Gouty nephropathy is an uncommon renal complication arising from chronic hyperuricemia, and its coexistence with Amyloid A (AA) (secondary) amyloidosis is exceedingly rare. We describe a 60-year-old man with a long-standing history of untreated polyarticular gout who presented with progressive joint pain, nephrotic-range proteinuria, and renal impairment. Laboratory evaluation showed elevated serum uric acid levels and impaired renal function. Renal biopsy revealed urate crystal deposits (tophi) with associated inflammatory changes consistent with gouty nephropathy, along with Congo red-positive amyloid deposits that were confirmed as AA amyloidosis by immunohistochemistry. This report highlights the critical diagnostic value of renal biopsy in identifying the rare coexistence of gouty nephropathy and AA amyloidosis within the same renal specimen. Recognizing this association is essential for prompt diagnosis and appropriate management, particularly in patients with gout who present with renal impairment and significant proteinuria.

Cryoglobulinemia is an immune complex-mediated disorder that can be associated with autoimmune diseases, lymphoproliferative disorders, and chronic infections. Renal involvement can be a prominent manifestation and may occasionally be the initial clue to an underlying systemic condition. Here, we describe a 33-year-old woman who presented with pedal edema, intermittent arthralgia, hematuria, and impaired renal function. Kidney biopsy demonstrated characteristic intraluminal pseudothrombi with dominant immunoglobulin M deposition, consistent with cryoglobulinemic glomerulonephritis. Subsequently, serologic testing confirmed mixed cryoglobulinemia. Further evaluation revealed strong positivity for anti-Sjögren syndrome-related antigen-A and anti-Sjögren syndrome-related antigen-B antibodies, and a labial salivary gland biopsy fulfilled the 2016 American College of Rheumatology European Alliance of Associations for Rheumatology criteria for Sjögren syndrome, despite the absence of sicca symptoms. Treatment with corticosteroids and rituximab led to significant improvement in renal function. The clinical course was complicated by secondary thrombotic microangiopathy, which responded to plasma exchange. This report highlights the diagnostic value of kidney biopsy in uncovering occult systemic autoimmune disease and emphasizes that Sjögren syndrome may initially present with isolated renal manifestations. Early recognition is essential for the timely initiation of appropriate immunomodulatory therapy.

OBJECTIVES:To evaluate whether Banff 2018 classification of BK polyomavirus nephropathy better predicts graft outcomes compared with baseline graft function and viremia levels, we correlated clinicopathologic features and morphologic BK polyomavirus nephropathy classes with graft outcomes. MATERIALS AND METHODS:We retrospectively analyzed 23 cases of biopsy-proven BK polyomavirus nephropathy over 10 years (2014-2023 ). We stratified biopsy cases into polyoma virus nephropathy class 1, 2, or 3 per the Banff 2018 classification, based on intrarenal viral load (pvl score ) and interstitial fibrosis (ci score ). Outcomes included graft function (serum creatinine, estimated glomerular filtration rate) at 6 and 12 months and graft loss. RESULTS:Among classes, class 2 was the most common (60.86 % ), followed by class 1 (26.08 % ) and class 3 (13.04 % ). Baseline serum creatinine level, BK viremia, and acute inflammation scores did not differ significantly across classes. Cases classified as class 3 showed significantly worse renal function at 6 and 12 months than cases classified as class 1 and 2 (6-month serum creatinine level of 6.19 ± 3.72, 2.19 ± 0.54, and 2.15 ± 0.95 mg/dL for class 3, 1, and 2, respectively; P < .001 ). Graft loss occurred in 0 of 6 cases with polyoma virus nephropathy class 1, 1 of 14 cases with class 2, and 1 of 3 with class 3. Mortality was observed in 2 of 14 patients with class 2 (14.28% ). Tubular atrophy (ct score ) was significantly higher in class 2 and 3 cases versus class 1 cases (P = .046 ). CONCLUSIONS:The Banff 2018 polyoma virus nephropathy classification is a robust predictor of graft outcomes. Class 3 was strongly associated with worse renal function and increased graft loss, largely driven by extent of interstitial fibrosis and tubular atrophy. Histopathological assessment is critical for prognostication as viral load alone does not predict outcomes and severity of BK virus nephropathy.

