Journal of nephropathology
Volume:12 Issue: 3, Jun 2023

 Acute kidney injury (AKI) is a complex syndrome requiring special management. It also complicates the prognosis of many hospitalized patients. Some essential yet nephrotoxic medications and the use of certain procedures that may alter renal hemodynamics further complicate the management of AKI patients. Fortunately, as part of the renal care team, pharmacists can have a significant role in the multidisciplinary approach used to optimize renal patients’ health-related quality of life by delivering safe and effective pharmaceutical care.

 The present review aims to explore pharmacists’ contributions to the management of patients with AKI as well as their influence on improving renal patients’ care.

 An online search was performed in the databases PubMed, Scopus, and ScienceDirect for relevant articles published in English between 1 January 2015 and 31 December 2021. Review articles, books, guidelines, websites, and conference proceedings were excluded.

 Only 12 articles out of 51 initially gathered met the eligibility criteria for this review. The three main roles that pharmacists play in the management of AKI patients are patients’ education, collaborating with other renal care practitioners, and identifying and solving drug-related problems (DRPs). The latter task span includes medication reconciliation, dosage adjustments, and identifying adverse drug reactions.

 In view of the complexity of the AKI course, trained pharmacists, as members of the renal care team, can play a pivotal role in managing AKI patients and minimizing their medications burden. This can positively impact the overall renal care process as well as the patient’s outcome. Further studies can provide more support to the importance of pharmacists’ role in managing AKI.

A 48-year-old male patient presented with dialysis dependent renal failure with biopsy showing crescentic glomerulonephritis and Positron emission tomography–computed tomography (PET-CT scan) revealing features of pericardial, pulmonary tuberculosis with positive urinary GeneXpert test for tuberculosis bacilli. Clinicians should keep in mind the atypical presentations of tuberculosis while managing rapidly progressive renal failure especially in tropical countries with high prevalence of tuberculosis.

 Tenofovir remains the cornerstone drug in various antiretroviral regimens and is commonly associated with renal failure in susceptible individuals with a renal biopsy suggestive of proximal tubular injury.

 To investigate clinical, histopathological and outcome findings in tenofovir-induced nephrotoxicity patients.

 Between August 1, 2014, and March 31, 2017, an observational study was conducted in a government-run tertiary care facility in South India. All patients receiving a regimen based on tenofovir disoproxil fumarate (TDF) and testing positive for human immunodeficiency virus (HIV) were included. A renal biopsy was performed when needed.

 A total of 27 cases were identified, with a mean age of 45.03± 12.95 years, while 19 (70%) of them were men. Mean creatinine and mean proteinuria among the participants were 5.78 ±2.71 mg/dL and 1643.96 ±1056.44 mg/dL, respectively, at the time of the renal biopsy. Interval between TDF treatments to kidney biopsies ranged between 7 to 52 weeks with mean (±SD) of 30.8±22 weeks. Phosphaturia and glycosuria were found in 10 (37.03%) and 8 (29.5%) patients respectively, all of whom had normoglycemia. In contrast to the remaining 13 instances, which all had moderate to severe diffuse inflammation, 14 patients exhibited toxic proximal tubular damage along with mild and localized interstitial inflammation. Hemodialysis was required by 10 individuals. A total of 22 patients were monitored after TDF was stopped, while 17 (77.27%) of them had fully recovered renal function at the end of monitoring period.

 This study demonstrates that TDF nephrotoxicity is a reversible form of toxic acute tubular necrosis with concurrent interstitial inflammation that affects the proximal tubules. As a result, it is crucial to carefully monitor renal parameters in these patients.

 Chronic kidney disease (CKD) poses a financial burden on most patients from low/ middle income countries. Glycaemic control with affordable hypoglycemic agents may influence on the prognosis of diabetic nephropathy.

 We aimed to compare the rates of CKD progression and proteinuria in the type 2 diabetic population in response to the use of various hypoglycemic agents.

 A retrospective cross-sectional study of a total of 250 patients of Afro-Caribbean descent at the University hospital of the West Indies between 2018 and 2019 was conducted. The use of hypoglycaemic agents and changes in albuminuria were calculated as odds ratios with a 95% confidence interval (CI). A P value<0.05 was considered statistically significant.

