Complementary and Alternative Medicine Use and Glomerular Disease: A Contemporary Case Series.

Rationale & Objective: Complementary and alternative medicine (CAM) intake is widely prevalent in many parts of India. Heavy metals are known ingredients in some of these formulations. We studied the spectrum of glomerular diseases in patients using CAM. Study Design: Case series. Setting & Participants: Patients with proteinuria or unexplained acute kidney injury, who underwent a kidney biopsy between May 2021 and September 2022, and who provided a history of recent CAM intake were included in the study. For patients enrolled prospectively, blood and urine samples were analyzed using mass spectrometry for the presence of mercury, lead, arsenic and cadmium. The CAM formulation, when available, was analyzed using inductively coupled plasma-optical emission spectroscopy. Results: Twenty-eight patients were enrolled in the study, with a median duration of CAM intake of 4 months (interquartile range, 2-6 months). Heavy metal screening was performed in 17 patients, of whom 15 had elevated urine mercury levels, 10 had elevated blood mercury levels, and 1 had elevated blood and urine arsenic levels. Of the 6 CAM formulations that were analyzed, all had high levels of mercury. Kidney biopsy findings were membranous nephropathy (n = 19), minimal change disease (n = 8), and mesangial proliferative glomerulonephritis (n = 1). Of the 19 patients with membranous nephropathy, 14 were associated with neural epidermal growth factor-like protein 1 (NELL-1). With conservative management alone, 17 patients achieved complete remission. Limitations: Not all patients underwent blood and urine mercury testing, and only 6 patients provided the CAM samples for analysis. Furthermore, occupational and residential exposure to mercury could not be excluded. Conclusions: The most common kidney pathology noted in our study was membranous nephropathy, which was predominantly associated with neural epidermal growth factor-like protein 1. A significant proportion of the patients recovered completely after withdrawal of the offending agent and initiation of renin-angiotensin system blockade.

Complementary and alternative medicine (CAM) intake is widely prevalent in many parts of India, and heavy metals are known ingredients in some of these formulations. We describe the clinical spectrum of kidney disease, among patients who had recently ingested CAM. All patients underwent a kidney biopsy, and the most common finding was an entity called "NELL-1-associated membranous nephropathy," which is known to be associated with heavy metal toxicity and CAM intake. Of 17 patients screened for such heavy metals, 15 had greater-than-permissible levels of mercury. Furthermore, 6 patients provided the CAM formulations that they had consumed for analysis: all contained high levels of mercury. Most such patients recovered following withdrawal of the offending CAM agent.

A Pilot Study on the Safety and Adequacy of a Novel Ecofriendly Hemodialysis Prescription-Green Nephrology.

Introduction: Hemodialysis (HD) units require large quantities of water. To reduce water consumption without compromising the adequacy and safety of dialysis, we studied a novel HD prescription with high temperature and low flow dialysate. Methods: This was a single-center nonrandomized open-label cross-over pilot trial in patients with end-stage kidney disease on maintenance HD. Each participant was subjected to 3 different dialysis prescriptions for 1 month each as follows: (i) normal temperature with normal flow dialysate (NTNF prescription), (ii) high temperature with normal flow dialysate (HTNF prescription), and (iii) high temperature with low flow dialysate (HTLF prescription). The primary outcome, assessed at the end of each dialysis session, was the delivery of "adequate" dialysis, as defined by a single-pool Kt/V (spKt/V) ≥1.2. Outcomes were evaluated by comparing the NTNF and HTLF prescriptions. Results: A total of 863 sessions of HD were performed in 30 patients over 3 months, with 287 to 288 sessions in each of the 3 dialysis prescriptions. The primary outcome was not significantly different between the NTNF prescription (202 sessions [70.14%]) and the HTLF prescription (198 sessions [68.75%]) (odds ratio, 1.07; 95% confidence interval, 0.75 to 1.52; P = 0.45). The mean spKt/V and urea reduction ratio (URR) were not significantly different. Clinically evident hemodynamic instability occurred in only 1 dialysis session in the HTNF prescription. Conclusion: Increasing dialysate temperature while reducing dialysate flow rate (QD) can be used as a water conservation strategy without compromising the adequacy and safety of dialysis in young and hemodynamically stable patients. Reducing the QD from 500 ml/min to 300 ml/min reduces water consumption by 40%.

