Immunoglobulin A Nephropathy Presenting in Young Adults as Advanced Chronic Kidney Disease and Posttransplant Early Recurrence: A Case Series.

Immunoglobulin A nephropathy (IgAN) is the most common glomerular disease, leading to chronic kidney disease. The disease is characterized by microscopic hematuria, gross episodic hematuria, hypertension, and subnephrotic proteinuria with or without renal function impairment. It affects individuals of all age groups, commonly seen in 10-40 years of age. It is progressive in nature and leads to chronic kidney disease, necessitating renal replacement therapy. This case series of in a tertiary care hospital in Western India highlights the presentation of this disease in young adults, its aggressive course, its rapid progression, and its early recurrence in the posttransplant period. It also summarizes the treatment recommendations for IgA recurrence in kidney recipients. The disease is known to have a high chance of posttransplant recurrence. Optimizing renin-angiotensin-aldosterone system (RAAS) blockade, blood pressure control, and increasing immunosuppression in rapidly deteriorating cases are the strategies recommended to treat IgA recurrence in kidney transplant recipients.

Acute Kidney Injury in COVID-19: Clinical Profile and Outcome.

Introduction: Acute kidney injury (AKI) can be a severe complication of the coronavirus 2019 (COVID-19) infection. Follow-up data of these AKI patients, including the rate of progression to chronic kidney disease (CKD), is limited. Methods: COVID-19 patients with AKI, admitted from June 1, 2020, to August 25, 2020, were enrolled prospectively. Their clinical profile, biochemical investigations, urine analysis, treatment, and outcome in terms of mortality or discharge were analyzed. The discharged patients were followed up 3 months later to determine their renal recovery status. Results: AKI was noted in 146 out of 4,613 COVID-19 patients with an incidence of 3.16%. The outcome was available for 111 patients. According to the KDIGO (Kidney Disease Improving Global Outcomes) AKI criteria, 20 (18%) patients were in Stage 1, 16 (14%) in Stage 2, and 75 (68%) in Stage 3 AKI. Proteinuria and hematuria were present in 66% and 41%, respectively. Renal replacement therapy (RRT) was required in 45 (40.5%) patients. A total of 53 (47.7%) patients turned RT-PCR negative and were discharged. The renal recovery at discharge was complete in 31 of 111 (28%), partial in 20 of 111 (18%), and none in two (2%) patients. At 3 months follow-up of discharged patients, total mortality rate was 55.85%. Twenty three of 53 (43%) recovered their renal functions to baseline and 26 of 53 (49%) had progressed to CKD. Diabetes mellitus, dyspnea, altered sensorium, severe acute respiratory distress syndrome, need for RRT, lymphopenia, high neutrophil-lymphocyte ratio, hyperglycemia, raised inflammatory markers, and hematuria were associated with high mortality rate and reached statistical significance. Conclusion: AKI in COVID-19 patients has a high mortality rate (55.85%) with a high CKD progression rate among survivors (49%).

Clinical Profile and Outcome of Hemodialysis Patients with SARS COV2 Infection in a Tertiary Care Centre in Mumbai, India.

INTRODUCTION: CKD5D is a high risk subgroup with high comorbidity burden, need for frequent visits to dialysis centre and a compromised immune system. The effect of SARS COV2 virus on this population is not well known. METHODS: This prospective study enrolled, all CKD5D with COVID 19 infection, admitted to our hospital, from 23rd April to 30th June 2020 & whose outcome as discharge/mortality was known. Their clinical profile, investigations, treatment and outcome in terms of mortality or discharge after clearing infection was noted and analysed. RESULTS: Total 203 dialysis patients with COVID 19 were referred to our institute. Of these total, 131 were analysed. Median age was 50 years (19-80 years) with 57% were males. Hypertension (76%) was the commonest comorbidity followed by diabetes (29%) and coronary artery disease (22%). Dyspnoea, fever and cough were present in 50%, 40%, and 33% patients respectively. 26% were asymptomatic. None had dialyser clotting. Mortality was 20.6%. Time to turn RT PCR negative was 14 days (3-40 days). Comparing deceased vs survivors: Age [56 vs 49 yrs], diabetes [56% vs 22%], duration of symptoms at admission [5 vs 4 days], dyspnea [85% vs 40%] and encephalopathy [30% vs 1%] at admission, bilateral opacities on Chest X ray [93% vs 20%] and high leucocyte count [11,059 ± 5,929 vs 7,022 ± 2,935/cmm] were statistically significant variables associated with mortality. CONCLUSION: Asymptomatic group was 26% of the total CKD5D with COVID 19 infection population analysed. Mortality was 20.61%. Higher age, later presentation to hospital, diabetes, dyspnoea, & encephalopathy at presentation, bilateral opacities on Chest X- Ray & higher leukocyte counts were significantly associated with mortality.

