A Case Control Study of Risk Assessment of Diabetes and Nephropathy with eNOS (T786C and 27bp VNTR) Gene Polymorphisms

OBJECTIVES

To determine the association of eNOS (T786C and 27bp VNTR) gene polymorphism with the risk of type II diabetes mellitus and diabetic nephropathy in North India.

METHODS

The prospective case control study was conducted over a period of 18 months. A total of 100 patients of Type 2 Diabetes Mellitus (A1: 50 cases without Diabetic nephropathy-DN and 50 cases with DN) aged 18-75 years and 50 healthy adults as control (Group B) were included. The endothelial nitric oxide gene variant (T786C and 27bp VNTR) genotypes and alleles were studied. Odds ratio with 95% CI was calculated for genotype and alleles for the occurrence of diabetes and DN. p value of less than 0.05 was considered as significant.

RESULTS

With Bb as reference(27bp VNTR), the odds ratio for Ab in the three groups (A1,A2,B) was 2.243, 1.545 and 0.746 respectively; and for Aa was 3.043, 3.058 and 1.878 respectively; with TT as reference (T786C), it was 1.573, 1.55 and 1.055 respectively for TC; and for CC it was 2.121, 2.063 and 2.348 respectively. The OR was comparable among the study groups and control for all genotypes and alleles (p>0.05).

CONCLUSION

In conclusion, there was a trend towards higher predilection of DN with aa genotype and a allele in 27 VNTR, CC genotype and C allele of -786T>C polymorphism however it was not found to be statistically significant. Future large sample studies are required to account for the ethnic variation for a clearer association of the genes and their associated risk with Diabetes and its complications.

Chronic Kidney Disease of Unknown Etiology in India: What Do We Know and Where We Need to Go

Chronic kidney disease (CKD) not associated with known risk factors has been reported from parts of India and is presumed to be similar to CKD of unknown etiology (CKDu) that has been described from Central America. The reports from India have been fragmented without clear description of the disease phenotype or its determinants. This paper summarizes the current state of knowledge around CKDu in India based on a review of literature, multi-stakeholder consultation, and a survey of Indian nephrologists. We also contacted individual research groups to solicit data. Our findings suggest that that CKDu is reported from most regions in India; however, it is interpreted differently from the phenotype described from Central America and Sri Lanka. The differences include lack of a clear demographic or occupation group, older age of affected participants, and presence of mild hypertension and low-grade proteinuria. Well-designed prospective field studies with appropriate diagnostic workup are needed to establish the disease burden and identify etiologies, along with socioeconomic and health consequences, the intersection with the environment, and the public health response. Community-based research should phenotype the entire CKD population rather than be restricted to cases with presumed CKDu based on predefined criteria. Guidelines are needed for clinical evaluation, referral, management, and harmonization of clinical documentation and health records. More data are needed to support the existence of a unique CKDu phenotype in India.

A Systematic Study of the Prevalence and Risk Factors of CKD in Uddanam, India

Introduction

Despite reports of a high prevalence of chronic kidney disease (CKD) from the coastal Uddanam region of Andhra Pradesh, India, there are no accurate data on the distribution of kidney function abnormalities and CKD risk factors in this region.

Methods

A total of 2419 participants were recruited through multistage cluster random sampling from 67 villages. Serum creatinine and urine protein creatinine ratio were measured using validated methodologies. All abnormal estimated glomerular filtration rate (eGFR) and urine protein creatinine ratio values were reconfirmed after 3 months. A range of sociodemographic factors were evaluated for their association with CKD using Poisson regression.

Results

Of 2402 eligible subjects (mean ± SD age, 45.67 ± 13.29 years; 51% female), 506 (21.07%) had CKD (mean ± SD age, 51.79 ± 13.12 years; 41.3% female). A total of 246 (10.24%) had eGFR <60 ml/min/1.73 m², whereas 371 (15.45%) had an elevated urine protein creatinine ratio (>0.15 g/g). The poststratified estimates, adjusted for age and sex distribution of the region for CKD prevalence, are 18.7% (range, 16.4%–21.0%) overall and 21.3% (range, 18.2%–24.4% ) and 16.2% (range, 13.7%–18.8%) in men and women, respectively. Older age, male sex, tobacco use, hypertension, and family history of CKD were independently associated with CKD. Compared with those with higher eGFR, those with eGFR <60 ml/min/1.73m² were older, were more likely to be uneducated, manual laborers/farmers, or tobacco users, and were more likely to have hypertension, a family history of CKD, a diagnosis of heart disease, and a lower body mass index. Among those with low eGFR, there was no difference between those with urine protein creatinine ratio <0.15 or >0.15, except a lower frequency of males in the former.

Conclusion

We confirmed the high prevalence of CKD in the adult population of Uddanam. The cause was not apparent in a majority. Subjects with a low eGFR with or without elevated proteinuria were phenotypically distinct from those with proteinuria and preserved eGFR. Our data suggest the need to apply a population-based approach to screening and prevention and studies to understand the causes of CKD in this region.

Study to Test and Operationalize Preventive Approaches for CKD of Undetermined Etiology in Andhra Pradesh, India

INTRODUCTION

High prevalence of chronic kidney disease (CKD) not associated with known risk factors has been reported from coastal districts of Andhra Pradesh. The Study to Test and Operationalize Preventive Approaches for Chronic Kidney Disease of Undetermined Etiology in Andhra Pradesh (STOP CKDu AP) aims to ascertain the burden (prevalence and incidence) of CKD, the risk factor profile, and the community perceptions about the disease in the Uddanam area of Andhra Pradesh.

