Spectrum of Anemia in Indian children with Nephrotic Syndrome: a prospective observational study.

We aimed to estimate the prevalence of anemia in children with nephrotic syndrome (NS), determine its etiology, and correlate severity with disease duration and response to steroids. This was a prospective cohort study carried from 15th July 2019-14th July 2021 at the pediatric nephrology clinic, of a teaching hospital in India. We screened children aged 3 months-18 years with NS for eligibility. We excluded those suffering from chronic kidney disease and, on haematinics. All children underwent investigations for evaluation of nephrotic syndrome and anemia. To define the clinical phenotype of nephrotic syndrome, the patients were classified as infrequent relapsers, frequent relapsers, steroid dependent and steroid resistant NS as per ISPN guidelines. Children were followed up at least for a period of one year to define their response to steroids. A total of 125 children were finally analysed for all treatment outcomes. Of 125, 37 (30%) children presented with the first episode of NS. Remaining 88 were follow up cases of NS. Of 125 children, 41 (33%) were found to be anemic as per the WHO criteria. Iron deficiency anemia was found in 21 (51%) children. Steroid resistance was twice more prevalent in the anemic group compared to the non-anemic group, 7.3% vs 4.8% respectively, however this difference was not statistically significant, p = 0.65. Anemic group had a trend of higher no. of children receiving antihypertensives compared to non-anemics (38 (93%) vs. 67 (80%), p = 0.07. CONCLUSION: Iron deficiency anemia was the commonest cause of anemia and, anemia and need for anti-hypertensives to attain BP control and adequate proteinuria often coexisted in children suffering from nephrotic syndrome. WHAT IS KNOWN: • Anemia is a significant complication in children suffering from nephrotic syndrome. • Cause of anemia in nephrotic syndrome is multifactorial. WHAT IS NEW: • Iron deficiency anemia was the most common cause of anemia in Indian children with nephrotic syndrome. • Anemia and need for anti-hypertensives to attain adequate BP control and proteinuria often coexisted in children with nephrotic syndrome.

A wound inducible chalcone synthase gene from Dysoxylum gotadhora (DbCHS) regulates flavonoid biosynthesis.

Chalcone synthase (CHS) is a type III polyketide synthase and a key enzyme of the phenylpropanoid pathway that generates precursors for flavonoid biosynthesis. The tree species D. gotadhora is known for having an abundance of rohitukine, which has anti-inflammatory and immune-modulating effects. In this study, we used the leaves of D. gotadhora to clone CHS gene (DbCHS). The 1188-bp open reading frame (ORF) was part of the 1373-bp full-length DbCHS clone. Compared to other parts of the plant, DbCHS is expressed more in the leaves and fruits. This is linked to anti-microbial action against a panel of microbes in these tissues. The leaves and seeds extracts inhibit Bacillus subtilis, Streptococcus pyogenes, Bacillus cereus, and Candida albicans. When a plant is hurt, it leaves its tissues open to attack by microbes. To protect themselves, plants often make chemicals that kill microbes. We found that wounding had a big effect on the production of DbCHS. Based on these tests and the results of phylogenetic analysis and molecular docking, we believe that DbCHS is a wound-inducible enzyme that is needed to make flavonoids, which may give the plant antimicrobial properties. Supplementary Information: The online version contains supplementary material available at 10.1007/s12298-023-01344-2.

Early diagnosis of kidney injury in a paediatric population: a prospective cohort study (E-DRIP STUDY).

