Immunoglobulin A Deposits In Renal Allografts: A Prospective Longitudinal Single-Center Study.

AIMS AND BACKGROUND: To describe the prevalence of IgA deposits (IgAD) in renal allografts in a cohort of renal transplant recipients and to analyze their management strategies and histopathology. To assess graft function and proteinuria after 1 year of follow-up. MATERIALS AND METHODS: A prospective longitudinal follow-up study was carried out in VPS Lakeshore Hospital and Research Centre, Kochi, Kerala, over a period of 5 years (July 2015 to June 2020). Kidney transplant recipients with allograft biopsies that reported IgAD on immunofluorescence were included in the study. Light microscopy and immunofluorescence studies were performed. Mesangial hypercellularity (M); segmental glomerulosclerosis (S); endocapillary hypercellularity (E); tubular atrophy/interstitial fibrosis (T); crescents (C) (MEST-C) Scoring was done in patients with pathogenic IgAD. Treatment strategies included increased baseline steroid dosage, rituximab administration, and plasma exchange. Clinical details and management strategies were analyzed, and patients were followed up for 1 year after diagnosis. Changes in graft function (S. Creatinine) and proteinuria (Urine Protein/Creatinine ratio) were analyzed. Clinico-pathologic correlation with the MEST-C scores was also done. RESULTS: Out of 1036 kidney transplants done in the study period, 760 graft biopsies were performed. Sixty-four cases had post-transplant deposition of IgA (8%). The mean age was 45 ± 11.25SD years. The study had 51 men and 13 women. Induction immunosuppression comprised rabbit antithymocyte globulin in 29 (45%) patients and basiliximab in 35 (54%). Maintenance immunosuppression in all comprised tacrolimus, mycophenolate mofetil, and steroids. There were 2 groups: group A (pathogenic IgAD) and group B (incidental IgAD). Group A had 46 cases (71.9%), out of which 8 had "active" IgA nephropathy (endocapillary proliferation, crescents, and IgA vasculitis), and 38 had "inactive" IgAD. In patients with active deposits, 3 had cellular crescents (18%, 30%, and 23%), all 8 had endocapillary proliferation, and 2 had vasculitis. Group B had 18 cases (28.1%), comprising T cell-mediated rejections (5), antibody-mediated rejection (8), BK virus nephropathy (1), and interstitial fibrosis and tubular atrophy (4). In group A, 22 (47.8%) presented with graft dysfunction, 8 (17.3%) with isolated proteinuria, and 14 (30.4%) patients presented with a combination. Two (4.3%) patients had neither. Fourteen (30.4%) patients presented within 1 month of renal transplant. In patients of group A, at the end of 1 year of treatment, the mean S. Creatinine reduced to 1.68 mg/dL from 1.84 mg/dL, and the mean protein/creatinine ratio reduced from 1.2 to 0.5 (±1.17). In patients with "active IgA" lesions, at the end of 1 year of treatment, the mean S. Creatinine increased slightly to 1.68 mg/dL (±0.47SD) from 1.48 mg/dL (±0.52SD), and the mean protein/creatinine ratio reduced from 2.32 (±1.56SD) to 1.05 (±1.70SD). In the 16 patients with IgAD and proteinuria, at the end of 1 year of treatment, the mean S. Creatinine decreased to 1.41 ± 0.32 SD mg/dL from 1.47±0.37SD mg/dL and the mean protein/creatinine ratio reduced from 1.12 ± 1.31 SD to 0.39±0.75 SD. In the remaining 22 patients with acute tubular injury, at the end of 1 year, the mean S. Creatinine decreased to 1.920.32 SD mg/dL from 2.10.8SD mg/dL, and the mean protein/creatinine ratio reduced from 1.1 ± 1.31 SD to 0.66 ± 1.45 SD. In the MEST-C scoring analysis, all scores were 0 in 20 (43.4%) biopsies, only M1 score in 11 (23.9%) biopsies, only E1 score in 10 biopsies (21.7%), S1 in 13 (28.2%) cases. CONCLUSION: Immunoglobulin A deposits occur commonly after transplant; these may represent recurrence, de novo IgA, or donor-derived IgAD. Although commonly benign, some may cause significant graft dysfunction and graft loss. IgAD can present as varying combinations of graft dysfunction and proteinuria. Active IgA pathologies may occur early in the post-transplant course, may have significant graft dysfunction, and need proactive management. There is a correlation between segmental sclerosis and proteinuria. Evidence for the efficacy of Rituximab, plasma exchange, and prolonged courses of steroids is wanting; however, some benefits are possible. Long-term follow-up is essential.

Management of giant adrenal pseudocyst in pregnancy - A unique approach and review of literature.

Pseudocysts of the adrenal gland are rare and in the majority of cases are non- functioning. They become symptomatic only when they are complicated by hormonal excess, rupture, haemorrhage or infection. Described here is a 26-year-old woman who developed an acute abdomen at 28 weeks of gestation due to a left adrenal haemorrhagic pseudocyst. A conservative approach was adopted, which was followed by elective term caesarean delivery with surgical intervention at the same time. The described case is unique in terms of strategizing timing and mode of management and thus minimizing the risk of prematurity and maternal morbidity associated with interval surgery.

