The yeast AMP-activated protein kinase Snf1 phosphorylates the inositol polyphosphate kinase Kcs1.

The yeast Snf1/AMP-activated kinase (AMPK) maintains energy homeostasis, controlling metabolic processes and glucose derepression in response to nutrient levels and environmental cues. Under conditions of nitrogen or glucose limitation, Snf1 regulates pseudohyphal growth, a morphological transition characterized by the formation of extended multicellular filaments. During pseudohyphal growth, Snf1 is required for wild-type levels of inositol polyphosphate (InsP), soluble phosphorylated species of the six-carbon cyclitol inositol that function as conserved metabolic second messengers. InsP levels are established through the activity of a family of inositol kinases, including the yeast inositol polyphosphate kinase Kcs1, which principally generates pyrophosphorylated InsP7. Here, we report that Snf1 regulates Kcs1, affecting Kcs1 phosphorylation and inositol kinase activity. A snf1 kinase-defective mutant exhibits decreased Kcs1 phosphorylation, and Kcs1 is phosphorylated in vivo at Ser residues 537 and 646 during pseudohyphal growth. By in vitro analysis, Snf1 directly phosphorylates Kcs1, predominantly at amino acids 537 and 646. A yeast strain carrying kcs1 encoding Ser-to-Ala point mutations at these residues (kcs1-S537A,S646A) shows elevated levels of pyrophosphorylated InsP7, comparable to InsP7 levels observed upon deletion of SNF1. The kcs1-S537A,S646A mutant exhibits decreased pseudohyphal growth, invasive growth, and cell elongation. Transcriptional profiling indicates extensive perturbation of metabolic pathways in kcs1-S537A,S646A. Growth of kcs1-S537A,S646A is affected on medium containing sucrose and antimycin A, consistent with decreased Snf1p signaling. This work identifies Snf1 phosphorylation of Kcs1, collectively highlighting the interconnectedness of AMPK activity and InsP signaling in coordinating nutrient availability, energy homoeostasis, and cell growth.

Streeter's Syndrome of Lower Limb Associated with CTEV.

Introduction: The term Streeter's syndrome is a term used to describe rare congenital malformations that includes a variety of clinical presentations usually consisting of a constriction band around a part of the body which can be as superficial as involving just the skin which can be only cosmetic and asymptomatic or can be as deep as causing restricted circulation distally which may be in incompatible with life. Such conditions are remarkably rare accounting for an incidence range from 1:1.2 k to 1: 15 k live births and 178:10 k spontaneous abortions [1]. Males and females are uniformly affected. Almost all cases are sporadic; extremely rare evidence of familial transmission. The entity has been described in the literature in 34 different terms, (such as amniotic rupture sequence, ADAM complex, constriction band syndrome, Streeter's dysplasia, etc.) due to its extremely variable clinical features and lack of understanding of the etiology. This results in a lack of understanding and creates unnecessary stress for the surgeon/physician as well as the parents. Case Report: We discuss case reports of two such cases with their simple nature of treatment with their outcomes. Conclusion: There is a significant deficit in the education of cases with low incidence, such is the case with pediatric patients presenting with amniotic bands, which usually present and are associated with Congenital Talipes Equino Varus deformity. In such cases, improper or incorrect treatment and/or neglect of the constriction may lead to the vascular deficit and eventually auto-amputation of the segment distal to the amniotic band.

Prevalence of Vascular Calcification in Chronic Kidney Disease Stage 4 and 5 Patients and its Correlation with Inflammatory Markers of Atherosclerosis.

