Single Center Research Articles

#2682 Evaluation of clinical, pathological findings and treatment outcomes of patients diagnosed with lupus nephritis: a single center experience

Abstract Background and Aim Renal involvement of systemic lupus erythematosus (SLE) is known as lupus nephritis (LN). The prognosis of lupus patients with LN is worse than those without kidney involvement. Renal survival can be improved in patients with lupus nephritis with appropriate and timely treatment. The aim of our study is to compare the clinical and pathological findings of patients diagnosed with LN in our clinic by renal biopsy, the results of the treatment applied in our center, and renal survival with the literature. Method The local ethical committee approved the study design (date: 04/10/2021; reference number: 121/07) and all procedures were conducted in accordance with the Declaration of Helsinki. Forty-four patients diagnosed with lupus nephritis between January 2012 and January 2021 in the Nephrology Department of Ankara Dıskapı Yıldırım Beyazıt Education and Research Hospital were enrolled in this study. Patient data were analyzed retrospectively. Exclusion criteria were as follows: 1) Patients under 18 years of age, 2) patients with follow-up of period less than 6 months and who did not attend regular follow-ups, 3) patients with connective tissue diseases other than SLE. Results The mean age of the study population was 36.0 ± 10.8, and the majority were female. All patients had proteinuria at diagnosis. Class IV LN was the most common (36.4%). Majority of the patients were in the proliferative LN group (65.9%). A significant difference was found between patients diagnosed with proliferative LN (n = 29) and non-proliferative LN (n = 15) in terms of high serum creatinine levels, low serum complement, presence of anti-dsDNA antibodies and active urinary sediment with proliferative LN (p = 0.021, p = 0.024, p = 0.008, p = 0.008). Treatment responses at 6 and 12 months are shown in Table 1. A significant difference was found between the patients who were in complete remission (n = 16) at 12 months and those who were not in remission (n = 27) in terms of low systolic blood pressure and the estimated glomerular filtration rate (eGFR) at the time of diagnosis (p = 0.008, p = 0.016). It was observed that most of the patients who were not in complete remission at 12 months were in the proliferative LN group (p = 0.024). There was no significant difference in the partial and complete remission rates at 6 and 12 months between the group receiving steroids + cyclophosphamide (n = 14) and the group receiving steroid + mycophenolate mofetil (MMF) (n = 15) in the initial treatment of proliferative LN (p>0.05). In the group taking MMF treatment (n = 15) had a shorter time to reach complete remission than the group taking cyclophosphamide treatment, and it was statistically significant (Table 2) (p = 0.048). It was found that end-stage renal disease (ESRD) developed in 9% of the patients and 2 patients died during followed up period. Recurrence was detected in 8 patients, and it was observed that more than half of the patients with relapse could not achieve complete remission at 12 months. Patients with relapse had higher systolic blood pressure and serum total cholesterol level at the time of diagnosis compared to patients without recurrence (p = 0.013, p = 0.045). In addition, patients with relapse were found to have a higher level of proteinuria at the time of diagnosis (p = 0.036). Conclusion Lupus nephritis remains an important source of morbidity and mortality for SLE patients. SLE patients should be regularly examined for renal involvement. About 10-20% of patients diagnosed with lupus nephritis develop ESRD. Early diagnosis of LN and initiating appropriate treatment when diagnosed without delay is important for renal and patient survival. Although there were some different results, most of the statistically significant data in our study were found to be compatible with the existing literature. However, these data need to be confirmed by studies with high patient participation.

#1716 IgA nephropathy: our center's experience

Abstract Background and Aims IgA Nephropathy (IgAN) is the most common primary glomerulopathy worldwide. In the last years, significant advances have been made in understanding its pathophysiology and developing newer promising treatments. The accuracy of the International Risk-Prediction Tool in IgAN (IRP-IgAN) was already validated. Herein, we retrospectively analysed the relation of this risk score and the kidney outcomes. Method We performed a single center retrospective observational cross-sectional study of patients with histological diagnosis of IgAN between 2015 and 2023 in Centro Hospitalar de Setúbal, aiming to describe the demography, clinical presentation, histological characteristics, treatment and follow up of our cohort. The International Risk-Prediction Tool in IgAN was applied for patient stratification. Results Twenty-eight patients were diagnosed with IgAN in this eight-year period. Mean age was 46 years-old (SD ±12.2) and 71.4% were male. The majority were Caucasian (n = 26) with only two patients of Asian e African descent, respectively. The mean calculated Charlson Comorbidity Index was 1.43 (SD ±1.5). Eighteen patients (64.3%) had known arterial hypertension, diabetes was seen only in 2 patients, obesity in 4 patients, and hepatitis B in 2 patients. No cardiovascular disease or cancer was documented. On presentation, 71.4% (n = 20) had hypertension, 14.3% (n = 4) presented with rapidly progressive renal insufficiency, and 14.3% (n = 4) presented with nephrotic syndrome. Two patients (7.1%) required dialysis on presentation. Also, the mean glomerular filtration rate (GFR) was 55.3 ml/min (SD ±31.9) and mean proteinuria level (protein-to-creatinine ratio) was 2.42g/g (SD ±2.41). Most patients had hematuria (82.1%), C3 consumption was seen in only one patient while 10 patients had isolated higher levels of IgA. Mean time between the first symptoms or documented clinical features and dedicated Nephrology consultation was 2.9 years (SD ±3.78). Regarding the histological data and considering de MEST-C score, 71.4% had mesangial hypercellularity in more than 50% of the glomerulus (M1), 25% had endocapillary hypercellularity (E1), 17% had segmental glomerulosclerosis of at least one glomerulus (S1), 7% had interstitial fibrosis or cortical atrophy in 25-50% of the cortical area (T1) and 11% in more than 50% (T2), 17.9% had crescents in less than 25% of the glomerulus (C1) and 2.6% in more than 25% (C2). Fibrinoid necrosis was noticed in 7.1% of the patients. The presence of IgA in the mesangium on IF was universal and 18 patients (64.3%) had C3 co-stain. Approximately half of the patients (46.4%) were already on angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blockers (ARB) by the time of clinical presentation and nearly all (92.9%) by the time the diagnosis was established. SGTL-2 inhibitors were started in 42.9% of the patients. Eight patients (28.6%) started immunosuppression therapy, within a mean time from histological diagnosis of 0.7 years (SD ±1.03). Of those, all of them were on corticosteroids, one patient was additionally under oral cyclophosphamide and another one under mofetil mycophenolate. According to the IRP-IgAN, patients were stratified in low (35.7%), intermediate (10%) and high risk (8%) of kidney disease progression (GFR decline >50%) or ESKD. In a mean time of 0.53 (SD ±0.34) years of follow-up after diagnosis, 8 patients (28.6%) required renal replacement therapy, with 7 choosing hemodialysis and 1 peritoneal dialysis. Six patients lost follow-up. Three patients died a mean time of 1.2 years after diagnosis, one from immunosuppression-related adverse events. We also found an association between higher risk group and progression to ESKD (p < 0.001). Conclusion The IRP-IgAN tool is a useful tool for prediction of kidney disease progression and the need for renal replacement therapy. The supportive care in IgAN even with antiproteinuric approach could be insufficient for patients with high and intermediate risk. The risk progression to ESKD is indeed heterogeneous, and close follow-up of these patients should be guaranteed.

