Renal transplantation is the treatment of choice for children with end-stage renal disease (ESRD). We evaluated the outcome of renal transplantation in the pediatric and adolescent age groups in the perspective of a developing country as compared with developed nations while highlighting the challenges we have faced in a pediatric transplant programme.
Materials and Methods:
Seventy live related pediatric and adolescent renal transplantations were reviewed retrospectively. Variables analyzed were etiology of ESRD, pre-transplant renal replacement modality, donor relationship, surgical complications, rejection episodes, immuno-suppression regimens, compliance to immunosuppression, graft survival and overall survival.
The cohort consisted of 13 (18%) female and 57 male (82%) recipients. The mean age was 14 ± 1.4 years. The etiology of ESRD was chronic glomerulonephritis (n = 43), chronic interstitial nephritis (n = 26) and Alport's syndrome (n = 1). Fifty-six (80%) children were on hemo-dialysis and 10 (14%) on peritoneal dialysis prior to transplantation. 80.5% and 61% patients were strictly compliant to immunosuppresant medications at 1 and 5 years. The 1, 3 and 5 year graft survival rates were 94.3%, 89.2% and 66.8%, respectively. The overall survival rates were 95.7%, 96.4% and 94.1% for 1, 3 and 5 years, respectively.
The spectrum of etiology of ESRD differs in our patients from the west, with chronic glomerulonephritis being the most common etiology. Early graft survival is comparable, but the 5-year graft survival is clearly inferior as compared with developed countries.
Challenges; kidney transplantation; pediatric
Killer immunoglobulin-like receptor (KIR) gene shows a high degree of polymorphism. Natural killer cell receptor gets activated once they bind to self-human leukocyte antigens (HLAs) with specific ligand. KIR gene and HLA ligand incompatibility due to the presence/absence of KIR in the recipient and the corresponding HLA ligand in the allograft may impact graft survival in solid organ transplantation. This study evaluates the effect of matches between KIR genes and known HLA ligands. KIR genotypes were determined using sequence specific primer polymerase chain reaction. Presence of certain KIR in a recipient, where the donor lacked the corresponding HLA ligand was considered a mismatch. The allograft was considered matched when both KIR receptor and HLA alloantigen reveald compatibility among recipient and donor. The data revealed better survival among individuals with matched inhibitory KIR receptors and their corresponding HLA ligands (KIR2DL2/DL3-HLAC2, KIR3DL1-HLABw4). On the contrary, no adverse effect was seen for matched activating KIR receptors and their corresponding HLA ligands. One of the activating gene KIR2DS4 showed risk (P = 0.0413, odds ratio = 1.91, 95% confidence interval = 1.02-3.57) association with renal allograft rejection. We conclude that the presence of inhibitory KIR gene leads to better survival; whereas activating motifs show no significant role in renal allograft survival.
Acute renal allograft rejection; human leukocyte antigen-B; -C; killer immunoglobulin-like receptors; natural killer cells
We evaluated whether polymorphisms in interleukin (IL-1) gene cluster (IL-1 alpha [IL-1A], IL-1 beta [IL-1B], and IL-1 receptor antagonist [IL-1RN]) are associated with end stage renal disease (ESRD). A total of 258 ESRD patients and 569 ethnicity matched controls were examined for IL-1 gene cluster. These were genotyped for five single-nucleotide gene polymorphisms in the IL-1A, IL-1B and IL-1RN genes and a variable number of tandem repeats (VNTR) in the IL-1RN. The IL-1B − 3953 and IL-1RN + 8006 polymorphism frequencies were significantly different between the two groups. At IL-1B, the T allele of − 3953C/T was increased among ESRD (P = 0.0001). A logistic regression model demonstrated that two repeat (240 base pair [bp]) of the IL-1Ra VNTR polymorphism was associated with ESRD (P = 0.0001). The C/C/C/C/C/1 haplotype was more prevalent in ESRD = 0.007). No linkage disequilibrium (LD) was observed between six loci of IL-1 gene. We further conducted a meta-analysis of existing studies and found that there is a strong association of IL-1 RN VNTR 86 bp repeat polymorphism with susceptibility to ESRD (odds ratio = 2.04, 95% confidence interval = 1.48-2.82; P = 0.000). IL-1B − 5887, +8006 and the IL-1RN VNTR polymorphisms have been implicated as potential risk factors for ESRD. The meta-analysis showed a strong association of IL-1RN 86 bp VNTR polymorphism with susceptibility to ESRD.
