Non-simultaneous kidney exchange cycles in resource-restricted countries without non-directed donation - a prospective single-center cohort study.

Recent reports suggest that bridge-donor reneging is rare (1.5%) in non-simultaneous kidney exchange chains. However, in developing countries, the non-directed donors who would be needed to initiate chains are unavailable, and furthermore, limited surgical space and resources restrain the feasibility of simultaneous kidney exchange cycles. Therefore, the aim of this study was to evaluate the bridge-donor reneging rate during non-simultaneous kidney exchange cycles (NSKEC) in a prospective single-center cohort study (n = 67). We describe the protocol used to prepare co-registered donor-recipient pairs for non-simultaneous surgeries, in an effort to minimize the reneging rate. In addition, in order to protect any recipients who might be left vulnerable by this arrangement, we proposed the use of standard criteria deceased-donor kidneys to rectify the injustice in the event of any bridge-donor reneging. We report 17 successful NSKEC resulting in 67 living-donor kidney transplants (LDKT) using 23 bridge-donors without donor renege and no intervening pairs became unavailable. We propose that NSKEC could increase LDKT, especially for difficult-to-match sensitized pairs (25 of our 67 pairs) in countries with limited transplantation resources. Our study confirms that NSKEC can be safely performed with careful patient-donor selection and non-anonymous kidney exchanges.

Impact of single centre kidney paired donation transplantation to increase donor pool in India: a cohort study.

In a living donor kidney transplantation (LDKT) dominated transplant programme, kidney paired donation (KPD) may be a cost-effective and valid alternative strategy to increase LDKT in countries with limited resources where deceased donation kidney transplantation (DDKT) is in the initial stages. Here, we report our experience of 300 single-centre KPD transplantations to increase LDKT in India. Between January 2000 and July 2016, 3616 LDKT and 561 DDKT were performed at our transplantation centre, 300 (8.3%) using KPD. The reasons for joining KPD among transplanted patients were ABO incompatibility (n = 222), positive cross-match (n = 59) and better matching (n = 19). A total of 124 two-way (n = 248), 14 three-way (n = 42), one four-way (n = 4) and one six-way exchange (n = 6) yielded 300 KPD transplants. Death-censored graft and patient survival were 96% (n = 288) and 83.3% (n = 250), respectively. The mean serum creatinine was 1.3 mg/dl at a follow-up of 3 ± 3 years. We credit the success of our KPD programme to maintaining a registry of incompatible pairs, counselling on KPD, a high-volume LDKT programme and teamwork. KPD is legal, cost effective and rapidly growing for facilitating LDKT with incompatible donors. This study provides large-scale evidence for the expansion of single-centre LDKT via KPD when national programmes do not exist.

Experiences of healing therapy in patients with irritable bowel syndrome and inflammatory bowel disease.

BACKGROUND: The use and value of different complementary therapies requires investigation. In particular, qualitative research is required to understand the perceptions and experiences of patients who undergo healing therapy as one type of complementary therapy. The aim of this research is to consider patients perceptions and experiences following a course of healing therapy. METHODS: Twenty two patients took part in this study. This included 13 patients with irritable bowel disease (3 male, 10 female, 47.6 ± 15.0 years), 6 patients with ulcerative colitis (3 male, 3 female, 48.5 ± 25.6 years) and 3 female patients with Crohn's Disease (45.0 ± 5.2 years). Each patient undertook a single semi-structured interview following a course of healing therapy. The data was analysed using a thematic analysis. RESULTS: Three broad themes were identified from patient interviews (1) The understanding and expectation of healing (2) Experiences and reflection on healing (3) Impact and outcome of healing. The details of each theme are explored within the text, often revealing a unique experience of healing therapy. CONCLUSION: Patients were open towards the benefits that could be attained by healing, although most patients were not sure what healing would entail. Some patients expected to be relaxed by the sessions. However, the most consistent reports were that patients experienced a relaxing sensation that was generated within the session and lasted for a time period after the sessions. In addition to this the healing appeared to be associated with patients feeling more tolerant of their symptoms. Patients valued the therapist and their input into the healing process. It should be noted however, that this report cannot consider the efficacy of the treatment. Further details and experiences are considered within the article, including one negative experience.

Attitude and awareness towards organ donation in western India.

