Brain abscess following kidney transplantation: A single centre observational study from North India.

Background: Amongst the infections in kidney transplant recipients, brain abscess represents an uncommon life-threatening complication. Mortality continues to be high despite improvements in diagnostics and therapeutics. Method: We conducted an observational study, describing the incidence, presentation, implicating pathogen, management and outcome of brain abscess following kidney transplantation at our centre. Result: Amongst the 1492 patients who underwent kidney transplantation at our centre between June 1991 and January 2023 (cumulative follow-up: 4936 patient-years), five females and four males, developed brain abscesses. The incidence proportion (risk) is 0.6% with an incidence rate of 6.03 cases per 1000 patient years. The median duration from transplant to development of brain abscess was 5 weeks (range: 4 weeks to 9 years). The commonest presentation was a headache. A definitive microbiological diagnosis was established in eight out of nine patients. The commonest implicated organism was a dematiaceous fungus, Cladophialophora bantiana (3 patients, 33.3%). Despite the reduction in immunosuppression, surgical evacuation and optimal medical therapy, five (55.55%) patients succumbed to their illness. Conclusions: Brain abscesses following kidney transplantation is an uncommon, life-threatening condition. It usually occurs in the early post-transplant period and the presentation is often subtle. Unlike immunocompetent individuals, a fungus is the most common causative organism in those with solid organ transplants. The management includes a reduction in immunosuppression, early antimicrobial therapy, and surgical decompression.

Effect of treatment regimens in severe COVID pneumonia at an Indian tertiary care hospital: An observational, real-world study.

Background: Corticosteroids have attracted attention as a treatment option for severe Coronavirus disease (COVID-19). However, published data on steroid therapy is debatable, and real-world data is lacking. This study evaluated the effect of treatment regimens, especially Pulse steroid therapy (Injection Methyl Prednisolone 250 mg iv once a day for three days) in severe-COVID-19 pneumonia at an Indian tertiary care hospital. Methods: This observational cross-sectional study included severe COVID-19 pneumonia patients aged >18 years, requiring assisted ventilation. As part of the hospital protocol, patients received either pulse steroid therapy, remdesivir or tocilizumab in addition to the recommended steroid doses i.e., injection of dexamethasone 6 mg iv once a day. The association of factors and treatment regimens to patient outcomes was evaluated. Results: Data of eighty-three patients were assessed, majority being above 60 years (n = 30, 36.14%) and males (n = 45/83, 54.21%). The commonest comorbidities were hypertension (n = 26), diabetes (n = 23) and obesity (n = 19), fifty-five patients (66.26%) reported at least one comorbidity. Sixty-one patients (73.49%) had received pulse steroid regimen, forty-eight patients (57.83%) were administered remdesivir-based regimen while twelve patients (14.46%) had received tocilizumab treatment. 54.1% patients managed with pulse steroid regimens were discharged after treatment, statistically similar to remdesivir-managed subgroup (62.5%, p > 0.05). On sub-group analysis, pulse steroids showed better outcomes in young males with no comorbidities. No comorbidity had significant relationship with patient outcomes (p > 0.05). Conclusion: Pulse steroid therapy is an effective therapy in management of patients with severe COVID-19 pneumonia in a real-world setting, with better outcomes in young males without comorbidities. Pulse steroids can be considered a viable option for severe-COVID-19 pneumonia management.

Use of immunoadsorption columns in ABO-incompatible renal transplantation: A prospective study at a tertiary care center in India.

