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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
Coverpage
March-April 2019
Volume 30 | Issue 2
Page Nos. 281-559

Online since Tuesday, April 23, 2019

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EDITORIAL  

Burden, access, and disparities in kidney disease p. 281
Deidra C Crews, Aminu K Bello, Gamal Saadi, for the World Kidney Day Steering Committee
DOI:10.4103/1319-2442.256834  
Kidney disease is a global public health problem, affecting over 750 million persons worldwide. The burden of kidney disease varies substantially across the world, as does its detection and treatment. In many settings, rates of kidney disease and the provision of its care are defined by socio-economic, cultural, and political factors leading to significant disparities. World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. Here, we highlight that many countries still lack access to basic diagnostics, a trained nephrology workforce, universal access to primary health care, and renal replacement therapies. We point to the need for strengthening basic infrastructure for kidney care services for early detection and management of acute kidney injury and chronic kidney disease across all countries and advocate for more pragmatic approaches to providing renal replacement therapies. Achieving universal health coverage world-wide by 2030 is one of the World Health Organization’s Sustainable Development Goals. While universal health coverage may not include all elements of kidney care in all countries, understanding what is feasible and important for a country or region with a focus on reducing the burden and consequences of kidney disease would be an important step towards achieving kidney health equity.
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REVIEW ARTICLES Top

Therapeutic plasma exchange for children with kidney disorders: Definitions, prescription, indications, and complications Highly accessed article p. 291
Khalid A Alhasan
DOI:10.4103/1319-2442.256835  
Therapeutic plasma exchange (TPE) is a procedure that involves the removal of a large volume of plasma that is replaced with a replacement fluid, which is usually 5% albumin or fresh-frozen plasma. This therapeutic modality presents several technical challenges in children but has become increasingly used in pediatric nephrology. Owing to advances in technology, scientists have gained substantial knowledge of the molecular pathogenesis underlying many pediatric renal diseases, supporting the use of TPE in treating these disorders. This review presents a synopsis of the literature as it relates to the accepted indications for TPE in children, the technical aspects of the procedure, and the associated complications. Increased collaboration between pediatric nephrologists will hopefully allow scientists to obtain more data in children to assess the benefits of TPE in various renal disorders and improve the quality of care provided in children with renal disorders.
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Birth weight, gestational age, and blood pressure: Early life management strategy and population health perspective p. 299
Issa Al Salmi, Faisal A M. Shaheen, Suad Hannawi
DOI:10.4103/1319-2442.256836  
The incidence of hypertension (HTN) is rising worldwide with an estimated prevalence of 22%, 7.5 million deaths (12.8%). It is a major risk factor for coronary heart diseases and hemorrhagic strokes. In Oman, the crude prevalence of HTN was 33.1%, whereas the age-adjusted prevalence was 38.3%. Among Gulf Cooperation Countries, 47.2% of the individuals were hypertensive, and women were more likely to have HTN than men. Similarly, the prevalence of low-birth-weight (LBW) is also rising globally with the more prevalent incidence in developing countries reaching almost a rate just lower than 20.0/100 births. In Oman, the prevalence of LBW was 4.2% in 1980, which doubled (8.1%) in 2000 and has shown a slow but steady increase reaching 10.2% in 2013. LBW term is the most commonly used surrogate measure of intrauterine growth retardation and has been related to increased cardiovascular mortality, due to increased risk of cardiovascular risk factors, including blood pressure (BP), diabetes, cholesterol level, and other risk factors. The epidemiologic evidence clearly points to an inverse association between birth weight and many hemodynamic cardiovascular risk markers. Possible mechanisms operating in fetal life that might determine BP include the structural development of resistance arteries, the setting of hormone levels, and nephron endowment. Retarded fetal growth leads to permanently reduced cell numbers in the kidney. Patients with high BP had almost 50% less number of glomeruli compared to that of the normotensive individuals, and subsequent accelerated growth may lead to excessive metabolic demand on this limited cell mass. It is not merely a reduced nephron number that is responsible for HTN, but compensatory maladaptive changes that occur internally when nephrogenesis is compromised. The likelihood of an adverse outcome is greatly amplified in those born with LBW who later develop obesity or an increased ponderal index.
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Chyluria in pregnancy: Etiology, diagnosis, and management perspective p. 309
Bimalesh Purkait, Gaurav Garg, Manmeet Singh, Ashish Sharma, Siddharth Pandey, Satya Narayan Sankhwar
DOI:10.4103/1319-2442.256837  
Chyluria is clinically described as passage of milky urine. Chyle is absorbed by intestinal lacteals and is composed of emulsified fats, few proteins, and fibrin in varying proportions. Parasitic chyluria is caused mainly by Wuchereria bancrofti infection. The incidence of chyluria in pregnancy is not uncommon in endemic regions. The literature pertaining tomedical management of chyluria in pregnancy is scant. The antifilarial drugs have potential teratogenic risk and are not recommended in pregnant patients. Hence, there is a management dilemma for managing patients with chyluria during pregnancy. In this review, we have tried to highlight the evidence-based diagnosis and management of chyluria in pregnancy.
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ORIGINAL ARTICLES Top

Association of hepcidin and anemia in early chronic kidney disease Highly accessed article p. 315
Satyendra Kumar Sonkar, Neeraj Kumar Singh, Gyanendra Kumar Sonkar, Sant Pandey, Vivek Bhosale, Anil Kumar, Kauser Usman
DOI:10.4103/1319-2442.256838  
Hepcidin is being extensively studied for anemia and inflammation in chronic kidney disease (CKD) patients. Hepcidin is thought to regulate iron metabolism by iron blockade through various mechanisms. Patients with CKD have early cardiac mortality due to anemia and subclinical inflammation; hence, we studied hepcidin as a biomarker in patients with early stage of CKD in relation to anemia and inflammation. In our cross-sectional study, a total of 80 patients were enrolled of whom, there were 25, 26, and 29 patients in CKD stages 1, 2, and 3, respectively. Patients were divided into normal iron level (39), functional iron deficiency (FID) (18), and absolute iron deficiency (AID) (23) based on transferrin saturation and ferritin. We found significantly high level of hepcidin (P <0.05) and high-sensitivity C-reactive protein (hsCRP) (P <0.05) in FID as compared to AID as well as normal iron level. We also found other inflammatory markers such as albumin, transferrin, and ferritin to be significantly associated with FID. In univariate analysis, hemoglobin (Hb) varied significantly with serum total iron-binding capacity (r = 0.40, P <0.001), log hsCRP (r = -0.32, P <0.01), and log ferritin (r = -0.23, P <0.05); however, Hb was not affected significantly with log hepcidin (r = -0.07, P >0.05). The study indicates that among early CKD patients with FID, there was high level of hepcidin along with other inflammatory parameters, which may be associated with poor cardiovascular disease outcome due to increased inflammation.
