Validation of Diagnostic Utility of Salivary Urea in Patients with Chronic Kidney Disease in Chennai: A Cross-Sectional Study.

BACKGROUND: Serum urea levels are essential for the diagnosis of chronic kidney disease (CKD), as they are a measure of renal function. Salivary urea has been used as an alternative to serum urea in patients with CKD. AIM: To estimate serum urea levels and their correlation with salivary urea levels in order to validate the use of saliva as an alternative diagnostic tool for renal dysfunction. PATIENTS AND METHODS: Thirty healthy individuals and 150 patients with CKD (30 from each CKD stage) were recruited for the study. Serum and salivary samples were collected to estimate the urea levels, and statistical analyses were performed. RESULTS: Statistically significant (P < 0.05) differences in the mean serum and salivary urea levels were observed between the healthy and each stage of the CKD group; significance at P < 0.05 was observed within the stages of CKD as well. Correlation analysis also showed significant differences between the serum and salivary urea levels at each stage of the disease. Receiver operating characteristic analysis revealed a higher area under the curve of 0.917 at a 95% confidence interval with a salivary urea cut-off of 28.25 mg/dl (sensitivity and specificity: 88% and 84%, respectively). CONCLUSION: The variability in salivary urea levels in the early and late stages suggests the use of salivary urea in the late stages of CKD. It is suggested that salivary urea levels may be used as an alternative to serum to assess and monitor the progression of renal impairment along with other standard renal function markers.

Assessment of knowledge and awareness of forensic odontology among dentists in Tamil Nadu - A systematic review.

Aim: The aim of the study is to analyze the knowledge, attitude and practice of forensic odontology among dental practitioners in Tamil Nadu. Materials and Methods: Forensic odontology has immense importance in examining dental evidence and in the identification of victims of mass disaster, abuse or organized crimes. Hence, a cross-sectional survey study was conducted in a sample of 252 dental practitioners practicing in various cities in Tamil Nadu. A questionnaire comprising 22 questions (both open ended and close ended) was prepared, and the survey was conducted to analyze the knowledge and attitude of dentists toward forensic odontology. Results: Many of the practicing dentists had a basic knowledge about forensic odontology, but only 22% knew about the existence of a national association for forensic odontology. Forty-five percent of them knew about cheiloscopy. Seven percent of them only knew about the forensic courses available in India. Ninety-eight percent of them did not have any formal training related to forensic odontology. Seventy-two percent of them were not confident about giving an opinion for a forensic case. Most of them felt that our country has very limited resources for forensic odontology. Conclusion: This study showed that the branch of forensic odontology is still in the infant stage in the state. This condition, however, could be improved if more formal training courses are conducted by the specialist associations imparting knowledge and training in the field.

Systemic Lupus Erythematosus and Myasthenia Gravis: A Rare Association.

Systemic lupus erythematosus (SLE) and myasthenia gravis (MG) are two autoimmune diseases that have a higher incidence in young females, relapsing-remitting course, and positive antinuclear antibodies. SLE and MG are two different clinical syndromes, which can coexist or precede each other; however, their occurrence in the same patient is rare. We report a 38-year-old female with biopsy-proven lupus nephritis on steroids and cyclophosphamide, later developed MG. Nerve conduction studies showed the decremental response of 15%-25% over facial muscles with no decremental response over limb muscles. Although antianticholinesterase receptor (AchR) antibodies were negative, she was treated with oral pyridostigmine 60 mg twice daily and clinical improvement of ocular symptoms was seen within 48 h. At present, she is on oral prednisolone and mycophenolate mofetil with follow-up creatinine of 1.4 mg/dl and no neurological symptoms.

Spectrum of Hypokalemic Paralysis from a Tertiary Care Center in India.

Hypokalemic paralysis is an important and reversible cause of acute flaccid paralysis. The treating physician faces unique diagnostic and therapeutic challenges. We did a prospective study and included all patients with acute flaccid weakness and documented serum potassium of <3.5 mEq/L during the period between January 2009 and August 2015. We studied the incidence, etiology, clinical profile, and acid-base disturbances in patients presenting with hypokalemic paralysis and analyzed the significance of periodic and non-periodic forms of hypokalemic paralysis on patient's outcome. Two hundred and six patients were studied with a mean follow-up of 3.6 ± 1.2 years. Mean age was 37.61 ± 2.2 years (range 18-50 years). Males were predominant (M:F ratio 2.1:1). The nonperiodic form of hypokalemic paralysis was the most common (61%). Eighty-one (39%) patients had metabolic acidosis, 78 (38%) had normal acid-base status, and 47 (23%) patients had metabolic alkalosis. The most common secondary cause was distal renal tubular acidosis (RTA) (n = 75, 36%), followed by Gitelman syndrome (n = 39, 18%), thyrotoxic paralysis (n = 8, 4%), hyperaldosteronism (n = 7, 3%), and proximal RTA (n = 6, 4%). Patients with non-periodic paralysis had more urinary loss (40.1 vs. 12.2 mmol, P = 0.04), more requirement of potassium replacement (120 vs. 48 mmol, P = 0.05), and longer recovery time of weakness (48.1 vs. 16.5 h, P = 0.05) than patients with periodic paralysis. Non-periodic form of hypokalemic paralysis was the most common variant in our study. Patients with periodic paralysis had significant incidence of rebound hyperkalemia.

