Progression of hepatic aspergillosis following second renal transplantation in a patient with recurrent glomerulonephritis.

Invasive aspergillosis is a serious complication in renal transplant recipients. Hepatic involvement, although seen in liver transplant recipients, has not been reported following renal transplantation. We describe here an interesting occurrence of hepatic Aspergillus infection in a renal transplant recipient. The infection responded to anti-fungal therapy, but there was re-activation following a second renal transplant. In addition, the patient had recurrence of the underlying membrano-proliferative glomerulonephritis following both transplants. The relevant existing literature relating to these problems has been reviewed.

Treatment of chronic hepatitis C in end stage renal disease: experience at a tertiary care centre.

Introduction: Treatment of patients with chronic hepatitis C (CHC) is difficult in the setting of end stage renal disease (ESRD). The present study aimed to analyze the treatment outcome in patients with CHC and ESRD, being evaluated for kidney transplantation. Methods: Data of 65 patients of ESRD with CHC (males: 53, mean age: 39.2±14.4 years) was analysed retrospectively. Patients were treated with either pegylated or conventional interferon (IFN) without ribavirin. Treatment response was assessed for rapid virological response (RVR), early virological response (EVR), end of treatment response (ETR) and sustained virological response (SVR). Results: All patients were receiving hemodialysis (duration 1-60 months). Sixteen patients (25%) (genotype 1: 11, genotype 3: 4, genotype 2: 1) agreed for treatment (13 pegylated IFN and 3 conventional IFN). RVR was achieved in 7 patients (44%) and out of 11 patients (69%) who achieved EVR, ETR was achieved in 7 (44%) patients. Seven patients (44%) dropped out during treatment (2 because of side effects). SVR could be demonstrated in one of 7 patients who achieved ETR (6 patients were lost to follow up after ETR). Conclusions: In our experience, dropouts before, during and after treatment are a major problem in patients with CHC and ESRD. Of those who complete treatment, around half of them are able to achieve the end of treatment response.

Renal histology in pauci-immune rapidly progressive glomerulonephritis: 8-year retrospective study.

Context: The need to perform reporting of renal biopsies of antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides in a more uniform manner required relook at our eight-year data. Aims: To document detailed renal histopathology of pauci-immune rapidly progressive glomerulonephritis (RPGN) and also to seek any significant differences in renal histology of C-ANCA-positive, P-ANCA-positive, and ANCA-negative patients. Materials and Methods: A detailed analysis of the histopathologic features of renal biopsies of 48 patients in whom a diagnosis of pauci-immune glomerulonephritis was concluded on renal biopsy and who presented clinically as rapidly progressive renal failure was done. Statistical Analysis Used: One-way ANOVA and Pearson Chi square tests. Results: Compared with ANCA +ve patients, the ANCA -ve patients were much younger (46.85 ± 16.12 years vs 34.28±15.94 years). No significant differences were found between renal lesions of C-ANCA, P-ANCA, and ANCA-negative patients, except for diffuse tubular atrophy which was more severe and more frequently present with P-ANCA positivity (P value=0.013). Conclusions: Pauci-immune RPGN (irrespective of ANCA status) is a relatively rare disorder in patients who are undergoing the renal biopsy at our institute, constituting 2% of all renal biopsies submitted. It is mandatory to have ANCA serology status during reporting of a kidney biopsy showing pauci-immune crescentic or necrotizing glomerulonephritis. Also, if a uniform reporting strategy is followed throughout the country, the studies from this vast country will be comparable.

Referral pattern of patients with end-stage renal disease at a public sector hospital and its impact on outcome.

Background. Late referral of patients with chronic kidney disease (CKD) to a nephrologist has been shown to be associated with greater morbidity and adverse clinical outcomes. Methods. We did a prospective cross-sectional study of 2490 consecutive, newly diagnosed patients with end-stage renal disease (ESRD) referred to the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh over 2 years. The referral pattern was classified on the basis of the interval between first visit to a nephrologist and initiation of renal replacement therapy (RRT). If the patient reported later to a nephrologist, the disease would have progressed more, and the time interval to initiation of RRT would thus be shorter. A time interval of <3 months was classified as late referral (LR), 3–12 months as intermediate referral (IR) and >12 months as early referral (ER). The demographic and clinical characteristics and co-morbid conditions were compared, and factors associated with LR and outcomes were evaluated. Results. About 75% of patients were referred late. Poor socioeconomic status, low level of education and reduced access to reimbursement of treatment costs contributed to LR. The aetiology of ESRD could not be established in a larger number of LR patients as compared to the other groups. LR patients had a higher prevalence of uraemic complications and required emergency dialysis more frequently. A higher proportion of LR patients were lost to follow up because they could not afford to continue dialysis. Early mortality was higher in the ER group than in the other groups. ER patients were older, more likely to have diabetic nephropathy and a higher burden of co-morbid conditions. They were also more likely to choose continuous ambulatory peritoneal dialysis or undergo transplantation. Only 28% of all patients continued RRT beyond 3 months. Conclusion. A large majority of patients with ESRD in India seek medical attention late, usually in advanced stages of CKD with uraemic complications. LR is more frequent in younger patients and those with non-diabetic kidney disease, and is associated with poor socioeconomic status, lack of education and poor outcomes.