SARS-CoV-2 Antibody Seroprevalence and Humoral Response to Vaccination in Patients Undergoing Maintenance Hemodialysis: A Prospective Cohort Study.

Introduction: COVID-19, caused by SARS-CoV-2, has resulted in significant mortality and morbidity worldwide. Patients of chronic kidney disease who are on maintenance hemodialysis represent a vulnerable population cohort that is susceptible to severe disease. Hence, it is of utmost importance to prioritize vaccination in this population and to assess their response to said vaccination. Methods: This prospective analytical study was conducted at the Institute of Nephrology, Madras Medical College, between August 2021 and February 2022. Patients of chronic kidney disease stage 5 dialysis (CKD5D) who were on maintenance hemodialysis and who consented to receive COVID-19 vaccine were studied. Serum samples were obtained before vaccination, ≥28 days after receiving the first dose of the vaccine, and ≥28 days after receiving the second dose. Antibody titers against the spike protein were estimated using the Roche chemiluminescent immunosorbent assay. Patients were grouped into non-responders/seronegative (<0.8 U/ml) and responders/seropositive (≥0.8 U/ml), with a value ≥250 U/ml considered as robust response. Results: A total of 96 patients were included. The mean age was 36.70 (±11.53) years and 77.1% of them were male. The median dialysis vintage was 2 (IQR: 0.95-5) years. Twelve patients (9.9%) had a prior COVID-19 infection. Sixty-seven (69.8%) patients had received Covaxin and 29 (30.2%) had received Covishield vaccines. Among the 17 patients who were seronegative at baseline, 4 (23.52%) became seropositive after the first dose of the vaccine, and 11 (64.7%) were seropositive after the second dose, with high titers ("robust response") achieved in two patients (11.76%). No antibody response, despite two doses of the vaccine, was noted in six patients (35.29%). Conclusion: Our study showed a high baseline seropositivity rate, even prior to vaccination, which indicated a high rate of subclinical COVID infection. Among those who were seronegative at baseline, the seroconversion rate after two doses of Covaxin or Covishield was 64.70%.

Indian TrANslational GlomerulonephrItis BioLogy nEtwork (I-TANGIBLE): Design and Methods.

Background and Aim: Primary glomerular disease accounts for one-sixth of all chronic kidney diseases (CKDs) in India. We remain limited in our ability to effectively treat these conditions because of lack of understanding of the disease mechanisms and lack of predictors to identify the clinical course and therapeutic responsiveness. We propose to develop a network of investigators in glomerular diseases, collect information in a systematic fashion to understand the clinical outcomes, answer translational research questions better, and identify and recruit patients for clinical trials. Materials and Methods: This is a prospective, observational study. The Indian TrANslational GlomerulonephrItis BioLogy nEtwork (I-TANGIBLE) cohort will enroll patients (>18 years) with biopsy-proven minimal change disease (MCD), focal segmental glomerulonephritis (FSGS), membranous nephropathy (MN), IgA nephropathy (IgAN), or membranoproliferative glomerulonephritis (MPGN) (immune complex- and complement-mediated), with first biopsy taken within 2 years of enrollment. Patients with estimated glomerular filtration (eGFR) rate <15 ml/min/1.73 m2 for >3 months at the time of screening, kidney transplant or bone marrow transplant recipients, patients with active malignancy, and patients with active hepatitis B/C replication or human immunodeficiency virus (HIV)-I/II will be excluded. Clinical details including history, medication history and details, and family history will be obtained. Consenting patient's blood and urine samples will be collected and stored, aligned to their clinical follow-up. Expected Outcomes: The network will allow accurate ascertainment of disease burden of glomerular diseases across study sites, establishment of the treatment pattern of common glomerular diseases, investigation of medium- and long-term outcomes (remission, relapse, rate of eGFR decline), and building a suitable infrastructure to carry out clinical trials in primary glomerular disease.