Background: Renal transplantation is the preferred form of treatment in patients with end-stage renal disease. Despite potent immunosuppression, the patient can develop graft failure in early and late posttransplant period due to immune and nonimmune causes. Graft nephrectomy is uncommon procedure and is being performed for graft failure due to vascular thrombosis, hyperacute rejection, and acute rejection nonresponsive to immunosuppressive treatment in early graft failures and primarily due to graft intolerance in later graft failures. Studies on graft nephrectomy are limited with even fewer studies detailing the histopathology of graft nephrectomy exist in the present literature. The present study describes the detailed histopathology of both early and late graft nephrectomy specimen from a large transplant center in India along with their clinical profile and indications. Materials and Methods: Ten-year retrospective analysis of graft nephrectomy cases was performed from January 2014 up to December 2023. Clinical presentation, immunological profile, and biochemical parameters were obtained from the hospital records. Follow-up was recorded from the medical records. Histopathology changes in the graft nephrectomy specimen were retrospectively analyzed in detail by an experienced renal pathologist and were evaluated in detail along with C4d immunohistochemistry in both early and late graft nephrectomy specimen. Results: Majority of the patients in our cohort underwent early graft nephrectomy. Eleven cases of early graft nephrectomy were ABO incompatible as compared to just one patient with late allograft nephrectomy and the association was significant, P = 0.018. There was a significant association between acute antibody-mediated rejection and subsequent early graft nephrectomy (P = 0.008). The most common indication in cases of early graft nephrectomy was vascular thrombosis and histopathology showed extensive renal parenchymal necrosis with renal artery or vein thrombosis. In late graft nephrectomy group, graft intolerance formed the most common indication. Histopathology showed the features of mixed chronic and acute rejection. Interstitial fibrosis/tubular atrophy and arterial fibrous intimal thickening were common in late graft nephrectomy. Malignancy and infection were the rare diagnosis on histopathology of graft nephrectomy. Conclusion: This study provides a detailed description of the histopathology of early and late graft nephrectomy specimens along with their clinical profile with indications. Histopathology findings although correspond with clinical findings in the majority but may be beneficial in understanding the underlying immune mechanisms in patients experiencing graft intolerance syndrome and managing the transplant recipients in the event of unexpected diagnosis like fungal infection and malignancy.

Background:Torque teno virus (TTV) load is emerging as a biomarker of net immunosuppression in kidney transplant recipients (KTRs). This study investigated the dynamics of TTV DNA load, its correlations with immune profiles, and its clinical associations during the early posttransplant period. Methods:We prospectively analyzed plasma TTV DNA load in 41 KTRs at baseline, day 7, day 14, and 1 month posttransplant. Lymphocyte subsets (CD3+, CD4+, CD8+, CD19+, and natural killer [NK] cells) and cytokines (interleukin [IL]-6, IL-10) were assessed at day 14. Associations among TTV load, immune parameters, and clinical events, including infection and rejection, were examined. Results:TTV load increased significantly from baseline to day 14 (P<0.001) and to 1 month (P<0.001), with a progressive rise beginning at week 2. TTV load consistently exceeded that of healthy controls at all time points (P<0.001 for each comparison). Patients who experienced infections (n=16) had significantly higher TTV loads at days 7 (P=0.006), 14 (P=0.048), and 30 (P=0.044) than patients without infections. At day 14, TTV load showed positive correlations with CD8+ (r=0.677, P<0.001) and CD19+ (r=0.433, P=0.005) cell percentages, as well as with IL-10 levels (r=0.668, P<0.001). Inverse correlations were observed with CD3+ (r=-0.388, P=0.012), CD4+ (r=-0.478, P=0.002), and NK cell percentages (r=-0.340, P=0.030), and with IL-6 levels (r=-0.462, P=0.002). While the percentage of NK cell were significantly higher in patients with infection. Preliminary observations from a very small subset of patients (n=2) suggested that rejection may be associated with lower TTV loads at days 7 and 14; however, this finding requires further investigation. Conclusions:Early posttransplant TTV load reflects the degree of immunosuppression, correlates with specific immune alterations, and predicts infection risk. Monitoring TTV load may provide a valuable tool for personalized immunosuppression management in KTRs.

Dysphagia in renal transplant recipients is most commonly caused by opportunistic infections or medication-related injury. Tuberculosis (TB), although significantly more common in solid organ transplant recipients than in the general population, rarely presents as mediastinal lymphadenitis causing esophageal compression. We report a case of 42-year-old man who presented with low-grade fever and progressive dysphagia along with oral thrush 15 months after undergoing living-related renal transplant. Upper endoscopy revealed lesions consistent with severe candidal esophagitis and a submucosal swelling in the distal esophagus. Computed tomography demonstrated a 4.3 × 2.8 cm hypodense mediastinal collection (16 HU) extending 7.9 cm craniocaudally, compressing the distal esophagus, along with clustered pulmonary nodules. Endoscopic ultrasound-guided fine-needle aspiration yielded purulent material. Xpert Mycobacterium TB/Rifampicin assay detected Mycobacterium tuberculosis without rifampicin resistance, confirmed by culture. The patient improved with rifabutin-based antitubercular therapy and careful tacrolimus monitoring. This case highlights that mediastinal TB should be considered in transplant recipients presenting with dysphagia, particularly in endemic regions. Endoscopic ultrasound (EUS)–guided fine-needle aspiration is crucial for diagnosis, and rifabutin-based regimens help mitigate drug interactions with calcineurin inhibitors.

