Correlation of Serum Galactose-Deficient IgA1 and Oxford Class in Cases of IgA Nephropathy.

CONTEXT.­: Galactose-deficient immunoglobulin A1 (Gd-IgA1) deposition in the renal mesangium plays a role in the pathogenesis of IgA nephropathy. OBJECTIVE.­: To assess the serum Gd-IgA1 level in biopsy-proven IgA nephropathy cases on diagnosis and 3 months post treatment and its relation with histologic Oxford classification. DESIGN.­: In this hospital-based prospective cohort study, 40 cases and 20 controls were enrolled. Serum samples of biopsy-proven IgA nephropathy cases collected on the day of biopsy and 3 months post treatment were evaluated. Solid-phase ELISA (enzyme-linked immunosorbent assay) was performed for assessment of Gd-IgA1 level. All renal biopsies were scored by using Oxford Classification (C-MEST score). The association of serum Gd-IgA1 levels with other established prognostic parameters was assessed. To estimate the prognostic value of markers, logistic regression analysis and Kruskal-Wallis ANOVA (analysis of variance) were used. RESULTS.­: Significant difference was observed in the serum Gd-IgA1 level values in the IgA nephropathy cases and healthy controls (P = .001) at baseline. However, no significant correlation between serum Gd-IgA1 levels at baseline and 3 months of follow-up (P = .31) or between baseline levels and age, proteinuria, hematuria, or estimated glomerular filtration rate was noted. There was no significant correlation between C-MEST score and serum Gd-IgA1 levels at baseline (P > .05); however, the distribution of Gd-IgA1 at 3 months was found to differ significantly between different grades of S score (P = .008). CONCLUSIONS.­: Serum Gd-IgA1 levels may be of utility in predicting disease progression in IgA nephropathy cases. Measurement of serum Gd-IgA1 levels for the diagnosis and prognosis of IgA nephropathy may preclude the need for invasive renal biopsies.

Addition of bioimpedance-derived body cell mass improves performance of serum creatinine-based GFR estimation in a chronic kidney disease cohort.

PURPOSE: Serum creatinine-based glomerular filtration rate (GFR) estimating equations are imprecise and systemic overestimate GFR in chronic kidney disease (CKD) populations with low muscle mass. Bioimpedance devices can measure body cell mass (BCM), a surrogate for muscle mass which has been included in a published GFR estimating equation. This BCM GFR equation is validated and compared with MDRD and CKD-EPI 2021 equations in an Indian CKD population. METHODS: Patients with stable CKD stages 1-5 and voluntary kidney donors underwent measurement of serum creatinine, DTPA GFR and bioimpedance on the same day. BCM GFR was tested for consistency, agreement and performance with respect to DTPA GFR. RESULTS: A total of 125 study participants were enrolled, including 106 patients with CKD (Stage 1: 8; stage 2: 32, stage 3: 42, stage 4: 20 and stage 5: 4 patients) and 19 voluntary kidney donors, with 66% males, and a mean age of 43.3 (± 16.5) years. The median bias of BCM GFR was 5.45 ml/min/1.73 m2 [95% confidence interval (CI) 4.2-8.3], absolute precision was 10.16 ml/min/1.73 m2 [95% CI 4.5-12.6], P30 was 59.1% [95% CI 50.0-67.7] and accuracy was 8.62% [95% CI 6.4-20.0]. Kappa measurement of agreement was the highest for BCM GFR-based staging (0.628 vs 0.545 for MDRD and 0.487 for CKD-EPI). CONCLUSION: BCM-based GFR estimating equation performed better than MDRD and CKD-EPI equations in this Indian CKD population, and BCM GFR-based KDIGO staging was associated with lesser misclassification than the MDRD and CKD-EPI equations. TRIAL REGISTRATION (PROSPECTIVE): Clinical Trials Registry of India (CTRI/2019/11/021850).

