Soumita Bagchi

Renal allograft tuberculosis: report of three cases and review of literature

Renal transplant recipients are prone to a variety of infections due a persistent immunodepleted state. Incidence of tuberculosis in this population is much higher compared with the general population. While pulmonary tuberculosis still remains the commonest form in this population, renal allograft tuberculosis is very rare. We report two cases of isolated allograft tuberculosis and one case of allograft tuberculosis with coexistent pleuro-pulmonary and bone marrow involvement. All three cases had presented with pyrexia of unknown origin, wherein despite extensive investigations the cause was not found. In two cases the diagnosis was confirmed on histology. Two cases responded to non-rifampicin-based modified antitubercular treatment and one to conventional four-drug Rifampicin-based regimen. Graft function improved in two cases while in one case the graft was lost. Tuberculosis involving the renal allograft is a potential cause for graft dysfunction/loss and requires a high index of suspicion for diagnosis. Timely detection and early institution of therapy can help save the renal allograft.

Hemodialysis Patients Treated for Hepatitis C Using a Sofosbuvir-based Regimen

Introduction There is paucity of data on sofosubvir (SOF)−based therapy in patients on maintenance hemodialysis (MHD). The objective of this report is to describe our experience using SOF-based direct antiviral agent (DAA) therapy in MHD patients in India. Methods All patients on MHD and treated with SOF-based therapy were included in this study. Before starting treatment, viral load, genotype, liver fibroscan, and upper gastrointestinal endoscopy were performed in all patients. SOF 400 mg/d or on an alternate day, ribavirin 200 mg/d and daclatasvir 60 mg/d were used in different regimens. Hepatitis C virus RNA was assessed at day 10 and at 4 weeks, at end of therapy, and at 12 weeks after stopping therapy. Results A total of 62 treatment-naïve patients were included. Mean age was 33.3 ± 10.2 years; 66% were men. Median number of copies were 106/dl. None had clinical evidence of cirrhosis. The most common genotype was genotype 1 in 64.5% of cases, followed by genotype 3 in 29% of cases. Thirty-nine patients were treated with SOF every other day/ribavirin, 2 patients with SOF daily/ribavirin, 6 with SOF every other day/daclatasvir, and 15 patients with SOF daily/daclatasvir. All patients were treated for 12 weeks. Fifty-nine (95.2%) patients had a sustained viral response (SVR). There was no impact of genotype on SVR. Twenty-three patients (37%) had complications while on therapy; 13 (20.3%) had dyspepsia, 4 had tuberculosis, and 3 had bacterial pneumonia. Most of the patients (n = 23; 56%) in the ribavirin group required an increase in the erythropoietin dose. No patient discontinued therapy due to complications. Discussion SOF-based DAAs were well tolerated and efficacious in this cohort of patients on MHD.

Multiple intracranial space‐occupying lesions in a renal transplant recipient from an area endemic for tuberculosis (TB): TB vs. toxoplasmosis

Renal transplant recipients may present with intracranial space‐occupying lesions (SOLs) due to infections as well as a post‐transplant lymphoproliferative disorder (PTLD). Here, we discuss a renal transplant recipient who presented with neurologic symptoms and magnetic resonance imaging (MRI) of the brain showed multiple focal SOLs. Tuberculosis (TB), toxoplasmosis, nocardiosis, fungal infections, and PTLD were considered in the differential diagnosis. MRI spectroscopy was suggestive of an infectious cause, such as toxoplasmosis or TB. Serologic tests using Toxoplasma were negative. A brain biopsy followed by immunohistochemical staining using Toxoplasma antibody demonstrated multiple intravascular cysts of toxoplasma. This case highlights the diagnostic dilemma in an immunocompromised patient with multiple focal brain lesions, especially in areas where TB is endemic.

