarh; India
E-mail: niranjanav7@gmail.com
BACKGROUND: Glomerular crescents which arise from the accumulation of cells in Bowman’s space that encircle and The spectrum of kidney diseases in HIV-infected individuals is broad with common conditions like HIV-associated nephropathy (HIVAN) and immune complex kidney disease. However crescentic glomerulonephritis is a rare renal manifestation in people living with HIV/AIDS (PLHA). It can stem from various causes including HIV-associated immune complex kidney disease (HIVICK) IgA nephropathy viral infections and pauci-immune glomerulonephritis. ANCA (antineutrophil cytoplasmic antibody) positivity is observed in some PLHA with crescentic glomerulonephritis often associated with a poor prognosis. Treatment strategies remain uncertain involving a careful balance between immunosuppression and antiretroviral therapy. This retrospective review examines the clinical characteristics laboratory findings treatments and outcomes of crescentic glomerulonephritis in PLHA.
AIMS OF THE STUDY: There are no established treatment guidelines to manage patients of crescentic renal involvement in association with HIV. One has to be cautious and balance the risk of immunosuppression/HAART and infection risk. We hereby report an imperative retrospective review that describes the baseline characteristics laboratory findings treatment and outcomes of crescentic glomerulonephritis in HIV-infected patients.
METHODS: We conducted a search on Pubmed and Scopus database from 1996 to June 2023 using the following terms: Renal involvement in HIV Renal involvement in PLHA patients. Crescenticglomerulonephritis. Rapidly progressive renal failure in HIV patients. We included case reports with crescentic glomerulonephritis with renal dysfunction in HIV patients. The title abstracts and the full texts of the case reports were checked by authors NAV and PB individually and selected if agreed by both and met the inclusion criteria.
CONCLUSION: This comprehensive review provides insights into crescentic glomerulonephritis in PLHA, emphasizing its heterogeneity in terms of etiology and management. While pauci-immune crescentic glomerulonephritis predominated, infection-related cases and autoimmune overlap were also observed. The combination of antiretroviral therapy and immunosuppression appears promising, but larger prospective studies are needed to elucidate optimal treatment strategies and long-term outcomes. This work enhances our understanding of the complex relationship between HIV, renal involvement, and therapeutic approaches.
16TH DECEMBER 2023
ABSTRACT NO. 261
MEMBRANOUS NEPHROPATHY (MN) - DO WE KNOW ENOUGH? (AN INTERESTING CASE SERIES)
Ankur Laskar, D K Agarwal, Ankit Data
Department of Nephrology; Indraprastha Apollo Hospital; New Delhi; India
E-mail: drankurlaskar@gmail.com
BACKGROUND: The field of glomerular diseases has seen many new advances in the preceding decade. This includes a plethora of new antigens being discovered which has aided in our understanding of the pathogenesis of MN. Yet much of this remains unknown and the treatment of MN still remains challenging. Here we present 3 cases of MN similar in presentation but responded to treatment in varied manner.
AIMS OF THE STUDY: 3 cases of biopsy proven MN without any identifiable secondary cause which presented with adult onset nephrotic syndrome were evaluated. All 3 cases were Anti PLA2R Ab negative (serum) and kidney tissue antibody staining negative for Anti PLA2R THSD7A NELL1 Exostosin 1 & Sema 3b antibodies.
METHODS: 3 cases MN were treated with different modalities of treatment.
CONCLUSION: The above discussed cases reiterate the fact that there still remains both diagnostic (primary vs secondary) and therapeutic dilemma in the management of MN. The patients who are symptomatic with nephrotic range proteinuria & at times with reduced GFR, need one or the other mode of therapy like immunosuppressants, to be symptomatically better if they are not responding to conventional therapy.
16TH DECEMBER 2023
ABSTRACT NO. 262
NEPHROTIC SYNDROME IN A RETROVIRAL DISEASE DUE TO AA AMYLOIDOSIS - A RARE PRESENTATION
Prasad Gurjar, Manish Balwani, Amit Pasari, Kapil Sejpal, Shubham Dubey, Pranjal Kashiv, Sunny Malde, Sushrut Gupta
Department of Nephrology; JNMC; Datta Meghe Institute of Higher Education and Research; Wardha; Maharashtra; India
E-mail: dr.prasadgurjar1@gmail.com
BACKGROUND: Kidney disease pose a significant burden on individuals with HIV infection. In the pre-ART era HIV associated nephropathy (HIVAN) was the most common renal pathology identified in individuals with HIV. However widespread use of ART has led to change in the spectrum of renal pathologies associated with HIV. HIV infection is an unclear cause of AA amyloidosis. Here we report a rare case of HIV positive patient presenting with nephrotic syndrome which turned out to be AA amyloidosis on renal biopsy.
AIMS OF THE STUDY: To present a case of nephrotic syndrome due to AA amyloidosis in a newly diagnosed HIV positive patient.
METHODS: Case report.
CONCLUSION: AA amyloidosis is a rare cause of Nephrotic syndrome in HIV infection. It is associated with a high risk of progression to CKD and ESRD. Thorough screening for the underlying infection is warranted. HIV infection solely leading to AA amyloidosis is rare and seldom reported in literature. Treatment is mainly directed towards underlying chronic infection and HIV.
16TH DECEMBER 2023
ABSTRACT NO. 263
UNUSUAL PRESENTATION OF POSTRENAL TRANSPLANT HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS ASSOCIATED WITH PARVOVIRUS B19
K R Rahul, Venkatesh Moger
Department of Nephrology; Karnataka Institute of Medical Sciences; Hubballi; Karnataka; India
E-mail: rahulkrajendran87@gmail.com
BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterised by hypercytokinemia and systemic inflammation causing multiorgan failure. In adults the leading cause of sHLH worldwide is viral infection with EBV the predominant trigger in the USA and Asia.
AIMS OF THE STUDY: Hemophagocytic lymphohistiocytosis is a rare hematological disorder associated with high mortality. Pancytopenia is common condition seen is post transplant patient as drugs given after transplant are bone marrow suppressive. HLH should be sought as a differential diagnosis in those situations.
METHODS: A case of 30 year old male cadaveric renal transplant recipient who had delayed graft function fever post surgery. He was taken up for renal replacement therapy on account of decreased urine output. Lab tests bone marrow examination kidney biopsy contributed to the diagnosis.
CONCLUSION: Parvovirus B19 infection complicated by HLH is uncommon among renal transplant patients. IVIG and steroids are the most effective treatment strategy. Early identification and treatment will prevent graft dysfunction and mortality.
16TH DECEMBER 2023
ABSTRACT NO. 264
C3 GLOMERULONEPHRITIS PRESENTING WITH PULMONARY HEMORRHAGE: A CASE REPORT
M P Ayesha Nishad
Department of Nephrology; Karnataka Institute of Medical Sciences; Hubballi; Karnataka; India
E-mail: venkydoc72@yahoo.co.in
BACKGROUND: This report discusses a rare instance of C3 Glomerulonephritis (C3GN) coupled with pulmonary hemorrhage observed within the broader context of pulmonary renal syndrome marked by glomerulonephritis and lung bleeding.
