Chronic Kidney Disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide. Kidney Health and Women's Health: a case for optimizing outcomes for present and future generations

Atypical hemolytic uremic syndrome (aHUS) is characterized by microangiopathic hemolytic anemia, consumptive thrombocytopenia, and widespread damage to multiple organs including the kidney. The syndrome has a high mortality necessitating the need for an early diagnosis to limit target organ damage. Because thrombotic microangiopathies present with similar clinical picture, accurate diagnosis of aHUS continues to pose a diagnostic challenge. This article focuses on the role of four distinct aspects of aHUS that assist clinicians in making an accurate diagnosis of aHUS. First, because of the lack of a single specific laboratory test for aHUS, other forms of thrombotic microangiopathies such as thrombotic thrombocytopenic purpura and Shiga toxin-associated HUS must be excluded to successfully establish the diagnosis of aHUS. Second, application of the knowledge of complement-amplifying conditions is critically important in making an accurate diagnosis. Third, when available, a renal biopsy can reveal changes consistent with thrombotic microangiopathy. Fourth, genetic mutations are increasingly clarifying the underlying complement dysfunction and gaining importance in the diagnosis and management of patients with aHUS. This review concentrates on the four aspects of aHUS and calls for heightened awareness in making an accurate diagnosis of aHUS.

Brucellosis is a multisystem disease that may present with a broad spectrum of clinical manifestations. Until now, no studies have been performed on renal tubular disorders in patients with brucellosis. The present study aims to investigate renal tubular disorders in patients with brucellosis. This prospective case–control study includes a total of 31 brucellosis patients (Group 1) and 30 healthy controls (Group 2) matched for age and sex. Renal tubular functions of children who were diagnosed as having brucellosis in outpatient pediatric clinics were evaluated. First-morning urine samples were collected from Group 1 and Group 2 at the same time. Urea, creatinine, potassium, sodium, and phosphorus were determined in serum and urine by an autoanalyzer. Tubular reabsorption and excretion of urine electrolytes were calculated using the related formulas. Patients with brucellosis had significantly lower levels of tubular reabsorption of phosphorus and serum phosphorus than those of the control group. Furthermore, urine sodium and serum potassium levels and fractionated sodium excretion of brucellosis patients were significantly higher than healthy control group. Estimated glomerular filtration rate was remarkably higher in the patient group (P < 0.001).We concluded that tubular and glomerular functional parameters demonstrate deterioration in patients with brucellosis compared to those in healthy participants.

Nephrotic syndrome (NS) is the most common primary glomerular disease among children. It runs a relapsing course involving prolonged periods of treatment with corticosteroids and other immunosuppressive medications. Soluble urokinase plasminogen activator receptor (suPAR) has been regarded as an inflammatory as well as a permeability factor. The aim of our study was to evaluate serum suPAR levels in children with NS and its relation to steroid responsiveness. Our study was carried out on 75 children who were already diagnosed as having NS; they were classified into three groups (steroid sensitive, steroid dependent, and steroid resistant). Furthermore, 40 apparently healthy children, age and sex matched with the NS patients, were enrolled as controls. All children had undergone assessment of serum suPAR, renal function tests (urea and creatinine), serum albumin, C-reactive protein, and 24-h protein in urine. The study found that suPAR level was significantly different between the studied groups (P <0.05), being highest in steroid-resistant NS (66.52 ± 9.7 ng/mL), followed by steroid dependent (56.82 ± 11.09 ng/mL), and steroid-sensitive patients (26.22 ± 3.86 ng/mL), and lowest in the control group (20.29 ± 0.69 ng/mL). When receiver operating characteristics curves were plotted, suPAR had high sensitivities and specificities in predicting steroid responsiveness, [area under the curve (AUC) = 0.99, 95% confidence interval (CI) = 0.911–1.000, P <0.001], steroid dependence (AUC = 1.00, 95% CI = 0.929–1.000, P <0.001), and predicting steroid resistance. Our study indicates that suPAR is significantly higher in children with primary NS and varies according to their response to steroid therapy. It may act as a marker for steroid responsiveness in these children.

