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   Table of Contents - Current issue
July-December 2020
Volume 3 | Issue 2
Page Nos. 41-105

Online since Thursday, December 31, 2020

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‘Highlights’ Highly accessed article p. 41
Arvind Bagga
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Daily levamisole versus mycophenolate mofetil in patients with frequently relapsing or steroid-dependent nephrotic syndrome: An open-label non-inferiority randomized controlled trial Highly accessed article p. 43
Jyotsana Singh, Kamran Afzal, Shaad Abqari
Introduction: The therapy of choice for children with frequently relapsing and/or steroid-dependent nephrotic syndrome (FRNS/SDNS), who are unable to maintain remission with tapering doses of prednisolone, is unclear. Aim: The aim of the study was to examine the non-inferiority of daily levamisole versus mycophenolate mofetil (MMF) in preventing relapses in FRNS/SDNS over a 1-year period. Methods: Children with FRNS/SDNS, 1:1 were randomized to receive either daily levamisole at 2.5 mg/kg/day or MMF 1000 mg/m2. Patients on non-corticosteroid immunosuppression, late steroid resistance, secondary nephrotic syndrome, or non-minimal change disease were excluded. Primary objective was to compare the percentage reduction in relapse frequency at 1 year between the groups. Secondary objectives were safety (side effects), time to first relapse, proportion of patients free of relapse, cumulative steroid dose used, and failure of trial medication (CTRI/2018/07/015143). Results: Baseline characteristics were similar in groups (n = 21 each) except for age at enrolment, which was 120 months in MMF group and 60 months in the group receiving levamisole (P = 0.02). Relapse frequency decreased by 65% and 56% in the levamisole and MMF groups, respectively (mean difference: 9.1; 95% confidence interval, -16.9 to–35.2;], P = 0.48). Secondary outcomes did not differ between the groups. Prednisolone could be discontinued in 8 and 6 patients, while 6 and 5 patients were in sustained remission in the levamisole and MMF groups, respectively. There was one treatment failure in MMF group. Conclusion: Daily levamisole is not inferior to MMF in preventing relapses in children with FRNS/SDNS without significant adverse effects.
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Reservoirs of infection with shiga toxin-producing Escherichia coli in Iran: Systematic review p. 49
Nakysa Hooman, Mahmoud Khodadost, Martin Bitzan, Amjad Ahmadi, Shahrbanoo Nakhaie, Rama Naghshizadian
Introduction: Shiga toxin-producing Escherichia coli (STEC) infection, an important cause of hemorrhagic colitis and hemolytic uremic syndrome, is associated with high mortality and morbidity. The chief sources of STEC are contaminated food and drinking water. Aim: This study aimed to identify relevant sources of STEC transmission in Iran. Methods: Search engines of PubMed, EMBASE, OVID, SCOPUS, Web of Sciences, Google Scholar, and Iranian databases of health.barakatkns.com, IranMedex, MagIran, SID, dociran, PDFiran, and ganj.irandoc were used to review studies published about food and animal sources of STEC in Iran between 1985 and 2018. Quality and risk of bias were assessed to estimate point prevalence and proportions, which are reported with their 95% confidence intervals (CIs). Results: A total of 58 articles describing 17480 specimens were eligible for inclusion in the final analysis. Most studies, except two case control studies, had a cross-sectional design. While 39 studies had good quality, the remainder had poor quality with low to moderate risk of bias. Of 6779 samples positive for E. coli, 1587 were positive for STEC; the pooled prevalence of STEC was 5.7% (95% CI, 3.4–8.6) in food studies and 10.2% (95% CI, 7.0–13.9) in animal studies. Conclusion: A significant proportion of food and animal samples in Iran are contaminated with STEC. Registration Number: PROSPERO 2016: CRD42016033019.