Comparing the Reliability of the Glomerular Filtration Rate Estimated with 99m-Technetium Diethylene-Triamine-Pentaacetate versus the Effective Renal Plasma Flow Obtained with 99m-Technetium Ethylene Dicysteine: A Prospective Observational Study.

The glomerular filtration rate (GFR) is important for assessing renal function and must be calculated reliably and reproducibly. This study aimed to compare the reliability and accuracy of GFR estimated with 99m-technetium diethylene-triamine-pentaacetate (99mTc-DTPA) versus that calculated from the effective renal plasma flow (ERPF) (GFR is 20% of ERPF) determined by the 99m-technetium ethylene dicysteine (99mTc-EC) technique. Forty-five patients suffering from cancer requiring platinum compound-based chemotherapy or from chronic renal failure were recruited. The patients were divided into two cohorts: (1) those with normal serum creatinine (SCr) levels (≤2 mg/dL) and (2) deranged SCr levels (>2 mg/dL). For all patients, the relative renal function was estimated by the 99mTc-DTPA and 99mTc-EC methods, 2-4 days apart. A 24-h urine sample for estimating 24-h creatinine clearance (CrCl) was obtained. GFR was also calculated using the Modification of Diet in Renal Disease (MDRD) formula. The GFR estimated via 24-h urine CrCl, 99mTc-DTPA, and ERPF obtained with 99mTc-EC were examined by quantile comparison plots, and all showed evidence of following a non-Gaussian distribution. For SCr values ≤2 mg/dL, the GFR estimated by the MDRD formula consistently shows significantly higher values than the GFR estimated with 99mTc-DTPA or 99mTc-EC. We found a high degree of correlation between the 99mTc-DTPA and 99mTc-EC radionuclide methods of estimating GFR. However, in patients with renal dysfunction, GFR estimated through Gates' method using a gamma camera overestimated the GFR; in these patients, calculating the GFR from the ERPF obtained with 99mTc-EC is more accurate.

Theoretical Study of the Two-Dimensional Vibrational Sum Frequency Generation Spectroscopy of the Air-Water Interface at Varying Temperature and Its Connections to the Interfacial Structure and Dynamics.

We performed a theoretical study of the temperature variation of two-dimensional vibrational sum frequency generation (2D-VSFG) spectra of the OH stretch modes at air-water interfaces in the mid-IR region. The calculations are performed at four different temperatures from 250 to 325 K by using a combination of techniques involving response function formalism of nonlinear spectroscopy, electronic structure calculations, and molecular dynamics simulations. Also, the calculations are performed for isotopically dilute solutions so that the intra- and intermolecular coupling between the vibrational modes of interest can be ignored. We have established the connections of temperature variation of various frequency- and time-dependent features of the calculated spectra to the changes in the underlying structure and dynamics of the interfaces. The results reveal that interfacial water is dynamically more heterogeneous than bulk water, with three dominant dynamical processes exhibiting their corresponding time-dependent features in the 2D-VSFG spectrum. These are the spectral diffusion of hydrogen-bonded OH groups at the interface, conversion of an initially hydrogen-bonded OH group to a dangling OH which is a stable state for surface water, unlike the bulk water, and the third one, which involves the conversion of an initially free or dangling OH group to its hydrogen-bonded state at the interface. The temporal appearance of the cross peaks corresponding to interconversion of the hydrogen-bonded state to the dangling state or vice versa of an interfacial OH group is found to take place at a slower rate than the dynamics of spectral diffusion of hydrogen-bonded molecules at the interface, which, in turn, is slower than the corresponding spectral diffusion of bulk water molecules. The temperature variation of these dynamic processes can be linked to the decay of appropriate hydrogen-bond and non-hydrogen-bond time correlation functions of interfacial water molecules for the different air-water systems studied in this work.

Dynamical Crossover of Interfacial Water upon Melting of a Lipid Bilayer: Influence of Different Parts of the Headgroups.

