Patchy Cortical Necrosis Research Articles

#4767 ACUTE CORTICAL NECROSIS IN PREGNANCY IS STILL AN IMPORTANT CAUSE FOR END-STAGE RENAL DISEASE IN DEVELOPING COUNTRIES

Abstract Background and Aims Renal cortical necrosis (RCN) is a serious complication of acute kidney injury (AKI) and pregnancy is a clinical state closely associated with it with poor renal outcomes. The incidence is much higher in obstetrical AKI compared to other causes of RCN. Despite better medical care facilities available, this continues to be an important cause of morbidity and mortality in developing countries. Method This is a retrospective analysis among all pregnant females presenting with AKI from January 2000 to December 2020 at a tertiary care center in the northern part of India. We looked for the incidence of obstetrical-related RCN in our renal biopsies performed in the last 20 years and to evaluate precipitating factors responsible for RCN. Results RCN constituted 8.1 % of pregnancy-related AKI cases in our institution. The overall incidence has been declining which was 9.09% from 2000 to 2008 to 8.7 % from 2009 to 2014 and 8.1% from 2014-2020. The patient's median age was 28.4 ± 4.6 years. The average time to presentation from the day of delivery was 7.8 ±3.0 days. The mortality was observed in 10.4 % of them with sepsis and multiorgan dysfunction present in all of them. The most common etiology for RCN was found to be septic abortion and puerperal sepsis accounting for - 16.2 % each. Postpartum hemorrhage was a cause in 9.67 % of patients. The most important cause of RCN was postpartum thrombotic microangiopathy which was observed in 49.5% of patients. Kidney biopsy was helpful in diagnosis in 36 patients while computed tomography scan abdomen alone helped in diagnosis in five patients. Patchy cortical necrosis in histology was seen in 36.7% of patients and morbidity in terms of prolonged hospitalization was seen in 23.4 % while dialysis dependency in 63.4% of the study population Conclusion Strategies need to be implemented in reducing the preventable causes for RCN which is not only catastrophic in terms of renal outcomes but also for social and psychological perspectives as well.

Pregnancy-related Acute Kidney Injury in Public Hospital in South India: Changing Trends.

Pregnancy-related acute kidney injury (PRAKI) is a common problem in the developing world. In this retrospective observational study at a tertiary care hospital in South India we evaluated records for the maternal, fetal, and renal outcomes in women with PRAKI. Over a 10-year period, 395 patients of PRAKI were seen constituting 8.1% of all acute kidney injury (AKI). The mean age of patients was 27 ± 3 years. A total of 176 (44.5%) had pre-eclampsia, 132 (33.4%) had puerperal sepsis, 76 (19.2%) had antepartum hemorrhage or postpartum hemorrhage (APH 30/PPH 46), nine (2.2%) had hemolytic uremic syndrome (HUS). Obstruction was seen in two patients. Eleven had underlying glomerulonephritis out of three had lupus nephritis. Forty-five of 395 (11.39%) had hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, that is, 25.5% of those with pre-eclampsia. Sixteen (4.0%) had placental abruption. A total of 288 (72.9%) presented postpartum. Renal biopsy done in 103 (26%) showed patchy cortical necrosis (PCN) in 25 (22.3%), diffuse cortical necrosis (DCN) in 23 (20.3%), acute tubular necrosis (ATN) in 20 (19.4%), acute interstitial nephritis (AIN) in 10 (9.7%), while nine (8.7%) had thrombotic microangiopathy (TMA). Glomerular disease was seen in 11. Cortical necrosis (CN) was seen in 48 patients of which 10 (20.83%) had abruption placenta, 25 (52%) had puerperal sepsis, 11 (22.9%) had postpartum hemorrhage (PPH), and two (4.1%) had TMA. A total of 290 (73.4%) required dialysis. About 76% improved while 8.3% progressed to end-stage renal disease (ESRD). Maternal mortality (MM) was 5%. There were 42 intrauterine deaths and 30 deaths in the neonatal period. Pregnancy-related acute kidney injury in developing countries is more common as compared to the West. Only 49% patients had booked pregnancy, that is, received regular antenatal care. Apart from pre-eclampsia which is also the major cause in the West and was the etiology in 44% of patients with PRAKI in our study, sepsis (33%) and maternal hemorrhage (19%) were also significant. Immediate recovery from PRAKI was 75% however about 8% develop end-stage kidney disease (ESKD) while in the west ESKD occurred in only about 2%. Pregnancy-related acute kidney injury is an important cause of maternal and fetal morbidity and mortality. Pre-eclampsia emerged as the most common cause of PRAKI and CN was the most common histological lesion. Proper antenatal care and management may improve pregnancy outcomes.