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Acute cortical necrosis in pregnancy still an important cause for end-stage renal disease in developing countries p. 325
Anupma Kaul, Hiral Lal, Prabhakar Mishra, Manoj Jain, Narayan Prasad, Mandakini Pradhan, Manas Ranjan Patel, Amit Gupta, Raj Kumar Sharma
DOI:10.4103/1319-2442.256839  
Renal cortical necrosis (RCN) is a serious complication of acute kidney injury (AKI) and pregnancy is a clinical state closely associated with it with poor renal outcomes. The incidence is much higher in obstetrical AKI compared to other causes of RCN. Despite better medical care facilities available, this continues to be an important cause of morbidity and mortality in developing countries. This is a retrospective analysis among all pregnant females presenting with AKI from January 1999 to December 2014 at a tertiary care center in the northern part of India. We looked for the incidence of obstetrical-related RCN in our renal biopsies performed in the last 15 years and to evaluate precipitating factors responsible for RCN. RCN constituted 8.3% of pregnancy-related AKI cases in our institution. The overall incidence has been declining which was 9.09% from 1999 to 2008 to 7.8% from 2009 to 2014. The patient’s median age was 29.3 ± 5.2 years. The average time to presentation from the day of delivery was 8.7 ±2.1 days. The mortality was observed in 11.7% of them with sepsis and multiorgan dysfunction present in all of them. The most common etiology for RCN was found to be septic abortion and puerperal sepsis accounting for - 15.3% each. Postpartum hemorrhage was a cause in 9.09% of patients. The most important cause of RCN was postpartum thrombotic microangiopathy which was observed in 48.7% of patients. Kidney biopsy was helpful in diagnosis in 31 patients while computed tomography scan abdomen alone helped in diagnosis in five patients. Patchy cortical necrosis in histology was seen in 35.4% of patients and morbidity in terms of prolonged hospitalization was seen in 22.7% while dialysis dependency in 61.5% of the study population. In conclusion, strategies need to be implemented in reducing the preventable causes for RCN which is not only catastrophic in terms of renal outcomes but also for social and psychological perspectives as well.
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Seroconversion following hepatitis B vaccination in children with chronic kidney disease p. 334
Nivedita Kamath, Anil Vasudevan, Arpana Iyengar
DOI:10.4103/1319-2442.256840  
Seroconversion following hepatitis B vaccination is low in children with chronic kidney disease (CKD). This study aimed to assess the seroconversion and persistence of protective immunity following hepatitis B vaccination in children with CKD. This prospective observational study was conducted in a tertiary pediatric nephrology centre to assess the seroconversion and maintenance of antibody titers (>10 mIU/mL) at one year following hepatitis B vaccination (10 μg at 0, 1, and 2 months) in children with CKD Stages II to V. Those who did not seroconvert after the schedule were re-vaccinated, and antibody titers were checked. Categorical data were expressed as proportions and analyzed using the Chi-square test. Pearson’s correlation test was used to determine the correlation of antibody titers with other continuous variables. Seroconversion was observed in 72% (n = 26/36) after vaccination. Only 60% (n = 6/10) had seroconversion after the second course of vaccination. Only 60% of children (n = 12/20) who seroconverted had protective antibody titers at one year. Seroconversion following three doses of hepatitis B vaccine is low in children with CKD. Antibody titers should be monitored periodically as the protective immunity wanes rapidly.
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Status of fasting in Ramadan of chronic hemodialysis patients all over Egypt: A multicenter observational study p. 339
Abir Farouk Megahed, Ghada El-Kannishy, Nagy Sayed-Ahmed
DOI:10.4103/1319-2442.256841  
There is a paucity of data concerning safety of fasting in Ramadan in chronic kidney disease patients on hemodialysis (HD). The aim of the present study was to assess the frequency of fasting in Ramadan in HD patients in Egypt and the possible effect of fasting on clinical and biochemical variables. This observational multicentric study was carried out during 2016 when fasting duration was around 16 h.
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A study of detection and comparison of immunofluorescence on formalin-fixed paraffin-embedded tissue with fresh frozen renal biopsy specimen p. 350
Ranjana Solanki, Madan Kumar Solanki, Deepika Hemrajani, Jayesh Saha
DOI:10.4103/1319-2442.256842  
Direct immunofluorescence on the fresh frozen tissue is established way of demonstrating of immunoglobulins and complement deposition in renal biopsies. IF studies can be done on paraffin-fixed tissue (IF-P) and give comparable results to those obtained on frozen tissue for most pathogenic immunoglobulins and immunoglobulin fragments; although, the detection of C3c may be more problematic. In our study, we used proteinase-K method for antigen retrieval. We aimed to detect immunoglobulins and complements in formalin-fixed paraffin-embedded (FFPE) tissue sections from renal biopsies and have comparison of IF staining intensity on FFPE sections with conventional IF on fresh frozen tissue. Based on our results, we conclude that IF-P can serve as salvage technique and has significant diagnostic utility.