BACKGROUND: We present our experience of ABO-incompatible renal transplant using immunoadsorption (IA) columns. We have compared efficacy of two commercially available columns. METHODS: This single-center prospective study was conducted at Army Hospital Research and Referral, Delhi. All consecutive ABO-incompatible renal transplants from January 2014 to February 2018 were analyzed. Of 30 patients who underwent transplantations, 28 underwent antibody depletion with immunoadsorption columns. Of them, 14 cases were in the "Glycosorb group," while 14 in the "Adsopak group." RESULTS: The donors in the Adsopak group were older than those in the Glycosorb group (p < 0.05). Both groups had spousal donors in majority. The cutoff for the antibody titer was 1:8. The median titer in the Adsopak group was 128 (range, 1:4 to 1:2048), while that in the Glycosorb group was 24 (range, 1:8 to 1:128). All patients in the Glycosorb group had baseline titers ≤1:128, while 13 patients in the Adsopak group had baseline titers ≤1:512. Nil titer was achievable with Glycosorb® (50%,7/14) but not with Adsopak® (P < 0.01). Around 4 sessions were required for the Glycosorb group, while around 8 sessions were required for the Adsopak group before transplantation (p < 0.001). The Glycosorb group was advantageous in terms of graft failure because no rejection was noticed in these patients in their follow-up period. Three patients in the Adsopak group developed rejection (two had mixed rejection, and one had antibody-mediated rejection). Four patients died of sepsis (three in the Glycosorb and one in the Adsopak group). Lower baseline serum creatinine level was achieved in the Glycosorb group. CONCLUSIONS: Results of ABO-incompatible renal transplantation were satisfactory, and the use of immunoadsorption columns could effectively deplete antibody titers. Glycosorb columns were more efficient than Adsopak columns. Graft survival was better with Glycosorb. Posttransplant infections were a major cause of mortality.

A single-center experience in use of tocilizumab in COVID-19 pneumonia in India.

BACKGROUND: IL-6 receptor antagonist tocilizumab (TCZ) has been used in several reported studies in the treatment of COVID-19 pneumonia and pieces of evidence are still emerging. METHODS: All patients with COVID-19 pneumonia showing features of hyperinflammatory syndrome receiving TCZ at a tertiary care center in India were included in the study and a retrospective descriptive analysis was done. RESULTS: Between May 2020 to August 2020, 21 patients received TCZ out of which 13 survived and 8 died. All non-survivors had longer duration (median 12 days, minimum 9, maximum 15 days compared to median 6 days, minimum 3 and maximum 14 days in survivors) of symptoms and severe disease requiring mechanical ventilation at the time of TCZ administration. Among survivors, 8 patients had severe disease, 3 had moderate disease, and 2 patients had mild disease. Six out of 8 (75%) among non-survivors and 8 out of 13 (62%) among survivors had preexisting medical comorbidities. The non-survivors had higher baseline neutrophil-to-leukocyte ratio (10.5 vs 8.8), serum ferritin (960 ng/ml vs 611 ng/ml), lactate dehydrogenase (795 IU/L vs 954 IU/L), and D-dimer (5900 µg/ml vs 1485 mg/ml) levels. No drug-related serious adverse effect was noted among the patients. CONCLUSION: In a scenario of emerging evidence for the role of TCZ in the management of severe COVID-19, our study provides useful data on its use in the Indian scenario. Deliberate patient selection and timing initiation of TCZ at a crucial stage of the disease may be beneficial in COVID-19 pneumonia with good safety returns.

Reaching Out to the Millions: A 5 Key Messages Rapid IEC Campaign During the COVID-19 Pandemic.

The ongoing COVID-19 pandemic has necessitated providing populations with simple and relevant, actionable informational messages for them to be informed on individual and community level measures to combat the pandemic. Distilling guidance from various sources into simple actionable message themes in a short time frame should be the hallmark of any rapid health promotion campaign. We developed and disseminated actionable Information, Education and Communication (IEC) messages on prevention and control during the ongoing COVID-19 pandemic by selecting five key message themes of prevention. A modified Delphi technique was used for the development process which was peer reviewed after consensus was generated. An online training model using specifically developed YouTube videos and Zoom Meetings was utilized to train Master Trainers and the further hierarchy reaching out to 6989 Community Resource Persons at the peripheral echelons. Conservatively the population reached out has been estimated to be more than 6 million (across 1.2 million households), over a two week period in April 2020. The implementing agency has created 300 videos in around 22 languages based on the 5 Key Messages, which are available online for universal access. A rapid IEC campaign that can be developed, designed and rolled out in a short span is required for emergency situations such as the ongoing pandemic. NGOs play an important role in reaching out relevant messages to the community, filling in the gaps by virtue of their relative systemic agility.

