OBJECTIVE:This is a single-center retrospective cohort study on the demographics and clinical outcomes including the response to therapy of patients with primary membranous nephropathy (PMN) over the past decade. With the spread of diverse therapeutic agents available today, this study seeks to present an interesting array of varied responses. MATERIALS AND METHODS:All histology-proven PMN cases diagnosed between 2008 and 2018 were analyzed for their clinical, laboratory, and histological characteristics including treatment that could influence disease progression and renal outcome. RESULTS:There were two sub-groups of patients, those with nephrotic syndrome and those without nephrotic syndrome. All secondary causes of secondary membranous nephropathy were excluded. The response to therapy including RAS blockers, steroids, and immunosuppressants all showed a consistent reduction of proteinuria with therapy for the whole cohort, nephrotic as well as non-nephrotic syndrome with only 10% of the 102 patients in end-stage renal disease (ESRD) at 10 years. CONCLUSION:Our data show that membranous nephropathy is a disease responsive to most forms of therapy with decreasing proteinuria. The progression of the disease is slow with a gradual decline to ESRD.

End stage kidney patients opting for PD as choice of modality can either start PD with a PD catheter or with interim hemodialysis (HD) via a tunnelled vascular catheter before transitioning to PD. This study examined how the timing of the transition to PD influences patient outcomes. This single-center retrospective cohort study included adult PD patients from 2005 to 2015, classified into three groups: PD-first (started directly on PD), Rapid PD Transition (interim HD with PD catheter insertion within ≤2 weeks), and Delayed PD Transition (interim HD with PD catheter insertion between >2 weeks and ≤6 months). The study investigated how the timing of PD transition affected the risk of bacteremia. The study included 807 PD patients, comprising 257 in the PD-first group, 169 in the Rapid PD transition group, and 381 in the Delayed PD Transition group. Compared to the PD-first group, the Delayed PD Transition group had higher rates of diabetes and cardiovascular disease and, a greater proportion of patients not seen by a nephrologist before dialysis. Patients in the Delayed PD Transition group had significantly higher odds of bacteremia compared to the PD-first group (adjusted odds ratio (AOR) 2.08; 95% confidence interval (CI) 1.46–2.99; P < 0.001), whereas no such association was observed in the Rapid PD Transition group (AOR: 1.45; 95% CI: 0.93–2.26; P = 0.10) Additionally, the time to the first episode of bacteremia was shorter in both the Rapid PD Transition group (adjusted hazard ratio (AHR) 1.60, 95% CI 1.10–2.33; P = 0.01) and Delayed PD Transition group (HR 1.97, 95% CI 1.46–2.67; P < 0.01) compared to the PD-first group. Patients with Delayed PD Transition were significantly associated with an increased risk of bacteremia and a shorter time to its onset compared to those who initiated PD with PD catheter. Future multicenter studies are needed to confirm these findings.

