Background and objectivesBacterial infection-related glomerulonephritis occurs concurrent to or following known or unknown infections. It's important to understand the clinical implications of the bacterial isolates, anti-microbial resistance patterns and impact of latency-based classification on kidney and patient outcomes. Design, setting, participants, and measurements501 consecutive adults diagnosed with bacterial infection-related glomerulonephritis between 2005-2017 were included from biopsy registry of 15545 patients at a single center in South India and follow up data collected from electronic medical records till December 2019. Latency was defined as time between resolution of infection and onset of glomerulonephritis and was classified as para-infectious, peri-infectious and post-infectious glomerulonephritis. Longitudinal kidney and patient outcomes were studied. ResultsThe mean age of the cohort was 40 (15) years, 6% were above 65 years and 330 (66%) were men. Diabetes was present in 93 (19%) of patients. 70% (353/501) patients had known infections, with the median latent period for para-infectious (115/353, 33%), peri-infectious (97/353, 27%) and post-infectious (141/353, 40%) glomerulonephritis being 0, 5 (4-7) and 15 (10-31) days respectively. The most common predisposing organism was Streptococcus pyogenes (137/353, 39%). Drug resistant non-streptococcal bacteria were methicillin resistant Staphylococcus aureus 25% (4/16), extended-spectrum beta-lactamases 20% (12/59) and carbapenem resistant organisms 10% (6/59). 20/22 (91%) of the drug resistant organisms were isolated from para-infectious group. The most common site of infection was skin in peri- (23/97, 24%) and post-infectious glomerulonephritis (61/141, 43%), and urinary tract in para-infectious glomerulonephritis (35/115, 30%). Out of 321 patients with more than three months follow-up, 48 (15%) developed kidney failure over a median period of 10 (2-37) months and 14 (4%) died. Para-infectious glomerulonephritis, eGFR <30 ml/min/1.73m2, moderate to severe interstitial fibrosis and tubular atrophy, and non-treatment with renin angiotensin system blockers were significant risk factors for progression to kidney failure by Cox proportional-hazards model. ConclusionsAlong with clinical and histological predictors, para-infectious glomerulonephritis caused predominantly by non-streptococcal and drug resistant bacterial infections was associated with poor kidney prognosis.

Chronic kidney disease related-mineral bone disorder (CKD-MBD) has been poorly studied in pre-dialysis Indian CKD patients. We aimed to study the clinical, biochemical and extra skeletal manifestations of untreated CKD-MBD in pre-dialysis Stage 4 and 5 CKD patients attending nephrology out-patient clinic at a tertiary care hospital in South India. A hospital based cross-sectional survey including, demographic profile, history of CKD-MBD symptoms, measurement of serum calcium, phosphate, parathyroid hormone, 25 hydroxy vitamin D (25(OH) D) and alkaline phosphatase; lateral abdominal X-rays for abdominal aortic calcification (AAC) and echocardiography for valvular calcification (VC) was carried out. Of the 710 patients surveyed, 45% had no CKD-MBD related symptom. Prevalence of hypocalcemia, hyperphosphatemia, hyperparathyroidism (>150 pg/mL) and 25(OH) D levels <30 ng/mL was 66.3%, 59%, 89.3% and 74.7% respectively. Echocardiography was carried out in 471 patients; 96% of whom had VC (calcification score ≥1). Patients with VC were older and had lower 25(OH) D levels than those without. Lateral abdominal X-rays were obtained in 558 patients, 6.8% of whom were found to have AAC, which was associated with older age. Indian patients with incident CKD-MBD have a high prevalence of hypocalcemia, 25(OH) D deficiency and VC even prior to initiating dialysis while AAC does not appear to be common. The association between 25(OH) D deficiency and VC needs further exploration.