Atypical hemolytic uremic syndrome (aHUS) is characterized by microvascular thrombosis resulting in thrombocytopenia, hemolytic anemia, and multiorgan dysfunction. It is associated with genetic or acquired disorders of regulatory components of the complement system. For our study, we collected data from 16 patients diagnosed with aHUS between January 2010 and January 2014. The mean age was 33.6 years. The female-to-male ratio was 3. The median follow-up duration was 27 ± 3.5 months. The most common clinical presentation was hypertension. Renal involvement was noted in all cases. Ten patients had extrarenal manifestations. Semi-quantitative dysfunction of the alternative pathway of complement was found in all cases. A genetic study was not available for our patients. During the acute stage, all patients received plasma therapy, and among them, seven required dialysis and five were still on dialysis at the time of discharge. One patient underwent renal transplantation. None of our patients received eculizumab perfusion. The renal survival was inversely correlated to young age (<30 years) (P = 0.001), presence of anti-factor H antibodies (P = 0.003) and serum creatinine at diagnosis >5 mg/dL (P = 0.02). Mortality rate was significantly correlated to young age (<30 years old) (P = 0.01). Collecting multicentric data on adult patients with aHUS will enable better characterization of the spectrum of adult aHUS in our country and the evaluation of current treatments and different outcomes.

Severe deficiency of ADAMTS-13 leads to thrombotic thrombocytopenic purpura. Few studies have reported reduced activity of ADAMTS-13 in patients with atypical and typical hemolytic uremic syndrome (HUS). We hypothesized that ADAMTS-13 deficiency might play a role in the pathogenesis of severe HUS. This study aimed to evaluate the ADAMTS-13 level in severe typical HUS. This prospective case–control study was carried out in the Pediatric Nephrology Unit and Clinical Pathology Department, Faculty of Medicine, Zagazig University from February 2013 to February 2014. The study included 15 consecutive children with typical HUS as well as 15 healthy children as a control group. Routine laboratory investigations were performed. Assessment of serum ADAMTS-13 level was performed using the Quantikine human ADAMTS-13 ELISA kit. Data were analyzed using Statistical Package for Social Sciences version 16. Nonparametric values were expressed as median and range, and the median of two groups was tested by Mann–Whitney test. The serum ADAMTS-13 level was significantly lower in HUS patients when compared to the control group (P < 0.05). There were significant negative correlations between ADAMTS-13 level and duration on dialysis, as well as serum urea and creatinine. Furthermore, there were significant positive correlations between serum ADAMTS-13 level and both hemoglobin level and platelet count. Our study suggests that the ADAMTS-13 level was decreased in children with severe typical HUS and its deficiency correlated with disease severity.

The outcome of chronic kidney disease (CKD) patients admitted to the Intensive Care Unit (ICU) is difficult to predict. This study assessed the outcome of CKD patients admitted to the ICU and evaluated prediction of 30-day mortality using the Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS II), and Sequential Organ Failure Assessment (SOFA) score. One hundred consecutive CKD patients admitted to the ICU at a tertiary care hospital, Ahmedabad between 2011 and 2013 were included prospectively. Data on demographics, indication for admission, cause of CKD, use of vasoactive drugs and mechanical ventilation (MV), mode of renal replacement therapy (RRT), and 30-day mortality were recorded. The APACHE II, SAPS II, and SOFA scores were calculated based on the admission characteristics. The mean APACHE II, SAPS II, and SOFA scores were 28.22 ± 7.53, 43.04 ± 16.40, and 10.39 ± 5.20, respectively, and area under receiver operating characteristics curve in predicting 30-day mortality were 0.961, 0.994, and 0.950, respectively. The scores were significantly higher in 30-day nonsurvivors as compared to survivors (P = 0.001). During the ICU stay, MV and vasoactive drugs were required in 57% and 67% of the patients, respectively, and the requirement was significantly greater in nonsurvivors as compared to survivors (P = 0.001). About 85% of patients were on intermittent hemodialysis and 15% of patients were on continuous venovenous hemodiafiltration. Sepsis was the main reason for hospital admission, and the mean length of stay in the ICU was 7.74 ± 5.34 days. The study indicates that all three scores (APACHE II, SAPS II, and SOFA) perform equally well and have equal diagnostic utility in predicting 30-day mortality.

