Rituximab as add-on therapy in patients with resistant lupus nephritis who have failed induction or maintenance therapy with other agents: A real-world experience from a single center in Mumbai.

BACKGROUND: Lupus nephritis (LN) is associated with poor outcomes and a significant risk of progression to end-stage renal disease (ESRD). Some patients with resistant LN do not respond adequately to current treatment options and need alternative strategies or therapies. OBJECTIVE: The objective is to evaluate the efficacy and safety of rituximab as a re-induction therapy (Re-RTX) followed by maintenance therapy for patients with resistant LN. METHODS: Twenty-four patients with resistant LN (failed initial induction therapy or severe relapse after remission) were analyzed. Re-RTX was co-administered with other immunosuppressants. The primary KDIGO criteria outcomes included renal response (complete and partial), disease progression, relapses, and infections. RESULTS: The median age was 28 years (IQR 24.5-42), and the female-to-male ratio was 11:1. All patients had active LN, and 91.3% had proliferative LN. Baseline creatinine was 1.075 mg% (IQR 0.7-1.38), and mean urine protein-to-creatinine ratio (UPCR) was 4.9 (IQR 2.8-6.65). Of the patients receiving RTX as re-induction therapy, 66.6% (16/24) had failed initial induction therapy with other immunosuppressants, whereas 33.3% (8/24) had severe relapse during maintenance therapy.Re-RTX had a favorable renal response at 6 months, with 91.7% of the patients responding (20.8% complete response and 70.8% partial response). At 12 months, 58.3% of the patients maintained a renal response (25% complete response and 33.3% partial response). Approximately one-third of patients relapsed within a year.Fourteen patients (58.3%) continued RTX maintenance therapy with two different treatment regimens. At 6 months, Regimen-1 (500 mg every 6 months) resulted in a partial response in 43% (3/7) and relapse in 57% (4/7) of patients. Regimen 2 (1 g dose per year) achieved a complete response in 28.5% (2/7) and a partial response in 71.5% (5/7) with no relapses at 6 months.At a median follow-up of 29 months, adverse renal outcomes were observed in 29.16% of the patients with progression to advanced chronic kidney disease (CKD) or end-stage renal disease (ESRD). The overall use of Re-RTX was considered safe, with a reported infection prevalence of 16%, which is comparable to the existing data. CONCLUSION: Re-RTX demonstrated efficacy and safety as an induction therapy for resistant LN. However, the response waned after 1 year, underscoring the need for optimized maintenance therapy.

Long-term outcome and predictors of long-term outcome in patients with lupus nephritis managed at a tertiary hospital in Mumbai.

AIM: Study the long-term outcome of the patients with LN and identify the baseline factors that can predict the long-term outcome of these patients. METHODS: All biopsy-proven LN patients who attended our regular 'lupus nephritis' clinic from 2013 to 2021 were studied. Data of these patients were collected from the hospital patient records. Standard therapy was given as per the KDIGO guidelines, and the renal response was evaluated according to KDIGO outcome criteria. Cox' regression analysis was used to determine predictors of chronic kidney disease (persistent doubling of serum creatinine with creatinine ≥1.5 mg%). Kaplan-Meier analysis was used for renal survival. RESULTS: Eighty patients with at least 1 year of follow-up were included. Median age of onset was 24 years (IQR18-35). Median follow up was 6.5 years (IQR 3-10). World Health Organisation renal biopsy profile was Class I 1(1.2 %), Class II 6(7.5 %), Class III 9(11.2 %), Class IV 36(45 %), Class V 18(22.5 %) and Mixed Class IV + V 10 (12%). Complete remission was achieved in 63.75%, 70 % and 66.6% patients at 1, 2 and 5 years, respectively. Survival with normal renal function was 88.5 %, 85.8% and 60 % at 5, 10 and 15 years, respectively. Risk factors for poor outcome on univariate analysis were presence of Raynaud's phenomena-hazard ratio(HR) 7.78 (CI 1.944-31.207; p < .004), baseline hypertension-HR 5.356 (CI 1.479-19.403; p < .011), tubulointerstitial involvement-HR 1.076 (CI 1.032-1.222; p < .001), time to complete response-HR 1.036 (CI 1.036-1.067; p < .02 ), serum creatinine at 6 months HR 10.51 (CI 2.19-50.39; p < .003), failure to achieve complete response at 2 years HR 6.271 (CI 1.567-25.092; p < .009) and the number of nephritic flares HR 1.868(CI 1.103-3.164 ; p < .02). Renal relapses were quite common, with 1.8 flares per 10 patient-years of follow up. Infection was the most common cause of death, with bacterial lower respiratory infections and pulmonary tuberculosis being the most common. CONCLUSIONS: Apart from conventional risk factors, other predictive factors like the presence of Raynaud's phenomenon, tubulointerstitial fibrosis and tubular atrophy on kidney biopsy, and initial response to induction therapy by 6 months have a significant impact on the long-term outcome in patients with LN.

