Pakistan Journal of Kidney Diseases

Nephropathology quiz Postpartum hemolytic uremic syndrome

Muhammed Mubarak — Tue, 31 Mar 2026 00:00:00 +0500

Rituximab Rescue in Pregnancy: Triumph over Membranous Nephropathy

Dr. Merina Khan, Dr. Mahnoor Ali, Dr. Syed Nayer Mahmud — Tue, 31 Mar 2026 00:00:00 +0500

A 18-year-old South Asian female developed nephrotic syndrome. Subsequent renal biopsy showed thickened glomerular basement membrane on light microscopy Periodic Acid Schiff (PAS) stain, with spikes on silver stain. Immunofluorescence showed IgG and C3 deposits while IgA, IgM and C1q were negative. This led to a diagnosis of Membranous Nephropathy (MN). As IgG4 staining was not introduced in the country at that time, and rest of the findings were typical for MN, patient was presumed to have Primary Membranous Nephropathy(PMN). She was treated with oral Prednisolone (60mg/day) along with Tacrolimus (0.05mg/kg/day). Prednisolone was successfully tapered off however attempting to taper tacrolimus, albeit prematurely, resulted in relapse twice. Her first presentation to us was at the age of 20. At that time, she was normotensive with pitting edema to her mid-shins. Urine routine examination showed 3+ proteinuria with no active sediment. She had a urine protein to creatinine Ratio (UPCR) of 5.8g/g, albumin of 2.47g/dl, LDL of 150 mg/dl and creatinine 0.5mg/dl. Phospholipase A2 Receptor Antibodies (anti-PLA2R) could not be checked due to unavailability of the assays at our setup at that time. Further workup was ordered to exclude secondary causes of MN. Hepatitis serology (for Hepatitis B and C) were negative. Complement levels were ordered that were normal. Erythrocyte Sedimentation Rate(ESR) was elevated at 35mm/hr. Her tacrolimus trough levels were suboptimal and her dose was optimized at 2mg twice a day. Ramipril 2.5mg twice a day was continued for proteinuria, furosemide 40 mg once a day for her pitting edema and rosuvastatin 20 mg at night for primary prevention of cardiovascular disease. She achieved partial clinical remission the following year with UPCR of 0.56g/g. After that, at the age of 21, she got married and wished to conceive. Ramipril was switched to Diltiazem. She was advised to wait till further reduction in proteinuria. She miscarried twice during this time, at the age of 22 and 24. At 25 years of age, she achieved complete clinical remission (UPCR of 0.06g/g). At her next presentation to us, she was in her 5^th week of gestation with UPCR of 4.8g. Given that her proteinuria had increased before the 20^th week mark and her blood pressure was normal, the increase was attributed to relapse of her primary disease. Tacrolimus trough levels were confirmed to be optimal. Based on available evidence of Rituximab in pregnancy, potential risks and benefits were discussed with the patient and she subsequently opted for it. She was offered a low dose regime of Rituximab 100mg/week for 4 weeks which was administered at weeks 13, 14 16 and 17. Tacrolimus was continued at the same dose of 2mg twice a day. Her UPCR, albumin and LDL were followed closely throughout her pregnancy.

At 34 weeks of gestation, due to low Amniotic Fluid Index (AFI), labour was induced and a baby boy was born. He required admission in the nursery for a week due to prematurity. Post discharge, he remained stable. He is currently 2.5 years old, healthy and developing normally.

The mother was started on Valsartan 80mg once a day post-delivery and Diltiazem was discontinued. She achieved complete remission (UPCR 0.17g/g) 1-year post Rituximab administration and is in remission to date.

