APASL clinical practice guidelines on the management of acute kidney injury in acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a syndrome that is characterized by the rapid development of organ failures predisposing these patients to a high risk of short-term early death. The main causes of organ failure in these patients are bacterial infections and systemic inflammation, both of which can be severe. For the majority of these patients, a prompt liver transplant is still the only effective course of treatment. Kidneys are one of the most frequent extrahepatic organs that are affected in patients with ACLF, since acute kidney injury (AKI) is reported in 22.8-34% of patients with ACLF. Approach and management of kidney injury could improve overall outcomes in these patients. Importantly, patients with ACLF more frequently have stage 3 AKI with a low rate of response to the current treatment modalities. The objective of the present position paper is to critically review and analyze the published data on AKI in ACLF, evolve a consensus, and provide recommendations for early diagnosis, pathophysiology, prevention, and management of AKI in patients with ACLF. In the absence of direct evidence, we propose expert opinions for guidance in managing AKI in this very challenging group of patients and focus on areas of future research. This consensus will be of major importance to all hepatologists, liver transplant surgeons, and intensivists across the globe.

Incidence, Risk Factors, and Outcomes of Transition of Acute Kidney Injury to Chronic Kidney Disease in Cirrhosis: A Prospective Cohort Study

Transition to chronic kidney disease (CKD) after an episode of acute kidney injury (AKI) is known in patients without cirrhosis. We studied the incidence and risk factors for development of CKD in patients with cirrhosis. Competing risk analysis was performed to identify risk factors for CKD development. Of 818 patients with cirrhosis (age, 50.4 ± 11.8 years; 84% males; Model for End-Stage Liver Disease [MELD], 19.9 ± 9.9), 36% had AKI at enrollment, 27% had previous AKI, and 61% developed new episodes of AKI during the follow-up period. CKD developed in 269 (33%) patients. Serum cystatin C (CysC; subdistribution hazard ratio [SHR], 1.58; 1.07-2.33), episodes of previous AKI (SHR, 1.26; 1.02-1.56), and AKI stage at enrollment (no AKI [SHR, 1] vs. stage 1 [SHR, 3.28; 1.30-8.25] vs. stage 2 [SHR, 4.33; 1.76-10.66] vs. stage 3 [SHR, 4.5; 1.59-12.73]) were identified as baseline risk factors for CKD development. On time-varying competing risk analysis, MELD (SHR, 1.01; 1.00-1.03), number of AKI episodes (SHR, 1.25; 1.15-1.37), and CysC (SHR, 1.38; 1.01-1.89) predicted CKD development. Development of CKD was associated with higher risk of death. Reduction in glomerular filtration rate (GFR) not meeting CKD criteria was observed in 66% of patients with cirrhosis, more so in those with previous AKI episodes and a high CysC level and MELD score. Renal histology, available in 55 patients, showed tubulointerstitial injury in 86%, cholemic nephrosis in 29%, and glomerular changes in 38%. Conclusion: Almost two-thirds of patients with cirrhosis develop episodes of AKI and reduction in GFR; one-third progress to CKD, resulting in adverse outcomes. Higher MELD and CysC levels and number of AKI episodes predict development of CKD in patients with cirrhosis.

Observational study to evaluate the safety and efficacy of saroglitazar in Indian diabetic dyslipidemia patients

Saroglitazar is a dual PPAR α/γ agonist approved in India for the management of diabetic dyslipidemia.

AIMS

The objective of this study was to evaluate the safety and efficacy of saroglitazar 4 mg once daily in clinical practice.

METHODS

This was an observational, multicenter, single-arm study. Patients with type 2 diabetes (with on-going antidiabetic medication), age above 18 years, and triglycerides ≥200 mg/dL were included.

RESULTS

A total 2804 patients with a mean duration of diabetes 6.29 yrs were included in this analysis. The baseline demographic profile was: mean age of 53 yrs, mean body weight 72.3 kg and mean BMI of 27 kg/m(2). 62.5% patients were male and 57.8% were reported to be on statin therapy at baseline. All 2804 patients were on antidiabetic medications with 15.4% patients on monotherapy and rest were on two or more than two antidiabetic medications at baseline. The baseline triglycerides and HbA1C values were 312.3 mg/dL and 8.3% respectively. At 3 months follow-up, use of saroglitazar 4 mg led to significant reduction in TG (35.8%), LDL-C (16.4%), total cholesterol (19%) and non-HDL-C (23.4%). Addition of saroglitazar to baseline antidiabetic medications showed a significant 0.9% absolute reduction in HbA1c with significant improvement in fasting and post prandial plasma glucose. No serious adverse events, alteration in liver or renal enzymes and edema or weight gain were reported.

