Humoral Response After Two Doses of COVISHIELDTM Vaccine in Patients Undergoing Maintenance Hemodialysis.

OBJECTIVES: Maintenance hemodialysis (MHD) patients are at increased risk of contracting coronavirus disease 2019 (COVID-19). Vaccine against COVID-19 offers the benefit of protection from severe illness. In this study, we assessed the humoral response after two doses of the COVISHIELDTM vaccine in MHD patients. MATERIALS AND METHODS: In a prospective cohort study, the humoral response with two doses of the COVISHIELDTM vaccine was assessed after 14 ± 2 days of the second dose. The COVIPROTECT antibody titers against the spike protein were measured using the electrochemiluminescence immunoassay (ELECSYS, Roche Diagnostics International Ltd.). Data were analyzed to determine the predictors of antibody response. RESULTS: Between February and October 2021, 50 MHD patients were assessed. The mean age was 55.8 ± 10.8 years, and 72% were males. A total of 48 (96%) MHD patients have seropositivity. The median level of spike protein antibody was 579 U/mL [interquartile range (IQR25-75) 166-1852.75]. Compared to patients with no COVID-19 infection history, the median levels of antibodies were significantly higher in those with a history of COVID-19 (1047 vs 297 U/mL, p = 0.011). The antibody titers did not differ by age (p = 0.269), presence of comorbidities such as hypertension (p = 0.341), diabetes mellitus (p = 0.719) or ischemic heart disease (IHD) (p = 0.695), dialysis vintage (p = 0.660), and timing of diagnosis of COVID-19 in relation to vaccination (p = 0.261). Adverse events (AEs) occurred in one-third of patients that were mild and self-limiting. No serious AEs were observed in any patient. CONCLUSION: In MHD patients, two doses of the COVISHIELDTM vaccine induced a substantial humoral response. Prior history of COVID-19 resulted in a higher antibody response. Thus, the COVISHIELDTM vaccine is efficacious and safe for use in patients with MHD. How to cite this article: Balwani MR, Pasari AS, Bawankule C, et al. Humoral Response After Two Doses of COVISHIELDTM Vaccine in Patients Undergoing Maintenance Hemodialysis. J Assoc Physicians India 2023;71(9):56-60.

Hospitals may Become "Disease Hotspots" for COVID-19 amid Shortage of Personal Protective Equipment.

How to cite this article: Patel MP, Kute VB, Goswami J, Balwani MR. Hospitals may Become "Disease Hotspots" for COVID-19 amid Shortage of Personal Protective Equipment. Indian J Crit Care Med 2020;24(11):1145-1146.

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.

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.

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 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.

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.

ABO Incompatible Kidney Transplant in a Patient With Atypical Hemolytic Uremic Syndrome: Case Report.

Kidney transplant (KT) or renal transplant is 1 of the preferred treatment options for patients with end-stage renal disease, but the presence of atypical hemolytic uremic syndrome (aHUS) further increases the risk of reoccurrence with graft rejection, and poor outcomes. ABO incompatibility further adds to the rejection risk. Here, we present a case of a young adult with a history of aHUS undergoing a successful ABO-incompatible (ABOi) renal transplant. ABO incompatibility desensitization was carried out, and the antibody titer was reduced to nullify the risk of rejection. Graft acceptance was facilitated by triple immunosuppression (steroid, tacrolimus, and mycophenolate mofetil), and 4-month serum creatinine follow-up indicated the absence of antibody-mediated rejection and recurrence of aHUS. This case demonstrates that in patients with aHUS, ABOi renal transplant can be performed successfully.

CYP3A5 Polymorphism in Renal Transplantation: A Key to Personalized Immunosuppression.

