Transcription
Are permanently allowing the participants? Once you have 100, we can start.
Yes, sir. Just wait for about 800, then you can start.
No, that's all right, even if it is 60 plus, have already are in. I think we can we can go ahead.
Okay. Good evening, Manisha. [Music] Pleasant to welcome you here. This is very nice. Nice to have you. We are ready to go. Live streaming is also started.
All right. Okay. So, uh, so good evening, uh, uh, all these senior consultants, students, DM students. We are happy to welcome you once again for your Master Bedside Clinics in Nephrology, uh, episode two. Um, it's been a very a great honor to, uh, have you all once again to join us and spend your valuable time for this knowledge dissemination program, uh, which has been with the help of our course directors. We are very happy to initiate on behalf of Micro Labs Limited. So I take this opportunity to welcome our course directors, Dr. Um, General P.P. Verma as well as Dr. Vijay Kher for this program, and I request them to introduce today's examiners as well as the discussion and and take this program forward.
Over to you, Dr. Varmaji.
Thank you. Thank you, Mr. Raja, and thank you, Microlab, for the support for this program. Uh, we are in the second edition of, uh, Masters Clinic in the field of nephrology, and today we are talking on thrombotic microangiopathy. We know this is one of the emergencies in the field of nephrology, uh, though rare, but it can be a life-threatening condition. Uh, we all know that TTP and HUS are the prototypes of this condition. Previously, we used to think these conditions are interchangeable, but over a period of time, the things have changed, and I think today we are going to have a good discussion on that. To introduce the topic and speakers, I'll request Professor Vijay Kher to take over.
Good evening, ladies and gentlemen, and thank you, General Roma. I must say that today we have again another session of master class clinical discussion on thrombotic microangiopathy, and we have countries, uh, most experienced, uh, people to talk about it and discuss it with, uh, Dr. Vardhan, who is going to present a case of thrombotic microangiopathy, and the two, although we call them examiners, I think they are not going to be traditional hard examiners as you do in a typical examination, but they are going to be helpful examiners who will probably answer most of the questions which the candidate or Dr. Vedan will not be able to do. And to talk about, uh, this subject today is Professor Baga. Professor Bhaga is, I don't think he requires any—he is one of the most illustrious professors of pediatric nephrology from the country, world-renowned. I think I'm extremely honored to know him for, loss, many, many years, and it's it's such a pleasure to have him, uh, here and talk about robotic mechanic. He's published extremely well from this country, not only on this subject but on many other subjects in this, and I can tell you that in one of the sort of research publications, and when people were looking at the contributions from India, he comes from 0.1 percent top most researchers of our country, and extremely proud to have been associated with him and having known him and very, very glad to be here to talk to listen to him today. And no less is our own Manisha Sahai. Manisha is Professor and Head of Nephrology at the Osmania University Hospital. Extremely, again, I don't know how she gets time to manage all the things, and she does it so well, and I I feel she's managing home, her parents, the husband, the family, and then he she's everywhere, and I find it extremely, extremely useful to learn from her these techniques of how she manages this, and she is extremely good again, uh, in in this subject, thrombotic microangiopathy, and being donning both pediatric and the adult hats, she is going to be our participant providing also pediatric portion. I'm sure Dr. Buga is going to take care, and then Manisha is going to continue to participate in that, but I think provide an adult perspective as well because she practices adult, uh, nephrology as well. So without any further ado, I think, uh, let's start with the case, and I think, uh, Dr. Vadhan. Dr. Vadan is a nephrology resident at the Olympia Institute of Medical Sciences. I guess examiners, yes. Look at for the—yes, yeah. Now it's better. Dr. Bhagavati. Dr. Bhagava, I don't see him. Dr. Baga, he's there, so he's there. Music one. I don't see Dr. Baga, sir. We can see, sir. You can just, uh, we look at the—good to see you. Good to see you. Good evening, street. I think please go ahead.
Yes, evening everyone. Uh, respected, uh, faculties and professors here. I would first of all like to thank the Micro Labs team and, uh, my mentor, Professor Rajvin Bhagav, for giving me an opportunity, uh, to present the case in the such national forum. Can you go to slideshow? Uh, what then? Yeah. So, uh, I would be presenting an interesting case on thrombotic microangiopathy as the initial presentation, uh, dates back to May 2014. I would like to start the history from May 2014. We have a Master T, who is a six-year-old boy who presented with a fever for three days, which was two weeks back to the presentation, a low-grade fever which was intermittent, however, was not associated with chills and reiger. He also had a history of vomiting around one to two episodes which contained undigested food particles for the past four days, and associated with this, he also had paler and cola-colored urine and decreased urine output for the past four days. However, there was no history of, uh, pedal edema, facial puffiness, or anuria. There was no history of eloise discoloration of ice, erythemas rash, or PTK. No history of any photosensitivity, and there was no history of any joint paints or oral ulcers. There was no history of loose tools, blood in stools, or pain in abdomen. There was no history of cough or hemoptysis, and there was no history of any abnormal body movements or any altered sensorium and blurring of vision. So coming to the, uh, examination, anthropometry wise, his height and weight were normal for his age according to the Indian Academy of Pediatric Standards, and vitals, he had a stage one hypertension, and on general examination, he had severe paler and periorbital puffiness. However, there was no pitting pedal edema, no actress, no lymphadenopathy, and petty gay. In view of hypertension, a fundus examination was also performed which didn't reveal any evidence of hypertensive changes. On systemic examination, his cardiovascular system was normal, and there was no organomegaly or no ascites, and in neurological system, his mental function was intact, and there were no any focal deficits. So, uh, summarizing the history and examination, we have a six-year-old boy who presented with an acute female illness associated with oliguria and severe paler. On examination, he had periorbital puffiness and stage one hypertension. With this, uh, the initial possibilities considered were infection associated with AKI. The common infections which can be associated with AKA include malaria, especially severe malaria, which can also present with a severe paler. However, for severe malaria, there were no other end organ involvement in the form of, uh, the sensorium was intact, and there was no any specific neurological manifestations. Dengue can also present with acute kidney injury. However, severe paler, child presenting with severe paler is little odd for a dengue-like presentation in a child who is having hypertension rather hypotension, and leptospira and scrub typhus can also present with acute kidney injury. However, a severe pillar is again contradictory to the diagnosis. The, uh, possibility that is well fitting into the diagnosis would be hemolytic rhythmic syndrome as there is severe paler and there is evidence of periorbital puffiness and oliguria suggesting an acute kidney injury. Other possibilities would be acute nephritic syndrome with the possibility of infection-related glomerulonephritis as there was a preceding prodromal history of fever which would have triggered, uh, glomerulonephritis-like presentation in the form of acute kidney injury and a cola-colored urine. Uh, unsystemic illnesses like lupus nephritis can also have a similar presentation in the form of a fever and a paler could be due to a manifestation of the lupus lupus, and they can also present with a nephritic presentation. A feature which should now initially be manifested would be an intravascular hemolysis which would have been triggered by a fever-like illness, and then due to excessive intravascular hemolysis that would be cola-colored urine, and the child would have severe paler later because of the bile cast nephropathy. They can result in acute kidney injury. However, the absence of ictress would be an oddity for this diagnosis. So can you stop here? Can you stop your stimulus?
Manisha, do you have any questions here?
