COVID-19 in CKD patients: Report from India

Background:

Methods:

Result:

Conclusion:

Hypervitaminosis D and acute interstitial nephritis: Tale of injections

A 33-year-old man came with nausea, vomiting and abdominal pain due to hypercalcaemia and renal dysfunction following two doses of intramuscular vitamin D injections. Levels of vitamin D were repeatedly above 300 ng/ml over a period of 10 months. Whole-body PET CT scan revealed a thin-walled collection in the right gluteal region. The patient refused a surgical intervention for the same. After 7 months of follow-up, the abscess ruptured spontaneously and was then surgically debrided. At this point, a history of pentazocine addiction was uncovered. One month later, vitamin D levels began to fall along with improvement in serum calcium and creatinine. This case unravels a diagnostic odyssey which ended with a simple surgical debridement. We aim to highlight that vitamin D supplementation in ‘megadoses’ in the presence of active infection can have an exaggerated response and may take months to resolve.

Immunoadsorption Column Reuse

Introduction:

Selective immunoadsorption (IA) is a technique to remove preformed Anti-ABO antibodies in ABO-incompatible renal transplants (ABOiRT). Since the cost of a single IA column is high and single use rarely achieves the target anti-ABO titers, its use is not widely spread. We studied the safety and efficacy of the reuse of IA columns in ABOiRT.

Methods:

Single-center, retrospective analysis of all patients who underwent ABOiRT with IA column reuse from January 2016 to July 2018. The column was reused after sterilization with ethylene oxide and flushed with normal saline before use. Target titers (IgG) were 1:4 preoperatively. Baseline IgG titers, plasma volume processed in each session, postoperative titer rebound were recorded. The primary outcome was IgG titer reduction after each use and adverse reaction during the IA column reuse. Patients were followed up until 1 year.

Results:

16 patients underwent ABOiRT using IA columns. Baseline IgG titer ranged from 1:32 to 1:512. Reuse of IA column was done 23 times and underwent 2^nd reuse for 9 times. The average plasma volume treated was 22 L. Efficacy of the IA column in log titer reduction of anti-ABO titer was 4 logs after the first use, 3 logs after 1^st reuse, and 1.5 logs after 2^nd reuse. 12 (75%) patients successfully reached the target IgG titer of ≤1:4 solely with column reuse. One patient received a single session of plasma exchange before transplantation. Postoperatively, one patient received one session of plasma exchange due to a rebound in anti-ABO antibodies. No serious side effects were noted during the reuse.

Conclusion:

IA column reuse up to two times showed efficacy in the successful reduction of antibody titers. Column reuse was not associated with any significant side effects.

Agricultural labor, COVID-19, and potential implications for food security and air quality in the breadbasket of India

To contain the COVID-19 pandemic, India imposed a national lockdown at the end of March 2020, a decision that resulted in a massive reverse migration as many workers across economic sectors returned to their home regions. Migrants provide the foundations of the agricultural workforce in the 'breadbasket' states of Punjab and Haryana in Northwest India.There are mounting concerns that near and potentially longer-term reductions in labor availability may jeopardize agricultural production and consequently national food security. The timing of rice transplanting at the beginning of the summer monsoon season has a cascading influence on productivity of the entire rice-wheat cropping system. To assess the potential for COVID-related reductions in the agriculture workforce to disrupt production of the dominant rice-wheat cropping pattern in these states, we use a spatial ex ante modelling framework to evaluate four scenarios representing a range of plausible labor constraints on the timing of rice transplanting. Averaged over both states, results suggest that rice productivity losses under all delay scenarios would be low as compare to those for wheat, with total system productivity loss estimates ranging from 9%, to 21%, equivalent to economic losses of USD $674 m to $1.48 billion. Late rice transplanting and harvesting can also aggravate winter air pollution with concomitant health risks. Technological options such as direct seeded rice, staggered nursery transplanting, and crop diversification away from rice can help address these challenges but require new approaches to policy and incentives for change.