BACKGROUND: Tacrolimus is essential for the maintenance of immunosuppression after a kidney transplant. CYP3A5 is the gene that metabolizes tacrolimus, and polymorphism in this gene affects the metabolizing status. AIM: To assess the genetic polymorphism status of patients undergoing kidney transplantation and determine its impact on graft function and complications in the post-transplant period. METHODS: We retrospectively included the patients who had undergone a kidney transplant and had positive genetic polymorphism of the CYP3A5 gene. Based on loss of alleles, patients were categorized as non-expresser (loss of both alleles), intermediate expresser (loss of one allele), and expresser (no loss of allele) denoted by CYP3A5*3/*3, CYP3A5*1/*3, and CYP3A5*1/*1, respectively. Data were analyzed with descriptive statistics. RESULTS: Of 25 patients, 60%, 32%, and 8% were non-expressers, intermediate-expressers, and expressers, respectively. The mean tacrolimus trough concentration to dose ratio after 6 months of the transplant was higher in non-expressers than intermediate-expressers and expressers (213 vs 85 and 46 ng/mL/mg/kg/d, respectively). The graft function was normal in all 3 groups except for graft rejection 1 patient in the expresser group. Compared with expressers, urinary tract infections (42.9% and 62.5%) and new-onset diabetes after transplantation (28.6% and 12.5%) were more frequent in non-expresser and intermediate expressers, respectively. The proportion of patients developing new-onset diabetes after transplantation was lower with the pre-transplant diagnosis of CYP3A5 polymorphism (16.7% vs 23.1%). CONCLUSION: Genotype-based dosing of tacrolimus helps achieve the desired therapeutic concentrations that can help to optimize graft outcomes and reduce the tacrolimus-related adverse effects. Pre-transplant evaluation of CYP3A5 can be more helpful in planning treatment strategies for optimized outcomes after kidney transplantation.

Profile and Post-Kidney Retrieval Outcomes in Asymptomatic Kidney Donors With Genetic Mutations in Complement Factors-Related Genes.

BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a rare disorder triggered by various stressors. Most of the time, stressors may not be identified in patients with aHUS. The disease may remain quiescent without manifestation throughout life. BACKGROUND: To assess the outcome of an asymptomatic carrier of genetic mutations of patients with aHUS who had undergone donor kidney retrieval surgery. METHODS: We retrospectively included the patients diagnosed with a genetic abnormality in complement factor H (CHF) or CHF-related (CFHR) genes without manifestation of the aHUS and who had undergone donor kidney retrieval surgery. The data were analyzed with descriptive statistics. RESULTS: Among patients who were the kidney recipients from the prospective donors, 6 donors were screened for genetic mutations in CFH and CFHR genes. Four donors showed positive mutation for CFH and CFHR. The mean age was 54.5 years (range, 50-64 years). After over a year since donor kidney retrieval surgery, all prospective mother donors are alive without aHUS activation and with a normal kidney function on a single kidney. CONCLUSION: Asymptomatic carriers of genetic mutations in CFH and CFHR can be the prospective donors for their first-degree family member who have active aHUS. A genetic mutation in an asymptomatic donor should not be a contraindication for refuting the prospective donor.

Kidney Transplant Outcomes in Patients with Atypical Hemolytic Uremic Syndrome.

BACKGROUND: Atypical hemolytic uremic syndrome (aHUS) is a rare disorder with a high probability of recurrence after a kidney transplant and can adversely affect the graft outcome. Our objective was to assess the transplant outcome of patients with aHUS who had undergone a kidney transplant. METHODS: We retrospectively included patients who had undergone a kidney transplant and been diagnosed with aHUS based on an anti-complement factor H (AFH) antibody level >100 AU/mL and the presence of a genetic abnormality in complement factor H (CHF) or CHF-related (CFHR) genes. Data were analyzed with descriptive statistics. RESULTS: Among 47 patients with AFH antibody levels >100 AU/mL, 5 (10.6%) had undergone a kidney transplant. The mean age was 24.2 years, and all were male. Atypical hemolytic uremic syndrome was diagnosed before transplant in 4 (80.0%) cases, whereas 1 was diagnosed after transplant owing to disease recurrence in the transplanted graft. Genetic analysis of all cases revealed one or more abnormalities in CFH and CFHR genes 1 and 3. With an average of 5 sessions of plasma exchange and the use of rituximab in 4 cases, there was a reduction in the disease severity with no recurrences in the post-transplant period. At the latest follow-up of 223 days, the mean serum creatinine level was 1.89 mg/dL, indicating good graft function. CONCLUSIONS: Among patients diagnosed with aHUS, the use of pre-transplant plasma exchange and rituximab can be beneficial in terms of preventing graft dysfunction and reducing disease recurrence in the post-transplant period.

Clinical and Histopathological Profile of Immunoglobulin A Nephropathy Patients in Central Part of India: A Single-Center Study.