#1023 Patient outcomes and graft survival among kidney transplant recipients with chronic hepatitis C infection: a single center study

Abstract Background and Aims Previous studies have shown that kidney transplant_(KT) recipients with chronic hepatitis C (HCV) infection have lower survival rates after transplantation. With the emergence of direct-acting antiviral therapy for HCV infection, the long-term outcomes for these patients are still unknown. This aims to evaluate the 5-year graft and patient outcomes of kidney transplant recipients with HCV infection at the National Kidney and Transplant Institute. Method A retrospective cohort study of HCV-positive KT recipients which were compared to HCV-negative patients in the same post-transplantation period. Data gathered from the patient's in-hospital and outpatient records and MEDSYS database. Results Twelve(12) out of 117 KT recipients with HCV infection were included. Half of these patients had detectable HCV RNA before KT. There was no difference in recipients' age, gender, and donor type between the groups. HCV infection is significantly associated with and an independent predictor of graft loss, rejection, and mortality. Patient survival between groups did not show any significant difference. Rates of graft rejection, graft loss, and patient mortality among HCV-positive recipients did not show statistically significant difference between groups. Graft survival rates at 6 months, 1-, 3-, and 5 years post KT were significantly lower among HCV-positive KT recipients compared to HCV-negative recipients. There were no significant differences in renal function, presence of proteinuria, liver enzyme levels, and incidence of cirrhosis between the groups. Conclusion Graft survival was shorter in HCV-positive KT recipients. Patient survival, measures of kidney function, and liver-related complications were similar between HCV-positive and HCV-negative KT recipients after transplantation.

#1212 Trends in real-world lipid lowering therapy use among adult patients with chronic kidney disease: 5-year single center experience in the Philippines

Abstract Background and Aims Patients with chronic kidney disease (CKD) carry an extremely high burden for atherosclerotic cardiovascular disease (ASCVD), which worsens as CKD progresses. Several international guidelines, including the 2013 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, have recommended the use of lipid-lowering therapy (LLT) in this high-risk population. To evaluate the implementation of these recommendations in real-world practice, we assessed patterns of dyslipidemia management among patients with CKD. Specific objectives include describing the prevalence and intensity of LLT prescription [stratified by estimated glomerular filtration rate (GFR) and whether requiring renal replacement therapy or not] as well as adherence to guideline recommendations on LLT use. Method We conducted a single-center, cross-sectional study covering the period of January 2019 to December 2023. A review of inpatient and outpatient medical records of the Department of Medicine, University of the Philippine—Philippine General Hospital was done. Eligible patients were at least 18 years of age, and diagnosed with CKD. Exclusion criteria included having a concomitant diagnosis of Acute Kidney Injury, and being pregnant or breastfeeding at any point in the study period. Sociodemographic, clinical, and laboratory data were based off the latest entry in each patient's medical record. No clinical data were collected beyond those that were available on the records. Classification of statin intensity was based on the 2019 American Heart Association/American College of Cardiology Guidelines on the Management of Blood Cholesterol as well as the 2020 Philippine Clinical Practice Guidelines on the Management of Dyslipidemia. All analyses were descriptive and done using STATA 18. Categorical variables were summarized as frequencies and percentages. Continuous variables were reported as measures of central tendency [i.e. mean (SD) or median (IQR), as appropriate]. Results Of the 3845 patients included in the study, 2922 (76%) were prescribed LLT. The most common LLT were statins (92%), followed by statin/ezetimibe combinations (6%), then statin/fibrate combinations (2%). None were prescribed PCKS9 inhibitors, niacin, omega-3 fatty acids, or bile acid sequestrants. Among non-dialytic patients, the distribution of LLT use was as follows: a) eGFR ≥ 60 ml/min/1.73 m2: 40% (173/431) b) eGFR 30-60 ml/min/1.73 m2: 76% (1198/1576) c) eGFR <30 ml/min/1.73 m2: 84% (1551/1838). Among dialytic patients, 68% (601/884) were already on LLT prior to initiation of dialysis while 35% (283/884) were started on LLT after dialysis initiation. Notably, 89% (786/884) of these dialytic patients were still on moderate-to-high-intensity statin doses. Based on recommendations from the 2013 KDIGO guidelines, only 78% (2610/3334) of eligible patients were prescribed on LLT, while 61% (312/511) of ineligible patients were prescribed on LLT. Similar rates of adherence were seen to other international guideline recommendations on the management of dyslipidemia in CKD (e.g. 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol, 2019 European Society of Cardiology/European Atherosclerosis Society guidelines for the management of dyslipidaemias, 2020 Clinical Practice Guidelines for the management of dyslipidemia in the Philippines). Conclusion Real-world LLT use among CKD patients remains high, even at lower eGFRs. More importantly, a large proportion of patients remain under- and over-treated, highlighting significant gaps between guideline recommendations and real-world clinical practice. Further investigation regarding the underlying reasons for these practice variations is necessary to improve quality of care, and safely reduce the burden of dyslipidemia and ASCVD among CKD patients.