End stage renal disease; haplotype; interleukin-1 gene cluster; meta-analysis; pro-inflammatory; variable number of tandem repeats
Idiopathic minimal change disease is a disorder of T-cell dysfunction. The relative predominance of regulatory T cells (Tregs), Th1, and Th2 cells in nephrotic syndrome (NS) remains controversial. Imbalance in peripheral blood regulatory and effector T cells (Teff) are linked to cell mediated immune response and may be associated with steroid response in NS. Peripheral blood CD4 + CD25 + FoxP3 + (Tregs), CD4 + IFN-γ+ (Th1), and CD4 + IL-4 + (Th2) lymphocytes were analyzed in 22 steroid-sensitive NS (SSNS) patients in sustained remission, 21 steroid-resistant NS (SRNS) and 14 healthy controls. The absolute percentage values and ratio of Th1/Tregs, Th2/Tregs, and Th1/Th2 were compared between SSNS, SRNS and control subjects. The percentage of Tregs was lower in SRNS patients (P = 0.001) compared with that of SSNS and healthy control. The percentage of Th1 cells was higher in SRNS (P = 0.001) compared to that of SSNS patients; however, it was similar to healthy controls (P = 1.00). The percentage of Th2 cells in SRNS (P = 0.001) was higher as compared to SSNS and controls. The ratio of Th1/Treg cells in SRNS (P = 0.001) was higher as compared to SSNS patients and controls. The ratio of Th2/Treg was also higher in SRNS as compared to SSNS and controls. The ratio of Th1/Th2 cells in SSNS, SRNS, and healthy controls were similar. The cytokines secretion complemented the change in different T-cell subtypes in SSNS, SRNS and healthy controls. However, the IFN-γ secretion in healthy controles was low inspite of similar percentage of Th1 cells among SRNS cases. We conclude that greater ratio of Tregs compared to that Th1 and Th2 favor steroid sensitivity and reverse ratio results in to SRNS. The difference in ratio is related to pathogenesis or it can be used as marker to predict steroid responsiveness needs further evaluation.
Childhood nephrotic syndrome; effector T cells; regulatory T cells
A numerical investigation of incompressible and transient flow around circular pipe has been carried out at different five gap phases. Flow equations such as Navier-Stokes and continuity equations have been solved using finite volume method. Unsteady horizontal velocity and kinetic energy square root profiles are plotted using different turbulence models and their sensitivity is checked against published experimental results. Flow parameters such as horizontal velocity under pipe, pressure coefficient, wall shear stress, drag coefficient, and lift coefficient are studied and presented graphically to investigate the flow behavior around an immovable pipe and scoured bed.
During the present investigation the effect of α-tocopherol (100 μmolL-1) in prevention of testicular toxicity induced by atrazine in goat Capra hircus have been analyzed. Vitamin E (α-tocopherol) at dose level 100 μmolL-1 provides attenuation over the histopathological changes generated by pesticide atrazine (100 nmolml-1). Small pieces (approximately 1mm3) of testicular tissue were divided into three groups (one control group + two experimental groups). Experimental group (A) was supplemented with 100 nmolml-1 concentration of atrazine and experimental group (B) was supplemented with 100 nmolml-1 atrazine and 100 μmolL-1 concentrations of vitamin E (α-Tocopherol) and harvesting was carried out after 1, 4 and 8 hrs of exposure. Control was run along with all the experimental groups. In the experimental group (A) treated with atrazine at dose level 100 nmolml-1, revealed histomorphological alterations in the seminiferous tubule. After one hour of exposure duration small vacuoles in cytoplasm of the Sertoli cells and spermatogonia were observed. Chromolysis at pycnosis were also noticed in the spermatogonia and spermatids. In the experimental group (B) exposed with atrazine and simultaneously supplemented with Vitamin E also showed degeneration but it was milder as compared with experimental group treated with atrazine without antioxidant. Atrazine exposure induced a decline in diameter of spermatocytes from 10.51 ± 0.2052 μm in control to 7.915 ± 0.2972, 7.5 ± 0.211 and 7.14 ± 0.225 μm after exposure of 1, 4 and 8 hrs respectively but in case of atrazine supplemented with vitamin E [experimental group (B)], there was less decline in cell diameter that was 8.5 ± 0.1865, 8.1 ± 0.1201 and 7.8 ± 0.2066μm after exposure of 1, 4 and 8 hrs respectively. The result demonstrated that vitamin E delays the degenerative changes induced by atrazine.