METHODS

Study participants will be sampled from the Uddanam area using multistage cluster random sampling. Information will be collected on the demographic profile, occupational history, and presence of conventional as well as nonconventional risk factors. Glomerular filtration rate (GFR) will be estimated using the Chronic Kidney Disease Epidemiology Collaboration equation, and proteinuria will be measured. All abnormal values will be confirmed by repeat testing after 3 months. Cases of CKD not associated with identified etiologies will be identified. Biospecimens will be stored to explore future hypotheses. The entire cohort will be followed up every 6 months to determine the incidence of CKD and to identify risk factors for decline in kidney function. Qualitative studies will be performed to understand the community perceptions and expectations with respect to the interventions.

IMPLICATIONS

CKD is an important public health challenge in low- and middle-income countries. This study will establish the prevalence and determine the incidence of CKD not associated with known risk factors in a reported high-burden region, and will provide insights to help design targeted health systems responses. The findings will contribute to the policy development to tackle CKD in the region and will permit international comparisons with other regions with similar high prevalence.

The 2017 International Joint Working Group White Paper by INDUSEM, the Emergency Medicine Association and the Academic College of Emergency Experts on Establishing Standardized Regulations, Operational Mechanisms, and Accreditation Pathways for Education and Care Provided by the Prehospital Emergency Medical Service Systems in India

The government of India has done remarkable work on commissioning a government funded prehospital emergency ambulance service in India. This has both public health implications and an economic impact on the nation. With the establishment of these services, there is an acute need for standardization of education and quality assurance regarding prehospital care provided. The International Joint Working Group has been actively involved in designing guidelines and establishing a comprehensive framework for ensuring high-quality education and clinical standards of care for prehospital services in India. This paper provides an independent expert opinion and a proposed framework for general operations and administration of a standardized, national prehospital emergency medical systems program. Program implementation, operational details, and regulations will require close collaboration between key stakeholders, including local, regional, and national governmental agencies of India.

Genetic association of NAD(P)H quinone oxidoreductase (NQO1*2) polymorphism with NQO1 levels and risk of diabetic nephropathy

NAD(P)H quinone oxidoreductase 1 (NQO1) catalyzes reactions having a cyto-protective effect against redox cycling and oxidative stress. A single base polymorphism (C/T) at nucleotide 609 of the NQO1 gene impairs the stability and function of its protein. Its role in the development of diabetic nephropathy (DN) has not been deciphered. Therefore, this study aimed to evaluate the association of NQO1*2 (rs1800566) polymorphism with plasma NQO1 levels and DN. This study screened 600 participants including healthy controls (HC), type 2 diabetes mellitus without complications (T2DM) and diabetic nephropathy (DN): 200 each for studying NQO1*2 gene polymorphism using the PCR-RFLP. Plasma NQO1 levels were measured by ELISA. Analysis of variance and logistic regression were used to evaluate the association of NQO1 polymorphism with plasma NQO1 levels and DN. The allelic frequencies of NQO1*1/NQO1*2 were 0.88/0.12 in HC, 0.765/0.235 in T2DM and 0.65/0.35 in DN. Carriers of the NQO1*2 allele had significantly lower plasma NQO1 levels (p<0.05) and revealed higher risk towards the development of DN (OR=1.717, p=0.010). NQO1*2 SNP is a functional polymorphism having a significant effect on NQO1 levels. Our results indicate that NQO1*2 genotype may increase susceptibility to DN in north Indian subjects with T2DM.

Association of NFKB1 gene polymorphism (rs28362491) with levels of inflammatory biomarkers and susceptibility to diabetic nephropathy in Asian Indians

AIM

To investigate the association of NFKB1 gene -94 ATTG insertion/deletion (rs28362491) polymorphism with inflammatory markers and risk of diabetic nephropathy in Asian Indians.

METHODS

A total of 300 subjects were recruited (100 each), normoglycemic, (NG); type 2 diabetes mellitus (T2DM) without any complications (DM) and T2DM with diabetic nephropathy [DM-chronic renal disease (CRD)]. Analysis was carried out by polymerase chain reaction-restriction fragment length polymorphism and ELISA. Pearson’s correlation, analysis of variance and logistic regression were used for statistical analysis.

RESULTS

The allelic frequencies of -94 ATTG insertion/deletion were 0.655/0.345 (NG), 0.62/0.38 (DM) and 0.775/0.225 (DM-CRD). The -94 ATTG ins allele was associated with significantly increased levels of urinary monocyte chemoattractant protein-1 (uMCP-1); uMCP-1 (P = 0.026) and plasma tumor necrosis factor-alpha (TNF-α); TNF-α (P = 0.030) and almost doubled the risk of diabetic nephropathy (OR = 1.91, 95%CI: 1.080-3.386, P = 0.025).

CONCLUSION

-94 ATTG ins/ins polymorphism might be associated with increased risk of developing nephropathy in Asian Indian subjects with diabetes mellitus.

The 2017 Academic College of Emergency Experts and Academy of Family Physicians of India position statement on preventing violence against health-care workers and vandalization of health-care facilities in India

There have been multiple incidents where doctors have been assaulted by patient relatives and hospital facilities have been vandalized. This has led to mass agitations by Physicians across India. Violence and vandalism against health-care workers (HCWs) is one of the biggest public health and patient care challenge in India. The sheer intensity of emotional hijack and the stress levels in both practicing HCWs and patient relative's needs immediate and detail attention. The suffering of HCWs who are hurt, the damage to hospital facilities and the reactionary agitation which affects patients who need care are all together doing everything to damage the delivery of health care and relationship between a doctor and a patient. This is detrimental to India where illnesses and Injuries continue to be the biggest challenge to its growth curve. The expert group set by The Academic College of Emergency Experts and The Academy of Family Physicians of India makes an effort to study this Public Health and Patient Care Challenge and provide recommendations to solve it.