Yeah. So going back to the history slide, what about history of drugs? Have you have not included that drug history? You should mention that because you have drugs which can present with ATIN. Though the characteristic picture is not of APIN, even you mentioned that HUS is a possibility here, and there are many triggers, some of them drugs for HUS. So that history is pertinent and should be mentioned here.
Okay. Uh, for the, uh, history of drugs, uh, drug, uh, drug intake which can, uh, now resulting in paler and cola-colored urine would be a little odd, and, uh, uh, the the child was pre-morbidly normal, and there was no any specific medications he was ongoing.
Yeah, but I think the question is valid.
Yeah, yeah. It's good to mention also they may be triggered by drugs. You have put that as a positivity itself can be triggered by drugs, but here HUS also can be triggered by drugs to complete that that history should be there.
Fine. The attitude is—what about any past history? Family history? History of vaccinations which the child has received?
Mom, the child was immunized for his age, and there was no any family history of similar illness in this family. I should have mentioned.
Yeah, you can mention that because for us, uh, it's the first time he's presented in, uh, in this manner. So any such episodes?
What about developmental history?
The child was absolutely normal.
Yes, ma'am.
Okay. So I think what you can do is just add those because I mean there are some varieties of HOS where you will have developmental delays and all that. So we don't know, I mean, for the completeness sake of completeness, you could have included all those histories as well. And then, uh, parlor is not a history, probably that's an observation, so you put it on the left side in the history. So with the history, the child presented with fever, vomiting, polar color given, and decreased urine output. So what would be the syndromic diagnosis? You have put in, uh, it the fever was, uh, two weeks prior to the presentation, so, uh, and after the three days of history of fever, the fever has subsided, uh, so after a fever and the child is now presented with, uh, cola-colored urine and decrease urine output, I would consider acute nephritic syndrome which has been triggered by some infection.
So what is against the acute nephritis? So what are the common causes of—what is a syndromic diagnosis? We are saying it's an acute nephritic syndrome.
Yes, ma'am.
Okay. So what are the, I mean, uh, what are the common cause of acute nephritic syndrome in order of occurrence? What's the commonest cause, ma'am?
Uh, first would be a post-infectious glomerulonephritis, IRGN, now called IRGN.
Yeah. What is against IRGN in this child? Why did you not consider that first first possibility? What is grassley against IRGN in this chain? That that is usually due to a dilutional component, so the child was not, uh, significantly edibles, uh, in in this scenario where, uh, which would not lead to a pillar.
Fine. Absolutely. Now coming to the examination, what all could you have mentioned on the examination? Pallor you did mention, but what else, ma'am?
There was periorbital puffiness which would, uh, attribute to a renal pathology.
When do you—what are the physical signs of a scrub typhus in a child?
The child with scrub typhus would usually present with a multi-system involvement, uh, that could be jaundice, uh, the interest that could be lymphadenopathy, and that could be, uh, organometallically in the form of hepatosplenomegaly.
How common are H charts in a child with peptides?
Uh, around 50 to 60 percent they can be present, but they are very specific for scrub typhus.
Yeah, but you should mention that because you have entered entertain that as a DB there, and it's, uh, a DB for, I mean, uh, just sort of a picture. So I think you should mention, uh, that as well.
Okay. Okay. I think it's okay. It's a very long history, so maybe we can—shall we carry on, you know?
Yeah, yeah. Please carry on.
Uh, so, uh, just go to your diagnosis. Dr. Minisha, do you think of any other diagnosis apart from this? Anything else that you're missing here?
No, I think it's fair enough. I mean, yeah, I I think it is fair enough. I mean, the diagnosis what he has made and the possibility is common questions. Technically, we thought of these possibilities. So can you go on?
Yes, sir. Uh, so, uh, coming to the, uh, baseline investigations, uh, the child had a severe anemia with a hemoglobin of 5.5 grams, uh, however, the total leukocyte counts were normal. There was a in the peripheral smear, uh, there were around seven percent, uh, cystocytes, uh, under lower platelet counts. This is a representative image where we could, uh, see here the broken cells or the cystocytes, which is, uh, evidence of hemolysis. Other evidence of hemolysis which would we could see in this child is a the elevated lactate dehydrogenase, which is which was around 1474 units per liter, and the child also had thrombocytopenia to the lowest count of around 54,000 and deranged renal function with a urea of 170 and a creatinine of 4.2 milligram per deciliter, which is corresponding to an eGFR of 10 ml 1.73 meter square. There were no electrolyte abnormalities, and the liver function tests were normal, uh, and the albumin levels were 3.2 gram per deciliter. On evaluation further, the child had a low C3 with a value of 41 milligram per deciliter. However, the C4 levels were normal, and the ANA test done by ELISA to rule out the lupus nephritis which was also negative. Uh, on urine analysis, the child had a persistent protein urea with a dipstick protein of around two plus two three plus and I had microscopic hematuria and, uh, with, uh, 30 to 40 RBCs in various occasions. However, there were no casts on microscopic examination. On quantifying further, the child had a spot urine protein creatinine ratio of 1.1 milligram per milligram of creatinine. Going further, uh, on, uh, the, uh, for the evaluation on the basis of the etiological causes, uh, his dengue NS1 and IgM were negative, uh, his malaria smear and quantifying blood buffy coat layer was negative, uh, for the, uh, investigations for leptospirosis were also negative. Direct Coombs test was done, uh, to, uh, rule out, uh, the pneumococcal associated hemolytic uremic syndrome as well as the autoimmune hemolytic anemia which were also negative. The coagulation profile was normal which really excludes the disseminated intravascular coagulation which can be one of the complication in infection-related hemolytic limit syndrome. The homocysteine levels were also normal limits, uh, I will be discussing this regarding in the next slide. So, uh, summaries—go back. Can you just send to us? Can you just go back?
Yes. Manisha, do you have any comments on any things that you think that were important that I'm missing here?
Yeah. So actually he's worked it up quite nicely, but I, uh, would like to know, I mean, if suppose histocites were not there, uh, would you still entertain HUS?
That is elevated lactate dehydrogenase which could be an evidence of, uh, hemolysis. However, in context of the infections like dengue, malaria, and scrub typhus, it can be falsely elevated. So, uh, what we routinely do is when, uh, there is a doubtful evidence of cystocytes in the peripheral smear, we would perform heptoglobin level which would be a surrogate marker for hemolysis. However, as we had cystocytes, we have not performed initially in this child.
So can you have PMA without histocytes?
Yes, you can. You can. I mean, yeah, but at times, you know, we are a bit worried, you know, making a diagnosis of active HUS. Just keep discussing this so often, but you're right, Manisha, that you can have a thing without, but generally we are a bit careful making a diagnosis of active, uh, TMA without seeing evidence of microengineering chromatic anemia. But your plasma heptoglobin does help us. It's not always available so easily. Therefore, we don't resort to it. You know, it's not available in the hospital. Um, LDH can rise because of multiple other reasons as well, you know, and, um, but but we should remember that malaria per se can cause, uh, uh, hemorrhagic anemia or anemia can also cause thrombosis without causing issues. So I would imagine loved one should be, uh, trying to document sister sites, and I must say, you know, for the participants who are here that our residents would be examining this in the in the casualty per se, you know, they would make a smear and they would look for exercise. They can even diagnose it on even without staining. So I think the residents and fellows must have the ability to be able to diagnose sister sites on a potential smear.
Absolutely. We can ask him for benefit of adult. What do you mean by significant fiscal sides?
