Narayan Prasad

Is reversible posterior leukoencephalopathy with severe hypertension completely reversible in all patients

Leukoencephalopathy with severe hypertension is a recently described entity in nephrology, with only a few case reports to date in children. We prospectively studied 18 children with severe hypertension to evaluate the clinical features, severity, reversibility, and prognosis. All were subjected to clinical and biochemical tests, magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Headache was reported in 16 children, 13 had confusion and drowsiness, 12 had nausea and vomiting, and 9 had visual disturbances, seizure, and dyspnea. Only 2 had focal neurological deficit (1 with right facial palsy and another with right lateral rectus palsy). Of these 18 children, 14 patients had hypertensive retinopathy and 4 had normal fundus. MRI revealed leukoencephalopathic changes in 16 of 18 patients. These changes were bilateral occipito-parietal in 9 patients, diffuse white/gray matter lesion in 2, brain stem hyperintensity in 2, and hemorrhagic lesion in 3. On MRA, 11 of 18 patients had attenuation of cerebral arteries of different degree. On follow-up, MRI findings resolved in all except 3 patients and all patients had normal MRA, except for 1 with persistent minimal attenuation and another with spasm in all vessels. We conclude that leukoencephalopathy with severe hypertension is reversible both clinically and radiologically in the majority of children after the control of hypertension. However, a few patients may have residual damage and may need psychometric analysis and follow-up for neurodevelopmental sequelae.

Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis: a single centre Indian experience

BACKGROUND Fungal peritonitis (FP) is a serious complication in patients on continuous ambulatory peritoneal dialysis (CAPD). We reviewed our FP cases to analyse the causative agents and possible risk factors in relation to FP and its outcome and mortality. METHODS Records of all FP cases were reviewed. FP was diagnosed based on effluent cell count and positive fungal culture in suitable media. RESULTS Between October 1993 and November 2001, 261 patients underwent CAPD. FP was detected in 28 patients, one episode in each patient (14.3% of the total peritonitis episodes). Candida species and dematiaceous fungi+/-Candida species were responsible for 89.3 and 10.7% of episodes, respectively. Patients with preceding bacterial peritonitis (BP) developed FP more frequently (25.6%) than de novo cases (2.9%) (P<0.0001) and lower proportion of them continued CAPD (8.6% vs. 60%; P=0.007). Mortality in patients having abdominal pain with and without fever, and catheter in situ was significantly higher than in those patients who did not have these risk factors (9/11 vs. 6/17, P=0.01; 13/17 vs. 2/11, P=0.003; 6/6, vs. 9/22, P=0.01, respectively). CONCLUSIONS Higher proportion of our patients had FP; preceding BP was a significant risk factor for development of FP and technique failure. Abdominal pain+/-fever in patients and catheter in situ were identified as risk factors associated with mortality.

Chronic hepatitis C virus infection in renal transplant: treatment and outcome

Abstract:  Background:  Chronic hepatitis C virus (HCV) infection is a common cause of liver disease in post‐renal transplant period and causes poor patient and graft survival. We analyzed the effects of antiviral therapy using ribavirin monotherapy or ribavirin in combination with interferon (IFN)‐alpha in our kidney transplant recipients with chronic hepatitis C.

Functional renal reserve capacity in different stages of chronic kidney disease

Aim:  There is conflict in published reports on the extent of availability of the functional renal reserve (RR) in healthy adults and in various stages of chronic kidney disease (CKD). The aim of the present study was to determine the RR in various stages of CKD.

MDR-1 gene polymorphisms in steroid-responsive versus steroid-resistant nephrotic syndrome in children