#1495 5 and 10 year kidney outcomes in acute interstitial nephritis: a retrospective single-centre cohort study

Abstract Background and Aims Acute interstitial nephritis (AIN) is a common cause of acute kidney injury (AKI), histologically characterized by an interstitial inflammatory cell infiltrate. Data regarding long term kidney outcomes is lacking. We performed a retrospective cohort study to evaluate the long-term kidney and mortality outcomes in patients with biopsy-proven AIN between 2011-2018. Method We serve as a tertiary referral centre and sole nephrology provider for a population of over 650,000 people. We identified biopsy-proven AIN cases from the years 2011-2018 from our pathology database. Demographic data, creatinine, eGFR (calculated using CKD-EPI 2021 formula), dialysis and mortality data were collected from our electronic medical record. Ethical approval was obtained. Results Between 2011 – 2018, 576 native kidney biopsies were performed in our centre. 66 (11.5%) cases had pathologically confirmed AIN as the primary kidney diagnosis. Long-term outcome data was available for 90.9% (60). The median age at time of biopsy was 52.5 years (IQR 41.5 - 68.3). 68% of patients were male. The aetiology of AIN was medication in 42%, autoimmune in 15% and infection-associated in 3%. Of the cases of drug-induced AIN the predominant culprits agents were non-steroidal anti-inflammatories 28%, proton pump inhibitors in 24%, antibiotics 20%, with other medications in 8%. The median eGFR at the time of biopsy was 13.6 (IQR 7.9 -25.4) mls/min/1.73 m2. The median eGFR at year 1 was 47.8 (IQR 30.7 - 72.7) mls/min/1.73 m2, 54.4 (IQR 31.2 -79.6) mls/min/1.73 m2 at year 5 and 69.4 (IQR 19.9 - 86.1) mls/min/1.73 m2 at year 10. See Table 1 for results. At one year 64.3% of cases had eGFR < 60 mls/min/1.73 m2 (CKD III or higher). Interestingly the rate of CKD was lower at years 5 and 10 (54.7% and 50% respectively). GFR <30 mls/min (CKD IV or higher) were present in 25% at year 1, 26% at year 5 and 37% at year 10. 23% (14/60) people had dialysis-requiring AKI at the time of biopsy. Of these 21.4% (3) remained dialysis dependent at one year. In this group, no additional cases of ESKD were seen between years 1 through 5, one additional case of ESKD occurred by year 10. A composite outcome of kidney failure (GFR <15, dialysis or kidney transplantation) occurred in 48.2% at year 1, 54.7% at year 5 and 56.2% at year 10. Mortality data was available on 58 patients. 18.9% (11) people had died at 10 years follow-up. 8 out of the 11 deaths were within 5 years, 2 of which were within 1 year of diagnosis. Conclusion In this single centre study, kidney failure occurred in 48% of people at 10 years of follow up. 78% of dialysis-requiring cases recover independent renal function.

Gallbladder perforation: Diagnostic accuracy of new CT difficulty score in predicting complicated laparoscopic cholecystectomy.

To formulate and evaluate the diagnostic performance and utility of a new CT difficulty score in predicting difficult laparoscopic surgery in cases of gallbladder (GB) perforation. This prospective single centre study included a total of 48 diagnosed cases of GB perforation on CT between December 2021 and June 2023, out of which 24 patients were operated. A new 6-point CT difficulty scoring system was devised to predict difficult laparoscopic approach, based on patterns of inflammation around the perforated GB that were found to be surgically relevant. The pre-operative imaging findings on CT were studied in detail and correlation coefficients of various imaging findings were calculated to predict difficult surgery. On CECT, the type of perforation, according to the revised Niemeier's classification could be exactly delineated in all 48 patients. A CT difficulty score of ≥ 3 was found to a good predictor difficult laparoscopic approach, with statistical significance (p = 0.001), sensitivity of 94.44%, specificity of 83.33%, PPV of 94.44% and NPV of 83.33%. Inflammatory changes around duodenum showed maximum correlation coefficient of 0.744 (p = 0.0001), around colon showed a correlation coefficient of 0.657 (p = 0.0005), and in the omentum had a correlation coefficient of 0.5 (p = 0.013)). Inter-observer agreement was also calculated for various findings and it was found to have moderate to strong agreement (κ value 0.5-1.0). The CT difficulty scoring system can be an effective tool in predicting difficult laparoscopic surgery in cases of GB perforation in an emergency setting which can help in decision making and improved patient outcome.

#52 Pulmonary hypertension in hemodialysis patients: prevalence and risk factors: a single center study

Abstract Background and Aims Pulmonary hypertension (PH) is an underestimated cardiovascular trouble in patients on hemodialysis (HD). Therefore, we studied its prevalence, risk factors, association with inflammation, and cardiac changes in HD patients. Method This was a single-center cross-sectional observational study conducted at Sfax CNSS polyclinic hemodialysis center during October 2023. Patients on hemodialysis for at least three months were included and divided into those with and without PH; patients with secondary causes for PH were excluded. Clinical characteristics, HD-related factors, lab parameters, and echocardiography details were compared. PH was defined as a mean pulmonary artery pressure (PAP) of > 25 mmHg at rest, and it was further divided as mild (26–39 mmHg), moderate (40–60mmHg), and severe (> 60 mmHg). Mean levels of PAP were compared in different groups according to the main clinical parameters. Results Of 30 patients, 21 patients had PH (mild:15, moderate:4, and two had severe PH) with a prevalence of 70%, and a mean age of 58 years old. No difference was found in clinical characteristics, dialysis-related factors, and biochemical parameters. Inflammation seemed to be more important in the PH group but the difference was not statistically significant (mean C-reactive protein in the PH group vs. 5,69 in the non-PH group; p=0,34). Otherwise, according to echocardiography findings, PAP was significantly higher in patients with left ventricular failure(HF) (mean PAP in HF group vs. 31,12 in the non-HF group; p=0,011), in patients with right ventricular dilation(RVD)(mean PAP in RVD patients=47,83mmHg vs 28,88mmHg in the non-RVD group; p=0,05) and in patients with mitral regurgitation(MR) (mean PAP in MR group=40,18mmHg Vs 28,32mmHg in the non-MR group; p=0,04). Conclusion Haemodialysis patients have a high prevalence of PH, especially in patients with heart failure and ventricular dilation. PH was significantly associated with the presence of mitral regurgitation on echocardiography. Inflammation was slightly higher in PH but our study did not find significant differences in traditional risk factors, and HD-related factors between the groups with and without PH.