Cadaveric renal transplantation: Our experience at a tertiary care centre in India.

BACKGROUND: Renal transplantation in developing countries like India is largely live donor transplantation. Cadaveric transplantation comprises <2% of all transplants in India. METHODS: Ninety-two cadaveric renal transplantations were included. Various donor and recipient characteristics were analysed along with graft and patient survival, using Kaplan-Meier method. RESULTS: The mean age of the recipients was 35.5 ± 10.9 years while that of cadaver was 43.9 ± 17.0 years. Proportion of females among recipients was 47.8% while that of donors was 34.8%. The most common underlying pathology was chronic glomerulonephritis (44.6%). Antithymocyte globulin was used as induction in 84.8% of cases. Tacrolimus-based triple-drug regimen was most commonly used as maintenance (80.4%). The mean follow-up time was 39.02 ± 28.24 months. The most common cause of death was sepsis (47%). More than 50% deaths (9/17) occurred within first 3 years, while 61.5% of graft loss occurred 5 years after transplantation. The mean graft survival time was 81.6 months (95% confidence interval [CI]: 72.8-90.4). Cumulative proportion of graft survival was 91.6% at 3 years and 77.1% at 5 years. Although females have better mean graft survival time (91.6 vs 73.5 months), it was not a significant difference as shown by log-rank test (p value = 0.062). Pretransplant haemodialysis has no significant effect on graft loss, but patients on peritoneal dialysis have significantly higher odds of graft loss (odds: 4.86, p value < 0.05 [0.018]). The mean patient survival time was 99.5 months (95% CI: 84.0-114.9). Cumulative proportion of patient survival was 83.3% at 3 years and 70.8% at 5 years. CONCLUSION: Graft and patient survival rate of cadaveric transplant at our centre was satisfactory. There is need to sensitise and augment the rate of cadaveric transplantation to increase the donor pool.

Pneumoperitoneum needle vs. introducer needle: Comparison of complications and short-term outcomes in percutaneously inserted peritoneal dialysis catheters in naïve abdomens.

Percutaneous peritoneal dialysis catheter (PDC) insertion for continuous ambulatory peritoneal dialysis (CAPD) entails a higher risk of complications such as bowel injury, vascular injury, and catheter migration compared to the surgical insertions. We conducted a comparative analysis of two techniques of peritoneal entry for PDC insertion by Seldinger technique. We performed a retrospective review of 426 percutaneously inserted PDCs in nonobese naïve abdomens for CAPD at two tertiary care teaching hospitals in India over 6 years. Comparison of various mechanical complications, and short-term catheter survival was done between use of introducer needle (Group "I") and spring-loaded pneumoperitoneum (Veress) needle (Group "V"). Group "I" to "V" patient ratio was 277:149. Group "I" had heavier patients (p = 0.03) whereas "V" group had a dominance of diabetes (p = 0.009) and prior hemodialysis patients (p = 0.03). At 3 months, the odds of mechanical complications (OR = 0.27, p = 0.004), PDC migration (OR = 0.18, p = 0.02), and omental wrapping (OR = 0.13, p = 0.04) were less in "V" group. No bowel injury occurred with Veress needle use. At 6 months, "V" group had higher odds of event-free sustained PDC tip position (OR = 0.39, p = 0.003), and catheter survival (p = 0.03), and the cumulative events were lesser too (p = 0.002). Refractory peritonitis and deaths with functioning catheter were comparable between both the groups. In this first-of-its-kind study, spring-loaded Veress pneumoperitoneum needle use was safer, entrusted sustained PDC tip position in pelvis, and had a better catheter survival compared to use of introducer needle for peritoneal entry in percutaneously inserted PDCs. These findings should be confirmed by a randomized controlled study.

