Vinay Malhotra

A clinicopathologic study of glomerular disease: A single-center, five-year retrospective study from Northwest India

Studies published from centers across India have reported different and contradicting patterns of glomerular disease. In this retrospective study, we report our experience from a Tertiary Care Center in Northwest India. A total of 702 renal biopsies performed between 2008 and 2013 were reviewed of which 80 were excluded from the study because of having insufficient records or if the biopsies were taken from an allograft. The study included 411 males (66.1 %) and 211 females (33.9%) with an age range of 12-70 years (mean 30.34 ± 7.04 years). Majority of the biopsies (93.9%) showed some form of glomerulonephritis (GN), either primary (79.4%) or secondary glomerular disease (SGD) (14.5%). Minimal change disease (MCD) was the most common type of primary GN (26.5% of primary GN), followed by membranous nephropathy (MN; 18.8%) and focal and segmental glomerulosclerosis (FSGS; 13.2%). Lupus nephritis (LN) was the most frequent SGD (52.2% of secondary GN). Amyloidosis was found in 41.1% and diabetic glomerulosclerosis in 4.4%. LN was also the second most common diagnosis in females after MCD, seen in 19.4% of females. MCD followed by membranoproliferative GN and diffuse proliferative GN were the most common entities in individuals <20 years of age. In the 20-39 years age group, MN was the most common pathology seen. MN was again the most common pathology seen in patients aged above 40 years followed by amyloidosis and FSGS. In this study, MCD was the most common primary GN observed overall from this part of India. MN was the most common GN in individuals above 20 years of age presenting with the nephrotic syndrome. The geographical and regional differences in the pattern of GNs point to the necessity of having a central biopsy registry.

Renal cortical necrosis: A rare complication of Plasmodium vivax malaria

A young female with Plasmodium vivax malaria presented with anemia, hyperbilirubinemia, thrombocytopenia, and advanced renal failure. She remained anuric for more than 3 weeks. Kidney biopsy confirmed the diagnosis of acute cortical necrosis. During follow-up, she became dialysis independent, but remained in stage 4 chronic kidney disease (CKD) at 3 month. P. vivax is supposed to be benign in nature, but can lead to rare and severe complication like renal cortical necrosis and progress to CKD.

Characteristics and outcome of postpartum acute kidney injury requiring dialysis: A single-center experience from North India

Postpartum acute kidney injury (AKI) is one of the serious complications of pregnancy and is associated with high mortality and morbidity. We conducted this study to determine the characteristics and outcome of the most severe form of postpartum AKI requiring dialysis. This prospective, observational study was conducted in Sawai Man Singh Medical College, Jaipur. All postpartum female suffering from AKI requiring dialysis between July 2014 and December 2016 were included in the study. Demographic, clinical and laboratory data of the patients were recorded. Outcome variables included survival at hospital discharge and estimated glomerular filtration rate (eGFR) at three months of follow-up. Sixty (88.2%) out of 68 women admitted with postpartum AKI required dialysis. The mean age was 26.5 ± 4.3 years and the majority (80%) had institutional delivery. The mean sequential organ failure assessment (SOFA) score was 8.0 ± 2.9. Puerperal sepsis (n = 37, 61.6%), preeclampsia (n = 21, 35%), and antepartum hemorrhage (n = 14, 23.3%) were the most common obstetric complication associated with postpartum AKI. Maternal mortality was 28.3%. Higher SOFA score (P = 0.015, odds ratio [OR]: 1.99, confidence interval [CI]: 1.14-3.45) and diagnosis of sepsis (P = 0.048, OR: 26.3, CI: 1.03-678.3) were the independent predictors of mortality. Out of 37 patients who were followed up at three months, 51.3% had eGFR <60 mL/min/1.73 m2. Duration of anuria (in days) was the only independent predictor of (eGFR <60 mL/min/1.73 m2 at three months of follow-up (P = 0.029, OR: 1.2, CI: 1.02-1.46). Postpartum AKI requiring dialysis was associated with high mortality. More than half of the survivors had eGFR <60 mL/min/1.73 m2 on follow-up highlighting the need of appropriate follow-up.