AIMS OF THE STUDY: Shed light on the need to include C3GN in the differential diagnosis of pulmonary renal syndrome for early detection and action curbing progression to End Stage Renal Disease (ESRD).
METHODS: A 50-year-old man exhibited pedal edema facial swelling shortness of breath blood in sputum and reduced urine output. Lab tests high-resolution computed tomography (HRCT) and renal biopsy contributed to the diagnosis.
CONCLUSION: In pulmonary renal syndrome diagnosis, considering C3GN is imperative due to its seldom association with pulmonary hemorrhage. Early identification and intervention are vital to hinder progression to ESRD. This case accentuates the importance of timely nephrology consultations and thorough evaluations.
16TH DECEMBER 2023
ABSTRACT NO. 265
A FATAL CASE OF UNILATERAL DIFFUSE ALVEOLAR HEMORRHAGE AS THE INITIAL PRESENTATION WITH MICROSCOPIC POLYANGITIS AND RPGN: A RARE CASE REPORT-DIFFUSE ALVEOLAR HAEMORRHAGE (DAH) IS A POTENTIALLY LIFE-
Prabhat Kumar Mallick, Tapas Ranjan Behera, Biswajit Mishra, Bishwaranjan Mohanty
Department of Nephrology; IMS and SUM Hospital; Bhubaneswar; Odisha; India
E-mail: mallick.prabhat79r@gmail.com
BACKGROUND: ANCA-associated vasculitis is an inflammatory disease of small blood vessels. Patients with vasculitis in the kidney may have normal function or mild-moderately reduced renal function or complete renal failure. Early diagnosis and initiation of effective treatment will lead to a better outcome. We report here on patient with RPGN with unilateral diffuse alveolar hemorrhage (UDAH). She was successfully managed with plasmapheresis and hemodialysis along with immunosuppressant.
AIMS OF THE STUDY: A rare case report.
METHODS: Observation of a rare case report.
CONCLUSION: As illustrated by this case diffuse alveolar hemorrhage is a live threatening condition that requires rapid evaluation and management. Early diagnosis and initiation of effective treatment will lead to better outcome.
16TH DECEMBER 2023
ABSTRACT NO. 266
PERSISTENT LEFT SUPERIOR VENA CAVA - A RARE ANOMALY
Chaitrali Uday Gawde, Zaheer Virani, V Krishna Priya, Virendra Chauhan, Madhavi Dadwe, Hepal Vora, Prashant Rajput, Shruti Tapiawala, Mita Shah, Bharat V Shah
Department of Nephrology; Global Hospitals, Mumbai; Maharashtra; India
E-mail: chaitrali.gawde@gmail.com
BACKGROUND: Hemodialysis central venous catheter insertion can be complicated in patients with anomalous vessel anatomy. We report one such case of a rare anatomy in the form of left sided superior vena cava.
AIMS OF THE STUDY: We report a case of unusual course of Tunneled cuffed catheter which led us to the diagnosis of a left sided SVC.
METHODS: 66 year old male with Right Internal jugular tunneled cuffed catheter (TCC) presented with poor blood flow. An X ray was done but exact position of the TCC could not be determined. Hence a CT venogram was done which revealed Persistent left Superior vena cava(PLSVC). A transthoracic echocardiography was done which revealed a dilated coronary sinus (CS) with normal left and right cavities. Injection of agitated saline from patient’s left antecubital vein resulted in early opacification of the coronary sinus before other right-side chambers thus suggesting the presence of a patent left SVC draining into the coronary sinus. The TCC was removed under fluoroscopy guidance and images were taken. A new right IJV TCC insertion was done under fluoroscopy guidance without complications. Fluoroscopy guided dye was injected during the TCC placement to look for any thrombus and confirm the guidewire placement which confirmed our findings of PLSVC draining into the coronary sinus and left atrium.
CONCLUSION: Persistent left superior vena cava is a rare congenital venous anomaly, resulting from the persistent left anterior cardinal vein with a prevalence of 0.3-0.5 % in the general population. Awareness about this is very important. When a chest X ray is done to evaluate position of the Hemodialysis catheter in a patient with PLSVC an abnormal position of the catheter may lead to removal of the hemodialysis catheter. Knowledge of this PLSVC is important to avoid such mistakes.
16TH DECEMBER 2023
ABSTRACT NO. 267
THREE CONSECUTIVE DAYS OF BLOOD TESTS TO IDENTIFY RECOVERY OF RENAL FUNCTION IN DIALYSIS PATIENTS
Chaitrali Uday Gawde, V Krishna Priya, Virendra Chauhan, Madhavi Dadwe, Hepal Vora, Zaheer Virani, Prashant Rajput, Shruti Tapiawala, Mita Shah, Bharat V Shah
Department of Nephrology; Global Hospitals, Mumbai; Maharashtra; India
E-mail: chaitrali.gawde@gmail.com
BACKGROUND: Maintenance dialysis patients are often presumed to have end stage kidney disease (ESKD) and are advised to continue life-long dialysis. However it is not uncommon for some patients to have partial recovery of renal function and come off dialysis. This can have significant socio-economic impact and substantially improve the quality of life of these patients.
AIMS OF THE STUDY: To present a group of dialysis dependent patients who had substantial recovery of renal function to be off dialysis indicators that guided us and how we identified them.
METHODS: The study includes 16 maintenance dialysis patients who presented to us in the outpatient clinic. A detailed history including review of past investigations and clinical examination was done to consider possibility of an acute reversible insult. In those with rapid decline in renal function accelerated hypertension good urine output with no interdialytic weight gain a simple exercise of holding dialysis and monitoring weight BUN creatinine and potassium on 3 consecutive days was done. A slow rise stability or improvement in parameters was considered to suggest possibility of recovery of renal function.
CONCLUSION: In dialysis dependent patients with history of rapid decline in renal function, accelerated hypertension and good urine output with no interdialytic weight gain, holding dialysis and observing stable weight, BUN, creatinine and potassium on 3 consecutive days can identify patients with partial recovery of renal function.
16TH DECEMBER 2023
ABSTRACT NO. 268
A CASE OF ALPORT SYNDROME - A RARE CAUSE OF NEPHROTIC SYNDROME
Abhishek Bhardwaj, Prit Pal Singh, Om Kumar, Amresh Krishna, Prem Shankar Patel
Indira Gandhi Institute of Medical Sciences; Patna; Bihar; India
E-mail: abhishekbhardwaj1709@gmail.com
BACKGROUND: Alport syndrome (AS) is a generalized inherited disorder of basement membranes caused by mutations affecting specific proteins of the type IV (basement membrane) collagen family. The major features of AS are hematuria progressive nephritis with proteinuria and declining renal function sensorineural deafness and ocular abnormalities. AS is a rare disease affecting approximately 1 in 50 000 people and is seen in all ethnicities and races.
AIMS OF THE STUDY: A case of alport syndrome a rare cause of nephrotic syndrome.