Bladder Carcinoma Associated with BK Virus in a Renal Allograft Recipient

Bladder carcinoma is a relatively rare carcinoma reported in renal allograft recipients. While many oncogenic viruses have been implicated as causative factors for certain malignancies, questions have been raised about possible role of BK virus in pathogenesis of urothelial cancers. In this report, we have described a patient who developed BK virus nephropathy followed 3 years later by bladder carcinoma. Interestingly, while the tumor tissue demonstrated BK virus, the adjacent normal urothelium was stained negative for BK virus. Considering the viral potential to inhibit tumor suppressors and its differential localization within tumor tissue, it is possible that the virus contributes to tumorigenesis.

Pulmonary Calcifications: Is it an Entity in the New World Dialysis Patient?

Metastatic pulmonary calcification (MPC) has been described in the literature to affect up to 60% of dialysis patients. Several case series of MPC were described in 1960s and 1970s. Patients are generally asymptomatic or may present with acute respiratory distress. This entity is associated with up to 60% mortality. We hereby report a case of chronic kidney disease on maintenance hemodialysis who presented with unexplained recurrent dyspnea despite adequate hemodialysis. She was evaluated and found to have a rare presentation of calciphylaxis.

BK Virus nephropathy in living donor renal allograft recipients: An observational study from a large transplant center in India

BK virus is a polyoma virus which remains in latent phase in the urinary tract, particularly in the renal tubular epithelial cells. In immunosuppressed patients, it is activated and manifests as tubule-interstitial nephritis causing renal allograft dysfunction. A total of 402 patients who underwent renal allograft biopsy from 2013 to 2016 were included in this study; six patients were diagnosed to have BK virus nephropathy. Histopathology showed ground glass intra-nuclear inclusions accompanied by acute tubular injury, interstitial inflammation, and varying degree of interstitial fibrosis and tubular atrophy. Patients were managed with reduction in the overall immunosuppression. Only one patient progressed to graft failure on follow-up. The overall prevalence of polyoma virus at our center is 1.49%.

Epitaxial strain driven crossover from Drude to Drude-Smith terahertz conductivity dynamics in LaNiO3 thin films

We investigate the hetero-epitaxial strain driven low-energy charge dynamics in compressive and tensile strained LaNiO₃ thin films employing terahertz (THz) time-domain spectroscopy. The complex THz conductivity exhibits a crossover from Drude type metallic behavior for the compressive film to a Drude-Smith type disordered behavior for the tensile film. This demonstration of strain driven crossover in THz conductivity dynamics, while the two films have qualitatively similar dc conductivities, (i) brings out the potential of THz technology in distinguishing between similar dc electronic phases and (ii) suggests that LaNiO₃ under compressive strain is a better candidate for applications as electrodes in oxides electronics.

Cation disorder and epitaxial strain modulated Drude-Smith type terahertz conductivity and Hall-carrier switching in Ca1-x Ce x RuO3 thin films

The CaRuO₃ is a non-Fermi liquid pseudo-cubic perovskite with a magnetic ground state on the verge of phase transition and it lies in the vicinity of the quantum critical point. To understand the sensitivity of its ground state, the effects of subtle aliovalent chemical disorder on the static and high frequency dynamic conductivity in the coherently strained structures were explored. The Ce-doped Ca_1-x Ce _x RuO₃ (0  ⩽  x  ⩽  0.1) thin films were deposited on LaAlO₃ (1 0 0) and SrTiO₃ (1 0 0) substrates and studies for low-energy terahertz (THz) carrier dynamics, dc transport and Hall effect. These compositions exhibited a very effective and unusual Hall-carrier switching in both compressive and tensile strain induced epitaxial thin films. The dc resistivity depicts a switching from a non-Fermi liquid to a Fermi liquid behavior without any magnetic phase transition. A discernible and gradual crossover from Drude to Drude-Smith THz dynamic optical conductivity was observed while traversing from pure to 10% Ce-doped CaRuO₃ films. Overall, a nearly Fermi liquid behavior, effective carrier switching and unusual features in THz conductivity, were all novel features realized for the first time in physically and/or chemically modified CaRuO₃. These new phases highlight the novel subtleties and versatility of the systems lying near the quantum critical point.

