High prevalence of chronic kidney disease in a semi-urban population of Western India

BACKGROUND

Globally there is an increase in incidence of chronic kidney diseases (CKDs). Diabetes mellitus (DM), hypertension and stone diseases are the major risk factors for CKD. We organized kidney disease screening camps in a semi-urban population of Gujarat, India on the occasion of World Kidney Day (WKD).

METHODS

Voluntary participants from six towns were screened. Estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease formula and CKD was defined as an eGFR <60 mL/min/1.73 m(2) or albuminuria ≥1+. Urogenital ultrasonography was performed with emphasis on stone burden. Participants with known diabetes, stone diseases, hypertension, kidney/liver/cardiac disease, hepatitis, HIV, transplant recipients, pregnant women and those <18 years were excluded from the study.

RESULTS

Of the 2350 participants (1438 men), CKD was found in 20.93% and eGFR <60 mL/min/1.73 m(2) was noted in 8.29% of participants. The prevalence of CKD peaked after the seventh decade of life in both genders. There was no significant difference in the prevalence of CKD between coastal and non-coastal regions, however, obesity, hypertension and diabetes were more common in the coastal belt, whereas stone burden was greater in the non-coastal region.

CONCLUSIONS

The prevalence of CKD in a semi-urban apparently healthy Indian population was higher than the reported prevalence in developed countries. Significant differences between regions point to the need to evaluate and correctregion-specific risk factors.

Membranous Nephropathy With MPO-ANCA-Associated Crescentic GN

Introduction:

Antineutrophil cytoplasmic antibodies (ANCA)-associated glomerulonephritis (GN) is characterized by necrotizing and crescentic GN with paucity of immunoglobulin (Ig) and complement deposition, which is also known as pauci-immune crescentic GN. Membranous nephropathy (MN) is characterized by the formation of subepithelial immune deposit with resultant changes in glomerular basement membrane (GBM), most notably spike formation.

Case Presentation:

A 48-year-old man presented with marked proteinuria, hypoalbuminemia, and renal dysfunction with positive results for myeloperoxidase (MPO) and ANCA. Renal biopsy revealed crescents and thick GBM with subepithelial spikes along with IgG deposition on immunofluorescent staining. The condition was diagnosed as MN with MPO-ANCA-associated crescentic GN. He was treated with intravenous methylprednisolone and cyclophosphamide. After one-month follow-up, antibody level and renal function did not improve.

Conclusions:

Coexistence of MN with MPO-ANCA crescentic GN is very rare and should be managed aggressively.

Transplantation tolerance; myth or reality?

Implication for health policy/practice/research/medical education: Transplantation is now a well-accepted therapy for end organ failure. However the recipients are required to take life-long immunosuppression to prevent rejection. This leads to immunosuppression associated morbidity in the form of viral/ fungal/ bacterial infections in addition to causing financial burden on the system. Over a long run these patients are at high risk to develop malignancies.In spite of all these efforts, the graft is lost over 7-10 years to chronic graftattrition/ rejection. The only answer to this problem is "Transplant tolerance" which means stable allograft function while maintaining third party immuneresponse intact in absence of rejections on no immunosuppression. Since last 60 years transplanters across the globe are in search of this "Mackenna's gold". The following editorial discusses how far have we progressed in our search for the promised land of "Transplant Tolerance."

IgM nephropathy; can we still ignore it

CONTEXT

IgM nephropathy (IgMN) is a relatively less recognized clinico-immunopathological entity in the domain of glomerulonephritis , often thought to be a bridge between minimal change disease and focal segmental glomerulosclerosis.

EVIDENCE ACQUISITIONS

Directory of Open Access Journals (DOAJ), Google Scholar, Pubmed (NLM), LISTA (EBSCO) and Web of Science has been searched.

RESULTS

IgM nephropathy can present as nephritic syndrome or less commonly with subnephrotic proteinuria or rarely hematuria. About 30% patients respond to steroids whereas others are steroid dependent / resistant. They should be given a trial of Rituximab or stem cell therapy.

CONCLUSIONS

IgM nephropathy (IgMN) is an important and rather neglected pathology responsible for renal morbidity in children and adults in developing countries as compared to developed nations with incidence of 2-18.5% of native biopsies. Abnormal T-cell function with hyperfunctioning suppressor T-cells are believed to be responsible for this disease entity. Approximately one third of the patients are steroid responders where as the remaining two thirds are steroid resistant or dependent. Therapeutic trials including cell therapies targeting suppressor T-cells are required.

Dual kidney transplantation from expanded criteria deceased donors: Initial experience from single center

Aim:

To evaluate results of dual kidney transplantation from expanded criteria deceased donors.

Materials and Methods:

Between January 2000 and December 2009, 23 dual kidney transplantations were performed from expanded criteria deceased donors; 11 were from non-heart-beating donors and 12 from brain-dead heart-beating donors. All transplantations were performed in monolateral iliac fossa.

Results:

Two perioperative deaths occurred due to sepsis and multiorgan failure in non-heart-beating group, and one in brain dead group. One- and five-year graft and patient survival in recipients having organs from brain-death heart-beating group were 91.67%. In non-heart-beating group, 1- and 5-year graft survival was 65.45% and 81.82%, and 1- and 5-year patient survival was 43.64% and 61.36%, respectively.

Conclusion:

Dual kidney transplantation from expanded criteria brain dead donors has better graft and patient survival than from non-heart-beating donors.

Radiation dose-benefit analysis of hematopoietic stem cell grafting for tolerence induction across MHC barriers in living related donor renal allograft recipients

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Background: Donor specific immunologic tolerance protects an allograft from chronic rejection and allows discontinuation of chronic immunosuppressive therapy. Ahmedabad-tolerance induction protocol (A-TIP) allows grafting in living related donor (LRD) renal allograft recipients with persistent low-level MLHC. Present study aims to define of the ideal radiation dose needed for tolerance induction in patients undergoing A-TIP. Methods: 210 consecutive end stage renal disease patients recruited between May '05 through Mar '07 underwent renal transplantation (RTx) following A-TIP and negative Lymphocytotoxicity cross match (LCM). A-TIP includes (a) 2 DLI's (b) low intensity conditioning, and (c) HSC grafting.The conditioning regimen included fractionated low dose target specific radiation, cyclosporine, cyclophosphamide, anti T-cell a.b and treosulfan. All patients underwent subtotal lymphoid irradiation (STLI) targeting spleen, abdominal, iliac and inguinal lymph nodes, thoraco-lumbar vertebra and 75% of pelvis. Patients were randomized into 3 groups of 70 each: STLI 600, STLI 800, STLI 1000, corresponding to doses of 600cgy, 800cgy and 1000cgy delivered conventionally using 6MV/15MV photons. Unfractionated HSC procured from donor BM was administered into portal circulation, within 24 hours of achieving CD4+/CD8+ T cell count ≤ 10% of baseline. Donor specific cytotoxic antibodies were eliminated before RTx. Immunosuppression (ISp) was withdrawn 3–6 mo after RTx for patients with consistently positive chimerism. Tolerance - Robust (R), Prope (P) and Metastable (M) is defined as RT: Stable allograft function (fn.) for >100 days without ISp; PT: Early adequate, stable grafts fn. with no rejection episodes on minimum ISp; MT: Adequate graft fn. on ISp with single episode of steroid responsive ac. rejection. Results: See Table. Conclusions: The safe and effective dose for tolerance induction in LRD renal transplantation is 1000 cGy.

[Table: see text]

No significant financial relationships to disclose.