Association between Intrapancreatic Fat Deposition and the Leptin/Ghrelin Ratio in the Fasted and Postprandial States

BACKGROUND

The clinical relevance of excess intrapancreatic fat deposition (IPFD) is increasingly appreciated. Leptin and ghrelin are key players in the regulation of food intake, energy balance, and body fat mass. The aim was to investigate the associations of the leptin/ghrelin ratio and its components with IPFD.

METHODS

All participants underwent magnetic resonance imaging on a 3T scanner to quantify IPFD. Both fasting and postprandial blood samples were analyzed for leptin and acylated ghrelin. Linear regression analysis was conducted, accounting for visceral/subcutaneous fat volume ratio, glycated hemoglobin, and other covariates.

RESULTS

A total of 94 participants (32 women) with a median age of 56 (interquartile range 44-66) years were studied. Their median IPFD was 9.6% (interquartile range 8.8-10.4%). In the fasted state, the leptin/ghrelin ratio (β = 0.354; 95% confidence interval 0.044-0.663; p = 0.025, in the most adjusted model) and leptin (β = 0.040; 95% confidence interval 1.003-1.078; p = 0.035, in the most adjusted model) were significantly associated with IPFD. Ghrelin in the fasted state was not significantly associated with IPFD. In the postprandial state, the leptin/ghrelin ratio, leptin, and ghrelin were not significantly associated with IPFD.

CONCLUSION

Fasting circulating levels of leptin are directly associated with IPFD. Purposely designed mechanistic studies are warranted to determine how high leptin may contribute to excess IPFD.

809 Evaluation of the Two Week Wait Colorectal Cancer Pathway in a District General Hospital

Introduction

Updated guidelines published by the National Institute for Health and Care Excellence in 2015 widened the referral criteria for the two week wait (2WW) pathway for suspected lower gastrointestinal cancer, in an attempt to increase early diagnosis. The aim of this study was to evaluate the compliance of referrals received via the (2WW) pathway for suspected lower gastrointestinal cancer.

Method

We conducted a retrospective study which utilised a local cancer registry to identify all patients who had been referred to United Lincolnshire Hospitals Trust over a two-month period. Electronic patient records were checked to establish whether patients fulfilled the 2015 referral criteria.

Results

Out of 615 patients referred, 51 (8%) had colorectal cancer. 92 (15%) referrals did not meet the criteria for the 2WW pathway. Whether or not the referral was ‘appropriate’ had no significant effect on the diagnoses of bowel cancer (X2 = .003, p>.05).

Conclusions

16% of all referrals did not meet criteria. This may appear as an inefficient use of resources, however there was no difference in rates of cancer between appropriate and inappropriate referrals. The referral criteria are likely to evolve over the course of time, and perhaps clinicians’ judgement should be taken into account.

Associations between ketone bodies and fasting plasma glucose in individuals with post-pancreatitis prediabetes

Context: Levels of ketone bodies are altered in both acute pancreatitis and type 1 and type 2 diabetes. However, the role of ketone bodies in the pathogenesis of abnormal glucose metabolism after pancreatitis is largely unknown.Objective: To investigate the associations between ketone bodies and glucose homeostasis in individuals with post-pancreatitis prediabetes (PPP) versus normoglycaemia after pancreatitis (NAP).Methods: Fasting blood samples were analysed for acetoacetate, β-hydroxybutyrate, and markers of glucose metabolism at a median of 26 months after acute pancreatitis. A series of linear regression analyses were conducted adjusting for patient- and pancreatitis-related characteristics.Results: The study included 27 individuals with PPP and 52 with NAP. β-hydroxybutyrate was significantly associated with fasting plasma glucose (p = .002) and explained 26.2% of its variance in PPP, but not in NAP (p = .814; 0%). Acetoacetate was not significantly associated with fasting plasma glucose in both PPP (p = .681) or NAP (p = .661).Conclusions: An inverse association between β-hydroxybutyrate and fasting plasma glucose characterises PPP and this may have translational implications.

Elevated Circulating Levels of Motilin are Associated with Diabetes in Individuals after Acute Pancreatitis

Aim The study aimed to investigate the associations between glycaemic control after acute pancreatitis and gastrointestinal motility, using plasma motilin concentration and gastroparesis cardinal symptom index score as proxies.

Methods This cross-sectional study recruited a total of 93 individuals after acute pancreatitis. Gastroparesis cardinal index scores, demographic and anthropometric factors, as well as pancreatitis-related factors were analysed. Fasting venous blood was collected to measure motilin, glycated haemoglobin, and fasting blood glucose. Linear regression analyses were conducted to investigate the associations between glycaemic control and gastrointestinal motility in unadjusted and adjusted models.

Results Motilin was significantly higher in individuals with diabetes across all adjusted models, with the highest ß-coefficient (95% confidence interval) of 588.89 (138.50, 1039.28); P=0.010. Fasting blood glucose was significantly associated with motilin across all models, with the highest ß-coefficient (95% confidence interval) of 156.30 (55.49, 257.10); P=0.002. Glycated haemoglobin was significantly associated with motilin in one adjusted model with ß-coefficient (95% confidence interval) of 18.78 (1.53, 36.02); P=0.033. Gastroparesis cardinal symptom index was not significantly associated with any measure of glycaemic control.

Conclusions Diabetes in individuals after acute pancreatitis appears to be characterised by elevated plasma motilin but not gastroparesis cardinal symptom index. The role of motilin in this setting warrants further investigations.

Serum lipid profile as a biomarker of intra-pancreatic fat deposition: A nested cross-sectional study

BACKGROUND AND AIMS

The relationship between intra-pancreatic fat deposition (IPFD) and lipid profile has been investigated in individuals with obesity and/or type 2 diabetes, but not in healthy non-obese individuals and those after acute pancreatitis. The aim of the study was to investigate the association between serum lipid profile and IPFD in the latter individuals and to determine the effect of abdominal fat distribution and other covariates.

METHODS AND RESULTS

A total of 90 individuals with a history of acute pancreatitis as well as 23 healthy non-obese individuals participated in the study. Magnetic resonance imaging was used to quantify IPFD and visceral-to-subcutaneous fat volume ratio, followed by fasting state measurement of high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), TC/HDL-C ratio, and triglycerides. In healthy non-obese individuals, IPFD was not significantly associated with any of the studied markers. In individuals after acute pancreatitis, IPFD was significantly associated with triglycerides in both unadjusted (β = 0.360; 95% CI, 0.090-0.629; p = 0.009) and adjusted models, with a β-coefficient of 0.280 [(95% CI, 0.016-0.545); p = 0.038] in the most adjusted model. Also, IPFD was significantly associated with TC/HDL-C ratio in both unadjusted (β = 0.336; 95% CI, 0.045-0.626; p = 0.024) and adjusted models, with a β-coefficient of 0.375 [(95% CI, 0.090-0.660); p = 0.010] in the most adjusted model. Multiple regression yielded triglycerides, but not TC/HDL-C ratio, as a significant marker of IPFD in individuals after acute pancreatitis.

CONCLUSIONS

Serum lipid profile is not associated with IPFD in healthy non-obese. Triglycerides, but not other components of lipid profile, is a promising biomarker for IPFD in individuals following acute pancreatitis.