Renal failure due to granulomatous interstitial nephritis in native and allograft renal biopsies: experience from a tertiary care hospital

Granulomatous interstitial nephritis is a rare cause of renal failure in both native and allograft renal biopsies. Drugs and sarcoidosis are the commonest causes of granulomatous interstitial nephritis as reported in Western countries. Unlike the west, tuberculosis is the commonest cause of granulomatous interstitial nephritis in Indian subcontinent. The etiological factors, clinical course, glomerular and tubulointerstitial changes associated with granulomatous interstitial nephritis have been analyzed in the present study along with the outcome in patients with granulomatous interstitial nephritis.

Burden and predictors of hypertension in India: results of SEEK (Screening and Early Evaluation of Kidney Disease) study

Background

Hypertension (HTN) is one of the major causes of cardiovascular morbidity and mortality. The objective of the study was to investigate the burden and predictors of HTN in India.

Methods

6120 subjects participated in the Screening and Early Evaluation of Kidney disease (SEEK), a community-based screening program in 53 camps in 13 representative geographic locations in India. Of these, 5929 had recorded blood pressure (BP) measurements. Potential predictors of HTN were collected using a structured questionnaire for SEEK study.

Results

HTN was observed in 43.5% of our cohort. After adjusting for center variation (p < 0.0001), predictors of a higher prevalence of HTN were older age ≥40 years (p < 0.0001), BMI of ≥ 23 Kg/M² (p < 0.0004), larger waist circumference (p < 0.0001), working in sedentary occupation (p < 0.0001), having diabetes mellitus (p < 0.0001), having proteinuria (p < 0.0016), and increased serum creatinine (p < 0.0001). High school/some college education (p = 0.0016), versus less than 9th grade education, was related with lower prevalence of HTN. Of note, proteinuria and CKD were observed in 19% and 23.5% of HTN subjects. About half (54%) of the hypertensive subjects were aware of their hypertension status.

Conclusions

HTN was common in this cohort from India. Older age, BMI ≥ 23 Kg/M², waist circumference, sedentary occupation, education less, diabetes mellitus, presence of proteinuria, and raised serum creatinine were significant predictors of hypertension. Our data suggest that HTN is a major public health problem in India with low awareness, and requires aggressive community-based screening and education to improve health.

A single arm, prospective, open label, multicentre study for evaluation of efficacy and safety of IV CERA for treatment of chronic renal anaemia in dialysis patients not currently treated with ESA

INTRODUCTION

CERA, a continuous erythropoietin receptor activator, has reported effective correction of anaemia in international clinical trials.

OBJECTIVE

Objective of this study was to evaluate efficacy and safety of CERA in Indian patients who were on dialysis and has not received erythropoiesis stimulating agent (ESA) therapy in last 8 weeks.

METHODS

In this open label, single arm, prospective, multi-centre study, 189 patients on dialysis, having Haemoglobin (Hb) between 8 - 10 g/dL and not receiving any ESA for last 8 weeks were included at 14 centers across India. CERA was given intravenous (IV) at the dose of 0.6 microg/kg every two weeks. Primary end point of the study was mean change in Hb concentration from baseline to end of the treatment period (TP) of 16 weeks.

RESULTS

Mean change of Hb from baseline to end of TP was 2.11 +/- 1.37 g/dL and 2.08 +/- 1.29 g/dL in intent to treat (ITT) and per protocol (PP) population respectively. Mean time to achieve Hb response was 6.10 +/- 3.87 weeks and 6.16 +/- 3.92 weeks in ITT and PP populations respectively. Out of 68 adverse events (AEs) seen during study period, 33 were serious adverse events (SAEs). As per investigators all SAEs were related to underlying disease and not to the study medication.

CONCLUSION

It is concluded that CERA administered once in two weeks in dialysis patients effectively corrected chronic kidney disease (CKD) related anaemia and was well tolerated with no significant untoward effect directly related to drug therapy in Indian population.

