Bharat Shah

Baseline anti-blood group antibody titers and their response to desensitization and kidney transplantation

In recent years, immunological barriers historically considered as absolute contraindications to transplantation are being reevaluated. One such barrier is the ABO blood group incompatibility. With better understanding of immunological mechanisms and effective various regimens for controlling it, ABO-incompatible (ABO-I) kidney transplantation is now being performed with increasing frequency. For good outcome, most important is to achieve and maintain low anti-blood group antibody titers (ABGATs). Twenty-two patients with ABO-I donors have been studied. The anti-A and anti-B antibody titers (IgG and IgM) were estimated by column agglutination technology using Automated Ortho BioVue System. For desensitization, pretransplant plasmapheresis and/or immunoadsorption and rituximab were used. ABGAT was determined before transplant and periodically after transplant. It was observed that one-third of the patients have low baseline ABGAT. In these cases with low ABGAT, transplant can be performed without any desensitization. In those with titers <1:256, rituximab (two doses of 200 mg weekly) and 3–6 sessions of plasmapheresis can bring down titers to <1:32. In those with titers >1:256, immunoadsorption may be used from the beginning to reduce ABGAT. After transplant, the titers drop to <1:8 in majority. Rise in titers to >1:64 require close observation and biopsy. If there is evidence of antibody-mediated rejection, treatment should be promptly started. Rise in titers 4–6 weeks after transplant is not associated with any graft dysfunction, and hence not of any clinical significance.

Unmasking of primary hyperparathyroidism by Vitamin D therapy

A 38-year-old female on Vitamin D therapy presented with hypercalcemia induced acute kidney injury. Evaluation revealed primary hyperparathyroidism (PHPT) and iatrogenic hypervitaminosis D. After medical stabilization, she underwent surgical removal of the parathyroid adenoma, and made a full recovery. This case highlights unmasking of subclinical hyperparathyroidism by vitamin D therapy leading to severe hypercalcemia.

Prevalence of chronic kidney disease and the incidence of acute kidney injury in patients with coronary artery disease in Mumbai, India

Background and Objective: To determine the prevalence of chronic kidney disease (CKD) and incidence of acute kidney injury (AKI) in patients with coronary artery disease (CAD) demonstrated on coronary angiography. Materials and Methods: Totally, 125 patients admitted to Lilavati Hospital and Research Centre, Mumbai, with CAD were included in the study. Results: Left anterior descending artery was the major vessel involved (40%), followed by a circumflex artery (21.6%). 49 out of 125 (39.2%) were found to have underlying CKD. 69% (34) of these CKD patients developed AKI. 21 out of 34 patients who developed AKI required hemodialysis. Only 47.1% (16 out of 34) of CKD patients had complete recovery, 29% had partial recovery, and 23% had no recovery of their renal function from AKI. Statistically significant number of patients in CKD group had no recovery from AKI as compared to non-CKD group (23.5% vs. 0%). Conclusion: Our study concludes that there is a very high prevalence of CKD (39.2%) in patients with CAD and AKI is a very important complication (38.4%) in these patients. Considering such a high prevalence of CKD, nephrology referral must be considered in patients with abnormal urinalysis, spot urinary protein to creatinine ratio and in patients whose creatinine clearance is <60 ml/min.