Primary Hepatic Sarcomatoid Carcinoma Presenting with Dysphagia: A Rare Presentation

A 50-year male presented with vomiting and dysphagia for 2 weeks. Laboratory workup showed a positive serology for hepatitis C and normal serum α-fetoprotein (AFP) levels. CT abdomen revealed a large lesion in the right lobe of the liver extending upto the lower esophagus causing significant luminal narrowing and dysphagia. The enhancement pattern on the CT scan was not consistent with hepatocellular carcinoma. Liver lesion biopsy showed an infiltrating spindle cell lesion exhibiting fascicles of spindle cells with moderately hyperchromatic nuclei and perinuclear vacuolization. Mitotic count was 2-3/10 HPFs. Immunohistochemical markers were positive for CK AE1/AE3 and vimentin. Thus, a diagnosis of sarcomatoid carcinoma was made on the basis of morphological and immunohistochemical features. Due to unresectable disease and poor functional status, palliative care was opted for. Key Words: Dysphagia, Vomiting, Liver biopsy, Sarcomatoid carcinoma.

Risk stratification and long-term kidney survival in IgA nephropathy with particular emphasis on Oxford classification; A narrative review

Introduction: IgA nephropathy (IgAN) is one of the most common forms of glomerulonephritis worldwide. It leads to end-stage renal disease (ESRD) in many patients. At the time of diagnosis, risk stratification is of paramount importance in planning proper management in individual cases. Several studies have been conducted to determine the utility of various demographic, clinical, laboratory, and pathological features on renal biopsy to stratify the risk of disease progression and predict the likely outcome. This review summarizes the emerging data on demographic, clinical, laboratory, and histological prognosis along with risk factors associated with renal outcomes in patients with IgAN. Methods: For this review, we searched DOAJ (Directory of Open Access Journals), PubMed/Medline, Web of Science, Scopus, Embase, and Google Scholar, using keywords including; "IgA nephropathy," "IgA nephritis," "IgAN," "Berger’s disease," "Berger’s syndrome," "chronic glomerulonephritis, "prognostic factors," "risk factors," "risk stratification," "renal survival," "ESRD," "MEST classification," "MEST-C classification" and "Oxford Classification." To identify other relevant studies, we manually scanned the bibliographic lists of the identified studies and reviewed articles from January 2009 through December 2020. All relevant articles were carefully reviewed, and relevant information was extracted for this narrative review. Results: A total of 152 articles were retrieved from the above literature database searches. The abstracts were carefully reviewed to identify 35 articles containing information on prognostic factors and longterm renal survival in IgAN patients. Relevant information was collected and summarized for this review. The main focus was on using demographic, clinical, and laboratory features, especially serial changes in these parameters during follow-up, for this purpose. Recently a standardized, evidencebased formulation has been devised to evaluate and categorize pathological features on renal biopsy to augment and refine the risk stratification and prognostic value of traditional risk factors; it is popularly known as the Oxford classification of IgAN. There have been numerous validation studies in various ethnic groups that have proven its clinical utility. Conclusion: In conclusion, the clinicians should also take into account the pathologic variables according to the revised Oxford classification in addition to demographic, clinical, and laboratory parameters for early and reliable risk stratification and prognostication in individual patients at the time of diagnosis in IgAN for optimal management and ultimate improvement in long-term outcomes.

Clinical Course and Long-term Outcome of Adults with Primary Focal Segmental Glomerulosclerosis: A Retrospective Cohort Study

INTRODUCTION

Focal segmental glomerulosclerosis (FSGS) is one of the common causes of end-stage kidney disease (ESKD) in adults with primary glomerular diseases. Information on clinical course and long-term renal outcome of primary FSGS in adults are scanty. We aimed to determine the clinical course and long-term outcome of primary FSGS in a large number of adult patients from a tertiary care kidney center in Pakistan.

METHODS

A retrospective review of the clinical charts of all adults (≥ 16 years) with a biopsy proven diagnosis of FSGS presenting to Sindh Institute of Urology and Transplantation, Karachi, between January 1995 and December 2017 was carried out. Cases with secondary FSGS were excluded. Relevant data items were retrieved both at baseline and on last follow-up.