Vascular calcification is one of the independent risk factors associated with cardiovascular disease (CVD) in chronic kidney disease (CKD) patients. This study evaluated the prevalence of vascular calcification in Indian patients with CKD stages 4 and 5. This was a prospective study conducted between January 2011 and June 2012. CKD stage 4 and 5 patients of either sex aged >18 years were screened for aortic vascular calcification using digital X-ray lumbar spine and multislice computed tomography (CT) scan. In addition, details of inflammatory markers [high-sensitivity C-reactive protein (hs-CRP) and interleukin (IL-6)] were also collected. A total of 150 patients (stage 4, n = 98; stage 5, n = 56) were screened for vascular calcification, and the mean age was 56.56 years. Patients with CKD stage 5 had significantly higher (P ≤0.05) serum creatinine and lower estimated glomerular filtration rate, total cholesterol, and low-density lipoprotein than CKD stage 4. Significantly, more patients with CKD stage 5 had a history of CVD. A total of 113 (75.3%) patients had vascular calcification [aortic calcification index (ACI) >0] with significantly higher prevalence in CKD stage 5 (85.72%) as compared to CKD stage 4 (69.15%). Patients having high aortic calcification (ACI >20%) were older (P = 0.0013); had a higher frequency of diabetes, and CVD; and had significantly (P <0.05) higher blood urea, serum creatinine, phosphorus, Ca × PO4 product, intact parathyroid hormone, hs-CRP, and IL-6. The higher CKD stage was associated with a higher prevalence of vascular calcification and higher aortic calcification index (ACI). CT techniques (electron beam CT and multislice CT) are the gold standards for detection and quantification of progression of vascular calcification.

A prospective, multi-centre, observational study to examine kidney disease progression in adults with chronic kidney disease - CKDOD - Study design and preliminary results.

BACKGROUND: The objective of this article is to describe the organisation of an international, clinical registry, the Chronic Kidney Disease Observational Database (CKDOD), the processes of enrolling patients and entering data and preliminary results to date. DESIGN: The Chronic Kidney Disease Observational Database (CKDOD) is designed to assess the association between different factors with a known influence on chronic kidney disease (CKD) progression as well as treatment strategies such as dietary modifications, blood pressure control and pharmacological interventions in Asian countries (India, China, Malaysia and Thailand). The only inclusion criterion is the presence of CKD stage 2 or higher as defined by the KDIGO guidelines. Demographic and clinical information are collected by a standardised electronic questionnaire, available in English and Chinese. The data are transferred to the CKDOD database either by e-mail or via web access. All data are checked for consistency and missing values. Collection of data started in September 2011 and by April 2015, data on 1323 individual patients had been submitted. The mean age at inclusion was 57 ± 14 years, 67 % were male and 36 % were diabetic. The baseline estimated glomerular filtration rate was 26 ml/min/1.73 m(2). Of all enrolled patients, 324 (24 %) received ketoanalogue supplementation during at least one recorded visit. DISCUSSION: The CKDOD is a very large and comprehensive data repository, currently focused in subjects recruited from Asia. The database is expected to provide important long-term information on CKD progression, nutritional and metabolic derangements that accompany CKD progression and treatment strategies to ameliorate progression and complications of CKD. TRIAL REGISTRATION: Clinical Trial Registry - India: CTRI/2012/06/002743 ; 25th July 2012.

Unusual metastatic presentation of carcinoma hypopharynx.

Cutaneous metastases from hypopharyngeal cancers is rare constituting about 0.8-1.3% and represent a sub-group of head and neck cancer patients who have very poor prognosis even when treated. We report a case of 65-year-old male diagnosed as carcinoma hypo pharynx stage IV who was on radiotherapy when he developed cutaneous metastasis over the chest wall, which initially presented as small nodules and later progressed into a proliferative lesion. Patient received further radiation to the metastatic lesion, but the disease was progressive, demonstrating that head and neck squamous cell cancer patients with skin metastasis fare poorly.

A rare case of type-I auto-immune hepatitis and thyroiditis presenting with crescentic glomerulonephritis.

A middle-aged female patient with a past history of non-alcoholic liver disease and hypothyroidism presented with swelling of the body, off and on, for six months and rapidly worsening renal function. Renal biopsy showed crescentic glomerulonephritis with negative immunofluorescence. Serological tests were positive for anti-thyroglobulin, anti-nuclear antibody (1:80), p-anti-neutrophil cytoplasmic antibodies; gamma globulin was 5.23 g/dL and viral markers were negative. The patient was diagnosed to have autoimmune hepatitis type-1 and treated with injection methylprednisolone pulse (500 mg/day for 3 days) and maintained on oral steroids and azathioprine 100 mg. She responded dramatically to this treatment and has remained in complete remission at last follow-up.