BACKGROUND: Renal Angina Index (RAI) is a bedside tool for risk stratification of patients to predict acute kidney injury (AKI). Kidney biomarkers are better indicators of real-time injury and give us lead time for diagnosing impending AKI. METHODS: We enrolled consecutive children aged 2 months-14 years admitted to a tertiary hospital in northern India over 2 years. RAI was calculated on day 0 (D0) and urinary (u) and plasma (p) neutrophil gelatinase-associated lipocalin (NGAL) were measured within 6 h of admission. Children were followed for the development of severe AKI on day 3 (D3) using Kidney Disease Improving Global Outcomes criteria to define and stage AKI. RESULTS: Of the 253 children enrolled and analysed, 44 (17.4%) developed D3-AKI (stage 1 in 52.2%, stage 2 in 20.5% and stage 3 in 27.3%). Renal angina (RAI ≥ 8) on D0 was present in 66.7% children who developed stage 2/3 D3-AKI vs. 43.5% in children who did not develop D3-AKI /stage 1 AKI (p = 0.065). Area under ROC (AUROC) curve for D0-RAI to predict D3-severe-AKI was 0.66 (95% CI, 0.55-0.77). AUROC curve for uNGAL and pNGAL to predict D3-severe-AKI was 0.62 (95% CI, 0.50-0.74) and 0.48 (95% CI, 0.35-0.61), respectively. The severe AKI group had greater requirement of ventilation and inotropic support with mortality being thrice higher compared to the non-AKI group. CONCLUSION: RAI ≥ 8 and uNGAL had a high negative predictive value but low sensitivity for predicting D3-severe-AKI. pNGAL had a poor predictive value for D3-severe-AKI. A higher resolution version of the Graphical abstract is available as Supplementary information.

Effect of fetal growth restriction on urinary podocalyxin levels at birth in preterm neonates.

BACKGROUND: Small-for-gestational-age (SGA) neonates are at a higher risk of adult-onset metabolic disorders because of fetal programming in the presence of growth restriction. Nephrogenesis may also be affected in fetal growth restriction. This study hypothesized that urinary podocalyxin levels, a marker of nephrogenesis, would be lower among preterm SGA neonates as compared to appropriate-for-gestational-age (AGA) controls. METHODS: This cross-sectional study enrolled gestation-matched SGA (n = 90) and AGA (n = 45) neonates born at 260-366 weeks of gestation. The SGA group comprised of 45 neonates with birth weight between 3rd and 10th centile and 45 neonates with birth weight <3rd centile. The primary outcome of the study was the difference in urinary podocalyxin levels between SGA and AGA neonates. Glomerular and tubular functions were also assessed. RESULTS: Urinary podocalyxin levels were similar in SGA and AGA neonates (ng/mg of creatinine; median [interquartile range]: 28.7 [4.8-70.2] vs. 18.7 [3.1-55.9]), P value 0.14). No correlation was observed between birth weight centile and urinary podocalyxin levels (r: -0.06). Glomerular filtration rate, fractional excretion of sodium, and serum ß-2-microglobulin levels were comparable across the study groups. CONCLUSIONS: Glomerular development as assessed by urinary podocalyxin levels and renal functions are comparable in SGA and AGA preterm neonates. IMPACT: Neonates born with fetal growth restriction are at a higher risk of adult-onset metabolic disorders because of fetal programming. This cross-sectional study investigated the effect of presence and severity of fetal growth restriction on glomerular development by measuring urinary podocalyxin levels in preterm infants. This study did not observe any effect of the presence or severity of fetal growth restriction on urinary podocalyxin levels and other markers of glomerular and renal tubular functions.

Recurrent Intracranial Bleed in 3 Siblings: Short of a Shot of Vitamin K!

We present a family who suffered recurrent sibling losses due to vitamin K deficiency bleed. The index child was asymptomatic at presentation, had normal clinical examination, and was investigated for coagulation disorders in view of previous 3 sibling losses as a result of intracranial hemorrhage. His investigations showed deranged coagulogram and clotting factors' assay. The baby was given vitamin K1 1 mg intramuscularly following which his coagulogram and clotting factors' assay returned to normal. The genetic analysis did not identify any inherited cause of bleeding tendency. The significant family history, exclusive breastfeeding, no diarrhea, failure to thrive or drug use, no prophylaxis with vitamin K at birth, recovery of clotting factors on vitamin K administration, and a corroborative molecular analysis confirmed diagnosis of vitamin K deficiency in the index child. This case gives a strong reminder not to miss birth dose of vitamin K in any neonate.

