Skip to main content
NCBI home page
Indian Journal of Nephrology logoLink to Indian Journal of Nephrology
. 2022 Dec;32(Suppl 1):S19–S166.

POSTER PRESENTATION

PMCID: PMC9997681
Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 1: STAT3 AND NFκB ACTIVATION IN RESPONSE TO IL-6 AMPLIFIER LOOP (IL-6+IL-17) ACTIVATION IN CHRONIC ANTIBODY-MEDIATED REJECTION IN PATIENTS TRANSPLANTED WITH RENAL ALLOGRAFTS WHEN PROLONGED IL-6 SECRETION OCCURS

Mantabya K Singh 1, Akhilesh Jaiswal 1, Mohit Rai 2, Vikas Agarwal 2, Durga P Misra 2, Narayan Prasad 1

BACKGROUND: IL-6 is a most important cytokine that plays a central role in the development of chronic inflammation. Recently, non-immune cells like fibroblast have been postulated to mediate chronic allograft rejection via activation of IL-6 amplifier loop (IL-6+IL-17) via NFκB and STAT3 signaling pathway.

AIM OF THE STUDY: We evaluated IL-6 amplifier loop activation by IL-6 and Il-17 in chronic antibody-mediated rejection (CABMR) in renal transplant recipient.

METHODS: Fibroblasts from grafted kidney from CABMR patients (n = 6) were cultured and stimulated with IL-6 (20 ng/ μl), IL-17 (50 ng/ μl), IL-6 plus IL-17 for 24 hours. Levels of IL-6, MCP-1, and CCL20 were estimated in culture supernatants by ELISA as marker of IL-6 amplifier loop activation. mRNA expression of IL-6, MCP1, CCL20, and SOCS3 genes were measured in the stimulated fibroblasts.

RESULTS: IL-6 and IL-17 synergistically induced more IL-6, CCL-20 & MCP-1 production from fibroblasts. Gene expression analysis of IL-6, MCP1, and CCL20 was significantly higher with synergistic activation of IL-6 and IL-17 as compared to either IL-6 or IL-17 alone, while SOCS3 gene expression was downregulated. Our results also suggested that IL-6 Amplifier loop activation induces the NFκB and STAT3 signalling pathway activation in the non-immune cells like fibroblast derived from CABMR patients. Additionally, concentrations of IL-6, CCL-20 & MCP-1 in sera were significantly higher in CABMR patients compared to non-rejection patients (p < 0.001)

CONCLUSIONS: In humans after kidney transplantation, IL-6 amplifier activation plays an active role in chronic rejection responses. Inhibition of IL-6 with Anti-IL-6 (Tocilizumab) and inhibition of IL-17 with Anti-IL-17 together reduces markers of tissue injury (IL-6, MCP1, CCL20) and rejection of allografts. So, IL-6 amplifier may be a therapeutic target for chronic transplant rejection.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 2: A NOVEL TECHNIQUE OF ACCESSING THE INACCESSIBLES-DEVANSH RAM TECHNIQUE

G Gireesh Reddy 1, CG Sreedhara 1, A Kishan 1, S Mythri 1, Aditya Shetty 1, Viswas 1, Seetha Mutalik 1, Gowri 1, S Ranjitha 1, H Haritha 1

BACKGROUND: Vascular Access is an essential component of the life-sustaining therapy in end-stage kidney disease patients relying on a sustained extracorporeal circulation for hemodialysis (HD) or hemodiafiltration (HDF) [1 2]. Indeed Vascular Access is often referred to as the lifeline or Achilles heel for a dialysis-dependent patient [3]. Vascular Access performance is a key factor to drive success or failure in all forms of extracorporeal renal replacement treatment [4]. Furthermore VA dysfunction or complication is the major cause of morbidity requiring interventional procedures. Exhausted central venous access is a potentially life-threatening situation for patients dependent on hemodialysis. If standard guidewire recanalization fails unconventional venous access or central venous needle recanalization can be considered but are often associated with higher rates of complications and/or dysfunction. Thoracic central venous obstruction (TCVO) resulting from venous wall thickening associated with de novo neointimal hyperplasia organized mural thrombus fibrosis or endoluminal obstruction is a common finding following repeated central venous catheter (CVC) insertions or prolonged use of catheters (1 2). Although the right internal jugular (RIJ) vein is the preferred anatomical location for CVC placement due to its ease of identification large diameter and direct path to the right atrium (3), the left internal jugular vein is often used for catheter placement when the RIJ is obstructed. Unfortunately the use of the left internal jugular vein can result in reduced rates of CVC blood flow and increased risk of venous obstruction due to the tortuous route and resultant increased vessel trauma (4 5).

AIM OF THE STUDY: 1. To report and describe Devansh Ram Technique a novel technique of accessing the chronically occluded central veins and utilize them for vascular access in end-stage renal disease patients with multiple vascular access failure and thoracic central venous obstruction (TCVO) 2. To assess the efficacy of Devansh Ram Technique in patients with thoracic central venous obstruction (TCVO) requiring central venous access (CVA).

METHODS: Patient demographics medical history comorbid conditions were documented at enrollment. Technical and adverse events were collected during the procedure and upon hospital discharge. Steps of the Devansh Ram Technique • Preparation of the patient • Identification of sweet spot (Proposed Occluded Segment of Vessel) by USG • Cannulation of the central venous system under ultrasound guidance bypassing the Occluded Venous Segment • Passage of the guidewire into the inferior vena cava • Serial dilatations of the vessel with PCNL Tissue dilators • Securing the vessel with a stiff guidewire • Insertion of the tunneled catheter

RESULTS: Mean time for accessing the occluded central vein and catheter insertion for the 41 patients who successfully completed the procedure was 24  ± 14.9 (range, 6—70) minutes. Mean fluoroscopy time was 8  ± 4.5 (range, 2.2—15.5) minutes. • 27 (60%) patients were males, 18 (40%) patients were females • 18 (40%) of the patients were on maintenance hemodialysis for less than a year. • 18 (40%) of the patients were of dialysis for 1 — 4 Years. • 9 (20%) of the patients were on dialysis for over 4 Years. • 42 (93.3%) Patients had peripheral vascular disease • 7 (15.6%) Patients had ischemic heart disease • 25 (55.6) Patients had diabetic nephropathy • 40 (91.1%) Patients had hypertension • 3 (6.7%) Patients had cerebral vascular accident • 31 (77.5%) Patients underwent Right IJ TCC insertion. • 6 (15%) Patients underwent Left IJ TCC insertion. • 19 (42%) Patients had primary access failure • 34 (78%) patients had secondary access failure • 73% of patients had history of HD Catheter for longer than 1 month duration. • 27% Patients had history of single HD catheter being in situ for > 2 months. • 33 Patients (75%) had functioning TCC on follow-up. • 6 patients were lost to follow-up. • 1 patient had TCC removed elsewhere due to CRBSI. • 5 patience expired— due to causes unrelated to TCC • only two patients underwent new AVF creation. • 8 of the Patients had history of CRBSI episodes. • On Four patients, we couldn’t access the central veins due to complete occlusion of SVC — Femoral TCC was inserted for them. • Two Patients developed hemoptysis during the procedure, which improved immediately on propping up the patient and hemodialysis. • On follow-up - 5 patients died due to unrelated causes.

CONCLUSIONS: We are 1st time reporting and describing this novel technique of accessing the thrombosed central veins under USG and fluoroscopic guidance • This technique had favorable outcomes with high technical success rate of 96% and was easily reproducible. • Devansh Ram Technique offers considerable hope to the patients with multiple vascular access failure and helps them to prolong their life by providing them with a long, sustainable, and efficient vascular access

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 3: THERAPEUTIC EFFICACY OF RESIN SORBENT BASED HEMOPERFUSION CARTRIDGE IN TREATING ACUTE POISONING CASES DUE TO LIPOPHILIC AND PARAQUAT POISONS IN A TERTIARY CARE CENTRE OF EASTERN INDIA

Alok Kumar Mohapatra 1, S K Parida 1, A Acharya 1, S B Rout 1, A Devi 1, R Gaude 1, V Vachhani 1, M Panda 1, L Sharma 1, S Devi 1, C Dash 1

BACKGROUND: The potential for an extracorporeal technique to enhance the elimination of a poison is largely determined by its physicochemical and pharmacokinetic properties. Water soluble poisons are cleared by most commonly available extracorporeal treatment such as hemodialysis (HD) and also by hemofiltration. Hence alternative extracorporeal modalities are needed for lipophilic poisons like Organophosphorus Benzodiazepines fish gallbladder poisoning. The classical example for poison in this category is Paraquat. With hemoperfusion (HP) especially with resin adsorbent containing columns clearance of lipophilic compounds is favored.

AIM OF THE STUDY: The objective of is to determine the clinical outcomes of acute poisoning (organophosphorus fish gallbladder and Paraquat poisoning) patients by using Resin Sorbent-Based Hemoperfusion Cartridge.

METHODS: This hospital-based study conducted from October 2019 to October 2021 in P.G. department of Nephrology and renal transplant SCBMCH Cuttack. Total 54 patients will be taken for study after consideration of exclusion and inclusion criteria. Baseline investigation (CBC RFT LFT ECG USG X-RAY CHEST CT THORAX PT INR) and clinical evaluation were done. Patient will be treated with standard treatment of poisoning and hemoperfusion

RESULTS: A total of 54 patients with three commonly encountered poisons in SCB Medical College and Hospital, Cuttack, such as Paraquat, Organophosphorus & fish gallbladder, were included in the study. The mean age of the Paraquat, Organophosphorus and fish gallbladder poisoned patients were 26Â ± 6.86 years with a median age of 23 years, 39Â ± 6.58 years with a median age of 38 years, and 34.9Â ± 7.84 years with a median age of 34.5 years respectively. Approximately 35%, 79%, & 60% of cases were males and 65%, 21%, & 40% were females with Paraquat, Organophosphorus and fish gallbladder poisons respectively. In this study, the total number of patients with Paraquat poisoning included was 20. Out of which, 19 patients died (95%) and 1 patient survived (5%). The total number of patients with Organophosphorus poisoning included was 24. Out of which, 5 patients died (20.8%) and 19 patients survived (79.2%). The total number of patients with fish gallbladder poisoning was 10. All the 10 patients survived (100%)

CONCLUSIONS: The current study showed that hemoperfusion is effective in improving the survival of 100% (n = 10) in fish gallbladder poison. Whereas the survival in patients with Organophosphorus poison using hemoperfusion is 79.2% (n = 24). Paraquat patients had the worst clinical outcome with the survival rate of 5% (n = 20), despite the intervention with hemoperfusion.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 4: ROLE OF RITUXIMAB IN MAINTAINING LONG TERM REMISSION OF IDIOPATHIC DIFFICULT TO TREAT CHILDHOOD ONSET NEPHROTIC SYNDROME

Arjun Ray 1, Arpita Raychaudhury 1

BACKGROUND: Idiopathic nephrotic syndrome is the most common chronic glomerular disease in children. At least 20% of children show frequent relapses and/or steroid dependence defined as complicated frequently relapsing/steroid-dependent nephrotic syndrome (FRNS/SDNS). Approximately 1–3% are resistant to steroids & other steroid sparing regimens defined as refractory steroid-resistant nephrotic syndrome (SRNS). The anti-CD20 monoclonal antibody rituximab (RTX) has been proposed as a rescue therapy for difficult-to-treat nephrotic syndrome (NS). We conducted a clinical trial to evaluate the efficacy & safety of fixed versus on demand RTX doses in children with difficult-to-treat NS.

AIM OF THE STUDY: The primary endpoint was the increase in median time to first relapse in maintenance over on-demand arm who has failed at least one steroid sparing agent & to compare the cumulative relapse free period between the two groups.

METHODS: Idiopathic CONS patients attending nephrology OPD at IPGMER were screened and divided into SDNS and secondary SRNS groups. Among them the maintenance or periodic group received 4+2+2 doses of RTX keeping in account baseline IgG levels who were compared with on-demand or rescue arm receiving RTX post-relapse followed up for next 1 yr 6 months period.

RESULTS: In the SDNS group, 39 patients were there in maintenance arm vs 35 in on demand arm. Mean time to remission after rituximab infusion was 3 months. Mean RTX doses in periodic arm was 6.3, way higher than 4.97 in rescue group. Total mean duration of remission was 14 months, maximum duration being 17 months in maintenance arm vs 11 months in relapse arm. 79.5% patients remaining in remission (70% in CR) were taken off steroids in the periodic RTX therapy arm. Steroid load was 2.88 gm in on-demand group, much more than 1.15 gm in periodic arm. There was a significant increase in mean time to first relapse, 13.8 months in maintenance vs 8.5 months in rescue therapy group. In the secondary SRNS group, 16 patients were there in maintenance arm vs 24 in on demand arm.58.4% showed evidence of steroid toxicity and 37.5% had growth failure at baseline in the on demand arm. Mean time to remission after rituximab infusion was 3.6 months. Mean RTX doses in periodic arm was 7.5, more than 4.75 in rescue group. Mean duration of remission was 13.38 months, with maximum duration amounting to 16 months in maintenance arm vs 9.92 months in relapse arm.42.5% patients remained in remission (35% in CR). Around 56.3% were taken off steroids in the periodic RTX therapy arm leading to total steroid load of 2.73 gm in on demand group, much more than 1.42 gm in periodic arm. There was an increase in mean time to first relapse, 14.25 months in maintenance vs 7.86 months in rescue therapy group. About 94% did not have any serious infections after RTX therapy, 25% had mild adverse reactions.

CONCLUSIONS: Maintenance therapy in our study could maintain long-term remission without other immune-suppressants, especially corticosteroids, thus could prevent the unwarranted side effect of prolonged steroid therapy. However, we cannot know for certain how long we should prolong the maintenance therapy. We conducted this study for a total duration of 18 months during which the maintenance cohort got supplemental RTX doses according to our institutional protocol at an interval of 6 months for 2 such courses after induction therapy. We suppose that maintenance therapy can be a good option to spare steroids for several months or years in patients with severe steroid toxicity. What we have successfully demonstrated that with periodic therapy, statistically significant time in remission was obtained, with increase in time to first relapse, along with a significant decrease in total steroid load but with a caveat that they required significant higher RTX doses. However we need a longer duration of study to adequately find out the nature of adverse effects of rituximab, which was beyond the scope of our study. What is the safe dose of rituximab will always remain an enigma at present, unless other long term studies are formulated.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 5: ACCIDENTAL METHANOL POISONING AT A TERTIARY CARE CENTRE OF NORTH INDIA: A RETROSPECTIVE OBSERVATIONAL STUDY

Noor Ahmad Lari 1, Mohd Aslam 1

BACKGROUND: Methanol poisoning is not uncommon in India especially in the rural areas and the victims often belong to the lower socio-economic strata. Several studies have demonstrated high morbidity and mortality in acute methanol poisoning including permanent blindness. Medical therapy initially followed by hemodialysis is often the treatment approach in such patients.

AIM OF THE STUDY: To study the symptomatology of Acute Methanol Poisoning along with Physical Examination findings as well as to study the trend of Arterial Blood Gas and other hematological and biochemical parameters before and after treatment.

METHODS: This was a Single-Center Retrospective Observational Case-series study of an accidental methanol poisoning involving 42 subjects at a tertiary care center in North India during May–June 2021. Patients were immediately prescribed hemodialysis upon arrival for three consecutive days.

RESULTS: 42 patients were included in the study, of which 2 died during the primary management itself. The rest of the 40 patients were given hemodialysis for 3 days consecutively. Nausea and vomiting were reported by 71.4% patients, while 61.9% reported abdominal pain, 66.7% complained of blurred vision. Drowsiness was observed in 52.4%. The average GCS of the patients was 13.62Â ± 1.61 (Median 15). Pupils were fixed and mid-dilated in 16.7% patients, sluggishly reacting in 47.6%, normal sized and normally reacting in 35.7%. Funduscopic examination was abnormal in 31% patients. The mean pH at presentation was 7.16Â ± 0.14, bicarbonate (HCO3) was 10.69Â ± 6.54 (Median 8.95), serum creatinine was 0.99Â ± 0.39 (Median 0.84), and blood urea nitrogen was 15.5Â ± 5.86 (Median 16). On an average, the patients received their first hemodialysis after 28.99Â ± 18.79 hours of consumption of methanol. After hemodialysis, there was a significant improvement in pH from admission [Median 7.19 (IQR 7.10-7.27)] to discharge [Median 7.28 (IQR 7.22-7.39)], (W = -3.65, P < 0.001). HCO3 on admission was 9.60 (5.23-17.48) while on discharge it was 26.70 (24.55-29.20) (W = -5.51, P < 0.001). HCO3 was found to be normal in 87.5% at discharge as opposed to 5% at admission which was significant. However, pH and BUN normalizing values were not statistically significant.

CONCLUSIONS: Methanol poisoning presents with gastrointestinal, visual, and neurological symptoms. Hemodialysis is very effective in preventing mortality from acute methanol poisoning as well as it results in significant improvement in biochemical parameters.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 6: CLINICO-RADIOLOGICAL PROFILE OF CENTRAL VENOUS STENOSIS IN PATIENTS ON MAINTENANCE HEMODIALYSIS

H Muralidhar 1, P K Bipi 1, Vishnu Dev 1, V N Unni 1

BACKGROUND: Central venous stenosis is a frequently observed complication in hemodialysis patients. There are only limited studies which have looked into the incidence association with patient characteristics or relationship with hemodialysis catheter placement

AIM OF THE STUDY: To study the incidence and clinico-radiological profile of central venous stenosis in maintenance hemodialysis patients

METHODS: Data was collected from electronic medical records. CT venogram findings were tabulated and analyzed. Patients with clinical features of central venous stenosis who underwent CT venogram were included. Observational retrospective study with a study duration of 1 year (January- December 2021); Sample size-27 patients.

RESULTS: Out of 27 patients, 23 were male (85%) and 23 were above 50 years of age (85%). Seventeen patients had type 2 Diabetes Mellitus (63%). Seventeen (63%) patients had a tunneled venous catheter; rest had AV fistula (37%). Thrombosis was seen in 16 patients (59%), rest of the patients had stenosis (41%). The most common vein involved was the right internal jugular vein (40%) followed by right/ left innominate vein (22% each) and left internal jugular vein (7%). Superior vena cava thrombus was seen in 6 patients (22%). The presenting symptoms were poor blood flow through the catheter in 18 patients (66%) and high venous pressures in 5 patients (18%). Average duration of the catheter days till appearance of symptoms was 1 year and 8 months. Ten patients underwent venoplasty with resolution of symptoms. None of the patients received anti-coagulation, although antiplatelets were used in 15 patients (55%).

CONCLUSIONS: Central venous stenosis is a frequently observed complication in hemodialysis patients. In our study, majority of the patients were male, elderly; Type 2 Diabetes Mellitus as an important risk factor. Tunneled venous catheter used for more than one year was associated with thrombosis. As the right internal jugular vein is commonly preferred for hemodialysis, it was the most common vein involved in our study. Successful venoplasty was done in 37% patients. None of the patients required anticoagulation. Our study emphasizes the need to do a CT venogram in patients with suspected central venous stenosis and the role of venoplasty as a definitive measure in the management of central venous stenosis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 7: COMPARATIVE ANALYSIS OF VARIOUS NUTRITIONAL TOOLS IN PROTEIN ENERGY WASTING IN CHRONIC KIDNEY DISEASE PATIENTS ON MAINTENANCE DIALYSIS AND ITS ASSOCIATED FACTORS IN A SUB URBAN TERTIARY CARE CENTER

Harish Sivagnanam 1

BACKGROUND: Protein Energy Wasting is associated with Chronic Kidney Disease. The prevalence varies among countries and dialysis centers (around 10–60%). It is associated with significant increase in All Cause Mortality and Morbidity in dialysis patients. There is no accepted definition available for PEW. The 2008 International Society of Renal Nutrition and Metabolism Readily Usable Criteria for PEW requires the need of multiple parameters to diagnose PEW. Hence various nutritional assessment tools and questionnaires have been developed aiming at rapid and effective diagnosis of PEW. However, various studies comparing the efficacy of various tools yield variable results. There is also a considerable lack of Indian data in this regard. Majority of the Indian Dialysis Centers have lack of advanced equipment like body composition monitoring and bioimpedance for nutritional assessment. So effective use of alternate nutritional tools is necessary to diagnose and consequently treat PEW in Indian CKD population.

AIM OF THE STUDY: To assess Protein Energy Wasting and its associated factors in Chronic Kidney Disease Patients on Maintenance Hemodialysis in our Center. To analyze the sensitivity specificity and validity of various tools to assess Protein Energy Wasting.

METHODS: Pre-designed, pre-tested interviewer administered semi-structured questionnaire for demographic and epidemiological data history of patients with dialysis requiring Chronic Kidney Disease • All patients undergoing maintenance hemodialysis for more than 3 months in our hospital through a permanent access (Avf/ perm cath) were included. Patients with acute infection malignancy on temporary access and who refused to sign an informed written consent were excluded. • Malnutrition universal screening tool is used for identification of patient at risk of malnutrition • Anthropometric measurements including height, weight, BMI, lean body mass, mid-upper arm circumference, waist–hip ratio at an interval of 2 months. All measures are taken post-dialysis • Dietary assessment is made by 24-hour dietary recall and 7-day dietary records on two separate occasions • Blood urea Serum creatinine levels Serum lipid profile Liver Function Test S. Albumin Complete hemogram before and after dialysis • The investigations are used to calculate values like Normalized Protein Catabolization Rate (nPCR) Urea Reduction Ratio (URR) Kt/V and creatinine index • Nutritional adequacy is graded by Subjective Global Assessment (SGA) Score Dialysis Malnutrition Score (DMS) Malnutritional Inflammatory Score (MIS). • Data analysis will be done using SPSS software.

RESULTS: A total of 146 patients were included in the study. The mean age of the population was 40.9 +_12.6, 71% were male and 24% had diabetes. The prevalence of Protein Energy Wasting was 56.8%. Protein Energy Wasting was significantly associated with Age, Socioeconomic Status, Mid-Upper Arm Circumference, Hospitalization Days, and Catheter days. The sensitivity and specificity of S. albumin, daily calorie intake, SGA, DMS, MIS, n PCR and Creatinine index were 71.1 and 69.9, 54.6 and 55.5,79.8 and 61.8, 80.7 and 61.9, 69.9 and 90.5, 95.2 and 57.1, 87.2 and 85.2 respectively. MIS had the best sensitivity and n PCR was more specific. Based on these data, an algorithm was devised for effective diagnosis of PEW with the tools at our disposal.

CONCLUSIONS: Protein Energy Wasting is highly prevalent in Indian CKD population and is associated with high morbidity and mortality. Current diagnosis of PEW may vary upon the tools used for assessment. There is lack of advanced equipment like Body Composition Monitor, Bio-impedance, Double X-ray emission densitometry in suburban and rural centers in India. However, combination of various assessment tools can help to diagnose and treat PEW in CKD dialysis population

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 8: ACUTE PANCREATITIS AFTER KIDNEY TRANSPLANTATION: WHAT ARE WE MISSING?

Abhijit S Chavan 1, Tushar A Dighe 1, Charan B Bale 1, Pavan Wakhare 1, Nilesh Shinde 1, Akshay R Kulkarni 1, Shreeharsh Godbole 1, Chetan Phadke 1, Anuja Makan 1, Atul Sajgure 1

BACKGROUND: Occurrence of acute pancreatitis (AP) after kidney transplantation immediately in the post-operative period is a rare complication. Development of acute pancreatitis in kidney transplant recipients has been reported attributed to various factors including immunosuppressant drugs, cholelithiasis, viral infections, hyperparathyroidism, etc.

AIM OF THE STUDY: To study various factors associated with acute pancreatitis in kidney transplant recipients in the post-operative period.

METHODS: We present a retrospective study of 5 patients who underwent living related kidney transplant in our institute and developed AP in the immediate post-operative period. Various factors including age, sex, time of occurrence and duration of symptoms, drugs used (induction agents, immunosuppression), laboratory investigations including CBC, liver and renal function tests, serum amylase, lipase, calcium, lipid profile, tacrolimus levels and ultrasonography were analyzed and studied.

RESULTS: All patients were of male gender with mean age of 43.5 ± 13.5 (range 31–58) years. All patients developed abdominal pain after 2nd post-operative day (POD) with significantly raised amylase and lipase levels on POD-3. Drug regimen for all patients included tacrolimus, mycophenolate sodium, and steroids with weight-based dosing. All patients had significantly higher serum tacrolimus trough levels (17.3 ± 5.1) done on POD-3. Clinical and lab parameters resolution of AP was seen with subsequent reduction of tacrolimus drug doses and supportive care.

CONCLUSIONS: Tacrolimus use may be associated with development of acute pancreatitis post-operatively in Kidney transplant recipients. A high index of suspicion for early diagnosis is necessary as AP can have an unusual presentation with lack of classical clinical and laboratory findings.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 9: BEDSIDE LUNG ULTRASOUND AND BIOIMPEDANCE SPECTROSCOPY FOR ASSESSMENT OF VOLUME STATUS IN CHRONIC KIDNEY DISEASE PATIENTS ON HEMODIALYSIS

Asheesh Malhotra 1, Rajan Isaac's 1, Timothy Rajamanickam 1

BACKGROUND: Fluid balance is important in patients with chronic kidney disease undergoing hemodialysis. •Overestimation of dry weight causes hypertension left ventricular hypertrophy and heart failure while underestimation is responsible for chronic dehydration leading to the risk of hypotension. Both complications have significant impact on the overall morbidity. •Dry weight of the patient is usually assessed by using clinical parameters (weight gain, edema, BP, JVP, etc.), biochemical parameters (BNP ANP), Bioimpedance Spectroscopy (BIS) IVC diameter and Collapsibility on ultrasound (VCI index), and Lung Comets on Ultrasound Chest.

AIM OF THE STUDY: To evaluate the feasibility of lung water measurement by chest ultrasound in hemodialysis patients. •To compare the lung water and body fluid volume status as assessed by Clinical Parameters Ultrasound Chest and Bioimpedance Spectroscopy (BIS).

METHODS: A cross-sectional study was conducted over a period of 6 months. Dry weight of the patient was assessed by the attending nephrologist based on clinical criteria such as: weight blood pressure presence of edema or vascular congestion. A longitudinal ultrasound scan of the chest was performed using MicroMaxx Ultrasound System with patient in supine position from second to fourth intercostal space of left hemi-thorax and second to fifth intercostal space of right hemi-thorax along parasternal midclavicular anterior axillary and midaxillary lines of each side in a total of 28 sectors. B-lines were defined as hyperechogenic linear artifact emerging from the pleural line up to the bottom of the screen. Pre- and post-dialysis comet score was determined by calculating the total B-lines in each sector. Bioimpedance spectroscopy using Bodystat QuadScan 4000 was performed. Pre- and post-dialysis total body water (TBW) intracellular water (ICW) extracellular water (ECW) and residual fluid overload (ECW pre-HD- ECW post-HD) were recorded.

RESULTS: We conducted 100 assessments on 34 patients presenting to the hospital for maintenance hemodialysis. The mean age of the study population was 54.3 + 11 years with a sex ratio (M/F) of 6:1. Mean systolic blood pressure was 141.1 + 19 mmHg, and diastolic blood pressure was 83 + 9.3 mmHg with 3 episodes of intradialytic hypotension. The mean dry weight was 59.8 + 10 Kg, and weight gain by clinical assessment was 2.1 + 1.5 Kg. Comet score assessed by ultrasound chest had a mean of 4.54 + 2.53 before dialysis and 1.73 Â ± 1.36 after dialysis. Residual fluid overload on Bio-impedance spectroscopy was 1.11 Â ± 0.85 liter. The residual fluid overload on Bio-impedance spectroscopy and lung ultrasound comet score after dialysis had a significant correlation (p value <0.0001). Of the 100 assessments, 40% had fluid overload after dialysis on Bio-impedance and 35% had lung congestion on ultrasound chest even after achieving euvolemia according to the dry weight assessed clinically.

CONCLUSIONS: Lung comets on ultrasound chest and residual volume on bio-impedance spectroscopy may precede the development of clinical sign and symptoms in a patient. Therefore, these methods are superior to clinical volume status assessment in chronic kidney disease patients on hemodialysis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 10: UTILITY OF RETEPLASE IN MANAGEMENT OF DYSFUNCTIONAL VASCULAR ACCESS IN INDIAN ESRD PATIENTS

Prasanna Bhat 1, Gireesh Reddy 1

BACKGROUND: In 2018, approximately 1 75 000 patients in the India were on maintenance Hemodialysis. Most of them were maintained with hemodialysis. Failure of hemodialysis access is a major cause of morbidity and hospitalization in these patients. Reliable vascular access is needed in order to provide long-term hemodialysis. Hemodialysis catheters and AV fistula are important means of vascular access for patients requiring hemodialysis as renal replacement therapy. Native arteriovenous fistula is the vascular access of choice but less than one-third of patients dialyze with fistula. In patients who have exhausted all other means of vascular access catheters may be the only remaining option. Dysfunctional catheter means the failure to attain and maintain an extracorporeal blood flow sufficient to perform hemodialysis without significantly lengthening treatment. National Kidney Foundation (NKF) recommends using urokinase to clear the thrombus before progressing to the more invasive and costly procedure of catheter replacement since urokinase was withdrawn from the market alternative thrombolytic agents are undergoing evaluation. Hence the United States Food and Drug Administration (FDA) issued a warning that the use of Streptokinase be avoided in the restoration of patency in intravenous catheters. Alteplase was approved by the food and drug administration for central venous catheter clearance but only limited data are available for Hemodialysis catheters. Also tenecteplase is being used in various studies involving Catheter Dysfunction. Reteplase is one of the 3rd-generation tissue plasminogen activator (TPA). Like Urokinase Reteplase initiates thrombolysis by catalyzing the cleavage of plasminogen generating plasmin that breaks down the fibrin matrix of the thrombus. Reteplase also has been shown to re-establish patency in Tunneled Cuffed Venous Catheters. There are studies wherein Reteplase has been compared to other TPA’s like Tenecteplase and Alteplase. But there is no data of utility of Reteplase for dysfunctional catheter and AV fistula in Indian & Subcontinental patients.

AIM OF THE STUDY: 1. To evaluate the efficacy of Reteplase in complete restoration of patency and flow in Dysfunctional Tunneled Cuffed Catheter 2. To evaluate the efficacy of different doses of Reteplase (2U and 0.5U each port) in flow restoration of Dysfunctional Tunneled Cuffed Catheter 3. To evaluate the efficacy of Reteplase (5U) in complete restoration of patency and flow in thrombosed Naïve AV fistula.

METHODS: This is an Open-label Ongoing Prospective Observational Study which is being conducted from 24 June 2022 till date of abstract submission. All hemodialysis patients at Institute of NephroUrology Bangalore center who had had Dysfunctional Tunneled Cuffed Catheter and Thrombosed AV fistula were involved. Around 17 patients had dual-lumen cuffed Tunneled dialysis catheters and 3 had AV fistula. Among catheter dysfunction cases 2 U Reteplase with 1 ml of 1: 5000U in each catheter lumen (total dose 4 U) in first 4 patients and 0.5U Reteplase with 1 ml of 1: 5000U in each catheter lumen (total dose 1 U) in next 12 patient of catheter dysfunction was used. Among the 3 AV fistula thrombosis cases which underwent thrombolysis with 5U Reteplase with 1 ml of 5000U Unfractionated Heparin. Among these 2 underwent thrombolysis post-angioplasty. And in other 1 patient Reteplase was utilized for lyse and wait technique with dwell of 40 min.

RESULTS: Among 17 catheter dysfunction cases which underwent thrombolysis with Reteplase, 100% patients had restored complete patency of catheter and underwent further Hemodialysis sessions without any flow issues. Among 3 cases of AV fistula thrombosis, with both methods of thrombolysis (one was with dwell time and rest 2 during angioplasty flushing of thrombolytic technique). All had successful restoration of patency (100%). Around 2 patients had recurrence of catheter dysfunction one among 2U Reteplase group and another of 0.5U Reteplase group. Both underwent successful thrombolysis with 0.5U Reteplase. There were no treatment-associated adverse events reported during the study period.

CONCLUSIONS: Reteplase at 0.5 U/port and 2 U/port is equally efficacious thrombolytic and very cost effective in cases of dysfunctional catheter even at lower dose. Reteplase at 5U dose was effective in AV fistula thrombolysis. And it was seen across both methods with or without dwell time of 40 min. Hence, Reteplase can be used as a preferred one for dysfunctional accesses in comparison to urokinase, tenecteplase, or alteplase. Ours is the first Asian (Indian study) looking at the utility of Reteplase for dysfunctional vascular access.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 11: HIFS AND BUTS: A NETWORK META-ANALYSIS OF HIF-PH INHIBITORS & ESAS IN NON-DIALYSIS DEPENDENT CKD PATIENTS WITH ANEMIA COMPARING THEIR SAFETY AND EFFICACY

Sandesh Warudkar 1

BACKGROUND: Hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) are a new class of oral medicines for the management of anemia in CKD patients. These agents are found to be efficacious in the management of renal anemia; however, safety is still under scrutiny. While ESAs (Erythropoietin stimulating agents) are available since long with a well-established clinical profile.

AIM OF THE STUDY: This network meta-analysis aimed to compare the safety and efficacy of HIF-PHI vs ESA in CKD patients with anemia not undergoing dialysis.

METHODS: An electronic database search was carried out in EBM (Evidence Based Medicine) Reviews Cochrane Library and PubMed from inception to July 2022 for phase III clinical trials comparing six different HIF-PHIs and ESA for treating anemia in non-dialysis-dependent (NDD) CKD patients. The outcomes included the serious adverse events (SAEs) and change in hemoglobin (Hb) levels.

RESULTS: Total 163 records were identified out of which 6 studies involving a total of 6847 patients were eligible for analysis. Compared to ESA, all HIF-PHIs increased risk for SAEs (daprodustat of RR, 1.21[95% CI, 0.825—1.77]; desidustat, 1.38[95% CI, 0.695—2.76]; enarodustat, 1.29 [95% CI, 0.568—3.02]; molidustat, 1.02[95% CI, 0.585—1.74]; roxadustat, 1.29 [95% CI, 0.674—2.57] and vadadustat, 1.01[95% CI, 0.693—1.47]) although these differences were statistically non-significant. When change in Hb was analyzed, there was no statistically significant difference between the two groups. The mean difference in change in HB with various HIFs as compared to ESA were: daprodustat (MD: 0.0796, 95% CI â€'0.676—0.838), desidustat (MD: 0.120, 95% CI: â€'0.626—0.883), enarodustat (MD: -0.600, 95% CI: â€'1.36—0.157), molidustat (MD: -0.309, 95% CI: â€'1.07—0.449), roxadustat (MD: -0.0702, 95% CI: â€'0.831—0.692) and vadadustat (MD: -0.0402, 95% CI: â€'0.802—0.720).

CONCLUSIONS: In terms of safety, HIF PHIs were associated with more SAEs compared to ESA although these differences are not statistically significant. Comparing efficacy, HIF-PHIs and ESA both effectively increase Hb level in NDD-CKD patients without any significant difference. Results of our network meta-analysis suggest the need for larger and long-term studies comparing HIF-PHIs with ESAs to have better understanding of their comparative efficacy and safety profiles.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 12: A CASE OF MEMBRANOUS NEPHROPATHY (?) STRONTIUM ASSOCIATED

Prabhjot Kaur 1, Arun Prabhahar 1, Vinod Kumar 1, Ashwani Kumar 1, Ritambhra Nada 1, Harbir S Kohli 1, Raja Ramachandran 1

BACKGROUND: Primary Membranous Nephropathy (PMN) an autoimmune disease is a well-identified consequence of heavy metal exposure especially mercury cadmium lead and chromium. Strontium (Sr2+) the 38th element on the periodic table is an essential element for bone strengthening. A single report highlights Sr2+ nephrotoxic and immunomodulatory potential. Here we report an interesting case of MN associated with Sr2+ exposure.

AIM OF THE STUDY: To study the association of membranous nephropathy with strontium

METHODS: An Indian male patient presented to the Nephrology clinic at PGIMER Chandigarh with complaints of pedal edema and frothuria of 1-month duration and his preliminary investigations revealed proteinuria. He has been taking two complementary and alternative medicine (CAM) powders for one and a half months before his presentation. The investigation obtained was biochemical analysis from the hospital laboratory and metal analysis (serum plasma urine and medications). Serum anti-PLA2R antibody levels were detected using ELISA and IIFT using a Euroimmune ELISA kit in LÃübeck Germany. We evaluated the kidney biopsy by light microscopy (LM) immunofluorescence (IF) and electron microscopy. Inductively Coupled Plasma Mass Spectrometry (ICP-MS) reported metal analysis in serum plasma urine and Ayurvedic powders.

RESULTS: A 19-year-old male had proteinuria of 10.8 g/day and serum creatinine of 0.6 mg/dl after consuming 10 g/day of CAM powder for one and a half months. Serum and biopsy tested positive for the PLA2R autoantibodies and enhanced staining in glomeruli. The LM revealed thickening of the glomerular basement membrane, and the IF findings showed granular deposits along the glomerular basement membrane for IgG (3+), IgM (1+), Kappa (2+), and Lambda (2+). There was no mesangial proliferation or hypercellularity. The findings were consistent with a diagnosis of PLA2R-related primary membranous glomerulonephritis. Metal analysis detected an increased concentration of Sr2+ in serum (3.30 mg/L), plasma (6.70 mg/L), urine (11.00 mg/L), and the CAM medicine (powders) (A;20.3 mg/L & B; 18.5 mg/L). After withdrawing the powders, the patient was started on Losartan, Atorvastatin, and Torsemide for edema. At three months of follow-up, the proteinuria was 0.23 g/day, and serum creatinine was 0.54 mg/dl. At ten months, a repeated Sr2+ levels decreased as in serum (0.30 mg/L), plasma (0.31 mg/L), and urine (0.81 mg/L).

CONCLUSIONS: The report depicts an under-recognized yet reversible association of Sr2+ with PMN. An inverse and exonerating effect of Sr2+ level was recorded, which needs validation with appropriate laboratory experiments.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 13: EFFECT OF CHOLECALCIFEROL ON IMMUNE AND VASCULAR FUNCTION IN CHRONIC KIDNEY DISEASE

Kajal Kamboj 1, Aruna Pariki 1, Manphool Singhal 1, Vivek Kumar 1, Ashok Kumar Yadav 1, Vivekanand Jha 1

BACKGROUND: Vitamin D deficiency is common in chronic kidney disease (CKD) and short-term studies have shown beneficial effect of vitamin D supplementation on vascular function in CKD.

AIM OF THE STUDY: In this study, we investigated the effect of cholecalciferol supplementation on vascular and immune function in non-diabetic early stage CKD subjects.

METHODS: In this ongoing pre-post-study non-diabetic CKD subjects with eGFR 15-60 ml/min/1.73 m2 and serum 25(OH) D levels <20 ng/ml are being enrolled. Participants receive 300000 IU of cholecalciferol at baseline and at 8 weeks. Clinical and laboratory assessments were done at baseline (before intervention) and 16 weeks. Primary outcome is change in circulating T cell subsets (Th1 Th2 Th17 and Treg). Secondary outcomes are changes in flow mediated dilatation (FMD) pulse wave velocity (PWV) vitamin D responsive genes mRNA expression (cathelicidin VDR Cyp27b1 TLR9 IL-10).

RESULTS: 40 patients have been enrolled till date. We present data of 27 participants who have completed 16-week follow-up. Mean age was 47.37 Â ± 13.44 years, 60% being males. 25 (OH) D levels increased at 16 weeks (15.22 Â ± 13.16 ng/ml vs 41.17 Â ± 14.72 ng/ml, p < 0.001). Treatment with cholecalciferol significantly increased Th2 cell population (CD3+CD4+IL4+, 11.20 Â ± 12.64% at baseline vs 26.36 Â ± 22.14% at follow-up, p = 0.002); and Th17 cell population (CD3+CD4+IL17+, 6.05Â ± 7.00% at baseline vs 8.54 Â ± 7.88% at follow-up, p = 0.03). There was no change in Th1 and Treg cell population after cholecalciferol treatment. Further, cholecalciferol supplementation significantly increased the mRNA expression of vitamin D responsive genes at follow-up (cathelicidin; 7 fold, IL-10; 12.5 fold, VDR; 9.5 fold; and Cyp27b1 12 fold).

CONCLUSIONS: Cholecalciferol supplementation increased expression of vitamin D responsive genes, changes T-cell phenotype to Th2 and Th17 in non-diabetic, vitamin D-deficient CKD patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 14: A RANDOMIZED CONTROLLED TRIAL COMPARING ONCE-A-DAY INSULIN GLARGINE VERSUS NEUTRAL PROTAMINE HAGEDORN (NPH) THERAPY IN POST-TRANSPLANT DIABETES MELLITUS

Abhilash Chandra Nigam 1, S N Rao 1

BACKGROUND: The management of insulin therapy against post-transplant diabetes mellitus (PTDM) is important for better graft survival and overall patient outcome. There are scarce data regarding the role of different type of insulins in this regard.

AIM OF THE STUDY: To compare insulin glargine with NPH for blood sugar control in PTDM patients

METHODS: Renal transplant recipients with PTDM of age ≥18 years visiting the Nephrology OPD were included in the study. Patients taking hypoglycemic agents before transplantation were excluded from this study. If patients had a glycosylated hemoglobin level between 7-9% then they were randomly assigned either to receive insulin glargine once daily or to NPH once or twice daily for 3 more months. Other oral hypoglycemic agents were continued in the same dose.

RESULTS: After applying exclusion criteria, out of 62 PTDM patients 28 were included in the study. 14 PTDM patients were treated with glargine, whereas 14 PTDM patients with NPH. A better hemoglobin A1c (HbA1c) level was seen in the glargine vs. NPH group (6.76  ±  0.44 vs. 7.56  ±  0.79, p-value 0.043). Our analysis revealed 14 episodes of hypoglycemia in glargine-treated patients compared to 5 in NPH-treated patients (p = 0.043). 11 out of 19 hypoglycemic episodes were nocturnal (57.9%). Analysis revealed that the doses of routine immunosuppressants and oral hypoglycemic agents were equivalent in both groups. The odds ratio for hypoglycemia with glargine compared to NPH was 1.224 (95% CI, 0.826-1.548).

CONCLUSIONS: The study shows better blood sugar control with glargine than with NPH. However, it carries a risk of more hypoglycemic episodes particularly nocturnal.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 15: NUTRITIONAL ASSESSMENT IN HAEMODIALYSIS PATIENTS USING MALNUTRITION UNIVERSAL SCREENING TOOL (MUST) - A PROSPECTIVE COHORT STUDY WITH 42 MONTHS FOLLOW UP

Sushmita Goswami 1, Avijit Chaki 1, Dayanath Mishra 1

BACKGROUND: Malnutrition is an important predictor of mortality in hemodialysis patients. The malnutrition universal screening tool (MUST) score is a simple and easy tool to assess nutrition risk derived from parameters routinely noted in dialysis units.

AIM OF THE STUDY: To determine the prevalence of malnutrition using the Malnutrition Universal Screening Tool (MUST) score in patients on hemodialysis for greater than 2 years with stabilized Fluid status Hypertension Diabetes and Anaemia and to determine their relative risk for mortality during a 42 month follow-up period

METHODS: Of 265 incident patients as on January 2019, on dialysis 71 patients were included who met the inclusion criteria were assessed for prevalence of malnutrition risk with MUST score and were followed till July 2022 with mortality as an endpoint.

RESULTS: Prevalence of malnutrition risk was scored as low 0 (58/71. 81.69%); moderate 1- (8/71. 11.25%) and severe -> 2 (5/71.7.04%). These patients were followed for 42 months or until death. Relative risk for mortality at the end of the study period was higher in the moderate and severe risk groups combined (11/13; 84.6% %, RR 1.4872; 0.95% CI 1.0774 -2.0528) and independently in the moderate (7/8; 87.5% RR 1.5623 95% CI 1.1325—2.1553) and severe groups (4/5- 80% RR 1.4061 CI 0.8595 -2.3002) than in the low-risk group (33/58; 56%).

CONCLUSIONS: The mortality in patients with moderate /severe malnutrition is greater than in the mild group as assessed by using Malnutrition Universal Screening Tool (MUST) score at the end of 42-month follow-up in hemodialysis patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 16: CIRCULATING MICROPARTICLES MONOCYTE ACTIVATION AND RENAL INJURY MARKERS IN IGAN

Snigdha Pratap Singh 1, Shubhi Kamthan 1, Narayan Prasad 1, Vikas Agarwal 1, Vinita Agrawal 1

BACKGROUND: Macrophages contribute to renal injury by a variety of mechanisms. CD163 a M2-macrophage marker has been shown to be associated with glomerular inflammation and renal fibrosis. MCP-1 is a strong chemotactic factor for monocytes while CTGF has role in chemotaxis of macrophages and profibrotic activity. KIM-1 renal injury marker enhances MCP-1 production. Microparticles (MPs) originate from cells on activation and injury.

AIM OF THE STUDY: We performed this study to quantify microparticles in IgAN and immunophenotype them as well as correlate it with other parameters of monocyte activation- urinary soluble CD163 (sCD163) MCP-1 CTGF and KIM-1.

METHODS: Twenty-five patients of IgAN diagnosed on histology and classified according to Oxford classification (MEST-C score) were included. Five age and sex-matched healthy controls were also included. Plasma MMPs (AnnexinV+/CD14+) and PMPs (AnnexinV+/CD42a+) were quantified by flow cytometry and estimated as a % of total MPs which were quantified using Trucount tube on flow cytometry Urinary sCD163 MCP-1 CTGF and KIM-1 levels were estimated by ELISA.

RESULTS: The mean age of patients of IgAN was 33Â ± 8 years, and sixteen were males. Mean level of circulating MPs in IgAN and healthy were 3.4 x 105/Âμl and 9.2 x 103/Âμl, respectively. The MMPs in IgAN and healthy formed 46% and 21% of the total MPs. The PMPs were 36% and 22% of total MPs in IgAN and healthy, respectively. MMPs negatively correlated with eGFR and endocapillary hypercellularity. PMPs correlated significantly with presence of endocapillary hypercellularity and mesangial hypercellularity. Levels of urinary sCD163, MCP-1, CTGF, and KIM-1 were significantly elevated in IgAN as compared to healthy controls. All the urinary markers showed positive correlation.

CONCLUSIONS: We found monocyte activation in IgAN. The MMPs, PMPs, and urinary sCD163 correlated with the severity of glomerular injury. Our findings suggest that in IgAN, urinary sCD163 may act as non-invasive biomarker in assessing the severity of glomerular injury and progression of disease.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 17: MONOCYTE DERIVED MICROPARTICLES AND MACROPHAGE TISSUE INFILTRATION IN ANTIBODY-MEDIATED RENAL ALLOGRAFT REJECTION

Shubhi Kamthan 1, Snigdha 1, Narayan Prasad 1, Vikas Agarwal 1, Vinita Agrawal 1

BACKGROUND: Macrophages contribute to both acute and chronic renal allograft injury. M2 macrophages are alternatively activated by exposure to certain cytokines as compared to M1 macrophages that are classically activated. CD163 is a marker of M2 macrophages.

AIM OF THE STUDY: To evaluate the degree of M2 macrophage infiltration in antibody-mediated rejection (ABMR). Urinary soluble CD163 total as well as monocyte derived microparticles were estimated to analyze their role as a non-invasive biomarker for macrophage infiltration in renal allografts

METHODS: The study included twenty patients presenting with renal allograft dysfunction and having a renal allograft biopsy. Ten patients were diagnosed as ABMR and ten as no evidence of rejection (NER) on a graft biopsy. Immunohistochemistry for CD163 (clone-EP324) was performed on renal allograft biopsies. Quantitative analysis of macrophage infiltration in glomeruli and tubulointerstitial compartment was performed using 40x objective. Urinary sCD163 level was estimated by ELISA as per manufacturer’s protocol and monocyte derived microparticles were quantified as PE-CD14+/APC-AV+ by flow cytometry.

RESULTS: All patients were males with mean age of 33.8Â ± 9 yrs. Graft biopsies with ABMR had higher infiltration (35.8Â ± 34.7/10glomeruli) of CD163+ macrophages in glomeruli as compared to NER (3.9Â ± 3.6/10glomeruli). The tubulointerstitial CD163+cells per 10hpf was slightly higher in ABMR (100.8Â ± 87.2) than NER (92.3Â ± 87.4). The mean level of urinary sCD163 in patients with ABMR was 1.48Â ± 1.2 ng/ml, and it was not detected in NER. MMPs were also elevated in ABMR with a mean of 26% of the total MPs (1.82 x 104) as compared to NER 20% of total MPs (1.4 x 104) and healthy controls 14% of total MPs (0.67 x 104). The degree of macrophage infiltration significantly correlated with urinary sCD163 levels (r = 0.886, p = 0.045). Urinary sCD163 level was also associated with total microparticles (r = 0.833, p = 0.003) as well as monocyte derived microparticles (r = 0.662, p = 0.039).

CONCLUSIONS: We found significantly increased CD163+ M2 macrophage glomerular infiltration and elevated urinary sCD163 levels along with circulating microparticles in ABMR. Further study is required to understand the prognostic significance of macrophage infiltration in ABMR.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 18: ASSESSMENT OF QUALITY OF LIFE (QOL) USING SF - 36 QUESTIONNAIRE IN PATIENTS ON MAINTENANCE HEMODIALYSIS

Kudithi Soundarya 1, Manjusha Yadla 1

BACKGROUND: Chronic kidney disease is a global public health problem due to rapid rise of risk factors such as Diabetes and Hypertension. CKD has severe impact on Quality of life (QoL). CKD negatively affects physical and psychosocial aspects of patients there by affecting QoL of both patients and their families.

AIM OF THE STUDY: To assess the factors affecting Quality of life (QoL) in maintenance hemodialysis patients using SF36 questionnaire.

METHODS: Study was done prospectively to assess the physical and mental component status using SF 36 questionnaire. Patients undergoing maintenance hemodialysis in Gandhi hub and spoke centers were included in study. These patients were given SF36 health survey questionnaire. Hub and spoke center patients were contacted telephonically and through Google Meet. Physical functioning role limitation due to physical health role limitation due to emotional problems energy emotional well-being social functioning pain general health and health change were assessed.

RESULTS: Total patients included in the study was 429. Males were 69%, females were 31% in study group. Majority of subjects were in the fifth decade (33.3%). Hypertension was present in 77% of patients, diabetes in 43% and Left ventricular dysfunction in 29%. Majority of patients had dialysis vintage of around 3 years. Patients on maintenance hemodialysis has statistically significant low SF- 36 scores. As dialysis vintage increases, there is significant decrease in mean scores of QoL parameters. There was significant negative correlation between age and QoL parameters. There was no significant difference in mean QoL scores with respect to gender. There was no significant difference in mean QoL scores between HTN and non-HTN subjects. Patients of diabetes, cardiovascular involvement had poor physical functioning scores. There was significant correlation between hemoglobin and physical functioning scores. There was no significant correlation between serum albumin, serum creatinine, and QOL parameters.

CONCLUSIONS: 1) Mean age of patients in the study was 44 +/- 8 years. 2) Male : Female ratio was 2 : 1 3) Patients with longer dialysis vintage has statistically significant low SF -36 scores. 4) There was significant negative correlation between age and QoL parameters. As age increases, SF- 36 scores decreases. 5) Patients with diabetes mellitus and cardiovascular involvement have poor physical functioning scores. 6) There was significant correlation between hemoglobin and physical functioning scores.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 19: EVALUATION OF BONE HEALTH AMONG KIDNEY TRANSPLANT RECIPIENTS IN INDIA €” A PROSPECTIVE OBSERVATIONAL COHORT STUDY FROM SOUTH INDIA

M Selvin Sundar Raj 1, Anna T Valson 1, Kripa E Cherian 1, Nitin Kapoor 1, Athul Thomas 1, Jeethu Joseph Eapen 1, Elenjickal Elias John 1, Suceena Alexander 1, Vinoi George David 1, Santosh Varughese 1, Thomas V Paul 1

BACKGROUND: There is a paucity of studies describing trabecular bone score (TBS) and bone mineral density (BMD) in kidney transplant (KT) recipients from India.

AIM OF THE STUDY: The aims of the study are to determine the prevalence of low BMD and TBS at the time of KT 3 and 12 months post-KT and to compare mean BMD TBS hip structural analysis (HSA) bone turnover markers at pre- and 12 months post-KT.

METHODS: This prospective observational study was conducted at a South Indian tertiary hospital in 2019-2022. Clinical biochemical parameters including bone turnover markers (P1NP CTX) and dual-energy X-ray absorptiometry (DXA) for BMD/TBS and hip structural analysis (HSA) were measured pre-KT 3 months and 12 months post-KT. Fractures were calculated by densitometric vertebral fracture assessment (VFA).

RESULTS: A total of 53 KT recipients (90.6% living related) were included in the study after informed consent. The mean age was 33.9 ± 10.4 years, mean BMI was 20.97 ± 3.18 kg/m2, 71.7% were males, and 11.5% had a history of pre-KT steroid use. Baseline fractures pre-KT as assessed by VFA were seen in four patients (7.5%). There was statistically significant decrease in phosphorous, PTH, bone turnover markers noted till 12 months post-KT. Mean BMD LS spine and HSA variables continue to decline till 3 months but stabilize at 12 months post-KT. However, TBS continues to decline till 12 months post-KT. There was no statistical difference seen in proportions of low TBS (<1.2) and osteoporosis (BMD Z score ≤ -2) at hip, neck, lumbar spine and forearm pre-KT, 3- and 12-months post-KT respectively. New onset fractures by VFA were seen in 2 (3.7%) at 3 months and 1 patient (2.3%) at 12 months post-KT. Baseline hip BMD quartiles were compared with means of BMD and TBS at 1 year which was statistically significant.

CONCLUSIONS: TBS and BMD of the spine significantly decrease mainly in the early post-KT period suggesting the effect of immunosuppressants on the bone despite significant improvement in kidney function post-transplant. This reduction is accompanied by a fall in markers of both bone formation and bone resorption. Baseline values pre-KT predetermines the bone health post-KT at least till 1-year post-KT.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 20: RIGHT ATRIAL CLOT IN LONG-STANDING TUNNELED DIALYSIS CATHETERS - A CASE SERIES

Sneha Lute 1, Ayan Dey 1, Rasika Sirsat 1, Mahesh Prasad 1, Alan Almeida 1

BACKGROUND: Catheter-related right atrial thrombus (CRAT) is well-known albeit under-reported and life threatening complication of dialysis catheters. While the traditional approach mandates catheter exchange/removal it is fraught with complications. Hence novel methods of management of CRAT must be explored.. We report a case series of CRAT over the past 5 years and enumerate various management strategies both invasive and non-invasive.

AIM OF THE STUDY: To study the clinical presentation causes and various management strategies of CRAT in hemodialysis patients.

METHODS: Medical records of patients who underwent outpatient hemodialysis at PD Hinduja Hospital were analyzed. Patients who had transthoracic echocardiography (TTE) proven CRAT were included. Clinical presentation management strategies success of management strategies based on echocardiographic follow-up access outcomes and patient outcomes were analyzed. Possible causes of formation of CRAT were also elicited. The data was entered into MS excel sheets and analysis performed. Results for Quantitative Variables were expressed as mean ( ± SD) and median [range]. Results for Qualitative Variables were expressed as frequency and percentages. For categorized variables Pearson’s chi-square test or Fisher’s exact test were used. Software used was “R software version 3.5.2â€

RESULTS: 7 out of the 8 patients identified with CRAT had right-sided perm cath. Heparin was the anticoagulant and locking solution. Mean age was 53.2 years (+ 17.3 years) with 62.5% being females. Commonest presentation was fever (100%). Catheter type was similar in all the patients. No intradialytic clotting episodes were encountered prior to CRAT but flow issues were noted (62.5%). 4/8 patients needed catheter manipulation prior with 2 needing fibrin sheath disruption and catheter exchange. One patient needed TEE confirmation for CRAT. Mean size of the masses was 2.3 cm x 1.8 cm. One patient presented with three RA masses. Tip of the catheter was the commonest position. 50% of the patients had concurrent fungal sepsis (trichospora in 25%) followed by staphylococci and streptococcal growth. The commonest management strategy was systemic anticoagulation with heparin followed by oral anticoagulants [warfarin (37.5%) or apixaban (37.5%)]. Thrombolysis with alteplase was done in 25% of the patients. Clot size reduction was achieved in all patients. Three patients underwent open heart surgery with clot retrieval. Mortality was 25% in the cohort.

CONCLUSIONS: This study throws light on the important issue of CRAT. Higher incidence of fungal infection was noted. All patients had echocardiography-proven improvement in clot size with thrombolysis and/or systemic anticoagulation. Mortality and morbidity remain high, and further studies are warranted.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 21: A STUDY OF LONG-TERM OUTCOME OF MYCOPHENOLATE DOSE MODULATION IN RENAL ALLOGRAFT RECIPIENTS WITH SARS-COV2 INFECTION DURING COVID-19 PANDEMIC

Jeyakumar Meyyappan 1, D S Bhadauria 1, V Vamsidhar 1, N Prasad 1, A Kaul 1, M R Patel 1, M R Behera 1, R S Kushwaha 1, M Yachha 1, M R Behera 1

BACKGROUND: A significant reduction of acute rejection rates was observed after using Mycophenolate mofetil (MMF) in renal transplant recipients (RTR). However side-effects like hematological and gastrointestinal intolerance often occur when MMF is used in routine doses. MMF dose reduction is required during its side-effects or coexisting infection in RTR. The outcome of MMF dose modulation in RTR is not well established

AIM OF THE STUDY: COVID-19 pandemic has given an opportunity to study the effect of MMF dose modulation on graft function as large number of RTR who had COVID-19 received MMF dose reduction or discontinuation. This study's objective was to determine whether MMF dose reduction or discontinuation was associated with the effect on allograft function after renal transplantation. We included all RTR who had an infection with SARS-CoV2 and received MMF dose reduction or discontinuation

METHODS: We prospectively collected data of renal transplant recipients developing COVID-19 infection during the first and second covid waves. Management including decision on admission immunosuppression modulation antibiotics were done based on clinician’s discretion subject to logistics and the prevailing guidelines by the ISOT. All patients were followed up for minimum 15 months for graft dysfunction biopsy rate biopsy-proven acute rejection (BPAR). The effect of immunosuppression modulation - MMF cessation (Group A) Vs MMF reduction/no manipulation (Group B) and its bearing on the incidence of rejection and was compared. Additional factors such as follow — up sub therapeutic CNI levels development of DSA (when done) steroid increment were studied regression model. Kaplan — Meier survival curves for 24 months drawn.

RESULTS: Among 251 renal transplant patients with SARS-CoV2 infection, 38 patients died during Index admission. 45 patients have not completed for 15 months. 168 patients completed 15 month follow — up. Among them, anti-metabolite were reduced in 115 (68.5%), stopped in 42 (25%), not manipulated in 5 (3%) and 6 patients were not on anti-metabolites and hence excluded from present analysis. Of the 162 patients, MMF had been stopped for 2 weeks or until presumed clinical recovery in 42 patients (Group A) and the rest in 120 patients (Group B). Mean age was 41.18 (ï' ± 12.8), and 75.6% had mild COVID. Median duration of follow-up was 18 months (14q1-22q3 months). Total readmission rate was 66 (40.7%) (Group A 21 (50%) Vs Group B 45 (37.5%). Graft biopsy was done in 16% of patients. 9.3% patients had acute rejection (11.9% Vs 8.3%, p 0.05). Among those who had rejection, ABMR was seen in 2, ACR in 3, CABMR in 5 and combined rejection in 1

CONCLUSIONS: MMF dose modulation to tackle an infectious episode may be associated with graft dysfunction and rejection on follow-up and close follow-up is needed in any patient in whom MMF dose in manipulated

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 22: PREVALENCE OF APOL1 GENE POLYMORPHISMS IN PATIENTS WITH KIDNEY DISEASE IN SOUTH INDIA- A SINGLE-CENTER OBSERVATIONAL STUDY

Chelvamalai Muthukumaran Balasubramanian 1, Venkatesh Arumugam 1, Guhan Senthilkumaran 1, Prem Kumar Devaraju 1, Vinoj Murugesan 1, VS Jibia 1, Vaishanavi Devi Rajarathinam 1, Tanuj Moses Lamech 1, Gopalakrishnan Natarajan 1

BACKGROUND: Incidence and prevalence of many types of severe kidney disease are much higher in Black individuals than most other ethnic groups. Much of this disparity is attributed to nephropathic APOL1 gene alleles found only in individuals with recent African ancestry. These variants greatly increase rates of hypertension-associated ESKD FSGS HIV-associated nephropathy and other forms of nondiabetic kidney disease.

AIM OF THE STUDY: We aim to study the prevalence of APOL1 gene polymorphisms in patients of South Indian ethnicity who have kidney disease.

METHODS: An observational study was conducted at the Institute of Nephrology Madras Medical College during the period of March 2021 to June 2021. Inclusion criteria: Patients aged 12–80 years with â— Biopsy-proven collapsing FSGS â—Primary FSGS â—Unexplained rapid progression of biopsy-proven Diabetic nephropathy â—Lupus nephritis refractory to immunosuppression â—Chronic kidney disease of undetermined etiology â—Hypertensive nephrosclerosis â—Patients with the above diagnosis even if they had undergone a kidney transplantation â—Donor of patients with post-transplant collapsing FSGS Exclusion criteria: Critically ill patients and those who did not provide informed consent. All patients meeting the above criteria were included in the study. Clinical and demographic characteristics were noted. Genetic polymorphism of G1 and G2 variants of the APOL1 gene were analyzed in the sera of these patients by PCR-RFLP principle (polymerized chain reaction-restriction fragment length polymorphism)

RESULTS: A total of 70 patients were included in the study. Median age of the population was 36.5 years (IQR 26 to 46) with male predominance (72.8%). Family history of kidney disease was present in 9 patients (11%). The underlying renal diagnosis for these patients is as follows: kidney disease No of patients CKD(u) - 44 Primary FSGS - 7 CKD with familial clustering (non-DKD)-8 Collapsing FSGS - 2 HIV associated nephropathy -1 Lupus Nephritis- 2 Hypertensive Nephrosclerosis - 5 Thrombotic Microangiopathy - 1 Genetic analysis did not demonstrate the presence of pathogenic risk alleles in the APOL1 gene for any of the 70 patients studied.

CONCLUSIONS: Unlike patients of African descent, the prevalence of APOL1 polymorphisms in the South Indian population appears to be extremely low. In our study, APOL1 polymorphisms were not detected in any patient, despite studying a population that had a high pre-test probability of APOL1 nephropathy. Even in patients with collapsing FSGS, APOL1 risk alleles could not be demonstrated.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 23: COMPARISON OF CLINICAL PROFILE AND IN-HOSPITAL OUTCOMES OF COMMUNITY-ACQUIRED VERSUS HOSPITAL-ACQUIRED ACUTE KIDNEY INJURY IN HOSPITALIZED PATIENTS IN A TERTIARY CARE HOSPITAL: A PROSPECTIVE STUDY

Gaurav Shekhar Sharma 1, Ranjeeta Kumari 1, Sharon Kandari 1, Anupama Bahadur 1, Farhanul Huda 1, Ravi Kant 1

BACKGROUND: Acute kidney injury (AKI) is a clinical syndrome denoted by an abrupt decline in glomerular filtration rate (GFR) sufficient to decrease the elimination of nitrogenous waste products (urea and creatinine) and other uremic toxins. Based on the type of setting AKI can be Community Acquired (CA-AKI) or Hospital Acquired (HA-AKI). These two types have different epidemiological etiological and outcome profiles and these characteristics have remained inconclusive. As far as the etiological spectrum is concerned; previous studies have demonstrated a varied spectrum in both these groups. Very few studies comparing the outcome of CA-AKI and HA-AKI were found in the literature search. There is a paucity of relevant comparative Indian studies on these two types of AKI. Hence this prospective observational study was undertaken to compare the demographic and clinical spectrum and short-term in-hospital outcomes of patients belonging to both these groups who were admitted to the largest tertiary care government teaching hospital in the state of Uttarakhand.

AIM OF THE STUDY: To compare the demographic and clinical spectrum and short-term in-hospital outcomes of community-acquired versus hospital-acquired Acute Kidney Injury in hospitalized patients

METHODS: It is a prospective cohort study conducted from October 2020 to December 2021. The study was conducted in the In-Patient Department (IPD) areas of the Department of Nephrology and all those departments whose consultations for patients with suspected AKI were sent to the Department of Nephrology at AIIMS Rishikesh. Patients fulfilling the following inclusion criteria were enrolled in this study- Age ≥18 years and the patients diagnosed as having AKI as per KDIGO 2012 definition. Those aged <18 years of age and those with CKD or Acute on CKD were excluded from the study. CKD was defined as per the KDIGO 2012 definition. Each enrolled patient was classified as having Community-acquired AKI (CA-AKI) or Hospital-acquired AKI (HA-AKI). Those admitted to the hospital with AKI were denoted as having CA-AKI. In contrast, patients were identified as having HA-AKI when AKI was not apparent upon hospital admission but was diagnosed beyond 24 hours of hospitalization. The sample size of 65 in community-acquired AKI and 32 in the hospital-acquired AKI group was calculated. Study subjects underwent detailed history clinical examination and relevant investigations required in the management of AKI episodes. The stage of AKI at presentation was assessed as per KDIGO Clinical Practice Guidelines for Acute Kidney Injury 2012. Ethical clearance was obtained.

RESULTS: A total of 65 patients with CA-AKI and 32 patients with HA-AKI were enrolled. The mean age of patients in the CA-AKI group was 46.7 years and in the HA-AKI group was 45.5 years. The CA-AKI group had significantly higher-baseline serum creatinine (P < 0.001), serum creatinine at admission (P < 0.001), proportion of male patients (P = 0.09), proportion of patients requiring renal replacement therapy (P = 0.02), proportion of patients getting admitted to medical IPDs (P < 0.001), proportion of patients whose baseline creatinine was unknown (P < 0.001), proportion of patients presenting in Stage 3 of AKI (P = 0.001), proportion of patients having oligoanuria (P = 0.09) and hyperkalemia (P = 0.06) at presentation. The HA-AKI group, on the other hand, was found to have a significantly higher- proportion of patients getting admitted to surgical IPDs (P < 0.001), proportion of patients who underwent a prior surgical procedure (P < 0.001), proportion of patients having coexisting lung disease (P = 0.09), liver disease (P = 0.03), heart disease (P = 0.06) and COVID-19 (P = 0.04). Sepsis was found to be the most common cause (70.7%) in the CA-AKI group and was also one of the common causes (28.12%) in the HA-AKI group. Despite more patients in the CA-AKI group being in AKI-Stage 3 at presentation, in-hospital mortality was observed to be lower in this group (35.4% versus 62.5%, P = 0.04). The median survival time of patients was found to be more than double in the CA-AKI than in the HA-AKI group (59 days versus 23 days). However, on comparing the overall survival using the log-rank test, both groups were found to be comparable (chi-square value 1.82, p-value 0.18). Univariate analysis for predictors of mortality showed that the type of AKI (CA vs HA) (P = 0.01), type of admission (ward vs ICU) (P = 0.001), surgical procedure prior to AKI onset (P = 0.018), presence of comorbidities such as DM (P = 0.038), lung disease (P = 0.000), and COVID-19 (P = 0.018) and requirement of vasopressor support (P = 0.009) were significant predictors of mortality of patients with AKI admitted to our center. Also, the length of hospital stay (P = 0.037), serum creatinine at admission (P = 0.002) and serum creatinine at discharge/death (P = 0.003) have been found to predict the mortality of these patients. However, Cox proportional hazard regression analysis for finding out independent predictors of mortality showed that only two factors, i.e., the presence of lung disease (HR 2.65, 95% CI 1.03-6.79, P = 0.042) and the requirement of vasopressor support at presentation (HR 5.28, 95% CI 1.75- 15.97, P = 0.003) predicted the survival of AKI patients. Thus, the present study showed that type of AKI was not an independent predictor of mortality in AKI patients admitted to our center.

CONCLUSIONS: The majority of patients in both groups of AKI presented in Stage 3. Sepsis was found to be the most common cause in the CA-AKI group and was also one of the common causes in the HA-AKI group. On comparing the in-hospital outcomes of AKI episodes, it was observed that both recovery (complete or partial) and dialysis dependency were more common in the patients with CA-AKI while mortality was found to be more in the HA-AKI group. However, on Cox proportional hazard regression analysis it was found that only two factors, i.e., the presence of lung disease and the requirement of vasopressor support at presentation predicted the survival of AKI patients admitted to our center. Thus, the present study showed that type of AKI was not an independent predictor of mortality in such patients. Further, more long-term and larger multi-center studies are required to study the course and outcome of patients with AKI and to outline the regional variances in its patterns in the Indian population.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 24: HIGHER IL-12 AND IL-23 LEVELS AND INCREASED P-GLYCOPROTEIN EXPRESSION DRIVE THE TRANSITION OF TH17 CELLS TO PATHOGENIC IFN-γ PRODUCING TH17 CELLS IN REFRACTORY NEPHROTIC SYNDROME

Akhilesh Jaiswal 1, Narayan Prasad 1, Mantabya Singh 1, Kritika Singh 2, Vikas Agarwal 2

BACKGROUND: Th17 cells are critical effectors mediating the autoimmunity in nephrotic syndrome (NS). Elevated IFN-γ has also been involved in NS; however, it remains unclear to what extent Th1 cells contribute to glucocorticoid resistance in NS. P-glycoprotein (P-gp) effluxes glucocorticoids outside the cells and selectively expressed differentially on T cell subtypes.

AIM OF THE STUDY: In this study, we investigated the role of P-gp and cellular source of IFN-γ and assessed its contribution to glucocorticoids resistance in NS.

METHODS: We analyzed the frequency of pathogenic IL-17A+IFN-γ+ Th17/1 lymphocytes and P-gp expression on their surface by flow-cytometry in SSNS (n = 32; mean age: 9.06 ± 5.84) and SRNS (n = 28; mean age: 11.29 ± 3.73) patients. All patients were recruited as per the criteria of ISKDC. We also included 15 age- and sex-matched healthy controls. All patients were of biopsy-proven minimal change disease, and all patients were treated with steroids.

RESULTS: We found a significant IL-17A+IFN-γ+ Th17/1 population (P < 0.001) in steroid-resistant NS (SRNS) as compared to steroid-sensitive NS (SSNS) patients. IL-12 and IL-23 are significantly higher in SRNS as compared to SSNS patients which are required for the transition of pathogenic Th17 cells to IFN-γ producers. Of the IL-17A+IFN-γ+ Th17/1 population 95.8% of cells were expressed P-gp on their surface in SRNS; however, only 30.1% of cells expressed P-gp in the SSNS group. We also observed that P-gp expression correlate positively with IL-17A+IFN-γ+ Th17/1 population (r = 0.739, p < 0.001) significantly.

CONCLUSIONS: The above findings clearly show that higher expression of P-gp on IL-17A+IFN-γ+ Th17/1 cells associated with steroid resistance in nephrotic syndrome through both IL-17A and IFN-γ.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 25: GROSS HEMATURIA IN YOUNG ADULT FEMALE- A RARE PRESENTATION OF RVT AND IT’S ASSOCIATION WITH HLA B27

Mohd Aquib Farooqui 1, Nagma Nigar 1

BACKGROUND: In renal vein thrombosis (RVT), the presence of thrombus in the major renal veins or its tributaries is a rare clinical entity. It can present acutely or go unnoticed and can result in acute kidney injury or chronic kidney disease. It is commonly associated with nephrotic syndrome primary hypercoagulability disorders malignant renal tumors extrinsic compression infections trauma or as a post-renal transplant complication. Renal vein thrombosis is a rare cause of gross hematuria in young adults. Poststreptococcal GN and IgA nephropathy are the most common cause of macroscopic hematuria that originates from kidneys. Renal disease is very uncommon in axial spondyloarthritis (axSpA) but nonspecific glomerulopathy immunoglobulin A (IgA) nephropathy and renal amyloidosis may be seen in Ankylosing spondylitis. Our patient had gross hematuria which is attributable to renal vein thrombosis and it’s association with Ankylosing spondylitis hints at the possibility of Ankylosing spondylitis presenting with rare early renal manifestation in the form of gross hematuria.

AIM OF THE STUDY: To establish renal vein thrombosis as a cause of gross hematuria in a late adolescent female and it’s relation with HLAB27 positive Ankylosing spondylitis.

METHODS: The patient was enrolled for case report after due consultation and consent. The relevant literature was reviewed from PUBMED and Cochranes database.

RESULTS: Renal vein thrombosis may present as gross hematuria for months causing severe anemia without evidence of nephrotic syndrome or acute kidney injury. Patient subsequently developing HLAB27 positive Ankylosing spondylitis hints at possibility of rare early renal manifestation of Ankylosing spondylitis in the form of gross hematuria secondary to renal vein thrombosis.

CONCLUSIONS: Gross hematuria can occur due to both glomerular or non-glomerular cause. In our case, patient was found to have left renal vein segmental branch thrombosis extending up to left ovarian vein causing left ovary inflammation. Patient subsequently developed Ankylosing spondylitis. However, there was no evidence in laboratory and histopathalogical evaluation that could suggest glomerular involvement. Renal vein thrombosis got resolved after anticoagulation with warfarin that was confirmed with follow-up CT urography after 6 months. This is the rare manifestation of gross hematuria in young adolescent causing severe anemia attributable to renal vein thrombosis and extremely rare association with Ankylosing spondylitis and possibly early renal manifestation of Ankylosing spondylitis causing gross hematuria secondary to renal vein thrombosis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 26: ACUTE KIDNEY INJURY IN ACUTE DECOMPENSATED HEART FAILURE PATIENTS UNDERGOING AGGRESSIVE DIURESIS & ITS EFFECT ON SHORT TERM OUTCOME

Anil Kumar Jhajhria 1, Neeru Aggarwal 1, Manoj Singhal 1, Manisha Dassi 1, LK Jha 1, Lovy Gaur 1

BACKGROUND: Acute Heart Failure (AHF) patients treated with diuretics often develop worsening of renal functions with resultant acute kidney injury (AKI) during hospitalization. This AKI could be a result of either renal tubular injury or simply indicate a hemodynamic or functional change in glomerular filtration.

AIM OF THE STUDY: To determine whether renal tubular injury is a predominant cause of acute kidney injury occurring in acute heart failure patients undergoing aggressive diuresis and its effect on outcome. Â

METHODS: 100 AHF patients who underwent aggressive diuresis were included (excluding patients requiring inotropic support or renal replacement therapy). Urine NGAL was measured in all patients on the day of admission and after 72 hours. Also serum creatinine levels were measured on day of admission at 48 hours and at 72 hours post-admission. AKI was defined as per KDIGO clinical practice guidelines as increase in serum creatinine by 0.3 mg/dL or more within 48 hours or urine output less than 0.5 mL/kg/h for 6 hours. All patients (or attendants) were contacted at 30 days from the day of admission and reviewed regarding requirement of readmission/mortality. All patients who developed AKI during the study by day 3 got their creatinine checked again at day 30 from the day of admission.

RESULTS: Mean eGFR of patients included in the study was 48.1 ml/min/m2. Mean NT-proBNP was 11001.6 pg/ml. Mean LVEF was 43.65%, with 38% patients having HFrEF and 62% patients had HFpEF (LVEF > 40%). Of total 100 patients, 37 (37%) developed AKI. Rise in NGAL from day 0 to day 3 was noted in 34 (34%) cases. There was no correlation found between rising creatinine levels and rising NGAL levels (including patients with AKI). Mean NT-proBNP was higher in patients with AKI as compared to those without AKI (p-value = 0.048). Of 37 AKI patients, 10 (27%) patients had creatinine value at day 30 higher than at day 3, while 27 (73%) patients had creatinine value at day 30 lower than at day 3. 30 patients required readmission within 30 days after discharge; 5 patients expired by day 30 (from start of study). Occurrence of AKI did not show association with readmission within 30 days or with mortality at 30 days.

CONCLUSIONS: AKI occurred in 37% patients with AHF undergoing aggressive diuresis in our study. This AKI had no correlation with serial NGAL levels (tubular injury biomarker) but was associated with an elevated baseline NT-proBNP levels. Furthermore, 73% AKI patients showed improvement in creatinine levels by day 30 post-discharge & occurrence of AKI did not affect short term morbidity (readmission at 30 days) and mortality at 30 days. This implies that AKI in the setting of AHF & aggressive diuresis is mild, mainly functional/hemodynamic and should not affect decisions with decongestive therapy.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 27: CLINICOPATHOLOGICAL FEATURES AND PREDICTORS OF POOR OUTCOME IN PROLIFERATIVE GLOMERULONEPHRITIS WITH MONOCLONAL IMMUNOGLOBULIN DEPOSITS

Zafirah 1, Asif Sadiq Wani 1

BACKGROUND: Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is an addition to the spectrum of renal diseases manifesting as glomerular monoclonal deposits with only a few case reports/series in the literature.

AIM OF THE STUDY: Our aim was to define the clinicopathological features treatment and outcome of this interesting disease entity in our population.

METHODS: This is a retrospective single-center cohort observational study. Patients diagnosed as PGNMID using light microscopy immunofluorescence and electron microscopy were included in the study.

RESULTS: Six patients of PGNMID were diagnosed over a period of two years. The mean age of patients was 46.17 (Â ± 13) years affecting mostly males. The commonest presentation was protienuria and hematuria (mean urinary protein 3.7 g/24 hrs) with varying degree of renal dysfunction. The light microscopic pattern was membranoproliferative (83.3%) or endocapillary proliferative (16.6%). Interstitial fibrosis and tubular atrophy (IFTA) was mild in 1, moderate in 3 and severe in 2 patients with mean glomerulosclerosis of 30%. Most common immunoglobulin type was IgG3K (83.3%). None of our patients had serum/ urinary M-spike or hematological malignancy. On follow-up two patients died, two were on maintenance hemodialysis and two achieved partial remission. High serum creatinine, higher degree of glomerulosclerosis, and IFTA were the poor prognostic factors.

CONCLUSIONS: PGNMID is a rare disease affecting mostly adult males and with a poor prognosis in our population. The type of immunoglobulin or treatment received by the patients did not affect the final outcome, but high creatinine and chronicity in biopsy are the predictors of poor prognosis. Larger studies are required for standardization of treatment protocols and better understanding of this upcoming disease.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 28: RELATIONSHIP BETWEEN PROTEIN ENERGY WASTING AND PSOAS MUSCLE INDEX IN CHRONIC KIDNEY DISEASE PATIENTS: A CROSS-SECTIONAL STUDY

Mahendra Kumar Jangid 1, Manish Chaturvedy 1, Santosh Kumar Maurya 1, Nitin Kumar Bajpai 1, Pawan Kumar Garg 1, Akhil Dhanesh Goel 1, Praveen Sharma 1, Rajesh Jhorawat 1

BACKGROUND: Chronic kidney disease (CKD) is a global health issue and syndrome of protein-energy wasting (PEW) that encompasses many nutritional and metabolic alterations which often coexist in patients with chronic kidney disease (CKD). PEW sarcopenia and frailty are commonly seen in advancing CKD and have been linked with adverse outcomes in various studies. Psoas Muscle index (PMI) is a new upcoming objective parameter that has been shown to be effective in predicting sarcopenia in CKD patients. This study was conducted to see the relationship between PEW and PMI.

AIM OF THE STUDY: To study the relationship between PEW and PMI in CKD patients

METHODS: This was a cross-sectional study and included diagnosed cases of CKD who were attending Nephrology outpatient care. We measured baseline parameters including BMI MUAC and SGA. The protein-energy wasting (PEW) was diagnosed by the criteria proposed by The International Society of Renal Nutrition and Metabolism (ISRNM). Psoas Muscle Index (PMI) was calculated on a CT scan. CT images were acquired by SOMATOM Definition Flash dual-energy source 2 x 128 slice CT scanner (Siemens Healthcare GmbH Germany). To calculate Psoas Muscle Index (PMI), the Manual Tracing (MT) method using RadiAnt DICOM viewer version 2021.2 (64-bit) was used.

RESULTS: A total of 90 patients were included. The mean age of the study population was 51.81Â ± 14.61 yrs., 68.9% were male, mean BMI was 19.85Â ± 3.20 Kg/m2. Male had significantly more PMI compared to females (4.512Â ± 1.929 vs. 3.229Â ± 1.231, p = <0.001). Age had strong relationship with PMI in our study (r = -0.375, 95% CI -0.539 to -0.180, p = <0.001) with serum urea and cholesterol (r = 0.217, 95% CI 0.040 to 0.010, p = 0.040 and r = 0.275, 95% CI 0.069 to 0.454, p = 0.009 respectively). Among nutritional parameters, BMI (r = 0.276, 95%CI 0.730 to 0.457, p = 0.008), SGA (r = -0.216, 95% CI -0.404 to -0.008, p = 0.041), and handgrip (r = 0.311, 95%CI 0.109 to 0.485, p = 0.003) had statistically significant correlation with PMI. In regression analysis, handgrip strength and PEW were independently associated with PMI (beta coefficient 0.282, 95% CI 0.003 to 0.245, p = 0.042 and beta coefficient 0.461, 95%CI 1.152 to 2.763, p < 0.001, respectively). Prevalence of PEW was 75.55% in our study. PMI was significantly low in PEW patients compared to those who had not (3.523Â ± 1.194 vs. 5.936Â ± 2.260, p < 0.001).

CONCLUSIONS: PMI is an important indicator of sarcopenia, and it has an independent and significant correlation with handgrip strength and protein-energy wasting (PEW) in CKD patients in our study.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 29: ACCURACY OF ESTIMATED GFR- ADDRESSING THE ELEPHANT IN THE ROOM

Nisha Jose 1, Jayapraksh 1, M Jayakumar 1

BACKGROUND: GFR estimation is done every day as a measure of renal function. GFR estimation equations (eGFR) have largely replaced measured GFR (mGFR) in routine clinical practice even though validation studies for these equations are sparse.

AIM OF THE STUDY: The aim of the study was to evaluate the accuracy and precision of currently available GFR estimation methods when compared to measured GFR estimation methods.

METHODS: A single-center study was done among patients with chronic kidney disease using diethylene-triamine penta-acetic acid (DTPA) as the gold standard. The eGFR equations that were evaluated were the CKD-EPI (CKD Epidemiology), MDRD (Modified Diet in Renal Disease), and the indigenous Prabhat equation

RESULTS: The study included 141 patients. The Prabhat formula was found to be the most accurate with a P30 (the percentage of patients who fall within 30% of the estimated GFR) value of 74.6% followed by the MDRD (61.1%) and then the CKD-EPI equation (57.5%). Bias was found to be the least with the Prabhat formula (2.52). Precision was found to be best for CKD-EPI equation which had a precision of 38.54.

CONCLUSIONS: Although all three equations did not meet the bench mark standard of having a P30 of 90%, the Prabhat formula was closest with a P30 of 74.6%. The CKD-EPI equation was noted to have the most precision and the least percentage error. Although all 3 equations had good correlation with the gold standard DTPA, correlation alone without accuracy or precision is insufficient when it comes to clinical relevance

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 30: UTILITY OF PROTOCOL BIOPSY IN KIDNEY TRANSPLANT RECIPIENTS

Jeena J Sathyan 1

BACKGROUND: Several studies suggest that early rejection episodes and chronic changes in allograft kidneys were often subclinical without a concomitant rise in serum creatinine or proteinuria. Early identification of subclinical pathology by doing protocol biopsy and appropriate intervention is likely to improve long-term graft outcomes.

AIM OF THE STUDY: To identify the subclinical pathology in protocol biopsy in kidney transplant recipients

METHODS: All adult patients who underwent live donor kidney transplantation from September 2019 to August 2021 with stable graft function were included in study. Stable graft function is defined as variation in serum creatinine values of less than 25% from the baseline serum creatinine. Protocol biopsies were taken at three months after transplant surgery. Biopsies were done using spring loaded biopsy guns percutaneously under local anesthesia and ultrasound guidance and patients were observed for 24 hours in the hospital for any complications. Biopsies were analyzed by light microscopy and C4D staining and scored based on Banff classification.

RESULTS: Seventy patients underwent protocol biopsy at a pre-specified time of 3 months after surgery. Mean age of recipients was 38.46+/- 11.9 years and mean age of donors 45.58 +/-11.88 years. Males constituted 82% of the recipients and 68.6% of the donors were females. Majority of our patients (74.3%) received kidney from first degree relatives and rest (25.7%) received kidneys from spouses. Induction therapy was given to 57% of the patients and rest (43%) were transplanted without an induction agent. Out of 70 specimens studied, 44 (62.9%) had normal histology and 26 (37.1%) had varying histological abnormalities. Thirteen (18.6%) had evidence of subclinical rejection of which, 12 (17.2%) showed borderline rejection and one (1.4%) had acute T-cell mediated rejection (TCMR). Other histological findings include chronic active TCMR in one (1.4%), varying degrees of interstitial fibrosis and tubular atrophy in five (7.1%), evidence of BK virus nephropathy in two (2.8%), features of Calcineurin inhibitor toxicity in two (2.8%), acute pyelonephritis, acute tubular injury, and acute interstitial nephritis in one patient each. None of the patients developed any complications after the procedure. With appropriate treatment interventions, all patients had stable graft functions at six months follow-up.

CONCLUSIONS: Thirty-seven percent of biopsy specimens showed some form of subclinical pathology which guided us to alter immunosuppression. While maintenance immunosuppression was increased in cases of rejection which constituted 13 cases (18.6%), the dose of immunosuppression was reduced in two cases of Calcineurin inhibitor toxicity and BK virus nephropathy, which helped in maintaining stable graft functions for all these patients on 6 month follow-up. None of our patients had any major complications after the procedure. Protocol biopsy under real-time ultrasound guidance has a very good safety profile and can help the clinician to optimize immunosuppression with more precision and on a long term it would prove cost-effective.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 31: LISTERIA MENINGOENCEPHALITIS IN KIDNEY TRANSPLANT RECIPIENT

Nikhil Dhope 1, Siddhivinayak Rajmane 1, Rejitha Kaimal 1, Ankita Metaliya 1, Hinal Rathod 1, Priyanka Lawangani 1, Ashay Shingare 1, M M Bahadur 1

BACKGROUND: Patients taking immunosuppressive medications following kidney transplant are at high risk of developing opportunistic infections. Listeria monocytogenes has long been recognized as a pathogen of immunocompromised hosts including solid organ and bone marrow transplant recipients. Its principal manifestations include bacteremia and meningitis. Rarely it can lead to potentially fatal life-threatening infections especially in hosts with impaired immune systems. Few cases of listeria infection have been reported after kidney transplants mostly from European countries.

AIM OF THE STUDY: - According to our literature review, we report the first case of listeria meningoencephalitis in kidney transplant recipient from India

METHODS: 18-year-old female ABO compatible kidney transplant recipient (2015) post-transplant diabetes mellitus and graft dysfunction due to chronic antibody-mediated rejection presented with fever and loose stools. Patient was on triple immunosuppression regimen of prednisone tacrolimus and mycophenolate. During hospital stay, she had seizures followed by altered sensorium. Patient had neck stiffness on examination with no signs of focal neurological deficit.

RESULTS: On evaluation detected with hyponatremia (Sr Na 119 meq/L) and hypocalcemia (Sr calcium 5.8 mg/dL; sr albumin 2.8 g/dL). Patient also had deranged renal functions with serum creatinine 6.56 mg/dL and BUN 69 mg/dL. Altered sensorium persisted even after slowly correcting hyponatremia and hopocalcemia and 2 dialysis sessions. MRI brain showed signal abnormality with mass effect in left basifrontal, left anterior temporal lobe, insular cortex region, and microabscesses in left inferior basal ganglia region. Cerebrospinal fluid (CSF) examination showed 390 nucleated cells with 70% lymphocytes and increased protein (81.4 mg/dL). CSF gene Xpert and AFB staining were negative. Blood and CSF cultures did not show any growth. CSF HSV PCR was negative. CSF biofire was positive for listeria monocytogenes. Even after initial treatment with ampicillin for 10 days, patient had marginal neurological improvement. Trimethoprim-sulfamethoxazole was added following which patient had marked improvement in neurological status.

CONCLUSIONS: Listeria should be considered in differential diagnosis of febrile gastroenteritis, particularly in immunocompromised patients which is often missed. Stool culture should be plated with special media in suspected cases. Biofire meningoencephalitis panel test of CSF should be considered particularly in immunocompromised patients, which provide results in as early as 12 hours. Trimethoprim-sulfamethoxazole should be considered early, particularly in listeria infection resistant to ampicillin.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 32: ACUTE KIDNEY INJURY IN PATIENTS TREATED WITH EXTRA-CORPOREAL MEMBRANE OXYGENATION (ECMO)

Aswin Surjit 1, P K Bipi 1, Vishnu Dev Urs 1, V N Unni 1

BACKGROUND: The reported incidence of Acute Kidney Injury (AKI) in patients undergoing Extracorporeal Membrane Oxygenation (ECMO) varies between 26 to 85% among various studies. There are only limited observational studies on the topic to understand the risk factors contributing to AKI and its association with mortality.

AIM OF THE STUDY: To study the incidence of acute kidney injury (AKI) in patients undergoing ECMO. To study the risk factors for AKI in patients undergoing ECMO. To study the effect of acute kidney injury on in-hospital mortality.

METHODS: A retrospective cohort study done at Aster Medcity Kochi. No. of patients: 50. The definitions and classification of terms were done as per KDIGO guidelines. All patients from 2015 to 2022 who underwent ECMO at our institute were included. The patients who expired within 48 hours of initiating ECMO and those on maintenance dialysis were excluded.

RESULTS: Mean age: 41.15  ± 19.67 years. Gender; Male: 28 (56%), Females:22 (44%). Diabetes Mellitus: 11 (22%); Hypertension: 12 (24%). History of nephrotoxic drugs: 11 (22%). Chronic kidney disease: 3 (6%). Cardiac Status : EF ≥50% LVEF : 35 (70%); <50% LVEF : 15 (30%). Types of ECMO: Veno-arterial type : 23 (46%). Veno-venous type: 27 (54%). Total mean days on ECMO: 6.6  ± 5.6 days. Incidence of AKI after ECMO: 26 (52%), 68% patients developed AKI within 3 days of ECMO initiation. Number of patients who needed renal replacement therapy during ECMO: 20 (40%); the most common indication for RRT was fluid overload (60%). The vascular access was from ECMO circuit in 13 patients (65%), and the remaining 7 were dialyzed through a double lumen catheter. 75% patients required SLED. Use of inotropes during RRT : 30 (60%). One patient developed lower limb ischemia (Veno-arterial ECMO). In hospital mortality : 30 (60%); Mean number of days from start of ECMO to mortality:7.42  ± 6.35 days. The risk of mortality increased with incidence of AKI and stage of AKI. AKI recovered in 19% patients. Risk factors for AKI were elderly age, systemic hypertension, longer duration of ECMO, higher APACHE II score, and use of inotropes

CONCLUSIONS: AKI is common in patients on ECMO; the outcome is poorer in patients with AKI, when compared to those who do not develop AKI. Identifying at risk individuals and early initiation of RRT to control fluid overload is likely to help in reducing the mortality.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 33: ”GENETICS IN NEPHROLOGY: IS THIS THE PATH FORWARD?” A PROSPECTIVE STUDY FROM A TERTIARY CARE CENTER IN SOUTH INDIA

Kajaree Giri 1

BACKGROUND: The genetics in kidney disease has undergone explosive growth in recent years due to significant advances in sequencing technology and genetics methodology. Multiple studies suggest that around 10% of the adult ESKD and 30% of the pediatric population have an identifiable genetic kidney disease. The exons which are protein encoding region of genes that make up only 1% of the whole genome known as the “exome†are estimated to carry at least 85% of the disease causing variants. Next-generation sequencing (NGS) can evaluate all >18000 genes or a targeted list of genes. NGS can be done on the whole genome (WGS) whole exome (WES) or a selection of genes within the exome (targeted NGS). The utility of WES or targeted NGS for the diagnosis and management of kidneys diseases in both adult and pediatric population has not been adequately studied in India. Genetic diagnostics play a significant role behind the pathogenesis and the management of several kidney diseases.

AIM OF THE STUDY: The aim of this study is 1. to determine the diagnostic utility of targeted next generation sequencing (NGS) and to assess the genetic basis of nephrotic syndrome and CKD in Indian patients and 2. to study its clinical and histologic correlation.

METHODS: It is an investigator initiated prospective study done on adult as well as pediatric patients presenting to Department of Nephrology Osmania General Hospital Hyderabad Telangana India. The study has been approved by Ethical committee of Osmania Medical College. The cases have been broadly divided in two groups; Group A - nephrotic syndrome and Group B - chronic kidney disease (CKD) (which includes chronic interstitial nephritis diabetic nephropathy cystic kidney diseases and thrombotic microangiopathy). Patients with nephrotic syndrome and CKD having any of the following indications have been screened for genetic studies: 1. Patients with positive family history, 2. Patients having syndromic features, 3. Congenital nephrotic syndrome, 4. Steroid resistant nephrotic syndrome, 5. Patients with CKD with unknown etiology. Informed and written consent have been taken from all patients. A total of 68 patients of which 40 cases of nephrotic syndrome (group A) and 28 (group B) cases of CKD have been included. Blood samples (5 ml) have been collected from the patients and genomic DNA has been extracted from peripheral blood leukocytes by phenol chloroform method. Appropriate genetic analysis has been performed. The genetic panel for nephrotic syndrome polycystic kidney disease and hemolytic uremic syndrome include 60 genes 6 genes and 40 genes respectively. The mutations are classified as per ACMG criteria that is — “pathogenic †“likely pathogenic †“uncertain significance †“likely benign †and “benign†—to describe variants identified in genes that cause Mendelian disorders. Data has been recorded on a predesigned pro forma and entered using Microsoft Excel 2007. The statistical software IBM SPSS Statistics version 20 has been used for all mathematical computations. Continuous data has been expressed as mean  ± SD or median and qualitative data expressed as number percentage.

RESULTS: Among the total number of cases included, 58.8% patients have nephrotic syndrome and 41.2% have CKD. Among patients with nephrotic syndrome, 13% patients are infants (4 - 12 months), 82.6% are children (1 - 18 years), and 4.4% are adults (>18 years). In group A, the mean age of the study population is 9.7 ± 5.4 years. 65.2% are males and 34.8% are females. Family history of consanguinity has been found in 21.7% cases. 73.9% patients with nephrotic syndrome have clinical SRNS, 21.7% have infantile onset of disease while the rest have SDNS. 4.3% of patients have deranged renal function tests. Renal biopsy has been done in all patients. The renal histology shows MCD in 56.5% cases followed by FSGS in 26.08% cases, IgM deposits in 13.04% cases and mesangioproliferative glomerulonephritis in two cases. Overall, abnormal genetic analysis has been found in 60.8% of patients with nephrotic syndrome. Among those patients, 28.5% have biopsy-proven FSGS while 57.14% have MCD. The gene mutations are “pathogenic†in 14.2% and are of “uncertain significance†in 85.8% cases. Hence, among those with indications for genetic testing 60.8% have gene mutations. Genetic analysis changed the treatment in 56.6% of patients. In group B, 53.3% patients are pediatric whereas 46.7% are adults (>18 years age). 66.6% of the total cases are males. 26.6% of patients have chronic interstitial nephritis followed by thrombotic microangiopathies (26.6%), cystic kidney diseases (20%), and chronic glomerulonephritis (13.3%) while the rest have unexplained CKD. On renal imaging, 20% have bilateral contracted kidneys, 20% have cystic kidney disease and the rest 60% have normal or borderline sized kidneys. Genetic analysis reveals abnormal reports in 46.6% of total patients. Of which, “pathogenic†gene has been noted in 28.5%, “likely pathogenic†in 14.2% and “uncertain significance†in 57.14% of cases. In four patients of clinically diagnosed ADPKD, PKD1 gene has been pathogenic in two, whereas in others it was detected as a variant of unknown significance. Thus, among those with indications for genetic testing 46.6% have gene mutations. Genetic analysis changed the treatment in 42% of patients.

CONCLUSIONS: In the present study, it is shown that among patients with SRNS, NS with infantile onset or those with syndromic NS, 60.8% have genetic mutations. These children do not respond to immunosuppression and thus genetic analysis may help in avoiding unnecessary use of severe immunosuppression in this group of children. Among CKD, genetic mutations are seen in 46.6%. As many of the genetic diseases may recur post-renal transplant, pretransplant genetic diagnosis may help in prognostication as well as planning appropriate management. Genetic literacy, antenatal genetic counseling, and preimplantation genetic diagnosis are upcoming concepts in this NGS era.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 34: DRUG INDUCED AIN; EXPERIENCE FROM STATE RUN TERTIARY HOSPITAL

Viswas Thazhathidath 1

BACKGROUND: Acute interstitial nephritis (AIN) represents an important cause of Acute Kidney Injury accounting for 15—27% of renal biopsies performed because of this condition. A myriad of etiologies including infections drugs and connective tissue disorders can lead to AIN. Drug-induced AIN is the most common accounting for 3—14% of biopsy-proven cases of AKI.

AIM OF THE STUDY: To study the incidence etiology and clinical profile of drug induced Acute Interstitial Nephritis

METHODS: We conducted a retrospective observational study in patients with biopsy-proven AIN at our institute during the time period from January 2019 to June 2022. We collected data of 90 patients with biopsy-proven AIN. Patients who had a temporal relation between intake of the suspected drug and development of AIN were included in the study. Patients with evidence of infectious diseases connective tissue disorders or other glomerular disorders on biopsy were excluded from the study.

RESULTS: Drug-induced AIN constituted 43.33% of the total cases of biopsy-proven AIN. Males constituted 82.05% and females 17.95%. The incidence was maximum in the age group above 60 years (33.3%). The most common culprit drug in the study was Tenofovir (41.03%) followed by NSAIDs (33.33%). Chemotherapy drugs constituted 10.25% of the cases. Percentage of patients who presented in KDIGO AKI Stage 1, 2, and 3 are 17.95%, 28.21%, and 53.85% respectively. Two patients (5.13%) had fever, and only one patient (2.56%) had rash at presentation. 15.3% of the patients had raised eosinophil count, but only one patient (2.5%) had a positive urine eosinophil test. 23.08% of the patients needed renal replacement therapy.

CONCLUSIONS: Drug-induced AIN constituted 43.33% of biopsy-proven AIN in our study. Tenofovir, NSAIDs, and chemotherapy drugs were the major culprits. Fever, rash, peripheral eosinophilia, and urine for eosinophils are not sensitive parameters and do not contribute significantly to the diagnosis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 35: PREVALENCE OF HUMAN LEUKOCYTE ANTIGEN ALLELES FREQUENCY IN NORTH INDIAN POPULATION

Ankita Singh 1, Brijesh Yadav 1, Narayan Prasad 1, DeependraYadav 1, Sonam Gautam 1, Sandeep Yadav 1

BACKGROUND: Human leukocyte antigens are highly polymorphic glycoprotein expressed on the surface of immune and non-immune cells, required for antigenic molecules presentation to T and B cell for their activation and triggering immune response, which determines the overall health of an individual in a community.

AIM OF THE STUDY: Organ sharing for transplantation requires an HLA matching for minimizing the risk of donor specific antibody formation and acute rejection. Therefore, knowing the HLA alleles frequency in a community may be helpful in determining the probability of getting a suitable organs donor and allocating the organs for transplantation.

METHODS: In the current study, we have analyzed the HLA antigen alleles A, B, DR alleles in 2336, and HLA-C, DQ alleles in 795 individuals by the polymerase chain reaction and single-strand specific oligonucleotide methods (PCR-SSO) using alleles specific primers and oligonucleotide probe following kit manufactures protocol (Immucor, diagnostic, USA) on xPonent Luminex platform.