Estimation of renal function in the intensive care unit: the covert concepts brought to light.

Frantic efforts have been made up to this date to derive consensus for estimating renal function in critically ill patients, only to open the Pandora's box. This article tries to explore the various methods available to date, the newer concepts, and the uncared issues that may still prove to be useful in estimating renal function in intensive care unit patients. The concept of augmented renal clearance, which is frequently encountered in critically ill patients, should always be taken into account, as correct therapeutic dosage of drugs sounds vital which in turn depends on correctly calculated glomerular filtration rate. Serum creatinine and creatinine-based formulae have their own demerits that are well known and established. While Cockcroft-Gault and 4-variable modification of diet in renal diseases formulae are highly inadequate in the intensive care setup for estimating glomerular filtration rate, employing isotopic methods is impractical and cumbersome. The 6-variable modification of diet in renal diseases formula fairs better as it takes into account the serum albumin and blood urea nitrogen, too. Jelliffe's and modified Jelliffe's equations take into account the rate of creatinine production and volume of distribution which in turn fluctuates heavily in a critically ill patient. Twenty-four-hour and timed creatinine clearances offer values close to reality although not accurate and cannot provide immediate results. Cystatin C is a novel agent that offers a sure promise as it is least influenced by factors that affect serum creatinine to a major extent. Aminoglycoside clearance, although still in the dark area, may prove a simple yet precise way of estimating glomerular filtration rate in those patients in whom these drugs are therapeutically employed. Optic ratiometric method has emerged as the most sophisticated one in glomerular filtration rate estimation in critically ill patients.

Analysis of case series of milky urine: A single center and departmental clinical experience with emphasis on management perspectives: A prospective observational study.

BACKGROUND: Milky urine can be due to chyluria or lipiduria due to nephrotic syndrome. Filarial chyluria usually responds to medical management while non-filarial cases may require surgical intervention. AIM: To perform a prospective observational study in patients presenting with milky urine in our centre over a period of one year from July 2011 to June 2012, a complete biochemical work up and imaging to find out the site of leakage of lymph if it is a case of chyluria, its response to medical management and the requirement of surgical intervention. MATERIALS AND METHODS: Routine blood and urine investigations, 24 hour urine protein excretion, USG abdomen, serum lipid profile and rapid filarial antigen test were done in all. MRI abdomen was done in affordable patients. Renal biopsy was done in some chyluria patients for academic purpose and in milky urine with negative urine ether test. Sclerotherapy was done with 50% dextrose and 0.2% povidone iodine. Patients were followed up with 24 hour urine protein and triglyceride estimation. RESULTS: 18 cases of milky urine were encountered. 8 were filarial chyluria, 9 non- filarial and 1 MCD. Mean urine TG level and median 24 hour urinary protein excretion were 37.2 ± 24.6 mg% and 4.96 g respectively. The mean age for filariasis (22.9 ± 4.5 years) was significantly different from that of non-filarial etiology (31.5 ± 4.8 years) (P = 0.005). The mean 24 hour urinary protein for normal MRI cases (4.64 ± 0.70 g) was significantly different from those with dilated lymphatics (8.15 ± 2.55 g) (P = 0.02). All the non- filarial and 4 filarial cases required sclerotherapy. One patient required a second sitting. CONCLUSION: Milky urine is most commonly due to chyluria and occasionally due to nephrotic syndrome. Nephrotic syndrome is managed in its own way while chyluria not amenable to pharmacological intervention is managed with sclerotherapy.

Post cardiac surgery acute kidney injury: a woebegone status rejuvenated by the novel biomarkers.