All-atom molecular dynamics simulations of a 1,2-dimyristoyl-sn-glycero-3-phosphocholine bilayer in contact with liquid water were performed at different temperatures ranging from 285 to 320 K. We have investigated the heterogeneity and dynamical transitions in interfacial water as the lipid bilayer undergoes a melting transition. Results are obtained for water at the outer surface of the bilayer and for those buried more deeply in the lipid chains of the bilayer. It is found that lipid bilayer melting influences both the structure and dynamics of interfacial water. The number of interfacial water molecules shows a jump in the melting of the bilayer. The temperature dependence of the diffusivity and orientational relaxation of interfacial water molecules exhibits a dynamical crossover upon melting of the bilayer. The extent of dynamical crossover is found to be rather strong with significant changes in activation barriers for interfacial water around the carbonyl groups, which are deeply buried toward the lipid chains of the bilayer. The dynamical crossover gradually decreases as one moves further away from the outer surface, and it essentially vanishes for water in the region of 5-10 Å from the outer surface. It is found that the lipid melting-induced dynamical crossover of interfacial water is significant only for water that is in close proximity to the bilayer surface or deeply buried into it. The current results reveal that water molecules in different parts of the interface respond differently on melting of the bilayer. The current study also shows that the carbonyl-bound water molecules can play an important role in the phase transition of the bilayer as the temperature is raised through its melting point.

Hypoglycemia with insulin in post-transplant diabetes mellitus.

INTRODUCTION: To prevent hypoglycemic episodes, the management of insulin therapy against post-transplant diabetes mellitus (PTDM) is important. We compared glargine (long-acting insulin) versus NPH isophane (intermediate-acting insulin) as an armamentarium against PTDM. Indeed, the study evaluated PTDM patients with hypoglycemic episodes treated with isophane or glargine. MATERIAL AND METHODS: We evaluated a total number of 231 living-donor renal transplant recipients with PTDM of age ≥ 18 years admitted to the hospital between January 2017 and September 2021. However, patients taking hypoglycemic agents before transplantation were excluded from this study. Out of 231 patients, 52 (22.15%) suffered from PTDM out of whom 26 were treated with glargine or isophane. RESULTS: After applying exclusion criteria, out of 52 PTDM patients 23 were included in the study: 13 PTDM patients were treated with glargine, whereas 10 PTDM patients with isophane. Our analysis revealed 12 episodes of hypoglycemia in glargine-treated PTDM patients compared to 3 in isophane-treated PTDM patients (p = 0.056). Clinically, 9 out of 15 hypoglycemic episodes were nocturnal (60%). Furthermore, no other risk factors were observed in our study population. Detailed analysis showed that both groups had equivalent doses of immunosuppressants and oral hypoglycemic agents. The odds ratio for hypoglycemia in the group treated with isophane compared to that treated with glargine was 0.224 (95% CI, 0.032-1.559). Glargine users recorded significantly lower blood sugar levels before lunch, dinner and at bedtime with p-values of 0.001, 0.009 and 0.001 respectively. A better hemoglobin A1c (HbA1c) level was seen in the glargine vs. isophane group (6.98 ± 0.52 vs. 7.45 ± 0.49, p-value 0.03). CONCLUSION: The study shows better blood sugar control with long-acting insulin analog, glargine, than with intermediate-actin analog, isophane. Overall, a higher number of hypoglycemic episodes was nocturnal. Long term safety of long-acting insulin analogs needs to be further studied.

Temperature Dependence of Non-Condon Effects in Two-Dimensional Vibrational Spectroscopy of Water.

