Dharshan Rangaswamy

Impact of body mass index on progression of primary immunoglobulin a nephropathy

The role of obesity in the progression of primary glomerular diseases is controversial. A few studies report overweight/obesity as a risk factor for disease progression in immunoglobulin A nephropathy (IgAN), and the real impact of it still remains unclear. The aim of this study was to elucidate the effect of body mass index (BMI) on disease progression and proteinuria in patients with IgAN in Indian population. A cohort of biopsy-proven primary IgAN patients diagnosed between March 2010 and February 2015 who had a follow-up for a minimum of 12 months were included in the study. We defined two groups of patients according to the BMI value at diagnosis: non-obese group (Group N) with BMI <23 Kg/m2 and the overweight/obese group (Group O) with BMI >23 Kg/m2 as per Asia-Pacific task force criteria. Baseline characteristics were compared between the groups. The estimated glomerular filtration rate (eGFR) and urine protein-creatinine ratio (UPCR) were followed up at entry time, 6 months, 12 months, and at the end of follow-up. Outcomes studied were change in eGFR, proteinuria, and progression to end-stage renal disease. Statistical analysis was done using the Statistical Package for the Social Sciences version 15.0. Of 51 patients, 25 (49%) had BMI <23 kg/m2 (Group N) and 26 (51%) had BMI >23 kg/m2 (Group O) (P = 0.01). The baseline clinical, histopathological, and treatment characteristics of both the groups were comparable. The BMI at the time of diagnosis did not have any significant effect on eGFR (P = 0.41) or proteinuria (P = 0.99) at presentation. At the end of follow-up, both the groups had a similar reduction of proteinuria (UPCR) (P = 0.46) and eGFR (P = 0.20). Two patients in each group have reached chronic kidney disease Stage 5. In the present study, BMI at presentation did not have any impact on eGFR or proteinuria, either at diagnosis or at follow-up. It needs further large multicenter randomized control studies to see the effect of BMI on progression of IgAN.

Cost-effectiveness of pharmaceutical care on patients undergoing maintenance hemodialysis – a multicenter randomized controlled study

ABSTRACT Objectives: The aim of the study is to assess the cost-effectiveness of pharmaceutical care versus usual care on the treatment costs in patients undergoing maintenance hemodialysis (HD) in the outpatient HD centers of academic, government, and corporate hospitals. Methods: An open-labeled randomized controlled study was registered under clinical trial registry of India (Ref. no. CTRI/2014/004900). The study was conducted for a period of 12-month follow-up in patients undergoing maintenance HD. The patients were randomized into Usual Care (UC) group and Pharmaceutical Care (PC) group by the block design method. The UC group received the usual care provided by the hospital staff like physicians, nurses, and technicians whereas, the PC group received the usual care along with the pharmaceutical care delivered by a qualified registered pharmacist. The patient perspective ‘out-of-pocket expenditures’ was considered for calculating the annual cost incurred for the treatment of HD patients. Results: Out of 153 patients, academic hospital (n = 83), government hospital (n = 18), and corporate hospital (n = 52). The incremental cost-effectiveness ratio for academic, government, and corporate hospitals HD patients of PC group compared with UC group were 86,230 Indian Rupee (INR)/Quality-adjusted life year (QALY), 231,016.66 INR/QALY, and 87,430 INR/QALY, respectively. Our study results revealed that PC group was costlier and more effective compared to the UC group. Conclusions: It depends upon the policymakers and regulators to take the decision, if they believe that the extra cost is worth the extra QALY.

Direct-acting antiviral drugs against hepatitis C virus in renal transplant recipients: Is it the dawn of an interferon-free Era?

Hepatitis C virus (HCV) is a significant problem among hemodialysis population, especially in India where renal transplant often gets delayed in the presence of live-related donors. An acceleration of liver cirrhosis and poor renal allograft outcomes are often witnessed in allograft recipients with high viral load. Use of interferon in the postrenal transplant setting for the treatment of hepatitis C viral infection was limited to a few grave situations, fearing the precipitation of allograft rejection and poor efficacy for sustained virological remission. However, the availability of newer direct-acting antivirals has opened a new tool box in the management of HCV in the postrenal transplant setting and in reducing the pretransplant waiting period.

