Mean Serum Creatinine Research Articles

#1649 Obinutuzumab is effective for the treatment of rituximab-resistant membranous nephropathy

Abstract Background and Aims Membranous nephropathy (MN) is a leading cause of nephrotic syndrome in nondiabetic adults. Rituximab has become the first-line therapy for patients with MN after the recognition of MN as an autoimmune disease. However, 40% of patients with MN do not respond to rituximab. Obinutuzumab is a humanized and glycoengineered type II anti-CD20 monoclonal antibody that has superior in vitro B-cell cytotoxicity compared with rituximab which might provide an attractive option for rituximab-resistant MN. We presented our single-center experience of treating MN with obinutuzumab. Method Fourteen patients with rituximab-resistant PLA2R-associated MN who received obinutuzumab at the First affiliated hospital of Xi'an Jiaotong university between January 2022 and June 2023 were included in this retrospective study. Resistance to rituximab was defined as the failure to achieve complete (urinary protein excretion <0.3 g/d along with normal serum albumin concentration and stable renal function) or partial (urinary protein excretion <3.5 g/d or with ≥50% reduction vs baseline, accompanied by improvement or normalization of serum albumin concentration and stable GFR) remission of NS in 3-6 months after 2 doses of rituximab administration. Clinical and laboratory parameters were evaluated at presentation, before and after obinutuzumab administration. Results Of all patients with an average age of 50.0 ± 13.6 years, 10 (71.4%) patients were men, 8 (57.1%) patients had hypertension and 4 (28.6%) patients had diabetes. The median disease duration was 1.3 (1.0, 4.8) years. At presentation, the proteinuria and albumin levels were 7.94 ± 4.23 g/d and 21.5 ± 3.6 g/L, respectively. The mean serum creatinine level was 70.5 ± 10.7 µmol/L and the patients had a median baseline anti-PLA2R level of 193.5 (104.5,299.2) RU/mL. Six patients had been previously exposed to steroids, alkylating agents, calcineurin inhibitors in different combinations in addition to rituximab. Both patients received 1 g of obinutuzumab on day 0 and day 15. At obinutuzumab administration, the proteinuria and albumin levels were 8.43 ± 3.36 g/d and 22.4 ± 4.0 g/L, respectively. The mean serum creatinine level was 85.1 ± 28.5 µmol/L and median anti-PLA2R level decreased to 32.7 (10.7,178.) RU/mL compared with that at presentation. After a median follow-up of 5.4 (4.0, 9.7) months after obinutuzumab therapy, complete remission was achieved in 4 (28.6%) and partial remission was achieved in 8 (57.1%) of patients. Of the remaining two patients who did not achieve complete or partial remission, 1 patient had a follow-up of 4 months and had a 33% decline in proteinuria accompanied by improvement in serum albumin. The other patient had an anti-PLA2R level higher than 1500 RU/mL (exceeding detection upper limit) at obinutuzumab administration and an inadequate follow-up of 3 months without proteinuria decline. Whereas, anti-PLA2R level decreased to 18.17 RU/ml accompanied by B-lymphocyte depletion (absolute CD19 count <5 cells/ml) at that time. Of the 12 patients who achieved complete or partial remission, the median time from treatment to remission was 4.7 ± 2.3 months. Two patients with longer follow-up maintained complete remission at 1 year. At first complete or partial remission, the proteinuria and albumin levels were 3.47 ± 1.99 g/d and 32.5 ± 3.3 g/L, respectively. The mean serum creatinine level was 74.8 ± 24.1 µmol/L and anti-PLA2R levels of 11 patients had a decline in the titer to <2 RU/ml (negative result for our immunology laboratory). B-lymphocyte depletion was achieved in all these patients. Conclusion Obinutuzumab may represent an attractive alternative therapy in patients with resistance to rituximab. Larger prospective studies are needed to validate these findings.

#1422 Exploring BAFF, APRIL, and clinical characteristics in IgA nephropathy: a decade-long study in the Bulgarian population

Abstract Background and Aims IgA nephropathy (IgAN) represents a significant global health concern, contributing substantially to chronic kidney disease and renal failure. Despite its widespread impact, the Bulgarian population lacks comprehensive epidemiological data and specific biomarkers for IgAN. This decade-long retrospective study, conducted at a tertiary Nephrology Clinic in Bulgaria, aims to explore the clinical characteristics and serum levels of BAFF and APRIL in biopsy-confirmed IgAN patients and healthy controls. Method The study includes 125 biopsy-confirmed IgAN patients and 30 healthy controls. Notably, 70.4% of IgAN patients were male, with an average age of 35.94 ± 11.91 years. Baseline characteristics reveal advanced disease stages at diagnosis, possibly linked to delayed biopsy (24.22 ± 32.9 months from initial symptoms) and the absence of a screening program. Analyses of serum biomarkers (C3, BAFF, and APRIL) are conducted to identify any significant variations between IgAN patients and healthy volunteers. Results The average baseline estimated glomerular filtration rate (eGFR) was 61.78 ± 27.72 ml/min/1.73 m², with a mean serum creatinine of 126 ± 67.83 μmol/l at the time of kidney biopsy. Among the patients, 51.2% had an eGFR below 60 ml/min, indicating CKD stage 3 or worse according to the KDIGO classification Binary logistic regression analysis identifies anemia as a significant contributor to disease progression, with a risk influence approximately 3.3 times higher for GFR decline over time. Anemia emerges as a crucial predictor for serum creatinine doubling, carrying a higher risk than hyperuricemia. Analyses of C3 (p = 0.658), BAFF (p = 0.432), and APRIL (p = 0.227), demonstrated no significant differences in their serum levels between IgAN patients and healthy volunteers. Conclusion This study provides comprehensive insights into IgAN in the Bulgarian population, addressing the dearth of epidemiological data and biomarkers. Anemia emerges as a significant predictor for disease progression, emphasizing its potential clinical relevance. However, C3, BAFF, and APRIL exhibit no notable variations, underscoring the need for additional biomarker exploration to enhance understanding of IgAN dynamics in this population.

