Nephrology Outpatient Department Research Articles

Serum Antidiuretic Hormone Level in Nocturnal Enuretic School Children in a Tertiary Care Hospital in Bangladesh: A Cross-Sectional Study.

Primary nocturnal enuresis (PNE) is a common pediatric condition characterized by involuntary nighttime bed wetting. Primary monosymptomatic nocturnal enuresis (PMNE) is associated with altered antidiuretic hormone (ADH) secretion and lacks lower urinary tract symptoms. This study aimed to compare serum ADH levels between children with PMNE and a comparison group to explore its potential role in the pathophysiology of PMNE. This cross-sectional study included 40 children aged 6-15 years with PMNE and 40 age-matched children without enuresis (comparison group) attending the Pediatric Nephrology Outpatient Department at the National Institute of Kidney Diseases and Urology (NIKDU) from January 2022 to July 2023. Blood samples and other clinical information along with laboratory investigation are done to ensure inclusion and exclusion criteria. Fasting serum ADH level, a competitive immunoassay was done with the Arg- Vasopressin ELISA kit. Relevant clinical and demographic data were analyzed using Student's t-test for continuous variables and Chi-square/Fisher's exact tests for categorical variables. The mean age of participants was 8.82 ± 2.71 years in the PMNE group and 9.01 ± 2.54 years in the comparison group (p = 0.760). There was no significant association between sex and PMNE (p = 0.370). Children with PMNE exhibited significantly lower serum ADH levels compared to the comparison group (p < 0.05). Additionally, children with more frequent enuretic episodes demonstrated a trend of lower ADH levels (p < 0.05). This study provides evidence of a significant association between decreased diurnal serum ADH levels and PNE in children. These findings contribute to a better understanding of the pathophysiology of PNE and suggest potential avenues for novel treatment strategies, emphasizing the importance of evaluating ADH levels in PNE management.

The Assessment of Illness Perception among Patients with Chronic Kidney Disease

Background: Chronic Kidney Disease (CKD) is a significant global health concern, affecting approximately 14.5% of the world’s population. This high prevalence, influenced by factors such as aging populations and comorbidities like hypertension and diabetes, is linked with increased mortality and morbidity. Understanding patients' illness perception is crucial for improving adherence to treatment plans and overall disease management, as perceptions can greatly impact their health behaviours and outcomes. Objective: The objective of this study was to assess illness perception among patients with chronic kidney disease (CKD) by analysing levels of perception (low, moderate, good) using descriptive statistics. Methods: A descriptive cross-sectional study design was employed to evaluate the illness perception among CKD patients. A convenience sampling method was used to select a total sample size of 133 patients attending the nephrology outpatient department of Services Hospital, Lahore. The study utilized an adapted and translated Illness Perception Questionnaire to collect data, which was analysed using frequency distribution and descriptive statistics. Data normality was verified to ensure the reliability of findings. Results: The study revealed that among the 133 participants, 47 (35.3%) had a low level of illness perception, 41 (30.8%) demonstrated a moderate perception, and 45 (33.8%) exhibited a good perception. The majority of participants showed poor illness perception, indicating a need for interventions to enhance patient education and disease management strategies. Conclusion: The study concluded that a significant proportion of CKD patients exhibit poor illness perception, which could negatively impact disease management and treatment adherence. Future strategies should focus on targeted interventions to improve patients’ understanding and management of their condition.

Prevalence of urinary metabolic disorders and risk factors of kidney stones in Iranian children