CONCLUSION

Saroglitazar is a potential therapeutic option in type 2 diabetic patients with high TG levels, not controlled by statins, for comprehensive control of lipid and glycemic parameters with acceptable safety profile.

Role of Alpha Blockers in Hypertension with Benign Prostatic Hyperplasia

Hypertension and benign prostatic hyperplasia (BPH) are common disorders of aging men. As the world population is aging these two diseases are becoming a significant public health problem worldwide. Approximately 30% of men treated for BPH have coexisting hypertension. The α-Adrenergic Blockers: Prazosin, Terazosin and Doxazosin are established agents in the therapy of hypertension, and are also effective drugs in the treatment of BPH. It is reasonable to use α-Adrenergic Blockers as the treatment of choice for men with hypertension and BPH.

Bioaccumulation and localization of exogenous cadmium in a teleost by electron microscopy (TEM) and its specific quantitation by electron probe X-ray microanalysis (EPMA)

A cadmium bioconcentration study was carried out in a fresh water teleost, Colisa fasciatus, to study the bioaccumulation kinetics and fate of exogenous cadmium (Cd) in biological tissues. Study shows that on exposure of the fish to a sublethal concentration of cadmium in test water, Cd uptake results in its bioconcentration in gills, liver and muscle tissues. To explore whether the accumulated Cd reaches the membranes or inside the cells, transmission electron microscopy (TEM) of the thin sections of tissues was done after histochemical localization of Cd in cells by modified SST method. TEM studies of sections of gills, liver and muscle tissues showed the deposits of exogenous Cd (visualized as dense clouds) in biological cells. This suggests the presence of free or loosely bound Cd on the membranes and inside the cells, which in the presence of Na2S is converted into insoluble metal sulfides. Electron probe X-ray microanalysis (EPMA) studies confirmed the presence of Cd on the membrane surface as well as inside the cells of bioindicator organs suggesting involvement of membrane transport of exogenous Cd inside the cells and its deposition as loosely bound insoluble metal complexes.

Identification of metabolites of malathion in plant, water and soil by GC-MS

Metabolism of malathion (O,O,-dimethyl S-[1,2-bis(ethoxy carbonyl)-ethyl]phosphorodithioate) has been studied in plants, water and soil. A number of products identified by gas chromatography-mass spectrometry (GC-MS), have been formed by de-esterification, oxidation and hydrolysis of malathion. Hydrolysis of the P-S and C-S bonds occur in alkaline pH 8.0 and acidic pH 5.5, respectively.

Comparative evaluation of cell proliferative indices and epidermal growth factor receptor expression in gastric carcinoma

A total of 62 patients of gastric carcinoma were studied to find a correlation between newer prognostic indicators like cell proliferative indices including Nucleolar Organizer regions (AgNORs), Ki 67 Labelling Index and Epidermal Growth Factor Receptor (EGFR) expression with the various, histopathological criteria and compared with 30 controls of non neoplastic gastric diseases. EGFR expression was positive in 48(77.4%) cases. The Ki 67 labelling indices ranged from 0 to 50% with a mean of 21.35 +/- 17.88% among the cases. AgNOR counts ranged from 1.64 to 4.49 with a mean of 3.41 +/- 0.81 among the cases. Positive EGFR expression correlated strongly with differentiation of the tumour, poorly differentiated tumours showing a higher positivity. EGFR positivity also showed good correlation with metastasis as well as with the invasiveness of the tumour. Ki 67 labelling indices correlated significantly with metastatic status, microscopic types and degree of differentiation of the tumour. A strong correlation was observed between AgNOR counts and metastasis as well as the microscopic type of the tumour. EGFR expression correlated strongly with Ki 67 scores and weakly with AgNOR counts among the patients of gastric carcinoma.

Accumulation pattern of pesticides in tropical fresh waters

High-performance liquid chromatography has been used to study the persistence of commonly used organophosphorus and carbamate pesticides-carbaryl, carbendazim, carbofuran, dimethoate, malathion and methyl parathion in river water in the presence of bottom sediment in laboratory aquaria. The fate of pesticides in water and sediment in pre- and post-monsoon water from three sources has been compared. It has been established that rapid degradation occurs once the pesticide leaches into sediment from water. Degradation was at a much faster rate in post-monsoon water and sediment. It was found that pH and organic matter content affect rate of decay.

Parameters affecting the decay of some organophosphorus pesticides: a study by high-performance liquid chromatography

An HPLC procedure has been developed to follow the decay of malathion and methylparathion under control conditions using an mu-Bondapak C18 column with a mixture of acetonitrile and water to mobile phase and an ultraviolet detector for detection. Studies have been conducted to monitor their degradation in water and soil at different temperatures, pH and organic content. The results show that the persistence of the pesticides decreases with increase in temperature, pH and organic content.