See, said the cystocytes, uh, as as in this image, sir. This is a single field, uh, we count, uh, for every 100 cells, we would count the total number of total number of cystocytes and, uh, give it in a percentage. So, uh, the value of more than two percent would be considered a significant—
Yeah, more than two percent, and it also varies with age in three terms actually. I mean, more than five percent and all that, but most of that is—it's more than two percent which are—so that point is well taken which Dr. Bhaga made that it's better to examine the peripheral smear ourselves. In many of the adult cases of TMA, schistocytes are not there. The second important point is if there is no thrombocytopenia and no sister cells, we just don't rule out TMA, and then we have still, uh, we have to keep PMA in mind as well even in those conditions. So there are other conditions where cystocytes may be present. So Dr. Srinivas, can you highlight some other conditions where you can have schistocytes?
Any condition which can cause intravascular hemolysis like disseminated intravascular coagulation can result having cystocytes, and the evidence of the thrombotic thrombocytopenic purpura that can also have the presence of cystocytes, and other thing is, I mean, it's always better sites—no, you have to look at the sample quickly. I mean, we shouldn't delay the analysis of the sample for more than, uh, four hours because again, I mean, uh, the you won't be able to find the sister science. So it's important that it should be prepared and examined immediately. So those are the practical points which I would like to just add. Always examine before giving blood, you know, never not because you can't give blood and then try to examine.
Absolutely. So so one of the first tests that you would be doing in this patient in the emergency would be to make a good peripheral smear, uh, it also gives you an estimate of the platelet count in many ways, you know, you can also have a strained vent.
Yes, thank you. Yeah, you can proceed like this.
Yes, ma'am. So, uh, summarizing now with the investigations, uh, uh, we have a six-year-old boy who presented with an acute febrile illness and severe paler with evidence of hemolytic anemia and thrombocytopenia on examination having stage 1 hypertension with a acute kidney injury stage 3 and low C3 levels. So now a syndromic diagnosis of thrombotic microangiopathy has been made. So I would like to go with a systematic approach. So any child who presents with an triad of anemia with a hemoglobin of less than 10 gram per deciliter as with the evidence of active hemolysis and thrombocytopenia with acute kidney injury, the initial steps would be to rule out the mimickers of HUS in terms of sepsis, DIC as we have already discussed, and other infections which can mimic as well as trigger the hemolytic uremic syndrome like malaria and dengue. Also, although, uh, if it is not a very common, uh, condition in pediatric age group, uh, considering thrombotic thrombocytopenic purpura is also necessary, uh, however, the analysis for ADAMTS13 activity is not easily available, uh, storing the samples in a situated plasma would be, uh, helpful in case, uh, later we consider that the possibility of HOS is not very significant, and although in this case there was no significant thrombocytopenia like less than 30,000 and there was a predominant renal involvement, the possibility of TTP would be less likely. And now after ruling out these conditions, uh, the labeling of hemolytic uremic syndrome has been made, and, uh, to be leading further, we should initially, uh, rule out the common causes of hemolytic remix syndrome, uh, although not in India, overall in the international forum, the, uh, shiga toxin associated HOS is more common in comparison to the atypical host. So in children who present with a history of pro-drama history of loose tools or bloody dysentery, a possibility of sugar toxin associated should be considered, and the stool samples should be assessed for stick PCR, and the cultures should be done for the E coli. However, in this child, there was no any prodromal even, so this possibility would be less likely. And coming to the another rare possibility which is around having a six percent incidence would be a cobalamin C deficiency HUS where there is a defect in the cobalamin, uh, C pathway that is, uh, that can be, uh, see noticed by, uh, doing a homocysteine level. This is the reason why, uh, previously I have shown the values of homocysteine which was absolutely normal, uh, in these conditions there will be homosexual levels, uh, higher in the tune of around 50 to 100 micromoles per liter. However, there could be some other extraordinary manifestations like developmental delay and feeding difficulties which are and the age group would be a little earlier presentation, and so this possibility is also not considered. Other conditions like infection-associated hatus, these children will usually be very sick. However, this child was not that sick. And one more important possibility as has already, uh, uh, highlighted is the, uh, evidence of systemic lupus erythematosus which can also, uh, manifest with anemia, thrombocytopenia, and nephritic representation. Here we have done an A which is negative, and there was only high low C3 levels which is normal C4 which rules out lupus nephritis. Other conditions like malignant hypertension associated hemolytic uremic syndrome can also have a manifestation like this because of the arteriosclerosis. However, this child didn't have a very significant malignant hypertension as already mentioned by mam. Drugs can also drugs like, uh, cirrolimus, CNAS can also, uh, result in hemolytic unique syndrome-like picture. So this history is also important. So in this child after ruling out all these possibilities, uh, he fits into, uh, the possibility of an atypical, uh, hemolytic uremic syndrome. So, uh, typically—just go back. Go back straight across. Just go back.
Yes. So, uh, so one point, you know, Dr. Verma had also had it initially was the possibility of TDP. And when do you consider TDP? So can you just tell us again, you know, when would you think about TDP in a child or in an, uh, uh—
Sir, thrombotic, uh, thrombocytopenic purpura, although it is a it comes under the spectrum of the thrombotic microangiopathy, uh, the, uh, they usually present with, uh, severe, uh, thrombocytopenia in the tune of less than thirty thousand, and, uh, they are usually, uh, the clinical manifestations they usually present with more of a neurological involvement which is usually called as the TTP pentad. Although there are reports that they can also present with the significant renal involvement, however, a very severe active kidney injury would be more in terms of hemolytic rhythmic syndrome rather than a TTP. And in TTP, there are two causes: one would be an acquired TTP and another would be in congenital TTP. The acquired TTP is especially, uh, due to, uh, the, uh, decreased activity of the ADAMTS13, uh, enzyme which is mainly due to the presence of auto antibodies against it, and the congenital one is due to the decreased production which is also called as Upshaw-Schulman syndrome, uh, these usually present in younger age group, uh, but overall the most common cause would be, uh, the, uh, around, uh, 60 to 80 percent would be an acquired cost, and for evaluating this we would do a FRET assay where the activity of ADAMTS13 would be assessed.
So just adding to what he is already told from audits perspective, it is slightly different. TTP is an important differential, and we know that initially we used to talk about pentad and neurological symptoms, fever, all those things, but now the mechanistic, uh, definition of TPP is based on ADAMTS as we have already said, and we definitely store the sample before we start plasmapheresis, and as Dr. Buga has already pointed out, it's difficult to get it done, but, uh, that doesn't mean that in adults we do not store the sample.
We should, in children, PM is slightly different. Like there are so many congenital causes, then sugar toxin associated with HUS is quite common, as we have rightly highlighted the approach in adults. We get to see, uh, TMA in certain situations. One is post-transplant, very commonly; the other thing is we see it as a part of pregnancy TMA. The third one, what we see, is generally as a part of autoimmune disease TMA. So these are quite common. Now, TTP, um, as you said, it's not that common, but again, I, I mean, generally the PDP once would be admitted in ICUs and I'm in neurological wards. But we also know that even if the neurological involvement is not there, we should always think of it as a diagnosis; should never miss it. Store the sample, even if you are not able to immediately ascend it.
The other important point what I wanted to, uh, highlight here is that we all know that the Shiga toxin associated with HUS is generally associated with a diarrhea—bloody diarrhea to be precise—but again, it can occur without that as well. So this possibility should also be entertained. Though, as in papers by Dr. Bhaga, he has, uh, clearly shown that, uh, Shigella dysentery is not a very important cause here. But again, I mean, a bloody diarrhea may not always be a feature of Shiga toxin associated with HUS, though it's mostly there. And this bloody diarrhea is generally—we see more commonly in children; in adults, uh, very few cases we've seen—not that it doesn't occur, but it's very infrequent.