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.

We report our experience of renal disease associated with bodybuilders who had been on high-protein diet, anabolic androgenic steroids (AASs), and growth hormone (GH) for years. A total of 22 adult males who volunteered information about use of high protein diet and AAS or GH were seen over a six-year period with renal disease. Kidney biopsy revealed focal segmental glomerulosclerosis (FSGS) in eight, nephroangiosclerosis in four, chronic interstitial nephritis in three, acute interstitial nephritis in two, nephrocalcinosis with chronic interstitial nephritis in two, and single patients with membranous glomerulopathy, crescentic glomerulopathy, and sclerosing glomerulonephritis. Patients with FSGS had a longer duration of exposure, late presentation, and worse prognosis. Those with interstitial disease had shorter exposure time and earlier presentation and had improved or stabilized after discontinuation of their practice. There is a need for health education for athletes and bodybuilders to inform them about the risks of renal disease involved with the use of high-protein diet, AAS, and GH.

Only a few studies have been published on the nutritional status of hemodialysis (HD) patients in Arab countries. The aim of this study was to determine the nutritional status and prevalence of malnutrition and its predictors among HD patients at An-Najah National University Hospital, Nablus, Palestine. A cross-sectional study was carried out on HD patients in this hospital. Seven-Point Subjective Global Assessment (7-point SGA) was used to assess the nutritional state of HD patients. Biochemical tests were obtained during the study period from medical files of the studied patients. A total of 106 HD patients were recruited for this study and assessed for nutritional status. More than half (60, 56.6%) of the recruited patients were males. The majority of the patients (86.8%) were above 45 years of age. Hypertension (65, 61.3%) was the most common comorbid conditions followed by diabetes mellitus (51, 48.1%). The median SGA score was 5.57 (5–6). More than half of the HD patients (56; 52.8%) were well-nourished while the remaining (50, 47.2%) had mild-to-moderate malnourishment. Univariate analysis indicated that SGA score was significantly higher in HD patients with college education (P = 0.026), nondiabetic (P = 0.044), nonhypertensive (P = 0.037), and those with current occupation (P = 0.025). No significant correlation was found between SGA score and potassium level (P = 0.134), calcium level (P = 0.883), albumin (P = 0.282), and phosphate level (P = 0.419). However, significant positive correlation was found between SGA core and hemoglobin level (P = 0.019; r = 0.227). Multivariate analysis showed no significant predictors of SGA score. In this pilot single-center study, malnutrition was detected in almost half of HD patients using SGA scale. Development of nutritional assessment protocols for HD is an important issue and needs to be followed up by health-care teams in HD centers.

Numerous studies have addressed the predictive value of pathology findings from the Oxford Classification. Whether this influences treatment choice has not been determined. We evaluated patients with IgA nephropathy who were immunosuppressed and correlated our findings with both clinical and histological features as per the Oxford Classification. This was a retrospective observational study of 45 patients who had biopsy-proven IgA nephropathy with a mean follow-up of 2.6 years. Primary outcomes were time to end-stage renal disease (ESRD) or a 50% rise in serum creatinine. Immunosuppression was not associated with lower hazards for both ESRD and 50% rise in serum creatinine. From the Oxford Classification, only T0 was associated with significantly lower hazards for ESRD [hazard ratio (HR), 0.067; confidence interval (CI) 0.01–0.58]. Patients who had crescents and/or necrotizing lesions on biopsy were more likely to be immunosuppressed (odds ratio 9.99; 95% CI 1.99–50.06, P = 0.005) but demonstrated a statistically nonsignificant higher hazard for both renal end points (HR, 1.61; CI 0.19-13.89). Such lesions were also associated with a higher incidence of hypertension (149 vs. 135 mm Hg) and greater proteinuria (2.7 vs. 1.9 g/day) at presentation. The use of the Oxford Classification did not aid decision-making with regard to the use of immunosuppression. Crescents and/or necrosis identified on histology were associated with the use of immunosuppression. Hence, there is a need for these lesions to be evaluated further in large cohorts and incorporated into future disease classifications.