BACKGROUND: To determine the knowledge, attitudes and practices regarding organ donation in western India. METHODS: Convenience sampling was used to generate a sample of 250; 200 interviews were successfully completed and used for analysis. Data collection was carried out via face to face interviews based on a pre-tested questionnaire in selected public areas of Ahmedabad, Gujarat state of India. Data entry was made in excel software in codes and analysis was done by SPSS software. RESULTS: About 86% of participants were aware of the term organ donation but knowledge about its various aspects was low. About 48% aware people heard about organ donation through medical fraternity, whereas only about 21% became aware through mass media. About 59% of aware people believed there is a potential danger of donated organs being misused, abused or misappropriated. About 47% of aware people said they would consider donating organs, while only 16% said they would definitely donate irrespective of circumstances. Around 97.67% participants said they would prefer to donate to nonsmokers. About 74.41% participants were unaware about any legislation regarding organ donation. About 77% participants showed their will to donate to mentally sound persons, and 42.04% participants showed their will to donate even physically challenged people. Around 78 participants felt that they would donate organs to persons irrespective of their religion. About 81% of aware people were of the opinion that consent for organ donation after death should be given by family members. None of the interviewed participants had a donor card. CONCLUSION: Better knowledge and awareness will help in promoting organ donation. Effective campaign needs to be driven to educate people with relevant information with the involvement of media, doctors and religious scholars.

Increasing access to renal transplantation in India through our single-center kidney paired donation program: a model for the developing world to prevent commercial transplantation.

Because access to transplantation with HLA-desensitization protocols and ABO incompatible transplantation is very limited due to high costs and increased risk of infections from more intense immunosuppression, kidney paired donation (KPD) promises hope to a growing number of end-stage renal disease (ESRD) patient in India. We present a government and institutional ethical review board approved study of 56 ESRD patients [25 two-way and 2 three-way pairs] who consented to participate in KPD transplantation at our center in 2013, performed to avoid blood group incompatibility (n = 52) or positive cross-match (n = 4). All patients had anatomic, functional, and immunologically comparable donors. The waiting time in KPD was short as compared to deceased donor transplantation. Laparoscopic donor nephrectomy was performed in 54 donors. Donor relationships were spousal (n = 40), parental (n = 13), others (n = 3), with median HLA match of 1. Graft survival was 97.5%. Three patients died with functioning graft. 16% had biopsy-proven acute rejection. Mean serum creatinine was 1.2 mg/dl at 0.73 ± 0.32 months follow-up. KPD is a viable, legal, and rapidly growing modality for facilitating LDRT for patients who are incompatible with their healthy, willing living donor. To our knowledge, this is the largest single-center report from India.

Increasing access to kidney transplantation in countries with limited resources: the Indian experience with kidney paired donation.

According to the Indian chronic kidney disease registry, in 2010 only 2% of end stage kidney disease patients were managed with kidney transplantation, 37% were managed with dialysis and 61% were treated conservatively without renal replacement therapy. In countries like India, where a well-organized deceased donor kidney transplantation program is not available, living donor kidney transplantation is the major source of organs for kidney transplantation. The most common reason to decline a donor for directed living donation is ABO incompatibility, which eliminates up to one third of the potential living donor pool. Because access to transplantation with human leukocyte antigen (HLA)-desensitization protocols and ABO incompatible transplantation is very limited due to high costs and increased risk of infections from more intense immunosuppression, kidney paired donation (KPD) promises hope to a growing number of end stage kidney disease patients. KPD is a rapidly growing and cost-effective living donor kidney transplantation strategy for patients who are incompatible with their healthy, willing living donor. In principle, KPD is feasible for any centre that performs living donor kidney transplantation. In transplant centres with a large living donor kidney transplantation program KPD does not require extra infrastructure, decreases waiting time, avoids transplant tourism and prevents commercial trafficking. Although KPD is still underutilized in India, it has been performed more frequently in recent times. To substantially increase donor pool and transplant rates, transplant centres should work together towards a national KPD program and frame a uniform acceptable allocation policy.

Outcome of renal transplantation from older living donors compared to younger living donor in developing country.

