Concomitant Case of Anti-Glomerular Basement Membrane (GBM) Antibody Disease and Membranous Nephropathy.

Anti-glomerular basement membrane (GBM) disease is a form of rapidly progressive glomerulonephritis with acute deterioration of kidney function. Atypical forms of this disease have been described which do not show positive serology for the classical anti-GBM antibody (Ab) but their presence on kidney biopsies. Furthermore, concomitantly any other separate glomerular pathology along with anti-GBM disease has been only rarely seen. A 40-year-old male patient presented with complaints of lower limb swelling and hematuria. Initial blood investigations revealed nephrotic range proteinuria and hypoalbuminemia. The patient underwent a renal biopsy. Initial reports showed the presence of "linear" deposits for immunoglobulin G (IgG) Ab and crescent formation in the majority of glomeruli. Treatment with plasmapheresis was initiated for the same. Electron microscopy, which later revealed subepithelial deposits raised suspicion of concomitant membranous nephropathy (MN). This finding was confirmed with a staining biopsy block with an anti-PLA2R Ab stain. Treatment was initiated to treat both glomerular pathologies, which very rarely present together and do not have standard guidelines for treatment. The patient responded to treatment with a reduction in serum creatinine values and did not require maintenance hemodialysis. There have been only a handful of documented cases, only in the form of a few case series that have described the presence of both anti-GBM disease and MN in the same kidney biopsy.

Study of the Urinary TGF-ß1 Profile in Diabetic Nephropathy: A Single-Center Experience From India.

Background Diabetic nephropathy is one of the important causes of end-stage kidney disease (ESKD). Of the various cytokines playing a role in the pathogenesis of diabetic nephropathy, transforming growth factor beta-1 (TGF-ß1) is an important one. Its major role is to mediate extracellular matrix deposition. Increased renal expression of TGF-ß1 is found in diabetic nephropathy and its urinary excretion can serve as a useful marker of outcomes. Material and methods A prospective observational study was conducted, which included 10 cases of diabetic nephropathy in group A with age ≥ 18 years and a urinary protein creatinine ratio (UPCR) value of > 0.5 mg/mg and 10 healthy controls in group B. Patients with active urinary tract infection, chronic kidney disease (CKD) stage Vd patients on maintenance hemodialysis, and renal transplant recipients were excluded from the study. Urinary TGF-ß1 level estimation in a 24-hour urine sample, 24-hour urine protein, and other baseline laboratory investigations were done. Results In diabetic nephropathy cases (group A), the mean value of urinary TGF-ß1 levels was 88.33± 12.44 ng/24 hours. In the control group (group B), the mean value of urinary TGF-ß1 was 29.03 ± 3.23 ng/24 hours. Urinary TGF-ß1 levels were significantly elevated in group A as compared to group B (p<0.001). There was no significant correlation between urinary TGF-ß1 levels and estimated glomerular filtration rate (eGFR) (r=0.376, p= 0.285) as well as the urinary TGF-ß1 levels and 24-hour urine protein levels (p = 0.334, r = 0.341) in diabetic nephropathy cases. Glycosylated hemoglobin (HbA1c) levels didn't correlate with the urinary TGF-ß1 levels (r = -0.265, p = 0.46). Conclusion The urinary TGF-ß1 levels were significantly elevated in diabetic nephropathy patients as compared to healthy controls. There was no significant correlation between urinary TGF-ß1 levels and proteinuria, eGFR, or HbA1c levels in diabetic nephropathy patients.

Measured Glomerular Filtration Rate in Live Related Kidney Donors Three Months Post-Kidney Donation: A Single-Center Experience From Western India.

Background Glomerular filtration rate (GFR) estimation is pivotal in the evaluation of kidney donors. There are various methods available for assessing GFR, but there has been a lack of consensus on the measurement of GFR and the frequency of renal evaluation after kidney donation. Our study aims to analyze the measured GFR (m-GFR) before and three months after kidney donation and note the compensatory abilities of the remnant kidney in live related kidney donors. Methods This prospective observational study was conducted at the Department of Nephrology, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Pune, from April 2021 to December 2022. The study included 30 donors from both genders aged between 23 and 73 years. The measured GFR was calculated using a technetium-99m diethylene triamine pentaacetic acid (Tc-99m DTPA) scan. We analyzed donor characteristics and various parameters that included demography, anthropometry, blood pressure, and serum creatinine and measured GFR (m-GFR) using a Tc-99m DTPA scan, which was compared before and three months after donor nephrectomy. Results Of the 30 donors, 25 (83.3%) were females and five (16.7%) were males. The mean age of donors was 49.23 ± 12.29 years. The mean body mass index (BMI) was noted to be 24.73 ± 5.58 kg/m2, whereas the mean body surface area (BSA) was 1.59 ± 0.12 m2. In terms of the measured GFR by DTPA scan, pre-donation and post-donation, the average GFR for our population was 103.83 ± 10.07 mL/minute/1.73 m2 and 60.47±6.57 mL/minute/1.73 m2, respectively. The mean measured GFR of remnant kidney increased by 9.21 ± 4.39 mL/minute/1.73 m2 in 28 donors, while two donors had a fall in the mean measured GFR by 6.8 ± 1.69 mL/minute/1.73 m2. Conclusions To safeguard donor health, accurate measurement of GFR at various timelines after kidney donation should be considered as there are various limitations associated with the use of serum creatinine-based GFR estimating equations for solitary kidneys. However, long-term studies are required to analyze the changes in GFR after nephrectomy and determine the adequacy of compensatory changes in the remnant kidney post-kidney donation.

Metastatic methicillin-resistant Staphylococcus aureus infection with infective endocarditis, pulmonary septic emboli, axillary abscess with a subacute presentation in a patient with chronic end-stage kidney disease on maintenance haemodialysis.

A male adult patient on maintenance haemodialysis due to end-stage diabetic nephropathy presented with low-grade intermittent fever, cough and generalised weakness for 3 weeks. Initial blood investigations revealed an elevated neutrophil count with raised inflammatory markers. Chest CT revealed loculated hydropneumothorax with multiple cavitary nodules. Repeated blood cultures from the cuffed tunnelled catheter site and the right arm and sputum cultures were negative for pyogenic bacteria and yeast aetiology. The patient complained about left axillary pain on the fourth day of admission. Ultrasound-guided percutaneous aspiration from an axillary focal collection and subsequent culture revealed a methicillin-resistant Staphylococcus aureus (MRSA) infection. Echocardiography detected multiple vegetations on the tricuspid valve. The patient responded clinically to vancomycin and removal of the permanent catheter. This was a case of a tunnelled catheter-related metastatic MRSA infection with infective endocarditis, pulmonary septic embolism with a subacute presentation, and repeated blood culture negativity.

Unusual causes of obstruction to transplant ureter.

Surgical complications remain a significant clinical problem following renal trans-plantation. Ureteral obstruction following transplantation is not uncommon. Persistent obstruction of the ureterovesical anastomosis is the most common urologic complication. Obstruction occurring beyond the first post operative month remains frequent (2-7.5%) and mostly related to ureteral stenosis. We report here a case of ureteral stenosis due to an unusual cause and review the literature.

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Guide wires are frequently used in various endourologic procedures to access the upper as well as lower urinary tract. Flexible guide wires have lesser complication rate of tissue injury as compared to stiff guide wires. Flexible guide wires are however more prone to bending and kinking due to their mechanical properties. We report an unusual complication of knotting of flexible guide wires during endourologic procedure and the trick to remedy this problem. We have also discussed the structural design and mechanical properties of commonly used guide wires.