α-tocopherol; antioxidant; atrazine; capra hircus; goat; pesticide; testis
Malnutrition inflammation syndrome (MIS) is common among ESRD patients. In the present study, we have investigated the association of genetic markers associated with appetite and energy regulation with malnutrition inflammation syndrome among end-stage renal disease (ESRD) patients. Two hundred and fifty-seven patients on maintenance hemodialysis and 200 normal healthy controls were included in the study. Nutritional assessment was done by subjective global assessment scores (SGA). Genotyping of leptin-2548 G/A (rs7799039), ghrelin Leu72Met (rs696217-408 C/A), Arg51Gln (rs34911341-346 G/A) and uncoupling protein 2 (UCP2) 45 bp insertion deletion was done using PCR–RFLP. Levels of leptin and acyl ghrelin were assessed using ELISA. Leptin-2548 AA genotype was associated with twofold higher risk of disease susceptibility while UCP2 insertion–deletion heterozygotes showed protective effect. Ghrelin Gln51Gln and Met72Met genotype were associated with 3.4- and 2.5-fold higher disease susceptibility. The Met72 and Gln51 allele showed 3.3- and 2.1-fold higher susceptibility to malnutrition in severe SGA group. Further, the levels of acyl ghrelin were significantly less in severe category of malnutrition and in poor appetite group. On combined analysis, the group 2 (presence of 3–4 risk alleles) showed 1.5- and twofold higher susceptibility to disease and malnutrition, respectively. On docking analysis, it was observed that higher receptor binding energy was associated with the mutant form of ghrelin (Gln51). Moderate and severe SGA were associated with 2.2- and 4.1-fold higher death hazard. Our study suggests that ghrelin may be major marker contributing to susceptibility to MIS among ESRD patients.
Electronic supplementary material
The online version of this article (doi:10.1007/s12263-013-0353-7) contains supplementary material, which is available to authorized users.
End-stage renal disease; Malnutrition inflammation syndrome; Leptin; Ghrelin UCP2
Exposure to arsenic has been associated with several health hazards. Worldwide the main reason for chronic human intoxication with arsenic is intake of contaminated drinking water. Air acetylene type of atomic absorption spectrophotometer in combination with hydride generator accessory was used to analyze arsenic level in 25 water samples collected from 25 booster pumping stations and 313 water samples collected from tap water supply of 62 areas of Delhi. Results were analyzed using SPSS and Barlett’s Chi Square Test. Mean arsenic level detected in water samples collected from booster pumping stations was 0.00976 ppm (Range 0.000–0.017 ppm, Standard Deviation 0.006 and Standard error of Mean 0.00118). Maximum arsenic level (0.017 ppm) was found in water samples of booster pumping stations of Mehrauli, Punjabi Bagh and Ramjas Road. Mean arsenic level detected in samples collected from tap water supply was 0.013 ppm (Range 0–0.0430 ppm, Standard Deviation 0.00911 and Standard error of Mean 0.000515). In water samples of 42 areas arsenic level detected was exceeding WHO/EPA permissible limit of 0.01 ppm (10 ppb). The mean arsenic level detected in water samples of booster pumping station was within WHO/EPA permissible limit while mean arsenic level detected in tap water samples was marginally higher. Mixing of ground water and contamination through broken or leaking channel could be the possible reason of higher arsenic level in tap water. Continuous monitoring of quality of drinking water is required particularly in view of water contamination caused by industrial waste and uncontrolled ground water extraction.