Ecosystem studies on upper region of Ganga River, India

A multi-disciplinary research programme on the Ganga River Ecosystem was launched by the Government of India in 1983 to collect information on its attributes. Monitoring of the initial 509 km unpolluted and unmonitored region of the river falling in partly mountainous and partly upper plain stretches for two years revealed good water quality. The Song River (a tributary) catchment, a victim of extensive mining activity in the past, was found to add maximum mineral load. The Bhagirathi River was found to carry maximum suspended solid load. Organic pollution was low throughout, occasionally showing seasonal and local peaks. The river exhibited a high oxidative state with pH falling in a slightly alkaline range and nutrient levels being very low.Diatoms formed a major part of the encountered genera of phytoplankton. Zooplankton were mainly represented by protozoans. Saprophytic bacteria underwent large spatial and temporal fluctuations. Coliforms exhibited an increasing trend with downstream river distance. The source of pollution could not be specifically characterized from an FC/FS ratio. Only one sample tested positive for enteric virus. The forms of benthic macroinvertebrates indicated a clean stream environment. It was observed that diversity indices, together with evenness and community comparison, could provide a promising approach to determine the state of the community.Eight heavy metals investigated, Cu, Zn, Fe, Cd, Mn, Pb, Ni and Co, were found to be present in the river water and bed sediments. The prominent mode of metal transport was found to be via the suspended load. The concentration of dissolved metals was found within WHO permissible limits. The heavy metal status of the Ganga River was compared with other rivers of the world. Sorptive properties of sediments were found to be similar to the general sorptive behaviour of the clays. Laboratory studies exhibited reasonable short t 90 values for coliform survival in Ganga water. Faecal streptococcus survived longer.

Degradation of organophosphorus and carbamate pesticides in soils--HPLC determination

Best conditions suited for the extraction and trace analysis of dimethoate, malathion, methyl-parathion, carbaryl, carbendazim and carbofuran in soils, using HPLC, were established. This was followed by studies related to persistence of residues in different soils. Half-life and time taken for 95% dissipation were determined in each case. Higher pH, moderate moisture and high calcium carbonate content aided degradation while organic matter increased persistence.

Simultaneous determination of a mixture of organophosphorus and carbamate pesticides by high performance liquid chromatography

A simple HPLC procedure has been developed for the simultaneous determination of a mixture of standard carbaryl, carbofuran, carbendazim, dimethoate, malathion and methyl parathion from a spiked agricultural soil sample. The pesticide mixture has been extracted using methanol-water. A concave gradient elution with acetonitrile-phosphate buffer for 15 min followed by linear elution for 5 min, using a wavelength of 224 nm for detection, has been found to resolve the mixture efficiently.

Pancreatic endometriosis presenting as a hypovascular renal mass

We report a case of pancreatic endometriosis that presented as a renal mass. The patient had a history of recurrent left loin pain and pathological examination revealed pancreatic endometriosis, with huge cyst formation around the kidney. The clinicopathological features and the possible pathogenesis are discussed.

Orbital apex syndrome due to rhinoscleroma. A case report

A case of Rhinoscleroma of the left maxilla and ethmoid with involvement of the orbital apex, in a female diabetic, is reported. The significance of the associated diabetes is discussed.

Evaluation of brodifacoum against T. indica, M. hurrianae and R. rattus

Brodifacoum was evaluated in the laboratory against the two gerbils, Tatera indica and Meriones hurrianae and the house rat, Rattus rattus. The acute oral LD50 for these rodents was found to be 0.10 mg/kg, 0.083 mg/kg and 0.77 mg/kg respectively. Feeding tests with 0.002% and 0.005% brodifacoum produced a 100% mortality after a 3-day feeding period in the gerbils and after a 4-day period in R. rattus. The anticoagulant is toxic at both the concentrations to all three species but is less palatable in comparison to plain baits. Results of this laboratory evaluation indicates that 0.002% brodifacoum-treated bait can be effectively used against T. indica, M. hurrianae and R. rattus.

Laboratory evaluation of anticoagulant-treated baits for control of the northern palm squirrel, Funambulus pennanti Wroughton

Individually caged northern palm squirrels, Funambulus pennanti, were fed with bait containing 0.025% warfarin or fumarin, 0.0075% chlorophacinone or 0.005% brodifacoum for a fixed number of days varying from 1 to 14. Brodifacoum (WBA 8119) was found most toxic since 66% and 70% of the animals died after one and two days' feeding respectively. Chlorophacinone killed 70% of the squirrels after three days' feeding. Squirrels were relatively tolerant to warfarin and fumarin since the mortality after a period of 14 days' feeding was only 58% and 75% respectively.