#1828 Venous thromboembolic events in ANCA associated vasculitis patients—data from Croatian referral center

Abstract Background and Aims Our aim was to investigate the prevalence of venous thromboembolic events (VTE) in a cohort of patients with ANCA-associated vasculitis (AAV) and define factors associated with the frequency of VTE considering there is data on high incidence of VTE in AAV patients. In these cohorts VTE occurred mostly early in the course of disease. Method This study included 114 consecutive AAV patients with biopsy proven renal involvement in the period from 2007-2017. Patients were classified according to clinical: granulomatosis with poliangitis (GPA), microscopic polingitis (MPA) and eosinophilic granulomatosis with poliangitis (EGPA) and serological phenotype: MPO-ANCA positive, PR3-ANCA positive, MPO- and PR3-ANCA positive and ANCA-negative. Ordinal variables were analysed using logistical regression test. Statistical analysis was done in MedCalc Statistical Software version 18.11.6 (MedCalc Software Bvba, Ostend, Belgium). Results In the cohort there were 64 (56%) females, mean age was 58 (IQR 16-84) with mean follow up time 46.9 months (IQR 1-127). Clinically there were 84 (73%) patients with MPA, 26 (22%) with GPA and 4 (5%) with EGPA. Serologically there were 20% PR3-ANCA, 54% MPO-ANCA, 8% MPO- and PR-3 ANCA positive patients and 18% ANCA-negative patients. Mean serum creatinine levels (SCr) was 380.9 μmol/l (IQR 65-1402). Mean BVAS (Brimingham vasculitis score) at the time of diagnosis of AAV was 17 (IQR 5-50) and at the time of VTE 0, 9 (0-22). Mean body weight was 71kg (IQR 48-110) and mean CRP was 84 mg/ml (IQR 0, 3-256). During the follow up 7 (6.14%) of the patients had VTE, with 4 having VTE in first month after the diagnosis and other two at month 14 and 19. Logistic regression showed the connection of weight (P = 0.0052) and CRP (0.0138) with VTE with odds ratio of 1,0829 for CRP (1.003-1.027) and 1.0150 for weight (1.0284-1.1736) respectively. There was no statistical significance for clinical or serological phenotype being associated with VTE nor for other clinical or laboratory parameters. Conclusion In our cohort patients with AAV were at risk of VTE, particularly within the first year following onset of disease. In this cohort the frequency of VTE did not depend of clinical or serological AAV phenotype, age or gender. Only CRP and body weight were associated significantly with VTE occurrence. Despite VTE rates in AAV patients, routine anticoagulation is not recommended in AAV patients, given the potential risk of bleeding complications. Prospective studies are needed to assess VTE risk stratification in AAV patients and to evaluate the both benefits and potential risks ratio of prophylactic anticoagulation in AAV patients.

#1392 MEST-C score correlation with proteinuria reduction after SGLT2i treatment in patients with IgA nephropathy

Abstract Background and Aims Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are associated with better cardiovascular outcomes and with nephroprotection independent of diabetes status. Recent data suggest that SGLT2i significantly reduce proteinuria in patients with IgA nephropathy (IgAN). Data available for the use of the MEST-C score to determine if treatment would benefit IgAN patients is scarce. The aim of our study was to assess the degree of proteinuria reduction after SGLT2i treatment in IgAN and its possible association with the MEST-C score. Method 63 adult patients with biopsy-proven IgA nephropathy, eGFR ≥ 30 mL/min/1.73 m2 (CKD-epi), and total urine protein of >0.5 grams/day at screening were included. Patients with secondary IgAN and crescents were excluded. All receiving maximally tolerated RASi for at least 12 weeks. All patients started dapagliflozin 10 mg once per day after baseline data were registered. The total follow-up was 12 months. The main outcome was the decline in eGFR and the reduction in 24-hour proteinuria from SGLT2i initiation to 1,3, 6, 9, 12 months, end-stage renal disease, or kidney or cardiovascular death. Three repeated measurements of proteinuria (mg/24H) were performed, 90 days before SGLT2i treatment initiation, and only patients with stable proteinuria were enrolled in the study. Results 49 patients (35/14 M/F), with mean age of 41,9 ± 19,6 years, completed follow up. 8 patients discontinued treatment due to adverse events attributed to dapagliflozin. At baseline eGFR was 68.21±18,1 ml/min/1.73 m2 and Upr: 2196±1091 mg/24H. The MEST-C scores were correlated with the serum creatinine level, proteinuria, and hematuria. The mean serum creatinine level was higher in M1, E1, S1, and T1 compared with score “0”. It was statistically significant (p = 0.03) only in the T-score. The mean proteinuria level was again higher in M1, S1, and T1 but reached statistical significance (p = 0.037) in only the T1-score. E1 has higher hematuria. The Upr/24H difference for dapagliflozin was −24.7% (95% CI −27.5, −23.2; p < 0.001) at the end of follow-up (month 12). Proteinuria reduction was similar across all eGFRs, age, and baseline proteinuria. Among MEST-C score parameters, T1 had a negative impact on the antiproteinuric effect of dapagliflozin (p = 0.01) No hypoglycemic events were reported and no deaths occurred. Conclusion In the present study, the use of SGLT2i was associated with a significant reduction of proteinuria in patients with IgA nephropathy and maximally tolerated RASi. We analyzed renal outcomes in association with pathologic features. We established that the presence of the T1 score has a negative impact on proteinuria reduction after SGLT2i treatment. Further studies are needed to investigate the impact of the use of the Oxford Classification score for developing individual treatment therapies.

