Novel oncogenic transcriptional targets of mutant p53 in esophageal squamous cell carcinoma

Missense mutations in the DNA binding domain of p53 are observed frequently in esophageal squamous cell carcinoma (ESCC). Recent studies have revealed the potentially oncogenic transcriptional networks regulated by mutant p53 proteins. However, majority of these studies have focused on common "hotspot" p53 mutations while rarer mutations are poorly characterized. In this study, we report the characterization of rare, "non-hotspot" p53 mutations from ESCC. In vitro tumorigenic assays performed following ectopic-expression of certain "non-hotspot" mutant p53 proteins caused enhancement of oncogenic properties in squamous carcinoma cell lines. Genome-wide transcript profiling of ESCC tumor samples stratified for p53 status, revealed several genes exhibiting elevated transcript levels in tumors harboring mutant p53. Of these, ARF6, C1QBP, and TRIM23 were studied further. Reverse transcription-quantitative PCR (RT-qPCR) performed on RNA isolated from ESCC tumors revealed significant correlation of TP53 transcript levels with those of the three target genes. Ectopic expression of wild-type and several mutant p53 forms followed by RT-qPCR, chromatin affinity-purification (ChAP), and promoter-luciferase assays indicated the exclusive recruitment of p53 mutants-P190T and P278L, to the target genes leading to the activation of expression. Several functional assays following knockdown of the target genes revealed a significant suppression of tumorigenicity in squamous carcinoma cell lines. Rescue experiments confirmed the specificity of the knockdown. The tumorigenic effects of the genes were confirmed in nude mice xenograft assays. This study has therefore identified novel oncogenic targets of "non-hotspot" mutant p53 proteins relevant for ESCC besides validating the functional heterogeneity of the spectrum of tumor-specific p53 mutations.

To study the expression of estrogen, progesterone receptor and p53 immunohistochemistry markers in subtyping endometrial carcinoma

Background

Endometrial cancer is one of the most commonly diagnosed cancers in women worldwide.

Aim and Objectives

To study the expression of estrogen receptor (ER), progesterone receptor (PR) and p53 immunohistochemistry (IHC) markers in subtyping endometrial carcinoma. Materials and Methods: A total of 100 cases of carcinoma endometrium submitted during January 2016 to October 2018 were included in our study. The ER, PR and p53 expressions were scored as per the adopted scoring system. Agreement between ER, PR and p53 IHC expression and the consensus HE diagnosis, FIGO grading and tumour staging were assessed using Chi square tests.

Results

There was a statistical association between ER, PR and p53 status and tumour histologic type with a P value < 0.01. There was no statistical significance observed between ER and PR expressions and different FIGO grades. Statistical significance (P = 0.036) between p53 and different FIGO grades seen. No statistical significance was observed between ER, PR and p53 expressions and different tumour stages and tumour invasiveness. There was a statistical association between ER and PR status and lymph node metastasis. p53 did not show a statistical significance.

Conclusion

Combination of ER, PR and p53 IHC markers can be used to distinguish type 1 and type 2 endometrial cancers. PR expression is more specific than ER in endometrioid carcinomas. p53 expression is more specific in serous carcinoma, however, p53 IHC alone cannot be used to distinguish different grades of endometrioid carcinomas as there is variability of staining in endometrioid carcinomas.

A Study of Focal and Segmental Glomerulosclerosis according to the Columbia Classification and Its Correlation with the Clinical Outcome

Introduction  Focal and segmental glomerulosclerosis (FSGS) is a leading cause of nephrotic syndrome in both adults and children. The "Columbia classification of FSGS" includes five variants; not otherwise specified (NOS), tip, perihilar, cellular, and collapsing variants that may have different prognostic and therapeutic implications. Materials and Methods  This is a retrospective study and was carried out in the Department of Histopathology, Apollo Hospitals, Hyderabad. Of a total of 11,691 kidney biopsies over a 7-year period, from 2006 to 2012, 824 cases were diagnosed as FSGS, of which 610 cases in which detailed clinical findings were available were included in this study. FSGS was then categorized according to the Columbia classification. Results  FSGS, NOS was the predominant histomorphological variant. Serum creatinine was significantly high in the collapsing variant, followed by NOS. Follow-up data was available for 103 cases,72.8% had complete remission, 10.6% had partial remission, and in 16.5 % there was no remission. Relapses were observed in 6.7% cases, two patients (1.9%) succumbed, and 4.8% cases progressed to chronic kidney disease. Conclusion  This study showed that perihilar variant was less prevalent, with tip and cellular variants being more prevalent in Indian subcontinent compared to Western literature. Collapsing variant was also less common.

