Government Vellore Medical College

To develop a simple rapid procedure for bioreduction of silver nanoparticles (AgNPs) using aqueous leaves extracts of Catharanthus roseus (C. roseus). Characterization were determined by using UV-Vis spectrophotometry, scanning electron microscopy (SEM), energy dispersive X-ray and X-ray diffraction. SEM showed the formation of silver nanoparticles with an average size of 67 nm to 48 nm. X-ray diffraction analysis showed that the particles were crystalline in nature with face centered cubic geometry. C. roseus demonstrates strong potential for synthesis of silver nanoparticles by rapid reduction of silver ions (Ag+ to Ag0). This study provides evidence for developing large scale commercial production of value-added products for biomedical/nanotechnology-based industries.

, a medicinal plant. The gold nanoparticles were synthesized rapidly by the involvement of microwave heating. By changing of plant extract concentration, gold solution concentration, microwave heating time and power of microwave heating the optimized condition was identified. The surface Plasmon resonance found at 520 nm confirmed the gold nanoparticles synthesis. The spherical sized nanoparticles in the size range of 16-30 nm were confirmed by Transmission Electron Microscope (TEM). The stability of the nanoparticles is very well proved in the invitro stability tests. The biochemical like alkaloids and flavonoids play a vital role in the nanoparticles synthesis was identified using the Fourier Transform Infrared Spectroscopy (FTIR). Combining the phytochemical and microwave heating, the rapid synthesis of gold nanoparticles is the novel process for the medically applicable gold nanoparticles production.

OBJECTIVES: To study the prevalence of occult stress urinary incontinence (SUI) among Indian women with genitourinary prolapse, and determine the risk of developing SUI after vaginal hysterectomy and pelvic floor repair in Indian women with occult SUI. METHODS: A prospective cohort study of 78 women with significant genitourinary prolapse without symptoms of SUI was conducted at Christian Medical College, Vellore, India. Before the surgical intervention, the prolapse was repositioned using a pessary and a Pyridium (Parke Davis, Morris Plains, NJ, USA) pad test was performed to detect occult SUI. The primary outcome studied was the risk of developing postoperative urinary incontinence. RESULTS: Preoperatively, 67.9% of women were found to have occult SUI. The prevalence of SUI was 43.6% postoperatively, and 64.2% of the women with a positive result to the preoperative Pyridium pad test after pessary insertion were found to have urinary incontinence postoperatively. Postmenopausal women had twice the risk of developing occult SUI. CONCLUSION: Preoperative testing is useful to identify women with genitourinary prolapse who have occult SUI. Women with a positive result may need a systematic clinical evaluation and urodynamic studies to characterize the incontinence. They can be then counseled preoperatively regarding concomitant anti-incontinence procedures.

AIM: To assess outcome of 10 'difficult to treat' patients with Takayasu arteritis (TA) treated with tocilizumab. METHODS: Records of 10 patients with TA who received at least six infusions of tocilizumab were studied and data related to demography, medications, investigations, angiography and outcome were analyzed. RESULTS: Median age, disease duration and Indian Takayasu Arteritis Score (ITAS) of 10 patients were 24.5 (13-53) years, 25.5 (1.5-60) months and 4.5 (0-13), respectively. All patients had active disease with ITAS of ≥ 1 and/or they were angiographically active in spite of treatment with steroids and second line agents for a median duration of 27 (15-60) months. Tocilizumab led to a clinical response with ITAS of 0 and reduction in acute phase reactants (APR) in 100% of patients by the fourth infusion. Six patients (60%) maintained clinical response with radiologically stable disease and normal APR up to the sixth infusion. Two out of three patients (66%) with normal APR at baseline achieved and maintained stable disease state up to the last infusion, in contrast to 49.2% (4/7) responders in those with baseline high APR. Tocilizumab facilitated rapid reduction in steroid dose from 24 ± 15 to 5.4 ± 4.9 mg/day (P = 0.003). However, following discontinuation of toclizumab therapy after six infusions, only two patients maintained stable disease state and the majority of them needed rescue therapy. There was no major adverse event or fatality. CONCLUSION: Tocilizumab may be an effective steroid-sparing option for rapid control of refractory disease activity in patients of TA. However, the benefit is not sustained after its withdrawal.