Background: Hemodialysis (HD) in patients with cirrhosis often poses several challenges. Continuous ambulatory peritoneal dialysis (CAPD) has emerged as an alternative, particularly those with refractory ascites. However, concerns regarding hypoalbuminemia, peritonitis, and long-term outcomes remain. Materials and Methods: This retrospective, single-center study included 34 cirrhotic patients with refractory ascites on maintenance HD who underwent CAPD catheter placement between January 2018 and March 2023. Clinical, biochemical, and procedural data were collected, including ascites management protocols, nutritional status, and peritonitis episodes. Primary outcomes included patient survival, peritonitis rate, and changes in serum albumin over 12 months. Results: The mean follow-up was 12 +/- 2.1 months, and 94% survived at 1 year. Two transitioned to HD due to ultrafiltration failure after episodes of peritonitis. The peritonitis rate was 1 episode/45 patient months. A modest initial decline in serum albumin (-6%) occurred during the first 2 months of therapy, which later stabilized. Mechanical complications, pericatheter leaks, omental wrapping requiring omentopexy, and one umbilical hernia, were managed with a combination of conservative measures and minor invasive procedures as indicated. Conclusion: CAPD is a feasible and effective modality for ESKD patients with refractory ascites, offering high 1-year survival, stable serum albumin levels, and acceptable peritonitis rates when compared to standard peritoneal dialysis (PD) cohorts.

Nonpathogenic Torque Teno Virus (TTV), a component of the human virome may serve for quantifying immune status in kidney transplant recipients. TTV load can rise dramatically in immunocompromised patients such as kidney transplant recipients. This study aims to explore TTV dynamics in living renal transplant recipients and its potential as an immunometer. It is an initial data from a prospective observational study conducted among 36 (Mean Age- 38.44 ± 10.34, Females-11) living donor kidney transplants patients. All patients were on triple immunosuppression Tacrolimus, Mycophenolate Mofetil and Prednisolone and 28 on induction therapy also. Plasma TTV DNA load was assessed using next-generation sequencing (NGS). T-cell phenotype was analysed on fresh peripheral blood mononuclear cells. The prevalence of TTV in our study cohort was 100%. The TTV load was decreased at Day 10 (P = 0.003), and 1-month (P = 0.043)) however increased after 3-month (P = 0.036) post-transplant significantly than that of pre transplant period prior to start of immunosuppression (Fig. 1). At post-transplant Day 10, TTV load positively correlate with CD8+ cell (r = 0.771, P = 0.001) and negatively correlate with CD4+ cell (r = −0.894, P = 0.001) and CD19+ B cells frequency (r = −0.754, P = 0.038), however there was no correlation with Natural Killer (NK cell) cell frequency. Interestingly, patients with infection had significantly higher TTV load compared to patients without infection (6.82 Log10 Vs 2.53 Log10 copies/mL, P = .006) and two Acute T-cell mediated rejection patients had significantly low TTV load (P = 0.042). Lower TTV loads were with incidence of acute rejection, while higher TTV loads were linked to CD8+ T cell and an increased risk of opportunistic infections. TTV quantification predicts infection after kidney transplantation and might be a potential tool to tailor immunosuppressive drug therapy.

Kidney biopsy is a critical procedure in nephrology, enabling accurate diagnosis and guiding patient management. Despite its widespread use, practice patterns can vary based on institutional protocols and physician preferences. This survey aimed to characterize current kidney biopsy practices among nephrologists across India. An online survey was disseminated via Google Forms to nephrologists practicing in various regions of India. The questionnaire captured demographic information, institutional affiliations, frequency and techniques of kidney biopsy, pre- and post-biopsy evaluation criteria, and post-procedure monitoring practices. Responses were analyzed to identify trends and areas of consensus. ?hsp 10pt?>1. Participant characteristics: A total of 202 nephrologists responded, with 73.2% affiliated with corporate or private institutions. The largest contingent practiced in northern India, and 32.4% had over 15 years of nephrology experience. 2. Biopsy volume & technique: Approximately 79% reported performing 1–4 biopsies weekly. A majority (64%) preferred an 18G biopsy gun needle. 3. Patient admission & observation: Two-thirds (67%) admitted patients for the procedure; among those who performed biopsies in a daycare setting, the most common observation period was 8–12 hours. 4. Pre-biopsy evaluation: Over half of the respondents (54.5%) did not routinely use Doppler imaging. Nearly half (47.5%) reported transfusing red blood cells at hemoglobin <8 g/dL. For assessing uremic risk, 64% considered both blood urea nitrogen (BUN) and serum creatinine, while 31% relied solely on creatinine. 5. Dialysis thresholds: Thirty-seven percent set a pre-biopsy serum creatinine threshold of 5.5–6.5 mg/dL for dialysis. The most common upper cutoff for BUN before biopsy was 120–140 mg/dL. A post-dialysis creatinine <5 mg/dL was a frequently cited target prior to proceeding with biopsy. 6. Coagulation monitoring: Beyond standard coagulation tests (aPTT, PT/INR, platelet count), only 10.1% routinely measured bleeding time (BT) and clotting time (CT). Thromboelastography (TEG) was employed by 3% in selected high-risk scenarios. 7. Post-biopsy care: Most nephrologists prescribed complete bed rest after the procedure. Routine ultrasound to screen for hematomas was performed by 64% of respondents. This nationwide survey highlights considerable uniformity in certain aspects of kidney biopsy practice (e.g., choice of biopsy gun needle, RBC transfusion thresholds), alongside notable variability in pre-biopsy evaluation strategies, dialysis thresholds, and coagulation monitoring. These findings underscore the need for standardized guidelines to optimize safety and outcomes in kidney biopsy procedures across India.