RESULTS: The top 5 most abundant major HLA-A1 antigen alleles were HLA-A*01(17.8%), HLA-A*02 (16.1%), HLA-A*11 (17.6%), HLA-A*24 (10.4%), HLA-A*03 (8.9%). HLA-B1 antigen alleles were HLA-B*35 (20.4%), HLA-B*15 (15.6%), HLA-B*40 (12.0%), HLA-B*07 (8.9%), HLA-B*44 (7.7%). HLA-C1 antigen alleles subtype was HLA-C*70 (27.4%), HLA-C*40 (19.4%), HLA-C*30 (15.4%), HLA-C*60 (13.4%), HLA-C*12 (5.5%). HLA-DRB1 alleles subtype were HLA-DRB1*07 (15.8%), HLA-DRB1*15 (8.0%), HLA-DRB1*4 (11.7%), HLA-DRB1*10 (9.0%), HLA-DRB1*11 (8.4%). HLA-DQA1 subtype were HLA-DQA1*30(36.2%), HLA-DQA1*20(30.0%), HLA-DQA1*50(21.0%), HLA-DQA1*60(9.6%), HLA-DQA1*40(1.4%).

CONCLUSIONS: The most frequent HLA alleles were HLA-A*01(17.8%), HLA-B*35 (20.4%), HLA-C*70 (27.4%), HLA-DRB1*07 (15.8%), HLA-DQA1*30 (36.2%) in North Indian population.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 36: AKI IN PATIENTS HOSPITALISED WITH COVID-19 INFECTION

H Muralidhar 1, P K Bipi 1, Vishnudev 1, V N Unni 1

BACKGROUND: COVID-19 is primarily a respiratory tract infection, but it should be regarded as a systemic disease involving multiple systems including kidneys. The incidence of acute kidney injury in hospitalized patients with COVID-19 varies ranging from 10% in Indian subcontinent to 37–45% from Western studies.

AIM OF THE STUDY: To study the incidence of acute kidney injury in patients hospitalized with COVID-19 infection. To study the risk factors for acute kidney injury in patients with COVID-19 infections. To study the impact of acute kidney injury on the outcomes in COVID19 infected patients.

METHODS: All hospitalized COVID-19-infected patients diagnosed by RT-PCR and rapid antigen tests were included. Patients with structural abnormalities of the urinary tract renal transplant recipients patients on maintenance hemodialysis those with incomplete records and outpatients were excluded from the study. Variables analyzed included age, gender, comorbidities, vital signs S. Creatinine values. Urinary abnormalities mortality need for hemodialysis recovery of renal function and duration of hospital stay.

RESULTS: Out of the 400 patients in our study, 50 patients (12.5%) had acute kidney injury. Of theses 50 patients, 27 patients had acute kidney injury stage 1, seven had stage 2, and 16 had stage 3. There were 31 males and majority (41 out of 50 patients) were above 60 years of age. Diabetes mellitus was present in 45 out of 50 patients, 42 patients had systemic hypertension, 30 had coronary artery disease, and 16 had bronchial asthma. Thirty-six out of 50 patients had COVID-19 category B and 14 belonged to COVID-19 category C. Urinary abnormalities included albuminuria (42 patients), microscopic hematuria (16 patients), pyuria (21 patients) and normal in 3 patients. Most common urinary abnormality among the AKI group was proteinuria (84%), whereas in non-AKI group urine was bland in majority of cases. Hemodialysis was needed for 16 patients. Thirteen patients required vasopressor support, and 12 patients required ventilatory support. Twenty-nine patients had complete recovery, and 10 patients had partial recovery of renal functions and eleven patients expired (22% of those with AKI); the mortality in the non-AKI group was 6.5%. All those who died had AKI stage 3.

CONCLUSIONS: Among COVID-19-infected patients, 12.5% had acute kidney injury with majority in AKI stage 1 (54%). Majority of the patients were males and elderly (>60 years). Most common comorbidity was diabetes mellitus, followed by systemic hypertension and coronary artery disease. Majority of patients belonged to COVID-19 category B (72%). Most common urinary abnormality was proteinuria (84%). Need for vasopressor support, duration of ICU stay, hospital stay, and mortality were more in the AKI group.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 37: €ŒA SINGLE CENTER PROSPECTIVE OBSERVATIONAL STUDY TO COMPARE CLINICAL AND BIOCHEMICAL PARAMETERS AND QUALITY OF LIFE IN END STAGE RENAL DISEASE PATIENTS UNDERGOING CONVENTIONAL HAEMODIALYSIS VS HDF

Yogesh Kumar Gaur 1, Srikanth Gundlapalli 1

BACKGROUND: DIALYSIS

AIM OF THE STUDY: To establish the effectiveness of HDF compared with conventional HD in adult patients with ESKD on maintenance thrice weekly in-center HD

METHODS: Single-center study conducted in the Department of Nephrology at Asian Institute of Nephrology and Urology Banjara hills Hyderabad from April 2020 to October 2021 (12 months). Patients were dialyzed thrice-weekly with a 4-hour schedule either post- or pre-dilutional HDF (as per hemodynamic stability and tolerance of patient) using a Fresenius 5008 console and polysulfone high-flux filter (FX60 and FX80) and HD using Fresenius 4008 console — MIDDLE FLUX NIPRO M dialyzer. Clinical parameters including age, body weight BMI, dialyzer characteristics, dialysis time, blood flow rate, dialysate flow rate, vascular access, dry body weight, inter-dialytic weight gain convective volume, and pre- and post-dialysis systolic and diastolic blood pressures (BPs) doses of erythropoiesis-stimulating agents antihypertensive drugs phosphate binders were recorded at baseline and every 3 months till end of study. Serum levels of albumin hemoglobin calcium phosphorus iPTH at baseline and every 3 months till end of study. The Kidney Disease Quality of Life 36-item short form survey (KDQOL-36) was used to measure Quality of Life for patients in both groups at 6 months 12 months and end of study.

RESULTS: Majority of patients in our study were males 122 (74%) out of 165, with age distribution between 46-60 years. Most common cause of ESRD in study patients was diabetes mellitus — 75 (45%) out of 165. Hypertension was reported in 95% (158 out of 165) of study patients. 4) Mean convection volume during HDF was 20.62 ± 1.767 liters. Study patients on HDF tolerated higher blood flow during intervention. Mean blood flow rate during HDF was higher than HD (approximately 288 ml/min vs 285 ml/min), although the difference was not statistically significant Inter-dialytic weight gain was lower in patients on HDF, and the difference was statistically significant at 12 months. Mean pre-dialysis SBP was lower in HDF group, although the difference was not statistically significant. Mean pre-dialysis DBP did not differ much in both groups. Mean post-dialytic SBP and DBP did not differ much in both groups. Hypertension was better controlled in patients on HDF who required a smaller number of antihypertensive tablets when compared to patients on HD although difference was not statistically significant. Mean requirement for EPO was lower in HDF group, and the difference was statistically significant at all study points. Mean requirement of phosphate binders was lower in HDF group, and the difference was statistically significant at 12 months. Mean hemoglobin was higher in HDF group, and the difference was statistically significant at all study points. Mean serum phosphate was lower in patients on HDF, and the difference was statistically significant at all study points. Mean serum calcium was lower in HDF group, and the difference was statistically significant at all study points. Mean serum intact PTH was lower in HDF group, and the difference was statistically significant at all study points. Mean serum albumin was lower in HDF group, and the difference was statistically significant at all study points. Quality of Life scales were comparable in both groups, with a statistically significant improvement in symptoms, cognitive function, sleep, and physical health in HDF group. Mortality in HDF group was lower when compared to patients on HD although difference was not statistically significant

CONCLUSIONS: We conclude that: 1. There is better control of interdialytic weight gain, pre-dialysis SBP, lower requirement of number of antihypertensive drugs, lower weekly EPO requirement, and lower phosphate binders in patients undergoing thrice weekly 4-hour HDF than to patients undergoing thrice weekly 4-hour conventional HD. 2. There is improved anaemia control, lower weekly EPO requirement in patients undergoing thrice weekly 4-hour HDF than to patients undergoing thrice weekly 4-hour conventional HD. 3. Hyperphosphatemia is better controlled in ESRD patients undergoing thrice weekly 4-hour HDF than to patients undergoing thrice weekly 4-hour conventional HD. 4. There is a need for monitoring of serum albumin and calcium levels in patients on HDF as our study showed lower serum albumin and calcium levels in ESRD patients undergoing thrice weekly 4-hour HDF than to patients undergoing thrice weekly 4-hour conventional HD. 5. ESRD patients on HDF have better control of uremic symptoms, cognitive function, sleep and physical health when compared with HD patients, using KDQOL SF 36 questionnaire, 6. There is low mortality in ESRD patients undergoing thrice weekly 4-hour HDF.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 38: ASSESSMENT OF NEUTRALIZING ANTIBODY AGAINST RBD OF SPIKE PROTEIN OF SARS-COV 2 VIRUS IN CKD-HD PATIENTS

K Mahesh Prasad 1, P Tamboli 1, Devangini 1

BACKGROUND: The Covid-19 infection has become a pandemic now. The rapidly changing morphology of the virus is a great challenge for accurate diagnosis management and for making effective preventive strategies. Understanding the development of neutralizing antibodies after vaccination in different subgroups of the population is important to curb the disease more so in CKD-HD group which is known for blunted immune response. As of now we have limited data regarding covid vaccinated CKD patients’ protection status against SARS-COV-2 Virus. The recently published COVID-FRIAT study has presented a worrisome conclusion for CKD patients. It says that the antibody levels in patients on dialysis declining more rapidly than previously reported for the general population.

AIM OF THE STUDY: AIM - This study is done to assess the development of covid neutralizing antibodies their adequacy and sustainability after vaccination in CKD-HD patients. Have analyzed the immune response according to the patient’s age, sex, comorbidities, adequacy of dialysis, and types of vaccine.

METHODS: Material and method - Stage 5 CKD Patients who were on regular hemodialysis are selected for the study. Patients and vaccines related to various factors were recorded. Antibody level was checked by VIDAS II (9COG) kit which detects IgG specific for SARS COVID 2 Receptor Binding Domain (RBD) of the spike protein by ELFA (Enzyme-linked fluorescent assay) technique. The most patient had received either COVAXIN or COVISHIELD

RESULTS: Result -The study confirms that CKD-HD patients are showing good responses after vaccination. The extraneous variables like gender, comorbidities didn’t significantly affect the COVID-19 IGG antibodies formation The peak antibody level is seen around an average of 125 +_ 25 days (4 months). The significant declining trend is seen around 225 +_ 25 days (8 months). The robust response seen when the gap is around 100 days between 2 doses. Nonresponders were 66% in the no-vaccinated group, 23% in the single dose, and 5.88% in the double-dose group.

CONCLUSIONS: Conclusion-Two dose regimen is helping in mounting better antibody response, but there is no significant effect on declining trend when compared to single vaccinated cohort. Both indigenously developed vaccines, Covaxin and Covishield are showing good and comparable efficacy.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 39: ASSOCIATION OF HUMAN LEUCOCYTE ANTIGENS WITH ANTI-SARS-COV-2 SPIKE PROTEIN ANTIBODY FORMATION IN RESPONSE TO VACCINATION IN RENAL ALLOGRAFT RECIPIENT

Sonam Gautam 1, Narayan Prasad 1, Brijesh Yadav 1, Deependra Yadav 1, Ankita Singh 1, Sandeep Yadav 1

BACKGROUND: Cellular and humoral response are required for SARS-CoV-2 eradication. Antigen-presenting cell loads SARS-CoV-2 peptides on human leukocyte antigen with different avidity and present to T and B cell for humoral and cellular activity. Due to immunosuppression, renal transplant recipient patients are speculated to poorly form the antibody against SARS-CoV-2 virus. Therefore, determining the association of specific HLA alleles with anti-SARS-CoV-2 spike protein antibody formation will be helpful in managing the renal transplant recipient patients having specific HLA alleles from SARS-CoV-2 infection and vaccination.

AIM OF THE STUDY: To study the association of human leukocyte antigens with anti-SARS-CoV-2 spike protein antibody formation in response to vaccination in renal allograft recipient

METHODS: In this study, anti-SARS-CoV-2 spike protein antibody in 78 renal allograft recipient patients were determined by the chemiluminescent microparticle immunoassay methods and human leukocyte antigen alleles were determined by the polymerase chain reaction-single strand oligonucleotide methods and analyzed to study the association of human leukocyte antigens with anti-SARS-CoV-2 spike protein antibody formation in response to vaccination in renal allograft recipient

RESULTS: The mean age of the patients in seroconversion vs non-seroconversion (45.88  ± 8.86 vs 45.55  ± 8.74, p value — 0.90). The post-transplant interval in seroconversion vs non-seroconversion (103.63  ± 57.57 vs 77.45  ± 35.25, p value — 0.14). The duration between the vaccination with both the doses and sample collection of renal transplant recipients in seroconversion vs non- seroconversion (47.58  ± 30.18 vs 45.55  ± 35, p value — 0.85). The anti-SARS-CoV-2 spike protein antibody seroconversion rate in renal allograft recipients were 85.9% with median titer in seroconversion vs non- seroconversion 3175.00 (IQR, 798.50 - 8391.70) vs 5.50 (IQR, 4.10 - 8.20, p value — 0.001). In covishield vs covaxin group 2500.70 (IQR, 146.40 - 7705.60) vs 1828.70 (IQR, 665.00 - 3765.10, p value - 0.63). The frequency of HLA class I alleles A*26 was 18.18%, B*08 was 18.18%, C*05 was 25% and Class II HLA alleles — DRB1*03 was 18.18%, and HLA-DQA1*20 was 25% of patient were significantly associated with non-seroconversion and C*06 was 18.75% were significantly associated with seroconversion.

CONCLUSIONS: Renal transplant recipients with anti-SARS-CoV-2 vaccination developed a robust seroconversion rate of 85.9% and alleles of A*26, B*08, C*05, DRB1*03, and DQA1*20 were significantly associated with non-seroconversion

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 40: TUBERCULOSIS IN RENAL TRANSPLANT RECIPIENTS- A SINGLE CENTRE EXPERIENCE

V S Jibia 1, Sivakumar Dhakshinamoorthy 1, Vaishanavi Devi 1, S Guhan 1, Vinoj Murugesan 1, Chelvamalai Muthukumaran 1, Premkumar Devaraju 1, Gopalakrishnan Natarajan 1

BACKGROUND: Renal transplant recipients (RTRs) are at an increased risk of opportunistic infections. Prevalence of tuberculosis (TB) among transplant recipients in endemic countries has been reported to be as high as 10–15%. In transplant recipients, tuberculosis occurs commonly as a result of reactivation of latent infection but also may arise from an infection in the allograft or by acquisition of new infection after transplantation.

AIM OF THE STUDY: To study the clinical profile of tuberculosis in renal transplant recipients

METHODS: This retrospective study included patients who underwent renal transplantation at Madras Medical College Chennai between 2012 and 2022. Tuberculosis (TB) was diagnosed by demonstration of acid fast bacilli in sputum BAL or other body fluids histopathological evidence of TB in biopsy specimens or using other ancillary tests like adenosine deaminase (ADA). Patients who were on anti-tuberculosis therapy pre-transplant either for confirmed TB or latent TB and continued treatment post-transplant were excluded.

RESULTS: A total of 387 patients were included, out of whom 16 (4.1%) patients had tuberculosis. Majority were men (93.8%) and the mean age was 34 years. Thirteen (81.3%) patients had undergone live related renal transplantation and three (18.8%) deceased donor renal transplantation. Nine (56.2%) RTRs had received induction immunosuppression and 15 (93.7%) were on standard triple immunosuppression. Five (31.2%) RTRs had pulmonary TB, 3 (18.7%) had pulmonary TB with pleural effusion, 1 had pulmonary TB with tuberculous cervical adenitis. One patient had disseminated TB involving lung, cervical lymph node, spine, and psoas abscess. Four (25%) patients had pleural effusion. Unusual sites like thigh abscess and peri-anal abscess were seen in two patients. In 10 (62.5%) patients, TB was microbiologically confirmed. The diagnosis of TB was made at a median time of 32 months post-transplantation. Onset of TB post-transplant was < 1 year in 7 (43.8%) and beyond 1 year in 9 (56.2%) RTRs. CMV infection had occurred in 3 (18.7%) patients, hepatitis C infection in 2 (12.5%) patients. Three (18.7%) patients received prior anti-rejection therapy. One patient had had a past history of TB and had received anti-tuberculous therapy (ATT). Post-transplant diabetes mellitus was seen in 7 (43.7%) patients. Ten (62.5%) patients had chronic graft dysfunction. All of them received modified ATT, where rifampicin was replaced by rifabutin in 6 (37.5%) patients, and quinolone-based ATT was given for 10 (62.5%) patients. The mean duration of ATT was 10 months. ATT-induced hepatitis was seen in one patient. There was no mortality related to TB.

CONCLUSIONS: The prevalence of post-transplant tuberculosis in the study population was 4.1%. The diagnosis of TB was made at a median time of 32 months post-transplantation. Early diagnosis and treatment with modified four drug ATT regimen had good outcomes.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 41: COMPARISON OF STANDARD AND GLOBAL COAGULATION TESTS IN HEMODIALYSIS PATIENTS

Kushal Kekan 1, Kushal Kekan 1, Sarah Chahal 1, Madhumita Premkumar 1, Jasmina Ahluwalia 1, Narender Kumar 1, HS Kohli 1, Smita Divyaveer 1

BACKGROUND: Patients of chronic kidney disease on dialysis are at risk of both bleeding and increased thrombosis. Conventional tests of coagulation are not accurate at predicting bleeding risk and do not provide information on thrombotic risk. Hence, we planned this study with the following objectives: 1. To compare coagulation parameters in chronic kidney disease patients on hemodialysis (CKD-5D) using standard (SCT) and global, i.e., Sonoclot (GCT) coagulation tests. 2. Association of these tests with clinical hemostatic events. Background: Patients of chronic kidney disease on dialysis are at risk of both bleeding and increased thrombosis. Conventional tests of coagulation are not accurate at predicting bleeding risk and do not provide information on thrombotic risk. Hence, we planned this study with the following objectives: 1. To compare coagulation parameters in chronic kidney disease patients on hemodialysis (CKD-5D) using standard (SCT) and global, i.e., Sonoclot (GCT) coagulation tests. 2. Association of these tests with clinical hemostatic events.

AIM OF THE STUDY: To compare standard and global coagulation tests in hemodialysis patients

METHODS: This is a prospective observational single arm cross-sectional study conducted at Department of Nephrology, PGIMER, Chandigarh, India. A feasibility sample of 50 patients were enrolled for this pilot study. All patients with chronic kidney disease on dialysis. Inclusion criteria: Age >18 years. Exclusion criteria: Pre-existing diseases of coagulation sepsis disseminated intravascular coagulation malignancy patient on therapeutic anticoagulation pregnancy.

RESULTS: 162 patients were screened, and 50 patients were enrolled. Underlying etiology was glomerular diseases, n = 13 (26%), diabetic kidney disease, n = 10 (20%), hypertensive nephrosclerosis n = 6 (12%), unknown n = 9 (18%), and others n = 12 (24%). Mean age was 40.54Â ± 15.88 years. 37 (74%) were males, and 13 (26%) were females. Mean dialysis vintage was 16.354 + 20.28 months. 54% (n = 27) of patients were undergoing HD through arteriovenous fistulas, 28% (n = 14) through temporary venous catheter (IJV or femoral) and 18% (n = 9) through Permcath. 35 (70%) patients (8 on standard dose and 27 on low dose heparin) were given heparin during current HD while 15 (30%) patients were given heparin free HD. Five patients had thrombotic events, and seven had bleeding events during admission. The baseline values and association with thrombotic and bleeding events are shown in Table 1. The correlation of standard and global coagulation test parameters are shown in table 2.

CONCLUSIONS: Only a few SCT and GCT parameters correlate with each other, however the correlation is not strong. The association with bleeding events was insignificant for all parameters. Some SCT and GCT parameters were significantly different in those with and without thrombosis, but the cause–effect relationship was conflicting in case of SCT only. Hence, GCT are better than SCT.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 42: HYPERVISCOSITY SYNDROME COMPLICATING IGG MYELOMA €” COGNIZANCE OF EARLY PLASMAPHERESIS IS CRUCIAL

Vivek Sood 1, Dogra Manu 1, Vishal Singh 1, Suman Pramanik 1, Kundan Mishra 1, Rajat Bahl 1, Gaurav Singhal 1

BACKGROUND: Hyperviscosity syndrome (HVS) is an infrequent but life-threatening complication of multiple myeloma (MM) and classically presents with the triad of mucosal bleed neurological and visual disturbances. HVS is typically associated with Immunoglobulin M (IgM) MM and very rarely may complicate IgG MM. Even suspicion of HVS necessitates therapy based on clinical severity rather than the calculated degree of viscosity. While plasmapheresis promptly decreases serum viscosity by 30–50% early initiation of anti-myeloma therapy is crucial to prevent rebound phenomena.

AIM OF THE STUDY: In this context, we report a case of IgG MM which despite being complicated by HVS had gratifying outcome attributable to early clinical suspicion and consequent prompt therapeutic intervention.

METHODS: Case report -- A 60-year-old lady presented with headache altered sensorium blurring of vision and bleeding from both nostrils of two days duration. She also had breathlessness on exertion and generalized fatigue for one month. Clinical evaluation was remarkable for pallor hypertension (blood pressure - 160/96 mm Hg) tachypnea (respiratory rate - 26/minute) with blood clots in nostrils bleeding from gums dry tongue and skin bruising on the arms. Besides altered mentation neurological evaluation revealed bilateral venous congestion and perivenular flame-shaped hemorrhages on direct ophthalmoscopy. There were no features of heart failure peripheral lymphadenopathy or organomegaly. Her initial blood sampling was difficult as blood was rapidly clogging during sampling itself. After rapid saline infusion, samples could be drawn and processed. Hemogram showed normocytic normochromic anemia (hemoglobin-6.3 g/dL) thrombocytopenia (platelets -71 000/mm3) and rouleaux formation without hemolysis or blast cells on peripheral blood smear. SARS-CoV-2 PCR was negative. She had reversal of albumin–globulin ratio (total protein -10.6 g/dL; albumin -2.1 g/dL) hypercalcemia (corrected calcium - 14 mg/dL) and raised creatinine of 2.5 mg/dL. Her coagulation profile was essentially normal. Computed tomography images of head chest and abdomen were essentially normal. Further evaluation revealed M-spike (5.3 gm/dL) on serum protein electrophoresis raised IgG (4.69 g/dL) increased kappa light chain (kappa 171 mg/L lambda 24.3 mg/L; ratio -7) on serum-free light chain assay monoclonal band of IgG Kappa on serum immune-fixation electrophoresis. Bone marrow aspiration revealed 60% plasma cells (Figure-1) with sheets of plasma cell on bone marrow biopsy having kappa-restriction on immunohistochemistry thereby confirming multiple myeloma and ruled out remote possibility of lymphoplasmacytic lymphoma-related HVS. In view of presumptive HVS complicating multiple myeloma patient was managed with urgent plasmapheresis and consequently initiated on bortezomib-based anti-myeloma triplet therapy including lenalidomide and dexamethasone (VRd) besides supportive therapy for hypercalcemia and acute kidney injury. After three sessions of plasmapheresis patient showed complete resolution of symptoms of HVS with remarkable change in plasma color (Figure-2). Her acute kidney injury also recovered by day-7, and she went home walking on day-10 of her hospitalization. Two months later she was tolerating her chemotherapy well with complete resolution of hypergammaglobulinemia. Six months later she is in complete remission and is being planned for autologous hematopoietic stem cell transplant.

RESULTS: Discussion - Classical triad of HVS include mucosal bleed, neurological disorders, and visual disturbances.5 Presence of oro-nasal bleed mandates thorough retinal evaluation since hemorrhages may occur without visual symptomatology. Furthermore, clinical signs include hypertension, congestive heart failure5, priapism6, and decreased hearing merit consideration. Structure of protein is an important determinant of viscosity, whereby spherical proteins rotate through plasma and contribute very little and large linear proteins spin end over end and raise viscosity disproportionately. Likewise, IgM (molecular weight of 950 Kd) has a high axial length-to-width ratio and, therefore, raises plasma viscosity at levels above 5 g/dL. IgA circulates as a dimer, and results in HVS at levels above 7 g/dL7. HVS complicating IgG MM with IgG circulating as a monomer (molecular weight of 180 Kd) is rare and accounts for less than 5% of cases and requires IgG level usually above 10 g/dL7. Even presumptive suspicion of HVS necessitates therapy based on clinical severity rather than the calculated degree of viscosity as correlation between serum viscosity and clinical manifestation is not precise; nevertheless, symptoms attributable to HVS are rare if serum viscosity is less than 4 centipoise (CP) [normal value -1.5 CP]. With rapid symptomatic relief following plasmapheresis, absence of further therapeutic and prognostic implications and logistic constraints, serum viscosity and Ig G subtyping8 couldn’t be estimated in the index case. As IgM is predominantly limited to intravascular space (over 80%), only a single session of plasma exchange (removal of 1—1.5 plasma volume) typically, decrease plasma viscosity by 30% to 50%, and reduce IgM level by 60%9 and is generally sufficient to abate acute symptoms in patients with IgM-related HVS. In contrast, maximum of three sessions of plasmapheresis10 may be needed in IgG-related HVS (due to late and less efficient removal of IgG as it is near equally distributed between the intravascular space and extravascular space) or if the viscosity remains over six CP11. Although International Myeloma Working Group does not specifically identify HVS as myeloma-defining event, clearly its presence warrants Bortezomib-based chemotherapy for rapid decline of Ig levels.5 However, pharmacological treatment should never be considered as an alternative to plasma exchange for immediate hyperviscosity reduction.5 Moreover, patients with HVS tend to have plasma volume expansion; hence, actual anemia may be partially dilutional. Consequential red blood cell transfusion can have negative rheological impact of adding red cells to the circulation and further increase in blood viscosity and worsen HVS.5 Therefore, red blood cell transfusion is recommended only after blood viscosity reduction. Symptomatic HVS consequent to IgG MM with IgG levels below 5 g/dL7 is infrequent and hence reported for its novelty. Moreover, early clinical suspicion of HVS and consequent pre-emptive plasmapheresis (even before completion of work-up of MM) may improve clinical outcome as evident in the index case.

CONCLUSIONS: To conclude, neurological dysfunction at presentation of MM with / without mucosal bleed and visual disturbance should caution us toward an albeit infrequent, yet devastating complication of HVS, which is otherwise potentially reversible subject to early clinical suspicion and prompt initiation of appropriate therapy.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 43: OVERCOMING THE CHALLENGES OF POST-TRANSPLANT URINARY TRACT INFECTION WITH CARBAPENEM RESISTANT ENTEROBACTERIACEAE – A PROSPECTIVE STUDY

Vamsidhar Veeranki 1, Dharmendra Singh Bhadauria 1

BACKGROUND: Urinary tract infection (UTI) is the most common infection among renal transplant recipients (RTR's) and was found to be associated with impaired graft function, associated with worse patient and graft outcomes and significant morbidity. Despite the increasing incidence of infections caused by carbapenem-resistant-Enterobacteriaceae (CRE) among the RTR's, there is paucity of data.

AIM OF THE STUDY: We analyzed the clinical profile, therapeutic response and patient and graft outcomes among the renal transplant with symptomatic UTI due to CRE.

METHODS: In this single-center prospective 6-year study, RTRs admitted with symptomatic UTI and a urine culture positivity for CRE were included and were followed for 5 years. All patients received high-dose Meropenem/ Colistin with either oral Fosfomycin/ Minocycline for 2 weeks followed by Oral Faropenem+Fosfomycin/Minocycline for 4 weeks followed by prophylactic dose for 3 months. Data regarding the clinical presentation, complications, treatment response, time to clinical recovery were analyzed. 1-year recurrence, patient and graft-survival at 5-year follow-up were analyzed.

RESULTS: A total of 28 patients were admitted in the study period with CRE-associated UTI. The median duration of occurrence of UTI post-transplant is 7 days (IQR: 4-7.5). Klebsiella pneumonia was the most common organism isolated (53.5%). With the above therapeutic regimen, all the patients have responded (100%) and the median 1-year recurrence rate was 2 (IQR:1-2). 12 (42.8%) had CRAI at 5 years. The 5-year death-censored graft-survival and patient-survival were 96.4% and 89.2% respectively.

CONCLUSIONS: With the combination of high-dose Meropenem and Fosfomycin/Minocycline for an extended duration followed by oral prophylaxis for 3 months, there was improved therapeutic response and the graft and patient-survival at 5 years.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 44: TREATMENT AND LONG-TERM OUTCOMES OF POST-TRANSPLANT RECURRENT FSGS €” A SINGLE-CENTER EXPERIENCE

Vamsidhar Veeranki 1, Dharmendra Singh Bhadauria 1

BACKGROUND: Post-transplant recurrence rates of focal-segmental glomerulosclerosis (rFSGS) vary from 30 to 55% with graft loss of up to 60%. Though the previous studies conducted have evaluated the efficacy of Rituximab (RTX) or therapeutic plasma-exchange (TPE), there is lack of consensus on their role in rFSGS due to the wide variations in the efficacy. We report the experience from our center over a 11-year time period in the current study.

AIM OF THE STUDY: To analyze the clinical profile pre- and post-transplant treatment regimens remission rates major infections long-term patient and graft-survival of patients with rFSGS.

METHODS: In this single-center retrospective study data of renal transplant recipients (age > 18 years) with biopsy-proven recurrent primary-FSGS between 2011 to 2021 were collected from the electronic database. Data regarding the pre-transplant and post-transplant clinical profile treatment received and remission rates follow-up of these patients including graft and patient survival hospitalizations and infectious disease episodes were collected and analyzed.

RESULTS: A total of 18 patients with biopsy-proven rFSGS were included in the study. The median time to disease recurrence was 45.6 days (IQR 5.4 — 225 days). Presentation in the allograft was mostly nephrotic (17 of 18 patients). 72.2% presented early, within the first 6 months the rest had presented late beyond 6 months of transplant. 5 — 7 sessions of TPE was done in 12 patients with RTX added in 9 patients. Four of these patients were continued on maintenance TPE. Remission was seen in 10 patients (55.6%). Remission rates with TPE, TPE+RTX combination and with neither TPE+RTX was 30%, 75 — 80% and 50% respectively. Continuation of Maintenance-TPE prevented relapses but with similar remission rates. 3-year death-censored graft-survival and patient-survival was 52.9% and 88.2% respectively.

CONCLUSIONS: The use of TPE with Rituximab has resulted in better remission and graft survival rates compared to the TPE alone although associated with increased rate of infections seen with the former.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 45: ELEVATED URINARY MITOCHONDRIAL DNA INDUCES INFLAMMATION AND ASSOCIATED WITH ACUTE KIDNEY INJURY IN SARS-COV-2 INFECTED RENAL ALLOGRAFT RECIPIENT

Brijesh Yadav 1, Narayan Prasad 1, Ankita Singh 1

BACKGROUND: Severe acute respiratory coronavirus-2 (SARS-CoV-2) affected multiple organs including kidney. SARS-CoV-2 open reading frame protein 3a induces necroptosis in infected cell leading release of mtDNA which binds to TLR9 and trigger innate immunity which may lead to acute allograft injury.

AIM OF THE STUDY: To determine the specificity and sensitivity of urinary mitochondrial DNA (umt-DNA) and neutrophil gelatinase-associated lipocalin (NGAL) in predicting COVID-19-associated acute kidney injury (AKI) mitochondrial stress and inflammation.

METHODS: Live-related RTRs (n = 66) who acquired SARS-CoV-2 infection and were admitted to a COVID hospital were included and subclassified into AKI (N = 19) with >25% spike in serum creatinine level from the pre-COVID-19 serum creatinine level and non-AKI (N = 47) whose serum creatinine value remained stable similar to the baseline value or a rise of < 25% of the baseline values of pre-COVID-19. A 50 ml urine sample was collected and umt-DNA and N-GAL was determined by the RT-PCR and ELISA methods respectively. A 1 x 106 PBMCs were stimulated for 24 hrs. with 1Âμg/ml of urinary DNA or CpG oligodeoxynucleotide (5’-tcgtcgttttcggcgc:gcgccg-3’) in duplicate. Unstimulated PBMCs served as control. The gene expression of IL-10 IL-6 and MYD88 was analyzed by the RT-PCR and IL-6 IL-10 level in supernatants by the ELISA.

RESULTS: Both the urinary mitochondrial gene ND-1 and NGAL level were significantly higher in AKI group compared to non-AKI. The mean ND-1 gene Ct in AKI group was (19.44Â ± 2.58 a.u) compared to non-AKI (21.77Â ± 3.60; p = 0.013). The normalized ND-1 gene Ct in AKI was (0.79Â ± 0.11 a.u) compared to non-AKI (0.89+0.14; P = 0.007). The median urinary NGAL level in AKI group was (453.53; range, 320.22-725.02, 95% CI) ng/ml compared to non-AKI (212.78; range, 219.80-383.06, 95%CI; p = 0.015). The median urine creatinine normalized uNGAL was 4.78 (0.58-70.39) ng/mg in AKI group compared to 11.26 ng/mg (0.41-329.71) in non-AKI group. The area under curve of ND-1 gene Ct was 0.725, normalized ND-1 Ct was 0.713, and uNGAL was 0.663 and normalized uNGAL was 0.667 for detecting the AKI and mitochondrial stress. The IL-10 gene expression was downregulated in umt-DNA-treated PBMCs compared to control (-3.5Â ± 0.40 vs 1.02Â ± 0.02, p < 0.001). IL-6 and Myd88 gene expression was upregulated. The culture supernatant IL-10 and IL-6 level in umt-DNA treatment PBMCs vs control was 10.65Â ± 2.02 vs 30.3Â ± 5.47, p = 0.001 pg/ml; and 200.2Â ± 33.67 vs 47.6Â ± 12.83pg/ml, p = 0.001 respectively.

CONCLUSIONS: Urinary mt-DNA quantification can detect the Covid-associated AKI and mitochondrial distress with higher sensitivity than uNGAL in RTRs and induces inflammation in PBMCs.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 46: EFFECT OF INTRADIALYTIC EXERCISE ON DIALYSIS EFFICACY IN ESKD PATIENTS ON HEMODIALYSIS IN A TERTIARY CARE CENTRE

Harsha 1, D P Giridesh 1, P Zachariah Paul 1, Anil Mathew 1, George Kurian 1, Rajesh R Nair 1

BACKGROUND: Chronic kidney disease patients requiring renal replacement therapy are emerging public health problems in developing countries, and hemodialysis is the most common modality of RRT. Measures to improve dialysis adequacy are being researched. Intradialytic exercise is one among such intervention which is being under research in the present decade which can be affordably implemented.

AIM OF THE STUDY: To evaluate the effects of intradialytic exercise on efficiency of hemodialysis in patients undergoing maintenance hemodialysis in our center.

METHODS: This was a prospective interventional study conducted at hemodialysis center in Amrita Institute of Medical Science Kochi Kerala. 119 patients were screened; 54 patients were included. They were made to perform 10 minutes of aerobic exercise followed by 10 minutes of resistance exercise during hemodialysis for a period of eight weeks. Single pool Kt/V (spKt/V) urea reduction ratio (URR) and various biochemical parameters were assessed pre- and post-intervention.

RESULTS: Among the 54 patients 39 (72%) of the study population were males and 15 (28%) were females. The mean URR pre- and post-intervention was 64.4% and 68.1% which showed statistical significance with p value of <0.001. The mean spKt/V at baseline was 1.27. With 8 weeks of intradialytic exercise, the mean spKt/V was 1.40 and p value was 0.001 which was statistically significant. No cardiovascular decompensation was observed during the exercise program. There was no significant change in levels of calcium, phosphorous, hemoglobin, albumin, or potassium.

CONCLUSIONS: This study suggests that a 10-15 minutes’ duration of aerobic exercise of moderate intensity/ 10 minutes of resistance exercise in the initial first 2 hours of hemodialysis can safely improve the efficacy of hemodialysis. Long-term studies are required to assess the effect of intradialytic exercise on various biochemical parameters.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 47: HLA ALLELES GENOTYPES AND HAPLOTYPES FREQUENCIES IN POTENTIAL RENAL TRANSPLANT DONORS AND RECIPIENTS AT TERTIARY CARE HOSPITAL

Kavish Sharma 1, Dhananjai Agrawal 1, Shashank Bhardwaj 1, Niranjan 1, Arjun 1

BACKGROUND: HLA is also known as the main histocompatibility complex which is encoded by highly polymorphic set of genes located on the short arm of chromosome 6 matching of HLA has significance in hematopoietic and solid organ transplant. There is lack of data of HLA allele genotype and haplotype frequency among Indian population such data may help in formation of transplant registry and allocation of graft.

AIM OF THE STUDY: Establish the frequencies of HLA alleles genotypes and haplotypes in renal transplant recipients and donors and there family members to characterize their frequency distribution.

METHODS: Sample size -100 who met in inclusion criteria over a period of one year. HLA typing will be carried out using Polymerase Chain Reaction-Sequence Specific Primer.

RESULTS: The most frequent HLA A alleles among recipients was HLA A*02 (0.25), HLA B alleles was HLA B*51 (0.19), and HLA DRB1 alleles was DRB1*27 (0.21), whereas the most frequent HLA A alleles among donors was HLA A*01 (0.19), HLA B alleles was HLA B*51 (0.19), and HLA DRB1 alleles was DRB1*07 (0.23).

CONCLUSIONS: The knowledge of HLA allele and haplotype frequencies will help in understanding the Indian population genetics and help the organ transplant team to find suitable matched donors for transplant recipients and form transplant registry.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 48: ASSOCIATION OF COL4A1 GENETIC VARIATIONS WITH RISK OF DIABETIC NEPHROPATHY (DN) IN THE NORTH INDIAN POPULATION

Neha Shukla 1, Shivani Kumari 1, Poornima Verma 1, Aneesh Srivastava 1, Naveen Kumar Gautam 1

BACKGROUND: Diabetic nephropathy (DN) is late-stage diabetes associated microangiopathic complication. The prevalence of DN is projected to grow rapidly causing increased morbidity and mortality. Besides established environmental factors several single nucleotide polymorphisms (SNPs) have been associated with the DN pathology.

AIM OF THE STUDY: The main aim of the study was to identify the risk associated with genetic variant (rs605143) of COL4A1 gene in the development of DN in North Indian population.

METHODS: This study involved peripheral blood sample samples from 193 subjects (60 Type 2 diabetes mellitus patients with nephropathy (DN) 60 Type 2 diabetes mellitus without nephropathy (DWN) and 73 healthy controls (HC). The SNP was evaluated by polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP). Genotypic allelic frequency and carriage rate frequencies as calculated from SPSS software version 23 and Graph Pad prism 5

RESULTS: These findings suggest that COL4A1 genetic variants may involve susceptibility for diabetic nephropathy and the A allele is the risk allele for diabetic nephropathy.

CONCLUSIONS: We found a significant association of COL4A1 (rs605143G/A) gene polymorphism with DN in North Indian patient indicating the role of this variant in developing risk for DN.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 49: TO STUDY THE OUTCOME OF PLASMA EXCHANGE IN ACUTE LIVER FAILURE DUE TO RATOL POISONING: A NEPHROLOGIST ROLE

Sridatta Gurudatta Pawar 1, T Sugan Gandhi 1

BACKGROUND: Ratol poison is widely available rodenticide in India which contents yellow phosphorus which is a protoplasmic poison that causes acute liver failure and can be fatal. PLEX tends to remove toxins and other inflammatory mediators. Newer guidelines recommend PE as an essential and urgent treatment of choice for critically ill patients with ALF until recovers or as bridging support for liver transplantation. Here we share our experience in PE as a modality when liver transplants are not easily available and to assess the effect of PE on patient outcome and lab parameters.

AIM OF THE STUDY: 1. To compare the outcome of plasma exchange with patient outcome 2. To compare liver function tests pre- and post-PLEX

METHODS: Prospective observational study is done in a tertiary hospital between May 2021 and May 2022 Inclusion criteria. All Yellow phosphorus poisoning patients with ALF requiring PLEX. Exclusion criteria Age <18 YRS Preexisting liver disease All causes of ALF other than YP Patients age sex and baseline laboratory profiles including complete hemogram liver function tests (LFT) and coagulation parameters were noted s before and after each PLEX With time to admission after consuming YP in days. Patient outcomes were recorded as survival or expired liver parameter outcomes as recovered or not. Those patients who survived were followed up till their liver functions were normalized

RESULTS: Total of 20 patients, mean age was 26 yrs. Males predominance with 70%, all cases being suicidal in nature. 14 patients (70%) had recovery from ALF, patient who recovered were started of PE at 1st sign of coagulopathy or encephalopathy, i.e., early initiation and were referred earlier to our center for PE. Six patients (30%) expired were referred late and presented with higher levels of bilirubin, coagulopathy, and higher grade of encephalopathy. The study showed significant improvement in total bilirubin, liver enzymes, and INR before and after PE, with P value 0.001 and normalized among survivors. A significant association was noted between success of treatment, time taken to reach our center, and early initiation of PE.

CONCLUSIONS: Acute liver failure is the major cause of mortality in acute ingestion of yellow phosphorus. We in our experience found that the early initiation of plasmapheresis in patients with any of following, i.e., any degree of encephalopathy or INR >1.5 has lead to improved survival and better outcomes. This modality of treatment requires more awareness among doctors as many still are unaware and patient are referred in late stage of liver failure which increased mortality among the patients. Early initiation of PLEX was found to have significant benefits in patient survival.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 50: ASSESSMENT OF DIETARY ACID LOAD (DAL) IN CHILDREN WITH CHRONIC KIDNEY DISEASE (CKD) AND IN THOSE ON DIALYSIS-AN OBSERVATIONAL STUDY

Sravani Madhileti 1, Sheeba Collins 1, Arpana Iyengar 1

BACKGROUND: Dietary acid load (DAL) that reflects the balance between acid and alkali-inducing foods is a modifiable risk factor for metabolic acidosis in CKD. With paucity of data in the Indian context, this cross-sectional study was undertaken to estimate DAL and assess acid/alkali food consumption in children with CKD2-5D.

AIM OF THE STUDY: To estimate dietary acid load (DAL) and assess acid/alkali food consumption in children with CKD2-5 and in those on dialysis

METHODS: Clinical profile dietary assessment of energy protein intake/deficits and nutrient intake were computed for Indian foods from the United States Department of Agriculture in clinically stable children with CKD2-5D. DAL was estimated using Potential Renal Acid Load (PRAL meq/day) = (0.49 × protein intake g/day)+(0.037 × phosphorus intake mg/day)—(0.02 × potassium intake mg/day)âˆ'(0.013× calcium intake mg/day)âˆ'(0.027 × magnesium intake mg/day). Positive dietary PRAL (>0) suggests acidic content and negative PRAL (<0) suggests alkali content. PRAL was stratified by quartiles for interpretation. Reference values of PRAL for Indian foods were noted.

RESULTS: Eighty-one children (mean age 122+47 months, 69% boys, 39.5% on dialysis, 76.5% non-vegetarians) were studied. One-third were on bicarbonate supplements. Positive PRAL (9.97+7.66 meq/day) was observed in 74 (91.36%) children with comparable proportions in those with CKD 2-5 and those on dialysis (90.1% vs 93% respectively, p > 0.05). Protein intake was significantly higher in the highest quartile compared to lowest quartile of PRAL in CKD2-5 (55+16 g/day vs 40+14 g/day, p < 0.001) and dialysis groups (47+15 g/day vs 25+11 g/day, p = 0.002). Majority (74%) consumed highly acidic and limited alkali foods.

CONCLUSIONS: In children with CKD2-5D, PRAL estimation revealed high DAL in the majority with a high consumption of acidic foods. These findings provide implications for appropriate dietary counseling.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 51: EFFICACY OF REMOTE ISCHEMIC PRECONDITIONING IN LIVING DONOR RENAL TRANSPLANTATION: A RANDOMISED CONTROLLED TRIAL

Nikita Pawar 1, Vaibhav Tiwari 1, Vinant Bhargava 1, Shiv Chaddha 1, Anurag Gupta 1, Manish Malik 1, Ashwani Gupta 1, Anil K Bhalla 1, D S Rana 1

BACKGROUND: In kidney transplantation, ischemia reperfusion injury (IRI) is an inevitable complication. Whenever there is an ischemic injury to the organ cell, death and tissue injury occur. If ischemic tissue is timely perfused injury can be prevented. However paradoxically an additional injury occurs upon reperfusion which limits the amount of tissue that can be salvaged. Together this is termed as ‘ischemia—reperfusion injury’ (IRI). Limiting this injury can increase patient and graft survival and can decrease complications associated with transplantation. Different strategies have been tried to reduce ischemic reperfusion injuries. Ischemic preconditioning is one of such strategies. Many studies have proven that remote ischemic preconditioning (RIPC) is safe simple low cost and non-invasive preventive procedure including renal transplantation. Thus we have conducted RIPC a randomized controlled trial in patients undergoing renal transplantation.

AIM OF THE STUDY: To study efficacy of remote ischemic preconditioning in living donor renal transplantation. The efficacy was evaluated as proportion of patients achieving 50% decline in serum creatinine level at 72 hours after transplantation and oliguria on day 1, 2, and 3. Secondary objectives were measured as proportionate change in pre- and post-transplant plasma and urinary concentration of neutrophil gelatinase-associated lipocalin (NGAL) level eGFR at 3 months of transplantation acute rejections and delayed graft function.

METHODS: Randomized controlled trial was done at our tertiary care center to assess the efficacy and safety of remote ischemic preconditioning in living donor renal transplantation. Enrolment of subjects was started from June 2020 to September 2021. This study was conducted on a total of 110 ABO compatible live donor Kidney transplant recipients. Randomization was done 58 patients in RIPC group 52 patients in control group were studied. They were followed for 3 months in study.

RESULTS: Mean age in both groups was comparable, 37.09 years in RIPC group while 38.3 years in control group. Majority of recipients were male in both groups; 72.4% in RIPC and 75% in control group while majority of kidney donor were females, 82.8% in RIPC group and 71.2% in control group. Basic diseases of CKD were comparable in both groups. Chronic glomerulonephritis as the most common cause of chronic kidney disease (55.4%). Diabetic kidney disease was present in 17.2% cases. Total 91.8% of cases received induction therapy. Most commonly used is ATLG (52.7%) followed by ATG (37.3%), while basiliximab in least cases (1.8%). Induction agent was not used in 8.2% cases. This distribution was comparable in both groups. All patients showed >50% decline in creatinine level at 72 hours of transplant. The mean serum creatinine on day 7 of transplant level in RIPC group was 1 mg/dL and 1.1 mg/dL in control group. There was no oliguria in 1st 3 days. Mean urine output were 13.1 L, 10 L, 7.8 L on day 1, 2, 3 respectively in RIPC group, while 14 L, 10.7 L, 7.9 L on day 1, 2, 3 respectively in control group. There was no difference in urine output in both groups. The stable graft function was present in 83.6% of cases. It was higher in RIPC group compared to control group. Delayed graft function was present in 3.8% cases of control group and 1.7% in RIPC group. Similarly, slow graft function was present in 17.3% in control group while 10.3% in RIPC group. The mean serum creatinine level in both groups was same at 3 months, 1.2 mg/dL. Similarly, mean eGFR value calculated by CKD-EPI (2021) formula was same, 74.8 ml/min/m2. Urinary tract infections were most common in 1st 3 months of transplant, 13.7% in RIPC group and 17.3% in control group. Other complications like lower respiratory tract infection (3.8%), fungal infection, herpes, parvovirus were found in control group, 1.9% in each. Acute pancreatitis was present in 2 patients, 1 in each group. Acute tubular necrosis was most common finding on biopsy (63.6%). Cellular rejection (5.4%) was more common than antibody-mediated rejection (0.9%). 3.6% biopsies showed normal findings despite of graft dysfunction. The median duration of hospitalization was 10 days in both groups RIPC by blood cuff inflation was safe as all patients tolerated it without any major side effects.

CONCLUSIONS: Remote ischemic preconditioning by blood pressure cuff inflation is safe method without any major side effects. There was no effect of RIPC on short-term primary end points. The fall in serum creatinine by &gt;50% at 72 hours was similar among the groups. No patient experienced oliguria in 72 hours. There was little evidence of low graft dysfunction and low rejection rate in RIPC group. There was no evidence of beneficial clinical effect of RIPC on eGFR at 3 months. Thus, RIPC is safe method and has little beneficial effects on graft outcome. Longer follow-up period is needed to know the effect of RIPC in subsequent years.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 52: LONG TERM OUTCOMES OF PATIENTS WITH LUPUS NEPHRITIS- A SINGLE CENTRE EXPERIENCE

Vaishanavi Devi Rajarathinam 1, Shivakumar Dakshinamoorthy 1, P Shankar 1, Guhan Senthilkumaran 1, VS Jibia 1, Vinoj Murugesan 1, Premkumar Devaraju 1, Chelvamalai Muthukumaran 1, Natarajan Gopalakrishnan 1

BACKGROUND: Lupus nephritis (LN) is a frequent complication of systemic lupus erythematosus (SLE) affecting 60% of adult SLE patients with a considerable impact on morbidity and mortality. There is a paucity of data on the long-term outcomes of LN in South India. This study describes the long-term clinical course of patients with lupus nephritis.

AIM OF THE STUDY: To describe the long-term clinical course of patients with lupus nephritis.

METHODS: This retrospective study included patients with biopsy-proven LN diagnosed on or before January 1, 2020, attending Nephrology OPD at Madras Medical College Chennai. Data regarding demographic clinical and histopathological features and the treatment regimens used was extracted. Outcomes in terms of remissions relapses progression to dialysis dependency obstetric events and patient survival were studied.

RESULTS: We included 84 patients with lupus nephritis, with a mean age of 33.3 years, and a female: male ratio of 16:1. LN was histopathologically verified in all the patients with a class distribution as follows: class 2 in 3 (3.5%), class 3 in 22 (26.2%), class 4 in 46 (54.7%), class 5 in 12 (14.3%), and class 6 in 1 (1.1%). Fourteen patients with class 3 LN and 16 patients with class 4 LN additionally had features of class 5 LN. The median duration of follow-up was 6.8 years (IQR 5.5). Complete remission was seen in 38% of the patients, partial remission in 30.9% and non-response/ persistent proteinuria in 21.4%. Five patients (5.9%) had progressed to dialysis dependent CKD and 3 (3.5%) had died. Lupus flares were seen in 44 patients with 36 of them having a renal relapse. Histopathological class switch was demonstrated in 12 patients. Cyclophosphamide was used as induction regimen in 58 (69%) of patients, while MMF was used in 26 patients (30.9%). The flare rates were 41.3% in the cyclophosphamide group and 46.15% in the MMF group. A high rate of non-adherence to treatment was noted (72%). The factors predicting poor outcomes were higher serum creatinine at presentation, non-adherence to treatment and failure to achieve remission at the end of one year. Major infections requiring modification/reduction of immunosuppression were seen in 25 (29.7%) patients, of whom 2 had tuberculosis. Eight patients had confirmed pregnancies after the diagnosis of SLE, of whom 4 had successful outcomes, 3 resulted in miscarriages, and one IUD. Gestational hypertension/ preeclampsia occurred in 2 patients. The overall patient survival rate was 96.4%.

CONCLUSIONS: Complete/partial remission was achieved in 69% of the patients. Non-adherence to treatment was a major problem (72%). The overall patient survival rate was 96.4%.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 53: PLANNING THE SEQUENCE FOR MULTIPLE AVFS IN A PATIENT ON HEMODIALYSIS. WHICH LOCATION TO PRIORITIZE?

Deepa Usulumarty 1, Ravi Brahmabhatt 1, Manoj Kumar 1, Narayan Rangaraj 1, Santosh Noronha 1, Jatin Kothari 1, Shrirang Bichu 1, Rajesh Kumar 1, Viswanath Billa 1

BACKGROUND: An AV fistula is considered the best vascular access option for a patient on hemodialysis. In comparison to catheters, AVFs are economical and have a lower morbidity. While this fact is established there is not adequate data to guide the optimal sequence of AVF creation.

AIM OF THE STUDY: To determine the optimal AVF site sequence when multiple accesses need to be created in the lifetime of a patient with CKD on MHD.

METHODS: A retrospective study was conducted to evaluate the life cycle of all AVFs created between 2015 to 2022 at 5 dialysis centers of Apex Kidney Care in Mumbai. 280 patients underwent 344 AVF surgeries during this period. Patients were analyzed on Quality of life with an AVF, and fistula survivals were calculated between the various anatomical sites.

RESULTS: 280 patients underwent 344 AVF surgeries during this period, with a mean AVF creation rate of 1.22/patient. Males constituted 64% of all patients. Most patients had a single AVF (81%), a second AVF was done in 17% patients, and a small minority had a third AVF (2%). Out of 344 AVFs, 174 were proximal and 170 were distal. 81% of all AVFs were created on the non-dominant arm. Primary failure occurred in 52 AVFs (15%), secondary failure occurred in 59 patients (17%). Secondary failure occurred in 27% of proximal and 38% of distal AVFs. The AVFs remained functional in 223 (63%) patients until their death, transplant or end of the study period. In descending order, the median survival of ND distal AVF was 91 mths, ND proximal AVF was 84 mths, D distal AVF was 72 mths, D proximal AVF was 48 mths. There was a significant difference (p < 0.0001) in the QOL decline for patients with an AVF on D hand (0.3) as against the ND hand (0.27).

CONCLUSIONS: Considering the projected AVF survival as well as the QOL decline after AVF creation, any first AVF creation should prioritize the ND hand over the D hand and the distal location over proximal, for either hand.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 54: INCIDENCE OF TUNNELED CATHETER RELATED INFECTIONS AND THE PREDISPOSING RISK FACTORS- SINGLE CENTRE EXPERIENCE

Mohd Umair 1, Ajinkya Patil 1

BACKGROUND: Tunneled cuffed catheters (TCC) have emerged as a substitute in CKD patients as a bridge between non-cuffed catheters and AV fistula. The prior being limited mainly by risk of infections and life of the catheter per se and the latter by time taken for maturation and thrombosis mainly. Owing to only a meager amount of patients with a functioning AV fistula TCCs are a crucial access option. However in developing countries like India, infection forms probably the most common limiting factor to the use of these

AIM OF THE STUDY: We intended to study the incidence of TCC-related infections at our center along with the risk factors related to them if any and the microbiological profile of the organisms isolated

METHODS: We included all patients with TCC on hemodialysis from July 1, 2021 until March 31, 2022. A catheter-related infection was to be suspected clinically, and blood cultures were taken and interpreted according to the CDC definition. We noted the basic demographic data age of catheter time from initiation of dialysis basic laboratory parameters like hemogram serum albumin. We calculated the incidence of catheter related infections and expressed it as infections per thousand patient number days. The common microbes and their antibiogram were recorded additionally.

RESULTS: We enrolled 317 patients and observed them for a total of 32,825 days. There were 42 episodes of CRBSI, and the incidence was 1.2 episodes per 1000 patient days. There was a gram negative preponderance (57%) among the microbes that were isolated. We found that lower hemoglobin levels (Mean- 7.6+/- SD- 1.60; p < 0.001) and lower Sr. albumin (Mean- 3.17+/- SD- 0.48; p < 0.004) were significant independent risk factors for CRBSI. Demographical factors like age, sex, native kidney disease, presence of diabetes mellitus, and use of immunosuppression did not significantly affect the occurrence of CRBSI in our study population.

CONCLUSIONS: The incidence of CRBSI in patients on hemodialysis with TCC is 1.28 per 1000 patient days. Lower hemoglobin and albumin levels were significantly associated with more CRBSI occurrences and thus, maintaining hemoglobin levels and adequate nutritional status as per the recommended levels suggested in guidelines by KDIGO cannot be overemphasized. This reiterates the importance of supportive management in hemodialysis population apart from the access and dialysis related issues

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 55: OUTCOMES OF STANDARD VERSUS CYP3A5 GENOTYPE ADAPTED DOSING OF TACROLIMUS IN RENAL TRANSPLANT RECIPIENTS: A RANDOMIZED CONTROL STUDY

Vivek Goel 1, Anil K Bhalla 1, Manish Malik 1, D S Rana 1

BACKGROUND: Renal transplantation is the best form of renal replacement therapy. Tacrolimus is considered a cornerstone of maintenance drug therapy after kidney transplantation but has a narrow therapeutic index. Therapeutic drug monitoring of tacrolimus is thus very essential and trough blood concentration (C0) is the usually accepted tool because empiric dosing does not lead to predictable systemic drug concentrations. Tacrolimus pharmacokinetics is mainly influenced by the CYP3A5 subfamily of metabolizing enzymes. Our study aimed to utilize pharmacogenomics in transplant patients and evaluate the effect of genotype-based tacrolimus dosing by pre-transplant adaptation and compared it with standard weight-based dosing.

AIM OF THE STUDY: To compare the proportion of patients within the target trough levels of tacrolimus on post-operative day 3 between the genotype adapted dosing group and the control group in renal transplant recipients. To compare the number of dose modifications required for tacrolimus during the first 3 months. Graft function and incidence of urinary tract infections and graft rejection were also compared.

METHODS: We conducted a randomized controlled trial at the Department of Nephrology SGRH with 113 patients undergoing renal transplantation. Patients undergoing kidney transplant were randomized into two groups. First group (Cases) were tested for CYP3A5 genotype at least 25 days prior to transplant and they received genotype adapted dosing of tacrolimus. CYP3A5 genotyping involves DNA extraction Polymerase Chain Reaction (PCR) followed by Sanger's gene sequencing. However, the second group (Controls) was not tested for CYP3A5 genotype and received standard tacrolimus dosage. All the patients were serially monitored for tacrolimus trough levels graft function and complications for 3 months. Tacrolimus 12-hour trough level assay was performed by microparticle enzyme immunoassay (MEIA) from peripheral blood sample collected in EDTA vial. Target tacrolimus trough level was considered to be 8- 10 ng/ml for the first month after transplant and 5-8 ng/ml for subsequent months.

RESULTS: Total 113 patients were studied, 58 Controls and 55 Cases. The graft function (mean eGFR) in Controls and Cases was comparable on Days 10, 30, and 90. Greater number of patients achieved the target tacrolimus trough levels on and POD3 (p value 0.029) who received genotype adapted dosing. The controls required a mean duration of 18.19 Â ± 20.7 days (median, IQR 7, 4.25 -11) to achieve first target Tac C0. The cases required significantly lesser number of days, 10.84 Â ± 15.49 (median, IQR 5, 2-10); p value 0.036. The total number of dose modifications of Tac required in the control group was to 232 which was significantly more than 153, required in the cases (p value < 0.001). Other findings like ATN and tacrolimus toxicity and the incidence of UTI were statistically comparable between the two groups. Among the Cases, according to genotypes, 61.9% were expressors (16.4% were rapid metabolizers & 45.5% were intermediate metabolizers), and 38.1% were non-expressors. The mean time to achieve the first target that level was higher among the expressors as compared to the non- expressors.

CONCLUSIONS: To conclude, we have observed significant association of CYP3A5 adapted dosing with trough levels of tacrolimus on early post-operative days in our study. Our intervention (genotype-based dosing) enabled the early achievement of target trough levels, lesser number of dose modifications and a shorter delay in reaching target C0 level. So, we demonstrated pharmacogenetic dose adaptation based on CYP3A5 genotype which allows individualization of the first doses of tacrolimus administered after kidney transplantation. The above-mentioned advantages, however, did not translate into clinical benefits in the form of lesser complications like graft rejection, UTI, and tacrolimus nephrotoxicity.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 56: EFFICACY OF REGIONAL CITRATE VERSUS HEPARIN ANTICOAGULATION IN PATIENTS WITH ACUTE KIDNEY INJURY REQUIRING CONTINUOUS RENAL REPLACEMENT THERAPY: A RANDOMIZED STUDY

Gaurav 1, Manish Malik 1, A K Bhalla 1

BACKGROUND: Commonest modality of choice in critically ill patients with acute kidney injury (AKI) requiring renal replacement therapy (RRT) is continuous renal replacement therapy (CRRT). However for the functioning of any RRT and adequate hemoperfusion, it needs an anticoagulation to prevent extracorporeal circuit from clotting. Although heparin is cheap and easy monitoring can be done, bleeding risks are high. Regional citrate anticoagulation (RCA) acts only in the extracorporeal circuit and thus appears safe. KDIGO suggests use of RCA as a preferred anticoagulation for CRRT in AKI patients. Thus we conducted a randomized controlled trial in patients requiring CRRT to assess efficacy and safety of RCA over heparin.

AIM OF THE STUDY: To evaluate efficacy and safety of RCA versus heparin anticoagulation in critically ill patients with AKI requiring CRRT. Efficacy was evaluated in terms of filter lifespan and effective delivered RRT dose. Safety was assessed in the form of complications like bleeding episodes hypocalcemia citrate toxicity (ratio of total calcium to ionized calcium) metabolic complications.

METHODS: A randomized controlled trial was done in Intensive Care Unit and Nephrology department at SGRH. AKI patients requiring CRRT were randomized into two groups based on anticoagulation used. Group 1 were the patients who received RCA as an anticoagulation while group 2 was heparin group. Total of 52 patients were taken. 26 patients received regional citrate anticoagulation (RCA) while the remaining 26 patients received heparin as an anticoagulation for CRRT. Efficacy and safety parameters were analyzed in both the groups.

RESULTS: Demographic data were comparable among both the groups. Sepsis was the most common cause of hospital admission in both the groups (38.5% vs 50%). Oliguria was the most common indication for CRRT (53.8% in RCA group and 61.5% in heparin group). Mean filter lifespan in the RCA group was 45.11 hours while in heparin group was 26.11 hours, and it was clinically significant (P &lt;0.001). Mean effective delivered RRT dose was higher in RCA group (26 ml/kg/hour) compared to heparin group (24.23 ml/kg/hour) and was clinically significant (P &lt;0.001). Bleeding was higher in heparin group than RCA group (42.3% vs 11.5%), and it was clinically significant (P = 0.027). 4 patients (15.4%) experienced hypocalcemia in RCA group but were corrected with calcium and decreasing RCA dose. Zero cases of citrate toxicity were seen, and only two patients (7.7%) were found to have metabolic alkalosis which was also corrected by reducing RCA dose and stopping bicarbonate infusion if going on.

CONCLUSIONS: In critically ill patients with AKI on CRRT, regional citrate anticoagulation, when compared to systemic heparin, is safe and effective than heparin. Heparin was associated with significant bleeding complications and increased heparin-induced thrombocytopenia episodes.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 57: RECURRENT HEMATOSPERMIA €” AN UNUSUAL PRESENTATION OF AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

Vivek Sood 1, Manu Dogra 1, Vishal Singh 1, Gaurav Singhal 1, Somali Pattanayak 1, B Viswanadh 1

BACKGROUND: Hematospermia is described as frank blood in the ejaculate. It requires assurance and watchful monitor¬ing after excluding pseudo-hematospermia which can be either be due to misinterpretation by hematuria or the source being patient’s sexual partner (e.g., men¬struation vaginal microtears). Hematospermia if recurrent refractory or painful mandates thorough evaluation to rule out underlying infections ejaculatory obstruction malignancy (especially in elderly) and vascular malformations. Seminal vesicle cysts in autosomal dominant polycystic kidney (ADPKD) usually remain asymptomatic nevertheless infrequently can present as recurrent urinary tract infection recur¬rent epididymitis painful ejaculation hematuria pelvic pain and rarely as hematospermia particularly if associated with cyst hemorrhage as in index case.

AIM OF THE STUDY: In this context, we describe a case of recurrent hematospermia whereby evaluation revealed hemorrhage in seminal vesicle cysts and unveiled autosomal dominant polycystic kidney disease.

METHODS: A middle-aged male presented with recurrent episodes of hematospermia for 6 months. Prior evaluation suggested no symptomatic relief despite prolonged oral antibiotics for presumable urinary tract infection. He however denied history of fever dysuria hematuria flank pain weight loss and pelvic trauma. Naked eye examination of ejaculate suggested hematospermia. Clinical evaluation was remarkable for bilaterally enlarged ballotable and non-tender kidneys. Prostate was non-tender on digital rectal examination (DRE). Laboratory investigations including complete blood count liver and renal function tests and coagulation profile were normal and urine sediment was bland. Microscopy of semen confirmed erythrocytes along with spermatozoa (Figure 1) in absence of leukocytes. Sentinel cultures including urine blood and semen were sterile. Prostate-specific antigen level was normal. Transabdominal ultrasound showed bilateral enlarged cystic kidneys (Right kidney -16.7 X 9.8 cms and Left kidney -17.4 X 9.5 cms) with multiple cysts in liver. Magnetic resonance imaging (MRI) abdomen was consistent with polycystic kidneys with extra-renal cysts in liver and bilateral seminal vesicles. MRI pelvis revealed cysts in bilateral seminal vesicles. Few of these cysts showed shading on T2 weighted image sequence with susceptibility artifacts on gradient echo sequence consistent with hemorrhage within the cysts (Figure 2) presumable etiology of hematospermia in index case. Patient was counseled about natural history of hemorrhage in renal and extra-renal cysts in ADPKD and consequently initiated on conservative medical management for ADPKD. Symptoms of patient resolved spontaneously. He was emphasized for screening of family members and need of periodic monitoring and regular follow-up. His younger brother although asymptomatic was also detected to have polycystic kidneys with extra-renal cysts in liver. Patient has remained asymptomatic with no recurrence thereafter till one year of follow-up.

RESULTS: Discussion - Extrarenal cysts in ADPKD are most frequent in liver (over 50%), followed by pancreas (10%), arachnoid cysts (5%), and spleen (3%). Cysts in lower male genitourinary tract [1,2] (epididymis, seminal vesicle,[3] testicular and prostate [4] cysts) are relatively infrequent. Seminal vesicle cysts in ADPKD [5] are congenital and usually asymptomatic. Occasionally patient may present with recurrent urinary tract infection, epididymitis, painful ejaculation, hematuria, and pelvic pain secondary to in¬fection and mass effect or obstruction of adjacent organs. Cyst hemorrhage and gross hematuria are frequent complications of ADPKD. Gross hematuria resulting from cyst hemorrhage, nephrolithiasis, infection and rarely, renal cell or urothelial carcinoma may at times result in pseudo-hematospermia. Episodes of cyst hemorrhage in ADPKD are usually self-limiting and resolve within a week. Hemorrhage in seminal vesicle cysts manifesting as hematospermia is infrequently reported [6]; however, ADPKD presenting as recurrent hematospermia consequent to seminal vesicle cyst hemorrhage is inconceivable.[7] Diagnostic workup [8] of hematospermia includes careful history, physical examination, laboratory testing, and imaging. DRE for assessment of prostate guides to etiology; tenderness and induration of prostate is indicative of infection, whereas a hard or nodular feel is indicative of neoplasm, especially in an elderly patient. MRI [9] is the modality of choice for evaluation of recurrent hematospermia. Hyperintense signal at precontrast T1-weighted MRI with no enhancement after contrast administration is indicative of hemorrhage in seminal vesicles as well as in prostate. T2-weighted MRI with fat saturation is the key sequence for assessment of inflammation. In addition, MR angiography may provide further information for localizing bleeding in re¬fractory or unremitting hematospermia. Mainstay of management for hematosper¬mia is relieving patient’s anxiety especially in younger patients as it is a self-limiting benign condition. Definitive treatment [10] depends on management of underlying pathology.

CONCLUSIONS: Recurrent hematospermia consequent to hemorrhage in seminal vesicle cysts is an infrequent presentation of ADPKD and hence reported for its novelty. Learning Points - • Hematospermia is a self-limiting benign condition, particularly in a sexually active male. • Recurrent, refractory, or painful hematospermia mandates thorough evaluation. • Seminal vesicle cysts in ADPKD are relatively infrequent, and usually asymptomatic. • Recurrent hematospermia consequent to hemorrhage in seminal vesicle cysts is an infrequent presentation of ADPKD.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 58: COMPARISON OF SONOGRAPHICAL AND BIOIMPEDENCE SPECTROSCOPY METHODS TO ESTIMATE VOLUME STATUS IN MAINTENANCE HEMODIALYSIS PATIENTS AND ITS CORRELATION WITH CARDIAC OUTCOME: AN INTERIM ANALYSIS

Sutanay Bhattacharyya 1, Himansu Sekhar Mahapatra 1

BACKGROUND: Assessment of volume status is important in hemodialysis patients as both over hydration and fluid depletion is a risk factor for cardiac mortality and morbidity. However, appropriate method to detect hydration status and hydration impact on cardiac status is inadequately studied.

AIM OF THE STUDY: In this 6 months follow-up study, we compared Inferior Vena Cava (IVC) Lung Ultrasound (LUS) and Bioimpedence Spectroscopy (BIS) for volume estimation in maintenance hemodialysis patients considering BIS as the gold standard. We also correlated fluid status of these patients with cardiac outcome.

METHODS: In this comparative prospective study in a tertiary hospital over 6 months clinically normovolemic CKD patients more than 18 years on thrice weekly maintenance hemodialysis for at least 3 months underwent pre- and post-HD clinical examination IVC assessment Lung US and BIS at 0 3 and 6 months. IVC Collapsibility Index of ≥ 50% B lines on LUS of ≥15 and Over Hydration/Extra Cellular Water (OH/ECW) ratio of ≥15% were taken as cut off for Fluid Overload state. Echocardiography assessment (Ejection Fraction Left Atrial Volume and Left Ventricular Mass) was done prior to dialysis at 0, 3, and 6 months. Heart failure ischemic heart disease including myocardial infarction stroke cardiac arrest and sudden cardiac death were recorded at 3 and 6 months. The current study is ongoing with an expected total sample size of 100. Statistical analysis was done using SPSS software version 25.

RESULTS: Out of 55 patients, 36 (%) of them were males. There was significant difference in B line on LUS pre- and post-HD at 0, 3, and 6 months (23% vs 1% at 0 months [p value: 0.002]; 32% vs 4% at 3 months [p-value: 0.0004]; 16.6% vs 2.2% at 6 months [p-value 0.03]). Only pre- and post-HD OH/ECW values at 3 months were statistically significant in estimating Over Hydration (65% vs 40- p value 0.01). Both pre- and post-HD LUS were more specific (100% specificity at 3 and 6 months post-HD) than IVC assessment in predicting Fluid Overload taking Bio Impedance as the gold standard. 50% of the study population had a MACE at 3 months and 40% at 6 months. Left atrial dilatation at 0, 3 and 6 months was significantly associated with composite MACE events (p-value 0.03, p-value 0.04 and p value 0.01 respectively). Fluid overload state assessed by both LUS and BIS at 6 months was associated with Major Adverse Cardiovascular Events (composite of non-fatal myocardial ischemia, new onset heart failure, stroke, cardiac arrest). Four patients expired on follow-up, 2 of them attributed to sudden cardiac death, 1 as a result of sepsis, and another to brainstem hemorrhage.

CONCLUSIONS: Lung ultrasound can be an effective and simple alternative to Bioimpedance in estimating hydration status in these patients and combined with Bioimpedance can predict cardiac outcomes in maintenance hemodialysis patients. Fluid overload assessment in hemodialysis patients is important in planning an approximate target weight in such patients, thus subsequently lowering risk of cardiovascular events and mortality.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 59: BRACHIOCEPHALIC VEIN TUNNELLED CATHETER-EXTREME SOLUTIONS FOR EXTREME SITUATIONS

Deepa Usulumarty 1, Amish Mhatre 1, Ganesh Sanap 1, Jatin Kothari 1, Rajesh Kumar 1, Shrirang Bichu 1, Viswanath Billa 1

BACKGROUND: Hemodialysis patients are at continuous risk of vascular access site exhaustion due to fistula failures and catheter thrombosis. There has been a significant increase in survival of hemodialysis patients over the past decade necessitating a need to improve access survivals and access options.

AIM OF THE STUDY: Securing a successful brachiocephalic tunneled catheter as a salvage option in a hemodialysis patient with multiple vascular access failures.

METHODS: We present the case of a 50-year woman who also had diabetes hypertension and CKD and was on maintenance hemodialysis since 2019. She had undergone a temporary right femoral right Internal jugular vein [IJV] catheterization a left brachiocephalic AVF a right radio-cephalic AVF a left temporary followed by a left femoral perm cath a left subclavian and a left femoral Permcath in that order over the past 3 years. The currently used left femoral Permcath had no flow, and a new vascular access was needed at the earliest. Her vascular anatomy was studied in the Cath lab with USG guidance. Both the right and left IJV and SV were thrombosed with reformation of the Brachiocephalic vein (BCV) downstream. Both Iliac veins were occluded. Given the emergent need for hemodialysis the left BCV was cannulated, and a Terumo guide wire passed into the left BCV up to the SVC. A 7 Fr sheath was guided over it and a super-stiff wire passed through sheath and the BCV was dilated. A dilator with peel-off sheath was passed over the Terumo wire and a 33 cm. cuffed Palindrome catheter was passed over the Terumo wire. Post-procedure a good blood flow was achieved in both the venous and arterial ports.

RESULTS: Successful cannulation of the brachiocephalic vein was achieved, and the tunneled catheter remains patent to date after 2 months of insertion, delivering good blood flows.

CONCLUSIONS: In cases where all the standard access sites are exhausted, it is necessary to explore extreme options to secure an access. The brachiocephalic vein tunneled catheters placed under fluoroscopic guidance are perhaps the next safe bet before a translumbar technique, in this patient population.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 60: ANCA NEGATIVE PAUCI-IMMUNE CRESCENTIC GLOMERULONEPHRITIS; A SINGLE CENTRE EXPERIENCE IN A TERTIARY CARE CENTRE IN EASTERN INDIA

Sourav Sadhukhan 1, Taniya Bhuniya 1, Arpita Raychaudhury 1, Koushik Bhattacharjee 1, Atanu Pal 1, Debabrata Sen 1

BACKGROUND: Pauci-immune crescentic glomerulonephritis (CrGN) is the most common cause of rapidly progressive glomerulonephritis (RPGN). Although majority of cases have the anti-neutrophil cytoplasmic antibodies (ANCAs) positivity, a subgroup of patients are ANCA negative. There are only few studies regarding this subgroup of patients.

AIM OF THE STUDY: To compare the prevalence clinical manifestations histopathology and outcomes of ANCA-negative pauci-immune crescentic glomerulonephritis with those of ANCA-positive disease.

METHODS: Total 27 patients who were diagnosed with pauci-immune crescentic glomerulonephritis between January 2020 to July 2021 were enrolled in this study with a minimum follow-up of 1 year. This was a retrospective observational study data was captured using preformed pro forma after taking consent tabulated using MS excel. Differences of quantitative parameters between groups were assessed using the t test (for data that were normally distributed) or nonparametric test (for data that were not normally distributed). Differences of qualitative results were compared using ‡2 test. Kaplan–Meier curves were used to analyze patient and renal survival. P < 0.05 was considered significant.

RESULTS: In our study, out of 27 patients, 74.07% were females. MPO positive were 37.03%, PR3 positive were 33.3%. ANCA negative patients were 29.6%. ANCA negative patients were similar in age distribution with ANCA positive CrGN (35.75 Â ± 16 vs 38.4Â ± 18.32, p = 0.72). ANCA negative patients had significantly more baseline proteinuria than ANCA positive patients (2.26Â ± 1.2 gm vs 1.38Â ± 0.84, p = 0.03). Nephrotic presentation also was significantly higher in ANCA negative patients (p < 0.05). Baseline s.cr was higher in ANCA negative patients (5.43Â ± 1.37 vs 4.7Â ± 2.9, p = 0.42) but not statistically significant, similarly dialysis requirement at presentation (62.5% vs 47.3%, p = 0.47). ANCA positive patients had more extrarenal manifestation including pulmonary involvement (68.42% vs 25%, p = 0.038). In renal histopathology, ANCA negative patients significantly had lower no of normal glomeruli (7.2%Â ± 10.8 vs 17.3%Â ± 18.8, p = 0.05), more no of cellular crescents (56.4%Â ± 21.8 vs 41.7%Â ± 13.9, p = 0.04), have more IFTA burden (IFTA > 25%- 50% vs 15.7%, p = 0.06). ANCA negative patients had significantly poorer renal survival at 1 year (12.5% vs 52.6%, p = 0.05), but no significant difference in patient survival at 1 yr (p = 0.57).

CONCLUSIONS: Findings from our study suggests that ANCA-negative pauci-immune CrGN remains a distinct clinical entity with higher proteinuria, less extrarenal involvement and poor renal outcome. Studies with Longer duration and follow-up with more no patients are required for further analysis, identification of novel antigens in pathogenesis and potential therapeutic interventions.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 61: RIGHT ATRIAL CLOT IN LONG-STANDING TUNNELED DIALYSIS CATHETERS - A CASE SERIES

Sneha Manoj Lute 1, Ayan Dey 1, Rasika Sirsat 1, Mahesh Prasad 1, Alan Almeida 1

BACKGROUND: Catheter-related right atrial thrombus (CRAT) is well-known albeit under-reported and life-threatening complication of dialysis catheters. While the traditional approach mandates catheter exchange/removal, it is fraught with complications. Hence novel methods of management of CRAT must be explored. We report a case series of CRAT over the past 5 years and enumerate various management strategies both invasive and non-invasive.

AIM OF THE STUDY: To study the clinical presentation causes and various management strategies of CRAT in hemodialysis patients.

METHODS: Medical records of patients who underwent outpatient hemodialysis at PD Hinduja Hospital were analyzed. Patients who had transthoracic echocardiography (TTE) proven CRAT were included. Clinical presentation management strategies success of management strategies based on echocardiographic follow-up access outcomes and patient outcomes were analyzed. Possible causes of formation of CRAT were also elicited. The data was entered into MS excel sheets and analysis performed. Results for Quantitative Variables were expressed as mean ( ± SD) and median [range]. Results for Qualitative Variables were expressed as frequency and percentages. For categorized variables Pearson’s chi-square test or Fisher’s exact test were used. Software used was “R software version 3.5.2â€

RESULTS: Seven out of the eight patients identified with CRAT had right-sided permcath. Heparin was the anticoagulant and locking solution. Mean age was 53.2 years (+ 17.3 years) with 62.5% being females. Commonest presentation was fever (100%). Catheter type was similar in all the patients. No intradialytic clotting episodes were encountered prior to CRAT, but flow issues were noted (62.5%). 4/8 patients needed catheter manipulation prior with 2 needing fibrin sheath disruption and catheter exchange. One patient needed TEE confirmation for CRAT. Mean size of the masses was 2.3 cm x 1.8 cm. One patient presented with three RA masses. Tip of the catheter was the commonest position. 50% of the patients had concurrent fungal sepsis (trichospora in 25%) followed by staphylococci and streptococcal growth. The commonest management strategy was systemic anticoagulation with heparin followed by oral anticoagulants [warfarin (37.5%) or apixaban (37.5%)]. Thrombolysis with alteplase was done in 25% of the patients. Clot size reduction was achieved in all patients. Three patients underwent open heart surgery with clot retrieval. Mortality was 25% in the cohort.

CONCLUSIONS: This study throws light on the important issue of CRAT. Higher incidence of fungal infection was noted. All patients had echocardiography-proven improvement in clot size with thrombolysis and/or systemic anticoagulation. Mortality and morbidity remains high, and further studies are warranted.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 62: BACTERIAL INFECTION RELATED GLOMERULONEPHRITIS IN PATIENTS WITH DIABETES MELLITUS

Elenjickal Elias John 1, Sanjeet Roy 1, Reka Karuppusami 1, Selvin Sundar Raj 1, Joseph Johny 1, Nisha Jose 1, Rizwan Alam 1, Jeethu Joseph Eapen 1, Athul Thomas 1, Sabina Yusuf 1, Anna T Valson 1, Vinoi George David 1, Santosh Varughese 1, Succeena Alexander 1

BACKGROUND: Patients with underlying diabetes mellitus are prone to develop various infections thus making them a unique cohort at risk of developing bacterial infection related glomerulonephritis (IRGN).

AIM OF THE STUDY: It is important to understand the nature of infections infecting organism anti-bacterial susceptibility renal histology use of immunosuppressants long-term renal outcomes and factors associated with progression to kidney failure in diabetic patients who develop IRGN.

METHODS: In total, 1693 adult diabetic patients underwent kidney biopsy between 2005 and 2021 at our tertiary care hospital in South India. Of these 121 cases which met the diagnostic criteria of bacterial IRGN (biopsy incidence of 7%) were included in this study and follow-up data were collected from electronic medical records till March 2022.

RESULTS: The mean age of the cohort was 53.1  ± 10.1 years, 16/121 (13%) were above 65 years, and 83/121 (69%) were males. The median duration of diabetes at kidney biopsy was 6 (IQR, 2-12) years. 64/121 (53%) patients were on insulin (with or without oral hypoglycemic agents), 41/66 (62%) had underlying diabetic retinopathy and 86/121 (71%) had a known source of infection. The most common sites of infection were skin [47/121 (39%)] and urinary tract [15/90 (12%)]. Para-infectious glomerulonephritis (GN) characterized by an ongoing infection at onset of GN was seen in 61/121 (50%) patients. The median latent period between resolution of infection and onset of symptoms of GN in 25/121 (21%) post-infectious GN cases was 17 (IQR, 12-232.5) days. The most common isolated infectious organism was Streptococcus Pyogenes (22/121, 18%). Gram-negative and drug-resistant organisms were isolated in 21/121 (17%) and 24/121 (20%) cases. Median estimated glomerular filtration rate (eGFR) at presentation was 10.8 (IQR, 6.7-25.4) ml/min/1.73 mÂ2 with 43/121 (35%) requiring dialysis at presentation. Two-thirds of the cohort had nephrotic range proteinuria at biopsy. The most common light microscopy and immunofluorescence pattern on renal biopsy were diffuse exudative and endocapillary GN (98/121, 81%) and “starry-sky†pattern (53/120, 44%) respectively. 106/121 (88%) patients had renal histological features of diabetic kidney disease (DKD), and 58/121 (48%) had features of advanced DKD. Short-course oral steroids were given to 86/121 (71%) patients. 16/59 (26%) patients treated with immunosuppressants developed infections over the follow-up period, majority belonging to para-infectious group (11/16, 69%). Of the 90 patients with follow-up details > 3 months, 46 (51%) progressed to kidney failure over a median period of 0.5 (IQR, 0-7.2) months. eGFR <30 ml/min/1.73 mÂ2 at presentation, NRP, para-infectious GN, advanced DKD and moderate to severe interstitial fibrosis and tubular atrophy on kidney biopsy were the significant predictors of kidney failure by Cox-regression hazard model. Patients with parainfectious GN had significantly more microvascular complications, fever at presentation, congestive heart failure, urinary tract and lung infections, isolated gram negative and drug-resistant organisms, renal dysfunction at biopsy and glomerular neutrophil infiltration and diffuse interstitial inflammation on kidney biopsy. Nine percent (8/90) deaths occurred during the follow-up period, majority due to infections.

CONCLUSIONS: Bacterial IRGN in diabetic patients is associated with poor renal outcomes with 50% patients progressing to kidney failure. Presence of an ongoing infection and advanced DKD are risk factors for kidney failure.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 63: EFFECT OF CHOLECALCIFEROL ON IMMUNE AND VASCULAR FUNCTION IN CHRONIC KIDNEY DISEASE

Kajal Kamboj 1, Aruna Pariki 1, Manphool Singhal 1, Vivek Kumar 1, Ashok Kumar Yadav 1, Vivekanand Jha 1

BACKGROUND: Vitamin D deficiency is common in chronic kidney disease (CKD), and short-term studies have shown beneficial effect of vitamin D supplementation on vascular function in CKD.

AIM OF THE STUDY: In this study, we investigated the effect of cholecalciferol supplementation on vascular and immune function in non-diabetic early stage CKD subjects.

METHODS: In this ongoing pre-post study, non-diabetic CKD subjects with eGFR 15-60 ml/min/1.73 m2 and serum 25(OH)D levels <20 ng/ml are being enrolled. Participants receive 300000 IU of cholecalciferol at baseline and at 8 weeks. Clinical and laboratory assessments were done at baseline (before intervention) and 16 weeks. Primary outcome is change in circulating T cell subsets (Th1 Th2 Th17 and Treg). Secondary outcomes are changes in flow-mediated dilatation (FMD) pulse wave velocity (PWV) vitamin D responsive genes mRNA expression (cathelicidin Cyp27b1 TLR9 IL-10).

RESULTS: 40 patients have been enrolled till date. We present data of 27 participants who have completed follow-up. Mean age was 47.37 Â ± 13.44 years, 60% being males. 25 (OH) D levels increased at 16 weeks (15.22 Â ± 13.16 ng/ml vs 41.17 Â ± 14.72 ng/ml, p < 0.001). Treatment with cholecalciferol significantly increased Th2 cell population (CD3+CD4+IL4+); and Th17 cell population (CD3+CD4+IL17+) (Table 1). Expression of cathelicidin, IL-10, VDR, and Cyp27b1 was increased at follow-up (Figure1).

CONCLUSIONS: Cholecalciferol supplementation increased expression of vitamin D responsive genes, changes T cell phenotype to Th2 and Th17.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 64: STUDY OF PROFILE OF URINARY TGF-β1 IN GLOMERULAR DISEASES

Akshay R Kulkarni 1, Atul Sajgure 1, Charan B Bale 1, Pavan Wakhare 1, Nilesh Shinde 1, Abhijit S Chavan 1, Chetan Phadke 1, Shreeharsh Godbole 1, Anuja Makan 1, Tushar A Dighe 1

BACKGROUND: Transforming Growth Factor-β1: Transforming growth (TGFβ1) is associated with fibrosis in many organ systems including the kidney, where it can be induced by angiotensin, proteinuria, and hypoxia. Numerous studies have identified TGF-β1 as being upregulated during the course of progressive renal injury. Similarly, inhibition of TGF-β1 has been shown to ameliorate renal injury. TGF-β1 is not only involved in extracellular matrix accumulation, fibrosis, and progressive renal impairment, but also plays a role in changes to the glomerular filtration barrier and induction of proteinuria. Direct inhibition of TGF-β1 in models of renal disease reduces proteinuria. Our study aimed to study the profile of urinary TGF-β1 in glomerular diseases.

AIM OF THE STUDY: To study the profile of urinary TGF-β1 in glomerular diseases

METHODS: It was a prospective, observational study, done at a tertiary care center in Western India, over a period of 1 year. 15 subjects with biopsy-proven glomerular diseases, and five healthy controls were enrolled in the study. These participants underwent all routine laboratory investigations and urinaryTGF-β1 estimation on a 24-hour urine sample by flow cytometry method. Cytometric array capture beads of 20 ul were mixed in 20 ul of urine in 1.5 ml tubes. After mixing, samples were incubated at room temperature for 2 hours. After incubation, 50 ul phosphate buffered saline was added and centrifuged at 5000 rpm for 5 minutes. After centrifugation, 70 ul volume was removed. In the sample, 20 ul detection beads were added and samples were incubated for 2 hours. After incubation, 160 ul buffer was added and samples were analyzed using multicolor flow cytometry. Every sample was processed thrice, and average value (pg/ml) was considered for analysis of all the subjects.

RESULTS: Of the 20 study participants, 11 were males and 9 were females. Average age in glomerular disease patients (group A) was 35.73 ± 14.25 years and that in control group (group B) was 30.2 ± 5.02 years. UrinaryTGF-β1 level in group A had mean value of 50.35 ± 6.52 (pg/ml), while that in group B was 19.29 ± 3.48 (pg/ml). The values for TGF-β1 in test samples (group A) were found significantly higher in comparison to control (group B) (p < 0.0001). Mean value of UPCR was 5.50 ± 5.11 mg/mg in group A and 0.17 ± 0.11 mg/mg in group B.

CONCLUSIONS: Urinary TGF-β1 levels were significantly high in glomerular disease patients compared to healthy individuals.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 65: ARTERIO-VENOUS FISTULA CREATION BY NEPHROLOGISTS AND ITS OUTCOME IN A TERTIARY LEVEL HOSPITAL OVER TWO YEARS INCLUDING COVID-19 PANDEMIC PERIOD

Saswat Das 1, Himansu Sekhar Mahapatra 1, Lalit Pursnani 1, B Muthukumar 1, Lakshman 1, Chandra Krishnan 1, Anamika Kumari 1, Vipul Gupta 1, Rajesh Tarachandani 1, Preeti Choudhary 1, Sutanay Bhattacharya 1, Beauty Suman 1, Tanvi Thakker 1, Mahboob Alam 1, Abhishek Jha 1

BACKGROUND: Currently, AVFs are created by vascular surgeons urologists and nephrologists. Nephrologists may be better placed to create AVFs and conduct follow-up as they’re well versed with the usage of AVF.

AIM OF THE STUDY: This observational prospective study aims to find the outcome of AVFs created by nephrologists over two years in a tertiary level hospital.

METHODS: All the patients in whom an AVF was created by nephrologists between March 2020 and August 2022 were included. On the day of surgery vitals were recorded and vein mapping was done. Side-to-side anastomosis with 6-0 proline between artery and vein were performed under local anesthesia in a single sitting. Patients were observed for post-op complications. During the COVID-19 pandemic, RT PCR was only performed in suspected in suspected patients indentified during screening. All patients staff and surgeons wore N-95 masks in addition to usual sterile measures. Patients were followed up at 6th week and 12th week post-AVF construction to do clinical examination and evaluate blood flow diameter of AVF by high-quality Doppler. Patients were asked to use AVF for dialysis after 6th week of creation after they have matured. AVF maturation was defined radiologically as a combination of blood flow of 600 ml/min and diameter of 6 mm or more and clinically usable. Else it was considered immature. Primary failure was defined as AVFs that had not matured till 12th week of creation. All the data were analyzed by appropriate statistical tools using the SPSS software.

RESULTS: A total of 1323 fistulae (including 376 during COVID-19 pandemic) were created in 1102 patients. Of them 928 (84.21%) were males, and 537 (48.72%) of the patients were having underlying diabetes mellitus. A total of 1008 (76.19%) were radio-cephalic while 262 (19.8%), 19 (1.43%) were brachio-cephalic, and brachio-basilic respectively. 1013 (76.56%) fistulae were left sided. 944 (85.66%) were already on hemodialysis while 158 (14.33%) were planned for elective initiation after fistula maturation. Of the 1102 patients, 150 patients required fistula creation twice, 17 patients thrice, and 4 patients underwent fistula creation four times. Out of 556 (50.45%) patients who completed three months follow-up, 65 patients (11.69%) expired. Primary failure was observed in ¬¬¬¬¬¬¬¬107 (19.21%) fistulae and 24 (4.30%) patients developed local site infection. 8 (1.43%) and 4 (0.71%) patients developed fistula rupture and aneurysms respectively requiring admission for AVF closure. Mean AVF blood flow and diameter were 674.92 ± 317.40 and 5.42 ± 1.33 at 6th week and 983.60 ± 289.41 and 9.36 ± 54.58 at 12th week respectively. During the COVID-19 pandemic, out of 376, 15 (7.1%) patients were found to be COVID-19 positive during follow-up, and only 2 out of 18 staff and 4 nephrologists were found to COVID-19 positive.

CONCLUSIONS: Nephrologists are well positioned to create AVFs successfully. However, collaboration with vascular surgeons and radiologists will further improve the success rate and management of complications. AVF creation is safe during pandemics and should be continued.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 66: COVID AND KIDNEY- €œA FRIEND OR FOE?â€

Sanjay Mittal 1, Rajesh Agarwal 1, Gulshan Kumar 1, Saranpreet 1

BACKGROUND: Covid-19 has been associated with worsened prognosis in patients with kidney involvement. The incidence of acute kidney injury (AKI) in Coronavirus-19 disease (COVID-19) patients ranges from 0.5% to 35%.

AIM OF THE STUDY: We evaluated the prevalence severity risk factors and prognosis in patients with COVID-19 having AKI or CKD.

METHODS: We conducted a retrospective analysis of 70 patients with Covid-19 presenting to nephrology department. Outcome of patients with CKD stage 1-2 was compared with that of patients with AKI kidney transplant and CKD stage G3a-G5D.

RESULTS: In this study, 15 (21.4%) patients had CKD stage G1-2, 18 (25.71%) had CKD stage G3a-5c and 11 (15.7%) had CKD stage G5d. Eight patients (11.4%) were with functioning renal allograft (CKD-T). Four (5.71%) developed AKI and 14 patients (20%) had acute on CKD. Overall; in-hospital mortality was 27.14% (n = 19). Of these, 3 patients (15.78%) had CKD stage G1-G2, 7 (36.84%) had CKD stage G3a-5c, 3 had CKD G5D, 2 (10.55%) had acute on CKD, one had AKI and 3 patients had a functioning kidney allograft. Baseline & nadir serum creatinine & eGFR of CKD stage 1-2, CKD Stage 3a-5c and stage CKD-t was 0.87 (eGFR 82), 7.34 (eGFR 11.61), 3.24 (eGFR-24.86); and 0.74 (eGFR 93.55), 5.37 (eGFR 16.55) and 1.85 (eGFR 42.28) respectively.

CONCLUSIONS: A rather low prevalence of AKI in our Covid-19 patients, lower mortality in acute on CKD patients & improvement in eGFR in CKD & transplant patient in our study suggest that coronavirus has minimal, if any direct toxic effect on kidney. But presence of renal failure worsens the outcome of Covid-19 disease.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 67: CAUSES OF DELAY IN CREATING PERMANENT VASCULAR ACCESS IN HAEMODIALYSIS PATIENTS: A SINGLE CENTRE OBSERVATIONAL STUDY FROM EASTERN INDIA

Satyam Mohan 1, Amresh Krishna 1

BACKGROUND: Well-functioning vascular access is the mainstay of performing efficient extracorporeal dialytic therapies and is the lifeline for patients on maintenance hemodialysis (MHD). Despite the Fistula First initiative hemodialysis catheter use remains high.

AIM OF THE STUDY: To identify the causes of delay in arteriovenous fistula (AVF) creation and identify the clinical and demographic factors associated with AVF failure in order to improve the quality of care and prevent complications related to vascular access.

METHODS: It was a cross-sectional descriptive study on CKD 4 and CKD 5 ND patients who did not opt for AVF creation or had delayed AVF creation. We analyzed various factors that lead to delay in AVF creation using a Questionnaire (reasons categorized as a patient physician and hospital factors).

RESULTS: In a total of 289 participants, the most important factors associated with delay in AV Fistula creation were patient-related (60.5%, p-0.03) which included late acceptance of kidney disease or the need for dialysis, fears of dialysis, or iv cannulation, and patient refusal for AV Fistula. The most critical physician (10.5%) and hospital factors (29%) were late referral to a nephrologist and prolonged waitlist for AVF surgery after referral.

CONCLUSIONS: A validated approach to patient selection, pre-dialysis education, and referral to vascular access should be made in patients with CKD 4 and CKD 5 ND to decrease morbidity and mortality associated with temporary dialysis catheters.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 68: LUPUS NEPHRITIS IN ELDERLY: IS IT RARE?

Harshita Sharma 1, Anupma Kaul 1, D S Bhadauria 1, M R Patel 1, Monika Yachha 1, M R Behera 1, Ravi S Kushwaha 1, Narayan Prasad 1

BACKGROUND: Late onset SLE is often initially missed leading to a significant delay in diagnosis. There is dearth of the literature on this specific subgroup of SLE. Our study aims to study the clinical, serological features, prognosis, and treatment of elderly-onset SLE.

AIM OF THE STUDY: Our study aims to study the clinical, serological features, prognosis, and treatment of elderly-onset SLE.

METHODS: The study was designed as an observational study of electronically captured data on hospital information system of late onset SLE between June 2010 and June 2021.

RESULTS: Between June 2010 and June 2021, 53 patients with mean age of 59.51 ± 7.90 years, 5 males (9.4%) and 48 females (90.6%) were followed up for median duration of 82 months (IQR = 20.5-119 months). Five patients (9.6%) had a sole presentation of lupus nephritis. Synovitis and acute cutaneous lupus (64.2%) were the most common extrarenal symptoms. 50 patients (94.3%) had oliguria, and 28 patients (52.8%) had renal failure. Eight patients (15.1%) required RRT. Majority of patients belonged to class IV (20 cases; 37.7%). Follow-up biopsy was performed in 9 patients, and 7 patients show upgradation of class. Cyclophosphamide (54.7%), oral steroid (24.5%), iv methylprednisolone (11.3%), and 5 patients (9.4%) received mycophenolate mofetil as an induction therapy. At the end of induction therapy, complete remission was seen in 14 patients (50%) while 14 patients (50%) showed partial or no recovery. Four patients (7.5%) died of either sepsis or acute coronary syndrome. None of the patient was refractory to the treatment.

CONCLUSIONS: Late onset SLE needs timely diagnosis which shows good response to the treatment.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 69: COMPARISON OF OUTCOMES OF SUSTAINED LOW EFFICIENCY DIALYSIS (SLED) VERSUS CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) IN PATIENTS ADMITTED IN INTENSIVE CARE UNIT (ICU) WITH ACUTE KIDNEY INJURY (AKI)

Rishabh Nitin Naik 1, Manoj Gumber 1

BACKGROUND: Comparison of outcomes of Sustained Low Efficiency Dialysis (SLED) versus Continuous Renal Replacement Therapy (CRRT) in patients admitted in Intensive Care Unit (ICU) with Acute Kidney Injury (AKI) requiring Renal Replacement Therapy (RRT).

AIM OF THE STUDY: The primary objective was comparison of all-cause morbidity and mortality at 30 days following RRT initiation with SLED/CRRT. The secondary objectives were comparing clinical deterioration based on SOFA score between the two modalities RRT dependence up to 30 days prognosis of patients on SLED/CRRT according to the etiology complications occurring during SLED/CRRT the length of the ICU stay and cost of SLED/CRRT.

METHODS: We prospectively observed 110 patients with AKI who required SLED/CRRT admitted in ICU at AHIL Gandhinagar from January 1, 2020 to September 31, 2021. Patient’s clinical data and laboratory parameters were analyzed on the day of RRT initiation and observed up to 30 days. Evaluation was done based on the primary and secondary objectives.

RESULTS: The statistically significant results were : In both CRRT and SLED groups, those who underwent complete or partial recovery showed reduction in the mean SOFA score and vice versa for those who underwent no recovery when compared at baseline and up to 48 hours post-RRT initiation. In the CRRT group, majority patients of cardiogenic shock (90%) showed complete recovery. Majority of the CRRT group (73.80%) had complications while majority of the SLED group (67.60%) did not have any complications. Hypotension being the most common in both groups. Mean cost of the modality in the first 24 hours of RRT initiation in the CRRT group was much more (almost 2.5 times higher) than that of the SLED group. Statistically insignificant results were : In the CRRT group, the 30 day all cause mortality and the 30 day RRT dependence was 59.50% and 41.2% respectively, whereas that in the SLED group was lower that is 42.60% and 30.8% respectively. Mean length of stay in ICU for the CRRT group was 6.8 Â ± 3.5 days while that for the SLED group was 8.1 Â ± 4.1 days.

CONCLUSIONS: In the CRRT group, the majority outcome of cardiogenic shock was favorable and the analysis being statistically significant, but the 30-day RRT dependence and 30-day mortality was more, with more number of complications, was costlier and with a poorer final outcome as compared to the SLED group. The rise in the mean SOFA score was associated with unfavorable outcome and vice versa in both the groups. It is difficult to conclude the absolute superiority of one modality over the other for treatment of AKI in the critically ill patients in the ICU with each having its own advantages and disadvantages as well as unavoidable patient selection bias.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 70: ANTIBODY RESPONSE AFTER CHADOX1-NCOV (COVISHIELD) AND BBV-152 (COVAXIN) IN POST KIDNEY TRANSPLANT RECIPIENTS

Neha Manhas 1, Shyam Bihari Bansal 1

BACKGROUND: Coronavirus disease 2019 (COVID-19) has had a major effect on kidney and other solid organ transplant recipients. Vaccination has emerged as a key tool for controlling the pandemic. Kidney transplant recipients (KTR) are highly vulnerable to the serious complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and thus stand to benefit from vaccination. Various studies reported varying responses to different COVID vaccines; however, most data is available for SARS-CoV-2 messenger RNA (mRNA) as compared to other vaccines. This study aims to assess the humoral immune response to replication defective viral vectors [ChAdOx1-nCOV (Covishield)] and whole inactivated one [BBV-152 (Covaxin)] that are currently being administered in India in post-renal transplant patients after the first and second dose.