Spectrum of Multiorgan Dysfunction in Scrub Typhus Infection.

OBJECTIVES: We planned this study to determine the clinical spectrum and compare incidence of multiorgan dysfunction in children hospitalized with scrub typhus with other etiologies of tropical fever. DESIGN: Prospective cohort study. SETTING: Pediatric emergency and PICU services of a university teaching hospital situated in the sub-Himalayan region. PATIENT: Children aged 2 months to 14 years with acute undifferentiated fever of more than 5 days. INTERVENTIONS: Detailed fever workup was performed in all children. We compared scrub typhus IgM positive children (cases) with remaining febrile children who were negative for scrub IgM assay (controls) for mortality and morbidity. MAIN RESULTS: We enrolled 224 febrile children; 76 children (34%) were positive for scrub typhus IgM ELISA. Scrub typhus group had a significantly higher incidence of multiorgan dysfunction [OR 3.5 (95% CI 2.0-6.3); p < 0.001] as compared to non-scrub typhus group requiring supportive care. The incidence of altered sensorium [OR 8.8 (95% CI 3.1-24.9)], seizures [OR 3.0 (95% CI 1.1-8.3)], acute respiratory distress syndrome [OR 17.1 (95% CI 2.1-140.1)], acute renal failure (5% vs. 0%), meningitis [OR 6.2 (95% CI 1.2-31.6)], thrombocytopenia [OR 2.8 (95% CI 1.5-5.1)], transaminitis [OR 2.7 (95% CI 1.6-4.8)], requirement of oxygen [OR 17.8 (95% CI 4.0-80.3)], positive pressure support [OR 3.7 (95% CI 1.2-10.5)] and shock requiring inotropes [OR 3.0 (95% CI 1.3-6.7)] was significantly higher in scrub typhus group as compared to the non-scrub typhus group (Table 1). CONCLUSIONS: Pediatric scrub typhus who were hospitalized had severe systemic manifestations when compared to other causes of fever.

Successful Use of Entecavir in Hepatitis B-associated Membranous Nephropathy.

We report the case of a 7-year-old unimmunized boy who presented with generalized anasarca for the first time, along with nephrotic-range proteinuria, hypoalbuminemia, microscopic hematuria and hypertension. Special investigations revealed ELISA test to be positive for hepatitis B surface antigen (HBsAg) and hepatitis B envelope antigen (HBeAg); hepatitis B viral DNA load (HBV DNA) level (real-time polymerase chain reaction) was 54 360 903 IU/ml. For hepatitis B virus (HBV)-related glomerulopathy, he was started on enalapril and lasilactone, and percutaneous renal biopsy was performed, which revealed membranous nephropathy (MN). A diagnosis of MN secondary to HBV infection contracted via horizontal transmission was made. The patient was started on peginterferon alfa-2b (50 µg/week) for 24 weeks. He failed to attain remission and seroconversion after interferon (IFN) therapy. Then, oral therapy with entecavir was started, and he attained remission as well as seroconversion after 3 months of therapy. He maintained his seroconversion status at his 6-month and the recent 12-month (quantitative HBV DNA level was 373 IU/ml) follow-up visit. Entecavir seems a promising drug for HBV-related glomerulopathy, especially in IFN-resistant cases.

Mining and characterization of EST-SSR markers for Zingiber officinale Roscoe with transferability to other species of Zingiberaceae.