Successful Renal Transplant in Castleman Disease - First Case Report from India

Castleman disease (CD) comprises a rare group of heterogenous benign lymphoproliferative disorders with pathologic similarities. However, they present with diverse clinical manifestations. Renal involvement is rare in CD and is mainly reported with plasma cell type of multicentric disease. Various glomerular pathologies, interstitial involvement, or thrombotic microangiopathies have all been reported, some of which progress to end-stage renal disease (ESRD). Progression of CD to ESRD is well documented; however, a patient on dialysis developing CD is rare. Moreover, kidney transplantations have seldom been performed on patients with CD. We report a patient with ESRD of unknown etiology who developed multicentric CD while on dialysis. He was treated with four doses of rituximab and later underwent a living kidney transplant with his wife as a donor. He has been clinically well ever since. We believe that this is possibly the first successful case of renal transplantation in CD with ESRD being reported from India.

Proliferative Glomerulonephritis with Monoclonal Immunoglobulins in a Child with Recurrence in the Allograft

Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is among the spectrum of monoclonal protein-associated renal diseases, with only about 15 case reports in children. We report a 7-year-old boy with biopsy-proven crescentic PGNMID who progressed to end-stage renal disease within a few months of presentation. He then received a renal transplant with his grandmother as a donor. Proteinuria was detected at 27 months post-transplant and an allograft biopsy revealed a recurrent disease.

Fetal sepsis: a cause of stillbirth

Infection is considered a leading cause of fetal death, responsible for approximately 20% of cases. Such estimates are derived from the frequency of acute histological chorioamnionitis and funisitis in cases of fetal death rather than direct detection of microorganisms in the fetal compartment. We report a case of clinically unexplained fetal death at 38 weeks of gestation in an uncomplicated pregnancy resulting in delivery of an appropriate-for-gestational-age fetus. The mother did not have any clinical signs of infection. Overwhelming bacterial invasion in multiple fetal organs, including the heart, liver, spleen, and kidneys, was observed despite the lack of evidence of maternal clinical infection. The bacteria were visualized by using standard histologic techniques (e.g. H&E/ tissue Gram stain) highlighting the value of autopsy in determining the cause of death.

Unusual cause of irreversible acute kidney injury postgastrectomy

A 56-year-old male was diagnosed to have carcinoma stomach following evaluation of lack of appetite and weight loss. He underwent neoadjuvant chemotherapy and gastrectomy. Following surgery he developed progressive renal failure. A renal biopsy led to the diagnosis of oxalate nephropathy. Despite treatment his renal functions never recovered. Oxalate nephropathy is an underappreciated cause of renal failure postgastrectomy. It can cause irreversible renal failure unless detected and treated early.

Banff classification from 1991 to 2019. A significant contribution to our understanding and reporting of allograft renal biopsies

The Banff schema of classification of renal allograft biopsies, first proposed at the meeting in Banff, Canada in 1991 has evolved through subsequent meetings held once in two years and is the internationally accepted scheme of classification which is consensual, current, validated and in clinical use. This review traces the evolution of the classification and our understanding of renal transplant pathology, with emphasis on alloimmune reactions. The proceedings of the meetings and the important studies which have shaped the classification are covered.

Acute Kidney Injury as an Initial Presentation in Mantle Cell Lymphoma- A Rare Case Report

Mantle Cell Lymphoma (MCL) is a rare aggressive lymphoid neoplasm accounting for 3-7% of all Non Hodgkin Lymphomas (NHL). Kidney involvement in MCL is rarely reported in biopsies from living patients, being caused by direct lymphoid infiltration. Only 19 cases have been documented of Acute Kidney Injury (AKI) with lymphomatous infiltration. This case report is of a 50-year-old male who presented with AKI and was found to have a MCL infiltrating the kidneys.

Renal lymphoma diagnosed on kidney biopsy presenting as acute kidney injury

Introduction:

Renal manifestations associated with hematolymphoid malignancies are known. Primary or secondary involvement of the kidney by lymphomatous infiltration has various clinical presentations. Acute kidney injury is not an uncommon finding in relation to lymphomatous interstitial infiltration proven on kidney biopsy. However, diagnosing it solely on renal biopsy remains a challenge and needs expertise and aid of immunohistochemistry as the prognosis is dismal.

Methods:

This is a retrospective study of kidney biopsy-proven cases of renal lymphoma presenting with acute kidney injury.

Results:

The study included 12 patients with ages ranging from 4 to 50 years who presented with serum creatinine ranging 2.1–9.6 mg%. Renal biopsy findings showed interstitial lymphomatous infiltrate. Two cases were diagnosed as primary lymphoma and the other 10 as secondary lymphomas. Among the 12 cases, nine were B-cell non-Hodgkin lymphoma, of which diffuse large B-cell lymphoma was diagnosed in six (50%), low-grade B-cell type in two (16.6%), chronic lymphocytic leukemia in one (8.3%), and three were T-cell-type. Two were acute T-cell lymphoblastic lymphoma and one other was a high-grade T-cell lymphoma. Four patients succumbed. The other four patients are alive; one is on chemotherapy, while two of them are on hemodialysis.