So the take-home of the table what you have shown in the flow chart—it's an excellent flow chart, very useful—in adults, TTP, uh, is not that uncommon; that's my first point. And second point is even Shiga toxin associated HUS can occur in adults and even without the diarrhea, so should always keep that in mind as well. Uh, Cobalamin C, then Thrombomodulin, DGK, all those other things are more commonly seen in children, and I mean, some of them have onset less than one year; some can occur throughout the person's age, but still they remain more common in children. Thank you. Okay, can we go forward? Yeah.
So, so, uh, now, uh, narrowing down further, uh, now we are—we have reached the possibility of atypical hemolytic uremic syndrome, uh, which would comprise the broader two possibilities. One would be, uh, the anti-factor H antibody associated HUS, and another would be the presence of significant variance in the complement regulatory genes, as mentioned already, uh, would be most common—would be in the complement factor H, complement factor I, and CD46 are membrane complex protein, and the upregulation of C3 or complement factor B. And as already—mam—as mentioned, there are other non-complement mutations that can result in—especially in DGK epsilon mutation and also in thrombomodulin gene.
So, uh, considering this possibility, uh, we further performed the anti-factor H antibody assay by the in-house ELISA, uh, and there was—and it was noted to be very high, uh, to against the, uh, arbitrary cutoff of 150 arbitrary units per ml. And, uh, the CD46 expression performed in this child was absolutely normal. There is no significant role of performing the levels of complement factor H, complement factor I, as they can be normal, although they are—these some of the functional defects can result in HUS. So these are routinely not performed. With this, we labeled the diagnosis of anti-factor H antibody associated HUS in this child.
So here I would just like to ask them—and generally in the address guidelines, investment guidelines—even if anti-factor H antibody is positive, they advise that it's better we rule out the other complement defects as well. And in your guideline, in the pediatric guideline in 2019, you have written that it's not very common, and if you get that anti-factor H antibody titers high, you can go ahead with this diagnosis, and at a later point of time if the patient is not responding, you can look at other genes. So what would you suggest the adult nephrologist to do? So we are, as of now, looking at the whole gamut of the thing—anti-uh—factor H antibody plus all the other genes as well. So I think I'll just wait for, uh, about 10 more slides; we will address this specific question. You know, I think it's a very important question that do patients with anti-factor H auto antibodies need a more, uh, comprehensive genetic screen or not? And we will try to answer that, you know, to your satisfaction. But clearly, you know, there is no role for doing factor H or factor I levels. CD46 should be done, uh, in any—in any tertiary care hospital—can be done easily using flow cytometry. So this is something that's easy—easy enough to do. So we normally don't measure CFH—factor H or factor I levels—when we did it, you know, it never helped us make a diagnosis. So we would kind of rely on these and obviously C3 levels as well. Can you carry on? Yes, sir.
So once we have, uh, uh, we had the label of, uh, hemolytic uremic syndrome, uh, we, uh, started the standard protocol of plasma exchanges. He received seven daily plasma exchanges till he achieved the hematological remission. Dermatological remission, uh, is defined as the absence of hemolytic activity in terms of, uh, schistocytes less than two percent and the LDH with the cut off of less than the upper limit of normal and also platelet count more than one lakh for three consecutive sessions. Followed by that, he was continued on gradual tapering of plasma exchanges, and totally he has received 20 plus plasma exchanges. And for his acute kidney injury, he required a key motor initiation of chemo dialysis, and he has underwent almost 32 sessions, following which he was made off dialysis, and his renal function start improving. Once his diagnosis was made as anti-factor H antibody associated HUS, he was started on immunosuppression with oral steroids initially, and he also—he has also received five IV cyclophosphamide monthly pulses. Followed by that, he was, uh, continued on maintenance immunosuppression with the mycophenolate mofetil, and the oral steroids were gradually tapered. For his hypertension, he initially required around four antihypertensive agents, and, uh, on follow-up, uh, his anti-factor H titers were gradually, uh, were frequently monitored, and we could see here the anti-factor H levels were always below 150 arbitrary units per ml. We usually, uh, have follow and frequently monitor the anti-factor H titers as the higher titers during follow-up can predict—have an increased risk of relapse. And here we could see that his renal functions are also gradually improved, uh, however his—there was a proteinuria persisting; his hypertension also was gradually controlled and was tapped down to, uh, two antihypertensive agents. Um, he was followed up till, uh, 2017, and later, as the child was fined for the parents, they are lost to follow-up to us.
Summarizing the, uh, treatment protocol for atypical hemolytic uremic syndrome, once a label of atypical hemolytic uremic syndrome is made, the child should be initiated on, uh, daily plasma exchanges within the, uh, within 24 hours of the diagnosis. And, uh, all children who have been labeled as atypical HUS has to be screened for, uh, the anti-factor H antibody levels. If the anti-factor H antibody levels are more than the, uh, upper limit of the cutoff, then, uh, the child should be continued on plasma exchanges for five to seven days till the hematological remission. And in the era of eculizumab, however, although in developing countries the availability of eculizumab is still very difficult, uh, this eculizumab is still reserved only in conditions where we have complications with plasma exchange or the child is having a refractory illness with plasma exchange or additionally there is some complement effect. So along with this plasma exchange, we would also start immunosuppression with oral steroids. And once the child achieves a hematological remission, uh, the, uh, he—they will also be started on an induction with cyclophosphamide pulses at 500 mg per meter square for every monthly dose at around five doses, and followed by that they will be switched to, uh, maintenance therapy with mycophenolate mofetil or azathioprine.
So, uh, the teaching points here would be, uh, although, uh, plasma would be helpful, uh, in, uh, supplementing the, uh, uh, complement factors, uh, in especially in an anti-factor H antibody associated HUS, the main role of plasma exchange would be the removal of the anti-factor H antibodies and supplementing the active complement factors. So plasma infusions will not be helpful in case of the atypical HUS and unless otherwise we have a value of anti-factor H antibodies elevated, immunosuppression should not be tried as we try in other, uh, glomerular nephritis chemicals. Can I just come in? Just go back. Yes, I think the important messages are two. You know, once you have a diagnosis of atypical HUS, the therapy—at least currently with us in the lack of complement inhibition—is plasma exchanges. Uh, plasma infusion theoretically can be done, but by—when you do plasma exchanges, you can replace a much larger volume of plasma—up to almost 50 to 60 ml per kg per person per exchange, you know. So clearly it's—and you can also, you know, take out some abnormal proteins which could even be the case of say even with—when you have a factor H mutation, you may have abnormally shaped proteins which are there but which need to be removed and replaced with normal—functionally—functionally active factor H. So in all atypical HUS, I think I would prefer to do plasma exchanges in the acute stage, uh, and clearly. So in anti-factor HUS, uh, given that, you know, anti-factor H antibodies would account for about 50 of all atypical HUS in children—particularly in kids between the age of five to 15 years—what we have seen over the years is that at times our colleagues are starting immunosuppressive therapy without confirming anti-factor H antibodies. I don't think that's good practice, you know, because, uh, you need to show, for example, that the patient has autoantibodies before you put kids on immunosuppression, uh, so clearly, you know, one should be—one should avoid doing that. And the third message is that whenever you are taking samples for say antibodies or for, you know, even C3, do that before you start plasma exchanges. At times your kids are sent to us who have received multiple exchanges or multiple infusions, and now you're asked to do anti-factor H antibody—the levels are not going to be that good, you know. So do take samples prior to beginning plasma exchanges. Venetian. Yeah.