#1848 Body composition and multimorbidity in patients with chronic kidney disease

Abstract Background and Aims Frailty and multimorbidity are increasingly prevalent, particularly in the chronic kidney disease (CKD) population, and they seem to be more pronounced and accelerated in people receiving haemodialysis. We aimed to study the relationship between body composition, frailty and multimorbidity in people with CKD and end stage renal disease (ESRD) on haemodialysis (HD). Method This was a single centre study, involving 42 patients with CKD stage 3 to 5 (pre-dialysis) and 29 patients receiving in-centre haemodialysis. InBody 770 was used to measure body composition using bioelectrical impedance analysis. Multimorbidity of participants were assessed using the simplified Cambridge multimorbidity score. Frailty assessment was performed using the Clinical Frailty Scale. Results Phase angle was lower in later stages of CKD—mean phase angle in CKD stage 3 was 5.28°, stage 4 was 4.44 and stage 5 was 4.13 (p = 0.008). Visceral adiposity correlated with multimorbidity scores but in a multivariate regression analysis (including albumin and visceral fat area) only whole body phase angle independently predicted multimorbidity in CKD stage 4-5 (adjusted R2 for the whole model = 0.47, p = 0.007). In haemodialysis patients, there was no correlation between multimorbidity and phase angle (r = −0.149, p = 0.441). However, there was a significant correlation between frailty score and whole body phase angle in this group (r = −0.559, p = 0.002). In a univariate analysis, age (R2 = 0.2, Beta = 0.045, p = 0.015), albumin (R2 = 0.217, Beta = −0.214, p = 0.009) and skeletal muscle mass (R2 = 0.282, Beta = −0.101, p = 0.003) predicted frailty score in haemodialysis patients. In multivariate regression analysis age, albumin level and skeletal muscle mass continued to independently predict frailty scores in HD patients (adjusted R2 for the whole model = 0.503). Conclusion Phase angle measurement refers to cell membrane integrity and fat-free mass, with higher values suggesting improved cell health. Using body composition measures, in particular phase angle, is a useful measure to predict multimorbidity and frailty in CKD patients. They are quick, accessible and easy to use tools that can be incorporated in clinical practice routinely. The relationship between visceral adiposity and multimorbidity merits further investigation. Preservation of skeletal muscle mass through nutritional and exercise interventions could be a clinical target to reduce frailty in this population.

#3115 Effectiveness of SGLT2 inhibitors in patients with glomerulonephritis: a single center experience

Abstract Background and Aims Sodium-glucose cotransporter 2 (SGLT2) inhibitors have become widely used in recent years because of favorable outcomes on kidney function in people with diabetes mellitus and chronic kidney disease (CKD). The main effect of SGLT2 inhibitors is inhibiting sodium and glucose reabsorption, acting precisely in the early proximal tubule of the renal nephron. Although these drugs developed as glucose-lowering agents for their capability to induce glycosuria, cardiovascular outcome studies found that the reduction in kidney function was significantly delayed, and the incidence of severe decline in kidney function was reduced in patients taking SGLT2 inhibitors. Later on, these outcomes were confirmed by the results of the DAPA-CKD, EMPA-KIDNEY, and CREDENCE studies, which were specific outcome trials in patients with CKD. However, data about the use of SGLT2 inhibitors in patients with glomerulonephritis at routine clinical practice are still limited. The purpose of this study is to investigate the impact of SGLT2 inhibitors use in patients with glomerulonephritis. Method Patients diagnosed with biopsy-proven GN who continued their routine follow-up in Etlik City Hospital nephrology clinic were retrospectively examined. Patients with a steroid treatment history for GN were excluded from this study. We identified 29 patients who were treated with SGLT2 inhibitors for proteinuria. We analyzed the baseline characteristics, comorbidities, GN types, and laboratory parameters (baseline, sixth and twelfth months at the follow-up). Each patient was matched to the control with a similar baseline feature under conservative therapy (n = 29). Both patient groups were treated in line with the KDIGO glomerulonephritis guideline and were received RAAS blockers at the maximum tolerated dose. According to baseline levels, the reduction rate in proteinuria and eGFR of the sixth and twelfth months were calculated as percentages. The study was performed in accordance with the Declaration of Helsinki. The local ethical committee approved the study design. Results Our study involved 58 patients diagnosed with 32 (55%) IgA nephropathy, 16 (28%) with membranous nephropathy, and 10 (17%) with focal segmental glomerulosclerosis. In the treatment group, 23 (79%) patients used dapagliflozin, and 6 (21%) used empagliflozin as SGLT2 inhibitors. Baseline proteinuria levels at [1940 (1780-2700 mg/d) vs. 1890 (1670-2400 mg/d); p = 0.8], eGFRs [60 (44-82) vs. 64 (46-80) ml/min/1.73 m2; p = 0.8] and serum albumin levels (39.6 ± 0.3 vs. 39.1 ± 0.2; p = 0.4) were similar between both groups. The proteinuria reduction rate in the sixth month was 34% (27.3-40.5) for the treatment group and 12% (6.9-20.7) for the control group (<0.0001). Besides, the reduction rate was still higher in the treatment group at the 12th month [50.5% (39-52.6) vs. 26.3% (17.2-35.4); p ≤ 0.0001]. eGFR declining rate at 6th months and 12th months were lower in SGLT2 group than the control group [3.1% (0-6.2) vs. 8.6% (4.1-16.6); p = 0.004 and 0.8% (0-5) vs. 5.9% (3.3-15.2); 0.005, respectively] (Table 1). Proteinuria levels at 6th months were 1170 (970-1890) mg/d and 1730 (1180-2100) mg/d for treatment and control group, respectively. At 12th months, median proteinuria level of SGLT2 group was 940 (840-1480) mg/d and control group was 1250 (1120- 2040) mg/d (Fig. 1). Conclusion In this study with a well-matched control group, we found that SGLT2 inhibitors demonstrate efficacy in mitigating the decline in estimated GFR and reducing albuminuria in patients with GN. However, randomized-controlled trials are still required specific to patients with GN.

Effects of palivizumab prophylaxis on respiratory syncytial virus (RSV) infections in Montenegro

Background. Respiratory syncytial virus (RSV) is one of the most common pathogens causing severe lower respiratory tract disease in infancy and childhood. In newborns, young infants, and in infants with co-morbidities, the risk of severe infection is increased. Current protection against severe RSV infection is immunoprophylaxis with the monoclonal antibody palivizumab. The study aimed to assess the effects of palivizumab prophylaxis in the Republic of Montenegro in comparison to the pre-prophylaxis period. Methods. The study was conducted in prospective/retrospective single center format in Montenegro in the Clinical Center of Podgorica, for the period 2009-2019. Results. A total of 104 high-risk infants in the palivizumab prophylaxis program (2014-2019 RSV seasons) and 168 high-risk children without palivizumab prophylaxis (2009-2013 RSV seasons) were enrolled. A total of 51 children (49.0%) received prophylaxis for prematurity, 33 (31.7%) for bronchopulmonary dysplasia (BPD), 13 (12.5%) for hemodynamically significant heart disease/defect (HSCHD), and 7 (6.8%) for “miscellaneous” indications. In the control group most children had prematurity (101, 60.1%), followed by BPD (59, 35.1%), HSCHD (3, 1.8%), and “miscellaneous” (5, 3.4%) conditions. Readmission to the pediatric intensive care units (PICU) due to RSV infection was significantly lower in prophylaxis group (0.0 vs 16.1%, p<0.001). No lethal outcomes were observed in high-risk children with palivizumab prophylaxis compared to 2.4% in the control group. Conclusions. The introduction of RSV immunoprophylaxis as well as other new protective treatment strategies for high-risk newborns led to significant improvements in infant and childcare in Montenegro. This is the first report on palivizumab prophylaxis in Montenegro, demonstrating the effectiveness and safety of palivizumab use in clinical settings.