METHODS: A 14 year old male presented with progressive generalized body swelling since 2 months. Patient was diagnosed with nephrotic syndrome and a kidney biopsy was performed. Kidney biopsy revealed a non proliferative GN with negative immunofluorescence. Electron microscopy showed prominent alterations in arrangement of collagen in glomerular basement membrane with splitting and basket weave appearance and widespread effacement of foot processes of visceral epithelial cells (70-80%).
CONCLUSION: Alport syndrome usually presents as a nephritic syndrome but can have a nephrotic presentation. Though a rare cause of nephrotic syndrome in children, it should be kept in differential diagnosis especially if there is a family history present.
16TH DECEMBER 2023
ABSTRACT NO. 269
SYSTEMIC LUPUS ERYTHEMATOSUS IN A YOUNG FEMALE PRESENTING AS DILATED CARDIOMYOPATHY: A RARE ASSOCIATION
Abdullah, Saif Quaiser
Department of Nephrology; Jawaharlal Nehru Medical College; Aligarh; Uttar Pradesh; India
E-mail: abdullah.08.am33@gmail.com
BACKGROUND: Systemic Lupus Erythematosus (SLE) an autoimmune connective tissue disease with multiple organ system involvement has variable presentations. The cardiac manifestation usually includes pericarditis leading to pericardial effusion myocarditis and endocarditis. Valvular and conduction abnormalities have also been reported. However SLE presenting as dilated cardiomyopathy is rather unusual the evidence of which is not sufficiently available in the literature.
AIMS OF THE STUDY: This a case report of a rare presentation of SLE.
METHODS: A 22 year female presented with shortness of breath and generalised body swelling. On examination BP was 140/88 PR-110/min Spo2- 85% and chest auscultation revealed bilateral fine crepts. There was history of decreased urine output and orthopnea. Routine initial investigations revealed anemia (Hb- 8.4) renal failure (3.6) and decompensated heart failure with BNP >25000. Urine routine microscopy showed blood3+ Protein 3+. Direct Coomb’s test was positive. ANA was positive (2+) with a dilution factor of 1:100 speckled pattern. C3 was decreased and C4 was normal. 2D Echo findings were global LV hypokinesia dilated LA and LV with ejection fraction of 44%.
CONCLUSION: We have reported a case presenting as Acute Decompensated Heart Failure(ADHF), turning out to be Systemic Lupus Erythematosus with Dilated Cardiomyopathy. ADHF as an initial presenting clinical feature of SLE is rather infrequent and its association with DCMP is rarely reported. Such association in a young patient requires timely intervention to prevent further morbidity and mortality. Therefore, a high degree of clinical suspicion is warranted for diagnosis and management of connective tissue disorders in young patients.
16TH DECEMBER 2023
ABSTRACT NO. 270
LATE RELAPSE OF MEMBRANOUS NEPHROPATHY: CASE SERIES AND LITERATURE REVIEW
Asheesh Kumar, Samriti Gupta, Kush Dev Singh Jarial, Dhiraj Sharma, Sukhwinder Sangha, Kishore Arigya
Department of Nephrology; All India Institute of Medical Sciences; Vijaypur; Jammu and Kashmir; India
E-mail: drasheesh03.kapil@gmail.com
BACKGROUND: Late relapse of PMN (after five years of remission) is rare. The literature regarding the relapse is from the pre-PLA2R (M-type phospholipase A2 receptor) era. The duration for monitoring after complete remission and the need for rebiopsy in patients with late relapse is still confusing.
AIMS OF THE STUDY: To examine the characteristics of PMN patients who relapse late.
METHODS: Retrospective single-center observational study.
CONCLUSION: This study highlighted the entity of late relapse of PMN with many unanswered questions which need further research: (1) duration and method of monitoring of patients with PMN in complete remission, (2) treatment plan in late relapse- upfront immunosuppression vs. wait and watch policy as in new case.
16TH DECEMBER 2023
ABSTRACT NO. 271
COLLAGENOFIBROTIC GLOMERULOPATHY IN PRIMARY MYELOFIBROSIS - ONE OF ITS KIND!
Kanupriya Agrawal, Kanupriya Agrawal, Megha Agrawal, Mahendra Meena, Niranjan Gogoi, Rakesh Gupta, Dhanajai Agrawal
Department of Nephrology; SMS Medical College and Associated Hospital; Jaipur; Rajasthan; India
E-mail: niharika010198@gmail.com
BACKGROUND: Collagenofibrotic glomerulopathy is a rare renal disease of unknown etiology that is secondary to deposition of type III collagen within the glomerulus. Only rare case series exist in the literature. To date fewer than 50 cases have been reported in the literature mainly as isolated case reports and mostly from Japan. Primary myelofibrosis (PMF) is a type of myeloproliferative neoplasm (MPN). Renal involvement in PMF is rare. This case report presents the clinical course of a patient who presented with nephrotic range proteinuria and was treated with modified Ponticelli regimen in accordance with initial renal biopsy. He subsequently turned out to be a rare case of collagenofibrotic glomerulopathy on EM study. Increased kappa and lambda free light chains and anaemia with thrombocytopenia hinted towards a hematological disease. Bone marrow biopsy revealed primary myelofibrosis. Treatment of myelofibrosis also led to renal improvement. Thereby proving collegenofibrotic glomerulopathy in our patient was due to rare myelofibrosis mediated fibrotic deposition in glomeruli.
AIMS OF THE STUDY: Enhance our understanding of the disease but also help in understanding the role of overall clinical picture especially CBC and bone marrow biopsy in renal diseases.
METHODS: Patient was a 50 year old male with a past history of right nephrectomy and left PCNL for b/l nephrolithiasis and pyelonephritis; and TURP 14 years back. He presented with bilateral pedal edema for 6 months and hypertension. On routine investigations he had Hb = 6 TLC = 4.3 and platelet count = 1.19 lakh; Cr = 2.02 24 hr urinary protein = 1.2 g/dl. Renal biopsy was done to rule out secondary FSGS or any other cause of nephrotic syndrome. LM study showed glomeruli with thickened capillary walls and membrane texture alterations significant endocapillary hyper cellularity 15% IFTA and no significant glomerular immune complex in DIF. EM was advised but deferred by relatives due to financial constraints. He was labelled as membranous nephropathy and modified Ponticelli regimen started. PLA2-R was negative. 6 months later he presented on routine follow up with BP = 140/70 Cr = 2 urine protein 2+ and RBC = 4-6/HPF. Repeat renal biopsy was done and EM study performed. It showed subendothelial and mesangial expansion with accumulation of fibrillary material s/o collagenofibrotic glomerulopathy. He was then evaluated further. Ca = 7.85 PO4 = 2.14 ALP = 155 with USG s/o b/l normal sized kidneys. A/G reversal was present. Serum vit B12 and folate levels were normal to rule out nutritional cause of bicytopenia. Hence bone marrow biopsy was done to r/o plasma cell dyscrasias. Bone marrow aspirate and biopsy showed 70-80% cellularity with myeloid and megakaryocytic hyperplasia and numerous dwarf megakaryocytes s/o prefibrotic phase of myelofibrosis. No plasma cell clusters were seen. MPN extended panel was done and it was negative. He was then started on Tab Danazol 200 mg BD and inj. Darbopoietin 200 mcg sc/2 weekly. He was monitored monthly. After 2 months his Hb level has increased from 6 to 8 and Cr = 1.5. Treatment of primary disease i.e. myelofibrosis led to spontaneous remission of renal disease.