Non-Condon effects in vibrational spectroscopy refers to the dependence of a molecule's vibrational transition dipole and polarizability on the coordinates of the surrounding environment. Earlier studies have shown that such effects can be pronounced for hydrogen-bonded systems like liquid water. Here, we present a theoretical study of two-dimensional vibrational spectroscopy under the non-Condon and Condon approximations at varying temperatures. We have performed calculations of both two-dimensional infrared and two-dimensional vibrational Raman spectra to gain insights into the temperature dependence of non-Condon effects in nonlinear vibrational spectroscopy. The two-dimensional spectra are calculated for the OH vibration of interest in the isotopic dilution limit where the coupling between the oscillators is ignored. Generally, both the infrared and Raman line shapes undergo red shifts with decrease in temperature due to strengthening of hydrogen bonds and decrease in the fraction of OH modes with weaker or no hydrogen bonds. The infrared line shape is further red-shifted under the non-Condon effects at a given temperature, while the Raman line shape does not show any such red shift due to non-Condon effects. The spectral dynamics becomes slower on decrease of temperature due to slower hydrogen bond relaxation and, for a given temperature, the spectral diffusion occurs at a faster rate upon inclusion of non-Condon effects. The time scales of spectral diffusion extracted from different metrics agree well with each other and also with experiments. The changes in the spectrum due to non-Condon effects are found to be more significant at lower temperatures.

Ultrasound for thigh muscle thickness is a valuable tool in the diagnosis of sarcopenia in Indian patients with predialysis chronic kidney disease.

Objectives: Patients with chronic kidney disease (CKD) are known to develop sarcopenia, an aging-related disorder, with low muscle mass, strength and physical performance. Ultrasound-derived thigh muscle and rectus femoris thickness (TMT and RFT) can be measured easily in clinical practice, but need validation for use in predialysis CKD (stages III through V) for muscle mass estimation. The study aims to compare ultrasound-derived TMT and RFT with bioelectrical impedance analysis (BIA)-derived muscle mass estimation in the diagnosis of sarcopenia in predialysis CKD. Methods: Patients with stable CKD stage III, IV, V and not yet on dialysis were recruited, and underwent anthropometric assessment, BIA and ultrasound examination of midthigh region. Appendicular skeletal muscle index (ASMI)/height2 derived from BIA was taken as a standard for the diagnosis of low muscle mass. Gait speed and handgrip were also measured. The Asian Working Group criteria were applied. Cutoff values for low muscle mass by TMT and RFT were obtained using receiver operator curve (ROC) analysis. Results: Of the total of 117 enrolled study participants, 52 (45%) had low muscle mass, 34 (29%) had sarcopenia, of whom 79% were male, majority (38%) were CKD stage IV and had a mean age of 58 years. Using ROC analysis, TMT cutoffs of 19 mm in males and 17 mm in females were computed. Comparison of TMT cutoffs and ASMI/h2 showed good agreement between the 2 methods using Bland-Altman plots. Conclusions: Ultrasound-derived TMT and RFT can be used for muscle mass estimation in the diagnosis of sarcopenia.

Impact of COVID 19 pandemic on patients requiring renal biopsy.

INTRODUCTION: The disruption of healthcare services in coronavirus disease (COVID)19 pandemic was widespread particularly due to lockdown curbs. This study was undertaken to see the effect of this pandemic on subjects requiring renal biopsy. MATERIALS AND METHOD: Renal biopsies performed during the COVID 19 pandemic between April 2020 and December 2020 (Group 1) were compared with those in pre-COVID period between June 2019 and February 2020 (Group 2). Indication of biopsies, syndromic diagnosis and all baseline laboratory characteristics were retrieved from the hospital records. RESULTS: 130 and 191 patients were biopsied in groups 1 and 2, respectively. Patients in group 1 were younger compared with group 2 (32.55 ± 15.60 and 36.37 ± 16.96 years, respectively, p value 0.038). The mean serum creatinine value in group 1 was significantly higher than in group 2 (3.21 ± 2.08 and 2.68 ± 2.02 mg/dl respectively, p value: 0.023). Group 1 comprises a significantly higher percentage of rapidly progressive renal failure patients (RPRF) (39.3 vs 28, p value 0.046). A higher percentage of nephrotics was biopsied in group 2 vs group 1 (46.9 vs 30.4 respectively, p value 0.008). The treatment protocol remained similar in both the groups. Evaluation of the transplant biopsies revealed a nonsignificant higher number of rejections in group 1 (11 out of 18) as compared to group 2 (5 out of 16), p value 0.100. Combined rejection saw a lesser use of rATG in group 1. CONCLUSION: COVID pandemic induced restrictive measures could have led to selective high risk patients with RPRF as presumptive diagnosis and higher creatinine values getting biopsied. Higher rejections were noticed in transplant recipients pointing towards the need of establishing a more efficient support system for managing such patients.