In conventional PD (CPD), ultrafiltration (UF) will decline over time with diminishing glucose gradient; necessitating fresh dialysate instillation to reestablish the gradient. Viva Kompact (previously AWAK) is a steady concentration sorbent-based peritoneal dialysis (PD) device which tidals 250 mls per cycle, up to 64 cycles, and regenerates new solution at the rate of 2 L/hour after the initial instillation of dextrose solution1. Fig. 1 illustrates a simulated scenario of glucose concentration in the peritoneum over a therapy. In Viva Kompact the rate of glucose infusion can be adjusted between 4 settings (0.4–1.6 ml/cycle of 70% dextrose) based on subject’s need, guided by a nomogram. Therapy time can vary between 7 to 9 hours. This study aims to evaluate the UF patterns and efficiency, with subjects as their own control, while on the Viva Kompact device as compared to CPD. At Singapore General Hospital between May 2023 to February 2024, 14 subjects were screened and underwent a titration period (up to 21 days), a washout (minimum 2 days), and an at-home treatment period (7 days). Three subjects were offered an optional extension (23 days). During titration a nomogram guide for steady concentration PD was employed to determine cartridge type, therapy duration, initial fill tonicity (Dianeal Low Calcium 1.5%, 2.5% or 4.25%). Overall, as a UF surrogate, dry body weight was used. The aim was to have subjects maintaining their body weight within 5% of target dry weight (average dry weight of Screening and pre-Titration Day 1). CPD (baseline) 24-hour dialysate data was collected at Screening. Daily weight and UF data were collected on all participants when they started the use of Viva Kompact. Fill volumes were kept similar during CPD and Viva Kompact therapy. Dialysate samples were collected on Treatment Day 1 (Cycle 4, 8, 40, 54 and Final drain). Safety bloods were done throughout the study (Day 4, 7, 14, 21 and 30). Calculation of UFEexp / UFEabs (UF generated in 24 hours per gram of glucose monohydrate exposed/absorbed) were derived from these datapoints Descriptive statistics (median, min, max) were used in analysis, with significance testing reported using Wilcoxon signed rank test. 11 out of 14 subjects were enrolled in the study; 2 failed screening and 1 withdrew during the Titration phase. 10 subjects completed the 7-day Treatment period and 3 subjects continued to the 23-day Optional Extension period. 1 subject withdrew on the sixth day of Treatment and was included in the analysis. Table 1 shows the demographic summary of the analysed subjects. Subjects with last fill (n = 6) were continued on Icodextrin 7.5%. All subjects maintained their body weights within 5% of their target body weight (% change in body weight = −0.7% [−4.3–1.3%] during the 7-day Treatment as well as Optional Extension period. Table 2 compares body weight, glucose exposure, absorption, UFEexp, and UFEabs for CPD vs. Viva Kompact. The UFE (exposed) as significantly better in Viva Kompact as compared to CPD; UFEexp = 5.5[2.9–9.6] mL/g vs 1.8[−0.8 – 5.4] mL/g of glucose exposed, p = 0.0034. Whereas, UFE (absorbed) was similar; Viva Kompact = 8.9[4.8–20.3] mL/g vs CPD = 3.1[−2.1–28.7] mL/g of glucose absorbed, p = 0.1835. Throughout the study, subject serum sodium levels also remained stable; Baseline = 138[134–146] mmol/L vs Viva Kompact = 137[132–141] mmol/L. This medium-term study demonstrates that steady concentration PD with Viva Kompact is able to maintain patients at their target weight while achieving individually appropriate UF. This approach provides similar UFEabs (UF per gram of glucose absorbed) but significantly improves UFEexp (UF per gram of glucose exposed). The significant reduction in glucose exposure with Viva Kompact may help preserve the peritoneal membrane. Further studies are needed to assess the longer-term impact on technique survival, membrane integrity, and outcomes in PD patients with diabetes.2

The disease burden of chronic kidney disease (CKD) and its impact on healthcare systems has been poorly studied in Asia, a socioeconomically diverse region with wide variations in availability, access, and quality of CKD care. The high CKD burden in this region is predominantly driven by an increased prevalence of risk factors including diabetes mellitus, hypertension, obesity, and use of traditional medicines and is further aggravated by challenges associated with effective implementation of population-based screening and surveillance systems in early detection and intervention of CKD. The Asian continent mostly comprised of low- and middle-income countries with resource restraints lacks robust population-based CKD registries resulting in a paucity of data on CKD incidence and prevalence, various treatment modalities, uptake of current guidelines, and the overall impact of implementation of developmental programs. There is an urgent need for a collaborative action plan between the healthcare community and governments in this region to detect CKD in its early stages and prevent its complications including kidney failure, cardiovascular disease, and death. Research- based evidence on the impact of early detection, sustainable treatment options, quality of life, delay or avoidance of dialysis, and related cost analysis is the need of the hour. We highlight successful implementation of strategic and policy-sharing programs adopted in a few countries; also, consolidate available region-specific data, quantify estimates of CKD burden and propose strategies with a multidisciplinary approach involving patients, the healthcare community and governmental bodies to combat CKD and its complications.

AIMS:This study aimed to (i) evaluate the effectiveness of mindfulness-based interventions in improving self-efficacy, reducing stress and anxiety among peritoneal dialysis patients, and (ii) compare the most effective method of mindfulness based interventions.METHODS:This randomized three-arm controlled trial recruited first-time peritoneal dialysis patients from the peritoneal dialysis outpatient clinic in Singapore. Patients were randomly allocated to either video-assisted mindfulness training, therapist-assisted mindfulness training or treatment-as-usual. All groups received 4.5 days of structured peritoneal dialysis training at the peritoneal dialysis centre, while video-assisted mindfulness training and therapist-assisted mindfulness training groups were taught additional mindfulness-based techniques. The perceived stress scale, self-efficacy, and anxiety (State and Trait Anxiety Inventory) were measured at baseline, 4- and 12 weeks post-randomization, using reliable and valid instruments.RESULTS:Thirty-nine patients were recruited (13 in each group). All the therapies showed a significant time trend in anxiety. Only therapist- and video-assisted mindfulness training showed a significant trend in perceived stress scale scores but not treatment-as-usual. All Intervention X Time interactions were not significant. Patients in therapist- and video-assisted mindfulness training groups had reduced perceived stress scale scores compared to treatment-as-usual at week 12.CONCLUSION:This study demonstrated the potential of mindfulness-based interventions in reducing stress among first-time PD patients.