Introduction: Nephrolithiasis and urolithiasis, characterized by the formation of calculi in the kidney and lower urinary tract, respectively, pose a significant health concern for millions of children worldwide, particularly in developing countries. Objectives: This research aims to explore the prevalence of abnormal concentrations of urinary solutes as potential risk factors for kidney stones in Iranian children under the age of 14 years. Patients and Methods: A cross-sectional investigation spanning from January 2021 to January 2022 targeted children diagnosed with nephrolithiasis or urolithiasis through renal sonography, who were subsequently referred to the nephrology outpatient department of our hospital or our private pediatric nephrology office. Laboratory assessments encompassed urine calcium, oxalate, citrate, uric acid, creatinine, and urine cystine. Demographic attributes, stone composition (when available), and urinary metabolic disorders were scrutinized. Data analysis involved SPSS version 24, utilizing descriptive statistics such as mean, standard deviation, and frequency, categorized by variable type. Chi-square tests were employed for statistical analysis, with a significance threshold set at P&lt;0.05. Results: The study encompassed 486 children, with a mean age of 55.58 months and a male majority of 50.8%. Among those with kidney stones, 77.2% exhibited unilateral stones, while 22.8% presented with bilateral stones. Predominant urinary metabolic disorders included hypercalciuria (30.2%), hyperuricosuria (22.6%), and hyperoxaluria (20.6%). Notably, 25.7% of the children manifested a combination of multiple metabolic disorders. Significant variations in the prevalence of hyperuricosuria were observed across different age groups. Boys exhibited higher incidences of hypercalcemia and metabolic abnormalities compared to girls, though no statistically significant differences were noted in other disorders. Conclusion: In summary, our findings indicate the presence of abnormal urinary metabolic risk factors in over half of children diagnosed with kidney stones. Hypercalciuria was the more frequent risk factor following hyperuricosuria and hyperoxaluria, cystinuria with prevalence of 30.2%, 22.6%, 20.6%, and (2.1%) respectively.

Evaluation of self medication practices and prescription patterns in patients of chronic kidney disease: A cross-sectional, questionnaire based study.

Pharmacotherapy of chronic kidney disease (CKD) consists of prescribing myriad of drugs such as antihypertensives, antidiabetics, and phosphate binders to delay disease progression and control the comorbidities, resulting in inherent variability in prescriptions. In addition, tendency to self-medicate may further aggravate the condition. Hence, the present study was planned to assess self-medication practices and variability in prescription patterns in CKD patients. A cross-sectional, questionnaire-based study approved by the ethics committee was conducted in CKD patients attending the nephrology outpatient department. The prescription details which included drug name, dosage form, dose, frequency, duration, and dosage instructions were recorded and prescription completeness was checked. To assess the tendency of CKD patients to self-medicate, each patient was administered a prevalidated [Content Validity Ratio (CVR) = 0.76] 8-item questionnaire which had dichotomous responses "Yes" and "No" and was scored as 2 and 0, respectively (total score 16). Three hundred CKD patients (150 on hemodialysis and 150 nondialysis) yielded 300 prescriptions with 1272 drugs. It was evident that 33% of patients did self-medicate themselves with analgesics, and the mean score (7.81 ± 3.01) of self-medication practices was perceived significantly higher in the nondialysis group (8.41 ± 3.46). The most common classes of drugs prescribed in CKD patients were calcium channel blockers (41%), antidiabetic drugs (39%), diuretics (35%), gastrointestinal drugs (35%), and multivitamins (27%), with the average number of drugs being 5.84 ± 0.51. Nearly one-third of CKD patients were self-medicating with paracetamol, nonsteroidal anti-inflammatory drugs; more in the nondialysis group emphasizing reinforcement of patient education programs. The most common drugs prescribed were amlodipine, followed by metformin, and the average number of drugs was less in our setting, indicating vigilant dose prescribing in CKD patients.

The Impact of Frailty and Severe Cognitive Impairment on Survival Time and Time to Initiate Dialysis in Older Adults With Advanced Chronic Kidney Disease: A Prospective Observational Cohort Study.