Circulating levels of lipocalin-2 are associated with fatty pancreas but not fatty liver

Lipocalin-2 (LCN-2), a peptide with diverse expression pattern, has been identified as a biomarker of various diseases as well as a factor contributing to inflammatory responses associated with excess adiposity and ensuing metabolic disorders. Although the inter-relationship between LCN-2 and excess adiposity is increasingly recognized, little is known about the inter-relationship between LCN-2 and ectopic fat deposition. The present study aimed to investigate the associations between LCN-2 and fatty pancreas as well as fatty liver. In addition, the associations between LCN-2 and pro-inflammatory cytokines were studied. Magnetic resonance imaging was used to quantify intra-pancreatic fat deposition and visceral-to-subcutaneous fat volume ratio whereas magnetic resonance spectroscopy was used to quantify liver fat deposition. Fasting venous blood was analyzed for LCN-2, C-C motif chemokine ligand 2, interleukin-6, leptin, tumor necrosis factor-α, glycated hemoglobin, glucose, and insulin. Binary logistic regression and linear regression analyses were conducted. Three statistical models were built to adjust for demographics, comorbidities, levels of glycated hemoglobin, insulin resistance, and abdominal fat distribution. A total of 79 individuals were studied, of whom 20 had fatty pancreas, 14 had fatty liver, and 4 had both. Lipocalin-2 was significantly associated with fatty pancreas in all the adjusted models (p = 0.014 in the most adjusted model) but was not significantly associated with fatty liver in any of the studied models. Lipocalin-2 was significantly associated with interleukin-6 and tumor necrosis factor-α, in both the unadjusted and adjusted models. Leptin and C-C motif chemokine ligand 2 were not significantly associated with LCN-2 in any of the studied models. These findings suggest that LCN-2 is a potential biomarker of fatty pancreas, independent of abdominal fat distribution, insulin resistance, and other covariates. The role of LCN-2 in intra-pancreatic fat deposition and related low-grade inflammation warrants further investigations.

Intrapancreatic fat deposition and visceral fat volume are associated with the presence of diabetes after acute pancreatitis

Ectopic fat and abdominal adiposity phenotypes have never been studied holistically in individuals after acute pancreatitis (AP). The aim of the study was to investigate phenotypical differences in ectopic fat and abdominal fat between individuals after AP (with and without diabetes) and to determine the role of pancreatitis-related factors. Eighty-four individuals were studied cross-sectionally after a median of 21.5 mo since last episode of AP and were categorized into "diabetes" and "no diabetes" groups. Twenty-eight healthy volunteers were also recruited. With the use of magnetic resonance imaging, intrapancreatic fat percentage, liver fat percentage, visceral fat volume (VFV), subcutaneous fat volume, and visceral-to-subcutaneous (V/S) fat volume ratio were quantified. Analysis of variance was used to investigate the differences in these phenotypes between the groups. All analyses were adjusted for age and sex. Linear regression analysis was used to investigate the association between pancreatitis-related factors and the studied phenotypes. Intrapancreatic fat percentage was significantly higher in the diabetes group (10.2 ± 1.2%) compared with the no diabetes (9.2 ± 1.7%) and healthy volunteers (7.9 ± 1.9%) groups (P < 0.001). VFV was significantly higher in the diabetes (2,715.3 ±1,077.6 cm³) compared with no diabetes (1,983.2 ± 1,092.4 cm³) and healthy volunteer (1,126.2 ± 740.4 cm³) groups (P < 0.001). V/S fat volume ratio was significantly higher in the diabetes (0.97 ± 0.27) compared with no diabetes (0.68 ± 0.42) and healthy volunteer (0.52 ± 0.34) groups (P = 0.001). Biliary AP was associated with significantly higher intrapancreatic fat percentage (β = 0.67; 95% CI, 0.01, 1.33; P = 0.047). C-reactive protein levels during hospitalization for AP were associated with significantly higher VFV (β = 3.32; 95% CI, 1.68, 4.96; P < 0.001). In conclusion, individuals with diabetes after AP have higher intrapancreatic fat percentage, VFV, and V/S fat volume ratio. Levels of C-reactive protein during AP are significantly associated with VFV, whereas biliary AP is significantly associated with intrapancreatic fat percentage. NEW & NOTEWORTHY Individuals with diabetes after acute pancreatitis have significantly higher intrapancreatic fat percentage and visceral fat volume compared with individuals without diabetes after acute pancreatitis and healthy controls. C-reactive protein levels during hospitalization for acute pancreatitis and biliary etiology of acute pancreatitis are associated with significantly larger visceral fat and pancreatic fat depots, respectively.

Relationship of Anthropometric Indices to Abdominal Body Composition: A Multi-Ethnic New Zealand Magnetic Resonance Imaging Study

Background

Conventional anthropometric indices (body mass index (BMI) and waist circumference (WC)) have limitations, in part, due to ethnic differences in fat distribution. Assessment of abdominal body composition using magnetic resonance imaging (MRI) is increasingly used to gain deeper insights into the pathophysiology of diabetes mellitus, cardiovascular diseases and metabolic syndrome, but the knowledge of abdominal volumes in indigenous populations is scarce. This study aimed to assess abdominal fat distribution and total abdominal volume using MRI in a multi-ethnic cohort that includes Maori (the indigenous people of New Zealand) and Pacific Islanders (PI).

Methods

MRI was used to quantify subcutaneous adipose tissue (SAT) volume, visceral adipose tissue (VAT) volume and total abdominal (TAb) volume by two independent raters in a blinded fashion. WC and BMI were also measured. Multinomial regression was used to compare the volumes between ethnic groups. Linear regression was used to investigate the ethnicity-specific associations between anthropometric indices and abdominal volumes. Three statistical models were built to adjust for age, sex, prediabetes/diabetes status and other covariates.

Results

A total of 87 individuals (37 Caucasians, 24 Maori/PI and 26 others) were studied. Maori/PI had a significantly higher VAT volume compared with Caucasians across all statistical models, with the highest odds ratio of 2.1 (95% confidence interval: 1.1 - 4.2; P = 0.026). SAT and TAb volumes did not differ significantly between the groups. WC explained up to 72.9% of variance in VAT volume among Maori/PI and up to 50.7% among Caucasians. BMI explained up to 67.6% of variance in VAT volume among Maori/PI and up to 52.1% among Caucasians.

Conclusions

Greater visceral fat deposition among Maori/PI might go some way towards explaining the increased rates of metabolic disorders observed in this ethnic group. Conventional anthropometric indices do not correspond to the same abdominal volumes across different ethnic groups.

Associations between gastrointestinal humoral factors and pancreatic proteolytic enzymes in alcohol-related versus non-alcohol-related pancreatitis

BACKGROUND

Alcohol-related pancreatitis is common and the gastrointestinal tract plays an important role in the regulation of pancreatic exocrine function. While the relationship between pancreatic proteolytic enzymes and insulin (as well as other pancreatic hormones) has been investigated in detail, little is known about the relationship between pancreatic proteolytic enzymes and gastrointestinal humoral factors. The aim of this study was to study the associations between trypsin, chymotrypsin, and a panel of gastrointestinal humoral factors in patients after an episode of alcohol-related versus non-alcohol-related pancreatitis.

METHODS

Fasting venous blood samples were analyzed for trypsin, chymotrypsin, cholecystokinin, gastrin, ghrelin, gastrin-related peptide, neuropeptide Y, peptide YY, secretin, and vasoactive intestinal peptide. Linear regression analysis was used in three statistical models, adjusting for covariates (age, sex, ethnicity, smoking, exercise, body mass index, dysglycemia, recurrence of pancreatitis, duration of pancreatitis, and severity of pancreatitis).

RESULTS

The study included 21 patients with alcohol-related pancreatitis and 72 with non-alcohol-related pancreatitis. Gastrin, cholecystokinin, and vasoactive intestinal peptide were significantly associated with chymotrypsin in all three statistical models and resulted in a 1.06, 1.98, and 2.74 times higher chymotrypsin level in alcohol-related pancreatitis, respectively. Ghrelin was significantly associated with trypsin in all three statistical models and resulted in a 2.64 times higher trypsin level in alcohol-related pancreatitis. Other associations did not demonstrate a consistent significant pattern.