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Postoperative complications in living liver donors: A retrospective study, single-center experience in Saudi Arabia p. 359
Nouf Abdulaziz Althonaian, Alanoud Saleh Alsaiari, Weaam Ahmed Almanea, Norah Jezaa Alsubaie, Awatif Ali Almuharimi, Alaa Althubaiti, Abdulrahman Rashed Altamimi, Khalid Omer Abdullah, Wael Abdulaziz Ohali
DOI:10.4103/1319-2442.256843  
Living donor liver transplantation (LDLT) offers life to patients with end-stage liver disease. The balance between the benefit to the recipient and the risk to the donor plays a central role in justifying LDLT. However, the incidence rates of complications posttransplant differ widely. This study is designed to identify postoperative complications in LDLT in a tertiary care center King Abdulaziz Medical City (KAMC). This was a retrospective cohort study. All donors at KAMC between January 2003 and December 2015 were reviewed through a hospital database and patient charts to determine the postoperative complications based on the modified Clavien classification system. All donors were relatives of the recipients and assessed before the surgery. A total of 101 donors underwent LDLT: 75 were male and 26 were female, with a mean age of 27.7 ± 6.6. The breakdown of specific surgical procedures was as follows: 65 (64.3%) donors underwent right hepatic lobectomy, 31 (30.6%) underwent left lateral hepatectomy, three (2.97%) underwent extended right hepatectomy with the inclusion of the middle hepatic vein, and two (1.98%) underwent left hepatectomy. Postoperative complications were determined in 20 patients (19.8%), but no mortality was observed. Complications were reported in 14 (21.5%) right and six (19.4%) left lateral hepatectomy donors. A total of 12 patients had Grade I complications, six patients had Grade II complications, and Grade III complications were reported in two cases. The most frequent complications were upper limb weakness to brachial plexus neuropathy and mild bile leak. Life-threatening complications in our center have not been reported in LDLT; however, some donors may experience postoperative morbidity, which usually were mild and had a good prognosis.
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Impact of age and gender matching on long-term graft function and actual graft survival in live-related renal transplantation: Retrospective study from Sindh Institute of Urology and transplantation, Pakistan p. 365
Madhu Mati Shahani, Tanweer Iqbal, Muhammad Khalid Idrees
DOI:10.4103/1319-2442.256844  
In renal transplantation, donor and allograft age are known to have an important influence on the outcome of the graft, reflecting functional renal mass. We evaluated the impact of gender and age matching in living-donor renal transplantation on long-term graft survival and actual graft function over five years from the day of transplantation. We retrospectively analyzed 500 primary live-related donor renal transplants performed from August 2007 to December 2008 at Sindh Institute of Urology and Transplantation, Karachi, Pakistan. Donors and recipients were divided into two age groups [young (YD) and elderly (ER)] with 40 years as cutoff line. Four donor recipient groups according to age match and age mismatch: YD/YR – ED/ER – YD/ER – ED/YR and four groups according to donor-recipient gender combinations: male recipients of male donors (MR/MD)–female recipients of male donors (FR/MD)–female recipients of female donors (FR/FD)–male recipients of female donors MR/FD) were studied. Serum creatinine was used to assess graft function after transplantation. The Kaplan–Meier method with the log-rank test was used to assess actual graft survival at five years. Actual graft function of four study groups based on age difference had no statistically significant difference at five years (P = 0.094). Regarding the actual graft survival, the best results were seen in young donor to elderly recipient group as compared to all other age combination groups. At five-year post-transplant, MD/MR had significantly better graft function than MR/FD and FR/MD had significantly better graft function than FD/FR and FD/MR. The actual graft survival was best in male-to-male (86%) compared to the lowest in female-to-female transplants (75%). The graft function at five years was better in elderly recipients of young donor kidneys. The actual graft survival was influenced positively by young donor age and negatively influenced by pre-transplant hepatitis C positivity of recipients.
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Acute-phase proteins as promoters of abdominal aortic calcification in chronic dialysis patients p. 376
Petar Avramovski, Maja Avramovska, Kosta Sotiroski, Aleksandar Sikole
DOI:10.4103/1319-2442.256845  
The aim of this study was to find a correlation between acute-phase proteins (APPs) and abdominal aortic calcification (AAC) as well as the impact APPs on AAC in chronic dialysis patients (CDPs). Native lateral lumbar radiography and biochemical analysis were performed in 112 CDPs (aged 60.0 ± 5.43 years) to estimate and score AAC and biochemical values of APPs. The mean AAC score was 8.39 ± 5.43. We detected 16 (14.28%) CDPs without AAC and 96 (85.71%) CDPs with AAC (10 ± 5.43). The number of CDPs with AAC ≤4 was 34 (30.36%) with mean AAC score of 1.85 ± 1.94. By multiple regression analysis, we found positive correlation between AAC and ferritin (β = 0.004398, P = 0.0085) and AAC and C-reactive protein [(CRP), β = 0.1972, P = 0.0178]. Sensitivity/specificity pairs and criterion variables (CrVs) were as follows: for CRP: 44.21%, 100%, and CrV ≥6 and for ferritin: 83.16%, 56.25%, and CrV ≥196.32. The area under curve (AUC) for CRP and ferritin was 0.721 (P <0.0001) and 0.730 (P <0.0026), respectively. Fibrinogen and serum iron AUC in the prediction of AAC were 0.533 (P = 0.5749) and 0.618 (P = 0.0795), respectively. CRP and ferritin were the most powerful APPs involved in the promotion of AAC; serum iron and fibrinogen were shown as lower activity promoters in CDPs. Serum albumin showed inverse activity on AAC.
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The role of matrix metalloproteinases 2 in atherosclerosis of patients with chronic kidney disease in type 2 diabetes p. 387
Amin R Soliman, Khaled M Sadek, Karem K Thabet, Dina H Ahmed, Osama M Mohamed
DOI:10.4103/1319-2442.256846  
Matrix metalloproteinase-2 (MMP2) has been implicated in chronic disease and cardiovascular disease. However, there is no knowledge about the correlations between serum levels of MMP-2, proteinuria and atherosclerosis in patients with diabetic nephropathy (DN). We investigated whether serum MMP-2 levels were associated with proteinuria, intima-media thickness (IMT) in DN patients. Diabetic patients not on hemodialysis (n = 50) were enrolled for the study. MMP-2 levels were measured using an ELISA system. IMT was evaluated by highresolution ultrasonography. Univariate analyses revealed that MMP-2 (P = 0.013) were independent correlates of proteinuria. Further, multivariate analyses revealed that MMP-2 levels (P = 0.001) were independent correlates of IMT. MMP-2 levels were significantly (P = 0.001) higher in patients with atherosclerosis than those without it. The present study demonstrates that serum levels of MMP-2 were one of the independent correlates of proteinuria and IMT in patients with DN. Our results suggest that serum MMP-2 levels may be one of the risk factors for renal damage and atherosclerosis in DN patients.