RESULTS

Among 401 adults with primary FSGS, 144 (35.9%) were followed for a mean duration of 66.6 ± 27.4 months, out of which, 129 (89.5%) were treated with steroids and immunosuppressants. Response to steroids was obtained in 62 (48%) patients, while 67 (52%) showed no response. Among responders, 24/62 (38.7%) relapsed after a mean duration of 24.2 ± 23.2 weeks, who were re-treated with same dose of steroids alone or combined with cyclosporine and all achieved remission. The long-term outcomes were significantly different between steroid responsive and nonresponsive cohorts. None of the patients in steroid responsive group developed ESKD or died, while 7 (10.4%) patients in nonresponsive group developed ESKD and 2 (3%) died.

CONCLUSION

Almost half of adults with primary FSGS achieved sustained remission with steroids and immunosuppressants and consequently exhibited excellent long-term outcome.  DOI: 10.52547/ijkd.6815.

Knowledge, attitudes and practices towards deceased organ donation among parents of children with End Stage Kidney Disease

OBJECTIVE

To assess the knowledge, attitudes, and practices (KAP) towards deceased organ donation (DOD) of the parents/ guardians of children with end stage kidney disease (ESKD).

METHODS

This cross sectional survey was conducted between April and December 2020. A structured questionnaire was filled to assess the sociodemographic information, knowledge, attitude, and practice about DOD.

RESULTS

A total of 130 participants with a mean age of 37±7 years were included in the study. Among all, 66 (50.8%) claimed that they had prior knowledge about DOD. However, on further questioning, no one knew who can be the deceased organ donor. Their responses about registration place and permission from religion were positive in 24(36.4%) and 31(47.0%) cases respectively. Regarding attitude, positive responses to willingness to get registered and discussing DOD in social circle were given by 37(56.1%) and 21 (31.8%) participants respectively. Only one participant was registered as donor. The remaining 64(49.2%) participants who had no prior knowledge were given relevant information and were interviewed after one week. Only 24(37.5%) showed willingness to get registered as donors and 06 (9.4%) participants discussed the topic of DOD in their social circle.

CONCLUSIONS

The results showed that the knowledge, attitudes, and practices of people who are most desperate for transplantation of their children were poor and did not change significantly even after providing them relevant information.

Ki-67 proliferative index in immunoglobulin A nephropathy; A pilot study

Introduction: IgA nephropathy (IgAN) regarded as the main type of primary glomerulonephritis globally. It has a diverse clinical course and unpredictable prognosis. Traditionally, clinical and pathological features are conducted to prognosticate the outcome of the disease. Recently, attention has been directed towards other indices that may have prognostic implications for IgAN progression. The Ki-67 index have been extensively detected as a proliferation marker of malignant cells for several years. Objectives: In this study, we aimed to determine the prognostic impact of Ki-67 expression in IgAN biopsies. Patients and Methods: This cross-sectional study was conducted on 18 biopsy-proven IgAN patients. IgAN was diagnosed by significant IgA deposits and according to the morphologic variables of Oxford (MEST) classification for this disease. The expression of Ki-67 in the glomeruli, interstitium and tubules was described as the intensity percentage of the immunohistochemical staining. Results: In all of the eighteen cases with biopsy-proven IgAN, the mean ± SD of age, degree of proteinuria and serum creatinine were 36.3±17 years, 1600±733 mg/day and 1.2±0.4 mg/dL, respectively. In this study, we found a significant correlation between glomerular Ki-67 immunohistochemical staining and MEST scores (r: 0.780, P< 0.001). We also detected a significant correlation between interstitial Ki-67 staining and MEST scores (r: 0.700, P=0.001). Moreover, Ki-67 immunohistochemical staining of the interstitium had a significant relationship with IgM deposits (r=0.544, P=0.02). Conclusion: In this pilot study, we found that interstitial and glomerular Ki-67 immunohistochemical staining had positive and significant associations with MEST scores. Our data also showed that interstitial Ki-67 staining had a significant relationship with IgM deposits. These preliminary results require further investigation in large-scale studies.

