A rare case of dialysis associated reaction presenting with urticarial vasculitis and haemoglobinuria.

Dialysis associated reactions presenting with urticarial vasculitis is rarely reported in medical literature. We report a 61-year-old gentleman who developed sudden onset dyspnea with diffuse erythema within 20 min of haemodialysis. Patient was started on Azilsartan 3 days prior to this clinical event. Labs revealed features of hemolysis and urine was positive for hemoglobinuria. All dialysis related factors responsible for this reaction were ruled out. Due to non-resolution of skin rash, skin biopsy was attempted which revealed fibrinoid necrosis of occasional vessels with predominant lymphocytic infiltration suggestive of drug induced urticarial vasculitis. Complement levels were normal. He was managed with steroids, anti-histaminic, discontinuation of azilsartan and change of dialyzer membrane. This case highlights a rare dermatological presentation of Type A dialysis associated reaction involving azilsartan with differential diagnosis and treatment strategies.

Hashimoto's thyroiditis masquerading as acute tubular injury and rhabdomyolysis.

Hashimoto's thyroiditis manifesting as hypothyroidism has been implicated in glomerular disorders due to autoantibody formation. Here we present the case of a 26-year-old male without any comorbidities presenting with easy fatiguability and weight gain for 2 months. He was found to have a creatinine of 2.1 mg/dL with a history of rhinitis treated with anti-histaminic three days prior to the hospital visit. He had symptoms of intermittent myalgia for the past two weeks. On laboratory evaluation, he was found to have raised CPK, elevated TSH, low normal T4, and positive anti-TPO and anti-Tg antibodies. Neck ultrasound revealed linear echogenic septations in the thyroid gland. Renal biopsy revealed acute tubular injury. Appropriate thyroxine supplementation was started and his creatinine decreased to 1.2 mg/dL after 1 month. It is important that clinicians should be aware of this rare kidney presentation in Hashimoto's thyroiditis.

Anti-tubercular treatment-induced granulomatous acute interstitial nephritis.

ABSTRACT: This case emphasizes the value of meticulous observation and regular follow-up of patients receiving rifampicin therapy. The prognosis for complete improvement in renal function in such cases was excellent, with prompt recognition and discontinuation of rifampicin. Teaching patients about these possible adverse effects and encouraging immediate reporting of signs and symptoms are likely to be beneficial because acute kidney injury can manifest itself very quickly after rifampicin is started. Even if renal failure can happen with any dose of rifampicin, primary physicians must have awareness about patients on intermittent or irregular therapy and those who have previously used this medication. It is challenging to determine the prevalence of adverse reactions to common antibiotics where a state- or country-wide reporting system is absent. Along with withdrawal of the causative agent patients were treated with corticosteroids (0.5-1 mg/kg/day) for an average period of 4-12 weeks showing significant recovery of renal function.

A rare presentation of isolated candidal hepatic abscess in a maintenance hemodialysis patient.

A 61-year-old female with diabetes and stage 5 chronic kidney disease on hemodialysis since 3 years via left brachiocephalic arteriovenous fistula presented with uncontrolled sugars, weight loss, and dysphagia. On evaluation, she was found to have an oral thrush with leucocytosis. Initial blood and urine cultures were sterile, and ultrasonography revealed hypoechoic lesions in the left lobe of the liver. She had high-grade fever followed by seizures on postadmission Day 10. Brain imaging and serum electrolytes were normal. Cerebrospinal fluid analysis was noncontributory, and urine culture revealed Candida non-albicans with elevated white blood cell counts. She was started on fluconazole; however, her clinical condition deteriorated, with hemodynamic instability. Repeat abdominal computerized tomography revealed increasing hypodense lesions in the left lobe of the liver with elevated beta D glucan levels. Percutaneous drainage of the abscess revealed no fungal elements. In view of clinical deterioration, amphotericin B was started, which resulted in clinical improvement. Clinician should have high index of suspicion for fungal etiology in hemodialysis patients presenting with liver abscess.

Prevalence and Risk Factors of Heart Failure with Preserved Ejection Fraction in Middle-Aged Maintenance Haemodialysis Patients on a Twice-Weekly Schedule: Experience from a Single Indian Centre.

