NOTTO Guidelines for Vaccine Induced Thrombotic Thrombocytopenia in Organ Donation and Transplantation.

From the context of organ donation, COVID-19 vaccine-induced thrombotic thrombocytopenia (VITT) is important as there is an ethical dilemma in utilizing versus discarding organs from potential donors succumbing to VITT. This consensus statement is an attempt by the National Organ and Tissue Transplant Organization (NOTTO) apex technical committees India to formulate the guidelines for deceased organ donation and transplantation in relation to VITT to help in appropriate decision making. VITT is a rare entity, but a meticulous approach should be taken by the Organ Procurement Organization's (OPO) team in screening such cases. All such cases must be strictly notified to the national authorities like NOTTO, as a resource for data collection and ensuring compliance withprotocols in the management of adverse events following immunization. Organs from any patient who developed thrombotic events up to 4 weeks after adenoviral vector-based vaccination should be linked to VITT and investigated appropriately. The viability of the organs must be thoroughly checked by the OPO, and the final decision in relation to organ use should be decided by the expert committee of the OPO team consisting of a virologist, a hematologist, and atreating team. Considering the organ shortage, in case of suspected/confirmed VITT, both clinicians and patients should consider the risk-benefit equationbased on available experience, and an appropriate written informed consent of potential recipients and family members should be obtained before transplantation of organs from suspected or proven VITT donors.

Effect of Coronavirus Disease 2019 on Transplantation and Nephrology in India: A Nationwide Report From India.

BACKGROUND: The effect of coronavirus disease 2019 (COVID-19) on a developing nation is sparsely reported and, more importantly, the discrepancies in public and private sectors are underexplored. METHODS: We retrospectively investigated the data on the effect of COVID-19 on renal transplantation between 2019 and 2020 in a nationwide analysis from 8 public and 10 private sector hospitals of India. RESULTS: On comparing the yearly data, the number of living-related transplants and deceased donor transplants declined by 48% (2610 vs 1370) and 49% (194 vs 99), respectively. The outpatient numbers and in-center admissions decreased by 40.4% (616,741 vs 367,962) and 30.8 % (73,190 vs 49,918). respectively. There was no increase in the number of renal or graft biopsies in the COVID-19 era. The number of waitlisted patients on hemodialysis was higher in public (304,898 vs 338,343) when compared with private (163,096 vs 150,292) in the last 2 years. Similarly, the number of waitlisted patients on peritoneal dialysis (4655 vs 3526) was higher in the public sector compared with private sector (932 vs 745). The decline in living transplants during the pandemic was higher in public sectors (58%) compared with the private (49%). However, the decline in deceased donation was higher in private (57.9%) relative to public (50.6%). CONCLUSIONS: COVID-19 has adversely affected the transplantation activities across the Indian transplantation centers, with a disproportionately higher impact on waitlisted patients in public sector programs. A sound prioritization of health care resources is mandated to safeguard the most deprived and high-risk waitlisted patients during the pandemic.

Membranous nephropathy and granulomatous interstitial nephritis due to tuberculosis.

Tuberculous involvement of the genitourinary tract is well reported in the literature. However, reports of glomerular lesions of the kidney due to tuberculosis are rare. Tuberculosis has been identified as the most common infectious cause of granulomatous interstitial nephritis (GIN). We report a 23-year-old female patient with a membranous nephropathy and GIN due to tuberculosis. She presented with renal failure and nephrotic-range proteinuria, both of which resolved with the treatment of tuberculosis. There is only one report, from Japan, of a patient with membranous nephropathy and tuberculous granulomatous nephritis. Our patient is the second with tuberculous GIN and membranous nephropathy. In our patient, the close temporal relationship between the infection and glomerulonephritis, an ulcerated tuberculin skin test, the response to the treatment and the absence of any other systemic disease that might cause the glomerulonephritis suggested an association between tuberculosis and membranous nephropathy. However, a causal association can only be speculation, because membranous nephropathy could remit spontaneously. It is also possible that it might relapse at a later date when the tuberculosis is inactive. Therefore, the association might be either coincidental or causal, and could become clearer as similar patients are reported.