#1847 Pregnancy impact on kidney transplant outcome

Abstract Background and Aims Renal transplantation improves the fertility of women of childbearing age. The possibility of a term pregnancy is one of the benefits of solid organ transplantation for women. Studies have also shown an increase in graft loss during and after pregnancy among sensitized patients and a higher risk of graft failure due to rejection in pregnancies occurring in the first and second-year post-transplantation. Most of these observations were found in studies using controls of non-pregnant recipients, but most did not match the study group in several critical clinical parameters, such as the gender of the controls, the creatinine level prepregnancy, or the cause of native kidney failure. The aim of our study is to investigate the long-term effects of pregnancy on graft function in female renal transplant recipients at Mansoura Urology and Nephrology center who experienced pregnancy after kidney transplantation. Method Retrospective cohort study conducted on 236 patients out of 3000 kidney transplant recipient who underwent renal transplantation (RT) at Mansoura Urology and Nephrology Centre between March 1976 and December 2019. divided into group I; 118 kidney transplant female's recipient experienced pregnancy at any time after kidney transplant and Group II; 118 kidney transplant female's recipients who didn`t experience pregnancy after renal transplantation, they were matched according to age and duration of renal transplantation and comparable in primary immunosuppressant drugs. all kidney recipients were reviewed for preoperative & operative and post-operative details also we record maternal and fetal complication. Results Our study included 118 kidney transplant recipients who got pregnant 191 times, 64 kidney transplant recipients got pregnant for the second time, while 9 of them got pregnant for the third time. We retrospectively evaluated the maternal, fetal complications and evolution of graft function after each pregnancy. Main maternal complications were gestational hypertension developed in 87 pregnancy cases out of 191 (45.5%), preeclampsia (25.1%), UTI (18.8%), gestational DM (9.9%), and graft rejection during pregnancy (4.1%). Longer hemodialysis duration (OR: 0.45, p value: 0.05), Calcineurin-based immunosuppressive protocols (Tacrolimus; OR: 2.3, p value: 0.02; Cyclosporine; OR: 0.36, p value: 0.007), Proteinuria more than or equal to 0.5 g/day (OR: 5.4, p value: 0.001) and/or serum creatinine more than or equal to 1.3 mg/dl (OR: 3.75, p value: 0.001) before pregnancy and rising of serum creatinine and/or proteinuria (Proteinuria; OR: 20.84, p value: 0.001; serum creatinine ≥1.3 mg/dl; OR: 4.3, p value: 0.001) are important risk factors associated with gestational hypertension. The mean serum creatinine level pre-pregnancy (mean ± SD) was (0.9 ± 0.2) mg/dL and 24-hour urinary protein mean ± SD before pregnancy was (0.4 ± 0.2) g/day. Serum creatinine and 24-hour urinary protein were higher during and after pregnancy with a statistically significant difference when compared to before pregnancy data (P-value: 0.001), (P- value: 0.04) retrospectively. At last follow-up, the majority of patients were alive with functioning graft with no statistically significant difference between two groups (P-value: 0.07), also no significant difference as regard graft failure incidence (p-value: 0.52). Conclusion Although the outcome of live births is favourable, the risks of maternal and fetal complications are high in kidney transplant recipients including pregnancy-induced hypertension, increased rates of preeclampsia, gestational diabetes, and caesarean section rates. The risk of miscarriage, prematurity, and low birth rate is also high. Serum creatinine and 24-hour urinary protein tend to increase during and after pregnancy which may impair the graft outcome. pregnancy counselling is necessary to avoid high-risk or unwanted pregnancies.

Evaluating Acetate as a Renoprotective Agent After Kidney Ischemia in a Porcine Model.

Objective: Renoprotection from reperfusion injury appears to be conferred by HIF-2a activation, which can be stimulated by exogenous acetate administration. The study objective was to assess whether administration of acetate in a porcine model can mitigate kidney injury related to ischemia-reperfusion after renal hilar occlusion. Methods: A porcine single-kidney model was created by performing a laparoscopic nephrectomy followed by animal recovery. After 2 days, the animals underwent laparoscopic hilar dissection. Block randomization was used to assign pigs into one of four experimental groups. One treatment block of pigs received 150 mEq of sodium acetate intravenously during 90 minutes of en bloc occlusion of the renal hilum (herein noted as "cross-clamping"). Another block received 0.75 g/kg of oral sodium acetate for 3 days prior to cross-clamping. A third block received no acetate and underwent hilar dissection without cross-clamping (negative control). The final block received no acetate and underwent cross-clamping (positive control). Serum creatinine was used to estimate renal function post-nephrectomy. Results: A total of 16 animals (4 pigs in each group) completed the study protocol. Median pig weight was 34.6 kg. One pig receiving IV acetate was excluded from the final analysis because of unrecoverable renal failure after cross-clamping. There was a significantly lower mean serum creatinine for the IV acetate group compared with the positive control group 72 hours after cross-clamping (p = 0.012). The same effect was not observed for the pigs receiving oral acetate. By day 7, renal function had recovered without significant difference in all groups. Conclusions: We observed that the administration of intravenous acetate conferred a significant renoprotective benefit in our single kidney ischemia-reperfusion porcine model 72 hours after hilar occlusion. This work is hypothesis-generating, and further work in human subjects undergoing renal hilar occlusion during partial nephrectomy is warranted.