AIM OF THE STUDY: Primary: To study antibody response after ChAdOx1-nCOV (Covishield) and BBV-152 (Covaxin) in post-renal transplant recipients Secondary: To study occurrence of adverse events related to COVID vaccine within one week of vaccination

METHODS: Anti-SARS-CoV-2 anti-spike antibody titers were measured in 285 KTR recipients at baseline prior to vaccination and then 3 weeks  ± 3 days after first dose and 3 weeks  ± 3 days after second dose of ChAdOx1-nCOV (Covishield) (n = 232) and BBV-152 (Covaxin) (n = 55) vaccine. Immune response was defined as seropositivity to the anti-spike antibody by chemiluminescence immunoassay method and chemiluminescent microparticle immunoassay. Primary outcome was seroconversion after two doses of COVAXIN TM and COVISHIELD TM. The secondary outcome studied was the occurrence of adverse events related to the COVID vaccine within one week of vaccination. Patients with a history of symptomatic COVID-19 infections were excluded from the study.

RESULTS: At baseline, 18 (33.3%) and 70 (30.3%) of KTRs were found to be seropositive before receiving COVAXIN TM and COVISHIELD TM vaccination respectively despite giving no history of previous symptomatic COVID-19 infection. After first dose of COVAXIN TM and COVISHIELD TM vaccination, 42 (77.8%) and 182 (78.8%) were found to be seropositive and after second dose 43 (79.6%) and 183 (79.2%) were seropositive respectively. Seroconversion was found in 81.2% of males compared to 66.7% of females after the first dose of Covid vaccine which was statistically significant (p = 0.022). Seroconversion rate in ≤ 50 years was 76.7% (232/285) and &gt;50 years was 90.6% (53/285) (p = 0.025). Seroconversion was not statistically different in KTR whether they were ABO compatible or incompatible, type of induction agent or maintenance immunosuppression used. Common adverse effects encountered were fever, myalgia, headache which settled in 1-2 days. There was no episode of acute rejection reported after the COVID vaccine.

CONCLUSIONS: Both ChAdOx1-nCOV (Covishield) and BBV-152 (Covaxin) were well tolerated and induced robust antibody formation in KTRs in the Indian population.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 71: RATE OF CHANGE IN ESTIMATED GFR: A 3-YEAR PROSPECTIVE POPULATION-REPRESENTATIVE SURVEY IN UDDANAM INDIA

Balaji Gummidi 1, Oommen John 1, Vivekanand Jha 1

BACKGROUND: High prevalence of chronic kidney disease (CKD) not associated with known risk factors has been reported from coastal districts of Andhra Pradesh India and dubbed Uddanam nephropathy. No data is available on the rate of change of kidney function in the inhabitants of the region.

AIM OF THE STUDY: This study was undertaken to evaluate the annual rate of eGFR change in the adult residents of the Uddanam region of Andhra Pradesh who are participating in the STOP-CKDu study.

METHODS: A population-representative cohort of adult subjects between the ages of 18 and 75 years was created through a multistage cluster random sampling methodology. A total of 2419 participants were recruited between May and December 2018 from 67 villages. In addition to socio-demographic and occupational data information on kidney disease risk factors was collected in all subjects. Serum creatinine and urine protein creatinine ratio was estimated at baseline and annually in all subjects. All abnormal eGFR (estimated using CKD-EPI equation) and proteinuria values were reconfirmed after 3 months. We used the linear mixed model for investigating risk factors linked with renal function trajectories.

RESULTS: A total of 2419 subjects were recruited. The median eGFR among the population was 103.6 (86.86, 114.38) ml/min/1.73 m2. The eGFR was <60 ml/min/1.73 m2 in total of 246 (10.23%) subjects at baseline. At the follow-up, the median eGFR in this population was 76.41 (61.04, 91.88). Over a mean follow-up of 2.9 years, the annual rate of eGFR decline was 10.5 ml/min/1.73 m2. The average rate of eGFR decline was 9.42 ml/min/1.73 m2 in males and 12.27 ml/min/1.73 m2 in females (mean difference in annual decline; adjusted Î2 coefficient = 2.34 [95% CI: 1.39 - 3.28}). Overweight subjects (11.88 ml/min/1.73 m2) also had a higher average eGFR decline than those underweight (10.83 ml/min/1.73 m2; adjusted Î2 coefficient = 0.53 [95% CI: -0.56 - 1.61]. Interestingly, non-albuminuria subjects exhibited a higher rate of eGFR decline compared to those with albuminuria (UACR >300 mg/g).

CONCLUSIONS: This first of its kind population-based longitudinal study documents a high rate of eGFR decline in this high-CKDu burden region. The rate of decline is greater among females, obese subjects and those without albuminuria. Additional research is needed to understand the drivers of eGFR change.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 72: A COMPARATIVE LONG TERM OUTCOME STUDY OF DIFFUSE CRESCENTIC IMMUNOGLOBULIN A NEPHROPATHY AND ANCA ASSOCIATED PAUCI-IMMUNE CRESCENTIC GLOMERULONEPHRITIS

Mudit Khurana 1, Narayan Prasad 1, Ravi Kushwaha 1, Manas Patel 1, Manas Behera 1, Monika Yachha 1, Dharmendra Bhaduaria 1, Anupama Kaul 1

BACKGROUND: Diffuse crescentic IgAN (IgAN with more than 50% crescents on renal biopsy) is an uncommon phenotype of IgAN. Very few studies have examined the outcomes of diffuse crescentic IgAN and the treatment protocols used are similar to ANCA associated pauci-immune crescentic glomerulonephritis (PCGN) with no comparative study.

AIM OF THE STUDY: To study the long-term outcomes of CIgAN

METHODS: In this single-center retrospective cohort study, we compared the clinical features pathological presentation and renal outcomes of 59 patients with diffuse crescentic IgAN (CIgAN) and 46 patients with PCGN during a period from January 2000 to December 2019

RESULTS: The mean age of CIgAN patients was less (30.5Â ± 13.8 yrs vs 46.1Â ± 11.8 yrs) (p < 0.001). Prevalence of hypertension was significantly higher in the crescentic IgAN group (76.3% and 41.3%; (p < 0.001) as was proteinuria (4.2Â ± 2.7 g/24 hr vs. 2.3 Â ± 1.16 g/24 hr; p < 0.001). Pathologically, global glomerulosclerosis (24.5Â ± 19.3% and 10.1Â ± 10.9% respectively; p < 0.001) and moderate-to-severe tubular atrophy (more than 25% of sampled cortex) was significantly more with IgAN compared to PCGN. Rate of remission with immunosuppression was significantly higher in the PCGN group compared to CIgAN group (p = 0.016) and ESRD or death within 1 year of diagnosis was significantly more in the CIgAN group and occurred in 62.3% (N = 33/53) cases, while in the PCGN group it occurred in 39.1%. Among patients who were dialysis dependent at presentation, primary outcome of ESRD or death within 1 year was seen in majority of 90.9% (20/22) crescentic IgAN (90.9%) and 44.1% (15/34) in the PCGN group with a p value <0.001.

CONCLUSIONS: This study highlights the fact that diffuse CIgAN is a very different form of RPGN when compared to ANCA-associated PCGN and has a higher prevalence of hypertension, higher degree of proteinuria, and more chronicity on renal biopsy. It carries a poor prognosis despite aggressive immunosuppression.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 73: EFFECT OF AMINO GUANIDINE AN ADVANCED GLYCATION END PRODUCT INHIBITOR TREATMENT ON STZ-INDUCED DIABETIC RATS: ASSESSMENT OF PHYSIOLOGICAL AND RENAL FUNCTION

J Ram Mukka Raju 1, Anupama T Row 1, Athar H Siddiqui 1

BACKGROUND: Diabetes mellitus (DM) is a multi-factorial metabolic disease characterized by sustained hyperglycemia leading to the formation of advanced glycation end products (AGEs). The accumulation of AGEs plays an important role in the etiology of diabetic complications. Various evidences suggest that aminoguanidine (AG) an inhibitor of AGE is effective in preventing diabetic complications.

AIM OF THE STUDY: In the current study, our main objective was to assess the physiological and renal hemodynamics in the Streptozotocin (STZ)-induced diabetic rats and how AG an AGEs inhibitor treatment on STZ-induced diabetic rats affects the renal functions of the STZ-induced diabetic rats.

METHODS: Male Sprague Dawley rats weighing 200-225 g were divided into four groups (n = 6-8): vehicle treated STZ-treated vehicle + AG treated and STZ + AG treated. Animals were administered single IP injection of vehicle and 55 mg/kg BW of Streptozotocin. Post 48 hours of injection hyperglycemia was confirmed by determining the blood glucose levels in the rats. The AG-treated group of rats were administrated AG (1 g/L) in drinking water after confirming the induction of diabetes. Urine of the animals was collected by placing them in metabolic cages. Data are expressed as Mean ± SEM, and statistical significance was set at p < 0.05

RESULTS: The STZ-induced diabetic rats had a significantly increased blood glucose levels (462.3+ 18.6 mg/dl vs 107.1 ± 1.81 mg/dl (Vehicle), 111.6 ± 1.49 mg/dl (Vehicle +AG treated). The blood glucose levels in the STZ + AG treated group were found to be 351.5 ± 48.16 mg/dl n = 6-8). Urinary protein was significantly increased in the STZ-induced diabetic rats (52.23 ± 7.16 Âμg/Âμl vs 15.14 ± 1.94 Âμg/Âμl (Vehicle treated), 42.35 ± 7.45 Âμg/Âμl (Vehicle + AG) treated, 56.59 ± 7.02 Âμg/Âμl (STZ + AG treated), n = 4-6). The glomerular filtration rate (GFR) was determined to be significantly increased in the STZ-induced diabetic rats (1.54 ± 0.45 ml/min vs 0.36 ± 0.08 ml/min (Vehicle), 0.41 ± 0.12 (Vehicle + AG treated) ml/min and 1.30 ± 0.14 ml/min (STZ + AG treated), n = 4). The extent of glomerulus damage, expressed as percentage damage, was assessed by observing and comparing the obliteration and narrowing of the capillary space within the Bowman’s capsule, hypercellular glomerus, occlusion of capillary lumens and associated changes as visualized under the microscope in the H&E stained slides of the renal sections in the various rat groups. These indices served as an indicator of the extent of damage in the kidneys in the various rat groups. In comparison to the Vehicle rats, the diabetic rats demonstrated a significant damage in their glomerus structure and the extent of glomerular damage (%) was recorded as (43.34 ± 7.60 vs 7.79 ± 4.60 -Vehicle, p < 0.05 compared to the Vehicle rats), 10.67 ± 1.76 (Vehicle+AG treated p < 0.05 compared to the diabetic rats), and 41.50 ± 2.06 (STZ+AG treated), n = 3-5). The effect of AG-treatment on STZ-induced diabetic rats have shown a significant decrease (p < 0.05) in blood glucose, compared to the STZ induced diabetic rats. Also, the GFR in the STZ + AG treated rats decreased significantly (p < 0.05) compared to the STZ-induced diabetic rats. However, STZ + AG treatment does not affect the glomerulus damage (41.50 ± 2.06% vs 43.34 ± 7.60%), and the urinary protein (52.23 ± 7.16 Âμg/Âμl vs 56.59 ± 7.02 Âμg/Âμl) in comparison to the STZ-induced diabetic rats. Similarly, AG-treated STZ rats have shown increased blood glucose (351.5 ± 48, vs 107.1 ± 1.81, 111.6 ± 1.49) urine protein (56.59 ± 7.02, vs 15.14 ± 1.94, 42.35 ± 7.45), GFR (1.30 ± 0.14 vs 0.36 ± 0.08, 0.41 ± 0.12), and glomeruli damage (41.50 ± 2.06 vs7.79 ± 4.60, 10.67 ± 1.76) as compared to Vehicle and AG-treated vehicle rats. Moreover, Vehicle+ AG-treated rats have shown no change in blood glucose levels (111.6 ± 1.49 vs 107.1 ± 1.81), GFR (0.41 ± 0.12 vs 0.36 ± 0.08), and glomeruli damage (10.67 ± 1.6vs 7.79 ± 4.6) in comparison to the Vehicle rats, but significantly increased urine protein (42.35 ± 7.45 vs 15.14 ± 1.94) as compared to vehicle rats.

CONCLUSIONS: While the AG administration on diabetic rats was effective in not raising the blood sugar levels to that of the diabetic rats, it did not show any effect on reversing the glomerular damage, as induced under diabetes. On the other hand, it did show a reversion of the increased GFR as compared to the diabetic rats, but it did not have any effect in decreasing the proteinuria as observed in the diabetic rats. The AG administration has no significant improvement on the renal dysfunction as compared with the STZ-induced rats. However, we do observe a significant effect in preventing the induction of high blood glucose levels and GFR as seen in the STZ-induced diabetic rats. We observe an anomalous and differential response to the physiological and renal function of AG administration in the diabetic rats.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 74: SURVIVAL OUTCOME IN C3 GLOMERULONEPHRITIS WITH IMMUNOSUPPRESSANT THERAPY: A SINGLE CENTRE EXPERIENCE

Nidhi Gupta 1, Narayan Prasad 1

BACKGROUND: C3 glomerulonephritis (C3GN) is a clinicopathologic entity defined by the presence of isolated or dominant deposits of C3 on immunofluorescence. Data on effect of immunosuppressives treatment in adult C3Gn is lacking.

AIM OF THE STUDY: To study the impact of immunosuppression on C3GN outcomes on follow-up.

METHODS: The study included 68 patients of C3GN with a mean follow-up of 32 months (maximum 130 months) who reported to the institute between January 2011 to July 2022. Patients satisfying pathological criteria for a diagnosis of C3GN were identified. All patients were treated with steroids with and without mycophenolate mofetil (MMF). We have compared the outcomes of the patients with and without MMF.

RESULTS: A total of 68 patients (35 male, age mean 33 Â ± 16 SD) were included. Of them, 43 had hypertension, and 9 had a hypertensive emergency. Active urine sediment was observed in 53, and 11 had macroscopic hematuria. A total of 27 had the nephrotic syndrome, four nephritic syndromes, 16 nephrotic-nephritic, 2 had CGN, and 19 had RPGN presentation. A low c3 level was seen in 36 patients. Mean eGFR 55 ml/min/1.73 m2, mean serum creatinine 3.2 mg/dl, 24 hour mean proteinuria 4.7 gm/day and mean serum albumin at presentation was 2.9 mg/dl. Histologically, out of 68 patients, 29 had MPGN pattern, 13 had DPGN, 12 had DPGN, 8 had MesPGN. 42 had mild to moderate IFTA, 14 had crescents (8- fibrocellular crescents), all had c3 deposit in renal biopsy. Nine patients received no treatment, 31 had received RAAS blockade, 59 steroid, 34 MMF, 3 CNI, 9 cyclophosphamides. They were followed with a mean of 32 months maximum being 130 months. A total of 59 patients were treated with immunosuppression; 34 received steroids with MMF, and 25 only steroids without MMF. Either complete (CR, n = 20) or partial remission (PR, n = 28) was achieved in 48 patients (P = 0.0001). Of the 34 patients with steroids plus MMF, 13 (%) had CR, 19 (%) had PR, and only 2 had no response (P = 0.01). Of the 25 patients treated with steroids without MMF, 9 (%) had partial remission, 8 (%) had complete remission, and 8 (%) had no response. The relative risk of no response was 0.5 (95% CI 0.17-1.4) in patients without MMF. The doubling of serum creatinine on follow-up was significantly high without MMF as compared to with MMF. On Kaplan–Meier survival analysis, the renal survival was significantly better in MMF group as compared to non-MMF group, at 12 month, 60 month, and 120 month was 96%, 50%, and 5% patient who received steroid plus mycophenolate and compared to steroid without mycophenolate was 66%, 18% and 6% respectively.

CONCLUSIONS: Overall remission rate was significantly better in group with steroid and MMF as compared to patients without MMF. Renal survival and number of patients achieving clinical remission were significantly higher in patients treated with steroid plus mycophenolate mofetil as compared with patients treated with other immunosuppressive regimens and untreated patients. Thus, immunosuppressive treatments, particularly steroid plus mycophenolate mofetil, can be beneficial in C3 glomerulonephritis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 75: URINARY TRACT INFECTION IN RENAL TRANSPLANT RECIPIENTS: INCIDENCE MICROBIOLOGICAL PROFILE AND PREDISPOSING FACTORS IN INDIA

Sourabh Sharma 1, Himanshu Varma 1, Ananth Rao 1, Debabarata Mukherjee 1, Kailash Sharma 1

BACKGROUND: Urinary tract infection (UTI) is the most common bacterial infection faced by renal transplant recipients. At least three fourths of renal transplant recipients acquire UTI in the post-transplant period. With stronger immunosuppression and improved surgical techniques, graft survival has improved, but there has been a concomitant rise in infectious complications is worrisome.

AIM OF THE STUDY: To determine incidence predisposing factors and microbiological profile of urinary tract infection (UTI) in renal transplant recipients.

METHODS: This was cross-sectional observational study conducted from 2015 to 2022 at various centers. A total of 435 renal transplant recipients were studied over seven years.

RESULTS: Out of 432 transplant recipients, 135 (31.25%) had UTI. Majority (405/432) had undergone live renal transplantation and twenty seven cases had received cadaveric grafts. Ninety-two patients had primary infection while forty-three patients had recurrences. Incidence of UTI was higher in females than males (p < 0.05). Majority of patients in younger age group (age < 30 years) were female. Males were predominantly affected in higher (>30 years) age group. Most common causative agent was Escherichia coli (74%). Gram negative bacilli accounted for 90.37% (122/135) while Gram positive cocci for 9.63% (13/135) of positive cultures. Multidrug resistance was highest in Klebsiella pneumonia (100%). Fifteen cases with UTI were detected to have underlying urinary tract abnormalities, most common being urethral stricture (63%). Three patients were detected to have broken double J stent in renal pelvis which led to recurrent E coli infection in two patients and recurrent multidrug resistant Klebsiella infection in one patient. Ninety-eight patients (72.6%) developed acute graft dysfunction secondary to UTI. Female sex (p < 0.05), 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 < 0.05) were statistically significant predisposing factors for UTI in renal transplant recipients.

CONCLUSIONS: Incidence of UTI is related strongly with female sex, anatomical alterations in urinary tract, prolonged hospitalization/indwelling catheterization, and immunomodulatory conditions like NODAT and HCV infection. Patients with these predisposing factors should undergo regular surveillance for UTI. The choice of immunosuppression therapy, source of the allograft and level of graft function didn’t influence the incidence of UTI post-transplantation.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 76: OBSERVATIONAL STUDY OF CONTINUOUS RENAL REPLACEMENT THERAPY USING OXIRIS FILTERS AND SUSTAINED LOW EFFICIENCY DIALYSIS IN PATIENTS WITH ACUTE KIDNEY INJURY DUE TO SEPTIC SHOCK

K S Lingaraju, Prashant Dheerendra 1, GA Deepashree 1, Gokulnath 1

BACKGROUND: Few studies have been done comparing SLED v/s CRRT in septic AKI patients and results do not favor CRRT. As of our knowledge, this is the first prospective study comparing outcomes of CRRT with oXiris filter and SLED in patients with septic AKI

AIM OF THE STUDY: The aim of the study was to compare clinical utility of CRRT with Oxiris filter and SLED in septic AKI patients with respect to ICU mortality ICU stay and renal recovery.

METHODS: We included adult septic acute kidney injury patients with shock admitted in ICU who underwent renal replacement therapy either with CRRT (blood flow = 100-150 ml/min and target effluent rates = 20-35 ml/kg/hr) using oXiris filter or with SLED (blood flow = 150 ml/min and dialysate flow = 300 ml/min for a duration of 6 hours). The severity of illness was assessed by APACHE II and SOFA score. Ventilatory requirements inotropic requirements procalcitonin levels lactate and bicarbonate levels were documented at admission and at three days. We compared mortality renal recovery weaning from ventilator ICU stay and followed up the patients at 1 and 3 months post-discharge from the hospital.

RESULTS: Total 60 patients were included in this study, with 30 patients each in CRRT and SLED groups. We found a significantly higher mortality in the CRRT (83.3%) group compared to the SLED (50%) group. Renal recovery in CRRT patients was found to be 10% while it was 40% in the SLED group of patients. Three patients in the SLED group and two in the CRRT group continued to remain on dialysis at three months of discharge. Patients in the CRRT group were more critically ill based on a number of parameters which were significantly worse in the CRRT group, both at presentation and at three days of admission: inotropic requirement, ventilatory requirements, SOFA score, procalcitonin levels, and lactate levels

CONCLUSIONS: Previous studies of CRRT with oXiris filters have shown high mortality rates with the therapy. Our study confirms the finding in a prospective, observational study. The higher mortality is likely because the patients in the CRRT group were more critically ill.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 77: €ŒKIDNEY HEALTH FOR ALL€ - STUDY ON THE ROLE OF SETTING UP A DIGITAL LIBRARY THAT WORKS IN BOTH OFFLINE AND ONLINE MODE- CAN IT BRIDGE DIGITAL DIVIDE

Palani Ravichandran 1, Evamaria B Kaiser 1

BACKGROUND: Health literacy is importantly recognized to combat the increasing incidence of kidney disease in the community and kidney health for all campaigns. Various kinds of digital platforms and tools are used to bridge the gap in health literacy to improve kidney health. Fifty percent of the world population is devoid of internet connection or poor connectivity. Digital library plays a vital role in digital literacy

AIM OF THE STUDY: This present study is done to see if sever specially designed can work both online and offline with the same digital library software

METHODS: A specially designed server that can connect with a digital device along with a regular internet-based server was individually loaded with digital library software. Devices with regular browsers were to access the server with the web address juxtaguide.com. Users included the admin who had full control over the device, and other users were divided into teachers group I N = 25 for online and group II N = 20 for offline study, and they were allowed to upload various format digital files for their students to access. Students in the study group were n = 250 online and n = 80 in an offline group. They were assessed if they can access the digital material search and also participate in chat functions with their teachers. Links were shared through social media for online mode

RESULTS: Teachers in both offline and online mode were able to access the server register and upload files in all formats like mp3, mp4, PDF, documents, links, blogs, and images, using a digital device including a laptop or mobile phone. Students were able to communicate in offline mode to servers similar to online mode with various digital devices. The offline server was portable and could run on a backup inverter power source and could run continuously with a hot spot range of 50 meters. The speed of upload and download for the offline version was not affected but for online mode when the internet was of low speed, 2G bigger files were not downloadable. The maintenance cost of the offline server was minimal compared to the offline server.

CONCLUSIONS: Diginet digital library device completed all its requirements to be a cost-effective device for offline literacy and gives a new hope to bridge not only the health literacy barrier but also opens huge potential for its use in future research and education. Further research is on to extend its range up to 12 Km.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 78: EXTRACELLULAR FLUID ESTIMATION IN PATIENTS ON MHD BY VARIOUS METHODS

Prem Mohan Jha 1, Neeru P Aggarwal 1, L K Jha 1

BACKGROUND: In the past, multiple attempts have been made to develop an ideal method to assess the fluid status in hemodialysis (HD) patients. The aim of this study was to estimate the fluid status by clinical examination, ultrasonography (measuring lung comet scores, inferior vena cava diameters and collapsibility index), and biochemical methods (brain natriuretic peptide) and to compare them with the bioimpedance spectroscopy (gold standard) in chronic hemodialysis patients and to assess the effectiveness of these methods in detecting the change in fluid status after ultra filtration.

AIM OF THE STUDY:

METHODS: We evaluated 65 subjects of age >18 years and undergoing at least twice per week MHD for more than 3 months. Those having features like interstitial lung disease, pulmonary fibrosis, NYHA class III and IV, amputated limbs, acute complications within previous one month before the study, poor IVCD image, and refusal of consent were excluded. Bedside evaluation was done before HD and 30 minutes after HD by clinical examination, multifrequency BIS, ultrasound (ULCs, IVCD (max), IVCD (min), IVC Collapsibility index. BNP levels were measured immediately before and 30 minutes after HD. Continuous variables were expressed as mean ± standard deviation. Correlation coefficients were measured by Spearman's rank correlation method. Statistical comparisons between pre- and post-scenarios (null hypothesis: difference being zero) among continuous variables were tested using the non-parametric Wilcoxon signed rank test. A 5% level of significance (p-value <0.05) was considered for hypothesis testing.

RESULTS: Among 65 subjects 36 (55.38%) were males. Mean age was 59.29 years, and most of the study subjects (40%) were in 61 –70 years age group, while mean BMI was 25.94. Diabetes mellitus, cardiovascular events, and hypertension were present in (60%), (29.2%), and 65 (100%) of subjects respectively. 27 (41.54%) subjects were in NYHA class I while remaining 38 (58.46%) were in NYHA class II. Mean blood pressure was 152/90 mm Hg. On clinical examination, presence of leg Edema, raised JVP, crepitations on chest examination and congestive hepatomegaly were present in 21.54% (14), 32.31% (21), 58.46% (38), and 21.54% (14) of subjects. Mean weight loss was 2.82 kg. Duration of MHD (months) was 37.37 ± 29.09.

CONCLUSIONS: Bioimpedance spectroscopy is simple, bedside, safe, convenient, reproducible, and objective method of extracellular fluid status estimation in hemodialysis patients. Whenever available, it should be preferred over other methods. Clinical examination is not a reliable method to access volume status in end-stage renal disease patients those are on maintenance hemodialysis therapy. Correlation of estimation of volume status through ultrasonographic methods like inferior vena cava diameters and inferior vena cava collapsibility index is very good with the gold standard bioimpedance spectroscopy. Correlation of estimation of volume status through brain natriuretic peptide measurement with the gold standard bioimpedance spectroscopy is poor; hence, it is not an appropriate method for the detection of extracellular fluid status in these patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 79: CLINICO-PATHOLOGICAL PROFILE OF IGA NEPHROPATHY AT A TERTIARY REFERRAL CENTRE IN SOUTH INDIA

H Aditya Shetty 1, Kishan Aralapuram 1, Mythri Shankar 1, Sravani Venu 1, Gireesh G Reddy 1, S Ranjitha 1, T Viswas 1, Gouri Satish 1, H Haritha 1, Sreedhara C Gurusiddaiah 1

BACKGROUND: IgA nephropathy (IgAN) is most common primary glomerulonephritis worldwide.(1) It is now recognized that IgAN is not a benign disease with about 50% of patients progressing to ESRD within 30 years despite treatment.(2) The clinical manifestations of IgAN are variable from asymptomatic microscopic hematuria nephrotic syndrome progressive CKD to rapidly progressive GN.(3) IgAN is more frequent in Asian populations than in Caucasians. The incidence and prevalence of IgA nephropathy is varied in different studies from India with overall prevalence of primary IgAN in India of 7-16%.(4). Marked severity characterizes IgAN in India with a relatively rapid progression and more “malignant†nature. It is apparent that IgAN seems to have a poor outcome in India.(4)

AIM OF THE STUDY: To study the clinicopathological profile of patients diagnosed with IgA nephropathy during the study period. Factors assessed will be- 1) clinical syndrome at presentation, 2) urine abnormalities, 3) histopathological findings at the time of diagnosis.

METHODS: All percutaneous renal biopsies performed at Institute of Nephrourology Bangalore between January 2021 and June 2022 were reviewed retrospectively. Patient’s clinical history syndromic diagnosis on presentation laboratory reports at the time of biopsy was gathered from hospital records.

RESULTS: A total of 1387 renal biopsies were included in this study. A total of 136 patients (9.8%) of them had IgA nephropathy. Among patient diagnosed with IgAN, mean age was 37.9 years. A total of 95 patients (69.8%) were men, and 100 patients (73.5%) had hypertension at time biopsy. Only 6 (4.4%) of patients had normal renal functions at time of biopsy, with mean serum creatinine at presentation of 6.53 mg/dl, 42 patients (30.8%) had microscopic hematuria, and 46 patients (33.8%) had nephrotic range proteinuria. Mean proteinuria was 3225 mg/day: 114 patients (83.8%) had CKD, 9 patients (6.6%) had RPRF, 8 patients (5.8%) had nephrotic syndrome, and 1 patient had macroscopic hematuria at presentation. On biopsy, 86 patients (63.2%) with chronic sclerosing glomerulonephritis was the most common pattern of injury, followed by diffuse mesangioproliferative glomerulonephritis (25.7%), focal mesangioproliferative glomerulonephritis (5.8%). Only 3 patients (2.2%) had crescentic glomerulonephritis, and 86 patients (63.2%) had interstitial fibrosis and tubular atrophy of >50%.

CONCLUSIONS: IgA nephropathy had a prevalence of 9.8% in our study. Most of the patients were diagnosed in the fourth decade of life. Patients presented late in the disease process with nearly 84% of patients with CKD at presentation and significant chronicity on biopsy at the time of diagnosis. Nearly one-third of the patients had microscopic hematuria and nephrotic range proteinuria each at presentation. Further, most patients were known hypertensives. Hence, in our population, emphasis should be directed toward screening of the population with regular blood pressure checks and urine analysis so as to facilitate early diagnosis and treatment of IgA Nephropathy.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 80: AN OUTBREAK OF PNEUMOCYSTIS JIROVECII PNEUMONIA AMONG KIDNEY TRANSPLANT RECIPIENTS

Virendra Chauhan 1, Madhavi Dadwe 1, Saumya Vishnoi 1, Krishnapriya 1, Chaitrali Gawde 1, Ishan Parekh 1, Hepal Vora 1, Zaheer Virani 1, Prashant Rajput 1, Shruti Tapiawala 1, Bharat Shah 1

BACKGROUND: Pneumocystis pneumonia (PCP) is a potentially fatal opportunistic infection by Pneumocystis jirovecii in kidney transplant patients.

AIM OF THE STUDY: Pneumocystis pneumonia (PCP) is a potentially fatal opportunistic infection by Pneumocystis jirovecii in kidney transplant patients. We present eight cases of kidney transplant patients who developed PCP during this covid pandemic

METHODS: All patients who presented during covid pandemic have been included. A thorough clinical examination was done in all. Laboratory work up included CBC CRP procalcitonin chest X-ray ABG and if required HRCT chest was done. Based on clinical presentation and radiologic finding, additional investigations like Serum LDH Beta D glucan (BDG) levels were done. All patients underwent bronchoscopy, and broncho-alveolar lavage was sent for microbiologic evaluation including PCP by PCR.

RESULTS: There were 6 males and 2 females with age ranging from 14 years to 67 years. These patients were 3 months to 20 years post-transplant. All presented with fever and 7 out of 8 had cough, breathless, and hypoxia on presentation. In all patients who were tested, LDH and BDG were high. Incidentally, five patients had hypercalcemia which was not due to vitamin D toxicity or hyperparathyroidism. Most patients had diffuse ground glass opacities on HRCT chest. All were treated with cotrimoxazole with steroids. Three cases died. These cases had polymicrobial infection

CONCLUSIONS: In this covid pandemic, besides covid infection, PCP pneumonia should be suspected in kidney transplant patients presenting with fever, cough, breathlessness, and hypoxia. Hypercalcemia done as a part of routine biochemistry may be the first clue. The elevated LDH and BDG levels are other important clues. While those with PCP infection alone do improve, those with polymicrobial infection do poorly

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 81: POST RENAL TRANSPLANT GRANULOMATOUS INTERSTITIAL NEPHRITIS: A RARE OCCURRENCE

V Santosh Kumar 1, Manish Chaturvedy 1, Rajesh Jhorawat 1, Aasma Nalwa 1

BACKGROUND: Granulomatous interstitial nephritis is an uncommon cause of impaired kidney function in kidney transplant recipients; the incidence of interstitial nephritis has been reported to be <1% with only a fraction of these containing granulomas [1]. Although drug-related disease remains the most common etiology of granulomatous interstitial nephritis accurate diagnosis is particularly important in kidney transplant recipients due to concern over the consequences of altering immunosuppression in the early post-transplant period. Drug-induced AIN secondary to TMP-SMX although an uncommon cause of allograft dysfunction over the study period accounts for over 10% of cases of allograft dysfunction within the first month of transplantation [2]

AIM OF THE STUDY: We report a case of granulomatous interstitial nephritis in a renal transplant recipient in the immediate post-transplant period. He had slow graft function and biopsy was suggestive of granulomatous nephritis autoimmune, infective causes were ruled out, and a diagnosis of Cotrimoxazole-induced granulomatous nephritis was considered. Following stoppage of the drug patient graft dysfunction resolved and repeat biopsy showed no evidence of granulomas suggesting that patient had Cotrimoxazole-induced granulomatous interstitial nephritis.

METHODS: A 31-year-old male CKD patient on regular twice weekly hemodialysis underwent live-related renal transplantation with his mother as donor. The left kidney of the donor was harvested by Lap Donor Nephrectomy for transplantation without any intra op complications. Patient had fever of 100 deg F in immediate post-op period on D0 patient urine output was 5L day0 for intake of 10 L Day 1 creatinine was 3.1 mg from Day 1 to Day 4; there was gradual drop in urine output from 5 L to 1L along with hypertension and drop in platelet count. Patient continued to have low-grade fever antibiotics were escalated to Piperacillin tazobactam, and cultures were sent and USG was done to rule out HUN. Patient was also started empirical MPS 500 mg IV along with 1 cycle of PLEX and IVIG in suspicion of acute rejection. Patient's graft tenderness settled with MPS and on Day 4 patient underwent renal biopsy. Renal biopsy showed evidence of granulomatous interstitial nephritis with ATN without evidence of any rejection. By POD6, patient fever had settled and patient's urine output started to improve from Day 9 onward and patient BP also started to normalize from Day 10 onward. In view of evidence of granulomatous interstitial nephritis in biopsy work up was done to rule out infective causes including Fungal and TB culture- 3 urine samples (no growth). Serum Ace levels were done to rule out Sarcoidosis, and a diagnosis of drug-induced interstitial nephritis was arrived after having ruled out infective and autoimmune etiology. Trimethoprim Sulfamethoxazole Piperacillin Tazobactam and Pantoprazole were stopped in view of their propensity to cause drug-induced GIN. By day 10, patient urine output had started matching to input creatinine started to decrease and reached a nadir of 1.3 mg after 2 weeks patient was shifted from Cotrimoxazole to Clindamycin with primaquine for Pneumocystis Jiroveci prophylaxis. Patient is currently on triple immunosuppressants, and latest creatinine on follow-up is 1.5 mg

RESULTS: LIGHT MICROSCOPY: The tissue is examined at 12 levels of the section with H&E, PAS, Trichrome, Jones Silver, and EVG stains along with immunohistochemistry for C4d and antibody to the simian virus (SV40) large T antigen. The biopsy comprises a skeletal muscle fragment along with a linear core of the cortex. The up to 15 glomeruli per level of section for evaluation demonstrate variable glomerulomegaly, one of which is globally sclerosed. Occasional glomerulus exhibits glomerulitis (g1) in the form of the presence of leukocytes with endothelial swelling of occasional capillary loop. There is mild mesangial hypercellularity (mm1) with focal neutrophilic exudation. No capillary wall reduplication (cg0), segmental sclerosis or crescent formation is identified. The interstitium displays edema. There is patchy moderate interstitial inflammation of 40–45% (i2) in the non-scared areas. The inflammation comprises predominantly lymphocytes and histocytes along with a few plasma cells and neutrophils. Many of these histocytes transform to form small non-necrotizing epithelioid cell granuloma with the presence of neutrophilic karyorrhectic debris in and around them. Tubules show marked acute tubular injury in the form of tubular simplification and epithelial degeneration along with the presence of regenerative changes such as basophilic nuclei and mitosis in nuclei. Many of the tubules show red blood cell casts. No definitive evidence of tubulitis was identified (t0). Interstitial fibrosis and tubular atrophy is mild (ci1, ct1). Total cortical inflammation (ti1), including all cortical inflammation, even subcapsular, perivascular, and fibrotic areas, comprises approx. 25-50% of the biopsied parenchyma. Inflammation in areas of interstitial fibrosis and tubular atrophy is less than 10% of scarred cortical parenchyma. On the Ziehl–Neelsen stain, no acid-fast bacilli were seen. On Gomori methenamine silver stain, no fungal profile was identified. On IHC, no linear staining on the peritubular capillaries was seen (C4d0). CMV was immunonegative. Polyoma large T antigen, SV 40 does not show nuclear immunopositivity in any of the tubules (pvl0) IMMUNOFLUORESCENCE MICROSCOPY (IF 48/22) shows 9 glomeruli with four globally sclerosed. All the glomeruli do not show any deposits with the antisera specific for IgG (0), IgA (0), IgM (0), Complement C3 (0), and C1q (0), kappa light chain (0), lambda light chain (0). Fibrinogen is not highlighted. No definite extraglomerular staining is seen. Final Interpretation: Graft Kidney, needle biopsy shows Granulomatous interstitial nephritis (non-necrotizing). No evidence of rejection was seen C4d negative.

CONCLUSIONS: In view of the complex drug history in our patient, ascertainment of the causative drug is difficult, although it appears clear for the above reasons that the illness in our patient was due to drug hyper sensitivity. DRUG-INDUCED acute interstitial nephritis is a common cause of dysfunction in native kidneys, and the most frequently implicated agents are nonsteroidal anti-inflammatory agents and antibiotics.3,4 By contrast, there are only rare reports of drug-induced interstitial nephritis as a cause of acute renal insufficiency in renal allograft recipients 5,6 despite the antibiotics and other drugs associated with acute interstitial nephritis many renal transplant patients receive. A potential explanation is that most renal transplant recipients receive corticosteroids as part of their immunosuppressive drug regimen, and corticosteroids are often used in the treatment of drug-induced acute interstitial nephritis. Cotrimoxazole is commonly used as a prophylactic agent for pneumocystis agent in all renal transplant patients, apart from usual side effects of cytopenia and dyselectrolytemia, it has the propensity to cause drug-induced interstitial nephritis in immediate post-transplant period leading to acute allograft injury. D-GIN closely resembles to allograft rejection clinically and responds to steroids but needs stoppage of the offending agent to prevent further allograft insult. The rapid resolution of symptoms, and renal impairment, temporally associated with drug withdrawal, and the self-limiting granulomatous interstitial nephritis in the absence of immunosuppressive treatment, all strongly support the diagnosis of drug hypersensitivity in our patient.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 82: EFFECT OF KIDNEY TRANSPLANT ON MINERAL AND BONE DISORDER PARAMETERS IN CHRONIC KIDNEY DISEASE PATIENTS

Satish Chaudhary 1, Saumya Gupta 1, Mohit Gupta 1, Sita Paikra 1, Nitish 1, Harsha 1, B K Upadhyay 1, Reetesh Sharma 1

BACKGROUND: Renal transplant recipients have an increased risk of cardiovascular events and premature death compared with the general population though lower than in patients with end-stage kidney disease receiving maintenance dialysis. In RTRs, vascular disease is a major contributor to chronic allograft nephropathy and recipient death. This increased risk cannot fully be accounted for by the higher burden of traditional cardiovascular risk factors an observation that has prompted the search for new and possibly modifiable risk factors Progressive chronic kidney disease results in secondary hyperparathyroidism (SHPT). After a successful renal transplant theoretically SHPT should rapidly regress. But residual parathyroid overactivity may persist and many recipients have lingering abnormalities of Ca and P metabolism related to persistent hyperparathyroidism and immunosuppressive drugs. Understanding the patterns and pathophysiology of MBD pre- and post-renal transplant is important to accurately interpret laboratory parameters and to guide therapy to reduce complications including cardiovascular morbidities. Thus it is important to study the impact of this paradigm shift on post-transplantation mineral and bone metabolism. Indian reports of post-transplant hyperparathyroidism are sparse.

AIM OF THE STUDY: To determine the natural history of biochemical markers of mineral bone disorders in CKD (serum calcium phosphate intact parathyroid hormone 25(OH)D and total alkaline phosphatase) after renal transplantation.

METHODS: This is a non-randomized prospective observational study. All the patients with chronic kidney disease who opt for renal transplantation as renal replacement therapy were included in this study. Patients with primary parathyroid disorders and mineral metabolism disorders obstructive liver disorders surgical parathyroidectomy recipient death or graft loss within three months of transplant were excluded. Taking lost to follow-up as 5% the total sample size taken is 139. Laboratory variables included measurements of complete hemogram serum creatinine serum albumin phosphate calcium alkaline phosphatase 25(OH)D and intact parathyroid hormone (iPTH) based on standard laboratory techniques within 1 month before renal transplantation and at 3 months 6 months and then at 12 months after renal transplantation. The eGFR was calculated using the Modification of Diet in Renal Disease (MDRD) formula. During transplant surgery, patients received induction therapy depending on their immunological risk. Methylprednisolone (500 mg) was given intravenously the night prior to surgery. Post-surgery intravenous hydrocortisone (100 mg x 6 doses) followed by oral prednisolone from postoperative day 2 onward with starting doses of 40 mg with tapering of 2.5 mg each day. The dose of prednisolone was continued at 0.5 mg/kg/day for a month after transplantation and was tapered by 2.5 mg/week to reach 7.5 mg/day at 16 weeks. The dose was reduced to 5 mg/day at the end of 6 months. A triple immunosuppressant regimen was followed in our hospital with the initial dose of tacrolimus (0.1 mg/kg/ day), antimetabolite (mycophenolate sodium or azathioprine), and prednisolone (0.5 mg/kg/day). Tacrolimus dose was optimized based on therapeutic drug monitoring.

RESULTS: This study was a non-randomized prospective observational study including 139 chronic kidney disease patients who opted for renal transplantation as renal replacement therapy. Out of 139, 3 died, 1 had an acute myocardial infarction within 3 months of transplant, 1 had sudden death at home and another had post-transplant sepsis with multiorgan dysfunction and 1 patient had graft loss due to hyperacute rejection, leaving 135 patients included in study analysis. The mean age group of the study population was 40.17Â ± 12.2 years. Males formed the predominant study population (81.5% males vs. 18.5% females). At the time of transplantation, 124 were on hemodialysis, and the remaining 11 were transplanted pre-emptively. The mean dialysis vintage was 7.19Â ± 4.57 months (mo). The most common etiology of CKD in our study population was diabetic nephropathy (20.7%) followed by IgA nephropathy (14.1%). Out of the total 135 patients studied, 28 (20.7%), 123 (91.1%), and 14 (10.4%) of subjects had type 2 diabetes mellitus, hypertension, and hypothyroidism respectively. 15 (11.1%), 4 (3%), and 5 (3.7%) of subjects had cardiovascular disease, hepatitis B and hepatitis C respectively who underwent renal transplantation. In our study, pre-transplant induction therapy was given in 125 (92.6%) high immunological risk subjects and 10 (7.4%) subjects who did not receive any form of induction therapy. 90.4% (122) of study subjects were receiving tacrolimus based maintenance immunosuppressants and 9.6% (13) were receiving cyclosporine based maintenance immunosuppressants. Among 135 subjects, 6 (4.4%) had biopsy-proven acute graft rejection within 1 month of post-transplant and 19 (14.1%) of subjects developed new-onset diabetes after transplant. Out of the total 135 patients studied, 14.8% of subjects had suboptimal graft function at 3 mo follow-up compared to 20% and 27% at 6 mo and 12 mo respectively. The mean eGFR, post-transplant at 3mo, 6mo, and 12 mo follow-up were 79.86Â ± 22.29, 76.67Â ± 24.55, and 74.76Â ± 24.47 ml/ min/ 1.73 m2 respectively. At 12 mo follow-up, iPTH had a significant weak negative correlation with eGFR. (r = -.236, P value = 0.006). The iPTH levels declined significantly (p-value <0.001) from median (IQR) value 300 (181-423.70) pg/mL before transplantation to 136 (97.1-167.3) pg/mL at 3 mo, 79.3 (49.8-100.3)pg/mL at 6 mo and 80.3 (59-98.7) pg/mL at the end of the study period. The prevalence of persistent severe HPT remained at 3.7% at 3 mo follow-up and 0.7% at 6 mo follow-up. The prevalence of persistent moderate secondary hyperparathyroidism was 68.1% at 3 mo follow-up and 24.4% at 6 mo and 12 mo follow-up respectively. The prevalence of persistent mild secondary hyperparathyroidism was 16.3% at 3 mo follow-up and 41.5% at 6 mo and 12 mo follow-up respectively. Post-transplant corrected calcium levels were within the normal range in 84.4% of subjects at 3 mo follow-up and 91.9% and 93.9% at 6 mo, 12 mo follow-up respectively. The prevalence of persistently elevated calcium levels remained in 14.8% of the patients at 3 mo, 8.1% at 6 mo, and 6.7% at 12 mo. Post-transplant at 3 mo follow-up, iPTH had a significant weak positive correlation with corrected calcium. (r value = 0.291 p-value = 0.001) Multivariate regression analysis showed that iPTH level (p value = 0.037) was found to be independently associated with post-transplantation corrected calcium level hence pretransplantation parathyroid function is an important predictor of Ca metabolism after transplantation. Elevated phosphorus levels stabilized within the normal range by 3 mo after transplantation, but mild-to-moderate hypophosphatemia was observed in 22.5%, 9.6%, 5.9% of the patients at 3 mo,6 mo and 12 mo respectively. Post-transplant at 3 mo follow-up, iPTH had a highly significant moderate weak negative correlation with phosphate (r value = -.597, p-value (0.000)). Pre-transplant, median (IQR) of 25(OH)D was 19.6 (13-28.8) ng/ml, and post-transplant at 3 mo and 12 mo follow-up were 24.2 (21-28.5), and 37.3 (32.2-41.3) ng/ml respectively. At 6 mo post-transplant, the mean of 25(OH)D was 32.54Â ± 5.60. Pre-transplant prevalence of 25(OH)D insufficiency was 65.2%, whereas 80% at 3 mo follow-up and 29.6% and 17.8% at 6 mo and 12 mo respectively after transplant. Median (IQR) of total alkaline phosphatase, pre-transplant was 78 (78-155) and post-transplant at 3mo, 6mo, 12mo follow-up were 89 (69-111), 89 (77-98) and 89 (70-110) IU/L respectively. High post-transplant PTH levels were accompanied by increased serum calcium and decreased serum phosphate levels and high rates of hypercalcemia and hypophosphatemia at 3 mo after transplant.

CONCLUSIONS: This study depicts that kidney transplant recipients with high serum levels of iPTH at the time of transplantation were at risk for persistent hyperparathyroidism, especially when pretransplant secondary hyperparathyroidism is severe. At 12 months post-transplant, iPTH had a significant negative correlation with eGFR, which suggests that good graft function may reverse the persistent hyperparathyroidism. This study observed renal phosphorus wasting regresses by 12 months after renal transplantation. Multivariate regression analysis confirmed that pretransplantation parathyroid function is an important predictor of calcium metabolism after transplantation. 25(OH)D insufficiency may aggravate secondary hyperparathyroidism, hence should be addressed in post-renal transplant settings to prevent this condition. Secondary hyperparathyroidism should be identified and managed properly before transplantation, graft function should be monitored closely after renal transplant to minimize the risk for persistent hyperparathyroidism. Serum calcium and phosphorus levels should be monitored closely at 3 months of follow-up after transplant.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 83: FACTORS DETERMINING OUTCOME OF ACUTE KIDNEY INJURY PATIENTS: A FOLLOWUP STUDY

Rajesh Tarachandani 1, Himansu Mahaptra 1, Lalit Pursnani 1, Muthukumar 1

BACKGROUND: Acute Kidney Injury (AKI) is associated with significant morbidity and mortality, and as no specific treatment is available to reverse AKI early identification of patients with AKI is likely to result in superior outcomes.

AIM OF THE STUDY: (i) To evaluate risk factors of AKI for the patients reporting at RML hospital New Delhi and (ii) to assess three months follow-up outcome among patients suffering from AKI.

METHODS: This was a prospective cohort study which included all patients with clinical diagnosis of AKI reporting at ABVIMS and Dr RML Hospital New Delhi over the duration of six months which enrolled 173 participants. The patients were followed up to record their three-month outcome.

RESULTS: 54.3% of participants were male and 61.8% had non-oliguric type of AKI. 79.2% and 53.8% presented with evidence of hypovolemia and sepsis respectively. 27.2% of participants reported associated comorbidities. After 3 month follow-up, 43.9% of participants reported complete recovery, whereas death occurred in 39.3% of patients. Univariate analysis showed that parameters such as age, evidence of hepatorenal syndrome, evidence of sepsis, patient on mechanical ventilation, patient on vasopressors and RRT requirement by patients were significantly associated (p < 0.05) with patient outcome at 7th day, 1 month and 3 month follow-up.

CONCLUSIONS: AKI is associated with significant 3-month mortality. This emphasizes the immediate need for AKI prevention, early detection and intervention in extenuating reversible risk factors in order to optimize clinical outcomes. KEYWORDS: Acute kidney injury, prospective study, univariate analysis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 84: PERI PROCEDURAL STEROIDS FOR AV ACCESS DECLOT IN ESRD PATIENTS

Ankita Raisinghani 1, Sreedhara CG 1, A Kishan 1, Gireesh Reddy 1, Mythri Shankar 1, Sravani 1

BACKGROUND: Thrombosis is the dominant cause of failure of arteriovenous fistulas for hemodialysis access. Vascular inflammation an important pathologic change in various human vascular diseases may be involved in the thrombotic process of arteriovenous fistulas. Chang et al. (2005) in his study published in kidney international showed that the macrophage and lymphocyte contents of the thrombosed group were abundant and markedly greater than those of the non-thrombosed group. They also demonstrated that the infiltration of macrophages and neovasculature were spatially closely correlated; expressions of VCAM-1 IL-6 and TNF-alpha but not ICAM-1 were significantly higher in the thrombosed group. Immediate post-procedural period characterized by fever flu-like symptoms and neutrophil leukocytosis has been observed in terms of the systemic inflammatory response syndrome in 60–80% of patients undergoing declot of thrombosed AV access. The administration of perioperative glucocorticoids has been shown to reduce the inflammatory response after various types of surgery resulting in improved recovery. The ability of glucocorticoids to preserve the endothelial glycocalyx and thereby the vascular barrier is of particular interest in vascular surgery where injury-induced disruption of the endothelial glycocalyx results in impairment of the vascular barrier promotion of interstitial edema and inflammation. Gerasimidis et al. (2005) reported the use of 500 mg of hydrocortisone during EVAR, and finally Nano et al. (2014) described the administration of 1 g of hydrocortisone intravenously on the third postoperative day in case of post-implantation syndrome. In all three non-randomized reports, the timing of glucocorticoid is suboptimal considering the physiological functions of steroids. The effects of preoperative glucocorticoids in EVAR have only been tested in a recent randomized controlled trial (de la Motte et al. 2014). The POMEVAR trial which studied the effect of high-dose methylprednisolone (30 mg/kg) two hours prior to EVAR showed a pronounced reduction of the postoperative components of the systemic inflammatory response syndrome response from 92% to 27%.

AIM OF THE STUDY: To describe the effect of intravenous hydrocortisone in ameliorating the systemic inflammatory response syndrome response post-declot of thrombosed AV access in ESRD patients.

METHODS: After informed consent history and general physical examination of the fistula was done for all patients. They were explained the procedure. Intravenous hydrocortisone 100 mg was given at the end of the procedure when inflammatory response comprising of sever chills and rigor fever and flu-like symptoms were noted.

RESULTS: A total of 64 patients who underwent declot of the thrombosed AV access were included in this study. Age group included ranged from 17 years to 79 years with an average of 56.26 years. Sixty percentage of included population were male, and forty percent were female. There was prompt response to intravenous hydrocortisone observed by immediate cessation of chills and rigor. They were followed up every 3 months to check for patency of the fistula and the 6th month patency was 95% in both the groups which was at par with the international data.

CONCLUSIONS: Our observations were in concurrence with POMEVAR trail (effect of high-dose steroids in EVAR). Hence we conclude that intravenous hydrocortisone is a very cost effective and efficient therapy with both long-term and short-term benefits. Short-term benefits being prompt cessation of inflammatory response and long term being increased patency of vascular access. Ours is the first study of its kind to look into the benefits of steroids in endovascular procedures to salvage vascular access. Large volume randomized controlled trials may be warranted to ratify our observations.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 85: CUTANEOUS CRYPTOCOCCAL INFECTION AS ULCERATIVE LESIONS IN POST RENAL TRANSPLANT - A CASE REPORT

Rajesh Tarachandani 1, Himanshu S Mahaptra 1, Lalit Pursnani 1

BACKGROUND: Cryptococcosis is a serious post-transplant infectious complication in solid organ transplant (SOT) recipients due to long-term immunosuppressant therapy with an overall incidence of around 2.8%. After central nervous system (CNS) and the lung skin and osteoarticular tissue is the most common site of cryptococcal disease.

AIM OF THE STUDY: To study cutaneous cryptococcal infection in a patient with post-renal transplant

METHODS: 49-year-old male with diabetes mellitus underwent live-related ABO compatible HLA mismatch 3/7 renal transplant in March 2020. He was on maintenance immunosuppression with prednisolone tacrolimus and mycophenolate. He was admitted with multiple skin lesions which initially presented as nodular swelling later on ulcerated and had pus discharge. Patient thoroughly examined and result recorded.

RESULTS: On examination patient has multiple fluctuating swellings along with ulcerative nodular lesions, initially involving both forearms which gradually progressed to shin of left tibia. Empirical antibiotics were started but failure of conventional therapy prompted a skin biopsy which confirmed cryptococcal colonies. MRI of left leg reported multiple cutaneous nodular abscesses, while culture of abscess confirmed multiple cryptococcal colonies. Treatment included reduction in immunosuppression regimen. Targeted treatment for cryptococcal disease with liposomal amphotericin B followed by fluconazole maintenance therapy was given which achieved a good clinical response for our patient.

CONCLUSIONS: Immunocompromised case presenting with multiple cutaneous lesions non-respondent to usual antibiotic therapy, may need a low threshold for investigation even in the absence of other symptoms or signs. Key words: Ulcerative lesions, Cryptococcal infection, post-renal transplant, immunocompromised.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 86: NETWORK-BASED EXPRESSION ANALYSIS TO IDENTIFY POTENTIAL MOLECULAR BIOMARKERS AND ASSOCIATED PATHWAYS FOR ACUTE KIDNEY INJURY

Amisha Garg 1, Sanjeev Puri 2, Veena Puri 1

BACKGROUND: Acute Kidney Injury (AKI) is the abrupt loss of kidney function leading to chronic kidney disease increased risk of cardiovascular complications and long-term mortality. AKI is associated with poor prognosis due to absence of specific biomarkers. Studies have shown that miRNA can be used as an AKI biomarker as they are involved in all cellular functions including development differentiation growth metabolism and regulation of numerous physiological and pathophysiological processes. This study focused on determining potential biomarkers and presenting the molecular processes involved in the manifestation of AKI in patients after kidney transplantation.

AIM OF THE STUDY: To determine potential biomarkers and presenting the molecular processes involved in the manifestation of AKI in patients after kidney transplantation

METHODS: Microarray analysis was done to investigate the miRNA transcriptome data with ID GSE53771. Differentially regulated miRNAs were identified by comparison of samples of patients with and without AKI at different time points which is at 0 hour or before transplantation and post-transplantation without rejection using the limma package in R-studio. To identify the miRNA-gene interaction target identification was performed for each miRNA using miRTargetLink 2.0 a bioinformatics tool. Following target identification, a network study between the miRNA their target genes transcription factors and signalling pathways were done using NetworkAnalyst 3.0 software.

RESULTS: From a total of 25,015miRNAs, there were 220 which were downregulated while 359 were found to be upregulated. According to the network analysis, the major target genes involved in the disease for these miRNAs were MYC, MAX, MAPK1, AKT1, and SP1 and the minor nodes engaged in the disease were FOXO, hsa-let-7b-5p, MDM4, NFIC, and AR. The observations revealed the involvement of dysregulated miRNAs in processes like programmed cell death, apoptosis, cell cycle regulation, proliferation, angiogenesis, and in cancer-causing cells. Some of the target genes were found to be involved in fibrosis, inflammation, and differentiation. An extensive understanding of the genes and miRNAs involved in disruptive molecular processes of AKI can help in better diagnosis and treatment options of AKI patients.

CONCLUSIONS: This study provides a deeper understanding into the miRNAs and genes dysregulated in the patients suffering from AKI and the pathways that can lead to the progression of the disease. These genes can act as potential targets for the treatment of the patients, as there is lack of therapies for the treatment of patients as of now. Our study also provided strong evidence that these biomarkers are mostly involved in cell death, apoptosis, cell migration, cell proliferation, differentiation, and progression of human cancer.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 87: TO STUDY THE EFFICACY OF RITUXIMAB IN FREQUENTLY RELAPSING/STEROID DEPENDENT NEPHROTIC SYNDROME

Rohit Gaude 1, Amruta Devi 1, Vijay Vacchani 1, Alok Mohapatra 1

BACKGROUND: Nephrotic syndrome is a persistent renal disease in children with an average incidence of 2—16.9 per 100 000 children worldwide and large variability in incidence between different ethnicities and regions. Although the initial treatment with prednisone (60 mg/m 2) leads to long-term remission in a variable proportion of patients up to 40—60% will relapse. However at least 50% will develop multiple relapses and may develop steroid dependent NS or frequent relapsing NS. Several reports show a role of anti-B-cell treatment in SDNS which is difficult to control including larger series from France, Japan, India, and an international study.

AIM OF THE STUDY: 1) To measure the remission rates (PR and CR) and relapse rates in patients of FR/SDNS. 2) To determine treatment related side effects occurring in FR/SDNS after receiving Rituximab regimen. 3) To assess changes from baseline in proteinuria eGFR se creatinine level.

METHODS: Patients aged 2—18 years in complete remission or partial remission and with clinical history of SDNS and estimated eGFR of more than 30 ml/ min/ 1.73 m2 of BSA to receive IV CD 20 ABs (rituximab) (4 infusions 375 mg/m2 mg each wkly and another dose at 6 months in case of partial response). Patients were randomly divided in 2 groups. 1 st group received IV CD 20 ABs (rituximab) along with steroid antiprotienuric agents. The control group received steroid along with antiproteinuric agents and placebo. Patients were followed for 12 months.

RESULTS: In Rituximab Group, the mean 24-hour urinary protein at 6 month and 12 month was 0.6750 and 0.5965 respectively and in control group, the mean 24-hour urinary protein at 6 month and 12 month was 1.8500 and 1.1525 respectively. In rituximab and control group, the mean No of Relapse/ Year was 1.00 and 3.75 respectively.

CONCLUSIONS: The current study showed that rituximab decreased the number of relapses, 24 hr urinary protein at 6 months and 12 months of follow-up, and side effect profile was better with rituximab in comparison to control group.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 88: CT PERITONEOGRAPHY IN PATIENT ON CONTINOUS AMBULATORY PERITONEAL DIALYSIS WITH PATENT PROCESSUS VAGINALIS

Asheesh Malhotra 1, Jasmine Dass 1

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) is a useful modality for the treatment of end-stage renal disease (ESRD). In a properly selected patient, this method is usually well-tolerated and is associated with minimal complications. Localized genital edema is a common complication in CAPD patients and may result from abdominal inguinal hernias and peritoneal leaks. The incidence of hernia in patients undergoing PD varies from 0.04 to 0.08 per patient per year 1 2 3. We report a case of intermittent genital edema secondary to patent processus vaginalis in a patient receiving CAPD. The diagnosis of patent processus vaginalis which was strongly suggested by intermittent nature of the symptoms was confirmed by computerized tomography (CT) peritoneography.

AIM OF THE STUDY: To assess the role of CT peritoneography in diagnosing fluid leaks in patients of CAPD.

METHODS: Before performing CT peritoneography, the peritoneal cavity was completely drained of dialysate. Next 1 mL/kg of non-ionic contrast material (iodine 300 mg/mL) was mixed with 30 mL/kg of dialysate and infused into the peritoneal cavity. Patient made to walk and strain to ensure appropriate fluid distribution mixing and to delineate any leak. Scanning was performed with the patient in the supine position 1 hour after contrast injection. The contrast material dialysate mixture was drained at the end of the procedure.

RESULTS: CT peritoneography revealed free passage of contrast material-dialysate mixture into the right inguinal canal and the scrotum. The diagnosis of patent processus vaginalis was thus confirmed.

CONCLUSIONS: CT peritoneography is a useful tool in diagnosing the etiology of genital edema, and it also allows anatomical definition for planning appropriate surgical correction in patients on continuous ambulatory peritoneal dialysis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 89: EPIDEMIOLOGY CLINICAL PRESENTATION AND OUTCOME OF PATIENTS WITH PAUCI- IMMUNE CRESCENTIC GLOMERULONEPHRITIS: A COMPARISON BETWEEN ANCA POSITIVE VERSUS ANCA NEGATIVE VASCULITIS

J Meyyappan 1, N Prasad 1, M R Behera 1, A Kaul 1, D S Bhadauria 1, M R Patel 1, R S Kushwaha 1, M Yachha 1, V Vamsidhar 1

BACKGROUND: Pauci-immune crescentic glomerulonephritis (CrGN) is one of the most common causes of rapidly progressive glomerulonephritis (RPGN). Approximately 80–90% of patients with pauci-immune CrGN had circulating ANCA which can be either cytoplasmic ANCA (cANCA) or perinuclear ANCA (pANCA). A number of patients with pauci-immune CrGN are negative for either cANCA or pANCA. The clinical presentation and outcome of this group of patients are rarely reported

AIM OF THE STUDY: To study the clinical presentation and outcome of pauci-immune ANCA negative CrGN and to compare it with ANCA positive vasculitis

METHODS: A retrospective single-center observational study conducted at a tertiary healthcare center India, between January 2005 and December 2020. All patients with biopsy-proven pauci-immune crescentic glomerulonephritis in the study period were included in the study and followed until June 2021. Patients with secondary vasculitis immune-complex mediated vasculitis or with anti—glomerular basement membrane antibodies were excluded from the study. Patient-related information such as age, gender, BMI, comorbidities, clinical parameters, laboratory parameters, and histopathology-related data were collected from the hospital informatics system and hospital record section. Clinical parameters BVAS score baseline urine output treatment-related information (induction and maintenance immunosuppressant) total duration of hospitalization rate of hospitalization rate of infection-related hospitalization time to end-stage renal disease duration of patient survival and causes of death. Laboratory parameters and biopsy data reviewed by pathologist were compared between the two groups. Primary outcome was renal and patient survival. Secondary outcomes were rate of infection-related hospitalization duration of hospitalization and loss to follow-up.

RESULTS: A total of 176 patients were included in the study, 138 (78.4%) ANCA positive and 38 (21.6%) ANCA negative. Mean age was 46.13 (47.69 Vs 40.45, p 0.004). Median duration of follow — up was 8 months. The clinical characteristics, mean BVAS score, were not statistically different between the two groups. Patients with ANCA negative vasculitis had lesser extra-renal manifestations, mainly arthritis 40.3% (47.8% Vs 13.2% p < 0.001). Among ANCA positive group, 52.1% were ANCA positive. By Berden histological class, 70.4% had crescentic class (70.3% Vs 71.1%, p 0.647). Plasma exchange was done in 30.1% (36.2% Vs 7.9%, 0.003). Any renal response was achieved in 58.5% (62.3% Vs 44.7%, p 0.05) while 25% (22.5% Vs 34.2%, p 0.1) patients died within 1 year follow-up. Late presentation, low eGFR at presentation and sclerotic berden class were independently associated with poor outcomes.

CONCLUSIONS: ANCA negative vasculitis seems to affect relatively younger patients. Renal and overall survival among patients with ANCA Negative Pauci-immune crescentic glomerulonephritis is poor as compared to their ANCA positive counterparts. Translational research in ANCA negative patient subgroup to identify disease mechanisms and unidentified autoantibodies is needed in addition to possible separate treatment protocols for these patients

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 90: EPIDEMIOLOGY CLINICAL PRESENTATION AND OUTCOME OF PATIENTS WITH PAUCI- IMMUNE CRESCENTIC GLOMERULONEPHRITIS: A COMPARISON BETWEEN ANCA POSITIVE VERSES ANCA NEGATIVE VASCULITIS

J Meyyappan 1, N Prasad 1, M R Behera 1, A Kaul 1, D S Bhadauria 1, M R Patel 1, R S Kushwaha 1, M Yachha 1, V Vamsidhar 1

BACKGROUND: Pauci-immune crescentic glomerulonephritis (CrGN) is one of the most common causes of rapidly progressive glomerulonephritis (RPGN). Approximately 80–90% of patients with pauci-immune CrGN had circulating ANCA which can be either cytoplasmic ANCA (cANCA) or perinuclear ANCA (pANCA). A number of patients with pauci-immune CrGN are negative for either cANCA or pANCA. The clinical presentation and outcome of this group of patients are rarely reported.

AIM OF THE STUDY: To study the clinical presentation and outcome of pauci-immune ANCA negative CrGN and to compare it with ANCA positive vasculitis

METHODS: A retrospective single-center observational study conducted at a tertiary healthcare center, India, between January 2005 and December 2020. All patients with biopsy-proven pauci-immune crescentic glomerulonephritis in the study period were included in the study and followed until June 2021. Patients with secondary vasculitis immune-complex mediated vasculitis or with anti—glomerular basement membrane antibodies were excluded from the study. Patient-related information such as age, gender, BMI, comorbidities, clinical parameters, laboratory parameters, and histopathology-related data were collected from the hospital informatics system and hospital record section. Clinical parameters BVAS score baseline urine output treatment-related information (induction and maintenance immunosuppressant) total duration of hospitalization rate of hospitalization, rate of infection-related hospitalization time to end-stage renal disease duration of patient survival, and causes of death. Laboratory parameters and biopsy data reviewed by pathologist were compared between the two groups. Primary outcome was renal and patient survival. Secondary outcomes were rate of infection-related hospitalization duration of hospitalization and loss to follow-up.

RESULTS:

CONCLUSIONS: ANCA negative vasculitis seems to affect relatively younger patients. Renal and overall survival among patients with ANCA Negative Pauci-immune crescentic glomerulonephritis is poor as compared to their ANCA positive counterparts. Translational research in ANCA negative patient subgroup to identify disease mechanisms and unidentified autoantibodies is needed in addition to possible separate treatment protocols for these patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 91: PAGE KIDNEY - AN UNCOMMON CAUSE OF SECONDARY HYPERTENSION

Deepa Usulumarty 1, Riteish Kamath 1, Jatin Kothari 1, Rajesh Kumar 1, Shrirang Bichu 1, Viswanath Billa 1

BACKGROUND: Secondary etiologies constitute 10% of all causes of hypertension. While renal parenchymal reno-vascular and endocrine causes dominate the etiologies of secondary hypertension Page kidney is a rare cause of the same.

AIM OF THE STUDY: Presentation and management of hypertension arising out of Page Kidney

METHODS: A 44-year-old gentleman chronic smoker who was diagnosed to have hypertension at age 22 years (2002) and has been on Telmisartan beta blockers and Calcium channel blockers with suboptimal BP control. He was investigated thoroughly for renovascular renal parenchymal and endocrine etiologies which did not lead to a diagnosis. All of his radiology images over the past 20 years showed large perinephric collections with a calcific rim around both kidneys with kidney sizes of 9.8 cm and 10.1 cm. There was no history of trauma or UTI, and these perinephric collections were left alone for 20 years. His current 24 hr Cr Cl was 105 ml/min. The perinephric fluid was drained under ultrasound guidance. 700 cc were drained from the left kidney and 150 cc from the right kidney. The fluid was a transudate.

RESULTS: Post-drainage the BP dropped sharply to normal levels and his BP drugs had to be withdrawn. Within a week, there was a rebound increase in BP, the drugs had to be reintroduced, and a reasonable control of BP was achieved.

CONCLUSIONS: Perinephric collections around the kidney can mechanically compress the kidney and activate the RAAS system to induce hypertension. Timely diagnosis and decompression can mitigate this kind of hypertension.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 92: COVID-19 IN RENAL TRANSPLANT RECIPIENTS: CLINICAL OUTCOMES AND EFFECT OF VACCINATION

Harsha 1, George Kurian 1

BACKGROUND: COVID-19 has been associated with high morbidity and mortality in renal transplant recipients. However, risk factors for COVID-19 disease in patients with kidney transplants remain poorly defined. The outcome following vaccination in renal transplant recipients is less reported.

AIM OF THE STUDY: To assess effect of vaccination in renal transplant recipients with COVID-19

METHODS: We enrolled patients who underwent kidney transplantation at our center who tested positive for COVID-19 from the beginning of the pandemic till June 2022. Patients were screened for baseline and transplant characteristics functional parameters comorbidities immunosuppressive therapies vaccination status and treatment received. COVID-19 disease severity was assessed. Patients were followed up during the pandemic until June 2022 of those admitted or home quarantined via teleconsultation. Data was collected compiled and analyzed.

RESULTS: A total of 85 renal transplant recipients with COVID-19 infection were studied. The mean age was 42.5 years. Nine were not vaccinated, 11 had taken 1 dose of vaccination, and rest completed 2 doses of vaccination. 23 had received antibody cocktail, 65 survived, and 20 succumbed to COVID-19. A total of 48 of them had graft dysfunction, 22 had severe graft dysfunction requiring hemodialysis. Among those who expired only had received antibody cocktail, all of them had severe graft dysfunction and only 2 were not vaccinated. Among those who expired most expired in the second wave of the pandemic.

CONCLUSIONS: Renal transplant recipients with COVID-19 have a high risk of mortality. Comorbidities like obesity, diabetes mellitus, asthma, and chronic pulmonary disease were associated with higher risk of developing COVID-19 disease. Effect of vaccination and outcome of COVID-19 infection in renal transplant recipients is under reported. There is risk of severe COVID-19 infection despite vaccination. Therefore, safety preventive measures to be continued. More work needed to find a definitive treatment for COVID-19 infection and much more efficacious vaccines and vaccination strategies to be designed.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 93: UNMASKING OF CENTRAL DIABETES INSIPIDUS IN A PATIENT AFTER RENAL TRANSPLANT

Mohammed S Khan 1, K P Benil Hafeeq 1, Jyotish Gopinathan 1, Feroz Aziz 1, Ranjit Narayanan 1, N A Ismail 1, Arvind Krishnakumar 1, Shafeeq Rahman 1, Shabna Sulaiman 1

BACKGROUND: Central diabetes insipidus (CDI) is characterized clinically by the presence of polyuria with the subsequent development of volume depletion and hypernatremia. In patients with dialysis-dependent end-stage renal disease (ESRD), neither of these findings can be expressed due to the absence of renal function the restoration of normal renal function following successful renal transplantation may uncover undetected CDI.

AIM OF THE STUDY: An 18-year-old girl with chronic kidney disease stage 5 on hemodialysis whose basic disease being chronic sclerosing glomerulonephritis underwent live-related kidney transplant with mother as donor. Her pre-transplant course was complicated by polyarthritis which was treated as rheumatoid arthritis by steroids and methotrexate. Later on she developed seizures and headache on imaging found ring-enhancing lesions which was treated as CNS tuberculoma. After starting antitubercular treatment, she showed clinical and radiological recovery. Headache reappeared and further imaging showed suprasellar lesion which was taken as tubercular etiology. Hence, she was continued on antitubercular drugs and low dose of corticosteroids. She also had hyperprolactinemia which was suggesting granulomatous hypophysitis for which she is getting cabergoline. Her TSH, ACTH, LH, and FSH were normal. Her serum electrolytes and sugars were within normal limits all the way. Transplant procedure was uneventful. The early post-operative course was notable for rapid raise in serum sodium from a pretransplant value of 136 mm to 152 on day one of transplant. Her sodium values remained high despite receiving hypotonic intravenous fluids. She was asymptomatic per se for degree of rise serum sodium. Her urine osmolality was low (180 mOsm/kg) with high serum osmolality (330 mOsm/kg)

METHODS: Desmopressin (DDAVP) was administered subcutaneously. Response to DDAVP was immediate with brisk increase in urine osmolality and marked decrease in serum sodium and osmolality. Her urine osmolality became 600 mOsm/kg with single dose of 5 mcgm of subcutaneous desmopressin. She was maintained on intranasal Desmopressin every 12 hour for next 2 days and given on demand basis on subsequent days

RESULTS: She is currently on her third month of transplant maintaining serum sodium around 140 mm with average daily urine output of 2500 ml. Her urine osmolality is still on lower side with normal serum osmolality

CONCLUSIONS: Unmasking of central diabetes should be anticipated in post-transplant period especially in patients with history of central nervous system lesions in past. Timely diagnosis and administration of DDAVP is important to maintain adequate fluid balance and serum sodium levels.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 94: UTILITY OF RITUXIMAB IN PMN PATIENTS WITH ANTI-PLA2R GREATER THAN 152 RU/ML

Deeksha Pal 1, Vinod Kumar 1, H S Kohli 1, Ranjana Minz¶ 1, Raja Ramachandran 1

BACKGROUND: Primary membranous nephropathy (PMN) is a leading cause of the adult nephrotic syndrome. Anti-PLA2R antibody (Ab) levels predict clinical activity, and preliminary signals suggest that an anti-PLA2R ab levels of >152 RU/ml responds poorly to rituximab compared to cyclical cyclophosphamide/corticosteroids (CYC/CS). In the present abstract, we report the response of 1st 33 patients with anti-PLA2R Ab > 152 RU/ml treated with either rituximab or cyclical CYC/CS

AIM OF THE STUDY: Utility of rituximab in PMN patients with anti-PLA2R greater than 152 RU/ml

METHODS: The study population included (consecutive) patients with primary membranous nephropathy (treatment naïve relapsing or resistant disease) enrolled in the PMN registry at PGIMER Chandigarh and anti-PLA2R Ab of >152 RU/ml and treated with either cyclical CYC/CS or rituximab and completing 18 months of follow-up. We defined the clinical response as per the KDIGO 2021 clinical practice guideline for man ¶aging Glomerular disease. Factoring delayed remission with immunosuppressive therapy in PMN, we defined the clinical outcomes (complete or partial remission (CR or PR) or resistant disease) at 18 months. We assessed the anti-PLA2R Abs levels using a Euroimmune ELISA kit (LÃübeck Germany) at baseline and six months of either immunosuppressive therapy.

RESULTS: Thirty-three patients received Rituximab (Male: Female; 21: 12, mean age: 38 yrs) therapy and completed 18 months of follow-up, and for comparison, we enrolled 33 consecutive cyclical CYC/CS-treated cases (Male: Female; 17:16, mean age:39 yrs) with an anti-PLA2R of >152 RU/ml. In the rituximab-treated group, the median baseline proteinuria, serum albumin, creatinine, and PLA2R Ab levels were 5.2 g/day, 2.34 g/dl and 0.99 mg/dl and 295.12 RU/ml, respectively. In the cyclical CYC/CS group, the median baseline proteinuria, serum albumin, creatinine, and PLA2R were 4.7 g/day, 2.3 g/dl, 0.899 mg/dl, and 378.29 RU/ml, respectively. After six months, there was a significant reduction in the serum anti-PLA2R antibody titer in both the treatment groups [Median anti-PLA2R of 40.5 RU/ml and 10.79 in the rituximab and cyclical CYC/CS group, respectively]. One patient was lost to follow-up in each test group, hence not included in the statistical analysis. In rituximab treatment group, 53.1% [clinical remission (n = CR); 5/32: partial remission (n = PR); 12/32] of patients achieved remission, while 71.8% (n = CR:9/32; n = PR:14/32) patients treated with cyclical CYC/CS achieved remission, the difference was not statistically significant (p > 0.05). One patient died in both treatment groups. The serious adverse events were comparable in both groups (p > 0.05

CONCLUSIONS: Patients with a baseline anti-PLA2R Ab titer greater than 152 RU/ml have a numerically superior but insignificant difference in their response to cyclical CYC/CS treatment compared to rituximab-only therapy

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 95: NEW ONSET CMV DISEASE IN POST RENAL TRANSPLANT PATIENTS IN ASSOCIATION WITH COVID19 INFECTION €” 2 CASES AND BRIEF REVIEW OF LITERATURE

Debapriya Saha 1, Nilesh Shinde 1, Pavan Wakhare 1, Charan Bale 1, A Sajgure 1, Tushar Dighe 1

BACKGROUND: Several cases of CMV syndrome and invasive CMV infection have been reported following COVID19 infection worldwide during COVID19 pandemic in both immunocompetent and immunosuppressed patients.

AIM OF THE STUDY: We intend to discuss more about the interrelationship of COVID19 and CMV infection in renal transplant patients.

METHODS: We discuss two clinical cases, and we present a brief review of literature. 30-year-old man with end-stage primary lupus nephritis underwent mother-to-son kidney transplantation. Post-transplant surgery the patient was discharged with 1.8 mg/ml baseline creatinine. After 3 months, he was admitted with complaints of fever for 4 days with no derangement of renal function. He tested positive for COVID 19 infection and was managed conservatively. Subsequently within 10 days, he was readmitted with chief complaints of loose stools abdominal pain and back pain with mildly raised creatinine and leukopenia. CMV PCR detected 128500 copies per ml. This patient was treated with injection ganciclovir and GM-CSF injection. Mycophenolate mofetil was withheld in view of CMV infection. However, the patient complained of persistent back pain with gradual decline in graft and renal function. With decreasing urine output, dialysis was initiated. Subsequently, the patient developed altered sensorium and had cardiac arrest. 34-year-old male with end-stage chronic nephritis had undergone cadaveric kidney transplantation. Post-transplant the patient had delayed onset graft function with baseline creatinine of 2 mgdl on the 10th post-operative day. Subsequently, the patient suffered from active antibody-mediated rejection, and the patient was managed with six cycles of plasmapheresis. One month later, the patient was admitted with fever and cough. The patient tested positive for COVID19 infection and was managed conservatively. Simultaneously, the patient developed multiple episodes of hematochezia pain in abdomen and diarrhea. Urine output was maintained with stable creatinine. Stool routine and microscopic examination revealed multiple RBCs few pus cells - however no parasite was detected. CMV PCR was positive with 3000 copies per ml. The patient was initially treated with injection ganciclovir and was switched to oral valganciclovir. The patient remained afebrile general condition improved with no further episodes of hematochezia and gradual decline of creatinine to baseline level.

RESULTS: In both our cases, COVID19 infection were managed conservatively, and CMV infection was treated with stoppage of mycophenolate mofetil and addition of ganciclovir injection and resulted into one positive and one negative clinical outcome.

CONCLUSIONS: CMV reactivation after COVID 19 infection in renal transplant patient may be a common phenomenon. Further studies are immediately needed to know whether CMV viremia should be routinely tested in all renal transplant patients in India who get COVID19 infection. Studies are also required to determine if clinical outcomes of CMV disease after COVID19 infection in renal transplant patients are different from CMV disease outcomes in other renal transplant patients who have no history of immediately preceding COVID 19 infection.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 96: BIOINFORMATICS TRANSCRIPTOMIC ANALYSIS TO IDENTIFY KEY GENES AND PATHWAYS INVOLVED IN CYST INITIATION OF AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

Gurleen Kaur Dhoat 1, Sanjeev Puri 2, Veena Puri 1

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is a hereditary disorder affecting renal tubules leading to multiple cysts formation and kidney enlargement. It is predicted to affect >10 million people worldwide with prevalence of affecting every 1 person out of 1000. This is one of the most heterogeneous diseases requiring an early diagnosis that also remains one of the major concerns in tackling this disorder. In this study, we aim to identify Pathways and Hub Genes involved in the initiation of cyst formation to understand the underlying molecular mechanisms which can further help in developing better diagnostics and therapeutics.

AIM OF THE STUDY: To identify Pathways and Hub Genes involved in the initiation of cyst formation to understand the underlying molecular mechanisms which can further help in developing better diagnostics and therapeutics

METHODS: The dataset GSE7869 is utilized to find DEGs (Differentially Expressed Genes) of ADPKD patients using RStudio. Potential functions of DEGs were analyzed for Gene Ontology (GO) and Pathway Enrichment Analysis using G:Profiler and Cytoscape plugin ClueGo. Hub Genes were identified using CytoHubba.

RESULTS: A total of 2028 DEGs were identified, out of which 959 are upregulated and 1069 downregulated genes. GO Enrichment revealed 218 pathways to be upregulated and 59 pathways to be downregulated. Functional Enrichment clusters were analyzed to identify genes that are coexpressed and coregulated using ClueGo. 72 and 8 groups were identified for upregulated and downregulated pathways, respectively. ClueGo Enrichment analysis identified 1 gene SLC22A7 with the GO term OAT1-3 transport organic anions with antiport of dicarboxylic acids for an upregulated pathway and 2 genes FAT4, RRAS with the GO terms animal organ maturation and face development for downregulated pathways associated with cyst initiation. Top 10 Hub Genes were identified for both upregulated and downregulated pathways. From Hub Genes analysis, 2 genes HRG and SLC2A2 were identified for upregulated pathways and 4 genes DAPL1, IGF1, RSPO3, and SFRP4 were identified for downregulated pathways association with disease initiation.

CONCLUSIONS: We identified total 9 genes linked to the initiation of cyst formation in ADPKD while 3 genes based on ClueGo Enrichment Analysis and 6 from Hub Genes analysis predicted role in cysts initiation during ADPKD development.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 97: ASSESSING FLUID STATUS IN CKD PATIENTS WHO ARE UNDERGOING MAINTENANCE HEMODIALYSIS

CH Nagarjuna 1, Satyanarayana 1

BACKGROUND: The assessment of fluid status in dialysis patients plays a pivotal role in their management. Inadequate volume management is one of the contributors to poor survival. Excessive fluid removal results in intra-dialytic hypotension tissue ischemia leading to cardiac stunning potentially loss of brain white matter and loss of residual renal function. Traditionally, fluid status is assessment based on clinical examination including JVP measurement pedal edema lung auscultation but assessment confounded by vascular stiffness cardiac dysfunction hypo-albuminemia. Bioimpedance can detect fluid status in a person by calculating the difference between the measured extracellular volume and predicted volume based on the hydration of lean mass and adipose tissue mass. Fluid overload is independently related to left ventricular hypertension cardiovascular risk malnutrition inflammation poor hypertension control and mortality. Dry weight adjusted based on bioimpedance analysis shown to improve blood pressure control reduced LVH risk resulted in decreased in intra-dialytic complications

AIM OF THE STUDY: To decide dry weight of patients to reduce intradialytic complications such as fluid overload optimal blood pressure control.

METHODS: As a pilot project in our hospital, we did predialysis bioimpedance analysis in 22 chronic hemodialysis patients. We measured hydration status lean tissue index.

RESULTS: In our study, 27.27% had uncontrolled blood pressure which correlated with fluid overload state. On an average, 3.6L of over hydration present among these patients, with maximum over hydration being 5L and minimum of 1.7L. 50% of patients are with fluid overloaded state and shortness of breath, they were over hydrated by 4.1L. 36.36% patients were experiencing cramps and hypotension during dialysis; their predialysis bioimpedance analysis showed they are under hydrated. 82% patients were having lean tissue index lesser than the predicted LTI suggested sarcopenia.

CONCLUSIONS: Bioimpedance analysis is a useful bedside tool for assessing fluid status, nutritional status in dialysis patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 98: CORONARY ARTERY CALCIFICATION (CAC) AND RISK OF CARDIOVASCULAR DISEASE IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Shankar Gadwal 1, Mukesh Goyal 1, Sreebhushan Raju 1

BACKGROUND: Cardiovascular (CV) disease is a leading cause of death and premature death among patients with chronic kidney disease. High cardiovascular mortality is strongly linked to calcification in the arteries. As CKD progresses, the prevalence and severity of coronary artery calcification (CAC) increase. For coronary heart disease and cardiovascular disease, overall coronary artery calcification is a better predictor than other traditional risk factors for the general population. It has been shown by the CRIC study that the risk of cardiovascular disease myocardial infarction heart failure and all-cause mortality in CKD patients is strongly and significantly associated with CAC levels. However, data on dialysis naive patients with CKD are scarce, and it is not clear whether CAC risk is associated with an increased risk of cardiovascular disease morbidity in these patients. It was therefore decided to investigate the link between coronary artery calcium (CAC) and cardiovascular morbidity in patients with CKD who had not previously been treated for renal failure.

AIM OF THE STUDY: AIMS AND OBJECTIVES • To investigate the association of Coronary Artery Calcification (CAC) with risk of cardiovascular disease in dialysis-naive patients with CKD • To assess whether inclusion of Coronary Artery Calcification improves cardiovascular disease risk prediction

METHODS: STUDY DESIGN: This was a single-centric observational prospective study conducted for period of 6 months in Department of Nephrology of a tertiary care hospital. STUDY PROCEDURE: 60 patients from nephrology wards fulfilling inclusion criteria were assessed and were enrolled after fulfilling inclusion and exclusion criteria. Demographic risk factors like age, gender, alcohol/tobacco abuse, diabetes, hypertension, ischemic and rheumatic heart disease, dyslipidemia, and history of similar episodes in past were assessed. Routine blood investigations complete hemogram renal function test, liver function test, serum lipid profile, blood sugar. 2D-Echo was performed and entered in pro forma and evaluated for various clinical manifestations. Calcium score was determined in all patients using CT scan. A cardiac CT scan for coronary calcium is a non-invasive way of obtaining information about the presence location and extent of calcified plaque in the coronary arteries which signals the presence of atherosclerosis and was correlated with clinical and laboratory findings.

RESULTS: RESULTS: The average age of patients enrolled in our study was 43.4 3 Â ± 13.57 years, male predominance was seen in our study population, i.e., 78.3%. Male-to-female ratio was 3.61:1. Hypertension and diabetes were the two common comorbid conditions. The average calcium score among all enrolled patients was 169.40 Â ± 255.65. Majority of patients had calcium scores in the range of 101–300. Calcium score was positively correlated with total cholesterol, triglycerides, hs troponin, NTproBNP, and hsCRP. Calcium score was negatively correlated with homocycteine, HbA1C, and ferritin. Calcium score was positively correlated with systolic and diastolic dysfunction; however, the correlation was not significant. No significant difference was seen in the level of CVD markers among patients with calcium scores 0, <100 and >100, with the exception of homocysteine score, which was significantly lower among patients with calcium scores less than 100 compared to those >100

CONCLUSIONS: CONCLUSION • Calcium score was positively correlated with total cholesterol, triglycerides, hs troponin, NTproBNP, and hsCRP • Calcium score was negatively correlated with homocysteine, HbA1C, and ferritin • Calcium score was positively correlated with systolic and diastolic dysfunction; however, the correlation was not significant • No significant difference was seen in the level of CVD markers among patients with calcium scores 0, <100, and >100, with the exception of homocysteine score, which was significantly lower among patients with calcium scores less than 100 compared to those >100.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 99: POST-TRANSPLANT MALIGNANCY AMONGST KIDNEY TRANSPLANT RECIPIENTS: A SINGLE CENTRE 20-YEAR EXPERIENCE AND LITERATURE REVIEW

Lakshmi Krishnan 1, George Kurian 1

BACKGROUND: Renal transplant recipients have an increased risk of malignancy compared with the general population. Malignancy is also an important cause of death in these patients. Early diagnosis may improve survival in these patients.

AIM OF THE STUDY: To study the incidence and clinical profile of malignancy in renal transplant recipients

METHODS: We analyzed our data retrospectively which included 804 patients who underwent renal transplantation at our center between January 2001 to July 2022. Patient’s native kidney disease donor details duration on hemodialysis immunosuppression details and duration till diagnosis of malignancies were collected. All details regarding the nature of the malignancy with detailed histopathology staging and treatment were also collected.

RESULTS: Of the total 804 cases of renal transplant recipients, 15 recipient (1.7%) were diagnosed with malignancy. Seven out of the 15 patients were males (46%). The mean age at diagnosis was 41Â ± 10 years, and mean duration of occurrence of malignancy following post-transplant was 38 months. Eight patients (46%) developed solid organ tumor and 7 (54%) developed post-transplant lymphoproliferative disease. Of the eight cases of solid organ tumors, 4 had squamous cell carcinoma of the tongue followed by one case each of adenocarcinoma of the pancreas, adenocarcinoma of colon, and squamous cell carcinoma of the lung and vulva. Seven out of 15 patients succumbed to their malignancy, resulting in a mortality rate of 46%. Of the seven cases of PTLD, six had expired (86%), making PTLD the most fatal post-transplant malignancy in our setting. Of the 804 post-kidney transplant cases reviewed in this single-center retrospective study, the incidence of malignancy was 1.8 per 100 population. At our center, there was a prevalence of PTLD as the major type of post-transplant malignancy, as compared to studies from other centers. PTLD being of poor prognosis is responsible for a higher post-transplant mortality rate of 54% in our population. The most aggressive histopathological variant of PTLD (monomorphous variant) was common in our cohort. This may represent either an ethnic predisposition to this disease or some environmental or immunological risk factors contributing to it occurrence.

CONCLUSIONS: This study points out the need for meticulous surveillance of all post-transplant cases for malignancy considering the associated high rate of mortality.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 100: A STUDY OF CLINICOPATHOLOGICAL CORELATION AND OUTCOME IN PATIENTS WITH GLOMERULONEPHRITIS WITH CRESCENT

Rajeshwar Rao 1, Pritpal Singh 1

BACKGROUND: Crescent is defined as the presence of at least two layers of cells that are filling totally (circumferential) or partially (circumscribed) the Bowman’s space, whereas crescentic glomerulonephritis (CrGN) histologically is defined as any glomerular disease characterized by crescents involving >50% of the glomeruli.

AIM OF THE STUDY: This study was undertaken to know the cause remission rate after treatment and subsequent development of renal dysfunction on follow-up in patients with glomerulonephritis with crescents.

METHODS: It was a retrospective cohort study done at IGIMS after reviewing biopsy reports of all patients between 2017 —2021. Patients will be divided into three groups based on the percentage of crescents—group I- Crescents < 25% group II -25-50% group III->50. who had a minimum follow-up of 1 year.

RESULTS: Crescents were identified in 11.6% of total biopsies evaluated in the study period, out of which 3.8% were Crescentic GN. Cellular crescents were seen in 40 cases, fibrocellular/ fibrous in 55 cases, and both in 50 cases. In the immune complex (IC)-mediated group, IgAN (35.2%) was most common followed by lupus nephritis (28.6%) and MPGN (19.7%). All cases of anti-GBM disease and pauci-immune renal limited vasculitis had CrGN. The most common CrGN were immune complex GN (65.2%) followed by pauci-immune GN (24.8%) and anti-GBM disease (10%) (p-0.03). Patients with fibrous crescents and pauci-immune GN and anti-GBM disease had more renal dysfunction and less remission on follow-up as compared to patients with cellular crescent and immune-complex GN on follow-up (p-0.03).

CONCLUSIONS: Crescents in renal biopsies are not rare. Although CrGN is more common in vasculitis and anti-GBM disease, as reported worldwide, our study differs as IC-GN is more in our study population. Renal outcomes depend on the percentage and type of crescent. Early diagnosis and treatment are associated with a favorable outcome.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 101: STUDY OF EFFICACY OF EQUINE ANTI THYMOCYTE IMMUNOGLOBULIN (EATG) AS INDUCTION AND ANTIREJECTION THERAPEUTIC AGENT IN RENAL TRANSPLANTATION

Pavan Kumar Rao Navva 1, Subhramanyam V Sreepada 1

BACKGROUND: Equine Anti-Thymocyte Immunoglobulin (eATG) has been used less as an induction immunosuppressant agent in renal transplantation compared to rabbit ATG (rATG). However, eATG is very economical compared to rATG. The cost of eATG as induction agent in renal transplant on an average is INR. 30 000/- per dose, and cost of rabbit ATG (rATG) as induction agent is INR 1 20 000/-.

AIM OF THE STUDY: To study the efficacy of eATG as induction and anti-rejection therapeutic agent in renal transplantation.

METHODS: Material and Methods: Renal transplant recipients were divided into two groups. Group A (GrA) recipients had renal donation from HLA matched first degree relatives and received only injection methylprednisolone (MP) as induction therapy. Group B (GrB) recipients had renal donation from deceased donors (brain dead) or spousal donors were administered eATG 10 mg/kg along with low dose MP as induction therapy. Outcomes were compared between GrA and GrB. Monitoring for eATG therapy-induced blood lymphocyte count depletion post-transplant was also done to assess eATG efficacy. eATG as antirejection therapy agent: eATG was administered in biopsy-proved acute T-cell-mediated rejection (TCMR). Repeat transplant kidney biopsy was done to assess improvement.

RESULTS: Number of renal transplant recipients in GrA were 29 and GrB were 35. All recipients of GrA and GrB had normal renal function by 14th post-transplant day (PTX). There was 20% decrease in blood lymphocyte count following MP therapy (GrA) compared to 85% decrease following therapy with eATG (GrB) and the difference was statistically significant (p < 0.05). Marked decrease in lymphocyte count indicated efficacy of eATG. Biopsy-proved acute TCMR was seen in 5% of GrA and 4% of GrB (p > 0.05). None from both groups had antibody mediated rejection. All patients with acute TCMR responded to eATG antirejection therapy. Opportunistic infections was noticed in 9% of GrA patients and 11% of GrB patients in the first 180 days PTX (p > 0.05). Two years graft survival was 83% in GrA and 80% in GrB (p > 0.05). During two-year followup one patient from each group died of Covid19 infection (p > 0.05).

CONCLUSIONS: Since excellent results were obtained with eATG as an induction and antirejection therapeutic agent, it can be used in renal transplant with high-risk immunological states as a polyclonal antibody. eATG is more economical compared to rATG.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 102: PREDICTIVE ABILITY OF NUTRITIONAL SCORES FOR PROTEIN ENERGY WASTING SYNDROME IN PATIENTS WITH CHRONIC KIDNEY DISEASE ON MAINTENANCE HEMODIALYSIS

Abhishek 1, D S Rana 1, Anurag Gupta 1

BACKGROUND: Protein-Energy Wasting (PEW) syndrome is a term used to describe the loss of body protein mass and fuel reserves in dialysis patients and is present in 18 — 75% of patients with advanced chronic kidney disease (CKD). Subjective Global Assessment (SGA) and Malnutrition Inflammation Score (MIS) as well as various anthropometric (Body mass Index Mid arm Circumference Mid arm muscle circumference Triceps Skin fold thickness Mid arm muscle area Mid arm fat area Lean body mass Ideal body mass Total body water Fat free mass Total body fat) and biochemical (serum albumin cholesterol iron total iron binding capacity protein catabolic rate) parameters are tools used by health care providers to assess nutritional status and aid in the prediction of nutrition-associated clinical outcomes. Though these scores and parameters are used widely, there is a paucity of literature on their standardization with regard to diagnosis of PEW especially in our demographic.

AIM OF THE STUDY: We aimed to evaluate the nutritional status of patients of CKD on maintenance hemodialysis in our dialysis unit using the aforementioned scores and compared the SGA-DMS MIS anthropometric and biochemical parameters with the PEW-ISRNM criteria in diagnosing PEW in our population setting.

METHODS: Study area — Dialysis unit Department of Nephrology Sir Ganga Ram Hospital New Delhi Study population —All adult patients of chronic kidney disease with age > 18 years undergoing maintenance hemodialysis for at least 3 months. INCLUSION CRITERIA — 1. Patients who gave a written informed consent EXCLUSION CRITERIA — Patients with: 1. Concurrent acute illness, 2. Infection in past 6 months, 3. Hospitalization in past 6 months, 4. Long term therapy with steroids, 5. Ryle’s tube feeding or Parenteral nutrition, 6. Known malignancy, 7. Dementia Sample size — 139 patients. Study design — observational cross-sectional study Study duration — From the December 2019 to November 2021. Method of measurement of outcome of interest — • Patients were enrolled for the study after obtaining a written informed consent their details furnished according to the study pro forma including name, age, sex, occupation, diagnosis - CKD on MHD basic disease; hemodialysis — duration frequency type dialyzer; comorbidities. • Nutritional evaluation was done using o The Subjective Global Assessment — Dialysis malnutrition Score of Malnutrition Inflammation Score of Protein Energy Wasting Criteria - It is the gold standard for the diagnosis of PEW. Anthropometric parameters - The following measurements were performed between 10- 20 minutes after termination of dialysis session: 1. Body mass index, 2. Mid arm circumference (MAC), 3. Triceps skin fold thickness (TSF), 4. Mid arm muscle circumference (MAMC), 5. Mid arm muscle area (MAMA), 6. Mid arm fat area (MAFA), 7. Lean body mass (LBM), 8. Ideal Body weight (IBW), 9. Total body water (TBW), 10. Body fat percentage (BFP), 11. Fat free mass of Biochemical parameters estimated for the study population after the dialysis session included serum albumin iron ferritin total iron binding capacity. o Protein Catabolic Rate (PCR)/Nitrogen Appearance (PNA)

RESULTS: Using the PEW score, 43.2% of our patients had Protein energy wasting. On the SGA-DMS score, using a cut-off score of 8, 127 patients (91.37%) were malnourished. On the MIS, 132 patients (94.96%) were malnourished. The ROC curve was computed for both the SGA-DMS and MIS to get new cut-off scores for PEW syndrome. An SGA-DMS of 12 or more predicted PEW syndrome with a sensitivity of 85% and specificity of 73.4%. For the MIS, score of 9 or more predicted PEW syndrome with a sensitivity of 68.3% and specificity of 89.9%. PEW score. SGA-DMS and MIS correlated significantly with all anthropometric parameters except body fat percentage. PEW score correlated significantly with serum albumin, total iron binding capacity, and normalized protein catabolic rate. ROC curve was also computed for mid arm circumference, triceps skinfold thickness, and serum albumin. In our study population, a mid-arm circumference of < 24.5 cm diagnosed PEW with a sensitivity of 61.7% and specificity of 87.3%. A Triceps skinfold thickness of < 1.75 cm diagnosed PEW with a sensitivity of 58.3% and specif1icity of 78.5%. Serum albumin of 3.74 mg/dl diagnosed PEW with a sensitivity of 76.7% and specificity of 55.7%.

CONCLUSIONS: PEW criteria are the gold standard to diagnose PEW; however, they are cumbersome. SGA-DMS is a simple and easy to administer tool for nutritional assessment, can be performed routinely by dialysis technicians, nurses, and dieticians. Addition of 3 laboratory parameters adds more objectivity to the MIS, which also relates with mortality, the quality of life and EPO requirement. In our study population, SGA-DMS score ≥ 12 diagnosed PEW with 85% sensitivity and 73.4% specificity, and MIS score ≥ 9 diagnosed PEW with 68.3% sensitivity and 89.9% specificity. In resource and personnel limited settings, simple anthropometric tools like triceps skinfold and mid arm circumference can diagnose PEW syndrome with acceptable accuracy.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 103: ACUTE KIDNEY INJURY IN CHILDREN WITH COVID-19 RELATED MULTISYSTEM INFLAMMATORY SYNDROME (MIS-C)

Asif Sadiq Wani 1, Zafirah Zahir 1, Ishaq Malik 1

BACKGROUND: Although children with coronavirus disease 19 (COVID-19) generally experience a mild disease a subset of them develop multisystem inflammatory syndrome (MIS- C) which can lead to multiorgan failure. There is relative rarity of literature regarding acute kidney injury (AKI) in MIS-C. We aim to characterize the clinical features laboratory findings and therapies for AKI in MIS-C in our setup.

AIM OF THE STUDY: We aim to characterize the clinical features laboratory findings and therapies for Acute Kidney Injury in Multi-system Inflammatory Syndrome in Children (MIS-C).

METHODS: This was a 1 ½ year prospective study with patients from GMC Srinagar, its associated hospitals, and Shifa Medical Centre Srinagar. Children &lt;21 years old who had AKI and met the criteria for MIS-C based on CDC guidelines were included in the study.

RESULTS: A total of seven cases were included in the study ranging from 4 to 20 years (mean 11.4Â ± 5) with 4 females and 3 males. Persistent fever was present in all patients. Six children had vomiting/diarrhea along with rashes and/or swelling of hands. Myocardial involvement was seen in four, respiratory in two and musculoskeletal in one patient. Oropharyngeal swab for SARS- Cov2 RNA was negative in all the patients. Anticovid antibodies were positive in five patients, and two had a history of contact with COVID-19 patients. AKI Stage 1 was present in 3, stage 2 and 3 in 2 patients each. Neutrophilia with lymphopenia was seen in all the patients and thrombocytopenia in 4 patients. Laboratory findings for inflammatory markers showed marked elevation of C-reactive protein (mean 87.6Â ± 72.1 mg/l), ferritin (mean 810Â ± 224ng/ml), procalcitonin (mean 4.9Â ± 2.1ng/ml), ESR (mean 64.6Â ± 21.9 mm/hr), fibrinogen (690Â ± 142.1 mg/dl), LDH (mean 578.2Â ± 370.1U/L), and D-Dimer (mean 7.8Â ± 9.4 ÂμgFFU/ml). The patients were treated with a combination of steroids, IVIg and inotropic support wherever needed. All of the patients recovered with a median duration hospital stay of 7 (IQR 5) days.