Fatal allograft mucormycosis complicating severe COVID-19 infection and bacterial pyelonephritis.

We herein present a case of live related kidney transplant recipient who initially developed severe coronavirus (COVID-19) disease associated with E.coli related pyelonephritis and graft dysfunction, who improved over one week only to deteriorate in the second week, with fever, oligoanuria and refractory shock. A postmortem allograft biopsy revealed angioinvasive mucormycosis. With the resurgence of mucormycosis during the COVID-19 pandemic, the transplant team should add allograft mucormycosis as a rare differential for severe graft dysfunction and oligoanuria in the COVID-19-infected kidney transplant recipient.

Phosphate Intake and Removal in Predominantly Vegetarian Patients on Twice-Weekly Hemodialysis.

Background: Hyperphosphatemia is linked to increased mortality and morbidity in patients on hemodialysis. Currently, the phosphate intake and dialytic removal in predominantly vegetarian patients on twice-weekly dialysis is not well studied. Materials and methods: This prospective, study recruited patients on twice-weekly dialysis of at least 3 months duration. Baseline clinical variables were measured. Dietary protein and phosphorus intake was assessed using a validated food frequency questionnaire. Phosphate binder use was assessed, hourly blood was collected for serum phosphorus during dialysis, and spent dialysate was collected to estimate cumulative phosphorus removal during the session. Results: Forty (67%) of the 60 patients studied were vegetarians. Twenty-eight (48%) were hyperphosphatemic, and 15 (25%) had serum parathormone (PTH) >500 pg/ml. The mean phosphorus intake was 1247 (±312) mg/day, the mean serum phosphorus was 5.49 (±2.01) mg/dl, and the mean dialytic phosphorus removal was 910 (±383) mg/session. Up to 67% of the study population took calcium-based phosphate binders, 25% took sevelamer carbonate, and 40% took activated vitamin D preparation. The lowest tertiles of phosphorus intake correlated with low energy-adjusted protein intake and hypoalbuminemia. Hyperphosphatemic subjects had better nutritional indices (mid-upper arm circumference and body mass index). Dietary intake and serum phosphorus levels were not mutually associated, but both were strongly correlated with total phosphorus removal in the spent dialysate. Serum phosphorus levels fell by 32% by thefirst hour of hemodialysis. Conclusion: Twice-weekly dialysis is often practised in resource-limited Asian countries. However, due to a predominantly vegetarian diet, hyperphosphatemia was noted only in up to half of the patients, despite twice-weekly hemodialysis schedules. This reinforces the fact that plant-based dietary phosphate is less well absorbed.

Recurrent proteinuria with graft dysfunction: a diagnostic and clinical conundrum.