Background. Data on the prevalence of cardiac failure with preserved ejection in the haemodialysis population, which impacts treatment strategy, mortality, and morbidity, are scarce. Aims and Objectives. Estimate the prevalence of heart failure with preserved ejection fraction (HFpEF) in haemodialysis patients Classify cardiac failure and ascertain the risk factors influencing HFpEF in haemodialysis patients. Methods. All consenting individuals on haemodialysis over 18 years of age were included. Lung ultrasound was performed as per the LUST study protocol, and the labs were documented. Echocardiographic parameters were measured using two-dimensional (2D ECHO). Results. A total of 102 patients consented to participate in the study, which included 63 males (61.8%) and 39 females (38.2%). The mean patient age was 53 ± 13.1 years. The dialysis vintage of the participants was 38.92 ± 6.947 months. 47 (46.1%) patients had diabetes and 88 (80.4%) had hypertension. ECG findings included sinus rhythm (51/102, 50%), sinus tachycardia (22/102, 21.6%), ST-T wave abnormalities (18/102, 17.6%), and atrial fibrillation (11/102, 10.8%). Heart failure with preserved ejection fraction (HFpEF) was present in 44/102 (43.14%), heart failure with mid-range EF in 14/102 (13.72%), and heart failure with reduced EF in 13/102 (12.7%) patients. The ejection fraction was positively associated with haemoglobin (r = 0.23; p = 0.044), and calcium levels (r = 0.25; p =0 .03). E/lateral e' ratio was positively correlated with NT pro-BNP (r = 0.63; p < 0.001), systolic blood pressure (r = 0.44; p = 0.003) and age (r = 0.353; p = 0.003) and negatively correlated with transferrin saturation (r = -0.353; p = 0.027) and diastolic blood pressure (r = -0.31; p = 0.040). Binary logistic regression analysis revealed that the odds of diastolic dysfunction increased by 2.3 times with each unit increase of creatinine, and diabetics have 7.66 times higher risk for diastolic dysfunction. Binary logistic regression involving ejection fraction (EF) and all laboratory and clinical parameters revealed odds of HFpEF increased by 1.93 times with each unit increase in age, odds of HFpEF increases by 1.53 times with each unit increase in phosphorous and odds of HFpEF increased by 1.1 times with a unit increase of systolic blood pressure. Conclusion. HFpEF is the predominant form of heart failure in haemodialysis patients. Haemoglobin and calcium were positively associated with ejection fraction. Advancing age, elevated creatinine and diabetes mellitus levels are independent predictors of diastolic dysfunction in haemodialysis patients.

An Unusual Case of Alcoholic Liver Disease Associated with Secondary IgA Vasculitic Nephritis presenting as Rapidly Progressive Glomerulonephritis.

IgA nephropathy (IgAN) is a fairly common association with alcoholic liver disease. However, IgA vasculitis (IgAV) is quite an uncommon association with alcoholic liver cirrhosis and only a handful of cases have been reported in literature. Secondary IgAN usually presents in a docile manner, progressing slowly in about 5-25 years. It is usually responsive to steroid therapy, very rarely progressing to End-Stage Renal Disease. Here, we present a man in his late 50s, a known hypertensive and alcohol related liver-cirrhotic, who presented to our hospital with rash and rapidly progressive renal failure (RPRF). He was diagnosed with IgA nephritis with IgA vasculitis (IgAVN). His diagnosis was confirmed with skin and renal biopsy. He was started on renal replacement therapy for his renal failure and began oral steroid therapy. After administration of steroid therapy for 6 months, the patient recovered and was dialysis independent with stable renal parameters.

Clinical implications of serum anti-PLA2R levels and glomerular PLA2R deposits in primary membranous nephropathy.