Acute fatty liver of pregnancy (AFLP) is a rare disorder which is fatal if not recognized and treated early. Delivery of the feto-placental unit results in dramatic improvement in maternal liver function, suggesting a role for the placenta. However, the mechanisms by which defects in the fetus or placenta lead to maternal liver damage are not well understood and form the focus of this study. Placenta and serum were obtained at delivery from patients with AFLP, and placental mitochondria and peroxisomes were isolated. Placental mitochondrial function, oxidative stress, and fatty acid composition as well as serum antioxidants, oxidative and nitrosative stress markers, and fatty acid analysis were carried out. Hepatocytes in culture were used to evaluate cell death, mitochondrial function, and lipid accumulation on exposure to fatty acids. Oxidative stress was evident in placental mitochondria and peroxisomes of patients with AFLP, accompanied by compromised mitochondrial function. Increased levels of arachidonic acid were also seen in AFLP placenta when compared to control. Patients with AFLP also had a significant increase in oxidative and nitrosative stress markers in serum, along with decreased antioxidant levels and elevated levels of arachidonic acid. These levels of arachidonic acid were capable of inducing oxidative stress in hepatocyte mitochondria accompanied by induction of apoptosis. Exposure to arachidonic acid also resulted in increased lipid deposition in hepatocytes. Conclusion: Oxidative stress in placental mitochondria and peroxisomes is accompanied by accumulation of toxic mediators such as arachidonic acid, which may play a causative role in maternal liver damage seen in AFLP. (Hepatology 2010;51:191–200.)

Type I collagen from outer skin of Sepia pharaonis was extracted and partially characterized. Yield of Acid Soluble Collagen (ASC) and Pepsin Soluble Collagen (PSC) were calculated as 1.66% and 3.93% and the total protein content of ASC and PSC were found as 18.4% and 48.6%. FT-IR spectrum of ASC and PSC recorded 12 and 14 peaks, respectively. 1H NMR spectrum of ASC showed singlets at 1.23 ppm, 3.1 ppm, 3.55 ppm and 3.7 ppm and PSC at 1.23 ppm and 2.08 ppm. The molecular weight for ASC was calculated as 102 kDa and for PSC as 110, 108 and 102 kDa through SDS-PAGE. Differential Scanning Calorimetry (DSC) results supported that PSC withstand high thermal stability (82.85 °C) than ASC (73.13 °C). Higher denaturation temperature with high molecular weight well support the property of type I collagen from skin of S. pharaonis and it could be used as another potent source for the extraction of collagen.

This study was conducted to determine the incidence of hospital admissions following acute poisoning, nature of agents involved and change in pattern of poisoning over a 5-year period. Data from hospital records of all admissions to emergency department following acute poisoning collected prospectively were analysed for the period January 1993 to January 1998. A steady increase in deliberate poisoning using pesticides, particularly among young adults, was noted. Kerosene (paraffin) was the commonest poison in children and plant poisons were also common. There were 52 deaths (3.3%) among the 1584 admissions. The majority of deaths were due to pesticides. Poisoning and mortality followed ingestion of readily-available and commonly used agents. Measures to increase public education, counselling and awareness could prevent a number of these admissions.

Low birthweight (LBW) individuals and offspring of women with gestational diabetes mellitus (GDM) exhibit increased risk of developing type 2 diabetes (T2D) and associated cardiometabolic traits in adulthood, which for both groups may be mediated by adverse events and developmental changes in fetal life. T2D is a multifactorial disease occurring as a result of complicated interplay between genetic and both prenatal and postnatal nongenetic factors, and it remains unknown to what extent the increased risk of T2D associated with LBW or GDM in the mother may be due to, or confounded by, genetic factors. Indeed, it has been shown that genetic changes influencing risk of diabetes may also be associated with reduced fetal growth as a result of reduced insulin secretion and/or action. Similarly, increased risk of T2D among offspring could be explained by T2D susceptibility genes shared between the mother and her offspring. Epigenetic mechanisms may explain the link between factors operating in fetal life and later risk of developing T2D, but so far convincing evidence is lacking for epigenetic changes as a prime and direct cause of T2D. This review addresses recent literature on the early origins of adult disease hypothesis, with a special emphasis on the role of genetic compared with nongenetic and epigenetic risk determinants and disease mechanisms.