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Renal manifestations of dengue viral infection Highly accessed article p. 394
Mahesh Eswarappa, Sujeeth Bande Reddy, Manns Manohar John, Sarita Suryadevara, Rakesh Parampalli Madhyashatha
DOI:10.4103/1319-2442.256847  
Dengue-related renal manifestations such as proteinuria, hematuria in the absence of thrombocytopenia, rhabdomyolysis, and acute kidney injury (AKI) are not uncommon. There is relatively sparse data on the renal manifestations of dengue viral infection (DVI). Hence, a retrospective study was conducted to investigate the incidence, characteristics, and clinical outcome of DVI with renal manifestations. A total of 2416 patients were admitted to our hospital with the diagnosis of dengue fever during the study period from 2012 to 2015. Data were collected from the electronic medical records and were analyzed retrospectively. The disease severity was classified according to the World Health Organization criteria. The renal manifestations were divided into AKI and non-AKI groups using AKI Network (AKIN) criteria. Proteinuria was defined as urinary protein >1+ (30 mg/dL) by dipstick test. A total of 218 patients were found to have proteinuria (9.56%). Most of the patients [135 (58.44%) with renal manifestations] were aged between 15 and 30 years. Comorbid conditions including diabetes mellitus, hypertension, and ischemic heart disease were seen in 10 (4.31%), 11 (4.76%), and six (2.59%) patients, respectively. Nephrotic-range proteinuria was seen in five patients (2.16%). AKI was seen in 82 patients (3.4%); 58 (70.73%) had AKIN-I, 19 (23.17%) had AKIN-II, and five patients (6.09%) had AKIN-III. Death occurred in 11 patients (39.28%) with AKI. The incidence of renal manifestations (proteinuria, hematuria, and AKI) is high at 9.59% among patients with dengue, and those with AKI had significant morbidity, mortality, longer hospital stay, and poor renal outcomes. Our findings suggest that AKI in dengue is likely to increase health-care burden that underscores the need for clinician’s alertness to this highly morbid and potentially fatal complication for optimal prevention and management.
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Short- and long-term follow-up of living kidney donors p. 401
Imen Abdellaoui, A Azzabi, W Sahtout, F Sabri, W Hmida, A Achour
DOI:10.4103/1319-2442.256848  
Living-donor kidney transplantation is a well-established treatment of end-stage renal disease in Tunisia. Over the years, concerns have increased about the harmlessness of kidney donation. This longitudinal single center study was carried out to evaluate the safety of nephrectomy as well as further medical and surgical outcomes among donors. We collected and analyzed clinical, biological, biochemical and kidney size data at the time of nephrectomy and at M1, M3, M6, Y1, Y2, and Y4 after donation measured by ultrasound. All donor nephrectomies performed in the nephrology and transplantation unit of Sahloul Hospital of Sousse since October 2006 were included. Criteria of exclusion were lost to follow-up or lack of complete data. Of the 106 donors (66 females and 40 males), 92 donors were included in the follow-up analysis after following exclusion criteria. The mean age at the time of nephrectomy was 42.8 ± 10 years with the sex ratio 0.6. and 27% of our donors were mothers. Twenty-two percent of the donors were obese and 4% were hypertensive. The median initial glomerular filtration rate (GFR) was 105 mL/min/1.73 m2. The surgical approach was costal lumbotomy in 96% of cases and laparoscopy for four cases. The kidneys were removed from the left side in 93% of cases. Postoperative mortality was zero and early postoperative morbidity was low. The median duration of hospital stay was nine days. During follow-up, 14% attended all recommended visits. The median follow-up duration was 26 months. After two years post donation, the prevalence of HTN was 28% and obesity was 26%. The prevalence of GFR decline (50–59 mL/min) was 14% using formula by modification of diet in renal disease. None of our donors reached stage 4 or 5 CKD. Twelve had proteinuria and one donor had diabetes, a comparable prevalence of morbidities to the general population.
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Acute kidney injury in children: A study of etiology, clinical profile, and short-term outcomes at the University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria p. 421
Emmanuel A Anigilaje, Adogah I Adebayo, Sunday A Ocheni
DOI:10.4103/1319-2442.256849  
A major hindrance in programs designed to reduce deaths from acute kidney injury (AKI) is that the extent and nature of AKI are often unknown. This article reports the etiology, clinical profile, and short-term outcomes of children managed for AKI at the University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria. Children aged one month to 15 years managed for AKI (identified by pediatric RIFLE criteria) from January 2017 to December 2017 were followed up for a short period of four weeks following the AKI. Multivariate Cox regression model was used to analyze the predictors of mortality. An annual prevalence of 26 AKI cases per 1000 children was recorded with 43 AKI cases from 1634 children seen during the 12-month period. The median age was 48 months. Twenty-two were males (51.2%). Sepsis (20, 46.6%), acute glomerulonephritis (5, 11.6%), diarrheal dehydration (5, 11.6%), severe falciparum malaria (4, 9.3%), and hemolyticuremic syndrome (4, 9.3%) were the major causes of the AKI. Fourteen children were managed conservatively, while 29 children that required dialysis had access to it. Thirteen children died (percentage mortality of 30.2%). The hazard of dying was eight times more in male gender [95% confidence interval (CI); 1.03–72.9, P = 0.017] and was lower in children without pulmonary edema by 0.14 (95% CI; 0.03–0.63, P = 0.01). In our setting, mortality from AKI is still high, and male children and those with pulmonary edema should be closely managed for AKI to reduce this high mortality.