Introduction. The clinical implications of serum anti-PLA2R with glomerular PLA2R deposits in primary membranous nephropathy (PMN) is scarcely reported. Hence the study was designed to demonstrate the prevalence of serum anti-PLA2R levels and PLA2R staining in glomeruli in PMN and the clinical implications of the two parameters. Objectives. Investigate the prevalence of anti PLA2R positivity in PMN. Ascertain correlation between serum anti-PLA2R levels and glomerular staining for PLA2R with clinical and lab parameters in PMN. Patients and Methods. Fifty PMN patients during the period from October 2017 to December 2018 were included. Labs were done and eGFR was calculated as per MDRD 6. Anti-PLA2R titres were done in all patients. Titres more than 20 RU/ml were considered positive. Glomerular staining for PLA2R was graded on fresh frozen tissue by immunofluorescence technique. Results. Anti-PLA2R antibody positivity and glomerular PLA2R deposition was observed in 42% (21/50) and 86% (43/50) patients respectively. 79.3% (23/29) had positive glomerular PLA2R deposition with negative serum anti PLA2R. Positive correlation were observed between serum PLA2R antibody and serum creatinine (p = 0.0001) and urine protein-creatinine ratio levels with tissue PLA2R staining grades (p = 0.04). Negative association was found between serum albumin (p = 0.026) and tissue PLA2R staining grades. Conclusion. Serum anti-PLA2R wasn't a sensitive marker of primary membranous nephropathy in our study group emphasising the need to consider a compendium of serological markers for diagnosis of primary membranous nephropathy and to rely more on glomerular deposition of PLA2R as a better clinical indicator for PMN.

An abysmal conundrum associated with a misplaced dialysis catheter.

A 25-year-old female patient with chronic glomerulonephritis, initiated on haemodialysis presented with high-grade fever, a dysfunctional catheter, low oxygen saturation and unstable blood pressure. Upon evaluation, the patient was febrile with elevated white blood cell counts. She was intubated, started on inotropes and transferred to the intensive care unit. Chest radiography showed that the tunnelled internal jugular dialysis catheter had migrated to the inferior vena cava. Echocardiography and transoesophageal echocardiography showed severe heart dysfunction with a large thrombus attached to the catheter, indicating catheter-related atrial thrombus (CRAT). CT pulmonary angiography revealed blockage of the segmental pulmonary arteries, suggesting pulmonary embolism. Blood and tracheal cultures revealed Methicillin-resistant Staphylococcus aureus (MRSA). The patient was administered appropriate antibiotics and anticoagulants and underwent surgical removal of the thrombus and the catheter. This case demonstrates the risks associated with improper placement of dialysis catheters and highlights the brief management of CRAT.

The Effect of Dialysate Temperature on Dialysis Adequacy and Hemodynamic Stability: An Experimental Study with Crossover Design.

Cool dialysate has variable impact on hemodynamic stability and dialysis adequacy. Hemodynamic stability and dialysis adequacy are crucial indicators for better life expectancy and cardiovascular mortality. This research aims to evaluate the impact of cool dialysate temperature (35.5°C) compared to standard dialysate temperature (37°C) on blood pressures, pulse rate, and dialysis adequacy (Urea reduction ratio and online Kt/V) in a cross over design. Material and Methods. Consenting ESRD patients on maintenance haemodialysis (HD) with minimum 3 months dialysis vintage and functioning permanent vascular access are included for the study. Each participant had two sessions of HD at 37°C followed by two sessions at 35.5° C on a Fresenius 4008S HD machine. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and Pulse rate are measured pre-HD, every hourly and post dialysis. Pre-HD Blood urea nitrogen (BUN) and post-HD BUN are measured, and Urea reduction rate was calculated for each HD session. Kt/V was calculated by ionic conductance by HD machine for each session. Results. 25 patients (5 females and 20 males) were enrolled. The mean age was 54 ± 9.58 years. Dialysis vintage was 21.48 ± 6.9 months for study participants 10 patients (40%) were diabetic nephropathy, 9 patients (36%) were presumed chronic glomerulonephritis, 2 patients (8%) were lupus nephritis and 4 patients (16%) were chronic interstitial nephritis. There was statistically no difference between pre-HD BUN (p = 0.330), post-HD BUN (p = 0.776), URR (p = 0.718) and Kt/V (p = 0.534) among the dialysis sessions done at 37°C and 35.5°C. SBP variability in the low temperature (35.5°C) group at 4th hour and post dialysis assumed statistical significance with p = 0.05 and p = 0.025 respectively. DBP variability in the low temperature (35.5°C) group at 3rd hour, 4th hour and post-dialysis demonstrated statistical significance with p = 0.027, p = 0.36 and p = 0.016 respectively. Pulse rate variability was more in the low temperature (35.5°C) group at 3rd hour and 4th hour which showed statistical significance with p = 0.037 and p = 0.05 respectively. Conclusion. Cool dialysate is non inferior to standard dialysate temperature in terms of dialysis adequacy and is associated with less variability in diastolic blood pressure, systolic blood pressure and more pulse rate variability thereby contributing to better hemodynamic stability.