Cholecystectomy is a common surgical procedure performed worldwide for acute cholecystitis. Acute cholecystitis occurs when the cystic duct is obstructed by a gallstone, which causes gallbladder distension and subsequent inflammation of the gallbladder. Acute cholecystitis is characterized by pain in the right upper quadrant, anorexia, nausea, fever, and vomiting. Cholecystectomy is the treatment of choice for acute cholecystitis. The two commonly performed types of cholecystectomies are open cholecystectomy and laparoscopic cholecystectomy. However, the approach of choice widely fluctuates with regard to various factors such as patient history and surgeon preference. It is imperative to understand the variations in outcomes of different approaches and how best they fit an individual patient when deciding the technique to be undertaken. This article reviews several studies and compares the two techniques in terms of procedure, mortality rate, complication rate, bile leak/injury rate, conversion rate, and bleeding rate.

BACKGROUND: A three-dose, oral rotavirus vaccine (Rotavac) was introduced in the universal immunization program in India in 2016. A prelicensure trial involving 6799 infants was not large enough to detect a small increased risk of intussusception. Postmarketing surveillance data would be useful in assessing whether the risk of intussusception would be similar to the risk seen with different rotavirus vaccines used in other countries. METHODS: We conducted a multicenter, hospital-based, active surveillance study at 27 hospitals in India. Infants meeting the Brighton level 1 criteria of radiologic or surgical confirmation of intussusception were enrolled, and rotavirus vaccination was ascertained by means of vaccination records. The relative incidence (incidence during the risk window vs. all other times) of intussusception among infants 28 to 365 days of age within risk windows of 1 to 7 days, 8 to 21 days, and 1 to 21 days after vaccination was evaluated by means of a self-controlled case-series analysis. For a subgroup of patients, a matched case-control analysis was performed, with matching for age, sex, and location. RESULTS: From April 2016 through June 2019, a total of 970 infants with intussusception were enrolled, and 589 infants who were 28 to 365 days of age were included in the self-controlled case-series analysis. The relative incidence of intussusception after the first dose was 0.83 (95% confidence interval [CI], 0.00 to 3.00) in the 1-to-7-day risk window and 0.35 (95% CI, 0.00 to 1.09) in the 8-to-21-day risk window. Similar results were observed after the second dose (relative incidence, 0.86 [95% CI, 0.20 to 2.15] and 1.23 [95% CI, 0.60 to 2.10] in the respective risk windows) and after the third dose (relative incidence, 1.65 [95% CI, 0.82 to 2.64] and 1.08 [95% CI, 0.69 to 1.73], respectively). No increase in intussusception risk was found in the case-control analysis. CONCLUSIONS: The rotavirus vaccine produced in India that we evaluated was not associated with intussusception in Indian infants. (Funded by the Bill and Melinda Gates Foundation and others.).

Development of green, eco-friendly, and efficient adsorbents for wastewater treatment is highly researched to mitigate the alarming rate of water pollution. In this work, a novel biocomposite of biosilica (BS)/silk fibroin (SF)/polyurethane foam (PUF) was prepared and studied for the adsorptive recovery of toxic copper (Cu2+) and chromium (Cr6＋) ions from synthetic wastewater. XRD and FTIR studies confirmed the formation of biocomposite with amorphous structure and –OH, –NH, C=O surface functionalities. SEM results confirmed the successful incorporation of SF and PUF into BS. The biocomposite possessed a specific surface area of 751.9 m2/g and a mean pore size of 7.21 nm. Further, effects of pH, adsorbent dose, contact time, and initial metal ion concentration on the adsorptive removal of Cu2+ and Cr6＋ metal ions by the BS/SF/PUF biocomposite were studied in detail. Equilibrium and kinetic analysis showed that the metal ions sequestration by the BS/SF/PUF biocomposite followed the Freundlich isotherm and Elovich model, respectively. Maximum adsorption capacities of 331.69 mg/g and 201.56 mg/g were estimated for the Cu2+ and Cr6＋ ions, respectively. A plausible mechanism for the adsorption of the metal ions onto BS/SF/PUF biocomposite is postulated. Reusability studies of the biocomposite using EDTA eluent showed that the biocomposite could be efficiently reused up to four consecutive adsorption/desorption cycles. Thus, this study provides comprehensive data for applying the BS/SF/PUF biocomposite to treat Cu2+ and Cr6＋ metal ions polluted wastewater streams.