Reinfection or Reactivation of Coronavirus-19 in Patients with Hematologic Malignancies: Case Report Series.

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been relentless. We are into the 10th month of the pandemic, and we are still getting surprised every day. Although neutralizing antibodies are generated in response to coronavirus disease-19 (COVID-19), these antibodies do not appear to confer lifelong immunity, as lately there have been reports from various parts of the world of reinfection with the virus, starting from Hong Kong, Belgium, and the USA. The Indian Council of Medical Research (ICMR) has been on-record claiming three cases of reinfection in India. Herein, we report three patients of hematologic malignancy who most probably had reinfection with SARS-CoV-2, after complete documented recovery from first infection. All three patients were immunocompromised owing to their primary hematologic malignancy coupled with ongoing therapy, and the second infection was documented to be severe in all the three cases from the first episode.

Clinical Triaging in Cough Clinic Alleviates COVID-19 Overload in Emergency Department in India.

The importance of this study is the efficacy of "symptoms only" approach at a screening clinic for coronavirus disease 2019 (COVID-19) diagnosis in low- and middle-income countries (LMIC) setting. The objective of this study was to assess how efficiently primary care physicians at the screening clinic were able to predict whether a patient had COVID-19 or not, based on their symptom-based assessment alone. The current study is a cross-sectional retrospective observational study. This study was conducted at a single-center, tertiary care setting with a dedicated COVID-19 facility in a metropolitan city in eastern India. Participants are all suspected COVID-19 patients who presented themselves to this center during the outbreak from 1 August 2020 to 30 August 2020. Patients were referred to the Cough Clinic from the various outpatient departments of the hospital or from smaller satellite centers located in different parts of the city and other dependent geographical areas. The main outcome(s) and measure(s) is to study whether outcome of confirmatory test results can be predicted accurately by history taking alone. From 01 August 2020 to 30 Aug 2020, 511 patients with at least one symptom suggestive of COVID-19 reported to screening clinic. Out of these, 65.4% were males and 34.6% were females. Median age was 45 years with range being 01 to 92 years. Fever was seen in 70.4% while cough was present in 22% of cases. Overall positivity for SARS-CoV-2 during this period in this group was 54.21%. At 50% pre-test probability, the sensitivity of trained doctors working at the clinic, in predicting positive cases based on symptoms alone, was approximately 74.7%, and specificity for the same was 58.12%. The positive predictive value of the doctors' assessment was 67.87%, and the negative predictive value was 66.02%. Rapid triaging for confirmatory diagnosis of COVID-19 is feasible at screening clinic based on history taking alone by training of primary care physicians. This is particularly relevant in LMIC with scarce healthcare resources to overcome COVID-19 pandemic.

Peritoneal Dialysis Catheter Insertion by Nephrologist Using Minilaparotomy: Do Survival and Complications Vary in Obese?

INTRODUCTION: Peritoneal dialysis catheter (PDC) placement for chronic kidney disease (CKD) amongst overweight and obese patients is difficult owing to deeper operating field. Literature being discordant on survival and complications in this patient subset, we attempted to analyse this research question in Indian population. MATERIALS AND METHODS: We retrospectively analysed PDC inserted by nephrologist using surgical minilaparotomy for survivals and complications amongst 'overweight and obese' cohort ('O') at two tertiary care government hospitals in India, and compared results with normo-weight cohort ('N'), with 12-36 months follow-up. RESULTS: 245 PDCs were inserted by surgical minilaparotomy and 'N' to 'O' ratio was 169:76. 'O' group were more rural residing (P = 0.003) and post-abdominal surgery (P = 0.008) patients. The 1, 2, and 3-year death censored catheter survival rate was 98.6%, 95.8%, and 88.2% respectively in 'O' group, and 97.6%, 94.5% and 91.8% in 'N' group respectively (P = 0.52). Patient survival (P = 0.63), mechanical complications (P = 0.09) and infective complications (P = 0.93) were comparable despite technically challenging surgery in 'O' group. Refractory peritonitis related PDC removal was comparable (P = 0.54). Prior haemodialysis or catheter related blood stream infections or diabetes were non-contributory to results. CONCLUSIONS: Catheter survival and patient survival amongst obese and overweight CAPD patients was non-inferior to normal weight patients. Mechanical, and infective complications were comparable despite technically challenging abdominal terrain in 'O' group. The overall CAPD performance was good amongst obese and overweight.

