Psychosocial Burdens of a Renal Transplant Recipient with COVID-19.

The impact of COVID-19 on transplant recipients is yet to be fully understood. Apart from the physical implications, little has been discussed regarding the psychosocial burden it exerts on the already chronically ill patients. Here, we discuss a case of a 40-year-old male who received kidney transplantation 2 years ago and has tested positive for COVID-19. At the time of admission, he presented with mild symptoms and subsequently developed fever for which he had been managed conservatively. However, a comprehensive approach addressing psychosocial, emotional, and spiritual domains from a palliative care physician's perspective is often overlooked, whether in times of COVID-19 or not and this report aims to identify and assess such gaps.

Antibiotic stewardship initiative in a Medicine unit of a tertiary care teaching hospital in India: A pilot study.

Background & objectives: The models for implementation of antibiotic stewardship programme (ASP) in the acute care settings of developing countries are lacking. In most of the hospitals, patient turnover is high and a proper system for recording antibiotic-related information and tracking hospital-acquired infections is not in place. This pilot study was conducted in a tertiary care teaching hospital in north India to assess the feasibility of implementation of an ASP in a Medicine unit and to evaluate the effect of implementation as per the criteria applicable in this set up. Methods: A pre-post-quasi-experimental non-randomized study was conducted in two phases. In the first phase, current practices in the Medicine wards were observed. In the second phase, the ASP was implemented in a single Medicine unit, along with prospective audit and feedback, tracking of the process, as well as outcome measures. Patient risk stratification, blood culture on day one, day 3 bundle, dose optimization, de-escalation and intravenous to oral conversion of antibiotics were the key elements focused upon. Results: There was a significant improvement in the appropriateness of antibiotic prescription (66 vs. 86%, P<0.001) and reduction in the mean number of antibiotics used per person (4.41 vs. 3.86, P<0.05) along with decrease in the duration of hospital stay (17 vs. 14 days, P<0.05). There was a significant improvement in sending of blood cultures on day one during the stewardship phase (P<0.001). Interpretation & conclusions: The ASP approach used in our pilot study may be feasible and beneficial. However, it needs further confirmation in other settings and on a large scale.

CRAB Manifestations in a Middle-Aged Female: A Diagnostic Dilemma.

A 56 year old lady, presented to our institute with six months history of low grade fever, generalized weakness, decreased food intake and fluctuating sensorium. Initial investigations revealed hypercalcemia, renal dysfunction and anemia. Initial working diagnosis of likely underlying hematological malignancy such as lymphoma or multiple myeloma (MM) was kept after hyperparathyroidism was ruled out. Her skeletal survey revealed lytic lesions in the skull, bone marrow aspirate showed 12% plasma cells and beta-two microglobulin level was markedly elevated. However, the criterion for MM was not fully satisfied. In view of persistent altered sensorium, MRI brain was done which suggested the diagnosis of disseminated tuberculosis and was further confirmed through MR spectroscopy, bone marrow biopsy (showing granulomas) and whole body PET. She was started on anti-tubercular therapy along with steroids with marked response within a week. We describe the details of this interesting case through a systematic approach to the various features.

Cavitating Lung Lesions with Encephalopathy in a Patient with Long Standing Sjogren's Syndrome: An Elusive Cause.

A known case of primary Sjogren's syndrome with chronic kidney disease presented with respiratory symptoms and subsequent altered sensorium. Chest imaging suggested cavitating lung lesions in both the lungs. Serum c-ANCA was positive without any upper respiratory tract involvement or active urinary sediments. Treatment with appropriate anti-microbials produced no improvement in the respiratory or neurological parameters. MRI brain revealed tell-tale signs of CNS vascultis. A diagnosis of GPA was made as per European Medical Agency algorithm and the patient was started on immune-suppressants to which there was dramatic response. Her respiratory and neurological parameters started recovering steadily. However her stay at hospital was complicated by severe hospital acquired pneumonia to which she succumbed. We review the intricacies of the case, discussing the diagnostic conundrum and treatment dilemma we faced, as well as the systematic approach employed to manage the patient.

Supportive Management of IgA Nephropathy With Renin-Angiotensin Blockade, the AIIMS Primary IgA Nephropathy Cohort (APPROACH) Study.

INTRODUCTION: Renin-angiotensin system (RAS) blockade using angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB) is first-line therapy for IgA nephropathy (IgAN). There is a paucity of information on the predictors and magnitude of response to this treatment. METHODS: In a prospective study, treatment-naive patients with IgAN with urinary protein ≥ 1 g/d and estimated glomerular filtration rate (eGFR) ≥ 30 ml/min per 1.73 m2 received supportive treatment including ACEi (ramipril) or ARB (losartan) in patients intolerant to ACEi, and optimal blood pressure (BP) control to ≤130/80 mm Hg, with a follow-up of 6 months. The primary outcome was remission of proteinuria. Complete remission (CR) was defined as proteinuria < 0.5 g/d and partial remission (PR) as proteinuria < 1g/d with at least a 50% decline from the baseline with stable renal function (≤ 25% reduction in eGFR). RESULTS: A total of 96 patients were analyzed, with a mean age of 33.3 ± 10.2 years, baseline eGFR 74.0 ± 30.9 ml/min per 1.73 m2, and urinary protein 2.6 ± 1.2 g/d. In all, 71.9% patients received ≥ 75% of the maximum approved dose of ACEi/ARB. Remission was observed in 36.5% (CR, 6.3%) patients at 3 months and in 55.2% (CR, 31.3%) at 6 months. Patients who failed to achieve remission had lower baseline eGFR (P = 0.002) and serum albumin levels (P< 0.001), asymptomatic hyperuricemia (P < 0.001), and higher proteinuria (P = 0.076). E1 (P= 0.053) and T1/T2 (P = 0.009) lesions were more frequent on histology. The ACEi/ARB had to be discontinued in 17 (17.7%) patients. These patients were older (P= 0.085) with lower eGFR (P < 0.002) and serum albumin levels (P = 0.001) and more E1 (P = 0.012) and T1/T2 (P = 0.001) lesions on histology. CONCLUSION: Meticulous supportive therapy with optimal use of ACEi/ARB achieved remission in half of IgAN patients in this study. Increasing the treatment duration to 6 months improved remission rates. Patients with severe clinical and histological disease were less likely to tolerate and respond to treatment with RAS blockade.