Sreejith Parameswaran

Community-acquired acute kidney injury in tropical countries

Community-acquired acute kidney injury (AKI) in developing tropical countries is markedly different from AKI in developed countries with a temperate climate, which exemplifies the influence that environment can have on the epidemiology of human diseases. The aetiology and presentation of AKI reflect the ethnicity, socioeconomic factors, climatic and ecological characteristics in tropical countries. Tropical zones are characterized by high year-round temperatures and the absence of frost, which supports the propagation of infections that can cause AKI, including malaria, leptospirosis, HIV and diarrhoeal diseases. Other major causes of AKI in tropical countries are envenomation; ingestion of toxic herbs or chemicals; poisoning; and obstetric complications. These factors are associated with low levels of income, poor access to treatment, and social or cultural practices (such as the use of traditional herbal medicines and treatments) that contribute to poor outcomes of patients with AKI. Most causes of AKI in developing tropical countries are preventable, but strategies to improve the outcomes and reduce the burden of tropical AKI require both improvements in basic public health, achieved through effective interventions, and increased access to effective medical care (especially for patients with established AKI).

Salivary Creatinine Estimation as an Alternative to Serum Creatinine in Chronic Kidney Disease Patients

Context. Sampling blood for serum analysis is an invasive procedure. A noninvasive alternative would be beneficial to patients and health care professionals. Aim. To correlate serum and salivary creatinine levels and evaluate the role of saliva as a noninvasive alternative to serum for creatinine estimation in chronic kidney disease patients. Study Design. Case-control study. Methods. Blood and saliva samples were collected from 37 healthy individuals and 105 chronic kidney disease patients. Serum and salivary creatinine levels were estimated using automatic analyser. Statistical Analysis. The serum and salivary creatinine levels between controls and cases were compared using t-test. Correlation between serum and salivary creatinine was obtained in controls and cases using Pearson correlation coefficient. Receiver operating characteristic analysis was done to assess the diagnostic performance of salivary creatinine. Cut-off values were established for salivary creatinine. Results. Serum and salivary creatinine levels were significantly higher in CKD patients than controls. The correlation was negative in controls and positive in cases. Area under the curve for salivary creatinine was found to be 0.967. A cut-off value of 0.2 mg/dL gave a sensitivity of 97.1% and specificity of 86.5%. Conclusion. Saliva can be used as a noninvasive alternative to serum for creatinine estimation.

Ulcerative colitis after renal transplantation: A case report and review of literature

Diarrhea is common after kidney transplantation and is usually related to immunosuppressive medication or is infective in etiology. Inflammatory bowel disease (IBD) is rare after kidney transplantation and is unexpected because the patient is already immunosuppressed. Specific immunomodulatory actions of calcineurin inhibitors have been hypothesized to play a role in the development of IBD in such patients. We report a case of IBD developing de novo after kidney transplantation. Our case is unique in that the patient was not on calcineurin inhibitors for 8 years prior to the development of IBD.

Tubulointerstitial nephritis with uveitis syndrome: A case report and review of literature

Tubulointerstitial nephritis with uveitis (TINU) syndrome is an unusual and under diagnosed cause of acute interstitial nephritis. The interstitial nephritis may precede, follow or develop concurrent to the uveitis. About 200 cases have been reported worldwide with only a single case reported from India. We report a 16-year-old male with TINU syndrome.

The increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016

Summary Background The burden of diabetes is increasing rapidly in India but a systematic understanding of its distribution and time trends is not available for every state of India. We present a comprehensive analysis of the time trends and heterogeneity in the distribution of diabetes burden across all states of India between 1990 and 2016. Methods We analysed the prevalence and disability-adjusted life-years (DALYs) of diabetes in the states of India from 1990 to 2016 using all available data sources that could be accessed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, and assessed heterogeneity across the states. The states were placed in four groups based on epidemiological transition level (ETL), defined on the basis of the ratio of DALYs from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL and vice versa. We assessed the contribution of risk factors to diabetes DALYs and the relation of overweight (body-mass index 25 kg/m2 or more) with diabetes prevalence. We calculated 95% uncertainty intervals (UIs) for the point estimates. Findings The number of people with diabetes in India increased from 26·0 million (95% UI 23·4–28·6) in 1990 to 65·0 million (58·7–71·1) in 2016. The prevalence of diabetes in adults aged 20 years or older in India increased from 5·5% (4·9–6·1) in 1990 to 7·7% (6·9–8·4) in 2016. The prevalence in 2016 was highest in Tamil Nadu and Kerala (high ETL) and Delhi (higher-middle ETL), followed by Punjab and Goa (high ETL) and Karnataka (higher-middle ETL). The age-standardised DALY rate for diabetes increased in India by 39·6% (32·1–46·7) from 1990 to 2016, which was the highest increase among major non-communicable diseases. The age-standardised diabetes prevalence and DALYs increased in every state, with the percentage increase among the highest in several states in the low and lower-middle ETL state groups. The most important risk factor for diabetes in India was overweight to which 36·0% (22·6–49·2) of the diabetes DALYs in 2016 could be attributed. The prevalence of overweight in adults in India increased from 9·0% (8·7–9·3) in 1990 to 20·4% (19·9–20·8) in 2016; this prevalence increased in every state of the country. For every 100 overweight adults aged 20 years or older in India, there were 38 adults (34–42) with diabetes, compared with the global average of 19 adults (17–21) in 2016. Interpretation The increase in health loss from diabetes since 1990 in India is the highest among major non-communicable diseases. With this increase observed in every state of the country, and the relative rate of increase highest in several less developed low ETL states, policy action that takes these state-level differences into account is needed urgently to control this potentially explosive public health situation. Funding Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Role of omentin 1 and IL-6 in type 2 diabetes mellitus patients with diabetic nephropathy

AIMS Diabetic nephropathy (DN) is one of the major chronic vascular complication of T2DM and leading cause of end-stage renal disease. Inflammation is one of the proposed pathway which explains microvascular complications in T2DM but exact mechanism is still unclear. Omentin-1 is an anti-inflammatory adipokine which promotes insulin signaling. IL-6 is a multifunctional cytokine having role in immune and inflammatory responses. The present study was conducted to elucidate the role of omentin-1 and IL-6 in the pathogenesis of DN and its association with insulin resistance. We aimed to assess and compare the serum levels of omentin-1 and IL-6 in T2DM patients with and without DN. MATERIALS & METHODS Our study comprised of 2 groups of 41 each. Group A (controls) included T2DM without nephropathy patients and group B (cases) included T2DM nephropathy patients. Parameters studied were serum omentin-1, insulin, IL-6, fasting blood glucose, urea, creatinine, lipid profile, HOMA-IR, eGFR and BMI. RESULTS & CONCLUSION Omentin-1 (p=0.03) was significantly decreased; concomitantly, significant increase in levels of insulin (p=0.004), IL-6 (p=0.023) and HOMA-IR (p=0.0004) were found in cases compared to controls. Bivariate analysis showed eGFR correlating positively with omentin-1 and negatively with insulin in the study population. Our study results, based on serum omentin-1 and IL-6 data suggest important role played by inflammatory mechanism and insulin resistance in the pathogenesis of diabetic nephropathy in type 2 diabetes mellitus patients.

Indian chronic kidney disease study: Design and methods.

The rate and factors that influence progression of chronic kidney disease (CKD) in developing countries like India are unknown. A pan‐country prospective, observational cohort study is needed to address these knowledge gaps.

Haemolytic uraemic syndrome associated with Pseudomonas aeruginosa sepsis.

Haemolytic uraemic syndrome (HUS) is a recognized complication of infection with Shiga toxin-producing Escherichia coli (STEC) and Shigella dysenteriae type 1. Infections with other micro-organisms, especially Streptococcus pneumoniae, have been cited as causes of HUS. In addition, influenza virus and other viruses may rarely be associated with this syndrome. A 2-year-old girl presented with severe Pseudomonas aeruginosa sepsis with renal failure and ecthyma gangrenosum. Further investigations revealed features of HUS. She was managed with antibiotics and other supportive measures including peritoneal dialysis, and subsequently made a full recovery. A possible role of neuraminidase in the pathogenesis of P. aeruginosa-associated HUS was proposed. This is the first reported case of P. aeruginosa sepsis leading to HUS.

Subcutaneous phaeohyphomycosis in kidney transplant recipients: A series of seven cases

Superficial and deep fungal infections are more frequent in transplant recipients primarily because of the failure of cell‐mediated immunity and lesser amount of antigen‐presenting Langerhans cells in their epidermis. Here, we report seven cases of post‐renal transplant subcutaneous phaeohyphomycosis, all of which manifested within 1 year after transplantation and were unresponsive to prolonged courses of itraconazole. This is the first case series, to our knowledge, of phaeohyphomycosis in transplant recipients in India.

Diffuse alveolar hemorrhage in IgA nephropathy: case series and systematic review of the literature.

To describe the spectrum of pulmonary involvement in immunoglobulin A nephropathy (IgAN).