From The Desk of Editor in Chief

Dr. Rubina Naqvi — Tue, 31 Mar 2026 00:00:00 +0500

Hyponatremia in Congestive Heart Failure (CHF): Harnessing the Horse with Tolvaptan

Chaudhry Adeel Ebad — Tue, 31 Mar 2026 00:00:00 +0500

Hyponatremia in Congestive Heart Failure (CHF) is a complex and ominous clinical entity that transcends simple electrolyte imbalance. It serves as a profound indicator of advanced neurohormonal derangement and stands as one of the most reliable predictors of morbidity and mortality in the heart failure population [12, 20]. While traditional loop diuretics remain the cornerstone of decongestion, they frequently exacerbate hyponatremia by causing natriuresis and further activating the renin-angiotensin-aldosterone system (RAAS), leading to a state of "diuretic resistance" [5, 15]. Tolvaptan—an oral, selective vasopressin V_2-receptor antagonist—offers a physiologically targeted alternative. By inducing "aquaresis" (the excretion of solute-free water) rather than natriuresis, tolvaptan allows clinicians to "harness" the runaway vasopressin response [7, 18]. This article provides a comprehensive exploration of the pathophysiology of hypervolemic hyponatremia, the foundational clinical evidence supporting vaptan therapy, and a structured, safe approach to managing these high-risk patients

Compliance with Anemia Management Indicators Among Maintenance Hemodialysis Patients: A Clinical Audit from a Tertiary Center

Tue, 31 Mar 2026 00:00:00 +0500

Background Anemia is a major complication among patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis (MHD). Effective management requires consistent adherence to guideline-recommended practices, including hemoglobin monitoring, iron assessment, and appropriate erythropoiesis-stimulating agent (ESA) titration. This audit aimed to evaluate compliance with key anemia management indicators in a tertiary hemodialysis unit.

Methods A cross-sectional clinical audit was conducted among 62 adult MHD patients at Evercare Hospital Dhaka. Data were collected using a structured checklist based on KDIGO 2021 anemia guidelines. Eight indicators were assessed: anemia screening, iron status documentation, correction of iron deficiency, post-ESA hemoglobin monitoring, maintenance of target hemoglobin, quarterly iron profile checks, ESA dose adjustments, and completion of patient education. Compliance levels were analyzed descriptively and compared across genders.

Results High compliance (82–100%) was observed in anemia screening, ESA dosing, post-ESA hemoglobin monitoring, and patient education. Hemoglobin maintenance within target ranges showed moderate adherence (62.9%). Iron documentation (35.5%) and quarterly iron monitoring (8.1%) demonstrated critically low compliance. Male patients achieved better hemoglobin control than females (80.8% vs. 50%). A strong positive correlation was found between appropriate ESA titration and hemoglobin stability.

Conclusion The audit identified strong adherence to ESA-related processes and patient education but highlighted major gaps in iron assessment and routine monitoring. Strengthening iron management practices is essential to optimize anemia outcomes in MHD patients. Targeted quality-improvement interventions are recommended to enhance overall compliance and align practice with international standards.

Patient-Reported Social Frailty and Its Relationship with Depression In End-Stage Renal Disease

Tue, 31 Mar 2026 00:00:00 +0500

Background and Objectives: Due to the associated impact on quality of life, chronic kidney disease leads to the development of depression. This study was done to assess the relationship between social frailty and depression in End-Stage Renal Disease patients.

Materials and Methods: This study was conducted at the Combined Military Hospital Lahore, including patients aged> 13 years of either gender with ESRD. All patients were evaluated for depression using the Patient Health Questionnaire-9 and for frailty using the Social Frailty Index-7 questionnaire. The effect modifiers such as age, duration of dialysis, concern regarding serum creatinine, fear of disability, dialysis-associated fatigue, and haematological parameters were also assessed using binary logistic regression analysis.

Results: A total of 150 patients with a mean age of 56.93 ± 13.78 years were enrolled. Among these, 106 (70.6%) were males, 61 (40.67%) had diabetes mellitus, 71 (47.33%) often felt fatigued, 103 (68.67%) had unintentional weight loss, and 59 (39.33%) reported slight concern about serum creatinine levels. Frailty and depression showed a significant correlation (r = -0.305, p<0.001). Similarly, socially frail patients had markedly higher odds of depression (adjusted OR 105.74, 95% CI 13.38–835.00; p < 0.001) compared with non-frail individuals. Associations observed for education, income, fear of disability or death, unintentional weight loss, polypharmacy, and serum albumin were no longer significant after adjustment for confounders; however, fatigue frequency and concerns about serum creatinine levels remained significant.