CONCLUSION: This case highlights the rare occurrence of collagenofibrotic glomerulopathy, that too secondary to Primary myelofibrosis. We recommend that patients with hematological neoplasms should be screened for urinary abnormalities, especially proteinuria. Vigilant monitoring, prompt diagnosis and timely initiation of treatment restored the hematological and renal function in our patient.
16TH DECEMBER 2023
ABSTRACT NO. 272
CADAVERIC RENAL TRANSPLANTATION IN CHRONIC GLOMERULONEPHRITIS PATIENT
Madhusudhan Manda, Vivek Sood, Jai Inder Singh, P K Sharma
Department of Nephrology; Command Hospital Eastern Command; Kolkata; West Bengal; India
E-mail: viverit@gmail.com
BACKGROUND: In south Asian countries including India end-stage renal disease (ESRD) is associated with high morbidity and mortality. In India the crude incidence rate of ESRD is 151 per million population per year and age-adjusted incidence rates is 232 per million population per year. In south Asian countries including India majority of ESRD patients die within months of diagnosis because of unaffordability or poor availability of renal replacement therapy such as haemodialysis peritoneal dialysis or renal transplantation. Renal transplantation has most favourable outcomes in ESRD and stays the treatment of choice for ESRD. In India 15 000 new patients begin maintenance haemodialysis 3000 patients are started on continuous ambulatory peritoneal dialysis and 3500 patients undergo renal transplantation in a year. Renal transplantation rates are around 3.20 per million populations per year. Cadaveric transplantation comprises around 2% of all transplants in India. Over 90% of patients awaiting renal transplantation die without getting the organ. Cadaveric transplantation can bridge this gap efficiently. However progress of cadaveric programs has been halted by lack of awareness religious stigmata and infrastructural deficiencies.
AIMS OF THE STUDY: Case report on experience of cadaver renal transplant in chronic glomerulonephritis patient.
METHODS: Case report - This 46-years-old serving soldier was detected with BP-146/98 mm Hg while posted in Leh in Jan 2017. He was started on antihypertensives but he did not follow-up and stopped taking antihypertensives after 2 months. On 22 Jul 2018 while on leave he presented to BHDC with sudden onset breathlessness generalised weakness diaphoresis for 1 hour. He denied h/o chest pain fever cough syncope swelling feet or oliguria. On evaluation he had BP of 190/100 mm Hg pallor with bibasilar crackles. Inv- Hb 8.5 gm/dL TLC 3300 cell/mm3 platelet count-92000/L BUN / creatinine-147/ 10.84 mg/dL calcium/ phosphate - 8.1/ 7.2 mg/dl urine Alb 2+ pus cells-1-2 RBC 1-2 USG RK/ LK- 9.07/9.23 cm b/l raised echogenicity and reduced CMD multiple cortical cysts grade 1 prostatomegaly ANA neg C3-89.5 mg/dl C4-34 mg/dl pANCA/cANCA neg anti-MPO-neg anti GBM antibody-neg. 2D Echo- Conc LVH no RWMA EF 60 %. Fundoscopy- Grade I HTN retinopathy. Haemodialysis was initiated and was vaccinated against hepatitis B and pneumococcus. His left RC AVF created on 20 Aug 2018 is functional till date. He underwent 39 sessions of HD in pre-transplant period and never received any blood transfusion. He underwent deceased donor renal transplant on 24 Nov 2018. [Deceased was a 52 yrs old Ex-serviceman a case of decompensated cirrhosis of liver with ICH; creatinine -0.9 mg/dL and benign urinary sediment at retrieval].
CONCLUSION: Graft and patient survival rate of cadaveric transplant was satisfactory. Patient was asymptomatic with baseline graft function.
16TH DECEMBER 2023
ABSTRACT NO. 273
CHRONIC PERITONEAL DIALYSIS IN END STAGE RENAL DISEASE PATIENT WITH SYMPTOMATIC RHEUMATIC HEART DISEASE
K Vinod Kumar, Vivek Sood, Jai Inder Singh, P K Sharma, Yashwinder Kumar, Ashish Shukla, Sanjeev Sengupta
Department of Nephrology; Command Hospital (EC); Kolkata; West Bengal; India
E-mail: viverit@gmail.com
BACKGROUND: Specific guidelines regarding treatment of patients with symptomatic rheumatic heart disease (RHD) and concomitant end-stage renal disease (ESRD) have not been published nevertheless complexity and fragility of patients with ESRD and concomitant significant RHD portends poor prognosis and mandates prompt multidisciplinary care.
AIMS OF THE STUDY: In this context we report a case of middle-aged lady with RHD (severe mitral re-stenosis severe aortic regurgitation and moderate tricuspid regurgitation) being complicated by ESRD (and not tolerating hemodialysis) had gratifying outcome consequent to prompt therapeutic intervention (early start chronic peritoneal dialysis followed by dual mechanical valve replacement with tricuspid ring placement).
METHODS: Case Report - A 40-year-old lady with ESRD on maintenance haemodialysis (MHD) for 4 weeks presented with worsening dyspnea during hemodialysis of two-week duration. Initial vascular access for dialysis was an uncuffed central venous catheter in right internal jugular vein and subsequently left radio cephalic arteriovenous fistula (AVF) was created one week after initiation of dialysis. Patient was a known case of RHD for 15 years and underwent percutaneous transluminal mitral commissurotomy 10 years back. General examination revealed pallor hypertension (blood pressure - 160/96 mm Hg) and tachypnoea (respiratory rate - 26/minute). Cardiovascular evaluation was remarkable for severe aortic regurgitation severe mitral re-stenosis and moderate tricuspid regurgitation. Further investigations confirmed echogenic shrunken kidneys with bland urinary sediment and non-invasive etiological work-up (ANA/ dsDNA/viral markers were negative & complements / thyroid profile) was non-contributory. Further patient had worsening dyspnea during hemodialysis and evaluation hinted towards precipitation of high output cardiac failure following AVF and hemodialysis. Patient underwent percutaneous insertion of peritoneal dialysis catheter using modified Seldinger technique and urgent start automated peritoneal dialysis (APD) with closure of AVF. Further patient underwent dual mechanical valve replacement (aortic & mitral) with tricuspid ring placement and was initiated on anticoagulation. With remarkable recovery patient went home walking on day-15 of her hospitalization. Two months later patient had near-complete resolution of symptoms on APD. Six months later patient is currently being worked-up renal transplant with her spouse as a voluntary kidney donor.
CONCLUSION: ESRD with symptomatic RHD portends poor prognosis and mandates urgent addressal. Prompt initiation of appropriate therapy (early start chronic peritoneal dialysis followed by mechanical valve replacement) results in better patient outcome.
