Ravindra Prabhu

Protein thiol oxidation and lipid peroxidation in patients with uraemia

Background: Patients with uraemia are exposed to increased oxidative stress. In this study, a series of oxidative stress markers were measured in patients with chronic renal failure (CRF) and patients with CRF on haemodialysis (HD) compared to normal controls to establish whether there is enhanced oxidative stress on HD therapy in uraemic subjects. Methods: Protein thiol oxidation, lipid hydroperoxides, albumin and uric acid concentrations were estimated in patients receiving HD and patients with CRF and compared with those in healthy controls. Results: There was a significant decrease in the level of protein thiols in CRF (p=0.0001) and HD patients (p=0.0001) compared with that in controls. Lipid hydroperoxides were significantly higher in CRF (p=0.026) and HD patients (p=0.003) than in controls. However, there was no significant difference in protein thiols and lipid hydroperoxides between CRF and HD patients. Serum protein thiols correlated negatively with lipid hydroperoxides and positively with serum albumin. Conclusions: These findings suggest that both CRF and HD patients have increased plasma protein oxidation and lipid peroxidation. However, HD therapy per se did not contribute to oxidative stress already present in uraemia. Owing to the variability in lipid peroxidation products as markers of oxidative stress and the vital role played by thiol antioxidants in the biological system, it is suggested that protein thiol oxidation may be a better marker of oxidative stress.

Acute renal failure and/or rhabdomyolysis due to multiple bee stings: A retrospective study

Although multiple bee stings are of rare incidence, they can cause many harmful reactions in humans. Massive inoculation of bee venom is reported to cause skin necrosis, shock hypertension, bleeding, hemolysis, thrombocytopenia, pancreatitis, (adult) respiratory distress syndrome, rhabdomyolysis, and acute renal failure (ARF).[1–12] Generally, three major reactions occur after bee inoculation as 1) local swelling and irritation, 2) generalized anaphylactic responses, and 3) serum sickness like symptoms, which include hemolysis, disseminated intravascular coagulation, rhabdomyolysis, and ARF.[13,14] In India, existences of honey combs are general in rural as well as urban areas but there are sparse data available in the literature on bee sting toxicity. To the best of our knowledge, there are no epidemiological studies reported until now on multiple bee sting-induced ARF and/or rhabdomyolysis in the Indian population. Hence, we performed a retrospective study for multiple bee sting-induced ARF and/or rhabdomyolysis. The cases under International Classification of Diseases 2010 (Code T63.4) i.e., “venom of other arthropods” were screened retrospectively from January 2009 to December 2011 after Institutional Ethics Committee (IEC) approval. A total 32 cases were found. The inclusion criteria were the adult cases diagnosed to have multiple bee sting-induced rhabdomyolysis, ARF and/or other complication. Nine cases were selected in the study [Table 1, Figure ​Figure11 and ​and2],2], out of which six were diagnosed with acute kidney injury (AKI) and rhabdomyolysis, two with AKI only, and one with rhabdomyolysis only. The following type of information was collected from the patient records: Age, sex, complaints on admission, diagnosis, medical, medication, social and family history, days between bee stings and hospital admission, number of hemodialysis given, length of stay in the hospital; laboratory results like serum urea, serum creatinine, aspartate (AST), and alanine (ALT) aminotransferases, alkaline phosphatase (ALP), creatine kinase (CK), lactate dehydrogenase (LDH), total leukocyte count (TLC), hemoglobin (Hb), presence of myoglobin in urine, and other relevant data as per the case were obtained. All the patients had no significant abnormalities in serum potassium and sodium. The distribution of the AKI cases as per the risk, injury, failure, loss, end-stage (RIFLE) criteria was 1-‘Risk’, 6-‘Failure’, 1-‘Loss’. Table 1 Details of the patients Figure 1 Serum urea levels of the patients Figure 2 Serum creatinine of the patients The unique points in each case are discussed below. In all the cases, for anaphylaxis standard treatment was given.

