Early versus Late acute graft pyelonephritis: A retrospective analysis of graft and patient outcomes.

BACKGROUND: Acute graft pyelonephritis (AGPN) is thought to affect graft and patient survival among renal transplant recipients. The objective was to compare outcomes among early AGPN (< 6 months from transplant) versus late AGPN (> 6 months from transplant). METHODS: This retrospective study analyzed 150 patients with AGPN dividing them into early and late AGPN from 2008 to 2016. Predictors of graft loss and mortality were compared using logistic regression analysis. Graft survival and patient survival were analyzed using Kaplan-Meyer survival plots. RESULTS: 55.3% (n = 83) had early AGPN and 44.7% (n = 67) had late AGPN. In early AGPN group, 13.3% had CMV disease on follow up compared to 3% in late AGPN group (p < 0.05). 26.5% had history of prolonged Foley's catheterization (> 5 days), 38.6% had prolonged DJ stent in-situ (> 2 weeks) following transplant surgery in the early AGPN compared to 7.5% and 19.4% respectively in the late AGPN group (p < 0.05). Recurrent GPN was more common in the late AGPN group - (35.8% versus 18.1%). Presence of renal abscess was predictive of graft loss in Univariate analysis (HR-6.12, p < 0.004). There was decreased death censored graft survival in the early AGPN group (p-0.035) with no significant difference in patient survival among the two groups. CONCLUSION: Occurrence of early AGPN had a significant impact on long term graft survival in renal transplant recipients with no significant effect on patient survival. This study underlines the paramount importance of the prevention of UTIs in renal transplant recipients.

Psycho-social health and quality of life among kidney donors following transplantation.

INTRODUCTION: Living kidney donation is a complex psychological experience for donors. The present study examined the psychosocial impact of kidney donation on donors. METHODS: The retrospective study included 506 donors who donated a kidney between 2010 and 2018 at a transplant centre in India. These donors responded via a donor insight questionnaire about their hospital anxiety, and their possible level of depression. The information included socio-demographic form with multiple information. The health survey was used periodically evaluate the psychosocial impact among donors following donation, including the transplant outcomes. RESULTS: The majority of donors were females (79.4%). There was a significant improvement in the quality of life among donors (SF-36) following the donation of a kidney, especially among those donors who maintained good graft functions themselves as well as those who were informed about good kidney function in transplanted recipients. These donors showed a lesser degree of depressive and anxiety scores (HAD score 3.5 and BDI II 4.8) than donors who had problems themselves and/or whose donated kidneys did not function well. Most living donors (89.1%) felt that the act of donation had a positive impact on their lives and those donors would encourage others to donate a kidney. Overall, the graft outcomes impacted the donor's state of mind. CONCLUSION: The study showed a very positive impact of the acknowledgment of the donor by the recipient, especially those donors whose kidney transplants were well functioning. The state of depression, anxiety, and psycho-social outcomes correlated with the graft outcomes. Donors showed positive insight towards donation, with inner conscience still conclusively willing to donate and encourage others.

Clinical profile and outcomes of De novo posttransplant thrombotic microangiopathy.

Thrombotic microangiopathy (TMA) after kidney transplant is rather uncommon but an important reversible cause of graft loss. This retrospective study of biopsy-proven posttransplant TMA was done to identify the important etiological factors, clinical features, and outcomes of post transplant TMA in a tertiary care referral hospital in northern India. This retrospective study was conducted among all renal transplant recipients who presented with graft dysfunction between 1989 and 2015. All the cases were looked for their etiology, clinical course, treatment modalities, and renal outcomes. The study was conducted in accord with prevailing ethical principles and reviewed by our own institutional review board. Seventeen patients out of 2000 (0.008%) transplants done during the study period had posttransplant TMA, out of which all the patients had de novo TMA, and the median time of presentation after transplantation was four months. Systemic TMA was noted in only four patients. Biopsy revealed associated rejection in five patients and associated calcineurin inhibitor (CNI) toxicity in 12 patients. Patients with TMA due to CNI toxicity were managed with CNI reduction or switching to alternate CNI or mammalian target of rapamycin inhibitors. In addition, antithymocyte globulin and plasma exchange were used in rejection-associated TMA. While four out of 12 patients (33%) in CNI-related TMA developed end-stage renal disease (ESRD), all patients in rejection-associated TMA developed ESRD. The overall one-year graft survival was 47%, whereas five- and 10-year survival was 35%. There was no significant difference in graft survival between localized and systemic TMAs (P = 0.4). Posttransplant TMA should be suspected even if there are no systemic features of hemolysis and early graft biopsy and prompt action is needed. The occurrence of TMA in the setting of rejection is associated with grave prognosis.