Background and objectives Frailty and cognitive impairment significantly impact survival time and time to initiate dialysis in older adults with advanced chronic kidney disease (CKD). This study aims to evaluate the effects of frailty and cognitive impairment on these outcomes and determine the most effective assessment tool for predicting early dialysis initiation and short survival time. Materials and methods This prospective observational cohort study involved 240 patients aged ≥65 years with stage 4 or 5 CKD, recruited from a nephrology outpatient department (ambulatory care) between March 2020 and March 2021. Frailty was assessed using the Physical Frailty Phenotype (PFP), PRISMA-7, Clinical Frailty Scale (CFS), and FRAIL scale. Cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA). The primary outcomes were time to initiate dialysis and survival time, with secondary outcomes including hospitalization rates, length of stay, and mortality after dialysis initiation. Results Frail patients only showed significantly shorter timeto dialysis initiation when identified by the PFP and FRAIL scale (28.3 months for frail vs. 31.2 months for non-frail, p = 0.028; 26.9 months for frail vs. 30.9 months for non-frail, p = 0.038). The PFP, FRAIL, and CFS tools indicated significantly shorter survival times for frail patients compared to non-frail patients (26.8 months for frail vs. 30.6 months for non-frail, p = 0.003). Frailty is strongly correlated with severe cognitive impairment, as 45.5% of frail patients (according to the FRAIL scale) have dementia compared to 15.1% of non-frail patients (p<0.001). However, cognitive impairment did not significantly affect the time to dialysis initiation or survival time. Hospitalization rates and length of stay in the hospital were significantly higher only for frail patients identified by PRISMA-7, with a median hospital length of stay of 9.15 days for frail patients vs 6.37 days for non-frail patients (p = 0.044). Overall, 37.5% of the patients did not survive during the study follow-up, with frail patients having a higher mortality rate. Conclusion Frailty, mainly when assessed by PFP and FRAIL, is a significant predictor of early dialysis initiation and reduced survival time in older adults with advanced CKD. Cognitive impairment, while prevalent, did not independently predict these outcomes. Regular frailty screening should be incorporated into CKD management to tailor interventions and improve patient outcomes.

Comparison of routine office blood pressure measurement versus standardized attended manually activated oscillometric office blood pressure measurement in patients with chronic kidney disease.

Erroneous blood pressure measurement could lead to improper treatment and hence progression of chronic kidney disease (CKD). In routine clinical practice, there is poor adherence to the various steps to be followed during blood pressure measurement. Automated oscillometric BP measurement is difficult to perform in routine clinical practice due to several practical limitations. To evaluate the quality of blood pressure measurement and to compare routine office blood pressure measurement with standardized attended manually activated oscillometric blood pressure measurement in patients with CKD attending the nephrology outpatient department (OPD) of a tertiary care referral center. This cross-sectional study was conducted in patients aged more than 18 years with CKD stage 3-5ND, and previously diagnosed hypertension, in the nephrology OPD of a tertiary care referral center between July 2022 and September 2022. The quality of blood pressure measurement was evaluated using a questionnaire. The study participants had their blood pressure checked by both methods-routine office blood pressure and standardized attended manually activated oscillometric blood pressure. Standardized attended manually activated oscillometric blood pressure measurement yielded a significantly higher systolic blood pressure (SBP) compared to routine office blood pressure measurement (Mean SBP: 139.53 ± 29.1 vs 132.57 ± 23.59; P < 0.001). However, the diastolic blood pressure did not differ significantly between the two methods of measurement. Standardized attended manually activated oscillometric BP measurement yields a higher systolic BP compared to routine office BP measurement. Further studies are required to compare the standardized attended oscillometric BP measurement used in this study with unattended automated oscillometric BP measurement and ambulatory BP measurement.

ANALYSIS OF DRUG UTILIZATION PATTERN IN CHRONIC KIDNEY DISEASE PATIENTS IN A TERTIARY CARE HOSPITAL, SOUTH INDIA

Objective: The objective of the study is to assess the drug utilization pattern of various drugs prescribed in chronic kidney disease (CKD) patients in a tertiary care hospital. Methods: As a cross-sectional study 200 prescriptions were randomly selected from both the nephrology outpatient department and the inpatient ward. Patient demographics details, CKD staging, classes of drugs prescribed, and number of drugs prescribed were noted and data were analyzed with the World Health Organization core prescribing indicators. Results: Incidence of CKD is more common in the age group of 40–50 years (45%) with male predominance (70%). Hypertension, diabetes, and anemia are the common comorbid conditions seen with CKD. Anti-hypertensives, anti-anemic drugs, calcium supplements, and anti-diabetic drugs are the commonly prescribed drugs in CKD. Number of prescription contains that generic names are near optimal and drugs from the National List of Essential Medicine are optimal. Majority of the prescriptions contain on average 5 drugs. Conclusion: Diabetes and high blood pressure are the two most common causes of CKD with male dominance. Since polypharmacy is common in CKD patients , they should be monitored for drug – drug interaction and adverse drug reactions.

