Utility of Oxford Classification in Post-Transplant Immunoglobulin A Nephropathy

BACKGROUND

With increasing graft survival, post-transplant immunoglobulin A nephropathy (IgAN) has emerged as an important cause of chronic graft dysfunction in renal allograft recipients. We studied the clinico-pathological features of post-transplant IgAN regardless of the primary disease. The aim was to study the usefulness of the Oxford classification in predicting survival.

METHODS

Indication graft biopsy specimens (n = 915) were received during a 10-year period; 27 biopsy specimens from 22 patients were diagnosed as IgAN.

RESULTS

Post-transplant IgAN was seen in 2.6% of biopsy specimens. Mean time to occurrence was 71.6 ± 47.6 months (range, 6.8 months to 16 years), occurring most commonly 4 to 8 years after transplant. Associated rejection was present in 4 biopsies; 72.7% (16/22), 91% (20/22), and 31.8% (7/22) presented with rise in serum creatinine, proteinuria, and hematuria, respectively. Four (21%) patients had nephrotic range proteinuria. Mesangial hypercelullarity (M1), endocapillary hypercelullarity (E1), segmental glomerulosclerosis (S1), and tubulo-interstitial fibrosis (T1-2) was present in 36.6%, 22.7%, 54.5%, and 31.8% biopsies, respectively. The most frequent Haas class was III (n = 7; 29.1%), followed by classes IV and I (n = 5; 20.8% each). The 2- and 5-year graft survival rates were 75% and 56%, respectively. High serum creatinine, low estimated glomerular filtration rate, E1 and T lesions, and degree of interstitial inflammation predicted graft survival. Interestingly, percentage (>25%) of segmentally sclerosed glomeruli and not S1 correlated with graft outcome.

CONCLUSIONS

The Oxford MEST scheme is useful in predicting graft survival in post-transplant IgAN. The degree of interstitial inflammation is also an important feature for determining graft outcomes in post-transplant IgAN.

Slow enteral feeding decreases risk of transfusion associated necrotizing enterocolitis

BACKGROUND

Necrotizing Enterocolitis (NEC) is a multifactorial condition where PRBC transfusion is associated with necrotizing enterocolitis (TANEC) in about a third of all cases of NEC. We have investigated the role of feeding practices in incidence of TANEC. We sought to compare infants diagnosed with TANEC versus infants diagnosed with classic NEC and investigated the effects of a standardized slow enteral feeding (SSEF) protocol on TANEC incidence as well as the effects of SSEF on growth of infants with NEC.

METHODS

We conducted a retrospective cohort study, where medical records of infants born in a tertiary care neonatal intensive care unit (level IIIb) from January 1997 to May 2014 with birth weight < 1500 grams and gestational age≤34 weeks with NEC stage IIa or greater according to the modified Bell's staging were reviewed.

RESULTS

During the study period, 111 infants developed NEC, and 41/111 (37%) were diagnosed with TANEC. Infants with TANEC were smaller, more premature, had higher SNAPPE scores and were more anemic prior to transfusion compared with infants with 'classic NEC'. The severity of NEC did not differ between the two groups, however, infants with TANEC had worse outcomes and longer NICU stays. Introduction of SSEF protocol, led to a significant decrease in TANEC. There was no difference in weight and head circumference of infants in the two groups at 2 years corrected age.

CONCLUSION

SSEF led to a significant reduction in the incidence of TANEC without impairing growth at 2 years corrected age.

Addition of Fentanyl to Ropivacaine Infusion in Continuous Thoracic Paravertebral Infusion Does Not Improve Its Analgesic Effect Following Modified Radical Mastectomy: A Randomized Controlled Trial