CONCLUSION

In alcohol-related pancreatitis, several gut-related peptides are significantly associated with pancreatic exocrine function. Further studies to investigate the effect of alcohol on the interaction between cholecystokinin (as well as gastrin, ghrelin, and vasoactive intestinal peptide) and pancreatic exocrine function are warranted.

Gut Hormone Responses to Mixed Meal Test in New-Onset Prediabetes/Diabetes After Acute Pancreatitis

The study was aimed to investigate gut hormone responses to mixed meal test in individuals with new-onset prediabetes or diabetes after acute pancreatitis (cases) compared with healthy controls, and the effect of body fat parameters. A total of 29 cases and 29 age- and sex-matched healthy controls were recruited. All participants were given standard mixed meal drink and blood samples were collected to measure dipeptidyl peptidase IV, gastric inhibitory peptide, glucagon like peptide-1, insulin, oxyntomodulin, and peptide YY. Body fat parameters were measured using magnetic resonance imaging. Repeated measures and linear regression analyses were conducted in unadjusted and adjusted models. Gastric inhibitory peptide levels were significantly higher whereas oxyntomodulin levels were significantly lower in cases compared with controls in both the unadjusted (p<0.001 and p<0.001, respectively) and adjusted (p<0.001 and p<0.001, respectively) models. In cases, liver fat % contributed up to 13.4% (vs. 2.9% in controls) to variance in circulating levels of gastric inhibitory peptide whereas body mass index - up to 20.8% (vs. 9.9% in controls) in circulating levels of oxyntomodulin. New-onset prediabetes/diabetes after acute pancreatitis is characterised by increased levels of gastric inhibitory peptide and decreased levels of oxyntomodulin. Further, liver fat % and body mass index appear to be the body fat parameters that contribute most significantly to gastric inhibitory peptide and oxyntomodulin levels, respectively.

Comprehensive analysis of body composition and insulin traits associated with intra-pancreatic fat deposition in healthy individuals and people with new-onset prediabetes/diabetes after acute pancreatitis

Current knowledge of biomarkers of intra-pancreatic fat deposition (IFD) is limited. We aimed to analyse comprehensively body composition and insulin traits as biomarkers of IFD in healthy normoglycaemic individuals as well as in individuals with new-onset prediabetes or diabetes after acute pancreatitis (NODAP). A total of 29 healthy individuals and 34 individuals with NODAP took part in this cross-sectional study. The studied biomarkers belonged to the following domains: body composition (anthropometric and MRI-derived variables); indices of insulin secretion; indices of insulin sensitivity; incretins and related peptides; and pancreatitis-related factors. All MRI-derived variables (including IFD) were measured using ImageJ software. Univariate and step-wise regression analyses were conducted to determine variables that best explained variance in IFD. Visceral fat volume and oxyntomodulin were the best biomarkers of IFD in normoglycaemic healthy individuals, contributing to 64% variance. The Raynaud index was the best biomarker of IFD in individuals with NODAP, contributing to 20% variance. Longitudinal studies are warranted to investigate the cause and effect relationship between oxyntomodulin and IFD in healthy individuals, as well as insulin sensitivity and IFD in individuals with NODAP.

Pro-inflammatory cytokine-induced lipolysis after an episode of acute pancreatitis

CONTEXT

Pro-inflammatory cytokine-stimulated lipolysis is one of the mechanisms underlying the pathogenesis of type 2 diabetes. However, whether it plays a role in the pathogenesis of post-pancreatitis diabetes mellitus (PPDM) remains unknown.

OBJECTIVE

To investigate the associations between markers of lipid metabolism and pro-inflammatory cytokines in individuals after acute pancreatitis (AP) in general, and in individuals with abnormal glucose metabolism (AGM) following AP in particular.

METHODS

Fasting blood samples were collected to measure markers of lipid metabolism (apolipoprotein-B, cholesterol, free fatty acids (FFA), glycerol, high and low-density lipoproteins, triglycerides) and cytokines (interleukin (IL)-6, monocyte chemoattractant protein (MCP)-1, and tumour necrosis factor (TNF) α). Linear regression analysis was conducted. Four statistical models were used to adjust for patient- and pancreatitis-related characteristics.

RESULTS

A total of 83 patients were recruited. IL-6 was significantly associated with glycerol in all models (p < .05), with glycerol levels increasing by 106% in individuals with AGM after AP (p <.05) compared to a 30.3% increase in individuals with normal glucose metabolism (NGM) (p >.05). TNFα was significantly associated with FFA (p = .015) in individuals with AGM after AP in the most adjusted model, with FFA levels increasing by 314% in these individuals compared to a 162% decrease in individuals with NGM after AP (p >.05).

CONCLUSIONS

Lipolysis appears to be an important pathogenetic mechanism in glucose derangements after diseases of the exocrine pancreas. IL-6 and TNFα are the driving forces behind lipolysis in individuals with AGM after AP. Modulation of lipolysis may be a promising therapeutic modality.

Abdominal obesity and insulin resistance after an episode of acute pancreatitis

BACKGROUND

Emerging evidence indicates that individuals after an episode of acute pancreatitis (AP) are at an increased risk of developing metabolic derangements. While the link between general obesity and insulin resistance (IR) is well established, only a few studies have investigated the association between abdominal obesity and IR. The aim of this study was to investigate the associations between abdominal obesity and several indices of IR in individuals after an episode of AP.

METHODS

Patients were eligible for this cross-sectional study if they were previously admitted with a primary diagnosis of AP based on the recent international guidelines. Fasting venous bloods were collected to measure glucose, insulin, free fatty acids, glycerol, adiponectin (AD), omentin (OM), and vaspin (VAS). The IR indices - HOMA-IR, Adipo-IR, insulin*glycerol (IG) index, HOMA-AD, HOMA-OM, and HOMA-VAS were calculated. Modified Poisson regression was conducted, with statistical model adjusting for patient-, metabolic-, and pancreatitis-related risk factors. Areas under ROC curve were calculated and Bland-Altman plots were created.

RESULTS

Of the 92 individuals recruited, 41 had abdominal obesity. HOMA-IR, IG index, HOMA-OM, and HOMA-VAS were significantly associated with abdominal obesity, both in unadjusted and adjusted models. Area under ROC curves for HOMA-IR, IG index, HOMA-OM, and HOMA-VAS were 0.698, 0.695, 0.756, and 0.735, respectively. There was a good agreement between observed HOMA-IR values and values obtained from HOMA-OM (P = 0.733) and HOMA-VAS (P = 0.595).

CONCLUSION

Individuals with abdominal obesity after AP have a significantly higher IR, independent of diabetes and other covariates. Visceral adipose tissue specific adipokines, omentin and vaspin, hold promise for future clinical investigation of tissue-specific IR.

Pancreas volume in health and disease: a systematic review and meta-analysis

The pancreas plays a central role in metabolism and is involved in the pathogenesis of several diseases. Pancreas volume is a holistic quantitative measure of pancreas size but the clinical relevance of pancreas volumetry is poorly understood. Areas covered: The aim was to systematically review studies in adults that used computed tomography or magnetic resonance imaging to measure pancreas volume in health and disease, to determine normal pancreas volume range, and to quantify changes in pancreas volume that are associated with disease. Expert commentary: The normal pancreas volume range in adults is 71-83 cm³, with no statistically significant difference between men and women. Type 2 diabetes and type 1 diabetes are associated with a progressively reduced pancreas volume. Overweight and obesity are associated with a progressively increased pancreas volume. There is a paucity of studies on pancreas volume in the setting of diseases of the exocrine pancreas, which should become a research priority in the future.