CONCLUSIONS: Children with covid 19 infection should be carefully followed for MIS-C. Although children with MIS-C develop AKI, most of them have full clinical recovery. The long-term prognosis of this syndrome is currently unknown until their follow-up data becomes available in future.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 104: CLINICAL PROFILE REQUIREMENT OF RRT AND OUTCOME OF SEPSIS ASSOCIATED ACUTE KIDNEY INJURY IN CRITICAL CARE IN A TERTIARY CARE HOSPITAL

Suresh Reddy Gajjala 1

BACKGROUND: Acute kidney injury (AKI) is a dramatic loss of kidney function which is potentially life-threatening. Sepsis is an important precipitating factor of AKI. Sepsis-associated AKI (SA-AKI) portends a high morbidity and mortality burden in adults and children with critical illness. AKI and sepsis frequently coexist in critical care patients. AKI precedes coincides or may follow a sepsis diagnosis. Despite an increasingly sophisticated understanding of AKI's epidemiology and pathobiology, current prevention strategies are inadequate and treatment options other than renal replacement therapy (RRT) are nonexistent. New methods for the prevention and treatment of AKI are desperately needed.

AIM OF THE STUDY: To find out the requirement of RRT and outcome in sepsis-associated AKI patients and assessing the proportion of patients requiring RRT among AKI patients with sepsis in ICU.

METHODS: This is a prospective observational study; patients aged ≥18y admitted in ICU with SA-AKI were included. Patients with CKD and those with abnormal kidney size and abnormal corticomedullary differentiation were excluded. Data was collected using a pretested pro forma. Comparison of continuous variables was done by independent sample t-test categorical variables by chi-square test and non-normally distributed continuous variables by Mann–Whitney U-test.

RESULTS: In the present prospective observational study of 120 patients’ either oliguria or anuria was present in 57.5% patients. Fever was the most common symptom (68.3% patients). Pneumonia (34.1%) was the most common cause of sepsis. Hypertension is the most common comorbidity associated with SA-AKI followed by diabetes mellitus. Mortality rate among patients with anuria was 76.5%. Hence, anuria can be used as an independent predictor of mortality in SA-AKI (p < 0.001). Higher the SOFA score, higher is the mortality (p = 0.001). RRT was required in 34.2% patients. CRRT was the most common modality of RRT. Overall mortality rate in our study was 30%. “Mortality rate among KDIGO stage 3 patients was 65.9%, whereas mortality rates among KDIGO stage 2 and stage 1 were 19.1% and 0% respectively.†Mortality rate in RRT received patients was 65.9%. Mortality rate in conservatively managed patients was 11.4%. (p < 0.001).

CONCLUSIONS: Anuria is independent predictor of mortality in SA-AKI. Our study showed that CRRT was superior to SLED in SA-AKI.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 105: NUTRITIONAL ASSESSMENT OF PATIENTS ON HAEMODIALYSIS: KNOWLEDGE EATING PATTERN RAW FOOD ENERGY AND PROTEIN INTAKE

Apeksha Ekbote 1, Kamal D Shah 1, Shyla Upadhyay Suresh Sankarasubbaiyan 1, Vivekananda Jha 1

BACKGROUND: Nutrition is a key component of health that impacts clinical outcome of hemodialysis patients. Challenges abound due to knowledge gap acceptance food preferences cultural factors and comorbidities.

AIM OF THE STUDY: 1. To study patient characteristics family structure and socioeconomics of study population. 2. To study eating pattern raw food energy and protein intake in hemodialysis patients

METHODS: Patients undergoing maintenance HD from 7 centers across regions were selected. A detailed questionnaire including family structure income occupation food preferences eating pattern 24-hour diet recall food frequency physical activity level was administered. Height, weight, and BMI were measured. Data is presented as mean sd and proportions.

RESULTS: n = 120. Age < 40 yrs: 15%, 41-60yrs: 46.7%, > 60 yrs: 38.4%. M = 70.8%, F-29.2% 67% were skilled, 23.3% housewives. 34.2% income < Rs 20,000, 32.5% 20-40,000 and 33.3% had income >40000/month. 51.7% lived in joint family. Mean weight: 61.9 + 12 Kg. 40% had BMI < 18.5 and 58.3% had BMI: 18.5 to 25 Kg/m2. 60.8% were non-vegetarians, 96.7% had at least 3 meals/day, 40.8% ate out at least 1/week, and 72.5% took supplements. Raw food intake daily: Wheat: 82.5%, rice: 54.2%, dairy products: 79.2%, fruits: 55.8%, roots and tubers: 15% other vegetables: 97.5%, bakery food:32.5%. Energy intake was 1117 + 339 Kcal/day, protein intake, Sodium: 2101 + 272 mg/day, Potassium: 1377 + 502 mg/day, and Phosphorus: 682 + 292 mg. Knowledge of appropriateness of intake of select foods: 78.5%; 56% engaged in some form of physical activity; walking was dominant: 89%, yoga: 46.9%. S Alb: 3.97 + .75 g%, S. Ph: 5.7 + 2 mg%, S. K: 5.4 + 1.S mEq/L,. Ca: 8.4 + .9 mg%

CONCLUSIONS: A middle income, dominantly male population in skilled labor, in urban HD centers had high proportion of vegetarianism, was well informed of appropriateness of food choices. Energy, protein, and sodium intake reflect over restriction or limited by other medical reasons; physical activity level is of low intensity while biochemical parameters were in optimal range.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 106: COMPARISON OF OUTCOME IN INTERMITTENT PERITONEAL DIALYSIS VERSUS SUSTAINED LOW EFFICIENCY DIALYSIS VS CRRT IN HEMODYNAMICALLY UNSTABLE ACUTE KIDNEY INJURY PATIENTS

Yogesh Yadav 1, Manisha Sahay 1, Kiranmai Ismal 1

BACKGROUND: Despite advances in renal replacement therapy (RRT) mortality is high among ICU patients with (AKI). The dialytic management of these patients is difficult because of the associated hemodynamic instability and multiple organ dysfunction syndrome. Hemodialysis (HD) has been used as therapy in AKI, but it is complicated by unstable blood pressure. PD is another option with excellent cardiovascular tolerance but is limited by the need for an intact peritoneal cavity peritonitis risk protein losses and overall lower effectiveness. Slow low efficient dialysis (SLED) and CRRT are both extracorporeal therapy with good cardiovascular tolerance and small solute clearance. This study was designed to explore the role of IPD VS SLED VS CRRT among patients with AKI.

AIM OF THE STUDY: Estimating the impact of IPD VS SLED VS CRRT as renal replacement therapy of choice in hemodynamically unstable acute kidney injury and outcome of patients

METHODS: We conducted a retrospective study comparing SLED (60) (target 6 h/session blood flow 150-180 mL/min) to IPD (60) VS CRRT (20) in ICUs at tertiary hospital. The primary outcome was mortality 30 days after RRT initiation adjusted for demographics kidney function and Sequential Organ Failure Assessment score. Secondary outcomes were persistent RRT dependence at 30 days and to assess recovery of renal function and metabolic profile.

RESULTS: Mean age of patients on SLED was 45.57+/-1.66yrs, IPD 46.88+/-1.93yrs, and CRRT was 44.36+/-2.3yrs. Mean pre-procedure blood urea and creatinine in SLED was 151.67+/-4.05mg%, 7.54+/-0.36mg%, in IPD was 121.33+/-5.56mg%, 7.00+/-0.34mg% in CRRT was 139+/-6.2mg%, 6.89+/-0.29mg%. Mean SOFA score in SLED patients was 13.73+/-0.33, IPD was 12.30+/-0.53, and CRRT was 11.20+/-0.36. Post-procedure creatinine in SLED was 4.11+/-0.34mg%, IPD was 3.87+/-0.34 mg/dl and 4.1+/-0.27 mg/dl. Outcome in SLED patients was equal to PD patients, i.e., 60% mortality.(p value is insignificant) but more compared to CRRT (50%). Mean duration to recover and hospital stay in IPD and CRRT was more compared to SLED (10.03+/-0.44 days VS 7.10+/-0.37days), and it was statistically significant with a p value of 0.00.

CONCLUSIONS: This study presents clear evidence that SLED, IPD, and CRRT are effective methods for treating AKI patients. These results provide evidence that the adequate prescription of IPD with a rigid PD catheter leads to outcomes comparable to those of SLED with overall less medical expenses. These results strengthen the rationale for using PD and SLED in hospitals where more sophisticated technologies are not available. Even in hospitals having sophisticated technologies SLED hold strong position compared to CRRT in view of cost effectiveness and good recovery rate.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 107: LONG TERM OUTCOME AFTER PARATHYROIDECTOMY IN SEVERE REFRACTORY HYPERPARATHYROIDISM

Satarupa Deb 1, Sayali Thakre 1, Ankita Patil 1, Sreyashi Bose 1, Divya Bajpai 1, Tukaram Jamale 1

BACKGROUND: Refractory Hyperparathyroidism is a common complication of chronic kidney disease often requiring surgery. Medical literature rarely describes Severe Refractory Hyperparathyroidism and outcomes of parathyroidectomy in this group. This is important since this subset of patients is different from the conventional group of secondary hyperparathyroidism †they have increased fracture risk more bone deformities poor cardiopulmonary reserves posing an increased risk of anesthesia and surgery.

AIM OF THE STUDY: We intend to look at the durable effect of parathyroidectomy on symptom improvement QoL and biochemical parameters in cases of Severe Refractory Hyperparathyroidism over a period of 12 months.

METHODS: We report our experience of managing 8 cases of Severe Refractory Hyperparathyroidism who underwent parathyroidectomy (7 total surgical parathyroidectomy 1 radiofrequency ablation). Median age was 41.7 years (range 26–60 years), median dialysis time- 6.5 years (range 1.5–11 years). All 8 patients were symptomatic for an average duration of 2.1 years and were under medical treatment for approximately the same duration. Uncommon clinical findings include uremic lion face syndrome seen in 2 patients spontaneous tendon rupture in one and calciphylaxis seen in one of the 8 patients. Mean PTH level was 1989 pg/ml. CECT was the primary modality used for localization of parathyroid gland. Findings were confirmed by Ultrasonography. Sestamibi scan was used only when there was a discrepancy between CT and USG findings. Supernumerary glands were found in 3 out of the 8 patients. For further accuracy, intra-operative PTH level monitoring was done. Average drop noted was by 87%. Total parathyroidectomy was intended in all patients.

RESULTS: Hungry bone syndrome (HBS) was observed only in the first case. Thereafter all cases were preoperatively loaded with active vitamin D as part of preventive measure of HBS. Calcitriol supplementation also significantly shortened hospital stay, and this serves as an important learning point. Uncomplicated hypocalcemia was seen in 3 patients. All patients were followed up for a mean duration of 5.7 months (ongoing study, intended follow-up of 12 months). Significant improvement in all domains of SF 36 was noted for all 8 patients, maximum improvement seen in the first 3 months (average improvement being 36%). On follow-up three patients had worsening of SF 36 scores equaling their pre-operative levels. Rest 5 continued showing sustained improvement. Biochemically 2 patients had persistent hyperparathyroidism (PTH levels going back to pre-operative value within one week of surgery). Thus clinical benefit was demonstrated in 5 out of 8 patients, and biochemical cure was shown in 6 out of 8 patients.

CONCLUSIONS: Hence, we demonstrate that parathyroidectomy remains a viable treatment option for Severe Refractory Hyperparathyroidism as well. It requires a multi-disciplinary approach where apart from nephrologists, contribution of radiologists, surgeons, and anesthetists are also of paramount importance.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 108: STUDY OF CLINICAL PROFILE OF CAPD PATIENTS IN SOUTH INDIA- OUTCOME AT ONE YEAR

Krishna Kumar 1, M Sreelatha 1

BACKGROUND: Approximately 272 000 peritoneal dialysis (PD) patients worldwide account for 11% of the global dialysis patients. Patterns of early outcomes in peritoneal dialysis (PD) are not well studied in South India, and dialysis providers need to establish a baseline of key outcomes for continuous quality improvement initiatives.

AIM OF THE STUDY: The purpose of the present study was to investigate the basic clinical features of PD patients associated prognostic risk factors and to establish a prognostic risk model of short-term all-cause mortality.

METHODS: A total of 156 chronic kidney patients opted CAPD as a kidney replacement modality were selected for the study. The study was conducted between 2019 to 2021 may. The clinical profile of the study peritonitis episodes and outcomes in terms of all cause mortality was studied. The data was analyzed using SPSS software. Qualitative variables were expressed in frequency and percentage.

RESULTS: Of the 156 patients studied, 67% were males and rest females with 83% of them having diabetes as the cause of CKD. Sixty eight percentage of them were self-motivated for CAPD. 85% had nil intraprocedural complication, and the failed procedure and bowel perforation was 4% and 2% respectively. Covid infection was very less in CAPD population, which was respectively 16% (category B) and 3% (category C). 77% were high average transporter status. Survival at one year was 84 percentage. Complications at first year were peritonitis (10%), fluid leak (6%), pancreatitis (6%), inflow/outflow pain (7%), exit site infection (3%), and 80% had no complications. 86% had no hospitalization in one year. There was no significant difference in survival based on different serum albumin levels (p-value 0.94 and chi-square 0.13.), serum phosphorus levels, with Fisher’s exact p-value 0.30 or diabetes status, (with p-value 0.43 and chi square 0.62.). Higher Kt/V reach rates are associated with a better prognosis in incident PD patients. Multivariate survival analysis showed (rGFR), SBP, Kt/V, and high PET type were independently associated with one-year mortality.

CONCLUSIONS: CAPD had overall a better one year mortality

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 109: EVALUATION OF TH17 CELL ON THE EXPRESSION OF P-GP IN THE PBMCS AND PLASMA CELLS OF REFRACTORY LUPUS NEPHRITIS

Kritika Singh 1, Akhilesh Jaiswal 2, Narayan Prasad 2, Durga Prasanna Misra 1, Vikas Agarwal 1

BACKGROUND: Refractoriness to the conventional glucocorticoid and/or immunosuppressive drug-based treatment is one of the major causes of mortality and morbidity in patients of Lupus Nephritis. Renal involvement occurs in up to 20–30% of male and up to 70–80% of women’s with SLE and lupus nephritis (LN) remains a major cause of morbidity and mortality. P-glycoprotein may be one of the factors responsible for resistance to glucocorticoid and/or immunosuppressive treatment in these patients. P-gp functions as energy dependent transmembrane efflux transporter of various metabolites and drugs. P-gp reduces intracellular concentration of various drugs including chemotherapeutic agents steroids and ISs. Autoantibodies produced by plasma cells. In particular long-lived PCs produce antibody persistently and are resistant to current therapies including glucocorticoids and/or immunosuppressive drugs and even B-cell depletion therapies. PCs have been observed in the kidney of LN in both animal model as well as patients. Resistance of these plasma cells could be mediated by expression of P-gp. This has never been documented previously.

AIM OF THE STUDY: 1. To evaluation of P-gp+ Th17 cell in PBMC at baseline and after 3-month of treatment. 2. Evaluation of T cell subsets (Th1, Th2, Th17, and Treg cells) in PBMCs. 3. To evaluation of P-gp+ Plasma cell in patients bone marrow (BM).

METHODS: 10 patients with refractory LN 05 treatment naïve LN patients and 10 LN patients in remission will be recruited for the study. 10 healthy controls will be recruited for the study. 10 ml peripheral blood shall be obtained before starting treatment. Bone marrow will be obtained from patients who undergo for routine bone marrow investigation only. Flow cytometric analysis was done in the PBMCs and BM samples.

RESULTS: The expression of Th1, Th2, T-reg cell number has increased expression in refractory group (p = Ë'0.05). There is also a significant increased expression of Th17 cells and Th17+P-gp cell population in the PBMCs of refractory LN patients as compared to patients who are in remission and healthy control (p = Ë'0.05) at baseline in PBMCs. The population of CD138+P-gp expression was also significantly increased in the bone marrow of refractory group (p = Ë'0.05).

CONCLUSIONS: P-gp expression on peripheral blood lymphocytes and plasma cells in renal tissue could be responsible for glucocorticoid/immunosuppressive therapy failure in lupus nephritis. By targeting this, pathways may be useful in treatment of refractory lupus nephritis which may provide newer therapeutic targets and repurposing of some of the drugs in refractory/relapsing LN and many other autoimmune diseases where glucocorticoid and/or immunosuppressive drugs are key to success.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 110: LUPUS NEPHRITIS: EXPERIENCE FROM A TERTIARY CARE CENTRE IN NORTH KERALA

Shilpa Devamare 1, M Sreelatha 1, E K Jayakumar 1, P T Hijaz 1

BACKGROUND: Systemic lupus nephritis (SLE) is a multi-systemic disease with a wide array of immunological abnormalities. Lupus nephritis (LN) remains an important cause of morbidity and mortality. The aims of treating lupus nephritis are to induce and maintain remission thereby reducing the risk of progression to renal failure. We analyzed our experiences in management of lupus nephritis patients.

AIM OF THE STUDY: Our aim is to study the clinical manifestations laboratory data pathological findings treatment modalities and outcomes in patients with lupus nephritis presenting to a tertiary care hospital in Kerala

METHODS: It was a retrospective study conducted at Government Medical College Kozhikode wherein the data of patients with lupus nephritis visiting the nephrology OPD from March to August 2022 was collected and analyzed.

RESULTS: Results: A total of 75 patients were recruited in the study. Male–female ratio of the study group was 1:3, with mean age of 29.6 years, and mean eGFR at presentation was 88.39 ml/min/m2. Fever and polyarthralgia were the most common presenting feature. Lupus nephritis was the presenting feature in 22% (16) of cases and Class 4 lupus was the most common group identified by renal biopsy. Steroid and mycophenolate mofetil was the most common induction and maintenance protocol used. Complete remission was not achieved in 20% (15) of cases and 28% (21) experienced treatment related complications.

CONCLUSIONS: We observed an improved outcome irrespective of the drug used for induction and maintenance therapy in majority of the patients with tolerable side effect profile. Pediatric LN had significantly worse outcome.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 111: EXTRACELLULAR FLUID ESTIMATION IN PATIENTS ON MHD BY VARIOUS METHODS

Prem Mohan Jha 1, Neeru P Aggarwal 1

BACKGROUND: INTRODUCTION: In the past, multiple attempts have been made to develop an ideal method to assess the fluid status in hemodialysis (HD) patients.

AIM OF THE STUDY: The aim of this study was to estimate the fluid status by clinical examination ultrasonography (measuring lung comet scores inferior vena cava diameters and collapsibility index) and biochemical methods (brain natriuretic peptide) and to compare them with the bioimpedance spectroscopy (gold standard) in chronic hemodialysis patients and to assess the effectiveness of these methods in detecting the change in fluid status after ultra filtration

METHODS: METHODS: We evaluated 65 subjects of age >18 years and undergoing at least twice per week MHD for more than 3 months. Those having features like interstitial lung disease pulmonary fibrosis NYHA class III and IV amputated limbs acute complications within previous one month before the study poor IVCD image and refusal of consent were excluded. Bedside evaluation was done before HD and 30 minutes after HD by clinical examination multifrequency BIS ultrasound (ULCs IVCD (max) IVCD (min) IVC Collapsibility index. BNP levels were measured immediately before and 30 minutes after HD. Continuous variables were expressed as mean  ± standard deviation. Correlation coefficients were measured by Spearman’s rank correlation method. Statistical comparisons between pre- and post-scenarios (null hypothesis: difference being zero) among continuous variables were tested using the nonparametric Wilcoxon signed rank test. A 5% level of significance (p-value <0.05) was considered for hypothesis testing.

RESULTS: Results: Among 65 subjects 36 (55.38%) were males. Mean age was 59.29 years, and most of the study subjects (40%) were in 61 —70 years age group while mean BMI was 25.94. Diabetes mellitus, cardiovascular events, and hypertension were present in (60%), (29.2%), and 65 (100%) of subjects respectively. 27 (41.54%) subjects were in NYHA class I while remaining 38 (58.46%) were in NYHA class II. Mean blood pressure was 152/90 mm Hg. On clinical examination presence of leg Edema, raised JVP, crepitations on chest examination and congestive hepatomegaly were present in 21.54% (14), 32.31% (21), 58.46% (38), and 21.54% (14) of subjects. Mean weight loss was 2.82 kg. Duration of MHD (months) was 37.37  ± 29.09.

CONCLUSIONS: CONCLUSION: Bioimpedance spectroscopy is simple, bedside, safe, convenient, reproducible, and objective method of extracellular fluid status estimation in hemodialysis patients. Whenever available, it should be preferred over other methods. Clinical examination is not a reliable method to access volume status in end-stage renal disease patients those are on maintenance hemodialysis therapy. Correlation of estimation of volume status through ultrasonographic methods like inferior vena cava diameters and inferior vena cava collapsibility index is very good with the gold standard bioimpedance spectroscopy. Correlation of estimation of volume status through brain natriuretic peptide measurement with the gold standard bioimpedance spectroscopy is poor; hence, it is not an appropriate method for the detection of extracellular fluid status in these patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 112: SLE WITH LUPUS NEPHRITIS IN ELDERLY

Parmeshar Singh 1, Joyita Bharati 1, Manish Rathi 1

BACKGROUND: The elderly SLE is rare with 12–18% incidence, and it differs from those with the classic form in their clinical presentations. The clinical course of disease is more benign in elderly. In order to prevent misdiagnosis or delays in diagnosis, more attention needs to be paid to this specific group of SLE patients.

AIM OF THE STUDY: To determine the prevalence clinical features immunological manifestations and response to the treatment in patients with elderly onset of SLE with lupus nephritis

METHODS: Out of 150 individuals diagnosed for SLE with lupus nephritis (LN) between 2016 and 2019 in the Department of Nephrology PGIMER, 27 patients falling under the age group of 50–65 were included. Clinical characteristics and laboratory markers were assessed in these subjects. The patients were followed up for 24 (IQR: 7-60) months. Cyc (ELNT) Cyc (NIH) and MMF were the treatments given to 22.2% 40.7% and 37.1% of these patients respectively. The response to treatment was finally analyzed in these subjects.

RESULTS: Elderly had 10.2% prevalence of SLE. Age at the onset of SLE was 53.3 Â ± 2.85 and at the onset of LN was 55.8 Â ± 2.94. The female-to-male ratio was 8. The biopsy of these patients has shown Class III/V (29.6%), Class IV (33.3%), and Class V lupus nephritis (37.1%). Nephrotic syndrome and RPGN were found in 66.6% and 22.2% of the cases, respectively. The patients most commonly presented with the clinical features including mucosal ulcers (55.5%), fever (51.8%), hypertension (48.1%), cutaneous rash (40.7%), photosensitivity (29.6%), neuropsychiatric problems (14.8%), increased creatinine (1.7 Â ± 1.5), proteinuria (1.7 Â ± 1.1), and hematological abnormalities. Anti-dsDNA serology was positive for 70% of patients. Low levels of C3 and C4 was present in 62.9% and 51.8% subjects respectively. At the 6-month follow-up, 18.5% of the patients had shown complete response to the treatment that risen to 59.3% by the last visit. There was a partial response and no response in 44.4% and 22.2% of the cases at 6 month follow-up, respectively, that decreased to 11.1% and 3.7% by 24 month. Mortality rate increased from 14.8% to 25.9% by the last visit.

CONCLUSIONS: Patients with late onset LN show classical symptoms of SLE with high rate of hypertension and renal impairment. For proper treatment, early diagnosis is necessary.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 113: ACELLULAR MESANGIAL EXPANSION IN RENAL BIOPSY NOT ALWAYS DIABETES - A SINGLE CENTER EXPERIENCE

Harish Sivagnanam 1, V Ramasubramaniam 1, V Kannan Bhaba 1, PK Senthil Kumar 1

BACKGROUND: Mesangial expansion is characteristic of diabetic nephropathy. It is caused by the deposition of Extracellular matrix proteins like collagen type 1, 3, and 4 fibronectin. Other causes include amyloid monoclonal immune deposition disease fibrillary and immunotactoid glomerulonephritis chronic MPGN collagenofibrotic glomerulopathy Takayasu arteritis cryoglobulinemic disease and finally idiopathic nodular glomerulosclerosis. Biopsy studies regarding distribution patterns of mesangial expansion are minimal.

AIM OF THE STUDY: To identify the spectrum of disorders presenting with mesangial expansion in a renal biopsy and their various clinicopathological correlations.

METHODS: A retrospective study of native kidney biopsies done from January 2016 to August 2022. Relevant clinical and laboratory variables were recorded. Data was analyzed using SPSS software.

RESULTS: A total of 728 kidney biopsies were performed during the study period. Mesangial expansion was present in 31 patients (4.67%). Nodular mesangial expansion was present in 25 patients (76.785%) and diffuse mesangial expansion in 6 patients (33.33%). Mean age of patients was 35 +/- 14 with 67% males. The most common lesion in biopsy was diabetic nephropathy (75.75%). The most common associations with diabetic nephropathy was IRGN (23%), ATN (11.5%), Crescentic GN (7.6%), and AIN (3.8%). The other lesions associated with mesangial expansion included amyloidosis (6.06%), heavy chain deposition disease (6.06%), idiopathic nodular glomerulosclerosis (6.06%), collagen fibrotic glomerulopathy (3.03%), and fibrillary GN (3.03%). Staining showed 92% nodules were PAS positive, 86% are silver positive. 5.8% showed Congo Red positivity. The interstitial fibrosis and tubular atrophy was 10.9%. The IFTA was considerably higher in the diabetic population.

CONCLUSIONS: Even though mesangial expansion is pathognomonic of diabetes, 24.25% of mesangial expansion in this center was associated with diseases other than diabetes. Heavy chain deposition disease, amyloidosis, fibrillary GN, collagen fibrotic glomerulopathy, and idiopathic nodular glomerulosclerosis were the other associations found in our center. Histochemical stains and in some cases electron microscopy was used to differentiate such rare disorders from diabetes.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 114: EPIDEMIOLOGY AND OUTCOMES OF PREGNANCY RELATED ACUTE KIDNEY INJURY IN A TERTIARY CARE CENTRE OF EASTERN INDIA - AN OBSERVATIONAL STUDY

Soumyadip Kar 1, Arpita Ray Chaudhury 1, Aniruddha Datta 1, Koushik Bhattacharjee 1, Atanu Pal 1, Debabrata Sen 1, Sambhunath Bandyopadhyay 1

BACKGROUND: Pregnancy-related acute kidney injury (PRAKI) has been one of the most challenging riddles faced by nephrologists as obstetric AKI has been associated with poor outcome in comparison to other causes of AKI affecting both fetal and maternal well-being. In India though the incidence has reportedly come down over the last few decades, still it constitutes a significant proportion of dialysis requiring AKI and is often multifactorial.

AIM OF THE STUDY: a. To analyze etiology and outcomes of pregnancy-related acute kidney injury b. To identify factors associated with poor prognosis c. To analyze the time trends with particular focus on factors amenable for intervention

METHODS: a. A hospital-based prospective observational study was conducted from January 2021 to June 2022 at IPGME&R and SSKM Hospital Kolkata. The need for renal replacement therapy was based on patients’ symptoms and clinical status in accordance with the recommendations by the KDIGO. Renal biopsy was done in case of non-recovering of renal function at the end of three weeks or in anuric patients as earliest. Maternal outcomes were recorded as complete recovery partial recovery non-recovery or death, and fetal outcomes were recorded as live birth IUGR IUFD or preterm delivery. All patients were followed up with laboratory investigations at four-week interval till six months after discharge and after six months at three-monthly interval.

RESULTS: During the study period, 53 patients were admitted with PRAKI, of whom 37 (69%) received hemodialysis (HD). A total of 887 patients including all cases of AKI underwent HD from September 2021 to August 2022. The incidence of dialysis requiring PRAKI was 53 out of the 887 patients (6%). The mean age of study population 25 years. Forty-seven percent of patients were diagnosed with PRAKI during their first pregnancy. PRAKI was observed most commonly in the postpartum period (62%), followed by third trimester (22%). The most common cause of PRAKI was sepsis (39%) followed by thrombotic microangiopathy (18%). There was a significant reduction of first-trimester AKI (3.7%) compared to a previous study published from this institute (8.6%). The maternal mortality and fetal mortality were 18.8% and 24.5% respectively. Nearly 34% of the patients have complete recovery of renal function. A total of 17 patients underwent renal biopsy for partial recovery and non-recovery of renal function. Among them, thrombotic microangiopathy and patchy cortical necrosis (18%) were most common pathology. Culture/sensitivity from high vaginal swab were positive in seven patients, most common being E. Coli. Complement and genetic study revealed two patients had anti-CFHR3 mutation and one patient had CFHR1 deletion. Total seven (13%) patients had postpartum cardiomyopathy, among them three patients died.

CONCLUSIONS: PRAKI was associated with high maternal and fetal mortality, with sepsis being the leading cause. As P-aHUS may have features overlapping with sepsis and associated with very poor renal outcome, a high index of suspicion should be maintained especially in postpartum PRAKI to detect this entity early, which may change the course the disease.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 115: RENAL TRANSPLANT OUTCOME FROM ELDERLY DONORS

Elsa George 1, A Feroz 1, N Sajith 1, N A Ismail 1, B Sreejesh 1, S Shysil 1, P Jithu 1, M Vaseem 1, B Aparna 1

BACKGROUND: Transplant community is forced to accept donors of increasing age due to absence of an effective deceased donor program and dearth of living donors with the trade-off being the concern for adverse graft outcomes. Studies have shown that the elderly living donors have outcomes similar to standard criteria deceased donors. There is lack of Indian studies on renal allograft outcome from elderly donors.

AIM OF THE STUDY: To compare the renal allograft and recipient outcome between donors more than 60 years (elderly group) and donors of age between 55 to 60 years (standard group).

METHODS: Single-center retrospective observational study. Study population was obtained from MIMS transplant registry for the period Jan 2007–Dec 2020.

RESULTS: Of the 812 transplants during the period, 57 belonged to elderly with mean follow- up of 3.4 years and 106 in Standard group with mean follow-up of 3.6 years. The average age of recipients in Elderly and Standard groups were 38.5 Â ± 7.1 years and 35 Â ± 6.9 years respectively (p = 0.01) and was significant. The incidence of delayed graft function, acute rejection, tacrolimus toxicity, death-censored graft loss, and patient loss were 8.8%, 14%, 14% 16%, and 3.5% in Elderly group compared to 2.8%, 13%, 9%, 14%, and 3% in Standard group respectively, and none of them were of significant difference. Graft survival was comparable in both groups.

CONCLUSIONS: Donors above 60 years provide comparable outcome with respect to donors of age group 55–60 years. Elderly donor kidneys were received by relatively elderly recipients. Multitude of donor factors other than age that contribute to good outcomes need to be identified with further studies.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 116: ASSOCIATION OF IL-23/IL-17 AXIS WITH PRIMARY MEMBRANOUS NEPHROPATHY

Prabhjot Kaur 1, Vinod Kumar 1, Ashwani Kumar 1, Ritambhra Nada 2, Harbir Singh Kohli 1, Raja Ramachandran 1

BACKGROUND: Primary membranous nephropathy (PMN) is an autoimmune disease and the most common cause of nephrotic syndrome in non-diabetic adults. Th1/Th2 paradigm may contribute to PMN pathophysiology. Th17 cells differ not only in their cytokine profile but also in need for differentiation drivers. IL-23 is one among them and critically defines Th17 cell proliferation and survival. Despite a defined involvement of the IL-23/IL-17 pathway in other autoimmune kidney diseases like lupus nephritis, no study evaluated the link of MN with this IL-23/IL-17 pathway to date. The current abstract reports the IL-23/IL-17 axis association with PMN.

AIM OF THE STUDY: To study association of IL-23/IL-17 axis with primary membranous nephropathy

METHODS: We enrolled patients with biopsy-proven PMN patients along with age and sex-match healthy controls. Using ELISA, we estimated the serum PLA2R (Euroimmune ELISA kit LÃübeck Germany IL-23 and IL-17 levels (R&D Systems, USA)) along with biochemical parameters. A nonparametric analysis predicted the change in IL-23, IL-17, and PLA2R among PMN and controls. In addition a one-way ANOVA test compared the IL-23 and IL-27 among the PLA2R tertiles. We present the parametric and nonparametric variables as mean ± SD and median (IQR) respectively.

RESULTS: We identified 140 PMN patients (mean age 41.41 ± 12.50 years) and a hundred controls (mean age 46.71 ± 10.75 years) for this study. The median serum PLA2R level among MN patients was 234.58 (275.00) RU/ml. Urine protein, serum albumin, and creatinine were 6.52 (4.83) g/day, 2.30 (0.81) g/dl, and 0.90 (0.36) mg/dl, respectively in PMN patients. Cytokines IL-17 and IL-23 were significantly elevated in PMN patients as compared to controls (Median: 12.31pg/ml (9.75, 26.45) vs median: 9.75pg/ml (8.13, 16.82) p = 0.008) vs (Median: 6.04pg/ml (3.85, 11.63) vs median: 5.46pg/ml (3.34, 9.96) p = 0.032), respectively. The tertiles of serum anti-PLA2R titer (First; 22.24 to 165.30 RU/ml (n = 44), Second; 165.73 to 341.00 RU/ml (n = 44) and third; 345.76 to 5259.54 RU/ml (n = 45)) depicted a declining trend in IL-17 and IL-23. Recorded median IL-17 and IL-23 levels were 24.09pg/ml;(10.71, 43.83), 12.19pg/ml;(9.09, 17.98), and 11.47pg/ml;(8.18, 21.44) (p = 0.029) for IL-17 and 8.83pg/ml;(5.18, 16.35), 5.35pg/ml;(3.92, 10.39) and 4.66pg/ml;(3.00, 8.25) (p = 0.029) for IL-23, respectively. Also, IL-17 and IL-23 negatively correlated with serum PLA2R levels (Spearman’s correlation: r = -0.253, p = 0.004 and r = -0.293, p = 0.002 for IL17 and IL23, respectively).

CONCLUSIONS: The study signals an association of IL17/IL23 axis with PMN. A negative correlation of anti-PLA2R autoantibodies MAY indicate a conspicuous role of IL17 and IL23 cytokines in PMN patients with lower anti-PLA2R titers.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 117: RETROSPECTIVE ANALYSIS OF SURGICAL MINI-LAPAROTOMY AND IMAGE GUIDED PERCUTANOUS TENCKHOFF CAPD CATHETER INSERTION TECHNIQUES

Jithu Purushotham 1, Sreejesh Balakrishnan 1

BACKGROUND: Home-based peritoneal dialysis (PD) is an alternative to facility-based hemodialysis and has lower costs and greater freedom for patients with kidney failure. For a patient to undergo PD a safe and reliable method of accessing the peritoneum is needed. The three main catheter insertion techniques are open surgical and advanced laparoscopy performed by experienced surgeons and percutaneous catheter insertion technique by trained nephrologists. Image guidance under fluoroscope and ultrasound is a further evolution of percutaneous technique aimed at equipping better vision of the field better technique survival and safety for the patients.

AIM OF THE STUDY: To compare the outcomes of Tenckhoff CAPD catheter placement by image guided percutaneous technique performed by nephrologist and mini laparotomy technique by a well-trained surgeon.

METHODS: A total of 85 consecutive CAPD catheter insertions from 2019 November to 2022 March were retrospectively analyzed. Among them two were primary advanced laparoscopic insertions which were excluded from the study. Data were analyzed using SPSS 21.0, and graphs will be depicted using Microsoft Excel. â€'Categorical variables were summarized in terms of frequency with percentage and tested using Fisher's exact testâ€'. For all test, a p value less than 0.05 was considered as statistically significant.

RESULTS: A total of 85 consecutive CAPD catheter insertions were analyzed, of these 45 have undergone image guided percutaneous insertions and 38 via mini laparotomy technique. In both the arms, there was 100% success in proper peritoneal placement of the catheter. Early mechanical complications were observed in 6 patients in surgical arm (15%) (3 were peri catheter leaks and 3 were catheter tip migration). Two patients (4%) in the percutaneous group had mechanical complications (one had pericatheter leak and other one was catheter tip migration - [p value 0.328]). Early procedure-related peritonitis was observed in two patients (5%) in surgical arm and none in the percutaneous group (p value - 0.207).

CONCLUSIONS: Image-guided percutaneous catheter insertion is a reliable, safe, and effective way of CAPD catheter placementâ€'. Mechanical complications and procedure-related peritonitis were less commonly observed in percutaneous arm in this studyâ€'. Image guidance is a tool which can give results on par or even better for percutaneous placement of CAPD catheters over more laborious surgical placement techniques.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 118: OUTCOME OF PATIENTS UNDERGOING SECOND KIDNEY TRANSPLANT

Ishan Parekh 1, Hepal Vora 1, Zaheer Virani 1, Prashant Rajput 1, Shruti Tapiawala 1, Bharat Shah 1

BACKGROUND: Second kidney transplant patients are sensitized and considered to be immunologically at high risk. How do they do after second kidney transplant?

AIM OF THE STUDY: This study aimed to evaluate the outcome of such patients.

METHODS: This retrospective observational study evaluated outcome of 27 [20 living related (LRD) 7 deceased donors (DD)] second kidney transplants performed between 2014 and 2022. Immunologic evaluation included only CDC cross-match for DD transplants. For LRD transplants before 2018 limited HLA typing (A B DR) of donor and recipient and CDC cross-match was done. After 2018 detailed HLA typing (A B C DR DQ DP) of recipient and donor CDC and flow cross-match and Panel Reactive Antibodies (PRA) was done. If PRA would be positive single antigen bead testing would be done to look for donor specific antibodies. Induction immunosuppression (IS) used was thymoglobulin or basiliximab based on immunological risk of the recipient, and maintenance IS was tacrolimus mycophenolate mofetil and prednisolone.

RESULTS: Mean recipient age was 41.3 + 11.7 years. Nineteen recipients were male and eight were female. The 1, 3, and 5-year patient survival rates were 91.7%, 91.7%, and 83% respectively and death censored graft survival rates were 96.5%, 82.2%, and 82.2% respectively. Four patients died (2 from cardiac cause with functioning graft and 2 due to infection following graft loss). Four grafts were lost (one from hyperacute rejection and 3 from chronic allograft nephropathy — possibly chronic antibody-mediated rejection. Rejection was more in those with limited immunologic evaluation.

CONCLUSIONS: Our study shows good outcome of patients undergoing second kidney transplant particularly with transplants done after detailed immunologic evaluation.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 119: ”CLINICAL PROFILE AND OUTCOMES OF NEPHROTIC SYNDROME WITH ACUTE KIDNEY INJURY IN ADULTS: A PROSPECTIVE COHORT STUDY”

Rajaram Yadav 1, Om Kumar 1, Amresh Krishna 1, Pritpal Singh 1, Prem Shanker Patel 1

BACKGROUND: Nephrotic syndrome (NS) is characterized by heavy proteinuria hypoalbuminemia and anasarca and generally has a relapsing-remitting course. In the context of NS, acute kidney injury (AKI) is a severe and alarming clinical problem. AKI is frequent among patients with NS with comorbidities while it has been correlated with an increased frequency of adverse outcomes including death and chronic renal failure

AIM OF THE STUDY: To evaluate the clinical profile risk factors and outcomes of NS with AKI in adults.

METHODS: It was a prospective study done on patients with NS who developed AKI. Demographic clinical and laboratory data were collected in all patients and followed up for a minimum of 3 months to assess clinical profile and outcomes.

RESULTS: In our study, 200 patients with NS were identified during the study period and 25 (8%) patients were found to have AKI. Logistic regression analysis showed that severe hypoalbuminemia, increase in age, intravascular volume depletion, and use of diuretics/NSAIDs were the main risk factors for AKI in NS. Patients with AKI in NS were classified using AKIN criteria. Fifteen (60%) patients entered AKIN stage 1, and 8 (32%) patients were found to be in AKIN stage 2, and 2 (8%) patients had AKIN stage 3. Cumulative recovery rates in 3 months for groups AKIN stage 1, stage 2, stage 3 were 100%, 100%, and 85% respectively (p = 0.02). Cumulative complete remission rates in 3 months for groups AKIN stage 1, stage 2, stage 3 were 92%, 95%, and 75% respectively (p = 0.01).

CONCLUSIONS: AKI is not uncommon in adult NS. Hypoalbuminemia, age, intravascular volume depletion, and use of diuretics/NSAIDs are the main risk factors for AKI in NS. Renal function recovers entirely in most of the patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 120: PHENOTYPIC AND GENOTYPIC HETEROGENEITY OF PRIMARY HYPEROXALURIA AND A NOVEL MUTATION IN AGXT GENE

Jawad Iqbal Rather 1, Rabiya Rasheed 1, Mohammad Ashraf Bhat 1, Muzafar Maqsood Wani 1, Imtiyaz Ahmad Wani 1

BACKGROUND: Primary hyperoxalurias (PH) are rare inborn errors of glyoxalate metabolism resulting in increased endogenous production of oxalate leading to excessive urinary oxalate excretion and deposition as calcium oxalate in various organs. In our part of world, primary hyperoxaluria remains a diagnostic challenge the incidence and prevalence of which remains unknown as it has a wide spectrum of clinical presentation and may present at any age.

AIM OF THE STUDY: To detect primary hyperoxaluria in patients with oxalate nephropathy nephrocalcinosis and nephrolithiasis.

METHODS: In this study, we evaluated five patients who presented with varied manifestations on the basis of clinical suspicion. The investigations included routine blood biochemistry 24 hour urinary analysis and stone analysis. The diagnosis was confirmed by genetic analysis.

RESULTS: Along with establishing the phenotypic and genotypic heterogeneity of primary hyperoxalurias, a novel nonsense truncating mutation was detected in exon 9 of AGXT gene (AGXT p.Ala295SerfsTer22) in patient with atypical presentation of post-partum AKI. We also detected other mutations in AGXT and GRHPR genes.

CONCLUSIONS: Conclusions 1. Because of low clinical suspicion and lack of diagnostic resources, primary hyperoxalurias may be missed as a diagnosis. 2. The disease presentation may vary from being asymptomatic to massive nephrocalcinosis, nephrolithiasis and ESKD as first presentation. 3. In some patients with primary hyperoxaluria, the disease may be asymptomatic and can be precipitated by a high dietary oxalate load as seen in one of our patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 121: RITUXIMAB THERAPY IN PRIMARY MEMBRANOUS NEPHROPATHY- A REAL LIFE STUDY

Deeksha Pal 1, Vinod Kumar 1, H S Kohli 1, Ranjana Minz¶ 1, Raja Ramachandran 1

BACKGROUND: In anti-proteinuric refractory PMN KDIGO recommends cyclical cyclophosphamide/corticosteroids (CYC/CS) or rituximab as the 1st line therapy. However, the two-year outcome of rituximab-treated patients is unavailable from the Indian subcontinent. So in the present abstract, we report the two-year outcome of managing treatment naïve or relapsing PMN with rituximab therapy.

AIM OF THE STUDY: Efficacy of rituximab therapy in Primary Membranous Nephropathy

METHODS: We report the 24-month clinical outcome of (consecutive patients) biopsy-proven PMN cases (treatment naïve or relapsing disease) treated with rituximab-only therapy; we excluded cases with lupus nephritis Hepatitis B/C or HIV-I/II. Baseline and sixth-month anti-M-type Phospholipase A2 receptor (PLA2R) antibody was available in all patients using a Euroimmun ELISA kit (LÃübeck Germany). We defined the clinical response as per the KDIGO definition.

RESULTS: 75 (male: female 44:31; mean age 40 years) patients received rituximab therapy: 02 (2.6%) received 375 mg/m2 x 4, 59 (78.7%) received 1g x 2, and 3rd dose if CD19> 5 cells and 14 (18.7%) received CD19 targeted therapy. Four patients were lost to follow-up (excluded from analysis), two died, and 2 developed end-stage kidney disease (ESKD). Seventy-one patients completed 24 months of follow-up. The median baseline proteinuria, serum albumin, creatinine, and anti-PLA2R Abs were 6.43g/day, 2.6 g/dl, 0.9 mg/dl, and 82.15 RU/ml, respectively. Six months post-treatment, there was a significant reduction in the serum anti-PLA2R antibody titer [Median anti-PLA2R (rituximab): 0.6RU/ml], P = 0.000. At 24 months of follow-up, 55 (77.5%) (18 CR and 37 PR) achieved remission. Four (5.6%) patients relapsed after achieving remission at 12 months.

CONCLUSIONS: Rituximab effectively induces remission in three-fourths of treatment-naïve or relapsing PMN patients

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 122: STUDY ON ROLE OF RENAL BIOPSY ELECTRON MICROSCOPY IN DIAGNOSIS OF RENAL DISEASES

Prasoon Sebastian 1, M Sreelatha 1, EK Jayakumar 1, PT Hijas 1

BACKGROUND: Electron microscopy is considered to be an essential component in renal pathology. It does ultrastructural view has improved sensitivity in picking up early glomerular changes. However in order to cut down expenses, electron microscopy has been avoided in routine renal biopsies leaving nephrologists with only light microscopy and immunofluorescence along with clinical data to reach a diagnosis and to plan treatment.

AIM OF THE STUDY: The purpose of the present study is to find out the role of electron microscopy study report in diagnosis of patients who had undergone renal biopsy.

METHODS: All patients who had undergone renal biopsy from government medical college Calicut between 2021 April to 2022 March have been included in the study. Electron microscopy has been sent for every patients. Post-transplantation graft biopsy as well as repeat biopsy were excluded from study. Data were collected retrospectively from hospital records and from patient’s records. Data collected includes the clinical diagnosis before biopsy as well the diagnosis made with light microscopy and immunofluorescence report and the final diagnosis after electron microscopy report. Contribution of electron microscopy in diagnosis was grades as necessary supportive or noncontributive. The data was analyzed using SPSS software. Qualitative variables were expressed in frequency and percentage.

RESULTS: A total of 132 patients had renal biopsy during the period of one year, excluding graft biopsy and repeat biopsies. Final diagnosis after biopsy report correlated with clinical diagnosis in 90% of those patients. 21% of patients were diagnosed to have IgA nephropathy. Second most group were of biopsy done to rule out non-diabetic kidney disease. Major indication for renal biopsy in these patients were short duration of diabetes at onset of renal disease followed by absence of diabetic retinopathy. 90% of them had diabetic kidney disease itself. Clinical diagnosis of IRGN was made in 8 patients, and none of them had an alternative diagnosis after biopsy report. Electron microscopy was found to be essential for diagnosis in only 9% of patients, and it gave helpful information but not changing treatment in another 37.8% of patients. Electron microscopy was not required for diagnosis in remaining 53% of patients. A total of 132 patients had renal biopsy during the period of one year, excluding graft biopsy and repeat biopsies. Final diagnosis after biopsy report correlated with clinical diagnosis in 90% of those patients. 21% of patients were diagnosed to have IgA nephropathy. Second most group were of biopsy done to rule out non-diabetic kidney disease. Major indication for renal biopsy in these patients was short duration of diabetes at onset of renal disease followed by absence of diabetic retinopathy. 90% of them had diabetic kidney disease itself. Clinical diagnosis of IRGN was made in 8 patients, and none of them had an alternative diagnosis after biopsy report. Electron microscopy was found to be essential for diagnosis in only 9% of patients, and it gave helpful information but not changing treatment in another 37.8% of patients. Electron microscopy was not required for diagnosis in remaining 53% of patients.

CONCLUSIONS: Diagnostic accuracy can be increased to cent percentage with the use of electron microscopy along with light microscopy and immunofluorescence. However, considering the cost of electron microscopy, nephrologists could use their discretion in performing electron microscopy study.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 123: OUTCOME OF TUNNELED CUFFED CATHETER AS HEMODIALYSIS ACCESS; A SINGLE CENTRE EXPERIENCE IN A TERTIARY CARE CENTRE IN EASTERN INDIA

Sourav Sadhukhan 1, A Roychowdhury 1, Kaushik Bhattacharjee 1, Atanu Pal 1, Debabrata Sen 1

BACKGROUND: Although AVFs are preferred vascular access for hemodialysis tunneled venous catheters (TVC) are increasingly being used as dialysis access in certain clinical situations such as in AVF failure or lack of suitable vessels for AVF creation or bridge to living donor transplant.

AIM OF THE STUDY: To study the characteristics of the population on TVC to identify the different indications complications and the catheter survival rate and the factors associated with complications and survival.

METHODS: In this retrospective observational study, data was captured using standard pro forma was tabulated using MS Excel, and all results projected in form of bar graphs, pie charts, histograms, or tables. Kaplan–Meier analysis was used to assess the survival of catheter. All patients included in the study consented for the procedure as well as collection of data. A total of 496 TVC placements were done in 461 patients by nephrologists without fluoroscopy between July 19 and July 21. Minimum follow-up was 12 months.

RESULTS: In our study cohort, 316 (68.5%) were males with mean age of 48.3Â ± 12.6 years. Most common cause of NKD was chronic glomerulonephritis (38.1%). Most common site was rt internal jugular vein (88.9%) followed by lt internal jugular vein, femoral tunneled catheter was done in 3 patients. 32.66% tunneled catheter were placed after initiation of HD through temporary catheter while being waitlisted for AVF creation, 17.54% after primary AV failure and 11.89% after secondary AV failure. The average duration of use of TVC was 201.9 Â ± 114.9 days. Catheter survival rates were (75.76%), (63.4%), and (32.17%) at 3 months, 6 months, and 12 months. Total CRBSI episodes-1.07/1000 catheter days, organisms isolated in 16.1% of cases. Mechanical complications were seen in (14.06%), most common was bleeding from tunnel. Other complications were catheter kink, displacement in azygos system, hemothorax. Most common late complication was catheter block (15.07%) due to catheter thrombosis and fibrin sheath and central venous stenosis in (5.29%) cases. Catheter salvage by local thrombolysis was done in 57 cases. Central venoplasty followed by second tunneled catheter insertion was done in 19 cases. Most common cause of catheter dropout was patient death unrelated to the TVCs followed by AVF maturation.

CONCLUSIONS: While AVF remains the most effective way for a better quality of hemodialysis, TVCS may be used for temporary and intermediate duration and also for the patients who are on living donor transplant list but requires strict monitoring and asepsis protocol.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 124: LONGITUDINAL ASSESSMENT OF HEALTH-RELATED QUALITY OF LIFE IN THREE DIFFERENT HYPERPHOSPHATEMIA MANAGEMENT GROUPS OF STAGE 3 AND 4 CKD PATIENTS

Himansu Sekhar Mahapatra 1, Himansu Sekhar Mahapatra 1, Navjot Kaur 1, Neera Sharma 1, Lalit Pursnani 1, Muthu Kumar 1, Neeraj Inamdar 1, Mansi Singh 1, Y P Gupta 1

BACKGROUND: Health-related Quality of Life (HRQoL) has emerged as an important outcome measure in patients with CKD. The lack of prospective studies on HRQoL and its relation with hyperphosphatemia control measures among the pre-dialysis patients necessitated the need for this study.

AIM OF THE STUDY: This longitudinal randomized controlled study was designed to determine the change in QoL and its components in relation to different low phosphorus treatment methods and the progression of the disease activity.

METHODS: This study is prospective randomized controlled open labeled conducted for one year with 120 CKD stages 3 and 4 patients divided equally into three groups:Group1-Dietary phosphorus modification, Group2-Calcium-based phosphate binders, and Group3- Non-calcium-based phosphate binders. Patients were assessed for HRQoL FGF 23 iPTH phosphorus and nutritional status along with dietary phosphorus control strategies at three time intervals 0, 6, and 12 months. HRQoL was measured by using 36-item Short-Form Health Survey (SF 36) providing a physical component (PCS) and mental component (MCS) scores ranging between 0-100. Higher scores indicate better health status. Two-way repeated measures ANOVA was done to test for mean variations in three groups across three time periods with PCS and MCS separately to analyze equality of group means time intervals and interactions. One-way repeated measures ANOVA was also done to see the mean differences in three time intervals in three groups separately. Multiple regression analyses were carried out with PCS and MCS as dependent variables, and other 13 were as independent variables.

RESULTS: At baseline, the mean PCS and MCS were equal in three groups. PCS improved significantly (p < 0.00) from baseline to one year in all the three groups, viz. group 1 PCS 66.5Â ± 13.5 to 75.1Â ± 9.76; group 2 the PCS score was 68.9Â ± 11.80 to 77.2Â ± 7.50; and in group 3 was 66.2Â ± 12.16 to 73.8Â ± 9.27. Initially, MCS declines substantially at sixth month but recovered at one year. The similar trend as was obtained for groups in both the stages. Multiple regression analysis in 13 associated parameters yielded R2of 13.7% and 18.1% in PCS and MCS respectively indicating little contribution of various parameters.

CONCLUSIONS: There has been a significant positive change in PCS scores in all form of hyperphosphatemia management groups over a period of 12 months. MCS showed an initial dip at sixth month which recovered to baseline at one year. Further, among the three groups, the incremental changes in PCS and MCS scores were insignificant.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 125: CORRELATION OF STAGES OF AKI WITH SHORT AND LONGTERM OUTOMES-PROSPECTIVE OBSERVATIONAL STUDY

Chetan Veeramaneni 1, Manisha Sahay 1

BACKGROUND: Acute kidney injury (AKI) is a well-known complication that affects critically ill patients in intensive care unit (ICU) and is associated with increased mortality morbidity and length of stay. The incidence of AKI is extremely variable between 2.5% and 92% which necessitate earlier detection and management to decrease risk for death prolonged hospitalization and future development of chronic kidney disease (CKD).

AIM OF THE STUDY: 1) To evaluate the cause of AKI. 2) To evaluate the need of renal replacement therapy which includes both peritoneal and Hemodialysis. 3) To evaluate in-hospital mortality. 4) To assess 30-day 90-day and 1 year mortality. 5) To assess percentage of patients progressing to CKD. 6) NEWS2 prognostication score at the time of admission and correlation with outcome.

METHODS: INCLUSION CRITERIA: Patients of age ≥18 years fulfilling the acute kidney injury definition according to KDIGO-2012. EXCLUSION CRITERIA: 1) All cases with previously documented chronic kidney disease (glomerular filtration rate [GFR] <60 ml/1.73 m2 proteinuria and abnormal renal imaging), 2) solid organ transplant recipients. MATERIALS & METHODS: Type of study: Prospective study Place of study: Osmania General Hospital Hyderabad Study duration: January 2021-August 2022 (20 months) Cases included: 256 Statistical analysis: Categorical variables: Numbers & percentage Continuous variables: Mean ± SD Median: In case of small number of extreme values. Outcomes: Chi-square test/ Fisher's exact test depending on degree of freedom and are presented as risk ratio. All analysis will be performed using statistical package for social studies (SPSS) 2022 version. A two-tailed p-value less than 0.05 will be regarded as statistically significant unless otherwise stated. The correlation between continuous variables will be examined by the Spearman's rank correlation coefficient. The random coefficient regression model will be employed to test the time-trend over time. Statistical significance was considered at a P < 0.05, and odds ratios with 95% confidence interval were also calculated.

RESULTS: Total 256 patients were included in the present study. Mean age was 46.6 ± 18.9 years. Male-to-female ratio was 1.6:1 (160:96). Patients diagnosed with acute kidney injury based on minimum criteria for Acute Kidney Injury according to serum creatinine were 104/256 (40.6%), according to urine output status were 152/256 (59.4%). Patients with AKI KDIGO-1 were 49 (19%); KDIGO-2 were 69 (27%); KDIGO-3 were 138 (54%). Community acquired AKI were 158 (61.7%); Hospital acquired AKI were 98 (38.3%). Most common etiology was Sepsis (144/256, 56.3%) followed by Tropical AKI (58/256,22.6%). NEWS2 prognostication score at the time of admission was 0-4 (25/256,10%); 5-6 (78/256, 30%); ≥7 (153/256,60%). Types of AKI- Pre-Renal AKI (40/256, 15.6%), Intrinsic AKI (172/256,67.2%), Post-Renal AKI (44/256, 17.2%). Patients who required renal replacement therapy were 96/256 (37.5%), of which 64/256 (25%) were treated with intermittent hemodialysis, 20/256 (8%) were treated with intermittent peritoneal dialysis, 12/256 (4.7%) were treated with both modalities. Renal biopsy was done in 36/256 (14%), of which Acute Tubular Injury was the most common interpretation. A total of 76 patients expired during hospital stay (66/256,25.8%); mortality during follow-up- at 30 days (76/256,29.7%); at 90 days (99/256, 38.6%); at 1 year (116/256, 45.3%). Patients expired in different stages of AKI at 1 year were AKI-1 (9/49, 18.4%), AKI-2 (21/69, 30.4%), AKI-3 (86/138, 62%, p < 0.01). Outcomes at the end of the study period- 62 patients recovered (24.2%); 116 patients expired (45.3%); 38 patients had de novo CKD (eGFR < 60 ml/min/1.73 m2 at 90 days) (14.8%), of which 14 patients were dialysis dependent; 40 patients lost to follow-up (15.6%). Age > 65 years (p < 0.001), NEWS2 prognostication score ≥7 (p < 0.001), septic AKI (P = 0.002), KDIGO stage (p < 0.001), inotrope requirement (p < 0.001), renal replacement therapy requirement (p < 0.001) best correlated with mortality at 1 year.

CONCLUSIONS: Sepsis was the most common etiology in the present study. Development of AKI per se has higher impact on short- and long-term mortality of the patients. Most of the etiologies of AKI being preventive, care should be taken to prevent AKI development rather than aiming at AKI treatment. Community programs should be conducted to avoid the use of nephrotoxins, NSAIDS, plant toxins, and in-hospital rigorous monitoring of at-risk patients should be done to prevent development of acute kidney injury.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 126: PARAQUAT POISONING: EXPERIENCE FROM A TERTIARY CARE CENTER IN INDIA

Nisha Jose 1, Indhumathy 1

BACKGROUND: Introduction: Although paraquat remains a commonly consumed poison within the Indian Sub-continent little remains known about the efficacy of various treatment options used in this lethal condition

AIM OF THE STUDY: To evaluate the efficacy of novel therapeutic options used in the treatment of paraquat poisoning

METHODS: A retrospective observational study was conducted among all patients admitted with ingestion of paraquat over a 5-year period to this tertiary level hospital.

RESULTS: All patients had acute kidney injury. Hemodialysis was required in 54% of patients. Hemoperfusion was provided to 30.8% of patients, but no survival benefit was noted due to this intervention. Dialysis was noted to delay time to death significantly, but no mortality benefit was noted.

CONCLUSIONS: Paraquat has high mortality despite various therapeutic advances. Dialysis may be able to delay time to death significantly.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 127: PHYSICAL ACTIVITY AND SLEEP ASSESSMENT USING FITNESS BAND IN MAINTENANCE HD PATIENTS USING HEALTH TRACKER TECHNOLOGY

Suresh Sankarasubbaiyan 1, Ankit Agarwal 1, Kamal Shah 1, Vivekananda Jha 1

BACKGROUND: Technological innovation helps us gain insights of physiological functioning like activity sleep and energy usage and improve lifestyle for health promotion. Such technology can help us learn about the about daily lives of dialysis patients

AIM OF THE STUDY: To study level and variation physical activity of dialysis patients across dialysis and non-dialysis days. To study sleep pattern and variation of dialysis patients across dialysis and non-dialysis days

METHODS: Mi Smart band 4 wrist was worn by dialysis patients for 7 days each including dialysis and non-dialysis days. They were instructed to wear the instrument continuously. Patient’s name, age, gender, height, weight, and BMI, duration of HD, cause of CKD, major comorbidity were reviewed. Duration of sleep deep and light sleep number of steps distance was analyzed. Steps distance walked, sleep duration, deep and light sleep, mean, and sd were calculated and compared between dialysis and non-dialysis days.

RESULTS: 50 patients from 10 urban HD centers wore the wrist band for total of 350 person days. 40 (80%) males and 10 (20%) females. Avg age: 47.12 + 15.05 yrs, median HD duration of 31 months. 41 (82%) had AVF, 9 (18%) had catheters for HD, Hb 9.87 + 1.58 g%. Table 1: Mean values of physiological parameters N = 350 activity & 343 = sleep Steps 3867 + 3078.92 Distance (Km) 2.11 + 1.83 Total sleep (hours) 5.42 + 2.40 Deep sleep. (hours) .94 + .87 Light sleep (Hours) 4.45 + 3..31 Sleep score 67.67 + 19.42 Table 2: Comparison of activity and sleep on Dialysis and Non-dialysis days Dialysis (n = 126) Non-dialysis (n = 224) P value Steps 3721 + 2912 3948 + 3172 NS Distance (Km) 2.03 + 1.71 2.15 + 1.90 NS Total sleep (Hrs) 5.50 + 2.43 5.37 + 2.39 NS Deep sleep (Hrs) .98 + .91 0.94 + .85 NS Light sleep (Hrs) 4.3 + 2.0 4.46 + 3.85 NS Sleep score 67.45+ 19.98 67.80 + 19.12 NS

CONCLUSIONS: Our study is a feasibility demonstration of being able to track and study physical activity and sleep pattern among dialysis patients. It provides early insights into patterns of these physiological parameters. Lack of variation between HD and non-dialysis days is partly due to small simple size and patient factors.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 128: EFFICACY OF RITUXIMAB IN CHILDREN AND ADOLESCENTS WITH DIFFICULT TO TREAT NEPHROTIC SYNDROME

Vishal Pooniya 1, Abhilash Chandra 1, S Namrata Rao 1

BACKGROUND: Nephrotic syndrome is the commonest glomerular disorder affecting children. Although most of them achieve complete remission with the use of steroids approximately 80% continue to have 1 or more relapses and many of them become steroid dependent. Additional 10% may become steroid resistant. Rituximab a chimeric monoclonal anti CD-20 antibody has shown promise in treatment of these cases. We did a retrospective analysis of children and adolescents aged 1 to 18 years suffering from nephrotic syndrome who were treated with rituximab at our center.

AIM OF THE STUDY: To find out the proportion of children and adolescents with steroid sensitive or steroid-resistant nephrotic syndrome who respond to rituximab. To find out the factors affecting response to rituximab.

METHODS: All children and adolescents between age 1 to 18 years suffering from steroid-dependent or steroid-resistant nephrotic syndrome who received rituximab during last 3 years were included in the study. Clinical and laboratory data was retrieved from hospital medical records. Response to rituximab was ascertained at 3, 6, and 12 months. Continuous variables were described as mean (standard deviation), and categorical variables were described as number (percentage). Student's t-test was used to compare means, and chi-square test was used to compare proportions. Statistical analysis was done using SPSS version 26.0.

RESULTS: Out of the 20 patients, 80% were males and mean age of study population was 12.2 (+5.3) years. Fourteen (73.7%) had FSGS, 2 (10.5%) had minimal change disease and C3 glomerulopathy each, and 1 (5.3%) patient had membranous nephropathy on kidney biopsy. Overall, 12 (60%) showed complete or partial response to rituximab over a period of 12 months, whereas rest were unresponsive. Two (16.7%) patients relapsed within 12 months of receiving rituximab. Mean serum albumin was significantly lower among non-responders, whereas age, sex ratio, spot urine–protein–creatinine ratio, eGFR, kidney biopsy finding, steroid responsiveness, and number of rituximab doses did not differ between responders and non-responders.

CONCLUSIONS: This study showed that rituximab is a viable option in children with difficult to treat nephrotic syndrome in children and adolescents with a fair response rate over short term. Well-designed prospective trials with adequate follow-up are required to substantiate these findings.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 129: A PROSPECTIVE OBSERVATIONAL STUDY TO ASSESS TREND OF FOUR URINARY BIOMARKERS IN PRE- ALBUMINURIC STAGES OF NON HYPERTENSIVE TYPE 2 DIABETIC NEPHROPATHY

Himansu Sekhar Mahapatra 1

ABVIMS DR R M L Hospital New Delhi, India

BACKGROUND: Thirty months longitudinal behavior of urinary Angiotensinogen Cystatin C Neutrophil gelatinase-associated lipocalin (NGAL) and Interleukin (IL) -18 have been studied in non-hypertensive pre-albuminuric diabetic patients.

AIM OF THE STUDY: To study the progression of clinical biochemical and urinary biomarkers during pre-albuminuric stages of non-hypertensive type 2 DN over thirty months.

METHODS: Total 120 early diabetic nephropathy (eGFR ï'3120 & ACRï'330) cases classifying into hyperfiltration (43), Normoalbuminuria (29), and Microalbuminuria (48) groups and 63 Diabetics without nephropathy were recruited as control. All were subjected to urine protein ACR HbA1C e-GFR along with urinary bio markers (IL-18 Cystatin-C NGAL and Angiotensinogen) at 12th 18th 24th and 30th month.

RESULTS: There was a progressive significant rise of NGAL/Cr from and IL-18/Cr levels from 18th to 30th month (6.8 to 14.28 mg/gm, and 521 to 656 mg/gm, p < 0.00) respectively. Angiotensinogen/Cr levels showed a non-significant rise from 24th to 30th month (24 to 41.8 mg/gm) while there was no change in the Cystatin/Cr levels during 30 months of follow-up. In all hyperfiltration, normoalbuminuria, and microalbuminuria groups, levels of ACR, eGFR IL18/Cr, Cystatin C/Cr, and Angiotensiogen/Cr levels were higher in cases compared to controls but not NGAL/Cr. Further, their progression also showed a similar trend as shown by total average levels.

CONCLUSIONS: In pre-albuminuric stages of DN, over thirty months, urinary NGAL and IL18 progressively increased, while individually in all three groups, Angiotensinogen, IL18, and NGAL except Cystatin also showed an upward trend.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 130: ANCA ASSOCIATED VASCULITIS: A RETROSPECTIVE OBSERVATIONAL STUDY OF CLINICAL PROFILE AND INDUCTION OF REMISSION: EXPERIENCE OF A TERTIARY CENTER

Taniya Bhuiya 1, Sourav Sadhukhan 1, Debabrata Sen 1, Arpita Raychaudhury 1, Atanu Pal 1, Koushik Bhattacharya 1

BACKGROUND: For treating ANCA-associated vasculitis in last few years, newer immunosuppressive regimens (Rituximab + steroid) are coming up with the aim of reducing cumulative dose and side effects of immunosuppression (EUVAS) while having same efficacy as induction agents.

AIM OF THE STUDY: 1. To describe the clinical spectrum of the disease and 2. describe the efficacy and safety of cyclophosphamide and Rituximab as induction agents. Methods: A single-center observational retrospective study consisting of 33 indoor patients of Nephrology department I.P.G.M.E & R SSKM HOSPITAL KOLKATA in between JAN 2021- MARCH 2022 with 6 months of follow-up. ANCA MPO PR3 were estimated by IIF and ELISA. Induction therapy was given according to institutional protocol (EUVAS / RAVE).

RESULTS: Total 33 patients were included; new cases were 90.9% (30) and 9.1% (3) were relapse cases, 10 were male (30.3%), 23 were female (69.9%). Mean age was (39.6 yrs  ± 16.9 yrs). 16 (48.48%) were MPO +, 10 (30.3%) were PR3, 1 (3.03%) was positive for both, 6 (18.18%) were ANCA- ANTI-GBM overlap. RPRF presentation was in 20 cases (60.6%), HD requiring at presentation 18 (54.54%), DAH in 12 patients (36.36%), other systemic symptoms were mostly joint pain, skin rash, fever, weight loss. Mean baseline creatinine —(5.6 ± 2.57) mg/dl, mean baseline 24 hours proteinuria — (1.5  ± 0.89 gms/day). 17 patients (51.51%) were given Plasmapheresis, however for 4 patients, it had to be discontinued after 2-3 sessions due to coagulopathy, severe thrombocytopenia, sepsis. Indications for plasmapheresis were DAH (70.58%), ANCA- ANTI GBM OVERLAP (29.4%), HD requiring at presentation (100%). For 2 (6.06%) patients, PLEX could not be initiated due to hemodynamic instability, severe anaemia, and thrombocytopenia. EUVAS protocol was used for induction therapy in 21 new patients (70%); RAVE protocol was used for induction therapy in 7 new patients (23.3%). For relapse cases, 1 (33.3%) patient was treated with EUVAS protocol, 2 patients (66.67%) were treated with RAVE protocol. For 2 new cases (6.67%), no induction therapy could be started because of severe sepsis at presentation. 13 (59.09%) had infections in EUVAS arm : 8 had LRTI (61.5%), 5 had G.I sepsis (38.46%), 4 had septic shock (30.76%). 11 (50%) had bone marrow suppression in EUVAS arm. 1 (11.1%) had symptomatic UTI in RAVE arm. EUVAS had to discontinued in 4 new patients (19.04%) due to severe sepsis, bone marrow suppression, and progression to CKD-5D. There was no discontinuation in RAVE arm. Total 7 deaths were recorded; out of 7, 3 had MPO vasculitis, 3 had PR3 vasculitis, 1 had ANCA-ANTI-GBM overlap. 3 patients died within 1 month of diagnosis (42.86%), 1 patient (14.29%) died within 1-3 months, 3 patients (42.86%) died after 3 months of diagnosis. Deaths within 1st 3 months were due to pneumonia, sepsis, DAH, coagulopathy. Deaths after 3 months were due to cardiac arrhythmia (1), infective endocarditis (1), and acute left ventricular failure (1). All of them were in EUVAS arm, none died in RAVE arm. In the EUVAS arm (22), 9 (40.9%) had complete remission (proteinuria : <500 mg/day, creatinine <1 mg/dl) at the end of 6 doses; 2 (9.09%) had partial remission (proteinuria reduction >50% from baseline, creatinine 50% reduction from baseline), 4 (18.18%) had early discontinuation and developed CKD-5D, 2 patients had complete course (1.64%) but progressed to CKD-5D. In the RAVE arm (9), 8 (88.89%) had creatinine <1 mg/dl within 3 months of completing induction, 100% had proteinuria of <500 mg/day. After 3 months of initial presentation, 6 (20.68%) had developed CKD-5D [(MPO+ 2),(PR3 +2),(ANCA- ANTI-GBM overlap 2)]. Rest all were HD free at the end of 3 months. Total 33 patients were included; new cases were 90.9% (30) and 9.1% (3) were relapse cases, 10 were male (30.3%), 23 were female (69.9%). Mean age was (39.6 yrs  ± 16.9 yrs). 16 (48.48%) were MPO +, 10 (30.3%) were PR3, 1 (3.03%) was positive for both, 6 (18.18%) were ANCA- ANTI-GBM overlap. RPRF presentation was in 20 cases (60.6%), HD requiring at presentation 18 (54.54%), DAH in 12 patients (36.36%), other systemic symptoms were mostly joint pain, skin rash, fever, weight loss. Mean baseline creatinine —(5.6 ± 2.57) mg/dl, mean baseline 24 hours proteinuria — (1.5  ± 0.89 gms/day). 17 patients (51.51%) were given Plasmapheresis; however, for 4 patients, it had to be discontinued after 2-3 sessions due to coagulopathy, severe thrombocytopenia, sepsis. Indications for plasmapheresis were DAH (70.58%), ANCA- ANTI GBM OVERLAP (29.4%), HD requiring at presentation (100%). For 2 (6.06%) patients, PLEX could not be initiated due to hemodynamic instability, severe anaemia, and thrombocytopenia. EUVAS protocol was used for induction therapy in 21 new patients (70%), RAVE protocol was used for induction therapy in 7 new patients (23.3%). For relapse cases, 1 (33.3%) patient was treated with EUVAS protocol, 2 patients (66.67%) were treated with RAVE protocol. For 2 new cases (6.67%), no induction therapy could be started because of severe sepsis at presentation. 13 (59.09%) had infections in EUVAS arm : 8 had LRTI (61.5%), 5 had G.I sepsis (38.46%), 4 had septic shock (30.76%). 11 (50%) had bone marrow suppression in EUVAS arm. 1 (11.1%) had symptomatic UTI in RAVE arm. EUVAS had to discontinued in 4 new patients (19.04%) due to severe sepsis, bone marrow suppression, and progression to CKD-5D. There was no discontinuation in RAVE arm. Total 7 deaths were recorded; out of 7, 3 had MPO vasculitis, 3 had PR3 vasculitis, 1 had ANCA-ANTI-GBM overlap. 3 patients died within 1 month of diagnosis (42.86%), 1 patient (14.29%) died within 1-3 months, 3 patients (42.86%) died after 3months of diagnosis. Deaths within 1st 3 months were due to pneumonia, sepsis, DAH, coagulopathy. Deaths after 3 months were due to cardiac arrhythmia (1), infective endocarditis (1), and acute left ventricular failure (1). All of them were in EUVAS arm, none died in RAVE arm. In the EUVAS arm (22), 9 (40.9%) had complete remission (proteinuria : <500 mg/day, creatinine <1 mg/dl) at the end of 6 doses; 2 (9.09%) had partial remission (proteinuria reduction >50% from baseline, creatinine 50% reduction from baseline), 4 (18.18%) had early discontinuation and developed CKD-5D, 2 patients had complete course (1.64%) but progressed to CKD-5D. In the RAVE arm (9), 8 (88.89%) had creatinine <1 mg/dl within 3 months of completing induction, 100% had proteinuria of <500 mg/day. After 3 months of initial presentation, 6 (20.68%) had developed CKD-5D [(MPO+ 2),(PR3 +2),(ANCA- ANTI-GBM overlap 2)]. Rest all were HD free at the end of 3 months.

CONCLUSIONS: In our study, EUVAS cohort had more evidences of infections and mortality. Based on this data, future RCTs are needed to avoid selection bias and for acquiring better comparative data.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 131: UTILITY OF CYP3A5 GENOTYPE IN DETERMINING TACROLIMUS DOSE REQUIREMENT IN RENAL TRANSPLANT PATIENTS AND ITS EFFECT ON GRAFT OUTCOMES

Deepakkumar Prasad 1, Ayan Dey 1, Kiran Bijapur 1, Anshul Mehta 1, Sneha Lute 1, Aditya Handargule 1, Rasika Sirsat 1, Alan Almeida 1

BACKGROUND: Successful long-term graft and patient outcomes post-renal transplantation depend on maintenance of optimum blood levels of immunosuppressants like tacrolimus. There remains significant individual variability in tacrolimus pharmacokinetics. Levels are strongly influenced by CYP3A5 genotypes with CYP3A5*3 carriers having higher blood levels than CYP3A5*1 carriers. Real-world clinical data in India is sparse, and hence, this study was conducted to assess this phenomenon and its impact on outcomes.

AIM OF THE STUDY: To assess the utility of CYP3A5 polymorphisms on Tacrolimus dosing post-renal transplantation and analyze the effects of dosing of Tacrolimus on long-term graft and patient outcomes.

METHODS: Medical records of patients who underwent renal transplantation at PD Hinduja Hospital since 2005 were analyzed. Patients who had Tacrolimus genotyping performed pre-transplantation were included for sub-analysis. Demographic data clinical presentation Tacrolimus trough levels graft and patient outcomes were collated from the medical records. Amplification-refractory mutation system (ARMS) - Polymerase chain reaction (PCR) was used for CYP3A5 genotyping. All the three genotypes (*1/*1 *1/*3 & *3/*3) were run along with the samples. The assay is standardized in-house and validated by DNA sequencing. The data was entered into MS Excel sheets and analysis performed. Results for Quantitative Variables were expressed as mean ( ± SD) and median [range]. Results for Qualitative Variables were expressed as frequency and percentages. For categorized variables, Pearson’s chi square test or Fisher’s exact test were used. Software used was “R software version 3.5.2â€

RESULTS: Since the Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines on Tacrolimus genotyping were released in 2015, 147 renal transplantations performed. 30 patients underwent pre-transplant Tacrolimus genotyping. All patients were initiated on 0.1 mg/kg Tacrolimus. Commonest allele was CYP3A5 (*1/*3) suggesting intermediate expressors (53.3%). Poor metabolizers [CYP3A5 (*3/*3)] were 30% followed by extensive metabolizers [CYP3A5 (*1/*1)] at 16.7%. Genotyping was strongly associated with abnormal Tacrolimus trough levels at Day 7 (p = 0.02). Poor metabolizers had supra-therapeutic Tacrolimus levels. Extensive metabolizers correctly predicted suboptimal levels. The genotype did not affect optimum Tacrolimus levels at 1-year post-transplant. Mean dose requirement at 1 year was 0.055 mg/kg (+ 0.025 mg/kg). Poor metabolizers needed low dose Tacrolimus to achieve therapeutic targets (0.03 mg/kg + 0.02) as compared to intermediate (0.063 mg/kg + 0.015) or extensive metabolizers (0.068 mg/kg + 0.02) at 1 year. Thus, the dose requirement of Tacrolimus to achieve therapeutic targets was lower in poor metabolizers as compared to other genotypes, which was statistically significant (p = 0.0004). Genotyping and its influence on first week Tacrolimus level failed to show significant association with rejection rates (p = 0.43).

CONCLUSIONS: This study highlights the growing relevance of performing Tacrolimus genotyping pre-transplant. It showed a significant predictability of genotype with Tacrolimus levels in the first week post-transplantation. There was a lower Tacrolimus dose requirement at 1-year post-transplant in poor metabolizers to achieve therapeutic targets. Increasing utilization of genotyping can avoid abnormal trough levels and preclude deleterious outcomes.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 132: SPECTRUM AND OUTCOMES OF ACUTE KIDNEY INJURY IN A NON-COVID INTENSIVE CARE UNIT DURING COVID PANDEMIC: SINGLE CENTRE STUDY FROM NORTH INDIA

P M Dogra 1, Bhupinder Singh 1, Vivek Sood 1

BACKGROUND: Acute kidney injury (AKI) is a major risk factor for mortality in ICU patients. The aim of this study was to evaluate the spectrum and outcomes of non-COVID related AKI admitted to non-COVID intensive care units of a tertiary care hospital during COVID pandemic.

AIM OF THE STUDY: To study the Spectrum and Outcomes of Acute Kidney Injury in a Non-COVID Intensive Care Unit during COVID Pandemic

METHODS: Patients were prospectively enrolled from February 2020 to June 2021 using a predesigned standardized pro forma as per the inclusion and exclusion criteria. Demographic details, comorbid conditions, biochemical parameters, urine output system affection, renal replacement therapy (RRT) details, and fluid replacement were recorded. Outcome measures assessed were serum creatinine at transfer-out from ICU serum creatinine at discharge days of ICU stay and days of hospital stay death/discharge and requirement of RRT after discharge.

RESULTS: 200 patients of AKI getting admitted to ICU were included in this study. Diabetes mellitus (19.5%) was the most common comorbidity. AKI was most seen in the post-surgery setting (33%), and severe non-surgical sepsis (37%). The most important risk factors predicting in-hospital mortality in AKI patients were hepatic dysfunction (HR-3.471, p = 0.001), septicemia (HR-3.342, p = 0.0001), age >60 years (HR-4.000, p = 0.026), higher baseline SOFA score (HR-1.107, p = 0.001), anemia (HR-0.879, p = 0.003), and reduced serum iron levels (HR- 0.982, p = 0.001).

CONCLUSIONS: Presence of age >60 years, hepatic dysfunction, septicemia, higher baseline SOFA score, anemia, and reduced serum iron emerged to be the most important predictors of mortality among intensive care requiring AKI patients. The surgical AKI incidence was less due to lesser number of elective surgeries during the COVID pandemic.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 133: RENAL DYSFUNCTION IN CANCER PATIENTS: A CLINICO-ETIOLOGICAL STUDY

Anish Kumar Gupta 1, Aditya Chaudhry 1, Nitika Joshi 1, Neeru P Aggarwal 2, Gopal Sharma 2, Narinder Pal Singh 1

BACKGROUND: With the increase in number and survival of cancer patients, the complications associated with it are also increasing. Renal dysfunction is increasingly being seen in such patients and is being recognized as a factor that is adding to the increased morbidity and mortality.

AIM OF THE STUDY: To find out the occurrence of renal dysfunction among patients who have been histopathologically diagnosed as having cancer. Also to find out the etiology behind the renal dysfunction and identify the risk factors involved.

METHODS: A descriptive cross-sectional study was conducted among 100 patients above the age of 18 years who were histopathologically diagnosed as having cancer. The lowest creatinine value during hospitalization served the purpose of baseline creatinine. Criteria for AKI and CKD were defined according to the KDIGO guidelines. General condition at the time of discharge was assessed, and length of stay was noted. Change in creatinine values was monitored during the stay. Patients who had developed AKI were assessed at 3 months for evidence of kidney damage and decreased eGFR.

RESULTS: A total of 100 patients (56% male) diagnosed with cancer were evaluated with a mean age of 61.09Â ± 10.84 years. Diabetes, hypertension, and CAD was found in 28%, 28%, and 10%. The most common tumor site was gastrointestinal tract (35%) followed by the genitourinary tract (19%), and head and neck tumors (16%). 34% of patients were found to have AKI (AKI Stage I, stage II, and stage III; 35.3%, 20.6%, and 44.1% respectively). 58.8% had pre-renal AKI, 29.4% had renal AKI, and 11.8% had post-renal. The most common cause of AKI was attributed to sepsis (38.2%) followed by volume losses (20.6%) and nephrotoxic chemotherapy (20.6%), and obstructive uropathy (11.8%). The average duration of hospital stay was observed to be longer in patients with AKI compared with non-AKI (12.3 Â ± 8.2 days vs. 10.2 Â ± 9.8 days). 41.2% of patients with AKI recovered to normal renal function at the end of 3 months. Among those with AKI, progression to CKD was observed in 17.6% of patients at the end of 3 months. Post-renal (obstructive uropathy in GUT malignancy) and renal (myeloma-related kidney disease and cisplatin-induced) causes were attributed as a cause of CKD.

CONCLUSIONS: Our study concluded that renal dysfunction is associated with cancer. It occurs commonly in the elderly with slight male preponderance. Sepsis was the most common cause followed by volume losses and nephrotoxic chemotherapy. The most common tumor sites that were found to have association with renal dysfunction in our study were gastrointestinal and genitourinary tracts. The duration of hospital stay was longer in patients with acute kidney injury. Obstructive uropathy was the most common etiology leading to CKD.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 134: PERCUTANEOUS NATIVE KIDNEY BIOPSY: A SINGLE CENTRE RETROSPECTIVE STUDY AT A TERTIARY CARE INSTITUTE IN EASTERN INDIA

Amruta Devi 1, Aruna Acharya 1, S B Rout 1, S K Parida 1, Rakesh Routray 1, Rudrashish Samal 1, Alok Kumar Mohapatra 1, Rohit Gaude 1, Vijay Vachhani 1, Snehalata Devi 1, Lalit Sharma 1, Chinmayananda Dash 1, Shilpa 1

BACKGROUND: Current knowledge regarding the pathology of renal diseases has been derived to a large extent following introduction of percutaneous needle biopsy of the kidney and the systematic study of these small samples of renal tissue by light microscopy electron microscopy and immunofluorescence microscopy. Our study provides information regarding the spectrum of renal diseases diagnosed on the basis of renal biopsy features in a single tertiary care center from Odisha.

AIM OF THE STUDY:1. To study the spectrum of glomerular diseases which require renal biopsy and to correlate the pathological findings of glomerular diseases with clinical and laboratory parameters.

METHODS: A retrospective study of all native kidney biopsies performed at SCB MCH between January 2012 and December 2020 was done. All patients who had undergone native kidney biopsy for various indications were included in the study. Anthropometric clinical biochemical data and biopsy reports were retrieved from departmental database and analyzed.

RESULTS: A total of 725 kidney biopsy reports were analyzed. The mean age at kidney biopsy was 32Â ± 14.1 years with male: female ratio of 1.03:1. The most common indication of kidney biopsy was nephrotic syndrome followed by lupus nephritis. RPGN was the presentation in 9% of cases. IgAN was the most common histological diagnosis in cases of RPGN, showing crescentic and more commonly sclerosing pattern which leaded to aggressive presentation of IgAN. The most common primary glomerular disease was MCD (28.5%) followed by FSGS (24.1%), MN (18.3%), and IgA nephropathy (12.5%). PSGN was prevalent in 5.1% of cases and MPGN in 6.8%. Lupus nephritis was the most common secondary glomerular disease comprising of 89.3% cases, and Class IV was the most common histopathological class.

CONCLUSIONS: This study will serve as database for further studies and clinical programs to improve the early diagnosis, management, and outcome of various glomerular diseases occurring in this part of our country.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 135: CLINICO-PATHOLOGICAL CORRELATION BETWEEN SERUM PARATHYROID HORMONE LEVEL AND PARATHYROID SCINTIGRAPHY AND ITS OUTCOME IN MAINTAINANCE HEMODIALYSIS PATIENTS; A SINGLE CENTER RETROSPECTIVE COHORT STUDY

Avinash P Thakur 1, Sree Bhushan Raju 1, Tushar Bahadure 1, Rahul Nair 1, Shankar Gadwal 1

BACKGROUND: Progressing Chronic Kidney Disease associated with imbalance in mineral homeostasis including calcium PO4 PTH and vit D. Renal hyperparathyroidism (RHPT) is a frequent and serious complication of long-term dialysis. There reported a strong association between elevated levels of serum phosphorus calcium calcium×phosphorus product parathyroid hormone (PTH) and mortality in dialysis patients. This study focused on parathyroid level with scintigraphy and effect on outcome in CKD patients.

AIM OF THE STUDY: Analysis of clinical profile of maintenance hemodialysis patients with secondary or tertiary hyperparathyroidism and correlation of clinical laboratory findings with parathyroid scintigraphy and its outcome Objectives: To assess the spectrum of clinical presentation and laboratory findings in secondary or tertiary Hyperparathyroid patients on maintenance hemodialysis 1. To correlate between serum parathyroid hormone level and parathyroid scintigraphy findings. 2. To correlate between laboratory parameter (calcium phosphorus hemoglobin alkaline phosphatase vitamin D3 and parathyroid scintigraphy findings. 3. Indication for parathyroidectomy. 4. Outcome of surgical management

METHODS: This is a hospital-based single-centric retrospective observational study done at tertiary health care hospital in Hyderabad. Demography clinical features necessary investigations treatment details and other necessary information pertaining to the study was be collected. Patients with serum PTH &gt;600 were enrolled under study. Among them how many patients underwent parathyroidectomy and its outcome was noted

RESULTS: In this study, 93 patients on end-stage kidney disease (ESRD) receiving maintenance hemodialysis at our tertiary care center were enrolled and evaluated. The average age of patients enrolled in our study was 40.88  ± 14.36 years. Male predominance was seen in our study population, i.e., 55.91% with male-to-female ratio was 1.26: 1. Hypertension (45.16%) and diabetes (27.95%) were the common comorbidities reported. Anemia (72.04%) was the most common associated condition among enrolled. Cause of CKD was CIN (19.35%), IgA nephropathy (16.12%), and CGN (15.05%). The average duration of CKD among enrolled patients was 4.36  ± 2.67 years, Majority 41.93% having CKD for ≤ 3 and 4 to 6 years each. Majority pf patients (95.69%) of CKD patients received hemodialysis as RRT modality. The average calcium was relatively less (average 8.11  ± 1.36), and phosphorous (average 5.28  ± 1.78) was relatively more among enrolled patients. Serum alkaline phosphatase was increased (average 465.63  ± 367.25). The average serum parathyroid (PTH) level among enrolled patients was 1263.53  ± 527.50 pg/mL. Relatively, majority of patients (34.40%) had PTH between 1001-1400 pg/mL. PTH scintigraphy revealed adenoma in almost 39.78% of patients and hyperplasia in 3.22%. PTH scintigraphy was negative in 56.98% of the patients. The majority of patients with adenoma on PTH scintigraphy had PTH &gt;1400 pg/mL. Adenoma and hyperplasia on HPE was reported more in patients with PTH &gt; 1400 pg/mL iPTH was strongly and positively correlation (r = 0.28, p = 0.006) with PTH scintigraphy. 87.5% of patients who were positive on PTH scintigraphy underwent surgery among HPE reported parathyroid hyperplasia in 57.14% patients Adenoma was reported in 28.57% patients

CONCLUSIONS: PTH scintigraphy positively correlated with serum alkaline phosphatase, phosphorous level with positive correlation with iPTH (r = 0.28, p = 0.006). Among patients who underwent surgery, HPE reported Parathyroid hyperplasia in 57.14% patients and Adenoma in 28.57% patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 136: ATYPICAL PRESENTATION OF ANTI-GBM DISEASE IN AN ADOLESCENT GIRL PRESENTING WITH NEPHROTIC SYNDROME

Satyam Mohan 1, Amresh Krishna 1

BACKGROUND: Anti-Glomerular Basement Membrane Disease (anti-GBMD) is a type of small vessel vasculitis that commonly presents with rapidly progressive glomerulonephritis and advanced renal failure, but its indolent course is not unknown. This slowly progressive course is more common with atypical anti-GBMD which is characterized by the absence of anti-GBM antibodies in serum and atypical kidney biopsy findings.

AIM OF THE STUDY: Study of atypical presentation of ANTI-GBM disease in an adolescent girl presenting with nephrotic syndrome.

METHODS: We report a case of a 14-year-old female who presented with gradually progressive bilateral swelling of the lower limb and facial puffiness for a three-month duration. She was evaluated at our institute. Her investigations revealed mild renal dysfunction (serum creatinine 1.78 mg/dL), hypoalbuminemia (serum albumin 2.3 gm/dL), and 24 hours urinary protein 4.28 gram. Urinalysis showed 3 + protein 3-4 red cells /HPF, and there were no WBC granular or red cell casts. This was suggestive of nephrotic syndrome and mild renal dysfunction, but her kidney biopsy revealed classical crescentic glomerulonephritis with 100% crescents fibrinoid necrosis and pattern-less linear staining of glomerular capillaries (Ig G 3+). Her serum anti-GBM antibody assay was negative. Anti-neutrophil cytoplasm antibodies (ANCA) and anti-nuclear antibodies were negative and serum complement level was normal. Treatment was started with intravenous methylprednisolone 250 mg/day for 3 successive days followed by oral prednisolone 30 mg daily and cyclophosphamide 2 mg/kg daily (total treatment of 10-week duration at present).

RESULTS: At the last follow-up after three months of presentation at our institute, her 24hr urinary protein is reduced to 2.68 gm, and serum creatinine is 1.5 mg/dL. No significant adverse effects of treatment occurred except steroid facies.

CONCLUSIONS: Our case emphasizes that atypical anti-GBM disease may have an indolent presentation and better prognosis despite having an underlying severe form of the disease as revealed in kidney biopsy as 100% crescents.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 137: COMPARISON OF CLINICAL EVALUATION AND DUPLEX ULTRASOUND PARAMETERS IN PREDICTING EARLY HEMODIALYSIS ARTERIOVENOUS FISTULA FAILURE

J Mithun 1, M Priya 1, S Gomathy 1, Mohandas 1, S Devisruthi 1

BACKGROUND: AV fistula is the lifeline of a CKD ESRD patient. Early arteriovenous fistula (AVF) failure is defined as an AVF that never develops adequately to support dialysis or fails with in the first 3 months of its use. National Kidney Foundation Kidney Disease Outcomes Quality Initiative vascular access guidelines correctly rank the arteriovenous fistula (AVF) as the best available access for providing hemodialysis. Majority of fistulae that have failed to mature adequately can be salvaged by percutaneous interventions and become available for dialysis if identified early. Early intervention regarding identification and salvage of a non-maturing AVF is hence important

AIM OF THE STUDY: To compare the diagnostic accuracy of clinical evaluation and duplex ultrasound parameters in predicting early arteriovenous fistula failure in patients undergoing hemodialysis. 2. To study the risk factors for early arteriovenous failure among chronic kidney disease patients

METHODS: This is an observational and interventional study done to compare the diagnostic accuracy of clinical evaluation and duplex ultrasound parameters in predicting early arteriovenous fistula failure in patients undergoing hemodialysis and to study the risk factors for early arteriovenous failure among chronic kidney disease patients. The study was conducted in wards and OP of Department of Nephrology Govt. T D Medical College Alappuzha. Study variables used in the study includes personal demographic details age sex smoking antiplatelet use systolic and diastolic blood pressure diabetes mellitus dyslipidemia coronary artery disease, etc. Investigational variables Hb FLP HbA1C serum calcium serum phosphorous iPTH serum ferritin. Physical examination of AVF and DUS was done at immediate postoperative period and at 2 weeks 6 weeks and followed up for 3 months

RESULTS: Physical examination (PE) of the AVF can detect early AVF dysfunction. To prove that the findings of PE should be validated by gold standard tests such as angiography or Doppler ultrasound. In this study, PE was validated with gold standard test Doppler ultrasound. 72 patients with newly created AVF were enrolled for study out of which 4 patients with non-functioning AVF immediately after surgery were excluded. 8 patients lost follow-up. 60 patients followed up at 2 weeks and 6 weeks. Out of the 29 cases which were predicted as successful by PE, 24 of them were finally successful. 5 of those 29 cases (which were predicted as successful by PE) were predicted failure by DUS and final status of them were failed. Out of the 31 cases which were predicted as failure by PE, 25 of them were finally failed. 6 of those 31 cases (which were predicted as failure by PE) were predicted successful by DUS, and final status of them were successful. Physical examination has a sensitivity of 83.3%, specificity of 83.3%, positive predictive value of 82.8%, and negative predictive value of 80.6%. Overall accuracy of the test was 81.6%.

CONCLUSIONS: The physical examination of the vascular access is a convenient, simple, and economic way to monitor AVF dysfunction, and is comparable with gold standard tests. Cephalic vein diameter > 6 mm and blood flow across AVF > 600 ml/min at 6 weeks are the two important factors determining success of AVF. Fistula first approach†is the preferred approach in CKD patients. Parameters like presence of central venous catheter, ↔Hb, â†'MPV, â†'iPTH have detrimental effect on AVF maturation. If the USG parameters of an AVF suggested failure at 2 weeks, it remained failed at 6 weeks unless an intervention is made.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 138: SPECTRUM OF RENAL DISEASES IN GERIATRIC POPULATION €” A STUDY FROM TERTIARY CARE IN SOUTH INDIA

Devidas Bantewad 1, Manjusha Yadla 1

BACKGROUND: Renal diseases are one of the common diseases causing high morbidity and mortality in otherwise asymptomatic individuals. With increase in longevity the older population is increasing worldwide. In India, the older population accounts for 7.5% of the total population. The older population is more prone to the deleterious effects of renal diseases be it an acute insult to the normal renal functions or a chronic disease. This being a dependent group the magnitude of the problem needs to be assessed carefully for proper planning and management of funds in this sector.

AIM OF THE STUDY: To find out spectrum of renal diseases in geriatric population.

METHODS: This retrospective study included 104 patients above age of 65 years which was admitted in our study center. All patients underwent necessary radiological and biochemical investigations during hospitalization. Data was collected from case records of all eligible patients collected data was analyzed using SPSS 2020.

RESULTS: Study comprised of 104 cases of elderly (>65 years) renal disease which was admitted in study center. Baseline charecteristics: Parameter Mean + SD Age 68.95 + 3.85 Males : Females 71 : 33 Hemoglobin 9.6+ 1.6 TLC 9.7+5.1 Urea 126.1+ 48.8 Creat 7.9+ 3.02 Albumin 2.9 + 0.4 Comorbidities among study group Disease Number of patients DM 50 (48.07%), HTN 74 (71.15%), CAD 23 (22.11%), CVA 13 (12.50%). Spectrum of renal disease Disease Number of patients AKI 28 (26.92%) CKD 45 (43.26%) AC CKD 21 (20.19%) Obstructive Uropathy 10 (9.61%) Treatment Treatment modality Number of patients HD 74 (71.15%) PD 16 (15.38%) Conservative 14 (13.46%) Outcomes Outcome Number of patients Complete Recovery 23 (22.11%) Partial Recovery 18 (17.30%) No Recovery 63 (60.57%) Deaths 28 (26.92%) Survivors vs non-survivors Parameters Survivors Non-Survivors P value Age (years) 68.7 + 3.7 69.3 + 3.09 0.13 Hb 10.2 + 0.27 9.6 + 0.41 0.04 TLC 9.65 + 4.94 10.11 + 5.73 0.69 Urea 127.2 + 51.3 122.9 + 42.1 0.68 creat 7.51 + 2.71 9.08 + 3.53 0.01 DM 32 18 0.04 HTN 55 19 0.65 CAD 18 5 0.52 CVA 26 2 0.31

CONCLUSIONS: 1. Most common disease presentation in geriatric patient at our study center was CKD (43.26%). 2. AKI was comprised of 26.92% 3. Obstructive uropathy comprised of 9.61%. 4. Mortality in study group was 26.92%. 5. Complete recovery was in 22.11% patients, partial recovery in 17.30% patients and no recovery in 60.57% patients. 6. Factors affecting mortality was presence of diabetes mellitus, anaemia, high creatinine (P value <0.05).

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 139: EFFECT OF PERIODONTAL THERAPY (PT) ON THE ENDOTHELIAL FUNCTION AND INFLAMMATION IN THE STAGE III/IV CKD PATIENTS SUFFERING FROM MODERATE TO SEVERE PERIODONTITIS

Manju Chaudhary 1, Ashish Jain 1, Mahesh Parkash 1, Vivek Kumar 1, Ashok Kumar Yadav 1, Vishakha Grover 1, Manish Rathi 1

BACKGROUND: Periodontitis inflammation of gums is caused by periodontal organisms that invade the host tissue and gain direct access to the circulation eliciting systemic inflammatory responses. This increased inflammatory load in CKD patients with periodontitis influences the cardiovascular health of these patients. An evidence suggests periodontal therapy improves cardiovascular health.

AIM OF THE STUDY: To investigate the effect of periodontal therapy (PT) on the endothelial function and inflammation in the stage III/IV CKD patients suffering from moderate to severe periodontitis.

METHODS: Seventy-one (71) stage III/IV CKD patients suffering from moderate-to-severe periodontitis were included in the study based on the inclusion/ exclusion criteria and were divided into the control (38) and case group (33). The control group patients were not given PT, whereas case group patients underwent non-surgical PT at baseline. Oral hygiene instructions were given to both the groups. Patients were followed up for 1 year. The endothelial function was evaluated at baseline and 12 month follow-up through flow-mediated dilatation which was measured by brachial artery diameter. CRP, MCP-1, and sCD-40L were measured as the markers of inflammation in the serum samples by ELISA.

RESULTS: In the control group, inflammatory markers found to be elevated, CRP [40.98Â ± 21.60 to 50.44 Â ± 23.13 (P < 0.05)], MCP-1 [3.38 Â ± 3.71 to 7.08 Â ± 5.32 (P < 0.05)], and sCD-40L [6.48 Â ± 5.72 to 6.89 Â ± 6.01]. While all these markers, CRP [58.57 Â ± 21.67 to 34.18 Â ± 21.36 (P < 0.05)], MCP-1 [3.23 Â ± 2.51 to 2.44 Â ± 2.19], and sCD-40L [7.32 Â ± 5.89 to 2.86 Â ± 3.14 (P < 0.05)] decreased in the case group patients. FMD found to be decreased in the control group patients from 9.78 Â ± 8.16 at baseline to 9.14 Â ± 6.48 at 12 month, whereas it increased significantly in the case group patients from 9.88 Â ± 9.93 to 16.39 Â ± 11.03 (P < 0.05).

CONCLUSIONS: These results show that periodontal therapy reduces systemic inflammation and increases FMD improving the endothelial function in CKD patients with moderate-to-severe periodontitis, hence reducing the risk of CVD.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 140: UTILITY OF RITUXIMAB IN PMN PATIENTS WITH ANTI-PLA2R GREATER THAN 150 RU/ML

Deeksha Pal 1, Vinod Kumar 1, H S Kohli 1, Ranjana Minz 1, Raja Ramachandran 1

BACKGROUND: Primary membranous nephropathy (PMN) is a leading cause of the adult nephrotic syndrome. Anti-PLA2R antibody (Ab) levels predict clinical activity, and preliminary signals suggest that an anti-PLA2R ab levels of > 152 RU/ml responds poorly to rituximab compared to cyclical cyclophosphamide/corticosteroids (CYC/CS). In the present abstract, we report the response of 1st 33 patients with anti-PLA2R Ab >152 RU/ml treated with either rituximab or cyclical CYC/CS.