Acute Kidney Injury Complicating Severe Acute Pancreatitis: Clinical Profile and Factors Predicting Mortality.

Introduction: Acute kidney injury (AKI) frequently complicates severe acute pancreatitis (SAP) among the critically ill. We studied clinical profile and risk factors predicting mortality in SAP-AKI. Materials and Methods: We conducted a prospective observational study of 68 patients with SAP-AKI from September 2015 to September 2019. Patient data and outcomes grouped as survivors and deceased were analyzed. Results: SAP-AKI constituted 2.14% (68 of 3,169) of all AKIs with 1.5%, 20.6%, and 77.9% in Kidney Disease Improving Global Outcomes (KDIGO) Stages I, II and III respectively. The mean age was 39.93 ± 11.79 years with males 65 (95.6%). The causes of acute pancreatitis were alcohol addiction 59 (86.8%), highly active antiretroviral therapy 1 (1.4%), hypercalcemia 1 (1.4%), IgG4-related disease 1 (1.4%), and unidentified 6 (8.8%). Complications were volume overload, shock, respiratory failure, and necrotizing pancreatitis in 21 (30.9%), 10 (14.7%), 6 (8.8%), and 14 (20.5%), respectively. Kidney replacement therapy done in 40 (58%), with intermittent hemodialysis 36 (53%) and acute intermittent peritoneal dialysis 4 (6%). The overall mortality was 23 (33.8%), three progressed to chronic kidney disease (thrombotic microangiopathy 2; biopsy inconclusive 1). In 45 survivors, AKI recovered in 22.7 ± 9.6 days. Death occurred within first 6 days. The risk factors associated with in-hospital mortality was necrotizing pancreatitis (odds ratio [OR] = 5.143; 95% confidence interval 1.472-17.972; P = 0.01), circulatory failure (OR = 6.125; P = 0.016), peak creatinine >3 mg/dL (OR = 7.118; P = 0.068), Bedside Index of Severity for Acute Pancreatitis score >3 (OR = 8.472; P = 0.001), need for kidney replacement therapy (OR = 3.764; P = 0.024), KDIGO III (OR = 9.935; P = 0.03). Conclusions: Alcohol addiction was the commonest cause of severe acute pancreatitis. The overall mortality was 33.8%. Necrotizing pancreatitis, circulatory failure, peak creatinine >3 mg/dL, BISAPs >3, KDIGO III, and the need for kidney replacement therapy were independent risk factors for mortality.

Efficacy of Corticosteroids in Infection-Related Glomerulonephritis-A Randomized Controlled Trial.

Introduction: Infection-related glomerulonephritis (IRGN) is associated with glomerular immune complex deposition along with complement activation. Steroids may attenuate glomerular injury and thereby improve renal outcomes. Methods: We randomly assigned patients who had biopsy-proven IRGN and serum creatinine greater than 1.5 mg/dl to receive corticosteroids plus supportive care (intervention arm), or supportive care alone (control arm). Patients were followed up for 6 months. The primary outcome was complete renal recovery at 6 months. Safety of steroid therapy was also assessed. Results: A total of 52 patients underwent randomization. At 6 months, 17 of 26 patients (65.4%) in the intervention arm and 14 of 26 patients (53.8%) in the control arm had complete renal recovery (odds ratio 1.6; 95% confidence interval, 0.5-4.9; P = 0.397). There was no statistically significant difference in any of the secondary outcomes. Adverse events occurred in 12 patients (46.2%) in the intervention arm and 2 patients (7.7%) in the control arm (P = 0.002). Conclusion: In this single-center trial, corticosteroids did not result in a statistically significant increase in rates of complete renal recovery at 6 months. There was a significantly increased risk of adverse events associated with the use of corticosteroids.

Clinical Profile and Outcomes of Coronavirus Disease 2019 (COVID-19) in Patients Undergoing Hemodialysis.