Collapsing Glomerulopathy and Thrombotic Microangiopathy in Postpartum Period: Two Case Reports.

Collapsing glomerulopathy (CG) is a distinct histopathologic pattern of glomerular injury characterized by global/segmental wrinkling of the glomerular basement membrane with podocyte hyperplasia and hypertrophy along with tubulointerstitial changes. There is no specific treatment for CG due to etiological heterogeneity, and newer insights into the pathogenesis may lead to the development of targeted therapy. The most common form of CG is the primary or idiopathic followed by secondary (due to viral infections, autoimmune disease, drugs, etc.) and genetic causes. Thrombotic microangiopathy (TMA) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ failure of variable severity. We here present two young women with preeclampsia who presented with acute kidney injury, anemia, and schistocytes in peripheral smear suggestive of TMA. Renal biopsy showed interesting histopathology of CG in addition to TMA in the first patient and CG alone in the second. Both the patients received supportive therapy while the first patient also received plasmapheresis. One patient had complete recovery, and other had partial recovery of renal function at last follow-up. Combined histopathological lesion of CG with TMA has never been reported in postpartum period so far in literature.

IgA-dominant Infection-related Glomerulonephritis in India: A Single-center Experience.

IgA-dominant infection-related glomerulonephritis (IRGN) is a distinct morphologic variant of IRGN, characterized by dominant or codominant glomerular deposits of IgA, mostly in elderly and patients with diabetes. More cases are being reported in recent times due to increased awareness of the disease entity and increased rate of Staphylococcus infection. It usually presents as rapidly progressive renal failure with proteinuria, and treatment guidelines for this disease entity are not well defined. We report here 12 cases of IgA-dominant IRGN seen over a period of 5 years from a single center. Clinical features, biopsy findings, treatment, and outcomes were analyzed. Out of 12 patients, eight were males. The mean age of presentation was 52.4 ± 21 years. Skin was the most common site of infection seen in six patients. Gross hematuria was seen in 4 patients and 11 had nephrotic proteinuria. Eleven had low serum C3. Only two patients had diabetes. Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism isolated in six patients. Most common histopathology was crescentic glomerulonephritis seen in seven patients, followed by endocapillary proliferation in three and diffuse proliferative glomerulonephritis in two. Hemodialysis was done in eight patients and six patients received steroid therapy. End-stage renal disease developed in three patients, chronic kidney disease in three, and three patients died due to sepsis. Various infections including MRSA and Escherichia coli were associated with IgA-dominant IRGN both in patients with diabetes and nondiabetics. Suspicion and recognition of the disease is important as it has therapeutic and prognostic implications.

Scrub typhus meningitis in a renal transplant recipient.

Scrub typhus is a rickettsial infection commonly seen in Asia. The clinical presentation ranges from nonspecific febrile illness to potentially fatal multiorgan involvement such as liver, kidney, or lung. Central nervous system involvement is uncommon. We report a 45-year-old female renal transplant recipient who presented with fever, headache, meningeal signs, graft dysfunction, and eschar. IgM antibodies against Orientia tsutsugamushi were positive by enzyme-linked immunosorbent assay. Despite oral doxycycline therapy for 5 days, she did not improve but responded well to intravenous azithromycin. To the best of our knowledge, scrub typhus as a cause of meningitis in a renal transplant recipient has not been reported so far.

Thrombotic microangiopathy due to Viperidae bite: Two case reports.

Snake bite is mainly an occupational hazard and causes serious health problems in rural India. Acute kidney injury (AKI) occurs in 5-30% cases. Renal pathologic findings include acute tubular necrosis, cortical necrosis, interstitial nephritis, glomerulonephritis, and vasculitis. Thrombotic microangiopathy (TMA) occurrence after a snake bite is reported rarely. Here, we present two patients who developed TMA after viper bite treated with hemodialysis and plasmapheresis. Renal biopsy showed fibrin thrombi in glomeruli and arterioles with cortical necrosis. One patient progressed to end-stage renal disease and other was lost to follow-up. TMA should be considered as a possible pathogenesis of AKI after snake bite. The role of plasma exchanges in snake bite TMA is yet to be defined.

Thrombotic microangiopathy: An unusual cause of renal failure in rheumatoid arthritis.