BACKGROUND The putative genetic regulation of multidrug resistance gene-1 (MDR-1) gene expression and P-glycoprotein function has not yet been clearly delineated in patients with nephrotic syndrome (NS). We undertook this study to examine the distribution of three most frequent MDR-1 exonic polymorphisms G3435C, G2677T/A and C1236T in patients with NS and control children to investigate their usefulness as markers of responsiveness of the disease to steroids. METHODS Two hundred and sixteen children with NS and 216 healthy controls were genotyped for three exonic MDR-1 polymorphisms (G3435C, G2677T/A and C1236T) by using the polymerase chain reaction-restriction fragment length polymorphism technique. The frequency distribution of genotypes/alleles was compared between patients with NS and controls and also between steroid-sensitive NS (SSNS) and steroid-resistant NS (SRNS) patients. RESULTS Of the total 216 cases of NS (median age of onset 5 years, 165 males), 137 had SSNS, and 79 had SRNS. Homozygous mutants of C3435T (TT versus CC, P = 0.034) and G2677T/A (TT + AA versus GG), P = 0.030) were significantly higher in patients with NS compared to controls. The frequency distribution of homozygous mutant TT + AA compared to wild genotype GG was significantly higher in SRNS than SSNS patients (P = 0.011) for G2677T/A, while the mutant genotypes for C3435T and C1236T were not different between SRNS and SSNS patients. The combination-bearing mutant genotype either of C3435T or G2677T/A exhibited a significantly higher frequency of mutant genotypes distribution in SRNS patients. MDR-1 haplotypes did not differ significantly between SSNS and SRNS patients. CONCLUSIONS Patients with NS carrying homozygous mutants of single nucleotide polymorphism (SNP) G2677T/A are prone to develop SRNS. The synergistic effect of mutant genotypes of SNPs G2677T/A and C3435T in different combinations increase the risk of developing steroid resistance in patients with NS.

Changes in Nutritional Status on Follow-Up of an Incident Cohort of Continuous Ambulatory Peritoneal Dialysis Patients

BACKGROUND AND OBJECTIVE The prevalence of malnutrition in continuous ambulatory peritoneal dialysis (CAPD) patients in India has not been studied in much detail. We studied various nutritional indices of end-stage renal disease patients at the initiation of therapy. METHOD Two hundred and eighty-three CAPD patients (204 were male; mean +/- SD age, 50 +/- 14 years) were assessed for their nutritional status at the initiation of therapy. Nutritional status was assessed by anthropometry, dietary diary, subjective global assessment (SGA), and serum albumin. The patients were categorized into different grades of malnutrition, based on their nutritional indices: (1) normal nutritional status, (2) mild-moderate malnutrition, and (3) severe malnutrition. RESULT Based on SGA, 71/283 (25.08%) had a normal nutritional status, 192/283 (67.84%) had mild-moderate malnutrition, and 20/283 (7.07%) had severe malnutrition. However, on categorizing patients in different grades of malnutrition based on serum albumin, 103/283 (36.4%) had a normal nutritional status, 175/283(61.84%) had mild-moderate malnutrition, and (5/283) 1.77% had severe malnutrition. Their mean calorie and protein intake was significantly lower than recommended (National Kidney Foundation Dialysis Outcome and Quality Initiative guidelines). Individual dietary counseling was performed, an individual diet chart was given to each patient, and counseling was repeated. There was a significant increase in nutrient intake and in grades of malnutrition of these patients during follow-up. CONCLUSION We conclude that the majority of the patients were already malnourished at the initiation of CAPD, and that nutrient intake and nutritional parameters improved during the follow-up of these patients.

Real-time ultrasound-guided percutaneous renal biopsy with needle guide by nephrologists decreases post-biopsy complications

Background Percutaneous renal biopsy (PRB) can result in serious complications. The study is aimed to compare the biopsy yield and complications rate of the real-time ultrasonagram (USG)-guided PRB and needle tracking with and without needle guide in two different study periods. Methods We compared the yield and complications of 2138 kidney biopsies performed in two different periods, 1510 biopsies during the first period from April 2004–December 2010 and 628 biopsies during second period from January 2011–March 2013. All biopsies in both periods were performed by nephrologists. Radiologists provided the real-time image without needle guide during the first period while nephrologists performed both imaging and biopsy with needle guide during the second period. Results Of all the 2138 patients, 226 (10.5%) patients developed 118 minor and 108 major complications. Only 13 (2.1%) major complications occurred in the second period and 95 (6.7%) in the first period (P < 0.001). The relative risk of developing a major complication without guide was 3.04 times greater than that of the biopsies performed with use of the guide. The mean number of glomeruli per biopsy obtained during the second period (17.98 ± 6.75) was significantly greater than that of the first period (14.14 ± 6.01) (P = 0.004). The number of passes to acquire adequate tissue (P = 0.001) and percentage of cortex on biopsy (P = 0.001) were also significantly better in the second period. The optimal observation period post biopsy is 24 h. Conclusions Real-time USG imaging supported by needle guide device is associated with better biopsy yield and fewer complications.

Differential alteration in peripheral T-regulatory and T-effector cells with change in P-glycoprotein expression in Childhood Nephrotic Syndrome: A longitudinal study.