Impact of type of calcineurin inhibitor on post‐transplant tuberculosis: single‐center study from India

Tuberculosis (TB) is an important cause of morbidity and mortality in renal transplant recipients. Immunosuppressive drugs are one of the most important risk factor for post‐transplant tuberculosis (PTTB). A paucity of data exists about the impact of the type of calcineurin inhibitor on PTTB.

Primary FSGS in Nephrotic Adults: Clinical Profile, Response to Immunosuppression and Outcome.

Aim: Primary focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic proteinuria in adults. Most studies on FSGS have combined pediatric and adult patients. This study aims at assessing the response to immunosuppression and its impact on renal survival in adults with primary FSGS. Methods: Patients with nephrotic proteinuria with primary FSGS seen from January 2010 to December 2014 were included. Clinical, laboratory and treatment details were recorded. Deterioration in renal function was defined as ≥50% decline in estimated glomerular filtration rate (eGFR) or progression to end-stage renal disease. Results: There were 116 patients with median follow-up of 23.6 (6-65.1) months. Baseline proteinuria was 5.1 ± 2.6 g/day and eGFR was 96.9 ± 35.1 ml/min/1.73 m2. One hundred one (94.4%) patients had received angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB). One hundred fourteen patients received steroids. Forty two of 114 patients (36.8%)were steroid resistant. Thirty eight received calcineurin inhibitors (CNI). Seventeen (44.7%) were CNI resistant of which 2 achieved remission with alternate immunosuppression. Eleven (9.5%) patients had worsening renal function - 9 had no remission, 2 had PR with none in CR (30 vs. 5.6% vs. 0, respectively, log-rank, p < 0.001). ACEi/ARBs use and remission of proteinuria were independently associated with better renal survival. Conclusion: Achieving remission, whether complete or partial, is the critical factor in predicting renal survival in nephrotic adults with primary FSGS. Steroid-resistant patients have reasonable renal survival, if proteinuria is reduced with timely use of alternate immunosuppression. CNI resistance is a major hurdle in management with limited treatment options.

Pegylated interferon monotherapy for hepatitis C virus infection in patients on hemodialysis: A single center study.

There is no published study from India on hepatitis C virus (HCV) treatment in dialysis patients. Patients on dialysis with HCV infection treated with pegylated interferon (Peg-INF) monotherapy were studied. All patients were subjected to HCV-polymerase chain reaction, viral load, genotype, and liver biopsy. Quantitative HCV-RNA was performed monthly. Patients with genotype 1 and 4 were given 12 month therapy while those with genotypes 2 and 3 were given 6 months therapy. Response was classified as per standard criteria of rapid virological response (RVR), early virological response (EVR), end of treatment response (ETR), and sustained virological response (SVR). A total of 85 patients were treated. Mean age was 35.2 ± 10.5 (range 15–67) years, and 77.6% were males. HCV genotypes were 1 in 40.9%, 2 in 12%, 3 in 36.1%, 4 in 3.6%, and others in 7.2%. Mean viral load was 106 copies/mL. Mean liver biopsy grade was 4 ± 1.7 and stage 0.8 ± 0.8. Mean time from diagnosis of HCV infection and the treatment start was 10.7 ± 14.3 months. One patient died of unrelated illness, one was lost to follow-up, and three could not sustain treatment due to cost. Forty-three of the 80 (54%) patients had RVR while 49 (61%) patients had EVR and ETR. There was no difference in term of RVR related to genotype. Fifty -four percentage had SVR. Mild flu-like symptoms were seen in all patients. Sixty-four (80%) patients required increase in erythropoietin doses. Twenty-eight (35%) patients developed leukopenia (three treatment-limiting) and 16 (20%) developed thrombocytopenia (one treatment-limiting). Five patients developed tuberculosis, five bacterial pneumonia, and one bacterial knee monoarthritis. None of the patients developed depression. Our study concludes that Peg-INF monotherapy resulted in 54% RVR and SVR in dialysis patients with HCV infection. Therapy was well-tolerated with minimal side effects. There was no effect of viral genotype on response to therapy.

