BackgroundThe management of proliferative lupus nephritis (LN) comprises timely and coordinated immunosuppressive therapy. This study aimed to evaluate and compare the effectiveness and safety profile of low dose mycophenolate mofetil (MMF) and cyclophosphamide (CYC) in induction therapy of LN in Nepalese population.MethodsWe conducted a prospective, open-label, randomized trial over a period of one and half years. Forty-nine patients with class III to V lupus nephritis were enrolled, out of which 42 patients (21 in each group) could complete the study. CYC was given intravenously as a monthly pulse and MMF was administered orally in the tablet form in the maximum daily dose of 1.5 g in two divided doses.ResultsThe mean age of the patients was 25.43 ± 10.17 years with female to male ratio of 7.3:1. Mean baseline serum creatinine was 1.58 ± 1.38 mg/dL and eGFR was 62.38 ± 26.76 ml/min/1.73m2. Mean 24-h urinary protein was 4.35 ± 3.71 g per 1.73 m2 body surface area. At 6 months, serum creatinine (mg/dL) decreased from 1.73 to 0.96 in CYC and from 1.24 to 0.91 in the MMF group with improvement in eGFR (ml/min/1.73 m2) from 60.33 to 88.52 in CYC and from 64.42 to 89.09 in MMF group. Twenty-four-hour urinary protein (gm/1.73m2) reduced from 4.47 to 0.94 in CYC and from 4.5 to 0.62 in the MMF group. Primary end point was achieved in higher percentage of patients with MMF than CYC (28.6% vs. 19%) while equal proportion of patients (67% in each group) achieved secondary end point in both groups. Number of non-responders was higher in CYC group than in the MMF group (14.3% vs. 4.8%). There was no difference in the rate of achievement of secondary end point in both CYC and MMF groups (3.16 vs. 3.05 months). The occurrence of adverse events was higher in the CYC than in MMF group (56 vs. 15 events).ConclusionPresent study has concluded that MMF, used in relatively lower dose, is equally effective in inducing remission with reduction of proteinuria and improvement of kidney function with lesser adverse events than CYC in the induction therapy of proliferative lupus nephritis.Trial registrationRetrospectively registered to ClinicalTrials.gov PRS. NCT03200002 (Registered date: June 28, 2017).

Background: Percutaneous renal biopsy is performed for diagnosis and prediction of prognosis of renal diseases. Adequacy of tissue and clinically significant bleeding are the main issues of the procedure. We aimed to compare these issues in renal biopsy by blind and real time ultrasound guided technique.Methods: It was a cross sectional, randomized study conducted between June 2016 to December 2016. In blind technique, marking for biopsy was done by ultrasound. Two attempts were performed for all and more if tissue was inadequate. Patients kept in bed rest for 24 hours, observed for post procedure hematuria and ultrasound done at 6 hours and 24 hours to diagnose perinephric hematoma.Results: Total 75 biopsies (blind = 37 and Ultrasound -guided = 38) were evaluated. Blind and Ultrasound-guided technique had significant difference of number of attempt (mean±SD) 2.4±0.6 and 2.1±0.3 (p<0.01) respectively with no difference of number of glomeruli in light microscopy. Bleeding complications were macroscopic hematuria (11(30%)vs15(40%)) and perinephric hematoma ( 5(13.5%)vs3(7.9%)) in blind and Ultrasound-guided technique respectively with no significant difference. Those patients who developed perinephric hematoma was observed in all at 6 hours.Conclusions: Ultrasound-guided technique of percutaneous renal biopsy is superior with fewer attempts and equivalent in adequacy of tissue and bleeding complication than blind technique.

OBJECTIVETo assess the nutritional status of patients on maintenance hemodialysis by using modified quantitative subjective global assessment (MQSGA) and anthropometric measurements.METHODWe Conducted a cross sectional descriptive analytical study to assess the nutritional status of fifty four patients with chronic kidney disease undergoing maintenance hemodialysis by using MQSGA and different anthropometric and laboratory measurements like body mass index (BMI), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), triceps skin fold (TSF) and biceps skin fold (BSF), serum albumin, C-reactive protein (CRP) and lipid profile in a government tertiary hospital at Kathmandu, Nepal.RESULTSBased on MQSGA criteria, 66.7% of the patients suffered from mild to moderate malnutrition and 33.3% were well nourished. None of the patients were severely malnourished. CRP was positive in 56.3% patients. Serum albumin, MAC and BMI were (mean + SD) 4.0 + 0.3 mg/dl, 22 + 2.6 cm and 19.6 ± 3.2 kg/m2 respectively. MQSGA showed negative correlation with MAC (r = −0.563; P = <0.001), BMI (r = −0.448; P = <0.001), MAMC (r = −0.506; P = <.0001), TSF (r = −0.483; P = <.0002), and BSF (r = −0.508; P = <0.0001). Negative correlation of MQSGA was also found with total cholesterol, triglyceride, LDL cholesterol and HDL cholesterol without any statistical significance.CONCLUSIONMild to moderate malnutrition was found to be present in two thirds of the patients undergoing hemodialysis. Anthropometric measurements like BMI, MAC, MAMC, BSF and TSF were negatively correlated with MQSGA. Anthropometric and laboratory assessment tools could be used for nutritional assessment as they are relatively easier, cheaper and practical markers of nutritional status.