INTRODUCTION Childhood Idiopathic Nephrotic Syndrome (INS) responds to glucocorticoid therapy, however, 60-80% of patients relapse and some of them become steroid non responsive. INS may occur because of T cell dysfunction, abnormal cytokines and podocytopathies which reverse on steroid treatment. The reason of relapses could be imbalances in T cells phenotypes and respective cytokines. Herein, we hypothesize that relapses in INS may occur due to imbalance in T-regulatory and T-effector cell with their respective cytokines and overexpression of P-gp on lymphocytes. METHODS The frequency of peripheral blood CD4(+)CD25(+)FoxP3(+) Treg, CD4(+)IFN-γ(+) Th1 and CD4(+)IL-4(+) Th2 lymphocytes and their respective cytokines and P-gp expression on peripheral blood lymphocytes (PBLs) were analyzed in INS patients at baseline (n=26), during remission (n=24) and at relapse (n=15). RESULTS Compared to baseline, the frequency of Tregs was significantly increased at remission and decreased during relapse. In contrast, the frequency of Th1 and Th2 lymphocytes was significantly decreased during remission and increased at the time of relapse. Similarly, expression of P-gp was significantly high at baseline and at the time of relapse as compared to remission. Levels of cytokines IL-10 and TGF-β in the supernatant of stimulated PBMCs was increased during remission and decreased during relapse. In contrast, levels of IFN-γ and IL-4 were decreased during remission and increased at the time of relapse. CONCLUSIONS Steroid therapy in INS induces decreased P-gp expression on PBLs along with increased frequency and cytokine response of T-regulatory cells, and reduced frequency and respective cytokine response of Th1 and Th2 cells during remission. However, reversal in the frequency and respective cytokines of T-regs, Th1 and Th2, and P-gp expression on PBLs occurs during relapses on follow-up.

Vascular endothelial growth factor gene polymorphisms in North Indian patients with end stage renal disease

CONTEXT Vascular endothelial growth factor (VEGF) is involved in the development and differentiation of the vascular system. VEGF is expressed constitutively by epithelial cells from embryonic to adult kidneys and may play a key role in progression of kidney diseases. It is required for the growth and proliferation of glomerular and peritubular endothelial cells. In the kidney VEGF expression is prominently found in glomerular podocytes and in tubular epithelial cells, while VEGF receptors are mainly seen on preglomerular, glomerular, and peritubular endothelial cells. OBJECTIVES We have investigated the role of VEGF gene polymorphisms (-2578C/A,-2549 18 bp I/D, -1154 G/A and +936 C/T) as a susceptibility marker for end stage renal disease (ESRD). PARTICIPANTS AND METHODS We genotyped VEGF gene polymorphism in three hundred patients and three hundred and fifty ethnically matched unrelated healthy controls free from any renal disease. These markers were studied using ARMS-PCR and PCR-RFLP methods. Patients were categorized on the basis of the histo-pathological subtypes into chronic glomerulonephritis (CGN=109), hypertensive nephrosclerosis (HTN=106) and chronic interstitial nephritis (CIN=60). RESULTS VEGF -2578C and -2549D alleles were found to be ESRD causative alleles. It was observed that there was significant differences in the frequencies of the T allele of +936C/T polymorphism among CGN, HTN and CIN respectively. VEGF -1154AA genotype and A allele were associated significantly with CGN. T-G-A-D, T-A-C-I,C-G-A-D,C-A-C-D,C-G-C-I,C-A-A-D and T-G-C-D were seven haplotypes concurred in all the ESRD patients irrespective of underlying disease. While C-G-C-D & C-G-A-I haplotypes showed risk association in CGN & CIN, C-A-C-I was observed to play predisposing role in HTN. CONCLUSION The results highlight the role of studied VEGF polymorphisms in end stage renal disease at large and subsequently in the three primary kidney diseases among the North Indian population.

Dengue virus infection in renal allograft recipients: a case series during 2010 outbreak

Dengue virus infection is an emerging global threat caused by Arbovirus, a virus from Flaviridiae family, which is transmitted by mosquitoes, Aedes aegypti and Aedes albopictus. Renal transplant recipients who live in the endemic zones of dengue infection or who travel to an endemic zone could be at risk of this infection. Despite multiple epidemics and a high case fatality rate in the Southeast Asian region, only a few cases of dengue infection in renal transplant recipients have been reported. Here, we report a case series of 8 dengue viral infection in renal transplant recipients. Of the 8 patients, 3 developed dengue hemorrhagic shock syndrome and died.