Introduction: Several months into the coronavirus disease 2019 (COVID-19) pandemic, there remains a paucity of data on the behavior of the disease in patients with end-stage kidney disease (ESKD) on maintenance hemodialysis (MHD). Here, we describe the clinical presentations, biochemical profile, and outcomes of 183 such patients from a large tertiary-care center in South India. Materials and Methods: This prospective, observational study, included all patients with COVID-19 and ESKD who received at least one session of hemodialysis at our center, from the start of the outbreak to July 9, 2020. Clinical features at presentation, laboratory and radiological data, and outcomes were analyzed. Results: A total of 183 patients were included in the analysis. Patients who had symptoms at presentation accounted for 49.18% of the cohort, with the most common symptoms being fever (87.1%), cough (67.7%), and breathlessness (63.4%). Factors independently associated with mortality on univariate analysis included age ≥60 years, having symptoms at presentation, neutrophil-lymphocyte ratio >6, C-reactive protein >20 mg/L, serum lactate dehydrogenase >250 IU/L, CT (computed tomography) Grades 3 and 4, and the need for respiratory support. However, on multivariate logistic regression analysis, the only factor that retained significance was an age >60 years. Conclusions: This analysis confirms the previous reports of higher COVID-19-related mortality in the dialysis population and identifies older age, higher inflammatory markers, and greater degrees of radiological lung involvement to correlate with increased mortality.

The Indian Chronic Kidney Disease (ICKD) study: baseline characteristics.

BACKGROUND: Chronic kidney disease (CKD) is an important cause of morbidity and mortality worldwide. There is a lack of information on epidemiology and progression of CKD in low-middle income countries. The Indian Chronic Kidney Disease (ICKD) study aims to identify factors that associate with CKD progression, and development of kidney failure and cardiovascular disease (CVD) in Indian patients with CKD. METHODS: ICKD study is prospective, multicentric cohort study enrolling patients with estimated glomerular filtration rate (eGFR) 15-60 mL/min/1.73 m2, or >60 mL/min/1.73 m2 with proteinuria. Clinical details and biological samples are collected at annual visits. We analysed the baseline characteristics including socio-demographic details, risk factors, disease characteristics and laboratory measurements. In addition, we compared characteristics between urban and rural participants. RESULTS: A total of 4056 patients have been enrolled up to 31 March 2020. The mean ± SD age was 50.3 ± 11.8 years, 67.2% were males, two-thirds of patients lived in rural areas and the median eGFR was 40 mL/min/1.73 m2. About 87% were hypertensive, 37% had diabetes, 22% had CVD, 6.7% had past history of acute kidney injury and 23% reported prior use of alternative drugs. Diabetic kidney disease, chronic interstitial nephritis (CIN) and CKD-cause unknown (CKDu) were the leading causes. Rural participants had more occupational exposure and tobacco use but lower educational status and income. CIN and unknown categories were leading causes in rural participants. CONCLUSIONS: The ICKD study is the only large cohort study of patients with mild-to-moderate CKD in a lower middle income country. Baseline characteristics of study population reveal differences as compared with other cohorts from high-income countries.

Renin-angiotensin blocker use is associated with improved cardiovascular mortality in Indian patients with mild-moderate chronic kidney disease-findings from the ICKD study.