To evaluate the phytochemical constituents and the antioxidant activity of hydroalcoholic extract of Nymphaea nouchali seed locally prescribed as a diet for diabetes mellitus. The antioxidant and free radical scavenging activity of hydroalcoholic extract of the plant was assessed against 1,1 diphenyl-2-picryl hydrazyl (DPPH), nitric oxide and lipid peroxidation using standard protocols. Total phenolics, flavonoids and tannins were also determined. Phytochemical analysis revealed the presence of phenols, flavones, tannins, protein, reducing sugars, glycosides, saponins, alkaloids and steroids. The activities of plant extract against DPPH, nitric oxide and lipid peroxidation was concentration dependent with IC50 value of 42.82, 23.58 and 54.65 μg/mL respectively. The total antioxidant capacity was high with 577.73 mg vitamin E/g of the extract and showed a moderately high vitamin C content of 197.22 mg/g. The total tannin content of hydroalcoholic seed extract was high (195.84 GE/g), followed by phenolics (179.56 GE/g) and flavonoids (23.55 QE/g). Our findings provide evidence that the crude extract of Nymphaea nouchali is a potential source of natural antioxidants and this justifies its use in folkloric medicine.

Despite significant advancements with recombinant AAV2 or AAV8 vectors for liver directed gene therapy in humans, it is well-recognized that host and vector-related immune challenges need to be overcome for long-term gene transfer. To overcome these limitations, alternate AAV serotypes (1-10) are being rigorously evaluated. AAV5 is the most divergent (55% similarity vs. other serotypes) and like AAV1 vector is known to transduce liver efficiently. AAV1 and AAV5 vectors are also immunologically distinct by virtue of their low seroprevalence and minimal cross reactivity against pre-existing AAV2 neutralizing antibodies. Here, we demonstrate that targeted bio-engineering of these vectors, augment their gene expression in murine hepatocytes in vivo (up to 16-fold). These studies demonstrate the feasibility of the use of these novel AAV1 and AAV5 vectors for potential gene therapy of diseases like hemophilia.

Abstract The prevalence of post-transplant diabetes mellitus in 222 consecutive live related renal allograft recipients over a 3-year period was found to be 11.7%. Most of them (20 of 26) developed diabetes mellitus within the first 4 months of transplantation. Post-transplant diabetic patients were older, and had a significantly greater incidence of avascular necrosis of bone. An assessment of risk factors showed that abnormal postprandial blood sugar pretransplant was a significant predictor for development of post-transplant diabetes, whereas cumulative oral steroid dose, weight gain after transplant, type of immunosuppression employed, and graft function were not important. We conclude that post-transplant diabetes mellitus frequently develops in patients with a predisposition by virtue of older age and pretransplant postprandial hyperglycaemia. While steroids are important in the pathogenesis, there was no demonstrable dose-response relationship; post-transplant diabetic patients may be a group with a greater propensity to steroid-induced complications.

Importance: The benefit of daily over thrice-weekly antituberculosis therapy among HIV-positive patients with pulmonary tuberculosis (TB) who are receiving antiretroviral therapy remains unproven. Objective: To compare the efficacy and safety of daily, part-daily, and intermittent antituberculosis therapy regimens in the treatment of HIV-associated pulmonary TB. Design, Setting, and Participants: This open-label, randomized clinical trial was conducted by the National Institute for Research in Tuberculosis, south India. Adults infected with HIV with newly diagnosed, culture-positive, pulmonary TB were enrolled between September 14, 2009, and January 18, 2016. Interventions: Patients were randomized to daily, part-daily, and intermittent antituberculosis therapy regimens, stratified by baseline CD4 lymphocyte count and sputum smear grade. Antiretroviral therapy was initiated as per national guidelines. Clinical and sputum microbiological examinations of patients were performed monthly until 18 months after randomization. Adverse events were recorded using standard criteria. Main Outcomes and Measures: The primary outcome was favorable response, defined as treatment completion with all available sputum cultures negative for Mycobacterium tuberculosis during the last 2 months of treatment. Unfavorable responses included treatment failures, dropouts, deaths, and toxic effects among regimens. Results: Of 331 patients (251 [76%] male; mean [SD] age, 39 [9] years; mean [SD] HIV viral load, 4.9 [1.2] log10 copies/mL; and median [interquartile range] CD4 lymphocyte count, 138 [69-248] cells/μL), favorable responses were experienced by 91% (89 of 98), 80% (77 of 96), and 77% (75 of 98) in the daily, part-daily, and intermittent regimens, respectively. With the difference in outcome between daily and intermittent regimens crossing the O'Brien-Fleming group sequential boundaries and acquired rifampicin resistance emergence (n = 4) confined to the intermittent group, the data safety monitoring committee halted the study. A total of 18 patients died and 18 patients dropped out during the treatment period in the 3 regimens. Six, 4, and 6 patients in the daily, part-daily, and intermittent regimens, respectively, had TB recurrence. Conclusions and Relevance: Among HIV-positive patients with pulmonary TB receiving antiretroviral therapy, a daily anti-TB regimen proved superior to a thrice-weekly regimen in terms of efficacy and emergence of rifampicin resistance. Trial Registration: clinicaltrials.gov Identifier: NCT00933790.