Melioidosis: Missed opportunities and opportunistic pathogens.

A 31-year Indian homemaker, known to have Systemic Lupus Erythematosus (SLE) and lupus nephritis, was admitted previously in another medical care unit with fever, hemoptysis, arthralgia, and joint swelling. She had been treated with antibiotics and corticosteroids for probable diffuse alveolar hemorrhage (DAH) with clinical and radiological resolution. She was readmitted one month later for similar complaints. Her autoimmune workup revealed evidence of active lupus. Her chest imaging showed the presence of well-circumscribed macronodular lesions with halo sign, but Bronchoalveolar Lavage (BAL) cultures and serum galactomannan were negative. BAL tested positive for hemosiderin-laden macrophages. She was treated with corticosteroids, plasmapheresis, and empiric antibiotics with partial clinical response. One week later, her fever recurred, and she developed new-onset myositis. Bactec blood cultures grew Burkholderia pseudomallei. She received treatment for 3 months with good clinical and radiological resolution. In hindsight, a CT-guided biopsy of the lung lesion may have provided an earlier diagnosis of melioidosis.

Belatacept and Long-Term Outcomes in Kidney Transplantation.

BACKGROUND: In previous analyses of BENEFIT, a phase 3 study, belatacept-based immunosuppression, as compared with cyclosporine-based immunosuppression, was associated with similar patient and graft survival and significantly improved renal function in kidney-transplant recipients. Here we present the final results from this study. METHODS: We randomly assigned kidney-transplant recipients to a more-intensive belatacept regimen, a less-intensive belatacept regimen, or a cyclosporine regimen. Efficacy and safety outcomes for all patients who underwent randomization and transplantation were analyzed at year 7 (month 84). RESULTS: A total of 666 participants were randomly assigned to a study group and underwent transplantation. Of the 660 patients who were treated, 153 of the 219 patients treated with the more-intensive belatacept regimen, 163 of the 226 treated with the less-intensive belatacept regimen, and 131 of the 215 treated with the cyclosporine regimen were followed for the full 84-month period; all available data were used in the analysis. A 43% reduction in the risk of death or graft loss was observed for both the more-intensive and the less-intensive belatacept regimens as compared with the cyclosporine regimen (hazard ratio with the more-intensive regimen, 0.57; 95% confidence interval [CI], 0.35 to 0.95; P=0.02; hazard ratio with the less-intensive regimen, 0.57; 95% CI, 0.35 to 0.94; P=0.02), with equal contributions from the lower rates of death and graft loss. The mean estimated glomerular filtration rate (eGFR) increased over the 7-year period with both belatacept regimens but declined with the cyclosporine regimen. The cumulative frequencies of serious adverse events at month 84 were similar across treatment groups. CONCLUSIONS: Seven years after transplantation, patient and graft survival and the mean eGFR were significantly higher with belatacept (both the more-intensive regimen and the less-intensive regimen) than with cyclosporine. (Funded by Bristol-Myers Squibb; ClinicalTrials.gov number, NCT00256750.).

Relationship between the Use of Aluminium Utensils for Cooking Meals and Chronic Aluminum Toxicity in Patients on Maintenance Hemodialysis: A Case Control Study.

