Acute kidney injury (AKI) is a well-known life-threatening systemic effect of snake envenomation which commonly happens secondary to snake bites from families of Viperidae and Elapidae. Enzymatic toxins in snake venom result in injuries to all kidney cell types including glomerular, tubulo-interstitial and kidney vasculature. Pathogenesis of kidney injury due to snake envenomation includes ischaemia secondary to decreased kidney blood flow caused by systemic bleeding and vascular leakage, proteolytic degradation of the glomerular basement membrane by snake venom metalloproteinases (SVMPs), deposition of microthrombi in the kidney microvasculature (thrombotic microangiopathy), direct cytotoxic action of venom, systemic myotoxicity (rhabdomyolysis) and accumulation of large amounts of myoglobin in kidney tubules. Clinical features of AKI include fatigue, loss of appetite, headache, nausea, vomiting, oliguria and anuria. Monitoring of blood pressure, fluid balance, serum creatinine, blood urea nitrogen and serum electrolytes is useful in managing AKI induced by snake envenomation. Early initiation of anti-snake venom and early diagnosis of AKI are always desirable. Biomarkers which will help in early prediction of AKI are being explored, and current studies suggest that urinary clusterin, urinary neutrophil gelatinase-associated lipocalin, and serum cystatin C may play an important clinical role in the future. Apart from fluid and electrolyte management, kidney support including early and prompt initiation of kidney replacement therapy when indicated forms the bedrock in managing snake biteassociated AKI. Long-term follow-up is important because of chances of progression towards CKD.
Coronavirus disease (COVID-19) vaccine and its utility in solid organ transplantation (SOT) needs to be revised timely and updated. These guidelines have been formalized by the experts -the apex technical committee members of the National Organ and Tissue Transplant Organization (NOTTO), and the heads of transplant societies for the guidance of transplant communities. In our general recommendations, we recommend that all personnel involved in organ transplantation should get vaccinated as early as possible and continue COVID-19 appropriate behaviour, despite a full course of vaccination. For specific guidelines of recipients, we suggest completing the full schedule before transplantation whenever the clinical condition permits. We also suggest a single dose, rather than proceeding unvaccinated for transplant, in case a complete course is not feasible. In case, vaccination is planned before surgery, we recommend a gap of at least 2 weeks between the last dose of vaccine and surgery. For those not vaccinated prior to transplant, we suggest waiting for 4-12 weeks after transplant. For the potential living donors, we recommend the complete vaccination schedule before transplant. However, if not feasible, we suggest getting at least a single dose of vaccine, 2 weeks prior to donation. We suggest that suitable transplant patients and those on the waiting list should accept a third dose of the vaccine when one is offered to them. In the context of Vaccine-induced thrombotic thrombocytopenia (VITT), we recommend organs from a deceased donor with suspected/proven VITT should be notified and best avoided and are justified only in case of emergency situations with informed consent and counselling.
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Introduction: Limited data exists on the incidence and outcome of early coronavirus disease (COVID-19) in kidney transplantation recipients (KTR). Methods: A retrospective multicentre research was conducted across 12 centers of India. We explored the symptomatology, demographic, laboratory findings and outcome of COVID-19 within 30 days of transplantation. The outcome was compared with the overall KTR and waitlisted patients acquiring COVID-19. Results: The incidence of early COVID-19 was 2.6% (n =22) for the cumulative 838 renal transplants performed since nationwide lockdown in March 2020 till May 2021. Overall, 1049 KTR were diagnosed with COVID-19 and 2% of those had early COVID-19. The median age of the early COVID-19 cohort was 43(31-46) years. COVID-19 severity ranged from asymptomatic (18.2%), mild (59.1%), moderate (9.1%) and severe (13.6%). Among clinical symptoms, Dyspnea and Anosmia were frequent and in laboratory parameters neutrophil lymphocyte ratio, high sensitive C reactive protein and D- dimer were higher in patients requiring oxygen. The mortality in early COVID-19 was not higher than overall KTR (4.5% vs 8.5%; p-value: 1). COVID-19 severity (23.9% vs 15.7%; p-value: 0.0001) and mortality (15.5% vs 8.5%; p-value: 0.001) among waitlisted patients (n = 1703) were higher compared to overall KTR. Conclusion: We report higher burden of COVID-19 in waitlisted patients compared to KTR and a favorable outcome in early COVID-19 in KTR. Our report will help the transplant physicians in dealing with the ongoing dilemma of halting or resuming transplantation in the COVID-19 era.