In the evolving landscape of chronic disease management, remote patient monitoring (RPM) has emerged as a pivotal tool, particularly for patients with chronic kidney disease (CKD) and those undergoing peritoneal dialysis (PD). The study aims to evaluate the acceptance and usability of a newly developed RPM mobile application (App) designed to track vital signs, dietary habits, medication adherence, and dialysis data.

BACKGROUND:Effective interventions during the coronavirus disease 2019 (COVID-19) pandemic require an understanding of patients' knowledge and perceptions that influence their behaviour. Our study assessed knowledge of COVID-19 among kidney transplant recipients and donors, hitherto unevaluated. METHODS:We conducted a cross-sectional survey among 325 kidney transplant recipients and 172 donors between 1 May 2020 and 30 June 2020. The survey questionnaire assessed knowledge levels of COVID-19, sociodemographic data, health status, psychosocial impact of COVID-19 and precautionary behaviours during the pandemic. RESULTS:The mean COVID-19 knowledge score of the study population was 7.5 (standard deviation: 2.2) out of 10. The mean score was significantly higher among kidney recipients compared to kidney donors (7.9 [1.9] vs. 6.7 [2.6]; P <0.001). Younger age (21-49 vs. ≥50 years) and higher education (diploma and higher vs. secondary and lower) were associated with significantly higher knowledge scores in donors, but not among recipients ( P -interactions ≤0.01). In both kidney recipients and donors, financial concerns and/or social isolation were associated with lower knowledge levels. CONCLUSIONS:Concerted efforts are needed to improve COVID-19 knowledge in kidney transplant recipients and donors, particularly older donors, donors with lower education and patients with financial concerns or feelings of social isolation. Intensive patient education may mitigate the impact of education levels on COVID-19 knowledge levels.

Objective: This is a study on the demographics and clinical outcomes in-cluding the response to therapy of patients with focal segmental glomerulosclerosis (FSGS) over the past decade. Materials and methods: All histologically proven FSGS cases diagnosed between 2008 and 2018 were analyzed for their clinical, laboratory, and histological characteristics including treatment that could influence the disease progression and renal outcome of these pa-tients. We used the Columbia Classification for FSGS for the renal biopsy. Results: There were two subgroups of FSGS patients; those with nephrotic syndrome and those without nephrotic syndrome. Patients with FSGS with non-nephrotic syndrome had poorer surviv-al rates compared to the nephrotic group. For those without nephrotic syndrome, the indices responsible for progression involved more tubular and blood vessel lesions in ad-dition to glomerular pathology compared to those with nephrotic syndrome. Pa-tients with FSGS with nephrotic syndrome responded to immunosuppressants more favorably compared to the non-nephrotic group, though both groups responded with decreasing proteinuria. The nephrotic group had a better 10-year long-term survival rate of 92 vs. 72% for the non-nephrotic group (log-rank 0.002). The 10-year survival for the whole group of FSGS patients was 64%. Con-clusion: Our data suggest that in FSGS, one of the significant components of the disease is the vascular and tubular damage, apart from the underlying glomerular pathology, resulting in varying responses to therapy, and the difference is reflected in inherently poorer response to immunosuppressant therapy in those without nephrotic syn-drome as opposed to those with nephrotic syndrome, who responded to immunosup-pressant therapy (IST) with stabilization of renal function and had less blood vessel and tubular lesions.