Preparation of Casein Biopeptide-Loaded Niosomes by High Shear Homogenization and Their Characterization.

The aim of this study was to develop a niosomal system to deliver milk bioactive peptides with potential for enhanced bioavailability. Milk casein was hydrolyzed with Flavourzyme, and the hydrolysates were ultrafiltered to obtain low-molecular-weight peptides with enhanced antioxidant activity. Biopeptide-loaded niosomes were prepared by a high shear homogenization method. Peptide-loaded niosomes exhibited a mean particle size of 37.64 ± 0.98 nm with narrow size distribution (PDI = 24.66 ± 0.008%) and high zeta potential (-23.36 mV). The niosomes encapsulated about 67% of peptides into the vesicles and showed controlled and sustained release under simulated gastrointestinal conditions as compared to free peptides. The antioxidant activity of the peptides was not affected due to their encapsulation into niosomes. Morphology of peptide-loaded niosomes was determined by scanning electron microscopy, transmission electron microscopy and atomic force microscopy, and the microstructural interactions analyzed by Fourier transform infrared clearly indicated the formation of peptide-loaded niosomes. High-performance liquid chromatography spectra of peptides in the niosomes and the free peptides were similar, thus confirming their entrapment into the niosomes.

Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis: a single-centre experience in India.

AIMS: The clinical features, treatment and outcome of fungal peritonitis (FP) in continuous ambulatory peritoneal dialysis (CAPD) patients were examined. METHODS: Dialysis records of all 303 end-stage renal disease (ESRD) patients initiated on CAPD treatment between January 1998 and February 2008 were reviewed retrospectively. RESULTS: In the 303 patients dialysed between January 1998 and February 2008, a total of 137 bacterial peritonitis and 43 FP episodes were recorded. The incidence rate of FP was 0.67/100 patient months or 1/148.67 months. It accounted for 23.88% of all peritonitis episodes. Three factors appeared to predict mortality: the presence of non-Candida species, the catheter being left in situ and a serum albumin level <3 g/dl. Multivariate analysis yielded only the latter 2 as predictors of mortality. The use of intraperitoneal antibiotics in the 3 months before infection and low serum albumin have been identified as risk factors for contracting FP. CONCLUSION: Risk factors for contracting FP and for mortality due to FP have been identified.

N-acetyl cysteine versus allopurinol in the prevention of contrast nephropathy in patients with chronic kidney disease: A randomized controlled trial.

Contrast media administration can lead to acute deterioration in renal function particularly in patients with pre-existing chronic kidney disease. This prospective, randomized controlled open-label parallel group study was undertaken at Nizam's Institute of Medical Sciences, Hyderabad, from June to December 2015. A total of 95 patients were included, of which 35 received n-acetylcysteine (NAC) + normal saline (NS), 30 patients received allopurinol (ALL) + NS, and 30 patients received placebo. In our study, the overall incidence of CIN was 24%. Incidence of CIN in NAC + NS, ALL + NS, and placebo group were 20%, 16%, and 36%, respectively. The major finding of this study was there was no significant difference between NAC and allopurinol in the prevention of contrast nephropathy. However, only allopurinol was superior to placebo. In our study, hyperuricemia and baseline serum creatinine were the only risk factors associated with CIN.

Galloway-mowat syndrome - unusual form of nephrotic syndrome in adolescent.

Galloway-Mowat syndrome (GMS), also acknowledged as Microcephaly-Hiatal hernia nephrotic syndrome, is an uncommon genetic disorder inherited as an autosomal recessive trait usually seen before two years of life. It is an exceptional multisystem genetic disorder with a collection of skeletal, neurological, facial, gastrointestinal, growth, and renal abnormalities. This case report describes GMS in a girl, suffering from developmental delay, stunted growth, and various dysmorphic features, in whom nephrotic syndrome became apparent at adolescent age.