Background The impact of COVID-19 in a developing nation is sparsely reported and more importantly the discrepancies in public and private sectors are underexplored. Methods We retrospectively investigated the data on the impact of COVID-19 on renal transplantation, between 2019-2020 in a nationwide analysis from 8 public and 10 private sector hospitals of India. Results On comparing the yearly data, the number of living-related transplants and deceased donor transplants declined by 48% (2610 vs 1370) and 49% (194 vs 99) respectively. The out-patient numbers and in-center admissions decreased by 40.4 % (6,16,741 vs 3,67,962) and 30.8 % (73,190 vs 49,918) respectively. There was no increase in the number of renal or graft biopsies in the COVID-19 era. The number of waitlisted patients on hemodialysis was higher in public (3,04,898 vs 3,38,343) when compared to private (1,63,096 vs 1,50,292) in the last 2 years. Similarly, the number of waitlisted patients on peritoneal dialysis (4655 vs 3526) was higher in public sector compared to private sector (932 vs 745). The decline in living transplants during the pandemic was higher in public setups (58%) compared to the private (49%). On the contrary, the decline in deceased donation was higher in private (57.9%) relative to public (50.6%). Conclusion COVID-19 has adversely affected the transplantation activities across the Indian transplantation centers, with a disproportionately higher impact on waitlisted patients in public sector programs. A sound prioritization of healthcare resources is mandated to safeguard the most deprived and high-risk waitlisted patients during the pandemic.
IntroductionScreening school children for urinary abnormalities is an inexpensive task but is not commonly undertaken in India. Although debated in western countries, its utility in early diagnosis of kidney disorders has been proved by studies from Asia. We examined the prevalence of asymptomatic urinary abnormalities (AUA), obesity, and hypertension in school children and analyzed data to identify potential risk factors among those detected with such abnormalities.MethodsChildren and adolescents 8 to 18 years of age of either gender, attending 14 public schools in West Bengal, were screened prospectively from July 2013 to July 2016 for detecting asymptomatic urinary abnormalities by a spot urine test using a dipstick. Sociodemographic profile, medical examination (weight, height, and blood pressure), and questionnaire-based data were recorded.ResultsA total of 11,000 children were screened. Of these, data from 9306 children were available for AUA, obesity, and hypertension. The prevalence rate was 7.44% (95% confidence interval [CI] = 6.91%−7.97%) for at least 1 AUA. Isolated hematuria was present in 5.2% (95% CI 4.75%−5.65%), whereas isolated proteinuria was present in 1.9% (95% CI = 1.62%−2.18%). The prevalence of prehypertension was 13.43% (95% CI = 12.74%−14.12%) and that of hypertension and abnormal body mass index was 4.05% (95% CI = 6.43%−7.47%) and 38.67 (95% CI = 37.68%−39.66%) respectively.DiscussionThe prevalence rates of AUA were comparable with those in some Asian countries but higher than in most developed countries. Of children and adolescents 8 to 18 years of age, those 13 to 18 years had significantly more high risk factors such as AUA, hypertension, and obesity.
Introduction: Subclinical hypothyroidism (SCH) is highly prevalent and associated with chronic kidney disease (CKD). However, it is still unanswered whether the restoration of euthyroid status in these patients will be beneficial in retarding a decline in glomerular filtration rate in early CKD patients. We aim to evaluate the efficacy of levothyroxine therapy versus placebo in slowing estimated glomerular filtration rate (eGFR) decline among CKD patients (stage 2–4) with SCH. Methods: This study will be a multicentric, double-blind, randomized, parallel-group, placebo-controlled study. A total of 500 CKD patients, 250 patients in the treatment group and 250 patients in the placebo group, will be randomized. The randomization between the treatment arm and placebo arm will be performed as per the computer-generated random number table in a 1:1 ratio. The sample size was calculated based on the assumed reduction in eGFR after 1-year follow-up in the treatment and placebo groups of 10% and 25%, respectively, at a minimum two-sided 99% confidence interval and 90% power of the study and considering 20% loss on follow-up. Each patient will be followed every 3 months for at least 1 year after randomization. Individuals completing 1-year follow-up visits will be considered for analysis. The baseline and follow-up data will be compared between the treatment and placebo groups. The study will evaluate the efficacy and safety of levothyroxine therapy versus placebo in slowing eGFR decline among CKD patients (stage 2-4) with SCH. The primary endpoint will be the end of follow-up of the patients, reduction of eGFR by ≥50% from a baseline of that patient, or development of ESKD or death of the patients. The secondary endpoint will be any cardiovascular event or arrhythmia after the institution of the drug.
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