Introduction: Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are the antihypertensive drug class of choice in patients with chronic kidney disease (CKD). Head-to-head comparisons of the renal or non-renal outcomes between ACEI/ARB users and nonusers have not been conducted in all population groups. We examined the renal and cardiovascular outcomes in users and nonusers enrolled in the Indian Chronic Kidney Disease (ICKD) Study. Methods: A total of 4,056 patients with mild-moderate CKD were studied. Patients were categorized as ACEI/ARB users or nonusers. Major adverse kidney events [ESKD (end stage kidney disease), ≥50% decline in eGFR and kidney death], all-cause mortality, and cardiovascular mortality were analyzed over a median follow-up period of 2.64 (1.40, 3.89) years between the two groups. Results: Out of a total of 4,056 patients, 3,487 (87%) were hypertensive. The adjusted sub-hazard ratio (SHR) and 95 % CI for ACEI /ARB users was 0.85 (0.71, 1.02) for MAKE, 0.80 (0.64, 0.99) for a 50% decline in eGFR, and 0.72 (0.58, 0.90) for ESKD. For cardiovascular mortality, ACEI/ARB users were at lower risk (SHR = 0.55, 95% CI: 0.34, 0.88). Diuretic users were at increased risk of all-cause mortality (HR = 1.95, 95% CI: 1.50, 2.53) and cardiovascular mortality (adjusted SHR = 1.73, 95% CI: 1.09, 2.73). There was non-significant association between the use of other antihypertensives and any of the end points. Discussion: ACEI/ARB use is associated with slower rate of decline in eGFR in those with CKD stage 1-3. ACEI/ARB users had a significantly lower risk of renal outcomes, and cardiovascular mortality.

Snake envenomation-induced acute kidney injury: prognosis and long-term renal outcomes.

BACKGROUND: Snake bite continues to be a significant cause of acute kidney injury (AKI) in India. There is paucity of data regarding long-term outcomes of such patients. In this study, we aim to assess the prognosis and long-term renal outcomes of such patients. METHODS: We analysed the hospital records of snake envenomation-induced AKI from January 2015 to December 2018. Predictors of in-hospital mortality were assessed. Survivors were advised to visit follow-up clinic to assess their kidney function. RESULTS: There were 769 patients with evidence of envenomation and of them, 159 (20.7%) had AKI. There were 112 (70.4%) males. Mortality occurred in 9.4% of patients. Logistic regression analysis identified shock (OR 51.949, 95% CI 4.297 to 628.072) and thrombocytopenia (OR 27.248, 95% CI 3.276 to 226.609) as predictors of mortality. Forty-three patients attended the follow-up. The mean follow-up duration was 30.4±15.23 months. Adverse renal outcomes (eGFR <60 mL/min/1.73 m2 or new-onset hypertension (HTN) or pre-HTN or urine protein creatinine ratio >0.3) occurred in 48.8% of patients. Older age (mean age (years) 53.3 vs 42.8, p=0.004) and longer duration on dialysis (median duration (days) 11.5 vs 5, p=0.024) were significantly associated with adverse renal outcomes. CONCLUSIONS: The incidence of AKI in snake envenomation was 20.7%. The presence of shock and thrombocytopenia were associated with mortality. Adverse renal outcomes occurred in 48.8% of patients in the long term.

Chronic Kidney Disease of Unknown Etiology in India: What Do We Know and Where We Need to Go.

Chronic kidney disease (CKD) not associated with known risk factors has been reported from parts of India and is presumed to be similar to CKD of unknown etiology (CKDu) that has been described from Central America. The reports from India have been fragmented without clear description of the disease phenotype or its determinants. This paper summarizes the current state of knowledge around CKDu in India based on a review of literature, multi-stakeholder consultation, and a survey of Indian nephrologists. We also contacted individual research groups to solicit data. Our findings suggest that that CKDu is reported from most regions in India; however, it is interpreted differently from the phenotype described from Central America and Sri Lanka. The differences include lack of a clear demographic or occupation group, older age of affected participants, and presence of mild hypertension and low-grade proteinuria. Well-designed prospective field studies with appropriate diagnostic workup are needed to establish the disease burden and identify etiologies, along with socioeconomic and health consequences, the intersection with the environment, and the public health response. Community-based research should phenotype the entire CKD population rather than be restricted to cases with presumed CKDu based on predefined criteria. Guidelines are needed for clinical evaluation, referral, management, and harmonization of clinical documentation and health records. More data are needed to support the existence of a unique CKDu phenotype in India.

Prescription Practices in Patients With Mild to Moderate CKD in India.