Association of glutathione-S-transferase with patients of type 2 diabetes mellitus with and without nephropathy

STATEMENTS OF THE PROBLEM

Hyperglycemia induced oxidative stress is implicated as a contributor to the onset and progression of type 2 diabetes mellitus (T2DM) and its complications like diabetic nephropathy (DN). Glutathione-S-transferase (GST) is primarily involved in the neutralization of reactive oxygen species (ROS) by enzymatic conjugation with the scavenger peptide glutathione (GSH). Therefore, present study was aimed to evaluate the role of GST along with oxidative stress markers and their correlation in patients with Type 2 diabetes mellitus with and without nephropathy.

METHODS

This study comprised of 300 participants divided into three groups of 100 each: healthy controls (HC), T2DM without complications and DN. Plasma GST, malondialdehyde (MDA), reduced GSH levels and ferric reducing ability of plasma (FRAP) were estimated spectrophotometrically.

RESULTS

Highest GST levels was observed in T2DM which was significantly higher (p<0.05) as compared to DN and HC. However, GSH and FRAP levels were found to be significantly lowest whereas MDA levels were significantly highest in DN as compared to T2DM and HC. GST showed a significant negative correlation with GSH, FRAP and positive correlation with MDA in both patients groups.

CONCLUSIONS

Highest activity of GST in T2DM might be as a compensatory mechanism in response to oxidative stress. GST is found to have significant negative association with decreased GSH. Altered redox milieu in DN collectively conspire to increase the risk of renal damage in T2DM.

Association of tumor necrosis factor (TNF) promoter polymorphisms with plasma TNF-α levels and susceptibility to diabetic nephropathy in North Indian population

AIM

The concept of diabetic nephropathy (DN) as a metabolic disease is now being replaced by chronic low-grade inflammatory disease. Tumor necrosis factor-alpha (TNF-α) is a proinflammatory cytokine which plays an important role in the pathogenesis and clinical outcome of DN. Therefore, this work was planned to evaluate the association of -863C/A (rs1800630) and -1031T/C (rs1799964) polymorphisms in TNF gene with plasma TNF-α levels and DN among subjects with type 2 diabetes (T2DM) in a population from North India.

METHODS

Age and sex matched 100 healthy controls (HC), 100 T2DM subjects without nephropathy (DM) and 100 subjects with DN were screened for above polymorphisms using the PCR-RFLP methods. Plasma TNF-α levels were measured by ELISA. Analysis of variance and logistic regression were used to associate individual polymorphisms with plasma TNF-α levels and DN.

RESULTS

The allelic frequencies of -863C/A were 0.86/0.14 in HC, 0.72/0.23 in DM and 0.84/0.16 in DN, and that of -1031T/C were 0.89/0.11 in HC, 0.95/0.05 in DM and 0.80/0.20 in DN. The carriers of -863A allele had significantly lower plasma TNF-α levels (p<0.05). The -863C/A (OR=0.439, 95% CI=0.244-0.789, p=0.006) and -1031T/C (OR=3.0, 95% CI=1.355-6.642, p=0.007) were strongly associated with risk of development of DN.

CONCLUSIONS

-863C/A was associated with low whereas -1031T/C with high TNF-α levels. The, results suggest that -863C/A polymorphism might be protective whereas -1031T/C may be associated with increased risk for DN in subjects with T2DM from North India.

Academic College of Emergency Experts in India's INDO-US Joint Working Group and OPUS12 Foundation Consensus Statement on Creating A Coordinated, Multi-Disciplinary, Patient-Centered, Global Point-of-Care Biomarker Discovery Network

Biomarker science brings great promise to clinical medicine. This is especially true in the era of technology miniaturization, rapid dissemination of knowledge, and point-of-care (POC) implementation of novel diagnostics. Despite this tremendous progress, the journey from a candidate biomarker to a scientifically validated biomarker continues to be an arduous one. In addition to substantial financial resources, biomarker research requires considerable expertise and a multidisciplinary approach. Investigational designs must also be taken into account, with the randomized controlled trial remaining the “gold standard”. The authors present a condensed overview of biomarker science and associated investigational methods, followed by specific examples from clinical areas where biomarker development and/or implementation resulted in tangible enhancements in patient care. This manuscript also serves as a call to arms for the establishment of a truly global, well-coordinated infrastructure dedicated to biomarker research and development, with focus on delivery of the latest discoveries directly to the patient via point-of-care technology.

Increased level of organochlorine pesticides in chronic kidney disease patients of unknown etiology: role of GSTM1/GSTT1 polymorphism

Chronic kidney disease (CKD) of unknown etiology represents about 16% of CKD patients in Indian subcontinents and 10% worldwide. The aetiology of CKD of unknown etiology remains unclear though epidemiological studies indicate the involvement of the environmental toxins. Organochlorine pesticides (OCPs) have been detected in general population in India. It is possible that polymorphism of xenobiotic metabolizing enzymes (XMEs) may play an important role in this process. In this we intend to find out blood levels of OCPs in CKD patients of unknown etiology and to evaluate the consequence of glutathione S-transferase (GST) gene polymorphism on the same. We have assessed 270 CKD patients and 270 age-sex-matched healthy controls for this study. The blood OCP levels were analyzed by gas chromatograph. GSTM1, GSTT1 genotyping were carried out by multiplex PCR. Blood levels of HCH, endosulfan and total pesticides were significantly higher in CKD patients and negatively correlated with eGFR. The combined frequency of GSTM1(-)/GSTT1(-) genotype increased the risk of CKD by 1.8-fold as compared to healthy controls. To find out the dependence of blood OCPs level on genotype, we carried out logistic regression analysis and results revealed that GSTM1(-)/GSTT1(-) genotype associated significantly with a number of OCPs namely γ-HCH, p,p'-DDT and total pesticides. Polymorphism of XMEs not only increased accumulation of pesticides but also aggravates kidney dysfunction as evident from significant decrease in eGFR.

