Neelakanthi Ratnatunga

Tubulointerstitial damage as the major pathological lesion in endemic chronic kidney disease among farmers in North Central Province of Sri Lanka

Chronic kidney disease of uncertain etiology (CKDu) in North Central Province of Sri Lanka has become a key public health concern in the agricultural sector due to the dramatic rise in its prevalence and mortality among young farmers. Although cadmium has been suspected as a causative pathogen, there have been controversies. To date, the pathological characteristics of the disease have not been reported. Histopathological observations of 64 renal biopsies obtained at Anuradhapura General Hospital from October 2008 to July 2009 were scored according to Banff 97 Working Classification of Renal Allograft pathology. The correlations between the histological observations and clinical parameters were statistically analyzed. Interstitial fibrosis and tubular atrophy with or without nonspecific interstitial mononuclear cell infiltration was the dominant histopathological observation. Glomerular sclerosis, glomerular collapse, and features of vascular pathology such as fibrous intimal thickening and arteriolar hyalinosis were also common. Although hypertension was identified as one of the common clinical features among the cases, it did not influence the histopathological lesions in all the cases. This study concludes that tubulointerstitial damage is the major pathological lesion in CKDu. Exposure(s) to an environmental pathogen(s) should be systematically investigated to elucidate such tubulointerstitial damage in CKDu.

An Integrative Study of the Genetic, Social and Environmental Determinants of Chronic Kidney Disease Characterized by Tubulointerstitial Damages in the North Central Region of Sri Lanka

An Integrative Study of the Genetic, Social and Environmental Determinants of Chronic Kidney Disease Characterized by Tubulointerstitial Damages in the North Central Region of Sri Lanka: Shanika NANAYAKKARA, et al. Department of Health and Environmental Sciences, Graduate School of Medicine, Kyoto University—

Risk factors associated with disease progression and mortality in chronic kidney disease of uncertain etiology: a cohort study in Medawachchiya, Sri Lanka

BackgroundThe alarming rise in the prevalence of chronic kidney disease of uncertain etiology (CKDu) among the low socioeconomic farming community in the North Central Province of Sri Lanka has been recognized as an emerging public health issue in the country.MethodsThis study sought to determine the possible factors associated with the progression and mortality of CKDu. The study utilized a single-center cohort registered in 2003 and followed up until 2009 in a regional clinic in the endemic region, and used a Cox proportional hazards model.ResultsWe repeatedly found an association between disease progression and hypertension. Men were at higher risk of CKDu than women. A significant proportion of the patients in this cohort were underweight, which emphasized the need for future studies on the nutritional status of these patients.ConclusionsCompared with findings in western countries and other regions of Asia, we identified hypertension as a major risk factor for progression of CKDu in this cohort.

Chronic kidney disease in snake envenomed patients with acute kidney injury in Sri Lanka: a descriptive study

Background Data on the long-term outcomes of acute kidney injury (AKI) in envenomed patients leading to chronic kidney disease (CKD) are scarce. The aim of the study was to investigate this issue and to determine the predictive factors in developing CKD. Methods The records of a series of 54 patients who had AKI following a snakebite during the period 2004–2009 and who had been followed up were reviewed in the nephrology unit, Kandy, Sri Lanka. The primary outcome measure was the failure of renal functions to return to normal within 1 year. The renal histology was studied in seven patients. Results The mean age of the group was 50 years (SD 13 years) and 39 (72%) patients were men. The offending snakes were Russells viper and hump-nosed viper in 15 (28%) and 13 (24%) patients, respectively. At 1 year, 20 patients (37%) had developed CKD (CKD group) and the rest (63%) had recovered (recovered group). The acute stage serum creatinine was high in both groups with no difference (on admission, p=0.134; on discharge, p=0.323), but the CKD group showed significantly high serum creatinine at 2 months after AKI (p=0.004). Mean duration of renal replacement therapy (RRT) of the recovered group and CKD group were 7 (SD 5) and 16 (SD 12) days, respectively (p=0.015). Renal histology of six CKD patients showed predominant glomerular sclerosis and interstitial nephritis. Conclusions CKD is an outcome of severe AKI following snake envenoming probably predicted by the length of RRT.

Profile of Hashimoto's Thyroiditis in Sri Lankans: Is There an Increased Risk of Ancillary Pathologies in Hashimoto's Thyroiditis?