Immunohistochemical Analysis of Anti-phospholipase A2 Receptor Antibody on Renal Biopsies: A Single Tertiary Care Center Study.

Membranous nephropathy (MN) is one of the common cause of nephrotic syndrome. The discrimination between primary MN (iMN) and secondary MN is essential because of treatment implications. Immunohistochemical (IHC) evaluation with the help of anti-phospholipase A2 receptor (PLA2R) antibody helps in tissue evaluation of iMN, which is an easy, cost-effective, and pathologist-friendly technique. The study included 82 cases of MN over a period of 3 years. IHC using PLA2R antibody was performed on iMN and secondary cases with adequate tissue. Cases of minimal change disease (MCD) were included as control. Granular staining along the basement membrane in the absence of staining of podocytes was considered positive. Medical records were verified for clinical information, baseline biochemical parameters, details of viral markers, connective tissue disease profile, and basic imaging workup. Of the 82 cases of MN, 51 were iMN and 31 secondary MN (sMN). Thirteen MCD cases were included as control. IHC with PLA2R antibody showed a sensitivity of 91.8% and specificity of 95.1%, positive predictive value of 95.7%, and negative predictive value of 90.7% in the diagnosis of iMN. The other parameters, either clinical or laboratory, did not show significant differences between iMN and sMN groups. The results of PLA2R staining by IHC were comparable with other studies and showed a higher sensitivity (91.8%) and specificity (95.1%). IHC with anti-PLA2R antibody can be considered as the standard diagnostic approach to identify iMN and offer scope for individualized treatment.

Reinitiation of peritoneal dialysis after catheter removal for refractory peritonitis.

AIM: A high proportion of patients whose catheters are removed are unable to successfully reinitiate peritoneal dialysis (PD) due to irreversible peritoneal injury or to decisions made by the patient or the nephrologist for different and often empiric reasons. The present study examined the outcomes of patients reinitiated on PD after peritonitis. METHODS: We reviewed all patients with end-stage renal disease who were initiated on continuous ambulatory peritoneal dialysis at our Institute in south India between 1998 and 2012, identifying those in whom the catheter was removed and the cases where PD was reinitiated, analysing the reasons and outcome. We compared data of patients who could be reinitiated on PD with those who could not be reinitiated and also data of patients who successfully continued PD after reinitiation with those who suffered technique failure. RESULTS: Peritoneal dialysis was reinitiated in 31 (19.4%) of 159 patients whose catheter was removed owing to refractory peritonitis, including after an episode of Pseudomonas aeruginosa and fungal peritonitis. Some patients had the catheter placed for a third time. No significant difference was found between patients who reinitiated PD vs. did not, or between those who were successful in reinitiating PD vs. unsuccessful. CONCLUSION: Notwithstanding the small cohort size, the present study demonstrates that reinitiating PD is feasible in a developing country, and also that reinitiation of PD is possible after an episode of P. aeruginosa and fungal peritonitis. However, future studies in a larger patient cohort and assessing dialysis adequacy are required to confirm and extend our findings.

Embolic occlusion of arteriovenous fistula due to infective endocarditis.

A 45-year-old male on maintenance hemodialysis through right radio cephalic arteriovenous fistula (AVF) also had mitral regurgitation. He presented with fever and chills of 2 days duration along with pain and swelling at median cubital fossa of right upper limb. Local examination revealed warmth, redness, and tenderness at median cubital fossa. AVF thrill was absent. Echocardiography revealed vegetations on the mitral valve. An extensive search of literature did not reveal an instance of embolic occlusion of AVF due to vegetations of infective endocarditis.

Membranous nephropathy superimposed on Churg-Strauss syndrome.

The association of membranous nephropathy with Churg-Strauss syndrome is not widely reported. We present a patient with myeloperioxidase-perinuclear antineutrophilic cytoplasmic antibody (MPO-pANCA)-positive necrotizing and crescentic glomerulonephritis who later developed membranous nephropathy.