Abnormal primary hemostasis is believed to be the most significant contributor to uremic bleeding. This study aimed to describe the prevalence and profile of primary and secondary hemostatic disorders in patients with chronic kidney disease (CKD) Stages 4 and 5 and to determine their association if any, with degree of uremia. Stages 4 and 5 predialysis CKD patients attending nephrology outpatient clinic were prospectively recruited and the following bleeding parameters were measured in all patients: platelet count, bleeding time (BT), Factor VIII assay, von Willebrand factor antigen (vWF:Ag), vWF:ristocetin cofactor activity (vWF:RCo), ratio of vWF:ristocetin cofactor activity to vWF antigen (vWF:RCo/vWF:Ag), prothrombin time (PT), and activated partial thromboplastin time (aPTT). Forty-five patients (80%, males) with a mean age of 39.4 years, 82% (n = 37) in Stage 5 CKD, were recruited for the study. The prevalence of thrombocytopenia was significantly higher among patients from West Bengal (15/26, 57.7%) compared to other study patients (2/19, 10.5%; P = 0.001); however, all had macrothrombocytes with normal BT, suggestive of the Harris syndrome. Factor VIII, vWF:Ag, vWF:RCo, vWF:RCo/vWF:Ag ratio, BT, PT, and aPTT were abnormal in 0 (0%), 0 (0%), 0 (0%), 4 (8.8%), 1 (2.2%), 7 (15.6%), and 5 (11.1%) patients, respectively. Except for thrombocytopenia, the prevalence of hemostatic abnormalities did not differ between CKD Stages 4 and 5. Hemostatic abnormalities are uncommon in Stages 4–5 CKD and except for thrombocytopenia, are not associated with degree of uremia. Constitutional macrothrombocytopenia is associated with normal BT even in CKD.

This study provides the largest data on biopsy proven renal disease in children from South Asia published till date and highlights important differences in the spectrum and trends of kidney disease compared to data from other regions.

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Two cases are described of previously unreported false positivity on the Luminex crossmatch assay due to non HLA specific antibodies directed against the beads. In both cases the Luminex crossmatch indicated the presence of donor specific antibodies to class II HLA antigens, which was not substantiated by the clinical scenario or other assays. We could demonstrate the non specificity of these antibodies through using the same assay in a modified form where beads were unexposed to cell lysate and therefore did not carry HLA antigens at all. These cases further serve to emphasize the absolute necessity of correlating positive results with the priming history, and confirming their relevance using other platforms.

Peritoneal dialysis (PD) penetration in India remains low despite the huge chronic kidney disease burden and unmet need for renal replacement therapy (RRT). In order to understand the socioeconomic reasons that govern patients' preference for hemodialysis (HD), we carried out an opinion survey among prevalent in-center HD patients at our institution using a multiple response questionnaire that was verbally administered to them at the dialysis facility by the investigators. Close to 80% were self-financed and 49.5% were on twice weekly HD. Despite the majority (95%) receiving RRT education from a nephrologist, 43.4% were not aware of PD as an RRT modality. The treating nephrologist's recommendation was the most important reason given for choosing HD (77.8%) and not choosing PD (69.7%). Other reasons for not choosing PD included lack of a dedicated caregiver or "clean area" at home (15.1%), fear of infection (15.1%), disruption of work (14.1%), and the high cost of PD (7%). The perceived advantages of HD over PD were greater convenience because of need for only twice or thrice weekly sessions (61%), supervised care received in a hospital setting (28.8%), and less disruption of the patient's and family's routine (22%). We discuss the implications of these findings and what policy makers and nephrologists in India and other developing countries can do to improve PD penetration and utilization.

Background Nontunneled hemodialysis catheters (NTHCs) remain the preferred vascular access at hemodialysis (HD) initiation in developing countries. We studied the incidence, risk factors and microbiological spectrum of jugular NTHC-associated bloodstream infections (CABSIs) at a tertiary care center in South Asia. Methods In this retrospective cohort study, all adult (≥18 years) incident patients who underwent jugular NTHC insertion for HD between January 2016 and June 2017, had no prior history of temporary vascular access insertion and were followed up for ≥14 days were included. Results A total of 897 patients underwent NTHC insertion during the study period and 169 patients fulfilled the inclusion criteria and contributed 7079 patient days of follow-up. CABSI incidence was 7.34 episodes per 1000 catheter days and median infection-free survival and time to CABSI were 96 and 24.5 days, respectively. In multivariate Cox regression analysis, immunosuppressive medication {hazard ratio [HR] 2.87 [95% confidence interval (CI) 1.09–7.55]; P = 0.033} and intravenous cefazolin use [HR 0.51 (95% CI 0.28–0.94); P = 0.031] was independently associated with CABSI. The cumulative hazard of CABSI was 8.3, 13.3, 17.6 and 20.9% at Weeks 1, 2, 3 and 4, respectively. Gram-negative organisms were the most common etiological agents (54.7%) and 40.3% of CABSIs were caused by drug-resistant organisms. Gram-negative and Gram-positive CABSIs were associated with neutrophil left shift and higher procalcitonin compared with coagulase-negative staphylococcal CABSIs. Conclusion In South Asia, NTHC-associated CABSIs occur early and are predominantly Gram negative. We hypothesize that poor hygiene practices may play a role in this phenomenon.