16TH DECEMBER 2023
ABSTRACT NO. 274
ANCA POSITIVITY IN IGA NEPHROPATHY: NOT A CO-INCIDENCE
Dhruvajyoti Choudhury
Department of Nephrology; Apollo Hospitals; Guwahati; Assam; India
E-mail: dhruvjchoudhury@gmail.com
BACKGROUND: RPGN is a common renal presentation. ANCA vasculitis and IgA Nephropathy are both important differential diagnosis. However in some patients both can co-exist causing diagnostic and management dilemma.
AIMS OF THE STUDY: I report a case which highlights the strong association of ANCA positivity and IgA nephropathy the management strategies used and the eventual outcome of the patient on follow up.
METHODS: As this is a case report it does not include normally used epidemiological study designs.
CONCLUSION: This case highlights the strong association of ANCA positivity and IgA nephropathy in a subset of patients who need aggressive immunosuppression, respond to treatment and has a favourable renal outcome.
16TH DECEMBER 2023
ABSTRACT NO. 275
A RARE CASE REPORT OF POST PTRA TTP IN AN UNUSUAL CASE OF VASCULITIS PRESENTING AS BILATERAL RENAL ARTERY THROMBOSIS
Harshal Khobragade, M S Khanpet
Department of Nephrology; Jawaharlal Nehru Medical College; Belagavi; Karnataka; India
E-mail: harshalbk3@gmail.com
BACKGROUND: Thrombotic thrombocytopenic purpura is a life threatening clinical syndrome characterized by thrombocytopenia and microangiopathic hemolyticanemia (MAHA). The annual incidence is 3 to 11 cases per million people and an annual prevalence of 10 cases per million people. The annual incidence of immune TTP is estimated at 0.25 to 1/250 000. Postprocedure thrombotic thrombocytopenic purpura (pTTP) is an uncommon and distinct entity that has been mainly labelled with cardiothoracic surgeries and vascular procedures. TTP is one of the dreaded but uncommon causes of thrombocytopenia and anemia. Although most cases of TTP are considered to be primary or idiopathic some cases have been reported to have a number of precipitating factors including malignancies immunological disorders toxic substances infectious agents and several medications (e.g. clopidogrel mitomycin ticlopidine quinine ticagrelor) and pregnancy. Of the medications ticlopidine ticagrelor and clopidogrel have been associated with TTP following coronary stenting. The greatest risk of developing life-threatening TTP has been reported to occur within 2 weeks after initiating drug. TTP is one of the dreaded but uncommon causes of thrombocytopenia and anemia. A clinical entity identical to classic TTP that rarely occurs postoperatively is called postoperative TTP and it occurs usually after 4-5 days of surgery. One should suspect it in a patient with normal hemoglobin preoperatively who subsequently develops MAHA and thrombocytopenia. The surgical procedures associated with pTTP include cardiac surgery such as CABG vascular surgery G.I surgery. In contrast to classical TTP the pentad of fever impaired renal function thrombocytopenia hemolyticanemia and altered mental status are usually not present making pTTP is a diagnosis of exclusion.
AIMS OF THE STUDY: To highlight this rare case of Post PTRA TTP in an unusual case of vasculitis presenting as Bilateral renal artery thrombosis.
METHODS: A 25 year old female patient presented to the outside hospital in the month of June - July 2022 with complaints of nausea vomiting reduced appetite pedal oedema and exertional breathlessness of 2-3 weeks duration where blood pressure of 200/110 mmhg was recorded. On routine investigations she was found to have Hb- 8.8 mg/dl Creatinine 8.8 mg% urine 3+ proteinuria and 8-10 RBCs/hpf C3 and C4 normal ANA IF Neg. Patient was considered for haemodialysis and renal biopsy was done which showed normal glomerular morphology and moderate degree of acute tubular injury. Patients attenders were counselled regarding the same and asked to continue haemodialysis till renal recovery. However even after 3 months of diagnosis patient remained oliguric and dialysis dependant. Hence patient was referred to KLEs PRABHAKAR KORE HOSPITAL. In our hospital patient was further evaluated she was on 5 classes of antihypertensives euvolemeic urine output of less than 50 ml/day and dialysis dependant. USG showed normal kidney sizes with preserved CMD. Patient was considered for 2nd biopsy which revealed normal glomeruli with wrinkled capillary walls and mild degree of interstial fibrosis and tubular atrophy. Patient attenders were counselled regarding the possibility of renal artery disease and requirement of renal angiography. Patient underwent renal angiography which revealed complete thrombotic occlusion of Bilateral renal arteries secondary to ? large/medium vessel vasculitis. Meanwhile patient was evaluated further: ANA profile- Negative ANCA profile- Negative Thrombotic risk profile Normal ESR 5 mm HsCRP 12 mg/l Brucella Ag-Negative. Patient was started on steroids anticoagulants continued haemodialysis and plan for renal artery stenting at later date. After one and half months patient underwent complete recanalization of bilateral renal artery occlusion using balloon angioplasty and stenting. Post procedure patient was started on dual antiplatelets aspirin and ticagrelor. POD1 patient was asymptomatic and had passed 50ml urine after procedure. However investigations showed massive drop in haemoglobin to 3.8mg% platelets 16 000. hemolytic workup was positive with LDH 1675 U/L retic count 4.4% peripheral smear showed schistocytes. Diagnosis of thrombotic microangiopathy secondary to procedure or drugs (?Ticagrelor) was made. antiplatelet were stopped and patient initiatated on plasmaphresis and pulse steriods.
CONCLUSION: In our case, early recognition and prompt introduction of plasmapharesis saved this patient’s life. Our case emphasizes the importance of this early recognition and treatment based on the presence of thrombocytopenia and MAHA in the absence of alternative causes, in order to prevent mortality from TTP. If a patient fails to improve despite plasma exchange, then refractory TTP should be considered and Rituximab or Caplacizumab should be instituted.
16TH DECEMBER 2023
ABSTRACT NO. 276
TYPE IV FAMILIAL HYPERALDOSTERONISM IN A PRIMIGRAVIDA FEMALE - A CASE REPORT
Akash Priyadarshi, Saif Quaiser
Department of Medicine; Jawaharlal Nehru Medical College Hospital; Aligarh Muslim University; Aligarh; Uttar Pradesh; India
E-mail: akashpriya1@gmail.com
BACKGROUND: Primary Aldosteronism (PA) is defined as an excess production of aldosterone which is independent of plasma renin and angiotensin II. With the first case reported in 1953 by Litynski it is the leading cause of endocrine hypertension having a classical presentation of hypertension along with hypokalemia. In about 90% of cases underlying causes are either bilateral adrenal hyperplasia or the aldosterone-secreting adenomas. Familial Hyperaldosteronism (FH) is the cause in only less than 10% cases. FH Type IV is caused due to germline mutation variants in the CACNA1H gene which encodes for a subunit of a T-type voltage-dependent calcium channel expressed abundantly in the glomerulosa layer of the adrenal cortex. There is significant phenotypic heterogeneity and some individuals never develop hypertension.
AIMS OF THE STUDY: The aim of the study is to highlight the rarity of the disease. PA classically presents with hypertension but our patient was normotensive throughout hospital stay with normal blood pressure readings in the past as well as in the follow-up visits. FH usually presents by the age of 10 years whereas our patient was 21 years old that emphasizes that FH can also present at a later age.