So adding to what Dr. Becker already raised those important points, we have already discussed when to suspect, uh, when you have the rPRF or aHUS picture with severe anemia, schistocytes, plus or minus thrombocytopenia, and the immediate messages—collect the sample and start plasma exchange now. Srinivas, I would like to ask you what are the situations where you won't prefer doing a plasma exchange in a case of aHUS in children who have—we have labeled as atypical hemolytic uremic syndrome. We would first proceed with the plasma exchange. However, in conditions especially like cobalamin deficient hemolytic uremic syndrome, in, uh, once we have a genetic diagnosis of CD46 associated hemolytic uremic syndrome, and in conditions like, uh, diacylglycerol epsilon—DGK epsilon mutation—here there will be no significant role of plasma exchanges. Rather—okay. And any other condition? I mean, like frequently we read about pneumococcal, uh, HUS. I mean, what is your take on that? What is the current opinion on that? Yes, ma'am. In, uh, also in pneumococcal associated HUS, we would not perform plasma exchanges as they are not significantly beneficial. Rather, we can use washed RBCs as the pathogenesis is based on the exposure of the antigen—surface antigen—in the RBCs. So generally in adults, what is the difference is mostly we end up using plasma exchange because the conditions where we don't do plasma exchange are not very common in adults. But anyhow, I mean, we should be mindful of those conditions, uh, especially the CD46 because that is seen in adults as well; others are also seen. Now regarding, uh, the prevalence of anti-factor H 50 in children, that is little bit less common in others to the tune of around say 20 to 30 percent, but it's also quite common in our country. Uh, the other question I would like to ask you at this point is the role of renal biopsy. I mean, many of our other postgraduates and fellows would like to know when would you do a renal biopsy? I mean, um, do you think it's important for diagnosis or the diagnosis can be made without the biopsy, and what are the specific indications when you would do a biopsy? Renal biopsy is not required for making the diagnosis of hemolytic uremic syndrome. We would perform—humility—renal biopsy in—in conditions where we still have a doubt of the diagnosis, where we have suspicion of other conditions which would be explained by the renal biopsy that we can perform biopsies. Okay. So biopsy is not indicated in most patients; it's only, you know, once you're not clear about the diagnosis—for example, you know, if you're not sure about the HUS, then maybe perhaps there—or, you know, for prognostic reasons, you know, if the child is not getting better and you really need to be sure at the end of say a month or say six weeks whether there's cortical necrosis or something of that sort—perhaps your biopsy—but for management of HUS, you don't require a biopsy. Yeah, neither for management nor for diagnosis.
So the carrier messages—high index of suspicion for a TMA and HUS—that's important; we often miss it. And sometimes we do a biopsy for rPRF, and then the biopsy shows TMA; that means we fail to pick it up. Yeah, uh, so, uh, this child, uh, again presented in June 2021 at 14 years of age with a history of fever and facial puffiness and again paleness of the body, uh, and along with this there was a history of COVID-19 illness. As we all know, during this period there was an active surge in the COVID-19 cases. He had a history of COVID-19 illness in his father. However, there was again—there was no history of any, uh, decreased urine output or hematuria; no history of cough, courage, difficulty in breathing in this child; and there was no history of any pain, abdomen, rash, or petticoat. His anthropometry was normal, and he had persistent stage one hypertension. And on examination, he had paler and periorbital puffiness. However, there was no significant pitting pedal edema and yellow is discoloration. The fundus examination, uh, this time showed grade 2 hypertensive retinopathy changes. And in systemic examination, his cardiovascular system, uh, there was, uh, uh, the heart zones were normal; there was no murmur or gallop. However, the apical impulse was felt in the, uh, sixth intercostal space, uh, lateral to the mid-clavicular lines, uh, suggesting the cardiomegaly. Other system examinations were within normal limits. Uh, so, uh, summarizing this again, we have a 14-year-old boy who is a case of anti-factor H antibody associated HUS presenting now with an acute femoral illness, paleness of body, and acute kidney injury with stage one hypertension and periorbital puffiness. So he was, uh, considered to have a relapse with the known case of anti-factor H antibody associated HUS now presenting again with the similar complaints; hence he was considered to have a relapse of the, uh, hemolytic uremic syndrome. And for this relapse, a trigger would be probably the COVID-19 illness, as, uh, in pediatric age group especially, uh, most children presented with, uh, without symptoms of COVID-19, however had manifestations which had an activity and a disease activity which was triggered by, uh, such an illness. Uh, at the same time, uh, during this presentation, we had similar presentation into two other children who also, uh, among which one child was having a similar kind of presentation who had an onset of disease in 2014 was labeled as anti-factor HUS and also had presented with relapse with the family history positive for COVID-19—MS. So this made us consider—made us consider that COVID-19 would have been a trigger for this relapse. Uh, to, uh, just summarize a single, uh, further point, uh, although, uh, relapses are more common in anti-factor H antibody associated HUS, most of the relapses usually, uh, occur in the initial, uh, 12 to 18 months. Here we could see—this is a graph of around 436 patients; it is a nationwide database—where here we could, uh, sorry, here we could see that the initial, uh, relapses were predominantly seen till the age of, uh, two years from the onset of the illness. These are the two children who presented very late, which would be, um, very hard for, uh, anti-factor H antibody associated HUS, uh, to happen. So, uh, we further evaluated him yesterday. So the message here was that, you know, that relapses after about two years are uncommon. The overall likelihood of relapse in anti-factor H HUS is more like 20, and the risk is highest in the first two years. And that's the reason, you know, there were some questions on how long do you give therapy; that's the reason, you know, why we often use immunosuppressive therapy for two years because the risk of relapse falls in these patients, you know, that we saw currently—they're clearly after a very long window, which is a bit odd, you know. Studios can ask you which of the genetic causes that you mentioned show, uh, show the highest risk of relapses. Uh, sir, uh, uh, CD46, uh, the membrane complex protein, and the complement factor H associated, uh, hemo—hemolytic uremic syndrome. So these two can have the highest risk of relapses. And CFH—normally—then CFH mutations normally present early enough; they can also present late, but CD46, as Manisha also said, you know, can it present later and very often, you know, it's an important differential in older children as well as in adults. And CD46 can typically have many relapses, but fortunately, you know, despite relapses, they don't go into, uh, ESRD or ESKD as often, uh, but Manisha, do you have any comments on this? Just wanted to know—I'm in—this relapsing course in this patient, uh, should we suspect that he has other genetic mutations apart from that antibody itself because the infection may be a second trigger—the second hit—and already he has some, uh, haplotype or some at risk. So at this point, should we have done the other, um, genetic tests as well for this patient? Yes, ma'am. We will be discussing in that—I think it's going to come to that exactly. I think your question is very valid, and it was at this time, you know, that you did the genetic—so can you carry on? Yeah. Yes, sir. Yes, sir. So, uh, the investigation showed a hemolytic anemia with thrombocytopenia and directional function. And, uh, again the urine analysis showed a nephrotic range proteinuria with microscopic hematuria. And on echocardiography, uh, there was concentric LV—left ventricular hypertrophy—which would be due to a consequence of the hypertension. So in this child, as we already know that he's a case of anti-factor H associated