Demographic Characteristics, Outcome and Complications of Renal Transplantations at a Tertiary Care Center in South India.

BACKGROUND: Renal transplantation is the treatment of choice for selected patients with end-stage renal disease. In this study, we present our experience and follow up data of renal transplantations done at this center with special emphasis on demographic characteristics, outcome and its complications. MATERIALS AND METHODS: All those patients who underwent renal transplantations and had been followed up at this center were studied and their details were recorded. For living donor transplantation, donor and recipient were evaluated in detail. Graft loss was defined as the patient became dialysis-dependent or underwent second renal transplantation. RESULTS: A total of 250 renal transplantations were done during the study period. 16.4% of total transplantations were cadaveric transplants. Recipients mean age was 38.5±11.64 yrs and donor mean age was 42.25 ±10.79 yrs. The majority of the recipients were male (72.4%) while female donors were predominant among living donors(59.3%). Mean graft survival time was 98.2 months (95% confidence interval [CI]:72.2-114.4). Mean patient survival time was 104.5 months (95% confidence interval [CI]:82.4-126.2). CONCLUSION: There is increasing no. of cadaveric renal transplants due to well established deceased donation programs in the state. Our patient and graft survival are comparable. Most of the immediate graft loss was due to acute rejection and late graft loss was due to chronic antibody-mediated rejection.

Open-label randomized control trial of hydroxychloroquine in patients with moderate to severe coronavirus disease 2019 infection.

BACKGROUND: At onset of coronavirus disease 2019 (COVID-19) pandemic, hydroxychloroquine (HCQ) was repurposed for treatment of patients based on reports that it had in vitro activity. The aim of this study was to find out if HCQ reduces number of days of hospitalization when given to patients with moderate to severe COVID-19 infections who require hospitalized care. METHODS: This was an open-label randomized control trial of HCQ administered 400 mg twice on day 1, then 400 mg once daily from day 2 to day 5 in patients with moderate to severe COVID-19 infection. Assessment was not blinded. Standard of care was given to both arms.Primary outcome was number of days of hospitalization till discharge or death. RESULT: One hundred ten patients (55 in each arm) were included. Mean age was 58 years. Baseline characteristics were well matched. There was no difference in the primary outcome (13.67 vs 13.89; p = 0.98). Number of deaths were more in HCQ arm (RR: 1.81; 95% CI: 1.13-2.93; p = 0.03). There was no difference in number of days on oxygen or normalization of oxygen saturation, number who needed ventilator, days to ventilator requirement and days on ventilator. Twenty-nine patients in control arm received remdesivir. When adjusted analysis was done after removal of these patients, there was no difference in primary or secondary outcomes. Number of deaths in adjusted analysis were not significant (RR: 1.28; 95% CI: 0.87-1.88; p = 0.37). CONCLUSION: HCQ does not change the number of days of hospitalization when compared with control.

Rhinovirus Pneumonia, Rhabdomyolysis-Induced Acute Kidney Injury, and Post-Viral Forme Fruste Lupus.

Viral interstitial pneumonia is rarely associated with rhabdomyolysis-induced acute kidney injury (AKI) and evolving systemic lupus erythematosus (SLE) with no lupus flare. Here, we report an adult male with human rhinovirus-associated viral pneumonia and rhabdomyolysis-related AKI requiring dialysis. He was detected to be anti-nuclear, anti-Smith, and anti-U1 ribonucleoprotein antibodies positive. His kidney biopsy revealed normal glomeruli, with immunofluorescence showing a full-house pattern. Renal function and lung function gradually improved to normal without any immunosuppressants.

Nephrotic Syndrome and Posterior Reversible Encephalopathy Syndrome as Clinical Presentations of Gemcitabine-Induced Thrombotic Micro-Angiopathy.