Association of CYP1A1 gene polymorphism with chronic kidney disease: a case control study

CYP1A1 is an important xenobiotic metabolizing enzyme, present in liver and kidney. Expression of CYP1A1 enzyme increases manifold when kidney cells are exposed to nephrotoxins/chemicals leading to oxidative stress-induced cell damage. To study the association of CYP1A1 gene polymorphism in patients of chronic kidney disease with unknown etiology (CKDU), we recruited 334 CKDU patients and 334 age and sex matched healthy controls. CYP1A1*2A and *2C polymorphisms were studied by PCR-RFLP and allele specific-PCR respectively. Subjects carrying at least one mutant allele of CYP1A1*2A (TC, CC) and *2C (AG, GG) were shown to be associated with 1.4-2-fold increased risk of CKDU. Also, genotypic combinations of hetero-/homozygous mutants of CYP1A1*2A (TC, CC) with hetero-/homozygous mutant genotypes of CYP1A1*2C (AG, GG) i.e. TC/AG (p<0.01), TC/GG (p<0.05), CC/AG (p<0.05) and CC/GG (p<0.01) were associated with CKDU with an odd ratio ranging 1.8-3.3 times approximately. This study demonstrates association of CYP1A1 polymorphisms with CKDU.

Association between high molecular weight apolipoprotein isoforms and lipoprotein levels in advanced chronic kidney disease and the effect of hemodialysis

To explore the association between high molecular weight apo(a) isoforms and lipoprotein(a) [Lp(a)] in chronic kidney disease (CKD) and the effect of maintenance hemodialysis (MHD), plasma Lp(a) and apo(a) isoforms were determined in age and sex-matched CKD stage 4 and stage 5 patients (repeated after 4 weeks of MHD) and healthy controls (n = 18). Median Lp(a) increased with severity of CKD. Upon HMW apo(a) isoform stratification, Lp(a) in S₂ isoform group was 37.6 mg/dl in CKD stage 4 and 64.0 mg/dl in stage 5 (P < 0.024 and P < 0.001 vs. controls), whereas in S₃ + S₄ group there was no significant increase. Following MHD, Lp(a) also decreased significantly only in the S₂ group. Increase in Lp(a) in CKD patients with HMW apo(a) isoforms is mainly restricted to S₂ isoform group, furthermore, decrease in Lp(a) levels in response to MHD is also seen in this group only.

Association of glutathione S-transferase M1 and T1 gene polymorphism with oxidative stress in diabetic and nondiabetic chronic kidney disease

BACKGROUND AND OBJECTIVE

Glutathione S-transferases (GSTs) belong to a family of ubiquitous and multifunctional enzymes that work as one of the endogenous antioxidants in our body. This study was designed to look into the association of GST polymorphism with oxidative stress in both diabetic and nondiabetic chronic kidney disease (CKD).

DESIGN AND METHODS

Three groups of patients (50 in each): diabetics without CKD (DM), diabetic CKD (DM-CKD), and nondiabetic CKD (NDM-CKD) and 50 age- and sex-matched healthy controls were recruited. Genotyping was done for GSTM1 and GSTT1 genes using a multiplex polymerase chain reaction. Serum GST and malondialdehyde (MDA) as a marker of oxidative stress were measured spectrophotometrically.

RESULTS

Based on genotyping, subjects were categorized as GSTM1+/GSTT1+, GSTM1-/GSTT1+, GSTM1+/GSTT1-, and GSTM1-/GSTT1-. Serum GST levels were lower among subjects with deletion in one/both GST genes, whereas MDA levels were found to be correspondingly raised. A negative correlation for MDA versus GST levels was observed among genotypes with one/both gene deletions. Presence of GSTM1+/GSTT1- and GSTM1-/GSTT1- was significantly higher among patients with CKD in both diabetics and nondiabetics.

INTERPRETATIONS AND CONCLUSIONS

GSTM1 and GSTT1 deletions singly or together were associated with lower GST levels and higher oxidative stress in both diabetic and nondiabetic CKD. Interestingly, GSTT1 deletion appears to be associated with both diabetic and nondiabetic CKD irrespective of the GSTM1 status.

Foe turned friend: multiple functional roles attributable to hyper-activating stem cell factor receptor mutant in regeneration of the haematopoietic cell compartment

OBJECTIVES

Stem cell factor receptor, c-kit, is considered to be the master signalling molecule of haematopoietic stem cells. It develops the orchestral pattern of haematopoietic cell lineages, seen by its varying degree of omnipresence in progenitors, lineage committed and mature cells. We have investigated the effect of over-expressing c-kit on early recovery of the haematopoietic compartment, in irradiated hosts.