OBJECTIVES: To evaluate whether the outcomes of renal grafts from living related donors older than 60 years are acceptable, in terms of renal function and patient/graft survival. MATERIAL AND METHODS: One hundred and forty-seven patients who received kidneys from donor age ≥60 years constituted the study group (group 1). The control group (group 2) consisted of 1310 patients who received renal transplants from donor age <60 years. Outcome measures included graft, patient survival, acute rejection rate and serum creatinine (SCr) in patients/donors. Graft and patient survivals were compared using the Kaplan-Meier method. RESULTS: The mean age of donors was 62.7 ± 3.39 years in group 1 and 43.45 ± 9.65 years in group 2. Patient survival at 1, 3 and 5 years was 95.7%, 89.4% and 82.6% in group 1 and 93.8%, 89.1% and 83.1% in group 2 (p = 0.785), respectively. Death-censored graft survival at 1, 3 and 5 years was 98.5%, 94.8% and 94.8% in group 1 and 96.1%, 92.9% and 89% in group 2 (p = 0.166), respectively. Biopsy-proven acute rejections were 21% and 16.8% (p = 0.206) and chronic rejections 5% and 3.4% in group 1 and 2, respectively (p = 0.542). Recipient SCr (mg/dL) was 1.8 ± 0.31 in group 1 and 1.58 ± 0.37 in group 2. The donor SCr levels at the last follow-up were 1 mg/dL and 0.9 mg/dL in group 1 and 2, respectively. CONCLUSIONS: Donor age did not affect patient and graft survival in the 5-year follow-up in our study. Age alone seems not to be an exclusion criterion to living kidney donation.

Significant benefits after renal transplantation in patients with chronic heart failure and chronic kidney disease.

BACKGROUND: Chronic heart failure (CHF) and chronic kidney disease (CKD) are serious medical conditions with significant morbidity and mortality and often coexist. Because of perioperative risks in these patients, they may not be considered a candidate for renal transplantation (RTx). MATERIAL AND METHODS: We compare retrospectively RTx outcomes [graft/patient survival, rejection rates and adverse cardiac events] in study group [low left ventricular ejection fraction (LVEF) ≤ 45% by echocardiogram, n = 63] and control group [normal LVEF ≥ 50%, n = 537] from a developing country. RESULTS: The mean EF was 35 ± 5.6 and 57 ± 3% for the study and control groups, respectively (p < 0.001). Majority of these patients (98%) showed normalization of LVEF post-transplant. The median EF was 60% at 1-3 months post-transplant. No difference was noted in graft survival, patient survival, rejection rates, serum creatinine and adverse cardiac events of study group at 1.3-year mean follow-up compared to control group. Outcome was not adversely affected by preexisting LV dysfunction. The study and control groups had nearly similar percent of patients with established CAD but significantly more hospitalization for CHF pre RTx in the study group compared with the control group. CONCLUSION: RTx may play a role in reversing LV systolic dysfunction. Once thought by many to be a contraindication for renal transplantation, this appears not to be the case. The outcomes between the 2 groups are comparable and transplant is an option for even low EF patients.

Successful three-way kidney paired donation with compatible pairs to increase donor pool.

Despite heightened international interest in performing living donor kidney paired donation (KPD) transplantation after the publication of a research protocol by Ross and colleagues in 1997, only a few hundred have been performed worldwide. The major obstacle is that many individuals in end-stage renal disease are of blood type O and can only receive an organ from a donor of blood type O, whereas blood type O donors are "universal donors" and will be able to donate directly with an intended recipient of any blood type unless there is a positive crossmatch. To overcome this, patients with compatible but non-HLA identical donors over 45 years of age should be approached for inclusion in KPD program especially O blood group donors. Inclusion of all these additional pairs into the algorithm greatly increases chances of possible matches for O blood group recipients. We report successful three-way KPD transplantation resulting in transplantation of O blood group patient using compatible O blood group donor from India. None of the patients had delayed graft function or rejection and all had stable graft function on discharge without any medical and surgical complications. We need to allocate O blood group kidneys from compatible donors to overcome the barrier of HLA, non-HLA antibodies and other donor related factors to improve transplant quality and long term outcomes. This will increase transplantation of O blood group patients.

Does donor-recipient age difference matter in outcome of kidney transplantation? Implications for kidney paired donation.