Water; arsenic; contamination; WHO/EPA permissible limit
Cytomegalovirus (CMV) is the most common viral infection following kidney transplant, has been recognized as a major factor for graft loss and increased incidence of acute rejection. Different studies have reported a variable incidence of CMV disease with the use of Mycophenolate mofetil (MMF). We retrospectively analyzed our renal transplant recipients to review the results of CMV disease and to compare CMV disease in patient on Azathioprine and MMF for this purpose we retrospectively reviewed 521 live related kidney transplant recipients at our institute. 74 (14.2 %) live related allograft recipients developed CMV disease after a median interval of 7.18 ± 4.35 months from transplantation. The mean age was 36.15 ± 10.7 years. 63 of the patients were male. Malaise, fever and diarrhea were among most common symptoms. 20 (27.02 %) of the 74 recipients developed transaminitis, 13 (17.2 %) developed CMV gastritis, 5 (9.13 %) recipients developed pneumonia, and 3 (4.05 %) patient developed colitis. 59 (80 %) patients had leucopenia and 41 (56.5 %) developed thrombocytopenia. Mean serum creatinine level was 1.5 ± 0.4 (0.9–2.4) mg/dl before the disease, 1.9 ± 0.6 (1.3–3.6) mg/dl at the time of the diagnosis, and 1.7 ± 0.06 (0.8–4.2) mg/dl at the end of the treatment. CMV disease developed in 9 (36 %) of recipients who received basiliximab as induction therapy and 13 (30.24 %) of recipients who received ATG (p > 0.05). The incidence of CMV disease was similar in cyclosporine based regimen (13.2 %) and Tacrolimus based regimen 27 (16.16 %) (p = 0.137) and was also similar in Azathioprine 41 (9.5 %) and MMF group 33 (14.3 %) (p = 0.163). There was no significant difference in severity of CMV disease in both groups, except a higher incidence of leucopenia in Azathioprine group (86 vs. 74 %, p < 0.05) as compared to MMF group. 51 (68.91 %) patient developed graft dysfunction during CMV disease. In conclusion we report a low incidence (14.2 %) and milder form of cytomegalovirus disease at our center. Use of universal cytomegalovirus prophylaxis was associated with a low incidence and milder form of the disease. Incidence of CMV disease was similar between Azathioprine and MMF groups.
Cytomegalovirus; CMV; Renal allograft recipient
Surveillance of drinking water is essentially a health measure intended to protect the public from water borne diseases. Hydride generator accessory coupled with atomic absorption spectrophotometer was used to analyze arsenic level in 49 ground water samples collected from different areas of Delhi. Arsenic level in ground water samples was in the range of 0.0170 to 0.100 ppm (Mean-0.0431, Standard Deviation-0.0136, Std. error of Mean-0.00194) with minimum concentration at Raney Well No. 7 (0.0170 ppm) and maximum at Kotla Mubarak Pur (0.100 ppm). Arsenic containing sediments and percolation of chemicals into soil as the result of dumping of garbage rich in chemicals into open landfills could be the possible source of arsenic in ground water of Delhi. Extensive survey and continuous monitoring is required to be made to assess the magnitude of problem and earlier intervention.
Arsenic; ground water; hydride generator accessory; atomic absorption spectrophotometer
Antiphospholipid syndrome (APS) often presents as a multisystem disorder characterized by recurrent arterial and venous thrombosis and pregnancy loss. We present a 46-year-old female who was admitted with oliguric acute renal failure. APS was suspected due to prolongation of activated partial thromboplastin time and history of miscarriages. Investigations for secondary causes were normal. Renal biopsy findings revealed thrombotic microangiopathy. A complete recovery of renal function was attained with a combination of plasma exchange and pulse methylprednisolone followed by oral steroids and warfarin. The case is presented for its rarity and therapeutic implications.
Acute renal failure; anticardiolipin antibody; plasma exchange; primary antiphospholipid syndrome; thrombotic microangiopathy
Background and objectives:
Tribal men's reluctance in sharing responsibilities as supportive partners in reproductive and sexual health matters debar women from their sexual rights coupled with their negligence in health care and lesser utilization of reproductive health facilities. As a matter of fact a large proportion of ill health particularly related to sexually transmitted infections (STIs) suffered not only by men but also by their spouses. The present study was planned among one of the primitive tribes of Madhya Pradesh to understand the knowledge of males about reproductive tract infection (RTI)/STI/HIV/AIDS, RTI symptoms suffered, perception on sexual health, utilization of health services and to improve the knowledge by intervention of need based IEC (information, education, communication) strategy.
The study was conducted among 400 currently married men in the age group of 15-40 yr in one of the primitive tribes, Baigas of Dindori district of Madhya Pradesh. Eighteen villages were explored in the study. The IEC intervention was made by using quasi-experimental before and after with control design.
The baseline data generated indicated that Baigas male were poorly informed about RTI (18%), STI (21.5%) and HIV/AIDS (10%). Further, men also projected misconception on different aspects of sexuality. Women's views recorded also suggested a disturbing trend regarding male involvement in reproductive health particularly related to STIs.
Interpretation & conclusions:
After intervention of IEC targeting male population in age group 15 - 40 yr by adopting a before and after with controls design the awareness was improved significantly. The utilization of the health services was also improved significantly. The study recommends replication of the IEC strategy designed in other Baiga villages for improving the reproductive health of the tribe.
