Noble Gracious | Kerala University Of Health Sciences (original) (raw)

Papers by Noble Gracious

PubMed, Jul 1, 2023

Background: Though the combination of an angiotensin receptor blocker (ARB) and a neprilysin inhi... more Background: Though the combination of an angiotensin receptor blocker (ARB) and a neprilysin inhibitor (ARNi) has been shown to be useful in heart failure with reduced ejection fraction (HFrEF), its use has mostly been restricted to chronic kidney disease (CKD) patients with an estimated glomerular filtration rate (eGFR) >30 mL/minute/1.73 m2 . We studied the role of ARNi in advanced CKD. Materials and methods: Patients with HFrEF and advanced CKD with an eGFR of <30 mL/ minute/1.73 m2 were given ARNi (sacubitril with valsartan) and prospectively studied for changes in hospitalization rate for HF, clinical symptoms, levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP), eGFR, and potassium. Results: Of 34 patients who received ARNi, five were excluded due to hyperkalemia and three due to a decrease in eGFR >30% occurring within 1 month. The remaining 26 patients included 17 with diabetes mellitus (DM) and 23 with underlying coronary artery disease. A total of eight patients had stage 4 and 18 stage 5 CKDs, amongst which eight required hemodialysis. Following ARNi, there was a significant decrease in the need for hospitalization for breathlessness (2.04 ± 1.03-0.23 ± 0.51; p < 0,05), New York Heart Association (NYHA) and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores (3.77 ± 0.43-2.19 ± 0.56 and 28.58 ± 9.04-64.81 ± 14.3, respectively, p < 0.001) and NT-pro-BNP levels (24761 ± 12157.51-20149.92 ± 13555.269, p < 0.05) without significant change in eGFR after 6 months. There were no significant differences in the need for hospitalization, changes in NT proBNP levels and eGFR between stages 4 and 5. Conclusion: Neprilysin inhibitor (ARNi) is effective and can be used with care even in patients with CKD stages 4 and 5 having HFrEF with monitoring of eGFR and potassium.

Kidney International Reports, Apr 1, 2021

Kidney International Reports, Mar 1, 2020

Transplantation, Nov 1, 2019

Journal of the Egyptian Society of Nephrology, 2021

The unnecessary need for hemodialysis based on abnormal laboratory investigations is rare. We rep... more The unnecessary need for hemodialysis based on abnormal laboratory investigations is rare. We report a case of a 36-year-old male patient who complained of abdominal pain and passing red colored urine, with documentation of azotemia and hyperkalemia. He underwent unnecessary hemodialysis before a diagnosis of factitious disorder could be made.

Transplant International, 2021

Kidney International Reports, 2020

Indian journal of nephrology

Encapsulating peritoneal sclerosis (EPS) is an infrequent but serious complication of long-term p... more Encapsulating peritoneal sclerosis (EPS) is an infrequent but serious complication of long-term peritoneal dialysis with 50% mortality and lack consensus on treatment. The pathogenesis of EPS is ill understood, and diagnosis lacks specificity and relies on clinical, radiographic and microscopic evaluation. Since there is no general agreement on managing EPS, we report a case treated successfully with surgery followed by immunosuppressive therapy with tamoxifen and steroids. He later successfully underwent deceased donor renal transplantation.

Kidney International Reports, 2021

Kidney International Reports, 2020

Vasculitis causing Dialysis dependent renal failure have poorer renal and overall survival. 2 Dua... more Vasculitis causing Dialysis dependent renal failure have poorer renal and overall survival. 2 Dual positive{ ANCA vasculitis and Anti GBM disease } and isolated anti-GBM disease is associated with worse outcomes as compared to those with pure ANCA vasculitis

Sensorineural hearing loss is considerably more prevalent in patients with Chronic Renal Failure ... more Sensorineural hearing loss is considerably more prevalent in patients with Chronic Renal Failure than in the general population.This study is aimed to find the proportion of Sensorineural Hearing Loss (SNHL) in End Stage Chronic Renal Failure (Stage 4 and 5 CRF), to describe the hearing impairment and determine the possible factors responsible for hearing loss. The sample of the study consisted of 115 patients, with in the age group of 15 to 60 years. Methods: All patients underwent clinical evaluation including ENT examination and Pure Tone Audiometry. Results: 40% (46/115 patients) of patients had SNHL. Majority had bilateral and symmetrical hearing loss, mostly affecting high frequencies. Among the factors studied, age, duration of CRF, usage of ototoxic drugs, number of hemodialysis and serum creatinine were found to have statistically significant association with SNHL. Conclusion: 40% of CRF patients had SNHL and hearing loss was associated with the age of the patient, duration...