BACKGROUND: Chronic aluminum toxicity (CAT) in end stage kidney disease (ESKD) patients is now a rare clinical disorder, unlike in the past, because of improvements in hemodialysis water purification systems and discontinuation of use of aluminum hydroxide as a phosphate binder. The use of aluminum utensils for cooking could be an unrecognised cause of the CAT. OBJECTIVE: To assess the association between aluminum kitchen utensils used for cooking meals and chronic aluminum toxicity (CAT) in patients on maintenance hemodialysis (MHD). MATERIAL AND METHODS: In this case control study, a total of 31 (cases n=10; controls n=21) patients on MHD for more than one year were included. Cases were defined as patients with clinical manifestations (including laboratory parameters) of CAT and high (>200 mcg/L) serum aluminum levels. Control group was chosen from the same hemodialysis facilities. Association between use of aluminum utensils for cooking and occurrence of CAT was assessed. RESULTS: The mean age of patients in the cases and the control group was 52.90 and 52.95 years respectively with on significant difference (p=0.99). There was no difference in mean duration of dialysis (p=0.78), serum calcium level (p=0.06), serum phosphate level (p=0.19), serum albumin level (p=0.06), history of hypertension (p=1.00) and history of diabetes (n=0.12) between two groups. Mean haemoglobin (p<0.05) and mean iPTH (p<0.05) was significantly lower in the cases as compared to control group. Thirteen patients had history of use of aluminum utensils [cases 10 (76.90%) and control 3 (23.10%); p<0.05]. All cases i.e. 10 (100%) had exposure to aluminum utensils whereas three (14.3%) patients in the control group had exposure to aluminum utensils whereas 18 (85.7%) patients had no exposure. The relative risk of having CAT because of use of aluminum utensils compared to not using was 28.46 (1.81 to 445.3) and the odd's ratio estimated was 120 (5.45 to 2642). CONCLUSION: Use of aluminum utensils for cooking meals is associated with CAT. Larger studies are required to confirm these findings.

Antibiotic Lock Therapy in the Era of Gram-Negative Resistance.

BACKGROUND: Central-line-associated blood-stream infection (CLABSI) is a highly consequential nosocomial infection. The most effective management includes the removal of the infected catheter. Retention of the catheter and antibiotic lock therapy (ALT) along with systemic antibiotics may be attempted only if there are unusual extenuating circumstances. CLABSIs due to Gram-negative bacteria (GNB) is more common in our setting and the organisms are often highly resistant. Hence, there is a need to explore the use of novel antimicrobials for catheter lock solutions along with antibiofilm agents. PATIENTS AND METHODS: We report the use of antibiotic lock therapy in the first 29 patients who had 37 episodes of bacteremia (CLABSI/symptomatic colonization) due to long-term catheters in our unit from February 2008 to September 2014. Patients received ALT if they had CLABSI or were symptomatic with a colonized catheter. Patients who needed removal of the catheter were ineligible for ALT. Patients received systemic antibiotic therapy and lock solutions were kept in the catheter for dwell times of 24 hours, and therapy was continued for 14 days. Successful treatment was defined as any of the following: 1) Clinical cure with disappearance of signs of sepsis 2) Microbiological cure with resolution of bacteremia (confirmed by a negative blood culture which was obtained through the catheter 2-5 days after stopping therapy. RESULTS: Among the 37 episodes treated with ALT, 30 episodes were caused by GNB and four episodes were caused by Gram-positive cocci (GPC); Enterococcus, methicillin-sensitive S. aureus (MSSA), methicillin-resistant S. aureus (MRSA), and methicillin-sensitive coagulase-negative staphylococcus (CoNS). There were three episodes of CRBSI due to Candida and one episode each due to L. monocytogens and Bacillus spp. Of the other 30 episodes due to GNB, Acinetobacter baumannii were isolated in eight episodes, Stenotrophomonas (n=6), E. coli (n=5), Flavobacterium (n=2), and P. aeruginosa (n=4), and B. cepacia in three episodes. The other organisms isolated were K. pneumoniae, and non-typhoidal Salmonella (1 episode each). Successful treatment with ALT was observed in 30 (81.08%) of the 37 episodes. CONCLUSIONS: In patients with CLABSI due to Gram-negative pathogens, the use of ALT along with systemic antibiotics has an excellent catheter salvage rate. Newer antibiotics (tigecycline and colistin) may be useful options as antibiotic lock solutions along with antibiofilm agents especially in the setting of resistant Gram-negative bacilli producing CLABSI.

A randomized, open-label trial of iron isomaltoside 1000 (Monofer®) compared with iron sucrose (Venofer®) as maintenance therapy in haemodialysis patients.