A randomized controlled trial was conducted to evaluate pain scores in patients given continuous thoracic paravertebral (TPV) block with ropivacaine alone or with fentanyl in modified radical mastectomy (MRM). Forty female patients ASA classes 1 and 2, aged 18 to 60 years, undergoing MRM were recruited. Preanesthesia with 0.5% ropivacaine, 20 mL, was injected at the T4 TPV space. After 2 hours, patients were randomly assigned to receive a 0.1 mL/kg/h infusion of either 0.2% ropivacaine (group R) or 0.19% ropivacaine plus fentanyl, 2 µg/mL (group RF). Postoperatively, patient-controlled analgesia (PCA) with fentanyl was provided. Visual analog scale (VAS) pain scores at rest and movement were significantly less in group RF at 8 AM on postoperative day 1 (R vs RF: rest: 2 [interquar-tile range, 0-7] vs 1 [0-6]; P = .016; movement: 2.5 [1-8] vs 2 [1-8], P= .042) and on movement 60 minutes postoperatively (R vs RF: 2 [0-9] vs 2 [1-2]; P = .01). Mean total fentanyl consumed via PCA in group R was significantly more (206 ± 31.68 µg vs RF 82.5 ± 35.07 µg, P < .001). Mean total fentanyl consumed via PCA plus TPV infusion was comparable (R: 206 ± 31.68 µg vs RF: 211 ± 25.52 µg, P < .2). Because the mean VAS score was below 3 in all timeframes, addition of fentanyl to ropivacaine in continuous TPV infusion in MRM had no clinical advantage.

The Epidemiology, Clinical Features, and Outcome of Infection-related Glomerulonephritis from East India: A Single Center Experience

Infection-related glomerulonephritis (IRGN) is an example of immunological renal injury due to non-renal infections. With the changing face of IRGN over the years, renal biopsy definitely has an important role to play in differentiating this disease from the other masquerades and helps in prognosticating the long-term outcomes. This prospective study includes biopsy-proven IRGN cases who presented to us from July 2010 to July 2013 from a single center in East India. Of the 168 patients suspected and screened, 137 patients were proved to have IRGN. About 11.67% cases were proven to be immunoglobulin A-IRGN variant. The mean age of presentation was 22.7 ± 15.8 years with a slight male preponderance. A nephrotic range of proteinuria was seen in 13.8% cases and 17.5% patient required renal replacement therapy at presentation. Around 8.75% patients had persistent proteinuria despite normal renal function beyond 6 months of follow-up and 8.09% patients progressed to chronic kidney disease. It may no longer be classified as a glomerular disease with the definite favorable outcome as an important number of patients may progress to chronicity following this disease. Renal biopsy plays an important role in the assessment of prognosis of IRGN and detection of the presence of other underlying glomerulonephritis and should be considered early, especially in patients with atypical presentation.

Embolization of cranial/spinal tumours and vascular malformations with hydrogel microspheres: An experience of 69 cases

Objective: To evaluate polymethyl methacrylate hydrogel microspheres (HMs) as an embolization material in the management of hypervascular craniofacial and spinal lesions.

Material and Methods: Sixty-nine patients with vascular lesions of the craniofacial and spinal regions underwent embolization with HM. The pathologies included craniofacial tumours (n=38), cranial arteriovenous malformations (AVMs) (n=7), dural AVM (n=1), cavernous carotid fistula (n=1), spinal tumours (n=7), spinal AVMs (n=6), orbital lesions (n=4) and scalp AVMs (n=5). Surgery was done in 56 patients. The blood loss at surgery, tumour shrinkage, surgical cleavage and ease of removal of tumour was noted from the records. Histopathology was available in 39 patients. A follow-up of 3 months to 6 years was available in 13 patients in whom embolization was the sole treatment. Surgical and histopathological findings were correlated with angio-embolization findings.

Results: HMs were easy to inject through the microcatheter with good control. Good devascularization was obtained in 61 patients and partial in 8 patients. Two patients developed complications due to presence of anastomoses between intra- and extracranial circulation and 1 patient due to tumor swelling. Histopathology showed presence of HMs in all the lesions, with minimal inflammatory reaction in 2 patients. Patients with spinal lesions treated with embolization only stabilised in neurologic deficits.

Conclusion: HMs are highly suitable as embolization agents in the management of craniofacial and spinal hypervascular lesions.