INTRODUCTION: Patients with chronic kidney disease (CKD) require multiple medications. There is no information on prescription patterns or the use of evidence-based therapies for management of CKD from low-middle-income countries. Using baseline data from the Indian CKD (ICKD) cohort, we describe the drug prescription practices in patients with mild to moderate CKD. METHODS: The ICKD study is a prospective, observational cohort study of mild to moderate kidney disease across 11 centers in India. We analyzed all the prescriptions captured at enrollment in the ICKD study. Drugs were categorized into 11 different groups. We provide descriptive data on prescription details and evaluate the appropriateness of medication use. RESULTS: Complete prescription data were available in 3966 out of 4056 (97.8%) subjects enrolled in the ICKD database. Most patients had stage 3 CKD, 24.9% had diabetic kidney disease, 87% had hypertension, and 25.5% had moderate to severe proteinuria. Renin-angiotensin-aldosterone system blockers were prescribed in less than half (47.9%) and in 58.8% of patients with proteinuric CKD. Metformin was prescribed in 25.7% of diabetic subjects with CKD. Only 40.4% of patients were taking statins; 31.1% and 2.8% subjects with anemia were receiving iron and erythropoiesis-stimulating agents, respectively. CONCLUSION: This study highlights the missed opportunities for improving outcomes through appropriate prescriptions of drugs in patients with CKD. There is need for dissemination of evidence-based guidelines and institution of sustainable implementation practices for improving the overall health of patients with CKD.

Efficacy and safety of convalescent plasma therapy in SARS-CoV2 patients on hemodialysis.

BACKGROUND: The passive immunization of patients with SARS-CoV2 with convalescent plasma (CP) is theoretically beneficial in patients with end-stage renal disease who are immunosuppressed and unable to mount an adequate immune response. Hence, this study was conducted to evaluate the safety and efficacy of CP in patients with chronic kidney disease on hemodialysis with moderate-to-severe SARS-CoV2 infection. METHODS: A prospective observational cohort study was conducted in consecutive 68 moderate-to-severe SARS-CoV2 infected patients who were on maintenance hemodialysis or with acute worsening of chronic kidney disease which required initiation of hemodialysis. Patients who received CP were compared with those who did not. The primary outcome was death during hospitalization. Clinical characteristics, duration of hospitalization and inflammatory parameters were compared between the two groups. A subgroup analysis was done to find whether early initiation of plasma was associated with better outcome. RESULTS: Sixteen patients (44%) in the plasma group and 14 (45%) patients in the control group died during hospitalization (p = 0.95). The median duration of hospitalization was 9 (6-14) days in the plasma group and 9 (6-16) in the control group (p = 0.60). There was no difference in mortality or duration of hospitalization with respect to early initiation of CP (p = 0.29). Fistula thrombosis occurred in two patients (11.1%) in the plasma group. CONCLUSION: Therapy with CP does not appear to confer any clinical benefit in moderate-to-severe SARS-CoV-2 infected patients with chronic kidney disease on hemodialysis.

INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease.

Renal dysfunction is very common among patients with chronic liver disease, and concomitant liver disease can occur among patients with chronic kidney disease. The spectrum of clinical presentation and underlying etiology is wide when concomitant kidney and liver disease occur in the same patient. Management of these patients with dual onslaught is challenging and requires a team approach of hepatologists and nephrologists. No recent guidelines exist on algorithmic approach toward diagnosis and management of these challenging patients. The Indian National Association for Study of Liver (INASL) in association with Indian Society of Nephrology (ISN) endeavored to develop joint guidelines on diagnosis and management of patients who have simultaneous liver and kidney disease. For generating these guidelines, an INASL-ISN Taskforce was constituted, which had members from both the societies. The taskforce first identified contentious issues on various aspects of simultaneous liver and kidney diseases, which were allotted to individual members of the taskforce who reviewed them in detail. A round-table meeting of the Taskforce was held on 20-21 October 2018 at New Delhi to discuss, debate, and finalize the consensus statements. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong and weak) thus reflects the quality (grade) of underlying evidence (I, II, III). We present here the INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease.

A clinical study on the changing dynamics of disease severity, management strategies and outcomes of COVID-19 in patients requiring haemodialysis.