SUN-169 Maternal and Fetal outcomes in woman with pregnancy associated acute kidney injury (PR-AKI): Single centre experience from developing country

The incidence of PR-AKI has been declining, but it remains a serious problem due to its association with significant adverse maternal and foetal outcomes. However, the detailed impact of PR-AKI on pregnancy outcomes (maternal & foetal) is sparse from developing countries. The aim of the present study is to evaluate the maternal and foetal outcomes in patients with PR-AKI from our centre. Four thousands seven hundred forty one (4741) pregnant women were enrolled from November 2014 to July 2016. They were screened for AKI. The causes of AKI, need for dialysis, maternal and foetal outcomes were analysed individually. All patients with PR-AKI were followed for three month or longer to determine the recovery of renal function or progression to chronic kidney disease (CKD). Of 4741 pregnant women, 132 patients developed acute kidney injury (2.78%). In the majority (91.6%), AKI developed in late 3rd trimester and postpartum period. Timing of PR-AKI is shown in Figure-1. Preeclampsia was the most common cause of PR-AKI (46.9%). The causes of PR-AKI are shown in Figure-2. Conservative management was given in 70(53%) patients and 62(47%) required hemodialysis along with conservative treatment. Normal vaginal delivery occurred in 63(47.7%) and 60(45.5%) patients underwent lower segment caesarean sections (LSCS) delivery. Maternal mortality was observed in 8(6.1%) cases, due to fulminant hepatitis (4), puerperal sepsis (3) and post- abortal sepsis in (1) cases. We noted complete recovery of renal function in 118(89.4%) cases. Puerperal sepsis was the sole cause of patchy cortical necrosis in 5(3.7%) cases. At three month or longer follow up, 6(4.5%) patients developed chronic kidney disease (CKD) and patchy cortical necrosis was the main cause of progression to CKD. Out of 6 cases of CKD, 3 patients progressed to end stage renal disease (ESRD) due to patchy cortical necrosis (2), and class V lupus nephritis in (1) patients. Foetal mortality was noted in 31(23.5%) due to intrauterine death (17.5%) and prematurity (6%). Full term delivery was observed in 47(35.6%) patients and premature delivery in 54(40.9%) cases.Figure 2Causes of PR-AKI durring pregnancy (n=132).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Despite decreasing incidence of PR-AKI, foetal morbidity and mortality is high. Thus, our results revealed foetal outcomes is more grave than maternal outcomes in women with PR-AKI.

Acute cortical necrosis in pregnancy still an important cause for end-stage renal disease in developing countries.

Renal cortical necrosis (RCN) is a serious complication of acute kidney injury (AKI) and pregnancy is a clinical state closely associated with it with poor renal outcomes. The incidence is much higher in obstetrical AKI compared to other causes of RCN. Despite better medical care facilities available, this continues to be an important cause of morbidity and mortality in developing countries. This is a retrospective analysis among all pregnant females presenting with AKI from January 1999 to December 2014 at a tertiary care center in the northern part of India. We looked for the incidence of obstetrical-related RCN in our renal biopsies performed in the last 15 years and to evaluate precipitating factors responsible for RCN. RCN constituted 8.3% of pregnancy-related AKI cases in our institution. The overall incidence has been declining which was 9.09% from 1999 to 2008 to 7.8% from 2009 to 2014. The patient's median age was 29.3 ± 5.2 years. The average time to presentation from the day of delivery was 8.7 ±2.1 days. The mortality was observed in 11.7% of them with sepsis and multiorgan dysfunction present in all of them. The most common etiology for RCN was found to be septic abortion and puerperal sepsis accounting for - 15.3% each. Postpartum hemorrhage was a cause in 9.09% of patients. The most important cause of RCN was postpartum thrombotic microangiopathy which was observed in 48.7% of patients. Kidney biopsy was helpful in diagnosis in 31 patients while computed tomography scan abdomen alone helped in diagnosis in five patients. Patchy cortical necrosis in histology was seen in 35.4% of patients and morbidity in terms of prolonged hospitalization was seen in 22.7% while dialysis dependency in 61.5% of the study population. In conclusion, strategies need to be implemented in reducing the preventable causes for RCN which is not only catastrophic in terms of renal outcomes but also for social and psychological perspectives as well.

Acute kidney injury in pregnancy with special reference to pregnancy-specific disorders: a hospital based study (2014-2016).