Malnutrition in dialysis population is associated with significant morbidity and mortality. Nutritional assessment is a neglected area in hemodialysis (HD) patients in developing countries. The aim of the study was to find out whether any traditional parameters have statistically significant correlation with malnutrition. All 58 end-stage renal disease patients on maintenance HD in our dialysis unit were enrolled in this cross-sectional study. The nutritional status was assessed by a predesigned questionnaire including subjective global assessment (SGA). Anthropometric measurements, peripheral neuropathy, and pertinent laboratory parameters were checked. The duration of HD ranged between three months to 10 years (mean 4 ± 1.5 years). Of these 49 patients, 26 (53%) were males with a median age 45 (25–76) years. Fifteen patients (31%) were well nourished and 34 (69%) were undernourished including nine (19%) patients classified as severely malnourished according to SGA. Malnutrition appeared more prevalent in males, however, statistically not significant (P = 0.063). On univariate and multivariate analysis, no significance was found across well-nourished and malnourished patients in terms of age, body mass index, calorie count, duration and frequency of dialysis, dry weight, interdialytic weight loss or gain in the past six months, body fat percentage, serum albumin, blood pressure, intradialytic hypotension, urea reduction ration, Kt/V_urea, peripheral neuropathy, and comorbidities. Psychosocial factors were identified in 24 (49%) patients with 19 (79%) having some degrees of malnutrition, but the finding did not reach the statistical significance. Surprisingly, the traditional factors studied in previous trials have not shown any significant association to malnutrition in our study based on the statistical analysis.

Our objective was to determine incidence, predisposing factors, and microbiological profile of urinary tract infection (UTI) in renal transplant recipients in our center. This was cross-sectional observational study, conducted at the Department of Nephrology, Army Hospital Research and Referral, Delhi, India. Two hundred and ten renal transplant recipients were studied over one year. Out of 210 transplant recipients, 69 (32.86%) had UTI. Majority (59/69) had undergone live renal transplantation and 10 cases had received cadaveric grafts. Forty-nine patients had primary infection while 20 patients had recurrences. The mean age of patients with UTI was 38.63 ± 10 years. The incidence of UTI was higher in females (42.25%) than males (28.06%, P = 0.038). Majority of patients in younger age group (age <30 years) were female (58.82%). Males were predominantly affected in higher (>30 years) age group (61.54%). Most common causative agent was Escherichia coli (72.46%). Gram-negative bacilli accounted for 94.20% (65/69) while Gram-positive cocci for 5.8% (4/69) of positive cultures. Multidrug resistance was highest in Klebsiella pneumoniae (100%). Fifteen cases with UTI were detected to have underlying urinary tract abnormalities, most common being urethral stricture (60%). One patient was detected to have broken double J stent in the renal pelvis which led to recurrent E. coli infection. Forty-eight patients (69.57%) developed acute graft dysfunction secondary to UTI. Female sex (P = 0.038), urinary tract abnormality (P <0.01), prolonged Foley's catheterization (P <0.01), prolonged hospitalization after transplantation (P <0.01), new-onset diabetes after transplantation (P <0.01), and coexisting hepatitis C infection (P = 0.012) were statistically significant predisposing factors for UTI in renal transplant recipients.

This study aimed to investigate and compare the effects of Xyla-P cream and cold compress on the pain caused by the insertion of a needle into the arteriovenous fistula (AVF) in hemodialysis (HD) patients. This clinical trial was conducted on HD patients who were selected using simple random sampling method. Using a visual analog scale, pain intensity was measured during two HD sessions in three stages including after the application of a placebo, after application of Xyla-P cream, and after the application of cold compress. The collected data were analyzed using descriptive statistics and repeated measures analysis of variance. Our results showed that there were statistically significant differences between the pain scores of the control group and Xyla-P cream group (P <0.001) and cold compress group (P <0.001) and between the pain scores of the Xyla-P cream group and cold compress group (P <0.001). The cannulation of an AVF causes moderate pain in HD patients. Cold compress is more effective than Xyla-P cream in reducing the intensity of the pain. Therefore, the nurses are recommended to use this pain relief method instead of medicinal methods.