<ns4:p><ns4:bold>Background: </ns4:bold>Self-reported family history of cardiovascular disease (CVD) is an independent risk factor for future coronary heart disease (CHD) events. However, inclusion of family history of CVD in the traditional risk scores failed to improve risk prediction of CHD. It is proposed that family history of CVD may substantially increase the risk of CHD among younger individuals.</ns4:p><ns4:p> <ns4:bold>Methods: </ns4:bold>We conducted a matched case-control study with 170 hospital-based premature CHD patients (&lt;55 years in men and &lt;65 years in women) from a tertiary care centre in Thiruvananthapuram, Kerala and age and sex matched community-based controls in 1:1 ratio. Conditional logistic regression analysis was conducted to assess the independent association of family history of cardiovascular disease (CVD) and premature CHD. We estimated McNemar's odds ratios and their 95 percent confidence intervals.</ns4:p><ns4:p> <ns4:bold>Results: </ns4:bold>The prevalence of any family history of CVD and CHD in the control population was 24% and 21%, respectively. The family history of CVD was independently associated with premature CHD (odds ratio (OR) = 9.0; 95% confidence interval (CI) 4.7–17.3). There was a dose-response relationship between family history and premature CHD as the risk increased linearly with increase in number of affected family members.</ns4:p><ns4:p> <ns4:bold>Conclusions: </ns4:bold>Family history of CVD is an independent risk factor for premature CHD. The risk of premature CHD increases linearly with increase in number of affected family members. Collecting family history beyond parental history of CVD is important for risk stratification. Targeting young individuals with family history of CVD for intensive risk reduction interventions may help to prevent future events.</ns4:p>

OBJECTIVE: To evaluate the antioxidant and cytotoxic effects of hexane extract of Morinda pubescens leaves and to find the primary bioactive compound responsible for antioxidant and cytotoxic activities. METHODS: The individual compounds were isolated using column chromatography and were characterized by spectroscopic techniques. The antioxidant activity was evaluated for all individual isolated compounds by DPPH method using L-Ascorbic acid as standard and cytotoxicity was assessed for the extract and the hyoscyamine by MTT assay, caspase test and RT-PCR study. RESULTS: The antioxidant activity of the isolated compounds and the extract increased as the concentration increased. One of the isolated compound hyoscyamine showed the high antioxidant activity. The extract and the hyoscyamine dose-dependently decreased the cell viability in HepG2 cells. Hyoscyamine induced caspase-3 mediated apoptosis. Up regulation of p53 gene expression provides cue for apoptotic activity of hyoscyamine. CONCLUSIONS: The results indicate that hexane extract possessed potent antioxidant and cytotoxic activity and hyoscyamine is the principal bioactive compound in hexane extract.

A study about an emerging approach to enhance the biological properties by incorporating nanoparticles within the hydrogel networks using citric acid, diethyleneglycol, and indole‐3‐acetic acid a three component hydrogels prepared by polycondensation. A stable and uniformly distributed silver and gold nanoparticles have been introduced successfully in hydrogel network resulted in nanocomposite hydrogels. The surface morphology of silver and gold hydrogel have been compared using scanning electron microscope with energy dispersive X‐ray spectroscopy analysis and transmission electron microscopy techniques and thermal stability was studied by thermogravimetric analysis. The swelling studies have also been carried out for nanocomposite hydrogels at various pH solution. The nanocomposite hydrogels have exhibited antibacterial activity and nontoxic nature confirmed by the cytotoxicity effect. The results of the study indicated that the nanocomposite hydrogels may be recommended for wound healing applications. Comparatively, silver nanocomposite hydrogel was better performance than gold nanocomposite hydrogel. POLYM. ENG. SCI., 58:2133–2142, 2018. © 2018 Society of Plastics Engineers