METHODS: This is a case report from a tertiary care medical center situated in Uttar Pradesh province from Nort India.
CONCLUSION: Familial Hyperaldosteronism (FH) classically presents with hypertension along with hypokalemia and is seen in age group less than 10 years. This case report emphasizes on the fact that FH can have presentation in old age groups. Also being a very rare genetic disorder, this case report also adds up it share in the existed literature. Our patient was normotensive and therefore all patients with FH do not mandate an elevated blood pressure recordings. FH also mimics Bartter and Gitelman syndrome as shown in this case report, henceforth indicating the importance of whole gene sequencing in making an otherwise challenging diagnosis.
16TH DECEMBER 2023
ABSTRACT NO. 277
DISSEMINATED HISTOPLASMOSIS WITH OBSCURE GASTROINTESTINAL BLEEDING IN A RENAL ALLOGRAFT RECIPIENT: ARE WE LURKING IN THE DARK?
K N Sree Raksha, Vinoi George David, Athul Thomas, Selvin Sundar Raj
Nephrology; Christian Medical College; Vellore; Tamil Nadu; India
E-mail: sreerakshaiyer@gmail.com
BACKGROUND: Histoplasmosis is a rare invasive endemic mycosis which often presents in immunocompromised individuals often with non-specific symptoms but poses a threat of dissemination. GI involvement in disseminated histoplasmosis is reported in about 11 % of the cases in solid organ transplant recipients with most common involvement of the ileocaecal junction. Jejunal involvement has not been reported so far to the best of our knowledge in a solid organ transplant recipient. It is often misdiagnosed as it mimics many common opportunistic infections or malignancies and poses a diagnostic challenge with tissue diagnosis being the gold standard. Here we present a rare case of a 45 yr old renal allograft recipient who was 10 years post-transplant with stable graft function presenting with disseminated histoplasmosis with rare involvement of the jejunum causing GI bleed.
AIMS OF THE STUDY: Case Summary: 45 yr old renal allograft recipient presented to us with cough fever and weight loss of 3 months duration with outside reports suggestive of lung nodules with right upper lobe cavitatory lesion and was empirically started on Antitubercular therapy presented to us with multifocal pneumonia with lung nodules with persisting symptoms of 3 months duration initial sputum evaluation was negative for infection CT guided biopsy confirmed the diagnosis of pulmonary histoplasmosis with lung tissue culture growing Histoplasma capsulatum. and he was initiated on Lipid emulsion of amphotericin B. 1 week after presentation he developed multiple episodes of GI bleed initial evaluation with UGI scopy and Colonoscopy was normal with normal CT abdomen and angiogram. He was hemodynamically stable and was managed conservatively. 3 days later he developed severe GI bleed causing hypotension and was shifted to the SICU. Bedside scopies were normal with normal CT angiogram of the abdominal vessels. Since patient continued to have GI bleed with hemodynamic instability he underwent exploratory laparotomy and intraoperative enteroscopy. The enteroscopy revealed a cicatrising lesion in the proximal jejunum which was resected and anastomosed. The histopathology of the lesion revealed yeast cells resembling histoplasma. He later succumbed to post-operative sepsis with multiorgan dysfunction.
METHODS: Not applicable.
CONCLUSION: Learning points:
Jejunal involvement in disseminated histoplasmosis is extremely rare and to the best of our knowledge, this is the first case report describing jejunal histoplasmosis in a renal allograft recipient
Often the lesion remains silent and presentation is catastrophic in the form of perforation, secondary peritonitis and GI bleeding
Diagnosis and management of histoplasmosis is often challenging and requires meticulous evaluation and proper tissue diagnosis as it mimics many common illnesses
Delay in diagnosis and treatment often leads to unnecessary surgical procedures and fatal outcomes.
16TH DECEMBER 2023
ABSTRACT NO. 278
UNUSUAL CAUSE OF POSTPARTUM ACUTE KIDNEY INJURY
K R Rahul, Venkatesh Moger
Department of Nephrology; Karnataka Institute of Medical Sciences; Hubballi; Karnataka; India
E-mail: rahulkrajendran87@gmail.com
BACKGROUND: This case report discuss a rare cause of acute kidney injury in postpartum period caused by antibody against complement factor H.
AIMS OF THE STUDY: Thrombotic microangiopathies though rare in postpartum period should be considered as differential diagnosis when patient presents with acute kidney injury with progressive fall in hemoglobin.
METHODS: 23 year oldprimi gravida with no prior comorbidties antepartum Delivered female baby by LSCS -breech presentation Had atonic PPH managed by ligating b/l uterine artery and internal iliac artery Discharged on POD 9 with normal blood parameters and normal urine output Readmitted again after 2 weeks with left lower limb swelling and decreased urine output.
CONCLUSION: Among the causes of post partum acute kidney injury Thrombotic microangiopathy per se is rare. Progression to ESRD is common if not properly evaluated and treated.
16TH DECEMBER 2023
ABSTRACT NO. 279
RARE CASE OF C3 GLOMERULONEPHRITIS PRESENTED AS DCLD
Udayan Saha, Deba Prasad Kar, Bihwaranjan Mohanty
Department of Nephrology; IMS and SUM Hospital; Bhubaneswar; Odisha; India
E-mail: udayansaha.tripura@gmail.com
BACKGROUND: C3 glomerulonephritis is a rare kidney disease resulting from dysregulation of alternative complement cascade. The estimated incidence of the disease is 1-3 cases per million per year.we here describe a case of young male with history of alcohol consumption presented with ascites & B/L PEDAL oedema suspecting a case of decompensated liver disease but later diagnosed as C3 GN. This case illustrates the clinical the clinical presentation of this disease & importance of being aware of of it for an adequate diagnostic and therapeutic approach. Patient evaluated urine analysis showed protein 3+ RBC plenty low c3 low c4 and ANA PROFILE & ANCA PROFILE neg. Patient gradually develop Anuria undergone haemodialysis patient managed with pulse steroids and IV Cyclophosphamide with other supportive medication. Patient gradually improved and maintained with MMF.
AIMS OF THE STUDY: To diagnose the cause of ANURIA.
METHODS: 23 Patient evaluated with urine routine CBC LFT RFT USG complements ANA profile ANCA renal biopsy.
CONCLUSION: We concluded that CASE OF DCLD can presented as C3GN.
16TH DECEMBER 2023
ABSTRACT NO. 280
UNMASKING THE GREAT MASQUERADER: VASCULITIS
Namesh Kamat, R Ram, V Sivakumar
Department of Nephrology; Sri Venkateswara Institute of Medical Sciences; Tirupati; Andhra Pradesh; India
E-mail: nameshkamat217@gmail.com
BACKGROUND: Vasculitis is a heterogeneous group of disorders linked by the primary finding of inflammation within blood vessel walls. Nearly 30 forms of systemic vasculitis are currently recognized. Few disorders in medicine are more challenging to diagnose and treat than the systemic vasculitides. The signs and symptoms of vasculitis can be as subtle as a rash or as deadly as rapidly progressive glomerulonephritis and in general are non specific and hence pose as a challenge to physicians in uncovering the right diagnosis.