We aimed to study the seroconversion rate in two arms of intradermal (ID) route: low dose with high-frequency and high dose with low-frequency hepatitis B (HB) vaccination in dialysis patients. A total of 56 patients, on either hemodialysis or peritoneal dialysis, were included. Patients were enrolled and randomized into two groups. The first group was immunized through the ID route and received weekly 10 μg of vaccine at 0, 1, 2, 3, 4, 5, 6, and 7 weeks (low-dose with high frequency). The second group was immunized through the ID route and received two doses of 40 μg at one-month interval (high dose with low frequency). Anti-HBs antibody titers were measured at one month and one month after completion of the vaccination, i.e., at three months in each group. At one month, each group had received 40 μg of vaccine. The seroconversion rate was 28.57% in each group. At one month after completion of vaccination, seroconversion rate in low-dose ID and high-dose ID was 60% and 58.33%, respectively (P = 0.911) at 80 μgm of total vaccine dose. The overall “good” responders in low-dose versus high-dose ID route were 30% and 50%, respectively (P = 0.179). However, among responders, anti-HBs antibody titers ≥100 mIU/mL in low-dose and high-dose ID route were 50% and 85.7%, respectively (P = 0.049). The rate of seroconversion is comparable in both low dose with high-frequency and high dose with low-frequency ID route.

The fistula first initiative has rekindled interest in transposition of basilic vein (TBV) in preference to arteriovenous grafts (AVG). TBV is considered to have advantages over AVG. The aim of this study was to analyze the outcome of TBVs in our center comparing them to a historically matched group of patients who had AVG. Thirty-two patients who underwent TBV as a vascular access procedure in Derriford Hospital between January 2010 and October 2014 were included in the study. The historical control group comprised 31 patients who had AVG inserted in the upper arm between January 1999 and December 2010. Patients who had looped AVG were excluded from the study. The primary failure rates were 22% (7/32) and 16% (5/31) for TBV and AVG, respectively (P = 0.7500). AVGs were associated with a higher incidence of infection and steal syndrome, but the differences were not statistically significant (P = 0.286 and P = 0.286, respectively). Twenty-two interventions were undertaken in the TBV group compared to 18 in the AVG group. This study shows that adoption of TBV reduces the need for AVG. To improve TBV access maturation and survival, it is necessary to consider adopting a selection criteria based on findings on vessel mapping.

Secondary renal amyloidosis (RA) is the most common type of renal involvement in ankylosing spondylitis (AS). We assessed the epidemiologic and clinico-biological profile of AS patients with RA, to analyze treatment modalities and prognostic aspects, and to determine predictive factors of RA during AS. This was a retrospective study including 13 cases of RA among 212 cases who presented with AS, during the period from 1978 to 2006. The median age of the patients at the time of diagnosing AS was 47 years (range: 19–67). There were 11 males and two females. RA onset was diagnosed after a mean follow-up of 144.6 months (range: 10–505) from the AS diagnosis. We noted erosive peripheral arthritis, lumbar stiffness with bamboo spine, and coxitis in 23.1%, 76.9%, and 30.8% of cases, respectively. Nephrotic syndrome was found in eight patients (61.5%). At the time of diagnosing RA, six patients had renal failure. Amyloid deposits were histologically proven by salivary gland biopsy in six cases (46.1%) and by renal biopsy in seven cases (53.8%). Four patients received a long-course treatment with colchicine but with a good outcome only in two cases. In our series, AS was more severe among patients with RA. Four predictive factors of RA were identified: smoking (P = 0.04), erosive peripheral arthritis (P = 0.002), bamboo spine (P = 0.001), and biologic indicators of inflammation (P = 0.0001). High erythrocyte sedimentation rate was identified as the only independent risk factor of RA during AS (P = 0.0001). Renal function as well as urinalysis should be monitored at regular intervals to detect early renal involvement during AS.