Individuals with kidney failure undergoing maintenance dialysis frequently report a high symptom burden that can interfere with functioning and diminish life satisfaction. Until recently, the focus of nephrology care for dialysis patients has been related primarily to numerical targets for laboratory measures, and outcomes such as cardiovascular disease and mortality. Routine symptom assessment is not universal or standardized in dialysis care. Even when symptoms are identified, treatment options are limited and are initiated infrequently, in part because of a paucity of evidence in the dialysis population and the complexities of medication interactions in kidney failure. In May of 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference-Symptom-Based Complications in Dialysis-to identify the optimal means for diagnosing and managing symptom-based complications in patients undergoing maintenance dialysis. Participants included patients, physicians, behavioral therapists, nurses, pharmacists, and clinical researchers. They outlined foundational principles and consensus points related to identifying and addressing symptoms experienced by patients undergoing dialysis and described gaps in the knowledge base and priorities for research. Healthcare delivery and education systems have a responsibility to provide individualized symptom assessment and management. Nephrology teams should take the lead in symptom management, although this does not necessarily mean taking ownership of all aspects of care. Even when options for clinical response are limited, clinicians should focus on acknowledging, prioritizing, and managing symptoms that are most important to individual patients. A recognized factor in the initiation and implementation of improvements in symptom assessment and management is that they will be based on locally existing needs and resources.

BACKGROUND:In advanced chronic kidney disease (CKD), patients face complex decisions related to renal replacement modality that can cause decisional conflict and delay. This study aimed to evaluate the prevalence of severe decisional conflict across decision types and to identify the psychosocial and clinical factors associated with decisional conflict in this population.DESIGN:Observational cross-sectional study.METHODS:Patients with CKD in renal care were recruited. The Decisional Conflict Scale (DCS), Functional, Communicative, and Critical Health Literacy (FCCHL), Health Literacy Questionnaire (HLQ), Hospital Anxiety and Depression Scale (HADS), Brief Illness Perception Questionnaire (BIPQ), and the Kidney-disease Quality of Life (KDQOL) questionnaires were used. Clinical data were obtained from medical records. Bivariate and multivariable logistic regression models were used to identify predictors of severe decisional conflict (DCS score ≥ 37.5).RESULTS:Participants (N = 190; response rate = 56.7%; mean age = 62.8 ± 10.8) reported moderate levels of decisional conflict (29.7 ± 14.5). The overall prevalence of severe decisional conflict was 27.5% (n = 46) with no significant differences across decision types (dialysis, modality, access). Ethnicity (Chinese), marital status (married), BIPQ treatment control, coherence, KDQOL staff encouragement, and all health literacy domains, except functional health literacy, were significant predictors of decisional conflict in the unadjusted models. In the multivariable model, only the health literacy domains of FCCHL Communicative, and HLQ Active Engagement remained significant.CONCLUSION:Even after pre-dialysis education, many CKD patients in this study still report severe decisional conflict, with rates remaining substantial across decision junctures. The associations of decisional conflict and health literacy skills related to communication and engagement with healthcare providers indicate that more collaborative and patient-centric pre-dialysis programs may support patient activation and resolve decisional conflict.

The heart and the kidney have a highly interdependent, heterogeneous and complex relationship. The relationship was noted in the 19th Century by Robert Bright who found structural changes in the heart in patients with advance kidney disease[1]. The pathological mechanism has eluded physicians over the years and the classification is based on “clinical description” of which organ is first affected and the time frame depicting chronicity or acute. Vasodilators were the cornerstone of treatment of heart failure (HF) as evident in the CONSENSUS I, SOLVD and V-HeFT trials in the early 1980s. The introduction of ACE inhibitors presented a new era where HF and kidney failure treatment merge as evident in HOPE and MICRO-HOPE study, targeting the neurohumoral dysfunction[2]. Altering and manipulating the renal-angiotensin system (RAS) has been the target for treatment for HF. Introduction of SGLT2 inhibitors is a game changer for both HF and CKD treatment irrespective of the presence of diabetes mellitus. The treatment mechanism targets the tubuloglomerular feedback (TGF) in the nephron, reducing hyperfiltration and restoring normal TGF. In the last 5 years there has been an avalanche of studies with SGLT2i, with groundbreaking results in reducing GFR decline and composite cardiovascular outcomes to the extent that they may be disease modifying, e.g. EMPEROR-Reduced, DAPA-HF, CREDENCE[3,4]. The heart and the kidney have a highly interdependent, heterogeneous and complex relationship. The relationship was noted in the 19th Century by Robert Bright who found structural changes in the heart in patients with advance kidney disease[1]. The pathological mechanism has eluded physicians over the years and the classification is based on “clinical description” of which organ is first affected and the time frame depicting chronicity or acute. Vasodilators were the cornerstone of treatment of heart failure (HF) as evident in the CONSENSUS I, SOLVD and V-HeFT trials in the early 1980s. The introduction of ACE inhibitors presented a new era where HF and kidney failure treatment merge as evident in HOPE and MICRO-HOPE study, targeting the neurohumoral dysfunction[2]. Altering and manipulating the renal-angiotensin system (RAS) has been the target for treatment for HF. Introduction of SGLT2 inhibitors is a game changer for both HF and CKD treatment irrespective of the presence of diabetes mellitus. The treatment mechanism targets the tubuloglomerular feedback (TGF) in the nephron, reducing hyperfiltration and restoring normal TGF. In the last 5 years there has been an avalanche of studies with SGLT2i, with groundbreaking results in reducing GFR decline and composite cardiovascular outcomes to the extent that they may be disease modifying, e.g. EMPEROR-Reduced, DAPA-HF, CREDENCE[3,4].