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BRIEF COMMUNICATIONS Top

Attendees’ feedback on king abdulaziz medical city pilot chronic kidney disease education class p. 440
Elwaleed A Elhassan, Mohammed Al-Ruwaymi, Aymun I Osman, Abdulla A Al-Sayyari
DOI:10.4103/1319-2442.256850  
Despite similar or better patient outcomes, peritoneal dialysis and pre-emptive kidney transplantation are underutilized in Saudi Arabia. Moreover, most patients with end-stage renal disease begin dialysis in unplanned fashion necessitating the commencement of dialysis using central venous catheter access. We aimed to investigate if early patient education can help in overcoming these barriers. The study is a survey-based study at King Abdulaziz Medical City, Riyadh Dialysis Center. In January 2017, we started a monthly Chronic Kidney Disease Education Class in our center. Since then, 14 classes have taken place attended by 54 patients referred from outpatient nephrology clinics with chronic kidney disease (CKD) stages IV and V. The mean age was 51.6 years (16–85); 32 of the attendees were male and 22 were female. The class consisted of a slide informative presentation, a display of educational materials, and interactions with a multidisciplinary team from dialysis, transplantation, vascular access, and dietician services. A feedback survey was given to attendees at the conclusion of the class covering three domains; speakers, the program, and their personal reflections. Feedback options were laid out as “excellent, very good, good, fair, and poor.” All class attendees responded to the questionnaire (100% response rate). The overall class evaluation was positive with the majority of attendees giving “excellent” rating for the speakers and the educational materials covered. Most thought that the class made them understand CKD nature better and helped them choose the right modality of renal replacement therapy. This initiative proves the feasibility of a sustained and attendee-gratifying education class to inform patients with advanced CKD about different options of renal replacement therapy and the need for timely preparation. To objectively measure the class’s effect, the next phase of this review will define the ultimate outcome of each of its attendees.
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Clinicopathological features and risk factors analysis of IgA nephropathy associated with acute kidney injury: A single-center retrospective study p. 445
PJ Mahanta, Bishal Agarawalla, Manjuri Sharma
DOI:10.4103/1319-2442.256851  
The aim of this study is to investigate the distinctive clinicopathological characteristics of acute kidney injury (AKI) in immunoglobulin A (IgA) nephropathy and identify the possible risk factors for AKI in IgA nephropathy. This study was a hospital-based retrospective analysis of clinicopthological data of IgA nephropathy. The study was conducted in the Department of Nephrology, Gauhati Medical College and Hospital, Assam, India from the period from January 2012 to December 2016. A total of 169 patients who met the inclusion or exclusion criteria were included in the study. Patient data (clinical/demographic and laboratory data including renal biopsy) were collected and were analyzed to assess the risk factors for AKI in IgA nephropathy. For the purpose of analyses, the patients were divided into two groups, AKI (n = 28) and non-AKI group (n = 141). Twenty-eight patients out of 169 developed AKI. The prevalence of AKI in IgA nephropathy patients in our center was 16.5% (28/169). Most AKI patients were hypertensive, hyperlipidemic, had pre-existing impaired kidney function, and higher baseline serum creatinine, higher serum uric acid, and proteinuria, with lower serum albumin and hemoglobin (P <0.05). Use of herbal medications was also significantly more common in the AKI group (P <0.003). Pathological features, like crescents (both cellular and fibrocellular) and interstitial fibrosis/tubular atrophy, were also more severe in the AKI group (P <0.003). In multivariate logistic regression analysis, we found that hypertension, proteinuria, cellular and fibro-cellular crescents, glomerular sclerosis were possible risk factors for AKI. Prevalence of AKI in IgA nephropathy is not as uncommon in north-eastern India as previously thought and knowledge of risk factors for AKI can help in early identification of individuals at risk.
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RENAL DATA FROM THE ARAB WORLD Top

Long-term clinical outcomes of peritoneal dialysis patients: 10-year experience of a single unit from Tunisia p. 451
Lilia Ben Lasfar, Yosra Guedri, Dorsaf Zellama, Imen El Meknassi, Awatef Azzebi, Sinda Mrabet, Asma Fradi, Salma Toumi, Ferdaous Sabri, Samira Ben Amor, Wissal Sahtout, Abdellatif Achour
DOI:10.4103/1319-2442.256852  
Published data on the outcome of maintenance peritoneal dialysis (PD) since the initiation of PD in Tunisia is poor. The purpose of this study is to report long-term clinical outcomes of PD patients through a 10-year experience at a single unit. This is a retrospective review of the medical records of 182 PD patients who were followed up from January 2006 to June 2016. All patients were followed till death, renal transplant, switch over to hemodialysis (HD) or the end of the study in June 2016. The mean age of the incident patients was 43.93 ± 16.95 years. Nineteen (10.4%) were aged >65 years and 59.3% were male. The average duration of follow-up was 27.75 ± 26.18 months. The mean duration of PD treatment was 27.75 ± 26.18 months. There were 186 episodes of peritonitis that occurred over the total study period (54 episodes during the 1st year). The overall incidence of peritonitis during the 10-year study period was 1 per 27.25 patient months. Mechanical complications were noted in 31.2% of cases. Thirty- two (17.6%) patients had catheter displacement. Only 26 cases of hemoperitoneum (14.3%) were recorded. Death occurred in 23.1% of cases. Twenty-two patients (27.5%) were transplanted; 56 patients (70%) were transferred to HD, one patient had renal recovery and one case had voluntarily interrupted PD. In Kaplan–Meier curves of residual renal function (RRF) loss, there was a significant difference between peritonitis group and peritonitis-free group (P = 0.01). Technique and patient survival were associated with diabetes with a significant difference. The main cause of technique failure was peritonitis (61.4%). Moreover, the main repertoried causes of death were cardiovascular and septic causes. The mortality of diabetic and elderly PD patients was higher than mortality in nondiabetic and nonelderly groups, respectively, in our study. Peritonitis was associated with loss of RRF and technique failure.
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RENAL DATA FROM ASIA-AFRICA Top

Lupus nephritis: An experience of a tertiary care center in Nepal p. 462
Bijay Bartaula, Manish Subedi, Sushil Dhakal, Bandana Mudbhari, Prashant Mani Tripathi, Sanjib Kumar Sharma
DOI:10.4103/1319-2442.256853  
Lupus nephritis (LN) is one of the common complications of systemic lupus erythematosus (SLE). Timely treatment will decrease progression to chronic kidney disease. Treatment varies with different stages for which biopsy is needed. Controversies still exist regarding its requirement in management. This is a retrospective study from September 2014 to August 2016 in B. P. Koirala Institute of Health Sciences, Dharan, Nepal among all patients with SLE and undergone renal biopsy. Of 92 patients, most were female 85 (92.4%) with a median age of 32 years. In this study, 80.4% had some clinical symptomatology. Of the clinical manifestations, 41.3% had polyarthritis, edema (20.7%), and malar rash (17.4%). Anti-nuclear antibody was positive in 80.4% and ds DNA in 70.7%. Renal biopsy showed more number of patients 27 (35%) had Stage IV LN, followed by Stage I, 19 (24%), and Stage II, 16 (20%) LN. Median urinary protein in Class I was 1.05 g, Class II (0.63 g), Class III (1.5 g), Class IV (2.44 g), Class V (3.99 g), and Class VI (4.7 g). Only Stage IV had Kappa of 0.269 {P = 0.003) showing agreement between proteinuria and histological staging which was statistically significant (P <0.005). However, overall Kappa analysis showed none to fair strength of agreement for different stages of LN (–0.014–0.269) with proteinuria. Kappa (k) analysis showed none to fair strength of agreement for different stages of LN and proteinuria. Hence, only proteinuria is not sufficient to replace the need of renal biopsy in LN.