Targeted screening of adult first-degree relatives for chronic kidney disease and its risk factors.

Background: First-degree relatives (FDRs) of chronic kidney disease (CKD) patients have a high prevalence of CKD and its risk factors. We evaluated adult FDRs of end-stage renal disease (ESRD) patients for the prevalence of CKD and its risk factors. Methods: Adult FDRs of ESRD patients were screened. Patients <18 years of age with CKD due to polycystic kidney disease, diabetic nephropathy and urological disease were excluded. Age, sex, hypertension, weight, blood pressure, urine analysis, fasting blood glucose, serum creatinine and cholesterol were done. Results: 606 FDRs of 145 index patients were screened; mean age was 39.8 years and 53.3% were male, 26 obese and 122 overweight. 29.7% had hypertension and 3.6% diabetes mellitus. Screening identified new cases of hypertension (21.5%), diabetes mellitus (2.0%), impaired fasting glucose (22.4%) and hypercholesterolemia (18.8%). 5.9% had proteinuria (≧1+). 61.2% of FDRs had eGFR in stage 1, 34.7% in stage 2, 3.6% in stage 3, and 0.5% in stage 4–5. 8.6% had CKD (88.5% were unaware). On multivariate analysis, older age, female sex, proteinuria and uncontrolled blood pressure had a significant association with eGFR <60 ml/min/1.73 m2. Conclusion: In India, CKD and its risk factors show a familial clustering, and screening of FDRs of ESRD patients will be a viable option for a CKD preventive program.

Dengue fever in renal allograft recipients: Clinical course and outcome

There are annual outbreaks of dengue infection in tropical and subtropical countries. This retrospective study aimed to assess the clinical manifestation of dengue and outcome in renal transplant recipients.

99mTc-DMSA planar imaging versus dual-detector SPECT for the detection of renal cortical scars in patients with CKD-3.

ObjectiveThe aim of this study was to compare planar technetium-99m-dimercaptosuccinic acid (99mTc-DMSA) cortical scintigraphy with 99mTc-DMSA single-photon emission computed tomography (SPECT) for the detection of renal cortical scars in patients with chronic kidney disease stage-3 (CKD-3). Patients and methodsData of 40 patients (mean age: 43.7±15.3 years, 29 men, 11 women) who underwent planar 99mTc-DMSA along with regional 99mTc-DMSA SPECT for the detection of renal cortical scars were prospectively evaluated. All the patients had CKD-3, with a mean serum creatinine level of 2.23±1.85 g/dl. Planar and SPECT 99mTc-DMSA images were evaluated by two nuclear medicine readers independently. Each kidney was divided into 12 cortical segments. A cortical segment was recorded as abnormal if it had reduced or absent radiotracer activity. The linear correlation coefficient (r value) for the number of abnormal segments detected between readers was calculated for planar imaging, SPECT, and between the two techniques for both the readers. ResultsFor both observers, the average correlation coefficient for SPECT (r=0.87) and planar imaging (r=0.90) was high (P<0.0001). A moderately strong linear correlation was also observed between readers for planar imaging and SPECT (r=0.78 and 0.71, P<0.0001). There was no significant difference in the average number of abnormal segments detected by planar versus SPECT imaging: 2.1 for planar imaging and 2.8 for SPECT (P=0.06, two-tailed). In 15% of patients, SPECT detected cortical defects not appreciated on planar imaging. Conclusion99mTc-DMSA renal cortical imaging using dual-head SPECT offers no statistically significant diagnostic advantage over planar imaging for the detection of cortical defects in patients with CKD-3.

Infection is the chief cause of mortality and non death censored graft loss in the first year after renal transplantation in a resource limited population: a single center study: Infections after renal transplantation

Few studies have assessed the impact of infections after renal transplantation (RTX) in low and middle income countries. This single centre study aimed to delineate the profile and impact of infections requiring hospitalization (IRH) occurring in the first year after RTX in India.