Background: Sex- and gender-related inequities in access to specialist kidney care remain insufficiently characterised in low- and middle-income countries despite the substantial burden of chronic kidney disease (CKD). We evaluated differences in utilisation of tertiary nephrology services by sex over a 10-year period in North India. Methods: We conducted a retrospective observational study using electronic health records from a high-volume tertiary nephrology referral centre in North India. All nephrology visits between Jan 1, 2010, and Dec 31, 2020, were included. Patient-level data were linked with district-level demographic and socioeconomic indicators from the 2011 Census of India. The primary outcome was utilisation of nephrology services by sex. Secondary outcomes included utilisation of kidney replacement therapies (haemodialysis, peritoneal dialysis, and kidney transplantation), post-transplant survival, temporal trends, and geographical patterns of access. Findings: A total of 492,857 nephrology visits from 104,512 unique individuals were analysed. Women accounted for 152,136 (30.9%) visits and 35,254 (33.7%) unique patients. The lower representation of women was consistent across administrative divisions and throughout the study period, including after a marked expansion in service utilisation in 2014 (30.9% after vs 31.1% before; p=0.24). Women were also less likely than men to receive kidney transplantation. Among 1,205 transplant recipients, 151 (12.5%) were women; transplantation rates among patients receiving nephrology care were 2.45% for women and 6.86% for men (p<0.0001). Post-transplant survival was similar between women and men (log-rank p=0.38). Districts located farther from the study centre contributed fewer patients, whereas greater female socioeconomic advantage at the district level was associated with higher utilisation by women. Interpretation: Women had consistently lower utilisation of tertiary nephrology services over a decade despite comparable post-transplant survival, suggesting that inequities occur primarily before access to specialist kidney care is achieved. Strategies that improve timely referral, equitable access to diagnostic and therapeutic services, and financial protection may help reduce sex- and gender-related inequities in kidney care in resource-constrained settings.

BACKGROUND:Immunological evaluation plays a central role in kidney transplantation, guiding donor selection, risk assessment, and graft outcomes. Although international guidelines are comprehensive, applying them in a real-world low resource setting can be challenging where laboratory capacity varies and access to advanced testing is limited. There is therefore a need for implementable guidelines that reflect local realities while maintaining clinical rigor. METHODS:The Indian Society of Organ Transplantation (ISOT) brought together a multidisciplinary panel of transplant nephrologists, surgeons, clinical immunologists, and histocompatibility laboratory scientists from centers across India. A focused review of international guidelines, systematic reviews, and key studies was undertaken. Draft recommendations were developed and shared ahead of a structured consensus meeting. These were discussed, refined, and finalized through iterative expert deliberation. Recommendations were classified as "Recommended" or "Suggested" based on consensus, and their evidentiary basis was clearly defined. RESULTS:A total of 48 consensus recommendations were developed across 13 thematic areas covering key aspects of immunological evaluation. These included immunological risk assessment, antibody screening and crossmatch testing including virtual crossmatch, sensitization assessment, serum sampling and waitlist monitoring, HLA typing, post-transplant monitoring, laboratory governance and immunological assessment in ABO-incompatible transplantation. Of these, 23 were "Recommended" and 25 "Suggested." Additional guidance focused on resource-adapted and cost-conscious approaches suited to the Indian context. CONCLUSIONS:These recommendations offer a practical and standardized framework for immunological evaluation in kidney transplantation within low- and middle-income settings. Their adoption has the potential to improve patient safety and optimize graft outcomes.

Metabolic-associated chronic kidney disease (MACKD), defined as CKD that is caused or exacerbated by metabolic abnormalities, represents a growing global health challenge driven by insulin resistance, obesity, type 2 diabetes mellitus (T2D), hypertension, and systemic inflammation. MACKD reflects kidney damage driven by systemic metabolic dysfunction, and is not limited to diabetes- and obesity-related kidney diseases but also encompasses fatty kidney, kidney disease associated with Metabolic Associated Fatty Liver Disease (MAFLD), and the negative impacts of metabolic disease on other primary kidney diseases. As a result, management of MACKD must move beyond traditional diabetic kidney disease (DKD) paradigms and address obesity, insulin resistance, dyslipidaemia, hypertension and chronic low-grade inflammation, irrespective of diabetes status. The goals of MACKD management are to slow CKD progression, reduce cardiovascular risk, improve metabolic health and preserve functional status. Early intervention is particularly critical in South Asian populations, where metabolic risk manifests at younger ages and lower body mass index (BMI) thresholds.This review outlines a step-wise approach to the evaluation of MACKD and examines the current evidence for optimal management, taking into consideration the challenges imposed by diverse cultures, healthcare infrastructure, policies, and available resources in the South-Asian region.