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Clinical profile of tuberculosis in patients with chronic kidney disease: A report from an endemic Country p. 470
Sanjay Vikrant
DOI:10.4103/1319-2442.256854  
The objective is to study the clinical profile of tuberculosis (TB) in chronic kidney disease (CKD). This is retrospective study of CKD patients who were diagnosed to have TB over a period of seven years at a tertiary care hospital. TB was diagnosed in 115 patients with an incidence of 4200/100,000. Mean age of the patients was 46.9 ± 16 years. Sixty-two patients (53.9%) were male. Causes of CKD were diabetic nephropathy and hypertension in 11.3% each, chronic glomerulonephritis in 31.3%, chronic tubulointerstitial nephritis in 39.1%, autosomal dominant polycystic kidney disease, and post-renal transplant CKD in 3.5% each. About 68.7% of patients with TB had advanced CKD stage of 4–5D, whereas 31.3% of patients had early CKD stage 1–3. Twenty percent of patients were on dialysis. Three-fourths of the patients had extrapulmonary TB. Pleuropulmonary (41.8%), kidney and urinary tract (20%), and abdomen and lymph node (13% each) were the most common sites for TB. The main clinical presentation of TB was: fever/pyrexia of unknown origin in 24.3%, constitutional symptoms of anorexia, fever, night sweats, and weight loss in 27.8%, abnormal chest radiograph in 31.2%, ascites/peritonitis in 13.9%, pleural effusion in 25.2%, lymphadenopathy in 20%, and sterile pyuria/hematuria/chronic pyelonephritis in 13%. Microbiological and/or histopathological diagnoses were made in 45.2% and in the other 54.8%, diagnosis of TB was made on clinical grounds. Adverse effects of anti-TB drugs were seen in 9.6% of patients. Ninety-three percent completed the treatment and survived. Eight patients (7%), all in CKD stage 5D, died. The incidence of TB was high among CKD stages 4 and 5 and in those receiving dialysis. Extrapulmonary disease such as pleuropulmonary, renal, peritoneal, and lymph node were the common forms of TB.
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Epidemiologic data of biopsy-proven renal diseases: Experience from a single center in South India p. 478
Varun Kumar Bandi, Ammanna Nalamati, Bharathi Kasinaboina, Sai Swapna Chundru
DOI:10.4103/1319-2442.256855  
An analysis of the renal biopsy data is important to understand the regional prevalence of various biopsy-proven renal diseases (BPRDs). We analyzed our renal biopsy registry over a period of 15 years. We retrospectively reviewed all the renal biopsies performed at Arun Kidney Centre, Vijayawada, Andhra Pradesh, from January 2004 to March 2018. All biopsies were analyzed using immunofluorescence and light microscopy. A total of 924 renal biopsies were considered for the analysis. The mean age of the patients was 32 ± 14.77 years, with a male:female ratio of 1.5:1. Nephrotic syndrome (46.1%) was the most common indication for renal biopsy, followed by rapidly progressive renal failure (11%) and rapidly progressive glomerulonephritis (9.9%). Primary glomerulonephritis (PGN) was the most common entity (66.8%), followed by tubulointerstitial disease (17.5%), secondary glomerulonephritis (SGN) (12.1%), and vascular nephropathies (3.5%). Among cases with PGN, the most common causes were minimal change disease (22.98%), immunoglobulin A nephropathy (21.3%), and membranous nephropathy (17%), whereas the most common SGN was lupus nephritis (60.7%). Acute tubulointerstitial nephritis (61.1%) was the most common tubulointerstitial disease, whereas antineutrophil cytoplasmic antibody vasculitis (56.3%) was the most common vascular nephropathy. We also noticed significant changing trends in many nephropathies. Our study provides epidemiologic data regarding the various BPRDs and also the changing trends of the individual renal diseases.
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The spectrum of renal diseases observed in native renal biopsies in a single North Indian tertiary care center p. 492
Dhruv Sarwal, Sanjay D'Cruz, Raj Pal Singh Punia, Ranjana Walker Minz
DOI:10.4103/1319-2442.256856  
We analyzed the spectrum of biopsy-proven renal disease in a single tertiary care center in North India from 2007 to 2016. A total of 420 biopsies were analyzed. Patients were excluded if clinical details were unavailable or if either the histopathology core or the IF core was inadequate. In the final analysis, 359 biopsies were included. All clinical, laboratory, histopathological, and immunofluorescence (IF) findings were recorded in each case. The usefulness of IF in reaching a definitive diagnosis was also analyzed. The patients were in the age range of 2–94 years; 23.1% were children and 76.9% were adults. Males (60.4%) outnumbered females (39.6%) in all the disease categories except lupus nephritis (LN). Primary glomerular diseases (PGDs) (n = 297, 82.7%) were more common than secondary glomerular diseases (SGDs) (n = 46, 12.8%) and tubulointerstitial diseases (n = 16, 4.5%). The most common PGD was focal segmental glomerulosclerosis (FSGS) (23.4%), followed by minimal change disease (17%) and membranous nephropathy (12.5%), whereas the most common SGD was LN, seen in 9.2%. In the present study, IF helped in reaching the final diagnosis in 44.3%. The entities in which IF was most useful in reaching the final diagnoses were FSGS (31.5%) and IgA nephropathy (14.5%). The final pathological diagnosis correlated with the first clinical possibility in 207 of 359 (57.7%) cases. This 10-year study provides descriptive data and highlights the changing pattern of renal disease possibly due to an increased awareness and referral to higher centers.