Kidney biopsy is one of the most important tools in the assessment of kidney disease as histopathological diagnosis promotes evidence-based practice in Nephrology. This study included 271 consecutive percutaneous kidney biopsies (145 males and 126 females) performed at EMS Memorial Cooperative Hospital, Perinthalmanna, Kerala, India, from September 2009 to March 2016. Among the biopsy-proven renal diseases (BPRD), primary glomerular diseases (PGD) were the most common (77.78%) followed by secondary glomerular diseases (SGD) (12.22%) and tubulointerstitial diseases (10%). The IgA nephropathy (IgAN) was the most common PGD and majority had mesangial hypercellularity (M1) (93.54%), tubular atrophy (T1 or T2 68.25%), and the most common pattern was M1, E0, S0, and T1, suggesting that patients of Indian subcontinent have aggressive disease type, unlike western literature. The focal segmental glomerulosclerosis (FSGS) was the second most common PGD and the majority were of not otherwise specified type. FSGS, membranous nephropathy and minimal change disease were the three most common causes for PGD causing nephrotic syndrome. Diabetic nephropathy and lupus nephritis were the two most common biopsy-proven SGDs. Among the patients of diabetes mellitus who underwent renal biopsy with suspicion of nondiabetic renal disease (NDRD), 58.33% had NDRD, 16.67% had DN+ NDRD, and 26.67% had DN alone. This study shows the changing pattern BPRD in comparison to earlier studies. This study also confirms the aggressive nature of IgAN in Indian patients and underlines the importance of renal biopsy in patients of DM.

In Pakistan, patients with chronic kidney disease (CKD) are commonly diagnosed at a late stage. There is little information about the refusal of hemodialysis by hospitalized CKD patients who need hemodialysis (HD) and reasons for acceptance and refusal among these patients. All patients with Stage V CKD who had medical indications to undergo HD and were hospitalized at a tertiary care facility over a six-month period were invited to participate in this study. Patients were surveyed regarding acceptance or refusing of HD and reasons for their decisions. Demographic, socioeconomic, and clinical characteristics of patients were compared between patients who accepted or refused HD. A total of 125 patients were included in the study. The mean age of the patients was 47.9 ±12.1 years. The mean duration of diagnosis of CKD was 2.5 ± 0.6 months. Of all patients, 72 (57.6%) agreed to do HD and 53 (42.4%) refused HD. Patients with arteriovenous fistula in place (27.1 vs. 9.1%, P 0.02) and those in the middle- or higher-income group (64.4% vs. 38.6%, p = 0.03) were more willing to undergo HD. Trust in doctor's advice (86.1%) was the most common reason for acceptance of HD. Frequency of HD per week (52.8%), lifelong and permanent nature of HD (50.9%), advice by family members or friends (37.7%), perception of poor quality of life on HD (35.8%), and fear of HD needles and complications during HD (33.9%) were the most common reasons for refusal. Refusal of HD is common among hospitalized CKD patients with medical indications to undergo HD, especially in lower income group.

Chronic kidney disease (CKD) is one of the leading causes of chronic diseases globally, with rising incidence and prevalence. It is a major risk factor for cerebrovascular disease and coronary artery disease, which are the main causes of death in this population. The etiology of CKD is varied. This study was performed to evaluate the various etiologies of CKD among patients presenting to the Department of Nephrology, Guwahati Medical College, a tertiary referral center. A total of 5718 CKD patients were evaluated to identify the cause of CKD. The most common cause was found to be diabetes mellitus in 42.2%, followed by chronic glomerulonephritis in 21.4%, hypertension in 19.5%, obstructive uropathy in 6.9%, chronic interstitial nephritis in 3.6%, and autosomal dominant polycystic kidney disease in 1.5% of the patients. Nearly 2.7% of the patients had CKD of unknown etiology. Most of the common causes of CKD are potentially treatable and initiating appropriate treatment early may prevent the development of CKD or progression to end-stage renal disease.