HUS, and the previous antibody titers were within the normal range, we performed again to confirm the, uh, relapse, and the values were again significantly higher—10 times above the upper normal limits—and in suspicion of the COVID-19 being the trigger for the current relapse. So we also performed a COVID-19 antibody which was also reactive. Uh, as, uh, although the anti-factor H associated HUS is—the genetic evaluation is not much needed—but conditions where they have a frequent relapses, they would require a genetic evaluation. So we have performed the clinical exome sequencing, uh, especially for the, uh, the genes which are commonly involved like the complement factor H, I, B, and, uh, the CD46, DGK epsilon, and thrombomodulin, and also, uh, there were no pathogenic variants in these, uh, genes. However, and also we have performed a multiplex ligation probe assay for the complement factor H related protein, uh, especially the genes which are in the chromosome one, just as a, uh, adjacent to the complement factor H gene, uh, and we found that there was a homozygous deletion in CFHR1, 2, 3 site. So, uh, this is the MLPA of this child, uh, here we could, uh, see that there is a normal expression of the CFH1 and CFH—CFS domain—however there is absent—absence of CFHR1, 3. The arrangement of the genes in chromosome 1 happens in this way—the complement factor H followed by the CFHR3, 1, 4, 2, and 5. So here we could see that, uh, the, uh, there is a complete absence of CFHR3, uh, and 1. So, uh, this suggests that there is a deletion in the, uh—and this is—and here we could see that there is a complete absence. So this is a homozygous deletion of both CFHR1 and 3 proteins. So these are the indications where a genetic testing—especially in, uh, anti-factor H associated HUS—would be considered, uh, which would be a younger age of onset at the time of presentation, a relapsing course as in our child, or a family history of similar illness, and illness which is refractory to the plasma exchange therapy—as if there is—the child not attaining hematological remission even after around 7 to 10 plasma exchanges—still there is a refractory to our therapy. And especially when these children—when they are planned for, uh, renal transplantation, uh, the—the genetic evaluation should be performed as the—they are helpful in prognostication as well as the risk of recurrence of the illness is also, uh—there is a phenotypic correlation with these genes. Can I—can you just—here. So clearly, you know, as Minisha had asked, you know, these would be the indications to do, uh, genetic testing in a setting of anti-factor H, and we have another slide about this; we'll tell you why we think so, uh, but then if it's not anti-factor H and if it's atypical HUS, then all children require genetic testing. And while Studios did mention, you know, that we are talking about the six common genes, but the current panel is of 26 genes, and that panel would look at the extent—the whole thing—but the common ones would really be factor H and CD46. Uh, the other thing—just is just a point about MLPA for, uh, CFHR genes—now, homozygous deletion of one is more important than three. So you may at times have only one. So don't always, you know, it's not necessary to have both; one is clearly the source, and there is a very strong association of MLPA—one deletion, uh, homozygous deletion of CFHR1 with anti-factor H. So almost 90 patients who have, uh, antibodies would have a homozygous deletion of CFHR1. Just one last point on this that 10 percent of the normal Indian population also has the same deletion. So this is really a polymorphism, and many of us are really carrying this relationship; 100-odd people, 150 people who are listening to this talk, maybe 15 of us have this deletion, uh, so clearly, you know, there is this—there's a background of this deletion, then there is perhaps a second hit, and that's the reason why you end up getting adequate lectures, uh, when indicated between five to fifteen years of age. So it's not a—it's not really a mutation in that sense. Yes, sir. Just to highlight further, do, uh, these children especially require genetic evaluation? As already highlighted, uh, this is a systematic, uh, review, uh, where, uh, the concurrent genetic defects along with children having anti-factor H antibody associated HUS—these are the European cohorts where the incidence was little higher, ranging from 25 to 30 percent. However, most of the Asian data suggested a total, uh, incidence of around six to seven percent. And here we could see that, uh, this is an—an unpublished data, uh, here we had around 107 patients, or among which, um, there were—they were subgrouped into children who have coexisting genetic abnormality versus absence of other coexisting genetic abnormality. Clearly, we could see from this—from this Kaplan-Meier curve—that, uh, there is a significant difference in the, uh, relapse-free interval. So this is the—yeah, sorry, since—please carry on. Sorry, I'm sorry. So this is, uh, this is the main reason, uh, that, uh, detecting the, uh, uh, additional, uh, uh, coexisting genetic abnormality is important as they are associated with frequent relapses. So, uh, overall, you know, we would think that given that the likelihood of picking up a genetic cause is less than seven or eight percent, as is shown in this forest plot, uh, we do not do genetic studies in all our patients. However, if obviously if you've got no antibodies, then clearly there is enough evidence that you should be doing—the overall likelihood of picking up a genetic cause in non-antibody patients is through the tune of about 30. So when we have looked at our children, it's more like 20; if you look at the ideal data, it should be more like 30, uh, so in one-third of the patients with atypical HUS—I mean 40—you may get an underlying cause, uh, so that's the other message here, you know, and obviously if you're having relapses, then perhaps you need to be evaluating. Manisha, any point on this? Yeah. So, uh, now for the adult fellows on the call, Dr. Bhaga has given important messages, uh, for adult nephrologists. What a message I would like to convey is, uh, repeatedly I'm telling—any rPRF for the anemia, please consider the possibility of HUS. The other—I already mentioned the settings where we generally see as other nephrologists—HUS—and whenever we see this, we rule out the secondary causes which she—
Has already shown the important thing is, uh, in pregnancy TMA. I mean, often we do, uh, biopsy post-pregnancy, pregnancy AKI, and all that. We get PMA on biopsy; don't leave it at that. Around 50 to 80 percent of these have genetic abnormalities, and it's mandatory that we send a complete gene panel because many of them, uh, in a paper by Dr. Raja from PGI, he has shown that especially pregnancy TM and particle necrosis, always be on the lookout for this atypical HUS complement abnormalities, do them because many of them end up going in ESRD, need a transplant further. And as shown beautifully in the last slide, that before transplant, it's an indication to do the complete workup. So that would be my message that we as adult nephrologists, we are a little bit slow in sending the genetic analysis, uh, because of the past constraints maybe, but it is important because post-transplant recurrence, I mean, nobody wants that, so it's important now.
Uh, the other important thing I would like to ask in this patient now, where would you consider the role of eculizumab? Do you think it's indicated? I know it's related to antibody, uh, here, but you have shown some associated genetic abnormalities. This patient, what is the long-term prognosis universe of this patient? What did you counsel the parents? What would you tell the child about the future of this shell? Uh, what is the likelihood of previous progressing to ESRD, and where would you place the eculizumab up for the treatment of this show? After the, uh, introduction of eculizumab into the field of hemolytic uremic syndrome, most of the guidelines are switched now by to the use of first, uh, first-line therapy of eculizumab rather than plasma exchanges. However, uh, in the context of the availability and the cost issues still in developing countries, the plasma exchanges holds the first-line therapy. And although the eculizumab has been shown to cause remission in around 80 to 85 percent of patients with hemolytic uremic syndrome, uh, even plasma exchanges with along with immunosuppression have also shown to have a similar efficacy in terms of the remission of the disease.
