Manisha Singh

Background: Percutaneous kidney biopsy is essential for diagnosing kidney disease but carries a risk of bleeding and other complications. Reported complication rates vary widely because of heterogeneity in outcome definitions. Patients with diabetes frequently have hypertension, vascular stiffness, and altered hemostasis, which may further influence biopsy safety. The multicenter Transformative Research in Diabetic Nephropathy (TRIDENT) study prospectively evaluated biopsy complications in adults with diabetes using standardized definitions across 21 sites from the United States. Methods: We analyzed 408 native kidney biopsies from participants with diabetes enrolled in TRIDENT (2017–2025). Complications were classified as minor (hematoma, biopsy site pain, or hemoglobin (Hb) drop), resource-intense (transfusion, radiologic or surgical intervention, or prolonged hospitalization), and major bleeding (≥2 grams/deciliter (g/dL) Hb decline, transfusion, or intervention). Logistic regression with site clustered robust errors was used to identify clinical and procedural associations with outcomes. Results: Among 408 biopsies, 81 complications (20%) occurred, most commonly hematoma (15%); resource-intense events were infrequent (5%). Use of an 18-gauge (vs 16-gauge) needle was associated with lower odds of resource intense events (odds ratio (OR) 0.32; 95% confidence interval (CI) 0.17–0.60). Procedures by fellows, hybrid teams, or interventional radiologists had higher odds than those by attendings (OR 3.12–13.4). Renin–angiotensin system inhibitors (RAASi) use was independently associated with lower odds (OR 0.13; 95% CI 0.02–0.73). Female sex (OR 4.88; 95% CI 1.02-45.3)and post-biopsy hematoma (OR 14.3; 95% CI 3.66-74.5) were associated with major bleeding, whereas the number of passes correlated with hematoma formation but not with adjusted major bleeding risk. Conclusions: In adults with diabetes, clinically significant biopsy complications were uncommon and were associated with procedural and operator factors rather than diabetes. Smaller gauge needles and experienced operators were associated with lower risk, whereas female sex and hematoma were associated with major bleeding. The higher overall complication rate mainly reflected comprehensive, prospective ascertainment of minor events, and supports standardized definitions and procedures to improve biopsy safety in diabetic kidney disease.

Background: Pregnancy with kidney failure is challenging, even more so with peritoneal dialysis (PD). The pregnancy rate is 50% lower while on PD than on hemodialysis, and usually, patients transition to hemodialysis to support better outcomes. There are only a few reported cases of pregnancy carried beyond 32 weeks’ gestation on PD alone. Methods: We present a patient treated with PD for over two years at the time of natural conception. Higher clearance needs arose during pregnancy, but the patient did not transition to hemodialysis due to fear of hematological infections and need for new dialysis access. With the patient's consent and discussions with the pharmacy medical liaison, at 30 weeks, her PD regimen was modified to include Icodextrin to support adequacy and volume control. This adjustment aided in pregnancy reaching 32w4d when she delivered a viable infant. Though our patient underwent a cesarean section, she stayed on PD with appropriate modifications, not needing hemodialysis at any time. Results and Conclusions: We present the challenges and report a successful outcome of such a pregnancy, along with the off-label use of Icodextrin as add-on therapy during the third trimester. We opine that Icodextrin did not adversely impact the course; it helped carry the pregnancy forward a few more critical weeks. This is also a unique case report of a pregnancy while on PD in a pacific islander and only one of five cases of Pregnancy on PD in women over 40.

Peritoneal dialysis (PD) is an effective renal replacement strategy for patients with end-stage renal disease utilizing the peritoneum as the filter and PD catheter as access. A survey of PD patients showed that some felt uncomfortable with the length of current catheters and would be interested to explore newer, shorter designs. We redesigned the transfer set and external portion of the catheter, addressing this barrier as a part of our multi-institutional design project led by a nephrologist from the University of Arkansas for Medical Sciences (UAMS) and an engineering design team from the biomedical engineering department at the University of Arkansas. Multiple designs were considered, including spiral, retractable, and collapsible bulbs, with an accordion-style mechanism being selected for prototyping. We created several prototypes, first by 3D printing as well as by silicone casting. Computational fluid analysis showed the design to be fully capable of delivering clinically relevant flows. The final design of our PD transfer set has a flexible accordion section that is 7 cm when extended and collapses to substantially shorten this length. We propose that the design can also be extended to the extra-abdominal section of the PD catheter.