REAL WORLD USAGE OF RANOLAZINE FOR ANTIARRHYTHMIC PURPOSES: SINGLE CENTER EXPERIENCE

Abstract Introduction Ranolazine is a late sodium current blocking drug developed as an antianginal agent, with good preliminary efficacy data even for antiarrhythmic purposes (both at atrial and at ventricular level). Objectives To evaluate patients’ clinical characteristics and antiarrhythmic efficacy of ranolazine in subjects with a history of atrial and/or ventricular arrhythmias, isolated or repetitive. Patients and methods we included patients who received a first prescription of ranolazine for antiarrhythmic purposes in our center from 1/2022 to 11/2023 and evaluated the survival free from major arrhythmic relapses/ablation. Results 93 patients were enrolled (66±13 years, 15% women): 59% with arterial hypertension, 26% diabetics, 46% with post–ischemic dilated heart disease, 32% with primary cardiomyopathy (including 11% with hypertrophic cardiomyopathy, 10% with LMNA, 14% with TTN), 46% with implantable cardioverter defibrillator, 9% with pacemaker. The mean LV ejection fraction was 42 ± 15%, the mean serum creatinine 1 ± 0.3 mg/dL. Half (50%) had a history of atrial arrhythmias in the 6 months before starting the drug, mainly paroxysmal atrial fibrillation (AF), 67% of ventricular arrhythmias (VAs), mainly isolated and repetitive premature ventricular beats (PVB, 47% of the total), but also sustained or treated VAs (n=18, 19%). Overall, 18% of patients had already undergone AF ablation, 13% ventricular tachycardia ablation, 3% cardiac sympathetic denervation. Finally, 95% of patients were on beta–blocker therapy and 28% were on amiodarone. Ranolazine was prescribed at an average initial dose of 535± 150 mg. The majority (54%) of patients (n=50) had a follow–up longer than 3 months (median 9 months, IQR 6–14); in 6% the drug was stopped due to intolerance and the average dose at the last FU was 641 ± 150 mg. Twenty–eight percent of patients with paroxysmal/persistent atrial arrhythmias had relapses, requiring ablation in 6%. Among patients with major VAs, 57% suffered recurrences, but only 19% required ablation (invasive in 2 cases, non–invasive in 1 case). Finally, among the patients with PVBs, none suffered major VAs or required PVB/VA ablation. Conclusions This is the largest available case–series reporting about the real–world usage of ranolazine for antiarrhythmic purposes. Our single center experience supports ranolazine’s good safety and tolerability and shows encouraging efficacy results in terms of clinical stabilization of complex patients.

Gentamicin concentration and acute kidney injury in term neonates treated for neonatal sepsis with gentamicin and ampicillin-cloxacillin combination.

Gentamicin is widely used to treat neonatal infections caused by both Gram-negative and Gram-positive bacteria, and the WHO recommends its use while monitoring serum creatinine and gentamicin concentrations to avoid drug-induced nephrotoxicity and ototoxicity. Yet in some resource-limited settings, the drug is used without monitoring. A population pharmacokinetics study involving term neonates with neonatal infection admitted to a neonatal unit. Participants were started on intravenous gentamicin 5 mg/kg once a day in combination with ampicilin-cloxacillin. Blood samples for serum gentamicin concentration were taken at 0.25, 0.5, 1, 2, 3, 5, 6, 8, 10, 12, 14, 16, 18, 20, 23, and 24 hours after the initial dose, each participant contributing two samples to the 24 hour sampling schedule. An additional sample for trough concentration was taken from each participant just before the third gentamicin dose while serum creatinine concentration was measured before and after treatment. Twenty-four participants were enrolled into the study and included in the final analysis. Mean (SD) peak and trough serum gentamicin concentrations were 16.66 (0.64) µg/mL and 3.28 (0.70) µg/mL, respectively. Gentamicin clearance (CL) was 0.40 mL min-1 kg-1 and volume of distribution (VD) was 0.31 L kg-1. Mean (SD) serum creatinine level after treatment was 209.7 (70.4) µmol/L compared to 103.3 (23.6) µmol/L before treatment [mean difference (106.4 ± 67.1; 95% confidence interval (CI): 78.1; 134.7 µmol/L; t (23) = 7.77; P < 0.001]. All participants fulfilled the Kidney Disease Improving Global Outcomes (KDIGO) criteria for acute kidney injury after treatment. Treatment of neonatal infection with antimicrobial regimen containing gentamicin, without renal function and gentamicin concentration monitoring, carries a significant risk for drug-induced acute kidney injury.

Exploring the Relationship Between Serum Phosphate Levels and Carotid Intima-Media Thickness in Chronic Kidney Disease Patients: A Correlational Analysis.