Hashimotos thyroiditis has been reported to be associated with many neoplastic and nonneoplastic thyroid pathologies. This retrospective study aims to determine the demographic profile of Hashimotos thyroiditis in Sri Lankans, document ancillary pathologies in Hashimotos thyroiditis, and determine whether there is an increased risk of occurrence of malignancies, benign neoplasms, and nonneoplastic benign lesions in Hashimotos thyroiditis by comparing with thyroids showing multinodular goiters, follicular adenomas, and colloid nodules. The mean age of Hashimotos thyroiditis is 43.3 years with the majority in the 41 to 60 year age group and a female to male ratio of 10.3 : 1. This study revealed a statistically significant increase of thyroid malignancies in association with Hashimotos thyroiditis. The association of Papillary carcinoma, Non-Hodgkins lymphoma, and Hurthle cell adenoma with Hashimotos thyroiditis was statistically significant.

Retrospective analysis of renal histology in asymptomatic patients with probable chronic kidney disease of unknown aetiology in Sri Lanka

OBJECTIVES To study the early pathological changes in renal lesions of asymptomatic patients with kidney diseases, with no definite aetiology living in regions endemic for chronic kidney disease of unknown etiology (CKDUe). Design Retrospective study. SETTING Regions endemic for CKDUe in and around the North Central Province of Sri Lanka. STUDY POPULATION Two hundred and eleven asymptomatic patients living in endemic regions detected with renal disease by screening for proteinuria using the dipstick method. Those with long standing hypertension, diabetes mellitus, histological diagnosis of primary glomerular diseases, immunocomplex mediated diseases or renal lesions secondary to systemic diseases were excluded. MEASUREMENTS Renal lesions were divided into seven histological categories depending on the pathological changes: Category 0: no detectable changes. Category 1: Interstitial fibrosis ± mild interstitial inflammation ± tubular atrophy; no glomerulosclerosis. Category 2: Interstitial fibrosis ± mild interstitial inflammation ± tubular atrophy; glomerulosclerosis. Category 3: Moderate or severe interstitial fibrosis, interstitial inflammation and tubular atrophy ± glomerulosclerosis; Category 4: Interstitial inflammation ± tubular atrophy ± glomerulosclerosis; no interstitial fibrosis. Category 5: The prominent change is interstitial inflammation with tubulitis. Category 6: Severely scarred kidney. Histological categories were compared with calculated glomerular filtration rates and age of the patients. RESULTS Number of cases in histological categories 0 to 6 were: 7 (3.3%), 71 (33.6%), 53 (25.1%), 63 (29.9%), 0, 2 (0.9%) and 15 (7.1%) respectively. The mean glomerular filtration rate was >90 ml/min in patients in category 0 and 1 and declined progressively in categories 2 and 3. Apart from category 0, all had interstitial fibrosis and in category 1, 62 (87.3%) had interstitial fibrosis without inflammation. Severity of interstitial inflammation increased from category 1 to 3. CONCLUSIONS The early disease among asymptomatic patients is characterized by interstitial fibrosis without significant interstitial inflammation and glomerular sclerosis with preserved glomerular function. Although the role of interstitial inflammation in the initiation of the disease is not clear, it appears to have a role in the progression of the disease.

Mantle cell lymphoma first presenting as immune complex-mediated glomerulonephritis: a case report

IntroductionKidney involvement in non-Hodgkin lymphoma is recognized but mostly diagnosed following a diagnosis of lymphoma. We describe a rare case of mantle cell lymphoma, a B-cell-type non-Hodgkin lymphoma, first presenting with immune complex glomerulonephritis.Case presentationWe report the case of a 58-year-old Sri Lankan man who presented with gross hematuria. Further investigation revealed bicytopenia with splenomegaly and elevated serum creatinine. He had a renal biopsy, which revealed acute immune complex glomerulonephritis with interstitial inflammation. Results from an initial bone marrow biopsy and blood imaging were inconclusive. Three months later his renal function had deteriorated and a lymph node biopsy revealed mantle cell lymphoma. Within three months of initiating chemotherapy, his renal function returned to normal levels and remained normal at one year of follow-up.ConclusionsIt is important to have a high degree of suspicion when patients present with acute immune complex glomerulonephritis with no other identifiable cause, because it could be the first presentation of a non-Hodgkin lymphoma such as mantle cell lymphoma.