BACKGROUND: Iron deficiency anaemia is common in patients with chronic kidney disease, and intravenous iron is the preferred treatment for those on haemodialysis. The aim of this trial was to compare the efficacy and safety of iron isomaltoside 1000 (Monofer®) with iron sucrose (Venofer®) in haemodialysis patients. METHODS: This was an open-label, randomized, multicentre, non-inferiority trial conducted in 351 haemodialysis subjects randomized 2:1 to either iron isomaltoside 1000 (Group A) or iron sucrose (Group B). Subjects in Group A were equally divided into A1 (500 mg single bolus injection) and A2 (500 mg split dose). Group B were also treated with 500 mg split dose. The primary end point was the proportion of subjects with haemoglobin (Hb) in the target range 9.5-12.5 g/dL at 6 weeks. Secondary outcome measures included haematology parameters and safety parameters. RESULTS: A total of 351 subjects were enrolled. Both treatments showed similar efficacy with >82% of subjects with Hb in the target range (non-inferiority, P = 0.01). Similar results were found when comparing subgroups A1 and A2 with Group B. No statistical significant change in Hb concentration was found between any of the groups. There was a significant increase in ferritin from baseline to Weeks 1, 2 and 4 in Group A compared with Group B (Weeks 1 and 2: P < 0.001; Week 4: P = 0.002). There was a significant higher increase in reticulocyte count in Group A compared with Group B at Week 1 (P < 0.001). The frequency, type and severity of adverse events were similar. CONCLUSIONS: Iron isomaltoside 1000 and iron sucrose have comparative efficacy in maintaining Hb concentrations in haemodialysis subjects and both preparations were well tolerated with a similar short-term safety profile.

Renal dysfunction in routine proton-pump inhibitor use may be linked to comorbidities: A real-world observational study.

INTRODUCTION: The use of proton-pump inhibitors (PPI) is linked with infrequent but serious adverse events, including acute kidney injury, chronic kidney disease (CKD) and progression of CKD. Data on renal safety in routine use of PPI are more relevant to clinical practice. We studied whether such use of PPI is associated with renal dysfunction. METHODS: Patients taking PPI for at least six weeks had serum creatinine tested pre (n = 200) and post (n = 180) recruitment. These patients were then advised to follow-up: those taking PPI for at least 90 days in the next six months (n = 77) and at least another 90 days in the following six months (n = 50), had serum creatinine tested at such follow-up. Renal dysfunction was defined as any increase in serum creatinine level above baseline. RESULTS: The 200 patients recruited had mean age 39.6 (SD 9.2) years. Ninety-eight (49%) patients had a history of previous PPI use (median six months; interquartile range [IQR] 3-24). Only 20 (11.1%) patients at six weeks, 11 (14.3%) at six months and six (12%) at one year had increase in creatinine level; a majority of them had less than 0.3 mg/dL increase. Ten of these 20 (six weeks), five of 11 (six months) and five of six (one year) had other risk factors for renal dysfunction. No patient developed CKD during the study period. CONCLUSIONS: Mild and non-progressive increase in serum creatinine occurred in 10% to 15% of patients on routine PPI use. A majority of them had other risk factors. Small sample size and short follow-up duration are a few limitations of this study.

A Simplified Risk Score to Estimate the Risk of Contrast-Induced Nephropathy after Contrast Exposure.

Introduction: Scores are available to predict the probability of contrast-induced nephropathy (CIN) after cardiac interventions, but not many scores are available for non-cardiac interventions and there are none for intravenous exposure to contrast. We designed this study to develop a simplified score to determine the probability of developing CIN in patients exposed to the parenteral contrast medium. Methods: This was a prospective study of patients who received parenteral contrast. Of 1300 patients, the first 1000 comprised the derivation cohort and the next 300 comprised the validation cohort. The patient variables in the development cohort were studied using univariate analysis. Statistically significant individual variables were used as independent variables, and CIN was used as the dependent variable in the final multivariate logistic regression model. Then, the risk score was obtained and validated. Results: The incidence of CIN was 3.8%. The risk factors, namely the presence of diabetes mellitus, e-GFR, and route and volume of contrast material were significantly associated with the risk of CIN (P < 0.05). The developed risk score had a sensitivity of 90.4% and specificity of 98.78%. The overall accuracy was 97.8%. The values of AUC of ROC in the development and validation datasets were high. This indicated that the predicted CIN risk score correlated well with the calibration and discriminative characteristics. Conclusions: The route and volume of contrast administered, low e-GFR, and diabetes mellitus were the significant risk factors. The developed risk score exhibited very good sensitivity and specificity and excellent accuracy in predicting the probability of CIN.