Background Compelling observational data suggestthat heightened levels of fasting blood phosphate are linked to a higher likelihood of cardiovascular disease, spanning across both the general populace and individuals grappling with chronic kidney disease (CKD). This study aimed to explore the possible correlation between carotid intima-media thickness (CIMT) and blood phosphate levels among those afflicted with chronic renal dysfunction. Objective The primary goal of this study is to determine the potential association between blood phosphate levels and CIMT in patients with CKD. Methodology In the department of nephrology, prospective research was conducted among patients who had a history of CKD. Atotal of 30 patients were included, with 20 males and 10 females. Every case had a thorough physical examination and history. Every patient underwent a laboratory evaluation, which included measurements of the CIMT and renal function testing. At a distance of 1 cm from the carotid bulb, the CIMTwas measured using B-mode ultrasonography. After compilation, the data were examined. Results The majority of the patients, according to this study, were male and over 50 years old. The Stage II patients in the study had a higher mean systolic blood pressure; however, the difference was not statistically significant. Patients with Stage V (D) disease exhibited higher diastolic blood pressure, but not statistically significant. An increase in the mean serum creatinine level that was statistically significant was linked to Stage V (D) renal disease. A higher mean blood urea was linked to Stage V (D) sickness; however, this relationship was not statistically significant. There was no statistical difference in the mean serum calcium levelsbetween the different stages of renal disease. Higher mean blood phosphate levels were linked to Stage III renal disease, but not in a statistically meaningful way. Although it was higher in Stage IV kidney disease, the mean CIMT was not statistically significant between the stages of renal illness. Conclusions Although a positive correlation was shown, a direct relationship between serum phosphate levels was not established by this investigation. The severity of renal disease has been demonstrated to correlate with elevated serum phosphate levels.

Assessment of High Serum Cystatin C as an Early Marker of Renal Impairment in Pre Eclampsia

Introduction: Preeclampsia is the most common medical complication during pregnancy and one of the leading causes of maternal and perinatal morbidity and mortality in Bangladesh. Kidney has role in both adaptive physiology of normal pregnancy and in pathophysiology of preeclampsia. Among the new biomarkers, serum Cystatin C can reliably reflect the GFR in both healthy and hypertensive pregnant women. It is important to evaluate the diagnostic efficiency of Cystatin C as a marker of renal function in preeclampsia. Aim: To assess high serum Cystatin C level as an early marker of renal impairment in pre-eclamptic patients. Materials and Methods: From March, 2021 to February, 2022 (A total of 12 months) a cohort study was conducted among 66 pregnant women, aged 18 to 40 years with pre-eclampsia and normal serum creatinine (0.5-0.8mg/dl) at their 20-28 weeks of gestation attending the antenatal clinic and admitted in the Department of Feto maternal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, selected by non random purposive and convenient sampling. Results: Out of 66 respondents, final analysis was done with 62 patients. Among 62 study samples, 76% patients had “High Cystatin C” level that was greater than 0.84 and renal impairment developed in 15% pregnant women. Majority of the participants were in 25-30 age groups (46.8%). The mean serum creatinine level of the pregnant women increased throughout follow up and it was statistically significant (p&lt;0.05) in both cases. No significant difference was found between serum Cystatin C in renal impaired and normal renal function pre eclampsia patients at a cut off value of 0.84. ROC analysis of serum Cystatin C level for detection of renal impairment among Pre eclamptic patients found a cut-off value of ≥1.49 showed the highest Youden index of 0.721. The sensitivity, specificity, PPV, NPV and accuracy of serum Cystatin C were 77.78%, 94.34%, 70.00%, 96.15% and 91.94%. Conclusion: Higher Cystatin C level in pre-eclampsia reflected renal impairment at an early stage even before conventional marker like serum creatinine raise. The diagnostic efficiency of Cystatin C as a marker of renal function in pre eclampsia can be used to reduce maternal morbidity and mortality of Bangladesh. Medicine Today 2023 Vol.36 (1): 12-16

Incidental Finding of Deranged Renal Function in Elderly Patients Presenting with Fractures in a Tertiary Care Hospital

Objective: To determine the incidental rate of renal impairment among elderly women with fractures who reported to the Orthopaedic OPD at a tertiary care Hospital. Methodology: This prospective cohort study was done at Orthopaedic department and OPD Fauji Foundation Hospital, Rawalpindi during a period of one year from March 2022 to February 2023. A total of 147 females aged &gt;60 years presented with Hip fractures, surgically managed and who had history of normal pre-fracture renal function were included. A 5ml blood sample was obtained and sent to the Hospital diagnostic laboratory to evaluate the renal profile, serum calcium and vitamin D levels. All the information was recorded via pre-structured study proforma. Results: The study enrolled 147 elderly participants with an average age of 66.82 years. Among the participants, 24 patients (16.3%) experienced Acute Kidney Injury (AKI), with 9.5% having stage-I AKI, 4.8% with stage II AKI, and 2.0% with stage III AKI. Before sustaining the hip fracture, the mean serum creatinine level was 67.04 µmol/L, and following the fracture, it increased to 81.95 µmol/L (p-value &lt; 0.0001). The severity of AKI did not exhibit a statistically significant correlation with the age of the patients. However, there was a statistically significant increase in serum creatinine levels among patients based on the duration of their fractures (p-value &lt; 0.001). Conclusion: The incidence of Acute Kidney Injury (AKI) in elderly patients following hip fractures was found to be 16.3%, with varying stages of severity.

Interstitial fibrosis increases the risk of end-stage kidney disease in patients with lupus nephritis.