Conclusion:

Acute kidney injury as a presenting feature with lymphomatous infiltration of renal parenchyma is not uncommon. The patchy involvement makes it challenging on kidney biopsy with definitive diagnosis being made with the help of immunohistochemistry. Appropriate multidisciplinary involvement improves patient outcome.

Myoglobinuria-induced Acute Kidney Injury Secondary to CovishieldTM Vaccination

Vaccination is the best strategy for the development of herd immunity and for the control of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic. As the number of immunizations across the globe reaches a record number, random cases of diverse adverse effects of the vaccines are being documented. We report a case of renal biopsy-proven myoglobin-induced acute tubular injury requiring dialytic support post-Covishield^TM vaccination. Awareness of this rare complication is necessary so that it can be recognized early, and renal injury avoided.

Kidney transplant dysfunction in a patient with COVID - 19 infection: role of concurrent Sars-Cov 2 nephropathy, chronic rejection and vitamin C-mediated hyperoxalosis: case report

Background

COVID-19 infection in kidney transplant recipients often lead to allograft dysfunction. The allograft injury has various histopathological manifestations. Our case illustrates the unusual combination of allograft rejection, acute kidney injury secondary to oxalate nephropathy and SARS CoV-2 nephropathy as the cause of irreversible allograft failure.

Case presentation

A 56 year old renal allograft recipient presented with a history of fever and diarrhoea for the preceding 4 weeks, tested positive for Sars-CoV2 on nasal swab and was found to have severe allograft dysfunction, necessitating haemodialysis. He subsequently underwent an allograft biopsy, which demonstrated antibody mediated rejection along with the presence of extensive oxalate deposition in the tubules. Ultrastructural examination demonstrated spherical spiked particles in the glomerular capillary endothelium and the presence of tubulo-reticular inclusions suggestive of an active COVID-19 infection within the kidney. The intra-tubular oxalate deposition was considered to be the result of high dose, supplemental Vitamin C used as an immune booster in many patients with COVID − 19 infection in India.

Conclusions

This case highlights the complex pathology that may be seen in following COVID-19 disease and the need for kidney biopsies in these patients to better understand the aetiology of disease.

Aberrant cytoplasmic localization of ARID1B activates ERK signaling and promotes oncogenesis

The ARID1B (BAF250b) subunit of the human SWI/SNF chromatin remodeling complex is a canonical nuclear tumor suppressor. We employed in silico prediction, intracellular fluorescence and cellular fractionation-based subcellular localization analyses to identify the ARID1B nuclear localization signal (NLS). A cytoplasm-restricted ARID1B-NLS mutant was significantly compromised in its canonical transcription activation and tumor suppressive functions, as expected. Surprisingly however, cytoplasmic localization appeared to induce a gain of oncogenic function for ARID1B, as evidenced from several cell line- and mouse xenograft-based assays. Mechanistically, cytoplasm-localized ARID1B could bind c-RAF (RAF1) and PPP1CA causing stimulation of RAF-ERK signaling and β-catenin (CTNNB1) transcription activity. ARID1B harboring NLS mutations derived from tumor samples also exhibited aberrant cytoplasmic localization and acquired a neo-morphic oncogenic function via activation of RAF-ERK signaling. Furthermore, immunohistochemistry on a tissue microarray revealed significant correlation of ARID1B cytoplasmic localization with increased levels of active forms of ERK1 and ERK2 (also known as MAPK3 and MAPK1) and of β-catenin, as well as with advanced tumor stage and lymph node positivity in human primary pancreatic tumor tissues. ARID1B therefore promotes oncogenesis through cytoplasm-based gain-of-function mechanisms in addition to dysregulation in the nucleus.This article has an associated First Person interview with the first author of the paper.

A Novel Glomerular C4d Scoring System: A Tool to Prognosticate Proliferative Exudative Pattern of Glomerular Injury

Aim:

Proliferative exudative pattern of glomerular injury is usually a manifestation of an infection related or a post-infectious glomerulonephritis (PIGN). Rarely, it may represent a C3 glomerulopathy, which is a dysfunction of the alternative pathway of complement activation, and is then termed an atypical PIGN (aPIGN). C4d deposits in the glomerulus are footprints of the classical and/or lectin pathway of complement activation and hence is expected to be positive in immune-mediated glomerulonephritis (GN) like classical infection-related GN, and could be used to differentiate classical PIGN from atypical PIGN.

Materials and Methods:

We report a novel C4d scoring system based on the intensity and the proportion of glomerular tuft staining, in a series of 104 biopsies with the proliferative exudative pattern of glomerular injury. Using a statistically derived cut-off score of 1.45, the cases were divided into C4d positive and C4d negative groups and compared to IF findings and the follow-up, available in 36 cases.