Iron: a Strong Element in the Pathogenesis of Chronic Hyperglycaemia After Acute Pancreatitis

Evidence shows an association between markers of iron metabolism and glucose metabolism in type 2 diabetes mellitus. Acute pancreatitis is the largest contributor to diabetes of the exocrine pancreas. However, the pathogenesis of new-onset pre-diabetes or diabetes after pancreatitis remains unclear. This study aimed to investigate associations between markers of iron metabolism and glucose metabolism following acute pancreatitis. Fasting blood samples were collected to analyse markers of glucose metabolism (haemoglobin A1c) and iron metabolism (hepcidin, ferritin, and soluble transferrin receptor). Participants were categorised into two groups: normoglycaemia after acute pancreatitis and chronic hyperglycaemia after acute pancreatitis. Binary logistic and linear regression analyses were conducted, and potential confounders were adjusted for in multivariable analyses. A total of 83 individuals following an episode of acute pancreatitis were included, of whom 19 developed chronic hyperglycaemia. Hepcidin was significantly increased in individuals with chronic hyperglycaemia after acute pancreatitis in two adjusted models (p = 0.045 and p = 0.048). Ferritin was significantly decreased in individuals with chronic hyperglycaemia after acute pancreatitis in three adjusted models (p = 0.016, p = 0.009, and p = 0.011). Soluble transferrin receptor was not significantly associated with chronic hyperglycaemia after acute pancreatitis. These findings suggest that iron metabolism is significantly altered in individuals with chronic hyperglycaemia after acute pancreatitis and may provide better insights into the pathogenesis of new-onset diabetes after pancreatitis.

Profile of Gut Hormones, Pancreatic Hormones and Pro-inflammatory Cytokines in New Zealand Maori

Background

Maori, indigenous people of New Zealand, have at least two times higher prevalence of obesity and diabetes in comparison with the general population in the country. Gut and pancreatic hormone profile differences as well as pro-inflammatory milieu may contribute to this disparity. The aim was to investigate the differences in gut hormones, pancreatic hormones and pro-inflammatory cytokines between Maori and non-Maori individuals.

Methods

This was a cross-sectional study. Fasting blood samples were collected to measure cholecystokinin, ghrelin, gastric inhibitory peptide, glicentin, glucagon-like peptide-1 and -2, oxyntomodulin, secretin, amylin, C-peptide, glucagon, insulin, pancreatic polypeptide, somatostatin, interleukin-6, monocyte chemoattractant protein-1 and tumour necrosis factor-α. Binary logistic regression analysis was conducted in one unadjusted and four adjusted statistical models adjusting for patient-, metabolic- and pancreatitis-related factors.

Results

A total of 8 Maori and 85 non-Maori individuals were included. Circulating levels of ghrelin, pancreatic polypeptide and interleukin-6 levels were significantly higher in Maori (P = 0.005, P = 0.003 and P = 0.011, respectively) in both unadjusted and all the four adjusted analyses. Other signaling molecules did not show consistently significant associations with ethnicity.

Conclusion

Profile of gut hormones, pancreatic hormones and pro-inflammatory cytokines appears to differ between Maori and non-Maori individuals, independent of obesity, diabetes and other covariates. This may go some way to explain the increased propensity to obesity and diabetes in the Maori population.

Lipid metabolism in patients with chronic hyperglycemia after an episode of acute pancreatitis

BACKGROUND

The importance of dyslipidemia is well recognized in the context of both risk factor for acute pancreatitis and prognostic factor for its in-hospital outcomes. With a growing appreciation of post-pancreatitis diabetes mellitus, there is a need to catalogue changes in lipid metabolism after hospitalization due to an acute pancreatitis attack and their associations with glucose metabolism.

OBJECTIVE

To investigate lipid metabolism in patients with impaired glucose homeostasis following acute pancreatitis.

METHODS

There were two study groups: newly diagnosed chronic hyperglycemia or normoglycemia after acute pancreatitis. During the fasting state, venous blood samples were collected to analyse markers of lipid metabolism (triglycerides, glycerol, low density lipoprotein, high density lipoprotein, total cholesterol, free fatty acids, and apolipoprotein-B) and glucose metabolism (HbA1c, insulin, index of adipose tissue insulin resistance (Adipo-IR), and HOMA-IR). Binary logistic and linear regression analyses were conducted, and potential confounders were adjusted for in multivariate analyses.

RESULTS

The study included 64 patients with normoglycemia and 19 - with chronic hyperglycemia. Glycerol was significantly associated with the development of chronic hyperglycemia in both unadjusted (p=0.02) and adjusted (p=0.006) models. Triglycerides were significantly associated with the development of chronic hyperglycemia in adjusted (p=0.019) model. Other markers of lipid metabolism did not differ significantly between the two groups. None of the markers of lipid metabolism was significantly associated with Adipo-IR or HOMA-IR.

CONCLUSION

Overall, patients with chronic hyperglycemia after acute pancreatitis appear to have a lipid profile indicative of an up-regulation of lipolysis, which is not significantly affected by either general or adipose tissue-specific insulin resistance.

Ectopic fat accumulation in the pancreas and its biomarkers: A systematic review and meta-analysis

Presence of fat in the pancreas increases the risk of metabolic co-morbidities. Detection and quantification of pancreatic fat is not a routine clinical practice, at least in part because of need to use expensive imaging techniques. We aimed to systematically review common markers of pancreatic fat in blood and to investigate differences in these markers associated with fatty pancreas. The search was conducted in 3 databases (EMBASE, Scopus, and MEDLINE). Studies in humans were eligible for inclusion if they reported on biological markers and percentage of pancreatic fat or fatty pancreas prevalence. Data were pooled for correlation and effect size meta-analysis. A total of 17 studies including 11 967 individuals were eligible for meta-analysis. Markers of lipid metabolism, including circulating triglycerides (r = 0.38 [95% confidence interval (CI) 0.31, 0.46]) and high-density lipoprotein cholesterol (r = -0.33 [95% CI -0.35, -0.31]), and markers of glucose metabolism, including glycated haemoglobin (r = 0.39 [95% CI 0.30, 0.48], insulin (r = 0.38 [95% CI 0.33, 0.43]), and homeostasis model assessment-insulin resistance (r = 0.37 [95% CI 0.30, 0.44], yielded the best correlations with percentage of pancreatic fat. Further, effect size analysis showed large and medium effects for the above markers of lipid and glucose metabolism. Circulating levels of triglycerides and glycated haemoglobin appear to be the best currently available markers of pancreatic fat. The approach of non-invasive and accurate detection of pancreatic fat by blood analysis should be further explored in the future, by investigating other potential biological markers of pancreatic fat.