To evaluate the risk of end-stage kidney disease (ESKD) in LN patients using tubulointerstitial lesion scores. Clinical profiles and histopathological presentations of 151 biopsy-proven LN patients were retrospectively examined. Risk factors of ESKD based on characteristics and scoring of their tubulointerstitial lesions [e.g. interstitial inflammation (II), tubular atrophy (TA) and interstitial fibrosis (IF)] were analysed. The mean age of 151 LN patients was 36 years old, and 136 (90.1%) were female. The LN cases examined included: class I/II (n = 3, 2%), class III/IV (n = 119, 78.8%), class V (n = 23, 15.2%) and class VI (n = 6, 4.0%). The mean serum creatinine level was 1.4 mg/dl. Tubulointerstitial lesions were recorded in 120 (79.5%) patients. Prior to receiving renal biopsy, nine (6.0%) patients developed ESKD. During the follow-up period (mean, 58 months), an additional 47 patients (31.1%) progressed to ESKD. Multivariate analyses identified serum creatinine [hazard ratio (HR): 1.7, 95% CI: 1.42-2.03, P < 0.001] and IF (HR: 3.2, 95% CI: 1.58-6.49, P = 0.001) as independent risk factors of ESKD. Kaplan-Meier analysis further confirmed a heightened risk of ESKD associated with IF. Tubulointerstitial involvement is commonly observed in the histopathological presentation of LN. However, IF, rather than II or TA, was found to increase the risk of ESKD in our cohort. Therefore, to predict renal outcome in LN patients prior to adjusting immunosuppressive treatment, the degree of IF should be reviewed.

A Chinese patent medicine's long-term efficacy on non-dialysis patients with CKD stages 3-5: a retrospective cohort study.

Chinese patent medicine is commonly used in China as an important treatment mechanism to thwart the progression of chronic kidney disease (CKD) stages 3-5, among which Niaoduqing granules are a representative Chinese patent medicine; however, its long-term efficacy on CKD prognosis remains unclear. Patients were grouped according to Niaoduqing granule prescription duration (non-Niaoduqing granule (non-NDQ) group vs Niaoduqing granule (NDQ) group). Serum creatinine (SCr) variation was compared using a generalized linear mixed model (GLMM). Multivariate Cox regression models were constructed, adjusting for confounding factors, to explore the risk of composite outcomes (receiving renal replacement therapy (RRT) or having an estimated glomerular filtration rate (eGFR)<5mL/min/1.73 m2, ≥50% decline in the eGFR from the baseline, and doubling of SCr) in individuals consuming Niaoduqing granules. A total of 1,271 patients were included, with a median follow-up duration of 29.71 (12.10, 56.07) months. The mean SCr Z-scores for the non-NDQ group and NDQ group were -0.175 and 0.153, respectively, at baseline (p = 0.015). The coefficients of the NDQ group from visit 1 to visit 5 were -0.207 (95% CI: -0.346, -0.068, p = 0.004), -0.214 (95% CI: 0.389, -0.039, p = 0.017), -0.324 (95% CI: 0.538, -0.109, p = 0.003), -0.502 (95% CI: 0.761, -0.243, p = 0.000), and -0.252 (95% CI: 0.569, 0.065, p = 0.119), respectively. The survival probability was significantly higher in the NDQ group (p = 0.0039). Taking Niaoduqing granules was a significant protective factor for thwarting disease progression (model 1: HR 0.654 (95% CI 0.489-0.875, p = 0.004); model 2: HR 0.646 (95% CI 0.476, 0.877, p = 0.005); and model 3: HR 0.602 (95% CI 0.442, 0.820, p = 0.001)). The long-term use of Niaoduqing granules improved SCr variation and lowered the risk of CKD progression by 39.8%.

Rituximab treatment in resistant lupusnephritis: A single-center prospective study.

Lupus nephritis (LN) is a serious manifestation of systemic lupus erythematosus (SLE) and failure to respond to traditional immunosuppression increases morbidity and mortality. Rituximab has been considered a novel therapeutic option for the management of SLE. We conducted a single-center, prospective, observational study from July 2018 to June 2019 to evaluate the effectiveness of rituximab in patients with resistant LN. Resistant LN was defined as the failure to respond to conventional immunosuppressive therapy including both cyclophosphamide and mycophenolate mofetil. All adult patients (>18 years) with biopsy-proven class III/IV LN were included in the study. Four doses of intravenous rituximab (375 mg/m2) on 0, 1, 2, 3 weeks were administered. Patients were followed for 6months, and the rates of complete renal response (CRR), partial renal response (PRR), or no renal response (NRR) were measured. The change in baseline 24-hour urine protein, mean serum creatinine levels, and mean serum CD-19 levels at 24 weeks were also measured. Six months after rituximab therapy, total sustained renal response (CRR+PRR) was observed in 52% cases of resistant LN (CRR was achieved in 24% of patients and PRR in 28%, respectively). Rituximab was associated with a significant decline in the 24-hour urine protein, even in non-responders. However, the improvement in eGFR and serum creatinine was not statistically significant. The mean absolute CD-19 count was significantly low in responders compared to the non-responder group. Rituximab is a safe and effective therapeutic strategy for patients with resistant LN.

Serum Zinc and Copper Levels in Children with Thalassemia Major

Background: Thalassemia is a frequent hereditary genetic with different clinical manifestations from mild to severe based on its genetic. Beta thalassemia major is the worse form of this disease caused by decreased or absent beta globin chains of hemoglobin. Regular blood transfusion is the main aim leads to iron overload and deposition of iron in different organs.Objectives: To determine different serum distribution levels and correlation of copper and zinc in transfusion dependent thalassemia patients Material and Methods: This was a descriptive cross-sectional study in which a non-probability convenient sampling technique was used for sample collection. This study was conducted in KPK in a total of 137 patients, who were diagnosed cases of thalassemia major by hemoglobin electrophoresis, enzyme linked immunosorbent assay (ELISA) method and receiving iron and folate therapy. SPSS version 22 was used and Pearson's correlation coefficient was applied. P-value 0.05 was considered significant.Results: In this study mean age was 6.7±3.49 years. 77 (56%) percent children were male while 64 (44%) children were female. Mean hemoglobin (Hb) level was 7.43±1.3 gm/dl. Mean SGPT score was 26.28 ± 7.51. Mean blood urea was 21.10 ± 8.49 mmol/l while mean serum creatinine level was 0.56 ± 0.26 mg/dl. Mean serum zinc level was 13.36 ± 11.12mg/dl while mean serum copper level was 1.21± 0.60 mg/dl and mean serum ferritin level was 6682 ± 533 Ug/l.Conclusion: This study showed hypozincemia in thalassemia major patients, but copper deficit was not present. There was no substantial variance between serum ferritin level and mean serum concentration of zinc and copper in this study. Ancillary assessments in this respect is recommended. Keywords: Copper, Thalassemia, Zinc