Background Mindfulness-based intervention (MBI) has not been evaluated for its feasibility and effectiveness in reducing stress and anxiety among family caregivers of patients on peritoneal dialysis (PD). Objectives (1) To evaluate the feasibility to include MBI during PD training for family caregivers. (2) To determine the effect of MBI on the caregivers’ levels of stress (perceived stress scale, PSS), anxiety state-trait anxiety inventory, STAI), QOL (short-form 36) and reactions to caregiving (caregiver reaction assessment, CRA). (3) To determine differences in the health-related QOL (Kidney Disease Quality of Life Instrument-Short Form, KDQOL PCS and SF-36 MCS) of care recipients with caregivers receiving MBI at 1 month, 3 months and 6 months when compared to those with caregivers receiving routine training. (4) To gather the caregiver’s feedback on the MBI. Methods This feasibility study recruited family caregivers to receive either mindfulness training (MT) or treatment-as-usual (TAU) group. Both groups received 4.5-days of structured PD training, but only caregivers in the MT group received 4 days of MT sessions, audio-guided mindfulness practice at home and weekly telephone follow-up. Results Forty-four family caregivers participated in this study. Including MBI as part of the PD training was feasible. There was a trend towards lower scores for PSS and T-STAI in the MT group compared to the TAU group. The baseline score of both PSS and T-STAI were positively correlated with post-intervention outcome scores. Conclusions Mindfulness-based intervention has the potential to improve psychological symptoms among caregivers of patients with PD.

Nodular glomerulosclerosis, typically diagnosed in patients with diabetes mellitus, has been reported in native kidneys of pre-diabetic patients but similar cases in kidney transplant recipients are lacking. We describe a case of nodular glomerulosclerosis in a kidney transplant recipient who had not been found to be diabetic despite regular screening and discuss the implications for the pathogenesis and diagnosis of nodular glomerulosclerosis and screening of post-transplant diabetes mellitus.

Background: Regeneration of peritoneal dialysis (PD) fluid using sorbent technology can provide flexibility and improve quality of life. This study examined the safety and efficacy of the automated wearable artificial kidney (AWAK) device in PD patients. Methods: This pilot study included prevalent PD patients from a single center in Singapore between 2016 and 2018. Participants underwent up to nine AWAK therapies over 72 h and were followed up for 1 month. Primary outcomes were serious adverse events (SAEs) and completion of nine therapies without device deficiency. Secondary outcomes were weekly peritoneal Kt/ V urea, solutes clearance and adverse events (AEs). Results: Twenty-one patients were screened and 15 were included in the study. Device alterations were required to overcome issues including flow occlusions initially, which resulted in three cohorts ( n = 2, 2 and 11 respectively). No SAEs were observed during the study and at the follow-ups. Common AEs were abdominal pain/discomfort (60%) and bloatedness (47%). The median estimated peritoneal weekly Kt/ V urea was 3.0 (interquartile range: 2.2–4.8). There were significant reductions in pre- and post-study median serum urea (20.8 vs. 14.9 mmol/L; p = 0.001), creatinine (976.0 vs. 667.5 µmol/L; p = 0.001), phosphate (1.7 vs. 1.5 mmol/L; p = 0.03), and β2-microglobulin (29114.0 vs. 26339.0 µg/L; p = 0.048). Fluid reabsorption occurred among patients with residual kidney function. However, median body weights were not significantly different pre- and post-study (66.4 vs. 65.7 kg; p = 0.83). Conclusions: This preliminary study demonstrated that no SAEs were observed with the AWAK-PD device; however, 60% of participants developed abdominal pain/discomfort. Further device enhancements are needed to improve ultrafiltration and reduce AEs.