374 Ana negative renal limited lupus nephritis –a rare entity

Background and aims Antinuclear antibodies (ANA) in serum is considered a decisive diagnostic test for SLE. ANA negative SLE is a subgroup of SLE that is infrequently recognised. We report an unusual case of seronegative SLE which presented as rapidly progressive renal failure with no other systemic manifestations. Methods 34 year old female presented with fever, nephrotic range proteinuria and rapidly progressive renal failure. She did not have any other systemic features of SLE. Her clinical, biochemical and serological findings are as shown in table 1. She had low complementemia, but her ANA, ANA profile including anti double stranded DNA (anti- dsDNA) antibodies and anti cardiolipin antibody was negative.Renal biopsy on light microscopy showed diffuse proliferative glomerulonephritis with a full house on immunofluorescence including C1q consistent with class 4 lupus nephritis (Figure 1). A diagnosis of ANA negative renal limited lupus nephritis was made. Abstract 374 Table 1 Abstract 374 Figure 1 Results She was treated with pulse methyl prednisolone followed by oral steroids1mg/kg/day and pulse cyclophosphamide 500–750 mg/m2 body surface area as per NIH protocol. She recovered completely and is on follow-up for two years. She has remained persistently negative for all ANA antibodies including anti-dsDNA antibodies. Conclusions Ours is an unusual case of ANA negative renal limited lupus nephritis. The low complement levels, full house nephropathy in immunofluorescence and response to therapy were important clues in diagnosing the case. We report this patient to highlight the possibility of SLE in seronegative patients as well in order to avoid delay in the management.

Paraneoplastic glomerulopathy in a case of collecting duct renal cell carcinoma

Paraneoplastic glomerulopathy has been described in established cases of the solid tumors of lung, gastrointestinal system, breast, etc., and rarely in patients with Renal Cell Carcinoma (RCC). Studies on secondary glomerular diseases have described a higher incidence of IgA nephropathy in patients with RCC compared to membranous glomerulopathy, which are commonly reported in malignancies of the lung and gastrointestinal tract. Collecting Duct Carcinoma (CDC), a rare high grade adenocarcinoma accounts for <1% of all renal malignancies. It arises from the cells of the collecting ducts of Bellini. We report a case of an elderly male who was diagnosed to have a disseminated CDC during his evaluation for nephrotic syndrome. Renal biopsy was suggestive of a secondary membranous glomerulonephropathy.

Clinicopathological characteristics and outcomes of diffuse crescentic glomerulonephritis - A single center experience from southern India

Introduction Diffuse Crescentic glomerulonephritis (CrGN) is characterized by rapidly progressive renal failure and has grave prognosis. There is significant regional and temporal variation in aetiology, prevalence and prognosis of diffuse crescentic glomerulonephritis (CrGN) with limited data available in adult Indian population. Aim This study aims to identify the aetiology, clinico-pathological features and outcomes of diffuse CrGN in south Indian population. Materials and Methods In this retrospective study, clinical records of all adults (>18 years) over a 5-year period (2010-2014) with a histopathological diagnosis of diffuse CrGN (>50% crescents) were reviewed. Clinical, serological, biochemical and histopathological data were collected. Follow-up data at six months including renal outcome and mortality were studied. Data was analysed using SPSS version 15. Results There were 29 cases of diffuse CrGN accounting for an incidence of 2.9% among 1016 non-transplant kidney biopsies. The most common cause was pauci-immune crescentic GN. The median creatinine at admission was 7.2 mg/dl {(interquartile range (IR) 3.3 - 10.4)} and 75.9% of patients required haemodialysis at admission. Complete/partial recovery was seen in 34.5%. At the end of six months 31% were dialysis dependent and the mortality was 27.6%. On univariate analysis, the significant predictors of renal loss and mortality were oliguria (p=0.02), requirement of haemodialysis and serum creatinine (p=0.001) at admission (>5.5mg/dl) (p=0.003). Histopathological features did not influence the outcome in our study. Conclusion In our cohort, the most common cause for diffuse CrGN is pauci-immune CrGN. Diffuse CrGN carries a poor prognosis. Patients with pauci-immune and AntiGBM disease have worst prognosis compared to immune complex CrGN. The presence of oliguria, high serum creatinine and requirement of haemodialysis at admission are associated with poor outcomes.

Multiple Intra-renal Pathological Injury Patterns in Resistant Myeloma

Renal dysfunction in patients with multiple myeloma has a heterogeneous aetiology ranging from pre-renal, intra-renal to post-renal causes. Common pathological forms of paraproteinemic disease include cast nephropathy,amyloidosis and Immunoglobulin chain deposition disease.Infrequently cryoglobulinemic glomerulonephritis and light chain proximal tubulopathy have also been described. The presence of multiple intra-renal pathological injury patterns has been described only once previously with immunoglobulin light chains. We report a patient with long standing treatment resistant multiple myeloma and new onset progressive renal failure with heavy and light-chain amyloidosis, cast nephropathy and proximal tubulopathy on renal biopsy.

Immune mediated crescentic MPGN secondary to HBV infection: A rare presentation for a common infection.

Hepatitis B virus (HBV) infection presenting as crescentic glomerulonephritis in the absence of cryoglobulinemia is an extremely rare phenomenon. We report a case of a 44-year-old male with HBV infection, who underwent kidney biopsy for rapidly progressive renal failure and nephrotic range proteinuria. Histopathological evaluation of the kidney biopsy was consistent with immune complex mediated crescentic membranoproliferative glomerulonephritis (MPGN). The patient achieved complete renal and virological remission with steroids, plasmapheresis and antiviral therapy. This case report summarises the importance of early initiation of immunosuppression and plasmapheresis under antiviral coverage for improved clinical outcomes.