Intestinal Spirochaetosis-A case series from the developing world

Spirochaetes comprise a heterogenous group of gram negative, motile, spiral shaped bacteria. Some of these pathogens are known to cause numerous human diseases such as Lyme disease, relapsing fever, syphilis and leptospirosis. However, intestinal spirochetosis is a rare condition. Patients frequently present with long-term complaints of loose stools, abdominal pain and weight loss and rectal bleeding. Hence to establish a diagnosis an endoscopy with biopsy is required. In this article, we describe four such cases, having different ages and socio- economic background, successfully treated with a short course of metronidazole.

Human papillomavirus-associated anal squamous intraepithelial lesions in men who have sex with men and transgender women living with and without HIV in Karachi Pakistan: implications for screening and prevention

BACKGROUND

Anal squamous intraepithelial lesions (ASIL), strongly related to human papilloma virus (HPV) infection, is more prevalent among men who have sex with men (MSM). However, no such data are available for Pakistan yet, and neither HPV vaccination nor anal-cytology screening is implemented in Pakistan. The purpose of this first ever study was to assess the prevalence of HPV-related anal cytological abnormalities among MSM and transgender women living with and without HIV infection in Pakistan.

METHODS

We conducted a cross-sectional study from March 2016 to November 2017 at sexual health centers run by the Perwaaz Trust and the National AIDS Control Program in Karachi. The study enrolled MSM and transgender women aged greater-than-and-equal-to-18-years who reported anal sex in the preceding 6 months. We collected two anal samples for liquid-based cytology and HPV type testing by PCR, and socio-demographic and behavioral data were collected through face-to face interviews. ASIL and its associations with biological and behavioral risk factors were analyzed through Cox regression for prevalence ratios (PR) and corresponding 95% confidence intervals (CIs).

RESULTS

Out of 271 qualifying participants, 79% were MSM and 21% transgender women. The mean age was 28.8 (± 8) years. Almost 35% (93/271) of the study population had ASIL detected, ASIL was significantly more common among participants living with HIV than in HIV negative ((50/118) 42.4%; vs. (43/153) 28.1%) (p ≤ 0.001). Among ASIL, 66% (61/93) had low-grade squamous intraepithelial lesions (LSIL), and 3.6% (3/93) had high-grade squamous intraepithelial lesions (HSIL). The overall, HPV16 positivity was 35.5% (33/93) among all abnormal anal lesions and all 3 HSIL were HPV16 positive, however, HPV16 positivity could show its association with ASIL detection in univariate model only (PR_crude: 2.11(1.39-3.18)). Moreover, any HR-HPV type (PR 3.04; 95% CI 1.75-5.26), concurrent sexually transmitted infection (STI) (2.13; (1.28-3.55)) and HIV + /HPV + coinfection (1.75; (1.07-2.88)) remained independently associated with ASIL in the multivariate model.

CONCLUSIONS

Abnormal anal cytology among MSM and transgender is prevalent enough to consider optimal screening regimens. Further studies are required to see if periodic anal cytology can be made part of HIV care and treatment programs among MSM in Pakistan.

Journal Prestige Index: Expanding the Horizons of Assessment of Research Impact

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Allograft bone banking experience in Pakistan

To share our experience of establishing a bone bank in Pakistan, and the clinical use of these indigenously produced bone grafts. We retrospectively reviewed our experience of the procurement, processing, and storage of bone grafts at a bone bank in Karachi, Pakistan, the first bone bank to be established in a public sector hospital in Pakistan. The bone bank was established at Sindh Institute of Urology and Transplantation (SIUT), Karachi, in collaboration with Department of Orthopaedic Surgery, Dow University of Health Sciences/Civil Hospital, Karachi (CHK) in May, 2015. Since then, a large number of bone grafts from the tissue bank have been used for various orthopedic procedures. This paper describes the problems and challenges faced in establishing and running a tissue bank in a Muslim and a developing country and the progress of the bone bank over the first 4 years. A total of 93 bone grafts were retrieved and preserved in the bone bank over the 4-year period. Among these, 56 (60.2%) bones were retrieved from male donors and 37 (39.8%) from females. The mean age of all donors was 55.9 ± 15.34 years (range: 16-90 years). All bone donors were living patients. No c bones were obtained from deceased donors. Types of bone grafts included: femoral heads, 68; head with neck of femur, 19; radius and ulna, 1; lower femur, knee joint, lower leg and foot bones, 4; and skull bone, 1. All grafts were subjected to aerobic and anaerobic bacterial cultures, as well as fungal cultures. Microbiological contamination was observed in 18/93 (19.35%). All culture positive bones were discarded. Bone grafts issued from the bank and transplanted were 51/93 (54.8%) in all. Bone grafts were used in a variety of tumor and non-tumor orthopaedic procedures in CHK. Nine bone grafts were donated to the other hospitals to be used for revision total hip replacement and tumor surgeries. There were no service charges. Two patients (3.92%) developed infections postoperatively, one superficial and one deep. No other complications were noted. This is the preliminary report on the establishment and functioning of a bone bank in a public sector hospital in Pakistan. The favorable outcome has inculcated confidence in orthopedic surgeons for greater use of bone allografts for a variety of indications in this country.