The Effect of Higher and Lower Protein Intakes on Nitrogen Balance in Renal Transplant Recipients with Underlying Graft Dysfunction.

It is essential to determine the optimum protein intake in renal transplant recipients on steroids with renal dysfunction to maintain a neutral nitrogen balance. Our aim was to study the effect of higher (1.2 g/kg/day) and lower (0.8 g/kg/day) protein intakes on nitrogen balance, body composition, glomerular filtration rate (GFR), and proteinuria in renal transplant recipients with low estimated GFR (eGFR) (15-44 mL/min/1.73 m2). This prospective, open-labeled, randomized, cross-over, interventional study enrolled patients who were ≥4 months posttransplant with eGFR between 15 and 44 mL/min/1.73 m2. Subjects were randomized to either Group 1 [Diet: proteins (1.2 g/kg/day), 35 kcal/kg/day] or Group 2 [Diet: proteins (0.8 g/kg/day) and 35 kcal/kg/day] for one month. Subjects crossed over to the other diet for 2nd month. Body composition analysis, serum creatinine, blood urea nitrogen, serum protein, serum albumin, 24-h proteinuria, GFR measurement (24 h creatinine clearance), three-day diet recall and nitrogen balance estimation were performed at baseline and at the end of the first and 2nd month. Statistical analysis was performed using IBM SPSS Statistics version 21. Thirty-two of 35 patients completed the study. Three-day diet recall showed that daily protein and energy consumption was 1.2 g/kg and 36.47 kcal/kg with higher and 0.94 g/kg and 31.94 kcal/kg with lower protein diets, respectively. Nitrogen balance was +3.61 g/day (P = 0.0002) with higher and +1.66 g/day with lower protein diets. A significant increase was noted in muscle mass (P = 0.0317), blood urea nitrogen (P = 0.0118), GFR (P = 0.0114), and proteinuria (P = 0.010) with a higher protein diet. Renal transplant recipients remained in positive nitrogen balance with both diets. Muscle mass and proteinuria increased significantly with a higher protein diet.

Plasma Cell Dyscrasia: A Case Series of a Masquerader.

Plasma cell dyscrasia is a result of an abnormal clonal proliferation of plasma cells. These cells arise from B cells in the bone marrow and produce immunoglobulins. Multiple myeloma is a type of plasma cell dyscrasia that commonly presents with symptoms secondary to hypercalcemia, hyperviscosity, renal failure, and bone pain. Here, we report three patients with unusual presentations of plasma cell dyscrasias.

Targeting Predialysis Glucose up to 180 mg/dl Reduces Glycemic Variability in End Stage Diabetic Nephropathy.

Context: Glycemic variability plays a major role in the development as well as the progression of cardiovascular disease in diabetes. Aims: We compared the mean plasma glucose and glycemic variability (GV) parameters on and off hemodialysis (HD) in patients with End-Stage Diabetic Nephropathy (ESDN) and End-Stage Renal Disease (ESRD). Settings and Design: Cross-sectional study. Methods and Material: We included 23 ESDN and 6 ESRD patients who underwent continuous glucose monitoring (CGM) (iPro2) for 6 days and a glucose-free dialysate for 4 hours thrice weekly. EasyGV software was used to calculate the variability parameters {mean glucose, Time in range (TIR), Time above and below range (TAR/TBR), CV (Coefficient of Variation) and MAGE}. Statistical Analysis Used: The quantitative data variables were expressed by using mean and SD. Unpaired t-test was used to compare the two groups. P value <0.05 was considered significant. Results: In the ESDN group, TIR was significantly lower whereas TAR and TBR were significantly higher on HD day. MAGE (101.88 ± 40.5 v/s 89.46 ± 30.0, P < 0.007) and CV (29.41% v/s 21.67%) were higher on HD day. Subjects with pre-HD glucose values ≥180 mg/dl (Group B, n = 24) had a rapid drop with a delayed higher rise in glucose values than those with pre-HD glucose values <180 mg/dl (Group A, n = 27). Ten patients had 13 episodes of hypoglycemia. The CGM parameters were not different in the ESRD group. Conclusions: Targeting a pre- HD glucose value <180 mg/dl could be a good strategy to prevent larger fluctuation during and post HD.