Charge-density wave condensate in charge-ordered manganites: impact of ferromagnetic order and spin-glass disorder

The behavior of charge-density wave (CDW) condensates with the systematic introduction of ferromagnetic (FM) and spin-glass phases in the charge-ordered (CO) lattice of Nd(0.5)Sr(0.5)MnO(3) (NSMO) and Eu(0.5)Sr(0.5)MnO(3) (ESMO) epitaxial thin films was investigated by terahertz time-domain spectroscopy. The optical conductivity of (100)-oriented NSMO film, in which the CO lattice has an insignificant volume of the FM phase, exhibits a peak with attributes of CDW collective excitation at ~3.2 meV. This peak becomes completely submerged in the Drude continuum as the volume of the epitaxial strain-induced FM phase increases in the CO state of (110)- and (111)-oriented NSMO films. In contrast, the ESMO (100) film, having a short-range CO phase amid a spin-glass-like state, displays a subtle CDW peak in conductivity. Modeling the optical terahertz conductivity with the phenomenological Lorentz-Drude relation and extracting the optical weight due to both contributions (Lorentz and Drude), it was found that the manifestation of CDW condensates is associated with the generic strength of charge ordering and that the condensate suffers a more pronounced suppression when FM order dilutes the CO lattice than when spin-glass disorder weakens the CO state.

What do we know about chronic kidney disease in India: first report of the Indian CKD registry

Background

There are no national data on the magnitude and pattern of chronic kidney disease (CKD) in India. The Indian CKD Registry documents the demographics, etiological spectrum, practice patterns, variations and special characteristics.

Methods

Data was collected for this cross-sectional study in a standardized format according to predetermined criteria. Of the 52,273 adult patients, 35.5%, 27.9%, 25.6% and 11% patients came from South, North, West and East zones respectively.

Results

The mean age was 50.1 ± 14.6 years, with M:F ratio of 70:30. Patients from North Zone were younger and those from the East Zone older. Diabetic nephropathy was the commonest cause (31%), followed by CKD of undetermined etiology (16%), chronic glomerulonephritis (14%) and hypertensive nephrosclerosis (13%). About 48% cases presented in Stage V; they were younger than those in Stages III-IV. Diabetic nephropathy patients were older, more likely to present in earlier stages of CKD and had a higher frequency of males; whereas those with CKD of unexplained etiology were younger, had more females and more frequently presented in Stage V. Patients in lower income groups had more advanced CKD at presentation. Patients presenting to public sector hospitals were poorer, younger, and more frequently had CKD of unknown etiology.

Conclusions

This report confirms the emergence of diabetic nephropathy as the pre-eminent cause in India. Patients with CKD of unknown etiology are younger, poorer and more likely to present with advanced CKD. There were some geographic variations.

Nano-engineering by implanting Al2O3 nano particle as sandwiched scattering centers in between the Lao.5Pr0.2Sr0.3MnO3 thin film layers

We report the use of non-magnetic Al2O3 nano particles deposited between two ferromagnetic La0.5Pr0.2Sr0.3MnO3 (LPSMO) manganite layers with an aim to improve the electronic and magnetotransport properties of the layered supper lattice grown on single crystal STO(100) substrate using Pulsed Laser Deposition (PLD) technique. We studied the electronic-transport and magnetotransport properties of this system wherein Al2O3 particles are expected to act as insulating scattering centers between two ferromagnetic LPSMO layers. The scattering due to additional scattering centers (insulating Al2O3 nano particles) could be controlled by application of external field, resulting in high magnetoresistance (MR) approximately 72% as compared to pristine LPSMO film (MR approximately 51%) at temperature close to their T(M) values. In addition, incorporation of nanostructured Al2O3 barrier between the two ferromagnetic LPSMO layers results in a 2-3 fold increase in the values of temperature coefficient of resistance (TCR) and the field coefficient of resistance (FCR) as compared to pristine LPSMO film, suggesting the use of such nanoengineered manganite layered structure for better device application.

Voice recognition for radiology reporting: Is it good enough?

AIM

To compare the efficiency and accuracy of radiology reports generated by voice recognition (VR) against the traditional tape dictation-transcription (DT) method.