Zingiber officinale is a model spice herb, well known for its medicinal value. It is primarily a vegetatively propagated commercial crop. However, considerable diversity in its morphology, fiber content and chemoprofiles has been reported. The present study explores the utility of EST-derived markers in studying genetic diversity in different accessions of Z. officinale and their cross transferability within the Zingiberaceae family. A total of 38,115 ESTs sequences were assembled to generate 7850 contigs and 10,762 singletons. SSRs were searched in the unigenes and 515 SSR-containing ESTs were identified with a frequency of 1 SSR per 25.21 kb of the genome. These ESTs were also annotated using BLAST2GO. Primers were designed for 349 EST-SSRs and 25 primer pairs were randomly picked for EST SSR study. Out of these, 16 primer pairs could be optimized for amplification in different accessions of Z. officinale as well as other species belonging to Zingiberaceae. GES454, GES466, GES480 and GES486 markers were found to exhibit 100% cross-transferability among different members of Zingiberaceae.

Clinical predictors of hospital admission in acute lower respiratory tract infection in 2 months to 2-year-old children.

BACKGROUND AND OBJECTIVE: Acute lower respiratory tract infections (ALRI) are a common cause of paediatric emergency visits in young children. We studied risk factors for hospitalization and developed a clinical score for predicting hospitalization among 2 months to 2-year-old children with ALRI. METHODS: We conducted this prospective cohort study in the paediatric emergency department of a tertiary-care teaching hospital in India. Consecutive children, aged 2 months to 2 years with ALRI were enrolled from 15 December 2011 to 14 December 2012. A total of 26 a priori identified, putative risk factors were studied among enrolled children. We determined independent predictors of hospital admission (primary outcome) through multi-variable logistic regression analysis and assimilated them into a clinical risk score using regression coefficients. RESULTS: A total of 240 children (130 admissions) with ALRI were enrolled. Eleven clinical risk factors, which displayed association with hospital admission on univariate analysis (P < 0.1), were entered into multi-variable logistic regression analysis. Five factors retained independent association and were incorporated in a predictive score for hospitalization: tachypnoea (score of 5), chest retractions (score of 3), temperature > 37.8°C (score of 3), SpO2 < 92% at room air (score of 4), GCS < 15 (score of 6). Area under the receiver operator characteristic curve was 0.80 (95% CI: 0.75-0.85, P < 0.001). CONCLUSION: Five clinical risk factors-tachypnoea, chest retractions, fever > 37.8°C, SpO2 < 92% and GCS < 15-independently predicted hospital admission in infants with ALRI. A novel clinical score predicting hospital admission is presented.

Changing trends in biotechnology of secondary metabolism in medicinal and aromatic plants.

MAIN CONCLUSION: Medicinal and aromatic plants are known to produce secondary metabolites that find uses as flavoring agents, fragrances, insecticides, dyes and drugs. Biotechnology offers several choices through which secondary metabolism in medicinal plants can be altered in innovative ways, to overproduce phytochemicals of interest, to reduce the content of toxic compounds or even to produce novel chemicals. Detailed investigation of chromatin organization and microRNAs affecting biosynthesis of secondary metabolites as well as exploring cryptic biosynthetic clusters and synthetic biology options, may provide additional ways to harness this resource. Plant secondary metabolites are a fascinating class of phytochemicals exhibiting immense chemical diversity. Considerable enigma regarding their natural biological functions and the vast array of pharmacological activities, amongst other uses, make secondary metabolites interesting and important candidates for research. Here, we present an update on changing trends in the biotechnological approaches that are used to understand and exploit the secondary metabolism in medicinal and aromatic plants. Bioprocessing in the form of suspension culture, organ culture or transformed hairy roots has been successful in scaling up secondary metabolite production in many cases. Pathway elucidation and metabolic engineering have been useful to get enhanced yield of the metabolite of interest; or, for producing novel metabolites. Heterologous expression of putative plant secondary metabolite biosynthesis genes in a microbe is useful to validate their functions, and in some cases, also, to produce plant metabolites in microbes. Endophytes, the microbes that normally colonize plant tissues, may also produce the phytochemicals produced by the host plant. The review also provides perspectives on future research in the field.

Salivary lactate dehydrogenase levels can provide early diagnosis of hypoxic-ischaemic encephalopathy in neonates with birth asphyxia.