Rheumatoid arthritis (RA) is one of the commonest rheumatological diseases. Renal involvement is not common but can occur as a result of chronic inflammation as part of disease process or drug toxicity. Thrombotic microangiopathy (TMA) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ failure of variable severity. Only a few cases of TMA in patients with RA were reported to date. We describe a 45-year-old female patient with RA who presented with oliguria and edema. Renal biopsy showed TMA with patchy cortical necrosis. She improved with hemodialysis and plasmapheresis.

Deceased donor renal transplantation: A single center experience.

Deceased donor renal transplantation (DDRT) constitutes less than 5% of all kidney transplantats in India. A retrospective analysis of 173 deceased donor renal transplants performed in a public funded government hospital was done. Mean age of the recipients was 36 years (male:female ratio 2.4:1), and that of the donors was 32.3 years (male:female ratio 6:1). The cold ischemic time was 340 ± 170 minutes. Mean follow-up period was 36 months. Forty one patients died, 75% of them in the first post - transplant year. Sepsis and cardiovascular disease were the most common causes of death. Twenty two percent had acute rejection. There was no significant difference in the incidence in the rate of acute rejection, bacterial, fungal infections and death rate between the cohorts of induction and non induction immunosuppression. The patient and death censored graft survival at 1 year were 80 and 82.6% and at 5 years were 76 and 80% respectively.

Clinicopathological correlation and treatment response of primary focal segmental glomerulosclerosis in adults and adolescents.

The incidence of focal segmental glomerulosclerosis (FSGS) is approximately 10% in children <6 years, 20% in adolescents, and 20-25% in adults. A retrospective observational study was done to document clinicopathological correlation, treatment response, and risk factors in the progression of chronic kidney disease (CKD) of primary FSGS in adults and adolescents. A total of 170 patients were studied with a mean follow-up of 4.32 ± 1.2 years. FSGS not otherwise specified was the most common subtype (56%) followed by tip variant (24%). About 32% had complete remission (CR) at a mean time of 6.4 months, 23% had partial remission (PR) at a mean time of 5.7 months, and 45% had no response to steroids. Persistent nephrotic proteinuria at 3rd and 6th month and presence of interstitial fibrosis and tubular atrophy >30% in renal biopsy are the independent predictors of poor response to treatment. Presence of anemia, interstitial fibrosis, and tubular atrophy of >30% in renal biopsy and the absence of remission after treatment were the independent predictors of CKD progression. Overall renal survival was 78% at 3 years and 54% at 5 years. Renal survival difference with or without nephrotic proteinuria at onset was 39% and 69% at 5 years. Renal survival was higher in patients with normal renal function (66%) compared with those who had renal failure (42%) at 5 years. Renal survival at 5 years for CR was 69%, PR was 49%, and no remission was 42%.

Two consecutive recurrences of crescentic immunoglobulin A nephropathy in a renal transplant recipient.

We report a 21-year-old male who developed end-stage renal disease, probably due to immunoglobulin A nephropathy (IgAN), received a renal transplant from his mother, which was lost due to crescentic IgAN after 18 months. Two years later, he received a second transplant from a deceased donor. He developed rapidly progressive graft dysfunction 3 years later. Allograft biopsy revealed crescentic IgAN, which was successfully treated with intravenous steroids and cyclophosphamide. Recurrence of IgAN in two successive allografts in one patient has not been reported previously.

Prevalence of serum anti M-type phospholipase A2 receptor antibody in primary membranous nephropathy: A single center experience.

We conducted a prospective study to assess utility of detection of antibodies to phospholipase A2receptor (PLA2R) in the serum of patients with membranous nephropathy. Seventy five patients with biopsy proven membranous nephropathy admitted between January 2011 and September 2014 were studied. Serum anti- PLA2R was tested by indirect immunofluorescence. The test was positive in 45 out of 60 patients with primary membranous nephropathy (PMN) and in none of the 15 patients with secondary membranous nephropathy, with a sensitivity of 75% and specificity of 100% for PMN. Anti PLA2R positivity also showed a significant correlation with quantum of proteinuria and negative correlation with serum albumin. This study has validated detection of serum anti PLA2R in PMN as a non invasive diagnostic tool in Indian patients.

Acute kidney injury and disseminated intravascular coagulation due to mercuric chloride poisoning.

Mercury is a toxic heavy metal and occurs in organic and inorganic forms. Inorganic mercury includes elemental mercury and mercury salts. Mercury salts are usually white powder or crystals, and widely used in indigenous medicines and folk remedies in Asia. Inorganic mercury poisoning causes acute kidney injury (AKI) and gastrointestinal manifestations and can be life-threatening. We describe a case with unknown substance poisoning who developed AKI and disseminated intravascular coagulation (DIC). Renal biopsy showed acute tubular necrosis. Later, the consumed substance was proven to be mercuric chloride. His renal failure improved over time, and his creatinine normalized after 2 months.