There are numerous reports in the literature describing acute kidney injury in pregnancy (P-AKI) due to various obstetric complications. However, there is a dearth of studies on AKI related to pregnancy-specific disorders from India. We aimed to analyze clinical features and outcome of P-AKI related to pregnancy-specific disorders compared to total pregnancy, in India. All pregnant women attending the department of Obstetrics and Gynecology from November 2014 to July 2016 were screened for AKI based on: (1) sudden elevation of serum creatinine ≥ 1mg/dl; (2) oligoanuria for > 12h; and (3) need for dialysis. The detailed clinical profile of AKI in patients with preeclampsia/eclampsia (PE/E), hemolysis/elevated liver enzymes/low platelet count (HELLP) syndrome, acute fatty liver of pregnancy (AFLP), and pregnancy-associated thrombotic microangiopathy (P-TMA) was analyzed. Laboratory investigations included: complete blood count, renal function tests, urinalysis, coagulation profile (platelet count, INR, prothrombin time and activated partial thromboplastin time), and immunological assay (C3, C4, ANA, anti-dsDNA antibody, antiphospholipid antibody). Contrast-enhanced CT scan of kidney ureter and bladder (KUB) and renal biopsy were performed in selected cases. Maternal and fetal outcome were analyzed individually. The patients were followed for 3 months or longer to determine the recovery of renal function or progression to chronic kidney disease (CKD). Overall, 4741 pregnant women (mean age 26.8 ± 4.8years) were evaluated for AKI. P-AKI was found in 132/4741 (2.78%) patients. In the majority (91.6%), AKI developed in the late 3rd trimester and post-partum period. P-AKI was related to obstetric complications (in 61.4%), pregnancy-specific disorders (in 57.5%) and miscellaneous factors (7.5%). Puerperal sepsis, ante-partum and post-partum hemorrhage were contributing factors for P-AKI in 34 (25.8%), 11 (8.3%) and 28 (21.2%) patients, respectively. P-AKI due to pregnancy-specific disorders developed in 76/4741 patients, i.e. in 1:62 pregnancies. PE/E was the cause of P-AKI in 62 patients (46.9%) followed by HELLP syndrome in 9 (6.8%) and AFLP in 05 (3.8%). P-TMA causing AKI was not observed. Complete recovery of renal function occurred in 89.4% of patients while 6 (4.6%) progressed to CKD (ESRD: 3 and CKD stage IV: 3). Maternal mortality was 6%. Puerperal sepsis was the sole cause of patchy cortical necrosis in 5 (3.7%) cases. Premature delivery occurred in 40.9% patients and full-term delivery in 35.6%. Perinatal mortality was 23.5%, mainly due to intrauterine death (17.5%) and prematurity (6%). PE/E was the commonest cause of P-AKI in our study, similar to the situation in developed countries. Post-partum hemorrhage was the second-most common (21.5%) cause. Puerperal sepsis contributed to AKI in one-fourth of pregnant women. P-TMA was not recorded in this study and AFLP was an uncommon cause of P-AKI in our country. Renal function returned to normal in all patients with P-AKI due to pregnancy-specific disorders. However, perinatal mortality was high despite the good prognosis of P-AKI.

A Single Center Experience of Kidney Transplantation From Donation After Circulatory Death From India

Introduction Donation after circulatory death (DCD) is a well-accepted source of organs worldwide. However, DCD has never been attempted in India so far due to lack of clarity in the country’s Transplantation Act. The present report describes the initial use of DCD organs in India and highlights its challenges. Methods Between Feb 2011 to Feb 2017 out of 82 deceased organ donations at our hospital 9 were DCD donor. Four had cardiac arrest after first brain death certifying committee evaluation. Two had cardiac arrest after brain death certification. Two donors were refused brain death certification. One patient with terminal lung disease had cardiac arrest in ICU. After declaration of death, donors received 25000 units of heparin. Chest compressions were restarted in 7 donors to maintain circulation and ventilation continued till organ retrieval. In rest of two donors, CPR was discontinued and shifted to operation theatre. All donors underwent rapid cannulation, infusion of cold preservative solution during retrieval surgery. All recipients got ATG induction except one who received Simulect. All recipients got Tacrolimus, Mycophenolate and steroids. Results Out of 18 kidneys retrieved from 9DCD donors, 15 were transplanted and three discarded. One recipient withdrew consent at an advanced stage. Kidneys from one donor could not be utilised due to high resistance during perfusion. All except one donor had head injury as cause of death. Recipient’s mean age was 39.9 + 8.6 yrs, M: F 11:4. All recipients except two required dialysis in immediate postoperative period. Mean postop day one urine output was 2543.33 ml (Range 10-13200 ml). The best baseline creatinine achieved was 1.41 + 0.38 mg% after mean duration of 22 days. The kidneys from donors where CPR was not continued after death declaration fared poorly when compared to those where CPR was continued. One of these kidneys never functioned. The other recipient of the same donor also had suboptimal function with lowest creatinine of 2.0 mg%. Both the kidneys from other donor where CPR was withheld showed evidence of patchy cortical necrosis (upto 25%) on protocol biopsies done at one week but these kidneys eventually regained normal renal function. The kidneys from donors where CPR was continued had earlier recovery of renal function. Conclusions Kidneys from donors after cardiac arrest in an uncontrolled situation can serve as a useful adjunct in deceased donor programme. Continuing CPR after declaration of death seems to help in improving outcomes in these patients.