AIM: Timely detection of hypoxic-ischaemic encephalopathy (HIE) is crucial for selecting neonates who are likely to benefit from neuroprotective therapy. This study evaluated the efficacy of salivary lactate dehydrogenase (LDH) in the early diagnosis of HIE among neonates with perinatal asphyxia. METHODS: We prospectively enrolled 30 neonates who needed resuscitation at birth or had a history of delayed cry into the HIE group if they developed HIE within 12 h of birth. The control group comprised 30 neonates who had no evidence of HIE, but had intrapartum foetal distress or needed resuscitation at birth. LDH was measured using saliva samples collected within 12 h of birth. RESULTS: Salivary LDH was significantly higher in the HIE group, with a median of 2578 and an interquartile range (IQR) of 1379-3408 international units per litre (IU/L), than in the control group (median 558.5, IQR: 348-924 IU/L, p < 0.001). The test demonstrated excellent discriminating ability: the area under the curve was 0.92 and the levels of 893 IU/L showed a sensitivity of 90% and a specificity of 73.3%. CONCLUSION: Measuring salivary LDH among neonates with birth asphyxia provided an early and accurate diagnosis of HIE and could be used as a triage tool.

Production of rohitukine in leaves and seeds of Dysoxylum binectariferum: an alternate renewable resource.

CONTEXT: Rohitukine is an important precursor for the synthesis of potential anticancer drugs flavopiridol (Sanofi-Aventis) and P-276-00 (Piramal Healthcare Limited, Mumbai, India). Trunk bark of Dysoxylum binectariferum (Roxb.) Hook. f. ex Bedd. (Meliaceae) is the widely used source for isolation of rohitukine. However, removal of trunk bark threatens the survival of the tree. OBJECTIVE: To investigate the amount of rohitukine accumulated in other tissues of D. binectariferum. MATERIALS AND METHODS: Rohitukine standard was isolated from leaves of D. binectariferum. Its purity was ascertained using HR-MS and NMR. Crude extracts were prepared from different tissues of D. binectariferum. Rohitukine content in all the tissues was quantified by HPLC. RESULTS: Rohitukine accumulates in a significant amount in seeds, trunk bark, leaves, twigs, and fruits of D. binectariferum. Seeds have the highest rohitukine content (2.42%, dry weight) followed by trunk bark (1.34%, dry weight), leaves (1.064%, dry weight), twigs (0.844% dry weight), and fruits (0.4559% dry weight). DISCUSSION AND CONCLUSION: Seeds and leaves of D. binectariferum could be used as alternate renewable sources for isolation of rohitukine.

CLINICAL PROFILE OF EXPANDED DENGUE SYNDROME IN CHILDREN.

The objective is to study the clinical profile and outcome of expanded dengue syndrome (EDS) in children. We conducted a retrospective cohort study and enrolled consecutive children (1 month to 18 years) who presented with dengue fever for over 1 year. The diagnosis of dengue fever was confirmed by the presence of dengue NS1 antigen and/or dengue IgM positivity. Subsequently, we identified children exhibiting EDS according to the revised World Health Organization guidelines (2011). We compared the clinical and laboratory profiles of children diagnosed with EDS and those without EDS. Of 178 children with dengue fever, 33 (18.5%) had EDS [95% confidence interval (CI): 13.1%-25.0%]. In these 33 children, neurological involvement was the most common manifestation [n = 16/33 (49%, 95% CI: 32%-65%)], namely encephalopathy, febrile seizures and encephalitis, respectively. Gastrointestinal involvement was the second most common [n = 10/33 (30%, 95% CI: 17%-47%)], which included fulminant hepatic failure, acalculous cholecystitis and acute pancreatitis. Renal presentation [n = 7 (21%, 95% CI: 10%-37%)] was limited to acute kidney injury. Children with EDS were significantly anemic and had leukocytosis, hyperkalemia, azotemia, hyperbilirubinemia, raised serum transaminases and fluid-refractory shock than their non-EDS counterparts. Children with EDS had a trend toward higher mortality (P = 0.07) and the survivors had a longer duration of hospital stay (5 days vs. 4 days in non-EDS, P = 0.001). In conclusion, we observed a high prevalence (18.5%) of EDS among children hospitalized for dengue fever. The common manifestations of EDS include neurological, renal and gastrointestinal involvement. Children with EDS showed a trend toward higher mortality and longer duration of hospital stay than children without EDS.