AIM OF THE STUDY: To study the utility of rituximab in PMN patients with anti-PLA2R greater than 150 RU/ml

METHODS: The study population included (consecutive) patients with primary membranous nephropathy (treatment naïve relapsing or resistant disease) enrolled in the PMN registry at PGIMER Chandigarh and anti-PLA2R Ab of >152 RU/ml and treated with either cyclical CYC/CS or rituximab and completing 18 months of follow-up. We defined the clinical response as per the KDIGO 2021 clinical practice guideline for managing Glomerular disease. Factoring delayed remission with immunosuppressive therapy in PMN, we defined the clinical outcomes (complete or partial remission (CR or PR) or resistant disease) at 18 months. We assessed the anti-PLA2R Abs levels using a Euroimmune ELISA kit (LÃübeck Germany) at baseline and six months of either immunosuppressive therapy.

RESULTS: Thirty-three patients received Rituximab (Male: Female; 21: 12, mean age: 38 yrs) therapy and completed 18 months of follow-up, and for comparison, we enrolled 33 consecutive cyclical CYC/CS treated cases (Male: Female; 17:16, mean age:39 yrs) with an anti-PLA2R of >152 RU/ml. In the rituximab-treated group, the median baseline proteinuria, serum albumin, creatinine, and PLA2R Ab levels were 5.2g/day, 2.34 g/dl, 0.99 mg/dl, and 295.12 RU/ml, respectively. In the cyclical CYC/CS group, the median baseline proteinuria, serum albumin, creatinine, and PLA2R were 4.7 g/day, 2.3 g/dl, 0.899 mg/dl, and 378.29 RU/ml, respectively. After six months, there was a significant reduction in the serum anti-PLA2R antibody titer in both the treatment groups [Median anti-PLA2R of 40.5 RU/ml and 10.79 in the rituximab and cyclical CYC/CS group, respectively]. One patient was lost to follow-up in each test group, hence not included in the statistical analysis. In rituximab treatment group, 53.1% [clinical remission (n = CR); 5/32: partial remission (n = PR); 12/32] of patients achieved remission, while 71.8% (n = CR:9/32; n = PR:14/32) patients treated with cyclical CYC/CS achieved remission, the difference was not statistically significant (p > 0.05). The anti-PLA2R response is shown in Figure 1. One patient died in both treatment groups. The serious adverse events were comparable in both groups (p > 0.05).

CONCLUSIONS: Patients with a baseline anti-PLA2R Ab titer greater than 152 RU/ml have a numerically superior but insignificant difference in their response to cyclical CYC/CS treatment compared to rituximab-only therapy.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 141: TRANSPLANT OUTCOMES IN PATIENTS WITH IGA NEPHROPATHY - A SINGLE CENTRE EXPERIENCE

Changanidi Aruyerchelvan 1, Gopalakrishnan Natarajan 1

BACKGROUND: IgA nephropathy (IgAN) is one of the most common glomerular diseases particularly common in Asians. Current literature shows that the presentation and progression of IgAN in India varies from that described in the Western population. Furthermore, recurrence of IgAN is common in the renal allograft.

AIM OF THE STUDY: To analyze the clinical characteristics risk factors for recurrence and post-transplant outcomes of kidney transplant recipients (KTR) with IgA nephropathy either in the native kidney or in the allograft

METHODS: We conducted a retrospective study at our institute to assess the outcomes of 66 KTRs who had documented IgAN either in a native kidney biopsy or in the renal allograft biopsy. We studied the various risk factors for recurrence and outcomes out of a total 1583 KTRs in total from 2003-2022.

RESULTS: A total of 66 patients were included in the study with a median follow-up period of 55 months. The mean age at presentation was 27.3 (Â ± 7.260) years, with majority being males (75.8%). A total of 9 patients (45%) had documented IgAN on a native kidney biopsy, while the remaining 11 patients (55%) developed either de novo or recurrent IgAN post-transplant. The median time to diagnosis of post-transplant IgAN was 72 months (IQR 41-108 months), and at the time of diagnosis the mean creatinine was 2.5 (Â ± 1.3) mg/dL. The development of post-transplant had no statistical association with gender (p = 0.118), age at onset (p = 0.878), time to ESRD (p = 0.516), living vs. deceased donor (p = 1.000), use of an induction agent (p = 0.102), choice of CNI (tacrolimus vs cyclosporine) (p = 0.13). Overall, graft loss occurred in 17/66 (25.75%) patients while in those with recurrent IgAN graft loss occurred in 6/20 (30%), and mortality rate was 16.6% (n = 11).

CONCLUSIONS: This subset of patients had a high rate of graft loss and mortality. None of the risk factors were found to correlate well with recurrence.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 142: POST-TRANSPLANT HYPOCALCAEMIA WITH HYPOPHOSPHATEMIA: A RARE CHALLENGE AMONG MANY

S G Duche 1, S Prakash 1

BACKGROUND: Patients with kidney transplant display various electrolyte abnormalities. Hyperphosphatemia and hypercalcemia are frequently observed in recipients of kidney transplant. A rare combination of hypocalcemia with hypophosphatemia may be seen after kidney transplantations.

AIM OF THE STUDY: To highlight a rare occurrence of hypocalcaemia with hypophosphatemia in immediate post-kidney transplant period and its complex management.

METHODS: We present an interesting case of hypocalcemia with hypophosphatemia after kidney transplant. A 60-year-old female a known case of hypertension and chronic kidney disease on maintenance hemodialysis since last 8 years underwent deceased donor kidney transplant. Induction was done with antithymocyte globulin (ATG). Other immunosuppression was MMF Tacrolimus and methylprednisolone. Patient had a rapid post-transplant recovery of serum creatinine and urine output. The patient developed tingling and numbness of fingers with tetanic spasms asthenia lethargy and pain in forearms. On evaluation was found to have hypophosphatemia hypocalcemia hypokalemia and hypomagnesemia. Her serum PTH levels were high with deficient Vitamin D levels. The patient was managed with calcitriol supplementation calcium infusion on SOS basis phosphate replacement and thiazides to cause hypercalciuria.

RESULTS: Post-transplant persistent hyperparathyroidism may present with rare combination of hypocalcemia and hypophosphatemia due to complex underlying pathology.

CONCLUSIONS: This subset of patients had a high rate of graft loss and mortality. None of the risk factors were found to correlate well with recurrence.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 143: CAPD PERITONITIS AND ITS OUTCOMES - A SINGLE CENTRE EXPERIENCE

D Nithya Dhinakaran 1, Janani 1

BACKGROUND: The number of patients with end-stage renal disease (ESRD) who receive peritoneal dialysis (PD) therapy has been increasing worldwide. PD-related peritonitis remains the leading cause of technique failure in PD therapy. Some studies showed that peritonitis was associated with an increased risk of all-cause mortality in PD patients. The fact that peritonitis onset in patients with a longer duration of PD was related to poor outcomes also indicates that there is potentially time-dependent effect of peritonitis on mortality. In this study, we evaluated whether peritonitis has a negative impact on mortality in our cohort of PD patients. We also assessed the changing impact of peritonitis on patient mortality and morbidity with respect to loss of follow-up removal of CAPD catheter and death.

AIM OF THE STUDY: To Analyze the Outcomes of CAPD Peritonitis in Terms of Morbidity & Mortality in Patients Initiated on CAPD Between Jan 2010 to May 2021. This study aimed to evaluate whether peritonitis has a negative impact on morbidity and mortality in a cohort of peritoneal dialysis patients.

METHODS: All patients who underwent CAPD catheter insertion at our center were included in the study. Data was collected from the case sheets and medical records of these patients. The data collection included monthly follow-up admission for peritonitis quality of life of these patients in terms of nutrition volume status and general well-being. Among these patients with episodes of peritonitis were analyzed further for the number of episodes of peritonitis outcomes of peritonitis after treatment. Outcome was grouped as resolution of peritonitis and doing well on CAPD recurrent peritonitis and removal of catheter CAPD peritonitis associated death and drop out following peritonitis episode. Data pertaining to these parameters were collected and analyzed.

RESULTS: In this study, total number of CAPD initiations from January 2010 to May 2021 is 270. No of patients who developed peritonitis is 93, of which 33 patients developed peritonitis the same year, and 3 patients had recurrent peritonitis. Total of 49 patients were shifted to HD from CAPD due to resistant peritonitis or recurrent peritonitis. 7 patients were successfully transplanted of which 6 were LRRT and 1 DDRT. Total number of deaths were 6 of which 4 were COVID related and 2 peritonitis related. Total 192 patients were lost for follow-up in the study period due to various reasons like shifting to other center (ESI or ECHS or Government hospital) or logistic reasons and discontinuation of therapy and death at home.

CONCLUSIONS: Based on this study, we observed a decline in peritonitis rate between Jan 2016 to May 2021 during which period we have upgraded to LAP-assisted CAPD catheter insertion. Compared to conventional bedside CAPD catheter insertion, LAP-assisted technique is found to be superior in terms of reduced rate of peritonitis. On the other side, number of patients who lost for follow-up was found to be high. Hence, we recommend better counseling and insist the importance of regular follow-up for the success of the CAPD program.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 144: THE €ŒUNUSUAL SUSPECTS€ €” CASE SERIES OF COMMON INFECTIONS CAUSED BY UNCOMMON ORGANISMS IN CKD

Bahaar Athavale 1, Hardik Shah 1, Akshay Ramteke 1, Sayali Dalvi 1, Sayali Kondkar 1, Asmita Sakle 1, Dilip Kirpalani 1, Shrirang Bichu 1, Ashok Kirpalani 1

BACKGROUND: Emergence of antimicrobial resistance and improved diagnostic tools has led to identification of those microorganisms which were hitherto not commonly encountered in the clinical scenario.

AIM OF THE STUDY: In this case series, we aim to highlight newer rarer pathogens in CKD patients who presented with routine common clinical symptoms.

METHODS: Retrospective analysis of hospital records from January 2021 to September 2022 and data collected.

RESULTS: Case 1: 65-year-old male, with gallstone pancreatitis developed AKI needing dialysis in the rural setting. Patient had febrile illness 5 days later with Bactec culture from the catheter and periphery growing Achromobacter denitrificans- a rare Gram negative aerobe. After stabilization, patient underwent laparoscopic cholecystectomy. 3 weeks later, he got readmitted with abdominal pain. Investigations revealed a large peripancreatic collection with necrosis in head and body of pancreas, needing pancreatic necrosectomy. Culture of this necrotic material grew a similar species- Achromobacter xylosoxidans and had a prolonged recovery with long term intravenous and oral antibiotics. Case 2: 61-year-old male, diabetic, HBsAg positive, live renal transplant recipient, presented with chronic non-healing wound over left leg. After repeated negative cultures of the pus aspirate, biopsy of the mass grew Aeromonas hydrophila, a rare Gram negative aerobe. Patient has partially responded to prolonged intravenous antibiotics followed by oral antibiotics for 4 weeks. Case 3: 54-year-old female, failed CAPD (due to Candida tropicalis peritonitis), on maintenance hemodialysis with recurrent growth of Candida parapsilosis from the tunneled cuffed dialysis catheter-resistant to Azoles, Echinocandins and change of catheter site. Patient has reverted to CAPD. Case 4: 60-year-old male, diabetic, renal transplant recipient came with one week history of fever, dry cough, mild dyspnea, and hypoxia. HRCT Chest- dense irregular area of parenchymal consolidation and large areas of cavitation in the apicoposterior segment of the left upper lobe of lung. The bronchoalveolar lavage (BAL) grew Serratia marcescens- a rare Gram negative anaerobe, sensitive only to carbapenems, given over three weeks with significant clinical improvement.

CONCLUSIONS: Active surveillance of uncommon organisms and their isolation on culture media early in disease course can ameliorate the disease process and hasten recovery.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 145: A STUDY OF RISK FACTORS CLINICAL PROFILE BIOCHEMICAL AND HISTOLOGICAL FEATURES IN PATIENTS WITH CHRONIC KIDNEY DISEASE OF UNDETERMINED ORIGIN (CKDU) AND ITS CORRELATION WITH OUTCOMES

R Anitha 1, Manisha Sahay 1

BACKGROUND: • Chronic kidney disease is an important cause of morbidity and mortality in India as its prevalence in India as per the SEEK study (screening and early evaluation of kidney disease project) is 17.2%. Chronic kidney disease of unknown etiology (CKDu) is emerging as an important cause for CKD in as many as 16% of all CKD subjects in India second only to diabetic kidney disease (31.3%). Etiology is unclear and a variety of hypotheses including prolonged dehydration leading to heat stress heavy metal toxicity pesticide exposure snake bite and genetics have been proposed. CKDu patients often present with advanced CKD with relatively short history few symptoms until late in the disease. Very limited data is available on CKDu in India. Hence, study of CKDu is the need of the hour. Such studies help in providing a basis for healthcare policy and planning preventive measures.

AIM OF THE STUDY: To study sociodemography and geolocalization profile clinical profile laboratory and histopathological parameters of chronic kidney disease of unknown etiology (CKDu) patients and correlate with outcomes

METHODS: Basic and specific investigations like complete hemogram USG KUB renal function tests including urine protein estimation was done. Whenever appropriate renal biopsy was performed. Drinking water analysis was done for all patients to screen for toxins and heavy metals in the drinking water at IPM. Genetic study was done for patients whenever indicated. Renal outcomes of these patients were analyzed in terms of GFR decline at 3 months, 6 months, 1 year, and 2 years. The time taken for 50% GFR decline and time to ESRD was also analyzed. Basic and specific investigations like complete hemogram USG KUB renal function tests including urine protein estimation were done. Whenever appropriate renal biopsy was performed. Drinking water analysis was done for all patients to screen for toxins and heavy metals in the drinking water at IPM. Genetic study was done for patients whenever indicated. Renal outcomes of these patients were analyzed in terms of GFR decline at 3 months, 6 months, 1 year, and 2 years. The time taken for 50% GFR decline and time to ESRD was also analyzed.

RESULTS: Mean age of my study population was 40.4 years. Male-to-female ratio was 2:1. Mean BMI was 19.31. The average heat exposure in the study population was 5hrs/day. Drinking water analysis of patients was normal in 83% population, while 17% had abnormal physical and chemical analysis reports. 72% had patient history of native medicine intake, while 23% had history of analgesic abuse. 20% of the study population underwent renal biopsy, while all the patients had a report suggestive of chronic interstitial nephritis. 16.6% patients underwent genetic analysis by clinical exome sequencing by NGS among which one patient has variant of unknown significance while others had normal. 46% of patients presented in ESRD, and 20% patients died during the study period.

CONCLUSIONS: From our study, we conclude that history of native medicine intake and analgesic abuse are strong risk factors for development of CKDu. Majority of patients with CKDu presented in ESRD. Histopathologic correlation revealed chronic interstitial nephritis pattern. Since the presentation and outcome of CKDu across various countries is so different our own indigenous data is required to understand the pathogenesis of CKDu and to formulate health policies in the future.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 146: TOWARDS ACCURATE DETERMINATION OF BURDEN OF KIDNEY DISEASE IN INDIA-DEVELOPMENT AND VALIDATION OF ACCURATE EQUATION TO ESTIMATE GLOMERULAR FILTRATION RATE (GFR) FOR INDIAN POPULATION: DESIGN AND METHOD

Jaskiran Kaur 1, Rupinder Kaur 1, JS thakur 1, Nusrat Shafiq 1, Sreejith Parameswaran 1, Sitansu Kar 1, HS Kohli 1, Vivek Kumar 1, Vivekanand Jha 1, Ashok K Yadav 1

BACKGROUND: GFR is essential for CKD diagnosis and risk assessment. The equations to infer GFR are serum creatinine testing dependent, and these equations have an ethnic-bias. Therefore, there is an urgent need to develop eGFR equations that are specific to the Indian population's ethnicity.

AIM OF THE STUDY: Derive and validate a new creatinine-based eGFR equation with measured GFR by multiple sample plasma clearance of iohexol.

METHODS: The study will have a cross-sectional design and will be conducted at Chandigarh and Puducherry. Participants having age between 18-65 years no history of kidney disease kidney stones, and any ongoing critical illness will be eligible for screening. Healthy subjects will be selected from community using stratified systematic random sampling by ‘Kish method’. A total of 1500 samples from the general population will be used for derivation and internal validation of the eGFR equation, whereas a second sample from general population (n = 230) and subjects with CKD (n = 500) will be used for external validation. 5 mL or 3 mL iohexol will be administered slowly through an intravenous route as a bolus based on weight of the participant. Venous blood samples will be drawn from the contralateral upper limb at 60, 120, 180, and 240 minutes after iohexol injection. Plasma iohexol extraction will be done using dichloromethane, and concentrations will be measured using high-performance liquid chromatography. The one-pool clearance model will be used for GFR calculation (dose of iohexol/AUC). Stepwise multiple regression on log-transformed data will be used to determine a set of variables that jointly predict GFR. The prediction equation will be a multiplicative model.

RESULTS: The study is ongoing, and 110 healthy subjects have been enrolled till date. Mean age of the subjects is 47 years, and 60% are females. Mean measured GFR was 82.9Â ± 20.8 ml/min/1.73 m^2, and CKD-EPI eGFR was 100.0Â ± 17.9 ml/min/1.73 m^2. Mean bias between mGFR and eGFR was 20.2Â ± 22.2 ml/min/1.73 m^2.

CONCLUSIONS: Initial data indicate the overestimation of CKD-EPI eGFR over measured GFR as descried previously. This study is intended to develop an accurate eGFR equation for Indian population. An accurate assessment of eGFR will aid in appropriately classifying Indian patients into various CKD stages and open the door for future research as well as the targeted application of screening and preventive interventions.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 147: HEMATOCRIT BASED CORRECTION OF TACROLIMUS C0 LEVELS €” EFFECT ON MONITORING AND DOSE ADJUSTMENT OF TACROLIMUS IN RENAL TRANSPLANT RECIPIENTS

Vineet Behera 1, P Pazare 1, P Chauhan 1, K Srikanth 1, R Ananthakrishnan 1

BACKGROUND: Tacrolimus has high intra- and inter-individual pharmacokinetic variability and a narrow therapeutic index. It accumulates in erythrocytes, and hematocrit is a key factor in the interpretation of tacrolimus whole blood concentrations.

AIM OF THE STUDY: To study the effect of hematocrit correction on tacrolimus levels in renal transplant recipients

METHODS: A retrospective observational study was conducted from Jan 2020 to Jun 2022 in a tertiary care hospital. All RTR on tacrolimus-based immunosuppression were included with tacrolimus C0 Level measured by LCMS/MS from Nexus Lab while levels done by other methods/lab faulty sampling reports with associated diarrhea were excluded. The immunosuppression protocol and target tacrolimus levels were followed as per institution protocol. The hematocrit-based dose correction was done using Schijvens Nomograph of hematocrit correction for predicted tacrolimus levels (Paed Nephrology 2019), and accordingly doses were modified.

RESULTS: 350 tacrolimus level tests conducted in 42 patients were included with 34 (80.9%) live transplants, 6 (14.2%) ABOiRT, with ATG induction in 18 (42.8%), and basiliximab in 24 (57.1%). The mean hematocrit level (in %) seen after transplant during this period was 28.6 ± 4.5 on POD1, 33.2 ± 3.9 on POD 30, 37.4 ± 3.2 after 3 months, and 40.2 ± 6.2 after 6 months. The total tacrolimus levels done, tacrolimus levels out of target range (needing dose modification), and hematocrit-corrected tacrolimus levels needing dose modification were 108 (30.8%), 92 (85.1%), and 75 (69.4%) respectively within 1 month (OR 2.5, p = 0.006); 81 (23.1%), 60 (74.1%), 45 (55.5%) from 2-3 months (OR 2.28, p = 0.01); 62 (17.7%), 45 (72.5%), 35 (54.4%) from 4-6 months (OR 2.04, p = 0.06); 44 (12.6%), 28 (63.6%), 22 (50%) from 7-12 months (OR 1.75, p = 0.19); and 55 (15.7%), 32 (58.1%), 28 (50.9%) after 1 year respectively (OR 1.34, p = 0.44), with statistically significant difference in ≤ 1 month and 1-3 months.

CONCLUSIONS: Hematocrit correction had a significant effect on tacrolimus levels. Corrected tacrolimus level had significant difference in number of levels needing modification 0-3 months post-transplant.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 148: EVIDENCE OF HEAVY METAL EXPOSURE IN CHRONIC KIDNEY DISEASE OF UNKNOWN ORIGIN - A CROSS SECTIONAL STUDY

Indradip Maity 1, Soumita Bagchi 1

BACKGROUND: Introduction: Chronic kidney disease (CKD) has emerged as global pandemic with reported prevalence of around 11—13%. While diabetes and hypertension are the top two causative factors worldwide CKD of unknown etiology (CKDu) is now a well-recognized entity. Exposure to agrochemical alternative medication heavy metals have been associated with CKDu in various studies. However, the findings are inconclusive. We tried to assess heavy metal exposure in a cohort of patients with CKDu.

AIM OF THE STUDY: To examine heavy metal exposure in patients with chronic kidney disease of unknown origin (CKDu)

METHODS: We analyzed urine and blood levels of Arsenic Mercury Lead Chromium and Cadmium in a cohort of 81 patients with CKDu. Blood and urine levels of Arsenic and Mercury were analyzed by Atomic Absorption Spectrophotometry - Vapor Generator Assembly. Trace Metal analyzer based on voltammetric/polarographic method was used for analysis of lead chromium and cadmium.

RESULTS: 28 (34.5%) patients were detected to have heavy metals, and all 28 patients had heavy metal levels above the normal range. The mean Blood Arsenic Levels were 11.30 Â ± 6.48 Îüg/L, mean Blood Pb Lead Levels were 11.7 Â ± 6.1 Îüg/L, mean Urine Pb Lead Levels were 5.00 Â ± 2.20 Îüg/L, median Blood Mercury Levels were 10 (10-21) Îüg/L, and mean Urine Mercury Levels were 22.50 Â ± 13.69 Îüg/L. The mean age of the cohort in which heavy metal was detected was 36.1Â ± 10.9 years. Heavy metals were detected in 16 females and 12 males. 22 (78%) patients belonged to urban area, and 6 (22%) belonged to rural area. There was no association between occupation and heavy metal exposure. Patients in whom heavy metal was detected had lower income levels. No association was found between alternative medication intake and heavy metal exposure. Patients in whom heavy metals were detected were more likely to have higher proteinuria (>0.5 g-<1 g/day) compared to those in whom heavy metals were not detected. 26 patients had chronic tubulointerstitial disease as their kidney biopsy finding and 1 patient had non-specific finding of benign nephrosclerosis.

CONCLUSIONS: There was a significant burden of heavy metal in the studied subjects. However, association between CKDu and heavy metal exposure could not be ascertained. Large-scale studies are needed to look for causality.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 149: HISTOLOGICAL PRESENTATIONS OF POST COVID AKI: A SPECTRUM OF PRESENTATIONS

Divya Reddy Baddam 1, Rajasekhara Chakravarthi 1

BACKGROUND: Covid 19 is relatively a new disease with varied presentations which can affect multiple organs including kidney. AKI is quite commonly associated with covid-19 infection. However, a lot of research is still needed in understanding of the pathophysiology associated.

AIM OF THE STUDY: To study the histological patterns of covid-associated AKI.

METHODS: This is a retrospective longitudinal study. 109 patients developing AKI after covid -19 infection have been identified. AKI was defined as per KDIGO criteria. Evaluation of AKI was done with routine analysis, and causes other than covid infection were ruled out. Renal biopsy was done, and core specimens were sent for light microscopy and immunofluorescence.

RESULTS: Patients varied from 2 to 76 years. The duration between Covid infection and AKI ranged from 2 weeks to 6 months. Out of 109 patients, 27 (24.7%) showed acute tubular injury, 26 (23.8) showed ATIN, 11 (10%) showed IRGN, 8 (7%) showed crescentic GN, 4 (3.6%) showed chronic TIN,6 (5.5%) showed TMA, 3 (2.75%) showed Ig A nephropathy and Granulomatous TIN each. FSGS and cast nephropathy were seen in 4 (3.6%) patients each. Lupus nephritis, MCD, and Papillary necrosis were seen in one patient each. Rest of the patients, i.e., 10 (9.1%), showed features of background disease.

CONCLUSIONS: AKI followed by covid 19 has a variety of pathologic mechanisms. Studying the patterns and their further follow-up will be beneficial since there is very limited data.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 150: SPECTRUM OF INTRADIALYTIC COMPLICATIONS DURING HEMODIALYSIS: A SINGLE CENTER PROSPECTIVE OBSERVATIONAL STUDY

Amit Roy 1, Manjuri Sharma 1, Prodip kumar Doley 1, Gayatri Pegu 1

BACKGROUND: Hemodialysis (HD) is one of the important modalities of renal replacement therapy in acute renal failure (ARF) as well as chronic renal failure (CRF). However, it is associated with various complications, some of which are intradialytic occurring during or immediately after the session. This study was undertaken to evaluate various intradialytic complications and their incidence among North-East Indian patients requiring hemodialysis

AIM OF THE STUDY: To evaluate and determine the incidence of various intradialytic complications among the patients undergoing hemodialysis and correlate its association with age, sex, kidney disease, vascular access.

METHODS: This was a single-center prospective observational study in patients undergoing hemodialysis in the Department of Nephrology Gauhati Medical College from June 2021 to May 2022. Patients above 18 years with AKI CKD RPGN requiring hemodialysis were included in the study. Pregnant and lactating patients were excluded from the study. Baseline characteristics such as age, sex, body mass index, systolic blood pressure, and diastolic blood pressure types of vascular access were recorded. Complications encountered were divided into three groups: patient-related complication technical complications and vascular access-related complications. The approval of study was obtained from the Institutional Ethical Committee

RESULTS: A total of 13068 hemodialysis session were performed on 2867 patients over a period of 1 year. 82.6% patients were diagnosed with CKD, 9.2% were of AKI, and 8.2% were undergoing hemodialysis due RPGN. 33.38% (N = 957) of the subjects faced one or more mentioned complications while 66.62% (N = 1910) patients had an uncomplicated procedure. Total of 825 (86.2%) patients developed patient-related complication. The frequency of vascular access-related complications was 22.24% (N = 215), and technical complications was 1.77% (N = 17). 89 (9.29%) patients had both patient related and vascular access-related complications, 7 (0.73%) developed both patient-related and technical complications, and 6 (0.62%) patients had both technical and vascular access-related complications. 2 (0.2%) patients developed complications belonging to all the three groups. Among the patient-related complications, hypotension was the most frequent complications (29.2%) followed by nausea and vomiting (20.4%), headache (16.8%), muscle cramp (13.8%), hypertension (10.1%), hypoglycemia (7.2%), chest pain (1.7%), seizure (0.8%). Among the vascular access-related complications, catheter infection (fever and chills) (65.1%) was most frequent followed by femoral hematoma (29.9%), malposition of catheter (3.6%), central vein obstruction (1.2%), AV Fistula thrombosis (0.2%). Among the technical-related complications, most common was blood clots in dialyzer (78%), followed by dialyzer reactions (22%). All the complications were managed in our department, and there were no deaths in the study.

CONCLUSIONS: Hemodialysis is associated with a vivid number of complications; some are even life-threatening. However, strict monitoring, proper assessment of patients, and good clinical acumen may help in the early detection and timely management of these complications, without the need of terminating this life-saving treatment modality.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 151: ROLE OF ENDOTOXIN ADSORPTION IN SEVERE GRAM NEGATIVE SEPSIS AFTER COVID 19 INFECTION IN A RENAL TRANSPLANT RECIPIENT. A CASE REPORT

Mahesh Kota 1, Rajasekara Chakravarthi 1

BACKGROUND: ROLE OF HEMOADSORBTION IN GRAM NEGATIVE SEPSIS

AIM OF THE STUDY: TO SEE THE EFFICACY OF NOVEL ALTECO LPS ADSORBER IN A PATIENT WITH SEVERE GRAM NEGATIVE SEPTIC SHOCK

METHODS: ALTECO LPS ADSORBER WAS USED IN A POST RENAL TRANSPLANT RECIPIENT WITH SEVERE SEPTIC SHOCK WITH ACTIVE COVID 19 INFECTION GRAM NEGATIVE SEPSIS ALONG WITH RENAL REPLACEMENT THERAPY USING PMMA FILTER.

RESULTS: SIGNIFICANT IMPROVEMENT IN HEMODYNAMICS, DECREASED VASOPRESSOR REQIUREMENT, RAPILDLY RECOVERED FROM SEPSIS AND SHOCK

CONCLUSIONS: This case report highlights the efficacy of a new adsorptive therapy for the clearance of endotoxins in septic shock caused Gram negative bacterial infection. Early application of an endotoxin adsorber showed a reduction of vasopressor requirements, elevation of blood pressure, and a decrease in inflammatory markers. Endotoxin elimination has a significant effect on the ICU length of stay or ICU mortality.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 152: COLLAGENOFIBROTIC GLOMERULOPATHY-A RARE GLOMERULAR DEPOSITION DISEASE WITH RAPID PROGRESSION DIAGNOSED AT OUR INSTITUTE

Rajeshwar Rao 1, Prit Pal Singh 1

BACKGROUND: Collagenofibrotic glomerulopathy (CFG) is a rare glomerular deposition disease of unidentified etiology. It is characterized by massive intraglomerular accumulation of Type III collagen fibers resulting in prominent mesangial expansion extending to subendothelial spaces of glomeruli. This disease may have an indolent course clinically but is capable of finally progressing to end-stage renal failure. Only a few cases have been reported in the Indian literature mostly from Japan.

AIM OF THE STUDY TO REPORT A RARE CASE OF COLLAGENOFIBROTIC GLOMERULOPATHY DIAGNOSED AT OUR INSTITUTE AND ITS OUTCOME

METHODS: A case of a 52-year-old female who presented with complaints of progressive bilateral lower limb swelling for 3 months. She had hypertension and hypothyroidism. She did not have a significant past or family history of connective tissue disease or renal disease. On examination, the patient had a blood pressure of 150/100 mm Hg and pedal edema. The rest of the systemic examination was unremarkable. Laboratory evaluation showed blood urea of 54 mg/dL serum creatinine of 1.8 mg/dL and serum electrolytes were normal. Urine routine showed 3+ Proteinuria occasional RBCs and 3—4 WBCs/HPF. The 24-hour urine albumin–creatinine ratio was 7196.3 mg/g. The patient underwent a renal biopsy which revealed features suggestive of nodular glomerulosclerosis which appeared pale on H&E stain PAS negative variably argyrophilic and non-Congophilic. This was subsequently confirmed as CFG by electron microscopy which showed an accumulation of banded fibrillary material showing periodicity of about 40-60 nm in subendothelial/mesangial areas.

RESULTS: During follow-up, there was a rapid progression of renal failure, and she developed ESRD within 2yr. She died after 3 months of initiation of dialysis.

CONCLUSIONS: This disease has an indolent course clinically, but in this case, rapid progression of renal failure occurred and the patient died within 3 years of disease onset.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 153: PNEUMONIA IN KIDNEY TRANSPLANT RECIPIENTS: SINGLE CENTER EXPERIENCE FROM TERTIARY CARE CENTER IN SOUTH INDIA

H Haritha 1, A Kishan 1, Mythri Shankar 1, L Umesha 1, C G Gireesh Reddy Shreedahra 1

BACKGROUND: Pneumonia is a frequent complication occurring in solid organ transplant patients. It is associated with significant mortality and morbidity and often requires hospitalization with intensive care monitoring.

AIM OF THE STUDY: To study the clinical characteristics and outcomes of patients admitted with pneumonia after renal transplantation

METHODS: It is a retrospective observational study. All renal transplant recipients hospitalized in our center between November 2019 to July 2022 were studied. Diagnosis was based on Clinical features Chest X ray Routine blood parameters High resolution CT of the Chest Microbiological examination of the sputum sample and BAL sample tissue biopsy and molecular methods. Complications of those infections resulting in Organ dysfunctions including graft dysfunction and need for various supports such as O2 inotropes ventilator and dialysis and treatment details and in hospital patient outcomes were analyzed. Descriptive statistics were used for analysis of the data.

RESULTS: Among 59 patients admitted with various infections, 35 (59%) patients had pneumonia. 32 (91.4%) patients among them were males. 26 (74%) patients underwent live related renal allograft transplant. Mean age of the study population was 35.2 years. 30 (85%) patients among the study population received induction agent, 29 (96.66%) received basiliximab, and 1 patient received ATG induction. 16 (45.714) patients had PTDM, 6 (17.5%) patients had less than one month, and 9 (25.71%) patients had pneumonia in the time period of one to 6 months, 20 (57.14%) patients had infections in the period of more than 6 months The microbiological diagnosis was confirmed in 33 (94.42%) patients. Multiple organism were isolated in 6atients (17.5% cases) 10 (28.57%) patients had ICU admission, and 3 patients (30%) among them were on ventilatory support. 6 (17.5%) patients required ionotropic support, 16 (45.71%) patient had requirement of 02 support. 6 (17.5%) patients expired during in hospital stay. The mean hospital stay was 24 days.

CONCLUSIONS: Patients who undergo renal transplantation are subjected to immunosuppression which increase the burden of infections in the post-transplant period. They are prone for infection with multi drug resistant organism, atypical organism, and sometimes classic signs and symptoms will be absent. All the patient with suspected respiratory tract infection need to be extensively evaluated to prevent morbidity and mortality.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 154: OUTCOME OF TEMPORARY DOUBLE LUMEN (NON-TUNNELED) HEMODIALYSIS CATHETER: A SIX MONTH SINGLE CENTRE PROSPECTIVE OBSERVATIONAL STUDY

Lakshman 1, Himansu Sekhar Mahapatra 1, Lalit Pursnani 1, B Muthukumar 1, Saswat Das 1, Chandra Krishnan 1, Anamika Kumari 1, Rajesh Tarachandani 1, Preeti Choudhary 1, Vipul Gupta 1, Sutanay Bhattacharya 1, Beauty Suman 1, Tanvi Thakker 1, Mahboob Alam 1, Abhishek Jha 1

BACKGROUND: Non-tunneled catheters are commonly used as an initial vascular access for hemodialysis in most of the centers in India. However, the catheter survivals reason of its removal and patient survival in these patients have not been studies adequately.

AIM OF THE STUDY: To study the outcome of temporary double lumen hemodialysis catheter (non-tunneled) factor responsible for its removal and patients survival among hemodialysis requiring patients.

METHODS: Study was conducted from Feb 2022 to July 2022 over the period of 6 months in a tertiary hemodialysis center. All patients of CKD & AKI requiring hemodialysis requiring non-tunneled double lumen catheter insertion under ultrasound guidance with standard sterilization technique were included. Detail demographic records previous catheterization comorbid factors; catheter insertion procedure-related complications were recorded. All patients were followed up in every week to observe infection rate nature of organism (if any) catheter removal (if any), and other complications were also recorded. All data were put in SPSS, and necessary statistical analyses were carried out including Kaplan–Meier survival analysis.

RESULTS: A total of 679 catheters were inserted in 493 patients. Of them 263 (53.4%) were males and 229 (46.6%) were females. Among them 424 (85.8%) patients were completed followed up till their catheter removed; 104 (21.1%) patients have completed 8 weeks post-catheter insertion follow-up and 69 (14%) patients were dropped out. Comorbidity HTN 328 (66.5%), DM 116 (23.52%). Among the total inserted catheters, infection rates at 2, 4, 6, and 8 weeks were 26 (3.9%), 53 (7.8%), 76 (11.19%), and 98 (14.5%) respectively. Most common organism is klebsiella. Catheter survival was 196 (28.9%) at 2 weeks, 125 (18.4%) at 6 weeks, 100 (14.8%) at 8 weeks. Similarly, patient death was 47 (9.5%), 22 (4.5%), 2 (0.4%), and 3 (0.6%) respectively. Mechanically catheter removed were 156 (22.97%) at 2 weeks, 51 (7.5%) at 4 weeks, 16 (2.35%) at 6 weeks, and 8 (1.17%) at 8 weeks.

CONCLUSIONS: Non-tunneled double lumen jugular catheter survival is 85% at 4 weeks and 70% at 6 weeks after following all standardized sterilization techniques during catheter insertion and heparin catheter lock during post-dialysis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 155: ANATOMICAL SNUFF BOX €” NOT JUST AN ANATOMICAL LANDMARK BUT ALSO A FEASIBLE ALTERNATIVE TO RADIOCEPHALIC FISTULA INTERVENTION

M N Athish 1, Girish Reddy 1, C G Sreedhara 1, A Kishan 1, Mythri 1, Shravani 1, Sairam 1, Prasanna 1, Ankita 1

BACKGROUND: Direct fistula access is considered safer and preferred to arterial access for fistula intervention, but there are advantages to a single access site as it gives access to the entire dialysis circuit without causing inconvenience to the patient or the interventionalist and keeps the setup intact as well. Standard wrist radial artery access is close to the fistula anastomosis and is a risky attempt to use for intervention. Brachial artery lacks adequate bony support to achieve adequate hemostasis.

AIM OF THE STUDY: This retrospective study compares the outcomes of snuff box radial artery (SBRA) access with direct fistula access for radiocephalic fistula (RCF) intervention.

METHODS: Fifty consecutive RCF interventions between March 2018 and October 2019 were reviewed. Doppler ultrasound of radial artery was performed prior to cannulation with the hand in neutral position. Access of SBRA was done with a 20G x 32 mm Jelco® I.V. Catheter (Smiths Medical) followed by a 0.025&quot; (0.64 mm) x 45 cm hydrophilic guidewire was passed into SBRA and a 6 French Terumo vascular sheath exchanged with over the guidewire. Handheld pressure was applied for hemostasis. The procedure times success and complications of SBRA access procedures were reviewed.

RESULTS: SBRA access was used in 66% (33/50) of RCF interventions. All access procedures were successful. The mean diameter of the radial artery was 2.325  ± 0.4 mm prior to cannulation. Indications for procedures among SBRA group were stenosis-related dysfunctions (60%, n = 20), thrombosis (25%, n = 8), and immature fistula (15%, n = 5). Inflow segment accounted for the majority of stenosis with arterial anastomosis narrowing noted in all patients. Juxta anastomosis stenosis (n = 15) and outflow stenosis (n = 5) were noted concurrent with arterial anastomosis stenosis. The mean procedure times for SBRA access and direct fistula access were not significantly different at 29.1  ± 16.3 min (range = 10—81) and 26.8  ± 14.0 min (range = 5—70), respectively. Minor hematoma occurred in 9% (3/33) at the Cannulation site among SBRA group and 5% (1/17) with direct fistula access. There were no major complications in either group.

CONCLUSIONS: Procedural outcomes and complications with SBRA access are comparable to direct fistula access. Snuff box radial access is a suitable alternative to direct fistula access for RCF interventions and advantageous in sparing the distal radial artery, which can be used for coronary interventions, if required.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 156: DIETARY PATTERN AND NUTRITIONAL INTAKE IN HEALTHY INDIVIDUALS FROM COMMUNITY POPULATION: PILOT DATA

Rupinder Kaur 1, Pratima Agnihotri 1, J S Thakur 1, Vivek Kumar 1, V Jha 1, Ashok Kumar Yadav 1

BACKGROUND: Dietary and lifestyle interventions are increasingly recognized as important yet under-utilized tools for reducing the burden of risk factors and complications in non-communicable diseases including CKD. Dietary patterns change with time, and it is important to elucidate the same if any intervention is planned.

AIM OF THE STUDY: In an ongoing community and hospital-based study to validate/derive estimating equations for glomerular filtration rate (GFR) in Indian subjects. We are also investigating the dietary patterns in enrolled participants.

METHODS: Individuals are being screened from the community and at the outpatient nephrology clinic. Healthy subjects are being enrolled using stratified random sampling by KISH method from community. Subjects with pre-dialysis CKD are being enrolled through clinic. Inclusion criteria include age 18-65 years and stable clinical state for last 3 months. Basic demographic profile socio-economic status occupation dietary habits and physical activity details are being recorded. 24-hour urine collection just prior to the scheduled procedure of measurement of GFR is being stored and analyzed for excretion of urea creatinine protein sodium potassium and phosphorus. GFR is being measured by plasma clearance of iohexol. We are presenting the data about dietary intake and patterns in participants enrolled from the community.

RESULTS: Total of 110 subjects have been enrolled in this study and have been analyzed in current analysis. Mean age of subjects was 44ï' ± 12 year, and 66% were females. 58% were self-reported vegetarians. Among those who were non-vegetarians, the frequency of meat intake was 2.8 per month. Total protein intake was 0.92ï' ± 0.39 g/kg/day, and 40% were consuming less than recommended protein intake of 0.8 g/kg/d. Similarly, salt intake, potassium intake, and phosphorus intake were 6.3ï' ± 3.5 g/day, 1.3ï' ± 0.6 g/day, and 745ï' ± 357 mg/day respectively. Around 60% were using more than WHO recommendation of 5 g of daily salt intake. Almost 100% subjects were using salt during cooking food and >40% subjects admitted that they used to add salt on top of it. Around 95% subjects were aware about the need of reduction in salt intake, and 90% agreed that high consumption of salt might lead to health problems. 18.5% subjects used low salt/sodium alternatives in diet. Only 16.7% subjects consumed fruits daily and number of serving/day was 1.35Â ± 0.78. Similarly, 33.3% study subjects consumed vegetables everyday and number of serving/day was 2.04Â ± 0.78. 98% of the study subjects consumed less than the recommended 5 daily servings of fruits and vegetables.

CONCLUSIONS: Indian diets are perceived to be dominantly vegetarian. Though frequency of non-vegetarian food intake is low, dietary patterns indicate that the intake of fruits and vegetables are also low. Average salt intake is higher than the recommended. This modifiable risk factor can be addressed through interventions.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 157: CLINICAL PROFILE AND OUTCOMES OF PIGMENT INDUCED NEPHROPATHY: A TERTIARY CARE EXPERIENCE

D Sathiyan 1, T Sugan Gandhi 1, T Balasubramaniam 1, R Venkatraman 1, J Dhanapriya 1, A Shanmugasundaram 1, P Dileep Kumar 1

BACKGROUND: Pigment nephropathy is characterized by a rapid decline in renal function as a consequence of rhabdomyolysis or hemolysis.

AIM OF THE STUDY: To assess the clinical profile and outcomes of pigment induced nephropathy

METHODS: This was a retrospective observational study done at our tertiary care center to analyze the etiology clinical manifestations laboratory profile and outcomes in patients with biopsy-proven pigment-induced nephropathy between January 2017 and January 2022. History clinical examination findings laboratory investigations and outcomes were documented.

RESULTS: Our study population included 25 patients, out of which 80% were males. The mean follow-up was 6 Â ± 2.5 months. Mean age was 41.8 Â ± 14 years. 88% (22) had oliguria, and mean serum creatinine at presentation was 6.7 Â ± 2.5 mg/dL. Rhabdomyolysis was noted in 68% (17) and hemolysis in 32% (8). Etiology of rhabdomyolysis includes snake envenomation (3), seizures (2), trauma (2), sepsis (3), pancreatitis (3), drug induced (2), thyroid myopathy (1), and multiple substance abuse (1). Etiology of hemolysis includes rifampicin induced (2), leptospirosis (1), mismatched blood transfusion reaction (1), snake bite (2), sepsis (1), and sickle cell disease (1). The mean duration of hospital stay was 10 Â ± 2.36 days. 22 patients (88%) required hemodialysis (HD) during hospital stay and mean number of HD sessions was 8 Â ± 5. Mortality was 8% (2). On statistical analysis, there was no significant difference between AKI due to rhabdomyolysis and hemolysis except for high creatine phosphokinase in patients with rhabdomyolysis and lactate dehydrogenase level in patients with hemolysis. At follow-up, 12% (3) progressed to chronic kidney disease (CKD).

CONCLUSIONS: Pigment nephropathy due to rhabdomyolysis and hemolysis is an important cause of dialysis requiring AKI. The prognosis was relatively good and depends on the etiology and complications.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 158: A RARE CASE OF ANTI GBM DISEASE PRESENTING IN THIRD TRIMESTER OF PREGNANCY

Gita Bipin Chandra 1, Manish Chaturvedi 1, Rajesh Jhorawat 1, Vikarn Vishwajeet 1

BACKGROUND: A 25-year-old primipara at 34 week of gestation presented with complain of oliguria and mild pedal edema. Pt was normotensive routine urine examination showing field full of RBCs diagnosed as rapid progressive glomerulonephritis. ANA ANCA was negative C3 C4 within normal limit anti-GBM titer was higher normal range. Pt started complaining of mild hemoptysis. Pt was biopsied after giving blood transfusion and two session of hemodialysis. pt condition deteriorated further hence pregnancy was terminated in the mean time provisional biopsy report showed Crescentic GN. Again anti GBM titer was repeated which came to positive with high titer. Patient was given 14 session of plasmapheresis along with cyclophosphamide and methyl prednisolone. Patient was discharged in stable condition, but no significant improvement in renal function patient is still on maintenance hemodialysis.

AIM OF THE STUDY:

METHODS:

RESULTS:

CONCLUSIONS: Anti-GBM should be kept as one of d/d of pregnant patient presenting with oliguria. methyl prednisone, cytotoxic drugs, and plasmapheresis should be considered for treatment. Placenta acting as adsorptive surface for antibodies, as patient condition deteriorated after removal of placenta and anti-GBM titer became positive.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 159: IF YOU CAN'T BEAT IT BEND IT DR VELU ARAVIND€S TECHNIQUE OF TUNNELING NON TUNNELED CATHETER FOR BETTER OUTCOMES IN END STAGE RENAL DISEASE PATIENTS

Gireesh Reddy 1, Velu Aravind 1, C G Sreedhra 1, A Kishan 1, S Mythri 1

BACKGROUND: • The estimated prevalence of chronic kidney disease (CKD) in India is 17.2% with approximately 130 000 patients on dialysis and annual growth of 10 to 20%. The use of non-tunneled catheters for initiation of dialysis is highly prevalent in our country • Majority of the patients with end-stage renal disease present with uremic complications and volume overload symptoms necessitating immediate initiation of dialysis. • It has been a common practice in our country to retain the non-tunneled catheters for a long time because the permanent AV access creation has been delayed • the major drawbacks with current non-tunneled catheter R • Cosmetically very disfiguring for the patient since the pub out from the neck • Since they are cosmetically disabling patients tend to cover them by various methods thereby predisposing these catheters for infection and subsequent complications • That current design is in such a way that the venous puncture site is always open and vulnerable for entry of various pathogens

AIM OF THE STUDY: To describe a novel and innovative technique proposed by Dr Velu Aravind for inserting non-tunneled catheters. To study the efficacy of this technique in improving the outcomes of non-tunneled catheters

METHODS: About 19 end-stage renal disease patients underwent catheter insertion using this novel technique. After informed consent, patients were enrolled in this study. All the patients underwent thorough vascular evaluation by ultrasound. Internal jugular vein was accessed under real time ultrasound guidance. Puncture of internal jugular vein was done close to the clavicle at the junction of distal internal jugular vein and proximal brachiocephalic vein. After the vein was punctured and guidewire was appropriately positioned in central veins, serial dilations were done. The exit site was planned using surface marking technique to ensure the tip of the catheter ended in right atrium. After anesthetizing the skin adequately with local anesthetic, the dilator was used for tunneling. The catheter was tunneled and brought out at the venous puncture site. At this point the guidewire was inserted into the catheter, and the catheter was inserted over the wire into the right atrium. After confirming adequate flows across both the ports of the catheter. The venous puncture site was sutured, and the catheter was fixed to the skin by suturing both ports of the hub. A post-procedure chest X-ray was done to confirm the position of the tip of the catheter.

RESULTS: Results- • Around 19 patients underwent non-tunneled catheter insertion with this technique the mean time for the procedure was around 20 minutes. 16 patients were males, 3patients were females. • All the patients were on maintenance hemodialysis for less than a year. • 16 patients had peripheral vascular disease • 3 patients had ischemic heart disease • 14 patients had diabetic nephropathy • 3 patients had cerebral vascular accident • All 19 patients underwent Right IJ TCC insertion. • None of the patients had history of CRBSI episodes. There were no intraprocedural or postprocedural complications. The procedure was easily reproducible and the success rate was 100%.

CONCLUSIONS: 95% of the patients initiating hemodialysis undergo initiation through non-tunneled catheters. Current catheters and the insertion technique are unable to achieve desired outcomes of providing a long-term sustainable vascular access with lesser complications. The technique proposed by Dr Velu Aravind offers solution for majority of the shortcomings with current non-tunneled catheters. This technique is very promising in the sense that it is very easily reproducible. Patients are very happy as it is cosmetically very appealing. It is very economical as the current technique doesn't add up to the cost of the patient care. This technique has the potential to convert current non-tunneled catheter into a poor man's tunneled catheter. Larger patient population studies will ratify our current observations as the results so far have been very promising in terms of patient satisfaction and outcomes.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 160: STUDY OF CLINICAL PROFILE AND TREATMENT OUTCOME IN TISSUE PLA2R POSITIVE MEMBRANOUS NEPHROPATHY A TERTIARY CENTER EXPERIENCE

Ranjitha Siddalingappa 1, Mythri Shankar 1, Kishan Aralapuram 1, Umesha Lingaraj 1, Leelavathi 1, Sravani Venu 1, Gireesh G Reddy 1, Aditya H Shetty 1, Gouri Satish 1, T Viswas 1, H Haritha 1

BACKGROUND: Membranous nephropathy (MN) is common cause of nephrotic syndrome in adults over 40 years of age. (1) PLA2R is the major target autoantigen in primary MN contributing approximately 70%. Immunosuppressive therapy indicated in moderate to high-risk and very high-risk patients as recommended by KDIGO 2020. Considering the known facts about the advantages and disadvantages of cyclophosphamide rituximab and calcineurin inhibitor therapy, this study helps to compare the efficacy of drugs in achieving complete remission in primary membranous nephropathy and adds information in choosing the therapy to patients

AIM OF THE STUDY: 1. To study the clinical profile of biopsy-proven tissue PLA2R positive membranous nephropathy patients. 2. To compare the various modalities of treatment in bringing change in proteinuria at 6th and 12th month post-therapy.

METHODS: We reviewed all biopsy-proven MGN cases in our center Institute of Nephro Urology Bengaluru from January 2018 to August 2021. Inclusion criteria 1. Proteinuria > 3.5gm/day tissue PLA2R positive Exclusion criteria 1. Double positive diseases 2. Secondary cause of MN, e.g., hepatitis B and C Systemic Lupus Erythematosus (SLE) medications malignancies. Clinical profile treatment received and change in proteinuria at 6th and 12th month post-therapy were recorded.

RESULTS: Among 2920 biopsies 62 cases were membranous nephropathy and 56 (1.91%) were primary MGN, 35 (61.4%) male, 22 (38.5%) females, 52 (91%) presented as nephrotic syndrome, 4 (8.7%) as CKD, 3 had thrombotic episode at presentation. Among 56 cases, 28 lost to follow-up, 2 cases initiated on HD at diagnosis, 26 cases received treatment, 11 (42.3%) received modified Ponticelli, 15 (57.6%) received rituximab. Mean proteinuria in rituximab group was 8.1gm/day and 9.03gm/day in modified Ponticelli group. Mean age was 42.2 and 39.3 in Ponticelli and rituximab group respectively At the end of 6 months, 4 (36.3%) in Modified Ponticelli group and 4 (26.6%) in Rituximab group achieved complete remission with p value of 0.55. 3 cases (27.2%) in Modified Ponticelli and 6 (40%) in Rituximab group had no remission. 1 (6.6%) in Rituximab group had relapse after complete remission. At the end of 12 months, 7 (28%) partial remission cases in both the group achieved complete remission expect one case in Modified Ponticelli and one complete remission case in Rituximab had relapse. At one year 4 cases in rituximab group after receiving modified Ponticelli achieved partial remission, total 3 cases (12%) had no remission even after receiving alternate regimen.

CONCLUSIONS: Though our study had higher complete remission rate at 6th month in Modified Ponticelli group, p value (0.55) was not statistically significant indicating noninferiority of the regimens. Partial remission at 6th month were comparable in both groups. 40% of the cases in rituximab group remained with no response at 6 month post-therapy who later at 12th month achieved either complete or partial and only 13.3% in Rituximab grouped remained with no response. Further highlights the remission from Modified Ponticelli regimen. Thus, our study strengthens the role of Modified Ponticelli in Membranous nephropathy.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 161: A CASE REPORT OF TRAPS (TNF RECEPTOR ASSOCIATED PERIODIC FEVER SYNDROME) AS A CAUSE OF SECONDARY RENAL AMYLOIDOSIS

Arjun Agarwal 1, A Dhananjai 1, G Rakesh 1, S Seetaram 1, S Kavish 1

BACKGROUND: Secondary renal amyloidosis is a very common condition and in usually seen following chronic infection and rheumatological condition. Here we are presenting a case of secondary renal amyloidosis secondary to TRAPS. 20-years-old male admitted to us with unexplained recurrent fever since early childhood for this he was thoroughly evaluated and there was no focus of infection and no evidence of any rheumatological disease. Patients mother elder brother and maternal grandfather also have similar type of febrile illness though range and frequency are less.

AIM OF THE STUDY: A case report of TRAPS (TNF receptor associated periodic fever syndrome) as a cause of secondary renal amyloidosis.

METHODS: Patients' exom analysis was done which showed TNFRSF1A exon 3 c295T>C (p.Cys99Arg) mutation. Patient was prescribed inj etanercept for TRAPS, and he took that irregularly.

RESULTS: Patient noticed gradually increasing swelling from last 2 years with nephrotic range proteinuria and bland sediment for which renal biopsy was done which shows diffuse irregular mesangial matrix expansion due to deposition of material that exhibits tinctorial properties of amyloid, with arteries and arterioles exhibit variable thickened walls showing amyloid deposition, immunohistochemistry was positive for SAA.

CONCLUSIONS: TRAPS syndrome is a very rare inflammatory autosomal dominant disorder associated with heterozygous mutations in the tumor necrosis factor (TNF) receptor super family 1A (TNFRSF1A) gene. 10-20% of TRAPS patients have association with amyloidosis. TRAPS should be considered in patients with history of recurrent febrile episodes and family history of autosomal dominant disorder.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 162: THE IMPACT OF DIABETES MELLITUS ON PERITONEAL DIALYSIS: A SINGLE CENTER STUDY OF A 20- YEAR EXPERIENCE IN NORTH EAST INDIA

Prabin Kumar Majhi 1, T Brojen Singh 1, N Sarat Kumar 1, L K Sharat Chandra 1, Pranab Kumar Medhi 1, M Chetan 1, Tenzin Gyaltsen 1

BACKGROUND: Chronic ambulatory peritoneal dialysis (CAPD) has been an established form of therapy in adult patients with end-stage renal failure in India for more than three decade. It has emerged as accepted form of renal replacement therapy in north east part of India. Since the year 2001, CAPD has been carried out on a regular basis at Regional Institute of Medical Sciences Imphal

AIM OF THE STUDY: The purpose of this study is to determine the overall predictor of survival compared mortality and morbidity between Diabetic and Non-Diabetic RIMS Peritoneal Dialysis (PD) patients

METHODS: We conducted a single-center retrospective study with 672 PD patients [318 had diabetes mellitus (DM)] were taken between September 2001 and May 2021. Serum biochemical and pathological parameters comorbid diseases and peritoneal transport characteristics as well as peritonitis episodes mortality were studied.

RESULTS: Majority patients of study population were male 428 (63.7%). The diabetic patients were older (60.22 Â ± 11.41 vs 51.33Â ± 16.22 years, pË'0.001) at the time of PD implantation and had more comorbidities than non-DM patients. Main causes of CKD were type 2 DM (47.3%) followed by hypertensive nephropathy (32.6%). Peritoneal Equilibrium Test (PET) showed diabetic patients had more low or low average peritoneal membrane (53% vs 46% p = 0.184). No. of peritonitis episodes were lower in diabetic group (24.5% vs26.27%, p = 0.605). Median survival of diabetics was significantly inferior to non-DM patients (12 vs 15 patient-months, p = 0.001). The diabetic patient had less survivability. Majority of death were due to cardiovascular diseases in both diabetic and non-DM patients (61% vs 39%, p < 0.001) followed by Uremia (7.3% vs 12.5%).

CONCLUSIONS: Patient survival was inferior in diabetic compared to non-DM patients on PD. Peritonitis rates were higher in non-DM PD patients. DM, older age, peritonitis, anemia, malnutrition, and cardiovascular comorbidities are predictors of mortality.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 163: THE ROLE OF RITUXIMAB IN FLOMERULAR DISEASES: A SINGLE CENTRE EXPERIENCE

P Sunayana 1, M Sreelatha 1, EK Jayakumar 1, PT Hijaz 1

BACKGROUND: B-cell antigen CD20 plays a significant role in the pathogenesis of many diseases including glomerular diseases. These and other findings underpin the central concept of B-cell-depleting therapies that target CD20 antigen as treatments for lupus nephritis idiopathic membranous nephropathy focal segmental glomerulosclerosis cryoglobulinemic glomerulonephritis antibody mediated renal allograft rejection and recurrent glomerulonephritis in renal allograft. Recently rituximab has emerged as an additional therapeutic agent in the armamentarium for the treatment of glomerular disease in both native and transplant kidneys

AIM OF THE STUDY: To study the benefit of Rituximab (RTX) in patients with various glomerular diseases.

METHODS: A prospective study of 55 patients who had biopsy-proven different glomerular diseases and treated with 4 weekly injection RTX 375 mg/m2 during the period May 2021 to April 2022 was done. Patients were followed up at 1 month, 3 months, 6 months, and 1 year after the last dose of RTX. Response was assessed based on changes in S.creatinine proteinuria, and the response was defined according to KDIGO 2021 definitions for respective glomerular diseases. Patients were assessed for complete /partial remission of disease immediate and late complications. The data was analyzed using SPSS software. Qualitative variables were expressed in frequency and percentage.

RESULTS: Total 55 patients were assessed. 51% patients had nephrotic syndrome, 20% had membranous nephropathy, 12.7% had lupus nephritis, 9.1% had MPGN, and 7.3% had vasculitis. In patients with nephrotic syndrome, 82.1% had steroid-dependant, CNI-dependant NS (SD CNID NS) and 17.9% patients had CNI-resistant nephrotic syndrome (CNIR NS). 92.9% MCD patients had SD CNI D NS had 7.1% had CNIR NS. 71.4% FSGS had SD CNI D NS, and 28.6% had CNIR NS. In SD CNID NS at 6 months 8.7% had no response, 8.7% had partial remission, 78.3% had complete remission and 1 yet to be assessed. In CNIR NS, at the end of 3 months and 6 months 60% had no response and 40% had complete remission. 4 patients with biopsy-proven Pauci-immune glomerulonephritis, all were ANCA negative. At 6 months 50% had complete remission, 25% had partial remission and 25% had no response and at 1 year 1 attained complete remission. 5 patients with MPGN: Of the 3 C3 GN patients at 6 months 1 had no response, 1 attained partial remission and 1 attained complete remission. At 1 year, 1 attained partial remission and 2 yet to be assessed. Of the 2 patients with immune complex MPGN at the end of 6 months, 1 attained partial remission and 1 had no response. Total 7 patients with lupus nephritis: Of the 3 patients with class IV LN at the end of 3 months 1 attained complete remission and 2 had no response. At 6 months and 1 year, 1 had no response and 2 yet to be assessed. Of the 4 patients with Class 5 LN at 6 months 1 had partial and 2 had complete remission, 1 yet to be assessed. In 11 patients with MN 36.4% were anti PLA2R positive and 63.6% were negative. Of the 3 patients with initial RTX treatment, at 6 months, 1 had partial and 1 had complete remission. At 1 year 1 attained complete remission and 2 yet to be assessed. Of the 5 patients treated with RTX for relapse of MN at the end of 3 months 2 had no response and 3 had complete remission. At 1 year, 1 had partial remission, 1 had complete remission, and 1 had no response. Only 1 patient (1.8%) had infusion reaction as urticaria. 3 patients (5.4%) had infectious complication

CONCLUSIONS: Patients with steroid-dependant, CNI-dependant nephrotic syndrome responded well to Rituximab. CNI-resistant patients showed poor response. Patients with membranous nephropathy and MPGN also had good response. 5 out of 7 patients with resistant lupus nephritis responded to RTX. Hence, Rituximab was found to be beneficial in most of the glomerular diseases especially in resistant lupus nephritis. Patients with steroid-dependant, CNI-dependant nephrotic syndrome responded well to Rituximab. CNI-resistant patients showed poor response.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 164: UNCONVENTIONAL APPORACH TO DECLOTTING

B Sairam 1, Gireesh Reddy 1, C G Shreedhara 1, Kishan Aral 1, Mythri Shankar 1, M Sravani 1

BACKGROUND: Percutaneous approach rather than surgical approach is preferred for thrombosed vascular access. Several endovascular methods have been proposed to declot the fistula. Conventional method uses a only arteriovenous access puncture with push and pull technique for the declot procedure. Arterial puncture is rarely used in the past. However in this retrospective observational study, we have compared and analyzed an unconventional method of declotting the arteriovenous access and its advantage in declotting the native arteriovenous fistulas.

AIM OF THE STUDY: To compare an unconventional method of declotting the arteriovenous access and analyze its advantages.

METHODS: After informed consent was obtained, general physical examination of the fistula was done for all patients. Patients were explained the procedure attempted, and those who consent were included in the case group and non- consenting patients were subjected to the conventional method. Both the procedures were done on outpatient basis. Technical and clinical success rates and 6th month patency were evaluated. Procedure done: Under local anesthesia, left upper extremity and the skin surrounding the patients fistula was then prepped and draped in the usual sterile fashion. A skin entry site was then identified, and the skin and underlying subcutaneous tissues were infiltrated with lidocaine. A gelco needle was then advanced into the patients radial artery via retrograde manner, and 6 French Vascular Sheath was inserted. The dilator and the guide-wire were then removed, and a fistulogram was performed. Pharmaco-mechanical thrombolysis of the fistula was done using UHP balloon along with a mixture of 5 lakh units urokinase with 5000 units of heparin.

RESULTS: Total of 64 patients with were included in this series. Age group included ranged from 17 years to 79 years with an average of 56.26 years. Sixty percentage of included population were male. Of the 64 patients, 45 patients consented for our novel procedure while 19 patients underwent conventional procedure. They were followed up every 3 months to check for patency of the fistula and the 6th month patency was 95% in both the groups which was at par with the international data. Average time required for the procedure was 25 +- 3 minutes while the conventional method took 45 +_ 3 minutes. No serious complications were recorded in both the groups.

CONCLUSIONS: Endovascular procedures are minimally invasive and effective for the treatment of thrombosed arteriovenous fistulas. By using this novel method, we have demonstrated a reduction in duration of the procedure and also the exposure to radiation without compromising the quality of the procedure.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 165: CLINICAL SPECTRUM OF RECURRENT URINARY TRACT INFECTIONS -A SINGLE CENTRE STUDY

Durga Deorukhkar 1, Hardik Shah 1, Ravi Brahmbhatt 1, Dilip Kirpalani 1, Shrirang Bichu 1, Ashok Kirpalani 1

BACKGROUND: Urinary tract infections are one of the most frequent community associated and healthcare derived infections that drive antibiotic usage and hospitalizations around the world. They are commonly caused by Gram-negative bacteria such as Escherichia coli, Proteus species, Pseudomonas aeruginosa, Acinetobacter species, Klebsiella species, Enterobacter species, and Citrobacter species. However, even Gram-positive bacteria such as Staphylococcus saprophyticus, Enterococcus species, and Coagulase-negative Staphylococcus are frequently associated with UTI in recent times. The spectrum of UTI ranges from cystitis to pyelonephritis with severe complications of UTI such as emphysematous pyelonephritis (EPN) emphysematous cystitis renal abscesses and renal papillary necrosis contributing to higher morbidity and mortality. Recurrent UTI is described as patients having two or more infections in 6 months or having three or more infections in 1 year. From the clinical perspective, the second episode of UTI can be considered as a recurrence and requires a diligent approach to diagnosis and management. Majority of these recurrences can be categorized as reinfections rather than relapses or failures of initial treatment. In this observational retrospective study, we aim to evaluate the clinical spectrum of recurrent urinary tract infections in a tertiary care hospital and identify etiological factors contributing to this entity.

AIM OF THE STUDY: A retrospective observational study to evaluate the clinical profile of recurrent urinary tract infections in a tertiary care hospital.

METHODS: The study was conducted from January 1, 2021 to December 31, 2021. Patients < 18 years kidney-transplant recipients those on immunosuppressive agents or on indwelling catheters prior to recruitment and pregnant patients were excluded. Patients with two or more episodes of culture positive urinary tract infections were included. Demographic details clinical symptoms signs radiological and laboratory data including urine and blood cultures of all patients were recorded. The details of treatment received and outcomes in hospital were noted.

RESULTS: 48 patients satisfied the inclusion criteria. 37.5% were females, and 62.5% were males. Mean age was 57.8 + 11.2 years. Fever (79%), dysuria (60%), and flank pain (50%) were the most common symptoms. Common manifestation of UTI were : Acute Pyelonephritis (52%), Emphysematous Pyelonephritis (20%), and Cystitis (25%). ESBL E.coli (44%) was the most frequent organism isolated followed by Klebsiella spp. (26%) and Pseudomonas spp. (21%). Recurrent episodes of UTI with same organism were noted in 62% patients. 12.5% patients died due to septic shock. Antimicrobial resistance pattern was as follows: Colistin -8%, carbapenems — 72%, Piperacillin/tazobactam — 80%, Cefoperazone/sulbactam — 75%, Aminoglycosides -72%, Fluoroquinolones — 80%, third-generation cephalosporins — 92%, Penicillin’s -95%. Renal calculi (24%), DJ stent placement (30%) and de novo immunosuppressive administration (15%) were associated with recurrent UTI though not statistically significant. Diabetes (62.5%, r = 0.79), urological procedure (39.5%, r = 0.68), prior hospitalization (75%, r = 0.84), history of UTI prior to the study period (44%, r = 0.72), and need for PUC beyond 7 days (35%, r = 0.74) had significant correlation with recurrent UTI.

CONCLUSIONS: Resistance to higher antibiotics, urological interventions and diabetes contribute to the rising incidence of recurrent urinary tract infections.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 166: DOES THE USE OF HIGH-DOSE CORTICOSTEROIDS IN RENAL TRANSPLANT RECIPIENTS DURING LONG-TERM IMPACT COVID-19 HAVE?

Vamsidhar Veeranki 1, Narayan Prasad 1

BACKGROUND: The long-term outcomes of renal transplant recipients (RTR) affected by SARS-COV2 infection are an unexplored area particularly given the heightened immunosuppression and post-COVID-19 sequelae and increased fungal infections. We aimed to analyze the patient and graft outcomes, infectious and non-infectious sequelae in RTR with COVID-19 over a long-term follow-up of 24 months.

AIM OF THE STUDY: To analyze the patient and graft outcomes, infectious and non-infectious sequelae in RTR with COVID-19 over a long-term follow-up of 24 months.

METHODS: This retrospective study included the RTR admitted during the two pandemic waves between March 25, 2020, and July 31, 2021. The survivors were followed for a maximum period of 24 months (till September 2022) and were studied for readmission rates, serious infection requiring hospitalization (SIRH), graft dysfunctions and biopsy-proven acute rejections (BPAR), patient and graft survival.

RESULTS: Of 251 RTRs with SARS-COV2 infection, 104 were treated during the first wave and 147 during the second wave. After an index mortality noted in 38 patients (15.1% - 11.5% in first wave vs 17.5% in second wave, P = 0.23), follow-up data of 213 patients were analyzed. 45 patients were lost to follow-up, and a complete follow-up data was available for 168 patients. A total of 70 patients (41.7%) required readmission with SIRH being the most common indication for readmission (19.6%) followed by rejection (8.9%). Patients who received high dose steroids during the COVID-19 illness had higher SIRH (32.4% vs 16%, p = 0.027). However, graft dysfunctions (13.5% vs 16%, p = 0.70) and the BPAR (8.1%vs9.2%, p = 0.84) were similar in both the groups. Overall mortality (5.4% vs 6.9%, p = 0.75) and graft loss (10.8% vs 5.3%, p = 0.23) were also similar at 24-month follow-up.

CONCLUSIONS: The high-dose corticosteroid dosing in the RTRs during COVID-19 appears to be associated with increased infectious complications over long-term although the overall patient and graft survival was similar.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 167: USE OF NOVEL HYBRID VASCULAR GRAFT AS A RESCUE TO ESTABLISH VASCULAR ACCESS IN PATIENTS WITH COMPLEX ANATOMICAL STRUCTURES

Siddhavinayak Rajmane 1, Sudhiranjan Dash 1, Ashwin Patil 1, Rushi Deshpande 1

BACKGROUND: Recurrent infections vascular thrombosis and vascular stenosis are common cause of vascular access failure in chronic hemodialysis (HD) patient.

AIM OF THE STUDY: To establish successful use of GORE® Hybrid Vascular Graft (GHVG) implantation for difficult HD access placement.

METHODS: A 56-year-old female presented with end-stage renal disease and had significant comorbidities including obesity hypertension mixed connective tissue disease chronic atrial fibrillation. She was started on maintenance hemodialysis (MHD) via right internal jugular vein tunneled cuffed catheter (TCC) in 2018 which was removed after 1 year because of infection and replaced with left-sided TCC. Arterio-venous fistula (AVF) created in 2020 but failed in 15 days. Second TCC removed for fungal infection in 2021and femoral HD catheter inserted. Small target veins that prohibited the implantation of conventional PTFE graft and insufficient autologous veins for additional native AVF development were seen during an ultrasound scan of extremities. She subsequently had left TCC and a 7 mm x 45 cm GVHG implanted in right-sided subclavian artery-subclavian vein wire loop configuration.

RESULTS: Due to multiple vessel catheterization and instrumentation, she developed superior vena cava (SVC) syndrome, and most of her accessible veins, including brachiocephalic veins, became thrombosed. This condition was treated with alteplase thrombolysis and digital subtraction angiography-guided angioplasty. Patient recovered fully and discharged with stable condition.

CONCLUSIONS: In certain circumstances, GHVG can give an effective option for chronic hemodialysis patients who have exhausted all other central venous access options, provided that the SVC is patent, and can increase survival rate of such patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 168: TO ASSESS THE ROLE OF GENETIC ANALYSIS IN CLINICAL NEPHROLOGY PRACTISE

Dan Elizabeth Sunny 1, M Sreelatha 1, Ek Jayakumar 1, PT Hijas 1

BACKGROUND: Genetic analysis to support clinical diagnosis is more commonly used nowadays as the sequencing cost has come down increased availability and gene of various disease become more complete. One study found that genetic diagnosis provided new clinical insight in nearly 75% of solved cases by identifying reclassifying or specifying disease etiology or informing prognostication treatment or transplant decisions

AIM OF THE STUDY: To assess the role of genetic analysis in clinical diagnosis of renal disease.

METHODS: A total of 57 patients blood sample who had clinically and biopsy-proven glomerular disease and tubulointerstitial and cystic disease were sent for whole exome sequencing during the period of January 2020 till may 2022 were collected, and the results are analyzed.

RESULTS: A total of 57 samples were analyzed. 35 were males, and 22 were females. Among 57 cases, 34 were glomerular disease (59.6%). Mutation detected in 20 patients. 50% were common mutations described, while 50% were variant of unknown significance (VUS). Most common indication studied was aHUS (n = 10). Mutation detected in 6 cases. 4 being common mutation (partial gene deletion CFHR1&R3) and 2 being VUS (PLG &NUP93). This PLG is a protein found to be related to aHUS while NUP93 found as a cause of genetic SRNS. SRNS was second most indication (n = 6) studied with mutation found in 5 cases with 2 being common mutation (CD2AP&CRB2) and 3 were VUS (LAMA5&Partial gene deletion CFHR1&R3). In studies, a novel model of nephrotic syndrome results from point mutation in LAMA5. 1 case of congenital NS was sequenced and a VUS was detected (ACTN4). Mutation in ACTN4 has found to be cause of familial FSGS. C3GN, n = 4. mutation detected in all cases with 1 being common mutation (CFHR1) and 3 being VUS (NPHP4, CRB2). CRB2 defect cause SRNS. Familial IgA 3 cases with mutation detected in 2 cases: 1 being common mutation (COL4A5) and 1 being VUS (NOTCH2). Alport syndrome 2 cases with common mutation (COL4A5&COL4A4) detected in both. No mutation detected for biopsy-proven MN (n = 1), MPGN (n = 3), TTP (n = 1) and CKD-CGN/bilateral contracted kidney (n = 3). Among 57 cases, rest were (n = 23) 40.3% cystic and tubular disorders. Mutation detected in 17 cases (73.9%) with 7 being common mutation and 10 being VUS. Most common indication studied was nephronophthisis (n = 4). Mutation detected in 3 cases, 2 being common mutation (NPHP4&NPHP18) and 1 being VUS (CRBI &SPINK5). Distal RTA 4 sample. Mutation detected in 3 cases with 1 was common mutation (SLC4A1) and 2 were VUS (FLNA&WNK4) WNK4 implicated in hyperkalemic dRTA. Primary hyperoxaluria 3 cases. VUS found in all cases (GRHPR, PKD1, APOLI1) GRHPR mutated in primary hyperoxaluria type 2. ADPKD 3 samples, common mutation detected in all cases (PKD2&NOTCH2). ARPKD, 2 cases and mutation detected in 1 case, being VUS (AGXT). Liddle syndrome 2 cases with mutation found in 1 sample, being VUS (POLGgene). CTID-bilateral contracted kidney, 2 sample sent. Mutation found in 1 sample and was a common mutation (SLC22A12). One sample each of medullary nephrocalcinosis and suspected gitelman syndrome. No mutation found in both. Proximal RTA 1 sample. No mutation was found

CONCLUSIONS: Though designated as VUS, correlation was found between various genetic mutation and suspected disease condition in addition to common mutation described.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 169: PROLIFERATIVE GLOMERULONEPHRITIS WITH MONOCLONAL IGG DEPOSITS IN A PEDIATRIC PATIENT AND RECURRENCE POST TRANSPLANT WITH A 5 YEAR FOLLOW UP- A CASE REPORT

Aman Jha 1, Aswini Panighrahi 1, P Shwetha 1, G Swarnalatha 1

BACKGROUND: Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) is an uncommon but notable entity characterized by glomerular deposits of IgG containing an intact (whole) Ig composed of a single light-chain isotype and a single Î3 δ ΰ heavy-chain subclass. This entity affects adults and most patients present with nephrotic-range proteinuria and hematuria with or without renal failure and has risk of recurrence with poor graft outcomes. We report a unique case of PGNMID occurring in a 7-year-old male child with post-transplant recurrence

AIM OF THE STUDY: To evaluate the impact of PGNMID on recurrence and outcomes in a child.

METHODS: A 7-year-old boy presented to us with nephrotic syndrome within 2 weeks duration preceded by chicken pox. A renal biopsy was done in view of proteinuria hematuria and renal failure which showed MPGN type 1. He was treated with 3 doses of cyclophosphamide following which he landed in sepsis and renal failure associated with worsening of proteinuria and hematuria. A repeat biopsy was done which showed light chain restriction and IgG deposits suggestive of PGNMID. The patient did not achieve renal recovery and required MHD. The child was transplanted at the age of 9 years with grandmother as donor (3/6), and rituximab was given pre-transplant and post-transplant; the boy recovered and was discharged with triple immunosuppression and a creatinine of 0.8 during the pandemic cause of the irregular follow-up had worsening of his proteinuria hematuria and rise in serum creatinine to 1.2 at 21 months follow-up A transplant kidney biopsy was done which showed recurrence of the disease with PGNMID given rituximab therapy with improvement in proteinuria and serum creatinine to 0.8 three years post-rituximab therapy at the age of 12 years (5 years post follow-up); his serum creatinine has risen to 2.05 with edema. Repeat renal biopsy showed no evidence of rejection on background of persistent PGMID

RESULTS: Our patient had recurrence of basic disease with graft dysfunction within 2 years fulfilling all diagnostic criteria. Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) is a recently recognized entity caused by monoclonal deposition of IgG leading to dysproteinemia. The diagnostic criteria used for PGNMID are renal biopsy finding of glomerulonephritis with presence of the following: (i) glomerular immune deposits staining positive for Î3 heavy chain (IgG), with negative stain for Î ± (IgA) and Îü (IgM) heavy chains, indicating restriction to a single (Î3) Ig class; (ii) positive staining for a single Î3 (IgG) subclass (IgG1, IgG2, IgG3, or IgG4); (iii) positive staining for a single light-chain isotype (ΰ or Δ), indicating monoclonality; (iv) predominantly granular electron-dense deposits in mesangial, subendothelial, and/or sub epithelial locations by electron microscopy (EM), resembling immune complex glomerulonephritis; and (v) no clinical or laboratory evidence of cryoglobulinemia. In our case the presence of deposits of a single Ig class which is IgG and a single light-chain, kappa, and the absence of other immunoglobulins, makes the diagnosis of PGNMID most definitive. It has a risk of recurrence as was seen in our patient with graft dysfunction. This disease has no clear treatment recommendation to follow in pediatric age group

CONCLUSIONS: ï'§ PGNMID is unusual in children. Only two pediatric patients with PGNMID have been reported in Japan since 2013; our present case of PGNMID is a male child of 12-years and is possibly the first case reported in a pediatric case from India.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 170: URIC ACID LEVELS AND ITS CORRELATION WITH LIPID RATIOS IN NON -DIABETIC CHRONIC KIDNEY DISEASE PATIENTS

Nidhi Arora 1, Sanjay D’Cruz 1, Shivani Jaswal 1

BACKGROUND: CKD is associated with metabolic disturbances like hypertension impaired glycemic control hyperuricemia dyslipidemia and malnutrition. Recent studies have focused on using these lipid parameters and lipid ratios as biomarkers in detecting early renal dysfunction and as a predictor of morbidity and mortality. Uric acid is being linked to metabolic syndrome and as a marker of endothelial injury.

AIM OF THE STUDY: 1. Estimation of uric acid levels and lipid profile in nondiabetic CKD patients. 2. To find correlation between uric acid levels and lipid ratios in non-diabetic CKD patients.

METHODS: Cross-sectional observational hospital-based study. 200 non-diabetic CKD patients >18 yrs were enrolled. EXCLUSION CRITERIA: Patients on dialysis acute kidney injury on urate lowering agents on lipid lowering therapy and diabetics (HbA1c>6.5)

RESULTS: 200 nondiabetic CKD patients were studied. Among these 24 (12.0%) of the participants had CKD Stage G1, 27 (13.5%) of the participants had CKD Stage G2, 51 (25.5%) of the participants had CKD Stage G3, 41 (20.5%) of the participants had CKD Stage G4, 57 (28.5%) of the participants had CKD Stage G5. Spearman rank coefficient was used to correlate uric acid with e GFR, lipid ratios with eGFR and to correlate uric acid with following lipid ratios: TC/HDL, TG/HDL, LDL/HDL, Non-HDL/HDL and APO B/APO A1, and p value of <0.05 was significant. The mean uric acid was 7.63  ± 2.52. Uric acid levels were negatively correlated with eGFR with spearman correlation coefficient (r) of -0.42, and it was significant (p value < 0.001). There was a significant difference between the 5 groups in terms of uric acid (χ2 = 41.193, p = <0.001), with the median uric acid being highest in the CKD Stage: G5 group. The mean TC/HDL ratio was 5.03  ± 4.36 among the studied non-diabetic CKD patients. Mean TG/HDL ratio was 6.07  ± 10.87, mean LDL/HDL ratio was 2.98  ± 2.50, mean Non-HDL/HDL ratio was 4.02  ± 4.37, and the mean Apo B/Apo A1 Ratio was 0.92  ± 0.89. Lipid ratios across eGFR values were observed to be significantly correlated. As the eGFR declined, lipid ratios decreased, which was not as reported in literature. TC/HDL was statistically significant with (r = 0.26, p < 0.001), LDL/HDL (r = 0.32, p < 0.001), Non-HDL/HDL (r = 0.24, p < 0.001) and ApoB/apoA1 (r = 0.27, p < 0.001) while no significant correlations were observed between e GFR and TG/HDL ratio. Overall, none of the lipid ratios correlated with uric acid. On subgroup analysis, it was found that in stage G2 uric acid levels were significantly correlated with TC/HDL ratio with r = 0.39 (P < 0.05), LDL/HDL ratio with r = 0.48 (p < 0.05) and ApoB/ApoA1 ratio with r = 0.39 (p < 0.05). Also, in stage G4 statistically significant correlations were observed between uric acid and TC/HDL ratio with r = 0.34 (P < 0.05), LDL/HDL ratio with r = 0.42 (p < 0.05), NonHDL/HDL ratio r = 0.34 (p < 0.05), and ApoB/ApoA1 ratio with r = 0.36 (p < 0.05).

CONCLUSIONS: In our study, increase in uric acid levels was observed with declining e GFR, which was similar to previous studies. In our study in stage G2, uric acid was found to be significantly correlated with TC/HDL, LDL/HDL, and ApoB/ApoA1 ratio. In stage G4, stage significant correlations were observed between uric acid and TC/HDL, LDL/HDL, NonHDL/HDL, and ApoB/ApoA1 ratios. Overall correlation of uric acid with any of the calculated lipid ratios was not statistically significant in our study. Our study indicates increasing uric acid level is associated with declining e-GFR. However, uric acid was not directly associated with dyslipidemias in non-diabetic CKD patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 171: CLINICAL AND BIOCHEMICAL PROFILE OF PATIENTS WITH PLASMA CELL DYSCRASIAS PRESENTING WITH RENAL INVOLVEMENT

Akshay Zalavadiya 1, Shivendra Singh 1

BACKGROUND: Plasma cell dyscrasias are commonly encountered hematological malignancies with frequent renal involvement. Renal involvement in plasma cell dyscrasias can range from mild renal dysfunction to overt renal failure requiring RRT

AIM OF THE STUDY: The aim of the present study is to analyze clinical spectrum and biochemical parameters of patients with plasma cell dyscrasia who initially presented with renal involvement

METHODS: Analyzed 30 (males 25; females 5) patients of plasma cell dyscrasias admitted with renal dysfunction during the period from April 2021 to July 2022. All the patients were investigated and classified based on updated International Myeloma Working Group (IMWG-2014) criteria for diagnosis of plasma cell dyscrasias

RESULTS: Mean age of patients was 56.13 (+/-12.08) years. The main clinical presentation was AKI in 60% and nephrotic range proteinuria in 23.3% patients. 3 patients had RPGN like presentation and 2 patients had unexplained CKD as initial presentation of underlying plasma cell dyscrasia. Anemia was present in majority of the patients at presentation (83.3%), with mean Hb of 8.9+/- 2.09 gm%. Albumin globulin ratio reversal and hypercalcemia was seen in 83.3% and 43.3%, respectively. Skeletal lesions were seen in 53.3% of the patients. Other clinical features included body pain (16, 53.3%), fever (13,43.3%), edema (18,60%), oliguria (4,13%), nausea, vomiting (19,63.3%). Serum M protein was seen in 73% patients; however, only 7 patients have M protein more than 3 gm%. Serum immunofixation and serum-free light chain assay were found to be abnormal in 76% and 90%, respectively. 18 patients had heavy chain myeloma, Ig G kappa being the most common form, and 12 patients had light chain myeloma out of which 8 patients had lambda chain myeloma. Renal biopsy was done only in 13 patients, out of which 7 patients had amyloidosis and 6 had cast nephropathy. One patient had light chain proximal tubulopathy.

CONCLUSIONS: In our study subset, most common plasma cell dyscrasia was heavy chain myeloma with IgG myeloma being the most common. AKI was the most common renal manifestation of plasma cell dyscrasia. Even in the absence of serum M protein, serum free light assay can be found abnormal and can provide valuable clue to the diagnosis. Plasma cell dyscrasia should be in the differential diagnosis of unexplained AKI in adult population

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 172: RARE ASSOCIATION OF SYSTEMIC LUPUS ERYTHEMATOSUS

Ahmad 1

BACKGROUND: Systemic Lupus Erythematosus is a rheumatological disorder with multisystem involvement. However, it can present with other disease with their own spectrum.

AIM OF THE STUDY: This is a case series of 3 patients who were diagnosed with systemic lupus erythematosus along with multiple myeloma discoid lupus erythematosus and posterior reversible encephalopathy syndrome

METHODS: This is a case series 3 patients who were diagnosed with systemic lupus erythematosus with due to lack of treatment response along with association of signs and symptoms not classically associated with the primary disease

RESULTS: Case 1) A 28-year-old male presented with reduced urine output along with symptoms of uremia; he also had symptoms of joint pain; no history of hypertension or hematuria were present; during admission, he had 3 episodes of GTCS on MRI; it was found to be PRESS; his BUN was 140 creat 11; urine routine was suggestive of proteinuria 3+ TUP 2.3gm/24hours;ANA+ and dsDNA + and his renal biopsy was suggestive pf SLE LN class IV. Case 2) A 40-year-old female presented with reduced urine output along with backpain. On presentation BUN 110 creat 9.8 her urine routine was suggestive of proteinuria 1.9gm/24 hours along with blood 1+ and pus cells her NCCT KUB was suggestive of normal sized kidney along with lesion on L1 vertebrae ANA and dsDNA were + and SPEP was also positive (900 mg of myeloma proteins); her renal biopsy was suggestive of lupus nephritis Class II along with deposition of light chains. Case 3) A 40-year-old female presented in dermatology OPD with complaints of hair loss, oral ulcers generalized bodyache. Hair loss was cicatricial and patchy. On routine workup, her creatine was 1.3 albumin 2+ in urine; her ANA, dsDNA were positive; renal biopsy was suggestive of SLE LN class IV.

CONCLUSIONS: Although systemic lupus erythematosus is a complex disease along with wide spectrum of presentation, a high index of suspicion should be present.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 173: EFFECT OF INDIVIDUALIZED DIALYSATE SODIUM ON INTER-DIALYTIC WEIGHT GAIN IN MAINTENANCE HEMODIALYSIS PATIENTS

Vipul Sanghavi 1, Sagar Kulkarni 1, Vipul Chakurkar 1, Valentine Lobo 1

BACKGROUND: Dialysate sodium levels (DNa) may influence blood pressure (BP) and interdialytic weight gain (IDWG) in maintenance hemodialysis patients. While use of higher DNa may lead to sodium gain and increased IDWG, the use of individualized DNa has shown inconsistent results.

AIM OF THE STUDY: To study the effect of individualized DNa on IDWG pre-dialysis systolic BP episodes of intradialytic hypotension and hypertension during dialysis sessions & anti-hypertensive drugs requirement

METHODS: In this randomized cross-over trial, we enrolled thirty patients on thrice-weekly maintenance hemodialysis. They were randomized to receive dialysis against either a DNa of 136 (Control arm) or against individualized DNa [equal to the plasma sodium obtained from the online-clearance monitoring (OCM) readings on Fresenius 4008S-OCM during the preceding month] (Intervention arm). The cross-over led to second phase.

RESULTS: The mean age of patients (18 males, 12 females) was 51.46 years. The mean serum pre-HD sodium level was 136 mEq/L in the control arm and 136.58 mEq/L in the intervention arm. The mean (SD) IDWG was not different between the groups [1.79 (0.99) kg and 1.74 (0.96) kg in the control & intervention arms respectively; (P = 0.33)]. Also, the mean (SD) pre-HD systolic BP was not different between the groups [148.91 (17.63) mmHg and 145.35 (15.22) mmHg in the standard and individualized arms; (P = 0.054)]. There was also no difference in intradialytic hypotension episodes (P = 0.130), but the number of intradialytic hypertension episodes was significantly less in intervention arm [83 (23.05%)] than in the control arm [103 (28.61%)]; P = 0.0007

CONCLUSIONS: Use of Individualized dialysate sodium showed no difference in IDWG or pre-HD systolic BP levels, but it resulted in less episodes of intradialytic hypertension

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 174: ANTI PLA2R LEVEL IN PRIMARY MEMBRANOUS NEPHROPATHY: CAN THAT PREDICT RESPONSE TO THERAPY?

Tarak Choudhury 1, Prof Arpita Ray Chaudhury 1

BACKGROUND: Membranous nephropathy is the most common cause of adult-onset nephrotic syndrome. Our institute biopsy registry data reveals membranous nephropathy incidence is 10%. Recent KDIGO guideline has included quantitative antiPLA2R as a risk stratifying measure which may prove useful for treatment allocation. We are reporting the outcome of a single-center prospective follow-up cohort of 122 patients with biopsy-proven membranous nephropathy allocated to 3 arms of immunosuppressive therapy intervention commonly used for IMN based on PLA2R positivity and idiopathic membranous nephropathy patients.

AIM OF THE STUDY: The study was undertaken to identify the role of anti PLA2R antibody in predicting treatment response to different immunosuppressive regimens in primary Membranous Nephropathy.

METHODS: A total of 172 patients with biopsy-proven membranous nephropathy from IPGMER and SSKM hospital in last five years were collected in the study. All the patients were given six months of maximal tolerated antiproteinuric therapy and 20 (11%) PLA2R positive and 30 (17%) Pla2R negative responded to conservative treatment but the p value (0.23) is not statistically significant. The patients who did not respond to conservative therapy were divided into three groups and treated with Modified Ponticelli (MP) Rituximab and Tacrolimus-based regimen. Baseline characteristics between three groups were comparable. In MP regimen, alternating glucocorticoids and cyclophosphamide-based regimen were given for 6 months. In rituximab-based regimen, two doses of 1gm rituximab were given at an interval of 15 days. In tacrolimus-based regimen, standard dosage of tacrolimus was given to keep whole blood tacrolimus trough level (T0) in between 5-7 ng/ml.

RESULTS: Among 122 patients, 48 (26 pla2R pos and22 pla2r neg) patients were treated in MP,42 (24 pla2R pos and 18 pla2r neg), with rituximab and 32 (17 pla2R pos and 15 pla2r neg) with calcineurin inhibitor group. Serum creatinine, 24-hour urinary protein, serum albumin, and total cholesterol values were collected at baseline, six months, and 12 months. Results were compared between PLA2R positive and negative groups. We have defined complete remission, partial remission and no remission, and total remission (complete+partial) according to standard definition. It has been observed that at 6 months in MP regimen total remission rate (72.72% vs 80.76%, p value 0.436) and complete remission rate (22.7% vs 19.23%, p value 0.688) were lower in PLA2R negative group than positive group and at 12 months total remission rate (72.72% vs 80.76%, p value 0.436) and complete remission rate (31.81% vs 46.15%, p value 1) persisted to be lower. But both the values are not statistically significant. Mean serum creatinine level at 6 and 12 months between groups were comparable. In rituximab group, total remission rate (72.2% vs 83%, p value 0.802) and complete remission rate (5% vs 8.3%, p value 0.405) were lower in PLA2R negative group than positive group at 6 months and total remission (77.7% VS 87.5%, p value 0.268) and complete remission rate (38.8% vs 45.83%, p value 0.286) persisted to be lower inPLA2R negative than positive group, but the values are not statistically significant. In tacrolimus group, total remission rate (70% vs 66.6%, p value 0.05) and complete remission rate (13.3% vs 5.8%, p value 0.685) were higher in PLA2R negative group than positive group which persisted at 12 months follow-up TR (73.3% vs 70.5%, p value 0.030) and CR (33.3% vs 29.4%, p value 0.063), and the value is statistically significant. Among the three immunosuppressive regimens CNI group treatment showed statistically significant better remission in PLA2r negative group but with other two immunosuppressive regimen PLA2r positive group showed better response, though not statistically significant.

CONCLUSIONS: Quantitative PLA2R estimation is an emerging prognostic tool to predict the outcome of membranous GN. Our study compared the outcome of PLA2R positive vs negative membranous GN treated with conservative management and existent three different options of immunosuppressive therapy. However, we failed to find any statistically significant correlation of PLA2R positivity with worse outcome.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 175: TWO PHASE III TRIALS EVALUATING CROVALIMAB IN PATIENTS WITH ATYPICAL HAEMOLYTIC UREMIC SYNDROME (AHUS): COMMUTE-A AND COMMUTE-P

Sidharth Kumar Sethi 1, Neil Sheerin 1, Larry A Greenbaum 1, Shuichi Ito 1, Chantal Loirat 1, Shoichi Maruyama 1, Ming-Hui Zhao 1, Khaled Benkali 1, Christelle Pieterse 1, Mona D Shah 1, Alexandre Sostelly 1, Sasha Sreckovic 1, Fadi Fakhouri 1

BACKGROUND: aHUS is a life-threatening disease of complement dysregulation characterized by thrombotic microangiopathy (TMA). While treatment with C5 inhibition is effective currently approved therapies require regular intravenous infusions. Crovalimab a novel anti-C5 monoclonal antibody allows for small-volume subcutaneous self-injections. Crovalimab is being tested for treatment of aHUS in two global Phase III single-arm trials: COMMUTE-a and COMMUTE-p.

AIM OF THE STUDY: i) Global Phase III single arm trial to test efficacy and safety of Crovalimab in adult participants with Atypical Hemolytic Uremic Syndrome (aHUS) (COMMUTE-a), ii) Global Phase III single arm trial to test efficacy and safety of Crovalimab in pediatric participants with Atypical Hemolytic Uremic Syndrome (aHUS) (COMMUTE-p)

METHODS: COMMUTE-a (NCT04861259) will enroll 3 cohorts of patients globally with aHUS aged ≥ 12 years and weighing ≥ 40 kg (N ≈ 90): 1) Naive (n ≈ 60): complement inhibitor-naive patients; 2) Switch (n ≈ 30): patients switching from eculizumab/ravulizumab; and 3) C5 SNP (n < 5): patients with a known single-nucleotide polymorphism (SNP). In India, planned enrollment is 12 patients from Naïve and C5 SNP cohort COMMUTE-p (NCT04958265) will enroll 3 cohorts of patients globally with aHUS aged ≥ 28 days to < 18 years and weighing ≥ 5 kg (N ≈ 35): 1) Naive (n ≈ 20): complement inhibitor-naive patients; 2) Switch (n ≈ 10): patients switching from eculizumab/ravulizumab; and 3) Pretreated (n < 10): patients who received and discontinued prior eculizumab/ravulizumab treatment. In India, planned enrollment is 6 patients from Naïve cohort. In both COMMUTE-a and COMMUTE-p trials, patients will receive weight-based crovalimab as a weekly loading series (Weeks 1-4; intravenous dose on Day 1 followed by subcutaneous dosing for subsequent loading doses) followed by self-administered subcutaneous maintenance doses once every 4 weeks (or once every 2 weeks if <20 kg; Week 5 onward). The primary objective for both studies is to evaluate the efficacy of crovalimab in Naive patients based on the proportion of patients with complete TMA response any time from baseline to Week 25.

RESULTS: COMMUTE-a and COMMUTE-p are currently enrolling.

CONCLUSIONS: Both COMMUTE-a and COMMUTE-p will assess the efficacy and safety of crovalimab in patients with aHUS.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 176: SEVERE ANEMIA AND METABOLIC ACIDOSIS WITH TOPICAL BRINZOLAMIDE IN A KIDNEY TRANSPLANT PATIENT

Saumya Vishnoi 1, Ishan Parekh 1, Madhavi Dadwe 1, Virendra Chauhan 1, Krishnapriya 1, Chaitrali Gawde 1, Hepal Vora 1, Zaheer Virani 1, Prashant Rajput 1, Shruti Tapiawala 1, Bharat V Shah 1

BACKGROUND: Carbonic anhydrase inhibitors (CAI) are known to cause anemia and metabolic acidosis. However, topical (eyedrop) formulation is not commonly associated with these side effects. We present a case where topical instillation of Brinzolamide led to severe anemia and metabolic acidosis.

AIM OF THE STUDY: Our aim is to report a case of severe anemia and metabolic acidosis due to brinzolamide eye drops in a kidney transplant recipient with chronic allograft nephropathy.

METHODS: A 36-year-old female with ESKD due to IgA nephropathy underwent ABO compatible living donor kidney transplant in August 2019. She did well after transplant and was discharged with serum creatinine of 0.93 mg/dl. In January 2022, she presented to us with severe anemia (hemoglobin- 6.5 mg/dl) metabolic acidosis and allograft dysfunction for which she was evaluated.

RESULTS: Renal profile revealed raised S. creatinine (2.3 mg/dl), and normal anion gap metabolic acidosis. Hb was 6.5 mg/dl, TLC was 4500/mm3, and platelets were 195000/ mm3. Iron studies and S.LDH were normal. Direct and indirect Coombs test and parvovirus PCR were negative. Corrected reticulocyte count was 2.6%. Bone marrow biopsy revealed a normocellular marrow. Kidney biopsy revealed interstitial fibrosis with tubular atrophy (IFTA) for which tacrolimus was reduced. On enquiry, she revealed being on brinzolamide eye drops for glaucoma. The eyedrops were stopped. Over next few months, her Hb and metabolic acidosis improved, and creatinine stabilized at 1.5-1.7 mg/dl.

CONCLUSIONS: This case highlights that topical brinzolamide can cause severe anemia and metabolic acidosis in a patient with impaired kidney function. After ophthalmic instillation, some amount of Brinzolamide enters the systemic circulation via the conjunctival blood vessels. It is slowly eliminated via the kidneys, and it is likely that adverse effects of brinzolamide seen here were due to allograft dysfunction.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 177: CLINICAL PROFILE AND OUTCOME OF ADULT PODOCYTOPATHY; A SINGLE CENTRE RETROSPECTIVE COHORT STUDY

Rahul R Nair 1, Anwitha Varamudhy 1, Sree Bhushan Raju 1, Avinash Thakur 1, Shankar Gadwal 1

BACKGROUND: Podocyte injury without immune complex deposits called as primary podocytopathies produce different histopathological lesions pattern on biopsy. The four types distinguished are minimal change disease, focal segmental sclerosis, diffuse mesangial sclerosis, and collapsing glomerulopathy. We studied the clinical profile and outcome of adult podocytopathy.

AIM OF THE STUDY: Aim: Analysis of clinical profile of podocytopathies and correlation of clinical laboratory and pathological features of podocytopathies that might help predict progression of the disease and to assess the response to the treatment given Objectives 1. To assess the spectrum of clinical and biochemical features of patients with podocytopathy. 2. To assess the response to treatment in each pattern of podocytic injury. 3. To assess the association of biochemical histopathologic features with remission. 4. To identify the incidence of CKD at follow-up. 5. To assess patient outcome in terms of survival

METHODS: Retrospective observational study done in Department of Nephrology in Nizam Institute Of Medical Sciences, Hyderabad. All patients with biopsy-proven podocytopathy were included. A semistructured pro forma was used to collect data. Clinical and laboratory features kidney biopsy findings treatment details and outcome noted.

RESULTS: There were a total of 51 patients finally enrolled in the study. Mean duration of follow-up was 19.10+/-13.932 months with minimum follow-up period of being 53 months from the time of histological diagnosis. 41.2% presented with nephrotic syndrome, 23.53% presented with subnephrotic range proteinuria, 29.4% presented with nephrotic syndrome with renal dysfunction, and 5.88% with subephrotic range proteinuria with renal dysfunction. MCD (60.80%), FSGS (29.40), FSGS with ATN (2%) were the pathological findings. 39.20% responded to steroids, and 23.50% were steroid resistant. 25.5% (n = 13) had CKD. 3 out of 51 patients (5.9%) became dialysis dependent. Mortality rate in our study was 7.8%.

CONCLUSIONS: Minimal change disease and absence of IFTA on histology are associated with higher rates of remission. Baseline urine spot PCR and creatinine values did not predict remission pattern in our study. There were no identifiable electron microscopic features studied in the analysis that could be used for prognostication.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 178: CHRONIC AMBULATORY PERITONEAL DIALYSIS WITH SINGLE 7.5% ICODEXTRIN CYCLE- A NOVEL APPROACH TO TREAT REFRACTORY HEART FAILURE WITH CHRONIC KIDNEY DISEASE

Amit Kumar Mohanty 1, Vineet Behera 1, Prabhat Chauhan 1, R Ananthakrishnan 1

BACKGROUND: Refractory heart failure (RHF) presents with worsening chronic fluid overload despite diuretics. Presence of chronic kidney disease (CKD) aggravates the problem leading to poor quality of life and higher morbidity. Peritoneal dialysis (PD) has been tried as an option for RHF but there is scarce data in this regard.