Improvement in Thrombocytopenia after Direct Acting Anti-Viral (DAA)Therapy in Patients with Hepatitis C Virus-Related Chronic Liver Disease in Pakistani Population-A Single Centered Study

Background: Hepatitis C Virus (HCV) infection remains a significant global health challenge, often leading to chronic liver diseases such as cirrhosis and associated complications like thrombocytopenia. Directly acting antivirals (DAAs) have revolutionized HCV treatment due to their high efficacy and favorable safety profiles but the impact on thrombocytopenia, particularly in the Pakistani population, has been less studied. Objective: This study aimed to evaluate the effects of DAA therapy on platelet count and other laboratory parameters in chronic HCV patients with thrombocytopenia in Pakistan and to establish correlations between treatment outcomes and baseline laboratory values. Methods: A retrospective observational study was conducted at the Sindh Institute of Urology and Transplantation from January 2018 to December 2022. Patients with chronic HCV genotype 3a infection, compensated cirrhosis, and a baseline platelet count of less than 150 × 10^9/L were included. Exclusion criteria encompassed decompensated liver disease, liver cancer, and other specific conditions. The treatment regimens were Sofosbuvir plus Daclatasvir or Velpatasvir plus Ribavirin over three months. Parameters such as complete blood counts, serum creatinine, liver enzymes, and Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease (MELD) scores were recorded at baseline and post-treatment. Statistical analysis was performed using SPSS version 25, employing paired t-tests and Pearson correlation coefficients. Results: A total of 195 patients were studied, with a mean baseline platelet count of 100.7 × 10^9/L, which significantly increased to 122.2 × 10^9/L post-treatment (p &lt; 0.001). Improvements were also noted in mean serum creatinine (0.96 mg/dL to 0.87 mg/dL; p = 0.009), total bilirubin (1.6 mg/dL to 1.2 mg/dL; p &lt; 0.001), liver enzymes (ALT from 63.9 IU to 45.9 IU; p &lt; 0.001 and AST from 86.8 IU to 59.5 IU; p &lt; 0.001), and MELD scores (11.5 to 9.3; p &lt; 0.001). Hemoglobin levels and total leukocyte counts also showed significant improvements. Conclusion: DAA therapy significantly improves platelet counts and other laboratory parameters in chronic HCV patients with thrombocytopenia, suggesting a positive impact on liver function and patient management. This study highlights the importance of DAAs in the therapeutic regimen for HCV in the Pakistani population, contributing to better clinical outcomes and healthcare practices.

Distinguishing Clinical Features of Cannabinoid Hyperemesis Syndrome and Cyclic Vomiting Syndrome: A Retrospective Cohort Study

ObjectiveTo identify clinical characteristics that distinguish cannabinoid hyperemesis syndrome (CHS) from cyclic vomiting syndrome (CVS), two conditions marked by episodes of nausea, vomiting, and abdominal pain. Study designWe performed a retrospective chart review of patients admitted to a large children’s healthcare system from 2015 through 2022. CHS and CVS patients were identified by the electronic medical record using ICD-9/10 codes. ResultsOf 201 patients screened, 125 were included. CHS patients were older than those with CVS (mean [SD] 18.06 [1.41] vs. 14.50 [2.91] years, p<0.001). There were no significant differences in gender, race, ethnicity, or hospital length of stay between groups. CHS patients were more likely to have a positive urine drug screen (86% vs. 2.9%, p<0.001), lower mean (SD) serum potassium (3.62 [0.77] vs. 3.88 [0.49], p<0.001), and higher mean (SD) serum creatinine (0.83 (0.41) vs. 0.63 (0.17), p<0.001). The average (SD) systolic blood pressure (SBP) was significantly higher in CHS patients (SBP 124.46 [10.66] vs. 118.55 [10.99], p=0.032) compared with CVS children of comparable age range. Imaging was obtained in 36% of all patients and only 2.4% had abnormalities. ConclusionsClinical features including older age, higher systolic blood pressure, positive urine drug screen, and select electrolyte findings might distinguish CHS from CVS. Abdominal imaging in both conditions is of low yield. These findings may allow for early recognition and appropriate therapy in CHS patients.