AIMS OF THE STUDY: To present a patient of vasculitis presenting as acute red eye with renal failure.
METHODS: A 40 year old male with History of hypertension since 9 years in Stage IIIa CKD since 1 year a history of right testicular infarct 1 year back was diagnosed with Retinal Vasculitis and choroiditis in the right eye and was referred to Nephrology dept. He had H/O fever on and off associated with myalgia for last 6months and also an episode of redness and pain of right eye for 6months. Physical examination revealed a pulse rate of 76 bpm and blood pressure of 122/90 mmHg with no significant difference in BP between the limbs. Fundus showed findings consistent with retinal vasculitis and choroiditis in the right eye. Laboratory testing revealed hemoglobin (12.1 g/dl) white blood cell count (15 470 cells/cumm) ESR (82 mm 1 hr) blood urea (52 mg/dl) serum creatinine (1.9 mg/dl) ANA (negative) RA factor 4.94 IU/ml (negative) P-ANCA and C-ANCA negative Mantoux test was positive with induration of >12 mm liver function tests and lipid profile normal and also work up for tuberculosis and infective endocarditis was negative. Imaging revealed normal sized kidneys with few calculi in right and left kidney midpole on ultrasound of abdomen. Ct angiography showed fusiform aneurysm in infra-renal aorta and saccular aneurysm posteriorly at the site of bifurcation of aorta with occlusion of left main renal artery from 5mm lateral to its origin with left renal calculi and inferior mesenteric artery showing significant narrowing with an infarct in segment IV of liver.
CONCLUSION: PAN being a challenging diagnosis should be considered in differential diagnosis of a young patient with hypertension with multisystem involvement. PAN is an uncommon cause of retinal vasculitis and infrarenal aortic aneursym. Strong suspicion, early diagnosis and management can help prevent late complications.
16TH DECEMBER 2023
ABSTRACT NO. 281
MINIMAL CHANGE DISEASE FOLLOWING THERAPY WITH D-PENICILLAMINE IN A PATIENT WITH WILSONS DISEASE
Deep Mukhopadhyay, Pinaki Mukhopadhyay, Architaben Ramanbhai Patel
Nil Ratan Sircar Medical College and Hospital; Kolkata; West Bengal; India
E-mail: drdeepnephrology@gmail.com
BACKGROUND: Wilson’s disease is an autosomal recessive disorder of hepatobiliary copper metabolism with symptoms related to hepatic and neurological copper toxicosis. Treatment is mandatory and initial therapy consists of a chelating agent for most symptomatic patients. Because of its therapeutic efficacy low cost and safe clinical experience D-penicillamine has been used frequently as first line therapy for Wilson’s disease. However significant side effects can occur including nephrotoxicity that usually presents with proteinuria and in severe cases nephrotic syndrome. Membranous glomerulopathy is most commonly associated with nephrotic syndrome but isolated cases of minimal change lesions have also been reported.
AIMS OF THE STUDY: Establish the cause of frothy urine and proteinuria in the child and also to look for its relation with penicillamine therapy per se.
METHODS: We report a case with Wilson’s disease who developed nephrotic syndrome one year after starting D-pencillamine. After stopping D-penicillamine only zinc was given for maintenance. His proteinuria resolved after four weeks of full dose prednisolone administration for nephrotic syndrome.
CONCLUSION: The most likely cause of nephrotic syndrome in this child was the late complications of D-penicillamine. It also reemphasizes the importance of early monitoring for proteinuria and the need to shift to an alternative agent if side effects develop.
16TH DECEMBER 2023
ABSTRACT NO. 282
RAPIDLY PROGRESSIVE IGA NEPHROPATHY - A CLINICAL ODDITY
Tejaswini Bhatlawande, J P Tiwari, Shital Lengade, Rohit Gaude
Nephrology; Goa Medical College; Bambolim; Goa; India
E-mail: tejaswini2840@gmail.com
BACKGROUND: IgA nephropathy is the most common primary glomerulopathy characterised by IgA deposits in the mesangial area of glomerulus. Approximately 20-30% patients develop chronic renal failure in about 20 years time. However a patient developing end-stage renal disease within months is unheard of.
AIMS OF THE STUDY: To study and follow a case of rapidly progressive IgA nephropathy.
METHODS: A 30 year-old male who was apparently alright prior to 2 months presented with features of renal failure over a period of 2 months. On work up and imaging renal pathology was suspected. Biopsy proved the diagnosis of IgA nephropathy.
CONCLUSION: Rapidly progressive IgA nephropathy is a rare but fatal entity. Further research with regards to etiology and evaluation regarding the effectiveness of renal transplantation in curing the disease.
16TH DECEMBER 2023
ABSTRACT NO. 283
AN UNUSUAL CASE OF HISTOPLASMOSIS AND PULMONARY TUBERCULOSIS IN A SYSTEMIC SCLEROSIS PATIENT
Tanvi Thakker, H S Mahapatra, Lalit Pursnani, B Muthukumar, Beauty Suman
Nephrology; ABVIMS and Dr. RML Hospital; New Delhi; India
E-mail: tanvithakker92@gmail.com
BACKGROUND: Patients with systemic sclerosis have an elevated risk of infections especially respiratory infections because of impaired immune responses immunosuppressive therapies restricted chest wall movements in advanced disease and the possibility of presence of underlying lung involvement in the form of interstitial lung disease.
AIMS OF THE STUDY : To study a case of pulmonary tuberculosis with histoplasmosis in a systemic sclerosis patient.
METHODS: 41 year old female diagnosed with systemic sclerosis in 2017 was on treatment with low dose prednisolone. Patient remained well for 5 years with baseline craetinine of 3-4 mg/dl. Patient presented in June 2022 with history of fever on and off since 6 months and cough with expectoration since 3 months. History of loss of appetite and weight loss was present. On examination patient was febrile. Auscultation revealed coarse crepitations over bilateral lung fields.
CONCLUSION: High prevalence of Tuberculosis in immunosuppressed patients in our population may mislead us, resulting in delayed diagnosis of other atypical infections. A high index of suspicion for opportunistic fungal infections is crucial when evaluating respiratory symptoms in patients on long term immunosuppressive therapy, as prompt diagnosis and treatment are essential for managing these conditions effectively.
16TH DECEMBER 2023
ABSTRACT NO. 284
A DELAYED COMPLICATION OF ABDOMINAL HYSTERECTOMY PRESENTING AS RAPIDLY DEVELOPING ASCITES AND RENAL FAILURE
Mohd Umair, Anupama Kaul, Manas Ranjan Behera, Harshita Sharma
Department of Nephrology; Sanjay Gandhi Postgraduate Institute of Medical Sciences; Lucknow; Uttar Pradesh; India
E-mail: umairbhu.65@gmail.com
BACKGROUND: We present a case of urinary ascites in a 34 year old female who presented 3 months after total abdominal hysterectomy with complaints of increasing abdominal distension and recently detected renal failure.