AIM OF THE STUDY: Peritoneal dialysis (PD) as a novel approach to treat Refractory Heart Failure with Chronic Kidney Disease.

METHODS: A retrospective observational study was conducted from Jun 2019 to Jun 2022 in a tertiary care hospital. All patients of RHF and CKD stage 4-5 who were treated with chronic ambulatory peritoneal dialysis (CAPD) — single cycle of 7.5% icodextrin were included in study. Patients with >1 CAPD cycles or hemodialysis patients lost to follow-up were excluded. Details of demography cardiac status CKD status CAPD clinical and laboratory parameters were recorded.

RESULTS: Eighteen cases of RHF and CAPD were recruited of which three were on 03 CAPD cycles and were excluded. All patients had history of frequent hospitalization with the most common underlying cause of heart disease being CAD. 15 cases (on single 7.5% icodextrin exchange of > 12 hours/day) were included in study. 10 (66.7%) were males with mean age of 56.4 ± 7.2 years and GFR of 12 ± 4.2 mg/dL. The patients had an average urine output of 820.5 ± 112.2 ml/day with CAPD ultrafiltration of 610.5 ± 92.2 ml/day. 13 patients (86.7%) reported significant subjective improvement in heart failure symptoms, with 5 (33.3%) reporting hospitalization over 1 year (decrease in 66.7%). CAPD peritonitis was seen in 2 (13.3%), mechanical flow problems in 2 (13.3%), and 4 (26.7%) patients progressed to require >1 CAPD cycles. Mortality was seen in 3 (20%) (01 — cardiac cause/acute RHF, 01- right pneumonia/sepsis, 01 — hemorrhagic stroke).

CONCLUSIONS: Single 7.5% icodextrin CAPD exchange is an effective option for patients with RHF and CKD with improvement in symptoms and reduced hospitalization and no major complications of CAPD.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 179: A STUDY OF CLINICAL CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH ACUTE KIDNEY INJURY (AKI) HOSPITALIZED IN TERTIARY CARE CENTRE IN SOUTH INDIA

Prafull B Chege 1

BACKGROUND: Acute kidney injury (AKI) is a major public health concern associated with high mortality morbidity and long-term risk of chronic kidney disease. Significant differences exist in the epidemiology and outcomes of AKI from the developed and developing world. More than 85% of the global burden of AKI is from developing countries. AKI can be community-acquired AKI (CAAKI) or hospital-acquired AKI (HAAKI). AKI in developed countries tends to affect elderly patients with comorbidities and results in higher mortality rates. AKI in tropical low- and middle-income countries like India is characterized by a higher burden of CAAKI occurring in relatively young patients without significant comorbidities. The proportion of CAAKI is more and most often a single reversible factor such as infection toxin volume depletion or drugs might be responsible. AKI is common in critical care units and is a major factor contributing to adverse outcomes. Existing literature from India reports CAAKI as the leading cause of AKI in critically ill. HAAKI is often under recognized and under reported in the developing world. This study aim to identify the etiology short-term outcomes and determinants of mortality in patients with AKI admitted in a tertiary care center.

AIM OF THE STUDY: A Study of Clinical characteristics and outcomes of patients with Acute Kidney Injury (AKI) hospitalized from January 2020 to April 2022 in Tertiary Care Centre in South India.

METHODS: This retrospective study with 859 AKI patients admitted at Gandhi Hospital Secunderabad from January 2020 to April 2022 at having a serum creatinine level greater than 1.4 mg/dl and blood urea greater than 40 mg/dl. The AKI patients aged less than 18 years at the time of enrollment and ultrasound evidence of bilaterally small kidneys suggestive of chronic renal failure were excluded from the study. Evaluation included a detailed history taking (includes past medical and/or surgical history signs of azotemia (nausea and vomiting) altered sensorium or other symptoms associated with AKI) clinical examination for assessing volume status and laboratory investigations. Patients were followed up until discharge or death. Hemodialysis was conducted as and when required. Statistical analysis of the categorical variables was expressed as frequencies and percentages and continuous variables as mean and standard deviation. The data were analyzed using statistical package for the social sciences (SPSS) version 20. Study design: This is Observational Retrospective study. Analysis includes clinical profile epidemiological data lab parameters and outcomes. Inclusion Criteria Patients above age more than 18 years Exclusion criteria Patients with Age less than 18 years Patients with bilateral small kidneys on ultrasound pregnancy

RESULTS: A total of 859 patients were included in this study, and analysis includes clinical profile, epidemiological data, lab parameters and outcomes. Mean Age 52.2+_7 Sex Ratio (M:F) 1.4:1 (502:357) DM 78 09.08% HTN 65 07.56% CAD 39 04.54% COPD 28 03.25% Old CVA 15 01.74% Table 2: Presenting symptoms Symptoms No. Percentage Fever 245 28.52% Breathlessness 179 20.83% Pedal edema 98 11.40% Abdominal pain 89 10.36% Decreased urine 459 53.43% Nausea and vomiting 305 35.50% Altered sensorium 76 08.84% Bleeding 45 05.23% Chest pain 46 05.35% Cough 42 05.28% Syncope 10 01.16% Dysuria 28 03.25% Cellulitis 79 09.19% Trauma 21 02.44% Icterus 68 07.91% Diarrhea 85 09.89% Headache 145 16.88% Hemorrhage 08 0.09% Seizures 18 02.95% Backache 79 09.19% Facial puffiness 112 13.03% Hiccoughs 45 05.23% Table 3: Lab Parameters. Blood parameters Mean (mg/dl) Urea 118.07 Creatinine 5.65 Hemoglobin 9.32 Leukocyte 10950 Platelets 138000 Sr. Albumin 2.8 Table 4: Treatment modalities. Treatment No. Percentage Acute PD 78 09.08% Acute PD F/B Hemodialysis 72 08.38% Hemodialysis 709 82.53% Table 5: Treatment outcomes Outcome No. Percentage Complete Recovered 259 30.15% Partially Recovered 238 27.70% Chronic Kidney Disease 41 04.77% Non-Traceable (Mortality Excluded) 182 21.18% Table 6: Treatment outcomes in terms of Survival. Outcome No. Percentage Survival 538 62.60% Mortality 139 16.18% Non-Traceable 182 21.18% Table 7: Etiologies of acute kidney injury Etiology No. Percentage Snake bite 21 02.44% Dengue Malaria Leptospirosis 59 06.86% Cellulitis 61 07.10% Cerebrovascular accident 39 04.54% Poisoning 113 13.15% CLD 87 10.12% Sepsis 229 26.65% Cardiogenic shock 57 06.63% Fracture femur 3 0.03% Gastroenteritis 62 07.21% Malignancy 28 03.25% Obstructive uropathy 61 07.10% Table 8: Characteristics of survivor’s versus nonsurvivors Parameter Survivor’s (n = 538) Nonsurvivors (n = 139) P Age 45.94 ± 16.722 51.54 ± 8.092 <0.01 Creatinine 5.19 ± 1.79 6.31 ± 1.89 0.65 Leukocyte count 13.05 ± 0.57 15.81 ± 0.16 0.24 Platelet count 1.78 ± 0.83 1.33 ± 0.88 0.02 Vasopressor use 32 (5.56) 85 (61.1) <0.01

CONCLUSIONS: Conclusion: Sepsis was most common cause for Acute Kidney Injury. Decreased urine output was most common presenting symptom followed by fever breathlessness. Patients recovered completely were 30.15%, Partially recovered 27.7% and CKD in 4.77%. Out of 859 patients, 538 (62.60%) survived and 139 (16.18%) died. Factors affecting mortality were age, thrombocytopenia, and patients on vasopressors. Limitations: Many patients present status (21.18%) couldn’t be traced.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 180: OCCULT HEPATITIS-B INFECTION IN HEMODIALYSIS PATIENTS IN A TERTIARY HEALTH CARE CENTRE

Y Kranthi Rekha 1, Vinay Rathore 1, Anuditha Bhargava 1, Sanjay Singh Negi 1

BACKGROUND: Occult Hepatitis B (OBI) is defined as serologically undetectable Hepatitis-B surface antigen (HBsAg-ve) despite presence of circulating Hepatitis-B Virus (HBV) DNA. This study aims to estimate the prevalence of OBI among hemodialysis patients and identify risk factor associated with it.

AIM OF THE STUDY: To estimate the prevalence of Occult Hepatitis-B Infection in hemodialysis patients

METHODS: The study was conducted at AIIMS-Raipur a tertiary care institute in central India between October 2020 to September 2021. All HBsAg negative patients visiting Department of Nephrology aged more than 18 years undergoing hemodialysis for more than three months were included in the study. Clinical and demographic details were collected using standard proforma. DNA was extracted from the plasma and used as template for performing real-time PCR. HBV DNA PCR was done using commercial standardized kit (My lab discovery solutions pvt.ltd) targeting conserved region of ‘S’ gene. Serum samples of the patients showing positive results with HBV real-time PCR were then subjected to anti-HBc total antibodies and anti-HBs antibody testing by ELFA.

RESULTS: 201 patients undergoing dialysis were included in the study. 67% (n-134) were male. The mean age was 47.8 ± 14.84, and mean duration on maintenance hemodialysis was 15.5 ± 8.0 months. Only eighty-three patients (41%) patients had received vaccination for Hepatitis-B, among these only two patients received complete vaccination. 32% (n = 64) of the patients were having history of at least one blood transfusion. Six patients (2.9%) had OBI. Quantitative PCR was done for samples which showed virals loads, 4.3×109, 8.7×105, 1.07×107, 2.3×105 IU/ml

CONCLUSIONS: The prevalence of OBI was 2.9%. RT-PCR test for detection of HBV-DNA, anti-HBc total antibodies, and anti-HBs antibodies testing should be done in high-risk cases like CKD patients on hemodialysis to identify cases of OBI.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 181: PREDICTING THE ROLE OF SERUM ANTI-PHOSPHOLIPASE A2 RECEPTOR (PLA2R) ANTIBODY IN THE OUTCOME OF PRIMARY MEMBRANOUS NEPHROPATHY

Chinmayananda Dash 1, Sarat Kumar Parida 1, Aruna Acharya 1, Rakesh Kumar Routray 1, Rudrashis Samal 1

BACKGROUND: Primary membranous nephropathy (PMN) is one of the major causes of the nephrotic syndrome in adults characterized by sub-epithelial immune complex deposits with glomerular basement membrane thickening. Approximately 75% of primary MN cases are due to renal deposits of immunoglobulin G4 (IgG4) antibodies against the M-type phospholipase A2 receptor (PLA2R) expressed in the podocytes. If left untreated about one-third of MN patients achieved spontaneous remission (SR) while a similar percentage may progress to chronic renal failure. As a high percentage of patients may go to spontaneous remission immunosuppressive treatment is reserved for those when there is a high risk of progressive loss of renal function. The current guidelines indicate that by categorizing patients as low, moderate, high, and very high risk of progressive loss of kidney function allows one to identify those who are more likely to develop spontaneous remission within less than 24 months. For patients in the low-risk and medium-risk categories, it is considered reasonable to start immunosuppressive treatment depending on the evolution of proteinuria six months after diagnosis.

AIM OF THE STUDY: 1. To study the correlation of serum anti-PLA2R antibody titers with likelihood of spontaneous remission. 2. To evaluate the prognostic value of anti-PLA2R antibody levels regarding disease activity and clinical outcome.

METHODS: Patients newly diagnosed with nephrotic syndrome secondary to anti-PLA2R associated membranous nephropathy were taken as the study population. Patients with membranous nephropathy associated with anti-PLA2R antibody confirmed by renal biopsy were included in the study. Patients with secondary membranous nephropathy and also those who lost follow-up within the first 6 months after diagnosis were excluded. Baseline and follow-up data were collected. Data recorded at baseline included age, gender, diagnosis of diabetes mellitus (DM), serum albumin, serum urea, creatinine, lipid profile, urine routine, and microscopy 24h urine protein spot urine PCR anti-PLA2R antibody and eGFR. Anti-PLA2R antibody titers will be taken at 3 and 6 months. During the observation period, all patients were treated with diuretics statins and renin—angiotensin system blockers or immunosuppressive treatment as required and as per latest KDIGO guidelines.

RESULTS: It was observed that low anti-PLA2R levels at diagnosis are associated with spontaneous remissions in PLA2R-related MN, whereas persistent proteinuria and/ or the need for immunosuppressive agents were less frequently observed in these patients. It was found that combined assessment of circulating anti-PLA2R and proteinuria may be instrumental to monitor disease activity and guide treatment decisions in PLA2R-related MN.

CONCLUSIONS: Anti-PLA2R quantification as determined at the time of diagnosis is of predictive value in patients with PLA2R-related MN. Low antibody levels are associated with spontaneous remissions in the patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 182: CEET PROCEDURE (CATHETER EXCHANGE WITH ELONGATION OF TUNNEL) €”A NOVEL TECHNIQUE FOR CUFF EXTRUSION OF TUNNELED DIALYSIS CATHETER: SURGICAL EXPERIENCE AND EARLY OUTCOMES

Vineet Behera 1, Vishwanath 1, G Shanmugraj 1, P Chauhan 1, R Ananthakrishnan 1

BACKGROUND: Cuff extrusion of tunneled dialysis catheter (TDC) is a common non-infectious complication. Definitive management is to remove TDC and reinsert new catheter by new venous puncture and tunnel which may be difficult and may not be possible in all cases.

AIM OF THE STUDY: To study the surgical experience and early outcomes of a novel “Catheter Exchange with Elongation of Tunnel (CEET) †procedure for cuff extrusion.

METHODS: The retrospective observational study included all cases of hemodialysis with TDC with partial or complete extrusion with part of catheter remaining in central veins and excluded complete catheter dislodgement tunnel infection or any catheter related infection. We developed novel technique “Catheter Exchange with Elongation of Tunnel (CEET) †for managing cuff extrusion of TDC. In this technique, J tip Terumo 0.025†guide wire was passed through existing TDC into IVC catheter cuff was released from the subcutaneous adhesions and pulled out new tunnel of required length was created including a part of the old tunnel, and a new TDC was threaded through guide wires into the IJV.

RESULTS: Nine cases of cuff extrusion were included of which 08 underwent CEET procedure (females 60%, mean age 48Â ± 5.6 years), 05 (55.5%) were diabetic, 03 (33.4%) had prior catheter related infection, and 06 cases (66.6%) had short tunnel length which likely predisposed to cuff extrusion. The mean duration of previous TDC was 8Â ± 1.6 months, and it involved the right internal jugular vein (IJV) in 6 (74.2%) and left internal IJV in 2 (25.6%). A short tunnel length was seen in 6 (74.2%) cases which was corrected after the CEET procedure by doing tunnel elongation. The procedure was successful in 8 cases (88.4%) with appropriate functioning and position of new TDC. No recurrence was seen in any case and no other complications were seen.

CONCLUSIONS: CEET procedure is a successful alternative technique for correction of cuff extrusion of TDC with good success rate and minimal complications.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 183: ACUTE KIDNEY INJURY AFTER BISMUTH INTOXICATION: CASE REPORT

Ranjit Singh 1, S Namrata Rao 1, Abhilash Chandra 1

BACKGROUND: Bismuth salts were hitherto commonly used in the management of peptic ulcers. However, their use has declined considerably over the years mainly owing to the availability of PPI. Colloidal bismuth subcitrate has been reported in the literature to be nephrotoxic in humans when taken in high doses.

AIM OF THE STUDY: This a case report

METHODS: A 28-year-old female presented in OPD with complaint of alleged ingestion of 100 ml of CBS-containing antacid (equivalent of 50 ml of CBS/1400 mg of Bi2O2) with suicidal intent one week prior. She did not take any other medicines along with the bismuth-containing syrup. Four days later she developed sudden onset of nil urine output nausea vomiting and swelling in both lower limbs. There was no medical history of previous intoxication or any other health problems. At the time of admission, her vitals were stable but she was anuric. Laboratory investigation showed deranged RFT (blood urea 58 mg/dL blood serum creatinine 6.9 mg/ dL), and rest investigation were noncontributory. During hospital stay, she underwent 3 sessions of hemodialysis on 0, 2, and 4 days of admission. The patient’s oliguric phase of the ARF subsided from 7th day of admission, and arterial blood gases returned to normal while the serum creatinine levels remained high. In view of persistent high S. creatinine on 14th day of index event, her renal biopsy was done and result of which were conclusive for the diagnosis of acute tubulointerstitial nephritis. With further conservative management her urine output is increase and serum creatinine level started to decreasing. She was discharged on day 18th post-index event and day 114th after admission. During discharge time, her serum creatinine level was 2.3 mg/dl and was showing a decreasing trend.

RESULTS: Bismuth intoxication may cause acute kidney injury in the form of acute interstitial nephritis.

CONCLUSIONS: We conclude that bismuth intoxication may cause acute kidney injury due to acute interstitial nephritis. Timely management with hemodialysis and supportive care is the appropriate therapy for such case.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 184: ROLE OF RITUXIMAB IN PATIENTS WITH RESISTANT NEPHROTIC SYNDROME

Hapani Nikita Nanjibhai 1, Seetaram Singh 1, Dhananjai Agarwal 1, Rakesh Gupta 1

BACKGROUND: Resistant nephrotic syndrome is a group of disorders with diverse histological findings which are by definition resistant to corticosteroids given in adequate dose for adequate duration, and many are resistant to other therapy as well 1 2. In many patients, progression to end-stage renal disease is the ultimate outcome. The role of B cells has not been fully explained in man agents that specifically interfere with B cells would ideally represent the first step toward selective therapy.

AIM OF THE STUDY: To study short-term and long-term effects of rituximab in patients with resistant primary nephrotic syndrome.

METHODS: Study was conducted at SMS-Medical College and Hospital, Jaipur, and patients were given four doses of rituximab weakly in fixed dose of 500 mg per dose, and proteinuria was evaluated before start of therapy and at 3 months 6 months and 12 months of therapy. Patients with resistant primary nephrotic syndrome who failed to respond to other therapies with stable eGFR >30 and controlled BP were included in study. Patients with active infection uncontrolled hypertension pregnancy were excluded from study.

RESULTS: 10 patients were enrolled in study out of which 7 FSGS and 3 were MGN, 5 were female and 5 were male, age 17-61years (avg 34.6), wg were 48-70 kg (avg 57.9), BMI 19.4-23 (AVG 21.18), all patients have normal renal function (avg creatinine value of 0.8, range = 0.5 to 1.1). At 3 months, 1 patient had partial response and 9 had no response. At 6 months of treatment, 2 patients had partial response, 3 had complete response, and 5 no response. At 12 months of treatment, 4 had partial response, 5 had complete response, and 1 no response. Out of 10 patients, no one had relapse of Nephrotic syndrome at 12 month of therapy. Renal function remains normal in all patients over 12 months follow-up.

CONCLUSIONS: This prospective, observational study evaluated 3 month, 6 month, and 12 month outcome of 3 IMN and 7 FSGS patients, with persistent nephrotic range proteinuria and showed that rituximab promoted sustained remission in proteinuria in resistant nephrotic syndrome with normal renal function.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 185: RISK FACTORS AND THEIR RELATIVE STRENGTHS IN PREDICTING INCIDENCE OF NEW ONSET DIABETES AFTER TRANSPLANT (NODAT) - A SINGLE CENTRE STUDY

Saumya Gupta 1, Reetesh Sharma 1

BACKGROUND: Renal transplant offers the best treatment modality for patients with ESRD. With increasing number of renal allograft recipients, there have been many advances in the immunotherapy and there has been a transition from chronic graft dysfunction to the death of patient from cardiovascular morbidity. One such reason for increased cardiovascular mortality is development of new onset diabetes after transplant. The current definition of NODAT follows ADA guidelines (2003). The peak incidence of NODAT occurs till 6 months post-transplant. As it has now become a major determinant of graft survival, this study was conducted to study the determinants of incidence of NODAT and to prevent its occurrence.

AIM OF THE STUDY: To identify risk factors and their strength in predicting incidence of NODAT

METHODS: Non-randomized Prospective Observational study with sample size of 70 patients who underwent renal transplant at our center. Patients who were known diabetics were excluded from the study. Pre-transplant risk factors like age family history waist/hip ratio BMI hepatitis C status pre-diabetic state were taken into account. Other factors like immunosuppressant drugs and their cumulative doses (steroids) and trough levels (CNIs) were taken into account. Pre-transplant oral glucose tolerance test was performed for all patients and post-transplant FBS PPBS and HBA1C were taken for comparison purpose between the 2 groups : NODAT and non-NODAT.

RESULTS: The incidence of NODAT in our study was found to be 35.6%. Male gender with higher BMI was more associated with development of NODAT. 75 gm oral glucose tolerance test came out as a single most important factor in predicting incidence of NODAT with all 3 parameters having positive correlation. Among other metabolic parameters, lipid profile had no relation, whereas HBA1C was found to be a predictive tool. Among infections, neither hepatitis C nor CMV status predicted NODAT. Cumulative steroid dose did not show any correlation. Similarly, tacrolimus levels also did not predict the incidence of NODAT. As the rate of rejection of low in our study population, no relation could be established. In most patients, hyperglycemia resolved within 3 months of transplant suggesting the role of higher doses of immunosuppressants.

CONCLUSIONS: NODAT is a severe metabolic complication after an organ transplant and poses many adverse long-term influences on patients' quality of life. The risk factors and incidence of NODAT have shown wide variability in previous studies and in our study as well. The cause of this variability could be lack of proper definition of NODAT.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 186: IMPORTANCE OF GENETIC TESTING IN FAMILIAL PRIMARY GLOMERULOPATHY

Madhavi Dadwe 1, Parekh Ishan 1, Vora Hepal 1, Virani Zaheer 1, Rajput Prashant 1, Tapiawala Shruti 1, Shah Bharat 1

BACKGROUND: Familial primary glomerulopathy is caused by genetic abnormalities. It usually presents as steroid resistant nephrotic syndrome and often progresses to end-stage kidney disease (ESKD). There is often a family history of similar kidney disease in the family. Identifying genetic cause in such cases is important because it helps in planning appropriate therapy prognosticating outcome of transplant and in family planning.

AIM OF THE STUDY: To show importance of genetic testing in patients presenting with familial primary glomerulopathy.

METHODS: We present 3 cases to show importance of genetic testing in 3 patients with familial primary glomerulopathy. Two cases presented with steroid-resistant nephrotic syndrome which progressed to ESKD while 1 case presented with advanced chronic kidney disease requiring dialysis. All the 3 cases had family history of similar kidney disease. In all 3 cases, the technique used for genetic testing was next-generation sequencing (NGS) which can identify disease-causing mutations in the entire genome (whole-genome sequencing)

RESULTS: Genetic study in case 1 revealed a heterozygous mutation in the inverted formin 2 (INF2) gene, exon 2 [c.230T>A (p.Leu77Gln)]. Case 2 revealed mutation in exon 2 of LMX1B gene, and case 3 revealed heterozygous mutation in the INF2 gene, exon 2 [c.396_404del (p.ser135_val137del)].

CONCLUSIONS: Our study shows the importance of identifying genetic cause of familial primary glomerulopathy based on clinical clues of a positive family history, early age at onset of disease, and/or severe therapy-resistant disease. This can obviate need for kidney biopsy, potential harmful therapy and help prognosticate better outcome after transplant. This can also help family planning for affected patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 187: A RARE CASE OF BORTEZOMIB INDUCED TOXIC EPIDERMAL NECROLYSIS IN A POST RENAL TRANSPLANT GRAFT DYSFUNCTION

Priyanka Lawangani 1, Hinal Rathod 1, Ankita Metaliya 1, Siddhivinayak Rajmane 1, Nikhil Dhope 1, Rejita R Kamal 1, Ashay Shingare 1, Madan Bahadur 1

BACKGROUND: Bortezomib, a selective reversible proteasome complex inhibitor which is commonly used in malignancy like Multiple Myeloma chronic lymphocytic leukemia, etc., is also being used in humoral rejections in renal grafts. Rare and fatal adverse drug reactions like Toxic Epidermal Necrolysis can occur with this drug.

AIM OF THE STUDY: To make people aware about this rare adverse drug reaction in Humoral graft dysfunction.

METHODS: We present a case of a 45-year male patient diagnosed as systemic hypertension diabetes mellitus with chronic kidney disease (cause unknown) received MHD for 3 months. Renal transplantation was done in August 2021 ABO incompatible mother being donor. He was on Tacrolimus Mycophenolac Mofetil Steroids. He presented this time in view of rising creatinine since Feb 2022 (3-5.6) and decreasing urine output. Renal biopsy was done suggestive of Active Humoral Rejection. Considering rejection he was started on pulse therapy with MPS 500 mg and PLEX Inj Rituximab; there was no improvement in s.creatinine levels considering resistant rejection he was given Inj. Bortezomib 2 mg IV one dose. Patient started having skin peeling rashes. Diagnosis of Toxic Epidermal Necrolysis was made. Further immunosuppression not escalated after reaction due to ?secondary skin infection. Graft failed. MHD initiated.

RESULTS: The only new drug which was started was Bortezomib in view of antibody-mediated rejection. Ruling out all possibilities, TEN was attributed secondary to Bortezomib as all other medications including Rituximab had been given without reactions.

CONCLUSIONS: Reported severe drug reactions like TEN caused by Bortezomib are very rare. Hence, it is necessary to be aware that such reactions can occur with Bortezomib.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 188: SURVIVAL AND FACTORS INFLUENCING MORTALITY AMONG WOMEN ON HD IN INDIA

Suresh Sankar 1

BACKGROUND: Women form minority among HD in India but characteristics clinical outcome and predictors are not known

AIM OF THE STUDY: 1. To study predictors affecting mortality patients on HD. 2. To analyze differences between men and women on HD

METHODS: Deaths that occurred in large dialysis network between Jan and Mar 2021 were analyzed. An age matched control was selected to study factors influencing mortality including educational status BMI duration of HD type of HD center payer type access Hb Albumin Albumin diabetic status h/o heart failure and h/o hospitalization were studied. A multivariate analysis identified factors and these were compared between men and women to identify unique differences

RESULTS:

CONCLUSIONS: Significant socioeconomic and certain HD characteristics differences exist between women and men on HD in India

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 189: SYNERGY OF PDE5-INHIBITOR AND 5-HT2B RECEPTOR MITIGATES FIBROTIC POTENTIAL OF HUMAN RENAL ALLOGRAFT FIBROBLASTS

Akhilesh Jaiswal 1, Narayan Prasad 1, Mantabya Singh 1, Saurabh Chaturvedi 1, Vikas Agarwal 2

BACKGROUND: Despite improvements in immunosuppressive therapy long-term allograft survival after kidney transplantation remains as low as 50%. The primary cause of chronic allograft nephropathy is “interstitial fibrosis and tubular atrophy†(IF/TA). Serotonin (5-HT; 5-Hydroxytryptamine) produces extracellular matrix proteins in presence of TGF-Î21 dependent manner. TGF-Î21 activates resident fibroblasts and trans-differentiate into myo-fibroblasts which is the hallmark of the pathogenesis of fibrosis.

AIM OF THE STUDY: We aimed to evaluate the anti-fibrotic role of inhibitors of Phosphodiesterase V Inhibitor (PDE5 inhibitor) in human renal fibroblasts (HRFB) isolated from renal allograft rejection patients.

METHODS: Renal fibroblasts isolated from renal allograft rejection patients (n = 9; 5 with rejection and 4 without rejection) and controls (n = 4) were incubated with TGF-Î21 (10ng/ml) for 1 hour and later with TGF-Î21 (10ng/ml)/ [Sildenafil (10ÂμM) or SB204741 (1ÂμM)] and their combination for 24 hours (post-treatment strategy). HRFBs were pre-treated with [Sildenafil (10ÂμM) or SB204741 (1ÂμM) and combination of the two for 1 hour and later with only TGF-Î21 (10ng/ml) for 24 hours in pre-treatment strategy. Real-time PCR was performed for pro-fibrotic (COL1A1 ACTA2 CTGF FN1 TGF-Î21), and anti-fibrotic genes (MMP2/TIMP1) expression was performed. Levels of cytokines IFN-ï §ï€Â¬ï€ IL-4 IL-17 IL-1Î2 IL-6 TNF-ï ¡ï€ ï€¨pro-inflammatoryï€©ï€ and IL-10 (anti-inflammatory) in culture supernatant of HRFBs were determined by ELISA.

RESULTS: In this study, anti-fibrotic effect of combination of Sildenafil and SB204741 was greater than that of each drug alone. In TGF-Î21 stimulated HRFBs, up-regulated expression of all pro-fibrotic genes was observed (p < 0.05). Expression of pro-fibrotic genes reduced significantly (p < 0.05) with almost complete amelioration of ACTA2, CTGF, and FN1. Ratio of anti-fibrotic genes (MMP2/TIMP1) was restored (p < 0.05). Production of pro-inflammatory cytokines also reduced (p < 0.05) with increase in IL-10 levels (p < 0.05).

CONCLUSIONS: Study suggests that the combination of Sildenafil and SB204741 may be advantage in treating allograft fibrosis in its active phase.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 190: CLINICAL PROFILE AND ETIOLOGY OF CKD IN KRISHNA AND GUNTUR DISTRICTS OF ANDHRA PRADESH

Perumallapalli Abhishek 1, Uttara Das 1

BACKGROUND: The clinical course of CKD (chronic kidney disease) is typically a progressive loss of renal function ultimately leading to end-stage renal disease (ESRD) requiring some form of renal replacement therapy. As this puts a significant burden on global resources planning for prevention of CKD by early identification of kidney damage by screening all individuals at risk is the most practical solution.

AIM OF THE STUDY: To study the clinical profile and etiology of newly diagnosed cases of CKD patients visiting the Dept of Nephrology AIIMS, MANGALAGIRI.

METHODS: This study was conducted between NOVEMBER 2021 to JULY 2022 in the DEPT OF NEPHROLOGY at ALL INDIA INSTITUTE OF MEDICAL SCIENCES MANGALAGIRI. All newly diagnosed cases of CKD were included in this study.

RESULTS: Of the total 200 patients included in the study, 136 (68%) were males and 64 (32%) were females. Majority 189 (94.5%) of the patients were between 21-70 years of age. About 47% had diabetes mellitus while 40% of the patients had hypertension. Those with both HYPERTENSION AND DIABETES constituted about 38.5% of the study population. The different stages of CKD include stage 2- 9% (18), stage 3-36% (73), stage 4 -31.5% (63), stage 5- 18% (36). The most common etiology is multifactorial-the presence of both hypertension and diabetes, followed by hypertension alone and diabetes alone. In significant proportion of cases (16% - about 32 cases), the cause is unknown due to NSAID abuse, dehydration, and environmental factors (chemicals, toxins). The mean hemoglobin in the study is 10.5 g/dl. There is significant statistical correlation between hemoglobin level and stage of CKD and also between serum phosphate level and stage of CKD. PARAMETER (MEAN ± SD) STAGE 2 STAGE 3 STAGE 4&5 REFERENCE MEAN HEMOGLOBIN 12.3 ± 2.3 12.1 ± 2.2 10.54  ± 2.15 13 - 16 MEAN AGE 46.7 ± 13.7 55.8 ± 12.5 52.6 ± 12.2 - MALE: FEMALE RATIO 11:07 62:11 57:42 - SERUM CREATININE 1.18 ± 0.17 1.79 ± 0.3 3.87 ± 1.94 0.6 — 1.1 SERUM URIC ACID 5.9 ± 1.5 6.75 ± 1.8 7.24 ± 2.02 4.4 — 7.6 SERUM SODIUM (Na+) 138 ± 5.1 138.1 ± 3.7 137.7 ± 5.5 136 - 145 SERUM POTASSIUM (K+) 4.3 ± 0.4 4.5 ± 0.5 4.6 ± 0.7 3.5 — 5.1 SERUM CALCIUM 8.7 ± 1.5 9.26 ± 0.57 8.93 ± 0.98 9.0 — 10.2 SERUM PHOSPHOROUS 4.5 ± 1.2 4.1 ± 0.89 5.28 ± 3.8 2.8 — 4.7 TSH 4.3 ± 4 4.12 ± 3.07 3.8 ± 2.4 0.4 — 4.2 TOTAL T3 114 ± 63 106.8 ± 28 95.69 ± 30.3 70 - 204 TOTAL T4 6.78 ± 2.4 7.85 ± 2.3 8.1 ± 2.2 4.6 - 10.5 SERUM ALBUMIN 3.54 ± 0.8 3.6 ± 0.7 3.89 ± 3 4.4 — 5.3 SERUM CHOLESTEROL 184.1 ± 46.2 184.6 ± 50.6 177.46 ± 65.3 <200 LDL 101.4 ± 26.6 108.4 ± 41.1 106.98 ± 51.6 <100 TRIGLYCERIDES 167 ± 98 172.3 ± 117.9 149.17 ± 86.4 <150

CONCLUSIONS: Early detection of CKD by screening of high-risk individuals will help in retarding the progression to ESRD. This will help in bringing down the huge burden due to mismatch between demand and availability of resources for renal replacement therapy in developing countries like India, especially for patients belonging to lower socioeconomic group.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 191: CONTINUOUS RENAL REPLACEMENT THERAPY IN CRITICALLY ILL PATIENTS: A 10 YEAR RETROSPECTIVE COHORT STUDY

Mathini Sundaramurthy 1, Prasanna Kumar 1, Namesh Kamat 1, Ram Rapoor 1, Sivakumar 1

BACKGROUND: Acute kidney injury (AKI) is a common complication in critically ill patients and is associated with substantial morbidity and risk of death. Approximately 5% to 10% of patients with AKI require renal replacement therapy (RRT) during their ICU stay (1) with mortality rates of 30% to 70%. (2) (3) (4) Over the past 2 decades, the incidence of RRT-requiring AKI has increased by approximately 10% per year. Although CRRT and SLED are most commonly used in hemodynamically unstable patients, there is marked variation in practice. In low-middle-income and developing country like India, the epidemiological data about the practices of RRT in various hospitals setups are lacking. Renal replacement therapy although is being widely practiced in India however is not uniform or standardized. This study was conducted to record the perceptions and current practices in CRRT management of critically ill patients in a tertiary care center and to assess the mortality and its predictors.

AIM OF THE STUDY: 1. To assess the demographic and laboratory characteristics of patients with AKI who underwent CRRT from 2013 to 2022 a tertiary care center in SVIMS Tirupati. 2. To study the primary and secondary outcomes of the patients initiated on CRRT: the primary outcome was survival and the secondary outcome was renal recovery..

METHODS: A retrospective cohort study was conducted among AKI patients admitted in SVIMS and who were initiated on CRRT over a period of ten years from Jan 2013 to June 2022. Their clinical laboratory characteristics and outcome- renal and overall outcome were studied. The factors which contributed to mortality were also analyzed

RESULTS: There were a total 134 patients who were initiated on CRRT during the study period. The mean age was 48.57 Â ± 19.33. Of the 134 patients, Female -55 (41%); Male -79 (59%). The mean serum creatinine was 3.45 Â ± 2.54. Of the 134 patients, 120 (89.6%) patients were diagnosed with sepsis. Of the 134 patients, 120 (97.8%) patients were on mechanical ventilatory support and 122 (91%) were on ionotropic support. The mean systolic blood pressure, total count on the day of initiation of CRRT were 114.13 Â ± 90.2, 9065 Â ± 2.16 respectively. The primary outcome was survival, and the secondary outcome was return of serum creatinine to baseline or improvement in urine output or non-dependency of dialysis. Of the 134 patients majority of patients -122 (91%) died and remained on CRRT until death or until CRRT was withdrawn for palliative care. Of the 134 patients 12 (9%) patients survived. Five of the 12 survivors recovered renal function and were not dependent on dialysis; 2 were discharged on chronic intermittent hemodialysis and 1 was discharged to continue Continuous ambulatory peritoneal dialysis and 3 were discharged to home hospice without renal recovery.

CONCLUSIONS: CRRT is the key RRT component in improving AKI outcome in critically ill patients. The mortality rate in our study group was 91% which was higher than other studies. In our study, patients in the non-survival group had low bicarbonate, low hemoglobin which was statistically significant. Even though there was no statistical significance patients with older age, low systolic BP succumbed in our study. Comparison of CRRT dose of 20,25, 30,35 between the survivors and non-survivors did not have any significant effect on the mortality. The strategic improvement of CRRT adoption in developing countries should be based on the understanding of the context of environment, socioeconomic, process of care, exposure, and inherent patient characteristics. All these components in developing countries have unique aspects which are different from the other parts of the world. In future, prospective studies defining relative importance of risk factors causing mortality can assist in building up guidelines to affect the outcome. Key Words: AKI, CRRT, Mortality

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 192: CORRELATION OF VENOUS BLOOD GAS WITH ARTERIAL BLOOD GAS VALUES IN PATIENTS ADMITTED TO EMERGENCY: A PILOT STUDY

Isha Sharma 1, Sanjay D'Cruz 1, Seema Gupta 1

BACKGROUND: Arterial blood gas sampling is one of the most commonly done investigations in patients admitted in emergency. However apart from being extremely painful, it has complications like hematoma formation aneurysm at puncture site ischemia of digits or gangrene. On the contrary, venous sampling is easier with little pain and lesser chances of complications.

AIM OF THE STUDY: To determine correlation between venous blood gas and arterial blood gas values in patients admitted to emergency

METHODS: Cross-sectional observational hospital-based study. Sample size was 140. Inclusion criteria is age 18 years and above admitted to emergency department. 2 simultaneous samples were taken from each patient from his/ her radial artery followed by a venous sample. Exclusion criteria were positive Allen’s test coagulopathy thrombocytopenia (<50 000) peripheral vascular disease.

RESULTS: 140 patients were studied. Spearman rank coefficient was used for correlation between ABG and VBG parameters. P value of <0.05 was considered significant. Univariate regression equations were also derived to predict arterial values from their venous counterparts. Mean venous pH was 7.360 while mean arterial pH was 7.390. The correlation coefficient for venous pH with arterial pH is 0.679 with a p value of <0.0001. The linear regression equation to convert venous pH to arterial Ph was 3.904+0.474*Ph (Venous). Mean venous pCO2 was 40.8 mm Hg, while mean arterial pCO2 was 37.14 mm Hg. The correlation coefficient of venous pCO2 with arterial pCO2 is 0.671, with a p value of <0.0001. The equation to convert venous pCO2 to arterial was 12.573+0.602*PCO2 (mmHg) (Venous). Mean venous bicarbonate was 22.9 mmol/L while mean arterial bicarbonate was 22.28 mmol/L. Venous bicarbonate had a correlation coefficient of 0.737 with the arterial bicarbonate values and a p value of <0.0001. The equation for conversion of venous to arterial bicarbonate was 3.828+0.806*Bicarbonate (mmol/L) (Venous). Mean venous pO2 was 43.36 mm Hg, and mean arterial pO2 was 85.42 mm Hg. However, on the applying the derived regression equation, 65.34+0.463*PO2 venous (mmHg), the corrected mean venous pO2 came out to be 85.41 mm Hg. Mean venous SpO2 was 63.71%, and mean arterial SpO2 was 90.68%. As in pO2, on applying derived regression equation for SpO2, 88.09+0.041*SpO2(%) (Venous), the corrected mean venous SpO2 was 90.70%.

CONCLUSIONS: Venous bicarbonate values have the highest correlation with corresponding arterial values followed by pH and then pCO2. PaO2 and SpO2 had no significant correlation between arterial and venous values; however, on applying the derived equations, PaO2 and SpO2 can be accurately predicted. Venous pH, bicarbonate, and pCO2 values have a good correlation with their arterial values and may be done in patients admitted in critical care areas and can be used in clinical practice, thereby reducing the morbidity and risk of complications due to ABG.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 193: NORMATIVE DATA FOR GLOMERULAR FILTRATION RATE IN HEALTHY KIDNEY DONOR POPULATION

Ashish Bhoyar 1, Ashwani Gupta 1

BACKGROUND: The glomerular filtration rate (GFR) is widely accepted as the index of kidney function in health and disease. GFR estimation is essential for clinical practice; it is important for deciding the symptoms signs and laboratory abnormalities that might signify kidney disease for dosing of drugs and for diagnosing managing and estimating the prognosis of chronic kidney disease (CKD). GFR has been measured by clearance of Inulin Diethylene Triamine Pentaacetic Acid (DTPA) and iohexol and estimated from various creatinine-based equations like 4 variable Modification of Diet in Renal Disease (MDRD) Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 24-hour urinary creatinine. Since muscle mass and dietary protein intake in particular that of animal meat are important determinants of serum creatinine concentration GFR estimated by 24-hour urinary creatinine varies widely with different ethnic groups. GFR estimation is important in the evaluation of kidney donor

AIM OF THE STUDY: To develop age-specific normative data for glomerular filtration rate as measured by DTPA 2- sample method in healthy kidney donor population. To compare glomerular filtration rate measured by DTPA 2 sample method and 24-hour urinary creatinine clearance method.

METHODS: 250 individuals were enrolled in this study after following inclusion and exclusion criteria which included individuals evaluated as prospective kidney donor. GFR was estimated by 24-hour urinary creatinine clearance and 99m Tc DTPA 2 sample method. Enrolled subjects were divided into 3 age groups- Group 1: 20 to 40 years, Group 2: 41 to 60years, and Group 3: 61 to 80 years. Age-specific normative data for GFR was developed. The comparison between GFR measured by DTPA 2 sample method and 24-hour urinary creatinine was also done.

RESULTS: A total of 250 subjects were included in this study. Of these, 191 were females constituting 76.4% of total subjects while 23.6% were males. Majority of the subjects in all three age groups were females (70% or more). The majority of donors were wives (34%) followed by mother (27.6%). Majority of the donors were in the age group of 41 to 60 years (Group 2). Group 1 had 24.4% of total kidney donors, Group 2 had 63.6% of total donors and Group 3 had only 12% of kidney donors. The mean age for Group 1 was 32.8 years, Group 2 was 50.0 years, and Group 3 was 66.7yrs. The age of our subjects ranged from 20-77 years with a mean age of 47.8 years. The mean GFR obtained by DTPA was 89.6 ± 11.1 ml/min/1.73 m2. Males had mean GFR of 88.4 ml/min/1.73 m2 while females had mean GFR of 89.9 ml/min/1.73 m2. The mean GFR for Group 1, Group 2, and Group 3 obtained by DTPA 2 sample method was 101.4  ± 9.7 ml/min/1.73 m2, 86.9  ± 8.2 ml/min/1.73 m2, 79.4  ± 6.9 ml/min/1.73 m2 respectively. The mean GFR along with standard deviation for the study groups Group 1, Group 2, and Group 3 obtained by 24-hr creatinine clearance was 102.2  ± 14.5 ml/min/1.73 m2, 85.5  ± 16.0 ml/min/1.73 m2, 75.0  ± 12.8 ml/min/1.73 m2 respectively. Pearson’s correlation coefficient between measured GFR by DTPA 2 sample method and 24-hr urinary creatinine clearance showed a value of 0.45 indicating positive correlation. The trend of mean GFR was observed in the study groups, and it was found to be declining with increasing age.

CONCLUSIONS: Majority of the Indian kidney donors are spousal donors (mainly wives). Prospective healthy living Indian kidney donors have low values of GFR when compared to western population. This was confirmed by both exogenous and endogenous filtration markers. Our study showed significant age-related decline in GFR, and thus GFR reference range for various age groups was calculated for Indian kidney donors by DTPA sampling method. 24-hour creatinine clearance closely correlates with DTPA when done in appropriate manner for GFR measurement.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 194: OUTCOME AND CLINICO-ETIOLOGICAL PROFILE OF PATIENTS WITH ACUTE KIDNEY INJURY REQUIRING DIALYSIS

Sridatta Gurudatta Pawar 1, Pooja 1

BACKGROUND: AKI previously known as Acute Renal Failure is a clinical syndrome characterized by an abrupt decline in glomerular filtration rate sufficient to decrease the elimination of nitrogenous waste products (urea and creatinine) and other uremic toxins. The clinical and public health problem of AKI is still at the tip of iceberg, and requires more in depth research and awareness due to the association with high mortality and its separate independent effect on the risk of death and resource use. This study was conducted to describe the clinical profile and outcome of adult Acute Kidney Injury (AKI) patients treated with intermittent hemodialysis at our dialysis center

AIM OF THE STUDY: 1. To study the outcome and etiology of patients with AKI 2. To look for progression to CKD among survivors

METHODS: A hospital-based prospective observational study on AKI. Hundred AKI patients requiring HD diagnosed by KDIGO criteria were selected. Patients with pre-existing chronic kidney disease were excluded.

RESULTS: A total of 100 cases AKI requiring dialysis were included for the study. Overall, the patients were middle aged mostly between 51-60 years of age. The most common causes of AKI system wise were gastrointestinal system (43%) followed by urinary tract system (14%). Nearly 63% recovered, 24% expired, and 13% progressed to CKD, out of which highest mortality were due to burns. Renal biopsy was done in 14% of cases. Based on staging, subjects presenting with higher stage at admission had higher mortality. Other parameters like comorbidity played significant role to progression to CKD.

CONCLUSIONS: Gastrointestinal system and urinary tract system pathologies were the primary causes of dialysis requiring AKI. Most of these causes can be prevented with simple interventions such as health education on oral rehydration, appropriate management of infections, and creating awareness among non-nephrology branches about management of AKI. I would like to end with a quote “Kidney health for everyone and everywhere

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 195: PARAPROTEIN RELATED KIDNEY DISEASES: A TERTIARY CARE CENTRE EXPERIENCE

Gouri Satheesh 1, N Monica 1, CG Sreedhara 1, A Kishan 1, S Mythri 1, L Umesh 1, V Leelavathi 1, S Ranjitha 1, S Aditya 1, T Viswas 1, H Haritha 1, M Shravani 1, G Gireesh 1

BACKGROUND: Paraprotein—related kidney disease represents a complex group of diseases caused by an abnormal paraprotein secreted by a clone of B cells which cause a diversity of kidney disorders.

AIM OF THE STUDY: We undertook this study to analyze the clinical characteristics and renal pathological manifestations of patients with Paraprotein-related kidney disease.

METHODS: This was a single-center retrospective study conducted at a tertiary care hospital in South India. The study population comprised patients with biopsy-proven paraprotein related kidney injury as defined by International Myeloma Working Group (IMWG) admitted from January 2018 to August 2022. Demographic clinical and laboratory data of the patients were recorded in a standard pro forma.

RESULTS: There were 73 patients with biopsy-proven paraprotein related kidney disease during the study period in our center with an incidence of 1.8%. Mean age was 52 years with no significant sex predilection. Majority of the patients were having light chain cast nephropathy (32.3%) followed by light chain deposition disease (19.7%) and AL amyloidosis (18.3%). Most common nephrological syndrome on presentation was CKD (33.8%), followed by AKI (32.4%). Hypertension (72.8%), anemia (94%), albumin-globulin ratio reversal (67%) and greater than or equal to normal kidney size on USG (70%) were seen more frequently than hypercalcemia (13%), M spike in serum protein electrophoresis (26%) and osteolytic lesions (15%) in these patients. 43% were requiring hemodialysis on presentation.

CONCLUSIONS: There should be a high index of clinical suspicion for paraprotein-related kidney disease in patients presenting with renal dysfunction either acute or chronic, in the fifth decade or higher as most will not have all the classical, clinical, and laboratorial parameters as seen in multiple myeloma. A kidney biopsy is essential for diagnosis which will help in tailoring specific and efficient therapy for the disease.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 196: EMERGENCY HEMODIALYIS IN CKD MAINTENANCE HEMODIALYSIS-OBSERVATIONAL STUDY

Ramprasad Ramalingam 1, S Ramakrishnan 1, Dilip Rangarajan 1, Kavitha Mudhaliar 1

BACKGROUND: Emergent hemodialysis in CKD 5D population has high morbidity and mortality higher financial burden and resource shortage on availability of dialysis staff bed vacancy, etc. Knowing the incidence and causative factors will help in reduction in number of such presentations and their outcomes.

AIM OF THE STUDY: Incidence of emergency dialysis in our unit. Analysis of causative factors.

METHODS: Observational prospective data was collected from our dialysis unit. Analyses of causative factors and outcomes in the individual patients will be done. Study Population: CKD5D on maintenance hemodialysis of NU dialysis unit patients who require Emergent HD. From November 1, 2021 to June 31, 2022.

RESULTS: Total no of actual events were 16. There was missing data for 1 event. Hence, 15 events were taken up for analysis. Total number of events was 15 (Male 6). Eight had AVF; one had untunneled CVC and six had tunneled CVC as dialysis access. Among 15 event patients, the prevalence of diabetes, hypertension, and ischemic heart disease were 74%, 94%, and 14% respectively. Two patients had history of cerebrovascular accidents. During the event, 12 had accelerated hypertension, three had hemoglobin less than 9gm/dl, and eight had hypoalbuminemia less than 3gm/dl. Six required hospital admission, and three among them required ICU care. The identified causes for these events were skipped hemodialysis in 20% events, error in weight gain calculation in one event and requiring change in frequency of HD in 3 events. In one event, patient had intercurrent illnesses and two had cardiac cause. Four presented with excess fluid intake than usual. 3 events had previous events of emergency hemodialysis in last 6 months. Four out of 15 had interdialytic weight gain more than 4 kg and in 6 events not able to record weight due to breathlessness in patients. Only two among 15 events occurred within 6 months of initiation of hemodialysis. Nil mortality in any of these events.

CONCLUSIONS: Incidence of emergency hemodialysis in our dialysis unit with prevalent CKD on maintenance hemodialysis (population of above 80 patients per month) is 15 patients in 8 months duration. Skipped hemodialysis sessions and excess fluid intake are the dominant modifiable factors. Cardiac evaluation should be considered in all cases.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 197: RENAL AND OVERALL SURVIVAL AT 1 YEAR IN A RETROSPECTIVE COHORT OF ANTI-GBM DISEASE- A SINGLE CENTRE EXPERIENCE

Asheesh Kumar 1, Ashish Chauhan 1, Ram Singh 1, Dheeraj Sharma 1, Naresh Chauhan 1

BACKGROUND: Anti-glomerular basement membrane (anti-GBM) disease is a rare condition with estimated incidence of 1 per million population per year. Despite the availability of potent immunosuppressive agents only less than oneâ€'third patients of antiâ€'GBM disease retain preserved kidney function after 6 months.

AIM OF THE STUDY: To evaluate one year survival of anti-GBM disease

METHODS: This is a retrospective analysis of 14 patients seen in our renal clinic from October 2019 and March 2022. Anti-GBM disease was defined by either (i) the presence of circulating anti-GBM antibodies in association with clinical manifestations of alveolar hemorrhage and/or rapidly progressive glomerulonephritis or (ii) biopsy-proven crescentic glomerulonephritis with linear deposition of IgG along the GBM in the absence of another attributable cause (such as diabetes mellitus or paraproteinemia).

RESULTS: There were 14 patients in the study group, with 78.55% (11/14) females. Mean age of the study population was 50.8Â ± 13.8 years. Follow-up data was only available for 12 patients. The diagnosis of anti-GBM disease was made on the basis of anti-GBM levels along with histological linear IgG deposition along GBM in 12 patients, and based on histological staining in 2 patients. Cyclophosphamide and Rituximab was given in 66% (8/12) and 33.33% (4/12), respectively. One-year survival was 41% (5/12), whereas renal survival was meager 8% (only one patient was dialysis free at 1-year follow-up).

CONCLUSIONS: Anti-GBM disease has a dismal overall survival and renal survival at 1 year. There is need for newer therapies to improve outcome in these patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 198: INFECTIVE ENDOCARDITIS PULMONARY SEPTIC EMBOLI DUE TO MRSA IN A PATIENT WITH CHRONIC END STAGE KIDNEY DISEASE ON MAINTENANCE HEMODIALYSIS €” A CASE REPORT AND FEW LEARNING POINTS

Debapriya Saha 1, Nilesh Shinde 1, Pavan Wakhare 1, Charan Bale 1, A Sajgure 1, Tushar Dighe 1

BACKGROUND: Small percentage of catheter-related bloodstream infection may present atypically with persistent low-grade fever without chills and rigor and in some of these cases blood culture can be negative. These may lead to diagnostic confusion and delay in detection of the common entity of catheter-related blood stream infections.

AIM OF THE STUDY: Case discussion with learning points

METHODS: We report a case with multiple pictorial images and discuss differential diagnosis with few learning points.

RESULTS: 42-year-old male patient, a known case of end-stage chronic kidney disease on maintenance hemodialysis through a tunneled catheter, presented with a history of intermittent, low-to-moderate fever for 3 weeks. The fever associated with generalized weakness, night sweats but was not associated with chill and rigor. His past medical history included end-stage chronic kidney disease due to chronic glomerulonephritis and was on maintenance hemodialysis thrice weekly for last 6 months through tunneled catheter in right IJV. On physical examination, the patient had tachycardia, normotension with a blood pressure of 120/70 mmHg, normal saturation at room air with respiratory rate of 20 /minute. On auscultation, there was reduced breath sounds on left side and normal heart sounds. The catheter site showed no heat, erythema, swelling, tenderness. Chest radiograph revealed left hydropneumothorax with multiple focal pulmonary nodular opacities. CECT chest showed left loculated hydropneumothorax with multiple cavitary nodules with reverse halo sign (Figures 1 and 2). Lab investigations showed significant leukocytosis with neurophilia, random serum glucose of 250 mg/dL, and D-dimer of 3624 ng/mL. Blood cultures from hemodialysis catheter and contralateral peripheral vein were negative for pathogenic bacteria, mycobacteria, and fungal etiology. Urine analysis was sterile and did not have pus cells. On day 4 of admission, patient had left axillary pain. On clinical examination, there was focal tenderness on examination in the left axilla. On ultrasonography, there was a small collection which was aspirated under ultrasound guidance and showed gram-positive bacteria on microscopy. Trans esophageal echocardiography revealed multiple tiny vegetations on right side of interatrial septum on tricuspid valve (Figure 3). Subsequent culture results showed methicillin resistant staphylococcus sensitive to clindamyin, vancomycin, linezolid, ciprofloxacin (Figure 4 and 5). The patient was started on vancomycin and ceftazidine on empirical basis for microscopic findings, and after subsequent culture revealed methicillin-resistant Staphylococcus aureus, he was treated with vancomycin. Permanent catheter was removed. Hemodialysis was continued through temporary right IJV catheter. Blood cultures were cleared from MRSA on hospital day ten. She got discharged home on intravenous Vancomycin for 6-8 weeks and was reported doing well on follow-up.

CONCLUSIONS: The learning points are- 1. MRSA infection is common in chronic kidney disease patient on hemodialysis. 2. Clinical presentation of metastatic MRSA infection with infective endocarditis may be indolent with cardiovascular and respiratory stability with absence of fever spikes, chill, and rigor. 3. Common infective causes of cavitary nodules in lung are typical and atypical mycobacterial infection, fungal infection, and pyogenic septic emboli. 4. Uncommon infective causes of reverse halo sign on CT chest need to be remembered and include bacterial pneumonia, septic embolism, mycobacterial infection, invasive aspergillosis, in addition to common infective etiology of reverse halo sign like mucormycosis infection and COVID19 infection.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 199: SERUM ANTI PLA2R ANTIBODY LEVEL IN PRIMARY MEMBRANOUS NEPHROPATHY: CAN THAT PREDICT RESPONSE TO THERAPY?

Tarak Choudhury 1, Arpita Ray Chaudhury 1, Debabrata Sen 1, Koushik Bhattacharjee 1, Atanu Pal 1

BACKGROUND: Membranous nephropathy is the most common cause of adult-onset nephrotic syndrome. Our institute biopsy registry data reveals membranous nephropathy incidence is 10%. Recent KDIGO guideline has included quantitative antiPLA2R as a risk stratifying measure which may prove useful for treatment allocation. We are reporting the outcome of a single-center prospective follow-up cohort of 122 patients with biopsy-proven membranous nephropathy allocated to 3 arms of immunosuppressive therapy intervention commonly used for idiopathic membranous nephropathy (IMN) patients based on PLA2R positivity.

AIM OF THE STUDY: The study was undertaken to identify the role of serum anti-PLA2R antibody in predicting treatment response to different immunosuppressive therapy regimens in primary membranous nephropathy.

METHODS: A total of 172 patients with biopsy-proven membranous nephropathy from IPGMER and SSKM hospital in last five years (January 2017–January 2022) were collected in the study. All the patients were given six months of maximal tolerated antiproteinuric therapy and 20 (11%) PLA2R positive and 30 (17%) PLA2R negative patients responded to conservative treatment, but the p value (0.23) is not statistically significant. The patients who did not respond to conservative therapy were divided into three groups and treated with Modified Ponticelli (MP) Rituximab and Tacrolimus-based regimen. Baseline characteristics between three groups were comparable. In MP regimen, alternating glucocorticoids and cyclophosphamide-based regimen were given for 6 months. In rituximab-based regimen, two doses of 1gm rituximab were given at an interval of 15 days. In tacrolimus-based regimen, standard dosage of tacrolimus was given to keep whole blood tacrolimus trough level (T0) in between 5-7 ng/ml.

RESULTS: Among 122 patients, 48 (26 PLA2R positive and 22 PLA2R negative) patients were treated in MP,42 (24 PLA2R positive and 18 PLA2R negative), with rituximab and 32 (17 PLA2R positive and 15 PLA2R negative) with calcineurin inhibitor group. Serum creatinine, 24-hour urinary protein, serum albumin, and total cholesterol values were collected at baseline, six months, and 12 months. Results were compared between PLA2R positive and negative groups. We have defined complete remission, partial remission and no remission, and total remission (complete+partial) according to standard definition. It has been observed that at 6 months in MP regimen total remission rate (72.72% vs 80.76%, p value 0.436) and complete remission rate (22.7% vs 19.23%, p value 0.688) were lower in PLA2R negative group than positive group and at 12 months total remission rate (72.72% vs 80.76%, p value 0.436) and complete remission rate (31.81% vs 46.15%, p value 1) persisted to be lower. But both the values are not statistically significant. Mean serum creatinine level at 6 and 12 months between groups was comparable. In rituximab group, total remission rate (72.2% vs 83%, p value 0.802) and complete remission rate (5% vs 8.3%, p value 0.405) were lower in PLA2R negative group than positive group at 6 months and total remission (77.7% VS 87.5%, p value 0.268) and complete remission rate (38.8% vs 45.83%, p value 0.286) persisted to be lower inPLA2R negative than positive group, but the values are not statistically significant. Mean serum creatinine level at 6 and 12 months between groups were comparable. In tacrolimus group, total remission rate (70% vs 66.6%, p value 0.05) and complete remission rate (13.3% vs 5.8%, p value 0.685) were higher in PLA2R negative group than positive group which persisted at 12 months follow-up TR (73.3% vs 70.5%, p value 0.030) and CR (33.3% vs 29.4%, p value 0.063), and the value is statistically significant. Mean serum creatinine level at 6 and 12 months between groups was comparable. Among the three immunosuppressive regimens, CNI group treatment showed statistically significant better remission in PLA2r negative group but with other two immunosuppressive regimen PLA2r positive group showed better response, though not statistically significant.

CONCLUSIONS: Quantitative PLA2R estimation is an emerging prognostic tool to predict the outcome of membranous GN. Our study compared the outcome of PLA2R negative vs positive membranous GN patients treated with conservative management and existent three different options of immunosuppressive therapy. However, we failed to find any statistically significant correlation of PLA2R positivity with worse outcome.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 200: SINGLE CENTRE STUDY OF PREGNANCY OUTCOME IN KIDNEY TRANSPLANT RECIPIENTS

Siddhavinayak Rajmane 1, Nikhil Dhope 1, Rejitha R Kaimal 1, Priyanka Lawangani 1, Hinal R Rathod 1, Ankitaben Metaliya 1, Ashay Shingare 1, Madan M Bahadur 1

BACKGROUND: Pregnancy in a kidney transplant recipient is a high-risk pregnancy with increased chance of graft rejection and other obstetric problems. There is paucity of information regarding post-transplant pregnancy in India.

AIM OF THE STUDY: To study maternal fetal and allograft outcomes during pregnancy in kidney transplant recipients.

METHODS: In this retrospective observational study 9 pregnancies in recipients after kidney transplant from 2008 to 2022 were included. Unmarried women and age < 18 years at pregnancy patients were excluded.

RESULTS: There were 8 patients who had conceived, out of which 1 patient conceived 2 times. One patient underwent medical termination of pregnancy (MTP) as pregnancy was unplanned. Median age at pregnancy was 37 years, and median duration from transplant to pregnancy was 6 years. Eight patients were shifted from mycophenolate mofetil to azathioprine prior to pregnancy and started on aspirin 75 mg daily. One patient who was on everolimus underwent MTP. Out of 9 pregnancies, 7 (77%) patients were on tacrolimus, 1 (11%) was on cyclosporine and all were on corticosteroids. Two (22%) patients developed preeclampsia, and 1 (11%) had gestational hypertension. Seven (77%) underwent caesarean section. Six (66%) had preterm delivery, 2 (22%) were low birth weight (LBW), and 1 (11%) had intrauterine growth retardation. There was no mortality, and only one patient developed allograft dysfunction 8 months after delivery. No neonatal complications were observed during breast feeding in all patients. As compared to older meta-analysis by Deshpande et al., our study shows increased preterm deliveries (45% vs 66% in present study) but less preeclampsia (27% vs 22%), gestational hypertension (54% vs 11%), and LBW (46% vs 22%).

CONCLUSIONS: Successful pregnancies can be achieved with medical optimization and counseling of kidney transplant recipients with stable creatinine, and normal or under control blood pressure. However, preterm labor and LBW are more likely to occur in pregnant kidney transplant recipients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 201: ANTI-GBM DISEASE €” ONE AND HALF YEARS EXPERIENCE IN A TERTIARY CARE CENTRE

Sudipta Ghosh 1, Arpita Ray Chaudhury 1, Debabrata Sen 1, Koushik Bhattacharjee 1, Atanu Pal 1

BACKGROUND: Anti-glomerular basement membrane (GBM) antibody GN is a rare glomerular disease (0.5—1 per million population) with poor outcome in terms of renal survival. It is caused by auto-antibodies against the non-collagenous domain of the a3 chain of type IV collagen and usually present as a rapidly progressive crescentic GN. Anti-GBM GN may present either as an isolated kidney disease or as a pulmonary—renal syndrome (Goodpasture’s syndrome) in 40%—60% of patients. Linear staining of the GBMs for immunoglobulin (Predominantly IgG & rarely IgA) in renal biopsy with anti-GBM antibodies in serum is pathognomonic of Anti-GBM disease. Initiating immunosuppression with steroids and cyclophosphamide plus plasmapheresis are the cornerstone of treatment whereas no treatment is recommended if dialysis dependent at presentation 100% crescents or >50% global glomerulosclerosis in an adequate biopsy sample or not having pulmonary hemorrhage.

AIM OF THE STUDY: To study demographic and clinical profile treatment administered and outcome (in terms of renal survival) in the patients with biopsy-proven anti-GBM disease.

METHODS: Single-center prospective observational study (January 2021 to June 2022) and study population being the admitted patients in Nephrology Department of I.P.G.M.E.R and SSKM hospital Kolkata.

RESULTS: Total 7 patients were diagnosed as having Anti-GBM disease in this time period with median age of 42 yrs (range from 11 yrs to 68 yrs), and Female : Male ratio was 5:2. Rapidly Progressive Renal Failure with Oliguria (71.4%) was the most common presentation and 85.7% required Hemodialysis on presentation. 57.1% patients had 100% crescent in renal biopsy. 1 out of 7 patients had overlap with MPO and did not required RRT at presentation. 1 out of 7 patients had associated pulmonary hemorrhage. 28.5% patients received PLEX while others were treated supportively as per protocol. 28.5% patients previously had COVID 19 infection which was diagnosed retrospectively by detecting COVID 19 IgG antibody in serum. 71.4% patients end up in HD requiring renal failure while 1 patient succumbed to death.

CONCLUSIONS: Most of the patients aged between 20 yrs to 60 yrs and were female (both 71.4%). Most of the patients (71.4%) received supportive treatment as per protocol. Only 1 patient (with MPO overlap) is dialysis free with discharge creatinine of 3.3 and receiving EUVAS protocol. Most of the patients who presented late with HD requiring renal failure end up in ESRD.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 202: DON€™T THINK ABOUT THE KINK- INNOVATION IN TUNNELLED CUFF CATHETER (TCC) INSERTION BY MODIFIED CREATION OF SUBCUTANEOUS TUNNEL TO AVOID KINKING OF TCC

Sudeep Prakash 1, Bhaskar Datt 1

BACKGROUND: Tunneled cuff catheter (TCC) is a soft catheter with a cuff which is placed for long-term dialysis in patients who do not have an AV fistula or a AV graft. The soft nature of the catheter sometimes results in its kinking in the subcutaneous tunnel leading to obstructed or poor flows. We innovated a new technique by modifying the creation of subcutaneous tunnel to avoid this phenomenon which is nightmare for nephrologist.

AIM OF THE STUDY: To study success of the innovated TCC insertion method so as to avoid kinking of the TCC and achieving good flow rates.

METHODS: From the period July 01, 21 to Jul 01, 22, 26 patients were enrolled in the study. The patients had the indications of needing renal replacement therapy but did not have any arteriovenous (AV) access. 20 patients had uremic features but had no AV access thus needing a TCC placement. 06 patients developed secondary AV fistula failure. Internal jugular vein (IJV) was cannulated with the introducer needle under real-time guidance of Doppler. Guide wire was inserted in the IJV through the insertion needle (site no.3) and its position was confirmed on fluoroscopy. The exit site (site no.1) is marked by measuring the length of the catheter while keeping the tip 6 cm cephalic to the xiphisternum. With the scalpel, the opening is made in skin at the exit site. The second incision (site no.2) is made 1 cm above and 4 cm lateral to the exit site of guide wire (site no.3). The skin incision at site no.3 is widened. The introducer trocar is then inserted from the site no.1 and taken out from the site no.2 along with TCC loaded on it. Then the trocar is inserted through site no. 2 again and then exited at site no. 3 with TCC loaded on to it. After this we follow the usual procedure of dilating the tract putting the ‘peel away sheath’ into the IJV over the guide wire. Then putting the TCC in IJV through the ‘peel away sheath’. The ‘peel away sheath’ is then peeled off and discarded. The catheter is properly buried in the subcutaneous tissue through incision at site no. 3. The 2 incision sites (site 2 and 3) are closed by single silk sutures. The catheter hub is secured with stay sutures. The track and position of the catheter were confirmed by the fluoroscopy.

RESULTS: The subcutaneous track in all patients was in form of inverted “Uâ€, and the tip of the catheter was in the cavity of the right atrium (as confirmed by fluoroscopy). 24 patients achieved the flow of more than 300 ml/min. There was obstructed primary flow in one patient and obstructed flow in another patient after 72 hours. The flow was restored in the second patient after thrombolysis with recombinant tissue plasminogen activator (rTPA), while the TCC had to be removed in another patient.

CONCLUSIONS: The creation of the subcutaneous tunnel in with this 2-step technique results in avoidance of a kink formation in the TCC in the subcutaneous tunnel and achieves good flow rates. An instructional video during oral presentation will be able to demonstrate the technique in a more vivid manner.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 203: CLINICAL PROFILE AND OUTCOMES OF PATIENTS WITH PURE RED CELL APLASIA IN THE ERA OF HIF STABILISERS

Arvind Krishnakumar 1, Shabna Sulaiman 1, Shafeeque Rahman 1, Benil Hafeeq 1, Feroz Aziz 1, Jyotish Gopinathan 1, Ranjit Narayan 1, N A Ismail 1

BACKGROUND: Pure red cell aplasia (PRCA) is a rare disease seen in patients on maintenance hemodialysis with significant comorbidities including repeated blood transfusions and hospitalizations and treatment-related infections. We present a case series of patients with PRCA in the era of hypoxia inducible factor (HIF) stabilizers

AIM OF THE STUDY: To describe the clinical profile and outcome of patients with PRCA

METHODS: Data was collected retrospectively from hospital records.

RESULTS: Eleven patients in our hemodialysis unit were diagnosed to have Erythropoietin (EPO)-related PRCA. The mean age was 48 years, and 91% were male patients. Two patients expired before treatment completion, both of whom received steroids and cyclophosphamide. Six patients who completed treatment received steroids and cyclophosphamide, out of which three responded. However, the three patients who did not respond showed a response to the HIF stabilizer Desidustat. Two patients who were treatment naïve were started on Desidustat, out of which one responded. Among the responders, the average time to respond to desidustat therapy was 1.5 months.

CONCLUSIONS: Desidustat is a promising agent in patients with EPO-related PRCA who are refractory to immunosuppression and also who are treatment naïve.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 204: COMPARATIVE SURVIVAL OUTCOME OF TUNNELED AND NON-TUNNELED HEMODIALYSIS CATHETERS ON INCIDENT HEMODIALYSIS REQUIRING END STAGE KIDNEY DISEASE PATIENTS - AN INTERIM ANALYSIS

Muthukumar Balakrishnan 1, Himansu Sekhar Mahapatra 1, B Muthukumar 1, Lalit Pursnani 1, Abhisek Gautam 1, Chandra Krishnan 1, Amandeep Singh 1, Manoj Prabhakaran 1, Sanket Patil Kishore 1

BACKGROUND: For long-term hemodialysis in end-stage kidney disease (ESKD) patients tunneled catheters (TC) are preferred over non —tunneled catheters (NTC) as temporary vascular access. High-cost fluoroscopy and expertise in its catheterization are major limitations. It is also unclear about the preference of high-cost TC over less costly NTC catheters as short-term access while awaiting AVF maturation.

AIM OF THE STUDY: To compare survival outcomes of tunneled and non-tunneled hemodialysis catheters on incident hemodialysis requiring end-stage kidney disease patients

METHODS: All ESKD patients requiring intermittent hemodialysis were recruited and studied from March 2021 to June 2022. All consecutive patients except under 18 years of age patient opting for peritoneal dialysis and patients initiating hemodialysis with arterio-venous fistula (AVF) or AV Graft were included in the study. These patients were randomized into two groups: one receiving TC and another NTC. All catheters were inserted by using standard protocol under aseptic precautions. All patients underwent an AVF within one week of initiation of dialysis. Patients were followed up at 2 weeks, 6 weeks, and 12 weeks. During this period, mechanical infective and catheter survival outcomes were studied. All infections were treated with standard protocols. All demography data were analyzed.

RESULTS: A total of 90 patients were randomized into TC (n = 41) and NTC (n = 49). The average patient’s age of tunneled and non-tunneled was 49.56 ± 13.95 and 39.79 ± 11.77 respectively. A total of 31 (63.3%) were males in tunneled and 38 (77.5%) males in non-tunneled groups. There were a total of 18 (20%) infections were reported. Of them, 6 (12.24%) in tunneled and 12 (24.5%) in non-tunneled. The most common organism was Klebsiella in both groups. The estimated days for catheter survival is 57 for TC and 43 for NTC while the estimated days for catheter infection are 51 for tunneled and 38 for non-tunneled (p-0.036).

CONCLUSIONS: In a resource-limited setting, with early creation of fistula, a non-tunneled hemodialysis catheter is a viable option in incident ESKD patients, however, with significant increased rate of infection.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 205: KIDNEY INVOLVEMENT IN MULTIPLE MYELOMA-OUR EXPERIENCE

Aniket Hase 1, Gauri Kulkarni 1, Dipanjan Haldar 1, Chetna Bakshi 1, Niwrutti Hase 1

BACKGROUND: Multiple myeloma is the commonest hematological malignancy affecting all compartments of the kidney with varied presentations. We report 21 patients in a year primarily presented with kidney disease and etiological evaluation revealed cause as Multiple Myeloma.

AIM OF THE STUDY: To report spectrum of kidney involvement clinical presentation Laboratory findings treatment and clinical outcomes in multiple myeloma presenting primary as kidney involvement

METHODS: It was a prospective study 21 diagnosed to be multiple myeloma while evaluating for the cause of kidney disease. Patients were followed for 90 days

RESULTS: Patients' age range was 45–83 years with mean age of 70 with 50% being females. Commonest presentation was rapidly progressive declining renal function (10/21), 9/21 had AKI, 1 as nephrotic syndrome, asymptomatic urinary abnormality proteinuria in 1, hyperuricemia in 2, and hypercalcemia in 3 patients. 11 patients had underlying diabetes. Predominant type of myeloma was IgG kappa type (16/21). M band was absent in 8 patients. Kidney biopsy was done in 3 patients, 2 had AL amyloidosis and 1 had proliferative glomerulonephritis. All patients were treated with supportive management and chemotherapy with bortezomib dexamethasone-based therapy and cyclophosphamide/ lenalidomide. At 90 days, hematological remission achieved in all, renal recovery was complete in 5 patients, 12 had partial recovery with progression to CKD, and 3 remained dialysis dependents.

CONCLUSIONS: Elderly patients presenting as rapidly progressive renal failure, with anemia, thrombocytopenia, hyperuricemia, plasma cell disorder should be ruled out, with high index of suspicion. This is becoming important cause of non-diabetic kidney disease in diabetic elderly population. Serum protein electrophoresis is not enough to rule out multiple myeloma in elderly patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 206: EATING EPILEPSY A RARE DISORDER IN A CASE OF CHRONIC KIDNEY DISEASE ON HEMODIALYSIS: A CASE REPORT

Puja Rajmane 1, Shalini Suralkar 1, Gautam Tripathi 1, Raman Malik 1

BACKGROUND: Reflex epilepsy in which seizures are provoked habitually by external stimulus or internal mental process. Eating epilepsy (EE) is distinct subtype of reflex epilepsy where seizures are triggered by the act of eating.

AIM OF THE STUDY: To report case eating epilepsy which remain undiagnosed most of time and describe the treatment response noted in patient.

METHODS: 77-year-old gentleman admitted for shortness of breath. He is known case of diabetes mellitus, hypertension, ischemic cardiomyopathy, and CKD on regular hemodialysis. He had episode of jerky movement of jaw followed by focal and then generalized seizure during dialysis. CT brain EEG autoimmune panel and CSF studies were normal. Patient started on series of anticonvulsant medications with dose escalation including valproate levetiracetam lacosamide and phenytoin with no improvement. MRI brain revealed encephalomalacic areas in left cerebellar hemisphere and right posterior parietal parenchyma. On observation and detailed history, patient had similar episodes at home specially during eating. patient was started on clobazepam and enteral feeding suspecting eating epilepsy. Surprisingly seizure improved with this treatment. Patient was discharged in stable condition with antiepileptics and enteral feeding having no seizure on follow-up after 1 month.

RESULTS: Eating epilepsy has shown male predominance with focal seizures and reduced awareness. Clobazepam was proven to be an effective add-on therapy in its management when given half an hour before a meal.

CONCLUSIONS: Eating epilepsy is a rare kind of reflex epilepsy. Since eating does not occur during the evaluation, it frequently goes untreated. Clobazam was successful in this situation.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 207: BLACK FUNGUS: A HIDDEN PATHOGEN WITH FULMINANT OUTCOME IN RENAL TRANSPLANT RECIPIENT

Disha Saxena 1, Dhananjai Agarwal 1, Vinay Malhotra 1

BACKGROUND: Mucormycosis is an invasive fungal infection that can cause significant morbidity and mortality among renal transplant recipients. Immunosuppressive agents given to improve graft survival increases the risk of life-threatening infection.

AIM OF THE STUDY: Early diagnosis and treatment of post-renal transplant recipient presenting with complaints of headache epistaxis and left periorbital swelling on post-transplant day 4.

METHODS: Patient was evaluated with routine blood investigations renal allograft biopsy CT head and paranasal sinus along with biopsy from paranasal sinus mucosa.

RESULTS: Non-contrast CT head & paranasal sinus was suggestive of fungal pansinusitis with bony erosion and intraparenchymal extension into basifrontal lobes. Diagnosis of mucormycosis was confirmed by KOH mount and biopsy from paranasal sinus mucosa. Despite prompt management with Amphotericin-B, patient’s condition deteriorated and expired.

CONCLUSIONS: One should keep a low threshold for suspecting fungal infections in solid organ transplant recipients for timely management and favorable outcomes.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 208: URINE NGAL IN ACUTE KIDNEY INJURY- IS IT A RENAL TROPONIN?

Chetan Veeramaneni 1, Manisha Sahay 1

BACKGROUND: Acute kidney injury (AKI) is a well-known complication that affects critically ill patients in intensive care unit (ICU) and is associated with increased mortality morbidity and length of stay. In the last few decades, serum creatinine (SCr) is used for the diagnosis of AKI in common practice but SCr is a functional marker and not an ideal biomarker to identify AKI. The values of SCr are influenced by multiple non-renal factors like age, gender, muscle mass, and metabolism dietary habits medications and hydration status.1 and SCr may not rise until more than half of the kidney function has been lost. uNGAL is a 25-kDa complex protein that belongs to the lipocalin family, and it was discovered as a complex protein with human neutrophil gelatinase in 1993. High uNGAL can be used to predict AKI discriminate intrinsic AKI from pre-renal AKI predict renal non-recovery in-hospital mortality long-term CKD progression ESRD and mortality.

AIM OF THE STUDY: The aim of the study was to evaluate urine NGAL for early prediction and prognosis of AKI and correlation with serum creatinine.

METHODS: INCLUSION CRITERIA: 50 patients who were ≥18 years with Acute Kidney Injury or who received contrast media were included. 50 patients served as controls. EXCLUSION CRITERIA: Patients with history of chronic kidney disease. Who were not willing to participate. TYPE OF STUDY: Prospective observational study Statistical Analysis: Statistical analysis was carried out utilizing R software. P values < 0.05 were considered statistically significant. Normally distributed data by the mean and standard deviation (SD) and skewed distributions by the median and interquartile range (IQR). Statistical tests used were Pearson correlation test and Mann–Whitney U-test.

RESULTS: Mean age in cases was 44.48 Â ± 13.8 years, in controls was 42.56 Â ± 15.6 years. Sex ratio was similar in both cases and controls (1.78:1). Of 50 cases of AKI, 32 cases had established AKI (64%); 12 were at risk of AKI (24%). 22 cases had Intrinsic AKI and 10 cases had pre-renal AKI. Most common etiology of AKI was sepsis 24/50,48%. Urine NGAL value in controls was <50ng/ml; in cases was 885 Â ± 1325 ng/ml. Mean urine NGAL value in AKI vs at risk of AKI patients was 875.5 ng/ml vs 50 ng/ml (p = 0.01); in pre-renal AKI vs Intrinsic AKI was 119.5 ng/ml vs 1440.5 ng/ml (p = 0.04). Mean uNGAL in different stages of AKI was AKI KDIGO-1 (6/32; 143.3 Â ± 161.6 ng/ml), AKI KDIGO-2 (6/32; 679.2 Â ± 1161.7 ng/ml) and AKI KDIGO-3 (20/32, 1856.5 Â ± 1534.9 ng/ml). 20 cases required renal replacement therapy (mean uNGAL was 1750 ng/ml vs 176 ng/ml in cases with conservative treatment, p < 0.01). 8 cases expired during hospital stay (mean uNGAL was 2100 ng/ml vs 850 ng/ml in discharged cases, p = 0.03). urine NGAL correlated well with serum creatinine and BUN/cr ratio of the cases.

CONCLUSIONS: 1. uNGAL values were statistically significant in differentiating Renal vs Pre-renal AKI. 2. uNGAL values were statistically significant in predicting need of Renal Replacement Therapy. 3. There were significant correlations between uNGAL and serum creatinine values, uNGAL and BUN/cr ratios. 4. uNGAL values were statistically significant in predicting in-hospital mortality. 5. Urine NGAL did not provide any additional information in predicting development of AKI. 6. Further large sample studies are needed to use urine NGAL as a RENAL TROPONIN in guiding management of AKI.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 209: COGNITIVE IMPROVEMENT IN END STAGE RENAL DISEASE PATIENTS POST RENAL TRANSPLANTATION- A PROSPECTIVE OBSERVATIONAL STUDY

Simran Sawhney 1, Dinesh Bansal 1, Shyam Bihari Bansal 1

BACKGROUND: Chronic kidney disease has shown to be an independent risk factor for cognitive decline across multiple domains of functioning including memory. Up to 30 — 70% of end-stage renal disease (ESRD) patients and 17-30% of advanced chronic kidney disease patients are reported to have significant cognitive deficits. Cognitive dysfunction may affect the patient’s daily functioning medical adherence and is an independent predictor of mortality. The etiology of cognitive impairment in CKD patients is multifactorial. The evidence of impact of renal transplant on cognitive function of the patient remains limited and controversial, and hence, this field needs to be explored. This study aims to determine the proportion of patients showing cognitive improvement post-renal transplant and the cognitive domain which shows maximum improvement post-transplant

AIM OF THE STUDY: Primary aim • To determine the proportion of patients showing cognitive improvement post-renal transplant using Montreal cognitive assessment test Secondary aim • To find the areas of cognition which show improvement 3 months and 6 months post-renal transplant

METHODS: This is a single-center prospective observational study of 100 patients who have undergone renal transplant in Medant hospital Gurugram between July 1, 2021 to July 1, 2022. Montreal Cognitive assessment test (MoCA) was conducted at the time of pre-transplant and then at 3 months and 6 months post-transplant. Seven cognitive domains are tested in MoCA test- executive functioning naming attention delayed recall abstraction language orientation.

RESULTS: A total of 100 patients have been recruited in the study with mean age of 34.9 years and male-to-female ratio of 4.8:1, out of which there were 12 pre-emptive transplants and 6 ABO incompatible transplants. Till now, 54 patients have been followed up to 6 months, and their data has been analyzed. Mean MoCA score pre-transplant, 3 months post-transplant and 6 months post-transplant is 23.9 Â ± 2.9, 24.5 Â ± 2.8 and 25.2 Â ± 2.4 and the difference between these scores (between pre-transplant and 3 months post-transplant and pre-transplant and 6 months post-transplant) has been found to be statistically significant (p value <0.001). Among these 54 patients, 31% of the patients had normal MoCA score (more than or equal to 26 out of 30) pre-transplant and this percentage increased to 42% three months post-transplant and 52% six months post-transplant. Among these 54 patients, 46% patients have shown improvement in MoCA score 3 months post-transplant as compared to their pre-transplant score and 61% patients have shown improvement in MoCA score 6 months post-transplant as compared to their pre-transplant score.

CONCLUSIONS: Out of 54 patients, in whom the study has been completed, more than half of the patients (61%) have shown improvement in the MoCA score 6 months post-transplant with maximum improvement in abstraction and delayed recall domains of cognition. The study is yet to completed and full data will be analyzed by November 2022. did not provide any additional information in predicting development of AKI. 6. Further large sample studies are needed to use urine NGAL as a RENAL TROPONIN in guiding management of AKI.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 210: SERUM IMMUNOGLOBULIN E IN CHILDREN WITH PRIMARY NEPHROTIC SYNDROME

Bipasa Kar 1, Bibekananda Kar 1

BACKGROUND: Nephrotic syndrome has an incidence of 2 -6/lakh population and prevalence of 12-16/lakh population. It may be primary or secondary. It is associated with immune dysfunction and raised serum IgE levels. Previous studies have shown an association between high serum IgE levels and susceptibility to relapse and therapeutic outcome (Steroid sensitive/resistance).

AIM OF THE STUDY: To find out the IgE levels in children with primary nephrotic syndrome hospitalized at their first attack and analyze IgE levels as a predictor of therapeutic outcomes (steroid sensitive/resistance) and overall prognosis (susceptibility to relapse) in these children.

METHODS: The patients between 1 year-14 years with clinical symptoms of nephrotic syndrome and nephrotic range proteinuria were enrolled. Children with comorbidities like heart disease connective tissue disorders liver disease immunosuppressant therapy in last 4 weeks were excluded. The serum IgE level were assayed and treatment initiated. The patients were followed up for a period of 2 years. The serum IgE levels were correlated with the treatment outcome in these patients (resistance /relapse — frequent/infrequent)

RESULTS: We studied 67 patients with primary NS. We defined the apparent onset of disease as the day of occurrence of facial swelling. The mean concentration of serum IgE was elevated in majority of patients. The patients were segregated into SRNS, FRNS, IRNS, SSNS. The mean serum IgE levels were higher in the SRNS and FRNS patients in comparison to IRNS and SSNS. The levels in SSNS was lower among all the groups (p < 0.05). further the incidence of complications, duration of hospital stay, time to remission was higher in patients with high serum IgE than normal or low serum IgE.

CONCLUSIONS: This study indicates that initial serum IgE level can be used to predict response to therapy and disease severity in primary nephrotic syndrome.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 211: CHRONIC KIDNEY DISEASE ON MAINTENANCE HEMODIALYSIS WITH COVID 19 INFECTION - A SINGLE CENTRE EXPERIENCE

Akhil Rahman 1, George Kurian 1

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 is a highly transmissible and pathogenic coronavirus that emerged in late 2019. This has been posing great threats to the world in many aspects. Comprehensive understandings on SARS-CoV-2 and the interaction of the virus with hosts are fundamentally important in the fight against SARS-CoV-2. SARS-CoV-2 is a positive-sense single-stranded RNA virus. The purpose of this study is to assess the clinical profile of ESRD patients undergoing maintenance hemodialysis with COVID-19 infection. Patients with Chronic Kidney Disease on hemodialysis are at an increased risk for any infections and often have unfavorable outcomes in case of serious infections. Here we present the data regarding the outcome of maintenance hemodialysis patients who had COVID 19 infection.

AIM OF THE STUDY: To study incidence of COVID 19 infection and clinical profile in Chronic Kidney Disease -Maintenance hemodialysis patients

METHODS: This is single-center cross-sectional observational study conducted at Amrita Institute of Medical Science and Research Centre Kochi between March 2020 to August 2022. All patients on maintenance hemodialysis who developed COVID19 infection was included in the study. Patients who become COVID positive were managed as per institutional COVID 19 protocols. Only patients who received 2 doses of COVID 19 vaccine and crossed 14 days after second dose of vaccination were considered as vaccinated in the study population.

RESULTS: The incidence of COVID 19 infection among our maintenance hemodialysis patients was 56%. 62 out of our 110 maintenance hemodialysis patients were COVID 19 positive. Majority were males, hypertension was common among this population. 30% developed COVID-19 pneumonia. 90% of the study population were vaccinated, 75% of them were infected after 6 months of taking second dose of COVID 19 vaccine. 88% of the vaccinated patients had only mild infection. The mortality was 31%. There was no mortality in patients who received the cocktail antibody.

CONCLUSIONS: The study shows that incidence of COVID 19 infection was high in our hemodialysis patients, frequent hospital visits and travel could be one of the reasons for the same. COVID 19 vaccination was effective especially during the first 6 months after the second dose of COVID 19 infection, it helps in reducing the severity of COVID 19 infection and has a good recovery rate. Cocktail antibody (Casirivimab and imdevimab) were effective in reducing the mortality rate in hemodialysis patients. More studies are warranted for scheduling further doses of COVID 19 vaccines in maintenance hemodialysis patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 212: PODOCYTOPATHY IN RENAL CELL CARCINOMA

B S Swheta 1, Sushanth Kumar 1, P Mayoor 1

BACKGROUND: Renal cell carcinoma is 7th most common form of neoplasm in world and often associated with Para-neoplastic syndrome caused by secretion of tumor cell products manifesting as impaired glucose metabolism hypercalcemia hypertension and cushing syndrome. However, paraneoplastic glomerulonephritis is often overlooked due to attribution of urinary abnormalities as part of tumor.

AIM OF THE STUDY:

METHODS:

RESULTS: A 58-year-old male, known case of hypertension and CKD (baseline creatinine-1.5) presented with Hematuria of 1 week. On routine investigation found to have Sr creatinine: 1.53 mg/dl, urine revealing hematuria and proteinuria (3+, PCR-5). Imaging reveals right upper and mid pole mass of 3.8 x 4.2 x 4.3 cm. Renal histopathology from right lower pole revealed normal glomerular morphology constituent with podocytopathy. Renal biopsy from right upper pole revealed high grade carcinoma. He underwent radical nephrectomy [renal cell carcinoma —unclassified (sarcomatoid differentiation-100%), grade 4, PT3aN1]. After 3 weeks, his proteinuria resolved (Urine PCR -0.08) with resection of tumor (no steroids) for podocytopathy. In 4th week, PET-CECT done suggestive of ill defined soft tissue thickening in right renal bed and lung and gallbladder neck metastasis and hence underwent 6 sessions of immunotherapy (Nivolumab- PD-1 inhibitor) and targeted therapy (cabozatinib- tyrosine kinase inhibitor). His sr. creatinine at follow-up after 6 cycles of targeted immunotherapy is 1.84.

CONCLUSIONS: Identification of glomerulopathy in renal cell carcinoma has prognostic implications. Minimal change disease resolves with resection of tumor mass.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 213: SPECTRUM OF ACUTE KIDNEY INJURY IN PATIENTS OF TROPICAL ACUTE FEBRILE ILLNESS IN A TERTIARY HOSPITAL

Rohit Badge 1, V Suresh Babu 1, Urmila Anandh 1, Vinay Rathore 1

BACKGROUND: Worldwide incidence of acute kidney injury (AKI) is variable and even more among the developed and the developing countries. Tropical acute febrile illnesses such as malaria typhoid leptospirosis dengue and others are a major cause of AKI in the tropics

AIM OF THE STUDY: To study the incidence clinical profile and outcomes of acute kidney injury (AKI) due to tropical acute febrile illness (TAFI) admitted in tertiary care hospital in a metro city.

METHODS: The prospective study was conducted in Yashoda hospitals Secunderabad a 700 bed multispecialty tertiary care hospital in India from April 2019 to March 2020. AKI was defined as per KDIGO. The clinical history physical examination and laboratory investigations were recorded in a standard proforma.

RESULTS: Hundred patients suffering from TAFI were admitted during the study period. Mean age of the study population was 43.12Â ± 14.33 years. Twenty-six (60.5%) were males. Most common presenting feature was fever (100%), chills (81.4%) and vomiting (67.4%). The most common cause of TAFI were Dengue (n = 49,49%), Leptospirosis (n = 20,20%), Malaria (n = 10,10%), Scrub typhus (n = 10,10%), and Undifferentiated fever (n = 6,6%). 43 patients (43%) had AKI as per KDIGO definition. 23 patients (53.5%) have stage 1 AKI, 11 (25.6%) had stage 2 AKI and 9 (20.9%) had stage 3 AKI at the time of enrollment. RRT was required in 16.3% of patients. Dengue and Leptospirosis were the most common causes for requirement of RRT. SLED was the most common mode of dialysis. Mortality was observed in 6.98% patients, and Dengue was the most common cause of mortality.

CONCLUSIONS: AKI is common in TAFI. RRT was however required only 16.3% and mortality was observed in 6.98%

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 214: MITIGATION OF HYPOBARIC HYPOXIA INDUCED RENAL INFLAMMATORY ALTERATIONS BY QUERCETIN PROPHYLAXIS

Vaishnavi Rathi 1, S Sarada 1, Surya Kumari 1

BACKGROUND: Nuclear factor-ΰB (NF- ΰB) is the major regulatory transcription factor involved in hypoxia-induced inflammation. Stimulus by low oxygen concentrations activates a number of pathways that lead to the accumulation of NF- ΰB and its DNA- binding in the nucleus. Its activation results in the aggravation of various pro-inflammatory cytokines under hypoxia.

AIM OF THE STUDY: 1. The objective of the present study is to decipher the role of NF- ΰB and its associated downstream genes involved in causing inflammation in the kidneys of rats under acute hypobaric hypoxia exposure. 2. The study also aims at finding out the efficacy of quercetin in prevention of renal inflammation caused due to hypoxia exposure.

METHODS: 1. Male Sprague Dawley rats (24 in number) were divided into four groups (n = 6): (i) Normoxia (control), (ii) Hypoxia (12h), (iii) Normoxia + Quercetin (50 mg/kg BW), (iv) Hypoxia + Quercetin (50 mg/kg BW) 2. The animals were preconditioned with 50m g/kg BW of quercetin 1h prior to hypoxia exposure (12h) at 25 000 ft. in a simulated hypobaric hypoxia chamber. 3. Blood and Kidneys were collected after appropriate dissection protocol and preserved at -20 degree celsius. 4. Tissue homogenates were prepared for performing various biochemical assays (ROS MDA GSH GPx and SOD) and western blotting for protein expression analysis of different inflammatory and pro-inflammatory markers.

RESULTS: 1. The results revealed a significant increment in reactive oxygen species (ROS) generation and MDA (p < 0.001) (lipid peroxidation) along with down-regulation of SOD, GPx, and GSH levels in kidney tissue homogenates of hypoxia-exposed rats as compared to control. 2. However, ROS and MDA declined significantly with enhancement in antioxidant molecules (SOD, GPx, and GSH) in quercetin-fed rats as compared to hypoxia exposed group (p < 0.05). 3. Protein expression analysis through western blotting and EMSA performed in nuclear extracts of kidneys, exhibit a significant upregulation of NF- ΰB under hypoxic stress as compared to control. Whereas pretreatment with quercetin aids in downregulation of NF- ΰB in comparison with the hypoxia exposed group. 4. Further, quercetin prophylaxis significantly reduced the expression of pro-inflammatory cytokines (TNF-Î ±, IL-1, and IL-18), along with reduced expression of cell adhesion molecules (VCAM-I and P-selectin) in kidneys of rats under hypoxia as compared to control. 5. Finally, the results were confirmed with histopathological analysis.

CONCLUSIONS: 1. The study observed an upregulated inflammatory cascade in response to hypoxia. 2. The results indicate that quercetin can be considered a potential phytochemical flavonoid moiety in the amelioration of acute renal inflammation under hypobaric hypoxia.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 215: CLINICAL SPECTRUM AND OUTCOMES OF IGA NEPHROPATHY

Aasish Peddu 1, Mudiyala Geetha Pavani 1

BACKGROUND: IgA nephropathy is the most common primary glomerulonephritis worldwide. It is defined as glomerular disease with IgA-dominant or codominant mesangial immunoglobulin deposits. First described by Berger et al.. in 1968 IgA Nephropathy still remains elusive because of its highly variable mode of presentation and disease progression. Clinical presentations include synpharyngitic macroscopic hematuria microscopic hematuria with proteinuria and hypertension and chronic kidney disease. The relatively rare presentations include malignant hypertension acute nephritic syndrome acute kidney injury and nephrotic syndrome. In the past, IgA nephropathy was thought to be a benign disease with a 10-year renal survival rate of greater than 80%. But the emerging data shows a different scenario with most of the patients developing progressive decline in renal function and about 40% end with ESRD.

AIM OF THE STUDY: 1. To study the clinical spectrum of patients with IgA Nephropathy. 2. To study the short-term outcomes of patients with IgA Nephropathy.

METHODS: This was an observational study conducted at the Department of Nephrology Andhra Medical College Visakhapatnam from January 2021 to December 2021 including 31 patients with biopsy-proven primary IgA Nephropathy after obtaining written informed consent. Considering the mode of clinical presentation and laboratory findings the clinical syndrome was classified into nephrotic syndrome nephritic syndrome rapidly progressive renal failure acute kidney injury chronic kidney disease and isolated macroscopic hematuria. The patients were followed up for 12 months, and their outcomes at the end of study were recorded as complete remission partial remission progression of the disease and end-stage renal disease based on KDIGO guidelines.

RESULTS: Male-to-female ratio in the study was 1.38:1 with males constituting 58.1% and maximum incidence was seen in patients between 26-35 years of age in both males and females constituting 44.4% and 46.2% respectively. The most common clinical presentation was chronic kidney disease (48.4%) and the least common was isolated macroscopic hematuria (3.2%). Nephrotic syndrome, nephritic syndrome and rapidly progressive renal failure constituted about 12.9% each. Acute kidney injury was seen in 9.67%. Complete remission was observed in all patients presenting with AKI and isolated macroscopic hematuria by 3 months. 13.3% of the patients presented with CKD had partial remission, 40% had progression of the disease over a mean follow-up period of 8 months with a mean loss of eGFR of 4.8 ml/min/1.73 m2 and 46.6% ended up in ESRD. 50% of the patients presented with RPRF were dialysis dependent, 25% achieved partial remission and 25% had progressive renal disease at 12 months of follow-up. 75% of the patients presented with nephrotic and nephritic syndromes had partial remission and 25% had progression of renal disease.

CONCLUSIONS: Chronic kidney disease was the most common clinical presentation among all age groups and in both genders. There was a marked severity with younger age of presentation. IgA Nephropathy in this study shown poor prognosis similar to other studies from India. Keywords: IgA Nephropathy, rapidly progressive renal failure, end-stage renal disease.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 216: STUDY OF PSYCHIATRIC ASSESSMENT OF PROSPECTIVE RENAL TRANSPLANTATION DONORS IN A TERTIARY CARE CENTER OF NORTH-WEST INDIA

Disha Saxena 1, Vinay Malhotra 1, Dhananjai Agarwal 1

BACKGROUND: Kidney transplant is the most efficient treatment for patients with terminal renal failure in relation to the quality of life. A thorough medical and psychosocial assessment of potential living kidney donors is required the main objective of which is to ensure that the physical and mental health of the donor is optimal identify possible contraindications and minimize the long-term risks.

AIM OF THE STUDY: Psychiatric assessment of depression and anxiety in prospective donors and their correlation with demographic variables.

METHODS: Preoperative psychiatric assessment of 52 prospective donors was done according to the Transplantation of Human Organs Act 1994. All prospective donors were assessed on HADS (Hospital Anxiety and Depression Scale-Hindi) in SMS Hospital Jaipur during 2020-2021.

RESULTS: 52 prospective donors were included in this study and assessed. 75% of donors were female. Out of total 13.46% were spouse, and 76.72% were blood relatives. In our study, anxiety was seen in 17 (32.69%) donors of which 35.9% were females. Similarly, parental relations and educational status was significantly associated with anxiety. 9.6% participants showed depressive symptoms. No significant association was found between depression and variables included in our study.

CONCLUSIONS: There should be measures for assessment of depression and psychiatric disorders in addition to physical and biochemical examination among kidney donors.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 217: ALL DARK BLOOD IS NOT HYPOXEMIA!! €” A USUAL SCENARIO€¦. AN UNUSUAL PROBLEM!!!

Gaurav Yadav 1, Sudeep Prakash 1

BACKGROUND: Methemoglobinemia is a rare and potentially life-threatening condition in which the iron atoms in circulating hemoglobin are converted from the reduced Fe2+ state to the oxidized Fe3+ state. This form of the hemoglobin molecule cannot bind oxygen efficiently causing tissue hypoxia. Methemoglobinemia may be due to congenital or acquired cause. Municipal water supplies are chlorinated to prevent bacterial growth. Dialysis water needs chloramine free water to prepare dialysate as their presence leads to methemoglobinemia and hemolysis. The carbon filters are designed to remove certain expected amount of chloramines form municipal water based on the size of the filter the contact period of water with the filter.

AIM OF THE STUDY: To highlight a rare case of methemoglobinemia associated with hemodialysis.

METHODS: We present a sentinel case of methemoglobinemia in a patient with acute kidney injury who developed methemoglobinemia during hemodialysis in the intensive care unit of a tertiary care teaching hospital. A 58-year-old diabetic female admitted with Guillain–Barre syndrome developed respiratory paralysis and acute kidney injury. The patient was placed on mechanical ventilation was also started on hemodialysis in intensive care unit from a newly installed RO plant. Within three hours of hemodialysis patient developed low spo2; however, her PaO2 on ABG was 300. On appearance the venous sample was dark maroon in color. The methemoglobinemia was confirmed by a bed side test by blowing oxygen into the blood sample along with also blowing oxygen in the control sample. The control venous sample turned bright red whereas the patients sample remained dark maroon after 1 min. Further evaluation showed raised methemoglobin levels to 4.5% features of hemolysis on peripheral blood smear raised LDH levels. Patient was managed conservatively with packed RBC transfusion and Injection ascorbic acid along with symptomatic care.

RESULTS: The high levels of chloramine in water supplied from freshly installed carbon filters in reverse osmosis (RO) plant led to development of methemoglobinemia and hemolysis.