Whole genome sequencing of emerging multidrug resistant Candida auris isolates in India demonstrates low genetic variation

Candida auris is an emerging multidrug resistant yeast that causes nosocomial fungaemia and deep-seated infections. Notably, the emergence of this yeast is alarming as it exhibits resistance to azoles, amphotericin B and caspofungin, which may lead to clinical failure in patients. The multigene phylogeny and amplified fragment length polymorphism typing methods report the C. auris population as clonal. Here, using whole genome sequencing analysis, we decipher for the first time that C. auris strains from four Indian hospitals were highly related, suggesting clonal transmission. Further, all C. auris isolates originated from cases of fungaemia and were resistant to fluconazole (MIC >64 mg/L).

Anti-glomerular basement membrane crescentic glomerulonephritis: A report from India and review of literature

Anti-glomerular basement membrane (anti-GBM) disease is an autoimmune disease that most commonly presents as rapidly progressive glomerulonephritis with or without pulmonary involvement. It is characterized by the presence of antibodies directed to antigenic targets within glomerular and alveolar basement membranes. This study was performed to evaluate the clinicopathological features and outcome in anti-GBM crescentic glomerulonephritis (CrGN) at a tertiary care center in North India over a period of 9 years (January 2004 to December 2012). A diagnosis of anti-GBM CrGN was made in the presence of >50% crescents, linear deposits of IgG along GBM, and raised serum anti-GBM antibody titer. Of 215 cases of CrGN diagnosed during this period, 11 had anti-GBM CrGN. Anti-GBM CrGN was found at all ages but was most common in the third to fifth decade with no gender predilection (mean age 48 +/- 15 years, 13–67 years). Patients presented with a mean serum creatinine of 10.2 +/- 5.3 mg/dl and sub-nephrotic proteinuria. Pulmonary involvement was present in two patients. Myeloperoxidase-antineutrophil cytoplasmic antibody was positive in two (2/11) elderly patients. Follow-up was available in four patients for a range of 30-270 (mean 99.5 ± 114.5) days, two remained dialysis dependent while two died due to uremia and sepsis. Our findings show that anti-GBM disease is a rare cause of CrGN in India, accounting for only 5% of patients. It usually presents as a renal-limited disease and is associated with a poor renal outcome.

Cytosolic phospholipase A2 regulates alcohol-mediated astrocyte inflammatory responses in HIV-associated neurocognitive disorders

Alcohol (EtOH) abuse and HIV-1 infection remain leading public health problems not only in the United States but also across the world. Alcohol abusers have a significantly greater risk of HIV-1 infection than non-drinkers globally. In the United States, prevalence of EtOH abuse is over two-fold higher in HIV-1-positive individuals than that of the general population. Although alcohol abusers show neurodegeneration, exacerbated neuroinflammation and oxidative damage, the mechanism(s) by which EtOH regulates astrocyte inflammatory responses in HIV-associated neurocognitive disorders is unknown. Thus, we explored signaling pathway(s) involved in EtOH-mediated activation of human astrocytes with HIV-1 and subsequent alterations in their inflammatory functions. Alcohol exposure altered the morphology of astrocytes, proinflammatory responses and induced cytotoxicity in a dose-dependent manner. Time-dependent changes were also evaluated. EtOH and HIV-1 cotreatment decreased cell viability and proliferation, while increasing apoptosis and mitochondrial depolarization. EtOH and HIV-1 together increased the levels of proinflammatory molecules, interleukin-1β, tumor necrosis factor-α, CXCL8, tissue inhibitor of metalloproteinases-1 and more importantly, arachidonic acid, a known downstream target of cytosolic phospholipase A₂ (cPLA₂). Consistent with this observation, phospho-cPLA₂ levels were augmented in HIV-1 and EtOH cotreatment as compared with HIV-1 or EtOH alone. Cyclooxygenase 2 was upregulated as measured by real-time PCR and western blot, whereas cotreatment of HIV-1 and EtOH decreased cytochrome P450-2E1 levels as compared with EtOH alone. Furthermore, we confirmed that blocking cPLA₂ with arachidonyl tri floro methyl ketone, a cPLA₂-specific inhibitor, effectively prevented cPLA₂ phosphorylation and downstream outcomes. Thus, the present findings suggest that cPLA₂ has a critical role in alcohol and HIV-induced astrocyte inflammation. In the future, cPLA₂ inhibitors may present novel therapeutic tools to treat alcohol abuse and HIV-associated neurocognitive disorder comorbidity.