PURPOSE: Although the use of steroids in the management of COVID-19 has been addressed by a few systematic review and meta-analysis, however, they also used data from "SARS-CoV" and "MERS-CoV." Again, most of these studies addressed only one severity category of patients or addressed only one efficacy endpoint (mortality). In this context, we conducted this meta-analysis to evaluate the efficacy and safety of steroid therapy among all severity categories of patients with COVID-19 (mild to moderate and severe to critical category) in terms of "mortality," "requirement of mechanical ventilation," "requirement of ICU" and clinical cure parameters. METHODS: 11 databases were screened. Only randomized controlled trials (RCTs) or high quality (on the basis of risk of bias analysis) comparative-observational studies were included in the analysis. RevMan5.3 was used for the meta-analysis. RESULTS: A total of 15 studies (3 RCT and 12 comparative-observational studies) were included. In the mechanically-ventilated COVID-19 population, treatment with dexamethasone showed significant protection against mortality (single study). Among severe and critically ill combined population, steroid administration was significantly associated with lowered mortality (risk ratio [RR] 0.83 [0.76-0.910]), lowered requirement of mechanical ventilation (RR 0.59 [0.51-0.69]), decreased requirement of intensive care unit (ICU) (RR 0.62 [0.45-0.86]), lowered length of ICU stay (single-study) and decreased duration of mechanical ventilation (two-studies). In mild to moderate population, steroid treatment was associated with a higher "duration of hospital stay," while no difference was seen in other domains. In patients at risk of progression to "acute respiratory distress syndrome," steroid administration was associated with "reduced requirement of mechanical ventilation" (single-study). CONCLUSION: This study guides the use of steroid across patients with different severity categories of COVID-19. Among mechanically ventilated patients, steroid therapy may be beneficial in terms of reduced mortality. Among "severe and critical" patients; steroid therapy was associated with lowered mortality, decreased requirement of mechanical ventilation, and ICU. However, no benefit was observed in "mild to moderate" population. To conclude, among properly selected patient populations (based-upon clinical severity and biomarker status), steroid administration may prove beneficial in patients with COVID-19.

BACKGROUND AND AIM: There is limited data on predictors of acute kidney injury in acute on chronic liver failure. We developed a PIRO model (Predisposition, Injury, Response, Organ failure) for predicting acute kidney injury in a multicentric cohort of acute on chronic liver failure patients. PATIENTS AND METHODS: Data of 2360 patients from APASL-ACLF Research Consortium (AARC) was analysed. Multivariate logistic regression model (PIRO score) was developed from a derivation cohort (n=1363) which was validated in another prospective multicentric cohort of acute on chronic liver failure patients (n=997). RESULTS: Factors significant for P component were serum creatinine[(≥2 mg/dL)OR 4.52, 95% CI (3.67-5.30)], bilirubin [(<12 mg/dL,OR 1) vs (12-30 mg/dL,OR 1.45, 95% 1.1-2.63) vs (≥30 mg/dL,OR 2.6, 95% CI 1.3-5.2)], serum potassium [(<3 mmol/LOR-1) vs (3-4.9 mmol/L,OR 2.7, 95% CI 1.05-1.97) vs (≥5 mmol/L,OR 4.34, 95% CI 1.67-11.3)] and blood urea (OR 3.73, 95% CI 2.5-5.5); for I component nephrotoxic medications (OR-9.86, 95% CI 3.2-30.8); for R component,Systemic Inflammatory Response Syndrome,(OR-2.14, 95% CI 1.4-3.3); for O component, Circulatory failure (OR-3.5, 95% CI 2.2-5.5). The PIRO score predicted acute kidney injury with C-index of 0.95 and 0.96 in the derivation and validation cohort. The increasing PIRO score was also associated with mortality (P<.001) in both the derivation and validation cohorts. CONCLUSIONS: The PIRO model identifies and stratifies acute on chronic liver failure patients at risk of developing acute kidney injury. It reliably predicts mortality in these patients, underscoring the prognostic significance of acute kidney injury in patients with acute on chronic liver failure.