Knowledge, Attitude, and Perceived Barriers of Arteriovenous Fistula among Chronic Kidney Disease Patients Attending a Tertiary Care Center

Abstract Introduction: Chronic kidney disease (CKD) affects 11% of the adult population worldwide. Hemodialysis (HD) therapy can be through either arteriovenous fistula (AVF), arteriovenous graft, or central venous catheter. Although AVF has better outcomes, many factors are responsible for its underutilization. Materials and Methods: A cross-sectional study was conducted in a tertiary care hospital among all adult patients diagnosed with CKD registered in the nephrology outpatient department for 3 months. The patients were subjected to a structured questionnaire. The questionnaire consisted of four parts, namely sociodemographic details, patients’ knowledge regarding AVF, attitude toward AVF, and perceived barriers toward the procedure. Data were analyzed using SPSS V-21. Demographic and knowledge data were summarized by calculating means and standard deviation. Attitudes and perceived barriers were analyzed as categorical variables. Association between categorical variables was done using the Chi-square test. Results: The mean age of the study participants was 52.24 (±15.47) years. The major cause of end-stage renal disease was hypertension (35.3%). Adequate knowledge was found to be among 79.8% of patients; which was significantly associated with patients who had dialysis session &gt;150 times and who underwent AVF. 65.5% of patients would recommend AVF to others who are undergoing HD. Fear of needles (18%) was found as a major barrier to undergoing AVF. Conclusion: A systematic health education regarding the advantages of AVF over other VA methods can be done before initiating HD which can reduce the perceived barriers. This will aid in increasing the acceptance of AVF procedure among CKD patients.

Demographic profile, spectrum, awareness, and cost of renal replacement therapy of chronic kidney disease patients in a public tertiary care center in Rajasthan, India

Objectives: Chronic kidney disease (CKD) is widely recognized as the leading cause of death worldwide. Diabetes and hypertension are common risk factors. This is the only study on CKD from Rajasthan that highlights basic CKD profiles in patients attending public tertiary care centers. Materials and Methods: This observation study included diagnosed cases of CKD attending nephrology outpatient department (OPD) from January to December 2020. Data regarding the cause of CKD, its stage, mode of renal replacement therapy (RRT), and direct cost of medication were collected. The state runs various schemes, including free dialysis facilities for all, below-poverty level cards (below poverty line [BPL] cards, which had complete free treatment), and state health cards Bhamasha Swasthya Bima Yojana (BSSY) under the government scheme. Results: A total of 252 patients were included in the study. Patients on dialysis were highest, followed by stage V and stage IV CKD, representing 33.73%, 18.65%, and 17.86%, respectively. Hypertension was the predominant cause of CKD, representing 29.37% and CKD (u) prevalence in our study was 14.68%. The direct cost of treatment at CKD stages I, II, III, IV, and V were Rs. 520 ($6.93), Rs. 2435.71 ($32.48), Rs. 3400 ($45.33), Rs. 3405.57 ($45.41), and Rs. 4815.97 ($64.21) per month, respectively. The monthly medicine cost of treatment on hemodialysis was Rs. 6730.60 ($89.74), Rs. 30,278 ($403.71) on peritoneal dialysis, and Rs. 5021.74 ($66.96) on renal transplant. BPL card holders were 8.33%, 39.68% had BSSY card, 16.27% had Insurance, and around one-third (35.71%) were without support. Conclusion: Age, socioeconomic status, and geographical location affect CKD etiology. The accessible dialysis facility, insurance, and government policies affect the selection of the RRT.

Shared decision-making for renal replacement treatment and illness perception in patients with advanced chronic kidney disease