h y p o c a l c a e m i a a n d c o m p e n s a t o r y hyperparathyroidism. But with advancing disease, the compensatory mechanism can no more maintain the mineral homeostasis and biochemical a b n o r m a l i t i e s l i k e h y p e r p h o s p h a t e m i a , hypocalcaemia and hyperparathyroidism become obvious at stage 4 CKD. 3,4 Besides, decreased kidney function, lack of adequate storage of vitamin D (25, OH vitamin D / calcidiol) is responsible for decreased calcitriol synthesis and its consequences in CKD. 5 Studies have shown vitamin D deficiencies (20-29 ng/ml) and insufficiency (<20 ng/ml) in CKD, both in pre dialysis and maintenance hemodialysis patients, MJSBH Vol 16 Issue 1 Jan-June 2017 30ABSTRACT Introduction: Abnormalities in mineral metabolism are invariable with progressive deterioration of kidney function in chronic kidney disease (CKD). These abnormalities are documented in CKD on dialysis in our population but not on pre dialysis. So, present study aims to estimate serum vitamin D, calcium and phosphorus in CKD stage 3-5ND. Methods: It was a cross sectional study of established new CKD patients not on dialysis, vitamin D, calcium, phosphate binders and corticosteroids therapy. Blood sample was drawn for estimation of serum vitamin D, creatinine, calcium, phosphorus and albumin and CKD staging done by KDIGO (2012) criteria. SPSS software version 19 was used for data analysis and chi-squared and ANOVA test was applied as the test of significance. Results: Sixty six (51 male and 15 female) CKD patients with a mean age of 54.3±14.8 years were studied. Hypovitaminosis D (<30 ng/ml) was present in 84.8%, with deficiency (<20 ng/ml) in 50% and insufficiency (20-30) ng/ml in 34.8%. Other abnormalities observed were hypocalcemia (60.6%), hypercalcemia (1.5%) and hyperphosphatemia (63.6%) with no difference of corrected calcium, significant difference of serum phosphorus (p<0.001) with hyperphosphatemia in stage 4 and 5 CKD and vitamin D insufficiency in stage 3b, deficiency in stage 3a, 4 and 5 CKD. There was no correlation of serum vitamin D with calcium and phosphorus in different stages of CKD. Conclusion: Present study concludes that hypovitaminosis D, hypocalcemia and hyperphosphatemia is common in our pre-dialysis CKD patients and serum phosphorus raises more with reduction of GFR.

Introduction: Hemodialysis is the preferred method of treatment for Nepalese patients with End Stage Renal Disease. Despite the technological advances and better understanding of physiology associated with hemodialysis, a number of complications are known to be associated with hemodialysis. This study was undertaken to study the frequency of acute intradialytic complications in patients undergoing hemodialysis. Methods: A cross-sectional study was conducted at Nephrology unit of a tertiary care hospital from 15 June, 2007 to 15 December, 2007. A total of 28 patients were included in the study. Patients with acute renal failure and acute on chronic renal failure were excluded from the study. Results: Total sessions of hemodialysis during the period were 1455. Hypotensive episode were 66 (4.5%) and was the commonest complication and followed by hypertensive episodes were 58 (3.8%). Other problems encountered were transfusion reactions were 23 episodes (1.5%), rigors not related to transfusions were 13 episodes (0.8%), nausea/vomiting were 20 episodes (1.4%), muscle cramps were 12 episodes (0.8%), hypoglycemia were 6 episodes 5(0.4%). Conclusions: The frequency of intradialytic complications is low and many of them are not life threatening. Keywords: complications; end stage renal disease; hemodialysis; hypertension; hypotension.

Parvo B19 is a single stranded DNA virus, which typically has affi nity for erythroid progenitor cells in the bone marrow and produces a severe form of anemia known as pure red cell aplasia. This condition is particularly worse in immunocompromised individuals. We herein report a young Nepali male who developed severe and persistent anaemia after kidney transplantation while being on immunosuppressive therapy. His bone marrow examination revealed morphological changes of pure red cell aplasia, caused by parvovirus B19. The IgM antibody against the virus was positive and the virus was detected by polymerase chain reaction in the blood. He was managed with intravenous immunoglobulin. He responded well to the treatment and has normal hemoglobin levels three months post treatment. To the best of our knowledge, this is the fi rst such case report from Nepal. Keywords: Intravenous immunoglobulin, kidney transplant recipient, Parvovirus B19, pure red cell aplasia.

Diffuse alveolar hemorrhage results from accumulation of red blood cells in the alveolar space originating from alveolar capillaries. Alveolar hemorrhage in Systemic Lupus Erythematosus is rare but catastrophic and can rapidly progress to respiratory failure. We report a 22-year old lady who presented with dyspnoea on exertion, hemoptysis, bilateral leg swelling and oliguria. Diffuse alveolar hemorrhage was confirmed by bronchoalveolar lavage fluid analysis. Serologic tests and renal biopsy confirmed lupus nephritis. She was treated with systemic immunosuppressive therapy and plasma exchange, to which she had a favourable response. Lupus presenting as alveolar hemorrhage is rare which warrants prompt diagnosis and treatment to prevent complications.

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