BACKGROUND: Kidney paired donation (KPD) is a rapidly growing modality for facilitating living donor kidney transplantation (LDKTx) for patients who are incompatible with their healthy, willing and living donor. The impact of donor-recipient age difference on long and short-term graft and patient survivals in LDKTx is still uncertain. METHODS: A total of 1502 LDKTx recipients who received regular follow-up in our center from 1999 to 2012 were studied. Donor-recipient age difference was divided into subgroups (donor-recipient 0-10, 11-20, 0-20, 21-30, 31-40, and 21-40 years). Outcome measures included death censored graft, patient survival and acute rejection rate. RESULTS: The 1-, 5-, 10-year patient survival of the donor-recipient age difference ≤20 years group showed no difference compared with the age difference >20 years group (94.5%, 83.2%, 71.9% and 95.2%, 86%, 77.8%, p = 0.053). The 1-, 5-, 10-year graft survival of the donor-recipient age difference ≤20 years group showed no difference compared with the age difference >20 years group (94.6%, 81.6%, 72.1% and 94%, 80%, 72.2%, p = 0.989). The rejection were also similar (17.5% vs. 16.5%, p > 0.05). There was no statistically significant difference in graft survival and acute rejection rate in all subgroups. CONCLUSIONS: Older donors (usually within families) are not associated with worse outcome is reassuring. KPD should not be prohibited due to high donor-recipient age difference, when size of donor pool is small as in single center KPD program.

Co-infusion of donor adipose tissue-derived mesenchymal and hematopoietic stem cells helps safe minimization of immunosuppression in renal transplantation - single center experience.

BACKGROUND: Stem cell therapy (SCT) is used for immunosuppression minimization in renal transplantation (RT). We carried out a prospective study to evaluate the benefits of co-infusion of donor adipose-derived mesenchymal stem cells (AD-MSC) + hematopoietic stem cells (HSC) in living donor RT (LDRT) under non-myeloablative conditioning. METHODS: In a demographically balanced three-armed LDRT trial with 95 patients in each arm, group-1 received portal co-infusion of AD-MSC + HSC, group-2 received HSC and group-3 received no SCT. Lymphoid irradiation and anti-thyroglobulin were used for conditioning. RESULTS: SCT was safe. At 1 and 5 years post-transplant, patient survival was 100% and 94.7% in group-1, 100% and 95.7% in group-2, and 94.7% and 84% in group-3, death-censored graft survival was 100% and 94.6% in group-1, 100% and 91.3% in group-2, and 98.9% and 94.4% in group-3 with mean serum creatinine (mg/dL) of 1.38 and 1.39 in group-1, 1.48 and 1.51 in group-2, and 1.29 and 1.42 and in group-3. Rejection episodes and immunosuppression requirement were lesser in SCT groups versus controls with best results noted in group-1. CONCLUSION: Coinfusion of donor AD-MSC +HSC in portal circulation pre-transplant under non-myeloablative conditioning is safe and effective for immunosuppression minimization in LDRT.

Outcome of renal transplantation from deceased donors: experience from developing country.

BACKGROUND: In India, there are a large number of end-stage renal disease (ESRD) patients waiting for renal transplantation (RT). Organ retrieval from brain dead deceased donor (DD) is getting increased attention as the waiting list for organ recipients far exceeds the organ donor pool. In our country, despite a large population, the number of brain dead donors undergoing organ donation is very less. DDRT is the possible solution to bridge the disparity between organ supply and demand. In India, the potential for DDRT is huge due to the high number of fatal road traffic accidents and this pool is yet to be tapped. PATIENTS AND METHODS: We report DDRT outcome in 294 patients (age: 36.5 ± 14.1 years; male:female, 200:94) between 2005 and 2012. All patients received single-dose rabbit-anti-thymocyte globulin for induction and steroids, calcineurin inhibitor, and mycophenolate mofetil/azathioprine for maintenance immunosuppression. RESULTS: Our retrospective study in 294 DDRT shows a fairly successful outcome. Over a mean follow-up of 3.93 years, patient and graft survival rates were 81.7% and 92.6%, respectively, with a median serum creatinine of 1.5 mg/dL. 20.7% had biopsy-proven acute rejection. CONCLUSION: Given the widespread organ shortage, DDRT has a potential to expand the donor pool and shorten the waiting list for RT, encouraging the use of this approach even in low-income countries. Aggressive donor management, increasing public awareness about the concept of organ donation, good communication between clinician and the family members, and a well-trained team of transplant coordinators can help in improving the number of organ donations.

An unusual case of Plasmodium vivax malaria monoinfection associated with crescentic glomerulonephritis: a need for vigilance.