 Of 250 patients with diabetic nephropathy, the number of rapid CKD progression was highest in patients on insulin (26.3%). In comparison, number of rapid progressions in patients receiving metformin, dipeptidyl peptidase 4 (DPP-4 inhibitors), sulfonylurea and pioglitazone were 19.1%, 22.2%, 21.9% and 20%, respectively. After eliminating confounding factors, comparison within the group analysis on DPP-4 inhibitors (n= 171) demonstrated 62.6% significant improvement in quantitative proteinuria with reduction of mean spot urine albumin creatinine ratio (ACR) from 362.1 ±338.9 mg/g to 303 ±300.1 mg/g (ORs, 0.77; 95% CI 0.41 to 0.97; P = 0.03).

 Type 2 diabetic patients requiring insulin were found to have progression of CKD than patients on oral hypoglycaemic agents. Among the affordable oral hypoglycaemic agents, DPP-4 inhibitors had an association with reduction in albuminuria.

 End-stage kidney disease (ESKD) is a major global public health problem. Knowledge of its epidemiology is crucial for its prevention and the optimal care.

 The objective was to study the epidemiological characteristics of patients on chronic hemodialysis, their outcomes and explore their perceptions of therapeutic modalities, through a prospective cohort.

 A prospective study conducted between February 2019 and January 2020, at two public hemodialysis centers in Oujda, Morocco.

 Around 183 patients were enrolled. The mean age was 53±17 years. The initial nephropathy was undetermined in 37% of cases and dominated by diabetes in 25.7%. About 43% of patients had pre-dialytic nephrology follow-up. Only 32% patients initiated their hemodialysis by an arterialvenous fistula (AVF). The mean hemoglobin rate was 10.3±1.8 g/dL. Moreover, 74 % of patients were under erythropoietin. Serum calcium, phosphorus, vitamin D, and parathormone were within target ranges in 67%, 52%, 61%, and 51% of cases, respectively. Since, 80% of patients were not clearly informed about therapeutic modalities. The majority of patients opted for kidney transplantation (KT), with two major constraints preventing its realization, consisting the lack of related living donors and financial resources. Besides, 29% of patients were hospitalized for cardiovascular and infectious causes during the study year. The survival rate at 1 and 5 years after the start of dialysis was 97.2% and 95% respectively.

 Early detection of chronic kidney diseases in high-risk people, their rigorous follow-up and early referral to the nephrologist would improve the quality of care. The promotion of KT and PD would better meet the hemodialysis patients’ needs with better outcomes and lower costs.

 Rituximab is the recent treatment of choice for primary membranous nephropathy However, dose of rituximab mentioned in literature is high and not economical in middle income countries. Low dose rituximab based on CD 19 cell count can be tried as an alternative for high dose rituximab for inducing clinical remission in appropriate clinical settings.

Case Series:

 Four patients were administered low dose rituximab and initial CD 19 count was monitored for optimal rituximab response. Three males and one female are part of this case series. Renal biopsies showed membranous nephropathy with tissue phospholipase A2 receptor (PLA2R) positivity in two cases. Serum PLA2R was positive for the same two cases. Two patients completely remitted after one year, one male patient required additional rituximab dose based on CD19 count, one patient required single dose of rituximab for partial remission in the background of tacrolimus with steroids. One patient failed to remit on low dose rituximab protocol.

 Low dose Rituximab can be tried as a favorable alternative for high dose Rituximab in appropriate clinical settings.

Severe rhabdomyolysis could lead to myoglobinuria and acute kidney injury (AKI). Acute interstitial nephritis (AIN) is commonly caused by drugs. AIN per se can cause ‘severe’ AKI. Renal recovery is delayed when several factors are involved in the pathogenesis of AKI. Survivors of AKI require long-term follow-up. Here, we report a case where both severe rhabdomyolysis and drug-induced AIN contributed to ‘severe’ dialysis-requiring AKI. Renal biopsy was diagnostic and showed characteristic features. Steroid therapy for AIN resulted in partial recovery.

Sjögren’s syndrome is a chronic inflammatory disorder mostly involving the exocrine glands. Extraglandular disease may occur in up to one quarter of patients. Kidney involvement is rare, more often manifested by tubular dysfunction secondary to tubulointerstitial nephritis. Primary glomerular disease is uncommon. The authors present the case of a 73-year-old woman with xerostomia and positivity for anti-Ro and anti-La antibodies admitted for acute kidney injury and exudative pleural effusion. Biopsy of salivary glands was compatible with Sjögren’s syndrome. Extraglandular involvement was also confirmed by renal and pleural deposition of AA-amyloid. The patient was started on prednisolone followed by azathioprine with rapid improvement of lung disease. However, due to progressing renal disease and clinical deterioration, prognosis was guarded and the patient died. We describe a case of secondary amyloidosis with systemic involvement and infrequent clinical manifestations, briefly reviewing the key aspects of Sjögren’s syndrome and AA-amyloidosis.