Gemcitabine-induced thrombotic micro-angiopathy (GiTMA) is a very rare pathology of micro-vascular occlusion with a poor prognosis. In this case report, we present a young male with pancreatic carcinoma who received gemcitabine as adjuvant chemotherapy and developed thrombotic micro-angiopathy (TMA) manifesting as nephrotic syndrome with renal dysfunction and posterior reversible encephalopathy syndrome (PRES). The case was successfully managed with discontinuation of the drug and conservative management. The pathogenesis of GiTMA might be direct endothelial dysfunction with consequent activation of the clotting system. The role of plasma exchanges and monoclonal antibodies is unclear in drug-induced TMA.

Improved Arterial Stiffness Indices 3 and 6 Months after Living-donor Renal Transplantation.

Arterial stiffness is a non-traditional risk factor of cardiovascular disease and may explain part of the excess cardiovascular risk in chronic kidney disease patients. Successful renal transplantation (RT) may restore renal function and improve several metabolic abnormalities involved in arterial stiffness. This prospective study conducted non-invasive assessments of arterial stiffness indices [the augmentation index (AI) and pulse wave velocity (PWV)] in end-stage kidney disease (ESKD) patients before RT and 3 and 6 months after living-donor RT, alongside the effects of age and calcineurin inhibitors on arterial stiffness. The study included 26 ESKD patients (22 males and 4 females; mean age, 34.07 years; median duration of dialysis, 10 months) scheduled for RT and followed up for three visits (within 1 week before transplantation, and 3 and 6 months after transplantation). Six months after successful RT, the patients had nearly normal serum creatinine and significantly improved serum phosphate and intact parathyroid hormone levels. The pretransplant AI was 21.53% ± 13.61% which reduced significantly 6 months after RT to 16.19% ± 10.74% (P <0.05). Although there was a reduction in PWV 6 months after RT from the pre-transplant PWV, it was not significant. A significant correlation between age and the augmentation index was noted 3 and 6 months after RT. Patients on tacrolimus-based immunosuppression after RT showed significant improvements in the AI compared with patients on a cyclosporine-based regimen. RT helped to improve arterial stiffness indices, resulting in reduced cardiovascular risk.

Burkholderia cepacia Bacteremia Complicated by Intracranial Abscesses and Immune Reconstitution Inflammatory Syndrome in a Renal Transplantation Recipient.

Burkholderia cepacia is almost always a colonizing organism rather than an infecting organism, but it may be pathogenic in immunocompromised individuals when isolated from body fluids that are ordinarily sterile. When recovered from blood culture it may present infection, pseuedo infection, or actual infection from contaminated intravenous fluids. We present a case of a renal transplant recipient patient who developed B. cepacia bacteremia following central venous cannulation. The subsequent clinical course was of worsening quadriparesis, which on neuroimaging revealed multiple brain and spinal abscesses. Following two weeks of intravenous antibiotics, his clinical features further worsened and the size of lesions further increased, which was suggestive of immune reconstitution inflammatory syndrome. With an increased steroid dose and continuation of the same anti-biotics, there was a regression of the lesions and significant clinical improvement.

Post Covishield (ChAdOx1 nCoV-19) Vaccination: New Onset Focal Segmental Glomerulosclerosis Resistant to Steroid and Calcineurin Inhibitor.

With the ongoing mass COVID vaccination program, various case reports link the COVID-19 vaccines with heightened off-target immune responses leading to de novo development or relapse of various glomerular diseases. Very few glomerular diseases (totally nine published cases to date) have been reported post ChAdOx1 nCoV-19 (Oxford-AstraZeneca) vaccination compared to more potent m RNA vaccine. In this case report, we present a case of de novo focal segmental glomerulosclerosis (FSGS) post ChAdOx1 nCoV-19 vaccination resistant to steroid and calcineurin inhibitor treatment. To our knowledge, this is the first case of FSGS tip variant reported after the ChAdOx1 nCoV-19 vaccination and the second de novo FSGS case post COVID vaccination (any types of COVID vaccines). We may expect more such types of cases resistant to conventional therapy as the global penetration of vaccination programs will improve.

Anaphylaxis: An Uncommon Cause of Rhabdomyolysis-Related Acute Kidney Injury.