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A prospective study of acute kidney injury in outborn neonates admitted in a tertiary care center in Western Rajasthan p. 58
Ramavtar Mitharwal, Mohan Makwana, Harish Kumar Mourya, Sangeeta Kumari, Shivji Ram
Background: Acute kidney injury (AKI) is common in critically ill neonates and is associated with increased risk of morbidity and mortality. Methods: This study was conducted in a tertiary care hospital of western Rajasthan over a period of 1 year on neonates born elsewhere. Neonates fulfilling the neonatal Risk, Injury, Failure, Loss, and End-Stage (nRIFLE) criteria for AKI were included and and were investigated as per protocol. Results: Out of 3422 neonates admitted in neonatal ICUs, 983 (28.7%) neonates had AKI as per the nRIFLE criteria. The majority (83.6%) of the neonates with AKI were from rural background. Most (75.6%) infants were admitted within the first 7 days of life, with male predominance (ratio of boys to girls 1.7:1), and the mean admission weight was 2.4 ± 0.5 kg. The rate of neonatal AKI was highest during summer months. The highest AKI stages by the nRIFLE criteria were risk (R) in 57.9%, failure (F) in 24.6%, and injury (I) in 17.4% of the cases. Factors associated with AKI were dehydration (53.7%) related to high ambient temperatures, sepsis (35.7%), perinatal asphyxia (19.9%), and respiratory distress (15.8%). Mortality rates were 11.9%, 10.5%, and 20.2% in category R, I, and F, respectively. Conclusions: High prevalence of neonatal AKI in this centre was due to dehydration related to high ambient temperatures. AKI was associated with high rates of morbidity and mortality.
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Atypical hemolytic uremic syndrome with large vessel involvement Highly accessed article p. 64
Alolika Nandi, Prabhas Prasun Giri, Agnisekhar Saha, Rajiv Sinha
Hemolytic uremic syndrome (HUS) is a rare, life-threatening disorder caused by thrombotic microangiopathy. Atypical hemolytic uremic syndrome (aHUS) is usually secondary to genetic mutation or autoantibody against the alternate complement pathway that produces a dysregulated complement activation, endothelial cell damage, and thrombosis. Here, we report the case of a 7-year-old boy who presented to us with aphasia, hemiparesis, and frank acute kidney injury and hemolysis, due to anti-complement factor H (anti-CFH) antibody associated aHUS. Investigations revealed multiple stenoses in bilateral internal carotid arteries and right proximal cerebral artery, producing a progressive massive infarct, an unusual finding in aHUS.
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Safety and efficacy of renal replacement therapy for acute kidney injury in tumor lysis syndrome p. 67
Abdul Rahim Ahmed, Anwar Ul Haque, Farhana Amanullah, Sadiq Mirza, Faiza Rahman, Sadia Muhammad, Khadijah Abid
Tumor lysis syndrome (TLS) defines a constellation of metabolic abnormalities resulting from tumor cell death leading to dreaded clinical complications, including acute kidney injury (AKI). The incidence of AKI in TLS varies from 14% to 76% and is associated with mortality in 36% cases, and up to 20% of patients require renal replacement therapy (RRT). This study was done to evaluate the therapeutic efficacy and safety of RRT in children with hematological malignancies who develop AKI with TLS. We retrospectively reviewed case records of patients, up to 5 years old,with AKI due to TLS who required RRT during November 2017–October 2019 admitted in the pediatric intensive care unit (PICU). The diagnosis of TLS was based on Bishop–Cairo criteria. The primary outcome was recorded as recovery of renal function. Out of total 400 patients with newly diagnosed hematological malignancy admitted in the PICU during the study period, 122 (30.5%) developed TLS with 32 (26.2%) having AKI, of which eight patients (2%) underwent dialysis. The mean estimated glomerular filtration rate on admission was 36.6 ± 9.8 mg/ml/1.73 m2 with a mean urine output being 0.32 ± 0.1 ml/kg/h. Seven of eight patients underwent hemodialysis. All cases had successful RRT with normalization of renal function and establishment of adequate urine output. RRT is safe and effective in children for AKI with TLS with the recovery of renal functions.
