Acute kidney injury due to overcorrection of hypovitaminosis D: A tertiary center experience in the Kashmir Valley of India

Vitamin D deficiency state is endemic in the Kashmir valley of the Indian subcontinent. Clinicians frequently treat patients with Vitamin D for diverse clinical symptoms to improve the general health and to reduce the frailty of elderly and these doses may at times be inappropriately high. Vitamin D toxicity-induced acute kidney injury (AKI), often considered rare, can be life-threatening and associated with substantial morbidity if not identified promptly. We aimed to describe clinical and biochemical features, risk factors, and management of AKI patients with Vitamin D toxicity seen at a single tertiary care centre in Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India, between January 2014 and January 2016. Evaluation included detailed clinical history and biochemical tests including serum calcium, phosphorus, creatinine, intact parathyroid hormone, and 25-hydroxyvitamin D [25(OH)D]. Nineteen patients with Vitamin D toxicity-induced AKI could be identified. Clinical manifestations included nausea, vomiting, altered sensorium, constipation, pancreatitis, AKI, acute on chronic kidney disease, and weight loss. Median (range) age was 64 (45–89) years. Median (range) serum 25(OH)D level and median (range) total serum calcium level were 99 (190–988) ng/mL and 139 (119–152) mg/dL, respectively. Overdose of Vitamin D caused by prescription of megadoses of Vitamin D was the cause of AKI in all cases. Median (range) cumulative Vitamin D dose was 6,000,000 (3,600,000–9,000,000) IU. On three- and six-month follow-up, the creatinine and estimated glomerular filtration rate normalized and returned to baseline in all patients except three cases who had underlying chronic kidney disease. Three patients needed rehospitalization for another episode of AKI. Our data demonstrate an emergence of Vitamin D toxicity as a cause of AKI in this part of the world. Irrational use of Vitamin D in megadoses resulted in AKI in all cases. Persistence of Vitamin D in the body for longer time resulted in rehospitalization of patients with AKI. Awareness among health-care providers regarding the toxic potential of high doses of Vitamin D and cautious use of Vitamin D supplements can have immense value to prevent this AKI

Pattern of glomerulonephritis in the Kashmir valley

Glomerulonephritis (GN) is a common cause of end-stage kidney disease (ESKD) that can affect patients at any age. With respect to ESKD, there are significant global variations in the percentage of the incident and prevalent patients secondary to GN. The present study was therefore conducted to know the pattern of GN in the Kashmir valley. Retrospective study was conducted in the tertiary center Sher-I-Kashmir Institute of Medical Sciences of Kashmir valley which included cases of different types of GN diagnosed on histopathology over a period of three years. Basic demographic profile including age, sex, clinical presentation, relevant investigations, and the histopathological type of GN was noted for each patient. Histopathological examination due to various nonneoplastic renal diseases was done in 336 cases and out of these, glomerular diseases were diagnosed in 298 cases. Proteinuria and edema was the most common presentation. Primary GN was observed in 81% of cases and secondary GN in 16% of cases. IgA nephropathy was the most common primary GN 42% and nephropathy due to lupus was the most common secondary GN. The study concluded that primary GN is the most common primary renal disease with IgA as the most common primary GN and most presented as renal failure, highest until date recorded in India and lupus nephritis as the most common secondary GN which is similar to other studies from India and other regions of the world. This study may be useful to pathologists, nephrologists, and health care providers to formulate a basic platform for effective diagnostic, therapeutic, and research base for glomerular diseases so as to prevent its complications

Drug-induced acute interstitial nephritis: Prospective randomized trial comparing oral steroids and high-dose intravenous pulse steroid therapy in guiding the treatment of this condition

The most important aspect of treating drug-induced acute interstitial nephritis (AIN) is timely discontinuation of the offending drug. Steroids, oral as well as intravenous (IV), are used in the treatment of drug-induced AIN. The present study was undertaken to compare the efficacy of oral prednisolone versus IV suprapharmacological doses of corticosteroids in the treatment of drug-induced AIN. This prospective randomized controlled study included drug-induced AIN diagnosed on histopathology over a period of two years. Patients were randomized to oral prednisolone (Group A) 1 mg/kg for two weeks or pulse methylprednisolone (Group B) 30 mg/kg for three days (maximum 1 g) followed by oral prednisolone 1 mg/kg for two weeks, tapered over two weeks. Response was reported as complete remission (CR) [improvement in estimated glomerular filtration rate (eGFR) to ≥60 mL/min/1.73 m2], partial remission (PR) (improvement but eGFR <60 mL/min/1.73 m2), or nonresponders to steroids (no CR/PR). Steroid therapy was instituted to 31 biopsy-proven AIN cases (Group A - 16 and Group B - 15). Drugs implicated in the causation of AIN included pantoprazole, diclofenac, rifampicin, naproxen, aspirin, imipenem, piroxicam, cefixime, lornoxicam, Chinese herbs, etoricoxib, ciprofloxacin, and phenytoin. There was no difference in the baseline parameters between the two groups. At the end of follow-up, 58.06% achieved CR and 41.93% achieved PR. In Group A, nine (56.2%) achieved CR and seven (43.7%) achieved PR. In Group B, nine (60%) achieved CR and six (40%) achieved PR. There was no significant difference between the two groups. Pulses of high doses of corticosteroids have a significant but transient anti-inflammatory effect. Both oral and IV suprapharmacological doses of corticosteroids are equally effective in the treatment of drug-induced AIN, if used early