Conclusions: Frailty, fatigue, and psychological concern about serum creatinine levels were independently associated with depression in ESRD patients

Peritoneal Transport Characteristics Among Pakistani Patients Undergoing Peritoneal Dialysis

Tue, 31 Mar 2026 00:00:00 +0500

Background: The peritoneal membrane acts as a biological filter to remove solutes and fluids during peritoneal dialysis, a well-known kind of renal replacement treatment. Dialysis prescriptions and clinical results are directly influenced by the four transport categories that the peritoneal equilibration test assigns to patients: low, low-average, high-average, and high. The published literature still lacks population-specific transport data from Pakistan.

Objective: To determine the distribution of peritoneal transport types among Pakistani patients undergoing peritoneal dialysis and to evaluate the demographic, clinical, and biochemical variables associated with transport status.

Materials and Methods: Four tertiary care hospitals in Lahore participated in a multicenter, cross-sectional, observational study. One hundred adult patients receiving continuous ambulatory peritoneal dialysis underwent a standard peritoneal equilibration test six weeks after dialysis began. Transport categorization was done using the Twardowski criterion and the 4-hour dialysate-to-plasma creatinine ratio.

Results: High-average and high transporters collectively constituted 77% of the study population (57% and 20%, respectively). Older age (p = 0.02), lower body mass index (p = 0.02), diabetic nephropathy (p = 0.03), hypoalbuminemia (p < 0.001), raised C-reactive protein (p < 0.001), and decreased net ultrafiltration volume (p < 0.001) were all substantially correlated with higher transport status.

Conclusion: A marked predominance of high peritoneal transport phenotypes was identified in this Pakistani population, attributed to the compounding influence of diabetic nephropathy, systemic inflammation, and nutritional deficits. These findings underscore the need for transport-guided dialysis prescription in this clinical setting.

The Burden of CKD–Mineral and Bone Disorder in Maintenance Hemodialysis: Insights from a Longitudinal Registry

Tue, 31 Mar 2026 00:00:00 +0500

Background

Chronic kidney disease–mineral and bone disorder (CKD–MBD) is a frequent complication in patients receiving maintenance hemodialysis and is associated with adverse skeletal and cardiovascular outcomes. Real-world longitudinal data describing biochemical burden and guideline target attainment remain limited.

Methods

We conducted a retrospective, registry-based descriptive study of adult maintenance hemodialysis patients between January 2021 and September 2025. Laboratory measurements of calcium, phosphate, calcium–phosphate product, and intact parathyroid hormone (iPTH) were extracted from monthly registry tables. Test-level analyses included all available measurements. For patient-level categorization, the most recent available value per patient per analyte was used. Parameters were classified according to KDIGO guideline-based targets, with iPTH interpreted using an upper limit of normal (ULN) of 65 pg/mL.

Results

A total of 1,042 calcium, 1,037 phosphate, 966 calcium–phosphate product, and 141 iPTH measurements were analysed. Mean serum calcium was 8.38 ± 1.02 mg/dL, mean phosphate 5.65 ± 2.17 mg/dL, mean calcium–phosphate product 47.2 ± 18.2 mg²/dL², and mean iPTH 593 ± 518 pg/mL, indicating substantial biochemical variability.

At the patient level, calcium was within target in 59.3% of patients, while phosphate was above target in 46.3%. An elevated calcium–phosphate product (>55 mg²/dL²) was observed in 27.0%. Among patients with iPTH measurements, 43.2% were within the KDIGO-recommended range (2–9×ULN), 36.5% were above target, and 20.3% were below target.

Conclusion

Maintenance hemodialysis patients in this registry demonstrated a persistent burden of CKD–MBD abnormalities with suboptimal attainment of KDIGO targets, particularly for phosphate and iPTH, highlighting the need for improved monitoring and guideline-aligned management.