Results:

The C4d positive group had a significantly greater proportion of cases with immune complexes compared to the group with C3 deposits alone. In the follow-up, C4d negative group had also a greater number with partial/incomplete response compared to the C4d positive group.

Conclusions:

We recommend that the C4d stain be done in all cases with a proliferative exudative pattern of glomerular injury to identify patients who would need a close follow up and further assays of complement function.

A Rare Case of APRT Deficiency with End-stage Renal Failure and Successful Renal Transplant

Renal calculus disease is a common cause of renal injury. However, crystal nephropathy (uric acid, oxalate, and dihydroxyadenine) can present as chronic kidney disease without any evidence of renal stones. If left undiagnosed, there is a potential chance of recurrence in the allograft leading to graft failure after transplantation. Pretransplant identification and management can avoid such complications. Here, we describe a case of APRT deficiency leading to crystal nephropathy and end-stage renal failure in a patient who underwent a successful kidney transplant.

The Utility of Assessing CD68+ Glomerular Macrophages in Assessing Endocapillary Hypercellularity in IgA Nephropathy

Introduction:

IgA nephropathy (IgAN) is the most common form of glomerulonephritis across the world. Oxford classification defines criteria and effects of endocapillary hypercellularity on E score but the reproducibility of the same is debatable. Hence, there is a need for an objective marker that could establish a gold standard in assessing endocapillary hypercellularity.

Methods:

Forty biopsies of proven IgAN were taken and grouped into two groups based on the presence or absence of endocapillary hypercellularity (n = 20 each). These biopsies were then stained by CD68 immune stain and the glomerular macrophages were quantified. Mean serum creatinine, presence of hypertension, degree of proteinuria and haematuria at the time of biopsy were also recorded and the correlation between these parameters and endocapillary hypercellularity was also studied.

Results:

Mean glomerular CD 68+ cell count was significantly higher in glomeruli showing endocapillary hypercellularity. Utilising the objective cutoff values of 0.6 CD68+ per glomerulus, more than 8 glomerular CD68+ cells in the entire biopsy and/or around 4 CD68+ cells in the most inflamed glomerulus, endocapillary hypercellularity can be predicted with a sensitivity of 70–80% and specificity of 70%. After regrouping the biopsies based on the cutoff values obtained from the receiver operating curve analysis the mean urine RBC count per high power field showed a significant correlation with endocapillary hypercellularity.

Conclusion:

Glomerular CD68+ macrophage count seems to be a promising approach in assessing endocapillary hypercellularity. Further studies with emphasis on correlation with the clinical outcome are needed to validate its utility as an objective tool.

Intravascular large B cell lymphoma of prostate, a rare entity

Intravascular large B cell lymphoma is a rare type of extranodal lymphoma characterized by selective growth of neoplastic cells in small vessels, especially capillaries, sparing larger arteries, veins and surrounding tissue. The absence of intravascular lymphoma in the traditional sites and difference in mode of presentation with no mass forming lesion as compared to other lymphomas, makes it unique and difficult to diagnose early. It is extremely heterogeneous in its clinical presentation depending on the organ involved. Primary intravascular large B cell lymphoma of the prostate is extremely rare and only 8 cases have been reported in English literature till date, limited to single case reports. This is a rare case of a 76 year old male patient, who came with complaints of urinary obstruction and fever of unknown origin since 15 days. Routine investigations were within normal limits including the complete urine examination, complete blood picture and PSA levels. Mild prostatomegaly was noted on radiology. Patient was catheterized and transurethral resection was done. On histopathological examination, prostatic acini and stroma were normal but the vessels in the stroma which were dilated and thin walled lacking a muscular coat, showed sheets of loosely cohesive cells with moderate eosinophilic to clear cytoplasm, vesicular nuclei, with 1 to 3 prominent nucleoli and mitoses, averaging 4-6/hpf. On immunohistochemistry, the tumor cells were positive for CD 20 and MUM 1 with high MIB1 index of about 90% and were negative for CD3, CD10, Bcl6, PSA, P63, CK7, CK20, HMWCK, and Pancytokeratin. CD31 stained and highlighted the endothelial cells of the vessels. Final diagnosis made after correlating light microscopy and immunohistochemistry was a Primary Intravascular large B-cell lymphoma of the prostate.