Clinicopathologic profile of glomerular diseases associated with autoimmune thyroiditis

Introduction: Thyroid hormones are known to influence renal function, development, and renal hemodynamics. In this study, we aimed to de ne the frequency and characteristics of various glomerular diseases associated with autoimmune thyroiditis. Methods: We reviewed retrospectively 36 patients with autoimmune thyroiditis referred for evaluation of proteinuria, hematuria, and/or renal impairment. Renal biopsy was performed in 32 patients and was examined with light microscopy and immunofluorescence. Six months follow-up data of 22 patients was reviewed. Results: The mean age of study population was 43.6 years. Most of them were females (n = 28). Mean duration of hypothyroidism (HT) was 1.5 years. Hypertension was seen in 16 patients and deranged renal function (estimated glomerular filtration rate <60 ml/min/1.73 m2) in 18 with a mean serum creatinine of 1.28 mg/dl at time of biopsy. 10 patients presented with nephrotic syndrome, 33 presented with isolated proteinuria and 22 presented with hematuria with or without significant proteinuria The most common histopathologic finding was membranous nephropathy (MGN) (n = 16), followed by minimal-change nephropathy (n = 5), focal segmental glomerulosclerosis (n = 5), immunoglobulin A nephropathy (n = 3), amyloidosis (n = 2), and membranoproliferative glomerulonephritis (n = 1). Membranous nephropathy was the most common finding inn patients with the nephrotic syndrome. Conclusion: Glomerular pathologies associated with HT are diverse and similar to those found in the general population; therefore, renal biopsy should be performed in cases with progressive renal failure or urinary abnormalities.

Leukocyte esterase reagent strip as a bedside tool to detect peritonitis in patients undergoing acute peritoneal dialysis

Peritonitis is a common and life-threatening complication of acute peritoneal dialysis (PD). Diagnosis requires the presence of clinical signs of peritonitis which are nonspecific and laboratory investigations [total leukocyte count (TLC), Gram-stain, and culture of PD effluent fluid] which are time-consuming and not available at the bedside. In this study, we evaluated the use of leukocyte esterase reagent strip (LERS) as a bedside test to diagnose peritonitis in patients undergoing acute PD. Patients who underwent acute PD were monitored for signs and symptoms of peritonitis. PD effluent fluid analysis included TLC, absolute neutrophil count, Gram-stain, and culture for the diagnosis of peritonitis. LERS (Multistix 10SG) was simultaneously dipped in PD effluent fluid and read at two minutes. Reading of + was considered as indicative of peritonitis. Twenty-one out of 166 (12.6%) patients undergoing acute PD developed peritonitis. LERS detected peritonitis in 20 patients. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of LERS were 95.2%, 95.2%, 74.1%, and 99.3%, respectively. LERS has very high sensitivity and NPV and can be used as a rapid bedside tool to exclude peritonitis in patients undergoing acute PD.

Profile of glomerular diseases associated with hepatitis B and C: A single-center experience from India

Hepatitis B and C are known to affect kidneys in a number of ways. Glomerular diseases associated with hepatitis B and C include membranous nephropathy (MN), membranoproliferative glomerulonephritis (MPGN), focal segmental glomerulosclerosis, immunoglobulin A nephropathy, rarely amyloidosis, and fibrillary and immunotactoid glomerulopathy. In a retrospective analysis of kidney biopsy of 534 patients, we found 16 (2.9%) patients of hepatitis B and 11 (2.05%) patients of hepatitis C with glomerular disease. The most common form of glomerulonephritis in hepatitis B patient was MN and in hepatitis C patient was MPGN.

Clinicoepidemiological profile of peritonitis complicating acute peritoneal dialysis: A single-center experience

A prospective observational study examining the incidence and microbiological aspects of peritonitis complicating acute intermittent peritoneal dialysis (IPD) was performed. A total of 145 acute IPD treatments were included involving 112 patients. The majority of patients suffered from acute kidney injury (72.3%) secondary to sepsis. Peritonitis occurred in 31 treatment sessions, giving a frequency of 21.4% of procedures performed. The mean interval between starting dialysis and the first sign of peritonitis was 2.9 days, with 58% of cases occurring in the Intensive Care Unit. Frequent catheter manipulation/repositioning and leakages were identified as significant predisposing factors for peritonitis, and the risk of peritonitis was increased with longer duration of IPD. Gram-negative infections were more common than Grampositive infections. The use of systemic antibiotics did not prevent the development of peritonitis.