CONCLUSIONS: High levels of chloramines may be encountered in situations like newly installed carbon filters, channel formation through the filter, sudden increase in chlorination levels in municipal water at supply level. This can lead to precipitation of methemoglobinemia and hemolysis in patients

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 218: PNEUMATURIA AN EARLY MARKER OF EMPHYSEMATOUS PYELONEPHRITIS

Solanki Darshansinh 1, Prakash Sudeep 1

BACKGROUND: Emphysematous pyelonephritis (EPN) is an acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma collecting system or perinephric tissue. EPN is associated with high mortality. Up to 95% of the cases with EPN have underlying uncontrolled diabetes mellitus. Escherichia coli is the most common causative pathogen with the organism isolated on urine or pus cultures in nearly 70% of the reported cases.

AIM OF THE STUDY: To discuss an unusual presentation of EPN

METHODS: 56-years-old male a known case of diabetes mellitus for past 20 years presented with high-grade fever associated with chills and rigors left-sided flank pain frothy urine sensation of passing air per urethra (pneumaturia) passage of fleshy masses per urethra. History of multiple admissions in the past with similar complaints. Patient had fever tachycardia and left renal angle tenderness. Evaluation revealed neutrophilic leukocytosis azotemia (creatinine 3.6 mg/dL) urine analysis showed numerous pus cells RBCs 2-3 Leukocyte esterase 3+ Nitrites + Ketones: negative. Urine culture revealed E.coli. Radiological evaluation revealed features suggestive of papillary necrosis with emphysematous pyelonephritis. He was managed with culture specific antibiotics DJ stent placement for hydroureteronephrosis glycemic control. Patient showed good response to therapy and recovered well.

RESULTS: Passage of air in addition to passage of fleshy mass per urethra may hint at presence of EPN

CONCLUSIONS: A diligent history taking to search for history of pneumaturia may result in early diagnosis of EPN.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 219: CLINICO-PATHOLOGICAL STUDY OF PAUCI-IMMUNE RENAL VASCULITIS AND ITS SHORT TERM OUTCOME

B Sangma 1, M Sharma 1, P Doley 1, G Pegu 1

BACKGROUND: Pauci-immune Crescentic Glomerulonephritis (PCGN) is one of the most common cause of rapidly progressive glomerulonephritis (RPGN). The incidence of PCGN is estimated to be 7-10 cases per million in the USA. PCGN has a predilection for whites compared to blacks with roughly equal representation in men and women. Western studies have reported the clinico-pathological features with PCGN however they were retrospective in nature. Some studies from northern India have also reported retrospective findings, but there were no major studies from the North Eastern part of the country. This study involving the North-east Indian population constitute an effort to prospectively analyze the clinicopathological features and asses the short term outcome.

AIM OF THE STUDY: 1. To study the clinico-pathological features of pauci-immune renal vasculitis 2. To study the short-term outcomes of pauci-immune renal vasculitis

METHODS: This was a single-center prospective and observational study done in a tertiary care hospital in the department of Nephrology Gauhati Medical College for the period from July 2021 to July 2022. All biopsy-proven pauci-immune renal vasculitis patients were enrolled into the study. The study participants received induction and plasma exchange as per protocol and followed up at 3 months and 6 months to study the short-term outcome.

RESULTS: The study included a total of 36 patients with pauci-immune renal vasculitis after satisfying all the inclusion and exclusion criteria. Four patients (11%) expired, 2 patients at 3 months follow-up and 2 patients at 6 months follow-up. Mean age of presentation was 33 years, male- 8 (22%) and female- 28 (77%). 23 (63%) patients needed hemodialysis on presentation and 17 patients (47%) received plasma exchange. 17 patients (47%) needed maintenance hemodialysis at 6 months follow-up. 15 patients (41%) achieved stable GFR at 6 months follow-up.

CONCLUSIONS: Our study population were of younger age group, females being the majority and predominantly had RPGN presentation and positivity for MPO- ANCA. Serum creatinine at presentation was found to be a good determinant of the renal outcome.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 220: IMMUNOSUPPRESSION MINIMIZATION STRATEGY FOR ABO INCOMPATIBLE KIDNEY TRANSPLANT RECIPIENTS DURING COVID-19 PANDEMIC

Siddhavinayak Rajmane 1, Ashwin Patil 1, Ashay Shingare 1, Sudhiranjan Dash 1, Rushi Deshpande 1, Madan M Bahadur 1

BACKGROUND: In the presence of COVID-19 illness immunosuppressed patients such as kidney transplant recipients (KTRs) have a higher mortality risk. ABO incompatible KTRs (ABOi — KTRs) are high-risk transplants and the use of low-dose maintenance immunosuppression during the COVID-19 pandemic is unknown.

AIM OF THE STUDY: To study effect of low dose maintenance immunosuppressive therapy on graft function and immunologic events in patients following ABOi-KTRs during COVID-19 pandemic.

METHODS: We present the results of a follow-up study of eight ABOi-KTRs done in Kidney Transplant Unit at Jaslok Hospital during COVID-19 pandemic.

RESULTS: Seven (87%) of the eight patients were male, while one was female. The median age was 49 years. Prior to transplant, all patients received rituximab (500 mg) and plasmapheresis. Six (75%) patients received antithymocyte globulin (1 mg/kg) induction, while two (25%) received basiliximab. Dose of one immunosuppressive agent tacrolimus was decreased to trough level of 6 to 8 ng/ mL instead of 8 to 12 as compared to our institutional protocol in pre-covid era. Antimetabolites and steroids were used in usual doses. Although immunosuppression was decreased, no rejection episodes or infection observed up at 10 days, 1 and 3 month after discharge, and no significant changes occurred in creatinine level during same period. Acute graft dysfunction was seen in 1 patient and the severity was related to tacrolimus trough levels, which were higher. All patients recovered baseline kidney function with no mortality during follow-up.

CONCLUSIONS: Our observational study suggests that the reduction of tacrolimus dose in ABOi KTRs performed during COVID-19 appears to be safe, since no patient experienced rejection episodes.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 221: PANEL REACTIVE ANTIBODY (PRA) TREND A GUIDE TO TREATMENT OF ANTIBODY MEDIATED REJECTION (AMR)

Bharat Shah 1, Ishan Parekh 1, Hepal Vora 1, Zaheer Virani 1, Prashant Rajput 1, Shruti Tapiawala 1

BACKGROUND: The primary aim of therapeutic approaches for AMR is removing circulating DSA and reducing DSA production. This is best achieved by plasma exchange (PLEX) and IVIG. There is no standard dose of PLEX and IVIg. We propose that PRA trend could be used as a guide to the dose of PLEX and IVIg

AIM OF THE STUDY: To use panel reactive antibody (PRA) trend as a guide to treatment of antibody mediated rejection (AMR).

METHODS: A 63-year-old male with ESRD due to ADPKD underwent ABO compatible living donor kidney transplant in 2014. He presented to us in August 2021 with swelling of legs increasing proteinuria and uncontrolled hypertension on multiple antihypertensive drugs. The investigations done included routine urinalysis CBC renal profile spot urine protein to creatinine ratio (UPCR) tacrolimus trough level kidney biopsy and PRA trend.

RESULTS: Routine urinalysis showed 3+ proteinuria, UPCR was 3.7, and serum creatinine was stable at 1.1 mg/dl. Tacrolimus trough level was 5.07 ng/ml. The transplant kidney Doppler showed reduced perfusion with increased cortical echogenicity. There was no renal artery stenosis. The PRA was positive to HLA class 2 antigens. Biopsy revealed features of AMR with C4D positivity. He was treated with 5 cycles of PLEX and 1 g/kg IVIg. Following this, there was significant reduction in the proteinuria and requirement of antihypertensive drugs. PRA done 3 months later showed low level of antibodies. He continues to do well with well-controlled BP, UPCR 0.18, and stable creatinine.

CONCLUSIONS: PRA trend could be used as a guide to PLEX and IVIg dose in treatment of AMR.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 222: METABOLOMICS APPROACH REVEALED THE INTERVENTION EFFECT OF COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) IN CKD PATIENTS

Deependra Kumar Yadav 1, Nikhil Gupta 2, Sonam Gautam 1, Ashish Kumar 2, Dinesh Kumar 2, Narayan Prasad 1

BACKGROUND: Chronic kidney disease (CKD) is the end point of a number of systemic chronic diseases. Recent epidemiological studies revealed high prevalence of CKD patients using complementary and alternative medicine (CAM). Clinicians believe that biochemical profiles of CKD patients using CAM (referred here as CAM-CKD) may be different compared to those on standard clinical treatment and should be managed differently.

AIM OF THE STUDY: The present study aims to explore the potential of NMR-based metabolomics approach to reveal the serum metabolic disparity between CKD and CAM-CKD patients and if the observed metabolic signatures can aid future drug development and clinical research studies through increasing understanding of the efficacy and safety of standard and alternative therapies.

METHODS: Serum samples were obtained from 30 CKD and 43 CAM-CKD patients and healthy normal controls (NC N = 47). The metabolic profiles were measured at 800 MHz NMR spectrometer using 1D 1H CMPG NMR spectra. The recorded spectra were further processed using various multivariate statistical analysis tools available on Metaboanalyst (freely available web-based software) such as partial least-squares-discriminant analysis (PLS-DA). The discriminatory metabolites were identified based on variable importance in projection (VIP) statistics and further evaluated for statistical significance (p-value < 0.05)

RESULTS: PLS-DA models were capable of clustering the CKD and CAM-CKD with considerably high value of Q2 and R2. Compared to CAM-CKD patients, the sera of CKD patients were characterized by (a) elevated levels of urea, creatinine, citrate, glucose, glycerol, phenylalanine, and phenylalanine-to-tyrosine ratio (PTR) and (b) decreased levels of various amino acids (such leucine, isoleucine, valine, and alanine), high-density lipoproteins, lactate, and acetate. These changes suggested that CKD patients are manifested with severe oxidative stress, hyperglycemia (with dampened glycolysis), increased protein energy wasting, and reduced lipid/membrane metabolism.

CONCLUSIONS: The study illustrated that serum metabolic changes are more aberrant in CKD patient’s compared to CAM-CKD patients. These observed metabolic changes provided useful information for the assessment of disease progression and further to guide the clinical treatment of CKD patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 223: PROSPECTIVE STUDY OF STRUCTURAL AND FUNCTIONAL CARDIAC CHANGES POST RENAL TRANSPLANT

Mehak Singla R P Mathur 1, P Venkata Siva Tez 1

BACKGROUND: CKD is a public health problem and is one of the major risk factors for cardiovascular disease. Pulmonary hypertension is recently recognized complication of CKD particularly ESRD. Patients with CKD have higher cardiovascular mortality than age/sex & race matched general population. These patients with CVD are considered less suitable candidates for kidney transplant due to increased risk of operative morbidity and mortality. However, kidney transplant may actually improve cardiac function though not universally observed in all studies.

AIM OF THE STUDY: To assess improvement in LVH and PAH post-renal transplant.

METHODS: It was a prospective observational study. 30 patients of ESRD with underlying cardiovascular disease were enrolled and followed for 6 months after transplant. Patients with underlying ischemic or valvular heart disease were excluded. Primary outcome measure was to assess improvement in LVH and PAH after kidney transplant. Secondary outcomes were to assess effect of transplant on systolic and diastolic kidney function association of LVH with various biochemical parameters like hemoglobin PTH and phosphorus. Various cardiac measurements were performed according to American Society of Echocardiography guidelines. LVH was defined by LVMI >95 g/m2 in females and >115 g/m2 in males. Pulmonary hypertension was defined as mPAP > = 25 mmHg and grading of severity was done based on guidelines from task force for diagnosis and treatment of PAH. Chi-square test and Mann–Whitney U-test were used where appropriate. P value < 0.05 was considered significant.

RESULTS: In our study, most patients were young — middle aged, with mean age of 36.4+9.56 years. Males outnumbered females with males accounting for 93.33%. Most of them underwent dialysis for 6-24 months before transplant. Serum phosphorus and PTH were adequately controlled with mean values of 5.15 mg/dl and 361.05 pg/ml respectively. Hemoglobin concentration improved from 9.84g/dl to 12.97g/dl 6 months after transplant. LVH was the most common cardiovascular abnormality, being present in 71.33% patients before transplant and reduced to 30% after transplant (p = 0.001). Mean LVMI improved from 131+22.52 g/m2 to 108.82+17.49 g/m2 (p < 0.01). LVH prevalence was higher in patients with anemia and older age group. However, it was not found to be associated with hyperphosphatemia, hyperparathyroidism, diabetes, or duration of dialysis. Similarly, pulmonary hypertension was also independent of above factors. PH was found in 30% of our patients, which improved post-transplant, with only 3.33% patients having PH. We found a significant increase in left ventricular ejection fraction from 55.1+5.78% to 61.4+5.39% at 6 months post-transplant. E/A and E/e’ respectively improved from 1.3+0.33 to 1.08+0.35 and 9.83+2.53 to 7.81+1.87 (p > 0.005).

CONCLUSIONS: Cardiac parameters like left ventricular structure and function as well as pulmonary hypertension improves after transplant. Though patients with cardiovascular disease are considered less suitable candidates for kidney transplant due to increased perioperative morbidity and mortality, these parameters may actually improve after transplant and should be taken into consideration while evaluating these patients for kidney transplant.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 224: A PROSPECTIVE OBSERVATIONAL STUDY TO ASSESS THE OUTCOMES OF TUNNELLED DIALYSIS CATHETERS IN PATIENTS ON HEMODIALYSIS

Pooja P Lokkur 1, Manish Jain 1, Dinesh Kumar Yadav 1, Shyam Bansal 1, Amit Mahapatra 1, Dinesh Bansal 1, Abhyuday Rana 1

BACKGROUND: Many chronic kidney disease patients present to nephrologists at end-stage renal disease (ESRD) thereby making planned dialysis initiation difficult. Tunneled dialysis catheters though not ideal are a necessary evil as they form a bridge before AV Fistula (AVF) or transplant. There are several advantages of a nephrologist centered insertion of tunneled dialysis catheters like rapid access better understanding of vascular access needs and streamlined care process. This study was done to determine the outcomes of tunneled dialysis catheter (TDC) insertion by nephrologists.

AIM OF THE STUDY: To determine the outcomes of tunneled dialysis catheter insertion by nephrologists.

METHODS: This was a single-center prospective observational study of patients with end-stage renal disease who underwent a tunneled dialysis catheter insertion by nephrologist between august 2021 and august 2022 at our institution. Analyzed data included clinical background demographics functioning of catheter complications if any reason for removal and catheter survival.

RESULTS: Total 150 patients were recruited in the study, 108 males and 42 females with a median age of 54 years. Tunneled dialysis catheter was the primary access in 40.7% of patients at dialysis initiation. Right internal jugular vein was the most common site of TDC insertion in our patients. Among the 150 patients, 11% had early bleeding from the exit site, 58% of whom were either on antiplatelet or anticoagulant and 33% of them required intervention in the form of resuturing. Catheter-related bloodstream infection (CRBSI) was seen in 16.7% of the patients and thrombosis was seen in 6 patients. Forty-one patients underwent catheter removal within 6 months, most common reasons being functioning AVF (34.9%), followed by renal transplant (27.9%) and CRBSI (18.6%).

CONCLUSIONS: Nephrologist-driven tunneled dialysis catheter insertion has a good success rate and safety profile with less cost. All nephrology departments should include this in their training curriculum for the trainee nephrologists.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 225: A CURIOUS CASE OF UNEXPLAINED AZOTAEMIA IN AN ELDERLY MALE WITH LATE ONSET SEVERE ASTHMA

S Sai Sumanth 1, Bhaskar Datt 1

BACKGROUND: • IgG4-related disease (IgG4-RD) is a rare potentially life-threatening fibro-inflammatory disease of unknown etiology. IgG4-RD is clinically characterized by the presence of fibro-inflammatory masses in various organ dense lymphoplasmacytic infiltration of IgG4-postitive plasma cells storiform fibrosis and elevated serum levels of IgG4 • Respiratory involvement is common in immunoglobulin G4-related disease (IgG4-RD). However, severe asthma as the initial clinical manifestation of IgG4-RD is rare and needs to be considered especially in late onset asthma with kidney dysfunction

AIM OF THE STUDY: To explore the clinical characteristics and prognosis of an elderly patient with immunoglobulin G4-related disease (IgG4-RD) manifesting as severe asthma.

METHODS: 73-year-old male former smoker was diagnosed as a case of bronchial asthma at age of 70 years. He was initially managed with low dose inhaled corticosteroids. In view of refractory asthma and raised IgE levels, he had to be started on injectable anti IgE monoclonal antibody- Omalizumab. He later presented with fatigue and loss of appetite of 6 month duration. His evaluation revealed mild anemia azotemia hyperglobulinemia. Urine–protein–creatinine ratio was 80 mg/g of creatinine. Ultrasound of abdomen showed bilateral enlarged kidneys. Work up for multiple myeloma was negative. SPEP showed no M spike but showed raised gamma globulin. To evaluate this unusual presentation, he was subjected to kidney biopsy which revealed interstitial fibrosis in storiform pattern dense inflammatory infiltrate of plasma cells eosinophils and lymphocytes 12-14 igG4 +ve plasma cells per HPF s/o IgG4 related tubulo-interstitial nephritis. He was managed with oral steroids. Presently he is symptom free with sr.creatinine 0.59 mg/dl.

RESULTS: A comprehensive evaluation of a late onset asthma with kidney dysfunction resulted in revealing IgG4 RD

CONCLUSIONS: Comprehensive evaluation of late onset asthma in middle to elderly patients with azotaemia is recommended as severe asthma can be an initial manifestation of a rare underlying multisystem immune fibroinflammatory disorder- IgG4-related disease - kidney disease

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 226: STUDY OF THE SPECTRUM OF PATHOLOGICAL FINDINGS IN RENAL TRANSPLANT RECIPIENTS WITH AN ASYMPTOMATIC SLOW RISE IN SERUM CREATININE AT A TERTIARY CARE CENTER IN NORTH INDIA

Niranjan Gogoi 1, Dhananjai Agarwal 1, Rakesh Gupta 1, Vinay Malhotra 1, Tushar Gupta 1, Kavish Sharma 1, SV Gigin 1, A Dhananjai 1, G Niranjan 1, G Rakesh 1, M Vinay 1, G Tushar 1, S Kavish 1, S Gigin 1

BACKGROUND: Creeping creatinine is defined as an unexplained increase in serum creatinine equal to or >30% over baseline (in the absence of potential confounding factors) for at least three months but not more than 12 months before the biopsy. This increase could occur at any time during any follow-up interval from renal transplantation.

AIM OF THE STUDY: Assessment of spectrum of all histopathological findings in a renal transplant recipient with an asymptomatic slow rise in serum creatinine.

METHODS: Hospital based cross-sectional study

RESULTS: We studied 30 cases of transplant recipients and divided the period of biopsy as within 3 months, 3-6 months, and >6 months. We found a high prevalence of acute tubular necrosis 20% (n = 6), the majority of which were presented within 6 months of transplantation found to be significant (p < 0.05), acute antibody-mediated rejection 20% (n = 6), chronic antibody-mediated rejection 20% (n = 6), chronic allograft nephropathy (CAN) 10% (n = 3), chronic T-cell-mediated rejection 10% (n = 3), acute cellular rejection 6%, non-adherence 6% (n = 2), de novo membranous nephropathy and C3 glomerulonephritis 3%, and cortical necrosis 3% (n = 1).

CONCLUSIONS: Graft dysfunction has a variety of causes that are multifactorial and time-dependent and is critical for better targeting therapies or taking preventative measures that improve long-term outcomes.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 227: SPONTANEOUS RESOLUTION OF LARGE PERICARDIAL EFFUSION AFTER CARDIOPULMONARY RESUSCITATION IN A CHRONIC KIDNEY DISEASE PATIENT ON MAINTENANCE HAEMODIALYSIS

Anil Kumar Jhajhria 1, Manoj Singhal 1, Lovy Gaur 1, Sourabh Gupta 1

BACKGROUND: Here we discuss a chronic kidney disease (CKD) patient with large pericardial effusion who arrested secondary to tamponade and had an unintentional pericardial decompression secondary to cardiopulmonary resuscitation (CPR) that subsequently saved his life.

AIM OF THE STUDY: To bring to light management difficulties in chronic kidney disease patients undergoing maintenance hemodialysis with large pericardial effusion

METHODS: 67-year-old male a case of CKD on maintenance hemodialysis (for last two years) but inadequately dialyzed over last two months after recent Covid pneumonia was detected to have large pericardial effusion on echocardiography. He was planned for intensive heparin-free dialysis in view of absence of frank clinical and echocardiographic findings of tamponade with close surveillance for pericardial effusion. 60 minutes into hemodialysis patient developed dyspnea hypotension and cardiac arrest. Return of spontaneous circulation was achieved after three cycles of cardiopulmonary resuscitation. Echocardiography (echo) guided pericardiocentesis was planned based on clinical suspicion of tamponade. But echocardiography revealed only mild pericardial effusion. Chest X-ray showed new left pleural effusion. Pleurocentesis revealed hemorrhagic fluid. Subsequently done CT thorax showed multiple rib fractures. Patient was discharged on day eleven in stable condition with repeat chest X ray and echocardiography showing no further collection.

RESULTS: Though cardiac tamponade is largely a clinical diagnosis, various other features like echocardiography aid in its diagnosis. Diagnosis of tamponade in CKD patient with pericardial effusion is difficult because of several reasons. All classical clinical features of tamponade like hypotension or elevated systemic pressures may not be manifested all the time in cases of tamponade. Our patient developed clinical signs of tamponade 60 minutes into dialysis session indicating that precipitation of tamponade was likely due to reduction in preload due to ultrafiltration (UF) during hemodialysis. Though, daily dialysis is the initial preferred treatment of choice for uremic pericardial effusions in CKD patients without clinical or echocardiographic signs of tamponade, there are case reports which support early pericardiocentesis as treatment of choice in all large pericardial effusions in CKD patients on maintenance hemodialysis (MHD). In our case of large pericardial effusion, due to absence of frank clinical/ echocardiographic evidence of tamponade, we were prompted to go for aggressive dialysis treatment plan, but had tamponade during dialysis. CPR can cause inadvertent injury to surrounding structures, ribs, abdominal organs, and vascular injury. In our case, CPR-associated injury leads to unintentional pericardial decompression probably due to rib injury or due to high force generated during CPR coupled with high pericardial pressures which overcame the tensile strength of pericardium resulting in pericardial decompression. Findings of fractured ribs on CT scan post-resuscitation in our case supports that high force and pressure were generated during CPR.

CONCLUSIONS: This case report supports early pericardiocentesis as treatment of choice for large pericardial effusion in CKD patients on MHD. Also, care should be taken while dialyzing these patient as rapid UF can precipitate tamponade.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 228: VERY HIGH PROCALCITONIN LEVEL IN ESKD PATIENTS WITH TB

Saumya Vishnoi 1, Madhavi Dadwe 1, Virendra Chauhan 1, Krishnapriya 1, Chaitrali Gawde 1, Hepal Vora 1, Zaheer Virani 1, Prashant Rajput 1, Shruti Tapiawala 1, Bharat V Shah 1

BACKGROUND: Procalcitonin (PCT) is usually high with bacterial infection but not with mycobacterial fungal and viral infections.

AIM OF THE STUDY: Our aim is to show that procalcitonin levels can be high even in TB in ESKD patients.

METHODS: Two ESKD patients presented with high-grade continuous fever. A thorough clinical examination was done. Laboratory work up included Urine R CBC CRP PCT smear for MP dengue NS 1 urine culture blood culture and chest X-ray. As this work up did not yield answer CT chest abdomen and pelvis was done.

RESULTS: In the first case, there was leukocytosis (25170/mm3), CRP was 209 mg/L and PCT was > 200 ng/ml. The CT scan revealed retroperitoneal and supraclavicular lymphadenopathy for which USG guided biopsy was done. Histopathology revealed caseating granulomatous inflammation suggestive of TB. In the second case, TLC was 8800/ mm3, CRP was 194 mg/L, and PCT was > 100 ng/ml. CT revealed omental thickening with ascites. USG guided ascitic fluid tapping was done. This showed exudative picture with raised ADA. Both were treated with antitubercular treatment and improved.

CONCLUSIONS: Our cases show that ESKD patients with TB can develop very high levels of PCT, an observation not yet reported in literature. While slightly high PCT levels are expected in ESKD patients, very high levels in these cases are most likely to be due to TB.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 229: A RARE REPORT OF THYMOMA ASSOCIATED MYASTHENIA GRAVIS PRESENTING AS STEROID RESISTANT NEPHROTIC SYNDROME

Sutanay Bhattacharyya 1, Himansu Sekhar Mahapatra 1

BACKGROUND: Nephrotic syndrome as a paraneoplastic manifestation of thymoma is a rare occurrence. Usually such patients are steroid sensitive. However, no steroid-resistant nephrotic syndrome has been reported in association with thymoma-related myasthenia gravis

AIM OF THE STUDY: To present a rare presentation of steroid-resistant nephrotic syndrome following diagnosis of thymoma-associated myasthenia gravis who responded to tacrolimus therapy

METHODS: A 25-year-old presented with bulbar symptoms and quadriparesis and was diagnosed as Myasthenia Gravis on serological and electrodiagnostic testing. Further workup revealed a mediastinal mass and subsequently transsternal thymectomy with histopathological examination demonstrating a grade 2b cystic thymoma.

RESULTS: He was started on steroids and pyridostigmine. Thereafter he developed features of nephrotic syndrome which on renal biopsy showed minimal change disease. His steroid dose was increased. However on subsequent visits, he was labeled as steroid resistant. He was started on tacrolimus and he went into remission, clinically as well as in terms of laboratory parameters. To the best of our knowledge, this is the second such case report from India and the only case of thymoma-associated MG presenting as steroid-resistant nephrotic syndrome who subsequently responded to tacrolimus.

CONCLUSIONS: Minimal Change Disease mostly occurs in children and if diagnosed in adults, a search for a potential cause such as Myasthenia Gravis and other associated thymic disorders should be undertaken. In spite of its rarity, clinicians should keep in mind the association between these two disorders and their presentation as steroid-resistant nephrotic syndrome.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 230: AN UNUSUAL CASE OF HYPERAMMONEMIA AFTER AN ABO INCOMPATIBLE RENAL TRANSPLANT

Mahesh Kota 1, M Rajasekara Chakravathi 1

BACKGROUND: ABO INCOMPATIBLE TRANSPLANT RECIPIENT

AIM OF THE STUDY: To evaluate the cause of unexplained altered sensorium

METHODS: Clinical and laboratory methods to find out the cause of unexplained altered sensorium

RESULTS: Hyperammonemia secondary to ureaplasma infection

CONCLUSIONS: To the best of our knowledge, this is a rare case of post-ABO incompatible renal transplant recipient developed hyperammonemia due to U.urealyticum infection, survived and recovered without any residual neurological dysfunction. Our case highlights the importance of considering elevated blood ammonia level in any patient with altered sensorium in particular with pre-existing renal dysfunction and considering Ureaplasma infections in all post-transplant recipients with elevated ammonia levels regardless of the transplanted organ, and specifically testing for them by PCR. These are readily treatable infections with resultant rapid improvement in ammonia levels and mental status, which was seen in our patient. As such, empiric specific antimicrobial treatment should be strongly considered for post-transplant patients with hyperammonemia syndrome.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 231: CLINICOPATHOLOGICAL CORRELATION OF VARIOUS RENAL DISEASE IN A TERTIARY CARE CENTRE IN INDIA

Aquib Farooqui 1, M Aslam 1

BACKGROUND: Biopsy-proven renal diseases give an insight into the prevalence of various renal diseases. There are uncommon diseases which differ according to geographical area demography age and race of a population. It becomes particularly important when diseases can be detected at an earlier stage and timely treatment can improve AKI and prevent CKD.

AIM OF THE STUDY: 1. This study was aimed to evaluate the histopathological spectrum of kidney diseases and correlate it with the clinical manifestations. 2. The secondary aim is to identify prevalence of glomerular diseases in local regional context and then to device strategy for better and early detection of endemic diseases in the region and ensure prompt treatment.

METHODS: The present study is an ambispective observational study conducted at a tertiary care hospital. Over one hundred native kidney biopsies have been performed under ultrasonographic guidance. Two renal core tissues which were obtained in each case were evaluated for light microscopy and immunofluorescence studies. An additional tissue core was preserved for electron microcopy studies done in select few cases.

RESULTS: Mean age: 31.36 years ranging from 12 years to 62 years Male to female- 1:1.02 Majority of patients with Nephrotic syndrome (48.2%) followed by nephritic syndrome (24.1%). Three patients (3.6%) with nephrotic syndrome were found to have normal histopathology.

CONCLUSIONS: Most common indication for biopsy was found to be nephrotic syndrome, FSGS being the most common disease. IgA nephropathy accounted for majority of primary glomerular diseases. Lupus nephritis was the most common secondary glomerular disease. Most patients with diabetes mellitus had nodular glomerulosclerosis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 232: RECURRENT OR DE NOVO GLOMERULONEPHRITIS AND ITS IMPACT ON GRAFT SURVIVAL IN RENAL TRANSPLANT RECIPIENTS; AN OBSERVATIONAL STUDY

S V Gigin 1, Dhanajai Agarwal 1, Rakesh Gupta 1, S Kavish 1, Shashank Bharatwaj 1

BACKGROUND: Glomerulonephritis (GN) is a major cause of end-stage renal disease (ESRD) is the third most common cause behind hypertensive and diabetic kidney disease. Recurrence of GN is reported in 6—20% of renal allograft recipients depending on duration of follow-up and type of primary GN. Recurrence of GN has got a negative impact on long-term graft outcomes with recurrence being the third most common cause of allograft loss after chronic rejection and death

AIM OF THE STUDY: This study aimed to assess the prevalence of recurrent or de novo glomerulonephritis in renal transplant recipient graft survival and patient outcome following glomerulonephritis

METHODS: This was a observational study. Renal allografts recipients with a graft biopsy-proven glomerulonephritis diagnosed between January 2017 and December 2021 were enrolled in the study. A total of 15 patients were enrolled in the study during after satisfying exclusion criteria.

RESULTS: About 112 renal graft biopsy done for allograft dysfunction between January 2017 and December 2021, among them 15 were found to have either de novo or recurrent GN. Out of 15, pretransplant biopsy was done in 4. IgA nephropathy detected in 2, FSGS in 1, membranous nephropathy in 1. In graft biopsy IgAN detected in 7, FSGS in 5, MPGN in 1, 3 patients had same native disease after renal transplant, one patient had IgAN in pretransplant biopsy and FSGS in graft biopsy. NODAT diagnosed in 2 patients on follow-up. On follow-up for minimum one year after graft biopsy average rise in creatinine 1.4 mg%. Urine protein remains same (2+). Thus early detection of GN in transplant recipient help to make arrangement for treating basic disease.

CONCLUSIONS: Early detection of post-transplant GN allows timely diagnosis and management to prevent further allograft failure and thus preventing graft loss

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 233: IMPACT OF COVID 19 ON CKD STAGE VD PATIENTS ON HAEMODIALYSIS: A SINGLE CENTRE OBSERVATION STUDY

Renjini Radhakrishnan 1, Noble Gracious 1

BACKGROUND: The outcome of COVID19 in CKD stage 5D is poorly understood. Maintenance hemodialysis patients are at high risk of acquiring COVID19 due to increased exposure. Given their multiple comorbidities mortality also seems to be higher than the general population. This study aims to identify the factors that influence the outcome of COVID 19 in maintenance hemodialysis patients.

AIM OF THE STUDY: To study the clinical course and outcome of CKD stage 5D patients with COVID19 in Government medical college, Thiruvananthapuram

METHODS: This is a single-center prospective observational study. Total of 144 CKD stage 5D patients on maintenance hemodialysis with COVID19 admitted at Government Medical College Thiruvananthapuram from April 1, 2021 to July 1, 2021, were included. SPSS version 28.0 was used for data processing and analysis. Continuous data were presented as median / interquartile range and analyzed using Kruskal–Wallis test or Mann — Whitney U-test. Categorical data were presented as frequency/ percentages and were analyzed using Fisher’s exact test or chi-square test. P value ≤ 0.05 was considered statistically significant. The study was conducted with strict adherence to ethical principles and with due approval of human ethics committee of Government Medical College Thiruvananthapuram.

RESULTS: Out of 144 patients, 54 died. Overall in hospital mortality was 37.5%; ICU mortality was 72%, mortality among ventilator patients was 80.6%. Mortality in non-ICU patients was 19.1%. Average hospital stay among recovered patients was 17.4 days. Patients with cough (p = 0.016), breathlessness (p < 0.001), altered sensorium (p = 0.024), hemoptysis (p = 0.024) on presentation had high mortality. Patients with older age (mean age 57.7years, p = 0.002), diabetes mellitus (p = 0.02), category C disease (p = <0.001), lower oxygen saturation at presentation (mean 92%, p < 0.001), mechanical ventilation requirement (p- < 0.001) had higher mortality. High d dimer (mean 5.18Âμg/ml, p ≤0.001), high CRP (mean 7.4 mg/l, p = 0.001), high LDH (mean 598.3IU/l, p = 0.001), high ferritin (mean 1121.5 ng/ml, p ≤0.001) low albumin (mean 3.34g/dl p = 0.022) at presentation were poor prognostic markers.

CONCLUSIONS: In our study, the overall mortality rate among patients with COVID 19 and chronic kidney disease stage 5D on maintenance hemodialysis was 37.5%. The mortality in ICU was 72% and mortality in non-ICU patients was 19.1%. Mortality in ventilated patients was 80.6%. Patients with older age, diabetes, category C COVID19, patients requiring ICU admission, mechanical ventilation had higher mortality. Cough, breathlessness, and altered sensorium on presentation were poor clinical prognostic markers. Higher C reactive protein, higher D dimer level, higher lactate dehydrogenase level, higher serum ferritin level, and lower serum albumin level were found to be poor lab prognostic markers

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 234: HYPOXIA INDUCIBLE FACTOR-PROLYL HYDROXYLASE INHIBITORS IN ANEMIA OF CHRONIC KIDNEY DISEASE

Smita 1, Tusti 1, Aniket 1, Salman Sayyed 1, Kalpana Mehta 1, Atim Pajal 1

BACKGROUND:

AIM OF THE STUDY: To share our early experience of HIF -prolyl hydroxylase inhibitors in CKD5

METHODS: This prospective study included CKD V patients with anemia from April 2022 to August 2022. Baseline CBC serum iron study serum ferritin including required hematinics replenishment were done before starting Desidustat. Other erythropoietin-stimulating agents (ESA) were discontinued. Desidustat was started at 75 100 or 125 mg thrice weekly dosage depending on the previous dosage of ESA. Iron supplementation was continued to maintain adequate iron status. The trend of hemoglobin rise was noted over a period of 2- 4 weeks. The dose of Desidustat was modified accordingly. Repeat serum iron study was done. Compliance and cost-effectiveness of Desidustat were compared with other ESA.

RESULTS: We reported 8 cases (Age 18 -60years). 7 were CKD VD, 1 CKDVND. M:F ratio 5:3. Mean Hb level at baseline was 7.7 g/dL. Mean Hb after 4 weeks of Desidustat was 9.9 g/dL. Mean change in Hb from baseline to 4th week was 2.2g/dL. The median time to achieve response was 2 weeks, where response was defined as post-treatment rise in Hb by > = 1g/dL. The proportion of hemoglobin responders was 87%.

CONCLUSIONS: Oral HIF-PHI achieved response in 87%, probably main factor being no cold chain maintenance. However, the study group is very small.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 235: CLINICO-ETIOLOGICAL PROFILE AND OUTCOME OF ACUTE PYELONEPHRITIS CASES IN A TERTIARY HEALTHCARE CENTRE IN ALIGARH

Kajal Choudhary 1, Mohd Aslam 1

BACKGROUND: Acute pyelonephritis is a severe form of UTI characterized by inflammation of renal parenchyma and collecting system. Most of the data for APN comes from international studies, and only a few studies regarding the local epidemiology of the disease are available.

AIM OF THE STUDY: The study is aimed at determining the clinical microbiological and biochemical profile of bacterial and culture negative acute pyelonephritis cases presenting to JNMCH. Complication rates and overall outcome in bacterial and culture negative acute pyelonephritis cases presenting to JNMCH.

METHODS: It is a single-center retrospective observational study. All clinically and radiologically diagnosed cases of acute bacterial and culture negative pyelonephritis presenting to JNMCH between June 2020 and June 2022 were included in the study. Relevant data was collected from available patient records, and analysis was performed.

RESULTS: Out of 22 patients, 12 (54.5%) were males. Most common symptom was fever, present in 72.7% patients, and classical triad of fever, flank pain, and LUTS was present in 4.5% patients only. Diabetes was present in 9 (40.9%) patients. Urine culture was sterile in 12 (54.5%) and positive for bacteria in 10 (45.4%) patients with 9 (90%) showing growth of E.coli with 70% being resistant to levofloxacin. USG was s/o pyelonephritis in 54% patients, and 13.6% patient had associated abscess which was managed conservatively and showed improvement while 2 (9%) out of 22 patients expired.

CONCLUSIONS: Pyelonephritis is severe infection of urinary tract with a higher incidence in diabetics and E. coli being the most common causative organism. USG is the first-line radiological investigation but if inconclusive, CT should be performed if index of suspicion is high or complications are suspected. Early and appropriate antibiotic therapy can prevent life threatening complications.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 236: ATYPICAL PATH OF LEFT INTERNAL JUGULAR HD CATHETER €”RARE CASE REPORTS

Sridatta Gurudatta Pawar 1, Deepak 1

BACKGROUND: Internal jugular vein is most commonly used site for hemodialysis catheter insertion. As post-procedure X-rays are taken to confirm position of the catheter, we rarely can detect congenital anomalies. Here we would like to report two cases of catheter taken an unusual path in our hemodialysis center and diagnosed to have persistent left superior vena cava and superior vena thrombosis receptively

AIM OF THE STUDY: To report unusually path taken by left internal jugular HD catheter

METHODS: Case 1- 45-yr-old male admitted with renal failure diagnosed as CKD stage 5 requiring HD. Attempt was made to cannulate right IJV initially which was difficult hence left internal jugular cannulation was done with ease. Post-procedure X-ray was taken to confirm the position in which it was incidentally detected with persistent left superior vena cava. Case 2- 35-yr-old male CKD5D came with fistula failure with history of one pervious cannulation of right IJV with tunneled catheter multiple access failure and post-graft nephrectomy status due to thrombosis at anastomotic site was readmitted for temporary catheter insertion. In view difficult right IJV cannulation left IJV was cannulated and placed with some resistance while passing the catheter. Post-procedure X-ray revealed catheter had curved entered the right IJV instead of passing into SVC.

RESULTS: We incidentally detected two cases of unusually path taken by HD catheter by post-procedure X-rays. First case, persistent left superior vena cava which is rare but important congenital vascular anomaly. It is most commonly observed in isolation but can be associated with other cardiovascular abnormalities. In our case, it was an isolated finding. Second case, left IJV catheter had curved entered the right IJV instead of passing into vena cava suggesting possibility of SVC thrombosis which could have been due to complications of previous tunneled catheter insertion.

CONCLUSIONS: The abnormal path taken by the catheters are usually incidental finding during central line insertion. We should always rule out other congenital cardiac anomalies and other iatrogenic cause also should be kept in the mind as in case reports. I would like to conclude with a quote “Each day holds a surprise†.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 237: UNDERSTANDING PATIENT CENTRE AND DIALYSIS CHARACTERISTICS VARIANCE AMONG PATIENTS ON DIALYSIS IN PUBLIC PRIVATE PARTNERSHIP CENTRES

Suresh Sankarasubbaiyan 1, K Kartheek 1, Rajesh P Venkatraman Subramaniam 1, Kamal D Shah 1

BACKGROUND: Payer characteristics is rapidly changing for dialysis in India. Public partnership is a an evolving model with its set unique challenges for patients and providers. An understanding of variance will help address the gaps in the health system

AIM OF THE STUDY: 1. To compare difference in patient center and dialysis characteristics between PPP and non-PPP centers 2. To assess gaps in health system for planning and improvement

METHODS: 797 Non-COVID deaths that occurred in large dialysis network between Jan and Mar 2021 were compared to age matched controls to study factors influencing mortality: gender educational status BMI duration of HD center size for staff and patient numbers payer type HD frequency access Hb S. Albumin diabetic status Htn h/o heart failure and h/o hospitalization. A multivariate analysis identified factors influencing mortality. In a sub-analysis of this study, we compared characteristics across centers under public–private partnership (PPP) and non-PPP of above characteristics and learn salient differences.

RESULTS: a. Comparison of patient, center, HD characteristics (mean + sd) PPP (n = 715). Non-PPP (n = 869). p value Age (yrs) 52 + 12.7 56.9 + 13.8 < .001 Height (cm) 160 + 9.5 161.7 + 9 < . 001 Weight (Kg) 57.7 + 11.7 59 + 12.4 .02 BMI 22.5 + 4.3 22.6 + 4.8 .63 Distance (km) 30. 8 + 34.8 30.7 + 10 <.001 No of staff 22.1 + 23.4 18.3 + 15.5 <.001 No of patients 22.1 + 21.3 15.7 + 11.3 <.001 HD (Months) 16.8 + 16.8 18.2 + 18.2 .08 HB (g%) 8.5 + 1.5 9.1 + 1.6 <.001 Adequacy 1.2 + .1 1.3 + .2 .003 Alb (g%) 3.5 + .7 3.5 + .5 . 17 b. Comparison of proportions of patient characteristics (as %) PPP Non-PPP p value Non-survivor: Survivor 59.6/40.4 41.4/58.5 <.001 Perm/Tem 75.9/24.1 75/25 .67 Gender M 74.7/25.3 68.1/31.9 .04 Educ: < College/College 89.4/10.6 69.7/30.3 <.001 HD frequency < /> 2x 51.8/49.8 66.3/31.1 <.001 Diab: Non-diabetic 24.9/75.1 44.8/552 <.001 Heart failure: Y/N 6.7/93.3 10.9/89.1 .004 Hospitalization: Y/N 16.1/83.9 31.1/68.9 <.001

CONCLUSIONS: Patients in PPP centers are younger and more likely to be men and shorter in height, less educated. They are more anemic, dialyzed thrice with lesser proportion who have diabetes and heart failure. Centers are less accessible and larger in size. Understanding these differences will help health systems direct more customized patient-centric interventions to improve outcome

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 238: BLOODSTREAM INFECTION (BSI) IN RENAL TRANSPLANT RECIPIENTS

Kavitha Mudaliar 1, R Dilip 1, S Ramakrishnan 1, Kiran Chandra Patro 1, R Ramprasad 1, S Karthik 1

BACKGROUND: BSI represents an important source of morbidity and mortality as well as an increasing therapeutic challenge among renal transplant recipients. Understanding the epidemiological and microbiological characteristics of BSI is paramount to the implementation of appropriate preventive and therapeutic measures to achieve a good outcome

AIM OF THE STUDY: To study the incidence associated factors and outcome of BSI in renal transplant recipients at our center - a tertiary care

METHODS: We conducted a retrospective review of all BSI episodes in renal transplant recipients that happened from 1 April 2014 till date. Retrieval and study of electronic data for patient demographics microbiological data course of management and their outcomes was done

RESULTS: n - 195 (120 on follow-up as on 1, April, 2014; 70 underwent renal transplant thereafter till date) Age group - 11 to 65 years Study period - April 2014 till date Total follow-up period - 996 years (5.11 years per patient) No of BSI - 32 Source of infection - Commonest being urinary tract (others included skin, soft tissue and gastrointestinal) Commonest organism - E.coli (others included S.aureus, S.haemolyticus, K.pneumoniae) Outcome - BSI Incidence of 0.03 per patient year, Mortality of 3.8% at discharge

CONCLUSIONS: Urinary tract infection remains the commonest source of BSI among kidney transplant recipients, thus prevention and early detection are crucial. Each unit needs to understand the epidemiology of the organisms causing BSI in their patients and their antibiotic susceptibility for better outcomes

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 239: CLINICAL PROFILE HISTOPATHOLOGICAL SPECTRUM AND OUTCOME OF IGA NEPHROPATHY IN A TERTIARY CARE HOSPITAL OF NORTHWEST INDIA

Tarun Kumar 1, Vinay Malhotra 1, Dhananjai Agarwal 1

BACKGROUND: Lack of Concrete data of IgAN in Northwest India

AIM OF THE STUDY: The present study is aimed to evaluate the Clinical Profile Histopathological Spectrum and Outcome of IgA Nephropathy in a Tertiary Care Hospital of Northwest India

METHODS: In this retrospective study, we evaluated all patients who have biopsy-proven primary IgAN. Patients with secondary causes of IgAN coexisting disease like diabetic nephropathy inadequate/missing clinical records inadequate kidney biopsy are excluded.

RESULTS: Out of total 430 native kidney biopsies done during the study period, 61 renal biopsies (14.2%) were diagnosed as primary IgAN. Mean age was 30.5 Â ± 12.2 years with male : female ratio of 3.3:1. Among all patients, hematuria, nephrotic range proteinuria, subnephrotic range proteinuria were present in 75.4%, 39.4%, 60.6% respectively. Majority of the patients had CKD (45.9%), followed by RPRF (29.5%), Nephrotic (14.8%), Nephritic syndrome (8.2%), and macroscopic hematuria (1.6%). 46 patients had eGFR <30 mL/min/1.73 m2, and 20 patients were hemodialyzed at presentation. According to Oxford MEST -C Classification of renal biopsy M1 (39.3%), E 1 (27.9%), S1 (96.7%), T1 (45.9%), T2 (29.5%), C1 (29.5%), C2 (6.6%) were found. Out of 61 patients, 9 patients lost to follow-up. Of the 52 patients with follow-up, 44.3% patients received ACEi/ARBs, 55.7% patients on steroids and 16.4% received cyclophosphamide. At present, majority of patients are suffering from CKD (23%), ESRD (19.7%), Remission (14.8%), ESRD & Transplant (13.1%), and ESRD & death (13.1%).

CONCLUSIONS: In our study, most cases of IgAN were seen in second and third decade of life with a male predominance. Patients with nephrotic syndrome were more likely to achieve remission. About one-third of our follow-up patients reached ESRD which stresses the fact that IgAN in our population is a very aggressive disease despite use of ACEi/ARBs and immunosuppression.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 240: COEXISTING MIDD AND CAST NEPHROPATHY IN A WASP BITE PATIENT

Shilpa Bansal 1, Aruna Aacharya 1, Sarat Parida 1

BACKGROUND: The insect order Hymenoptera consists of many medically important groups of stinging insects — Apoidea (bees) and Vespoidea (paper wasps hornets and yellow jackets commonly referred as wasps). The pathogenic mechanisms responsible for the clinical sequelae following insect stings of the order hymenoptera include allergic reactions rhabdomyolysis hemolysis and direct tissue toxicity. Their venom contains protein toxins biogenic amines and enzymes that allow the toxins to spread. The acute renal failure (ARF) due to wasp sting bites the toxic principles include active amines like histamine serotonin kinins phospholipase A2 hyaluronidase mellitin and apamine. In plasma cell dyscrasia kidney manifestations can be classified as glomerular nephropathies including AL amyloidosis and paraprotein deposition diseases and tubulointerstitial nephropathies including proximal tubular dysfunction leading to Fanconi syndrome and distal tubular precipitation of monoclonal protein leading to cast nephropathy. Occasionally 2 or more conditions can coexist in the setting of an underlying plasma cell dyscrasia.

AIM OF THE STUDY: Coexisting MIDD and cast nephropathy in a wasp bite patient

METHODS: We present a case of a 52-year-old male who presented to the department of nephrology SCB MCH Cuttack with C/O generalized swelling of body and oliguria since 10 days after a wasp bite. Patient had no history of diabetes and hypertension. On examination PR — 84/min BP — 124/82 mm Hg RR - 20/min afebrile. Urine examination showed 3+ hematuria 1+ proteinuria. Laboratory examination revealed S urea 144 S creatinine 16.8 Hb 8.6 TLC 10190 Platelet 3.1 lakh total protein/S albumin 5.4/3.4 S cholesterol/triglycerides 184/101. Urine PCR was 3.2 mg/g. ESR - 25 CRP 28 S Ca 1.0. LDH 532 PBF normal. X-ray skull pelvis LS showed no deformity. USG showing enlarged kidney size. ANA -ve ASO -ve C3 C4 normal. 3 doses of methylprednisolone given and total 7 sessions of HD were done. I/V/O persistent hematuria olig — anuria dysmorphic RBC we suspected of toxin-induced immunological phenomenon and early renal biopsy was performed that surprisingly turned out to be coexisting monoclonal immunoglobulin / light chain deposition disease (MIDD/LCDD) and cast nephropathy with lambda chain restricted immune deposits on DIF studies. So bone marrow biopsy serum free light chain assay serum / urine immunoelectrophoresis was planned.

RESULTS: In our case report, we found coexisting MIDD/LCDD with cast nephropathy following wasp bite.

CONCLUSIONS: Hymenoptera stings may result in a wide range of spectra of kidney disease. Thiruventhiran et al.. analyzed 24 cases of acute kidney injury due to hymenopteran bites. Altered liver function tests (9 cases), hemolysis (14 cases), hypotension (6 cases), and rhabdomyolysis (11 cases) were seen. Renal biopsy showed ATN. Nace et al.. reported a case of ARF without any evidence of hemolysis and rhabdomyolysis indicating direct venom toxicity as a cause of ARF. Humeda YS et al. found 1 case of MCD 1 month after wasp bite. Santhosh Pai et al. found a case of immune-mediated MPGN after bee sting.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 241: CASE SERIES OF EMPHYSEMATOUS INFECTIONS OF THE KIDNEY AND URINARY TRACT: A STUDY FROM A TERTIARY CARE CENTRE

Shreekant Markad 1, Vineet Behera 1, G Shanmugraj 1, P Chauhan 1, R Ananthkrishnan 1

BACKGROUND: Emphysematous pyelonephritis (EPN) is a severe and life-threatening infection of the renal parenchyma collecting system or perinephric tissue which is characterized by the presence of gas in the parenchymal tissue. The outÂcome of this condition has significantly imÂproved over the years due to early diagnosis by better imaging modalities and a change in treatment strategies from nephrectomy to a more conservative nephron-sparing approach. We present a clinico-radio-pathological profile of a series of patients with EPN in which the patients were aggressively managed and early percutaneous surgical drainage (PCD) was performed.

AIM OF THE STUDY: Case series of emphysematous infections of the kidney and urinary tract: A study from a tertiary care center

METHODS: A total of 06 cases were included over a two-year period. Five patients had pre-existing diabetes among whom two patients (40%) had uncontrolled hyperglycemia at presentaÂtion and one patient had diabetic ketoacidosis; the mean blood sugar of the patients at presentation was 270 mg/dL. One patient was positive for human immunodeficiency virus (HIV) antibody. The mean age of the study patients was 60.33 years (range 51-69 years), and there were an equal number of females & males.

RESULTS: Fever was seen in all patients, features of urinary infection (dysuria, pyuria) in 04 (66.66%) and flank pain were seen in all six patients (100%). Leukocytosis was seen in all patients (100%) (mean TLC 16,700/mm) and elevated serum creatinine was seen in all six patients (100%). All 06 patients had pyelonephritis, two (33.33%) had both cystitis withpyelonephritis. The left urinary tract was more comÂmonly involved (66.6%) than the right side (16.66%), and one patient had bilateral involveÂment. Urine culture was positive in three cases with growth of Klebsiella in two and Pseudomonas in one patient. The poor prognostic markers included presence of bilaÂteral disease, thrombocytopenia, hypotension, and elevated creatinine. Empirical i.v. antibiotics were administered to all patients as per our protocol and, subseÂquently, the antibiotics were changed based on the culture sensitivity. One patient required dialysis support. Of the 06 patients studied, 05 patients underwent PCD within 24 h. One patient expired, before PCD could be attempted. Among the 05 patients who underwent PCD, one patient had to undergo subsequent nephrectomy due to failure of proper drainage by PCD or extensive involvement of the renal system not improving with PCD. One death occurred among the 06 patients studied (mortality 16.66%). This patient had presented with fulminant bilateral pyelonephritis, septic shock, and multi-organ dysfunction and died within six hours of admission despite immediate medical and other resuscitative measures. All other patients responded well and recovered completely.

CONCLUSIONS: EPN is a potentially life-threatening condiÂtion commonly associated with diabetes and immune-suppressed states. It requires a high index of suspicion for an early radiological confirmation of diagnosis. Aggressive and prompt medical therapy with early PCD theÂrapy is the key for reducing morbidity and mortality. A combined team approach by a nephrologist, urologist, endocrinologist, intensivist, radiologist, and pathologist may be adopted for achieving better outcomes of this condition.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 242: TO STUDY THE EFFECT OF DAPAGLIFLOZIN IN PATIENTS OF CKD WITH AND WITHOUT TYPE 2 DIABETES MELLITUS

Nisha Kajla 1

BACKGROUND: Sodium—glucose cotransporter 2 (SGLT2) inhibitors decrease glycated hemoglobin levels and have shown favorable effects on kidney and cardiovascular outcomes in large clinical trials involving patients with type 2 diabetes. Although the underlying mechanisms are not completely understood, the benefits of SGLT2 inhibitors appear to be independent of their blood glucose lowering effects and may be mediated by natriuresis and glucose-induced osmotic diuresis leading to a reduction in intraglomerular pressure. This favorable hemodynamic effect may also preserve kidney function in persons with kidney diseases due to causes other than type 2 diabetes

AIM OF THE STUDY: To study the effect of dapagliflozin in patients of CKD with and without type 2 diabetes mellitus OBJECTIVES PRIMARY OUTCOME. To study the percentage of patients with ≥10% decline in eGFR from baseline in CKD patients with and without type 2 diabetes mellitus over the period of 6 months SECONDARY OUTCOME. To study the effect of dapagliflozin on composite renal outcomes in patients of CKD with and without type 2 diabetes mellitus. To study the effect of dapagliflozin on major adverse cardiac events (MACE) and all-cause mortality in patients of CKD with and without type 2 diabetes mellitus

METHODS: This was a hospital-based prospective observational cohort study to be done for a period of 18 months (15 July 2021 to 15 January2023 — recruitment of patients for 12 months and follow-up for 6 months). All adults between 18 and 75 years of age (both age inclusive) having chronic kidney disease with an eGFR between 25 and 60 mL/min/1.73 m2 were included in the study. Patients who were maintained on individualized tolerated dose of an ACE inhibitors or ARB for at least 4 weeks before screening if not contraindicated (patients with documented ACE inhibitors or ARB intolerance were allowed to participate in the study) were also included in the study. Participants with type 1 diabetes mellitus history of complicated UTI within 6 months history of diabetic ketoacidosis within 6 months autosomal dominant or recessive polycystic kidney disease lupus nephritis or antineutrophilic cytoplasmic autoantibody-associated vasculitis participants who had received cytotoxic or immunosuppressive therapy for primary or secondary kidney disease in the 6 months prior to study enrolment history of organ (including kidney) transplantation patients receiving therapy with an SGLT2 inhibitor within 8 weeks prior to enrolment were all excluded. METHODS Our study included eligible patients with estimated glomerular filtration rate (eGFR as per CKD EPI equation) between 25 and 60 mL/min/1.73 m2. Patients were consecutively assigned to either the diabetic or non-diabetic subgroups. All patients were started on tablet dapagliflozin 10 mg/day on the day of enrolment into the study. The follow-up was performed at 1-monthly intervals thereafter for 6 months. At each follow-up visit, vital signs were recorded blood and urine samples were sent for laboratory assessment for renal function tests and electrolytes every month. Urine ACR and HbA1c was done every 3 months. Information on potential outcomes adverse events concomitant therapies and adherence to the regimen were collected. OUTCOME MEASURES The primary outcome was the percentage of patients with ≥10% decline in eGFR from baseline in patients of chronic kidney disease with and without type2 diabetes mellitus. The secondary composite outcome was the first occurrence of any of the following: a decline of at least 50% in the estimated GFR (confirmed by a second serum creatinine measurement after ≥28 days) the onset of end-stage kidney disease (defined as maintenance dialysis for ≥28 days kidney transplantation or an estimated GFR of <15 ml per minute per 1.73 m2 confirmed by a second measurement after ≥28 days) or death from renal or cardiovascular causes. Major adverse cardiovascular event is record/diagnosis of either coronary artery disease; stroke; peripheral arterial disease; heart failure.

RESULTS: In our study of 61 patients, 26 (42.6%) were females and 35 (57.4%) were males. 14 patients (22.9%) had decline in eGFR of ≥10%, mean age of 67.2 ± 7.8 years, 6 were males and 8 were female patients (p value-.211), 6 had baseline eGFR ≥ 45 ml/min/1.73 m2 and 8 with baseline eGFR of less than 45 ml/min/1.73 m2 (p value- .005), 11 were diabetic, and 3 were non-diabetic (p value-.990). Of these, 3 patients had underlying history of LVF and 8 had underlying history of CAD (p value-.042) No patient had a decline of 50% in the estimated GFR / onset of end-stage kidney disease. MACE was observed in total 8 patients (13.1%), 6 had decline in eGFR of ≥10% (p value-.001), 7 patients had baseline eGFR of less than 45 ml/min/1.73 m2, age of 5 patients was ≥55years, 7 were diabetic patients. Cardiovascular death was observed in 1 patient with age more than 55 years of age and baseline eGFR of <45 ml/min/1.73 m2. Mean Hba1c values in diabetic patients were found to be 8.3 (SD ± 2.1) at 1st month followed by 7.7 (SD ± 1.7) at 3rd month and 7.1 (SD ± 1.4) at 6th month mean values of urine ACR at 1st, 3rd, and 6th month was found to be 0.96 g/L, 0.83 g/L, and 0.65 g/L respectively.

CONCLUSIONS: The results of this study indicate that dapagliflozin results in beneficial effects on renal function among patients with CKD, with or without DM. Even though the sodium—glucose cotransporter 2 (SGLT2) inhibitors were introduced as type 2 DM management drugs, results indicated a benefit in CKD management. This study enrolled a dedicated CKD population and conclusively shows a benefit in this patient population as their eGFR was maintained, irrespective of DM status. MACE was observed in patients with ≥10% decline in eGFR, more than 55 years of age and baseline eGFR of less than 45 ml/min/1.73 m2.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 243: WRIST TENOSYNOVITIS DUE TO TUBERCULOUS AND NON-TUBERCULOUS MYCOBACTERIAL INFECTIONS IN RENAL TRANSPLANT RECIPIENTS

Jeethu J Eapen 1, Elenjickal Elias John 1, Utkarash Mishra 1, Nisha Jose 1, Selvin Sundar Raj 1, Rizwan Alam 1, Athul Thomas 1, Sabina Yusuf 1, Jennifer Prabhu 1, Amish P George 1, Suceena Alexander 1, Vinoi G David 1, Santosh Varughese 1

BACKGROUND: Wrist tenosynovitis and spina ventosa (tubercular dactylitis) are uncommon manifestations of mycobacterial infections in renal transplant recipients. In this report we describe two cases of tenosynovitis caused by tuberculous and nontuberculous mycobacteria.

AIM OF THE STUDY: In this report, we describe two cases of wrist tenosynovitis in renal allograft recipients one caused by Mycobacterium tuberculosis and the other by Mycobacterium intracellulare (Mycobacterium Avium Complex).

METHODS: Case report of two cases of wrist tenosynovitis caused by tuberculous and nontuberculous mycobacterial infections

RESULTS: The first patient was a renal allograft recipient in 2006, native kidney disease being IgA nephropathy. He had chronic HBV infection and was on antivirals since prior to transplant, he had undergone a left native nephrectomy for a multilocular cystic renal neoplasm in 2018. He was on dual immunosuppression with prednisolone and mycophenolate, cyclosporine having been withdrawn in 2008. He presented with a four year history of swelling of the dorsum of the left hand extending to the forearm. Clinical examination showed nontender left wrist flexor and extensor aspect gross synovitis with firm globular 4x4cm swelling over the dorsum of the hand. There were no signs of inflammation. X-ray of the hand and wrist were unremarkable. USG showed nodular synovial thickening around the fourth extensor compartment of hand and flexor tendons at carpal tunnel extending to palms and up to its distal attachment to phalanx. MRI of the wrist showed diffuse synovial thickening and multiple loose bodies around the fourth extensor compartment and flexor tendons in the carpal tunnel and palm. He underwent a left flexor and IF volar synovectomy. Multiple rice bodies were noted on excision of the tenosynovium. Histopathology showed multiple ill-defined and discrete granulomas composed of histiocytes, lymphocytes, and Langhans type of multinucleate giant cells. Special stains for AFB and fungal organisms were negative. Mycobacterial MGIT cultures grew Mycobacterium tuberculosis with monoresistance to Isoniazid. He was started on four drug ATT which he is continuing till date. The second patient was a renal allograft recipient in 1990. He had stable graft function and was on dual immunosuppression with prednisolone and azathioprine. He presented with multiple swellings of the dorsum of the right hand, index finger, and forearm. USG showed tenosynovitis with collections involving the extensor tendons of the right wrist extending up to the level of the midshaft of the metacarpals and also the flexor tendons of the right index finger extending proximal to the second MTP joint up to the PIP joint and soft tissue swelling and periosteal reaction involving the proximal phalanx of the right index finger suggestive of dactylitis. A synovial biopsy showed large areas of necrosis with inflammatory infiltrates and epithelioid granulomas. The Xpert TB PCR on the tissue was however indeterminate. He was started on four drug ATT and Clarithromycin pending culture reports given the suspicion for NTM. Mycobacterial MGIT cultures subsequently grew Mycobacterium intracellulare — a species in the Mycobacterium Avium Complex. Drug regimen was subsequently modified to Rifampicin, Clarithromycin, and Ethambutol.

CONCLUSIONS: In this report, we present two rare cases of mycobacterial infections in renal transplant recipients presenting as chronic wrist tenosynovitis. The differentials of both tuberculous and non-tuberculous mycobacterium infections must be considered in patients presenting with chronic tenosynovitis. Radiological imaging, histopathology, and most importantly mycobacterial cultures help in identifying the etiological agent and tailoring the treatment.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 244: MONOCLONAL GAMMOPATHY OF RENAL SIGNIFICANCE: A SINGLE CENTRE EXPERIENCE

Aditya Kumar Mishra 1, Arpita Ray Chaudhury 1, Koushik Bhattacharjee 1, Atanu Pal 1, Debabrata Sen 1

BACKGROUND: Monoclonal gammopathy of renal significance is a group of heterogenous disorders characterized by renal dysfunction secondary to the production of a monoclonal immunoglobulin by a non-malignant B cell or plasma cell clone.

AIM OF STUDY: This study was undertaken to identify the demographics clinical profile immunosuppression regimen and outcomes of MGRS patients admitted to our hospital.

METHODS: This retrospective analysis included all the MGRS patients admitted to our hospital from Jan 2019 to April 2022. Data was captured using preformed proforma and was tabulated with MS Excel and then represented in the form of bar diagrams pie charts or tables.

RESULTS: Age of the patients ranged from 30 to 74 years with a median of 54 years; with the male: female ratio being 13:5 (total = 18). 50% (9) had comorbidities at the time of diagnosis. Patients presented as AONS (66.6%), ESRD (16.6%), Infections (11.1%) or severe anemia (5.5%). Based on the GFR; 30% (6) were in group G3b, 16.7% (3) were in G4, 16.7% (3) were in G5. On serum protein electrophoresis; M-band was detected in 66.7% (12). FLC ratio was altered in 50% (9). Beta 2 microglobulin values ranged from 7732-17104 ng/ml. All patients underwent renal biopsy for diagnosis. Biopsy findings varied from amyloidosis (8 AL amyloidosis), PGNMID (4), and LCDD (3 kappa and 1 lambda). Clone detection was done in 94.4% (17) patients via bone marrow aspiration and biopsy; plasma cell % ranged from 3 to 10%. 13 (72.2%) patients had more than 800 for NTproBNP. 71.4% (5) AL amyloidosis patients received CYBORD regimen, 33.3% (1) of PGNMID patient received treatment, and 75% (3) of LCDD patient received treatment. Out of the 8 amyloidosis patients, 6 (75%) received treatment with CYBORD protocol. 1patient was lost to follow-up, 2 patients died due to sepsis, 1 had a cardiac event, 1 had transformation to multiple myeloma and 3 patients have attained partial recovery and are in follow-up. In the PGNMID group, out of the 6 patients, 2 patients were put on CYBORD protocol. 1 became HD dependent and subsequently lost to follow-up, 2 patients died, 1 patient denied therapy and was lost to follow-up, and 1 patient is in partial recovery. In the LCDD group, out of the 4 patients, 3 patients received CYBORD therapy and 1 was lost to follow-up.

CONCLUSION: MGRS is a newly recognized entity with wide clinical spectrum which requires a high degree of clinical suspicion and is usually diagnosed late in the course of the disease; resulting in poor outcome or progression to overt myeloma. Two of our Amyloidosis patients are being worked up for bone marrow transplant after FLC normalization. In LCDD 75% of the patients achieved renal function stabilization. Increased awareness and early detection may improve the scope of treating the disease.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 245: IL-17/IFN- DOUBLE +VE TH17 CELLS SELECTIVELY EXPRESS P-GLYCOPROTEIN ARE REFRACTORY TO GLUCOCORTICOID

Akhilesh Jaiswal 1, Narayan Prasad 1

BACKGROUND: Idiopathic nephrotic syndrome (NS) is one of the most common glomerular disease in children. About 80-90% NS patients show response to steroids and others develop resistance during the course of disease. Almost 50-60% of steroid responsive NS have frequent relapses or steroid dependent and 10-20% patient develops steroid resistance.

AIM OF STUDY: To analyze the frequency of peripheral Th1, Th17, and IL-17/IFN-Î3 double-positive Th17 lymphocytes in remission and resistant NS. To analyze the expression of P-gp on Th1, Th17, and IL-17/IFN-Î3 double-positive Th17 cells in remission and resistant NS

METHODS: All patients were recruited as per criteria of ISKDC. Samples were isolated and stimulations of cytokines are done after which the biomarkers are being checked.

RESULTS: The means values in different groups were compared with analysis of variance (ANOVA) for parametric values. Pearson’s correlation test was used to analyze the correlation between variables. p < 0.05 is considered significant, and data analysis was done using SPSS 15.0 software. All the graphs are being plotted.

CONCLUSION: Double positive Th17.1 (IFN-Î3+IL-17+) cell seems to be most pathogenic. P-gp expressing Th17.1 (IL-17/IFN-Î3) double-positive T cells may be playing an important role in developing resistance to steroid in nephrotic syndrome

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 246: ASSOCIATION OF SERUM FERRITIN AND HEPCIDIN WITH RENAL RECOVERY IN COMMUNITY ACQUIRED ACUTE KIDNEY INJURY

Jasmine Sethi 1, Priyanka Kumari 1, Vivek Kumar 1, Ashok Kumar Yadav 1

BACKGROUND: Acute kidney injury (AKI) is an expanding overall health concern. The present study was designed to study the association of serum iron ferritin and hepcidin with renal recovery at 4 months in patients of community acquired AKI.

AIM OF STUDY: To study the association of serum ferritin and hepcidin with renal recovery in community acquired acute kidney injury.

METHODS: It is a prospective observational cohort study. All admitted patients aged between 13-70 years and diagnosed to have CA-AKI were eligible for screening. Patients with pre-existing CKD suspected glomerulonephritis chronic liver disease transplant recipients previous history of blood transfusion and suspected malignancy were excluded. The subjects had scheduled follow-up visits at 1 and 4 months after discharge with renal function test and spot urinary PC ratio.

RESULTS: Between October 2020 to July 2021, 100 patients of community acquired acute kidney injury were enrolled in the study after taking informed consent. Out of 100, 4 patients expired and 1 patient was lost to follow-up. Out of 95 patients, 76 patients had complete renal recovery, whereas 19 patients progressed to chronic kidney disease at the end of 3 months. The mean age of the study sample was 43.2 years with sex ratio of 2:1. Most common etiology of CAAKI was found to be sepsis related which accounted for 42% cases followed by tropical illness and pancreatitis contributing almost equally 17% and 16% respectively. Other rare causes include snake/ wasp bite (5%), poisoning (3%), acute gastroenteritis (10%). Around half of the cohort had stage 3 acute kidney injury at admission. Higher baseline serum Ferritin and hepcidin showed a statistically significant association with renal recovery at 4 months. On multivariate analysis, diabetes, ferritin, and hepcidin were significantly affecting renal recovery at 4 months.

CONCLUSION: Renal non-recovery was seen in a significant proportion of patients (n = 19, 20%) with community-acquired AKI. Elevated baseline serum ferritin and hepcidin were associated with a favorable renal outcome in CA-AKI. Ferritin and hepcidin can be used as prognostic markers in patients with AKI for predicting renal recovery.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 247: SUCCESSFUL MANAGEMENT OF A CASE OF BILATERAL URETER INJURY AFTER ABDOMINAL HYSTERECTOMY

Sanjay Mittal 1, Rajesh Agarwal 1, Gulshan Kumar 1, Saranpreet 1

BACKGROUND: Injury to the ureter is a risk of any pelvic or abdominal surgery. The morbidity associated with such injury may be serious resulting in increased hospital stay compromise of the original surgical outcome reoperation potential loss of renal function and deterioration of quality of life.

AIM OF STUDY: To study the outcome of Bilateral Ureter Injury after Abdominal Hysterectomy.

METHODS: We present the case of a 41 years old woman who developed post-hysterectomy acute kidney injury. She passed about 800 ml of urine on the day of surgery; but later became anuric. Her ultrasound of the abdomen was normal on second post-operative day. But she remained anuric on third post-operative day hence required dialysis. Her ultrasound was repeated which showed bilateral mild hydronephrosis; confirmed later on plain CT scan. She underwent right DJ stenting & left ureteric re-implantation on fifth post-hysterectomy day.

RESULTS: She had a brisk diuresis and her renal function became normal within 12 hours of surgery.

CONCLUSION: Bilateral total ureteric obstruction after abdominal hysterectomy can occur in spite of a good urine output and normal USG in early post-operative period. High index of suspicion and early intervention leads to total recovery of such patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 248: A RARE GENETIC CAUSE OF NEPHROTIC SYNDROME WITH AN EVEN RARER COMPLICATION POST TRANSPLANTATION

Shimna Kunhiraman 1, Aarthi Muthukumaran 1, Manoj Kumar 1, Deepak Selvanathan 1, R P Senthil Kumar 1, T Balasubramanian 1

BACKGROUND: The incidence of vascular complications after renal transplantation range from 3 to 15%. Pseudoaneurysms following renal transplantation are rare with an incidence rate of less than 1%.

AIM OF STUDY: To report a rare genetic cause of nephrotic syndrome with an even rarer complication post-transplantation

METHODS: Patient is a 24-year-old lady incidentally detected with renal impairment at the age of 11 years. Her preliminary workup revealed nephrotic syndrome with contracted kidneys and she was on conservative management for the next 3 years. Evaluation for primary amenorrhea at the age of 14 years revealed rudimentary gonads atrophic uterus with absent vagina. Karyotyping showed 46 XY pattern confirming Frasier's syndrome and she underwent bilateral gonadectomy (ovatestes). After 15 years of age, she reached end-stage renal disease and was on dialysis for 8 months before she underwent ABO compatible live related renal transplantation with mother as donor. She had normal graft function for 2.5 years after which she had a diarrheal episode with persistent graft dysfunction. Transplant kidney biopsy revealed acute tubular injury and she was conservatively managed. After 6 years of transplant, she developed recurrent episodes of urinary tract infections. Investigation revealed dilatation of transplant kidney pelvicalyceal system and proximal ureter due to distal urethral stricture for which urethral meatoplasty was done, and she was maintained on antibiotic chemoprophylaxis. In the current admission 10 years post-transplant she presented with symptoms of cystitis and mild graft dysfunction (serum creatinine was 1.5 mg/dL) for which she was treated with antibiotics and the graft function normalized. During the course of evaluation for the cystitis, ultrasonography showed a hypoechoic lesion 2x2cm adjacent to renal hilar vessels of the transplant kidney. Computed tomography also showed a hyperdense lesion 2x2cm in the interpole of transplant kidney and a diagnosis of pseudoaneurysm was suspected. For further clarification, magnetic resonance angiography was done and that confirmed focal dilatation of the upper pole intrarenal artery of the transplant kidney indicative of thrombosed pseudoaneurysm. Renal Doppler of the aneurysm was not taking up color signals. Since she was asymptomatic with normal graft function and the pseudoaneurysm was thrombosed patient was advised conservative management with close monitoring.

RESULTS: We believe our patient could have developed this pseudoaneurysm after the initial biopsy and had remained asymptomatic. Pseudoaneurysms that are symptomatic, larger than 2.5 cm size with coexisting infection, progressive enlargement and impending rupture are indications for repair.

CONCLUSION: Pseudoaneurysms following renal transplantation are rare, with an incidence rate of less than 1%. They are either at the anastomotic site (extra-renal) or intra-renal. Extra-renal pseudoaneurysms are caused by poor surgical technique or perivascular infection whereas intra-renal can occur at the level of arcuate arteries following needle biopsy, mycotic infection, acute or chronic rejection. We believe our patient could have developed this pseudoaneurysm after the initial biopsy and had remained asymptomatic. Pseudoaneurysms that are symptomatic, larger than 2.5 cm size with coexisting infection, progressive enlargement and impending rupture are indications for repair.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 249: POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME AFTER RENAL TRANSPLANT- A CASE REPORT

Sridatta Gurudatta Pawar 1

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is defined as an acute neurologic dysfunction accompanied by typical neurological and radiologic findings. Causes can be in hypertensive emergencies Tacrolimus and drugs like cocaine. When correctly identified PRES is rapidly reversible without residual deficits. We report a case of PRES within 24hous of transplant diagnosed radiologically and clinically. The uniqueness of this case report is we managed PRES without modification of immunosuppressive drugs and adequate blood pressure control.

AIM OF STUDY: A 45-year-old male who was diagnosed with IgA nephropathy by biopsy and progressed to ESRD in 3 years. Patient was started on hemodialysis with right IJV with eventually course of this HD patient had multiple access failure and central vein stenosis. we inserted left tunneled catheter as bridging purpose for renal transplant. He had undergone live related renal transplant for end-stage renal disease secondary to IgA Nephropathy with tunneled catheter. Past history of seizure or any neurological disease was absent. transplant completed uneventfully. Patient had immediate graft function. Patient was on immunosuppressive medications included prednisone tacrolimus mycophenolate and anti-hypertensive drug amlodipine. After 14 hrs post-transplant patient developed severe headache blurred vision and tonic-clonic seizure-with post-ictal confusion lasting for 10 seconds. In renal ICU IV midazolam 4 cc and injection Phenytoin 800 mg was given which led to a cessation of seizure activity. On examination- afebrile with blood pressure 200/120 mmhg and oxygen saturation 95% requiring oxygen support temporarily. The neurologic examination was limited by sedation his pupils reactive to light with no focal deficits.

METHODS: Labs report urea and creatinine of 43 and 3.8 mg/dl respectively; glucose was 123 mg/dl with normal sodium and potassium levels WBC count was 11.1 × 106 cells/Îül; hemoglobin and hematocrit were 9.0 g/dl and 30.3% respectively. A lumbar puncture revealed a normal opening pressure cell count 1 WBC glucose 88 mg/dl protein 47 mg/dl negative for Gram stain culture HSV and India ink preparation. The serum tacrolimus level was at 9.0 ng/ml, and CSF level was 1.5. Patient is poor metabolizer FOR CYP3A4. An MRI of the brain revealed non-diffuse restricting T2/ FLAIR sequences hyper intensity bilateral parietal-occipital and parietal-temporal region suggestive of PRES. Levetiracetam was started mainly for seizure prophylaxis. Patient blood pressure controlled with adequate drugs and had no further episodes of seizure. Full recovery was seen in two days. Patient in his course off hospitalization we removed tunneled catheter and discharged with normal graft function. At his 6 weeks -follow-up, the patient remained neurologically asymptomatic; his CNS lesions were completely resolved on repeat MRI.

RESULTS: The unique feature of this case report, most of the case reports available in literature PRES is managed with reduction in dose of immunosuppression and changing the drug itself. Here, no change in the immunosuppression was made, with adequate blood pressure patient remained asymptomatic and anti-epileptic medication was also stopped at 6 weeks of follow-up.

CONCLUSION: PRES can be non-fatal condition if promptly treated and cause is identified and treated. We managed the case with treatment of hypertension without change in immunosuppressive medications. In our patient, complete clinical resolution and a resolution of abnormalities on neuroimaging was also documented.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 250: POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME AFTER RENAL TRANSPLANT- A CASE REPORT

Sridatta Gurudatta Pawar 1, Deepak 1

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is defined as an acute neurologic dysfunction accompanied by typical neurological and radiologic findings. Causes can be in hypertensive emergencies Tacrolimus and drugs like cocaine. When correctly identified, PRES is rapidly reversible without residual deficits. We report a case of PRES within 24 hours of transplant diagnosed radiologically and clinically. The uniqueness of this case report is we managed PRES without modification of immunosuppressive drugs and adequate blood pressure control.

AIM OF STUDY: A 45-year-old male who was diagnosed with IgA nephropathy by biopsy and progressed to ESRD in 3 years. Patient was started on hemodialysis with right IJV with eventually course of this HD patient had multiple access failure and central vein stenosis. we inserted left tunneled catheter as bridging purpose for renal transplant. He had undergone live related renal transplant for end-stage renal disease secondary to IgA Nephropathy with tunneled catheter. Past history of seizure or any neurological disease was absent. Transplant completed uneventfully. Patient had immediate graft function. Patient was on immunosuppressive medications included prednisone tacrolimus mycophenolate and anti-hypertensive drug amlodipine. After 14 hrs post-transplant, patient developed severe headache blurred vision and tonic-clonic seizure-with post-ictal confusion lasting for 10 seconds. In renal ICU, IV midazolam 4 cc and injection Phenytoin 800 mg was given which led to a cessation of seizure activity. On examination- afebrile with blood pressure 200/120 mmhg and oxygen saturation 95% requiring oxygen support temporarily. The neurologic examination was limited by sedation his pupils reactive to light with no focal deficits.

METHODS: Labs report urea and creatinine of 43 and 3.8 mg/dl respectively; glucose was 123 mg/dl with normal sodium and potassium levels WBC count was 11.1 × 106 cells/Îül; hemoglobin and hematocrit were 9.0 g/dl and 30.3% respectively. A lumbar puncture revealed a normal opening pressure cell count 1 WBC glucose 88 mg/dl protein 47 mg/dl negative for Gram stain culture HSV and India ink preparation. The serum tacrolimus level was at 9.0 ng/ml, and CSF Level was 1.5. Patient is poor metabolizer FOR CYP3A4. An MRI of the brain revealed non-diffuse restricting T2/ FLAIR sequences hyperintensity bilateral parietal-occipital and parietal-temporal region suggestive of PRES. Levetiracetam was started mainly for seizure prophylaxis. Patient blood pressure controlled with adequate drugs and had no further episodes of seizure. Full recovery was seen in two days. Patient in his course off hospitalization we removed tunneled catheter and discharged with normal graft function. At his 6 weeks -follow-up, the patient remained neurologically asymptomatic; his CNS lesions were completely resolved on repeat MRI.

RESULTS: The unique feature of this case report, most of the case reports available in literature PRES is managed with reduction in dose of immunosuppression and changing the drug itself. Here, no change in the immunosuppression was made, with adequate blood pressure patient remained asymptomatic and anti-epileptic medication was also stopped at 6 weeks of follow-up.

CONCLUSION: PRES can be non-fatal condition if promptly treated and cause is identified and treated. We managed the case with treatment of hypertension without change in immunosuppressive medications. In our patient, complete clinical resolution and a resolution of abnormalities on neuroimaging was also documented.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 251: BACTERIOLOGICAL PROFILE OF URINE IN PATIENTS WITH DIFFERENT TYPES OF KIDNEY STONES IN TERTIARY CARE HOSPITAL

Jaish George 1, Rajsekhar 1, Jaish George 1

BACKGROUND: Association of bacteriology and urinary stones

AIM OF STUDY: Aim of the study was to find out urine bacteriological profile with kidney stones

METHODS: Retrospective study with urine cultures and stone analysis reports

RESULTS: Escherichia coli was the most common organism followed by klebsiella

CONCLUSION: Among kidney stones, most commonly seen is calcium phosphate with escherichia coli as leading common organism present in preoperative culture of urine in patient with kidney stone

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 252: A YOUNG PATIENT WITH HIV INFECTION PRESENTING WITH MEMBRANOUS NEPHROPATHY

Lalit 1, Aruna Acharya 1

BACKGROUND: We present a case of a rare etiology of membranous nephropathy in an HIV patient. Physicians should be judicious in detecting the etiology of renal dysfunction in HIV. INTRODUCTION-A human immunodeficiency virus (HIV) infection has long been associated with kidney disease. A variety of glomerular lesions are associated with HIV infected patients. In the pre-cART era, HIV-associated nephropathy (HIVAN) was the most common form of glomerulopathy found in HIV-infected patients. In the present era with the availability of cART a renal biopsy in an HIV-positive patient with viral loads less than 400 copies/mL is more likely to show hypertensive nephrosclerosis or diabetic nephropathy. However, the two main entities directly associated with HIV infection although uncommon are HIV-associated ICD (HIV-ICD) and thrombotic microangiopathy. HIV-ICD includes IgA nephropathy lupus-like glomerulonephritis postinfectious glomerulonephritis MPGN and cryoglobulinemic glomerulonephritis. A very small subset of patients also develops membranous glomerulonephritis.

AIM OF STUDY: We present a case of a rare etiology of membranous nephropathy in an HIV patient. Physicians should be judicious in detecting the etiology of renal dysfunction in HIV.

METHODS: We present a case of a 24-year-old young female who presented to the hospital with facial puffiness and bilateral lower limb swelling for one month. She is a known case of HIV positive since 2016 when she was 18 years and started on cART in 2018. She got married in 2020 with a HIV positive boy and delivered a HIV negative boy in 2021. The laboratory examination revealed Hb 12.6 g/dl TLC 8000/cubic mm, Platelet 2.26 lakh, urea/creatinine 15/0.6 mg/dl, total protein/albumin 4.2/2.1 mg/dl, total cholesterol/triglycerides 445/257 mg/dL. Urine examination showed 4+ proteinuria and 1+ hematuria with 24-hour urine protein 8.3 g. ANA was negative USG showing normal kidney size. BP was 130/80 mmHg and viral load was 30 copies/ml. Renal biopsy was performed and showed membranous pattern glomerulopathy with negative staining for anti PLA2R (phospholipase A2 receptor) thrombospondin (THSD7A) NELL-1 EXT-1 and sema 3b. She was continued on cART managed on antiproteinuric measures (ACE inhibitors) and diuretics.

RESULTS: We interpret with the abovementioned case that etiology of membranous nephropathy in an HIV patient is an enigma. In our case, the patient had HIV coexisting with membranous nephropathy with no other chronic infections and PLA2R negative which is a rare occurrence.

CONCLUSION: Among patients with HIV-ICD, membranous nephropathy (MN) has been reported in ~ 3—30% of cases. Several studies have demonstrated that patients with HIV and MN are often coinfected with hepatitis C (HCV), hepatitis B viruses (HBV), and/or syphilis which are themselves independently associated with MN, challenging a causal association between MN and HIV. To date, no study specifically investigating MN in patients with HIV who lack known coinfections has been reported. In the past decade, many important advances in the understanding of idiopathic MN have been made, including the discovery of antibodies to the M-type phospholipase receptor (PLA2R) antigen. The prevalence and role of PLA2R antibodies in MN in patients with HIV have thus far not been studied.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 253: CORRELATION OF SERUM VIT. D IPTH LEVELS AND CIMT (CAROTID INTIMAL MEDIAL THICKNESS) IN NON DIALYSIS DEPENDANT CKD PATIENTS AT A TERTIARY CARE CENTRE

Mohit Mishra 1, Shivendra Singh 1

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of mortality in patients with chronic kidney disease (CKD). Noninvasive measurement of structural changes in straight arterial segments as carotid intima—media thickness (CIMT) is a well-established surrogate marker of atherosclerosis. It helps to identify individuals at risk of future clinical endpoints including coronary and cerebrovascular events earlier than established risk factors. Increased parathyroid hormone (PTH) level is associated with coronary artery disease cerebrovascular event. We aim to correlate bone mineral metabolism markers (Vit.D iPTH) with CIMT thus predicting cardiovascular risk in the non-dialysis dependant population (CKD 3-5) in our study.

AIM OF STUDY: We aim to correlate bone mineral metabolism markers (Vit.D iPTH) with CIMT thus predicting cardiovascular risk in the non-dialysis dependant population (CKD 3-5) in our study.

METHODS: It is an observational cross-sectional study conducted in the Department of Nephrology Institute of Medical Sciences BHU Varanasi between April 2021 to July 2022 and included 84 CKD patients (Stage 3-5). Carotid intima-media thickness of the common carotid artery was measured with USG B mode. All the subjects underwent routine laboratory investigation Vitamin D levels iPTH levels serum calcium serum phosphate levels. Data was tabulated using MS Excel and appropriate test for correlation using SPSS version 21 was applied.

RESULTS: The mean age of our study population was 52.54+/-16.44. Mean CIMT was 0.61+/-0.13 mm, and mean iPTH level was 226.70+/-206.63 pg/ml. We found a positive correlation between CIMT and iPTH, Pearson correlation coefficient 0.22; (P value 0.04). However while correlating CIMT with serum calcium levels, phosphate levels and Vit. D levels, we found weak positive correlation which was statistically non-significant (P > 0.05).

CONCLUSION: In our study, iPTH levels correlated well with CIMT and may serve as a surrogate marker for atherosclerosis in CKD patients. Further larger studies are required to validate our findings.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 254: ROLE OF ANTI-ANGIOGENIC FACTORS SFLT-1 AND SENG AND COLOUR DOPPLER IMAGING PROCEDURE IN THE DIAGNOSIS OF PREECLAMPSIA

Athar H Siddiqui #

BACKGROUND: Mechanistic insights into the etiological basis of preeclampsia (PE) have revealed dysregulation of placental functions. The anti-angiogenic (sFlt-1 and sEng) and angiogenic factors (PlGF and VEGF) are critically involved in the onset and progression of PE.

AIM OF STUDY: In the present study, we have determined the levels of the anti-angiogenic factors in the serum of the patients with preeclampsia (PE) and normotensive (NT) pregnancy to identify the differences between the levels of these factors in preeclampsia and normotensive conditions.

METHODS: Blood was taken from the patients who came for their antenatal check-up at different points of time at the Fernandez Hospital. Serum and plasma were isolated from the blood samples. We have then determined the levels of the anti-angiogenic factors in the serum of the patients with PE and normotensive (NT) pregnancy by commercially available ELISA kits at the School of Medical Sciences. Color Doppler imaging was carried out the Fernandez Hospital. All experimental protocols obtained approval by the Institutional Ethics Committee at both the institutions.

RESULTS: The levels of sFlt-1 is significantly higher in the PE group compared to the normotensive (NT) group in the 3rd trimester (10.36Â ± 4.32 ng/ml, n = 11 vs. 1.25Â ± 0.26 ng/ml, n = 11, p < 0.05) and at term (13.77Â ± 3.2 ng/ml, n = 11 vs 5.86Â ± 2.05 ng/ml, n = 13, p < 0.05). The levels of sEng were found to be significantly higher only at the term in the PE group compared to the NT group (11.15Â ± 1.8 ng/ml, n = 13 vs. 6.39Â ± 1.36 ng/ml, n = 14 p < 0.05). Significantly enough, the levels of sFlt-1 correlated positively (r2 = 0.67) with the Mean Arterial Pressure (MAP) at term. No such correlation was observed at any other time point. The color Doppler imaging procedure demonstrated a significant increased pulsatality index (PI) values in both the right uterine artery (2.5Â ± 0.22, n = 11 vs 1.75Â ± 0.15, n = 18, p < 0.05) and left uterine artery (2.36Â ± 0.15, n = 11 vs 1.71Â ± 0.15, n = 18, p < 0.05), in the PE group compared to the NT group. However, the resistivity index (RI) values were found to be significantly higher only for the right uterine artery (0.87Â ± 0.03, n = 11 vs 0.75Â ± 0.03, n = 18, p < 0.05) between the PE and NT group, while it was not significantly different for the left uterine artery.

CONCLUSION: Further studies are warranted to employ the determination of these biochemical factors along with the color Doppler imaging procedure to diagnose preeclampsia for better management of the patient and the complex condition of PE.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO 255: PODOCYTOPATHY IN RENAL CELL CARCINOMA

BS Swheta 1, Sushanth Kumar 1, P Mayoor 1

BACKGROUND: Renal cell carcinoma is 7th most common form of neoplasm in world and often associated with para-neoplastic syndrome caused by secretion of tumor cell products manifesting as impaired glucose metabolism hypercalcemia hypertension and cushing syndrome.

AIM OF THE STUDY: However, paraneoplastic glomerulonephritis is often overlooked due to attribution of urinary abnormalities as part of tumor.

METHODS: A 58-year-old male, known case of hypertension and CKD (baseline creatinine-1.5), presented with Hematuria of 1 week. On routine investigation found to have Sr creatinine: 1.53 mg/dl, urine revealing hematuria and proteinuria (3+, PCR-5).

RESULTS: Imaging reveals right upper and mid pole mass of 3.8 x 4.2 x 4.3 cm. Renal histopathology from right lower pole revealed normal glomerular morphology constituent with podocytopathy. Renal biopsy from right upper pole revealed high grade carcinoma. He underwent radical nephrectomy [renal cell carcinoma —unclassified (sarcomatoid differentiation-100%), grade 4, PT3aN1]. After 3 weeks, his proteinuria resolved (Urine PCR -0.08) with resection of tumor (no steroids) for podocytopathy. In 4th week, PET-CECT done suggestive of ill defined soft tissue thickening in right renal bed and lung and gallbladder neck metastasis and hence underwent 6 sessions of immunotherapy (Nivolumab- PD-1 inhibitor) and targeted therapy (cabozatinib- tyrosine kinase inhibitor). His sr. creatinine at follow-up after 6 cycles of targeted immunotherapy is 1.84.

CONCLUSION: Identification of glomerulopathy in renal cell carcinoma has prognostic implications. Minimal change disease resolves with resection of tumor mass.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 256: AN OBSERVATIONAL STUDY ON ASSOCIATION BETWEEN FLUID ACCUMULATION AND MAJOR ADVERSE KIDNEY EVENTS (MAKE30) IN SEPSIS PATIENTS ADMITTED IN INTENSIVE CARE UNIT OF A TERTIARY CARE HOSPITAL IN SOUTH INDIA

Sruthi Balla 1, P Nagarajan 1

BACKGROUND: Fluid resuscitation is cornerstone treatment of hemodynamic instability during the early phase of sepsis. Conventional fluid resuscitation combined with the administration of maintenance fluids drug diluents and nutrition often leads to a degree of fluid accumulation typically reaching 2—4 liters on average after 2 days in the intensive care unit (ICU). In addition to fluid volume accumulation, fluid composition and adjunct ICU therapies may contribute to adverse renal outcomes. Finally the use of nephrotoxic antibiotics commonly used in patients with severe sepsis adds further insult to the kidneys. Whether early fluid accumulation is a risk factor for adverse renal outcomes in septic ICU patients remains uncertain. Hence, it is important to assess the association between early fluid accumulation and major adverse kidney events a composite of death dialysis or sustained renal dysfunction within 30 days (MAKE30) in ICU patients with sepsis.

AIM OF THE STUDY: To assess the association between cumulative fluid balance and major adverse kidney events within 30 days (MAKE30) in sepsis patients admitted in medical ICU.

METHODS: A retrospective observational cohort study was conducted on sepsis patients admitted between January 2022 to June 2022 in medical ICU in a tertiary care hospital in South India. Adult (18 years or older) patients admitted with a diagnosis of sepsis severe sepsis or septic shock (International Classification of Diseases 10th revision) on their first ICU admission. Patients with end-stage renal disease and patients who died who were discharged or who received renal replacement therapy within the first two days in ICU were excluded. Patients without data on fluid balance or creatinine were also excluded. About 204 septic ICU patients who fit into the inclusion and exclusion criteria were selected for the study. Appropriate statistical analysis tools were applied to assess the association between cumulative fluid balance during the first two days in ICU and subsequent risk of MAKE30 adjusted for demographic factors comorbidities baseline creatinine illness severity variables hemodynamic characteristics and nephrotoxic drug exposure.

RESULTS: The strength of significant exposure variables was analyzed using SPSS software (version 22). 63 (30.9%) ICU sepsis patients developed MAKE30. Median cumulative fluid balance was 5.3 liters in the MAKE30 group and 4.1 liters in the no MAKE30 group, with non-resuscitation fluids contributing to approximately half of total fluid input in each group. On analysis, the strongest factors regarding MAKE30 were baseline creatinine, cumulative fluid balance, and age of the patient. Lower urine output and early acute kidney injury were independently associated with MAKE30.

CONCLUSION: In ICU patients with sepsis, a higher cumulative fluid balance after 2 days in ICU was associated with subsequent development of major adverse kidney events within 30 days, including death, renal replacement requirement, or persistent renal dysfunction.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 257: CLINICAL DEMOGRAPHIC AND OUTCOME IN THROMBOTIC MICROANGIOPATHY WITHOUT ANY OBVIOUS SECONDORY CAUSE

Aniket Premanand Malve 1, Smita Patil 1, Tusti Kumari 1, Jyoti Bansode 1, Salman 1, Ruju Gala 1, Atim Pajai 1, Kalpana Mehta 1

BACKGROUND:

AIM OF THE STUDY: To study clinical demographic & outcome in thrombotic microangiopathy without any obvious secondary cause.

METHODS: This observational study included all patients from Jan 2021 to July 2022. Clinical demography details noted. Markers of microangiopathic hemolysis Kidney biopsies serum-factor H antifactor-HAb C3NeF done in all. Genetic studies done wherever financially feasible. TMA diagnosis made with MAHA &/or histopathology. Immunosuppression started as indicated. Outcome & prognostic factors evaluated.

RESULTS: Total AKI-1734. We report 14cases, age group (18-40)-11patients, (40-70yrs)-3patients; M: F(5:9). Presented with AKI-12, CKD-3, HTN-11, pregnancy related-7. Symptoms Duration 2-30days. Sr. creatinine 1.5-7.6 mg/dl. Hb 4.2-12 gm/dl, platelet 49000-282000; markers of hemolysis deranged-6. Increased antifactor-H-antibody- 5, complement-factor-Hmutation-3, CD46 mutation-1, genetic studies not done-8, kidney biopsy-11. Steroids-10 patients, mycophenolate mofitil-2 patients. HD required-11patients. Plasmapheresis-11. 7 recovered with plasmapheresis. 5/11 free of HD. 3 patients died (septic shock-1, disseminated koch’s-1, pulmonary oedema-1). 3patients-ESRD & are on HD, conservative management-4, completely recovered -4, Hypertension-10 patients. Steroid induced DM-1, Pulmonary koch's -2. Transplant -1 which was failed.

CONCLUSION: Early detection prompt treatment in the form of plasmapheresis and immunosuppression may prevent patient from progressing to ESRD.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 258: PICKING UP DIABETIC KIDNEY DISEASE (DKD) EARLIER AND MORE EFFECTIVELY: THE ROLE OF ELECTRON MICROSCOPY IN KIDNEY BIOPSY

Sudeep Prakash 1, Ranjith K Nair 1

BACKGROUND: The worldwide prevalence of diabetes is estimated to reach 592 million by 2035. Type 2 diabetes constitutes about 85%—95% of all diabetes cases. Duration of diabetes more than 10 years proteinuria > 3.5 gm and retinopathy in a type 2 diabetic patient are unable to predict diabetic kidney disease (DKD) with certainty where these clinical correlations are poor. Various studies have shown that there is high prevalence of non-diabetic kidney disease even in the presence of above features. The presence of kidney pathology other than DKD early DKD and absence of classical lesions of DKD may lead to missing the diagnosis on kidney biopsy if light microscopy (LM) and immunofluorescence (IF) only are performed.

AIM OF THE STUDY: To study the role of electron microscopy in establishing the etiology of kidney dysfunction in patients of type 2 diabetes mellitus

METHODS: Over a period of 18 months 56 patients who fulfilled the inclusion criteria (patients older than 18 yrs having type 2 diabetes mellitus with no evidence of preexisting chronic kidney disease with normal sized kidneys and any of the following: proteinuria more than 500 mg/day active urinary sediment or serum creatinine > 1.5 mg/dL), and those not having any contradictions to kidney biopsy were subjected to kidney biopsy. LM and IF were performed on all, and electron microscopy (EM) was performed in 46 patients. Statistical analysis was performed by using descriptive and inferential statistics with chi- square test/ Fisher exact test for categorical variables. One-way AVOVA followed by post hoc test to compare mean values between more than two groups was applied for real scale data. p value < 0.05 was considered as significant at 95% confidence level.

RESULTS: Diabetic kidney disease (DKD), mixed diabetic with nondiabetic kidney disease (MxKD), and isolated non-diabetic kidney disease (NDKD) were found in 46.4, 23.2, and 30.3% respectively. Chronic tubulointerstitial nephritis (CIN) was the commonest non-diabetic lesion occurring in 53% of patients with isolated NDKD and in 38% of patients with MxKD. Presence of diabetic retinopathy and insulin requirement strongly correlated with DKD; however, duration of diabetes and magnitude of proteinuria were unable to predict the presence of diabetic kidney disease. On EM, 81.82% with DKD had GBM thickness more than 460 nm. 95% patients with foot process effacement between 30-70% had evidence of DKD, either isolated or as MxKD.

CONCLUSION: Many times, the clinical features are not enough to predict the cause of kidney dysfunction in a type 2 diabetes patient. Electron microscopy can increase the sensitivity of diagnosis of DKD in such patients, especially at an earlier stage, when the classical diabetes lesions like capsular drops, fibrin caps, and Kimmelstiel–Wilson lesions are not present, and in simultaneous presence of lesions of NDKD

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 259: ISOLATED RENAL SARCOIDOSIS CAUSING GRANULAMATOUS INTERSTITIAL NEPHRITIS WITH PROTEINURIA: A RARE COMBINATION

Rajeev Bhatia 1, Ajay Marwaha 1

BACKGROUND: Sarcoidosis is a multisystem disorder and non-caseating granuloma is the pathological hallmark of the disease. However, sarcoidosis causing isolated granulomatous interstitial nephritis in the absence of extra renal lesions is very rare.

AIM OF THE STUDY: To describe about isolated renal involvement in sarcoidosis

METHODS: Isolated Renal Involvement of Sarcoidosis: Case Series and Review of the Literature.

RESULTS: A 58-yr-old man presented with a history of loss of appetite, weight loss of 12 kg, and increase in serum creatinine from 0.9 to 4.8 within the period of 8 months. At presentation hematuria was not present and proteinuria was also found. Serum angiotensin-converting enzyme was elevated, and calcium levels were normal and hypoalbuminemia was present. Renal biopsy was done, and that was suggestive of granulomatous interstitial nephritis with non-caseating epithelioid cells with granuloma with in granuloma. All other systems were checked for extrarenal manifestation, and all investigations were normal. Patient was started on oral steroids and followed after 2 weeks decreased creatinine levels.

CONCLUSION: This is a rare case report of sarcoidosis presenting as a granulomatous tubulointerstitial nephritis alone causing renal failure without any involvement of upper respiratory organ.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 260: CLINICAL PROFILE AND OUTCOME OF TROPICAL ACUTE KIDNEY INJURY

Sruthi S Nair 1, Goli Charan 1

BACKGROUND: Acute kidney injury (AKI) is one of the most challenging problems faced by clinicians in the tropical countries. AKI in the tropics is strikingly different from that in the developed world in terms of etiology and presentation. Snake bites, insect stings, chemical, and plant poisoning are some of leading causes of AKI among patients presenting at a tertiary care hospital in India. Community-acquired AKI is a major problem in developing tropical countries which is closely linked to other public health problems such as infections unclean water a predominantly rural population suboptimal antenatal care poor regulation of indigenous medical practices and unsafe births and abortions. The lack of easy access to hospitals can delay diagnosis and management of AKI Limited data on the incidence are available worldwide and causing high mortality. The data vary widely across studies depending on the setting and the populations investigated. Tropical countries are likely to face major challenges to kidney health as a result of climate change water scarcity degradation of ecosystem air and water pollution. According to the UK-based risk analysis firm Maplecroft, the top 10 countries at “extreme risk†from climate change are all tropical countries. Another area of concern is the evolution in the virulence of disease-causing organisms as noted by emergence of kidney injury in vivax malaria and scrub typhus antimicrobial resistance. So the study was considered to study the clinical profile and outcome of patients in Tropical AKI in tertiary care hospital in Southern India

AIM OF THE STUDY: • To Study the clinical profile in Tropical acute kidney injury. • To Study the Etiological Spectrum of AKI among various poisons and Tropical Infections admitted in Nephrology Department. • To Study the Histopathology of kidney in patients with Non-recovering AKI. • To Study the Outcomes of Tropical AKI.