Anti-glomerular Basement Membrane Disease with Atypical Associations

Anti-glomerular basement membrane (anti-GBM) disease is a systemic autoimmune disorder characterized by circulating immunoglobulin (Ig) G antibodies to carboxy-terminal, noncollagenous 1 domain of type IV collagen of GBM. Patients typically present with rapidly progressive glomerulonephritis and pulmonary hemorrhage. Anti-GBM disease has been reported to coexist with pauci-immune antineutrophil cytoplasmic autoantibody-positive glomerulonephritis and membranous glomerulopathy. The presentation of anti-GBM disease with thrombotic microangiopathy (TMA) and IgA nephropathy has been rarely described. We herein report two cases of anti-GBM antibody disease, both with crescentic glomerulonephritis and peripheral linear deposits of IgG, one case with clinical and histological findings of associated TMA and other with findings of extensive mesangial IgA deposits. Both the patients were treated with corticosteroid, intravenous cyclophosphamide, and plasma exchange but had poor renal recovery. Association of anti-GBM disease with TMA or IgA nephropathy could open up new pathogenetic mechanism and may help us to prognosticate anti-GBM disease.

Study of Ki-67 index in the molecular subtypes of breast cancer: Inter-observer variability and automated scoring

Background

Ki-67 index is an important prognostic marker in breast cancer and is also used to differentiate luminal A subtype from luminal B. Inter-observer variations in determining the index and the cut-off value to be considered in distinguishing the two subtypes remain problems in clinical practice.

Methods

MIB-1 immunohistochemistry was done on 200 cases of breast cancer with 50 cases in each molecular subtype. The Ki-67 scoring was done manually by two observers and automated method (using the software ImmunoRatio). The mean value of Ki-67 was calculated in each molecular group and in the entire estrogen receptor and progesterone receptor (ER/PR) positive group. The inter-observer variability between the two observers and the automated method was also assessed.

Results

The mean and median values of Ki-67 of all the 200 cases obtained by manual scoring was 31.13% and 29.65% by observer 1, 28.48% and 27.90% by observer 2, and 38.27% and 35.45% by the automated method. The mean Ki-67 value obtained by manual scoring, in luminal A, luminal B, HER2 enriched and triple negative was 21.07%, 37.19%, 33.72% and 27.27%, respectively. There was significant correlation between the two observers and with the automated scoring.. The mean value of the Ki-67 index in the ER/PR positive group was 29.1%.

Conclusion

The inter-observer correlation and the correlation with the automated scoring system of the Ki-67 index was good. 29.1% was the mean Ki-67 index in the ER/PR positive group and this value was within the acceptable range as per St Galen's recommendation.

Deregulation of signalling in genetic conditions affecting the lysosomal metabolism of cholesterol and galactosyl-sphingolipids

The role of lipids in neuroglial function is gaining momentum in part due to a better understanding of how many lipid species contribute to key cellular signalling pathways at the membrane level. The description of lipid rafts as membrane domains composed by defined classes of lipids such as cholesterol and sphingolipids has greatly helped in our understanding of how cellular signalling can be regulated and compartmentalized in neurons and glial cells. Genetic conditions affecting the metabolism of these lipids greatly impact on how some of these signalling pathways work, providing a context to understand the biological function of the lipid. Expectedly, abnormal metabolism of several lipids such as cholesterol and galactosyl-sphingolipids observed in several metabolic conditions involving lysosomal dysfunction are often accompanied by neuronal and myelin dysfunction. This review will discuss the role of lysosomal biology in the context of deficiencies in the metabolism of cholesterol and galactosyl-sphingolipids and their impact on neural function in three genetic disorders: Niemann-Pick type C, Metachromatic leukodystrophy and Krabbe’s disease.

Lymphomatous Interstitial Nephritis Coexistent with Paraneoplastic Crescentic Membranoproliferative Glomerulonephritis in a Case of Mantle Cell Lymphoma

Mantle cell lymphoma (MCL) is a rare aggressive lymphoproliferative disorders (LPD) of B-cell lymphoma, which usually presents in advanced stages at initial diagnosis. Renal involvement in MCL is very rare, especially the combined presence of both glomerular and interstitial disease. We report on a patient with lymphomatous interstitial nephritis (LIN) coexistent with paraneoplastic crescentic membranoproliferative glomerulonephritis (MPGN), subsequently diagnosed to have disseminated MCL with bone marrow and lymph nodal infiltration. He was treated with rituximab-based chemotherapy and went into complete renal remission at 6-months of follow up.