Renal cortical necrosis at autopsy: a 12 year experience at a tertiary care centre in Mumbai

Introduction: Renal cortical necrosis (RCN) is an unusual cause of acute renal failure but still causes significant mortality in developing countries. Objective: To review autopsies of histologically proven RCN reported in complete autopsies over the last 12 years. Methods: All autopsies performed from 2004-2016 with RCN were analyzed retrospectively. Results: A total of 13,896 autopsies were done at this centre over this twelve year period from 2004-2016. Of these, 26 cases were diagnosed as RCN, with an incidence of 0.19%. 978 of our total number of autopsies presented with Acute Kidney Injury (AKI) and the incidence of RCN in AKI was 2.7%. There were 844 maternal mortality deaths during this period of which 134 (15.9%) had AKI. RCN accounted for 2% of all maternal mortality deaths during this period. Obstetric cases amounted to 65.4% and non-obstetric cases to 34.6%. Pregnancy induced hypertension; intrauterine foetal death and postpartum hemorrhage were the leading causes of RCN amongst obstetric causes while septicemia, hemolytic uremic syndrome and poisoning were the leading non-obstetric causes. Microscopically, diffuse cortical necrosis was seen in 53.8% autopsies and patchy cortical necrosis was seen in 46.2% autopsies. Histopathology also showed intra-alveolar hemorrhage, bronchopneumonia, cerebral edema and acute respiratory distress syndrome. Conclusion: Our incidence of RCN was 0.19% at general autopsy, 2.7 % in autopsies with AKI and 2% of maternal mortality deaths at a tertiary care centre.RCN in AKI being 2.7% is significantly less than the 6-7% reported in developing countries. Diffuse pattern of cortical necrosis was more common than patchy cortical necrosis.

A Single-center Experience of Kidney Transplantation from Donation after Circulatory Death: Challenges and Scope in India.

Donation after circulatory death (DCD) has never been attempted in India because of legal constraints and lack of guidelines for the withdrawal of life support in end-of-life situations. The present report describes the initial experience of transplantation of organs from DCD donors in a tertiary care center in India. Between 2011 and 2015, five donors had kidneys retrieved after cardiac arrest. These patients were declared dead after waiting for 5 min with no electrocardiographic signal on monitor following cardiopulmonary resuscitation (CPR), which was restarted in three patients till organ retrieval. All donors received heparin and underwent rapid cannulation of aorta, infusion of preservative cold solution, and immediate surface cooling of organs during retrieval surgery. 9/10 kidneys were utilized. Mean donor age was 29.6 ± 16.3 years, M:F 4:1 and mean age of recipients was 38.7 ± 10.8 years, M:F 7:2. Seven patients required dialysis in postoperative period. Mean postoperative day 0 urine output was 1.9 ± 2.6 L. Baseline creatinine achieved was 1.38 ± 0.35 mg/dl after a mean duration of 26.12 ± 15.4 days. Kidneys from donors where CPR was continued after the declaration of death (n = 3) had better recovery of renal function (time to reach baseline creatinine 21.2 ± 7.2 vs. 34.3 ± 23.7 days, baseline creatinine 1.36 ± 0.25 vs. 1.52 ± 0.45 mg%). In donors without CPR, one kidney never functioned and others had patchy cortical necrosis on protocol biopsy, which was not seen in the kidneys from donors with CPR. Kidneys from DCD donors can serve as a useful adjunct in deceased donor program. Continuing CPR after the declaration of death seems to help in improving outcomes.