Verminoside mediates life span extension and alleviates stress in Caenorhabditis elegans

The discovery of bioactive molecules modulating aging in living organism promotes development of natural therapeutics for curing age-related afflictions. The progression in age-related disorders can be attributed to increment in intracellular reactive oxygen species (ROS) and oxidative stress level. To this end, we isolated an iridoid verminoside (VMS) from Stereospermum suaveolens (Roxb.) DC. and evaluated its effect on Caenorhabditis elegans. The present study delineates VMS-mediated alteration of intracellular ROS, oxidative stress, and life span in C. elegans. The different tested doses of VMS (5 μM, 25 μM, and 50 μM) were able to enhance ROS scavenging and extend mean life span in C. elegans. The maximal life span extension was observed in 25 μM VMS, that is, 20.79% (P < 0.0001) followed by 9.84% (P < 0.0001) in 5 μM VMS and 8.54% (P < 0.0001) in 50 μM VMS. VMS was able to alleviate juglone-induced oxidative stress and enhanced thermotolerance in worms. The stress-modulating and ROS-scavenging potential of VMS was validated by increment in mean survival by 29.54% (P < 0.0001) in VMS-treated oxidative stress hypersensitive mev-1 mutant strain. Furthermore, VMS modulates expression of DAF-16 (a FoxO transcription factor) promoting stress resistance and longevity. Altogether, our results suggest that VMS attenuates intracellular ROS and stress (oxidative and thermal) level promoting longevity. The longevity and stress modulation can be attributed to VMS-mediated alterations in daf-16 expression which regulates insulin signaling pathway. This study opens doors for development of phytomolecule-based therapeutics for prolonging life span and managing age-related severe disorders.

Comparative outcome of arthroscopic release for frozen shoulder in patients with and without diabetes

Our aim was to compare the outcome of arthroscopic release for frozen shoulder in patients with and without diabetes. We prospectively compared the outcome in 21 patients with and 21 patients without diabetes, two years post-operatively. The modified Constant score was used as the outcome measure. The mean age of the patients was 54.5 years (48 to 65; male:female ratio: 18:24), the mean pre-operative duration of symptoms was 8.3 months (6 to 13) and the mean pre-operative modified Constant scores were 36.6 (standard deviation (sd) 4.6) and 38.4 (sd 5.7) in the diabetic and non-diabetic groups, respectively. The mean modified Constant scores at six weeks, six months and two years post-operatively in the diabetics were 55. 6 (sd 4.7), 67. 4 (sd 5.6) and 84. 4 (sd 6.8), respectively; and in the non-diabetics 66.8 (sd 4.5), 79.6 (sd 3.8) and 88.6 (sd 4.2), respectively. A total of 15 (71%) of diabetic patients recovered a full range of movement as opposed to 19 (90%) in the non-diabetics. There was significant improvement (p < 0.01) in the modified Constant scores following arthroscopic release for frozen shoulder in both groups. The results in diabetics were significantly worse than those in non-diabetics six months post-operatively (p < 0.01) with a tendency towards persistent limitation of movement two years after operation. These results may be used when counselling diabetic patients for the outcome after arthroscopic treatment of frozen shoulder.

Depression and anxiety as potential correlates of post-transplantation renal function and quality of life

The objective of this study was to determine anxiety and depression and its relationship with quality of life (QOL) in renal transplant (RT) recipients. A total of 105 consecutive patients were assessed cross-sectionally at least 3 months after RT. Hospital Anxiety and Depression Scale was applied to assess anxiety and depression. QOL was assessed through the abbreviated version of World Health Organization QOL scale. Patients’ awareness of illness and treatment was assessed through Structured Interview for Renal Transplantation. Nine (8.57%) patients had syndromal anxiety and 9 (8.57%) had syndromal depression. Both these groups had significantly lower scores in almost all domains of QOL compared with their non-anxious and non-depressed counterparts. There were a higher number of hospitalizations and episodes of complication or rejection in post-RT patients with anxiety as compared to those without (P = 0.001). Syndromal depression and anxiety are associated with poor QOL and syndromal anxiety is associated with significantly higher number of hospitalizations, rejections and complications in post-RT patients.