How harmful can herbal remedies be? a case of severe acute tubulointerstitial nephritis

Acute interstitial nephritis (AIN) is a condition in which acute kidney injury (AKI) is characterized by the histological finding of interstitial inflammation. Hyponidd is an ayurvedic drug containing Momordica charantia, Gymnema sylvestre, Swertia chirata, etc., used for the treatment of Type 2 diabetes mellitus (DM) and polycystic ovarian disease as an insulin sensitizer. There are no case reports of AIN caused by this drug yet. We report a biopsy-proven case of AKI due to severe AIN associated with the use of hyponidd tablet in a 60-year-old male with DM and hypertension. As these types of various indigenous compounds are used as home remedies in our country, awareness about the possible adverse effects of these agents among physicians is very important in the early diagnosis and management.

Gitelman's syndrome presenting with hypocalcemic tetany and hypokalemic periodic paralysis

Gitelmans syndrome is an autosomal recessive renal tubular disorder characterized by hypomagnesemia, hypokalemia, hypocalciuria, and metabolic alkalosis. Hypocalcemic tetany as a presentation of Gitelmans syndrome has rarely been reported in literature. We report a rare case of Gitelmans syndrome presenting with hypocalcemic tetany along with hypokalemic periodic paralysis. A 17-year-old female was admitted to our hospital with a history of perioral numbness and carpal spasms of five days duration with progressive quadriparesis developing over a period of few hours. Past history was significant for three episodes of transient lower limb weakness. On examination, blood pressure was 110/70 mm Hg. Chvosteks sign and Trousseaus sign were positive. Neurologically, she was fully oriented. She had Grade 3 power in all the four limbs with intact sensation. Laboratory tests showed hypocalcemia (7.8 mg/dL), hypokalemia (2.2 mEq/L), hypomagnesemia (0.9 mEq/L), and hypocalciuria (104 mg/day). Arterial blood gas showed mild metabolic alkalosis with respiratory compensation. Thus, a clinical diagnosis of GS was made. The patient made a remarkable recovery after the correction of electrolyte imbalance. The aim of this case report is to re-emphasize the fact that hypocalcemia can rarely occur in Gitelmans syndrome.

Acute kidney injury in patients with Plasmodium vivax malaria: Clinicohistopathological profile

Context: There has been an unexplained increase in the number of cases with multiorgan dysfunction including acute kidney injury (AKI), attributed to Plasmodium vivax monoinfection. Only a few case reports in literature have published the renal biopsy findings in these patients. Aims: The aim of this study was to evaluate the clinical and histopathologic profile of patients with P. vivax malaria monoinfection and AKI. Settings and Design: A prospective study was performed in a tertiary care hospital in North-Western India. Subjects and Methods: The study included patients diagnosed with P. vivax monoinfection on peripheral smear blood films and rapid diagnostic test (positive for P. vivax specific lactate dehydrogenase). AKI was defined based on the WHO criteria for complicated malaria, i.e. serum creatinine >265 μmol/l or 3 mg/dl. The patients were initiated on hemodialysis for persistent hyperkalemia, fluid overload, severe metabolic acidosis, or uremic symptoms. Renal biopsy was performed in the presence of active urinary sediments (proteinuria, hematuria) or persistence of renal failure >14 days. Results: A total of thirty patients fulfilled AKI criteria. The patients with AKI were older (mean age 42.1 ± 10.9 years), male, with a longer duration of illness (mean 12.3 ± 10 days) and associated with multisystem dysfunction. The mean serum creatinine was 7.58 ± 3.2 mg/dl, thrombocytopenia was seen in 47%. Thirty percent had severe anemia requiring a blood transfusion. Renal biopsy was performed in six patients for various indications. The most common pattern was acute tubular necrosis (four patients), followed by acute cortical necrosis (1), and thrombotic microangiopathy (one patient). The complete renal recovery was seen in 24 (80%). Two patients became dialysis-dependent. Conclusions: AKI associated with P. vivax monoinfection is not rare as previously thought. Therefore, it should be considered in the differential diagnosis of any patient presenting with AKI.