A case report and literature review of IgA nephropathy presenting as nephrotic syndrome in polycythemia vera.

A 66-year-old non-smoker presented with a 2-week history of new-onset pedal oedema and gross haematuria. On evaluation, he was found to be hypertensive and oedematous with a haemoglobin of 19.1 g/dl, platelet count of 546,000/mm3, and creatinine of 2.6 mg/dl. Urine examination revealed abundant RBCs with 3+ albumin on three separate occasions. His 24-h urine protein level was 3830 mg/day, with a serum cholesterol level of 303 mg/dl. Secondary erythrocytosis and thrombocytosis tests were negative. Bone marrow examination revealed hypercellularity, erythroid hyperplasia, tight clusters of large megakaryocytes, and megakaryocytic hyperplasia suggestive of polycythemia vera. PCR analysis revealed a JAK2V617 F (exon 14) mutation. In view of nephrotic syndrome, azotemia, and microscopic haematuria, a renal biopsy was performed, which revealed features of IgA nephropathy with advanced interstitial fibrosis and tubular atrophy. He was started on angiotensin receptor blockers with hydroxy urea as a part of treatment. This case report highlights the association of glomerular disease with polycythaemia vera and the need of prompt renal biopsy for diagnosis and management.

Catheter related atrial thrombus caused by Abiotrophia defectiva: A case series and review of literature.

Catheter related atrial thrombus (CRAT) is a devastating complication associated with tunneled hemodialysis catheter. Abiotrophia defectiva is a rare fastidious pathogen implicated predominantly in culture negative infective endocarditis. Here we report three cases of CRAT in maintenance hemodialysis patients with variable clinical presentation caused by Abiotrophia defectiva. Video assisted thoracoscopic retrieval of atrial thrombus is a novel technique which is scarcely reported in medical literature for surgical management of large atrial thrombus. Our cases were managed by timely administration of antibiotics and anticoagulants followed by surgical retrieval of atrial thrombus with removal of tunneled dialysis catheter. This case series illustrates the importance of prompt diagnosis, appropriate anticoagulation with antibiotics, and mini-invasive surgical removal of atrial thrombus for the management of CRAT.

Correlation of Acoustic Radiation Force Impulse Imaging with Chronicity Markers in Native Renal Biopsy.

Introduction. Acoustic Radiation Force Impulse (ARFI) is an ultrasound parameter which has shown promise in assessing liver stiffness, but there are limited data on the correlation of ARFI with chronicity markers in renal biopsies. Objectives. Determine ARFI values in ultrasound and correlate with chronicity markers in renal biopsy. Determine whether ARFI can be used as a non-invasive chronicity predictor compared to renal length, Resistive Index (RI), and cortical thickness. Patients and Methods. Two hundred and fifty patients were enrolled in the study. The ultrasound variables ARFI, renal length, RI, and cortical thickness values were assessed by the radiologist prior to renal biopsy. The biopsy slides were graded as per the Mayo Clinic consensus report scoring system by an experienced pathologist. Results. Among 250 study participants, 167 were males and 83 were females. IgA nephropathy was the most common pathology (n=47;19%), followed by diabetic nephropathy (n=42;17%), membranous nephropathy (n=35;14%), FSGS (n=27;11%), and MCD (n=19; 8%). The mean eGFR was 55.9 ± 42.12 ml/min/1.73 m2. The average renal length was 10.086 ± 1.01 cm. The average cortical thickness was 0.707 ± 0.134 cm. Resistive index was 0.68 ± 0.09. Acoustic radiation force impulse had weak negative correlation (r=-0.286; p=0.0001) with total pathological score and weak positive correlation with eGFR (r=0.279; p=0.0001). RI was a better indicator for histologically evaluated chronicity with positive correlation coefficient (r=0.416; p=0.0005) compared to renal length, cortical thickness, and ARFI. Conclusion. ARFI didn't corelate with the pathological score in renal biopsies. RI had better predictive value for chronicity in native renal biopsies.