Acute kidney injury (AKI) in the elderly is characterized by high mortality. The objective of this study is to identify the causes of death in the elderly with AKI. This is a prospective cohort study with a descriptive purpose which was carried out during the period from January 2009 to December 2014 in the Department of Nephrology-Internal Medicine of Treichville University Hospital. The diagnosis of AKI was made on the basis of serum creatinine (SCr) values determined during hospitalization, according to KDIGO classification. Our study involved 107 elderly aged 65 and older with AKI. The hospital mortality rate was 46.7% (50/107). The average age of deceased patients was 71.8 ± 7 years with extremes of 65 and 90 years. We observed a male predominance with a sex ratio (41/9) of 4.55. AKI on admission was in Stage 1 in 16% of cases, in Stage 2 in 24%, and in Stage 3 in 60% cases. SCr was normal in 8%, the AKI was in Stage 1 in 34% (P = 0.09), Stage 2 in 18% (P = 0.001), and Stage 3 in 40% (P = 0.0001). AKI in deceased patients was organic in 36% of cases, obstructive in 30%, and functional in 6%. The etiologies of AKI were infections (46%), cancer (18%), benign tumors of the urinary tract (12%), malignant hypertension (6%), decompensated heart disease (6%), and drugs (6%). The main causes of death were sepsis (28%), cardiovascular disease (22%), severe renal failure (20%), pelvic cancers (16%), and liver failure (12%). All patients with cancer (P = 0.001) or HIV infected (P = 0.009) died. Sixty-eight percent of deaths occurred the 1^st week. Death was earlier by sepsis and cardiovascular disease than by cancer. Mortality is high in the elderly. The main causes of death were sepsis, cardiovascular disease, renal failure, pelvic cancer, and liver failure.

This is a case report of a 68-year-old hypertensive, diabetic woman who was on regular thrice weekly hemodialysis (HD). She presented with gradually worsening left lower limb pain and swelling. Clinical examination revealed significant edema over the left calf and ankle joint with significant calf tenderness. Extensive workup including magnetic resonance imaging of the lower limb and venous Doppler failed to show any significant abnormality. In view of developing papular lesions over the area, skin biopsy was performed, which finally confirmed reactive perforating collagenosis. This diagnosis ensured reassurance to the patient with halting of further extensive and probably expensive testing. Simple conservative management and symptomatic relief improved the pain over the next few days. This case report highlights the importance of keeping a wide differential for calf tenderness in diabetic HD patients and projects reactive perforating collagenosis as one of the important but frequently missed entities in such a scenario.

Although the relationship between Kaposi's sarcoma (KS) and renal transplant has been well described, there are rare cases of KS concurrent with membranous glomerulonephritis or other glomerular diseases. In this report, a patient with membranous glomerulonephritis that accepted long-term prednisolone and cyclosporine immunosuppressive therapy developed skin KS. Withdrawal of immunosuppressive treatment resulted in the disappearance of KS.

Abdominal symptoms are common in patients with lupus nephritis and are often attributed to drugs or uremia per se. Lupus mesenteric vasculitis (LMV) or lupus enteritis is a rare entity reported in patients with active systemic lupus erythematosus. It usually occurs in patients with a long-standing history of lupus with high disease activity. Usually, small bowel is predominantly affected. The stomach and rectum are spared in view of significant collateral circulation. Here, we describe an 18-year-old boy who presented with nephrotic syndrome without any extrarenal features of lupus. On subsequent evaluation, he was found to have active lupus nephritis. He developed acute gastric dilatation secondary to extensive LMV. Imaging showed an extensive involvement of gastrointestinal tract from the stomach to the sigmoid colon, sparing the rectum. To the best of our knowledge, this is the first report of LMV presenting as acute gastric dilatation.

With resurgence of multidrug resistance (MDR) bacteria and no new novel broad-spectrum antibiotic in research pipeline, usage of older generation antibiotics, once discarded due to their toxicity profile are becoming popular again. Often these drugs are the only option left in managing MDR bacteria-related sepsis. Colistin is one of such antibiotic which is often used in recent times after decades of its avoidance due to its diverse toxicity profile. In this case report, we present a rare myasthenic syndrome like neuromuscular complication developed in a patient after receiving colistin for treatment of MDR Klebsiella-related urosepsis.

Systemic lupus erythematosus (SLE) presenting as diabetes insipidus (DI) is a rare association; there is a case report of neurogenic DI in patients of SLE; however, SLE and nephrogenic DI has not been reported in literature. We present a case of SLE presenting as nephrogenic DI. We report a case who presented with DI (nephrogenic) and fulfilled criteria for SLE and Sjögren's syndrome with renal tubular acidosis.