A Unified Citywide Dashboard for Allocation and Scheduling Dialysis for COVID-19 Patients on Maintenance Hemodialysis.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has caused significant global disruption, especially for chronic care like hemodialysis treatments. Approximately 10,000 end-stage kidney disease (ESKD) patients are receiving maintenance hemodialysis (MHD) at 174 dialysis centers in Greater Mumbai. Because of the fear of transmission of infection and inability to isolate patients in dialysis centers, chronic hemodialysis care was disrupted for COVID-19-infected patients. Hence, we embarked on a citywide initiative to ensure uninterrupted dialysis for these patients. Materials and Methods: The Municipal Corporation of Greater Mumbai (MCGM) designated 23 hemodialysis facilities as COVID-positive centers, two as COVID-suspect centers, and the rest continued as COVID-negative centers to avoid transmission of infection and continuation of chronic hemodialysis treatment. Nephrologists and engineers of the city developed a web-based-portal so that information about the availability of dialysis slots for COVID-infected patients was easily available in real time to all those providing care to chronic hemodialysis patients. Results: The portal became operational on May 20, 2020, and as of December 31, 2020, has enrolled 1,418 COVID-positive ESKD patients. This initiative has helped 97% of enrolled COVID-infected ESKD patients to secure a dialysis slot within 48 hours. The portal also tracked outcomes and as of December 31, 2020, 370 (27%) patients died, 960 patients recovered, and 88 patients still had an active infection. Conclusions: The portal aided the timely and smooth transfer of COVID-19-positive ESKD patients to designated facilities, thus averting mortality arising from delayed or denied dialysis. Additionally, the portal also documented the natural history of the COVID-19 pandemic in the city and provided information on the overall incidence and outcomes. This aided the city administration in the projected resource needs to handle the pandemic.

From Infection to Immunity - Impact of COVID-19 Across Nine Hemodialysis Centres in Mumbai.

INTRODUCTION: There are several studies of symptomatic hemodialysis patients with proven COVID-19 infection. However, there is paucity of data on asymptomatic COVID-19 infection in the outpatient hemodialysis population. The true prevalence and transmission of this infection in hemodialysis centres is unknown. This study was conducted across hemodialysis centers by testing all patients and staff for COVID-19 PCR and later for IgG antibody, irrespective of their symptoms. METHODS: All 705 hemodialysis patients and 103 dialysis staff across nine centres, were tested for COVID-19 over a period of 54 days of the pandemic, and for COVID IgG antibody of available enrolled staff and patients, after 8 weeks of study termination. RESULTS: The period prevalence of infection in patients and staff was 7.1% and 14.6% respectively. Mortality in patients was 18%, and all staff recovered. Clustering of patients and staff occurred at 3 of 9 centers. Of 26 HIV positive patients, only one contracted the COVID-19 infection and has recovered. Of those infected, seroconversion occurred in 80% of patients and 83% of staff. Seroconversion also occurred in 16% of patients and 37% of staff, who were asymptomatic and COVID PCR negative during the study period. CONCLUSIONS: Testing a patient only when symptomatic, identified only 26% (13/50) of infected patients. For every single symptomatic patient who tested positive, there were 3 other asymptomatic infected ones. There was a high seroconversion rates in infected subjects. But antibodies also developed in asymptomatic subjects, indicating silent transmission and antibody generation in this population.

Diarrhea in kidney transplant recipients: Etiology and outcome.

