Successful Renal Transplant in End-Stage Renal Disease with Chronic Immune Thrombocytopenia using Thrombopoietin Receptor Agonists and Intravenous Immunoglobulin.

Chronic kidney disease in immune thrombocytopenia (ITP) is uncommon, and renal transplant in this setting is rare. We discuss the successful renal transplant of a 29-year-old male with chronic ITP. During transplant, he was managed with thrombopoietin receptor agonist eltrombopag, intravenous methylprednisone, and intravenous immunoglobulin to maintain adequate platelet level. He recovered well with no major complications and good graft function and has been stable during the follow-up period. The case report highlights that renal transplantation is a feasible option in patients with ITP, even in the presence of low platelet counts.

Effectiveness of Immune Checkpoint Inhibitors in Various Tumor Types Treated by Low, Per-Weight, and Conventional Doses at a Tertiary Care Center in Mumbai.

PURPOSE: The cost of immune checkpoint inhibitors (ICIs) limits their accessibility to a small number of patients with cancer in low- and middle-income countries. Early-phase clinical trials have shown target inhibition and high activity at doses lower than those registered and evaluated in clinical trials. Here, we report everyday experience of using ICIs in 100 Indian patients, many of whom received lower doses of ICIs. METHODS: Consecutive patients who received at least one dose of an ICI irrespective of tumor type at a tertiary care hospital in Mumbai, India, that was able to access ICIs for its patients were enrolled. The objectives were to study the doses used over a 3-year time period, and the effectiveness of therapy, assessed primarily by the overall response rate (ORR), overall survival (OS), and progression-free survival were secondary end points. RESULTS: Twenty-five patients were treated with conventional doses of ICIs, 29 patients received lower doses per body weight, and 46 patients received low-dose treatment. The median number of cycles received was 5 (range, 1-28). Seventy-eight patients received ICIs in a palliative setting. The median follow-up time was 10.2, 9.8, and 3.9 months for those receiving fixed approved dosing, per body weight dosing, and low-dose treatment, respectively. There was a trend with time to prescribe lower doses. Response evaluation was available for 92 patients. Twenty-one (five-adjuvant and 16-palliative) patients received ICIs only. The ORR did not differ statistically among different dosing groups, but comparisons are confounded by inclusion of different ICIs, different tumor sites, and concurrent treatments. The median OS was 6.8 (range, 4.6-9.0) months. CONCLUSION: Adoption of per-body weight and lower dosing of ICIs appears to give acceptable outcomes. Lower dosing can improve access and timely delivery of ICIs in low- and middle-income countries.

Plasma Renin-guided Therapy in Patients of Primary Hypertension on Antihypertensives: A Prospective Cohort Study.

BACKGROUND: Most guidelines for hypertension overlook the underlying pathophysiologic basis in deciding antihypertensives. Based on renin levels, hypertension may be classified as high-renin hypertension (HRH), low-renin hypertension (LRH), and normal-renin hypertension (NRH). The study examined the renin levels in a hypertensive population and assessed the effect of renin-guided antihypertensive management on blood pressure (BP) control. MATERIALS AND METHODS: This study was a single-center prospective cohort study. Subjects with primary hypertension (aged 20-60 years) on antihypertensives were included in the study. Initial BP was recorded and subsequently, all antihypertensives were discontinued. After 2 weeks, second BP was recorded and plasma renin assay (PRA) sample was collected. All patients were restarted on the previous antihypertensives and further modification of medication was performed based on their PRA. Anti V drugs, such as diuretics and calcium channel blockers (CCBs) were used in LRH while beta-blockers and antirenin drugs (Anti R drugs) were used in HRH. RESULTS: The study included 918 patients with hypertension and 896 cases were finally analyzed. Of these patients, 287 (32.03%) had LRH (<0.51 ng/mL/hr), 412 (45.98%) had HRH (>2.64 ng/mL/hr), while 197 (21.99%) had NRH (0.51-2.64 ng/mL/hr). Renin-guided management caused significant BP reduction. In controlled BP group, the systolic BP (SBP)/diastolic BP (DBP) before and after modification were 133.83 ± 3.36/84.77 ± 3.12 and 123.87 ± 10.59/84.05 ± 1.84, respectively (p-value < 0.05). In uncontrolled BP group, the corresponding SBP/DBP were 152.17 ± 2.95/90.36 ± 5.02 and 138 ± 1.23/87.78 ± 0.84, respectively (p-value < 0.05). The number of hypertensives used in patients also reduced with reduction in patients on two, three, or four drugs. CONCLUSIONS: Renin-guided therapy is useful for improving BP control in both controlled and uncontrolled hypertensive patients and in reducing the number of antihypertensive drugs.

Biologics Use in Asian Indian Patients with Ankylosing Spondylitis: A Physician's Perspective.

INTRODUCTION: Ankylosing Spondylitis (AS) with non-steroidal anti-inflammatory drug (NSAID) therapeutic failure is treated with biologics. AIM: To compare the clinical outcomes of different biologics for Asian Indian patients with AS who have NSAID therapeutic failure. MATERIALS AND METHODS: Thirty-five AS patients with NSAID failure were administered Etanercept (n=15) (50mg SQ, weekly) or Infliximab (n=20) (5mg/kg IV every 2(nd) month) based on patient convenience or physician discretion as per 2015 ACR/SAA/SPARTAN recommendations. Baseline demographic details, time to diagnosis, disease duration, presence of low backache, early morning stiffness, peripheral joint and extraarticular involvement, ESR, CRP values and HLA-B27 score were obtained. Baseline values of scores of BASMI-3 and MASES were calculated. To monitor the disease activity, BASDAI and ASDAS-ESR scores were recorded at baseline, and after 6 months and 12 months of therapy initiation. STATISTICAL ANALYSIS: Comparison of means: independent samples t-test; comparison of parameters over time: repeated measures ANOVA. RESULTS: Both groups were comparable in all parameters at therapy initiation except in the baseline BASMI-3 score which was significantly higher in patients who received Etanercept. Over 12 months of treatment, the reduction in disease activity, as evidenced by reduction in the mean BASDAI and ASDAS-ESR scores was statistically significant for all patients when considered together, as well as when Etanercept and Infliximab were considered separately (p<0.0001 in all cases). However, there was no statistically significant difference in the magnitude of reduction in the mean BASDAI and ASDAS-ESR scores between patients who received Etanercept and those who received infliximab (p=0.696 and 0.618 respectively). CONCLUSION: Etanercept and Infliximab offer statistically similar reduction in disease severity in Asian Indian AS patients with NSAID failure. Further studies with larger sample size are warranted.