Interplay between innate immunity and iron metabolism after acute pancreatitis

Emerging evidence shows that chronic low-grade inflammation and changes in markers of innate immunity are implicated in a range of metabolic abnormalities following an episode of acute pancreatitis. Also, deranged iron metabolism has been linked to type 2 diabetes mellitus, gestational diabetes, and new-onset diabetes after pancreatitis - the conditions characterized by high haemoglobin glycation index (HGI). This study aimed to investigate the associations between markers of innate immunity and iron metabolism in individuals after acute pancreatitis. Fasting blood samples were collected to analyse lipopolysaccharide binding protein (LBP), interleukin (IL)-6, tumor necrosis factor-α, hepcidin, ferritin, soluble transferrin receptor, HbA1c, and glucose. Participants were categorized into two groups: low HGI and high HGI. Linear regression analyses were conducted, and potential confounders (age, sex, ethnicity, body mass index, diabetes mellitus status, smoking status, aetiology of pancreatitis, duration, recurrence, and severity of pancreatitis) were adjusted for in 5 statistical models. A total of 93 patients following an episode of acute pancreatitis were included, of who 40 (43%) had high HGI. In the overall cohort, LBP was significantly associated with hepcidin and ferritin, and IL-6 was significantly associated with hepcidin, consistently in all the models. Further, LBP contributed to 7.7% and 9.5% of variance in hepcidin and ferritin levels, respectively, whereas IL-6 contributed to 5.3% of hepcidin variance. Upon subgroup analysis, the observed LBP associations were maintained in the high HGI subgroup only and the IL-6 association in the low HGI subgroup only. No consistently significant associations were found between any of the other markers. The interplay between LBP, IL-6, hepcidin, and ferritin characterizes metabolic derangements after acute pancreatitis and may play a role in the pathogenesis of new-onset diabetes after pancreatitis.

Fasting levels of insulin and amylin after acute pancreatitis are associated with pro-inflammatory cytokines

BACKGROUND

The prevalence of metabolic diseases continues to rise worldwide, with a growing recognition of metabolic dysregulation after acute inflammatory diseases such as acute pancreatitis (AP). Adipokines and cytokines play an important role in metabolism and the course of AP, but there is a paucity of research investigating their relationship with pancreatic hormones after AP. This study aimed to explore associations between pancreatic hormones and adipokines as well as cytokines to provide insights into the pathophysiology of altered pancreatic hormone secretion following AP [corrected].

METHODS

A total of 83 patients previously diagnosed with AP and no prior diabetes or pre-diabetes were recruited into this cross-sectional follow up study. Fasting venous blood samples were collected to analyse a panel of pancreatic hormones and derivatives (amylin, C-peptide, glucagon, insulin, pancreatic polypeptide, somatostatin), adipokines (adiponectin, leptin, retinol binding protein-4, and resistin), and cytokines (interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), and tumour necrosis factor-α (TNF-α)). Linear regression analyses were used, and potential confounders were adjusted for in multivariate analyses.

RESULTS

Insulin was significantly associated with IL-6 in both unadjusted and adjusted models (p = .029 and p = .040, respectively). Amylin was significantly associated with MCP-1 in the unadjusted model (p = .046), and TNF-α in unadjusted and adjusted models (p = .025 and p = .027, respectively).

CONCLUSIONS

Insulin and amylin have a strong positive association with pro-inflammatory cytokines in patients following an episode of AP. These associations have possible relevance in the development of diabetes associated with diseases of the exocrine pancreas, providing the opportunity to develop novel treatment paradigms.

Glucose Variability Measures as Predictors of Oral Feeding Intolerance in Acute Pancreatitis: A Prospective Pilot Study

BACKGROUND

Oral feeding intolerance (OFI) is a common complication in patients with acute pancreatitis (AP). Variations in blood glucose are associated with impaired gastrointestinal function but, to date, measures of glucose variability have not been investigated to predict OFI in patients with AP.

AIM

To investigate the usefulness of several glucose variability measures in predicting the occurrence of OFI early in the course of AP.

METHODS

In this prospective cohort study, six measures of glucose variability were calculated prior to the occurrence of OFI. Multivariate binary logistic regression analyses were conducted, and the diagnostic performance and accuracy of glucose variability measures were assessed.

RESULTS

Of the 95 prospectively enrolled patients, 21 (22%) developed OFI. After adjusting for confounders, admission blood glucose concentration and mean blood glucose concentration were significantly associated with OFI [odds ratio 1.49 (95% confidence interval 1.01-2.20) and odds ratio 1.67 (95% confidence interval 1.07-2.61), respectively]. Both admission blood glucose and mean blood glucose had an area under the curve of 0.83 and positive likelihood ratios of 6.45 and 10.19, respectively. Blood glucose concentration before refeeding, standard deviation of blood glucose concentration, coefficient of variation, and mean amplitude of glycemic excursions were not significantly associated with OFI.

CONCLUSION

In-hospital blood glucose concentrations are associated with subsequent development of OFI in patients with AP. In particular, admission blood glucose and mean blood glucose could be useful predictors of OFI in this setting.

Role of human lipocalin proteins in abdominal obesity after acute pancreatitis

Lipocalin proteins are small regulatory peptides implicated in metabolism, inflammation, and immunity. Although lipocalin proteins have been linked to various clinical conditions, their role in the acute inflammatory setting, such as acute pancreatitis (AP), has only been sparsely investigated. Two members of the lipocalin family, lipocalin-2 (LCN-2) and retinol binding protein -4 (RBP-4), play an important role in obesity and insulin resistance. In this study, we analysed circulating levels of LCN-2 and RBP-4 in 92 individuals after AP, of whom 41 individuals had abdominal obesity and 51 did not. Binary logistic regression analyses were performed to determine whether abdominal obesity was associated with the two lipocalin proteins. Lipocalin-2 was significantly associated with abdominal obesity in the unadjusted model (Odds ratio (OR)=1.014 [95% confidence interval (CI): 1.000, 1.028], P=0.05) and after adjusting for patient related (age, ethnicity, and diabetes mellitus) and pancreatitis related (aetiology, severity, recurrence, and duration of AP) characteristics (OR=1.018 [95% CI: 1.001, 1.036], p=0.04). Further, the association of LCN-2 with waist circumference was significant in individuals with alcohol aetiology of AP (β=1.082 [95% CI: 1.011, 1.158], p=0.02]. The association between RBP-4 and abdominal obesity was not significant in both unadjusted and adjusted models. These findings indicate that circulating levels of LCN-2 in patients after AP may play a role in chronic low grade inflammation associated with abdominal adiposity and that alcohol consumption may further exacerbate adipose tissue dysfunction.

Ectopic fat accumulation in the pancreas and its clinical relevance: A systematic review, meta-analysis, and meta-regression

OBJECTIVE

Growing evidence suggests that individuals with excessive fat in the pancreas are at an increased risk of chronic metabolic disorders. The aim was to systematically review studies on non-alcoholic fatty pancreas disease (NAFPD) with a view to determine its prevalence, associations with metabolic co-morbidities, and to suggest normal pancreatic fat percentage threshold.

METHODS

Three electronic databases (MEDLINE, Scopus, and Embase) were queried. Studies in humans were eligible for inclusion if they provided data on NAFPD and/or pancreatic fat percentage. Where possible, data were pooled using random-effects meta-analysis and the effect of covariates analysed using meta-regression.

RESULTS

Pooling data on pancreatic fat percentage from nine studies (1209 healthy individuals who underwent magnetic resonance imaging), yielded the weighted mean and weighted standard deviation of 4.48% and 0.87%, respectively. Pooling data on NAFPD from eleven studies (12,675 individuals), yielded the pooled prevalence of 33% (95% confidence interval, 24% - 41%). Meta-regression analysis showed that the prevalence of NAFPD was independent of age and sex. The presence of NAFPD was associated with a significantly increased risk of arterial hypertension (risk ratio 1.67; 95% confidence interval, 1.32-2.10; p<0.0001), diabetes mellitus (risk ratio 2.08; 95% confidence interval, 1.44-3.00; p=0.0001), and metabolic syndrome (risk ratio 2.37; 95% confidence interval, 2.07-2.71; p<0.0001).

CONCLUSION

The findings indicate that NAFPD is a frequent clinical entity, associated with significantly increased risk of metabolic syndrome and its components. The normal pancreatic fat cut-off point of 6.2% may be recommended for use in future prospective studies.