Renal cortical necrosis is a disappearing entity in obstetric acute kidney injury in developing countries: our three decade of experience from India

Rational: Obstetrical complications are the commonest causes of Renal Cortical Necrosis (RCN). However, the overall incidence of RCN in obstetric acute kidney injury in developing countries has been decreasing in recent years. Objective: The aim of this study was to evaluate the changing profile of RCN in obstetric AKI over the last three decades. Methods: This single center study included patients with biopsy proven renal cortical necrosis over a period of 32 years from 1982 to 2014. The diagnosis of RCN was suspected in patients with prolonged AKI (>4 weeks) with absolute anuria in the setting of hemorrhage, hypotension and sepsis; and was confirmed by renal biopsy. The changing pattern in the incidence, etiology and outcome of RCN in patients with obstetric AKI was compared in the three study periods, namely 1982–1991, 1992–2002 and 2003–2014. Results: Over a period of 32 years, RCN was diagnosed in 15/259(5.8%) cases of obstetric AKI. Diffuse and patchy cortical necrosis were noted in 8(53.3%) and 7(46.7%) patients, respectively. RCN occurred in 17%(11/65), 2.4%(3/125) and 1.44%(1/69) patients in 1982–1991, 1992–2002 and 2003–2014, respectively. Septic abortion was commonest cause of RCN in the first two study periods but no case was observed in last decade. The decrease in incidence of RCN over the three decades was statistically significant (p-value < 0.001). Maternal mortality decreased to zero in 2003–2014 from 72.7% in 1982–1991. Conclusions: The incidence of RCN in obstetric AKI in developing countries has declined low enough to label it as a disappearing entity.

Maternal, fetal and renal outcomes of pregnancy-associated acute kidney injury requiring dialysis.

Pregnancy-associated acute kidney injury (PAKI) is encountered frequently in developing countries. We evaluated the maternal, fetal and renal outcomes in women with PAKI who needed at least one session of dialysis. Of the total of 98 cases (mean age 28.85 ± 5.13 years; mean parity 2.65 ± 1.28) of PAKI, the most common cause of PAKI was postabortal sepsis. Eighteen patients died; those with oligoanuria, sepsis and central nervous system (CNS) involvement were at greater risk of mortality. The relative risk (RR) of neonatal mortality was lower after with full-term delivery (RR: 0.17, 95% confidence interval (CI): 0.03-0.96, P = 0.02) compared to preterm delivery. Of the 80 surviving patients, 60 (75%) patients achieved complete recovery of renal function at the end of 3 months; and of the remaining 14 had presumed (n = 4) or, biopsy-proven (n = 10) acute patchy cortical necrosis. The RR of non-recovery of renal function was high (RR: 24.7, 95% CI: 3.4- 179.5) in patients who did not recover at 6 weeks. Of the 14 patients with cortical necrosis, 3 (21.42%) became independent of dialysis at 6 months. PAKI patients should be watched for dialysis independency for 6 months.

Diagnosis and management of atypical hemolytic uremic syndrome in children: single centre experience.

Atypical hemolytic uremic syndrome (aHUS) although rare is the commonest cause of acute renal failure (ARF) in children and has poor prognosis. We present single centre experience of aHUS. Thirty six children (29 males, 7 females) with mean age, 7.9years presented with ARF, 2 children also had tonic-clonic type convulsions. Their hematology examination revealed hemolytic anemia with s. creatinine (SCr), 5.54mg/dl. Acute HUS was observed in 75%, acute on chronic HUS in 19.4% and patchy cortical necrosis (PCN) in 5.6% biopsies. Mean 5.4 plasma exchanges (PE) were carried out. Supportive management of anti-hypertensives and prednisone was also given. Recovery end points were establishment of urine output, improvement of SCr and hematological profile. Hematology and renal function profile improved variably in all children, 5.6% died, relapse was observed in 80.5% over mean 70days; 13.9% children are doing well over mean follow-up of 268.8days. Thus poor prognosis was observed in 86.1% children. Children with acute on chronic HUS and PCN did not recover. Six children who recovered had acute HUS. aHUS in Indian children occurs at an older age of around 8years and chronic/irreversible changes on histopathology examination are harbingers of poor prognosis. PE is life-saving however further research for developing strategies to improve long-term survival is needed.

Hemolytic Uremic Syndrome in Laboratory Medicine: Single Centre Experience in Children

Atypical hemolytic uremic syndrome (aHUS), although rare, is the most common cause of acute renal failure (ARF) in children and has poor prognosis. We present a single centre experience of aHUS. Thirty six children (29 males, 7 females), with mean age 7.9 years, presented with ARF, 2 children also had tonic-clonic type convulsions. Their hematology examination revealed hemolytic anemia with serum create-nine (SCr) of 5.54 mg/dL. Acute HUS was observed in 75%, acute-on-chronic HUS in 19.4%, and patchy cortical necrosis (PCN) in 5.6% biopsies. A mean of 5.4 plasma exchanges (PE) were carried out. Supportive management of anti-hypertensives and prednisone was also given. Recovery end points were establishment of urine output and improvement of SCr and hematological profile. Hematology and renal function profile improved variably in all children, 5.6% died, relapse was observed in 80.5% over a mean of 70 days; 13.9% children are doing well over a mean follow-up of 268.8 days. Thus, poor prognosis was observed in 86.1% children. Children with acute or chronic HUS and PCN did not recover. Six children who recovered had acute HUS. aHUS in Indian children occurs at an older age of around 8 years and chronic/irreversible changes on histopathology examination are harbingers of poor prognosis. PE is life-saving; however, further research for developing strategies to improve long-term survival is needed.