Serum Biochemical Evaluation of Patients with Chronic Renal Failure on Hemodialysis

Introduction: Chronic renal failure (CRF) is associated with aberrations in the metabolism of minerals, such as calcium, phosphates, sodium, and potassium and other biochemical parameters. Various studies have identified parathyroid hormone (PTH) as the main regulator of minerals and biochemical parameters homeostasis. This study was conducted to evaluate the biochemical profile in CRF patients on hemodialysis in Aden. Methods: This study is a descriptive, cross sectional study, conducted in Aden Hemodialysis Center for the period Jan.1st to June 30th, 2022. Included 82 patients with CRF on HD. The data collected included demographic with clinical data, and blood samples taken for complete blood count and serum creatinine; urea; sodium; potassium; total calcium, ionized calcium; phosphate; alkaline phosphatase, and parathyroid hormone. Results: More male were found than female patients with CRF (67.1% vs. 32.9% respectively), with a mean age of 48.8 ± 12.6 years. The mean body mass index was (23.3 ± 4.7 kg/m2) and the mean duration of CRF was (4.8 ± 2.9 years). For renal function, the mean serum creatinine, urea, and estimated creatinine clearance were (9.9 mg/dl, 128.6 mg/dl, and 7.1 mL/min per 1.73 m2 respectively). For minerals, the mean serum sodium, potassium, chloride, phosphorus, calcium and ionized calcium were (134.4 mmol/L, 5.04 mmol/L, 104.1 mmol/L, 4.37 mg/dl, 9.4 mg/dl, and 1.12 mmol/L, respectively). The mean Calcium x Phosphorus product was in the recommended range (40.7mg2/dl2). The mean alkaline phosphatase was (286.2 U/L), and the mean parathyroid hormone was (322.7 pg/ml). Secondary hyperparathyroidism (PTH level of ≥130 pg/ml) was detected in (58.5%) of them. Parathormone concentration showed significant positive correlation to alkaline phosphatase (r: 0.640, p:0.001) in patients with CRF on hemodialysis. Conclusion: This study concluded that in patients with CRF on HD, there is an increase level of alkaline phosphatase which is considered as an adjunct marker of high-turnover bone disease associated with disturbed level of calcium and phosphorus that increase serum PTH level.

Gender disparity in maintenance hemodialysis units in South India: a cross-sectional observational study.

Diseases manifest differently according to gender in many medical specialties. However, sex differences in kidney diseases have not been well explored worldwide, especially in India. These differences could also be attributed to sociocultural factors. Although CKD is more prevalent in women worldwide, most men are initiated on kidney replacement therapy (KRT). This study aimed to examine sex disparities in patients on maintenance hemodialysis. A cross-sectional observational study was conducted in two maintenance hemodialysis units at the Institute of Nephrourology, a tertiary care referral government center in Bengaluru, India. Demographic characteristics and laboratory parameters were also recorded. In total, 374 adult patients (aged >18 years) were included in the study. Most patients (72.7%) were men. Mean age in men was 46.95 ± 12.65 years, and women was 46.63 ± 13.66 years. There was no significant difference in marital status and the availability of caretakers between the groups. Spouses were the predominant caretakers for both sexes (64% men and 51% women, P = 0.14). Sons cared more for patients with mother than fathers (19.6% vs 8.8%, P = 0.074). Diabetic nephropathy was the most common cause of ESKD in both groups (33.1% vs 31.3%, P = 0.92). Men had a significantly longer duration of HTN and received more HD sessions per week than women. Mean hemoglobin (9.9 ± 1.79 vs 9.46 ± 1.47 g%) and mean serum creatinine (7.76 ± 2.65 vs 6.41 ± 2.27 mg/dl) were higher in men compared to women (P <0.002). Intradialytic complications, such as hypotension and cramps, were significantly more common in women than in men (P = 0.004). Most men (47.1%) were planning a kidney transplant (and were waitlisted) compared with fewer women (43%). There was no significant difference in the average number of hospitalizations per month or HD vintage. Women tend to initiate dialysis later, and a lesser number are waitlisted for kidney transplantation, which might be partly related to varying access to or delivery of health care services. Factors such as lack of education, insufficient identification of and strategies to address cultural obstacles to healthcare, and a shortage of financial means to afford medical care are potentially correctable elements that might explain this discrepancy.

Comparison of resistive index and shear-wave elastography in the evaluation of chronic kidney allograft dysfunction.

Detection of early chronic changes in the kidney allograft is important for timely intervention and long-term survival. Conventional and novel ultrasound-based investigations are being increasingly used for this purpose with variable results. To compare the diagnostic performance of resistive index (RI) and shear wave elastography (SWE) in the diagnosis of chronic fibrosing changes of kidney allograft with histopathological results. This is a cross-sectional and comparative study. A total of 154 kidney transplant recipients were included in this study, which was conducted at the Departments of Transplantation and Radiology, Sindh Institute of Urology and Transplan tation, Karachi, Pakistan, from August 2022 to February 2023. All consecutive patients with increased serum creatinine levels and reduced glomerular filtration rate (GFR) after three months of transplantation were enrolled in this study. SWE and RI were performed and the findings of these were evaluated against the kidney allograft biopsy results to determine their diagnostic utility. The mean age of all patients was 35.32 ± 11.08 years. Among these, 126 (81.8%) were males and 28 (18.2%) were females. The mean serum creatinine in all patients was 2.86 ± 1.68 mg/dL and the mean estimated GFR was 35.38 ± 17.27 mL/min/1.73 m2. Kidney allograft biopsy results showed chronic changes in 55 (37.66%) biopsies. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of SWE for the detection of chronic allograft damage were 93.10%, 96.87%%, 94.73%, and 95.87%, respectively, and the diagnostic accuracy was 95.45%. For RI, the sensitivity, specificity, PPV, and NPV were 76.92%, 83.33%, 70.17%, and 87.62%, respectively, and the diagnostic accuracy was 81.16%. The results from this study show that SWE is more sensitive and specific as compared to RI in the evaluation of chronic allograft damage. It can be of great help during the routine follow-up of kidney transplant recipients for screening and early detection of chronic changes and selecting patients for allograft biopsy.