Baiga tribe; currently married males; HIV/AIDS; IEC intervention; reproductive tract infections; sexual morbidities; STI
Self-mutilation of genitalia is an extremely rare entity, usually found in psychotic patients. Klingsor syndrome is a condition in which such an act is based upon religious delusions. The extent of genital mutilation can vary from superficial cuts to partial or total amputation of penis to total emasculation. The management of these patients is challenging. The aim of the treatment is restoration of the genital functionality. Microvascular reanastomosis of the phallus is ideal but it is often not possible due to the delay in seeking medical attention, non viability of the excised phallus or lack of surgical expertise. Hence, it is not unusual for these patients to end up with complete loss of the phallus and a perineal urethrostomy.
We describe a patient with Klingsor syndrome who presented to us with near total penile amputation. The excised phallus was not viable and could not be used. The patient was managed with surgical reconstruction of the penile stump which was covered with loco-regional flaps. The case highlights that a functional penile reconstruction is possible in such patients even when microvascular reanastomosis is not feasible. This technique should be attempted before embarking upon perineal urethrostomy.
Penile injury; Penile reconstruction; Penile amputation
Nephrolithiasis is associated with a variety of abnormalities in urinary composition. These abnormal urinary risk factors are due to dietary indiscretions, physiological-metabolic disturbances or both. Stone disease is morbid and costly, and the recurrence rates may be as high as 30-50% after 5 years. Efforts to prevent stone formation are, therefore, essential. Dietary factors play an important role in kidney stone formation. Tailored dietary recommendations based on metabolic evaluation should be offered to patients for the prevention of recurrence of stone formation. Dietary intervention and subsequent evaluations of therapeutic efficacy should be based on results from multiple 24-h urine collections. Urine flow of >1 ml/kg/h almost eliminates the risk of supersaturation for calcium oxalate, calcium phosphate and uric acid, thus protecting from the formation of corresponding kidney stones. In patients with cystenuria, the required urine flow may even be higher and, in cases such as primary xanthinuria, high fluid intake is required. Milk intake in these patients should be within the RDA of calcium and protein. In children, recommendation of a high fluid intake has only limited success. Nevertheless, each patient should be advised about adequate fluid intake to increase urine volume in accordance with body size. Although children with hypocitraturia may benefit from therapeutic agents that raise the urine citrate concentration, all children bearing residual fragments should be counseled on adequate fluid intake along with potassium citrate treatment to prevent stone regrowth or formation.
Calcium; diet; kidney stone
A number of organic molecules which contain the 1,5-diaryl-3-oxo-1,4-pentadienyl group, referred to hereafter as the dienone moiety, have antineoplastic properties. Emphasis is made on the attachment of this structural moiety to several molecular scaffolds, namely piperidines, N-acylpiperidines, cycloalkanes and 3,4-dihydro-1H-napthalenes. Many of these compounds are potent cytotoxins having micromolar and nanomolar IC50 values towards a wide range of neoplastic and transformed cells. On occasions, greater toxicity towards neoplasms than normal cells has been demonstrated. A number of these compounds have in vivo anticancer properties and in general excellent tolerability in rodents is demonstrated. The way in which a number of physicochemical properties such as redox potentials, torsion angles, atomic charges and logP values govern cytotoxic potencies are presented. The importance of the shapes of different compounds as determined by molecular modeling in contributing to antineoplastic properties is outlined. Arguments are presented in favour of designing antineoplastics which have multiple sites of action in contrast to those bioactive molecules which have only one molecular target. A number of compounds which possess the dienone group have different modes of action some of which are chronicled in this review, such as inducing apoptosis, affecting respiration in mitochondria, inhibiting macro-molecular biosynthesis and both inhibiting and stimulating certain enzymes. Other important properties of these compounds are discussed including their anti-angiogenic, MDR-revertant and antioxidant properties. It is hoped that this eulogy of the importance of the dienone group will encourage researchers to consider incorporating this structural unit into candidate cytotoxins in the future.