BACKGROUND AND AIM: Diarrhea in kidney transplant recipients influences outcome of transplantation. Data from India in this regard are sparse and do not address the differential outcome of infective and non-infective diarrhea. We studied the demographic data, laboratory findings, treatment response, disease duration, and outcome of diarrhea in kidney transplant recipients, and the differential outcome between infective and non-infective diarrhea, if any. METHODS: All kidney transplant recipients who were referred to the Division of Gastroenterology with diarrhea between June 2015 and February 2017 were prospectively included. Demographic, clinical and laboratory data, graft function, treatment administered, and outcome were noted, and the patients were followed up for 3 months. RESULTS: Forty-seven patients (median age 45 years, range 16-78; 34 men) with 64 episodes of diarrhea were studied. Thirty-three (51.5%) episodes were attributed to infections. Eleven (17%) were immunosuppressant-induced (mycophenolate 8, tacrolimus 2, cyclosporine 1). Twenty (31%) were due to other causes (antibiotics 6, laxatives 3, irritable bowel syndrome 3, sepsis 8). Fifty-three episodes (82%) had graft dysfunction during the diarrheal episodes. Mean increase in serum creatinine was 45% in the infectious diarrhea group and 95% in the non-infectious diarrhea group (p < 0.05). Median time to resolution of diarrhea was 3 days. With improvement in diarrhea, return to pre-diarrhea creatinine levels occurred in 87% of episodes at 3 months. CONCLUSION: One-half of episodes of diarrhea in kidney transplant recipients were non-infectious in origin. Seventeen percent were attributed to immunosuppressants, requiring dose modification. More than 80% were associated with worsening of graft function. Recovery of graft function to baseline was seen in a majority of cases with the resolution of diarrhea.

Routine double-J stenting for live related donor kidney transplant recipients: It doesn't serve the purpose, but does it serve a better purpose?

Purpose: Despite meticulous techniques, surgical complications continue to be problematic in kidney transplant recipients. Role of routine stenting to reduce complications is controversial. In this study, we compare incidence of early urological complications, lymphoceles, urinary tract infections (UTI) and graft function; with or without double-J stenting. Materials and Methods: All patients who underwent live related donor renal transplantation from February 2014 to February 2016 were included. Transplants prior to February 2015 were without routine stenting; subsequent transplants were with routine stenting. Patients with neurogenic bladder, previously operated bladder and delayed or low urinary output were excluded. Follow-up was for at least three months. Descriptive statistics was performed for all parameters. Chi square test and Fisher's Exact test were used for qualitative variables. For quantitative variables, Mann-Whitney test was used to test median difference and independent samples t-test for mean difference. The p-value ≤0.05 was considered significant. Results: We analysed 74 patients (34 stented and 40 non-stented). There was no difference in the incidence of urinary leak, anastomotic obstruction, lymphoceles or UTI (p>0.4 for all comparisons). However, mean estimated glomerular filtration rate at sixth day, 14th day, one month and two months were 76.1 vs. 61.5 (p=0.025), 72.1 vs. 56.6 (p=0.005), 79.4 vs. 63.1 (p=0.002) and 82.0 vs. 63.3 (p=0.001) in the stented versus non-stented groups. Conclusions: Placement of ureteral stent in renal transplant does not significantly affect the incidence of early urinary complications or UTI. However, graft function is significantly better in stented recipients, at least in the short term.

Volume expansion and sodium balance in peritoneal dialysis patients. Part I: Recent concepts in pathogenesis.

Cardiovascular disease is a leading cause of death in patients with end-stage renal disease. Uncontrolled hypertension and volume expansion contribute to alternations in left ventricular geometry and are independent predictors of poor survival in dialysis patients. Excessive salt intake is a major handicap with loss of residual renal function. Sodium removal becomes inadequate in the face of declining residual renal function. Continued salt intake and inadequate sodium removal lead to volume expansion, which aggravates arterial hypertension. In part I of this two-part review, we consider information on dietary salt intake and its relationship to blood pressure and volume control in peritoneal dialysis (PD) patients. In addition, we review recently published studies on the use of various PD modalities to remove sodium, emphasizing the significance of volume expansion and uncontrolled hypertension in PD patients. Part II reviews the various measures available to enhance sodium and fluid removal in PD patients.

Volume expansion and sodium balance in peritoneal dialysis patients. Part II: Newer insights in management.

As noted in part I of this article, emerging evidence indicates that overt and (more commonly) subclinical volume expansion is frequent in patients on peritoneal dialysis (PD). That expansion in turn leads to hypertension. With loss of residual renal function, the hypertension becomes difficult to control even with increasing doses and varieties of antihypertensive drugs. Poor volume and blood pressure control aggravates already existing left ventricular hypertrophy and leads to increased cardiovascular morbidity and mortality. Indeed, cardiovascular events are the leading cause of death in PD patients. Part II of this article reviews various strategies available to manage fluid overload and hypertension. Also, we discuss sodium removal with various PD modalities and clinical studies related to use of low-sodium dialysis solutions.