G6PD deficiency is not an uncommon cause of pigment nephropathy.

Acute kidney injury (AKI) with evidence of hemolysis is associated with tropical infections. However, pigment-induced AKI can happen with relatively uncommon genetic causes of hemolytic anemia, i.e., glucose 6-phosphate deficiency (G6PD). We share our experience of three such patients whose clinical presentation was similar to jaundice, AKI with hemolysis with suspicion of thrombotic microangiopathy. On evaluation, all had a history of usage of anti-malarial and with G6PD estimation revealing deficient status even during the episode while other tests such as Coomb's test and bone marrow biopsy was normal in all three patients. The kidney biopsy revealed acute tubular necrosis with red blood cell casts and pigments in all the cases. All patients were managed conservatively and showed complete recovery. Thus in tropical countries G6PD deficiency although is not common, should be considered among patients who have received antimalarial drugs presenting as AKI and a detailed hemolytic work-up needs to be carried out as an important cause of preventable recurrent AKI in tropical countries.

Pregnancy Check Point for Diagnosis of CKD in Developing Countries.

OBJECTIVE: Evidences suggest that females with CKD are associated with high risk of maternal and fetal complications. Early referral in CKD with pregnancy for specialist care may prove useful for maternal and fetal outcome. METHODS: Study looked for assessment of impact of CKD detection at the time of pregnancy and its impact on fetal and maternal outcome. RESULTS: A total of 465 females were retrospectively evaluated for renal status during their pregnancies, 172 females were unaware about their renal illness at the time of pregnancy, while 208 females were under regular obstetrical and nephrological follow-up during their pregnancy. 44.1% of these females in both groups had GFR < 60 ml/min. Preeclampsia was observed in 17.6% of planned pregnancies, while it was observed in 47.5% of unplanned pregnancies. Worsening of renal failure during and following pregnancy was observed among all stages of CKD, and there was greater decline in GRF with progression to ESRD earlier during or after pregnancy among unplanned pregnancies. Planned pregnancy group had better fetal outcome. Low birth babies weighing < 2500 g in unplanned group were much higher than in planned pregnancies. CONCLUSIONS: Chronic kidney disease is often clinically silent until renal impairment is advanced. Pregnancy can be a check point for detection of renal disease and managed appropriately for better maternal and fetal outcome.

Neutrophil Gelatinase-associated Lipocalin: As a Predictor of Early Diabetic Nephropathy in Type 2 Diabetes Mellitus.

This study was carried out to look for diagnostic and prognostic role of neutrophil gelatinase-associated lipocalin (NGAL) in early diabetic nephropathy (DN) in type 2 diabetes individuals. NGAL was measured in both urinary and serum sample of 144 type 2 diabetes individuals stratified into three categories based on urinary albumin-creatinine ratio and 54 control populations with estimated glomerular filtration rate >60 mL/min/1.73 m2 and serum creatinine <1.2 mg/dl. The serum NGAL (sNGAL), urine NGAL (uNGAL), and uNGAL/urine creatinine were significantly higher in diabetic individuals than in the control populations with significant difference in between the groups (P < 0.05). Difference of above values between control value and normoalbuminuria was also statistically significant (P < 0.05). Again, sNGAL and uNGAL correlate positively with albuminuria (P < 0.05). Tubular injury may precede glomerular injury in diabetic individuals, and NGAL can be used as a biomarker to diagnose DN even earlier to incipient nephropathy. Both sNGAL and uNGAL can predict albuminuria and be used as a noninvasive tool for diagnosis, staging, and progression of DN.

Vasculitis and vasculopathy in Lupus Nephritis: Clinical variability, outcome, and new insight into treatment.

More than 50% of patients with systemic lupus erythematosus (SLE) have renal involvement at presentation or during their illness. Lupus nephritis (LN) encompasses several patterns of renal disease, including glomerular, tubulointerstitial, and vascular pathologies. The presence and significance of renal vascular lesions (VLs) are often overlooked. VLs in LN are not rare with an incidence of 10%-40% on renal biopsies from various studies and their presence is often labeled as poor prognostic markers. The current treatment protocol for LN is mainly based on the glomerular pathology, and no guidelines/consensus exists for treatment of LN with VLs. We describe the clinical presentation, course, response to therapy, and outcomes in five patients with SLE with histological evidence of renal VLs.