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High BP can be either a cause or a consequence of CKD. Estimating the prevalence of CKD attributable to hypertension alone is difficult as individuals with presumed hypertensive nephrosclerosis are rarely biopsied, and strict clinical criteria are not routinely followed to make a diagnosis. The reported incidence and prevalence of ESRD owing to hypertension is, therefore, likely an overestimate because of alternative diseases that are undiagnosed or overlooked. However, a strong AbstractFive decades back, high blood pressure (BP) was considered as an essential malady and not a treatable condition. Gradually, evidences started accumulating through major trials and now hypertension is the most common comorbidity and a powerful risk factor for chronic kidney disease (CKD) and coronary artery disease (CAD) and an independent risk factor for CKD progression. Although hypertension is the second most common cause of end-stage renal disease, next to diabetes mellitus, only few patients of primary hypertension develop renal dysfunction. The risk of hypertensive nephrosclerosis is high in African americans, independent of age, sex, and prevalence of hypertension. The clear-cut benefits of lowering BP in CKD patients are renoprotection and reducing the risk of CV complications. The less clear is the optimal BP targets and the best method for measuring and achieving the targets. Recent evidences suggest a BP goal of <130/80 mmHg irrespective of age and proteinuria, despite controversies. Home BP monitoring is gaining importance and it should be emphasized in all hypertensive patients.

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Background and Aims Chronic diarrhoea in post-renal transplant recipients due to Cytomegalovirus (CMV) presents as Blood CMV PCR (polymerised chain reaction) positive chronic diarrhoea and Gut-invasive (rectal tissue PCR positive, blood PCR-negative) compartmentalised CMV. The available literature on compartmentalised gut CMV is scarce. The aim is to study the clinical presentation and outcome of patients with compartmentalized gut invasive CMV when compared with Blood CMV positive chronic diarrhea in renal transplant recipients. Method This is a retrospective single-centre follow-up study of patients with CMV disease who were transplanted between 2000 and 2020. Diagnostic variables like blood CMV PCR (polymerised chain reaction) positivity with constitutional symptoms, presence or absence of chronic diarrhoea, tissue PCR positivity and site of tissue biopsy were given harmony codes and 6 syndromes were identified – CMV diarrhoea (Blood PCR positive, presence of diarrhoea), compartmentalized gut invasive CMV (Blood PCR negative, presence of diarrhoea, rectal tissue quantitative CMV PCR positive), Acute CMV syndrome, CMV Esophagitis, CMV nephropathy, CMV cystitis. Out of which patients presenting with diarrhoea (first two groups) were included for analysis. The baseline descriptive statistical measures were carried out using analysis of variance. The time to CMV disease from transplant was computed by identifying the pattern of distribution at 10%, 50% and 90% between groups using reliability models. The time to death from diagnosis was analyzed by identifying the pattern by parametric log-logistic distribution. Survival analysis was done by a parametric reliability model identifying location, scale and threshold parameters, from which month-wise prediction of probabilities was found for survival. The proportion of adverse outcomes (relapse, death and graft loss) between the two groups were analyzed by one-way ANOVA and Tukey pairwise comparison. All the patients were followed up till death or last follow-up. Results Out of 2208 renal transplants done between 2000 and 2020, 118 (5.3%), patients developed CMV disease. Chronic diarrhoea was the presentation in 88 (57%), of which 47 had manifestations of CMV diarrhoea, and 41 had compartmentalized gut CMV. Induction agents used (CMV diarrhoea Vs compartmentalized gut CMV) were basiliximab (51% Vs 56%), ATG (27% Vs 17%), Grafalon (0% Vs,2.4%) and no induction (21%,24%). Only 31.9% and 26.8% received Valganciclovir prophylaxis for pre-specified indications respectively. The time to CMV diagnosis from transplant for 10%, 50% and 90% of patients (in months) was 12,63,154 for CMV diarrhoea;12,52 and 139 months for compartmentalized gut CMV. The mean duration (weeks) of diarrhoea was similar in both groups (7 Vs 7.3). Associated opportunistic infections causing diarrhoea were higher in compartmentalized gut CMV (28% Vs 46% p = 0.08); the commonest being cryptosporidium. Quantitative PCR in the blood ranged from 1245 to 2511345 copies/ml; whereas in gut tissue, it ranged from 1325 to 3517920/25 mg. The major histopathological finding in compartmentalized gut CMV was active inflammatory pathology in 34 (83%) patients. The probability of survival was significantly lower (72.6%; CI 60% to 83%) in CMV diarrhoea when compared with compartmentalized Gut CMV (87.2%; CI 76% to 94%) for initial 12 months (p&lt;0.05); however at 5 years (56.2%, Vs 58.5%) and 10 years (48.5% Vs 42.7%) the survival was similar. Compartmentalized gut CMV was associated with a higher relapse rate (19.5%) when compared with CMV diarrhoea (6.4%) on follow-up (p = 0.06). The mortality (36% Vs 29%; p = 0.490) and graft loss (25% Vs 22%; p = 0.692) were similar between both the group. Conclusion Compartmentalized gut invasive CMV represents a larger proportion of chronic diarrhoeal illness with a higher relapse rate, which needs invasive gut tissue PCR analysis, despite negative blood PCR, for early diagnosis and management.