#2331 Distal arteriovenous fistulas for hemodialysis – too many interventions?

Abstract Background and Aims Distal arteriovenous fistula (dAVF) for haemodialysis (HD) is preferred due to lesser complications, despite greater risk of maturation failure. In HD patients, age and comorbid conditions increased the risk of access failure and number of procedures necessary for fistula patency. Preferred location for AVF poses a challenging decision. Advantages of dAVF must be taken into account although these may lead an unreasonably high number of interventions. Our aim was to determine time to functioning distal AFV in our centre and number of procedures necessary to achieve such status. Method Single centre retrospective analysis was performed on a cohort of patients submitted to distal AFV construction from 2015-2021. Success rate was defined as AFV patency in time for dialysis. Results Of 528 patients submitted to AVF construction from 2015 - 2021, 110 radiocephalic fistulas were seen, 59% male patients, mean age 68.5±12,0 yrs. Comorbidities were prevalent (80.9%, n=89), DM (54.6%) and HF (41.1%). Outcomes at 6 weeks were adequate maturation in 4.5% (n=59), 31.8% (n=35) late maturation (LM) and 14.5%(n=16) primary failure (PF). Causes of LM included inflow and outflow stenosis, 34.3% and 37.1%, respectively. LM (> 6 weeks) requiring no further intervention was seen in 28.6%. PF patients had smaller artery diameters on pre-operative US, with no statistical significance (0.23±0.07; 0.30 ± 0.2; p=0,375). Assisted patency rate was 78.2%. Number of procedures for access permeability was 1, 2 e 3 in 40%, 25.5% and 6.4%, respectively. Mean of 1,5±0,7 interventions per patient. Median time-to-adequate AFV was 2.0 (IQR 2,0 - 6,45) months. Success rate was 72,8%. Conclusion Outcomes at 6 weeks in our cohort were similar to those reported in literature. Timely referencing may increase access patency with resort to vascular intervention. Individualized management is essential, discussing risks and benefits taking into account the treatment burden associated with numerous procedures. Patency rates and outcomes after HD initiation and even cost analysis are essential to guide recommendations.

#2257 Kidney outcomes in ANCA-associated vasculitis—application of Berden's Classification and ANCA Renal Risk Score in a single centre cohort

Abstract Background and Aims Anti-neutrophil cytoplasmic antibody (ANCA) -associated vasculitis is the most common cause of rapidly progressive glomerulonephritis and is a life-threatening condition. The course of the disease is variable and disease prognostication remains challenging. Histological and clinical scores have been developed to predict kidney outcomes, to tailor treatment. The aim of this study is to apply Berden´s histopathological classification (BHC) and ANCA renal risk score (ARRS), proposed by Brix and co-workers, in a cohort of patients with ANCA-associated vasculitis and to analyse their performance in renal outcomes prediction. Method In this retrospective observational study, we included patients with biopsy proven ANCA-associated vasculitis, diagnosed at our centre between March 2011 and March 2023. We consulted the clinical records and the kidney biopsy reports. Biopsies were categorized according to both scores. Follow up time was up to 48 months since the date of diagnosis. In BHC patients were divided into 4 groups (focal, crescentic, sclerotic and mixed) according to normal glomeruli, cellular crescents and globally sclerosed glomeruli proportion. When applying the ARRS, patients were divided into 3 groups: low, medium or high risk. This is a histopathological and biochemical score that combines normal glomeruli and tubular atrophy and interstitial fibrosis (IFTA) percentages with estimated glomerular filtration rate (eGFR) at time of diagnosis. Factors related to renal survival were evaluated by Spearman Rank Correlation, Binary Logistic Regression analysis and Kaplan-Meier curves were used for assessing time between diagnosis and end stage kidney disease (ESKD). Results Our study included 31 patients, 54.8% were male, median age at diagnosis was 62 (IQR, 53-69) years, with a median eGFR of 8.3 (IQR, 6.2-13.3) mL/min/1.73 m2 and a median urine albumin to creatinine ratio (uACR) of 1.5 (IQR, 0.88-2.2) g/g. 19 patients (61.3%) were positive for myeloperoxidase and 5 (16.1%) were proteinase 3 positive. Median follow up time was 36 (IQR, 9-48) months. 10 patients (32%) developed ESKD and 9 patients (29%) died. Regarding BHC, 4 patients (13%) presented a focal class, 18 (58%) crescentic, 7 (23%) mixed and 2 (6%) sclerotic. Progression to ESKD occurred in 7 patients with crescentic class (38.9%), 2 patients with mixed (28.6%) and 1 patient with sclerotic (50%). None of the patients with focal class developed ESKD. There were no significant differences in kidney survival curves by BHC class (Log Rank p = 0.47) (Fig. 1a). In ARRS, 1 patient (3%) was in the low-risk group, 19 patients (61%) in the medium risk and 11 patients (35%) in the high risk. Characteristics of the population by ARRS score group and detailed score discrimination are specified in Table 1. Progression to ESKD, occurred in 5 patients of medium risk group (26.3%) and also in 5 patients in the high-risk group which represented 45.5% of this group. Kidney survival curves by ARRS score group had no statistic difference (Log Rank p = 0.46) (Fig. 1b). ESKD was positively associated with serum creatinine (sCr) at admission (p = 0.02), highest sCr (p = 0.001) and leukocyturia (p = 0.05). By multivariate analysis adjusted to gender, age, sCr at admission, leukocyturia and BHC or ARRS, the only factor associated with ESKD was sCr at admission (OR 1.45, CI 1.03-2.06, p = 0.05). Conclusion In our cohort of patients, sCr at patient hospital admission was the best predictor for progression to ESKD. By ARRS, just one patient had low risk, and as expected, kidney survival was higher in the medium risk group (68.5%) than in the high-risk group (53%), although not reaching statistical significance. BHC also had no association with kidney outcomes, although kidney survival was 100% in focal class and sclerotic class had the lowest survival (50%), yet crescentic class revealed a worse kidney survival (57.1%) than mixed class (71.4%). The small number of patients, overall and in each group, and the short follow up period can be pointed as limitations of this study.