Printed titanium implants in UK craniomaxillofacial surgery. Part I: access to digital planning and perceived scope for use in common procedures

This first part of a two-part study examines perceived applications for and barriers to using printed titanium in light of current caseloads, funding pathways, and use of digital planning. It aims to demonstrate the scope for printed titanium in modern practice and to guide industry about the needs of UK surgeons. A cross-sectional study over 14 weeks was performed electronically with support from the British Association of Oral and Maxillofacial Surgeons (BAOMS) and a national trainee-led recruitment team. Ethics approval was obtained at the lead centre. A total of 132 participants joined the study (70% consultants, 25% specialty registrars, and 5% other), approximating a 29% response rate from consultant/registrar BAOMS members throughout mainland UK. Eighty-eight per cent used CAD-CAM design, with highly variable funding/access, design/manufacturing workflows (in-house/outsourced). Eighty-eight per cent were involved with trauma, 61% with orthognathic, and 52% with oncology-reconstruction surgery. Favourite applications for printed titanium were orbital floor repair (89%) and free-flap jaw reconstruction (87%). Most participants also cited maxillary/zygomatic osteotomies and cranioplasty (range 61%-73%). Although a popular application (78%), the evidence base in temporomandibular joint surgery is limited. Those performing orthognathic surgery perceived more indications than those who did not (p=0.013). Key barriers included cost, turnaround time and logistics, and the need to be trained in traditional techniques. Printed titanium was useful for both common and niche procedures, but was specifically limited in emergency trauma. Most surgeons had experience in CAD-CAM surgery but technical understanding appeared unclear. Limiting factors included variable funding and production pathways, perceived costs, and logistics, but in-house design can minimise them. In part II, we quantify perceived benefits and limitations and whether surgeons' understanding and knowledge are sufficient to rationalise them.

Printed titanium implants in UK craniomaxillofacial surgery. Part II: perceived performance (outcomes, logistics, and costs)

This second part explores perceptions and understanding of clinical performance, turnaround, and costs for printed titanium implants or plates in common procedures, evaluating both 'in-house' and 'outsourced' CAD-CAM pathways. A cross-sectional study, supported by the British Association of Oral and Maxillofacial Surgeons (BAOMS) and a national trainee-led recruitment team, was conducted over 14 weeks. A total of 132 participants took part (demographic data is reported in Part I). For fibular-flap mandibular reconstruction, most participants (69% - 91%) perceived printed titanium as superior to intraoperatively or preoperatively hand-bent plates for surgical duration, accuracy, dental restorability, and aesthetics. There was less agreement about complications and plate-failure risks. Most perceived printed plates to be superior to traditional wafer-based maxillary osteotomy for surgical duration (61%) and maxillary positioning (60%). For orbital floor repair, most perceived improvements in surgical duration (83%, especially higher-volume operators p=0.009), precision (84%), and ease of placement (69%). Rarely (less than 5%) was any outcome rated inferior to traditional techniques for any procedure. Perceived turnaround times and costs were variable, but the greatest consensus was for two-segment fibular-flap reconstructions and orbital floor repair. Industry estimates were generally consistent between two company representatives, but manufacturing-only costs differed when using in-house (departmental) designers. Costs and turnaround times are questionable barriers since few understand 'real-world' figures. Designing in-house can dramatically alter costs. Improved accuracy and surgical duration are common themes but biomechanical benefits are less-well understood. This study paints a picture of the potentially routine applications and benefits of printed titanium, capacity for uptake, understanding amongst surgeons, and areas for improvement.

MO063CHRONIC INTERSTITIAL NEPHRITIS IN AGRICULTURAL COMMUNITIES IS A TOXIN-INDUCED PROXIMAL TUBULAR NEPHROPATHY

Background and Aims

30 years after the detection of CINAC, there is no consensus on its etiology. Heat stress/dehydration and toxic exposure are the two most likely etiologies. There are no diagnostic criteria that can directly identify CINAC patients.

Method

Renal biopsies (RB) (18 Sri Lanka, 10 El Salvador, 1 India, 3 France) of patients with CINAC (CKD2-3) were examined by light (LM) and electron microscopy (EM) in comparison to RB of normal kidneys at implantation and 6 and 12 months of calcineurin inhibitor (CNI) therapy, transplant patients on CNI with indication biopsies (n=24), proteinuric nephropathies (n=15), light chain disease (n=4), cases on nephrotoxic drugs (lomustine, clomiphene, lithium, tenofovir, cisplatinum) and CKD of various causes (n=20). A rat study was conducted comparing histopathology of heat stress/dehydration with cyclosporine nephrotoxicity.

Results

In addition to previously described histopathological changes, there was a unique constellation of proximal tubular cell (PTC) findings: cellular/tubular atrophy, cell fragment shedding, weak to non-proliferative capacity of the PTC and dysmorphic lysosomes increased in size and number with a light-medium electron-dense matrix containing dispersed dark electron-dense non-membrane bound “aggregates”. Identical renal lesions were observed in 55-80% of renal transplant protocol biopsies taken after 6 and 12 months of calcineurin inhibitor (CNI) therapy and in indication biopsies, in implantation biopsies the prevalence was 6%. Several cases of nephrotoxic drugs (lomustine, clomiphene, lithium) and a subset of patients with light chain disease, all conditions that can be linked to CNI, presented the same lesion. Control RBs (n=66) of normal kidney, toxic nephropathies (tenofovir, cisplatinum), and overt proteinuric patients of different etiology to some extent could demonstrate the tubular cell changes observed by LM, but not or very rarely those that were observed by EM. Rats treated with cyclosporine for 4 weeks developed similar PTC lysosomal alterations, absent in a dehydration group.

