Levofloxacin based non-rifampicin anti-tuberculous therapy: An effective alternative in renal transplant recipients in resource limited setting.

INTRODUCTION: Rifampicin is one of the most effective components of anti-tuberculous therapy (ATT). Since rifampicin is a hepatic enzyme (CYP3A4) inducer, in a post-renal transplant recipient, the dose of calcineurin inhibitors needs to be up-regulated and frequently monitored. In resource-limited (low- and lower-middle-income countries) setting this is not always feasible. Therefore, we evaluated a non-rifampicin-based ATT using levofloxacin in kidney transplant recipients. METHODS: We retrospectively studied the medical records of renal transplant recipients diagnosed with tuberculosis in our institute between 2014 and 2017. After a brief discussion with patients regarding the nature and course of ATT, those who opted for a non-rifampicin based therapy due to financial constraints were included in the study and followed for a minimum of 6 months period after the completion of ATT. RESULTS: Out of the 550 renal transplant recipients, 67 (12.2%) developed tuberculosis after a median period of 24 (1-228) months following transplantation, of them, 64 patients opted for non-rifampicin-based ATT. The mean age was 37.6 years. Only 25% were given anti-thymocyte globulin based induction, while the majority (56; 87.5%) of them were on tacrolimus-based triple-drug maintenance therapy. Extrapulmonary tuberculosis was noted in 33% of cases, while 12 (18.7%) had disseminated disease. The median duration of treatment was 12 months and the cure rate of 93.7% (n = 60) was achieved at the end of therapy. CONCLUSION: Levofloxacin based ATT appears to be a safe and effective alternative of rifampicin in kidney transplant recipients who cannot afford heightened tacrolimus dosage.

High prevalence of vitamin D deficiency in north Indian adults is exacerbated in those with chronic kidney disease.

AIM: Vitamin D is being increasingly recognized as an important player in disease. Hypovitaminosis D is widespread in chronic kidney disease (CKD) populations around the world. The vitamin D status of Indian CKD patients is not known. METHODS: Levels of 25(OH) vitamin D and parathyroid hormone (PTH) were measured in adult north Indian male patients with newly diagnosed stage IV-V CKD and matched control subjects drawn from the same population. A total of 100 (34 stage IV and 66 stage V) patients with CKD and 72 controls were studied. RESULTS: Only 4% control and 1% of CKD subjects had normal (>30 ng/mL) vitamin D levels. Approximately 68% of control and 77% of the CKD population had vitamin D deficiency (<15 ng/ml) whereas the remaining 38% control and 22% CKD patients had insufficient (15-30 ng/mL) vitamin D levels. Levels were lower in CKD subjects compared to their family members, and the CKD patients were significantly more likely to have severe vitamin D deficiency (<5 ng/mL). A strong negative correlation was noted between vitamin D and PTH. No significant correlation was found between vitamin D levels and body mass index, bodyfat percentage, serum albumin or calcium levels. CONCLUSION: Vitamin D deficiency is highly prevalent in north Indians, and this is more pronounced in CKD subjects. There is a significant inverse correlation between the vitamin D and PTH levels. The clinical significance of this deficiency and the potential benefits to be derived from vitamin D supplementation in this population merits further studies.

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.