And I would counsel these parents that, uh, although anti-factor H antibodies HUS can have relapses, especially in the initial, uh, two to three years, they have to be insisted especially on the, uh, the compliance to the immunosuppression. And also, uh, especially, uh, one more point to highlight is that, uh, when children who have URI-like illness, then they should be having a close watch, especially, uh, to investigate further in terms of, uh, active hemolysis. And there are certain points like looking for hemoglobinuria with strip monitoring can also be counseled so that we can pick up the, uh, relapses a little early that can, uh, decrease the morbidity in terms of renal aspect. Although these children among around 20 percent they can further progress to, uh, end-stage renal disease. So you too. So yeah, sir, please. So Manisha, if it's, uh, if it's an anti-factor H or antibody disease, exactly that's why there is still, you know, a dilemma whether even in the western countries whether to choose the option of anti-factor H with immunosuppression or eculizumab alone because eculizumab would block the pathway, but the antibody levels would still stay high. Some of them would what they would do is that they would block with eculizumab, then they would add them in a separation. So there is an equivalence, you know, in some ways for anti-factor H disease, but for non-anti-factor H associated HUS when they do not have antibodies, I think there is unequivocal evidence, you know, that's emerging over the years that use the use of complement inhibitors is clearly beneficial. You can't manage anti-factor H, a factor H mutation or a factor I mutation, uh, without, uh, without complement inhibition. There is also an indication, you know, but, uh, if you have a factor H or a factor I mutation, the therapy of choice would be complement inhibition if available. If it's not available, you know, one would then rely on plasma exchanges, but knowing, you know, that the proportion of these patients might progress over a period of time. So yeah, carry on, I think yeah.
And then that same thing like, uh, in those who have factor H mutations, giving eculizumab, I mean, very few, around 15 percent progress to ESRD without that. If you keep on giving plasma exchange, it won't be that beneficial, and around 60 to 70 percent maybe more will progress to ESRD. So there, there is unequivocal evidence that we should use, uh, but, uh, regarding this patient as you rightly said, I mean, plasmapheresis has a greater evidence where the antibody antibodies positive. The other question to the universe would be now this patient sometimes antibody may be positive, but there may be no clinical or lab evidence of hemolysis or TMA. So would you still consider this patient is having a long relapsing course? So if you just and you need to monitor the antibody, you are monitoring the antibody, the antibody stays high, but the child is absolutely fine, no clinical or lab evidence. What would you do? Will you go for plasmapheresis or not? Uh, one of the studies from AIMS have shown that anti-factor H titers, uh, more than 1330 arbitrary units per ml are, uh, uh, are more chances of having risk of relapses. However, uh, only with, uh, evidence of anti-factor H titers, we would not, uh, perform plasmapheresis, rather we would have a close monitoring of these children for the relapse. So in this shell, what happened? I mean, in between he was quite fine from 2014 to, uh, 2021. What was his antibody titers? Was he on regular follow-up and what the titers, uh, till 2018 he was on regular follow-up, and the titers were always below 150, uh, were ranging around 90 to 100. Uh, but, uh, once, uh, we have after, uh, after a continuous remission, uh, we have even tapered and stopped the immunosuppression. However, parents didn't follow further as considering that the child was absolutely normal. Here, that's why we can, uh, considered a trigger of COVID-19 illness. Okay. So suppose this child got to progress to ESRD, what would you do for transplant? I mean, would you transplant him? What would be the precautions you will take? This child as of now doesn't need that, but I'm asking because many of the other cases of PMA they progress to ESRD, and that's a very common scenario. And many of the transplants we do are for biopsy-proven PMAs because that's sometimes the only point where we catch TMA because thrombocytopenia is not there, schistocytes are not seen in the smear. So what would you advise and for this shell, not for agitation, uh, especially for the children, uh, here when we are planning for a renal transplant, uh, it would be, uh, like, uh, any other transplant, but we should monitor the anti-factor H antibody, uh, titers. So in case if the anti-factor H antibody titers are more than a thousand arbitrary units per ml, then we would consider using, uh, the role of plasma exchanges and, uh, just prior to the transplantation and along with IVIG. And if it is very significantly higher, then maybe there would be a role of rituximab also to decrease the antibody production. Uh, especially I would like to make a note on, uh, the donor evaluation where, uh, the genetic analysis should also be performed in the donor as the um as Sarah rightly, uh, previously pointed, there is a role of homozygous deletion, uh, in the, uh, CFHR proteins which can be one of the, uh, cause for, uh, the production of anti-FH antibodies. Although they are asymptomatic, these should be also, uh, kept in mind while doing a transplant. Okay. So the overall risk in anti-factor H HUS as far as transplant is concerned is not too high, but it's obviously linked to the antibody levels. But if you are sending a patient for transplant, obviously do the genetics. Another thing, you know, that's come up when we are doing genetics routinely, Manisha and all colleagues is that we often get a duplication of CFHR1. This is being seen, you know, a lot more in C3G then in HUS, and there are there is data, you know, that even getting duplication could have an association, uh, with with the disease. But say, uh, and there's always a dilemma, you know, that if you get a duplication, should one transplant or not? In the absence of eculizumab, the overall experience that I have that I know, you know, we don't have too much experience, but I'm sure Medanta has experience on this, and, uh, we are often told, you know, that it doesn't really it doesn't really affect the the long-term codes post-transplant. But duplication also should be looked at, you know, duplication of the same area that we were talking about the CFHR 1-3 in patients who have who do not have antibodies. I think their risk is clearly high. So if you've got a factor H mutation or a factor I mutation that caused ESRD, I think in the current context, you either do a liver kidney or you do or you should have access to eculizumab. Without that, I think it would be perhaps foolhardy to go ahead and do a transplant in a factor H or a factor I mutation, uh, I would think so, you know, it should either do a combined liver kidney or you try and get access to these agents, you know, before this is done. Another question is when we do a post pre-transplant workup, I mean, doing this genetic analysis only by, uh, NGS may not be sufficient because that's what we generally do. We send up the samples for that, MLP unless specifically asked for is not, uh, done, and, uh, sometimes we, uh, burn our fingers with that. I mean, copy number variations and all which are sometimes not picked up, and we have a recurrence post-transplant. So what would your advice be because you have such a vast experience on, uh, yeah. So if yeah, so we would normally advise that one should be doing both. I'm not Manisha totally sure, you know, whether duplication does lead to recurrence because I said, you know, that whenever well maybe Professor can come in on this later, you know, I think he had to leave, he's probably left, but I think the experience in many adult nephrology units is that perhaps it's not as bad as it seems. But having said that, at times, you know, we do find duplications and patients with HUS as well, and I am all I would be worried, you know, and I would if I was transplanting somebody with a duplication, I think there should be access to complement inhibition at least in your system because suppose a transplant suppose a choice was to recur, at least you have some action that you can take. You, uh, yeah. The other thing that's important is that I think all tertiary care centers when they are or even large nephrology units, you know, should be able to interpret the the genetics reports themselves, you know, we are currently leaving it to the laboratories to interpret these reports, and, uh, I think most of us need to now kind of learn genetics, especially the younger colleagues, you know, they should be able to interpret these what these things mean, you know, what a visual means, what an LP means, and so on. So I think again that's something that we all have to learn with the passage of time. Okay. Yes, sir. So, uh, coming back to the, uh, uh, child, uh, so for this relapse he underwent the standard plasma exchanges and required three hemodialysis sessions for a circuit kidney injury. And this time for his hypertension, he really required five anti-hypertensive agents. However, during the follow-up, he was the gradually