Anaphylaxis is an acute, severe, and potentially lethal form of an allergic reaction. It can lead to a sepsis-like syndrome and multisystem involvement with complications. It can cause distributive shock with preferential blood supply to vital organs, at the expense of blood supply to skeletal muscle. Skeletal muscle ischemia leads to the fast depletion of myocyte energy source and a cascade of inflammatory reactions leading to myocyte injury and death. Myocyte lysis or rhabdomyolysis releases the cellular contents into circulation. Rhabdomyolysis is not an oft-discussed complication of anaphylaxis. We describe a 21-year-old male with no known comorbidity who presented with anaphylactic shock after consuming one tablet paracetamol + ibuprofen and was found to have rhabdomyolysis-related acute kidney injury.

A case of cholesterol embolization syndrome mimicking rapidly progressive renal failure causing end-stage kidney disease.

Cholesterol embolization syndrome is an uncommon complication of coronary angioplasty. Its clinical manifestations are nonspecific and may be ascribed to other causes mimicking vasculitis syndrome. In an appropriate clinical setting, the diagnosis can be confirmed by tissue biopsy. In this case report, we present a middle-aged male who presented with cutaneous and renal manifestations within two weeks of primary angioplasty. The patient had progressive clinical deterioration in the form of dry gangrene of toes and end-stage renal disease requiring surgical amputation and maintenance hemodialysis respectively within two months of symptoms onset.

The therapeutic dilemma in pre-transplant asymptomatic aspergilloma: A case report and review of literature.

Aspergillus species are ubiquitous, and inhalation of infectious conidia is not so uncommon. With immunosuppression, it can invade adjacent structures and lead to widespread invasive disease. There is no randomized, prospective trial for optimized treatment including the antifungal and surgical approach for aspergilloma. The available literature related to the management of asymptomatic aspergilloma in pre-renal transplant setting is scarce and debatable. Opinion favoring surgery is that it is necessary to eliminate the fungus reservoir before transplantation because of the inadequacy of pharmacological fungus control measures in immunocompromised patients. We present a case of end-stage renal disease that was planned for renal transplantation and during the workup, was detected to have asymptomatic right upper lobe aspergilloma. He underwent surgical resection of the aspergilloma before undergoing successful renal transplantation. In this case report, we will discuss this case and controversies related to its management before undergoing successful renal transplantation.

Disseminated Histoplasmosis Masquerading as Significant Weight Loss Eight Years Post Renal Transplant.

With the advent of potent immunosuppressive therapies, renal transplant recipients are more susceptible to a variety of infections with atypical pathogens and presentations. In the setting of many years post-renal transplant, weight loss may be due to occult systemic fungal infection and if left untreated it may evolve with multisystem involvement. We describe a case with significant weight loss who got admitted for the evaluation for post-transplant lympho- proliferative disorder. The 30-year-old male patient presented with weight loss eight years post- renal transplant and detailed evaluation revealed systemic fungal infection involving cutaneous, pulmonary, and hematopoietic systems.

Clinical Profile, Histopathological Features and Outcome of IgA Nephropathy in a Tertiary Care Hospital in India.

IgA nephropathy (IgAN) is reported to be more common in Asians and is considered to be a very progressive disease with worse outcome. The present study encompasses a cohort of biopsy-proven IgAN in a tertiary care hospital to characterize the initial clinical presentation, Oxford classification profile and one year follow up of patients with clinical and biochemical investigations. All renal biopsies with a diagnosis of primary IgAN were included. In all biopsies with ≥8 viable glomeruli, the MEST-C scores were analyzed, according to the Oxford criteria. Demographic and clinical data included age, gender, presence of hypertension, presence of hematuria and edema. Baseline investigations include urine protein semiquantitative, spot urine protein creatinine ratio, 24-h urinary protein, serum creatinine, and serum albumin. All the details of the use of antiproteinuric drugs and immunosuppressive drugs were recorded. Total 48 renal biopsies (21.62%) were diagnosed as primary IgAN. Thirty-seven (77.08%) had renal dysfunction on initial presentation out of which 31 (64.5%) patients had subnephrotic range proteinuria (SNRP). MEST-C lesions distribution were interpreted in 39 patients. 42.85% of patients with nephrotic range proteinuria (NRP) and 55.55% of patients with SNRP had renal deterioration during follow up period while 28.57% patients with NRP and 41.66% patients with SNRP had reached end-stage renal disease (ESRD). Our study population of IgAN has a unique clinical profile with hypertension, microscopic hematuria and subnephrotic proteinuria as the predominant clinical presentation. In spite of low MEST-C score in our study cohort, the disease has an aggressive course with 47.91% of patients with renal function deterioration and about one third follow up patients approaching ESRD during the study period.