AIMS OF THE STUDY: Case report.
METHODS: Routine blood investigations including RFT LFT CBC Urine examination were done. USG abdomen with color Doppler study of renal vessels and hepatic and portal vein was done. Ascitic fluid was tapped and was sent for biochemical and cytological examination. Contrast enhanced CT imaging of abdominal vessels and CT urography was performed.
CONCLUSION: The diagnosis of inadvertent ureteric injury may be delayed due to the insidious development of non-specific symptoms. High suspicion of urological injury following hysterectomy should be kept in patients presenting with rapid development of ascites with renal failure.
16TH DECEMBER 2023
ABSTRACT NO. 285
ACUTE GRAFT DYSFUNCTION IN A PEDIATRIC PATIENT IN THE EARLY POST TRANSPLANT PERIOD: A CASE REPORT
M P Ayesha Nishad, Venkatesh Moger
Nephrology; Karnataka Institute of Medical Sciences; Hubballi; Karnataka; India
Hubballi
E-mail: ayeshanishadmp@yahoo.in
BACKGROUND: This case report presents a unique instance of acute graft dysfunction in a pediatric patient. Patient had history of neonatal aortic thrombosis for which thrombophilia work up was done which was negative. The patient is a child from a second-degree consanguineous marriage with no history of type 2 diabetes hypertension tuberculosis seizures stroke coronary artery disease peripheral vascular disease or surgery. The patient’s family has no history of renal disorders or thrombotic disorders. Patient had acute graft dysfunction in the early post transplant period. Renal biopsy was suggestive of diffuse thrombosis at subarcuate level. No evidence of rejection no evidence of CNI toxicity.
AIMS OF THE STUDY: The aim of this case report is to provide insights into the diagnosis treatment and outcome of acute graft dysfunction in a pediatric patient and to underscore the need for further research in this area.
METHODS: The case report is based on a detailed review of the patient’s medical records including medical history symptoms diagnosis treatment regimen and outcome.
CONCLUSION: Despite extensive panel available for the thrombophilia work up, there might be some cases which elude the studies and may mandate anticoagulation in the intraoperative and postoperative period.
16TH DECEMBER 2023
ABSTRACT NO. 286
A CASE OF RAPIDLY PROGRESSIVE RENAL FAILURE IN BACKGROND OF LYMPHOMA
Ramiz Islam, Sandip Kumar Bhattacharya, R Jayasurya, Vivek Goel
Department of Nephrology; Apollo Multispeciality Hospital; Kolkata; West Bengal; India
E-mail: dr.ramiz.islam@gmail.com
BACKGROUND: 63 years old lady adequately controlled diabetes and systemic hypertension for 3 years, presented with 2 months history of fever and generalised palpable, purpuricrash, not worsening on sun exposure, weight loss, dyspnea on exertion, body ache, malaise was admitted with oliguria, volume overload and altered renal function. Urine examination showed, Albumin 2+; RBC >100. no cast seen.
AIMS OF THE STUDY: On evaluation found to have cervical and inguinal lymphadenopathy with hepato-splenomegaly and anemia.
METHODS: No evidence of diabetic retinopathy noted. She was initiated on hemodialysis. Lymph node biopsy revealed Mantle cell lymphoma, Kidney biopsy revealed crescentic glomerulonephritis along with IgG1 and kappa restriction. Diagnosis of PGNMID made and treated with Inj. Rituximab. Patient came off dialysis after two doses.
CONCLUSION: Mantle cell lymphoma induced PGMNID have been reported, however crescentic GN developed along with IgG1 and kappa restriction have been a rarer entity. PGMNID have to be differentiated from other varieties of membranoproliferative GN by its monoclonal deposit in glomerulus and absence of extra glomerular deposition.
16TH DECEMBER 2023
ABSTRACT NO. 287
AN UNUSUAL CASE OF RENAL ARTERY RE-STENTING WITHIN FEW MONTHS
Sibasish Mukherjee, Manish Kumar Jain
Department of Nephrology, Apollo Multispeciality Hospitals; Kolkata; West Bengal; India
E-mail: sibasish1990@gmail.com
BACKGROUND: 48year old lady, known hypertensive was admitted recurrently with complaints of recurrent episodes of shortness of breath with nausea and vomiting.
AIMS OF THE STUDY: On further evaluation, her JVP was raised, BP 200/130 mm Hg, with bilateral renal bruit. On blood investigations, she was found to have gradually increasing serum creatinine levels. She was managed conservatively with IV GTN, IV Frusemide and other supportive medications. Renal artery doppler showed bilateral renal artery stenosis. DTPA scan showed normal functioning Right kidney with less than 10% functioning of left kidney. She underwent stenting of right renal artery and was discharged in a haemodynamically stable condition with dual antiplatelet therapy.
METHODS: 5 months later, she was re-admitted with similar symptoms. Renal angiogram showed stent thrombosis of right renal artery, despite being on appropriate medications. CT aortogram was done- showed non specific aorto-arteritis of abdominal aorta from origin of coeliac trunk till the common iliac arteries, with involvement of bilateral renal arteries, which was previously not present. Re-stenting was done & patient was evaluated by Rheumatologist.
CONCLUSION: She was therefore initiated with immunosuppressive therapy with pulse dose of IV Methylprednisolone and Tocilizumab. She is now on daily dose of oral prednisolone and 2 weekly dose of Tocilizumab. Her clinical symptoms have not recurred since induction of immunosuppressive therapy.
16TH DECEMBER 2023
ABSTRACT NO. 288
SEVERE AND RECURRENT ACUTE KIDNEY INJURY FOLLOWING DICHORVOS EXPOSURE - A RARE CASE REPORT
Shadab Husain, Vansidhar Veeranki, Narayan Prasad, Manas Ranjan Patel, Ravi Shanka Kushwaha, Jayakumar Meyyappan, Vineeta Agarwal, Manoj Jain, Riti Yadav
Department of Nephrology and Pathology; SGPGIMS; Lucknow; Uttar Pradesh; India
E-mail: shadab.732@rediffmail.com
BACKGROUND: Dicholrvos, an organophosphate compound, can potentially cause acute kidney injury (AKI) besides its well- known neuromuscular complications.
AIMS OF THE STUDY: We report a case of severe recurrent AKI.which progressed to end-stage renal-disease (ESRD) following accidental exposure to Dichlorvos.
METHODS: Case report: A 52 year male farmer by occupation, presented with breathlessness following an accidental exposure to Dichlorvos while spraying in the field. He required mechanical ventilation due to allergic pneumonitis and developed anuric AKI, requiring renal replacement therapy (RRT). Biopsy revealed severe acute tubulointerstitial nephritis (ATIN), which responded to steroids, and the patient became dialysis independent by 4 weeks. Two weeks later, the patient had recurrent AKI requiring RRT. A repeat biopsy revealed severe ATIN. However, he progressed to ESRD, despite treatment with corticosteroids.
CONCLUSION: Organophosphate compunds have the potential to cause renal injury with a wide spectrum of presentation ranging from subclinical AKI to severe dialysis dependent renal failure which might eventually progress to end- stage renal disease.