Acute kidney injury due to acute cortical necrosis following vivax malaria.

Malaria is a parasitic infection of global importance but has a high prevalence in the developing countries. Renal failure is a common complication of severe Plasmodium falciparum malaria and has been reported in up to 40% of all cases. Acute kidney injury (AKI), however, is not commonly associated with Plasmodium vivax infection. In those patients who develop AKI following P. vivax infection, the cause is commonly attributed to mixed undiagnosed falciparum infection or coexistent sepsis, dehydration, or hypotension. Infrequently, an association of P. vivax infection with thrombotic microangiopathy (TMA) has been reported. The purpose of this report is to describe renal failure due to TMA following malaria caused by P. vivax. A 24-year-old female presented with a history of fever and jaundice of two weeks duration followed by progressive oliguria and swelling of the face and feet five days after the onset of fever. The evaluation revealed normal blood pressure, anemia, thrombocytopenia, azotemia, unconjugated hyperbilirubinemia with mildly elevated transaminases, and elevated lactate dehydrogenase. Peripheral smear was positive for P. vivax, and schistocytes were seen. She was given intravenous artesunate followed by oral primaquine for 14 days. Urine examination showed proteinuria and microscopic hematuria. She remained oliguric and dialysis dependent, and her kidney biopsy revealed patchy cortical necrosis involving 40% of sampled cortex with widespread fibrinoid necrosis of the vessel wall, red blood cell fragmentation, and luminal thrombotic occlusion. Hemodialysis was discontinued after three weeks when there was the improvement of renal function over time, and her serum creatinine decreased to 2.2 mg/dL by six weeks. Patients with P. vivax malaria developing renal failure may have TMA. Renal biopsy, if performed early in the course of the disease, may identify TMA and institution of plasma exchange in such patients could help in early recovery.

Urinary tract infection in renal transplant recipients at a tertiary care center in India.

Our objective was to determine incidence, predisposing factors, and microbiological profile of urinary tract infection (UTI) in renal transplant recipients in our center. This was cross-sectional observational study, conducted at the Department of Nephrology, Army Hospital Research and Referral, Delhi, India. Two hundred and ten renal transplant recipients were studied over one year. Out of 210 transplant recipients, 69 (32.86%) had UTI. Majority (59/69) had undergone live renal transplantation and 10 cases had received cadaveric grafts. Forty-nine patients had primary infection while 20 patients had recurrences. The mean age of patients with UTI was 38.63 ± 10 years. The incidence of UTI was higher in females (42.25%) than males (28.06%, P = 0.038). Majority of patients in younger age group (age <30 years) were female (58.82%). Males were predominantly affected in higher (>30 years) age group (61.54%). Most common causative agent was Escherichia coli (72.46%). Gram-negative bacilli accounted for 94.20% (65/69) while Gram-positive cocci for 5.8% (4/69) of positive cultures. Multidrug resistance was highest in Klebsiella pneumoniae (100%). Fifteen cases with UTI were detected to have underlying urinary tract abnormalities, most common being urethral stricture (60%). One patient was detected to have broken double J stent in the renal pelvis which led to recurrent E. coli infection. Forty-eight patients (69.57%) developed acute graft dysfunction secondary to UTI. Female sex (P = 0.038), urinary tract abnormality (P <0.01), prolonged Foley's catheterization (P <0.01), prolonged hospitalization after transplantation (P <0.01), new-onset diabetes after transplantation (P <0.01), and coexisting hepatitis C infection (P = 0.012) were statistically significant predisposing factors for UTI in renal transplant recipients.