Fulminant hepatic failure following marijuana drug abuse: Molecular adsorbent recirculation system therapy.

Marijuana is used for psychoactive and recreational purpose. We report a case of fulminant hepatic failure following marijuana drug abuse who recovered following artificial support systems for acute liver failure. There is no published literature of management of marijuana intoxication with molecular adsorbent recirculation system (MARS). MARS is effective and safe in patients with fulminant hepatic failure following marijuana intoxication.

Granulomatous interstitial nephritis: Our experience of 14 patients.

Granulomatous interstitial nephritis (GIN) is a rare condition. Drugs, infections, immune processes, and foreign body reaction are the main causes. We identified a total of 14 patients with GIN during a period of 13 years in 2798 renal biopsies. There were 8 males and 6 females in the age range of 20-70 (mean 35 ± 12) years. The serum creatinine at presentation was 6.7 ± 3.8 (range: 2.3-14.7) mg/dl. In nine patients tuberculosis was the causative agent. Drugs (n = 2) and Wegener's granulomatosis (n = 1) were other etiologies. Systemic lupus erythematosis (SLE) and Immunoglobulin A nephropathy (IgAN) were seen in one patient each. Patients with tuberculosis were treated with antituberculous therapy and three of them improved. Four out of six patients who required dialysis at presentation remained dialysis dependent, one of whom underwent renal transplantation. Two patients progressed to end stage renal disease after 7 years and 9 years each. The patients with drug induced GIN had improvement in renal function after prednisolone treatment. Patients with SLE, and Wegener's granulomatosis responded to immunosuppression. Patient with IgAN was on conservative management. Finally, six patients were on conservative management for chronic renal failure.

Allopurinol for prevention of progression of kidney disease with hyperuricemia.

Hyperuricemia is associated with hypertension and progressive chronic renal disease. This is a retrospective cohort study in chronic kidney disease (CKD) patients with hyperuricemia from 1998 to 2008. Patients were divided into two groups: treatment group who received allopurinol in a dose of 100 mg/day and the other group remained untreated. Clinical, hematologic, biochemical parameters and outcome were measured at baseline and 6 months, 1 year, and 2 years of treatment. A total of 183 patients were enrolled. Mean age of the allopurinol group was 50.15 ± 14.42 years and control group was 53.23 ± 13.86 years. Male-female ratios were 2.57:1 and 2.21:1 for the treatment and control groups, respectively. Baseline characteristics and the laboratory parameters were similar in both groups. Patients who received allopurinol had lower blood pressure at 6 months, 1 year, and 2 years when compared to baseline. There was a significant decrease in the serum uric acid (UA) levels in the treatment group at the end of 6 months, 1 year, and 2 years with respect to base line. An inverse correlation as noted between serum UA levels and the estimated glomerular filtration rate at 6 months, 1 year, and 2 years. Allopurinol treatment decreases blood UA levels and is associated with better blood pressure control and decreased progression of renal disease in CKD patients with hyperuricemia.

Rhabdomyolysis induced acute renal failure secondary to statins.

Rhabdomyolysis is a syndrome characterized by muscle necrosis and the release of intracellular muscle contents into the systemic circulation. We report a patient with chronic kidney disease who had deterioration of renal function due to combination of risk factors like hypothyroidism and interaction of amlodipine and clopidogrel with statins.

A 2-year follow-up study of patients on automated peritoneal dialysis.

Automated peritoneal dialysis (APD) is increasingly being used for the treatment of end stage renal disease. We present our experience of APD at a government run tertiary care institute. APD was initiated for 22 patients between 2002 and 2010. On comparing APD and continuous ambulatory peritoneal dialysis (CAPD) patients, no difference in patient survival and technique survival was observed. CAPD patients had higher number of peritonitis episodes, greater decline in the serum albumin and a greater number of patients failed to achieve adequacy targets compared to APD.

Tuberculosis in haemodialysis patients: A single centre experience.