Associations between circulating levels of adipocytokines and abdominal adiposity in patients after acute pancreatitis

Adipocytokines are strongly associated with abdominal adiposity during the course of acute pancreatitis (AP). This study investigated associations between a panel of adipocytokines and abdominal adiposity in AP patients after hospital discharge, as well as the effect of several covariates. Fasting venous blood samples were collected to measure adiponectin, interleukin 6, leptin, monocyte chemoattractant protein 1, tumour necrosis factor α (TNFα), resistin, and retinol-binding protein 4. Waist circumference (WC), waist-hip ratio, and waist-height ratio (WheightR) were used as measures of abdominal adiposity. Generalised linear models were built, adjusting for age, sex, ethnicity, diabetes status, aetiology, duration since admission for AP, recurrence, and severity of AP. A total of 93 patients were studied, on average at 22 months after AP. Interleukin 6, TNFα, and leptin were significantly associated with WC in both the unadjusted and all the three adjusted models. Also, they were significantly associated with WheightR in both the unadjusted and the three adjusted models. Other studied adipocytokines did not show a consistent association or were not significantly associated with the abdominal adiposity indices. The results suggest that excess abdominal adiposity favours pro-inflammatory milieu in AP patients after hospital discharge, independent of diabetes and effect of other covariates.

Relationship between circulating levels of pancreatic proteolytic enzymes and pancreatic hormones

BACKGROUND

While the close morphological relationship between the exocrine and endocrine pancreas is well established, their functional interaction remains poorly understood. The aim of this study was to investigate the associations between circulating levels of pancreatic proteolytic enzymes and insulin, as well as other pancreatic hormones.

METHODS

Fasting venous blood samples were collected and analyzed for trypsin, chymotrypsin, insulin, glucagon, somatostatin, and pancreatic polypeptide. Linear regression analysis was used in unadjusted and two adjusted (accounting for prediabetes/diabetes, body mass index, smoking, and other covariates) statistical models.

RESULTS

A total of 93 individuals with a history of acute pancreatitis were included in this cross-sectional study. Chymotrypsin was significantly associated with insulin in the two adjusted models (p = 0.005; p = 0.003) and just missed statistical significance in the unadjusted model (p = 0.066). Chymotrypsin was significantly associated with glucagon in both unadjusted (p = 0.025) and adjusted models (p = 0.014; p = 0.015); as well as with somatostatin - in both unadjusted (p = 0.001) and adjusted models (p = 0.001; p = 0.002). Trypsin was not significantly associated with insulin in any of the models but was significantly associated with glucagon in both unadjusted (p < 0.001) and adjusted models (p < 0.001), and pancreatic polypeptide in both unadjusted (p < 0.001) and adjusted (p < 0.001) models.

CONCLUSION

The state of hyperinsulinemia is characterized by a dysfunction of the exocrine pancreas. In particular, chymotrypsin is increased in the state of hyperinsulinemia and trypsin is significantly associated with glucagon and pancreatic polypeptide.

Comparison of conventional straight and swan-neck straight catheters inserted by percutaneous method for continuous ambulatory peritoneal dialysis: a single-center study

OBJECTIVE

To evaluate the incidence of mechanical and infectious complications of conventional straight catheter (SC) versus swan-neck straight catheter (SNSC) implanted by percutaneous method.

PATIENT AND METHODS

We retrospectively analyzed 45 catheter insertions being done by percutaneous method from January 1, 2011, to May 31, 2014. SC was inserted in 24 patients, and SNSC was inserted in 21 patients. Baseline characteristics for the two groups were similar with respect to age, sex and diabetic nephropathy as the cause for end-stage renal disease.

RESULTS

Incidence of mechanical and infectious complications in SNSC group was found to be low as compared to the SC group and was statistically significant (1 in 11.6 patient months vs. 1 in 14.4 patient months, p = 0.02). Catheter migration was found to be the most common mechanical complication (20 %), and peritonitis was found to be the most common infectious complication in conventional SC group (27 episodes in 420 patient months vs. 11 episodes in 333 patient months, p = 0.03). The incidence of exit site and tunnel infection rates revealed no difference between the groups.

CONCLUSION

SNSC insertion by percutaneous method is associated with low mechanical and infectious complications.

Comparative evaluation of fosinopril and herbal drug Dioscorea bulbifera in patients of diabetic nephropathy

Worldwide, diabetic nephropathy is one of the leading causes of end-stage renal failure. This hospital-based single-center prospective open-label randomized case-control interventional study was performed to evaluate and compare the native drug Dioscorea bulbifera with fosinopril in the management of diabetic nephropathy. Patients with diabetic nephropathy with proteinuria >500 mg/day or albuminuria >300 mg/ day, S Cr ≤2.5 mg/dL and hypertension controlled with a single drug were included into the study and were divided into three groups according to the interventional drugs that they were given; group A (n = 46) on fosinopril (5-40 mg/day), group B (n = 45) on Dioscorea bulbifera (500 mg BD) and group C (n = 46) on neither of these drugs. All necessary laboratory investigations needed to assess the effect of both the drugs were carried out. Patients were followed-up for six months. The study included 137 patients (M:F 2.61:1) with an age range of 19-76 years. At the sixth-month follow-up, a significant decrease in the systolic blood pressure was noted in all three groups whereas the diastolic blood pressure decreased significantly only in group B. There was significantly better control of both systolic and diastolic blood pressures in group B than in the other groups. Although fasting blood sugar was poorly controlled in the initial visit in all three groups, there was a significant decrease at the sixth-month follow-up in all three groups. Moreover, the decrease was significantly more pronounced in group B than in the other two groups. Low-density lipoprotein decreased significantly only in group B. Proteinuria, serum transforming growth factor-β, interleukin-6 (IL-6) and C-reactive protein decreased in both group A and group B, more so in the latter, but the differences between the groups were not statistically significant. Importantly, proteinuria and serum IL-6 showed an increasing trend in group C. It can be concluded that Dioscorea bulbifera was more effective than fosinopril in controlling blood pressure, glycemia, cholesterolemia and inflammatory state in diabetic nephropathy. Both agents decreased proteinuria. However, creatinine clearance significantly decreased with both the drugs, more so with Dioscera, and thus further evaluation with a larger trial is needed.

Prevalence and pattern of antiphospholipid antibody syndrome in a hospital based longitudinal study of 193 patients of systemic lupus erythematosus

BACKGROUND

Antiphospholipid antibody syndrome (APS) is a systemic autoimmune disease characterised by thrombophilic state and obstetrical complications. Prevalence of APS varies in different parts of the world. So this study was conducted to find out the prevalence and pattern of APS in systemic lupus erythematosus (SLE) in this region.

MATERIAL AND METHODS

In this hospital based longitudinal study from 2004 to 2011, we studied 193 patients of systemic lupus erythematosus (SLE) for prevalence of APS and its different characteristics. The diagnosis of SLE was made according to American College of Rheumatology (ACR) criteria and diagnosis of APS was made according to Sapporo criteria.

RESULTS

Prevalence of APS in SLE was 25.38%. Mean age at study entry was 25.5 +/- 6.9 years and majority of APS patients were in the age group 21-30 yrs (44.89%). The most common clinical manifestation in both SLE with APS and SLE without APS was musuloskeletal involvement (79.59% and 84.72% respectively). Among 49 patients of SLE having APS, multisystem involvement was present in 16 patients and life threatening complications were present in 12 patients. Late foetal loss was the most common obstetrical manifestation of APS (26.53%) and deep vein thrombosis was most common thrombotic manifestation (16.32%). Anticardiolipin antibodies(IgG aCL) were the most common antibody (85.71%) detected. Lupus anticoagulant was present in 71.42% cases of SLE having APS. ANA and anti-dsDNA antibodies were present in 97.95% and 77.55% cases of SLE having APS.