Plasmodium vivax infection is increasingly a major public health burden and the second most frequent human malaria. Higher levels of clinical severity and chloroquine resistance are major factors responsible for such increases. Malarial glomerular injury is uncommon and mainly observed in Plasmodium malariae-infected patients. Occasionally, transient immune complex-mediated glomerulonephritis is associated with Plasmodium falciparum infection. Coexistent crescentic glomerulonephritis and vivax malaria have not previously been reported. We report a fatal case of P. vivax malaria, who presented with acute renal failure. P. vivax monoinfection status was diagnosed with peripheral blood smear and rapid antigen test. Further evaluation for renal failure related to systemic illness and immunological markers were inconclusive. He was treated with antimalarial drugs, hemodialysis, and supportive therapy. Renal biopsy performed for nonrecovering renal failure reveled crescentic glomerulonephritis. This case highlights the need to thoroughly search for malaria-associated crescentic glomerulonephritis using renal biopsy after nonrecovering renal failure.

Postrenal transplant Plasmodium vivax malaria: neglected and not benign.

Plasmodium vivax is causing increasingly more cases of severe malaria worldwide. We reported a case of postrenal transplantation acute kidney injury (AKI) associated with P. vivax, a neglected human malaria parasite. The diagnosis of P. vivax monoinfection was confirmed by direct visualization of the parasite in blood smear and rapid diagnostic test. On admission, serum creatinine (SCr.) increased from 1.45 to 3.7 mg/dl. The other etiologies of fever and AKI were ruled out. He responded to prompt therapy with antimalarial drugs. There was no change in tacrolimus trough level before and after antimalarial drugs. Two weeks after discharge, his SCr. was 1.43 mg/dl. Our patient lived in an endemic malarial area and the transplant took place in December 2010. The patient subsequently presented with clinical malaria in June 2012, so we thought that posttransplantation transmission by the mosquito was a possibility and very less likely that other dormant form of the parasite had been the source of the clinical infection. P. vivax can lead to as AKI in renal transplant recipient. P. vivax should be considered in the differential diagnosis of fever in transplant recipients who had received organs or blood products from malaria-endemic area to facilitate a prompt diagnosis and adequate treatment.

Successful treatment of severe iron intoxication with gastrointestinal decontamination, deferoxamine, and hemodialysis.

Acute iron poisoning is a common and potentially serious problem in the pediatric population. Early recognition and treatment is crucial for a better outcome and to prevent morbidity and mortality. An 18-year-old female, who had accidental ingestion of 50 tablets of ferrous sulfate (100 mg of elemental iron per 335 mg tablet), 100 mg/kg of elemental iron, developed acute gastrointestinal and neurologic signs of toxicity and severe anion gap metabolic acidosis. The patient had received gastrointestinal decontamination, deferoxamine (DFO) infusion, and hemodialysis (HD) resulting in a decrease in serum iron concentration from 2150 to 160 mcg/dL at 24-h post-ingestion and improved mental status. Our cases demonstrate that HD may assist in decreasing serum iron concentration and improving clinical status in patients with massive overdose and life-threatening toxicity.

Comparison of kidney paired donation transplantations with living related donor kidney transplantation: implications for national kidney paired donation program.

BACKGROUND: Kidney Paired Donation (KPD) is a rapidly growing modality for facilitating living related donor kidney transplantation (LRDKTx) for patients who are incompatible with their healthy, willing, and living donors. Data scarcity on the outcome of KPD versus LRDKTx prompted us to review our experience. MATERIALS AND METHODS: This was a single-center study of 224 patients on regular follow-up, who underwent LRDRTx from January 2010 to June 2012 at our institute. The aim of this study was to compare short-term graft survival, patient survival and rejection rates of KPD (group 1, n = 34) with those of LRDKTx (group 2, n = 190). All the recipients received triple immunosuppression and thymoglobulin induction in KPD group. Kaplan-Meier curves were used for survival analysis. In group 1, mean recipient age was 35.5 ± 13.2 years, 29 were men and mean donor age was 44.4 ± 8.17 years, 10 were men. In group 2, mean recipient age was 29.1 ± 10 years, 155 were men and mean donor age was 47.5 ± 9.69 years, 74 were men. Mean human leukocyte antigen (HLA) matching in group 1 and 2 was 1 versus 3.2 (p < 0.05). RESULTS: One- and two-year patient survival showed no significant difference between the two groups (97.1%, 97.1% vs. 96.2%, 94.8%, respectively, p = 0.81). Death-censored graft survival also showed no significant difference between the two groups (97.1%, 97.1%, vs. 97.6%, 97.6%, p = 0.73). Acute rejection incidence was also similar (8.7% vs. 9.9%, p > 0.62). CONCLUSIONS: Our study showed similar graft survival, patient survival and rejection rates of KPD versus LRDKTx over 2 years post-transplantation, encouraging the use of this approach for national KPD program.