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Clinical and histopathological profile of lupus nephritis and response to treatment with cyclophosphamide: A single center study p. 501
Manjuri Sharma, Himanab Jyoti Das, Prodip Kumar Doley, Pranab Jyoti Mahanta
DOI:10.4103/1319-2442.256857  
Lupus nephritis (LN) is an immune-complex glomerulonephritis that is usually manifested by proteinuria, active urinary sediment, hypertension, and renal failure. The objective of this study is to study the clinical and histopathological profile of LN and the response to treatment with cyclophosphamide. This was a retrospective study conducted in a tertiary care center in Assam, India, where 176 LN patients who underwent renal biopsy were included. The presenting features, laboratory parameters such as proteinuria, hematuria, and the histopathological class of the patients were studied. Among the 176 patients, 89.8% were female and 10.2% were male and maximum patients (61.3%) were in the age group of 20–40 years. Pedal edema was present in 100% of the patients, decreased urine output in 43.7%, malar rash in 38%, joint pain in 42%, hair loss in 63%, hypertension in 41.4%, oral ulcers in 31.8%, seizures in 17%, psychosis in 13%, hematuriain 78.4%, anemia in 72.1%, thrombocytopenia in 51.1%, and leukopenia in 31.7% of patients. The anti-nuclear antibody was positive in all patients and anti-dsDNA was positive in 70.5% of the patients. The most common histopathological type was class IV (50%), followed by class III (17.6%). One hundred and two patients received intravenous cyclophosphamide as initial treatment of whom, 40 received the Eurolupus regimen and 62 received the NIH regimen. The number of patients who underwent remission in both the regimen was compared. The response rate of initial treatment with cyclophosphamide in the Eurolupus group was 62.5% and in the NIH group was 64.5% (P >0.05). Majority of the patients had proliferative LN in this study, of which class IV was the most common. Proliferative LN, if not detected and treated early, leads to poor outcome in terms of patient and renal survival. Hence, patients with systemic lupus erythematosus should be evaluated for kidney involvement and treated accordingly for better outcome.
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Etiology and frequency of hospital admissions in maintenance hemodialysis patients in chronic kidney disease p. 508
Jishu Deb Nath, Abul Kashem
DOI:10.4103/1319-2442.256858  
Chronic kidney disease (CKD) and end-stage renal disease are a global health problem worldwide. In developing countries, it is a particular challenge to deliver optimal hemodialysis (HD) due to prevailing socioeconomic conditions. This has multiple downstream effects, including frequent hospitalizations and increased morbidity. We conducted this retrospective study to identify the etiology of hospital admission in HD patients and to detect the duration and costs associated with their hospitalizations. A total of 42 maintenance HD patients were hospitalized during this time frame and their hospitalizations were studied for the purpose of this study. CKD is growing global public health problem causing socioeconomic impact. Hence, early detection and referral to nephrology services can reduce hospitalization rates after a planned dialysis start thus might improve patients’ quality of life.
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CASE REPORTS Top

Thiocolchicoside associated with epileptic seizures in a chronic hemodialysis patient p. 513
Fatih Yılmaz, Sevcihan Günen Yılmaz, Meryem Keleş
DOI:10.4103/1319-2442.256859  
Thiocolchicoside (TCC) is a widely used centrally acting muscle relaxant. Epileptic seizures from the use of TCC are rarely reported. A 67-year-old male patient with endstage renal disease that was caused by hypertension was on maintenance hemodialysis (HD) for 22 months. He had taken TCC 8 mg capsules twice daily for four days due to painful myofascial spasm in neck and face muscles. At the end of the HD session, he had generalized tonic–clonic seizures. Epileptic seizures were brought under control with sodium valproate, and no recurrence of epileptic seizures was observed.
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Ciclosporin-induced accessory breast tissue: Dramatic improvement after dose adjustment p. 517
Wieam Nabil Mahmoud Karrar, Alaa Abdalla Elsafi, Omar Ibrahim Abboud
DOI:10.4103/1319-2442.256860  
Accessory breast tissue is a relatively common congenital condition in which abnormal accessory breast tissue is seen as a mass anywhere along the course of embryologic mammary streak in addition to the presence of normal breast tissue. Ciclosporin therapy has been associated with benign breast disease in women. However, to the best of our knowledge, there are no reported cases of accessory breast tissue growth associated with ciclosporin therapy and regression after adjusting the dose. A 48-year-old woman had renal transplantation in 2009 with her brother as the donor. Her transplant follow-up over eight years had been unremarkable. She presented to our transplant follow-up clinic with bilateral painful axillary masses approximately 3 cm × 3 cm in diameter, not attached to the skin or underlying structures with no skin changes and no lymphadenopathy. Breast examination did not reveal any abnormalities. Her ciclosporin levels over the previous three years ranged between 130 and 150 ng/mL. These levels were within the acceptable recommended level of 100–150 ng/mL at that time (currently reduced to 80–120 ng/ml). Ultrasound of both axilla showed well-defined hypoechoic smooth outline masses in both axillary regions 3 cm × 4 cm. Fine-needle aspiration showed lesions consisting of cohesive ductal cells. The findings were consistent with accessory breast tissue with no evidence of inflammatory infiltrate or malignant changes. Her ciclosporin dose was reduced with the subsequent follow-up visits levels ranging between 90 and 110 ng/mL. Clinical examination four months later showed dramatic reduction in the axillary masses on both sides. Ultrasound confirmed the regression in the size of both masses. We conclude that ciclosporin was probably responsible for the formation of accessory breast tissue and reduction in the dose of ciclosporin resulted in substantial reduction in the tissue size.
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Lupus nephritis in a patient with retroviral infection p. 520
T Yashwanth Raj, S Sujith, ND Srinivasaprasad, K Thirumal Valavan, M Hema, Anila Abraham Kurien, Edwin Fernando
DOI:10.4103/1319-2442.256861  
A 38-year-old woman, diagnosed as Person Living with Human Immunodeficiency Virus (HIV) on Highly Active Antiretroviral Therapy (HAART) for three years, presented with features of fever, rashes, joint pain, dyspnea and pedal edema. On evaluation, a diagnosis of Systemic Lupus Erythematosus with Lupus Nephritis (LN) triggered by HIV infection was made based on clinical and serological evidence. She was continued on HAART, and immuno-suppressive therapy was co-administered resulting in the resolution of her symptoms. Lupus-like histopathological findings have been reported in patients with HIV-related kidney diseases. This case report is to highlight the co-existence of LN in a patient with HIV infection.