Renal cortical necrosis in tropics

The aim of this study is to review cases of renal cortical necrosis (RCN) that were seen on renal biopsy at our center over a period of seven years. All renal biopsy records over seven years at the Osmania General Hospital were reviewed to identify patients with histologically proven RCN. The demographic, clinical, laboratory investigations and follow-up data were noted. There were a total of 105 patients with RCN. The mean age was 28.13 ± 12.40 years. Forty-one cases (39.04%) resulted from obstetric complications. The most common histology type of RCN was patchy cortical necrosis in 65 patients (62%). All patients required dialysis, and the mean duration of dialysis was 3 ± 1 weeks. Thirty-three (31.42%) patients progressed to end-stage kidney disease while three patients underwent renal transplantation. Ten (9.5%) patients succumbed to acute kidney injury. The remaining patients recovered sufficient renal function and were dialysis-independent till the last follow-up. RCN is an important cause of chronic kidney disease. Obstetric complications are the leading cause of RCN in our setting. An early renal biopsy, especially in cases of anuric renal failure, helps in establishing the diagnosis.

Acute Renal Failure in Pregnancy, its Causes and Outcome, 1 Year Study at Shaikh Zayed Hospital Lahore

Abstract Objective: The objective of this study was to deter-mine the frequency, etiology, clinical course and out-come of pregnancy related acute renal failure. Type of Study: Observational and prospective hos-pital based study. Place of Study: Department of Nephrology, Shaikh Zayed Hospital Lahore. Duration of Study: One year from November 2010 - October 2011. Patients and Methods: Total 210 patients of Acute renal failure (ARF) were admitted with 92 (44%) males and 118 (56%) females during this period of which 40 (19%) females were pregnancy related ARF that were included in this study. A Pre-designed pro-forma was used. The clinical history and physical exa-mination was carried out. Relevant laboratory tests were performed. Renal biopsy was done in few cases. The final outcome was recorded. Twenty four (24) patients were from rural community of Punjab pro- vince and remaining (16) were from urban areas. Results: Pregnancy related ARF occurred in forty (40) patients. Twenty two (55%) were multi-para and 18 (45%) were primigravida. Their age was between 29 ± 4.5 years. Majority 32 (80%) patients had not received any antenatal care as compared to 8 (20%) patients who had adequate antenatal care. Twelve cases (15%) presented in their first and second tri-mester of pregnancy while 28 (70%) patients deve-loped ARF in their third trimester or the puerperium. Twenty four (60%) patients were anuric. Antepartum hemorraghe (APH) in 2 (5%) cases, postpartum hemo-rraghe (PPH) in 6 (15%) cases, Septic abortion in 6 (15%), puerperal sepsis in 8 (20%) and DIC in 4 (10%) cases, Intra-uterine fetal death (IUD) in 12 (30%) and HELLPS in 2 (5%) cases. Sepsis was the commonest cause of ARF. Thirty four (85%) patients received hemodialysis and 6 (15%) did not require any dialysis. Commonest clinical diagnosis was acute tub-ular necrosis (ATN). Complete recovery was seen in 8 (20%) cases .Acute renal cortical necrosis was seen in 14 (35%) cases and 18 (45%) patients had patchy cortical necrosis. Overall mortality was 30%. Conclusion: Pregnancy related acute renal failure has high mortality and morbidity. In addition to acute tub-ular necrosis (ATN) as a leading cause with reversible ARF, cortical necrosis contributes significantly to the permanent loss of kidney functions. It is a major health problem especially in the villages of Punjab province. Major identified issues are lack of poor healthcare facilities, fewer numbers of antenatal clinics and lack of prompt management of potentially reversible ARF. Key Words: Acute renal failure, Pregnancy.