#2265 The challenge of renal biopsy in diabetic patients: evaluation of a single center large cohort from North-West Italy

Abstract Background and Aims Diabetic kidney disease is one of the most severe long-term complications of diabetes. Currently, the international guidelines suggest diagnosis of diabetic nephropathy to be achieved on a clinical ground only. However, in the heterogeneous cluster of different conditions putatively co-existing with diabetes, renal biopsy is a unique tool for an accurate diagnosis and a guide for patient management. The aim of the study was to retrospectively analyze monocentric case history of kidney biopsies performed in diabetic patients over a period of 10 years. Patient's data were collected both at the time of histological examination and during follow-up. Method Data of renal biopsies (RB) performed in patients with diabetes mellitus from 1st January 2014 to 31th July 2023, were collected. Patient identification was performed by reviewing clinical histories and histopathological charts. Data on the indication for RB were collected from the medical report of the hospitalisation when the procedure was performed or from the visit when the indication was given. Atypical features were categorized according to an adaptation of the 2007 KDOQI guidelines for diabetes and chronic kidney disease. The significance of baseline differences was determined by the chi-squared test, Fisher's exact test or the unpaired t-test, as appropriate. Significance of univariate analysis were confirmed through the use of multivariate analysis. Correlation analysis, linear regression and Cox regression were also performed. A two-sided P-value <0.05 was statistically significant. All statistical analyses were performed using SPSS version 26.0 (IBM, Armonk, NY, USA). Results Among 1990 patients (pts) who underwent kidney biopsy during the study period, 297 had type 1 or type 2 DM (14.9%) and were therefore included in the study, regardless of diagnostic suspicion and histological findings. Histological examination revealed diabetic nephropathy (DN) in 112 cases (group 1), DN associated with another kidney disease in 56 cases (group 2) and nondiabetic renal diseases alone in the remaining 129 cases (62%) (group 3). In group 2 the kidney disease most frequently associated with DN was focal and segmental glomerulosclerosis, FSGS (24/56 pts) followed by IgA nephropathy, IgAN (14/56 pts). In this population the histological examination led to specific therapeutic indications in 22 patients. In group 3 the most frequently observed kidney disease was FSGS (37/112 pts) followed by ANCA-vasculitis (14/112 pts), membranous nephropathy (14/112 pts) and IgAN (10/112). In this population, histological examination led to a specific therapeutic indication in 67 pts. To determine predictors for histopathological diagnosis of DKD, we ran a logistic regression model. The covariates used in this model were the duration of diabetes, presence of retinopathy, hypertension, serum creatinine values, eGFR values and 24-hours proteinuria. None of them was found to be statistically significant. It should also be noted that 47 out of 112 pts (42%) with diabetic nephropathy had no retinopathy. In contrast, 9 pts (7%) with histological evidence of NDRD had diabetic retinopathy. 215 out of 297 pts had a follow-up of at least 6 months. During a mean follow up of 41.6±31.8 months, 53 pts (24 in group 1, 15 in group 2 and 14 in group 3) reached end stage kidney disease (16.5 months). In our population the presence of DN associated with another biopsy-proven nephropathy was especially prevalent. Having double nephropathy conferred a relative risk-RR for dialysis of 1.8089 (95% CI 1.0094 to 3.2415, P = .0464). Conclusion To our knowledge this is the largest cohorts of diabetic patients receiving renal biopsy even reported in a Western country. Our data proved kidney biopsy not to be an academic exercise in diabetic pts. Clinical and laboratory features do not predict histologic findings. Renal biopsy allowed the identification of unsuspecting nondiabetic kidney injuries and double nephropathies, which could be susceptible to different outcomes, and paved the pathway for treatment of potentially manageable histological changes.

#743 Clinical outcomes of patients hospitalized with the diagnosis of COVID-19 infection and undergoing hemodialysis: a single center experience

Abstract Background and Aims The main purpose of this study is to determine the effect of dialysis on the prognosis (admission to intensive care unit, intubation requirement, length of hospitalization, mortality) of patients with COVID-19 receiving hemodialysis treatment in our clinics. Another aim of this study is to examine the effect of the need for hemodialysis on COVID-19 prognosis in order to contribute to the data of our country. Method Cross-sectional study of 104 patients with hemodialysis and were diagnosed COVID-19 were conducted. In this study, patients were divided into three groups: (i) those with chronic renal failure (CRF) and receiving routine hemodialysis; (ii) those with chronic kidney disease (CKD) but needing urgent hemodialysis; and (iii) those who did not have a known kidney disease but needed urgent hemodialysis because of acute kidney injury (AKI) . The study was performed in accordance with the Declaration of Helsinki. The local ethical committee approved the study design (date: 21.03.2022; reference number: 133/13). Results When we evaluated the demographic, clinical and laboratory factors in our study, it was found that the factors affecting mortality were lymphopenia, emergency HD treatment under the presence of CKD, an increase in AST more than 2 times, the need for mechanical ventilation and high d-dimer (Table 1). Conclusion This case demonstrates that AKI associated with cytokine storm and developing multi-organ dysfunction situation is directly linked to mortality, particularly in patients with severe clinical condition. When the biochemical data of the patients were analysed, it was discovered that AST increase, lymphopenia, and d-dimer rise were directly found associated with increase mortality. In light of these observations, the above-mentioned biochemical laboratory values of the patients can be closely monitored, as can the clinical course of COVID-19 and renal-related mortality.

#2232 Personalized kidney replacement therapy in critically ill patients: unity makes strength!