A significant proportion of individuals with systemic lupus erythematosus (SLE) will have clinical or laboratory evidence of renal involvement at some point in the course of their disease. Lupus nephritis (LN) is one of the more important systemic manifestations of SLE and although progression to end-stage renal disease (ESRD) is not usually the norm, a significant minority of patients will do so, some in a rather dramatic fashion. It is in such instances that LN constitutes a true nephrologic emergency. Gratifyingly, it is rarely a silent emergency and heightened awareness amongst clinicians about its unpredictable course should lead to earlier recognition and intervention. For this reason, a case of LN presenting with historical and histologic evidence of chronic kidney disease and superimposed, acute acceleration of renal function decline, leading rapidly to ESRD is reported here. A brief review of the literature surrounding the pathophysiologic mechanisms, clinicopathologic characteristics and current therapeutic approaches to LN is subsequently explored.

Paraneoplastic glomerulopathy (PG) includes a group of glomerular lesions that are not directly related to tumor burden, invasion, or metastasis, but induced by products from tumor cells such as hormones, growth factors, cytokines, and tumor antigens. PG was first described by Galloway in 1922, in which nephrotic syndrome (NS) secondary to Hodgkin's lymphoma was reported. They can present before, at the time of diagnosis, during remission, or at relapse of the hematological malignancies. We present three cases of paraneoplastic NS associated with hematological malignancies. Early diagnosis and treatment can alter prognosis of these patients. Paraneoplastic syndromes would remit only with proper treatment of the neoplasia.

Secondary amyloidosis Amyloid A (AA) is an infrequent but a severe complication of Crohn's disease (CD). This complication results from the activity of the underlying inflammation disease to form amyloid fibril deposits in tissues. We present a case of a 34-year-old female patient with CD treated by azathioprine with inactive disease for three years and who developed a nephrotic syndrome secondary to AA amyloidosis. The treatment by infliximab for one year leads to a complete remission of the nephrotic syndrome. In this case, this complication occurred while the patient was clinically well, with biological and endoscopic markers showing an inactive or only mildly active disease. Infliximab could be a useful tool for a successful treatment of amyloidosis secondary to CD.

Adenine phosphoribosyltransferase deficiency is a rare, inherited autosomal recessive disease presenting with 2,8-dihydroxyadenine (DHA) urolithiasis, DHA nephropathy, and chronic kidney disease. The presence of DHA crystals in urine and renal biopsy is pathognomonic of the disease. We report a 23-year-old female with acute renal failure and nephrotic proteinuria. Urinalysis showed reddish brown, round crystals with dark outline, and central spicules consistent with 2,8-DHA crystals. Renal biopsy showed membranous nephropathy and 2,8-DHA nephropathy. Our patient improved with liberal fluid intake, restriction of high adenine content foods, and oral xanthine dehydrogenase inhibitor febuxostat. Early diagnosis and initiation of treatment prevent renal complications.

Peritoneal dialysis (PD)-associated peritonitis is an important contributor to morbidity and mortality; Gram-positive bacteria constitute the most frequent associated pathogens (45%–60%) followed by Gram-negative bacteria (25%–40%) and fungal infection (3%–6%). Salmonella peritonitis is an extremely rare cause of peritonitis (0.15%). Peritonitis attributed to Salmonella has been reported only in four cases. Herewith, we report a 68-year-old Sudanese female who presented to our PD unit with abdominal pain and diarrhea and was diagnosed to have Salmonella peritonitis. She was managed without catheter removal. To our knowledge, the association between Salmonella peritonitis due to Salmonella enteritidis in a patient on PD managed without catheter removal has been reported in only one case previously.

Interstitial nephritis and immune complex-mediated glomerulonephritis are the two common renal manifestations of primary Sjögren's syndrome (SS). Here, we discuss three cases of primary SS where presenting manifestation was distal renal tubular acidosis. The possibility of an underlying autoimmune disorder should be considered in a patient presenting with distal tubular acidosis or recurrent hypokalemic periodic paralysis as treatment of primary disease improves the outcome of illness.