MATERIALS AND METHODS

Normal bone marrow cells (BMCs) were transfected with Kit(wt) (wild-type c-kit) or its variant Kit(mu) (asp814tyr) by electroporation. Lethally irradiated mice were transplanted with normal or transfected congeneic BMCs. The effect of ectopic expression of c-kit on haematopoietic cell recovery was determined by analysing donor-derived cells. Furthermore, effects of both types of c-kit over-expression on progenitor and lineage-committed cells were examined by flow cytometric analysis of Sca-1 and lineage-committed (Lin(+)) cells respectively.

RESULTS

Hyper-activating Kit(mu) significantly improved recovery of the haematopoietic system in irradiated hosts. In vivo results showed that the donor-derived c-kit(+) cell population was increased to more than 3-fold in the case of Kit(mu)-transfected cells compared to normal and Kit(wt) over-expressing BMCs. In general, survival of progenitor and committed cell was improved in the Kit(mu) over-expressing system compared to the other two cohorts.

CONCLUSION

These results suggest that recruitment of the hyper-activating variant of c-kit (Kit(mu)) lead to early recovery of the bone marrow of lethally irradiated mice.

The structural insights of stem cell factor receptor (c-Kit) interaction with tyrosine phosphatase-2 (Shp-2): an in silico analysis

BACKGROUND

Stem cell factor (SCF) receptor c-Kit is recognized as a key signaling molecule, which transduces signals for the proliferation, differentiation and survival of stem cells. Binding of SCF to its receptor triggers transactivation, leading to the recruitment of kinases and phosphatases to the docking platforms of c-Kit catalytic domain. Tyrosine phosphatase-1 (Shp-1) deactivates/attenuates 'Kit' kinase activity. Whereas, Asp816Val mutation in the Kit activation loop transforms kinase domain to a constitutively activated state (switch off-to-on state), in a ligand-independent manner. This phenomenon completely abrogates negative regulation of Shp-1. To predict the possible molecular basis of interaction between c-Kit and Shp-1, we have performed an in silico protein-protein docking study between crystal structure of activated c-Kit (phosphorylated c-Kit) and full length crystal structure of Shp-2, a close structural counterpart of Shp-1.

FINDINGS

Study revealed a stretch of conserved amino acids (Lys818 to Ser821) in the Kit activation domain, which makes decisive H-bonds with N-sh2 and phosphotyrosine binding pocket residues of the phosphatase. These H-bonds may impose an inhibitory steric hindrance to the catalytic domain of c-Kit, there by blocking further interaction of the activation loop molecules with incoming kinases. We have also predicted a phosphotyrosine binding pocket in SH2 domains of Shp-1, which is found to be predominantly closer to a catalytic groove like structure in c-Kit kinase domain.

CONCLUSIONS

This study predicts that crucial hydrogen bonding between N-sh2 domain of Shp-1 and Kit activation loop can modulate the negative regulation of c-Kit kinase by Shp-1. Thus, this finding is expected to play a significant role in designing suitable gain-of-function c-Kit mutants for inducing conditional proliferation of hematopoietic stem cells.

Tuberculosis of sternum: three cases with different presentations

Sternum is resistant to infections and thus infrequent site of osteomyelitis. Involvement of sternum by Mycobacterium tuberculosis is rare. We report case of 37-year-old male with isolated tuberculosis of the sternum, a 14-year-old girl with tuberculosis of the sternum and Potts spine and a 55-year-old male with tubercular sinus of the sternum, three different presentations of the same disease.

Effect of Hemodialysis on Cognitive Function in ESRD Patients

BACKGROUND

Uremia is associated with impairment of different cognitive functions. However the pathogenesis of this cognitive dysfunction is unknown.

OBJECTIVE

In this study, long-latency event related potentials (ERPs) were used to assess changes in cortical function due to hemodialysis treatment.

METHODS

In this cross-sectional study, we measured event related potentials in 15 end stage renal disease (ESRD) patients maintained on hemodialysis, two hours before and two hours after they underwent hemodialysis and compared their data with a strictly age and sex matched healthy control group. The P3 was elicited by using standard auditory "odd-ball" paradigm and the data obtained was statistically analyzed (Wilcoxon signed ranks, Mann Whitney).

RESULTS

Before hemodialysis, the patients' P3 latency (347.73 +/- 39.47 ms) was significantly increased as compared with that of healthy control group (308.4 +/- 13.73 ms) (p = 0.001). After hemodialysis, P3 latency of the patients showed a significant decrease (347.73 +/- 39.47 ms to 325.20 +/- 37.15 ms, p = 0.001). P3 latency after dialysis was not significantly different from controls. No significant correlation was noted between various biochemical parameters (hemoglobin, blood urea, creatinine, uric acid and calcium) and P3 latency or amplitude.

CONCLUSIONS

Removal of uremic toxins by hemodialysis leads to an improvement in cognitive processing.

Dual genetic abnormality in the coagulation pathway as a cause of familial thrombophilia

Inherited deficiency of certain factors is responsible for increased tendency to vascular thrombosis; however two genetic defects in the coagulation pathway may coexist and cause recurrent thrombosis. Previously studies of thrombophilia have focused on the identification of single gene defects with the concept that familial thrombophilia is a single gene disorder. Now it has become accepted that familial thrombosis in protein C-deficient families is caused by co-segregation of one or more additional genetic factors that increase the risk of thrombosis. Co-existence of two or more genetic abnormalities increases the risk of thrombotic tendencies in affected persons. Simultaneous presence of factor V Leiden and deficiency of protein C results in higher risk of thrombosis. We report two such cases with additional analysis of the family tree highlighting that dual abnormality results in higher penetrance of the disease among family members.