Background: Scleroderma renal crisis (SRC) is a rare but severe complication of systemic sclerosis (SSc), often associated with high morbidity and mortality. Data from Indian population remains limited. Objectives: To describe the clinical features, predictors, and outcomes of SRC in a large, single-centre Indian SSc cohort over three decades. Methods: This retrospective cohort study included 880 SSc patients diagnosed between 1990 and 2019, classified by ARA 1980 or ACR/EULAR 2013 criteria. SRC was defined by new-onset hypertension and/or rapidly progressive renal failure, with supportive hematologic and urinary findings. Demographic, clinical, and serologic variables were analysed. Predictors of SRC were identified using multivariate logistic regression, and survival was assessed using Kaplan-Meier and Cox regression analyses. Results: SRC occurred in 27 patients (3.0%), with 85.2% developing SRC within one year of diagnosis. Steroid use preceded SRC in 66.6% of cases. SRC was associated with older age (OR 1.03, 95% CI 1.001-1.072), digital pitting scars (OR 6.16, 95% CI 1.60-23.65), and reduced by immunosuppressive therapy (OR 0.39, 95% CI 0.16-0.98). SRC patients had a significantly higher mortality risk (HR 3.66, 95% CI 1.94-6.89) and shorter survival (mean 7.2 vs. 23.8 years). Dialysis was required in 51.8% of SRC cases. Conclusions: SRC affected 3% of SSc patients and was associated with high mortality and dialysis dependence. Older age, steroid exposure, and digital pitting scars were key risk factors, while immunosuppression appeared protective. These findings highlight the importance of early identification and careful therapeutic strategies in high-risk patients.

Diabetic kidney disease (DKD) is becoming an increasingly common consequence of diabetes in India, where the number of affected individuals is rising at an alarming pace. The illness is often silent in its early stages, and many patients are diagnosed only when kidney damage is advanced, leading to high rates of kidney failure and cardiovascular complications. This consensus document was developed by a broad group of experts to provide practical, evidence-based recommendations tailored for Indian healthcare settings. It stresses the importance of timely screening using the urine albumin-to-creatinine ratio and estimated glomerular filtration rate, along with routine evaluation of cardiovascular risks. The guidance covers key management areas such as blood pressure and glycemic control, the use of renin-angiotensin system blockers, newer agents such as sodium-glucose cotransporter 2 inhibitors (SGLT2) inhibitors and finerenone, as well as lifestyle and dietary measures. Equal attention is given to affordability, patient education, and integrating care into national health programs. By adapting international standards to local realities, this document aims to improve early detection, reduce inequalities in treatment, and support better long-term outcomes for people living with DKD in India.

Kidney transplantation (KT) accounts for nearly three-fourths of organ transplants in India, with living donors contributing to 82% of cases. Induction immunosuppression is essential to optimize initial immunosuppression, reduce acute rejections, and enable tailored use of maintenance agents. Rabbit anti-thymocyte globulin (rATG) and interleukin-2 receptor anatagonists (IL-2RA/IL-2RBs) are the most widely used induction therapies. However, data on induction practices across India are limited. To evaluate induction immunosuppression practices across KT centers in India and establish a consensus for different subsets of KT recipients. A nationwide online survey was conducted by the Indian Society of Organ Transplantation (ISOT) among its members (400 KT centers). Responses were analyzed to assess induction practices across diverse donor types, age groups, and immunological risk profiles. Heterogeneity in practices prompted consensus building using a modified Delphi process. Literature review and expert panel discussions (April 2024) were followed by structured voting, and 16 consensus statements were finalized. Of 400 centers approached, 254 participated. rATG was the most commonly used induction therapy, followed by IL-2RBs; alemtuzumab was least used. Significant heterogeneity was observed in type, dose, and duration of induction therapy. Consensus recommendations were framed: rATG for high immunological risk recipients and deceased donor KTs; IL-2RB or low-dose rATG for low immunological risk; rituximab in ABO-incompatible KTs; and tailoring based on age, diabetes, donor type, infection risk, and affordability. This first ISOT consensus provides 16 India-specific statements on induction therapy in KT. It emphasizes risk-stratified, evidence-informed, and context-appropriate induction strategies, supporting standardization of care across the country.