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Biopsy-proven progressive multifocal leukoencephalopathy in a renal transplant patient p. 526
Pramod Kumar Guru, Megan B Vissing, Anjali Agarwal, Murli Krishna
DOI:10.4103/1319-2442.256862  
Progressive multifocal leukoencephalopathy (PML) is a rare demyelinating disease that affects immunocompromised hosts. Most often the disease is reported in association with leukemia, lymphoma, and AIDS. With recent advancements in immunosuppressive medications and subsequent rise in solid organ transplantations, it is becoming more prevalent in this population. Both the diagnosis and treatment of PML remains a challenge to the transplant community. The disease remains mostly underreported and undertreated. The diagnostic uncertainty in a renal transplant patient leads us to do the brain biopsy for suspicion and confirmation of PML.
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Primary membranous nephropathy with concomitant IgA nephropathy p. 531
Reza Khorsan, Ramy M Hanna, Khalid Ameen, Farid Arman, Niloofar Nobakht, Huma Hasnain, Ashley Hyunh, Anjay Rastogi
DOI:10.4103/1319-2442.256863  
Membranous nephropathy (MN), an autoimmune glomerulonephritis which can occur in primary and secondary forms, is one of the most common inflammatory glomerulopathies in elderly patients. The pathophysiology of the primary form is generally due to circulating immunoglobulin (IgG4) antibodies which often target phospholipase A2 receptors (anti-PLA2R) and Thrombospondin Type 1 Domain containing 7A (anti THSD7A). IgA nephropathy is one of the most common autoimmune glomerular diseases in the world and presents with a spectrum of disease ranging from asymptomatic mild hematuria and proteinuria to rapidly progressive crescentic glomerulonephritis. We present a rare case of concomitant IgA and primary MN in a single patient treated successfully with renin–angiotensin–aldosterone blockade, corticosteroids, and calcineurin inhibitors. The peak proteinuria was near 7.5–8 g protein/g creatinine by various measures. Serum creatinine remained normal, and anti-PLA2R was detectable and decreased with successful treatment. Clinicians should be aware of the possibility of two glomerular disorders in patients with glomerulonephritis and atypical presentations for any single disorder.
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Kaposi sarcoma development following microscopic polyangiitis treatment p. 537
Mehmet Biricik, Merve Eren, Feyzi Bostan, Üstün Yılmaz, Ayça İnci
DOI:10.4103/1319-2442.256864  
Kaposi sarcoma (KS) is a rare condition mostly seen in immunosuppressed patients due to a syndrome or organ transplantation. However, few cases have been reported in patients with rheumatologic diseases treated with long-term corticosteroid and cyclophosphamide. We present a case in which the subject developed KS following a course of immunosuppressive therapy for their systemic vasculitides.
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Complement factor H gene polymorphisms and vivax malaria associated thrombotic microangiopathy p. 540
Parimal Agrawal, Ashwani Kumar, Amber Parwaiz, Amit Rawat, Karalanglin Tiewsoh, Ritambhra Nada
DOI:10.4103/1319-2442.256865  
Acute kidney injury (AKI) occurs in about 1% of cases of malaria; however, in these cases, the mortality rate can be as high as 45%. Thrombotic microangiopathy (TMA) as a cause of AKI in malaria is rare with only a handful cases documented in literature so far. Alternate complement pathway (ACP) dysregulation as a major mechanism of injury in the development of thrombotic microangiopathies is well known. It is proposed that patients with preexisting defects in ACP are usually clinically silent, until stress condition such as infections help manifest them. Herein, we describe the presence of two complement factor H (CFH) variants in an 8-year-old female with vivax malaria associated TMA. The complement workup confirmed dysregulated ACP and revealed two single-nucleotide polymorphisms in CFH gene, i.e. exon-7 rs1061147 (p.Ala243Ala) and exon-9 rs1061170 (p.His402Tyr) which predisposed this patient to develop TMA precipitated by vivax malaria.
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Regression of renal angiomyolipomas with oral rapamycin therapy in a patient with tuberous sclerosis complex disease p. 545
Dilek Torun, Hasan Micozkadioglu, Murat Gedikoglu, Ruya Ozelsancak, Nihan Tekkarismaz
DOI:10.4103/1319-2442.256866  
We present a case of a 32-year-old female who had been diagnosed tuberous sclerosis complex (TSC) two years ago. In view of serious hemorrhagic complication risk of the selective embolization, we commenced her on oral rapamycin therapy for regression of angiomyolipomas (AMLs). On the 1st year of rapamycin treatment, bilateral renal AMLs were regressed and bilateral selective embolization of the AML was performed after the 1st year of treatment. Rapamycin therapy may regress renal lesions in TSC disease. Therefore, it may increase surgical intervention.
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A rare case of pancake kidney with glomerulonephritis p. 549
Varun Mamidi, Indhumathi Elayaperumal, Jaiju James Chakola, PM Venkata Sai, Jayakumar Matcha
DOI:10.4103/1319-2442.256867  
Developmental anomalies of the kidney and the urinary tract occur in 3-6 per 1000 live births. Pancake kidney is one of the rarest types of renal ectopia. Urinary system anomalies often coexist with malformations of other organs and systems. We report a case of pancake kidney which was detected incidentally while treating a patient with renal failure and nephrotic syndrome.
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LETTER TO THE EDITORS Top

Star fruit-induced renal failure: Summarization of cases from Thailand p. 553
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/1319-2442.256868  
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Daily pill burden and pill burden from phosphate binders in Japanese dialysis patients: Single center study p. 554
Naohiko Imai, Kiyomi Osako, Nagayuki Kaneshiro, Yugo Shibagaki
DOI:10.4103/1319-2442.256869  
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Microalbuminuria in dengue: Rate of occurrence and when it will be resolved? p. 557
Won Sriwijitalai, Viroj Wiwanitkit
DOI:10.4103/1319-2442.256870  
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CASE REPORTS Top

Serosurveillance and prompt treatment of toxoplasmosis among renal recipients is needed: A path probability analysis p. 558
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/1319-2442.256871  
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