Gallium 68-PSMA PET/CT for lesion characterization in suspected cases of prostate carcinoma.

OBJECTIVE: To assess the feasibility of gallium 68 (Ga)-prostate specific membrane antigen (PSMA) PET/computed tomography (CT) to identify patients who truly harbor clinically significant prostate cancer (PCa) in a cohort of patients with clinical and biochemical/radiological suspicion of PCa. PATIENTS AND METHODS: A total of 118 patients with suspected PCa who underwent Ga-PSMA PET/CT between May 2015 and June 2016 were prospectively included. Final decision on performing biopsy was left to the referring urologist after considering the clinical data, scan findings and discussion with the patient. RESULTS: Overall, 51 patients were scan negative, among whom six underwent biopsy but was negative for malignancy. In 45 patients, an immediate biopsy could be avoided and put on follow-up. None of these patients were documented to have PCa in the short average follow-up of 6 months. Among 67 patients who were scan positive, 56 patients underwent transrectal ultrasonography-guided biopsy, and malignancy could be documented in 46 of them. In addition, comprehensive initial staging information could be obtained in them, with organ-confined disease demonstrated in 33 patients and metastatic disease in 13 patients. CONCLUSION: Ga-PSMA PET/CT can act as a gate keeper in selecting patients with suspected PCa who should undergo an immediate transrectal ultrasonography-guided biopsy and who could be kept on active surveillance.

Child maltreatment and adult criminal behavior: does criminal thinking explain the association?

Criminal thinking styles were examined as mediational links between different forms of child maltreatment (i.e., sexual abuse, physical abuse, and physical neglect) and adult criminal behaviors in 338 recently adjudicated men. Analyses revealed positive associations between child sexual abuse and sexual offenses as an adult, and between child physical abuse/neglect and endorsing proactive and reactive criminal thinking styles. Mediation analyses showed that associations between overall maltreatment history and adult criminal behaviors were accounted for by general criminal thinking styles and both proactive and reactive criminal thinking. These findings suggest a potential psychological pathway to criminal behavior associated with child maltreatment. Limitations of the study as well as research and clinical implications of the results are discussed.

An unusual complication of a common gynaecological procedure.

A case of bilateral, but more of massive right sided transudative pleural effusion associated with bilateral ureteric trauma following laparoscopy for endometriosis is reported. The diagnosis of urinothorax was confirmed by demonstrating a pleural fluid to serum creatinine ratio of greater than one. Management of ureteric injury by insertion of Double J (DJ) stents on both sides resulted in resolution of the pleural effusion.

Gastrointestinal complications in patients with chronic kidney disease--a 5-year retrospective study from a tertiary referral center.

BACKGROUND: Gastrointestinal complications are frequent in patients with renal disease and are responsible for substantial morbidity and mortality among these patients in developing countries. Many times, these patients are subjected to endoscopic evaluation and mucosal biopsies are taken for definitive diagnosis. This study explores the various upper and lower nonneoplastic gastrointestinal complications in patients with chronic kidney disease (CKD) and the role of endoscopic mucosal biopsies in the management of these patients. METHODS: Sixty-three patients with CKD, who were referred to endoscopic evaluation and biopsy due to significant gastrointestinal symptoms between January 2007 and December 2011 form the study group. Patients were divided into two groups: group 1 and group 2. Group 1 consisted of patients with CKD stages 1-5 and group 2 consisted of renal allograft recipients. All biopsies were reviewed by an experienced pathologist. Clinical data were collected from patient's medical records. RESULTS: There were 38 patients in group 1 and 25 patients in group 2. Twenty-nine out of 38 patients in group 1 presented with upper gastrointestinal (GI) symptoms and underwent esophagogastroduodenoscopy (OGD) evaluation, which showed erosive gastritis as the most common biopsy finding followed by ulcerative esophagitis and duodenitis. These patients were also found to be susceptible to develop ischemic colitis due to hypotensive episodes during dialysis, which are likely to occur during the initial stages of dialysis. The most frequent symptom in group 2 was chronic diarrhea (13 out of 25 patients) for which a colonoscopic examination was done which revealed various infection and drug-related colitis, mycophenolate mofetil (MMF) being a major culprit. CONCLUSION: CKD patients with high urea level are prone to develop upper GI symptoms and mostly show erosive gastritis, ulcerative esophagitis, and duodenitis on biopsy. On the contrary, renal allograft recipients mostly develop opportunistic infections and drug-related toxicity in the colon. MMF-related GI toxicity is an underrecognized entity and further prospective studies are required for its better understanding.

Simultaneous determination of aspirin and isosorbide 5-mononitrate in formulation by reversed phase high pressure liquid chromatography.

A simple, precise and rapid reversed phase HPLC method was developed for the simultaneous estimation of aspirin (AS) and isosorbide 5-mononitrate (ISM) in combined formulation. The method was carried out on a Thermo Quest C18 column using a mixture of water:methanol (water pH adjusted to 3.4 using dilute orthophosphoric acid) and detection was carried out at 215 nm using chlorzoxazone as internal standard. Both the drugs showed linearity in the range of 2-10 microg/ml and limits of quantification was found to be 4 and 40 ng/ml for AS and ISM, respectively.