Background: Atypical hemolytic uremic syndrome (aHUS) is a severe thrombotic microangiopathy predominantly affecting the kidneys, often associated with complement dysregulation. This study is aimed to analyze the clinical characteristics, treatment outcomes, and long-term implications of aHUS in a resource-limited setting. Materials and Methods: A retrospective observational study conducted at an institute between January 2016 and December 2022 included all patients with aHUS, excluding secondary causes and renal transplant recipients. Demographic profiles, clinical features, laboratory parameters, treatment modalities (immunosuppression and plasma exchange), and outcomes were collected. Anticomplement Factor H (anti-CFH) antibody, complement levels, and genetic mutation analysis were performed to ascertain etiological factors. The patient and renal outcomes of anti-CFH positive and negative patients on long-term follow-up were compared. Results: Fifty-seven patients (mean age: 12.5 +/- 4.9 years; 63% males) were analyzed. Among them, 33 (57.9%) tested positive for anti-CFH antibodies and eight presented postpartum. Initial remission was achieved in 42 (73.6%) patients, with 13 (22.8%) partial and 29 (50.9%) complete remission. The median follow-up duration was 24 months [interquartile range (IQR) 8.5-84]; 12 (21%) patients died, with two deaths during the index admission, six among nonresponders, and 4 among responders. Dialysis-free renal survival was superior in anti-CFH seropositive patients (81.2%) compared to seronegative counterparts (55.9%), while patient survival was statistically similar between the two groups. Elevated anti-CFH titers (>4000 AU/ml), age >= 16 years, female gender, and seizures predicted nonresponsiveness. Conclusion: Anti-CFH antibody associated aHUS had better kidney outcomes than the seronegative counterparts. In resource limited settings, a combination of plasma exchange and immunosuppression showed promising results in the short and long term.

Patients with chronic kidney disease (CKD) display a variety of metabolic and nutritional irregularities, with majority of patients already being malnourished before starting dialysis. The screening, assessment and monitoring of nutritional status using an amalgamation of valid, complementary methods is crucial. Early and suitable dietary intervention is vital for preventing, diagnosing and treating malnutrition. All the misconceptions and myths about diet and food need to be resolved. Patient-centric realistic meal plans and dietary counseling are initiated at the early stages of CKD and the commencement of dialysis, with regular follow-ups on an ongoing basis with diet diaries that help prevent malnutrition. This review article will discuss the practical and simple dietary approaches for counseling patients to increase dietary compliance and meet the recommended requirements.

A 48-year-old female with anti-neutrophilic cytoplasmic antibody (ANCA)-associated vasculitis, initially responded well to standard therapy but later presented with diffuse alveolar hemorrhage (DAH), simulating disease relapse. Following renal remission with standard immunosuppressive therapy, the patient exhibited fever, hemoptysis, and declining renal function, suggestive of a relapse. Bronchoscopy revealed DAH, raising concern for vasculitis exacerbation. However, discordant laboratory findings prompted scrutiny, leading to the detection of Strongyloides larvae in bronchoalveolar lavage.

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.

Organ shortage remains a critical challenge in India's transplant landscape, despite established deceased donor organ transplantation (DDOT) programmes. Many potentially viable organs from brain-dead deceased donors (DBDs) are discarded due to uncertainties surrounding donor suitability in specific clinical scenarios. To address this gap, the Indian Society of Organ Transplantation (ISOT) convened a panel of national experts to develop a Delphi consensus statement aimed at guiding transplant professionals on the feasibility of organ donation from DBDs, particularly in complex or marginal donor situations. This position statement presents 19 consensus recommendations based on real-world clinical contexts such as extremes of age, acute kidney injury, infections (including HCV, HBV, HIV, tuberculosis, and tropical diseases), malignancy, diabetes, hypertension, and various surgical anomalies. The guidance is grounded in available literature, registry data, and extensive clinical experience, with the aim of expanding the DBD donor pool across Asia and improving access to transplantation for patients with end-stage organ failure. The consensus does not function as a formal clinical guideline but rather as a practical reference tool, acknowledging the limitations in India-specific data and the contextual differences from Western transplant settings. It encourages critical care and transplant teams to perform structured assessments of organ viability, apply ethical principles, and pursue informed consent in line with local regulations.