Abstract Background and Aims The complexity of the critically ill patient with kidney disease has increased in recent years. A holistic and multidisciplinary approach is, therefore, necessary in order to provide the best therapeutic guidance. Multiple modalities of kidney replacement therapies (KRT) are available in this setting, namely continuous kidney replacement therapies (CKRTs) and hybrid therapies, also such as sustained low-efficiency dialysis (SLED) and slow continuous ultrafiltration (SCUF). These techniques can be used in conjunction with other extracorporeal clearance therapies such as plasmapheresis (PF), and immunoadsorption (IA). Their prescription must be individualized according to the characteristics of each patient. In our hospital all KRT and extracorporeal techniques used are reviewed daily by a nephrologist. This study aims to describe the 20-year experience of our centre in individualized KRT prescription in intensive care. Methods A retrospective cohort, single centre study was conducted. We reviewed adult patients (age ≥18 years) admitted in all the ICUs of our hospital centre between January 2002 and December 2022, who required a KRT. We aimed to describe demographic data, different stages of kidney disease [AKI, AKI in CKD, chronic hemodialysis (HD), peritoneal dialysis (PD), kidney transplant (KT), rapidly progressive kidney failure (RPKF), other causes], the KRT used and the main outcomes. Results During the study period, 1578 patients who required a KRT were admitted to the ICU. Median age was 65 (IQR: 45-81) years old and 59.9% were male. Among these patients 715 (45.3%) had AKI, 380 (24.1%) were in HD, 315 (20%) had AKI in CKD, 130 (8.2%) had a KT and 31 (2%) were in PD. Four patients had RPKF and 3 patients had other causes for KRT, such as hyperammonemia and sodium valproate poisoning. The main KRT performed were: SLED—1365 (86.5%) patients; continuous venovenous hemodiafiltration (cvvHDF)—120 (7.6%) patients; SLED + cvvHDF—66 (4.2%). Other KRT executed were SLED + PF (11 patients), continuous venovenous hemofiltration (cvvHF) (8 patients) and SCUF (2 patients). Among all patients mortality rate was 42.3%, 33% had renal recovery and 7.4% started chronic HD. In AKI group the median age was 64 (IQR: 48-80) years and 56.3% were male. 576 (80.7%) performed SLED, 91 (12.7%) did cvvHDF and 36 (5.0%). Mortality rate was of 52.1%, renal recovery 45% and 2.9% started chronic HD. Conclusion Our ICU multidisciplinary approach model with a critical care nephrology specialists team translates into a large amount of accumulated experience with SLED. Our results are comparable to centres that predominantly use CKRTs. The range of different techniques used reflects the fact that KRT has become a complex treatment for critically ill patients, which allows for the prescription to be precisely tailored to the different daily clinical needs.

#525 SGLT2 inhibition in non-diabetic CKD: results in experimental lupus nephritis

Abstract Background and Aims Sodium glucose cotransporter type 2 inhibitors (SGLT2i) potently attenuate cardiovascular morbidity and progression of CKD in patients with type 2 diabetes. It has been proposed that SGLT2 inhibition may also elicit renoprotective effects in non-diabetic CKD. The aim of this work is to evaluate whether the treatment with an SGLT2i improves kidney disease progression in a mouse model of lupus nephritis (LN). Method We performed a single center randomized controlled preclinical trial using female MRLlpr/lpr mice. The animals were randomly assigned to (1) vehicle or (2) empagliflozin (EMP, 10 mg/kg/day) treatment once signs of active systemic lupus erythematosus (SLE) appeared: proteinuria >100 mg/dL (++ in reactive strips) or lymphadenopathy in minimum 2 bilateral sites with proteinuria >30 mg/dL (+ in reactive strips). We included 13 mice per group that were treated during 4 weeks. Empagliflozin was given as an admix into standard chow diet. Reduction of urinary albumin to creatine ratio (UACR) was considered the primary endpoint whereas glomerular filtration rate (GFR), renal histology (LN activity/chronicity index, glomerulosclerosis, interstitial fibrosis) and SLE markers (total serum IgG, anti-dsDNA IgG, glomerular IgG deposits, lymph node weight, spleen weight) were considered secondary endpoints. Results After 4 weeks of treatment, no significant differences in fasting blood glucose levels were found between the experimental groups. As expected, empagliflozin administration notably inhibited SGLT2 in the tubular cells demonstrated by a significant increase of urinary glucose (p < 0.0001). This is consistent with the increased water intake observed in MRLlpr/lpr mice treated with empagliflozin (p < 0.0001). At the end of the experiment, vehicle treated MRLlpr/lpr mice showed a significant increase in UACR (p = 0.0012) consistent with LN progression that was not attenuated by empagliflozin. In line, empagliflozin did not modify GFR and LN activity/chronicity indexes, glomerulosclerosis or interstitial fibrosis in kidney. Finally, regarding SLE markers, 4-weeks empagliflozin treatment was not able to decrease total serum IgG, anti-dsDNA IgG, glomerular IgG deposits or lymph node weight. Only spleen weight was significantly decreased in empagliflozin treated MRLlpr/lpr mice (p = 0.003). Conclusion In our experimental setting, empagliflozin treatment reduced spleen weight suggesting a protective role in SLE in MRLlpr/lpr mice. However, empagliflozin did not modify LN progression in MRLlpr/lpr mice probably because the acute LN phase. It is expected that the positive effect in terms of reducing proteinuria will be observed in patients with LN and residual proteinuria

Clinical Course after Carmustine Wafer Implantation for Newly Diagnosed Adult-type Diffuse Gliomas; A controlled propensity matched analysis of a single center cohort.

It remains unclear whether combining carmustine wafer (CW) implantation with the standard treatment for adult-type diffuse gliomas is safe and has a prognostic impact. This study aimed to investigate the prognostic value and safety of CW implantation. Adult patients with IDH-wild-type and -mutant gliomas, grades 3-4 treated with surgical resection, radiotherapy, and temozolomide chemotherapy between 2013 and 2023 were surveyed. CWs were implanted except in cases of intraoperative wide ventricle opening or marked preoperative brain swelling. For survival analyses, a case-matched dataset based on propensity score matching (PSM), including multiple factors (patient background, diagnosis, and extent of resection) was generated. Progression-free survival (PFS), overall survival (OS), and frequency of complications of CW implantation (brain edema, infection, and cerebrospinal fluid leakage) were compared between the CW and non-use groups. In total, 127 patients (75 in the CW use group and 52 in the non-use group) were enrolled. Regardless of stratification, no significant differences in PFS and OS were observed between the CW use and non-use groups. The frequency of postoperative brain edema was significantly higher in the CW use group than in the non-use group. An adjusted dataset containing 41 patients in the CW use and nonuse groups was generated. Even after PSM, CW implantation had no prognostic effect. CW implantation with standard treatment demonstrated little beneficial effect for the present strategy of CW use.