BACKGROUND: Acute kidney injury (AKI) is common after cardiac surgery, the incidence varying between 7.7% and 28.1%. It significantly increases morbidity and mortality. Creatinine considerably delays the diagnosis with its own attended demerits. Novel urinary biomarkers are emerging which help in rapid diagnosis thus reducing the morbidity and mortality. Biomarkers of our study were neutrophil gelatinase-associated lipocalin (NGAL) and Interleukin-18 (IL-18). OBJECTIVES: To find out the incidence of AKI in post-cardiac surgery patients in our hospital, the ability of the two biomarkers in early diagnosis in predicting the severity of AKI based on RIFLE's criteria and their ability to discriminate pre-renal from intrinsic AKI. PATIENTS AND METHODS: One-hundred patients who underwent cardiac surgery were selected. Midstream urine samples were collected at 3 time intervals (baseline before surgery, 24 hours and 7 days after surgery). Biomarkers were measured by ELISA using BIORAD processors. Fractional excretion of sodium and urea were used to discriminate pre-renal from intrinsic AKI. RESULTS: Out of 100 patients, 31 had AKI, 11 being pre-renal and 20 intrinsic AKI. Four patients required renal replacement therapy (12.9% among AKI cases and 4% in the overall study cohort). Four among 31 expired in intensive care unit. Identifiable risk factors for AKI included insulin requiring diabetes mellitus, chronic obstructive pulmonary disease, increased cardio-pulmonary bypass time, combined valvular surgery and coronary artery bypass grafting, employment of intra-aortic balloon counter pulsation, left main coronary artery occlusion and an ejection fraction of < 40%. NGAL was extremely sensitive (area under curve-0.96) in detecting intrinsic AKI at 24 hours followed by IL-18 ratio with an area under curve of 0.89. Creatinine at 24 hours was able to detect only 31.6% of intrinsic AKI. None of the pre-renal cases showed rise in the urinary biomarker levels. Patients with higher stages of AKI had higher levels of both biomarkers than those at lower stages. CONCLUSIONS: NGAL and IL-18 obviated the disadvantages of creatinine. They were efficient in early detection of AKI, in differentiating pre-renal from intrinsic AKI and in predicting the severity of AKI reliably in post-cardiac surgery patients.

Burden and predictors of hypertension in India: results of SEEK (Screening and Early Evaluation of Kidney Disease) study.

BACKGROUND: Hypertension (HTN) is one of the major causes of cardiovascular morbidity and mortality. The objective of the study was to investigate the burden and predictors of HTN in India. METHODS: 6120 subjects participated in the Screening and Early Evaluation of Kidney disease (SEEK), a community-based screening program in 53 camps in 13 representative geographic locations in India. Of these, 5929 had recorded blood pressure (BP) measurements. Potential predictors of HTN were collected using a structured questionnaire for SEEK study. RESULTS: HTN was observed in 43.5% of our cohort. After adjusting for center variation (p < 0.0001), predictors of a higher prevalence of HTN were older age ≥ 40 years (p < 0.0001), BMI of ≥ 23 Kg/M2 (p < 0.0004), larger waist circumference (p < 0.0001), working in sedentary occupation (p < 0.0001), having diabetes mellitus (p < 0.0001), having proteinuria (p < 0.0016), and increased serum creatinine (p < 0.0001). High school/some college education (p = 0.0016), versus less than 9th grade education, was related with lower prevalence of HTN. Of note, proteinuria and CKD were observed in 19% and 23.5% of HTN subjects. About half (54%) of the hypertensive subjects were aware of their hypertension status. CONCLUSIONS: HTN was common in this cohort from India. Older age, BMI ≥ 23 Kg/M2, waist circumference, sedentary occupation, education less, diabetes mellitus, presence of proteinuria, and raised serum creatinine were significant predictors of hypertension. Our data suggest that HTN is a major public health problem in India with low awareness, and requires aggressive community-based screening and education to improve health.

A Rare Case of Type I RenalTubular Acidosis with Membranous Nephropathy Presenting as Hypokalemic Paralysis.