INTRODUCTION: In this observational study, we describe the change in the clinical profile and outcome of Corona Virus Disease 2019 (COVID-19) over the course of the outbreak, among patients requiring dialysis, including chronic haemodialysis therapy. METHODS: This is a single-centre prospective observational study of patients with COVID-19 (as confirmed by RT-PCR) and renal failure requiring haemodialysis. Their clinical profiles and outcomes were analysed, vis-à-vis the changing disease severity. FINDINGS: A total of 483 patients were included, of whom 416 had end-stage renal disease and were on maintenance haemodialysis. Patients who were symptomatic at presentation had significantly higher levels of Neutrophil-lymphocyte ratio (NLR) (p < 0.001), C-reactive protein (CRP) (p < 0.001), lactate dehydrogenase (LDH) (p < 0.001), higher degrees of lung involvement (p < 0.001) and required more respiratory support (p < 0.001). The overall mortality observed was 18.8%. In the late phases of the outbreak, there was a significant increase in disease severity without a statistically significant increase in mortality. Predictors of mortality on univariate analysis were age, diabetes mellitus, acute on chronic kidney disease, presence of symptoms on admission, NLR, CRP, LDH, computed tomography (CT) chest grades 3 and 4, and need for respiratory support; however, only age and the renal syndrome of acute on chronic kidney disease retained significance on multivariate analysis (p0.003 and p0.019, respectively). CONCLUSION: Among patients on haemodialysis, higher mortality was observed in patients who were older, and among those with acute on chronic kidney disease. In the late phase of the outbreak, there was a statistically significant increase in disease severity without a corresponding increase in mortality.

Cavitary pulmonary disease in a patient on dialysis.

A 24-year-old man on maintenance hemodialysis presented with bilateral cavitary consolidations and methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia following ulceration of the skin over his arteriovenous (AV) fistula cannulation site. A diagnosis of septic pulmonary embolism was made, which presumptively originated from a localized MSSA infection of his AV access. He had an excellent response to a 28-day course of cloxacillin, with the resolution of the pulmonary lesions.

Use of Remdesivir in Patients With COVID-19 on Hemodialysis: A Study of Safety and Tolerance.

BACKGROUND: There are scarce data regarding the use of remdesivir in patients with severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) and end-stage renal disease as US Food and Drug Administration cautions against its use in patients with an estimated glomerular filtration rate <30 ml/min/1.73m2 unless the potential benefits outweigh the potential risks. We studied the compassionate use and safety profile of remdesivir in patients with end-stage renal disease and moderate to severe SARS-CoV-2 infection. METHODS: We conducted an observational prospective study in 48 dialysis-dependent patients with SARS-CoV-2 infection who received remdesivir as part of institutional treatment protocol. During the treatment period, 100 mg of remdesivir was given 4 hours before hemodialysis sessions. Liver function tests, inflammatory markers such as serum C-reactive protein, serum ferritin and lactate dehydrogenase levels, and oxygen requirement before and after remdesivir treatment were compared. RESULTS: There were no events of significant liver function test alterations with the administration of 2 to 6 doses of remdesivir. A significant decline in serum C-reactive protein level (P < 0.001) was noted. More than two thirds (68.57%) of patients showed an improvement in oxygen requirement. Early administration of remdesivir within 48 hours of hospital admission shortened the duration of hospitalization by a mean of 5.5 days (P = 0.001). CONCLUSION: Remdesivir was well tolerated and found safe in our study. If initiated within 48 hours of hospitalization, it reduces recovery time. Assessing the mortality benefits of remdesivir in these patients requires a randomized controlled trial with a larger population.

Hansen's disease with lepra reaction presenting with IgA dominant infection related glomerulonephritis.

Various renal abnormalities in leprosy have been described largely in literature but the occurrence of IgA dominant infection related glomerulonephritis in leprosy with type 2 lepra reaction has not been reported so far. We present here a 60-year-old man with a history of leprosy in the past admitted with type 2 lepra reaction, rapidly progressive glomerulonephritis with severe renal failure requiring dialysis and diagnosed to have IgA dominant infection related glomerulonephritis.