CONCLUSION

APS is a major cause of morbidity and mortality in patients of SLE. The incidence of secondary APS in SLE varies in different geographical regions and it was 25.38% in our study. Pregnancy morbidity and deep vein thrombosis were the most common complications of APS. IgG aCL was the most common antibody in APS patients. Screening for the presence of aPL antibodies in SLE patients and timely initiation of prophylactic treatment can prevent many of the complications.

Urinary MCP-1 as diagnostic and prognostic marker in patients with lupus nephritis flare

AIM OF THE STUDY

This study aimed to assess correlation of urinary monocytic chemoattractant protein-1 (UMCP-1) with severity of lupus nephritis and its role as predictor of outcome.

METHOD

Twenty patients with lupus nephritis flare were included in the study. Ten patients in each group of stable systemic lupus erythematosus and non-renal flare were taken as controls. Biopsy was done to define lupus nephritis stage. UMCP-1 levels were measured in all patients at the time of entry and at four and eight weeks of follow-up.

RESULTS

Mild, moderate and severe lupus nephritis flare was noted in one, five and 15 patients, respectively. UMCP-1 levels were high in patients with severe lupus nephritis flare (2.74 ± 0.95 ng/mg creatinine) as compared to patients with moderate (1.43 ± 0.46 ng/mg creatinine) and mild lupus nephritis flare (0.76 ± 0.57 ng/mg creatinine) (P = 0.0093). Baseline mean UMCP-1 levels in lupus nephritis flare, non-renal flare and stable SLE patients were 2.32 ± 1.06, 0.171 ± 0.03 and 0.213 ± 0.026 ng/mg creatinine, respectively. The difference among the three groups was very significant (P < 0.001). Also, mean UMCP-1 levels correlated significantly with severity of lupus nephritis class (P = 0.0358). During follow-up, 15 patients achieved complete or partial remission, and in these patients mean UMCP-1 levels had significant decline at eight weeks (P < 0.0001). However, mean UMCP-1 levels in the remaining five non-responders did not show significant changes at four and eight weeks (P = 0.4858).

CONCLUSION

Mean UMCP-1 levels were significantly higher in the lupus nephritis flare group as compared to non-renal flare and stable patients. Baseline mean UMCP-1 levels significantly correlated with both lupus nephritis class and severity of lupus nephritis flare, hence UMCP-1 could be used as a non-invasive marker for the judgement of lupus flare and lupus nephritis class.

Study on the role of humoral immunity in renal transplant rejections and its correlation with histopathological findings

Immunoglobulins (Ig) and complement, which are components of humoral immunity, are supposed to play a role in renal transplant rejection. The present study was undertaken to study the level of complement C3, C4 and IgG, A and M in patients with chronic renal failure (CRF) and in those with renal transplant rejection (Tx Rej) as well as stable transplant recipients (Tx Stb) and normal healthy controls (NHC) in order to assess their role in transplant rejection and to correlate them with histopathological findings. The mean level of C3 and C4 in the CRF, Tx Rej and Tx Stb groups was not significantly different from the NHC group (P > 0.05). The mean level of C3 in the Tx Rej group was not different from that in the Tx Stb group. However, the C4 level was significantly reduced in the Tx Rej group when compared with the Tx Stb group (P < 0.05). There was no histopathological correlation between C3 levels and acute cellular rejection (ACR) or chronic allograft nephropathy (CAN); however, C4 levels were reduced in about 50% of the cases with CAN. The mean serum IgG level was significantly reduced in patients with CRF and transplant recipients as compared with NHC. The serum IgA level was also significantly reduced in Tx Rej cases. Correlation of serum IgA with histopathology in cases with rejection showed that in ACR, a lower mean level of IgA was seen as compared with that seen in cases with CAN. The serum IgM level was significantly higher in the Tx Rej group as compared with the Tx Stb group. There was no significant correlation between serum IgM levels and renal histopathology in patients with ACR and CAN. The C3 level showed a significant positive correlation with IgG (r = +0.50, P < 0.05) in the Tx Stb group. This study shows that cell-mediated immunity is the main cause of rejection in both ACR and CAN while humoral immunity is also involved along with cellular immunity in some cases with CAN.

Evaluation of serum tumor necrosis factor alpha and its correlation with histology in chronic kidney disease, stable renal transplant and rejection cases

Tumor necrosis factor alpha (TNF alpha) is a cytokine secreted by macrophages, helper T cells, natural killer cells, B lymphocytes and non lymphoid cells e.g. endothelial cells, fibroblast and tumor cell lines. Aim of the study was to find the utility of TNF alpha in diagnosing renal transplant rejection among the renal transplant cases (n=29), and comparison with the levels in patients on maintenance hemodialysis (n=21) and healthy controls (n=20). TNF alpha in healthy controls varied from 2 to 15 pg/mL. In chronic renal failure and renal transplant rejection cases TNF alpha was above 45 pg/mL. In stable renal transplant patients it was higher than normal (16 to 30 pg/mL). In both acute and chronic transplant rejection TNF alpha increase correlated well with histology. Thus our study suggests that TNF alpha level more than 45 pg/mL can be taken as an immunological marker of renal transplant rejection.

A preliminary study on the significant value of beta-2-microglobulin over serum creatinine in renal transplant rejection and renal failure

INTRODUCTION

Beta-2-microglobulin (beta2M) is a light chain of HLA class I molecule, which is filtered by glomerulus, reabsorbed and catabolised by proximal tubule. It is one of the markers of transplant rejection. The aim of the present study was to find out the level of beta2M in acute renal failure (ARF), chronic renal failure (CRF), renal transplant rejection (TR) and renal transplantation stable (TS) cases, and correlation of beta2M with serum creatinine (SCr) in assessing renal failure.

METHODS

23 patients with ARF, 22 patients with CRF, six cases of TR, seven patients with TS, and 28 normal healthy controls were studied within a one-year period.

RESULTS

Highest mean value of beta2M was noted (12.97 +/- 3.83 microg/ml) in CRF, and all cases had elevated beta2M of which 81.8 percent of cases had beta2M above 10 microg/ml. In ARF, all cases had elevated beta2M and 78.3 percent patients had a value more than 10 microg/ml with a mean value of 11.75 +/- 2.09 microg/ml. TR cases also had elevated beta2M but 50 percent had mild elevation (less than 10 microg/ml) and 50 percent had marked elevation (more than 10 microg/ml). 42.8 percent of TS patients also had mild elevation of beta2M in the range 2.10-3.70 microg/ml. Interestingly, in normal healthy controls, 21.4 percent of patients had mild elevation of beta2M of 2.1-2.75 microg/ml, while 78.6 percent of cases had a normal range of beta2M (less than 2 microg/ml). All normal healthy controls and 71.4 percent of TS cases had normal SCr (less than 1.4 mg/dL). All cases of CRF and TR cases, and 28.6 percent of TS cases had elevated SCr. 81.8 percent of cases with CRF and 60.9 percent of cases with ARF had a marked rise of serum creatinine above 5 mg/dL.

CONCLUSION

Our study showed that beta2M is not superior over SCr for renal failure and TR cases, because it is also elevated in 21.4 percent of normal controls and 42.8 percent of TS cases. SCr is a cheaper, simpler and comparatively good test to assess renal failure and TR.