Formation of lysozyme oligomers at model cell membranes monitored with sum frequency generation spectroscopy

A growing number of studies suggest that the formation of toxic oligomers, precursors of amyloid fibrils, is initiated at the cell membrane and not in the cytosolic compartments of the cell. Studies of membrane-induced protein oligomerization are challenging due to the difficulties of probing small numbers of proteins present at membrane surfaces. Here, we employ surface-sensitive vibrational sum frequency generation (VSFG) to investigate the secondary structure of lysozyme at the surface of lipid monolayers. We investigate lysozyme aggregation at negatively charged 1,2-dipalmitoyl-sn-glycero-3-(phospho-rac-1-glycerol) (DPPG) lipid monolayers under different pH conditions. The changes in the molecular vibrations of lipids, proteins, and water as a function of pH and surface pressure allow us to simultaneously monitor details of the conformation state of lysozyme, the organization of lipids, and the state of lipid-bound water. At pH = 6 lysozyme induces significant disordering of the lipid layer, and it exists in two states: a monomeric state with a predominantly α-helix content and an oligomeric (za-mer) state. At pH ≤ 3, all membrane-bound lysozyme self-associates into oligomers characterized by an antiparallel β-sheet structure. This is different from the situation in bulk solution, for which circular dichroism (CD) shows that the protein maintains an α-helix conformation, under both neutral and acidic pH conditions. The transition from monomers to oligomers is also associated with a decreased hydration of the lipid monolayer resulting in an increase of the lipid acyl chains ordering. The results indicate that oligomerization requires cooperative action between lysozyme incorporated into the lipid membrane and peripherally adsorbed lysozyme and is associated with the membrane dehydration and lipid reorganization. Membrane-bound oligomers with antiparallel β-sheet structure are found to destabilize lipid membranes.

Low Molecular Weight Antioxidants (LMWA) and their Orchestration

Every day we hear more and more about free radicals and how they are linked with innumerable diseases and health conditions from ageing to muscular degeneration and even some forms of cancer. The problem is not in knowing that these microscopic enemies exist. We know that they do! The problem is how to fight them so that they are rendered harmless. Under normal metabolic conditions each cell of human body is exposed to about 1010 molecules of superoxide anions (primary free radical) each day. For a person weighing 150 pounds, this amounts to about 4 pounds of superoxide per year, a substantial amount! Once formed, superoxide can react through catalytic pathways in the cell to form many other reactive oxygen/nitrogen species (ROS/RNS). The antioxidant defense system in the human body is extensive and consists of multiple layers, which protect against different types of ROS/RNS. Many of the biological effects of antioxidants appear to be related to their ability not only to scavenge the deleterious free radicals but also to modulate cell signalling pathways.   Nepal Journal of Medical Sciences | Volume 02 | Number 02 | July-December 2013 | Page 171-180 DOI: http://dx.doi.org/10.3126/njms.v2i2.8971  

Novel mutations in typical and atypical genetic loci through exome sequencing in autosomal recessive cerebellar ataxia families

Nearly a thousand mutations mapping to 60 different loci have been identified in cerebellar ataxias. However, almost 50% of the cases remain genetically uncharacterized and there is a difference in prevalence as well as in the phenotypic spectrum of ataxia among various geographical regions. This poses a challenge for setting up a genetic panel for screening ataxia. In our ataxic cohort of 1014 families, 61% are genetically uncharacterized (UC). We investigated the potential of whole exome sequencing in conjunction with homozygosity mapping (HM) to delineate the genetic defects in three uncharacterized families with recessive inheritance each manifesting some unusual phenotype: (i) infantile onset ataxia with hearing loss (IOAH), (ii) Juvenile onset cerebellar ataxia with seizures (JCS) and (iii) Friedreich ataxia-like (FA-like). We identified a novel missense mutation in c10orf2 in the family with IOAH, compound heterozygous mutations in CLN6 in the family with JCS and a homozygous frame-shift mutation in SACS in the FA-like patient. Phenotypes observed in our families were concordant with reported phenotypes of known mutations in the same genes thus obviating the need for functional validation. Our study revealed novel variations in three genes, c10orf2, CLN6, and SACS, that have so far not been reported in India. This study also demonstrates the utility of whole exome screening in clinics for early diagnosis.