Renal and Hepatic Outcomes after Remdesivir Therapy in Coronavirus Disease-2019-Positive Patients with Renal Dysfunction at Baseline or after Starting Therapy.

We aimed to study the effect of remdesivir therapy on renal and hepatic function in coronavirus disease-2019 (COVID-19) patients with renal dysfunction at baseline or after starting therapy and identify the factors, if any, related to the efficacy of remdesivir therapy on patient outcome. Patients included in the study were those who met all the following criteria irrespective of baseline glomerular filtration rate [including those already on maintenance hemodialysis (HD)] or baseline deranged liver function test. (1) Age >18 years, (2) COVID-19 reverse transcriptase-polymerase chain reaction positive, (3) Meeting criteria for administration of remdesivir - [any one of the following: (a) COVID-19 pneumonia with respiratory rate >30/min or SPO2<94% on room air, (b) Acute respiratory distress syndrome (ARDS)]. (4) Renal dysfunction at baseline, during or within 48 h of completion of therapy. Thirty-four patients had renal dysfunction at baseline or developed it after remdesivir therapy - 16 were acute kidney injury (AKI), 10 chronic kidney diseases (CKD), four CKD stage 5D, and four were postrenal transplant. The overall mortality was 18/34 (52.9%). Eight out of 30 (26.66%) needed HD during or after therapy and of these, 15 died and among 15 survivors, 14 returned to their baseline renal function after cessation of therapy, one patient is still dialysis dependent. In the dialysis-dependent CKD (n = 4) subgroup, three died and one was discharged. In the postrenal transplant (n = 4) group, all developed AKI during or after the completion of therapy. None required HD, two returned to their baseline renal function, and two died. Only five had alanine aminotransferase elevation (×1 upper limit of normal) during or within 48 h of completion of therapy - three died and two returned to baseline. Lower PaO2/FiO2 (severe ARDS) (P = 0.0001), higher C-reactive protein (P = 0.022), higher serum lactate dehydrogenase (P = 0.038), and duration of symptoms before starting therapy (P = 0.05) were statistically significant variables at baseline associated with higher mortality. Remdesivir can be tried in moderate-to-severe COVID-19 cases with renal dysfunction as a complete recovery of renal function was noted in survivors. However, larger and well-controlled studies evaluating its safety and efficacy in patients with AKI and CKD are needed.

Idiopathic Systemic Capillary Leak Syndrome.

Idiopathic systemic capillary leak syndrome (ISCLS) is a very rare life-threatening disorder characterized by recurrent episodes of hypotension, hemoconcentration, and hypoalbuminemia. It is caused by transient endothelial dysfunction, leading to plasma leakage from intravascular to interstitial space. Here, we report a case of ISCLS with recurrent episodes of capillary leak which required a long-term prophylaxis with beta-2 adrenergic receptor agonist and theophylline. Although ISCLS is the rare entity, associated morbidity and mortality require physician's awareness to provide timely therapy. Under-recognition in the medical community and rarity of this syndrome has precluded analysis in rational clinical trial designs that are necessary to determine targeted and adequate therapy. This report is meant to enhance awareness of ISCLS among physician's community.