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Takayasu arteritis with ANCA associated vasculitis and anti-GBM antibodies p. 71
Mritunjay Kumar, Murtaza Sumbul, Alok Sharma, Ragini Singh
Vasculitides are conventionally classified according to the size of the vessels involved and characteristic clinical and histopathological findings. Anti-neutrophil cytoplasmic antibodies (ANCAs) and other serologies help characterizing small vessel vasculitis. While few cases of large vessel involvement are reported in association with ANCA-associated vasculitis, these reports were in adult patients and lacked typical large vessel involvement. We describe an adolescent girl with focal necrotizing glomerulonephritis and positive serologies for p-or myeloperoxidase ANCA, as well as large vessel arteritis and presence of anti-glomerular basement membrane antibodies. This report highlights the diagnostic difficulties in rare patients presenting with overlap in clinical and serological features of different forms of systemic vasculitis.
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Degree of proteinuria as a predictor of severity in diffuse proliferative glomerulonephritis: An experience from Sri Lanka p. 75
Kanchana Sanjeewani Liyanaarachchi, Neelakanthi Vajira Ratnatunga, Rajiv Shenal Thalgahagoda, Achala Budhdhika Galliyadda
Acute glomerulonephritis (AGN) or infection-related glomerulonephritis (IRGN) is the leading cause of acute nephritic syndrome in developing countries. We examined for differences in histopathological pattern and severity of injury in 48 patients with IRGN, categorized by the degree of proteinuria as nonnephrotic and nephrotic range, and compared the levels of serum albumin and degree of tubular injury between the two groups. Patients with nephrotic range proteinuria had a more severe glomerular and tubular injury and had double contours more often than patients with nonnephrotic range proteinuria.
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Clinicopathological spectrum and outcome of rapidly progressive glomerulonephritis p. 78
Gulshan Nigar Chaudhury, Tarannum Khandoker, Tahmina Ferdous, Rifat Asma Chowdhury, Shireen Afroz, Mohammed Hanif
Rapidly progressive glomerulhronephritis (RPGN) is a severe condition characterized by rapid loss of kidney function which is irreversible if not diagnosed and treated promptly. This study analyzed the etiology, histopathology, clinical course, treatment pattern, and prognosis of RPGN in 25 children presenting to the Department of Pediatric Nephrology in Dhaka Shishu (Children) Hospital between June 2017 and December 2019. All patients had proteinuria and edema, and presented with serum creatinine of 5.82 ± 4.27 mg/dL; 14 (56%) required renal replacement therapy. Immune-complex glomerulonephritis (GN) was the principal histological category, of which IgA nephropathy (28%) and postinfectious GN (24%) were the predominant etiology. No patients had pauci-immune or anti-glomerular basement membrane GN. Glomeruli displayed cellular crescent in 24% cases, fibrous in 8%, and fibrocellular in 40% biopsies. Interstitial fibrosis and tubular atrophy were present in 4% and 36% biopsies, respectively. Therapy for induction included intravenous (IV) methylprednisolone in all patients, IV cyclophosphamide in 36% cases and mycophenolate mofetil in 52% patients. While 15 patients recovered renal function completely, two each were dialysis-dependent and developed progressive chronic kidney disease; 3 died during hospital stay and 5 patients were lost to follow-up. RPGN is chiefly secondary to immune-complex-mediated GN in developing countries and is associated with adverse outcomes in a high proportion of cases, underscoring the need for prompt evaluation and aggressive management.
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Nephrotic syndrome in a child with cystinuria p. 82
Naifain Al Kalbani, Anisa Al Maskari, Suliman Al Saidi, Badria Al Ghaithi, Mohammed S Al Riyami
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Nephrotic syndrome and intussusception: A coincidence p. 84
Manoj Girdhari Matnani, Mosam K Maroo
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Cerebral sinovenous thrombosis in steroid-dependent nephrotic syndrome p. 86
Subhankar Sarkar, Priyanka Singh, Md Shakil Akhtar, Rajiv Sinha
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Journal scan p. 89
Menka Yadav
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Selected abstracts of the 32nd annual conference of the Indian society of pediatric nephrology, 12–13 december 2020 p. 92

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