The environment and kidney health: challenges and opportunities

The accelerating environmental degradation as a result of modernisation and climate change is an urgent threat to human health. Environment change can impact kidney health in a variety of ways such as water scarcity, global heating and changing biodiversity. Ever increasing industrialization of health care has a large carbon footprint, with dialysis being a major contributor. There have been calls for all stakeholders to adopt a ‘one health approach’ and develop mitigation and adaptation strategies to combat this challenge. Because of its exquisite sensitivity to various elements of environment change, kidney health can be a risk marker and a therapeutic target for such interventions. In this narrative review, we discuss the various mechanisms through which environmental change is linked to kidney health and the ways that the global kidney health communities can respond to environmental change.

A Rare Cause of Breathlessness in a Patient on Hemodialysis

Patients suffering from end stage renal disease (ESRD) often present to the emergency with breathlessness, mostly due to fluid overload. We report a rare case of recurrent unilateral massive pleural effusion in an ESRD patient on maintenance hemodialysis (MHD). The patient was on MHD thrice weekly for the last 2 years with right internal jugular vein (IJV) tunneled cuffed catheter (TCC). Chylothorax was identified as the cause of recurrent pleural effusion which was due to superior vena cava stenosis (SVCO). It was managed successfully by balloon venoplasty of SVC and anticoagulation. SVCO is a rare but a serious complication in patients on long term indwelling dialysis catheters. Physicians involved in the care of dialysis patients must be aware about complications of long term dialysis catheters like central vein stenosis. A strong suspicion of chylothorax should be reserved for a patient with recurrent unilateral pleural effusion and long term dialysis catheters.

Impact of COVID-19 on maintenance haemodialysis patients: The Indian scenario

There is a lack of data describing the impact of the novel coronavirus 19 pandemic on the patients of chronic kidney disease stage V-dialysis (CKD V-D) from resource-limited countries. A growing body of literature describes an increased susceptibility of CKD V-D to COVID-19 with adverse outcomes in those with severe disease. In the current retrospective report, we elucidate the outcome in consecutive 37 CKD V-D patients with COVID-19 from two dialysis centres in Mumbai, India. Of the 37 patients included in the study, 56.7% of patients were asymptomatic or had mild disease and 27% presented with severe symptoms. The recovery rate was 63%, all those who presented with a severe disease succumbed to the infection. Thirty per cent of patients presented with an extended dialysis break due to various logistic and social issues. Though the overall clinical presentation and outcomes of this cohort from a limited resource setting mimic the global scenario, unique social and logistic issues are an additional burden to the patient, caregivers and the health-care facilities, which may worsen the outcomes in the future as the pandemic continues to spread.

Cryptococcosis masquerading as disseminated tuberculosis in a patient on chronic hemodialysis

Chronic hemodialysis (HD) recipients are nearly ten times more prone to fungal infections compared to the general population. However, infections such as cryptococcosis usually affect immunocompromised patients, unusual in otherwise immunocompetent patients. Here, we describe a unique case of cryptococcosis in a human immunodeficiency virus negative end-stage renal disease (ESRD) patient. A 26-year-old female patient, diagnosed with ESRD, on maintenance HD for the past six months, presented with pyrexia of unknown origin associated with cervical lymphadenopathy, biopsy of which showed granulomatous inflammation. The patient was initiated on anti-tubercular treatment but did not respond to treatment. A month later, she developed skin lesions; biopsy and culture from scrapings of the lesions were suggestive of infection with Cryptococcus neoformans. She responded to antifungal therapy very well, with a resolution of fever and skin lesions within a month. This is a unique case report, in which cryptococcosis mimicked tuberculosis in an otherwise immunocompetent patient with ESRD.

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.