Outcome and prognostic factors of malaria-associated acute kidney injury requiring hemodialysis: A single center experience

Acute kidney injury (AKI) is one of the most dreaded complications of severe malaria. We carried out prospective study in 2010, to describe clinical characteristics, laboratory parameters, prognostic factors, and outcome in 59 (44 males, 15 females) smear-positive malaria patients with AKI. The severity of illness was assessed using Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA) score, Multiple Organ Dysfunction Score (MODS), and Glasgow Coma Scale (GCS) scores. All patients received artesunate and hemodialysis (HD). Mean age of patients was 33.63 ± 14 years. Plasmodium falciparum malaria was seen in 76.3% (n = 45), Plasmodium vivax in 16.9% (n = 10), and mixed infection in 6.8% (n = 4) patients. Presenting clinical features were fever (100%), nausea-vomiting (85%), oliguria (61%), abdominal pain/tenderness (50.8%), and jaundice (74.5%). Mean APACHE II, SOFA, MODS, and GCS scores were 18.1 ± 3, 10.16 ± 3.09, 9.71 ± 2.69, and 14.15 ± 1.67, respectively, all were higher among patients who died than among those who survived. APACHE II ≥20, SOFA and MODS scores ≥12 were associated with higher mortality (P < 0.05). 34% patients received blood component transfusion and exchange transfusion was done in 15%. Mean number of HD sessions required was 4.59 ± 3.03. Renal biopsies were performed in five patients (three with patchy cortical necrosis and two with acute tubular necrosis). 81.3% of patients had complete renal recovery and 11.8% succumbed to malaria. Prompt diagnosis, timely HD, and supportive therapy were associated with improved survival and recovery of kidney functions in malarial with AKI. Mortality was associated with higher APACHE II, SOFA, MODS, GCS scores, requirement of inotrope, and ventilator support.

Acute cortical necrosis following renal transplantation in a case of sickle cell trait

Renal transplant recipients who have sickle cell disease are at risk of infection, recurrent graft disease, and sickling crisis that affects the long-term outcome. We report a patient of sickle cell trait who developed patchy cortical necrosis in the perioperative period but had a good long-term outcome. The renal cortical necrosis was presumed to be secondary to cyclosporine-basiliximab interaction in the backdrop of sickling trait. The patient additionally had spontaneous closure of vascular access and severe hypertension immediately following transplantation suggestive of vaso-occlusive crisis. Cyclosporine and basiliximab drug interaction needs to be recognized and steps need to be taken in patients to avoid perioperative graft dysfunction.

Deceased Donor Organ Transplantation With Expanded Criteria Donors: A Single-Center Experience From India

Introduction Deceased donor organ transplantation (DDOT) accounts for <4% of renal transplants in India. Many volunteers come forth for organ donation with increasing awareness; unfortunately, the majority are marginal donors, but their rejection would hamper the DDOT program. Judicious use of marginal organs is a challenge for developing countries. Patients and Methods We performed 29 renal transplants from 21 expanded criteria donors (ECD) out of 115 DDOT between January 2006 to April 2009—10 dual (DKT) and 19 single (SKT). Fourteen donors had hypertension, a cerebrovascular accident as the cause of death, 9 had both, and 4 had diabetes. Mean donor age was 70.3 ± 8.9 years. Decisions on the procedure were based upon frozen section biopsy in 13 of 21 donors. Mean DKT donor age was 76 ± 9.7 years versu 64 ± 5.7 years of SKT donors. The native kidney diseases were chronic glomerulonephritis (n = 14), diabetic nephropathy (n = 7), tubulointerstitial nephritis (n = 4) and polycystic kidney disease, focal segmental glomerulosclerosis, lupus nephritis and patchy cortical necrosis, (n = 1 each). Mean recipient age of DKT versus SKT was 43.5 versus 42.3 years. All recipients received rabbit anti-thymocyte globulin, followed by steroid, mycophenolate mofetil/calcinueurin inhibitor. Results Over a mean follow-up of 341 days, the mean serum creatinine (SCr) of 25/29 patients was 1.60 mg/dL (range, 1.0–2.6). The mean SCr of SKT patients was 1.59 ± 0.63 mg/dL and of DKT, 1.62 ± 0.48 mg/dL. Ten patients had delayed graft function and 11 had biopsy proven acute tubular necrosis. Seven (24%) patients had rejection (grade 3 Banff update '05, type IA; 4, type 2A); 6 responded to antirejection; 1 graft was lost at 7 months due to chronic rejection. Three (10.3%) patients were lost, 1 each due to AMI, sepsis, and CMV disease. Conclusion In the circumstances of organ shortage, DDOT with expanded criteria donor is a feasible option.