Type 1 renal tubular acidosis (RTA), or distal RTA (dRTA), is a disorder of renal tubular acidification, which is generally asymptomatic but may rarely present as hypokalemic paralysis. Here, we report the case of a young male who presented with sudden onset weakness of all 4 limbs and a 2-month history of swelling of the legs. An investigation revealed hypokalemia, metabolic acidosis, and nephrotic syndrome. Additional analyses revealed normal anion gap metabolic acidosis with a positive urine anion gap and dRTA. Renal biopsy showed evidence of membranous nephropathy (MN). The patient's weakness improved with potassium supplements. Normalization of the serum potassium level and disappearance of proteinuria were established with an ACE inhibitor and potassium supplementation. This case is an unusual combination of dRTA with MN coupled with the rare presenting symptoms of hypokalemic paralysis and medullary nephrocalcinosis.

Cervical tumoral calcinosis with secondary hyperparathyroidism in a chronic hemodialysis patient.

Tumoral calcinosis is an uncommon and severe complication of chronic renal failure. It is generally associated with the presence of a high-serum calcium-and-phosphorus product. We report here a case of a patient on maintenance hemodialysis who presented with progressively increasing, solitary, tumor-like swelling over the nape of the neck. A 50-year-old female on thrice weekly maintenance hemodialysis for the last 3 years presented with a small swelling over the nape of the neck that had been progressively increasing over the last 1 year to cricket ball size. The patient was investigated and diagnosed as having tumoral calcinosis. The metastatic calcification occurring in the patient was most likely related to high calcium × phosphate product with coexistent secondary hyperparathyroidism possibly aggravated by vitamin D therapy. The patient was treated with withdrawal of vitamin D therapy, strict control of serum phosphate levels with noncalcemic phosphate binders, and subtotal parathyroidectomy. The neck swelling started decreasing in size after 2 months of parathyroidectomy and there was marked clinical improvement with drop in serum parathormone levels, over a period of 6 months. After 2 years of parathyroidectomy, the neck swelling again started increasing in size with increase in serum parathormone levels. The patient was treated with cinacalcet and the neck swelling gradually decreased in size along with control of serum parathormone and phosphate levels.

Adult primary pleomorphic leiomyosarcoma of forearm with axillary lymph node metastasis: a case report and literature review.

A rare case of advanced pleomorphic leiomyosarcoma of forearm with axillary lymph node metastasis in a young adult, diagnosed with the aid of immunohistochemistry and electron microscopic examinations together with a review of the literature are reported. The primary tumor involved the extensor and flexor aspect of forearm without bone involvement and metastasized to the axillary lymph nodes. Patient showed poor treatment outcome with adjuvant chemoradiotherapy following incomplete surgery.

A dominant role for meiosis-specific 3' RNA processing in controlling expression of a fission yeast cyclin gene.

Meiotic gene regulation provides a rich source of insight into mechanisms of temporal control during development. We previously reported that accumulation of many meiotic mRNAs in fission yeast is governed by changes in 3' RNA processing and elucidated the molecular basis of this regulatory mechanism for an early meiotic gene. Here, we report that cleavage/polyadenylation is also the nexus of negative control for middle meiotic genes. Parallel profiles of splicing and polyadenylation are observed over a meiotic time course for both rem1 and spo4 but not for a constitutive control gene. Nevertheless, polyadenylation of rem1 transcripts is restricted to meiosis by a splicing-independent mechanism. Through systematic sequence substitutions, we identified a negative control region (NCR) located upstream of the rem1 transcription start site and found that it is required to block 3' RNA processing in proliferating cells. Ablation of the NCR relieves inhibition regardless of whether the intron is present, absent, or carries splice site mutations. Consistent with the previous report of a polypeptide encoded by the first exon of rem1, we discovered a second 3' processing site just downstream from the 5' splice site. Polyadenylation within the intron is activated concurrent with the downstream site during meiosis, is controlled by the NCR, and is enhanced when splicing is blocked via 5' junction or branch point mutations. Taken together, these data suggest a novel regulatory mechanism in which a 5' element modulates the dynamic interplay between splicing and polyadenylation.