We prospectively followed-up new patients of tuberculosis while on maintenance hemodialysis at a State Government-run tertiary care institute. Between 2000 and 2010, 1237 new patients were initiated on maintainence hemodialysis. The number of patients diagnosed with tuberculosis after initiation of hemodialysis was 131 (10.5% of 1237). The age was 46.4 ± 10.4 (range 8-85) years and there were 90 (68.7%) males. The number of patients diagnosed with tuberculosis on the basis of organ involvement were: Pulmonary-60, pleural effusion-31, lymph node-21, meningitis-8, pericardial effusion-7, peritoneum-2, latent tuberculosis-2. The incidence of tuberculosis in hemodialysis was found to be 105.9 per 1000 patient years. Male gender, diabetes mellitus, past history of tuberculosis, mining as an occupation, low serum albumin, and duration of hemodialysis more than 24 months, and unemployment were found to be significant risk-factors on univariate analysis.

Strangulated umbilical hernia in a peritoneal dialysis patient.

Hernia is one of the commonest complications of peritoneal dialysis. It is recommended that patients undergo surgical repair of hernias immediately after the diagnosis. We report a patient on continuous ambulatory peritoneal dialysis presenting with strangulated umbilical hernia. He underwent resection of the gangrenous ileum and end-to-end anastomosis. He was shifted to hemodialysis on second postoperative day and was continued on hemodialysis for 2 weeks. In the third week, he was initiated on low volume PD exchanges and by the fourth week, he returned to normal CAPD exchanges.

Collagenofibrotic glomerulopathy - Case report with review of literature.

Collagenofibrotic glomerulopathy is a rare, idiopathic glomerular disease characterized by abnormal accumulation of type III collagen fibrils within the mesangial matrix and subendothelial space and a marked increase in serum type III procollagen peptide levels. Proteinuria (commonest feature), edema, hypertension, and occasional progression to end-stage renal disease are the various features of this disease. The etiology and pathogenesis remain elusive. There have been reports of the disease running in the family, suggesting the possibility of genetic transmission. We report two cases of this rare entity.

Oxidative stress in hemodialysis patients receiving intravenous iron therapy and the role of N-acetylcysteine in preventing oxidative stress.

To determine the contribution of injectable iron administered to hemodialysis (HD) patients in causing oxidative stress and the beneficial effect of N-acetylcysteine (NAC) in reducing it, we studied in a prospective, double blinded, randomized controlled, cross over trial 14 adult HD patients who were randomized into two groups; one group received NAC in a dose of 600 mgs twice daily for 10 days prior to intravenous iron therapy and the other group received placebo. Both the groups were subjected to intravenous iron therapy, 100 mg of iron sucrose in 100 mL of normal saline given over a period of one hour. Blood samples for the markers of oxidative stress were taken before and after iron therapy. After the allowance of a week of wash out period for the effect of N-acetylcysteine we crossed over the patients to the opposite regimen. We measured the lipid peroxidation marker, malondiaaldehyde (MDA), to evaluate the oxidative stress and total anti-oxidant capacity (TAC) for the antioxidant level in addition to the highly sensitive C-reactive protein (HsCRP). Non-invasive assessment of endothelial dysfunction was measured by digital plethysmography before and after intravenous iron therapy. There was an increase of MDA (21.97 + 3.65% vs 7.06 + 3.65%) and highly sensitive C-reactive protein (HsCRP) (11.19 + 24.63% vs 13.19 + 7.7%) after iron administration both in the placebo and the NAC groups. NAC reduced the baseline acute systemic generation of oxidative stress when compared to placebo, which was statistically significant with MDA (12.76 + 4.4% vs 9.37 + 4.40%: P = 0.032) but not with HsCRP though there was a declining trend (2.85 + 22.75 % vs 8.93 + 5.19%: P = 0.112). Pre-treatment with NAC reduced the endothelial dysfunction when compared to placebo, but it was not statistically significant, except for reflection index (RI). We conclude that in our HD patients NAC reduced the oxidative stress before and after the administration of intravenous iron therapy in addition to the endothelial dysfunction induced by this treatment.