The objective of the study was to assess clinical and histopathological profile of patients who were diagnosed as immunoglobulin A nephropathy (IgAN) on renal biopsy. Medical data were collected for this retrospective study at a single center from patients with biopsy-proven IgAN, from those biopsied between January 2017 and September 2020. A total of 347 renal biopsies were performed during the study. There were 52 patients with primary IgAN who met our inclusion criteria. Males were more commonly affected (61.5%). The mean age at the time of kidney biopsy was 35.26 ± 10.39 years. Hypertension was present in 84.5% of patients. Median serum creatinine and estimated glomerular filtration rate (eGFR) at presentation were 3.58 mg/dL and 15.8 mL/min/1.73 m2, respectively. Mesangial hypercellularity (M1), endocapillary hypercellularity (E1), segmental glomerulosclerosis (S1), tubular atrophy/ interstitial fibrosis (T1/T2), and crescents (C1/C2) were present in 46.2%, 38.5%, 88.5%, 75% and 36.6% of patients respectively. Thrombotic microangiopathy (TMA) and hypertensive vasculopathy were seen in 38.5% and 86.5% of patients respectively. The presence of tubular atrophy (T1/T2), hypertensive vasculopathy, and TMA on renal biopsy was significantly associated with low eGFR at presentation whereas no such correlation could be established with segmental glomerulosclerosis (S1), crescents (C1/C2), mesangial (M1) and endocapillary hypercellularity (E1). The presence of hypertensive vasculopathy and TMA on renal biopsy was associated with poor renal function at presentation. The most common clinical presentation of IgAN was hypertension and so we suggest patients with hypertension should be screened for microscopic dysmorphic hematuria and proteinuria, if present, should undergo a renal biopsy to diagnose this disease in early stages.

Spectrum of Biopsy-proven Native Kidney Disease in Central India.

Spectrum of native renal biopsy reports varies geographically. Here, we tried to determine the prevalence of renal biopsy disorders and compare it with other studies. Retrospective study was performed at Saraswati Kidney Care Center, Nagpur and Jawaharlal Nehru Medical College, Sawangi, India. All the native kidney biopsies from January 2017 to March 2020 were included in the analysis. Demographic details of all the patients were recorded. Renal diseases were classified as glomerular, tubulo-interstitial, predominant vascular involvement and other disease categories. Total 347 native kidney biopsies were performed during the study period. Mean age of the patients at the time of biopsy was 41.41 ± 15.75 years. Majority of patients were males (58.5%). Most common indication for kidney biopsy was nephrotic syndrome (36.3%) followed by nephritic syndrome (19.9%). Among the glomerular diseases (GDs), 69% were primary glomerulopathies and 31% were secondary GDs. Immunoglobulin (IgA) nephropathy (30.85%) was the most common primary GD followed by membranous nephropathy (MN) (26.59%), focal segmental glomerulosclerosis (FSGS) (17.02 %) and minimal change disease (14.36 %). Among secondary glomerulopathies, lupus nephritis was the most common histopathological diagnosis (31.8%) followed by diabetic nephropathy (26.1%), amyloidosis (17%), infection related glomerulonephritis (11.3%), light chain deposition disease (4%) and anti-neutrophil cytoplasmic antibody associated vasculitis (3.4%). In tubulointerstitial disease, 33.3% had acute tubulointerstitial nephritis, whereas each 26.6% had acute tubular injury and cast nephropathy. The most prevalent diagnosis in our only study from central India was IgA nephropathy followed by MN and FSGS. Data analysis at regular intervals helps in understanding the changing trend of prevalence of native kidney disease and also gives understanding of geographical variations.

Anti-phospholipase A2 Receptor Antibody-Positive Membranous Glomerulopathy due to Anti-Koch's Therapy in a Tuberculosis Patient.

Tuberculosis (TB)-associated glomerulonephritis is difficult to diagnose that usually presents with hematuria, proteinuria, edema, hypertension, or renal insufficiency, which is similar to symptoms of primary glomerulonephritis. Membranous nephropathy (MN) is uncommonly seen in TB patients. We report a case of a 30-year-old female with Koch's chest who developed anti-phospholipase A2 receptor antibody-positive MN after initiation of anti-Koch's therapy and resolved after completion of anti-Koch's therapy.

Diabetic muscle infarction: An unusual cause of acute limb pain in patients on maintenance hemodialysis.

Diabetic muscle infarction is underdiagnosed complication occurring in dialysis patients with advanced diabetes mellitus. Atherosclerotic vascular disease and long-standing diabetes are risk factors for this painful condition. Most common presenting symptom is localized pain in the affected limb. We present here a case of muscle infarction occurring in a diabetic patient on maintenance hemodialysis (HD). Our patient had low-grade fever and pain in right thigh which restricted his movements for one month. His pain worsened during and post-HD. External examination of right lower limb was normal except for tenderness in the right thigh region. Laboratory examination showed leukocytosis with normal serum creatine phosphokinase levels. Magnetic resonance imaging of the thigh was suggestive of muscle infarction. Patient was treated with bed rest, analgesics, antiplatelets and blood transfusion. HD prescription was changed to sustained low-efficiency dialysis with reduced ultrafiltration. Gradually, in a week, his fever and pain subsided and he was able to walk on his own. Thus, it is important to identify this clinical condition early in the course of illness to further prevent its progression.