Role of Direct Antiviral Agents in Treatment of Chronic Hepatitis C Infection in Renal Transplant Recipients.

BACKGROUND: Since the introduction of direct antiviral agents (DAAs), morbidity of HCV has considerably decreased but still no guidelines have been formulated in renal transplant recipients (RTRs). We studied efficacy and tolerability of direct antiviral agents in RTRs. METHODS: This prospective observational study was conducted at Army Hospital Research & Referral, Delhi, from June 2016 to May 2017. Forty-five HCV infected RTRs with stable graft function were included. RESULTS: Median time between renal transplantation and the start of anti-HCV therapy was 36 months (1-120 months). The majority (66.7%) were infected with genotype 3. Baseline median HCV RNA level was 542648 IU/ml (1189-55028534 IU/ml). Sofosbuvir-Ribavirin combination (24 weeks) was given to 30 patients including 3 cirrhotics, Ledipasvir-Sofosbuvir combination to 8 patients, and Daclatasvir-Sofosbuvir combination to 7 patients, including 2 cirrhotics. Rapid virological response was observed in 29 patients treated with Sofosbuvir/Ribavirin, all 8 patients on Sofosbuvir/Ledipasvir, and all 7 patients on Sofosbuvir/Daclatasvir. End treatment response and sustained virological response (12 weeks) were achieved in all patients irrespective of genotype or treatment regimen. Decrease in mean HCV RNA level and transaminase level was statistically significant (p < 0.01). Ribavirin was significantly associated with anaemia (p = 0.032). CONCLUSIONS: DAA regimens are well tolerated and highly efficacious. Response to DAA is good irrespective of genotype, drug combination, initial HCV RNA level, age or sex of patient, or graft age. However, Sofosbuvir/Ledipasvir and Sofosbuvir/Daclatasvir combination is preferable.

A rare presentation of nephrotic syndrome.

Nephrotic syndrome usually presents with oedema due to fluid accumulation in subcutaneous space. Renal subcapsular fluid accumulation is a rare presentation. We present a rare case of membranoproliferative glomerulonephritis which presented with bilateral subcapsular fluid collection and was successfully managed by percutaneous drainage and treating the underline pathology.

Risk factors for contrast-induced nephropathy after coronary angiography.

Contrast-induced nephropathy (CIN) is of concern after the use of radiocontrast media for coronary angiography (CAG) and percutaneous coronary intervention (PCI). We studied the incidence of CIN and its risk factors in patients undergoing CAG. In this prospective study, we included all patients with normal renal parameters undergoing CAG with nonionic radiocontrast media. We excluded patients with known chronic kidney disease, baseline creatinine more than 1.5 mg/dL, significant hypotension, anemia, and patients with acute myocardial infarction undergoing emergency PCI. Serum creatinine was done at baseline and serially for seven days after the procedure. Appropriate statistical tests were used to analyze the results and P <0.05 was considered statistically significant. The study population (n = 500, 348 males and 152 females) had a mean age of 56.6 ± 12.5 years. Twelve patients (2.4%) developed CIN and were equally distributed irrespective of the age, diabetes, or PCI procedure. CIN was observed to be more common in patients with hypertension than in those without hypertension (P = 0.0158). The total volume of contrast administered to CIN group (175 ± 59.3) was not significant as compared to that of non-CIN (159.1 ± 56) group (P = 0.334). None of the patients in our study required renal replacement therapy, and there was no mortality. CIN is observed in 2.4% of patients undergoing CAG and had a self-limiting course. Hypertension is the only observed risk factor, and further large-scale studies are necessary to delineate the novel risk factors for CIN in the general population with normal kidney function.