Carotid intima media thickness (CIMT) is a non-invasive and reproducible method of identifying and quantifying subclinical CVD. Primary objective was to assess predictive ability of maximum carotid intima media thickness for cardiovascular events in patients with chronic kidney disease on hemodialysis during 9 months follow up. Primary objective was to assess predictive ability of maximum carotid intima media thickness for cardiovascular events in patients with chronic kidney disease on hemodialysis during 9 months follow up. Secondary objective was to assess predictive ability of maximum carotid intima media thickness for mortality during 9 months of follow up in patients with chronic kidney disease on hemodialysis. This was a prospective, observational study enrolling 250 patients with chronic kidney disease on maintenance hemodialysis. The carotid intima media thickness was measured with B-mode ultrasound at three points on the right and left carotid artery: at common carotid artery (1 cm from bifurcation), bifurcation, and internal carotid artery (1 cm from bifurcation). Patients were followed up for a period of 9 months for cardiovascular events and all-cause mortality. 26 patients who underwent kidney transplant during follow up period were excluded in the study. Amongst 224 CKD patients on maintenance hemodialysis, 55.4% were males and 44.6% were females. Mean age of patients was 55.96 ± 13.53 years (range 18 to 84 years). 79.9% patients had hypertension. 42.4 % patients had diabetes mellitus. Mean duration of dialysis was 39.71 ± 36.3 months (range 3 to 158 months). Mean carotid intima media thickness was 0.91 ± 0.14 mm. On follow up there were 66 cardiovascular events which included cardiac events such as angina, Non-ST elevation myocardial infarction (NSTEMI), MI (n = 59), stroke (n = 7) and symptomatic peripheral artery disease (n = 10). Twenty patients expired during the follow up period. ROC curve analysis for the ability of CIMT to predict cardiovascular events found AUC to be 0.74 (95% CI: 0.67–0.81). A CIMT cut-off of ≥1mm for predicting the cardiovascular events (P-value <0.001) had a sensitivity of 81.8% , specificity of 57.0%, positive predictive value of 44% and negative predictive value of 88% (Fig. 1). ROC curve analysis for ability of CIMT to predict all-cause mortality found AUC to be 0.65 (95% CI: 0.54–0.77). A CIMT cut-off of ≥1 mm for predicted the all-cause mortality with a sensitivity of 80%, specificity of 48% , positive predictive value of 13% and negative predictive value of 96 % (Fig. 2). Our study showed that CIMT, measured with B-mode ultrasound predicted the cardiovascular events and all-cause mortality in patients on hemodialysis.

This guideline addresses the use of hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHIs) in patients >18 years with chronic kidney disease (CKD) and anemia in South Asia (Bangladesh, Bhutan, Nepal, India, Pakistan, Sri Lanka). It also summarizes recommendations for anemia treatment for individual HIF-PHI molecules under two categories: dialysis-dependent and non-dialysis-dependent CKD patients. The recommendations do not apply to pediatric (≤12 years) and adolescent (12 to 18) patients or those with primary anemia or anemia secondary to other causes such as blood loss, cancer (any type), polycystic kidney disease and infectious diseases.

Kidney impairment is common in multiple myeloma (MM), often progressing to end-stage kidney disease (ESKD). Although kidney transplantation was traditionally contraindicated, advances in chemotherapy and transplant management have made it a viable option for select MM cases with sustained hematological remission. A 55-year-old female with MM and ESKD achieved complete remission following six months of cyclophosphamide, bortezomib, and dexamethasone (CyBorD) therapy and continued on maintenance bortezomib. She declinined autologous stem cell transplantation, and underwent an ABO-incompatible renal transplant from her spouse. At 12 months post-transplant, graft function remained stable with no MM relapse.