Glycated hemoglobin--a public health perspective

The burden of diabetes mellitus across the world especially in India is substantial, and much of the morbidity and mortality is due to development of diabetic complications. Control of blood glucose is important to reduce occurrence of these complications. Measurement of glycated haemoglobin values provides valuable information about long term glycemic control, and is recommended for routine monitoring by several clinical guidelines on diabetes. Monitoring and appropriate management have been shown to improve outcomes in patients with diabetes in other parts of the world. However, the adoption of glycated hemoglobin as part of routine monitoring of diabetes patients in India will need to answer issues of availability, affordability and accessibility.

Cognitive impairment in chronic kidney disease

BACKGROUND

Although end-stage renal disease (ESRD) has been associated with cognitive impairment, the relation between lesser degrees of chronic kidney disease (CKD) and cognitive impairment is less well understood. The objective of this study was to assess the cognitive function in patients with varying severity of CKD using P3 event-related potentials (P3ERPs).

METHODS

In this cross-sectional study, 15 neurologically asymptomatic (Mini Mental State Examination >24) patients each of CKD stage 3, 4 and 5 (undialysed) were enrolled. Besides this, 15 healthy controls were also studied. All groups were age and sex matched. Glomerular filtration rate (GFR) was estimated using the Modification of Diet in Renal Disease equation. The P300 was studied in all subjects by using standard auditory 'odd-ball' paradigm and the data obtained were statistically analysed.

RESULTS

We noted significant prolongation of P300 latencies as severity of CKD increased from stage 3 (318.8 +/- 28.98 ms) to stage 4 (357 +/- 24.65 ms) (P < 0.002) and from stage 4 to 5 (388.47 +/- 31.67 ms) (P < 0.01). P300 latency in CKD stage 3 was not found to be significantly different from controls (308.4 +/- 13.73 ms). Significant positive correlation was noted between serum creatinine, blood urea and uric acid with P3 latency. Significant negative correlation was noted between GFR, serum calcium and haemoglobin with P3 latency.

CONCLUSIONS

Increasing severity of CKD is associated with progressive cognitive decline and this may have important clinical consequences.

Phagocytic polymorphonuclear function in patients with progressive uremia and the effect of acute hemodialysis

BACKGROUND

Susceptibility to infections is a major cause of high morbidity and mortality in patients with chronic kidney disease (CKD). Polymorphonuclear leukocytes (PMNs) play a major role in the host defense against various infections. Although the phagocytic function of PMNs in uremic patients has been subjected to repeated evaluation, results have been inconsistent. Also, the effects of progressive uremia and acute hemodialysis (HD) on polymorphonuclear function have been scarcely evaluated.

METHODS

In this study, we assessed the phagocytic index (PI) of PMNs following their uptake of IgG-coated sheep erythrocytes in patients with varying severity of CKD and in healthy controls. In patients with advanced renal failure, the effects of acute HD on PI pre- and post-HD were also studied.

RESULTS

A total of 30 patients with CKD and 15 healthy controls were studied. Patients with CKD were categorized into two groups: mild to moderate renal failure (S. Creatinine 2-6 mg/dL) and advanced renal failure (S. Creatinine >6 mg/dL) (n=15 for each). All three groups were age and sex matched. Patients with advanced renal failure had significantly impaired PI (4.03 +/- 1.15) as compared to patients with mild to moderate renal failure (7.17 +/- 2.62) and normal controls (8.13 +/- 3.31) (p < 0.001 for both). There was a statistically insignificant decline in the PI in patients with mild to moderate RF when compared to controls (7.17 +/- 2.62 versus 8.13 +/- 3.31). In patients with advanced renal failure, acute HD led to a significant improvement in PI (5.52 +/- 1.55 versus 4.03 +/- 1.15, p < 0.01).

CONCLUSION

In patients with CKD, there is a progressive decline in the phagocytic index of the PMNs with increasing severity of uremia. Significant improvement in the phagocytic index following acute hemodialysis suggests the role of a circulating uremic toxin in this PMN dysfunction.

A PROFILE OF WOMEN WITH ALCOHOL RELATED PROBLEMS AT BPKIHS, DHARAN

ABSTRACT

Effect of various antihypertensive drugs on plasma fibrinogen levels in patients with essential hypertension

In recent years, substantial evidence has accumulated to unambiguously implicate high plasma fibrinogen levels as a major cardiovascular risk factor. An open prospective and randomised pilot study was therefore undertaken in mild to moderate hypertensives to evaluate the effect of various antihypertensive drugs viz enalapril, felodipine and prazosin on the blood pressure and plasma fibrinogen levels. The systolic and diastolic blood pressures were determined at 0, 4 and 8 weeks whereas plasma fibrinogen assays were done at baseline and at the end of the 8th week of treatment in all the drug-treated groups. It was observed that although all the three drugs effectively controlled blood pressure, only enalapril significantly reduced plasma fibrinogen levels. Due to this additional effect, enalapril has potential to control two major cardiovascular risk factors--hypertension and high plasma fibrinogen levels--simultaneously.

Mumps with cerebellar encephalitis

A 30 years male patient, having typical symptoms of mumps, presented with acute cerebellar ataxia two days after the onset of parotid enlargement. The neurological symptoms showed complete recovery over the subsequent six weeks, suggestive of para-infectious cerebellar demyelination due to mumps.

