A Multicenter Retrospective Cohort Study on Management Protocols and Clinical Outcomes After ABO-incompatible Kidney Transplantation in India.

BACKGROUND: There is no robust evidence-based data for ABO-incompatible kidney transplantation (ABOiKT) from emerging countries. METHODS: Data from 1759 living donor ABOiKT and 33 157 ABO-compatible kidney transplantations (ABOcKT) performed in India between March 5, 2011, and July 2, 2022, were included in this retrospective, multicenter (n = 25) study. The primary outcomes included management protocols, mortality, graft loss, and biopsy-proven acute rejection (BPAR). RESULTS: Protocol included rituximab 100 (232 [13.18%]), 200 (877 [49.85%]), and 500 mg (569 [32.34%]); immunoadsorption (IA) (145 [8.24%]), IVIG (663 [37.69%]), and no induction 200 (11.37%). Mortality, graft loss, and BPAR were reported in 167 (9.49%), 136 (7.73%), and 228 (12.96%) patients, respectively, over a median follow-up of 36.3 mo. In cox proportional hazard model, mortality was higher with IA (hazard ratio [HR]: 2.53 [1.62-3.97]; P < 0.001), BPAR (HR: 1.83 [1.25-2.69]; P = 0.0020), and graft loss (HR: 1.66 [1.05-2.64]; P = 0.0310); improved graft survival was associated with IVIG (HR: 0.44 [0.26-0.72]; P = 0.0010); higher BPAR was reported with conventional tube method (HR: 3.22 [1.9-5.46]; P < 0.0001) and IA use (HR: 2 [1.37-2.92]; P < 0.0001), whereas lower BPAR was reported in the prepandemic era (HR: 0.61 [0.43-0.88]; P = 0.008). Primary outcomes were not associated with rituximab dosing or high preconditioning/presurgery anti-A/anti-B titers. Incidence of overall infection 306 (17.39%), cytomegalovirus 66 (3.75%), and BK virus polyoma virus 20 (1.13%) was low. In unmatched univariate analysis, the outcomes between ABOiKT and ABOcKT were comparable. CONCLUSIONS: Our largest multicenter study on ABOiKT provides insights into various protocols and management strategies with results comparable to those of ABOcKT.

Comparison between Urine Sodium and Clinical Evaluation to Assess Saline Responsiveness in Severe Hyponatremia - A Prospective Study.

INTRODUCTION AND BACKGROUND: Hyponatremia is a commonly encountered electrolyte disturbance seen in diverse clinical settings. The recently published European guidelines comprehensively summarize the present status of evaluation for hyponatremia. The guidelines emphasize the poor predictability of clinical criteria and instead suggest that the urine sodium (UNa) may be a better way to initially evaluate the cause of hyponatremia. AIMS AND OBJECTIVES: Aim of the study is to comparison between urine sodium and clinical evaluation to assess saline responsiveness in severe hyponatremia. MATERIALS AND METHODS: Prospective Cross sectional study carried out in Departments of Nephrology, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala. Study Period between October 2014 to October 2016 (2 years), Patients diagnosed as Severe hyponatremia S.Sodium < 125mEq/L based on clinical and laboratory evaluations. INCLUSION CRITERIA: All clinically and lab confirmed cases of severe hyponatremia, Age >18 years. Outpatients, Inpatients admitted to medical wards and ICU, who give informed consent and serum sodium of less than 125mEq/L constitute the study population. These patients meeting the following criteria: blood glucose level less than 200mg/dl would be included. EXCLUSION CRITERIA: Patients with overt hypervolemia due to cardiac, hepatic, and renal disease with gross edema were excluded. RESULTS: Among 50 patients in the study 70% were found at age group > 60 yrs. 30% patients were < 60 years age group. Youngest patient was 14 yrs old and oldest patient was 83 yrs old. 21 (42%) were Females and Males were 29 (58%). Majority of the cases were symptomatic at time of presentation n=38 (76%). All were having hypotonic hyponatremia among them 14 patients (28%) were euvolemic, 3 patients (6%) were hypervolemic and 33 patients (66%) were hypovolemic. 31 patients (62%) had serum Sodium levels between 115-125mEq/L and 19 patients (38%) had serum Sodium levels between 100-114mEq/L. Among the 33 patients (66%) Hyponatremia due to volume depletion by clinical assessment by the Nephrologist and who were given saline 26 (78%) were saline responsive and 7 patients (22%) were saline non responsive. Among the 7 patients who are saline non responders 6 patients (85.7%) had UNa > 20 and 1 patient (14.3%) had UNa < 20, which is statistically not significant (p=0.840). Among the 44 patients who are saline responders 18 patients are saline responsive. Among the 44 patients 20 (76.9%) had UNa > 20 and 6 (23.1%) had UNa < 20, statistically not significant (p=0.604). Duration for normalizing sodium was noted during the study 17 cases, 1-3 days were needed, 22 cases needed 4-7 days. CONCLUSION: Volume status of patients with hyponatremia can be assessed clinically with a high degree of reliability if the hyponatremia is severe. Thus we re-emphasize the importance of measuring volume status in patients with hyponatremia and classify patients on basis of volume status prior to triaging management. The measurement of UNa had a poor correlation with saline responsiveness and this shows that the laboratory measure is subject to errors due to prior treatments given to the patient and has to be interpreted with the prior clinical scenario in mind.

Bile cast nephropathy causing acute kidney injury in a patient with nonfulminant acute hepatitis A.

Hepatitis A is usually a benign self-limiting disease with few or no extrahepatic manifestations. Acute hepatitis A causing severe renal dysfunction is not very common, although described. Patients developing renal dysfunction post hepatitis A infection usually have prerenal acute kidney injury (AKI) or acute tubular necrosis due to vomiting, diarrhea, and poor fluid replacement. However, if renal dysfunction persists, other causes need to be evaluated. The term cholemic nephrosis or more specifically bile cast nephropathy has been described in the setting of cholestatic jaundice and decompensated liver failure where bilirubin levels reach above 20 mg/dL. Herein, we describe the clinical course of a patient who developed acute hepatitis A with severe liver dysfunction and subsequently AKI which persisted for six weeks. Renal biopsy showed the evidence of bile cast nephropathy. After six weeks of hemodialysis, urine output improved. He slowly recovered both hepatic and renal functions.

Recurrence of membranous nephropathy three weeks' postrenal transplant: A surprise in store.

Membranous nephropathy (MN) may occur in the transplanted kidney, either as recurrent disease in patients who had MN as the cause of end-stage renal disease (ESRD) in the native kidney or de novo, in patients who had another cause of ESRD initially. The reported incidence of recurrent MN ranges between 10% and 45%. Clinical manifestations of recurrent MN are typically observed 13-15 months after transplantation, although they may be observed much earlier (within weeks). Our patient had a recurrence in three weeks. Recurrent disease can lead to loss of the allograft.