PMID: 19519378 CAMSID: cams2169
1,5-Diaryl-3-oxo-1,4-pentadienes; cytotoxicity; cycloalkanones; 4-piperidones; 3,4-dihydro-1H-naphthalen-2-ones; anticancer activity; antineoplastics; diaryldienones
Glomerular filtration rate (GFR) prediction equations are widely used in clinical practice for quick assessment of kidney function. Gates method using radionuclide technique is an alternative to prediction equations for quick assessment of GFR. Aim of the study was to compare Gates method and modification of diet in renal disease (MDRD) equation in a sizeable patient population with wide range of renal function to evaluate their clinical utility. GFR was estimated in 897 subjects with wide range of renal function by gates method, and MDRD equation and results were compared against measured GFR. Subjects were divided in to 4 groups (0-30 ml, 31-60 ml, 61-90 ml, >90 ml) on the basis of measured GFR and comparison between two methods done through linear regression analysis. Analysis of R2 indicated that 56% of the interindividual variability for Gates GFR was in accordance to variation in measured GFR, in the GFR range of (0-30 ml), this value dropped to 39% in the GFR range of 31-60 ml, 40% in the GFR range of 61-90 ml, 26.4% in the GFR range of >90 ml, the corresponding figure for MDRD GFR were 47.9%, 31.1%, 17.6% and 16.1%, respectively. Gates method is more precise for GFR estimation at all levels of renal function.
Gates method; GFR measurement; MDRD equation; Tc99m–DTPA
In Indian traditional system of medicine Celastrus paniculatus extract has been used to improve intellect, memory and for the treatment of various mental disorders.
The present study was undertaken to evaluate the effectiveness of this medicinal plant on serum biochemistry.
Ethanolic extract of seed of Celastrus paniculatus (2g/kg/body weight) was orally administrated for 16 days in 20 months old albino rats. The results were compared with 3 months, 12 months and 20 months old control rats. The concentration of trace elements was determined by atomic absorption spectrophotometer.
Significant variation was observed in the concentration of trace elements. In case of copper there was decrease in content in early aged (0.240 ± 0.004) control and age control (0.115 ± 0.004) rats whereas an increase in treated aged rats (0.124 ± 0.004) was observed. Non significant variation was observed in zinc content. Young control rats possessed 0.683 ± 0.004 (µg/ml) zinc contents in cerebellum. Age control animal showed the highest level of Zn 0.954 ± 0.002. Celastrus paniculatus treated rat show revealed the lowest level of zinc 0.457 ± 0.003 (µg/ml) in cerebellum. Young control rat had 0.066 ± 0 (µg/ml) manganese content which was significantly decreased in early age control (0.022 ± 0.0008) followed the significant increase in age control (0.087 ± 0.002). Treated rats possessed the decreased content than age control but higher than young and early age control. Non significant decrease in cobalt content was observed during ageing as in young control the highest cobalt content was 0.084 ± 0.0007 followed by decrease in early age control 0.83 ± 0 and age control 0.006 ± 0.0007 (µg/ml). Treated rats showed an increase in cobalt content up to 0.032 ± 0.0007.
Results of the present study revealed that the determination of trace elements in blood and tissues has been widely used in the last two decades as a tool to understand their metabolic role in human and animals.
Brain; Neuron; Antioxidants; Free radicals
Nocardia is a rare pathogen of peritoneal dialysis-related peritonitis despite its universal presence in soil, organic matter, and water. Human infections are seen mostly in immunocompromized hosts. The usual primary site of lesions is lung. Nocardia can enter the peritoneal cavity through the Tenckhoff catheter. We describe the first case of nocardia peritonitis that had associated nocardia pneumonia. The Tenckhoff catheter was removed due to nonresolution of peritonitis. The organism was resistant to sulfamethoxazole–trimethoprim. The patient developed hypotension, disseminated intravascular coagulation, and respiratory failure and died.
Nocardia asteroides; peritoneal dialysis; peritonitis
This commentary presents the view of an Expert Group of Indian nephrologists on adaptation and implementation of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for evaluation and management of mineral and bone disorder in chronic kidney disease (CKD-MBD) for practice in India. Zonal meetings of nephrologists drawn from the cross-section were convened to discuss the KDIGO guidelines. Recommendations were presented in a central meeting of zonal representatives. The finalized recommendations were reviewed by all the participants. There was a broad agreement on most of the recommendations made by the KDIGO workgroup. Significant departures in the current guidelines from the previous Kidney Disease Outcome Quality Initiative (KDOQI) guidelines were also noted. The participants agreed that the available evidence did not allow more precise recommendations, and the recommended best practice suggestions were often based on relatively weak evidence. There is a remarkable lack of data from Indian patients. We comment on specific areas and amplify certain concepts where we feel that further guidance that goes beyond what is stated in the document might help Indian nephrologists in appropriate implementation of the KDIGO guidelines. This commentary is intended to help define practically implementable best practices based on current disease concepts and available research evidence, thereby positively affecting the quality of management of CKD-MBD in India, and eventually improving patient outcomes.