Ten kidney paired donation transplantation on World Kidney Day 2013: raising awareness and time to take action to increase donor pool.

BACKGROUND: Kidney paired donation (KPD) is feasible for any center that performs living related donor renal transplantation (LRDRTx). Lack of awareness, counseling and participation are important hurdles in KPD patients with incompatible donors. MATERIALS AND METHODS: This is an institutional review board approved study of 10 ESRD patients who consented to participate in the KPD transplantation at our center. All the surgeries were carried out on the same day at the same center on the occasion of World Kidney Day (WKD) (14 March 2013). All recipients had anatomic, functional and immunological similar donors. RESULTS: KPD were performed to avoid blood group incompatibility (n = 8) or to avoid a positive crossmatch (n = 2). None of the patients experienced delayed graft function and surgical complications. At 3 month follow-up, median serum creatinine was 1 (range 0.6 to 1.25) mg/dL and two patients developed allograft biopsy-proven acute rejection and responded to antirejection therapy. Due to impact of our awareness activity, 20 more KPD patients are medically fit for transplantation and waiting for permission from the authorization committee before transplantation. CONCLUSION: This is a report of 10 simultaneous KPD transplantations in a single day in a single centre on WKD raising awareness of KPD. KPD is viable, legal and rapidly growing modality for facilitating LRDRTx for patients who are incompatible with their healthy, willing LRD.

Kidney transplantation with positive complement-dependent lymphocytotoxicity crossmatch with negative flow crossmatching and Luminexx donor-specific antibodies.

The presence of positive anti-human, globulin-enhanced, complement-dependent cytotoxicity crossmatches (AHG-CDC-XM) generally has been considered as a contraindication to kidney transplantation (KTx). Flow cytometry crossmatch (FCXM) and solid phase antibody screening are most sensitive and specific methods for immunological assessment. The outcome effect of donor-specific antibody (DSA) positive by Luminexx platform and CDCXM negative has been evaluated, but not the outcome of CDCXM positive and DSA negative. This is a case report describing KTx in a patient with pre-transplant positive AHG-CDC-XM but negative FCXM and without detectable DSA by Luminexx single antigen beads. CDCXM, FCXM, DSA were negative after transplantation, and kidney allograft biopsy did not show immune injury with negative C4d. Our report suggests that KTx with positive AHG-CDC-XM can be considered if FCXM and DSA were negative with careful immunological monitoring after transplantation. In our case, the IgM-antibodies were responsible for the positive AHG-CDC-XM result. The patient with positive CDC XM has a good outcome in the absence of DSA. Further work is needed to determine under what circumstances CDCXM positive transplants can be performed with FCXM and DSA negative.

Lead nephropathy due to Sindoor in India.

We report a case of lead nephropathy due to Sindoor treated successfully with steroid, hemodialysis and chelating agent. Diagnosis of lead nephropathy was confirmed by identification of potential sources of lead exposure (Sindoor, 5-10 gm per year for 11 years) indicated by high blood lead level, 95 µg/dL and presence of extrarenal features of lead poisoning (hypertension, anemia, lead line, hyperuricemia). A search for the underlying systemic causes of renal failure yielded no results. A kidney biopsy showed acute or chronic tubule-interstitial nephritis with mesangioproliferative glomerulonephritis with no immune deposit on immunofluorescence consistent with lead nephropathy. He was discharged in good health after psychiatric consultation and continued with oral D-Penicillamine with normal renal function tests and urine output. This case identifies Sindoor as a potential lead exposure among Indians and clinicians should be aware of this risk factor and enquire about it when searching a source of lead exposure in high-risk population.

Bardet-biedl syndrome: a rare cause of chronic kidney disease.

Bardet-Biedl syndrome (BBS) is a rare autosomal recessive condition characterized by retinitis pigmentosa, postaxial polydactyly, central obesity, and renal involvement. Renal failure is the commonest cause of death. We report a case of BBS with chronic kidney disease (CKD) at younger age (17 year) from India. This diagnosis should be considered in patients with renal disease and the characteristic phenotype of retinitis pigmentosa, postaxial polydactyly and central obesity. These patients should undergo regular monitoring of renal function test to early diagnosis and treatment of CKD to prevent morbidity and mortality. Renal transplantation is a viable option of renal replacement therapy in these patients. These findings are valuable for comparing phenotype of BBS patients with CKD from various national and international centers.