Copyright © 2014 Sreeja Nair et al. This is an open access article distributed under the Creative... more Copyright © 2014 Sreeja Nair et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Plant toxins are known to cause acute kidney injury in tropical countries. We report two cases of acute kidney injury with tubular oxalate deposition following ingestion of Averrhoa bilimbi fruit juice. Both patients had complete renal recovery though one required dialytic support. 1.

Frontiers in Pharmacology, 2021

Tacrolimus, an immunosuppressant used in solid organ transplantation, has a narrow therapeutic in... more Tacrolimus, an immunosuppressant used in solid organ transplantation, has a narrow therapeutic index and exhibits inter-individual pharmacokinetic variability. Achieving and maintaining a therapeutic level of the drug by giving appropriate doses is crucial for successful immunosuppression, especially during the initial post-transplant period. We studied the effect of CYP3A5, CYP3A4, and ABCB1 gene polymorphisms on tacrolimus trough concentrations in South Indian renal transplant recipients from Kerala to formulate a genotype-based dosing equation to calculate the required starting daily dose of tacrolimus to be given to each patient to attain optimal initial post-transplant period drug level. We also investigated the effect of these genes on drug-induced adverse effects and rejection episodes and looked into the global distribution of allele frequencies of these polymorphisms. One hundred forty-five renal transplant recipients on a triple immunosuppressive regimen of tacrolimus, myc...

Plant toxins are known to cause acute kidney injury in tropical countries. We report two cases of... more Plant toxins are known to cause acute kidney injury in tropical countries. We report two cases of acute kidney injury with tubular oxalate deposition following ingestion of Averrhoa bilimbi fruit juice. Both patients had complete renal recovery though one required dialytic support.

Indian Journal of Transplantation

Experimental and clinical transplantation : official journal of the Middle East Society for Organ Transplantation, 2015

OBJECTIVES Tacrolimus is the cornerstone for immunosuppression in renal transplant and is metabol... more OBJECTIVES Tacrolimus is the cornerstone for immunosuppression in renal transplant and is metabolized by the cytochrome P 450 3A (CYP3A) subfamily of enzymes in the liver and small intestine. A polymorphism in intron 3 of the CYP3A5 gene affects the expression of this enzyme and tacrolimus trough blood levels. The purpose of this study was to identify the proportion of CYP3A5 gene polymorphisms in South Indian renal transplant patients and determine the effect of CYP3A5 gene polymorphisms on tacrolimus trough blood levels in patients with and without CYP3A5 expression. MATERIALS AND METHODS We included 25 adult patients who underwent renal transplant at Government Medical College, Trivandrum. All patients received tacrolimus (dose, 0.1 mg/kg/body weight, in 2 divided doses). Tacrolimus trough blood levels were determined on postoperative day 6. The CYP3A5 genotype analysis was performed by polymerase chain reaction amplification of target and detection by restriction fragment length...

Indian Journal of Transplantation, 2021

In India, live donor transplantation is more common than deceased donor transplantations which ar... more In India, live donor transplantation is more common than deceased donor transplantations which are quite contrary to developed nations. The enactment of The Transplantation of Human Organ and Tissue Act in India in the year 1994 legalized organ donation after brainstem death. However, it was only in the last few years that the deceased donor transplantation (DDT) program increased in popularity, possibly due to increasing public awareness and direct involvement of Government in the donation and transplant process through national and regional organizations. The Government of Kerala in association with Donation and Transplantation Institute Foundation of Spain implemented transplant procurement management (TPM model) in the state in the year 2019. In Kerala, Kerala Network for Organ Sharing, a local networking organization under Government acts as a public, private provider interface, ensuring a transparent and equitable organ allocation. The purpose of this article is to highlight t...