Investigation on thermodynamic performance analysis and environmental effects of various new refrigerants used in air conditioners.

The main aim of this present investigation is to evaluate performance and environmental impact analysis of various novel mixture refrigerants as R22 replacements theoretically. Refrigerants with lower global warming potential (GWP) can be adequate for bringing down emissions which are concerned for air conditioners. In this investigation, twenty-seven refrigerants were developed at several compositions. Important studies such as computation of CO2 emissions using total equivalent warming impact (TEWI), toxicity and flammability analysis of various considered refrigerants were also carried out in this investigation. Performance analysis of refrigerants was conducted under different operating conditions. Results showed that the energy efficiency ratios (EERs) of refrigerants such as R1270, RM30 (R152a/R1270/RE170 of 25/71/4 by mass percentage) and RM50 (R152a/R1270/RE170 of 10/85/5 by mass percentage) were closer to that of R22 and they are relatively lower than R22 by 0.95%, 1.34% and 1.80%, respectively. Toxicity investigation exhibited that all the refrigerants studied were classified into nontoxic category (A) whereas flammability investigation revealed that all the novel refrigerant mixtures (RM10 to RM50) were classified into flammable category (A3). CO2 emissions (TEWI) released from air conditioner working with R1270, RM30 and RM50 were 7.41%, 6.85% and 6.51%, respectively, lower than that of R22. In terms of several thermodynamic aspects, the performance of refrigerants such as R1270, RM30 and RM50 were superior to those of R22 and its various considered alternatives working under different operating conditions, although their EERs are fairly lower than R22 and hence, these refrigerants could be considered suitable environment-friendly alternatives to R22 used in air conditioners. The present study gives essential information and a road map towards the development of low GWP R22 alternative refrigerant blends from the viewpoint of toxicity, flammability, performance aspects, environmental and safety aspects, respectively.

Psychological Health Among Armed Forces Doctors During COVID-19 Pandemic in India.

BACKGROUND: A pandemic poses a significant challenge to the healthcare staff and infrastructure. We studied the prevalence of anxiety and depressive symptoms among armed forces doctors in India during the COVID-19 pandemic and the factors that contribute to these symptoms. METHODS: The study was conducted from March 30, 2020, to April 2, 2020, using a self-administered questionnaire questionnaire using the hospital anxiety and depression scale (HADS), which was sent through Google Forms. Responses were received from 769 respondents. Data were analyzed for demographic details and HADS scores using the chi-square test and backward logistic regression. RESULTS: Anxiety and depressive symptoms were seen in 35.2% and 28.2% of the doctors, respectively. In doctors with anxiety symptoms, significant associations were observed with age (20-35 years, 39.4%, P = 0.01), gender (females, 44.6%, P < 0.001), duration of service (0-10 years, 38%, P = 0.03), and clinical versus non-clinical specialties (non-clinical, 41.3%, P < 0.001) as opposed to marital status, education level, and current department of work.In doctors with depressive symptoms, significant associations were observed with age (P = 0.04), clinical versus non-clinical specialties (P < 0.001), duration of service (0-10 years, 30.1%, P = 0.03), and doctoral degree (P = 0.04) as opposed to gender, marital status, education level, and current working department. CONCLUSION: The study revealed a high prevalence of anxiety and depressive symptoms among armed forces doctors. The main contributing factors are female gender, young age group, non-clinical specialties, and having a doctoral degree.