Capacity for the management of kidney failure in the International Society of Nephrology South Asia region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA).

The South Asia region is facing a high burden of chronic kidney disease (CKD) with limited health resources and low expenditure on health care. In addition to the burden of CKD and kidney failure from traditional risk factors, CKD of unknown etiologies from India and Sri Lanka compounds the challenges of optimal management of CKD in the region. From the third edition of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA), we present the status of CKD burden, infrastructure, funding, resources, and health care personnel using the World Health Organization's building blocks for health systems in the ISN South Asia region. The poor status of the public health care system and low health care expenditure resulted in high out-of-pocket expenditures for people with kidney disease, which further compounded the situation. There is insufficient country capacity across the region to provide kidney replacement therapies to cover the burden. The infrastructure was also not uniformly distributed among the countries in the region. There were no chronic hemodialysis centers in Afghanistan, and peritoneal dialysis services were only available in Bangladesh, India, Nepal, Pakistan, and Sri Lanka. Kidney transplantation was not available in Afghanistan, Bhutan, and Maldives. Conservative kidney management was reported as available in 63% (n = 5) of the countries, yet no country reported availability of the core CKM care components. There was a high hospitalization rate and early mortality because of inadequate kidney care. The lack of national registries and actual disease burden estimates reported in the region prevent policymakers' attention to CKD as an important cause of morbidity and mortality. Data from the 2023 ISN-GKHA, although with some limitations, may be used for advocacy and improving CKD care in the region.

Equity in Transplantation Access in Nepal: An Analysis of Gender, Geographic, and Caste-Based Disparities in Transplants.

Transplantation is a lifesaving modality for addressing various organ failures. While kidney transplant services became available in Nepal in 2008, the introduction of liver transplantation is more recent. The government provides financial assistance to support lifelong dialysis and kidney transplantation. The importance of equitable access to transplantation cannot be overemphasized. This study aims to examine the equity in accessing transplantation services. This retrospective observational study encompasses patients who underwent kidney transplantation up until December 2022 across five major hospitals. Through standardized data collection and analysis, we evaluated the distribution of recipients based on gender, caste/ethnicity, and geographic location. A total of 2040 kidney transplantations were performed during the period. Notably, 79% of the recipients were men and, interestingly, 70% of the donors were women. Geographically, the highest proportion (31.8%) of recipients were from Bagmati, while the lowest (l2.8%) were from Karnali. Regarding caste and ethnicity, Janajatis accounted for 31% and Chhetris for 22.9%; Madhesis were lowest at 8.12%. Only 17 liver transplantations were conducted during the same period. Although access to kidney transplantation exists in Nepal, this study highlights persistent disparities. Women, rural and remote populations, as well as specific ethnic and caste groups encounter barriers to accessing transplantation services.

Renal Mucormycosis: Post-COVID-19 Infection Presenting as Unilateral Hydronephrosis in a Young Immunocompetent Male.

Mucormycosis is a rare invasive fungal infection with a high mortality rate caused by members of the family Mucoraceae. It mainly affects immunocompromised hosts such as poorly controlled diabetes mellitus, previous solid organ transplant, high-dose steroids, and hematologic malignancy. The most common sites of the disease are rhinocerebral, the skin, the lungs, and the gastrointestinal tract. In this era of COVID-19 infection, there has been a significant rise in invasive mucormycosis predominantly reported from southeast. We present a case of isolated renal mucormycosis in an apparently healthy individual with post-COVID-19 infection presenting as unilateral hydronephrosis. Timely identifying at-risk populations and having a high degree of suspicion with involvement of multidisciplinary teams are of utmost importance to diagnose and treat a rare and fatal infection. Even if there is a long history, antifungal drugs and removal of the source can result in a good outcome.

Urinary Tract Infection among Post-renal Transplant Patients in the Department of Nephrology of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Urinary tract infection is the most common infection among renal transplant recipients and increases the risk of hospitalization or even death. The study aimed to find the prevalence of urinary tract infection among post-renal transplant patients in the Department of Nephrology of a tertiary care centre. Methods: This is a descriptive cross-sectional study which was conducted among 217 post-renal transplant patients at the Department of Nephrology of a tertiary care centre from 1st November, 2017 to 31st October, 2018. The study was approved by the Institutional Review Committee (Reference number: 245(6-11-E)2074-75). Convenience sampling was used. The data were entered in Microsoft Excel 2011 and analyzed using the Statistical Package for the Social Sciences version 20.0. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data and mean with standard deviation for continuous data. Results: Among 217 patients, urinary tract infection was seen in 27 (12.44%) (8.05-16.83 at 95% Confidence Interval). One (3.70%) patient had the infection within three months of transplant, and 17 (62.96%) had infection after more than a year of transplant. Conclusions: The prevalence of urinary tract infection among kidney transplant recipients in our study was lower than previous studies done in similar settings. Keywords: Escherichia coli; hypertension; kidney; transplants.

International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in South Asia.

Information about disease burden and the available infrastructure and workforce to care for patients with kidney disease was collected for the second edition of the International Society of Nephrology Global Kidney Health Atlas. This paper presents findings for the 8 countries in the South Asia region. The World Bank categorizes Afghanistan and Nepal as low-income; Bangladesh, Bhutan, India, and Pakistan as lower-middle-income; and Sri Lanka and the Maldives as upper-middle-income countries. The prevalence of chronic kidney disease (CKD) in South Asia ranged from 5.01% to 13.24%. Long-term hemodialysis and long-term peritoneal dialysis are available in all countries, but Afghanistan lacks peritoneal dialysis services. Kidney transplantation was available in all countries except Bhutan and Maldives. Hemodialysis was the dominant modality of long-term dialysis, peritoneal dialysis was more expensive than hemodialysis, and kidney transplantation overwhelmingly depended on living donors. Bhutan provided public funding for kidney replacement therapy (dialysis and transplantation); Sri Lanka, India, Pakistan, and Bangladesh had variable funding mechanisms; and Afghanistan relied solely on out-of-pocket expenditure. There were shortages of health care personnel across the entire region. Reporting was variable: Afghanistan and Sri Lanka have dialysis registries but publish no reports, whereas Bangladesh has a transplant registry. South Asia has a large, but poorly documented burden of CKD. Diabetes and hypertension are the major causes of CKD throughout the region with a higher prevalence of infectious causes in Afghanistan and a high burden of CKD of an unknown cause in Sri Lanka and parts of India. The extent and quality of care delivery is suboptimal and variable. Sustainable strategies need to be developed to address the growing burden of CKD in the region.