Central nervous system complications in renal transplant recipients in a tropical environment

Renal transplant recipients are at risk of developing various infectious and non-infectious complications affecting the central nervous system (CNS). There is paucity of data regarding the spectrum of CNS complications and the epidemiology of infective agents varies according to geographical location. We retrospectively studied the spectrum of CNS complications seen in 792 renal allograft recipients followed up at this tertiary care centre in north India over a 19-year period. Autopsy findings of 78 allograft recipients who died in the hospital were also reviewed and included. The brain was examined in 22 of these patients. Overall, 79 (10%) patients developed some form of CNS dysfunction with a mortality rate of 60.8%. CNS infections occurred in 31 renal allograft recipients (3.9% of total) and accounted for the largest group (39.2%). Fungi were the commonest etiological agents (21 patients) and were associated with a 70% mortality, with cryptococcal meningitis occurring in 12, mucormycosis in six, aspergillosis in one, and other unusual fungal infections in the remaining two patients. All patients with mucormycosis had a fatal outcome. The second largest group comprised of patients with non-uremic encephalopathies (23 patients, 29.1%) with metabolic encephalopathy occurring in 13, toxic encephalopathy in nine and hypertensive encephalopathy in one patient) and was associated with an overall mortality rate of 60.9%. Cerebrovascular accidents occurred in 12 patients (15.2%) and were associated with a mortality of 91.7%. Other CNS complications included treatment related complications in four (5.1%), primary CNS lymphomas in three (3.8%), and miscellaneous complications in six patients (7.6%). Patients with non-cryptococcal fungal infections of the CNS, hepatic and toxic encephalopathy and those with cerebrovascular accidents had the worst outcome. There was no relationship between the development of infection or stroke and the type of maintenance immunosuppression used. We conclude that complications involving the CNS occur in 10% of all renal transplant recipients and are associated a with high mortality, warranting early diagnosis and aggressive treatment.

Impaired function of neutrophils in uraemic patients

BACKGROUND

Immunodeficiency explains the very high frequency of bacterial infections in patients with chronic renal failure (CRF), which leads to high mortality and morbidity, despite improved therapeutic interventions. Among several factors, the decreased functional capacity of phagocytic leucocytes appears to be responsible for the defective host defence mechanisms against infection in CRF. We evaluated both oxygen-dependent and oxygen-independent microbicidal activity of neutrophils isolated from uraemic patients.

METHODS

Forty patients with CRF (20 with mild-to-moderate CRF and 20 with advanced CRF) along with 20 age- and sex-matched healthy controls were studied. The assessment of phagocytic capability, ability to produce superoxide (O2.-) anion and H2O2, myeloperoxidase and granule-specific hydrolytic enzymes such as acid phosphatase, cathepsin D and lysozyme activity of the patient's neutrophils were performed to study their bactericidal activity.

RESULTS

The phagocytic index (PI) in the control group was found to be 50.38 (4.58). It was significantly reduced in both mild-to-moderate CRF and advanced CRF, as compared to controls. In mild-to-moderate and advanced CRF patients, O2.- production by resting polymorphonuclear neutrophils (PMN) was low. Also, on stimulation with PMA the O2.- production showed a relative reduction as compared to controls. H2O2 production by resting PMN from CRF patients was unaltered but on stimulation with PMA, the quantum of increase was significantly lower. A marked reduction in the level of intracellular myeloperoxidase activity in PMN was noted in CRF patients. Of the three intracellular lysosomal enzymes assayed, cathepsin D level was increased in the PMN of mild-to-moderate CRF patients; acid phosphatase level was elevated significantly in the PMN of both mild-to-moderate and advanced CRF patients. However, no change in lysozyme levels was observed.

CONCLUSION

With increasing severity of uraemia, neutrophils from uraemic patients showed progressive impairment of phagocytic ability. Impairment of oxygen-dependent microbicidal mechanisms was indicated by a decrease in O2.- and H2O2 production. Increased activity of lysosomal enzymes such as cathepsin D and acid phosphatase suggest a state of neutrophil activation in uraemia. It is likely that the immunodeficiency state in uraemics is partly due to reduced bactericidal activity of the neutrophil cell population.

Factitious disorder with oligoanuria: a case report

A 12-year-old girl presented with complaint of passing very 'scanty' amount of urine, approximately 50 ml every alternate day for the last five years. She had been admitted for investigations several times in different hospitals in the past. On evaluation, she was found to have no abnormality related to the urinary tract. Detailed psychiatric assessment revealed the factitious nature of her symptoms, suggesting the diagnosis of factitious disorder with physical symptoms.

Quantitative enzymuria following aorto-renal angiography

Quantitative estimation of urinary enzymes has been advocated as a more sensitive marker than conventional renal function tests to assess radio-contrast media induced nephrotoxicity. We studied 27 subjects with normal renal functions who underwent abdominal aortography for varied indications. Among these, 8 also required selective renal arteriography and 3 underwent arch aortography in addition. Sodium iothalamate was used as a radio-contrast medium and the average amount injected was 73 ml (45 to 120 ml) per subject. Standard renal function assessment including urinalysis, 24 hour urinary protein excretion, creatinine clearance done both before and after aortography did not show any significant alteration. Urinary excretion of tubular enzymes including leucine aminopeptidase (LAP), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT) and maltase (MAL) was estimated before and 2, 24 and 48 hours after aortography. All enzymes showed a significant rise at 2 hours. Urinary excretion of LAP, ALP and GGT peaked at 24 hours after aortography without a further change in MAL levels. Enzymuria returned to baseline values 48 hours following the procedure. It is concluded that an increase in the urinary excretion of the brush-border enzymes within 24 hours of contrast media administration may suggest an early nephrotoxicity.