Mesangioproliferative glomerulonephritis: an important glomerulonephritis in nephrotic syndrome of young adult

Mesangioproliferative glomerulonephritis (MesPGN) consists 10% of the total renal biopsy of glomerulonephritis. Aim of the present study was to find out clinicopathological changes in MesPGN and differences between diffuse and focal variety. MesPGN was seen mostly in young adults with mean age of 28.63 years for males and 26.3 years for females. Male predominance was noted (M:F ratio - 1.4:1). About 70.83% patient presented with edema feet, followed by hypertension (29.19%), fever (16.66%), oliguria, nausea and vomiting (10.41%). Urine analysis in 50 patients revealed that 70% patients presented with nephrotic-range proteinuria, 36% patients with microscopic hematuria and 56% patients with leukocyturia. Statistically, no significant difference was found in clinical features of diffuse and focal MesPGN. Microscopic comparison between diffuse and focal variety showed that significant increase of focal glomerular basement membrane thickening, focal endothelial cell proliferation, focal smooth muscle hyperplasia, hyaline sclerosis and vasculitis was more common in diffuse variety. In focal variety, Capillary loop congestion, periglomerulitis, cloudy swelling and vacuolar degeneration in tubules were significantly more as compared to diffuse variety. Details of the clinical features, special laboratory tests and histological details revealed that diffuse variety had systemic diseases, which included Wegner's granulomatosis, microscopic polyangitis, Henoch's schonlein purpura, systemic lupus erythematosus (two cases) and one case each of Kimura's disease, pyelonephritis and tuberculosis. Only one case of focal MesPGN showed tuberculosis. Thus, our study concludes that MesPGN is an important cause of nephrotic syndrome among young adults. Secondly, search for some other diseases should be made and thirdly, if biopsy shows focal mesangial cell proliferations in minimal change glomerulonephritis (MCGN), it should be diagnosed as focal MesPGN rather than MCGN because these cases show recurrences.

An unusual case of Acanthamoeba peritonitis in a malnourished patient on continuous ambulatory peritoneal dialysis (CAPD)

An unusual case of peritonitis in a 61-year-old patient is reported where culture for bacteria and fungi were negative. Acanthamoeba was isolated and the patient was treated with Ceftazidine, Cefazolin, Levofloxacin, Fluconazole and Rifampicin with regular haemodialytic support. The patient was completely cured of the infection and continuous ambulatory peritoneal dialysis (CAPD) fluid became clear after 2 weeks of treatment. Diagnosis and treatment of Acanthamoeba infections are difficult due to the rarity of the infections, lack of familiarity of most clinicians with disease syndromes, and limitations of therapeutics options. Even an experienced microbiologist can easily mistake the amoebae in ascitic fluid for peritoneal macrophages or lymphocytes.

Myeloma in young age

Total 14 cases of myeloma in young age group (<40 years) have been reported out of 178 cases of myeloma in a time period of 7 years (1993-1999). Males predominated overfe males. Like adult myeloma, patients presented mostly with the backache, pain in pelvis, lower spine and weakness in about 60% of cases followed by swelling of bone in 40% of cases. One case presented with bleeding gum, malena and hepatosplenomegaly and was diagnosed as plasma cell leukemia. Radiological examination revealed lytic lesion in almost all the cases with fracture femur and rib in 28.57% of cases. Anaemia and raised ESR was noted in all the cases. Myeloma typing revealed IgG myeloma in 10 cases, light chain myeloma in 3 cases and IgA myeloma in one case. None of the patient was traceable after 2 years. Thus our study concludes that myeloma in the young age in India occurs in increased frequency and clinically presents just like adult and elderly myeloma, but serologically are predominantly of IgG type. There is also an increased frequency of solitary plasmacytoma as compared to adult myeloma.

Aliphatics from Peristrophe bicalyculata

The isolation and spectral data of the new 14-methyl-tritriacont-14-en-15-ol (1) and 35-hydroxynonatriacontanal (2) from the aerial parts of Peristrophe bicalyculata are reported.

Severe mitral regurgitation due to mitral valve prolapse: risk factors for development, progression, and need for mitral valve surgery

Patients with mitral valve prolapse (MVP) may develop severe mitral regurgitation (MR) and require valve surgery. Preliminary data suggest that high body weight and blood pressure might add to the irreversible factors of older age and male gender in increasing risk of these complications. Fifty-four patients with severe MR due to MVP were compared with 117 control subjects with uncomplicated MVP to elucidate factors independently associated with severe MR: the need for valve surgery and the cumulative risk of requiring mitral valve surgery. Patients with severe MR were older (p<0.00005), more overweight (p = 0.002), had higher systolic (p = 0.0003) and diastolic (p = 0.007) blood pressures, and were more likely to have hypertension (p = 0.0001) and to be men (p<0.001). In both groups, men had higher blood pressure and relative body weight than women. In multivariate analysis, older age was most strongly associated with MR; higher body mass index, hypertension, and gender were independent predictors of severe MR in analyses that excluded age. Among the 54 patients with severe MR, the 32 (59%) who underwent mitral valve surgery during 11 years of follow-up were older, more overweight, and more likely to be hypertensive than those not requiring surgery. Among patients undergoing mitral valve surgery in 3 centers, mitral prolapse was the etiology in 25%, 67% of whom were men. Using these data and national statistics, we estimate that the gender-specific cumulative risk for requiring valvular surgery for severe MR in subjects with MVP is 0.8% in women and 2.6% in men before age 65, and 1.4% and 5.5% by age 75. Thus, subjects with MVP who are older, more overweight, and hypertensive are at greater risk for severe MR and valve surgery. Higher blood pressure and relative weight in men with MVP appear to contribute to the gender difference in risk for severe MR.

Evaluation of muscle changes in patients with chronic renal failure

Forty patients of chronic renal failure (CRF) and five patients of acute on chronic renal failure (ACRF) were evaluated clinically and electrophysiologically for involvement of muscles. EMG studies showed features suggestive of denervation myopathy in 10 of patients of CRF only. Histopathological study of muscle biopsies, done in 25 patients with CRF, showed constellation of histopathological features suggestive of denervation myopathy in 48 and toxic myopathy in 24. In five patients with ACRF,denervation myopathy was observed in 60 and toxic myopathy in 20 cases on histopathological examination.

Body mass index (BMI) in the Saudi population of Gassim

In a total cross-sectional population survey of the Faizia East Primary Health District of Buraidah, Gassim region of Saudi Arabia, 6,044 (2727 male and 3317 females) subjects out of a de facto population of 7695 got their BMI computed because infants and restless or bedridden subjects could not be examined. Mean (+/- SD) and percentiles (25th & 75th) were calculated in the conventional 5-year age cohorts as well as in functional age groups, namely, 0-5, 6-12, 13-49, 50-69 and 70+ years. 5th, 10th, 25th, 50th, 75th, 90th and 95th percentiles were computed only for the functional age groups. In general, the trend was for BMI to increase with age in both genders but the curve pattern showed some plateauing from about the age of 50 with slight decline in later life. Females had significantly higher indices than males, this becoming quite prominent from the 10-14 year age cohort. This difference persisted irrespective of the types of age grouping or residential location. Overall means (+/- SD) were 20.14 +/- 5.98 vs 22.22 +/- 7.21 for males and females respectively; df: 5771; p = 0.0000; 95% CI: -2.43, -1.735. Subjects in the urban living environment had significant higher indices than their rural counterpart: (21.666.92 vs 20.446.33: df: 5771; P = 0.0000; 95% CI: 1.595, -0.840). From the age of 15 about one quarter of females are overweight (BMI at the 75th percentile > 25) and from 30 years the same proportion are frankly obese (BMI > 30). Both systolic and diastolic blood pressure were significantly positively correlated with BMI in both genders: male SBP: r = 0.22, P < 0.0001; male DBP: r = 0.21, P < 0.00001; female DBP: r = 0.18, P < 0.00001.