Sodium–glucose cotransporter 2 (SGLT2) inhibitors are widely used in patients with kidney disease and have been shown to increase serum magnesium levels. Case reports have described their role in correcting hypomagnesemia; however, there is limited evidence regarding their efficacy in patients with renal magnesium wasting. Furthermore, data regarding their role in acute treatment and sustained efficacy to treat hypomagnesemia are lacking. We present a multicenter retrospective, observational case series from two U.S. medical centers describing five patients with refractory hypomagnesemia who experienced significant improvement following initiation of SGLT2 inhibitors. Patients 1–4 showed marked renal magnesium wasting with severe symptomatic hypomagnesemia which responded robustly to SGLT2 inhibitor therapy. Even though Patient 5 did not have renal magnesium wasting, hypomagnesemia still improved with the addition of an SGLT2 inhibitor. Furthermore, the addition of an SGLT2 inhibitor acutely improved the hypomagnesemia of Patients 1 and 2 in an inpatient setting, and Patients 3–5 demonstrated sustained improvement of hypomagnesemia across extended outpatient follow‐up. The improvement of hypomagnesemia was irrespective of the diabetic status of the patient. All cases resulted in substantial reduction or cessation of magnesium (Mg) supplementation. These findings suggest a novel therapeutic application of SGLT2 inhibitors for managing intractable hypomagnesemia, both acutely and chronically, regardless of the diabetes being the primary culprit.

Introduction: Autosomal dominant polycystic kidney disease (ADPKD) is one of the most prevalent heritable disorders, characterized by the progressive development of kidney cysts leading to renal failure. It is primarily caused by mutations in the PKD1 and PKD2 genes, which account for approximately 85% and 15% of cases, respectively. This case report describes a previously unreported mutation in the PKD1 gene, identified in a family involving an aunt and her niece with ADPKD. Case Presentation: The index case, a 56-year-old female with chronic kidney disease stage 3b secondary to ADPKD and hypertension, exhibited a strong family history of polycystic kidney disease (PKD). Initial genetic evaluations did not identify any recognized pathogenic mutations, leading to a more detailed investigation which revealed a novel mutation in the PKD1 gene. This mutation was also found in her niece, who presented with early-onset disease. Conclusions: The identification of a heterozygous six-nucleotide deletion, c.2084_2089del, resulting in the in-frame deletion of two amino acids, p.Pro695_Ala696del, in the PKD1 gene, has been linked with ADPKD in these patients. This report emphasizes the need for continuous updates to genetic data for a deeper understanding of the diagnosis and prognosis of ADPKD that could potentially aid in targeted therapy.

The US Renal Data System (USRDS) reports that 15% of the adult US population has chronic kidney disease (CKD), whereas only 10% of those with CKD know that they have it.1 Timely interventions can prevent the debilitating effects of CKD. This perspective aims to share the experience of an innovative platform created by state stakeholders to address CKD in Arkansas, one of the top 10 rural states...

In adults, membranous Nephropathy (MN) is a common cause of idiopathic nephrotic syndrome. Primary MN is caused by antibodies directed against podocyte antigens, while secondary MN with the deposition of circulating immune complexes in the same area of glomeruli. Most of the primary membranous are positive for PLA2R- and THSD7A- antibodies associated with the progression of the disease. Some of the novel antibodies like NELL 1 are primarily secondary causes, including malignancy but sometimes may present as a primary disease with no underlying reason or ingestion of lipoic acid. Our patient presented to the hospital with a rash and swelling of lower limbs, which was sudden in onset. With a history of diabetes mellitus with comorbidities, he used multiple medications, including over-the-counter supplements (lipoic acid). Renal biopsy revealed NELL 1 positivity likely secondary to over-the-counter supplement usage.