Chronic kidney disease; guideline; hyperparathyroidism; KDIGO; mineral and bone disorder
Infection is a leading cause of death in renal allograft recipients. Apart from the immunosuppressive drugs, immunomodulatory viral infections also predispose the recipient to many opportunistic infections. Kala-azar in renal allograft recipients is infrequently reported even in endemic areas. In majority of cases, there was delay in diagnosis and treatment. We report a case of renal allograft recipient, where we faced a diagnostic dilemma because of coinfection of cytomegalovirus and visceral leishmaniasis (kala-azar). Kala-azar was successfully treated with amphotericin B. Kala-azar should always be kept as differential diagnosis in patients with pyrexia and cytopenia, even in the absence of splenomegaly in patients residing in an endemic zone.
Cytomegalovirus infection; kala-azar; renal transplantation
The emergence of novel H1N1 has posed a situation that warrants urgent global attention. Though antiviral drugs are available in mainstream medicine for treating symptoms of swine flu, currently there is no preventive medicine available. Even when available, they would be in short supply and ineffective in a pandemic situation, for treating the masses worldwide. Besides the development of drug resistance, emergence of mutant strains of the virus, emergence of a more virulent strain, prohibitive costs of available drugs, time lag between vaccine developments, and mass casualties would pose difficult problems. In view of this, complementary and alternative medicine (CAM) offers a plethora of interesting preventive possibilities in patients. Herbs exhibit a diverse array of biological activities and can be effectively harnessed for managing pandemic flu. Potentially active herbs can serve as effective anti influenza agents. The role of CAM for managing novel H1N1 flu and the mode of action of these botanicals is presented here in an evidence-based approach that can be followed to establish their potential use in the management of influenza pandemics. The complementary and alternative medicine approach deliberated in the paper should also be useful in treating the patients with serious influenza in non pandemic situations.
Diabetes mellitus describes a metabolic disorder of multiple etiologies characterized by insulin resistance, relative insulin deficiency and hyperglycemia with disturbances of carbohydrate, fat and protein metabolism. The goal for treatment of diabetes is to prevent its acute manifestations and long-term microvascular and macrovascular complications. The present study was conducted to evaluate the efficacy and safety of an Ayurvedic formulation (GlucoCare Capsules) in non-insulin dependent diabetes mellitus. Fifty NIDDM patients of pitta-kapha prakriti attending the outpatient department of the Government Ayurvedic Medical College, Guwahati, Assam, India were included in the study, and randomly divided into 2 groups, GlucoCare and placebo. All received either GlucoCare or placebo in a dose of 2 capsules twice daily, before meals for 3 months. All 50 patients completed the study - no drop outs, withdrawals or patients lost to follow up. The GlucoCare group showed significant improvement in symptoms from the 2nd month till the end of the study. GlucoCare was well tolerated by all patients throughout the treatment period with no evidence of adverse effects. The study indicates clinical efficacy of GlucoCare Capsules in the management of NIDDM in those belonging to pitta-kapha prakriti. The formulation is well tolerated and appears safe in the dosage used.
Ayurvedic formulation; Ayurvedic formulation; non-Insulin dependent diabetes mellitus
In the title compound, C6H16N+·C15H13N2O2S2
−, the thione S atom is in a cis configuration with respect to the phenyl and benzene rings, while it adopts a trans configuration with respect to the carbonyl group. The dihedral angle between the benzene and phenyl rings is 78.81 (2)°. The molecular conformation is stabilized by intramolecular O—H⋯O and N—H⋯S hydrogen bonds, while intermolecular N—H⋯O, N—H⋯N and weak C—H⋯O interactions help to stabilize the crystal structure.
Massive vascular malformation involving tongue can cause significant functional impairment. In this report we describe a rare case of extensive venous malformation involving tongue leading to obstructive sleep apnoea, inability to speak, eat, severe discomfort due to exposure induced dryness and ulceration. Multimodality treatment approach comprising of sclerotherapy, electrocautery and radiation therapy was used in this case.
Macroglossia; venous malformation; Sclerotherapy; Electrocautery; Radiotherapy