Effect of captopril on serum angiotensin converting enzyme and blood pressure in hypertensive patients

The effect of chronic captopril therapy on serum angiotensin converting enzyme (ACE) was studied in 30 patients with essential hypertension. Patients were assessed for serum ACE levels serially every week for 4 weeks. Thirty healthy individuals served as controls. The basal serum ACE level among hypertensives (57.4 +/- 37.2 u/l) was found to be significantly higher (p < 0.001) than the controls (33.3 +/- 8.8 u/l). One week after starting captopril therapy, serum ACE levels fell to almost half the basal values (p < 0.001). However, thereafter, it rose to levels higher than the basal level even though the blood pressure remained well controlled. Our study suggests that besides its action on ACE, captopril may lower the blood pressure by other mechanisms as well.

Gastrointestinal complications after renal transplantation. 10 Year data from a North Indian Transplant Center

Gastrointestinal complications are responsible for substantial morbidity and mortality among renal allograft recipients in developing countries. During a 10 year period, 166 (62.6%) of 265 allograft recipients developed gastrointestinal complications. This figure reflects the high incidence of infectious complications, especially acute diarrheas. Also notable was the incidence of esophageal candidiasis (7.2%), ischemic colitis (2.6%), and gastrointestinal and peritoneal tuberculosis (3.0%). Almost one quarter of the complications developed in the first 6 months after transplantation. Mortality was the highest with acute ischemic colitis (100%), pancreatitis (60%), and upper gastrointestinal hemorrhage (40%). Improvements in standards of living and sanitary conditions, pre transplant evaluation and assessment of risk factors, prophylaxis with anti ulcer drugs, early diagnosis, and appropriate treatment are needed to decrease the frequency and severity of gastrointestinal complications in renal allograft recipients.

Bilateral renal angiomyolipomatosis in tuberous sclerosis presenting with chronic renal failure: case report and review of the literature

A 45-year-old patient with tuberous sclerosis and bilateral renal angiomyolipomas who presented with chronic renal failure is reported. Although bilateral renal angiomyolipomas are commonly associated with tuberous sclerosis, the occurrence of chronic renal failure in the absence of associated cystic disease of the kidneys as seen in this patient is very rare.

Renal mucormycosis: computerized tomographic findings and their diagnostic significance

Isolated renal involvement by mucormycosis has been reported rarely in immunocompromised individuals. We describe four patients with mucormycosis confined to the kidneys, three of whom did not exhibit any predisposing factors. Only one patient had acute viral hepatitis with fulminant hepatic failure as the preceding disease. Two patients presented with oliguric renal failure of undetermined etiology and investigations revealed bilateral extensive involvement of the kidneys. Computerized tomography showed diffuse enlargement of the kidneys and multiple low-density areas. Treatment included systemic amphotericin B therapy in all four patients and nephrectomy in three patients. Two patients recovered completely. Our experience emphasizes the need for a high index of suspicion and recognition of computed tomographic scan appearances for making a prompt diagnosis. Early surgical intervention and systemic antifungal therapy are necessary for survival in this life-threatening condition.

Emphysematous pyelonephritis and cystitis in a renal transplant recipient--computed tomographic appearance

A 35-year-old nondiabetic renal allograft recipient developed emphysematous pyelonephritis and cystitis emphysematosa necessitating graft nephrectomy. The patient received cyclosporin and prednisolone as immunosuppressive therapy. He developed the first episode of urinary tract infection one week after transplantation and another episode 3 months later. Abdominal CT scan revealed presence of gas in the graft kidney, urinary bladder, and surrounding tissues. Despite appropriate antibiotic therapy, his renal function deteriorated rapidly and he died on the first postoperative day.

Effect of vasodilator and surface active drugs on the efficacy of peritoneal dialysis

The effect of sodium nitroprusside (SNP), a vasodilator drug, and chlorpromazine (CPZ), a surface active drug, on the efficacy of peritoneal dialysis was studied in 25 patients with acute or acute on chronic renal failure in a double blind fashion. Each drug was added to the dialysate during different sets of cycles. In each patient, six clearance periods of 3 cycles each were studied and peritoneal clearances of creatinine and urea and ultrafiltration rates were measured during each clearance period. SNP increased the peritoneal clearance of creatinine and urea by 28.8 percent each (p < 0.001) while CPZ increased the peritoneal creatinine and urea clearance by 17.7 and 26.0 percent respectively (p < 0.001 each). Both drugs significantly increased the ultrafiltration rates (p < 0.001). SNP was found to be superior to CPZ and had prolonged effect even after cessation of administration.

Chronic granulocytic leukaemia presenting with mandibular mass

A case of chronic granulocytic leukaemia with extramedullary deposits in the mandible is reported. Systemic chemotherapy coupled with local irradiation resulted in regression of the mandibular mass.

Estimation of 24 hour protein excretion from single random urine specimen

The product of protein/creatinine ratio (in a random urine specimen) and estimated daily urinary creatinine excretion were evaluated as a function of 24 h urinary protein excretion in 40 patients with pathology proteinuria having varying grades of renal function. An excellent correlation was found between the results obtained by this method and those from the standard 24 h urine collection method in healthy controls (r = 0.99) and in patients with normal (r = 0.88) or mild to moderately impaired renal function (r = 0.99). However, this method did not give a good measure of quantitative proteinuria in patients with advanced renal failure (r = 0.56), possibly due to decreased urinary excretion of creatinine in patients with advanced renal failure as compared to the estimated value. The product of protein/creatinine ratio and estimated daily urinary creatinine excretion thus gave a quick and alternate reliable method of estimating 24 h proteinuria in patients having normal or mild to moderately impaired renal function. However, this method is not suitable for patients with advanced renal failure.