Open-labeled Randomized Controlled Trial on Efficacy of Azithromycin Versus Doxycycline in Pediatric Scrub Typhus.

BACKGROUND: Doxycycline (DX) is the first-line therapeutic agent for scrub typhus. Macrolides, especially azithromycin (AZ), have been found to be equally efficacious as DX for treating scrub typhus in adults. We conducted this study to compare the efficacy of AZ versus DX in pediatric scrub typhus. STUDY DESIGN: Open-label randomized controlled trial. METHODS: Children 1-14 years of age suffering from acute febrile illness of ≥5 days and with a positive scrub IgM serology were randomized to receive either DX (2.2 mg/kg/dose twice daily in <40 kg; 100 mg BD in >40 kg for 7 days) or AZ (10 mg/kg/day for 5 days). The primary outcome was defervescence within 7 days of DX or 5 days of AZ. RESULTS: We had 75 children randomized and analyzed using an intention-to-treat approach and 60 children analyzed via per-protocol analysis. The proportion of children achieving defervescence was comparable in 2 groups [per-protocol analysis: 90.9% in the DX group vs. 96.3% in the AZ group, RR: 0.94 (95% CI: 0.83-1.08)]. On Kaplan-Meier curves, AZ showed a significantly higher probability of defervescence at any time point during treatment as compared with DX (log-rank test P value 0.035). CONCLUSION: AZ and DX had comparable rates of defervescence among children with scrub typhus. Trial registration No.: CTRI/2020/01/022991.

Varicella vaccination in India's universal immunisation program -is it time?

We report two representative cases of complicated varicella in immunocompetent children highlighting the significant vaccine preventable varicella burden in the Indian population. A robust surveillance programme followed by incorporation of varicella vaccine in routine immunization would be the way forward to mitigate this illness.

Challenges in management of atypical hemolytic uremic syndrome: Bottle neck in resource limited settings.

Treatment of atypical hemolytic uremic syndrome cases is challenging right from establishing correct and timely diagnosis to execution of management protocol. A seven-year-old male child from poor socioeconomic status was admitted with chief complaints of fever, 3 episodes of vomiting and passage of cola coloured urine. Based on clinical and laboratory findings, diagnosis was established. However, ADAMTS13 levels and genetic studies required for diagnosis could not be performed due to financial constraints and non-availability of these tests. TPE kits were arranged from charitable organizations. Six TPE procedures were performed using Cobe Spectra cell separator. Central venous catheter was placed in femoral vein. TPE kit was primed with compatible packed red blood cells before each procedure. Patient was non-cooperative and irritable in first three procedures and was sedated. A total of 1300ml plasma was exchanged in each procedure with group specific fresh frozen plasma. After second TPE procedure, patient started improving with decrease in plasma discoloration and periorbital edema. Renal function tests along with hematological parameters became normal after 6th TPE procedure. Patient was discharged in a stable condition. On follow up, C3 levels were normal with adequate platelet count and normal renal functions suggesting complete remission.

A 16-Year-Old-Girl With Asthma, Palpable Purpura, and Hypereosinophilia.

CASE PRESENTATION: A 16-year-old girl presented to the ED with complaints of loose stools, abdominal pain, and rash over her legs for the last 7 days. There was no history of fever, vomiting, oral ulcers, or mucosal bleeds. In the past, she had received a diagnosis of asthma. She had been taking oral montelukast every day for the past year and using a formoterol-budesonide dry powder inhaler irregularly, only during episodes of acute exacerbations. There was a history of significant but undocumented weight loss. On day 3 of hospital admission, she developed numbness over her right foot.