The index case is a 45-year old male with unknown cause for native kidney disease, who received a kidney from his wife. Antithymocyte globulin (ATG) was used for induction, and tacrolimus, mycophenolate mofetil and prednisolone were prescribed for maintenance. His baseline serum creatinine was 0.9 mg/dl. Two years after the transplant, the patient developed 3+ proteinuria on routine urinalysis with stable graft function. His 24-hour urinary protein was 2.3 grams, serum albumin was 3.0 g/dl, and the total cholesterol was 251 mg/dl. The tacrolimus C0 levels were maintained between 6 and 8 ng/ml range. Allograft biopsy revealed diffuse thickening of glomerular basement membranes, with the immunofluorescence showing 2+ granular positivity along the loops for IgG and C3. Further, tissue staining for PLA2R and THD7A were both negative. Also, no donor-specific antibodies (DSA) were detected, and serum PLA2R antibody assay was also negative. The patient was managed conservatively with losartan 50 mg and atorvastatin 20 mg, with subsequent reports of proteinuria of 1.5-2.0 grams/day. After 52 months of renal transplant, the patient presented with a serum creatinine of 2.06 mg/dl and proteinuria of 6.8 grams/day. A repeat allograft biopsy revealed thickened glomerular basement membranes with spikes on silver staining. (Figure 1a) Further, immunofluorescence studies showed 2+-3+ granular positivity for IgG, C3, with the added findings of C4d positivity on the peritubular capillaries and tissue PLA2R positivity on the basement membranes by immunohistochemistry. (Figures 1b-d) The biopsy also revealed peritubular capillaritis and acute tubular injury. Antibodies to donor Class II (HLA DR) were positive with a mean fluorescence intensity (MFI) of 6885, but serum PLA2R antibodies remained negative. Based on these findings, the patient was treated with pulse methylprednisolone, 5 sessions of plasma exchange at 40 ml/kg with 5% human albumin and fresh frozen plasma replacement, intravenous immunoglobulin (at 100 mg/kg × 5) and rituximab (two doses of 1 g 2 weeks apart). Subsequently, the serum creatinine settled to 1.6 mg/dl, and DSA reduced to < 500 MFI. Three months after discharge, the serum creatinine is 1.5 mg/dl, 24-hour urine protein is 982 mg/day and follow-up DSA remains negative.

Recurrent proteinuria with graft dysfunction: a diagnostic and clinical conundrum.

The index case is a 45-year old male with unknown cause for native kidney disease, who received a kidney from his wife. Antithymocyte globulin (ATG) was used for induction, and tacrolimus, mycophenolate mofetil and prednisolone were prescribed for maintenance. His baseline serum creatinine was 0.9 mg/dl. Two years after the transplant, the patient developed 3+ proteinuria on routine urinalysis with stable graft function. His 24-hour urinary protein was 2.3 grams, serum albumin was 3.0 g/dl, and the total cholesterol was 251 mg/dl. The tacrolimus C0 levels were maintained between 6 and 8 ng/ml range. Allograft biopsy revealed diffuse thickening of glomerular basement membranes, with the immunofluorescence showing 2+ granular positivity along the loops for IgG and C3. Further, tissue staining for PLA2R and THD7A were both negative. Also, no donor-specific antibodies (DSA) were detected, and serum PLA2R antibody assay was also negative. The patient was managed conservatively with losartan 50 mg and atorvastatin 20 mg, with subsequent reports of proteinuria of 1.5-2.0 grams/day. After 52 months of renal transplant, the patient presented with a serum creatinine of 2.06 mg/dl and proteinuria of 6.8 grams/day. A repeat allograft biopsy revealed thickened glomerular basement membranes with spikes on silver staining. (Figure 1a) Further, immunofluorescence studies showed 2+-3+ granular positivity for IgG, C3, with the added findings of C4d positivity on the peritubular capillaries and tissue PLA2R positivity on the basement membranes by immunohistochemistry. (Figures 1b-d) The biopsy also revealed peritubular capillaritis and acute tubular injury. Antibodies to donor Class II (HLA DR) were positive with a mean fluorescence intensity (MFI) of 6885, but serum PLA2R antibodies remained negative. Based on these findings, the patient was treated with pulse methylprednisolone, 5 sessions of plasma exchange at 40 ml/kg with 5% human albumin and fresh frozen plasma replacement, intravenous immunoglobulin (at 100 mg/kg × 5) and rituximab (two doses of 1 g 2 weeks apart). Subsequently, the serum creatinine settled to 1.6 mg/dl, and DSA reduced to < 500 MFI. Three months after discharge, the serum creatinine is 1.5 mg/dl, 24-hour urine protein is 982 mg/day and follow-up DSA remains negative.