Urinary Protein Thiols In Different Grades of Proteinuria

Total thiol status of plasma, especially thiol groups over protein contributes maximum to the plasma antioxidant status of the body. Serum protein thiols were found to be decreased in various disease conditions including chronic renal failure patients. Only few studies determined the levels of urinary protein thiols in disease conditions. The current study was designed to know the levels of urinary protein thiols in patients with different grades of proteinuria. The study was conducted on urine of 40 healthy controls and 61 cases with proteinuria. Based on proteinuria cases were further divided into two groups; group I - microproteinuria (150–300 mg protein/d), 32 cases, group II - frank proteinuria (>300 mg protein/d), 29 cases. Urinary thiol levels were determined by spectrophotometric method using dithionitrobenzoic acid. A significant decrease (p<0.01) in urinary thiol in group I and group II cases was observed in present study and this decrease was associated with proteinuria.

Determination of urinary peptides in patients with proteinuria

Although considered useful in the diagnosis and prognosis of renal diseases, proteinuria can only be detected after significant renal paranchymal changes. There is considerable interest in the estimation of urinary peptides as an early marker of renal disease. In the current study, we have estimated urinary peptides in patients with different grades of proteinuria. Twenty-four hour urine samples were collected from 138 subjects and classified into three groups based on the urine protein excreted: group I (normoproteinuria, 0–150 mg/day, n = 37), group II (microproteinuria, 150–300 mg/day, n = 31), and group III (macroproteinuria, > 300 mg/day, n = 70). Urine proteins were determined using Bradfords method and urinary peptide levels were determined by subtracting Bradfords value from the Lowry value of the same sample. There was a significant decrease in the levels of urinary peptides in group III compared to group I (P < 0.01), however, there was no difference in peptides between groups I and II. The percentage of urinary peptides was decreased in both groups II and III compared to group I (P < 0.01), and there was a significant difference in % urinary peptide content in group II compared to group III (P < 0.01). On correlation, % urinary peptides correlated negatively with urinary proteins/g creatinine (r = - 0.782, P < 0.01) and positively with urinary peptides/g creatinine (r = 0.238, P < 0.01). Our data suggest that there is a marked decrease in urinary peptide levels with an increase in proteinuria. This may suggest impaired tubular protein reabsorption and degradation capacity of renal tubules.

Spontaneous tumour lysis syndrome in a case of multiple myeloma – A rare occurrence

We describe a case of a 40-year-old male patient who was found to have multiple myeloma with spontaneous tumour lysis syndrome (TLS), following a compression fracture of the L-2 vertebrae. Multiple myeloma was confirmed by bone marrow analysis and the M-band on serum protein electrophoresis. Hyperuricaemia (26.2 mg/dL), hyperkalaemia (> 7.0 mEq/L), hyperphosphatemia (16.2 mg of phosphorus/dL), normocalcemia and acute kidney injury, prior to anticancer treatment suggested spontaneous TLS. Inciting events for tumour lysis, such as chemotherapy, dehydration and exposure to steroids were absent. Patient received hydration, hypourecemic drugs and haemodialysis. This case report highlights the rare presentation of multiple myeloma with spontaneous TLS.

Evaluation of marginal and internal gaps of metal ceramic crowns obtained from conventional impressions and casting techniques with those obtained from digital techniques

Background: Accuracy in fit of cast metal restoration has always remained as one of the primary factors in determining the success of the restoration. A well-fitting restoration needs to be accurate both along its margin and with regard to its internal surface. Aim: The aim of the study is to evaluate the marginal fit of metal ceramic crowns obtained by conventional inlay casting wax pattern using conventional impression with the metal ceramic crowns obtained by computer-aided design and computer-aided manufacturing (CAD/CAM) technique using direct and indirect optical scanning. Materials and Methods: This in vitro study on preformed custom-made stainless steel models with former assembly that resembles prepared tooth surfaces of standardized dimensions comprised three groups: the first group included ten samples of metal ceramic crowns fabricated with conventional technique, the second group included CAD/CAM-milled direct metal laser sintering (DMLS) crowns using indirect scanning, and the third group included DMLS crowns fabricated by direct scanning of the stainless steel model. The vertical marginal gap and the internal gap were evaluated with the stereomicroscope (Zoomstar 4); post hoc Turkeys test was used for statistical analysis. One-way analysis of variance method was used to compare the mean values. Results and Conclusion: Metal ceramic crowns obtained from direct optical scanning showed the least marginal and internal gap when compared to the castings obtained from inlay casting wax and indirect optical scanning. Indirect and direct optical scanning had yielded results within clinically acceptable range.