METHODS: An observational study among 78 patients who fulfilled the inclusion criteria admitted in Nephrology Department, King George Hospital, Visakhapatnam, during April 2021–March 2022 after taking informed consent were included. ACUTE KIDNEY INJURY was diagnosed using AKIN criteria, and detailed clinical history including necessary lab investigations was taken; urine output was quantified; renal biopsy was done for light microscopy; and immunofluorescence in non-recovering AKI (more than 3 weeks of renal dysfunction). Course treatment progress and any significant event were recorded

RESULTS: 1) 78 patients are enrolled in the study. 2) The mean age of the study is 43.79 years with most patients between 51-60 years. 3) Males are more common than females with a ratio of male: female, 3.8:1. 4) On evaluation, oliguria is present in 84.62% of cases. 5) Among the study population, fever is the most common presenting symptom, followed by vomiting and shortness of breath. 6) Paraquat (37.84%) along with snakebite (37.84%) is the most common poison in the study. 7) Malaria is the most common infection in 15 patients (36.59%) followed by Dengue in 9 patients (21.95%). 8) Preexisting Hypertension is present in 11 patients (14.10%), and diabetes is present in 3 patients (3.85%). 9) The mean hemoglobin of the study population is 10.65 gm/dl. 10) Mean serum creatinine is 6.98 with a mean of 2.70. 11) The most common histological finding in renal biopsy is acute tubular necrosis (ATN). 12) Out of 78 patients in the study, 60 patients (76.92%) recovered and 18 patients (23.08%) expired. 13) Mortality was significantly high in the Paraquat patients in the poison group. 14) In the Infection group, highest mortality is seen with Leptospirosis, 2 out of 6 patients expired (33.33%). 15) In the study, 97.43% were dialyzed, in which 83.34% of cases had hemodialysis, and 13.33% had peritoneal dialysis. There is no significant association between dialysis and outcome. 16) Hypoalbuminemia is significantly observed among patients in Infection group. 17) There is no significant association between blood pressure and urine output with the outcome. 18) Duration of hospital stay is significantly high in the dead group compared to the recovered group. 19) Multiorgan dysfunction is more prevalent in the dead group compared to the survival group. 20) The number of patients requiring vasopressor support is significantly high in the dead group compared to the recovered group. 21) Significant number of patients required mechanical ventilation in dead patients group compared to recovered group. 22), Renal Biopsy is done in 7 patients with non-recovering AKI with 2 (28.57%) having pure Acute tubular necrosis, 1 patient each with ATN with occasional pigment casts, IgA Nephropathy and ATN with mesangial hypercellularity. Acute Tubulointestitial Nephritis is seen in 2 Patients with one having ATIN with Benign Nephrosclerosis. Immunofluorescence study showing IgG staining in 1 (1+) patient, IgM staining is absent in all 7 patients, IgA staining was 2+ and 1+ in one (14.39%) each patient with absent in 5 patients (71.42%), and C3 was positive in 1 patient with no staining in remaining 6 biopsies.

CONCLUSION: 78 patients presented to King George Hospital with AKI in AKIN stage 3 after applying exclusion criteria were studied. The mean age of the patients is 43.79 years with Males outnumbering females at a ratio of 3.8:1. Fever is the most common presenting symptom. Paraquat and snakebite are being the most common etiology among poisons. Malaria is the most common tropical infection in the study population. Acute tubular necrosis is the most common renal biopsy pathology finding consistent with other studies. Our study once again proves the high case fatality rate of paraquat ingestion as reported in earlier studies. Leptospirosis is found to be having highest mortality among tropical infections and diarrheal illnesses as etiology of severe AKI is reducing owing to improved living conditions and sanitation in the tropical countries. High mortality is seen in acute kidney injury patients secondary to multi-organ dysfunction. Prolonged duration of hospital stay, vasopressor support, and assisted ventilation are associated with increased mortality.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 261: ASSOCIATION OF MALNUTRITION AND QUALITY OF LIFE AMONG MAINTENANCE HEMODIALYSIS PATIENTS IN A TERTIARY CARE HOSPITAL

T Navaneethan 1, P Nagarajan 1

BACKGROUND: Malnutrition and health-related quality of life are significant predictors of morbidity and mortality among hemodialysis patients. Hence assessment of nutrition and quality of life and serial monitoring plays major role in preventing morbidity and mortality among hemodialysis patients.

AIM OF THE STUDY: The aim of the study is to correlate malnutrition with quality of life among hemodialysis patients in a tertiary care hospital.

METHODS: About 94 maintenance hemodialysis patients were randomly selected. Patients who are on hemodialysis for at least 3 months were included in the study. Nutritional assessment was done with the help of malnutrition inflammation score (MIS). They were divided into two groups, namely patients with mild-to-moderate malnutrition and patients with severe malnutrition based on MIS. Health-related quality of life assessment was done with validated short form-12 (SF-12) in both the groups. The results were compared between the two groups and analyzed.

RESULTS: Patients with severe malnutrition had higher MIS. Healt-related quality of life is significantly lower in patients with severe malnutrition group.

CONCLUSION: The study indicates that malnutrition leads on to poor health-related quality of life. Hence serial assessment of MIS starting from initiation of HD helps in improving health-related quality of life among maintenance hemodialysis patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 262: CHRONIC KIDNEY DISEASE IN A PATIENT WITH MATERNALLY INHERITED DIABETES AND DEAFNESS (MIDD): A CASE REPORT

S V GIGIN 1, Rakesh Gupta 1, Dhanajai Agarwal 1, B Sashank 1, S Kavish 1

BACKGROUND: Maternally inherited diabetes and deafness (MIDD) is a mitochondrial genetic disorder characterized by type 2 diabetes mellitus (DM) and hearing impairment. (MIDD) is caused by a change or mutation in mitochondrial DNA (the most common change is known as 3243A>G) Mitochondrial diseases constitute a rare group of disorders where renal involvement is rare. Mitochondria are abundant in the kidney especially in proximal tubules and glomerular epithelial cells mitochondrial dysfunction can cause renal damage. Although tubular cells are the most frequent renal targets renal involvement has been reported mostly in the form of FSGS.

AIM OF THE STUDY: Our case illustrates the value of a detailed medical and family history taking as it can help in the diagnosis of rare subtypes of diabetes on clinical suspicion alone. Consequently genetic testing should be done at an early stage.

METHODS: We present a case of a 37-year-old male with a history of diabetes bilateral sensorineural deafness and old pulmonary tuberculosis presented with gradually progressive lower limb swelling and shortness of breath. There was strong family history of DM in mother, elder sister, elder brother, and children of elder sister. Sensorineural hearing loss in elder brother renal failure in younger sister on evaluation found to have renal failure with elevated serum creatinine levels (4.10 mg/dL) with an estimated glomerular filtration rate of 20 ml/min/1.73 m2 Urine Protein was 2+. Ultrasonography of abdomen suggestive of bilateral contracted kidney hence renal biopsy not done. A diagnosis of CKD with MIDD was made considering clinical presentation strong family history of diabetes with maternal inheritance diabetes renal failure and hearing loss in siblings

RESULTS: Our case illustrates the value of a detailed medical and family history taking as it can help in the diagnosis of rare subtypes of diabetes on clinical suspicion alone.

CONCLUSION: Mitochondrial diseases constitute a rare group of disorders where renal involvement is rare. Mitochondria are abundant in the kidney, especially in proximal tubules and glomerular epithelial cells, mitochondrial dysfunction can cause renal damage. Although tubular cells are the most frequent renal targets, renal involvement has been reported mostly in the form of FSGS

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 263: MULTIPLE MYELOMA: A NEPHROLOGIST PERSPECTIVE

Abdullah 1, Hasan Aamir 1

BACKGROUND: Primary renal involvement without any other system involvement in MM is diagnostic and therapeutic challenge. To study this case report of 4 cases of MM patient with primarily renal involvement is reported here.

AIM OF THE STUDY: To report case series of 4 Cases of MM with primarily renal involvement

METHODS: Case Series

RESULTS: Improvement in renal function of Multiple Myeloma patient.

CONCLUSION: Reported various presentation of Multiple Myeloma.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 264: CYTOSORB DIALYSIS: AN ADJUNCT FOR SURVIVAL IN THE COVID-19 PATIENT IN CYTOKINE STORM? A CASE SERIES

R Dadegal Vinay 1, M S Khanpet 1

BACKGROUND: The COVID-19 pandemic has led to the biggest global health crisis of our lifetime. There is accumulating evidence that a substantial number of critically ill COVID-19 patients exhibit a dysregulated host response manifesting as cytokine storm or cytokine release syndrome which in turn contributes to the high observed rates of mortality. Just as in other hyperinflammatory conditions extracorporeal cytokine removal may have potential beneficial effects in this subgroup of COVID-19 patients. The CytoSorb blood purification device is the most extensively investigated cytokine removal platform with considerable evidence suggesting that early intervention can provide rapid hemodynamic stabilization and improvement in vital organ functions

AIM OF THE STUDY: Here we describe 4 cases of severely ill adult patients with coronavirus disease 2019 admitted to intensive care unit who were treated with CytoSorb therapy.

METHODS: All 4 patients were admitted in the ICU with CT severity score of >15/25. During their clinical course, all patients were prescribed tocilizumab (an interleukin-6 receptor blocker) antivirals hydroxychloroquine azithromycin and other antibiotics and general antipyretic drugs. All patients received low-molecular-weight heparin thromboprophylaxis adjusted to baseline weight and renal function Patient A and C required invasive mechanical ventilation whereas Patients B D were on NIV The mean age of the patients was 67.7 years (range = 29—79) Patients received a median of 2 attempts of hemoperfusion. The median CytoSorb perfusion time was 20hrs.

RESULTS: The level of IL-6 significantly decreased after treatments. It reduced by 95% for Patient A, 70% for Patient B, 99% for Patient D Mean Arterial Pressure improved by 15 mmHg average for Patients A, B, D PaO2/FiO2 Ratio improved by 143 average for Patients A, B, D HsCRP levels fell by average of 39 mg/l for patients A, B, D Patient A expired 2 days after the cytosorb dialysis (Refractory Shock) Patient C expired following Dialysis Albumin mildly decreased after CytoSorb. No significant changes were found in red blood cell counts, white cell counts, and platelets. Â ICU and in-hospital mortality was 50%.

CONCLUSION: In this case series, critically ill patients with COVID-19 with severe acute respiratory failure refractory to prone positioning and hypercytokinemia who received adjuvant treatment with cytokine hemoadsorption showed a significant reduction in IL-6 plasma levels and other inflammatory biomarkers. Improvements in oxygenation and MAP were also observed.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 265: CASE OF RHEUMATOID ARTHRITIS PRESENTED WITH NEPHROTIC SYNDROME -RITUXIMAB IS A BOON FOR THE SUCCESSFUL TREATMENT OF BOTH DISEASE ENTITIES

Niranjan Gogoi 1, Dhananjai Agarwal 1, Rakesh Gupta 1, Vinay Malhotra 1, Tushar Gupta 1

BACKGROUND: Introduction: Rheumatoid arthritis (RA) can cause clinically significant renal involvement with varied presentations. Kidney injury during RA includes secondary renal amyloidosis nephrotoxic effects of antirheumatic drugs and nephropathies as extra-articular manifestations (rheumatoid nephropathy). Rituximab (RTX) is an approved treatment for rheumatoid arthritis (RA) patients that do not respond adequately to disease-modifying antirheumatic drugs.

AIM OF THE STUDY: to study beneficial effect of rituximab in rheumatoid arthritis nephrotic syndrome

METHODS: case report study

RESULTS: A 45-year-old female patient suffering from long-standing RA with positive serology having signs and symptoms of multiple joint pain for 2 years and nephrotic range proteinuria with bland sediments. After failed treatment with oral antirheumatic drugs, she was administered rituximab once weekly for 4 weeks with other supportive care like prednisolone, hydroxychloroquine, ramipril, and atorvastatin. At the end of 2 months, she had gone into remission both in terms of rheumatoid arthritis and nephrotic syndrome.

CONCLUSION: Rituximab is beneficial for both rheumatoid arthritis and nephrotic syndrome and can be a boon for both disease entities. But there is little literature about using rituximab in nephrotic syndrome with RA. Therefore, randomized studies with extended follow-up will add important information regarding optimal treatment, relapse, and safety.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 266: AN OBSERVATIONAL STUDY OF THE PREVALENCE AND FACTORS ASSOCIATED WITH SPECTRUM OF RENAL DISEASES IN VARIOUS RHEUMATOLOGICAL DISORDERS IN A NORTH INDIAN TERTIARY CARE HOSPITAL

Ariba 1, M Aslam 1, Mujahid Beg 1, Ahmad Ghayas Ansari 1

BACKGROUND: Renal involvement is a common occurrence in subjects with rheumatological diseases and can develop either due to the disease itself or secondary to drugs used in the treatment. The prevalence of renal involvement and its severity depends on the underlying disease as well as aggressiveness of the therapy.

AIM OF THE STUDY: To determine the prevalence of spectrum of renal diseases in various rheumatological disorders and identify the clinico-laboratory correlations of various renal lesions and assess the course and outcome of renal diseases in patients with rheumatological disorders.

METHODS: This was an observational study of 30 patients with various rheumatological disorders diagnosed as per Standard Disease Criteria who presented with renal symptoms or/and asymptomatic urinary abnormalities.

RESULTS: Of the 30 patients under observation, females were more common (90%) than males (10%), with mean age of presentation of 35.7 Â ± 13.81 years. The most common rheumatological disorder presenting with renal disease among these patients was found to be systemic lupus erythematosus (60%) followed by rheumatoid arthritis (16.67%), Sjogren's syndrome (10%), and vasculitis of medium and small vessels (6.67%). The most common renal symptoms as complained by the patients was decreased urine output (56.67%) followed by generalized swelling over body (36.67%), whilst 23.3% of patients were asymptomatic at presentation. Lupus nephritis (53.3%) was the most common renal disease, of which Class IV/V lupus nephritis was seen in 75% of them, while Class I/II Nephritis was seen in the rest. Drug-induced acute kidney injury was seen in 26.6% of patients, and tubulointerstitial disease in 10%. About 57% patients were found to be Hypertensive at presentation with a blood pressure of >140/90, while 43% of them were normotensive. Severe anemia with a hemoglobin of <7g/dL was found in 30% of patients. 73.3% patients were managed conservatively, while 26.67% of them required intervention in the form of renal replacement therapy. 86.67% patients were discharged with favorable outcome, and only 13.3% succumbed to disease activity.

CONCLUSION: For most rheumatological diseases, renal involvement heralds a poor prognosis and warrants early and aggressive immunosuppressive therapy. It is thus, of utmost importance to diagnose renal involvement at early stages of disease illness. This study aims at sensitization of associated renal involvement of various rheumatological disorders which would result in better management and outcome of such patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 267: PROLIFERATIVE GLOMERULONEPHRITIS ASSOCIATED WITH MONOCLONAL IMMUNE DEPOSITS: A CASE REPORT

Rohit Badge 1, Vinay Rathore 1

BACKGROUND: Proliferative GN (PGN) with monoclonal IgG deposits (PGNMID) is a form of monoclonal gammopathy of renal significance (MGRS). Multiple myeloma is one the most frequent monoclonal gammopathy to involve the kidney and may present with deposition of immunoglobulin in the glomerulus.

AIM OF THE STUDY: To know the effect of chemotherapy with VCD regimen in a patient of PGNMID.

METHODS: A 62-year female with hypertension for 5 years presented with pedal edema. She was alert pale and edematous and had BP of 160/90 mmHg. Systemic examination was unremarkable. Her labs were Hb 9 g/dl TLC 74200/cumm platelets 3.36 lacs/cumm urine analysis Protein 3+ RBC nil /hpf WBC: occasional with no casts. 24 hrs urine proteins 7.7 gm/day urea 145 mg/dl creatinine: 2.98 mg/dl. Na/K/Cl 137/4.4/ 110 meq/L. Ca/P/- 8.3 mg/ 4.7 mg/dl. Serum total proteins /albumin 6.6/2.9 g/dl ALP 155 IU/l serum cholesterol 212 mg/dl triglyceride 178 mg/dl. C3 and C4 were normal, and serum cryoglobulin was negative. ANCA was negative, and serum PLA2R was negative. Viral markers were negative. Chest X-ray: X-ray skull and USG KUB were normal. SPEP showed no M bands, and free kappa and lambda light chain ratio were 1.54. Kidney biopsy showed 19 glomeruli with 4 globally sclerosed. Viable glomeruli were enlarged hypercellular with lobular accentuation and marked mesangial and endocapillary proliferation. Seven crescents were seen. IFTA seen in 30-35%. Vessels showed medial thickening subintimal sclerosis and arterioles showed hyalosis. IF showed significant peripheral and mesangial deposits of IgG C3c and kappa light chains. Bone marrow aspiration showed cellular marrow with trilineage hematopoiesis and plasma cells (8%).

RESULTS: Patient was initially treated with diuretics, CCB’s, ACE/ARB’s, statins and later on chemotherapy with VCD regimen. However, patient did not respond and progressed to early ESKD and became dialysis dependant.

CONCLUSION: Chemotherapy could not prevent the disease progression in all cases and patients can progress to early ESKD.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 268: HEAT STRIKES€¦ WITH DIFFERENT STROKES!

Ravi Kumar 1, Sudeep Prakash 1

BACKGROUND: Occurrence of environmental heat illness or heat stroke after exposure to exertion is a well-reported occurrence. These patients can present with features of rhabdomyolysis and acute kidney injury disseminated intravascular coagulation (DIC) liver injury seizures. The incidence of heat stroke increases in case of exposure to unaccustomed exertion especially in presence of humid weather. We present two cases of heat stroke that had different presentations.

AIM OF THE STUDY: To highlight the varied presentations of heat stroke.

METHODS: We present two patients with heat stroke who had widely different presentations and courses. Both the patient had been away from their physical training activity for the past 4 weeks before the presentation and ran a marathon race of 12 km in the humid month of July in Pune district. First patient an 18 yrs old male with no known comorbidities was brought to the emergency room with complaints of loss of consciousness after running 10 km marathon race. There was a history of generalized convulsions during the unconscious episode. The evaluation revealed mildly raised CPK 1500 IU/mL creat 2.9 mg/dL. He gradually developed oliguria. The patient had a delayed worsening in form of gradually reducing urine out and rising creatinine in the first five days to oliguria in the next five days. By the third week, he developed anuria hypertensive emergency cardiac dysfunction generalized seizures and CPK levels peaking to 2 94 000 U/L. The patient was managed with daily dialysis seizure and blood pressure control and gradually recovered by the fifth week of presentation. Second patient a 20 young male with no comorbidities presented to the emergency room with complaints of fever and altered sensorium after running 12 km marathon run. The patient was completely asymptomatic before the run. He had gradually worsening sensorium refractory seizures with raised CPK levels peaking to 38000 IU/ L features of DIC and multiple hemorrhagic and ischemic infarcts. Patient had a gradual recovery over three weeks. Both patients had normal oral temperatures, and the rectal temperatures could not be measured due to the non-availability of rectal thermometers. Both patients had raised liver enzymes. Result: The exposure to unaccustomed exertion in humid weather even in the trained athletes resulted in precipitation of heat stroke in them.

RESULTS: Heat stroke can occur in trained individuals if they have been out of practice from their routine. Heavy physical exertion in humid weather can precipitate heat stroke even in trained athletes. The cases highlight that heat stroke can have various different profiles of presentation. One of the patient had delayed worsening of rhabdomyolysis, with CPK levels peaking to 2,94,000 IU/ L, severe dialysis requiring AKI, the other patient had early worsening in form of DIC, refractory seizures, and rhabdomyolysis to lesser degree

CONCLUSION: Heat stroke can occur in trained individuals if they have been out of practice from their routine. Heavy physical exertion in humid weather can precipitate heat stroke even in trained athletes. The cases highlight that heat stroke can have various different profiles of presentation. One of the patient had delayed worsening of rhabdomyolysis, with CPK levels peaking to 2,94,000 IU/ L, severe dialysis requiring AKI, the other patient had early worsening in form of DIC, refractory seizures, and rhabdomyolysis to a lesser degree

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 269: OROFACIAL DYSKINESIA IN UREMIA

Nidhi Arora 1, Zainab Mehdi 1, Sanjay D'Cruz 1

BACKGROUND: Uremia is associated with wide spectrum of movement disorders. Uremic toxins may be associated with epileptiform discharges by excitotoxicity. Basal ganglia is particularly susceptible to toxin mediated injury attributable to metabolic and vascular endothelial damage. However, susceptibility to develop such movements varies between individuals with predisposition seen in Asians and diabetic patients.

AIM OF THE STUDY: To describe an unusual presentation of CNS toxicity in uremia.

METHODS: 47-yr-old male patient of autosomal dominant polycystic kidney disease presented with abnormal involuntary facial movements which were high-frequency symmetric rhythmic and localized to perioral and perinasal area involving cheeks and intermittent eyebrow twitches. Patient was a known case of polycystic kidney disease and was non-diabetic. Lab investigations revealed blood urea 277, creatinine 9.6, Calcium 5.9 mg/dl, Phosphate 9.6 mg/dl, metabolic acidosis, and microcytic hypochromic anemia. NCCT head of the patient was suggestive of hypodensity in right gangliocapsular region. T2 hyperintensity was found on MRI in region of right lentiform nucleus with T2/FLAIR hyperintensities seen in bilateral periventricular subcortical and deep white matter in bilateral fronto-parietal lobes. Involuntary movements did not respond to IV diazepam and haloperidol. Patient was hemodialyzed following which abnormal movements resolved.

RESULTS: Renal dysfunction is associated with wide spectrum of movement disorders. They can be due to uremic toxin mediated injury or secondary to electrolyte imbalance. They can often arise as complication of dialysis or drug toxicities in a patient with pre-existing renal disorder. Patient can present with myoclonus, tremors, restless leg syndrome, asterixis, twitch convulsive syndromes, and even generalized tonic-clonic seizures as first manifestation of azotemia. Movement abnormalities may be attributed to increased levels of guanidino compounds including creatinine, guanidine, guanidinosuccinic acid, and methylguanidine in serum as well as in CSF which leads to hyperexcitability as described in in vitro studies.4 It has also been postulated that uremia leads to vascular endothelial dysfunction leading to autoregulatory dysfunction causing vasogenic edema.5 Basal ganglia is found to be particularly sensitive to toxin injury. No characteristic risk factors could be found to predict occurrence of movement disorders. No renal threshold for development of abnormal movements was obtained. Neuroimaging usually reveals basal ganglia lesions with involvement of surrounding white matter is observed in many cases. White matter hyperintensities in small periventricular and subcortical lesions suggestive of small vessel ischemic insults in absence of clinical stroke manifestations are seen. Lenticular fork sign has been described mainly in Asian patients with diabetes and uremic encephalopathy on T2/FLAIR hyperintensities. Discrepancy between radiological findings and clinical outcomes is often observed.

CONCLUSION: Uremic encephalopathy presenting as involuntary movements of the orofacial region is important to recognize because of reversibility seen with resolution of azotaemia though residual neurological dysfunction might persist. Neuroimaging is important part of diagnosis with typical lesions involving basal ganglia seen mostly in diabetic patients. Our case highlights a patient with non-diabetic uremic encephalopathy with facial dyskinesia which is rare with a lesion in unilateral lentiform nucleus and small white matter hyperintensities. Resolution following dialysis pointed to uremia as etiology.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 270: FULMINANT RUPTURED ABDOMINAL AORTIC ANEURYSM COMPLICATING CATHETER RELATED BLOOD STREAM INFECTION IN A PATIENT ON HAEMODIALYSIS €” A CASE REPORT

Yashendu Sarda 1, Veeranki Vamsidhar 1, Narayan Prasad 1, Manas Ranjan Patel 1, Ravi Shankar Kushwaha 1

BACKGROUND: Infections and cardiovascular-related deaths are the most common cause of deaths in patients with end-stage renal disease (ERSD).

AIM OF THE STUDY:

METHODS: Case Presentation: We present to you a case of middle-age female suffering from ESRD on maintenance hemodialysis who succumbed to death due to fulminant sepsis secondary to Pseudomonas-associated catheter-related blood stream infection (CRBSI) resulting in multiple septic aneurysm and abdominal aorta rupture. Discussion: Though CRBSI is a commonly encountered complication in our routine practice this is the first reported case of a patient with disseminated septic aneurysm as a direct complication of CRBSI without underlying endocarditis.

RESULTS:

CONCLUSION: Conclusion: It is imperative to understand and implement KDOQI ESKD life plan in routine practice and prefer AV access over catheters to avoid such fatal outcomes.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 271: ANTINEUTROPHIL CYTOPLASMIC ANTIBODY ASSOCIATED RAPIDLY PROGRESSIVES GLOMERULONEPHRITIS WITH FULL HOUSE NEPHROPATHY WITH ANA NEGATIVE SEROLOGY AN UNUSUAL ASSOCIATION: A CASE REPORT

Manoj Umare 1, Venkata Pakki Reddy 1

BACKGROUND: Rapidly progressive glomerulonephritis is a acute medical condition with high mortality around 20%. It is characterized by crescent glomerulonephritis and progressive loss of kidney function hematuria and proteinuria. Its etiology should be based on clinical findings: immunological profile, age, sex, and histopathological characteristics. Literature review on serology negative LN, i.e., antinuclear antibody (ANA)-negative revealed the following patient presentations: (1) renal-limited or renal and extra-renal manifestations of SLE with negative serologies and (2) renal and extra-renal manifestations of SLE with negative serologies initially at presentation who develop positive serologies later in subsequent follow-up.

AIM OF THE STUDY: 1) To report an unusual case of a women presented with symptoms suggestive of RPGN with biopsy showing full house pattern on immunofluorescence with ANA negative and positive ANCA. 2) To present a case that prompted a literature review to better define these groups.

METHODS: A case of a 27-year-old woman with symptoms consistent with rapidly progressive glomerulonephritis and biopsy findings of a full-house kidney nephropathy with an early fatal outcome. An association of low incidence as it is a case with a full-house pattern and an autoimmune profile for negative systemic lupus erythematosus makes this a rare case.

RESULTS: ANA - Negative. DsDNA - Negative ANA profile - Negative. P-ANCA - POSITIVE C- ANCA - POSITIVE Progressive renal insufficiency. Renal biopsy - PDGN pattern of injury on LM study with full house pattern on immunofluorescence.

CONCLUSION: A case of ANCA-associated vasculitis with full-house kidney disease, an unusual condition with up to 3% presentation and few reports in the literature, highlighting the importance of its reporting and contribution to the literature.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 272: TMA IN ELDERLY. PLASMA CELL DISORDER AN EASILY OVERLOOKED CAUSE

Dola Jaswanth Kumar 1, Vinay Rathore 1

BACKGROUND: Thrombotic microangiopathy (TMA) describes a pathological process of microvascular thrombosis consumptive thrombocytopenia and microangiopathic hemolytic anemia leading to end-organ ischemia and infarction affecting particularly the kidney and brain. TMA is a pathological feature of several clinical disorders including thrombotic thrombocytopenic purpura hemolytic uremic syndrome and atypical hemolytic uremic syndrome. Rare but important TMA may also occur in malignancy connective tissue disease malignant hypertension and renal transplantation (rejection or drug toxicity). We present a very rare case where the patient developed rapidly progressing renal injury from TMA but found to have multiple myeloma as the possible underlying etiology.

AIM OF THE STUDY: A 62-year-old female patient presented to outside hospital with generalized weakness and easy fatigability for 15 days. The lab investigations revealed Hb 5.5gm% Platelets 3.83L Creatinine 2.02 mg/dL Urea 91 mg/Dl. The patient was managed outside conservatively. She presented to our institute after 15 days with shortness of breath nausea vomiting generalized weakness and decreased urine output since 3days. At the time of presentation creatinine was 6.8 mg/dL hemoglobin 6.7gm% (normocytic normochromic anemia) platelets 1.67L Urine showed 3+ protein plenty RBC 24 hours protein quantified to be 2.3gms/day. Based on clinical and lab parameters, rapidly progressing renal failure was considered. Further testing of viral serology was negative. The serological tests of autoimmune diseases and vasculitis like ANA Anti-dsDNA MPO PR3 ANCAs and Anti GBM were inconclusive. C3 and C4 were within normal range. ESR was elevated (130 mm/hr); serum albumin and globulin were 2.4gm/dL and 3.8gm/dL respectively. Percutaneous kidney biopsy was done under USG guidance since there was no conclusive evidence. Kidney biopsy under light microscopy revealed severe glomerular ischemic changes including wrinkled and pseudo thickened capillaries. Moderate interstitial fibrosis and tubular atrophy was seen. Few arteries and arterioles reveal vessel wall fibrinoid necrosis and luminal thrombotic occlusion. Few atypical casts with brittle appearance and associated inflammatory reaction were noted. Under direct immunofluorescence, there was no significant glomerular staining. Few atypical casts were stained for kappa light chains with negativity for light chains. The biopsy was interpreted as renal TMA with moderate tubular atrophy and interstitial fibrosis.

METHODS: Based on kidney biopsy findings, evidence of ongoing peripheral hemolysis workup was done which was inconclusive. Renal limited TMA was considered and further workup in the form of ADAMTS13 activity level APLA complement levels and alternate complement pathway dysfunction cryoglobulins were done which came out to be normal. Since there is a rare association of TMA with myeloma, bone marrow biopsy was done which showed clonal plasmacytosis with 40% cells. Serum protein electrophoresis showed M Spike, and serum immunofixation revealed M Spike as IgG Kappa. During hospitalization hemodialysis was continued along with supportive management. After myeloma was confirmed 5 sessions of PLEX were given along with anti-myeloma treatment and dialysis. Following this the patient was discharged without further requirement of dialysis. After two months of discharge, the patient is doing well on antimyeloma treatment from hematology department with a baseline creatinine of 2.3 mg/dL.

RESULTS: MM accounts for 1% of neoplastic disease and 13% of hematological malignancies. Renal impairment occurs in 20% to 40% of patients with MM, and more than 80% have proteinuria (12). The mechanisms of kidney injury can be grouped into immunoglobulin-dependent and immunoglobulin-independent categories. The 3 most common forms of monoclonal immunoglobulin-mediated kidney disease are cast nephropathy, monoclonal immunoglobulin deposition disease, and AL amyloidosis. The other rare causes of kidney injury in MM are glomerulonephritis, tubulointerstitial nephritis, minimal change disease, IgA nephropathy, and hyperviscosity syndrome (13). Myelomas that produce only light chains are responsible for 40%–60% of severe myeloma-associated kidney injuries, reflecting the nephrotoxicity of the filtered light chains (13). TMA in myeloma is very rare. There are various mechanisms hypothesized (13); it can result from either direct Ig-induced endothelial injury, or IgG antibody against ADAMTS13 leading to thrombocytopenic thrombotic purpura. The pathogenesis of Ig-induced endothelial injury involves the light chains that are filtered through the glomerulus. They undergo chemical degradation and induce proinflammatory cytokines, such as IL-6 and IL-8. These light chains lead to formation of redox-sensitive transcription factor NF-ΰB and mitogen-activated protein kinase, which in turn results in inflammatory cell infiltration, matrix deposition, and fibrosis (14). Other suggested mechanisms of TMA are that systemic chemotherapy or stem cell transplantation can damage endothelium (15). There is one case report of the successful use of eculizumab in a patient with MM and TMA suggesting a complement-mediated mechanism that has not been investigated (16). Herrera GA et al. conducted an autopsy series of 77 MM patients out of which 10 cases were TMA, some after allogenic hematopoietic stem cell transplant (15). Yui J et al. reported 9 cases of TMA with MM of which, 4 patients had TMA as the initial presentation of MM, and 5 patients were on treatment, most often bortezomib-based regimens. Another study demonstrates that TMAs can occur in MM outside the context of allogenic hematopoietic stem cell transplant. In roughly one-third of patients, TMAs were the initial presentation of MM and improved with treatment (17). There are reported cases suggesting that an acquired von Willebrand factor disease might develop during MM (16, 18-20). In these patients, the suggested mechanism is the prevention of the interaction of GP1b with von Willebrand factor due to the paraproteins (16, 18-21). Another study reported renal function improvement after administration of a monoclonal antibody against C5 (eculizumab) in a post—bone marrow transplant MM patient (22). This leads to the hypothesis that complement or complement mediated factors can also be one of the causative factors of renal damage in MM patients. Little data are available to support this statement.

CONCLUSION: This is a unique case of myeloma presenting as TMA in the form of rapidly progressing renal failure requiring dialysis. Our patient doesn’t have evidence of peripheral hemolysis and has TMA limited to kidneys with normal complements and ADAMTS13 activity level. SPEP, SIFE, and bone marrow biopsy confirmed the diagnosis of multiple myeloma. The patient was successfully managed with antimyeloma therapy and PLEX based on some case studies (23). Eventually patient is doing well after 2 months of treatment without being dialysis dependent.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 273: AN UNUSUAL CASE OF POST RENAL TRANPLANT EARLY AMYLOIDOSIS

Tarun Kumar 1, Vinay Malhotra 1, Dhananjai Agarwal 1

BACKGROUND: Amyloidosis is a multisystem disease caused by extracellular deposits of an insoluble fibrillary precursor proteinaceous material. Renal presentation is generally varied. But de novo amyloidosis in renal transplant is a rare presentation

AIM OF THE STUDY: Amyloidosis is a multisystem disease caused by extracellular deposits of an insoluble fibrillary precursor proteinaceous material. Renal presentation are generally varied. But de novo Amyloidosis in renal transplant is a rare presentation which can increase the chance of graft dysfunction rejection morbidity and mortality. We report a case of 35-year-old ESRD due to stone disease who had live-related renal transplant from father. No induction was given and nadir creatinine reached on postop day 2. From day 3 onward, the serum creatinine started rising with decreased urine output. TAC level on day 4 was 5.02ng/ml. Graft biopsy was done on day 7 which was suggestive of renal amyloidosis with severe ATN and acute mixed rejection. Tissue for IF was negative for light chains. IHC for SAA was also found to be negative. Patient was managed with pulse steroids plasmapheresis and IVIG. ATG couldn’t be given due to hypersensitivity. Donor was reevaluated for amyloidosis including urine examination which was found to be negative. On further course, graft biopsy was repeated which reveal similar findings and patient deteriorated due to bilateral pneumonitis and expired on postop day 32. So our case is an unexplainable presentation in immediate post-renal transplant period

METHODS: Graft Biopsy Serum protein electrophoresis

RESULTS: Graft biopsy was done on day 7 which was suggestive of renal amyloidosis

CONCLUSION: Our case is an unexplainable presentation in immediate post-renal transplant period.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 274: RELEVANCE OF EVIDENCE BASED MEDICINE IN CURRENT ERA: UNEXPLAINED CASE OF DIGITAL ISCHEMIA AND GANGRENE

R Dadegal Vinay 1, M S Khanpet 1

BACKGROUND: Peripheral vascular disease affects nearly 10 million of the Indian population. It is also associated with decrease in functional capacity and quality of life and an increased risk of amputations. The underlying clinical conditions which present with features of peripheral limb ischemia are numerous. Since the differential diagnosis of the peripheral ischemia is vast, there are a multitude of clinical and lab tests available for diagnosis of the condition. This is further complicated by the numerous invasive and non-invasive imaging modalities available at the clinician’s disposal. The choice of the best modality of investigation or treatment needs to be individualized in each clinical scenario for optimal management of the patient.

AIM OF THE STUDY: Here we describe a case of 55-year-old male patient who developed gangrenous changes of digits of upper and lower limbs and in spite of all the available workup diagnosis could not be made.

METHODS: A 55-year-old male patient non-smoker with no past history of diabetes hypertension CAD CVA presented with history of left lower limb pain and swelling of 8 days duration. Soon after initiation of pain and swelling, there was also associated discoloration with blue/black color changes. On further reviewing patient gave history of consuming some antibiotic and painkillers from local hospital and came to us when symptoms persisted. The patient otherwise denied any Raynaud’s phenomenon skin tightening oral ulcerations genital ulceration chest pain shortness of breath abdominal pain hematuria ear pain sinus pain fevers chills night sweats or smoking history. No past history of COVID and vaccination. No significant family history. Pt hemodynamically stable all peripheral pulses felt. Local examination revealed swelling of left lower limb up to knee. Blackish discoloration of left foot up to ankle with ulcer of 3cm * 3cm at the plantar aspect of great toe. By 4th day patient started developing ischemic changes in opposite leg as well as in B/L upper limbs. He developed tingling numbness discoloration of skin and blebs formation. Skin biopsy was taken. After counseling patient was subjected for left below knee amputation after SDP transfusion. Amputated foot was sent for histopathological examination. Post-operative period was uneventful

RESULTS: Due to rapid progression of disease and no evidence of sepsis, immune-mediated disease was thought of, and patient was started on pulse methylprednisolone therapy 500 mg for 3 days. Following steroid initiation patient skin lesions did not progress further. Renal function and liver parameters normalized; Platelets normalized. Patient gradually improved with skin lesions disappearing. Patient was discharged with oral steroids plus anticoagulation. Initial lab reports showed Hb — 14.3, TLC- 8600, Platelets- 19000, ESR — 29, Creatinine — 2.07, T.Bil — 4.27, D.Bil-4.13, SGOT- 219, SGPT- 69, Serum Procalcitonin — 0.1, Urine Examination - no sediments, C3 — 83, Coagulation profile normal, Direct and Indirect Coombs test negative, Virals- neg, Blood cultures — negative 2D ECHO — Normal Homocysteine Levels — 6.53 Coombs Test Direct/Indirect — Neg ANA Profile- PM- SCL Borderline positive, Rest all negative ANCA Profile — Negative APLA Antibodies — Negative Protein C Activity - Normal Protein S Activity - Normal Antithrombin Activity — Normal Factor V Leiden Mutation — Not Detected Cryoglobulin antigens negative Histopathology of amputated limb - arteriosclerosis

CONCLUSION: We have presented atypical unexplained case of vasculitis in 55-year-old male patient. This is an original case report of particular interest wherein diagnosis was made clinically even though all the investigations returned normal. We were unable to find in the literature any other case of unexplained vasculitis

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 275: VARIED PRESENTATION OF ANTI-GLOMERULAR BASEMENT MEMBRANE DISEASE: A CASE SERIES

Gita Bipin Chandra 1, Manish Chaturvedy 1, Rajesh Jhorawat 1, Vikarn Vishwajeet 1, Ambar Khalwadekar Uday 1

BACKGROUND: Anti-glomerular basement membrane (GBM) antibody disease is a rare autoimmune disorder characterized by rapidly progressive glomerulonephritis caused by autoantibodies against the Î ± 3-chain of type IV collagen in the GBM. An uncommon disease which has bimodal age of presentation. Patients with dialysis-dependent renal failure have poor renal outcomes. Data regarding the clinical presentation and outcomes of anti-GBM disease are rare. This prospective study aimed at analyzing the clinical presentation and outcomes of the disease in 3 patients at a tertiary care hospital. All 3 patients were biopsy-proven anti-GBM disease (light microscopic examination showing crescents and immunofluorescence examination showing linear deposition of IgG) with or without positive anti-GBM antibodies in serum were included in the study and followed-up. All the patients were treated with steroids cyclophosphamide and plasma exchange. First patient had decreased urine output and hemoptysis. Second patient had similar presentation but was a pregnant female in third trimester showing adsorption effect of placenta probably. Third patient presented with only decreased urine output and his anti GBM titer was negative. All the three patients had rapid progressive glomerulonephritis. All progressed to end-stage renal disease despite adequate immunosuppressive treatment along with plasma exchange. Currently all three patients are on maintenance hemodialysis.

AIM OF THE STUDY: Case Series

METHODS: Case Series

RESULTS: Case Series

CONCLUSION: ANTI GBM DISEASE CARRIES POOR PROGNOSIS EVEN PROPER TREATMENT PROVIDED

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 276: SPECTRUM OF MYCHOPENOLIC ACID DILI IN RENAL TRANSPLANT PATIENTS

V Santosh Kumar 1, Manish Chaturvedy 1, Rajesh Jhorawat 1, Ashish Agarwal 1

BACKGROUND:

AIM OF THE STUDY: Mycophenolate sodium (MPA) is an immunosuppressive agent commonly used as an adjunctive agent to prevent and/or treat acute cellular rejection (ACR) in solid organ transplant recipients and as a therapeutic agent in non-transplanted patients with various diseases with immune dysregulation. Major adverse effects of MMF include bone marrow suppression gastrointestinal neurological symptoms and teratogenicity. Rare sporadic cases with MMF-related hepatotoxicity have been reported in the native livers of non-transplant patients and renal transplant recipients (1 2) We report 3 renal transplant patients who had developed acute hepatitis due to Mycophenolate sodium that resolved after discontinuing MPA.

METHODS: CASE 1: 31-year-old renal transplant recipient with mother being donor on triple immunosuppressants was found to have transaminitis on routine follow-up 3 months post-transplantation. Patient had been on tacrolimus 3 mg bd with MPA 720 mg bd along with oral steroids of 20 mg prednisolone. Patient was evaluated for the same and infective causes were ruled out including HBV, HCV, HIV, CMV, EBV. Imaging showed normal liver echotexture. A possibility of MPA-induced hepatitis was considered, and MPA dose was reduced and stopped following which hepatitis resolved, and MPA was restarted with reduced dose of 360 mg BD. CASE 2: A 21-year-old live-related renal transplant patient with mother as donor on triple immunosuppressant was found to have transaminitis 3 months post-renal transplantation during routine follow-up work-up for infections was negative USG imaging of liver and biliary tract was normal. Patient was cotrimoxazole and valganciclovir prophylaxis along with cyclosporine mycophenolic acid and prednisolone. A possibility of drug-induced liver injury was considered and MPA was discontinued following which transaminitis resolved suggesting a possibility of MPA induced liver injury CASE 3 : 49-year-old male underwent live unrelated renal transplant with wife as donor patient started developing increase in liver enzymes on POD1 reaching a peak on day 7 gastroenterologist opinion was obtained a possibility of either cotrimoxazole tacrolimus or MPA was considered as offending agents. Tac levels within expected range MPA were stopped, and liver enzymes started to reduce and attained normal levels by Day 12. MPA was restarted at reduced dose 360 mg twice day but SGOT/SGPT started to increase again Hence MPA was stopped and replaced with Azathioprine

RESULTS: Mycophenolic acid and its pro-drug form (MMF) are potent inhibitors of inosine monophosphate dehydrogenase (IMPDH), a rate-limiting enzyme of the de novo GTP biosynthesis. Lymphocytes depend on IMPDH activity for their proliferation and immune-related activity and therefore, are sensitive to IMPDH inhibitors. Among the immunosuppressants routinely used in post-renal transplant period, hepatoxicity has been reported regularly with usage calcineurin inhibitors and cotrimoxazole. MMF hepatotoxicity is thought to be rare (3,4). Rare cases have been reported in non-transplant patients treated with MMF. MMF is generally administered as 2—3 g/day in divided doses. However, some patients cannot tolerate the full dose. The incidence of adverse events is higher in patients treated with MMF 3 g/day compared to patients receiving MMF 2 g/day, suggesting a dose-dependent effect. (5) Common side effects include gastrointestinal upset, diarrhea, nausea, headache, fatigue, and dizziness. Uncommon but potentially severe adverse events include blood dyscrasias, gastrointestinal bleeding or ulceration, increased risk for lymphoma or other malignancies, increased risk for serious infections, and embryo-fetal toxicity. In the literature, although hepatotoxicity has not been reported, Sollinger et al.. documented elevated liver enzymes in several patients receiving MMF (6) Recognition of drug-induced liver injury (DILI) can be challenging because DILI displays diverse, often nonspecific laboratory and histopathologic changes. Rare cases with mycophenolate mofetil (MMF) hepatotoxicity have been reported in non-transplant and renal transplant patients. Serum enzyme elevations occur in a small proportion of patients on mycophenolate mofetil, but the abnormalities are usually mild, asymptomatic and resolve spontaneously or with dose reduction. A small number of cases of clinically apparent liver injury have been reported in patients on mycophenolate. The onset of injury is usually during the first month of therapy, and the pattern of serum enzyme elevations is hepatocellular or mixed. The liver injury is usually mild and self-limiting. Autoimmune and immunologic features are uncommon. Mechanism of liver injury: Mitochondria are cellular powerhouses and regenerate ATP from ADP through the oxidative phosphorylation system. Mitochondria also provide intermediate metabolites, which are critical for cellular functions and proliferation (7) and regulate cell functions via reactive oxygen species (ROS) generated during the oxidative phosphorylation process (8). Mitochondria also have an important role in cell death, which is triggered by mitochondrial membrane disruption and then apoptosis and/or necrosis of the cell (9). Recent evidence suggests that hepatotoxic drugs can cause mitochondrial dysfunction in the liver through diverse mechanisms, such as direct inhibition of mitochondrial respiration and beta oxidation and damage to mitochondrial DNA, mitochondrial transcripts, and mitochondrial protein synthesis. In our patients with MMF-related hepatotoxicity: other side effects such as infection, malignancy, gastrointestinal adverse effect, and myelosuppression did not develop. In the literature, to our knowledge, there was only one report about increased liver enzymes with the usage of MMF in RTRs. Most symptoms are either self-limiting or resolve with reducing the dose of MMF or changing the dosing interval. In clinical practice, MMF dose reductions, interruptions, or discontinuations are often undertaken because of gastrointestinal symptoms.[11] The impact of MMF dose changes on clinical outcome has been assessed in a few retrospective studies And, it was concluded that the overall incidence of acute rejections was significantly higher in patients with gastrointestinal adverse events and patients who underwent MMF dosage adjustments or discontinuations compared with those that did not suffer gastrointestinal adverse events.[12] Although hepatotoxicity was more prominent in the first 3 months, clinically overt acute rejection or loss of renal function did not develop for 2 years in our patients. But it can be important to reduce or withdraw MMF for rejection in some patients.

CONCLUSION: To evaluate the elevated liver enzymes in the first 3 months of renal transplantation, MMF-associated hepatotoxicity must be kept in mind before further investigations. Consequently, in the postrenal transplantation period, hepatotoxicity can occur for a lot of reasons including MMF usage. If hepatotoxicity related to MMF is not considered, especially in the early period, resolution of hepatotoxicity can be required long-term. We did not find a distinctive cause for elevated liver enzymes in our patients and liver enzymes did not return to normal values unless we reduced the dosage of MMF or withdraw it. Our results and the previously reported cases, in which withdrawal or reduction of MMF improved liver function, are supportive evidence that MMF hepatotoxicity occurring in a subset of MMF-treated patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 277: DISTAL RTA AS AN INITIAL PRESENTATION OF PRIMARY SJOGREN'S SYNDROME IN ADOLESCENCE

Nagma Nigar 1, M Aslam 1

BACKGROUND: Primary Sjogren’s syndrome is a multisystem autoimmune disorder characterized by lymphoplasmacytic infiltration of the exocrine glands leading to sicca symptoms (dry eye and dry mouth). It rarely affects children and adolescents. Renal involvement in primary Sjogren’s syndrome occurs in less than 10% of the cases. In this we discuss a case of a 15-year-old girl who presented with complaints of passage of stone like substances in her urine and eventually diagnosed as primary Sjogren’s syndrome. She was managed by oral potassium and alkali replacement therapy.

AIM OF THE STUDY: To discuss a rare case of primary Sjogren's syndrome in adolescence with distal RTA and medullary nephrocalcinosis

METHODS: IVU was performed through IV iodine based non-ionic contrast showed cluster of multiple tiny radio-opaque stone shadows in bilateral renal region suggesting medullary nephrocalcinosis. On the basis of normal anion gap metabolic acidosis hypokalemia positive urinary anion gap and an alkaline urinary pH a diagnosis of distal renal tubular acidosis was made. Serological tests were positive for Anti-nuclear antibody (ANA) and anti SSA/Ro antibody. However, her anti dsDNA anti-Smith antibody anti SSB/La antibody anti U1 RNP and RA factor were negative leading to a diagnosis of primary Sjogren's syndrome.

RESULTS: Patient was managed conservatively and started on syrup potassium citrate 20 mEq thrice daily and oral sodium bicarbonate of 500 mg twice daily, and an improvement in serum potassium and pH was observed.

CONCLUSIONS: Children and adolescent present with heterogenous clinical findings inconsistent with the classic presentation of the disease (sicca symptoms) and Sjogren’s syndrome is one of the causes of CKD in 4th to 6th decade of life. An early diagnosis and management can prevent potentially fatal sequelae. Our patient presented at a very early age with nephrocalcinosis and distal RTA with no other organ involvement seen in follow-up. Over a period of 2 years of follow-up after correction of systemic acidosis IVU findings showed improvement.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 278: CHARACTERISATION OF CHRONIC KIDNEY DISEASE OF UNKNOWN ORIGIN IN PATIENTS ATTENDING NEPHROLOGY OPD OF AIIMS NEW DELHI- A CROSS SECTIONAL STUDY

Indradip Maity 1

BACKGROUND: Chronic kidney disease (CKD) has emerged as global pandemic with reported prevalence of around 11—13%. While diabetes and hypertension are the top two causative factors worldwide CKD of unknown etiology (CKDu) is now a well recognized entity. It has been found to be clustered in certain hotspots in South Asia and Central America in screening studies. In India, it has been reported from predominantly rural areas in Southern India especially in those people who belong to agricultural background. We examined the prevalence and clinical profile of CKDu in patients seeking nephrology care in a tertiary care hospital in northern India

AIM OF THE STUDY: To characterize the clinical profile of patients with chronic kidney disease of unknown origin (CKDu)

METHODS: We assessed the outpatient records of all patients with CKD attending our renal clinic from January 2015 till June 2022. We examined data on clinical and laboratory parameters. Patients were labeled as CKDu based on a set of inclusion and exclusion criteria as follows: • Inclusion Criteria: 1. Patients with eGFR less than 60 ml/min/1.73 m2 by CKD-EPI formula and/or subnephrotic proteinuria <1 gm/day confirmed twice at least 3 months apart with bland urinary sediment. 2. No hypertension or if present controlled (<140/90mm of Hg) with single anti hypertensive agent. The duration of hypertension should be less than 3 years without any evidence of target organ damage on fundus or ECG evaluation. 3. Kidney biopsy was done when feasible to rule out other causes and evaluate histopathology of CKDu Exclusion Criteria: 1. Absence of diabetes (defined as self-reported history of diabetes on treatment fasting blood sugar more than 126 mg/dl or HbA1C>6.5%). 2. Bilateral normal or shrunken kidneys on ultrasound without any other structural abnormalities like obstruction polycystic kidneys CAKUT nephrolithiasis etc 3. Hematuria>5 RBC/hpf 4. Hypertension present for more than 3 years and/or requiring ≥2 anti-hypertensive drugs and/or evidence of any target organ damage 3. Any other causes of CKD like probable or proven glomerular diseases other tubulointerstitial diseases (e.g., granulomatous interstitial nephritis) etc. Presumed Chronic glomerulonephritis CGN was defined in any patient with proteinuria ≥1 gm with or without edema who could not be biopsied due to clinical contraindication(s). 4. Patients unwilling to give consent (for collection of biosamples for analysis for heavy metals).

RESULTS: A total of 29663 patients were screened out of which 370 (1.2%) were detected to have CKDu. Mean age was 41Â ± 14.7 years with predominantly male population 215 (58.1%). 158 (42.7%) of the patients had CKD stage 3, 89 (24.1%) in CKD stage 4, 84 (22.7%) in CKD stage 5 and 39 (10.5%) were dialysis dependent. Generalized weakness (216, 58.4%) was the predominant symptom, while 100 (27.0%) patients were asymptomatic. 273 (74%) patients belonged to urban area. Hypertension was present in 87 (23.5%) patients, Hypertension < 1 year was present in 19 (21.8%) patients and hypertension of 1-3 years was present in 68 (72.8%) patients. Mean hemoglobin concentration was 10.1Â ± 4.4 g/dL, mean uric acid level was 7.2Â ± 2.0 mg/dL, 62.7% patients had urine protein excretion of less than 0.5 gm / day while 37.2% patients had urine protein between 0.5-1gm/day. 65 patients had undergone kidney biopsy, of which 62 patients had chronic tubulointerstitial disease (CTID), and 3 had nonspecific changes of benign nephrosclerosis.

CONCLUSIONS: Using stringent diagnostic criteria, the prevalence of CKDu was low in our cohort of CKD patients. They were usually asymptomatic or had non-specific symptoms like weakness. CTID was the predominant histopathological finding

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 279: A RARE CAUSE OF ANURIA IN A POST RENAL TRANSPLANT PATIENT

P S Martin 1, Srinivasaprasad 1

BACKGROUND: Prophylactic double J (DJ) stent insertion has been adopted as a routine procedure in renal transplant patients for internal urinary diversion and for protecting ureteroneocystostomy anastomosis. Stents augment better urinary drainage but them causing obstructive uropathy is unheard of. Here we describe a case of distal stent migration causing anuria in a post-transplant patient.

AIM OF THE STUDY: Case Report

METHODS: Case Report

RESULTS: Case Report: 35-yr female had undergone an ABO incompatible (ABOi) live related renal transplant (LRRT) 4 weeks back. Desensitization protocol practiced in the institution was followed. Basiliximab was used as the induction agent. The graft had an accessory artery which was sutured with the main renal artery to convert it into a single vessel which was then anastomosed end to end with the right internal iliac artery in the recipient. A Double J (DJ) stent was kept in situ. She had undergone a transplant renal biopsy on post-transplant day 5 for rising creatinine and decreased urine output. It showed T-cell-mediated rejection (TCMR-2A) which was treated with methylprednisolone pulse for 5 days with which graft function improved. She was later discharged with a discharge creatinine on 1 mg/dL. Patient presented with sudden onset anuria after 28days from day of surgery. She had passed 4 liters of urine the previous day. There was no cough, breathlessness, fever, dysuria, or loose stools. Clinical examination showed BP of 140/90mmHg, pedal edema, and sacral edema. Bladder was not palpable and suprapubic area was resonant on percussion. A Foleys catheter was inserted but no urine was draining. Ultrasound with Doppler showed empty urinary bladder with Foleys bulb and distal end of DJ stent in situ. Transplant kidney showed normal arterial and venous flow. Doppler also showed DJ stent in the transplant ureter. Emergency Contrast-enhanced CT with excretory urogram was done. Plan CT images showed a sub capsular collection over the transplant kidney and also another complex collection in the pelvis. Excretory urogram showed minimal hydroureteronephrosis (HUN) of the transplant kidney with distally migrated, coiled upper end of DJ stent causing obstruction of the proximal transplant ureter. A diagnosis of obstructive uropathy due to migrated DJ stent was made. The subcapsular collection can be explained by the hematoma caused by the graft renal biopsy one on day 5 of surgery and the complex collection by the residual seroma left back after the drain removal. Fig 1: Distally migrated coiled upper end of DJ stent causing HUN of transplant kidney and ureter. Patient was posted for an emergency DJ stent removal. Cystoscopy showed distal end of DJ stent exiting the uretero-neo-cystostomy site. DJ stent was removed using cold cup forceps under visualization. The stent showed no features of encrustation. Patient started passing urine on table. She was shifted to ICU for monitoring. 1st 5 days post-procedure was complicated by severe post-obstructive diuresis with urine output ranging up to 9 liters per day. Patient was supported with oral and IV fluids with prophylactic potassium supplementation to prevent hypokalemia. Patient was discharged after 8days of hospitalization with a discharge creatinine of 1 mg/dL. Discussion DJ stents have been in use since 1967. They are widely used in the management of obstructive uropathy and for intraoperative identification of ureters (2). In renal transplant surgeries, a stent provides continuous decompression of the ureters and avoid anastomotic tension (3). It also prevents kinking of the ureter and compression of the ureter by edema or a perigraft fluid collection (4). They provide easy passage of urine across the anastomosis and prevent urine leaks at the uretero-neo-cystostomy site. The disadvantages of stenting in renal transplant surgeries are the risk of urinary tract infections and the need to remove the stent at a later date by cystoscopy. Minor complications include hematuria, flank pain, urinary frequency and suprapubic pain. Other complications include stent migration, stone formation, encrustation and stent fracture (5). Intravenacaval and intracardiac migration of DJ stents are also reported (2, 6). Stent migration is uncommon complication which occurs 2%-10% (5). Distal migration depends on the shape and stent material. Stents with a full coil are less prone to migrate than those with a J shape. Stent materials with great memory such as polyurethane are less prone for migration than those made of silicone (7). Stents never causes obstruction to urine flow because of multiple holes on its surface and also at its ends. The presence of the stent causes dilation of the overlying ureter and widens its lumen. But when the J end of the stent migrates into the ureter it can acquire various three dimensional configurations which could possibly obstruct the urinary flow. When this occurs, the only way to circumvent it is by removing the same. Fig 2: Surface of DJ stent showing holes for urine flow. To our knowledge, there are no reported cases of DJ stent causing obstructive uropathy in transplant kidney. This is a rare presentation which due to early recognition led to timely treatment. Post-obstructive diuresis can be dangerous especially in a transplanted kidney because of the risk of volume depletion, shock, prerenal AKI and hypokalemia. This requires dedicated patient monitoring with respect to urine output, volume replacement and potassium supplementation. References 1. Kumar R, Das CJ, Seenu V, Seth A. Percutaneous removal of impacted double J stent in a transplant kidney. Indian J Radiol Imaging. 2016;26(4):466-468. doi:10.4103/0971-3026.195787 2. Emily J Burns, Peter M Smith, Matthew Liew, Proximal migration of a ‘double J’ ureteric stent in a patient with a staghorn calculus, Journal of Surgical Case Reports, Volume 2020, Issue 12, December 2020, rjaa527 3. Laftavi MR, Chaudhry Q, Kohli R, et al.. The role of ureteral stents for all ureteroneocystostomies in kidney transplants. Int J Organ Transplant Med. 2011;2(2):66-74. 4. Necmettin Guvence, Kemal Oskay, Irfan Karabulut & Deniz Ayli (2009) Effects of Ureteral Stent on Urologic Complications in Renal Transplant Recipients: A Retrospective Study, Renal Failure, 31:10, 899-903 5. Sugiyama M, Fujimura M, Nakamori H, et al.. Repeated spontaneous migration of ureteral stent in hemiplegia patient during ureteral stone treatment. Urol Case Rep. 2019;24:100854. Published 2019 Feb 21. doi:10.1016/j.eucr.2019 6. Farshi AR, Roshandel MR. Farshi AR, et al. Can Urol Assoc J. 2015 Sep-Oct;9(9-10):E661-4. doi: 10.5489/cuaj.2884. Epub 2015 Sep 9. Can Urol Assoc J. 2015. 7. Ahallal Y, Khallouk A, El Fassi MJ, Farih MH. Risk factor analysis and management of ureteral double-j stent complications. Rev Urol. 2010;12(2-3):e147-e151.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 280: LUPUS VASCULOPATHY WITH DIFFUSE PROLIFERATIVE GLOMERULONEPHRITIS WITH A FAVOURABLE PROGNOSIS: A CASE REPORT

Rajaram Yadav 1, Om Kumar 1, Amresh Krishna 1, Pritpal Singh 1, Prem Shanker Patel 1

BACKGROUND: Lupus nephritis encompasses several patterns of renal disease; including glomerular tubulointerstitial and vascular pathologies. Lupus vasculopathy is non-inflammatory necrotizing vascular lesions in SLE and is characterized by immunoglobulin and complement deposition along arterioles and small arteries resulting in luminal narrowing. Very few cases of Lupus vasculopathy have been reported to date; mostly associated with poor prognosis and effective standard treatment is yet to be defined. Therefore, the accumulation of case reports of lupus vasculopathy is important.

AIM OF THE STUDY: To report a case of lupus vasculopathy with Diffuse Proliferative Glomerulonephritis with a favorable prognosis

METHODS: We report here a case of a 21-year-old female who presented to us with fever, bilateral lower limb swelling, alopecia, and arthralgia for 2 months. On physical examination, she was pale and had bilateral symmetrical lower limb pitting edema. Laboratory tests showed pancytopenia nephrotic -range proteinuria (3.8gm/24 hrs). On immunological work-up she was found positive for ANA Anti-U1-RNP and Anti-Sm. Anti-dsDNA MPO and PR3-ANCA and APLA antibodies were negative. She has been treated with Steroids & IV cyclophosphamide. Her serum creatinine remained stable while proteinuria decreased and extrarenal manifestations subsided gradually.

RESULTS: we are reporting a case of lupus vasculopathy with Diffuse Proliferative Glomerulonephritis in a 21-year young female. Although many case reports suggest it portends an unfavorable prognosis, commonly associated with Hypertension but in our case was normotensive and had a favorable prognosis

CONCLUSIONS: Patients with lupus vasculopathy have a variable clinical course and response to treatment. Accumulation of cases and more research work is needed to develop standard management guidelines for lupus vasculopathy

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO: 281: EARLY RECURRENCE OF C3 GLOMERULOPATHY

Kavish Sharma 1, Rakesh Gupta 1, Vinay Malhotra 1, Gigin 1, Arjun 1

BACKGROUND: C3 Glomerulonephritis is one of the most common causes of chronic kidney disease in children and young adults. Recurrence after transplant is common but occurs late in majority of the patient’s; here we present a case of early recurrence of C3 Glomarulonephrities.

AIM OF THE STUDY: find a rare early post-transplant recurrence of C3 glomerulopathy.

METHODS: case study

RESULTS: early recurrence of C3 glomerulopathy

CONCLUSIONS: C3 Glomerulopathy is a condition which has very high recurrence rate after renal transplant, but has rapid recurrence in our case is rare. C3 Glomerulopathy is a condition which has very high recurrence rate after renal transplant, but has rapid recurrence in our case is rare. C3 Glomerulopathy is a condition which has very high recurrence rate after renal transplant, but has rapid recurrence in our case is rare. C3 Glomerulopathy is a condition which has very high recurrence rate after renal transplant, but has rapid recurrence in our case is rare. C3 Glomerulopathy has very high recurrence rate after transplant, but early recurrence is rare as found in our case.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 282: HISTO-MORPHOLOGICAL AND GENETIC SPECTRUM OF DIFFUSE MESANGIAL SCLEROSIS: A DESCRIPTION OF 03 CASES

Varun Bajaj 1, Adarsh Barwad 1, Aditi Sinha 1, Pankaj Hari 1, Arvind Bagga 1, Amit Dinda 1, Geetika Singh 1

BACKGROUND: Diffuse mesangial sclerosis (DMS) is one of the histologic patterns recognized in the spectrum of podocytopathies with a strong genetic basis usually encountered in pediatric population. Underlying genetic defects frequented are Phospholipase Cï ¥1 (PLCE1) Wilms' Tumor-1 (WT-1) and Laminin ï ¢ 2(LAMB-2) genes. Recently mutations in Transient Potential Cation Channel 6 (TRPC-6) were demonstrated. Three recent cases in our files demonstrated the histological variation diagnostic dilemmas and variable underlying genetics of this lesion.

AIM OF THE STUDY: Describe morphologic and genetic diversity in DMS.

METHODS: Cases diagnosed as DMS spectrum were correlated with genetic studies and described.

RESULTS: 03 cases correlated with genetics

CONCLUSIONS: Morphologic finding of DMS is a manifestation of varied genetic mutations and we describe known (WT-1, PLCE-1) as well as a novel TRPC 6 mutation encountered at our institute. It is important to recognize the histologic heterogeneity of DMS by the nephropathologist and mandate genetic evaluation.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 283: COMPARISON OF SONOGRAPHICAL AND BIOIMPEDENCE SPECTROSCOPY METHODS TO ESTIMATE VOLUME STATUS IN MAINTENANCE HEMODIALYSIS PATIENTS AND ITS CORRELATION WITH CARDIAC OUTCOME: AN INTERIM ANALYSIS

Sutanay Bhattacharyya 1, Himansu Sekhar Mahapatra 1

BACKGROUND: Assessment of volume status is important in hemodialysis patients as both over hydration and fluid depletion is a risk factor for cardiac mortality and morbidity. However appropriate method to detect hydration status and hydration impact on cardiac status is inadequately studied.

AIM OF THE STUDY: In this 6 months follow-up study, we compared Inferior Vena Cava (IVC) Lung Ultrasound (LUS) and Bioimpedence Spectroscopy (BIS) for volume estimation in maintenance hemodialysis patients considering BIS as the gold standard. We also correlated fluid status of these patients with cardiac outcome.

METHODS: In this comparative prospective study in a tertiary hospital, normovolemic CKD patients more than 18 years on thrice weekly maintenance hemodialysis for at least 3 months underwent clinical examination IVC assessment Lung US and BIS pre- and post-HD at 0 3 and 6 months follow-up. IVC Collapsibility Index of ≥ 50% B lines on LUS of ≥15 and Over Hydration/Extra Cellular Water (OH/ECW) ratio of ≥15% were taken as cut off for Fluid Overload state. Echocardiography assessment (Ejection Fraction Left Atrial Volume and Left Ventricular Mass) was done prior to dialysis at 0 3 and 6 months. Heart failure ischemic heart disease including myocardial infarction stroke cardiac arrest and sudden cardiac death were recorded at 3 and 6 months. The current study is ongoing with an expected total sample size of 100. Statistical analysis was done using SPSS software version 25.

RESULTS:

CONCLUSIONS: Lung ultrasound can be an effective and simple alternative to bioimpedence in estimating hydration status in these patients. Fluid overload assessment in hemodialysis patients is important in planning an approximate target weight in such patients, thus subsequently lowering risk of cardiovascular events and mortality.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 284: SLE MASQUERADING AS CHOREA AND RHEUMATIC HEART DISEASE LATER MANIFESTING AS LUPUS NEPHRITIS - AN UNCOMMON PRESENTATION

Ambar Khalwadekar 1, Rajesh Jhorawat 1, Manish Chaturvedy 1, Nitin Bajpai 1, Gitabipin Chandra 1, Uttayan Chakrabarti 1

BACKGROUND: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown cause that can affect virtually any organ of the body. Immunologic abnormalities especially the production of a number of antinuclear antibodies (ANA) are a prominent feature of the disease which may be negative in initial part of disease. Although neuropsychiatric manifestations can be seen up to one-third patients chorea as the initial and sole presentation of lupus is quite rare. Valvular involvement in SLE and predilection for mitral valve can further confuse the picture and patients are labeled as having rheumatic heart disease and rheumatic chorea. Typical musculoskeletal dermatological or renal manifestations can present after much delay leading to misdiagnosis of underlying condition and loss of precious time. We report the case of a 21-year-old female who was diagnosed as a case of rheumatic chorea at the age of 9 years and rheumatic heart disease with mitral and tricuspid regurgitation a year prior to presentation. Extensive workup for her chorea including ANA Wilson’s thyroid MRI brain and EEG was negative. She presented to us as nephrotic-nephritic syndrome with renal dysfunction and active sediments in urine positive ANA titers and reduced complements and had class 4 lupus nephritis with crescents on biopsy. Patient was pulsed with methyl-prednisolone and cyclophosphamide was given but unfortunately had pneumonia and septic shock and succumbed. This case highlights the heterogeneity of clinical presentation of SLE and isolated clinical manifestations which must be viewed suspiciously and close follow-up done. ANA antibody testing done during her course of illness in the last ten years was twice negative including a negative extractable nuclear antigens done by Immunoblot. This also underlines need to do ANA testing by immunofluorescence to avoid having false negatives.

AIM OF THE STUDY: Case Report

METHODS: Case Report

RESULTS: Case Report

CONCLUSIONS: Case Report

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 285: RENAL ALLOGRAFT MUCORMYCOSIS: CASE REPORT AND REVIEW OF LITERATURE

Preeti Chaudhary 1, H S Mahapatra 1, B Muthukumar 1, Vipul Gupta 1

BACKGROUND: Mucormycosis of renal allograft is an extremely rare and rapidly fatal infection with incidence of 0.2-1.2%. Major predisposing risk factors are uncontrolled diabetes mellitus immunosuppression anti-rejection treatment unrelated donors and cytomegalovirus (CMV) infection.

AIM OF THE STUDY: Case report

METHODS: Case report

RESULTS: Case report

CONCLUSIONS: Though early suspicion and diagnosis, appropriate antifungal agents and graft nephrectomy may improve the patient outcome, the case fatality rate of renal graft mucormycosis still remains very high.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 286: AN UNUSUAL CASE OF CMV RETINITIS WITH INVASIVE PULMONARY ASPERGILLOSIS AND KLEBSIELLA PNEUMONIA IN A RENAL ALLOGRAFT RECIPIENT

Preeti Chaudhary 1, H S Mahapatra 1, B Muthukumar 1, Tanvi Thakker 1

BACKGROUND: Cytomegalovirus (CMV) remains the most common infection after kidney transplant. CMV retinitis is a rare manifestation of CMV invasive disease and is potentially threatening to vision in immunocompromised individuals. Invasive aspergillosis (IA) is one of the major causes of invasive fungal infection in kidney transplant recipients

AIM OF THE STUDY: Case Report

METHODS: Case Report

RESULTS: Case Report

CONCLUSIONS: CMV and IA are both uncommon opportunistic infections and simultaneous or superadded infection with bacterial pneumonia is very rare. In the presence of persistent symptoms, early suspicion of another infection is crucial in patient management and long term prognosis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 287: PROFILE OF NEWLY RECOGNIZED CHRONIC KIDNEY DISEASE FROM AN UNDER RESOURCED PART IN NORTH EASTERN INDIA- A SINGLE CENTRE STUDY

Shobhana Nayak Rao 1, Arpita Panchal 1

BACKGROUND: Chronic kidney disease (CKD) is a worldwide health problem affecting at least 10% of the world’s population. CKD represents especially a large burden in low to middle income countries that are ill equipped to deal with its consequences. Although diabetes and hypertension account for much of this burden of CKD, there are regions where a surprisingly high rate of CKD of undetermined etiology (CKD-U) has been described. Significantly in these regions, the mean age of the CKD population is younger and of lower socio-economic status thereby compounding the management of CKD.

AIM OF THE STUDY: We aimed to look at the incidence and etiology of newly diagnosed CKD in our center in this prospective study.

METHODS: In our prospective single-center observational cross-sectional study, we attempted to look at burden and etiology of CKD in a predominantly rural referral center. An observational registry was established to look at newly diagnosed CKD among new patients /referrals diagnosed with CKD over the previous 6 months. Data of all consecutive incident and prevalent adult patients (>18 yrs of age) with CKD as defined by the KDIGO criteria was entered prospectively into the registry. Demographic socioeconomic status occupation domicile address family history of CKD h/o tobacco use, etc. were collected. Mean (SD) was used to summarize continuous variables and proportions used to summarize categorical variables. We present our data collected from Oct 2021 to July 2022

RESULTS: In our prospective single-center observational cross-sectional study, we attempted to look at burden and etiology of CKD in a predominantly rural referral center. An observational registry was established to look at newly diagnosed CKD among new patients /referrals diagnosed with CKD over the previous 6 months. Data of all consecutive incident and prevalent adult patients (>18 yrs of age) with CKD as defined by the KDIGO criteria was entered prospectively into the registry. Demographic, socioeconomic status, occupation, domicile address, family history of CKD, h/o tobacco use, etc. were collected. Mean (SD) was used to summarize continuous variables and proportions used to summarize categorical variables. We present our data collected from Oct 2021 to July 2022

CONCLUSIONS: Our initial study of newly detected CKD patients brings to focus another new and possibly as yet unrecognized hotspot for CKD-U in the Indian subcontinent. Given the vast diversity of the population and variable delivery healthcare resources, we believe that concerted efforts should be made by governmental and other agencies to better understand the nature of this hidden CKD epidemic so that adequate preventative strategies can be envisaged.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 288: CLINICAL PROFILE HISTOPATHOLOGICAL SPECTRUM AND OUTCOME OF IGA NEPHROPATHY IN A TERTIARY HOSPITAL OF NORTHWEST INDIA

Tarun Kunar 1, Vinay Malhotra 1, Dhananjai Agarwal 1

BACKGROUND:

AIM OF THE STUDY: To study the IgA profile in a Tertiary Care hospital of Northwest India

METHODS: Retrospective

RESULTS:

CONCLUSIONS: In our study, we found that most IgAN cases were seen in second & third decade of life with male predominance !

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO: 289: PREVALENCE OF CKD MBD AND OSTEOPOROSIS IN CKD3-5D AND POST RENAL TRANSPLANT PATIENTS

Samridhi Goyal 1, Rajasekhar Chakravarthy 1, G Jyothsna 1

BACKGROUND: CKD is associated with mineral and bone disease and is a common complication. CKD MBD is also linked with high rates of morbidity and mortality. Bone loss and fractures are common. Compared with general population, fracture incidence rates are more than fourfold higher and associated with greater morbidity and mortality. Prevention of fractures thus becomes an important area for clinicians to work on. However most anti fracture agents are not studied in depth for patients with CKD MBD. Prospective studies have shown that measurement of BMD by dual-energy X-ray absorptiometry predicts incident fracture providing nephrologists the ability to risk classify patients for skeletal fragility and target antifracture strategies. Furthermore, an expanding body of literature and anecdotal evidence suggests that pharmacologic agents used to treat osteoporosis in the general population can be safely used in patients with CKD. WHO uses T Score to differentiate patients as normal possessing osteopenia or osteoporosis. A score of less than -2.5 is considered as osteoporosis. Clinically fracture associated with low trauma irrespective of BMD score is also considered as osteoporosis. Diagnosis of CKD-associated osteoporosis can be on the basis of the 2017 KDIGO guidelines which recommend measurement of BMD to assess fracture risk and/or clinical risk factors for osteoporosis. Fracture risk classification can be on the basis of the WHO T score because the four longitudinal studies that influenced the update reported that T scores performed similarly in patients with and without CKD.4 5 Additionally aging itself is associated with both reductions in GFR and increased prevalence of osteoporotic fractures. Literature suggests that patients with advanced stage CKD who do not yet require renal replacement therapy are also at an increased risk of fragility fracture. Screening and diagnosis of osteoporosis is done by using bone mineral density (BMD) measurement that estimates bone strength. Dual-energy X-ray absorptiometry (DXA) is the most widely used validated technique to measure BMD. DXA is an established clinical tool for identifying patients with and without prevalent fractures and for identifying those who are at an increased risk of incident fracture. As the exact prevalence of osteoporosis among chronic kidney disease patients is not known this study intends to find the prevalence of osteoporosis in CKD patients. Despite of high prevalence patients are not considered as candidates for BMD assessment or as a preventive treatment for osteoporosis despite being highly prevalent in treatment with steroids. Newer antiresorptive agent like Denosumab is not excreted renally and can be a safe alternative in such CKD patients hence understanding the prevalence of osteoporosis in this population to explore the potential candidates who could benefit from use of Denosumab to prevent fractures is worth studying.

AIM OF THE STUDY: The aim of the study prevalence of CKD MBD and osteoporosis in CKD3-5D and post-renal transplant patients.

METHODS: • Study design —cross-sectional observational single-center study. • Study area- Star hospital Banjara hills Hyderabad • Study population — Patients suffering from Chronic Kidney Disease and attending the nephrology clinic • Sample size — 92 patients Sample size (N) = 92 which was selected by the formula N = 4pq/D2 (p = 36 q = 100-p = 64; D = 10) Study duration: till completion of 92 patients INCLUSION CRITERIA: • Adult patients with chronic kidney diseases in stages 3 to 5. • Adult patients on maintenance hemodialysis and/ or peritoneal dialysis • Adult kidney transplant recipients. EXCLUSION CRITERIA: • Patients who are not willing to or not ready to give consent to participate • Patients already taking treatment for osteoporosis or previously treated. • Patients with acute kidney injury. • Patient age less than 18 years and pregnant patients. • Those having severe osteoarthritis those with surgical hardware/implants or scoliosis. Data collection method- • Patients suffering from Chronic Kidney Disease and attending the nephrology clinic with CKD stages 3—5 and patients on dialysis (HD/PD) will be included. • Patients with CKD 4-5D will be screened for CKD MBD (high or low turnover bone disease) and will undergo bone mineral density (BMD) measurement using DXA scan. • BMD will be measured at Lumbar spine and femur neck. • Patients will be evaluated for alkaline phosphates serum albumin calcium phosphorus and vitamin D intact parathyroid hormone (iPTH) to further classify them as low turnover or high turnover bone disease. • For male patients with age less than 50 years and pre-menopausal females, it’s prudent to use Z score which will be calculated as a default for all patients.

RESULTS:

CONCLUSIONS:

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 290: POST TRANSPLANT VARICELLA ZOSTER INFECTION MANAGEMENT: A CASE REPORT

Divyansh Agrawal 1, D Agarwal 1, R Gupta 1

BACKGROUND: Post-transplant infection

AIM OF THE STUDY: To easy early diagnosis

METHODS: Prospective case report

RESULTS: Patient diagnosed and treated

CONCLUSIONS: Atypical presentation needs to be diagnosed tely for better management

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 291: NUT-CRACKER SYNDROME: A CASE OF EXERTIONAL HEMATURIA, A CASE REPORT

Sukhwinder Singh Sangha 1, Bhupesh Saini 1, Aditya Jha 2, Amit Kishore 2, Saikat Bhattachargee 1

BACKGROUND: Hematuria in adults is commonly encountered in both Nephrology and Urology practice. The initial evaluation is focused on ruling out coagulopathy and trauma. The subsequent work up is aimed to differentiate between glomerular and non-glomerular hematuria.

AIM OF THE STUDY: Presence of dysmorphic RBC >25% in urine indicates presence of glomerular diseases which warrant a kidney biopsy for confirmation. However differential diagnosis of non-glomerular hematuria is diverse and include infection, calculi, neoplasms and cystic diseases of kidney. Here in, we describe an uncommon case presenting with non-glomerular hematuria which has both diagnostic and prognostic implications.

METHODS: A 20-year-old gentleman cadet presented with recurrent episodes of painless red colored urine following moderate exertion. This was not associated with fever, flank pain, dysuria, frequency of micturition or passage of gravel or stones. There was no history of trauma, ingestion of herbs, beet roots, drugs or alternate medication. Hematuria was episodic and used to disappear during periods of rest. On examination, the patient did not have hydrocele. However, mild flank tenderness was noted on left side.

RESULTS: Investigations revealed normal hematology, biochemistry, and coagulation parameters. Urine routine examination during periods of exertion showed reddish tinged clear urine with numerous isomorphic RBC on microscopic examination. However, the urine was negative for myoglobin, cast, sugar, or protein. 24-hour urinary protein excretion was 52 mg/day. Urine was reported as normal during periods of rest. Ultrasonography of kidney and urinary bladder regions was normal. Urology evaluation including Cystoscopy was normal. CT urography did not reveal any stone or growth. However, there was significant compression of left renal vein (LRV) between aorta and superior mesenteric artery (SMA) leading to positive beak sign. The angle between aorta and SMA was 26%, less than 35% being diagnostic. A diagnosis of Nutcracker syndrome (NCS) was offered, and patient was advised to avoid exertion. Patient was counseled about the likelihood of spontaneous improvement with weight gain and physical growth.

CONCLUSIONS: NCS is characterized by LRV entrapment syndrome and was first defined anatomically by Grant in 1937. It occurs as a result of compression of the LRV by the aorta and SMA. It is an uncommon disease and early diagnosis avoid extensive invasive and unnecessary investigation. The term NCS should be restricted to patients who present with the characteristic clinical signs and symptoms, specifically: hematuria, proteinuria, flank pain, pelvic congestion in females, and varicocele in male patients. Diagnosis of this condition is confirmed on radiological investigation. Treatment depends on the severity of symptoms, which varies from conservative approach to surgical approach. Surgery include minimally invasive and open surgical technique, specifically LRV transposition and auto transplantation. However, laparoscopic and endovascular techniques are preferred as it reduces short term postoperative morbidity. NCS generally has benign course; however, renal vein thrombosis and loss of renal function are possible complications. Treatment is required to control disabling symptoms and prevent damage to the kidneys from chronic renal vein thrombosis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 292: AN INTERESTING CASE OF POLYURIA

Bhavani 1, Nagarajan 1

BACKGROUND: 52-year-old male patient admitted with history snake bite 3 days back, he took treatment in nearby hospital in view of worsening renal failure

AIM OF THE STUDY:

METHODS: he took treatment in nearby hospital in view of worsening renal failure

RESULTS: During recovery phase, polyuria 6000-9000 ml/day persisted even after 10 days. patient was having postural hypotension Patient was not on diuretics, patient's urine osmolality was 103 mOsm/L, serum osmolality was 288 mOsm/L. Patient's cortisol was3.62 microgram/dl, TSH 0.208 miIU/ml, FT4 0.414 ng/dl, MRI brain with pituitary was normal, ct abdomen with adrenals were normal

CONCLUSIONS: Patient was started on I.V hydrocortisone later changed to T.Prednisolone5mg 2-0-0, T. Desmopressin 100mig1-0-0 increased to bd dosing, T.Thyroxine 100 mi g 1-0-0. After desmopressin initiation, there was more than 50% increase in urine osmolality and polyuria decreased confirming a diagnosis of central diabetes insipidus as a part of panhypopituitarism developed as a consequence of snake bite

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 293: A CASE OF OXALATE NEPHROPATHY WITH PROGRESSION TO END STAGE RENAL DISEASE: A CASE REPORT

Abhijit Chavan 1, Tushar Dighe 1, Charan Bale 1, Pavan Wakhare 1, Nilesh Shinde 1, Akshay Kulkarni 1, Shreeharsh Godbole 1, Chetan Phadke 1, Anuja Makan 1, Debapriya Saha 1, Atul Sajgure 1

BACKGROUND: Oxalate nephropathy is characterized by tubular deposition of calcium oxalate crystals due to either abnormal oxalate production or excretion. This is a case of oxalate nephropathy progressing to ESRD, presumed to be due to malabsorption syndrome.

AIM OF THE STUDY: To study a rare manifestation of oxalate nephropathy

METHODS: A 30-year-old male presented with increase in serum creatinine from 1.31 to 11.66 mg/dl over a period of 14 months. There was history of diarrhea associated with weight loss and reduced urine output. There was no history of renal calculus. Patient was taking diet containing spinach and lemon grass in excess quantities. Patient was vitally normal on presentation. Routine laboratory investigations showed normal values except for raised RFTs. Ultrasound of the abdomen was normal. His stool was positive for fat globules, but with stool culture- no growth, a normal colonoscopy study and no evidence of calcifications on contrast CT of the abdomen pelvis and a normal fundus examination. His autoimmune profile and multiple myeloma panel came to be normal. A kidney biopsy demonstrated 12 glomeruli of which six were globally sclerosed. The tubular interstitial compartment showed foci of tubular damage with predominant intraluminal deposition of translucent crystals. The deposits were strongly birefringent consistent with calcium oxalate crystals. The immunofluorescence was negative. Patient was kept on maintenance hemodialysis.

RESULTS: We present a rare manifestation of oxalate nephropathy progressing to ESRD, presumed to be associated with malabsorption syndrome.

CONCLUSION: This is a case of oxalate nephropathy leading to acute kidney injury and end-stage renal disease associated with malabsorption syndrome with excessive intake of oxalate-rich foods.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 294: COLON CANCER OR EXTRAPULMONARY TUBERCULSOSIS? – SOLVING THE DILEMNA IN A PATIENT WITH END STAGE RENAL DISEASE

Anuja Makan Atul Sajgure 1, Charan Bale 1, Pawan Wakhare 1, Nilesh Shinde 1, Akshay Kulkarni 1, Abhijit Chavan 1, Shreeharsh Godbole 1, Chetan Phadke 1, Debopriya Saha 1, Tushar Dighe 1

BACKGROUND: Intestinal tuberculosis (TB) is not common in patients with chronic kidney disease (CKD) stage 5. We report a case of intestinal tuberculosis with a clinical presentation similar to that of colon cancer in a patient of chronic kidney disease stage 5 on hemodialysis.

AIM OF THE STUDY: 47-year-old man presented with a 5-month history of generalized weakness, anorexia, and significant weight loss. He had been treated for stage 5 CKD for the last 5 years. Hemodialysis was initiated for suspected exacerbation of uremia. Patient underwent cuffed tunneled catheter insertion a month later and developed fever post-catheter insertion. In view of persisting fever, the catheter was removed and inserted on the contralateral side. However, the patient had persisting low-grade fever, night sweats, weight loss, and abdominal discomfort.

METHODS: We assimilated a comprehensive medical history, consisting of clinical symptoms and examination, along with laboratory parameters in view of Pyrexia of Unknown Origin (PUO).

RESULTS: Abdominal computed tomography and whole-body 18FDG positron emission tomography were indicative of colon cancer involving cecum, IC junction, and ascending colon with lymph node involvement. Colonoscopy with biopsy showed a circumferential mass with ulcerations and irregular margins in the ascending colon, which mimicked a colonic cancer. Microscopic examination demonstrated chronic granulomatous inflammation with Langhans giant cells consistent with colonic tuberculosis.

CONCLUSION: Based on the findings of this case, if PUO along with non-specific uremic symptoms persists in a patient with advanced CKD, the possibility of extrapulmonary TB must be considered.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 295: LUPUS NEPHRITIS PRESENTING AS EOSINOPHILIC ENTERITIS IN A YOUNG FEMALE: A CASE REPORT

Chetan U Phadke 1, Tushar Dighe 1

BACKGROUND: Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease which can present with different combinations of symptoms and also tends to mimic other medical conditions, thus making it difficult to diagnose without delay in most cases

AIM OF THE STUDY: Because of its wide variety of manifestations, SLE has been previously dubbed as the “great mimicker.”

METHODS: After obtaining a complete history of her symptoms and examination along with laboratory parameters.

RESULTS: A 33-year-old female presented to the OPD with complaints of abdominal pain and loose stools with vomiting. Patient was admitted and treatment for acute gastroenteritis was started. Patient had no relief of symptoms and was planned for colonoscopy. Colonoscopy was showing evidence of eosinophilic enteritis. Patient was found to have subnephrotic proteinuria and hence renal biopsy was done. Serological workup for autoantibodies supported the diagnosis of SLE. Kidney biopsy showed ISN-RPS Class 1 lupus nephritis. Treatment of the patient was initiated and gradual resolution of symptoms.

CONCLUSION: The case highlights the spectrum of symptoms with which SLE may present and the challenges it poses in the diagnosis.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 296: PERITONEAL MEMBRANE TRANSPORT CHARACTERISTICS IN CAPD POPULATION AS ASSESSED BY STANDARDIZED ABRIDGED PERITONEAL EQUILIBRATION TEST- STANDARD PET

Akshay R Kulkarni 1, Ashwini Sharma 1,2, Tushar Dighe 1, Akshay Kulkarni 1, Charan Bale 1, Pavan Wakhare 1, Nilesh Shinde 1, Abhijit Chavan 1, Shreeharsh Godbole 1, Chetan Phadke 1, Anuja Makan 1, Atul Sajgure 1

BACKGROUND: Indians by stature and body mass differ from Western population. This difference is likely to result in difference in peritoneal membrane transport characteristics (PMTC). In Indian subcontinental population, limited data is available about PMTC

AIM OF THE STUDY: Study aimed to determine peritoneal membrane transport characteristics (PMTC) in Indian population and to compare the data obtained with available international data.

METHODS: All adult patients with end-stage renal disease undergoing CAPD or APD were included. Blood and dialysate samples were collected at 0, 2, and 4 hours for PET. Plasma and dialysate glucose estimation by hexokinase method, urea by glutamate dehydrogenase (GLDH) urease method, creatinine by modified Jaffe reaction were analyzed.

RESULTS: The mean dialysate/plasma (D/P) creatinine at 4 hours was 0.72 ± 0.15. The mean dialysate glucose at 4 hours/dialysate glucose at 0 hour (D/Do) was 0.39 ± 0.11. The average dialysate glucose at 4 hours was 705.36 ± 234.78 mg/dl. Twenty-six (65%) patients in our study were average transporters. In comparison with the data obtained by Twardowski et al.1, there was no significant difference for patients categorized under high average & low average transporters. A blood urea nitrogen clearance of 55.98 ± 16.15 and a creatinine clearance of 57.19 ± 30.08 was obtained in present study. The creatinine clearance values and PET results showed a linear correlation. The D/P Creatinine 4 hours correlated positively with the creatinine clearance (r = 0.36, p = 0.021) while the D/D0 glucose and the dialysate glucose at 4 hours correlated negatively (r = -0.056, p = 0.749 and r = -0.004, p = 0.981) with the creatinine clearance, showing trend in accordance with expected findings.

CONCLUSION:

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 297: ACUTE KIDNEY INJURY WITH LYMPHATIC FILARIASIS IN A KIDNEY TRANSPLANT RECIPIENT: A CASE REPORT

Shreeharsh Godbole 1, Charan Bale 1, Atul Sajgure 1, Pavan Wakhare 1, Nilesh Shinde 1, Akshay Kulkarni 1, Abhijit Chavan 1, Chetan Phadke 1, Anuja Makan 1, Debapriya Saha 1, Tushar Dighe 1

BACKGROUND: Parasitic infections post-Kidney transplant are not much studied and are associated with unfavorable outcomes in terms of patient morbidity and mortality. Post-Kidney transplant parasitic infections occur by a) acquisition of the parasite at the time of transplantation-donor derived (either with the allograft or with blood products), b) post-transplantation period, through the traditional route of infection or c) reactivation of a dormant infection due to use of immunosuppressive medications.

AIM OF THE STUDY: To study the manifestation of lymphatic filariasis in organ transplant recipients in an endemic country like India

METHODS: A 32/male live-related renal allograft recipient, with baseline creatinine of 1.2 mg/dL and on maintenance immunosuppression presented one year post-transplant with fever, vomiting, loose stools and decreased urine output right leg swelling, pain and redness. His complete blood count was suggestive of thrombocytopenia and Eosinophilia with urine protein 2+. A peripheral smear taken at 12 midnight showed presence of microfilaria with positive serum filarial antigen and he was started on DEC for 14 days along with immunosuppressive therapy.

RESULTS: Acute kidney injury associated with post-transplant infections can mask subtle signs of infection which can be misinterpreted as acute allograft rejection.

CONCLUSION: An awareness of sequelae of parasitic infections, investigations, and its treatment strategies is crucial, as organ donation by donors from endemic areas has been on the rise. For transplant recipients residing in endemic areas and considering clinical condition, screening of donors and recipients in pre-operative evaluation and monitoring post-transplant should be considered.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 298: TO EVALUATE THE PREDICTIVE ABILITY OF BIOMARKERS FOR MAJOR ADVERSE KIDNEY EVENTS AT DAY 30 IN CRITICALLY ILL CIRRHOTIC PATIENTS

Madhuri Kashyap 1, Smita Divyaveer 1, Madhumita Premkumar 1, Madhuri Kashyap 1, Kushal Kekan 1, Kamal Kajal 1, Deepy Zohmangaihi 1, Manish Verma 1, Ravjit Singh Jassal 1, Imran Rather 1, H S Kohli 1

BACKGROUND: To evaluate the predictive ability of biomarkers for major adverse kidney events at day 30 in critically ill cirrhotic patients

AIM OF THE STUDY: The objective of the study is to identify whether plasma KIM 1, NGAL, and Cystatin Care associated with MAKE 30, i.e., outcomes of major adverse kidney events. Make 30 is defined as the occurrence of either rise of creat > 40%, requirement of dialysis, death at day 30

METHODS: All cirrhotic patients with critical illness admitted to intensive care unit were screened. Clinical data of enrolled patients was recorded and plasma baseline samples of patients were collected. Patients were followed up for 30 days, and outcomes at 30 days were recorded. Achievement of either of MAKE 30 was considered a positive outcome. Biomarkers were tested by ELISA technique. Statistical analysis was done by multi-variate analysis. The OR and CI 95% values maintained for KIM 1, NGAL and Cystatin C were 0.6, 0.3-1.2; 1.0, 0.9-1.0; 1.0, 1.0, 0.9-1.0 respectively.

RESULTS: Total of 70 patients were analyzed. Following are the cirrhosis etiologies and their respective frequency: Hepatitis C: 4; Hepatitis B: 6; Alcoholic Hepatitis: 38; NAFLD/NASH: 14; malignancy: 7; sepsis: 10; others: 29. 8 patients solely exhibited other conditions, whereas 28 patients had overlapping conditions. AKI developed in 37 patients. Total of 55 patients developed any of MAKE 30 and 15 had no MAKE 30. Also, individual components of make 30 were recorded. Number of patients declared dead at 30 days were 52. 3 patients showed dialysis requirement. 25 events with rise in creatinine > 40% were observed. The known number of patients on ventilator was 1 as against 23 at baseline. The number of patients on vasopressor support was 24.

CONCLUSION: The main component of make 30 driving the outcome was death. The association of the kidney biomarkers KIM 1, NGAL, Cystatin C with MAKE 30 was not found to be statistically significant. Studies with larger number and testing of biomarkers at the earliest possible time, even before admission to ICU may establish whether the biomarkers have utility in predicting outcomes.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 299: EPIDEMIOLOGY AND OUTCOMES OF EXTRA-PULMONARY FUNGAL INFECTIONS AMONG RENAL TRANSPLANT RECIPIENTS (A TERTIARY CARE EXPERIENCE)

Abdullah 1, A Kaul 1, N Prasad 1, D S Bhadauria 1, M R Behera 1

BACKGROUND: With the advances in post-transplant care leading to improved kidney graft and patient survival, the incidence of fungal infections has also increased. The published data regarding extrapulmonary fungal infection is few and lacking. The aim is to study the clinical profile, etiology, risk factors, treatment, and outcome of extrapulmonary fungal infections in kidney transplant recipients.

AIM OF THE STUDY: This is a 15-year retrospective observational study from January 2007 to December 2021 conducted at Sanjay Gandhi Postgraduate Institute of Medical Sciences, wherein kidney transplant recipients with extrapulmonary fungal infection were included and followed.

METHODS:

RESULTS: Extrapulmonary fungal infections were diagnosed in 103 of 1,649 recipients (6.3%) with mean age of 44.56 years. Mean duration of acquiring infection posttransplant was 35.68 months, and mean serum creatinine at presentation was 2.00 mg/dL. Majority of donors were living related (n = 100). Ninety-seven transplants were ABO-compatible, whereas six were ABO-incompatible. Forty-six patients received basiliximab induction, 18 received thymoglobulin, one received daclizumab, whereas 35 did not receive any induction. Most common extrapulmonary fungal infection was phaeohyphomycosis (37.9%; 37 subcutaneous, one nasal, one CNS), followed by candidiasis (27.2%; 23 GI, one subcutaneous, one graft, three others) and cryptococcosis (18.5%; 18 CNS, one disseminated). Five patients (4.9%) had evidence of dual fungal infections. Diabetes mellitus (53.9%), CMV infection (9.7%), antirejection therapy (43.7%), hepatitis C (6.8%), and hepatitis B (7.8%) were risk factors identified. The immediate patient outcomes were nine death (8.7%), three discharge against medical advice (2.9%), and 78 normal discharge (75.7%). Thirty-nine patients (37.9%) had evidence of graft dysfunction, but only four (3.9%) had graft loss. During long-term follow-up, 12 patients (11.7%) had graft loss and 29 patients (28.2%) died. Further, 23 patients (22.3%) were lost to follow-up.

CONCLUSION: Extrapulmonary fungal infection may range from benign lesions like phaeohyphomycosis to fatal cryptococcal meningitis. Prevention, early diagnosis, and appropriate management are necessary to improve their prognosis and quality of life.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 300: NOCARDIA INFECTION IN KIDNEY TRANSPLANT RECIPIENTS: A TERTIARY CENTER EXPERIENCE

Abdullah 1, A Kaul 1, N Prasad 1, D S Bhadauria 1, M R Behera 1

BACKGROUND: Kidney transplant recipients are at increased risk of opportunistic infections, including Nocardia. The incidence of Nocardia infection in kidney transplant recipients is found to be 0.4-1.3%.

AIM OF THE STUDY: The data on Nocardia infection in kidney transplant recipients remains limited.

METHODS: This is a 10-year retrospective observational study from January 2012 to December 2021 conducted at Sanjay Gandhi Postgraduate Institute of Medical Sciences, wherein all kidney transplant recipients with Nocardia infection were included and followed.

RESULTS: 11 patients (0.9%) had a Nocardia infection. All were living donor kidney transplant recipients, and the mean age at the time of diagnosis was 52.3 ± 11.9 years. Nocardia infection occurred at a median of 26 months (range 4-235) after transplant, with four of the cases within one year. Breakthrough Nocardia infection occurred in 4 patients receiving daily single strength (80/400mg) cotrimoxazole as prophylaxis. The most common site involved was the lung (n = 8), followed by disseminated disease (n = 3). The risk factors associated with Nocardia included age >60 years (n = 4), history of second transplant (n = 1), history of rejection (n = 4), treatment with thymoglobulin (n = 2), and high calcineurin inhibitor trough levels in the month before diagnosis (n = 3). Diagnosis was made by sputum culture (n = 4), bronchoalveolar lavage (n = 3), tissue biopsy (n = 3), and pus culture (n = 1). Modified ZN staining was positive in all cases and culture was positive in 9 out of 11 cases. Cotrimoxazole was resistant in 6 out of 9 cases. All cultures were sensitive to amikacin, imipenem, and linezolid. Antibiotic combination therapy was used in most cases. All-cause mortality at 12 months was 36.4% (4 out of 11) with 9.1% Nocardia-related mortality

CONCLUSION: Nocardia infection incidence was 0.9%, but it has a significant morbidity and mortality. Cotrimoxazole was found to be resistant in more than half of the patients.

Indian J Nephrol. 2022 Dec;32(Suppl 1):S19–S166.

ABSTRACT NO. 301: DEVELOPMENT AND VALIDATION OF A PREDICTION SCORE SYSTEM IN CRESCENTIC GLOMERULONEPHRITIS FROM A SINGLE TERTIARY CARE RENAL CENTER

S Basavaraj 1, Dharmendra Badhauria 1, Narayan Prasad 1, Anupama Kaul 1, Manas Ranjan Patel 1, Manas Ranjan Behera 1, Ravi Kushwaha 1, Monica Yachha 1, Manoj Jain 1

BACKGROUND: The risk assessment for developing end-stage renal disease (ESRD) and or death remains a major challenge in patients with Crescentic Glomerulonephritis (CrGN). This study aimed to identify the predictors and to develop and validate a prediction score for estimating risk of ESRD and or death in patients with CrGN.

AIM OF THE STUDY: Retrospective observational study of 340 patients with biopsy-proven CrGN from January 2010 to December 2021. Patients were randomly divided into derivation cohort (n = 242) and validation cohort (n = 98). The risk factors for developing ESRD and or death were evaluated using a binary logistic regression. And variables were selected using backward stepwise (likelihood ratio) method. An equation was obtained using the Log (y) = b0 + b1x1 + b2x2 + b3x3 . . . and predicted value = ey/1+ey.

METHODS: A calculator was created in Microsoft Excel spreadsheet using this equation. With this, P cut-off values were calculated for all patients in validation cohort, and same was tested with AUC using ROC analysis.

RESULTS: Of the 340 cases identified, 154 (45.3%) were men, with an average mean age of 38.5 ± 16.6 (SD) years at kidney biopsy. The significant risk factors predicting ESRD and or death were oliguria, hypertension, interstitial fibrosis, and tubular atrophy (IFTA), Anti-GBM disease and s.creatinine at presentation, which were included in the final prediction model. The prediction model was validated in the validation cohort with AUC of 0.863 (0.79-0.935) with 86% specificity and 76% sensitivity at cut-off value of 0.409.

CONCLUSION: This study developed and validated a new prediction score system using five clinical and pathological risk factors for developing ESRD and or death in patients with CrGN.

Articles from Indian Journal of Nephrology are provided here courtesy of Scientific Scholar

RESOURCES