Kidney International Reports

PubMed, Jul 1, 2023

Background: Though the combination of an angiotensin receptor blocker (ARB) and a neprilysin inhi... more Background: Though the combination of an angiotensin receptor blocker (ARB) and a neprilysin inhibitor (ARNi) has been shown to be useful in heart failure with reduced ejection fraction (HFrEF), its use has mostly been restricted to chronic kidney disease (CKD) patients with an estimated glomerular filtration rate (eGFR) >30 mL/minute/1.73 m2 . We studied the role of ARNi in advanced CKD. Materials and methods: Patients with HFrEF and advanced CKD with an eGFR of <30 mL/ minute/1.73 m2 were given ARNi (sacubitril with valsartan) and prospectively studied for changes in hospitalization rate for HF, clinical symptoms, levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP), eGFR, and potassium. Results: Of 34 patients who received ARNi, five were excluded due to hyperkalemia and three due to a decrease in eGFR >30% occurring within 1 month. The remaining 26 patients included 17 with diabetes mellitus (DM) and 23 with underlying coronary artery disease. A total of eight patients had stage 4 and 18 stage 5 CKDs, amongst which eight required hemodialysis. Following ARNi, there was a significant decrease in the need for hospitalization for breathlessness (2.04 ± 1.03-0.23 ± 0.51; p < 0,05), New York Heart Association (NYHA) and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores (3.77 ± 0.43-2.19 ± 0.56 and 28.58 ± 9.04-64.81 ± 14.3, respectively, p < 0.001) and NT-pro-BNP levels (24761 ± 12157.51-20149.92 ± 13555.269, p < 0.05) without significant change in eGFR after 6 months. There were no significant differences in the need for hospitalization, changes in NT proBNP levels and eGFR between stages 4 and 5. Conclusion: Neprilysin inhibitor (ARNi) is effective and can be used with care even in patients with CKD stages 4 and 5 having HFrEF with monitoring of eGFR and potassium.

Kidney International Reports, Apr 1, 2021

Kidney International Reports, Mar 1, 2020

Transplantation, Nov 1, 2019

Journal of the Egyptian Society of Nephrology, 2021

The unnecessary need for hemodialysis based on abnormal laboratory investigations is rare. We rep... more The unnecessary need for hemodialysis based on abnormal laboratory investigations is rare. We report a case of a 36-year-old male patient who complained of abdominal pain and passing red colored urine, with documentation of azotemia and hyperkalemia. He underwent unnecessary hemodialysis before a diagnosis of factitious disorder could be made.

Transplant International, 2021

Kidney International Reports, 2020

Indian journal of nephrology

Encapsulating peritoneal sclerosis (EPS) is an infrequent but serious complication of long-term p... more Encapsulating peritoneal sclerosis (EPS) is an infrequent but serious complication of long-term peritoneal dialysis with 50% mortality and lack consensus on treatment. The pathogenesis of EPS is ill understood, and diagnosis lacks specificity and relies on clinical, radiographic and microscopic evaluation. Since there is no general agreement on managing EPS, we report a case treated successfully with surgery followed by immunosuppressive therapy with tamoxifen and steroids. He later successfully underwent deceased donor renal transplantation.

Kidney International Reports, 2021

Kidney International Reports, 2020

Vasculitis causing Dialysis dependent renal failure have poorer renal and overall survival. 2 Dua... more Vasculitis causing Dialysis dependent renal failure have poorer renal and overall survival. 2 Dual positive{ ANCA vasculitis and Anti GBM disease } and isolated anti-GBM disease is associated with worse outcomes as compared to those with pure ANCA vasculitis

Sensorineural hearing loss is considerably more prevalent in patients with Chronic Renal Failure ... more Sensorineural hearing loss is considerably more prevalent in patients with Chronic Renal Failure than in the general population.This study is aimed to find the proportion of Sensorineural Hearing Loss (SNHL) in End Stage Chronic Renal Failure (Stage 4 and 5 CRF), to describe the hearing impairment and determine the possible factors responsible for hearing loss. The sample of the study consisted of 115 patients, with in the age group of 15 to 60 years. Methods: All patients underwent clinical evaluation including ENT examination and Pure Tone Audiometry. Results: 40% (46/115 patients) of patients had SNHL. Majority had bilateral and symmetrical hearing loss, mostly affecting high frequencies. Among the factors studied, age, duration of CRF, usage of ototoxic drugs, number of hemodialysis and serum creatinine were found to have statistically significant association with SNHL. Conclusion: 40% of CRF patients had SNHL and hearing loss was associated with the age of the patient, duration...