Conclusion

A sensitive constellation of renal PTC lesions was detected associated with CINAC and CNI nephrotoxicity in several countries, suggesting a common new paradigm where CINAC patients are experiencing a tubulotoxic mechanism similar to CNI nephrotoxicity, the latter also being known as a direct or suggested indirect effect of pesticides.

P0125ELECTRON MICROSCOPIC DESCRIPTION OF A SENSITIVE DIAGNOSTIC PROXIMAL EPITHELIAL LYSOSOMAL LESION IN PATIENTS WITH CINAC/CKDU/MEN AND CNI NEPHROTOXICITY

Background and Aims

In CINAC patients from Sri Lanka, we recently observed a sensitive constellation of proximal tubular cell findings including cellular/tubular atrophy, cell fragment shedding and, by electron microscopy (EM), the presence of an increased number of enlarged lysosomes. Here we focused on precisely defining the EM lysosomal phenotype and evaluating its presence in CINAC/MeN/CKDu cases and controls from other countries.

Method

Thirthy-two renal biopsies (18 Sri Lanka, 10 El Salvador, 1 India, 3 France) of patients with a diagnosis of CINAC (CKD 1-3A, 3B) were examined by electron microscopy (EM) in comparison to renal biopsies of normal kidneys at implantation, patients with calcineurin inhibitor (CNI) toxicity (n=17), proteinuric nephropathies (n=15), light chain disease (n=4), several cases on nephrotoxic drugs (lomustine, clomiphene, lithium, tenofovir, cisplatinum) and patients with reduced renal function of various causes (n=20).

Results

The aberrant lysosomal phenotypes can be defined as enlarged (&gt;1.2µm) and dysmorphic with a light-medium electron-dense matrix containing dispersed dark electron-dense non-membrane bound round to irregular shaped “aggregates”. In addition, indicative clusters of 4-6 smaller lysosomes with the same features could be observed. No cristae or other features of mitochondria, autophagic vacuoles, lipofuscin/ceroid droplets, peroxisomes (marginal plate), lysosomal myeloid bodies (aminoglycoside nephropathy) or electron dense laminated lysosomal inclusions (Fabry disease) were observed. Patients with calcineurin inhibitor nephrotoxicity and several cases on nephrotoxic drugs (lomustine, clomiphene, lithium) and a subset of patients with light chain disease, all conditions that can either directly or indirectly be linked to calcineurin inhibition, presented the same lesions. We present an image set demonstrating the phenotypical consistency of the diagnostic lysosomal lesion versus similar features that are non-diagnostic.

Conclusion

A rather sensitive constellation of lysosomal lesions in renal proximal tubular cells was detected associated with CINAC/CKDu/MeN and CNI nephrotoxicity in several countries, suggesting a common new pathomechanistic paradigm where CINAC patients are experiencing a tubulotoxic mechanism similar to CNI nephrotoxicity.

Chronic interstitial nephritis in agricultural communities is a toxin-induced proximal tubular nephropathy

Almost 30 years after the detection of chronic interstitial nephritis in agricultural communities (CINAC) its etiology remains unknown. To help define this we examined 34 renal biopsies from Sri Lanka, El Salvador, India and France of patients with chronic kidney disease 2-3 and diagnosed with CINAC by light and electron microscopy. In addition to known histopathology, we identified a unique constellation of proximal tubular cell findings including large dysmorphic lysosomes with a light-medium electron-dense matrix containing dispersed dark electron-dense non-membrane bound "aggregates". These aggregates associated with varying degrees of cellular/tubular atrophy, apparent cell fragment shedding and no-weak proximal tubular cell proliferative capacity. Identical lysosomal lesions, identifiable by electron microscopy, were observed in 9% of renal transplant implantation biopsies, but were more prevalent in six month (50%) and 12 month (67%) protocol biopsies and in indication biopsies (76%) of calcineurin inhibitor treated transplant patients. The phenotype was also found associated with nephrotoxic drugs (lomustine, clomiphene, lithium, cocaine) and in some patients with light chain tubulopathy, all conditions that can be directly or indirectly linked to calcineurin pathway inhibition or modulation. One hundred biopsies of normal kidneys, drug/toxin induced nephropathies, and overt proteinuric patients of different etiologies to some extent could demonstrate the light microscopic proximal tubular cell changes, but rarely the electron microscopic lysosomal features. Rats treated with the calcineurin inhibitor cyclosporine for four weeks developed similar proximal tubular cell lysosomal alterations, which were absent in a dehydration group. Overall, the finding of an identical proximal tubular cell (lysosomal) lesion in CINAC and calcineurin inhibitor nephrotoxicity in different geographic regions suggests a common paradigm where CINAC patients undergo a tubulotoxic mechanism similar to calcineurin inhibitor nephrotoxicity.