Angiomyolipoma of donor kidney: Successful transplantation and 5-year follow-up.

Angiomyolipomas (AML) of the kidney are non-encapsulated benign neoplasms with the incidence of 45-80% in patients with tuberous sclerosis and 1-3% in sporadic cases. There are very few case reports in the literature in which kidneys with AML have been used for transplantation. We report here a 27-year-old female patient who received a live related renal transplant from her mother with isolated angiomyolipoma in donor kidney and on follow-up after 5 years, has stable graft function and tumor size.

Squamous cell carcinoma of the gingiva: A diagnostic enigma.

Oral squamous cell carcinoma (OSCC) is the most common epithelial malignant neoplasm affecting the oral cavity; early detection is an important criterion for achieving high cure rate. Occasionally, it may be misdiagnosed because of its variable and innocuous clinical appearance. Carcinomas of the gingiva are a unique subset of OSCC, constituting approximately 10% of OSCCs and can mimic a multitude of oral lesions especially those of inflammatory origin with benign features, often leading to delay in the diagnosis and hence delayed treatment. This article reports a rare case of gingival OSCC in a 62-year-old female patient mimicking an inflammatory gingival mass.

IgG4 related interstitial nephritis: A case report and review of literature.

IgG4 interstitial nephritis is a recently described entity. A middle-aged gentleman with bilateral parotid enlargement, hepatosplenomegaly and generalized lymphadenopathy was referred to us for evaluation of renal failure. He had trace proteinuria and large kidneys. Kidney biopsy revealed interstitial nephritis with characteristic storiform fibrosis. Immunohistochemistry demonstrated intense staining for IgG4-secreting plasma cells in the interstitium.

Acquisition of a stable mutation in metY allows efficient initiation from an amber codon in Escherichia coli.

Escherichia coli strains harbouring elongator tRNAs that insert amino acids in response to a termination codon during elongation have been generated for various applications. Additionally, it was shown that expression of an initiator tRNA containing a CUA anticodon from a multicopy plasmid in E. coli resulted in initiation from an amber codon. Even though the initiation-based system remedies toxicity-related drawbacks, its usefulness has remained limited for want of a strain with a chromosomally encoded initiator tRNA 'suppressor'. E. coli K strains possess four initiator tRNA genes: the metZ, metW and metV genes, located at a single locus, encode tRNA(1)(fMet), and a distantly located metY gene encodes a variant, tRNA(2)(fMet). In this study, a stable strain of E. coli K-12 that affords efficient initiation from an amber initiation codon was isolated. Genetic analysis revealed that the metY gene in this strain acquired mutations to encode tRNA(2)(fMet) with a CUA anticodon (a U35A36 mutation). The acquisition of the mutations depended on the presence of a plasmid-borne copy of the mutant metY and recA(+) host background. The mutations were observed when the plasmid-borne gene encoded tRNA(2)(fMet) (U35A36) with additional changes in the acceptor stem (G72; G72G73) but not in the anticodon stem (U29C30A31/U35A36/psi39G40A41). The usefulness of this strain, and a possible role for multiple tRNA(1)(fMet) genes in E. coli in safeguarding their intactness, are discussed.

An unexpected absence of queuosine modification in the tRNAs of an Escherichia coli B strain.

The post-transcriptional processing of tRNAs decorates them with a number of modified bases important for their biological functions. Queuosine, found in the tRNAs with GUN anticodons (Asp, Asn, His, Tyr), is an extensively modified base whose biosynthetic pathway is still unclear. In this study, it was observed that the tRNA(Tyr) from Escherichia coli B105 (a B strain) migrated faster than that from E. coli CA274 (a K-12 strain) on acid urea gels. The organization of tRNA(Tyr) genes in E. coli B105 was found to be typical of the B strains. Subsequent analysis of tRNA(Tyr) and tRNA(His) from several strains of E. coli on acid urea gels, and modified base analysis of tRNA preparations enriched for tRNA(Tyr), showed that E. coli B105 lacked queuosine in its tRNAs. However, the lack of queuosine in tRNAs was not a common feature of all E. coli B strains. The tgt and queA genes in B105 were shown to be functional by their ability to complement tgt and queA mutant strains. These observations suggested a block at the step of the biosynthesis of preQ(1) (or preQ(0)) in the B105 strain. Interestingly, a multicopy vector harbouring a functional tgt gene was toxic to E. coli B105 but not to CA274. Also, in mixed cultures, E. coli B105 was readily competed out by the CA274 strain. The importance of these observations and this novel strain (E. coli B105) in unravelling the mechanism of preQ(1) or preQ(0) biosynthesis is discussed.