Copyright © 2014 Sreeja Nair et al. This is an open access article distributed under the Creative... more Copyright © 2014 Sreeja Nair et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Plant toxins are known to cause acute kidney injury in tropical countries. We report two cases of acute kidney injury with tubular oxalate deposition following ingestion of Averrhoa bilimbi fruit juice. Both patients had complete renal recovery though one required dialytic support. 1.

Frontiers in Pharmacology, 2021

Tacrolimus, an immunosuppressant used in solid organ transplantation, has a narrow therapeutic in... more Tacrolimus, an immunosuppressant used in solid organ transplantation, has a narrow therapeutic index and exhibits inter-individual pharmacokinetic variability. Achieving and maintaining a therapeutic level of the drug by giving appropriate doses is crucial for successful immunosuppression, especially during the initial post-transplant period. We studied the effect of CYP3A5, CYP3A4, and ABCB1 gene polymorphisms on tacrolimus trough concentrations in South Indian renal transplant recipients from Kerala to formulate a genotype-based dosing equation to calculate the required starting daily dose of tacrolimus to be given to each patient to attain optimal initial post-transplant period drug level. We also investigated the effect of these genes on drug-induced adverse effects and rejection episodes and looked into the global distribution of allele frequencies of these polymorphisms. One hundred forty-five renal transplant recipients on a triple immunosuppressive regimen of tacrolimus, myc...

Plant toxins are known to cause acute kidney injury in tropical countries. We report two cases of... more Plant toxins are known to cause acute kidney injury in tropical countries. We report two cases of acute kidney injury with tubular oxalate deposition following ingestion of Averrhoa bilimbi fruit juice. Both patients had complete renal recovery though one required dialytic support.

Indian Journal of Transplantation

Experimental and clinical transplantation : official journal of the Middle East Society for Organ Transplantation, 2015

OBJECTIVES Tacrolimus is the cornerstone for immunosuppression in renal transplant and is metabol... more OBJECTIVES Tacrolimus is the cornerstone for immunosuppression in renal transplant and is metabolized by the cytochrome P 450 3A (CYP3A) subfamily of enzymes in the liver and small intestine. A polymorphism in intron 3 of the CYP3A5 gene affects the expression of this enzyme and tacrolimus trough blood levels. The purpose of this study was to identify the proportion of CYP3A5 gene polymorphisms in South Indian renal transplant patients and determine the effect of CYP3A5 gene polymorphisms on tacrolimus trough blood levels in patients with and without CYP3A5 expression. MATERIALS AND METHODS We included 25 adult patients who underwent renal transplant at Government Medical College, Trivandrum. All patients received tacrolimus (dose, 0.1 mg/kg/body weight, in 2 divided doses). Tacrolimus trough blood levels were determined on postoperative day 6. The CYP3A5 genotype analysis was performed by polymerase chain reaction amplification of target and detection by restriction fragment length...

Indian Journal of Transplantation, 2021

In India, live donor transplantation is more common than deceased donor transplantations which ar... more In India, live donor transplantation is more common than deceased donor transplantations which are quite contrary to developed nations. The enactment of The Transplantation of Human Organ and Tissue Act in India in the year 1994 legalized organ donation after brainstem death. However, it was only in the last few years that the deceased donor transplantation (DDT) program increased in popularity, possibly due to increasing public awareness and direct involvement of Government in the donation and transplant process through national and regional organizations. The Government of Kerala in association with Donation and Transplantation Institute Foundation of Spain implemented transplant procurement management (TPM model) in the state in the year 2019. In Kerala, Kerala Network for Organ Sharing, a local networking organization under Government acts as a public, private provider interface, ensuring a transparent and equitable organ allocation. The purpose of this article is to highlight t...

Kidney International Reports