The spectrum of glomerular diseases in a single center: A clinicopathological correlation

We report the spectrum of biopsy-proven glomerular disease (GD) in a single center in Eastern India. Medical records of 666 patients with biopsy-proven GD over a period of 2 years from July 2010 to July 2012 were retrospectively analyzed. The clinical, laboratory, and histological data were recorded. All biopsy specimens were examined by the same pathologist with light and immunofluorescence microscopy. Electron microscopic analysis was performed only in selected cases. Histologic spectrum of various GDs was studied along with its correlation with the clinical and laboratory parameters. The clinical diagnosis was nephrotic syndrome (NS) in 410 (61.56%), rapidly progressive renal failure/glomerulonephritis in 130 (19.52%), subnephrotic proteinuria/asymtomatic urinary abnormalities in 52 (7.81%), acute kidney injury/acute nephritic syndrome in 40 (6.01%), and macroscopic hematuria in 4 (0.6%) patients. Male: Female ratio was 1.05; 27.92% (n = 186) were < 18 years, 68.47% (n = 456) were 18–59 years, and 3.6% (n = 24) were ≥ 60 years of age. The most common GD was minimal change disease (MCD) (20.12%, n = 134); others were focal segmental glomerulosclerosis (FSGS) (18.02%, n = 15.32%), lupus nephritis (LN) (15.32%, n = 102), membranous nephropathy (MN) (12.01%, n = 80), and IgA nephropathy (IgAN) (8.11%, n = 54). Primary GD was present in 79.13% (n = 527) and common histologies were MCD (25.42%), FSGS (22.58%), MN (14.42%), and IgAN (10.25%). Secondary GD was present in 20.87% (n = 139), with the most common being LN (73.38%, n = 102). Among the NS (n = 410), the most common GD was MCD (31.46%), followed by FSGS (25.6%), MN (15.58%), LN (7.8%), IgAN (6.09%), and membranoproliferative glomerulonephritis (4.88%). FSGS was the most common primary GD in adults, MCD in children, and MN in the elderly patients. The spectrum of GD varies according to the area of study and changes over time. A biopsy registry is needed for documenting this variation.

Cytomorphology of gastrointestinal stromal tumors and extra-gastrointestinal stromal tumors: A comprehensive morphologic study

BACKGROUND

The term gastrointestinal stromal tumors (GIST) is used to refer to those mesenchymal neoplasms of the gastrointestinal tract (GIT) which express CD117, a c-kit proto-oncogene protein.

AIMS

To study the cytological features of GIST and extra-gastrointestinal stromal tumors (EGIST), to correlate them with histology and to determine cytological indicators of malignancy.

MATERIALS AND METHODS

Cytological smears from patients diagnosed as GIST/EGIST on histology were retrieved. From Jan 2000 to July 2010, 26 GIST (13 primary, 12 metastatic, one recurrent) and seven EGIST (5 primary, one metastatic, one recurrent) cytologic samples from 27 patients were identified.

RESULTS

The patients included 20 males and 7 females with a mean age of 50.6 years. Tumor sites included stomach (5), duodenum (5), ileum (2), ileocecal (1), rectum (1), liver (9), retroperitoneum (5), mesentery (1), subcutaneous nodule (1), supra-penile lump (1), ascitic (1) and pleural fluids (1). The smears were cellular with cohesive to loosely cohesive thinly spread irregularly outlined cell clusters held together by thin calibre vessels. The tumor cells were mild to moderately pleomorphic, spindle to epithelioid with variable chromatin pattern and variable cytoplasm. Cellular dyscohesion, nuclear pleomorphism, intranuclear pseudoinclusions, prominent nucleoli, mitosis and necrosis were more prominent in malignant, metastatic and recurrent tumors.

CONCLUSIONS

GISTs show a wide spectrum of cytological features and the presence of mitosis, necrosis and nuclear pleomorphism can help in prediction of malignant behavior. Further, cytology is a very useful screening modality in patients of GIST and EGIST to detect early recurrence and metastasis at follow-up.