#555 Acute graft pyelonephritis in a kidney transplant recipient—a single centre experience in northern India

Abstract Background and Aims Urinary tract infections (UTI) are the most common infections after kidney transplantation. Although clinical spectrum of pyelonephritis after kidney transplantation remain less clear. This study was conducted to evaluate the prevalence, clinical and microbiological profile with antibiogram of post-transplant pyelonephritis. Method We retrospectively reviewed and analysed the charts of 1684 patients, who underwent kidney transplantation at Medanta—The Medicity between January 2015 and May 2023. Patients were screened for the diagnosis of pyelonephritis and their clinical characteristics and outcome were evaluated. Results 93/1684 (5.5%) patients with a mean age of 41 ± 13.57 years had developed at least one episode of Pyelonephritis. 68 were males and 25 females. Older age, female gender, hyperglycaemia, use of induction immunosuppression were the risk factors for Pyelonephritis. Median time of occurrence was 44 days after transplantation. Most common symptoms were fever (n=64) followed by dysuria (n=40), and abdominal pain (n=11). Most common organism isolated was Escherichia coli (51.6%) followed by Klebsiella pneumonia (30.1%), and Pseudomonas aeruginosa (11.8%). This study showed a high percentage of resistance to commonly used antibiotics like Carbapenems (61.3%), third generation cephalosporin (49.5%). 41/93 (44%) patients had acute graft dysfunction at the time of presentation. Median duration of hospital stay was 7 days. 90/93 patients had graft recovery and one patient lost his graft after episode of UTI. Conclusion Pyelonephritis is a common cause of morbidity after kidney transplantation and occurs in an early post-transplant period. Gram negative bacilli are the major pathogens and carbapenems as an empirical therapy might be useful choice for management of Pyelonephritis and coverage of majority pathogens.

#2815 Single center, single arm, prospective, observational study of desidustat in chronic kidney disease-induced anemia

Abstract Background and Aims Anemia in chronic kidney disease (CKD) is multifactorial. Relative deficiency of erythropoietin is one of the key reasons for decreased RBC production. This anemia is associated with poor quality of life and increases morbidity in CKD patients. Injectable erythropoietin is the standard of care for CKD-anemia, which has safety concerns. Desidustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI), stimulates endogenous erythropoiesis and is approved for CKD anemia treatment. Hence, the present study identifies the real-world clinical efficacy and safety of the desidustat treatment for a short duration in CKD anemia. Method This is an open-label, single-center, prospective study. We analyzed the data of 130 patients who are currently in follow-up and received Desidustat as treatment for CKD-anemia. The study is for the duration of 24 weeks. We followed up on patent at 1 month, 3 months, and the end of the study (6 months). Patients were given a 100-mg Desidustat tablet orally three times in a week. The primary outcome is to assess the change in Hb from baseline, and the secondary outcome is the safety of the therapy. Results In this study, we enrolled 130 patients. Of these 130 patients, 58.4% (n = 76) were male and 41.5% (n = 54) were female. The mean age of the study population was 53.6 ± 12.3 years. The majority of the study population was in the pre-dialysis category; 80% (n = 104) and 20% (n = 26) were on dialysis. All the dialysis patients were on three times per week on Dialysis. Diabetes (68%) and hypertension (75%) are the most common co-morbid conditions in patients with CKD anemia. All the patients received desidustat at a 100 mg, three-weekly dose. During each follow-up visit, a significant rise in hemoglobin was observed (p<0.001), as shown in the figure. With desidustat therapy, adverse drug reactions were seen in 5.3% (n = 7) cases: three cases of abdominal pain, two cases of vomiting, and two cases of diarrhea. Conclusion Oral HIF-PHIs and Desidustat showed significant improvement in hemoglobin in CKD anemia patients. More studies require for safety and efficacy in Dialysis dependent CKD - Anemia patients.

#2262 Renal outcomes of postpartum atypical hemolytic uremic syndrome treated with plasma exchange

Abstract Background and Aims Postpartum acute kidney injury (AKI) with features of thrombotic microangiopathy (TMA) are particularly challenging and complex cases. Causes include Preeclampsia (PE), hemolysis, elevated liver enzymes and low platelet count syndrome (HELLP) and atypical hemolytic uremic syndrome (aHUS). In a limited resource setting, it is difficult to diagnose such cases with more than standard blood tests. Therapeutic Plasma exchange (TPE) is the only available option for treatment in the absence of complement inhibitors. This study evaluates renal outcomes in patients with aHUS treated with plasma exchange. Method This is a single centre observational study conducted in a Tertiary Obstetric Intensive Care unit. The data of women who were admitted with postpartum AKI from January 2021 to October 2023 was retrospectively collected and analyzed. We used the following criteria to diagnose postpartum atypical HUS (Serum creatinine ≥1.9 mg/dL, Lactate dehydrogenase (LDH) ≥1832 U/L, or serum creatinine ≥1.9 mg/dL in combination with LDH ≥600 U/L) [1]. Inclusion criteria include women older than 18 yrs with microangiopathic hemolytic anaemia, schistocytes on peripheral blood film, negative direct antiglobulin test (DAT) and platelet count <100 /mm3.Lack of improvement of kidney functions and hemolysis 72 hours after delivery. Patients with sepsis, disseminated intravascular coagulopathy (DIC), postpartum hemorrhage (PPH) and chronic kidney disease were excluded. We identified 10 patients with postpartum aHUS. Peak creatinine, LDH, AST and Nadir platelet count and hemoglobin were recorded. Patients were followed up in the nephrology outpatient clinic. Results Fifty-two patients developed postpartum AKI in the study period. Ten patients (19%) were diagnosed with aHUS according to the above-mentioned criteria. Mean age was 24.5 ± 6.9 yrs. Median peak creatinine 5.1 (2.6-7) mg/dl, LDH 1950 (612-4000) U/L, AST 246 (150-699) U/L. Median nadir hemoglobin 7.25 (6-8.2) g/dl and platelets 57 (41-95)/mm3. All 10 patients received 3 to 6 sessions of TPE guided by platelets and LDH levels. All patients required at least 3 sessions of hemodialysis. Eight patients received TPE with plasma filter and 2 had centrifugal TPE (due to lack of plasma filters). Two patients died during ICU admission. Two months after discharge 4 (50%) patients had partial recovery of kidney functions average creatinine (3.5 ± 0.8) mg/dl and four (50%) remained dialysis dependent. Six of these patients had kidney biopsies, three biopsies showed a picture of thrombotic microangiopathy and two showed thrombotic microangiopathy with renal cortical necrosis. The other patient was lost to follow up. Conclusion It is difficult to diagnose and treat aHUS in a resource limited setting. The available treatment with therapeutic plasma exchange has poor renal outcomes.