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.

Background: The spectrum and outcomes of crescentic glomerulonephritis (Cr.GN) in South Asia is vastly different from that reported worldwide and there is a paucity of information. The aim of the study was to study the demography, clinical presentation, histology and predictors of longitudinal outcomes of Cr.GN in this population. Methods: An observational cohort study of renal biopsies was performed in the largest tertiary center in South India over a period of 10 years (January 2006 to December 2015) with ≥50% crescents on renal histology indicating Cr.GN. Results: A total of 8645 kidney biopsies were done; 200 (2.31%) were Cr.GN. Patients were categorized into three etiological groups: anti-glomerular basement membrane (type I), immune complex (type II), and pauci-immune (type III). Type II was the most common (96, 46.5%), followed by type III (73, 38%) and type I (31, 15.5%). Female preponderance was seen across all types. About half of all patients presented with recent onset hypertension. Type II had the highest median proteinuria (4.2 (2.1-6) g/day, p=0.06) and the median estimated glomerular filtration rate was lowest in type I (5 (4-8) ml/min/1.73m2, p<0.001). Among type III, anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis was seen only in ~50% of patients. Nearly one third of patients with type I were also positive for ANCA making them ‘double positive’. Acute glomerular insults like tuft necrosis and chronic changes as evidenced by moderate to severe interstitial fibrosis, was a predominant feature of type I. Conclusions: ANCA-negative pauci-immune vasculitis, as well as double positive Cr.GN, are reported for the first time in South-Asia. Renal survival was significantly worse in type I/III compared to type II. Types I/III, moderate to severe interstitial fibrosis and tubular atrophy, presence of oliguria/anuria and increasing percentage of crescents in renal biopsy were significant predictors of end stage kidney disease in our cohort.

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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.

Dual anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) characterized by the presence of both anti-proteinase-3 (PR3-ANCA) and anti-myeloperoxidase (MPO-ANCA) antibodies is a rare clinical entity. Only few cases have been reported previously, most of which were associated with infections, drugs, autoimmune diseases and malignancies. Herein, we describe a young woman who presented with rapidly progressive glomerulonephritis with hypocomplementemia and markedly elevated anti-PR3 and anti-MPO titres. Meticulous work-up ruled out all possible secondary causes. Renal biopsy showed the presence of focal fibrocellular crescents with focal mesangial hypercellularity. Immunofluorescence and electron microscopy showed pauci-immune deposits. The patient was treated with an induction regimen comprising oral prednisolone and cyclophosphamide. She attained both clinical and serological remission at 3 months and is currently on an azathioprine-based maintenance regimen. We have extensively reviewed all previous cases of dual AAV and have formulated an approach to diagnose and treat this rare entity.

The diagnosis of non-diabetic kidney disease (NDKD) in a diabetic patient has significant therapeutic and prognostic implications. There are certain proven clinical predictors of NDKD, which, when present in an appropriate clinical setting, would warrant a kidney biopsy. Herein, we describe four cases of NDKD diagnosed in rather unusual clinical settings, which add to the list of clinical predictors of NDKD. The first case was a "parainfectious glomerulonephritis" diagnosed in a 50-year-old diabetic woman who presented with persistent renal dysfunction despite successful treatment of urinary tract infection. The second case was "membranous nephropathy" diagnosed in a 43-year-old man with long-standing type 1 diabetes, which was associated with other microvascular complications. In this case, the only predictor was disproportionately low serum albumin. The third case was "amyloid light chain (AL) amyloidosis" diagnosed in an elderly diabetic who presented with progressive anasarca over six months. In this case, the only clinical predictor was a disassociation observed between urine dipstick and 24-hour protein estimation. In the fourth case, an elderly diabetic woman without underlying diabetic retinopathy presented with sudden onset nephrotic syndrome. A kidney biopsy was suggestive of diffuse nodular glomerulosclerosis. Immunofluorescence and electron microscopic evaluation were diagnostic of "gamma heavy chain deposition disease." In all four cases, diagnosis of NDKD led to major therapeutic changes and attainment of renal remission. We have extensively reviewed all major biopsy cohorts of NDKD and have formulated an approach to the diagnosis of NDKD.

Introduction: Hepatitis B virus (HBV) reactivation in kidney transplant recipients is a serious and understudied complication which seems to occur in 3 to 6% of HBs antigen (HBsAg)-negative patients. No data exists regarding HBV reactivation in patients receiving belatacept, an alternative to calcineurin inhibitors in renal transplantation but with which viral infections seem more frequent. Methods: A retrospective study was performed in two French transplantation centres and included all kidney transplant recipients receiving belatacept. We reported HBV reactivation rate among antihepatitis B core antigen antibody (HBcAb)-positive patients, outcomes of patients that reactivated HBV and risks factors for HBV reactivation.Other frequent viral reactivations were also recorded. Results: Among 135 patients treated with belatatept, 32 were HBcAb-positive. HBV reactivation occurred in 21,7% of cases (7 reactivations) and in 16,7% of HBsAg-negative patients (5 reactivations), at a mean time of 54,8 (AE 70,94) months after transplantation. There was no significant difference in survival between patients that reactivated HBV and patients that did not: 5-year patient survival of 100% (28,6; 100) and 83,4% (67,6; 100) respectively (p=0,363) and 5-year graft survival of 100% (28,6; 100) and 79,8% (61,7; 100) respectively (p=0,335). No factor, including HBsAb positivity and antiviral prophylaxis, seemed statistically associated with the risk of HBV infection. Among the whole cohort, 56,3% of patients reactivated cytomegalovirus, 14,3% presented BK viremia and there were 2 Epstein-Barr virus-related posttransplant lymphoproliferative disorders. Conclusions: The rate of HBV reactivation appeared high when compared with other transplantation studies. Other studies are needed to confirm these results and better evaluate antiviral prophylaxis in this setting.

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