Large unilateral pleural effusion secondary to Moraxella catarrhalis infection.

A 43-year-old male with chronic kidney disease on maintenance hemodialysis presented with breathlessness, cough and right-sided abdominal pain. Examination revealed a large right-sided pleural effusion and subsequent thoracocentesis yielded an exudate. Although the fluid culture was sterile, sputum culture produced Moraxella catarrhalis. Tuberculosis was ruled out by pleural fluid analysis and pleural biopsy. Antibiotics were administered and subsequent radiograms indicated resolution of the effusion. This is a rare case of a large unilateral pleural effusion secondary to M. catarrhalis infection in a nonsmoker with no pre-existing pulmonary pathology.

Clinicopathological characteristics and outcomes of diffuse crescentic glomerulonephritis - A single center experience from southern India

Introduction Diffuse Crescentic glomerulonephritis (CrGN) is characterized by rapidly progressive renal failure and has grave prognosis. There is significant regional and temporal variation in aetiology, prevalence and prognosis of diffuse crescentic glomerulonephritis (CrGN) with limited data available in adult Indian population. Aim This study aims to identify the aetiology, clinico-pathological features and outcomes of diffuse CrGN in south Indian population. Materials and Methods In this retrospective study, clinical records of all adults (>18 years) over a 5-year period (2010-2014) with a histopathological diagnosis of diffuse CrGN (>50% crescents) were reviewed. Clinical, serological, biochemical and histopathological data were collected. Follow-up data at six months including renal outcome and mortality were studied. Data was analysed using SPSS version 15. Results There were 29 cases of diffuse CrGN accounting for an incidence of 2.9% among 1016 non-transplant kidney biopsies. The most common cause was pauci-immune crescentic GN. The median creatinine at admission was 7.2 mg/dl {(interquartile range (IR) 3.3 - 10.4)} and 75.9% of patients required haemodialysis at admission. Complete/partial recovery was seen in 34.5%. At the end of six months 31% were dialysis dependent and the mortality was 27.6%. On univariate analysis, the significant predictors of renal loss and mortality were oliguria (p=0.02), requirement of haemodialysis and serum creatinine (p=0.001) at admission (>5.5mg/dl) (p=0.003). Histopathological features did not influence the outcome in our study. Conclusion In our cohort, the most common cause for diffuse CrGN is pauci-immune CrGN. Diffuse CrGN carries a poor prognosis. Patients with pauci-immune and AntiGBM disease have worst prognosis compared to immune complex CrGN. The presence of oliguria, high serum creatinine and requirement of haemodialysis at admission are associated with poor outcomes.

Delayed Hypersensitivity with Ferric Carboxymaltose

Ferric Carboxymaltose (FCM) is widely used in the treatment of anaemia of Chronic Kidney Disease (CKD). The clinicians must be alert of the rare adverse events such as hypersensitivity with subsequent doses of Ferric carboxymaltose. Here, we report a case of a 59-year-old male a known case of CKD, with anaemia and thrombocytopenia. Ferric carboxymaltose was the treatment of choice. There was a hypersensitivity reaction to the second dose whereas, the first dose was well tolerated. This case report indicates the onset of adverse reaction with ferric carboxymaltose with the second dose even though the first dose was well tolerated.

Multiple Intra-renal Pathological Injury Patterns in Resistant Myeloma

Renal dysfunction in patients with multiple myeloma has a heterogeneous aetiology ranging from pre-renal, intra-renal to post-renal causes. Common pathological forms of paraproteinemic disease include cast nephropathy,amyloidosis and Immunoglobulin chain deposition disease.Infrequently cryoglobulinemic glomerulonephritis and light chain proximal tubulopathy have also been described. The presence of multiple intra-renal pathological injury patterns has been described only once previously with immunoglobulin light chains. We report a patient with long standing treatment resistant multiple myeloma and new onset progressive renal failure with heavy and light-chain amyloidosis, cast nephropathy and proximal tubulopathy on renal biopsy.