A decade long experience of anti-neutrophil cytoplasmic antibody testing in a tertiary care referral center in North India: Perspective from a developing country.

Background: In a developing, tropical country like India, discontinuous power supply, high temperatures during summer, and lack of consistent cold chain and funds provide a challenging atmosphere for anti-neutrophil cytoplasmic antibody (ANCA) testing and reporting. However, a simple in-house test and testing algorithm are described here, which have been developed and tested over time. Materials and Methods: An analysis of a decade of testing and reporting of ANCA in the Department of Immunopathology in a tertiary referral health care center was performed to highlight the importance of testing for ANCA in proposed 1999 guideline recommended indications. Results: A total of 4195 ANCA tests were conducted from 2000 to 2009. Overall, 2060 (49%) requests had indications which met the 1999 guidelines, while the remaining 2135 (51%) fell outside the guidelines. A total of 350 samples (8.3%) were positive for ANCA on indirect immunofluorescence (IIF), out of which 212 were guideline recommended and 138 (3.2%) were non-guideline recommended ANCA requests; thus, 3.2% of non-small vessel ANCA associated vasculitis (non-SVAAV) conditions showed false positive results when the population was otherwise unselected. Maximum requests (1432) were for rapidly progressive renal failure/acute renal failure. Conclusions: The audit shows that compliance with guidelines for ANCA testing would decrease the number of false positive results. In-house screening for ANCA by IIF is cost-effective and must be performed at least twice on two different samples from the same patient or on two different sets of ANCA preparations in all the cases who requested ANCA testing with a proposed 1999 guideline recommended indication.

Pathological spectrum of cytomegalovirus infection of renal allograft recipients-an autopsy study from north India.

This is a retrospective study of autopsy material to highlight the histo-morphological changes in cytomegalovirus (CMV) infection amongst renal allograft recipients. Nineteen out of 80 patients (23.75%) autopsied during a seventeen-year period (1985-2001) had CMV infection. Pulmonary infection was present in 14 out of 19 cases of which four had isolated lung involvement. Likewise, there were two cases each of isolated oesophageal and renal involvement; one case with isolated colonic involvement. The other 10 cases had multi-organ involvement and the organs involved were kidneys (4), esophagus (6), stomach (1), colon (5), adrenals (3), pancreas (3), liver (1) and spleen (1). Pulmonary infection with CMV was associated with acute pneumonitis in 3 cases and lymphocytic interstitial pneumonitis in 9 instances. Four out of 6 cases had acute tubulo-interstitial nephritis induced by CMV and only two cases had no significant inflammatory response. Glomerular involvement in the form of CMV inclusions in the glomeruli was present in only one case. Gastrointestinal CMV infection (15) presented as acute necrotizing ulceration because of predominant endothelial involvement. Post transplant survival period varied from one month to three years, with majority (14) of the patients having survived for less than one year.

Respiratory paralysis in Sjogren syndrome with normal renal function.

We report a 28-year-old woman who presented with quadriparesis and respiratory failure, and had severe hypokalaemia and distal renal tubular acidosis. She recovered completely on potassium and alkali supplementation. Biopsy and scintigraphy of the minor salivary glands confirmed the presence of Sjogren syndrome. A 6-month course of prednisolone did not correct the distal renal tubular acidosis.

Frosted branch angiitis associated with rapidly progressive glomerulonephritis.

Simultaneous occurrence of frosted branch angiitis and immune-mediated rapidly progressive glomerulonephritis is reported. The two diseases possibly share a common immune mechanism. Patients of frosted branch angiitis should undergo complete systemic evaluation including renal function tests even if the patient is systemically asymptomatic.