From Digital to Computational Pathology and Integrated Diagnostics: The Future of Histopathology

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Clinicopathologic Features and the Association with Short-Term Outcome of Primary Membranous Nephropathy in Children: A Single-Center Study from Pakistan

Membranous nephropathy (MN) is an uncommon cause of steroid-resistant nephrotic syndrome in children. Our study aimed to determine the clinicopathologic features of primary MN in children and their association with short-term outcome. This observational study was conducted from January 2009 to June 2017 at the Pediatric Nephrology Department. A total of 50 children were diagnosed with primary MN. Their clinical, laboratory, and histopathological findings on renal biopsy were recorded. The minimum follow-up was for six months. Clinicopathologic features were correlated with the outcome at the last follow-up. Data analysis was done using IBM SPSS Statistics for Windows software version 20.0. The mean age at onset was 10.92 ± 3.08 years (range: 4-17 years). The male-to-female ratio was 3:1. The serum albumin of ≤2.5 g/dL was seen in 40 patients (80%), hypertension was present in 38 (76%), and heavy proteinuria was seen in 32 children (70%). The mean estimated glomerular filtration rate (eGFR) at presentation was 178.71 ± 0.78 mL/min/1.73 m². At the initial visit, nine children (18.4%) were in chronic kidney disease stage 2 and one (2%) in stage 4. Phospholipase A₂ receptor antibody was present in five (15%) of 32 children tested. At the last follow-up (28 interquartile range: 25.5 months), 11 children (26%) were in complete remission and 25 (66%) had achieved partial remission. The mean eGFR had reduced to 145.84 ± 78.05 mL/min/1.73 m². Patients with normal initial eGFR were more likely to go into remission (P = 0.001). The short-term outcome of childhood primary MN is relatively good in our setup. A multicenter collaborative study is required to determine prognostic factors and to standardize treatment in this uncommon nephropathy.

COVID-19 and Kidney Disease: Update on Epidemiology, Clinical Manifestations, Pathophysiology and Management

Acute kidney injury (AKI) is relatively common in critically ill coronavirus disease 2019 (COVID-19) patients and it increases mortality and prolongs hospital stay. This article aimed to investigate the history, virology, epidemiology, clinical manifestations, pathophysiology and management of COVID-19 disease, in general, and the pathogenetic mechanisms of severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV2)-induced kidney damage, in particular. Keywords like SARS-CoV2, COVID-19, renal impairment, sepsis, viremia, etc. were used to find relevant publications from PubMed, Scopus, Google Scholar, and clinical trials registry websites. According to different studies, kidney involvement in COVID-19 typically occurs in patients who develop acute respiratory distress syndrome (ARDS) or multiorgan failure. The kidney damage in COVID-19 has been shown to be multifactorial, involving direct viral infection, indirect injury by sepsis, hemodynamic alterations, cytokine storm, disseminated intravascular coagulation and other unknown mechanisms. The presence in kidney of angiotensin-converting enzyme 2 (ACE2), a receptor for the virus, has been proven, but few cases of direct viral presence in kidney tissue have been published. Therefore, further studies are needed to investigate the exact mechanisms underlying kidney impairment. Since the development of AKI is one of the important risk factors for mortality in COVID-19 patients, optimal management of AKI may improve the outcomes. Key Words: Acute kidney injury, Angiotensin-converting enzyme, Sepsis, Cytokine storm, Kidney replacement therapy, Coronavirus disease 2019.