Decreasing incidence of renal cortical necrosis in patients with acute renal failure in developing countries: a single-centre experience of 22 years from Eastern India

Renal cortical necrosis (RCN) accounts for 2% of all cases of acute renal failure (ARF) in adults and 15-20% of ARF during the third trimester of pregnancy in developed nations. However, RCN incidence is higher in developing countries ranging from 6-7% of all cases of acute renal failure. The present study describes changing trends in the clinical spectrum of RCN in patients with ARF in Eastern India. Patients with ARF suspected to have RCN on clinical grounds underwent percutaneous renal biopsy. Patients showing cortical necrosis on histology were included in the present study. Diffuse and patchy cortical necrosis was classified based on standard histological criteria. The patients with cortical necrosis were studied over a period of 22 years; from July 1984 to December 2005. The results of our observation were compared with respect to etiology, incidence, prognosis and outcome of renal cortical necrosis in two study periods; namely, 1984-1994 and 1995-2005. The incidence of RCN was 3.12% of all cases of ARF of diverse etiology. RCN was observed in 57 patients; obstetric 32 (56.2%); non-obstetric 25 (43.8%). Diffuse cortical necrosis was the dominant lesion in 41 (71.9%) patients and the remaining 16 (28%) patients had patchy cortical necrosis. The overall incidence of RCN in obstetric ARF was 15.2%; the incidence being higher (11.9%) in the post-abortal group in comparison to 3.3% in late pregnancy. RCN had occurred complicating abruptio placentae, puerperal sepsis and postpartum haemorrhage (PPH) in late pregnancy, while septic abortion was the sole cause of RCN in early pregnancy. Haemolytic uraemic syndrome (HUS) was the major (31.5%) cause of RCN in the non-obstetric group and miscellaneous factors were responsible in seven (12.3%) patients. Partial recovery of renal function was observed in 11 (19.2%), and 16 (28%) patients had progressed to ESRD. The incidence of RCN decreased from 6.7% in 1984-1994 to 1.6% in 1995-2005 of total ARF cases. RCN following obstetrical complication decreased significantly; 4.7% in the 1990s to 0.5% of the total ARF cases, in the 2000s. The mortality decreased to 19% in 1995-2005 from the initial high mortality of 72% in 1984-1994. The renal prognosis improved as a result of the decreased mortality of patients. We observed a decreasing trend in the incidence of RCN in patients with ARF in recent years, which is associated with increased patient survival and better renal prognosis. This improvement was mainly due to declining incidence and severity of RCN in obstetrical ARF.

Acute Renal Cortical Necrosis—A Study of 113 Patients

Over a 28-year period, 113 out of 2986 (3.8%) patients dialysed for acute renal failure at a referral center in North India were diagnosed to have acute renal cortical necrosis (ACN). Obstetric causes were responsible for ACN in 56.6% patients and nonobstetric causes in 43.4%. Within the obstetric group, ACN developed in association with complications of late pregnancy in 37.1% and following septic abortion in 19.5%. The various nonobstetric causes included viperine snake bite in 14.2%, hemolytic uremic syndrome in 11.5%, renal allograft rejection in 5.3%, acute gastroenteritis in 4.4%, acute pancreatitis in 3.5%, septicemia in 2.7%, and trauma and drug-induced IV hemolysis in 0.9% patients. Total anuria was the commonest presenting feature and was noted in 78.8% of patients. Renal histology showed diffuse cortical necrosis in 62.8% and patchy lesions in 37.2% patients. Computerized tomography (CT scan) of the kidneys revealed characteristic diagnostic findings in all the 5 patients in whom it was done. Dialytic support could be withdrawn as a result of improvement in renal function in 19 patients with patchy cortical necrosis. Dialysis-free survival of as long as 12 years has been recorded. The present study shows that, in contrast to the Western world, ACN continues to be a common cause of acute renal failure in developing countries. CT scan of the kidneys is helpful in establishing an early diagnosis.

Hemolytic uremic syndrome in children in northern India

We observed 73 patients with the hemolytic uremic syndrome (HUS) in 9 years (1980-1988), comprising 34% of patients with acute renal failure treated over the same period. There were 53 boys and 20 girls; 59% were below the age of 2 years and 33% between 2 and 5 years. Acute, usually severe dysentery, responding poorly to various antibiotics, was the prodromal illness in 80%, whereas 12% had watery diarrhea. Most patients had severe renal involvement with anuria in 56% and oliguria in 30%. A polymorphonuclear leukocytosis was present in 85% of cases, but had no correlation with the highest levels of blood urea. Coagulation abnormalities suggesting consumption coagulopathy were found in 24 of 30 cases. The results of stool culture showed Shigella species in 7 cases and nontyphoidal Salmonella in 9. Escherichia coli were isolated in 11 cases, but were not further characterized. Renal biopsy showed total or patchy cortical necrosis in 20 of 50 cases. The patients were managed with supportive care, including transfusion of fresh blood or plasma and dialysis as required. The mortality was 60%, being chiefly related to the duration of renal failure and presence of renal cortical necrosis, whereas persistent dysentery and infections were complicating factors. The presence of convulsions and coagulation defects had no relation to the outcome. Our observations indicate that HUS in children in northern India is mostly related to dysentery, likely to be shigellosis, and is usually associated with severe renal damage and a high death rate.