Development and Validation of a Novel Food-frequency Questionnaire for Hemodialysis Patients in Lucknow, India.

INTRODUCTION: Food-frequency questionnaire (FFQ) is a preferred tool for longitudinal dietary assessment and has been recently validated in patients on hemodialysis in other countries. As dietary habits vary vastly across regions, this study was planned to develop and validate a novel dialysis FFQ in northern India. MATERIALS AND METHODS: Dietary recall data from patients on hemodialysis available from the previous year were used for identifying food items for inclusion in the FFQ. A nutrient database was created to estimate energy, protein, calcium, phosphorus, and potassium content of the foods included in the food list. The FFQ was validated against a 2-day dietary recall method (one predialysis, one on the dialysis day) in patients on maintenance hemodialysis in a tertiary care hospital in Lucknow, northern India. RESULTS: Dietary recall data from 78 patients on hemodialysis were used for the generation of the FFQ. A total of 84 patients completed the validation study. All the nutrients measured by the FFQ correlated significantly with the means of the 2-day dietary record (r values 0.31-0.76) both in crude- and energy-adjusted intakes. De-attenuation further improved the correlation (0.35-0.80). Bland-Altman plots showed higher estimates by FFQ than by dietary recall. Cross-classification analysis showed correct classification in the exact or adjacent quintile (average 60%) by both methods and 2% gross misclassification. Weighted kappa showed fair agreement for energy intake and slight agreement for others. CONCLUSION: This novel semiquantitative FFQ is a valid tool for measuring energy and nutrient intakes in hemodialysis patients.

Phialemonium obovatum Infection of the Renal Allograft: Case Report and Review of the Literature.

In this case report, we describe the first case of Phialemonium obovatum infection involving the renal allograft in a recipient beyond 1 year after living renal transplant. The patient presented with a locally invasive mycetoma caused by this melanized fungus in the anterior abdominal wall, which extended during the hospital stay to involve the allograft. The fungus was identified by its characteristic micromorphological features present on potato dextrose agar and Sabourad dextrose agar and on subsequent slide cultures. The patient did not survive despite repeated surgical procedures, including partial allograft nephrectomy and broad-spectrum antifungal medications. Other cases of Phialemonium infections involving renal and stem cell transplant recipients are reviewed.

Predialytic versus Intradialytic Nutrition: A Study to Assess Effects on Intradialytic Blood Pressure, Dialysis Adequacy, and Urea Removal.

BACKGROUND: Provision of oral protein in hemodialysis (HD) is desirable due to improved compliance to protein requirements and better nutritional status, but the risks of hypotension and underdialysis need to be considered. This study compared 2 different timings for administering oral nutritional supplements (ONS), predialysis and mid-dialysis, with respect to hemodynamics, dialysis adequacy, urea removal, and tolerability. METHODS: This single-center, prospective crossover study analyzed 72 stable patients with ESRD on twice a week maintenance HD with a mean age of 38.7 (±11.2) years and a dialysis vintage of 28.2 (±13.1) months. In the first week, all the patients received ONS (450 kcal energy, 20 g protein) 1 h prior to start of dialysis (group 1) and in the next week, the supplement was administered after 2 h of start of dialysis (group 2), with a predialysis fasting period of at least 3 h in both groups. Blood pressures, serum, and spent dialysate samples were collected and nausea occurrence was noted by severity. RESULTS: Predialytic intake (group 1) was associated with higher predialysis and 1st hour blood urea, dialysis adequacy, and urea removal than group 2. Both groups achieved mean Kt/V > 1.2, and the occurrence of symptomatic hypotensive episodes and nausea was not significantly different between the groups. On repeated measures ANOVA, changes in blood urea over time showed significant group effect. CONCLUSIONS: Predialytic supplementation was associated with better dialysis adequacy and urea removal than intradialytic supplementation. However, both timings were equally tolerated and not associated with underdialysis.