Pathology of Uddanam Endemic Nephropathy

In the last decade, pockets of endemic nephropathy have been recognized worldwide, in regions of Central America, Sri Lanka, and India. In India, the nephropathy has been recognized in the Uddanam area of north Andhra Pradesh and has been termed the Uddanam endemic nephropathy (UEN). The disease is distinctive in that besides the geographic distribution, it affects rural populations engaged in farm labor and agriculture, often silent in the initial phase with most patients presenting with advanced renal failure. The renal biopsy findings in all geographic areas including UEN have been one of a chronic tubulointerstitial nephritis with varying degrees of tubular injury, interstitial inflammation, tubular atrophy, and interstitial fibrosis with nonspecific glomerular obsolescence and lack of immune deposits. More recently, the demonstration of dysmorphic lysosomes in renal biopsies has favored a toxic etiology. There are thus many gaps in the understanding of this serious disease prevalent among poorer populations.

Dirofilaria hongkongensis - A first report of potential zoonotic dirofilariosis infection in dogs from Tamil Nadu

Dirofilariosisis, is a mosquito borne anthropo-zoonotic disease caused by the filarial nematodes of the genus Dirofilaria. The current paper reports a species of Dirofilaria, which has not been recorded in Tamil Nadu, in addition to differentiating it from the existing species of Dirofilaria spp. through morphological and molecular techniques. Micrometry of the microfilaria detected by Knott's technique as well as in Giemsa stained blood smears revealed that the length was on an average 280 μm to 310 μm whereas the width was 5 to 8 μm. The microfilariae were unsheathed with blunt heads and tapering tails. For molecular confirmation, the blood sample was subjected to genomic DNA isolation. PCR amplification using specific primers for D. hongkongensis was carried out using thermal cycler with the isolated genomic DNA as template. Molecular analyses revealed the band size of about 230 bp which confirmed the presence of D. hongkongensis. Phylogenetic analysis was done using UPGMA and MLM method. Dirofilaria is recognized as a zoonotic entity throughout the world, and dirofilariasis should be considered an emerging zoonosis in southern India. The control of ubiquitous mosquito population is essential to prevent the transmission of microfilaria from animals to arthropods and from arthropods to humans.

Fibronectin glomerulopathy - A sporadic case with unusual clinical manifestation

A 22-year-old nondiabetic young Indian female presented with short history of dyspnea, anorexia, and bilateral leg swelling. Her laboratory evaluation showed severe anemia, serum creatinine of 11.89 mg/dL, nephrotic range proteinuria and microscopic hematuria with 6-8 red blood cell/high-power field. Renal biopsy showed brightly eosinophilic, periodic acid-Schiff (PAS) positive, silver negative, and fuschinophilic deposits in the mesangium extending around the capillary loops with thickening of the basement membrane. Immunohistochemistry was strongly positive for fibronectin (FN). There was no family history of renal disease. Genetic screening revealed absence of mutations in the FN1 gene. She was put on maintenance hemodialysis.

Comparison of in-vitro bioassays for evaluation of the response of different stages of Rhipicephalus sanguineus sensu lato to calcium alginate encapsulated pheromone beads

Tick sex pheromone (SP), assembly pheromone (AP) and their combination (SP + AP) were encapsulated in calcium alginate beads. In vitro bioassays, namely Petri dish and olfactometer assays, were employed to estimate the level of attraction of the various stages of Rhipicephalus sanguineus sensu lato, namely unfed and engorged (fed) larvae, nymphs, females, and males to the different pheromones. The study revealed that only the Petri dish assay was suitable to evaluate the response of larval stages whereas the olfactometer bioassay could also be used for evaluating the response of all other stages. Attraction to pheromone encapsulated calcium alginate beads of all tick stage was higher in the Petri dish assay than in the olfactometer assay.

Collapsing Glomerulopathy Superimposed on Diabetic Nephropathy

Diabetic nephropathy (DN) is characterized by gradually progressive renal failure and proteinuria. Various types of nondiabetic kidney diseases may superimpose on DN, and affect the natural course, prognosis, and management. Collapsing glomerulopathy (CG) is a form of glomerular proliferative injury, characterized by rapid progression and associated with poor prognosis. CG may be idiopathic or secondary to other causes, and it has also been described with other forms of glomerular diseases. The association of CG with DN has not been reported widely. We report on a patient with DN who has undergone renal biopsy due to massive proteinuria and rapid loss of renal function. Renal biopsy was suggestive of CG superimposed on DN. He was treated conservatively, however, progressed to end-stage renal disease rapidly.