Heterozygous laminin ß2 mutation in C3 glomerulopathy.

C3 glomerulopathy is usually seen with the presence of C3 nephritic factor, homozygous or heterozygous mutations in the regulatory complement proteins factor H, factor I, or C3. We describe the presence of heterozygous laminin ß2 mutation in a patient of C3 glomerulonephritis with ocular and central nervous system involvement, the significance of which is unknown.

Knowledge about COVID-19 and Practices among Hemodialysis Technicians in the COVID-19 Pandemic Era.

INTRODUCTION: Hemodialysis technicians play a crucial role in infection control practices in hemodialysis units. Thus, it is important to assess the knowledge and attitude towards COVID-19 among hemodialysis technicians in this pandemic situation. MATERIALS AND METHODS: An online survey composed of 22 closed-ended questions using Google Forms was conducted in the month of April (13th to 19th) 2020. The survey consisted of questions regarding the knowledge of COVID-19 and current hemodialysis practice among hemodialysis technicians. The study was approved by the institutional ethics board. The survey was administered online through a mobile phone invitation. Basic statistics (mean and standard deviation or total number and percent) were computed for all covariates. RESULTS: Out of 150, 115 technicians participated in the survey. 80.9% of the participants were males. The mean age of respondents was 28.22 + 6.97 years. Most of the respondents could correctly identify fever (87.8%), breathlessness (86.08%), and dry cough (81.7%) as the symptoms of COVID-19 infection. 75.7% of the technicians were aware that it can be transmitted by asymptomatic persons. 61.1% of the technicians were segregating patients who had symptoms such as fever and cough to the last shift of the day. 81.1% of the technicians read the guidelines issued by the Indian Society of Nephrology-COVID-19 working group. But, only 25.5% of the respondents could rightly identify to keep a minimum distance of two meters between two beds while dialyzing a suspected patient of COVID-19 along with other patients to minimise risk of COVID-19 transmission. 60% of the technicians have received hydroxychloroquine as prophylaxis against coronavirus infection. CONCLUSION: Our study shows a significant knowledge gap among hemodialysis technicians about COVID-19. Effective COVID-19 education campaigns should be carried out intensively with relevant information among hemodialysis technicians to address the knowledge gap. A well-informed hemodialysis technician can prove to be a great tool to spread the right infection control practices among dialysis-dependent patients.

Widening spectrum of renal involvement in psoriasis: First reported case of C3 glomerulonephritis in a psoriatic patient.

Renal involvement in psoriasis is usually seen as mesangioproliferative glomerulonephritis (GN), IgA nephropathy, and focal segmental glomerulosclerosis. Microscopic hematuria is not uncommon in a patient of psoriasis with above-mentioned disorders. We found C3 GN as a cause when evaluated for macroscopic and persistent microscopic hematuria in a patient of psoriasis.

Awareness about kidney and its related function/dysfunction in school going children: A survey from the Central India.

In the absence of a national registry, the exact incidence and burden of chronic kidney disease in children in India is not known. The most common diagnosis for which children are likely to see a pediatric nephrologist is nephrotic syndrome constituting almost 40% of cases. Considering all the renal manifestations in the pediatric age group, we designed simply survey to find out the awareness among school going children about the kidney's function and dysfunction in our Indian scenario. More than 95% of children knew that normally humans have two kidneys. Around 50% of school children on an average were not aware of normal location of their kidneys. About 60%-75% of school going children was unaware of all the functions of a normal kidney. More than half of school children had no idea that even one normal kidney was sufficient to lead a normal life. Again more than half of the participant children were unaware of the basic symptoms of the kidney failure. Around 8%-9% of students reported a positive family history of kidney disease in their family. Pediatric population, especially the school going students should be educated from their early years about the basics of any vital organ like the kidney. Here, in the present study, we found that there is the scope of improvement in making children aware of normal functions of a kidney and the abnormalities that occur when the kidneys are malfunctioning. Early diagnosis will lead to reduced kidney-related morbidity and mortality.