MATERIALS AND METHODS

Two hundred and twenty previously reported computed radiography (CR) and cross-sectional imaging (CSI) examinations were separately entered into the Radiology Information System (RIS) using both VR and DT. The times taken and errors found in the reports were compared using univariate analyses based upon the sign-test, and a general linear model constructed to examine the mean differences between the two methods.

RESULTS

There were significant reductions (p<0.001) in the mean difference in the reporting times using VR compared with DT for the two reporting methods assessed (CR, +67.4; CSI, +122.1s). There was a significant increase in the mean difference in the actual radiologist times using VR compared with DT in the CSI reports; -14.3s, p=0.037 (more experienced user); -13.7s, p=0.014 (less experienced user). There were significantly more total and major errors when using VR compared with DT for CR reports (-0.25 and -0.26, respectively), and in total errors for CSI (-0.75, p<0.001), but no difference in major errors (-0.16, p=0.168). Although there were significantly more errors with VR in the less experienced group of users (mean difference in total errors -0.90, and major errors -0.40, p<0.001), there was no significant difference in the more experienced (p=0.419 and p=0.814, respectively).

CONCLUSIONS

VR is a viable reporting method for experienced users, with a quicker overall report production time (despite an increase in the radiologists' time) and a tendency to more errors for inexperienced users.

Assessment of hypertension control in chronic kidney disease patients by ambulatory blood pressure monitoring

BACKGROUND

Inadequate control of blood pressure (BP) increases cardiovascular mortality and morbidity in chronic kidney disease (CKD) and renal transplant patients. 24 hour ambulatory BP was recorded to evaluate the adequacy of BP control in these patients.

METHODS

60 CKD patients (25 conservative therapy, 16 maintenance hemodialysis, 19 renal transplant patients) were studied prospectively. After achieving clinic BP control, 24 hour ambulatory BP was recorded at 1 and 6 months. The patients were followed up for one year.

RESULTS

Mean daytime and nighttime systolic blood pressure (SBP) both at 1 month and at 6 month was higher in non-survivors than in survivors. The survivors had better control of their daytime (p=0.018) as well as nighttime SBP levels (p=0.018) at 6 months compared to those at 1 month. Survivors achieved nocturnal dipping of SBP at 1 and 6 months (p=0.047, p=0.025, respectively). Non-survivors failed to achieve lower daytime (p=0.375) or nighttime SBP (p=0.254) at 6 months as compared to SBP at 1 month in spite of optimizing antihypertensive therapy. Daytime (p=0.022) and nighttime (p=0.029) diastolic BP (DBP) in the non-survivors was higher than in survivors. Nocturnal dip in DBP was not seen in either survivors at 1 (p=0.177) and 6 months (p=0.434) or non-survivors at 1 (p=0.408) and at 6 months (p=0.081). Renal transplant patients did not exhibit nocturnal dipping of BP.

CONCLUSION

We conclude that, unlike survivors, there was worsening of 24 hour BP control in non-survivors. ABPM has a role in better management of total BP burden in CKD patients.

The pp67 mRNA assay in treatment and monitoring of cytomegalovirus disease in renal transplant patients in India

The present report describes use of nucleic acid sequence-based amplification (NASBA) technology to detect pp67 mRNA of cytomegalovirus (CMV) in transplant patients in India. In our experience, pp67 mRNA assay was an accurate, rapid, and effective diagnostic tool to detect active CMV disease in 40.7% (50/123) of symptomatic transplant cases. This assay also allowed us to monitor CMV therapy. As part of the immunosuppressive regimen mycophenolate mofetil was found to increase the risk of developing CMV disease. All positive cases with this assay were subjected to antiviral therapy, with complete remission of the disease. At our center CMV NASBA assay has become the gold standard for the diagnosis of CMV disease in transplant patients.

Optimising dialytic therapy

It is better to understand functions of kidneys, consequences of renal failure, aims of ideal replacement therapy and limitations of dialytic therapy as replacement therapy before discussing optimising dialytic therapy. Types of replacement therapy are as follows--haemodialysis, peritoneal dialysis and kidney transplantation. All patients of end stage renal disease require replacement therapy.