tapered to two anti-hypertensive agents. Saturday he was he has received a cyclophosphamide, uh, he was continued his oral steroids were restarted and, uh, along with, uh, mycophenolate mofetil. However, uh, there was a history of issue in the complaints in oral intake of mycophenolate mofetil. And in March 2022, after nine months of the initial, uh, of this first relapse, he again presented, uh, at 15 years of age in March 2022 with facial puffiness, and there was history of poor complaints to mycophenolate mofetil. Or there was no history of any decreased urine output or hematuria. On examination, he had paler and periorbital puffiness and with stage one hypertension, and other system examinations were within normal limits. On, uh, further, uh, investigations again revealed a microangiopathic hemolytic anemia, uh, with the thrombocytopenia and renal function. Hence, he was labeled as a second relapse, and the anti-factor H antibody titers performed were again up to the mark of 2500 arbitrary units per ml. So this time during this relapse, he has underwent standard plasma exchanges and was, uh, the complaints was counseled and was insured with the parents and currently he is on oral steroids and the mycophenolate mofetil for till for on the previous slide. Yeah. So what's your long-term concern to the parents, uh, sir? Uh, first thing would be, uh, accounts, uh, informing them that, uh, the frequency increasing in the number of relapses will cause increase the morbidity in terms of progression to renal failure. And, uh, so that I would first counsel them to improve the compliance and explaining them the importance of the immunosuppression. A second point would be, uh, that similarly in this child we have picked up earlier that, uh, the child, uh, we should always keep a watch on children who had a small URIs also as these infections can trigger a relapse in the in especially in this condition. So, uh, children who are having a fever or URI should be closely monitored for the relapse, and hydration should be ensured in these children. Uh, recently there was a paper which has been published in, uh, Journal of Nephrology where they have even used urinary dipstick to pick up hemoglobinuria which was also, uh, used as a surrogate marker in picking up the relapses earlier early relapses. Okay. Can you just go to the last slide? So this is really a summary slide, you know, what he has discussed and some points, you know, I think overall we need to have better facilities for Shiga toxin assays. Manisha pointed that out, you know, uh, because we don't know about the magnitude of really Shiga toxin disease worldwide. This is an important cause; we don't seem to pick it up. And obviously a damn assay is clearly important. We need to be having a dance activity assays. Currently, I don't think there are too many centers across the country that are doing it, and the sample has to be transported fresh, you know, collecting sodium citrate and frozen and then transported. So we need because other without this you really can't diagnose GDP. Now Srinivas has mentioned that anti-factor H disease is the leading cause of atypical HUS in our in our children, uh, and clearly, you know, we have tried to emphasize that patients who do not show antibodies need a more comprehensive evaluation. Adults because they are usually going not going to have outer antibodies also require a comprehensive evaluation, uh, almost 30 adults, you know, would show a genetic cause if they have atypical HUS. In our country, we probably still have eculizumab; we still have plasma exchanges as the main therapy, you know, but I think in the next two or three years you're likely to see complement inhibitors coming into our country. There are track trials that are beginning on on um and other drugs, you know, and I think some of the major adult centers are already getting involved in these trials. So it's possible that you may be able to have access to complement elevation. I'll stop here now, sir. And Dr. Barbara, I think, uh, all of you will agree, a large crowd of almost 150 students that this is a masterly class. I think you have heard the discussion on a difficult topic made very easy by the masters. I complement not only Professor Bhagava, Professor Manisha Sahai, even the student who was presenting Dr. Srinivas. I compliment you; you did very well; you presented the case very well. Just one or two questions. What do you think about the maintenance immunosuppression in this person? Uh, yeah, that now he has had three relapses; he had with COVID; he had but second time also you are giving him MMF for how long you wish to continue MMF? Maybe for two three years or you want to change it to azathioprine? What is that? So yeah, mostly you know we have worked with MMF; I think that this provided was a we did see about five patients due to COVID last year, uh, but without that, you know, kids were not relapsing after two years. But I agree, you know, we've had children who have had relapses even without COVID. It is a small group of patients. So number one, we do genetics, uh, we have at times used even a tacrolimus, so that after you if MMF is not we have tried at times used in a child; we even tried using the budesonide, you know, but I think that was the wrong decision, uh, but we have tried; we have given reduction our times in one or two patients, uh, so there are some kids who tend to relapse, and Manisha did have a question, you know, that there are some patients who despite being in remission show very high levels of antibodies. Our current practice is not to is not to over treat them, you know, we just monitor them carefully. And the only thing that we consult the parents is that when they get a URI or they get any infection because that's going to trigger the Indian community; we would then, you know, monitor them more closely but get easily used as a thyroid also. So one can use it for I think but two-year therapy is more than enough, you know, I don't think we need to get longer, uh, hopefully she should be okay after this. Very nice. Yeah, I'll go to one more, uh, problem which adults usually face, that is the drug-induced that tacrolimus induces HUS in our transplant patients. Logically you try to shift from tacrolimus to cyclosporine or you need to stop sometime. What else you can do in these patients? Generally what happens is like even if you shift to cyclosporine, that also has the same problem; even sirolimus also you have reports of, uh, sirolimus-induced, uh, HUS as well. So generally, I mean, uh, we end up shifting to cyclosporine many of the times; in many of the times we stop the drug and, uh, put the patient on, um, like dual immunosuppression, and most of the times, um, we have seen that it reverses back. So the mini papers have described shifting to cyclosporine though the risk is not minimal with that either. So, uh, that's what we do, and, uh, generally it improves. Plasmapheresis and all does not have I mean a major role there; you have to look for other causes of TMA post-transplant, drug being one of them; the others are rejections; we all know. So, uh, those cases we have to, uh, look for. But otherwise, if it's completely drug-induced, um, uh, stopping, uh, the drug definitely helps. I, I think I fully agree that possibly the plasma exchange and all doesn't have much role in these conditions; possibly stopping the drug, reducing the drug, it's more of a hit and trial method, and you generally try to get over it. I think so those things are there, but in India we're not using that, so we end up as, uh, you said probably, uh, stopping the drug or changing to cyclosporine though it may occur with that as well. I think many many lessons I have learned from today's talk, and one has been as Dr. Bhagava said that possibly people everybody has to get knowledge of genetics at the moment, and without a genetics knowledge possibly you cannot manage these cases. And it's all right; antibody-mediated problem was there; you can manage with the toxin cyclophosphamide, but if there's a genetic mutation, possibly you cannot do anything except for eculizumab, and it has to be around possibly it has already come in India, I think, and it is being available; possibly the company is asking the details of the case, then it becomes available. And secondly, the management problems and how the triggers, minor triggers can again precipitate or cause a relapse that is has been, uh, we have given the link to all the faculty also; we have got a faculty of 45 to 50 nephrologists. If any faculty member has got any questions, any question from any faculty, I think if there are none, I can only salute to Dr. Bhagava, Professor Manisha for wonderful exposition of the topic and making all the student wiser on the topic, how to approach it and how to manage such cases. I think the concepts of most of the people are becoming clearer. Thank you very much, and we meet after two weeks again. Thank you very much. Thank you, sir. Thank you for the opportunity. I would so thank you. Thank you very much. Thank you, sir. Thank you. Thank you. Bye-bye. Thank you. Thank you very much. Very, very well covered. Very welcome. I think you have become you are master of everything now. All that, no, there is no doubt what Dr. King was mentioning. Thank you. Yes, sir. Thank you, sir. I'll meet you in Delhi, sir, next week. Thank you, ma'am.