OBJECTIVE:In this study, we trace the changes in the clinical and histological pattern of IgA nephritis (IgAN) in Singapore as it has evolved over 4 decades and compare the clinical, demographic, histological, and renal outcome of patients with IgAN from the 1st decade and the 4th decade.MATERIALS AND METHODS:This is a retrospective study of all histologically proven IgAN diagnosed between 1976 and 2018. Clinical, laboratory, and histological characteristics between the 1st and the 4th decade, including treatment which could influence the disease progression and renal outcome of these two groups, were compared. We used the Oxford classification to compare the renal biopsy changes for these 2 decades as we were able to retrieve 125 renal biopsy tissues for the 1st cohort of IgAN studied in the 1970s for the comparative study.RESULTS:The commonest clinical presentation throughout the first 3 decades was asymptomatic hematuria and proteinuria (63, 52, and 49%, respectively). In the 4th decade, nephrotic syndrome (31%) was the commonest followed by asymptomatic hematuria and proteinuria (30%), hypertension (21%), and chronic renal failure (11%). The data showed that treatment can modify the Oxford MEST - Crescent scores. Renin-angiotensin system (RAS) blockers modified the S scores, immunosuppressants modified the T and C scores, and combination therapy with RAS blockers and immunosuppressants modified the E, S, and T scores.CONCLUSION:The Oxford MEST classification offers a robust and expressive classification for early and late disease progression with respect to the development of end-stage renal disease (ESRD). E and S seem to be indices of continuing disease activity with progressive glomerulosclerosis, probably still amenable to therapy, but T was a predictive indicator for those destined for ESRD and no longer amenable to therapy.

Anemia is an important complication in patients with chronic kidney disease. Peritoneal dialysis (PD) is one of the most common modalities of kidney replacement therapy for patients with end-stage kidney disease. PD is particularly prevalent in the Asian Pacific region. Among the different countries and regions, including mainland China, Hong Kong, Japan, Malaysia, Singapore, South Korea, and Thailand, PD accounts for 2.8% to 74.6% of the dialysis population. In addition, 82% to 96% of the PD populations from these countries and regions are receiving erythropoiesis-stimulating agents (ESAs). Asian Pacific countries and regions follow the latest KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the initiation of treatment of anemia in PD patients. The types of ESAs commonly used include shorter-acting (epoetin alfa and beta) and longer-acting agents, including darbepoetin alfa or methoxy polyethylene glycol-epoetin beta. The most commonly used ESAs in Mainland China, Malaysia, Singapore, and Thailand are the shorter-acting agents, whereas in Hong Kong, Japan, and South Korea, longer-acting ESAs are most common. Oral iron therapy is still the most commonly used iron supplement. The route and dosage of iron administration in PD patients requires more research studies. With the introduction of oral hypoxia-inducible factor prolyl hydroxylase inhibitors into clinical use, the landscape of treatment of anemia in the PD population in the Asia Pacific region may change in the coming years.

Objective: This study on the prevalence of diabetic nephropathy (DN) and coexistence of non-diabetic renal disease (NDRD) in a cohort of 255 non-insulin-dependent diabetes mellitus (NIDDM) patients aims to determine the value of performing renal biopsies in these patients and elucidate the factors which could affect their progression to end-stage renal disease (ESRD). Methods: Among 255 NIDDM patients, 93 had DN alone, 69 had NDRD alone, and the remaining 93 had DN plus NDRD (mixed group). The indications for renal biopsy were based on clinical suspicion of superimposed NDRD, including heavy or rapidly increasing proteinuria, renal impairment even though diabetes is of relatively short duration, rapidly declining renal function, and presence of hematuria with dysmorphic red blood cells suggesting presence of glomerulonephritis. Results: The following were predictors of ESRD: high systolic BP at biopsy, longer duration of diabetes, heavy proteinuria, and presence of diabetic retinopathy. Comparing patients in the NDRD group with the DN group and the mixed group, the NDRD group had lower serum creatinine and higher eGFR with lower urinary proteinuria and higher serum albumin at presentation and on follow-up. Kimmelstiel-Wilson nodules were associated with a poorer prognosis leading to a higher occurrence of ESRD among patients with DN. Conclusion: Renal biopsy is of value in indicating the prognosis of NIDDM patients with DN based on the diabetic lesions. For NIDDM patients with atypical course and suspicion of associated NDRD, a renal biopsy would enable us to diagnose the underlying NDRD and offer appropriate therapy. Most nephrologists would consider renal biopsy for an NIDDM patient based on clinical indications like atypical clinical course and suspicion of an associated NDRD, but they would not perform a routine renal biopsy like for a CKD patient, unless it is for a research indication.