Heterotopic brain tissue in the sacrococcygeal region

The sacrococcygeal region is the seat of frequent developmental anomalies and a favoured site for germ cell tumours in the paediatric age group.We report an unusual case of heterotopic brain tissue mimicking a teratoma in a neonate. To the best of our knowledge, this is the first such report. DOI: http://dx.doi.org/10.4038/cmj.v58i3.6106 Ceylon Medical Journal 2013; 58 : 126-128

Fulminant colitis and toxic myocarditis: a unifying cause?

In June, 2006, a 44-year-old previously healthy woman from a poor socio-economic background presented to us with a 5-day history of fever, dyspnoea, tight chest pain, and postural dizziness. This was preceded by an episode of diarrhoea over a week. On admission, respiratory rate was 40 breaths per min, radial pulse was regular at 130 beats per min, and blood pressure was 80/50 mm Hg. She had central cyanosis, was sweating profusely, and had cold peripheries. Heart sounds showed triple rhythm and she had fi ne basal crepitations in her lungs. Her abdomen was soft and non-tender; there was no sign of hepatosplenomagaly or ascites. She was promptly resuscitated with intravenous fl uids, but required intubation and mechanical ventilation in the intensive care unit. Broad-spectrum antibiotics including benzylpenicillin and ceftriaxone were given. Hypotension and tachycardia persisted despite maximum inotropic support. She subsequently developed acute renal failure and severe hepatic dysfunction; peritoneal dialysis and liver failure regimen were started. A 12-lead ECG showed ST segment depressions in leads I, aVL, and V2 to V6. Troponin T concentration was high. Initial echocardiography showed dilatation of all cardiac chambers and a hypokinetic left ventricle with left ventricular ejection fraction 42%; the latter declined to 36% on day 3. C-reactive protein was high (>1000 mg/L). White blood cell count was 10·8×109/L (76% neutrophils; 20% lymphocytes; 4% eosinophils). Blood and peritoneal fl uid cultures were repeatedly negative. No antibodies to the following were detectable: dengue virus, coxackievirus, infl uenza A and B viruses, parainfl uenza virus, adenovirus, RSV, hanta virus, herpes virus, HIV. Tests for leptospirosis were also negative. She had a generalised tonic-clonic convulsion on day 7; EEG showed generalised slow waves. The seizures were managed, but she died on day 15. At autopsy, purulent ascitic fl uid and organised pus on serosal surfaces were found. The caecum had multiple transverse ulcers and a perforation in the lateral wall. The heart was dilated, and the myocardium was fl abby and weighed 0·2 kg. There was a thin layer of pericardial eff usion. Staining of the myocardium for gram-negative bacteria and eosinophils was negative. However, fl orid colitis with Entamoeba histolytica in abundance was detected in the caecum, which also showed many fl ask-shaped ulcers, some of which had penetrated up to the serosa. The ulcer base and the adjacent caecal wall showed multiple amoebae with ingested red blood cells. Amoebae were also noted to be invading the muscular propria and the subserosal surface (fi gure A). However, molecular identifi cation was not done because of limited available resources. There were several foci of myocardial necrosis, some of which were organised with little infl ammation, suggestive of toxic myocarditis (fi gure B). A viral aetiology was initially considered because it is the most common cause of myocarditis. The possibility of an amoebic cause was not entertained antemortem, but the autopsy fi ndings confi rmed toxic cardiomyopathy. The absence of eosinophils and gramnegative bacteria in the myocardium supports the possible amoebic aetiology secondary/concurrent to bowel pathology. Pre-existing heart failure was unlikely because the patient was in good health just before the illness. E histolytica is primarily a bowel pathogen that causes colitis and liver abscesses. Rarely it causes mening oencephalitis and pericarditis. There are about 50 million cases of amoebiasis in the world and nearly 100 000 people die annually from complications. The case fatality rate remains high at 29% in some parts of Asia; the case fatality rate in Sri Lanka is 0·6/100 000 per year. Although E histolytica has been implicated in cases of dilated cardiomyopathy in animals, it has not been reported in human beings. Our case shows an uncommon consequence of a relatively common disease.

Accreditation of medical testing laboratories in Sri Lanka, the definite way forward !

No abstract available. DOI: http://dx.doi.org/10.4038/jdp.v7i1.5588 J ournal of Diagnostic Pathology 2012 (7); 1:4-5