BackgroundCurrent healthcare trends emphasize the use of shared decision-making (SDM) for renal replacement treatment (RRT) in patients with chronic kidney disease (CKD). This is crucial to understand the relationship between SDM and illness perception of CKD patients. Few studies have focused on SDM and illness perception status of CKD patients and the impact of illness perception on RRT after SDM.MethodsIn this cross-sectional study, we used a questionnaire with purposive sampling from March 2019 to February 2020 at the nephrology outpatient department of a medical center in southern Taiwan. The nephrology medical team in this study used the SHARE five-step model of SDM to communicate with the patients about RRT and Brief Illness Perception Questionnaire (BIPQ) was applied to evaluate illness perception of these patients at the beginning of SDM. According to the SDM decision time, the study participants were classified general and delayed SDM groups. The distribution between SDM groups was estimated using independent two sample t-test, chi-squared test or Fisher’s exact test. The correlation between illness perception and SDM decision time were illustrated and evaluated using Spearman’s correlation test. A p-value less than 0.05 is statistically significant.ResultsA total of 75 patients were enrolled in this study. The average time to make a dialysis decision after initiating SDM was 166.2 ± 178.1 days. 51 patients were classified as general group, and 24 patients were classified as delayed group. The median SDM decision time of delayed group were significantly longer than general group (56 vs. 361 days, P < 0.001). Our findings revealed that delayed group was significantly characterized with not created early surgical assess (delayed vs. general: 66.7% vs. 27.5%, p = 0.001) compared to general group. The average BIPQ score was 54.0 ± 8.1 in our study. We classified the patients into high and low illness perception group according to the median score of BIPQ. The total score of BIPQ in overall participants might increase by the SDM decision time (rho = 0.83, p = 0.830) and the linear regression line also showed consistent trends between BIPQ and SDM decision time in correspond cohorts. However, no statistically significant findings were found.ConclusionsThe patients with advanced chronic kidney disease took an average of five and a half months to make a RRT decision after undergoing SDM. Although there is no statistical significance, the trend of illness perception seems correlated with decision-making time. The stronger the illness perception, the longer the decision-making time. Furthermore, shorter decision times may be associated with earlier establishment of surgical access. We need more research exploring the relationship between illness perception and SDM for RRT in CKD patients.

Alexithymia; an often missed condition prevelant in the practice of nephrology

Aim: Alexithymia is a disorder associated with difficulty in recognizing and expressing feelings, which can lead to an increased susceptibility to disease development that makes alexithymia a possible risk factor for chronic kidney disease (CKD). This study was performed to evaluate for alexithymia in pre-dialysis CKD and end-stage renal disease patients undergoing hemodialysis.Material and Method: The study was conducted in the Nephrology Outpatient Department and Hemodialysis unit of Ümraniye Research and Training Hospital. The patients had to have a diagnosis of CKD. Demographic data form, routine biochemical follow up data of patients, Toronto Alexithymia Scale (TAS), and Hospital Depression and Anxiety Scale (HADS) were used in this study. The statistical significance level was determined as p&amp;lt;0.05.Results: A total of 111 patients (mean age 58.10±13.48 years, 61% female) were included in the study, 83.9% of whom were found to have alexithymia. The incidence of alexithymia in CDK patients was significantly higher than that in the control group (p=0.004); however, no statistically significant difference was detected in its incidence between the hemodialysis and pre-dialysis groups (p&amp;gt;0.05). The results showed that increased incidence of depression resulted in a 4.47-fold (p=0.035) increase in the incidence of alexithymia. Conclusion: Alexithymia has been found to be high in patients with chronic kidney disease. Therefore, it is essential that we be aware of patients’ emotional stress and assess them for depression, anxiety, and alexithymia.

Haemoglobin and Iron Studies in Chronic Kidney Disease Stage-5 Patients yet Not On Dialysis

Objective: To look for the low levels of haemoglobin and ferritin among the patients of chronic kidney disease (CKD) Stage-5 not undergoing dialysis and factors related to the presence of low levels of haemoglobin and ferritin.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Nephrology, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Feb 2019 to Jan 2021. Methodology: A total of 800 cases were included in the study, diagnosed as chronic kidney disease Stage-5 in the nephrology outpatient department (OPD) by a consultant nephrologist who did not require hemodialysis. Haemoglobin and ferritin levels were recorded in all patients at the time of assessment in the outpatient department. In addition, the relationship of various factors was assessed with low haemoglobin and ferritin among the study participants.&#x0D; Results: Out of 800 non-dialysis chronic kidney disease patients in the study, 421(52.7%) patients were males and 379(46.3%) were females. Of the participants, 471(58.9%) had either low ferritin or hemoglobin levels, while 329(41.1%) did not show low haemoglobin and/or ferritin levels. Long duration of illness and female gender was significantly associated with low haemoglobin/ferritin levels among the non-dialysis patients of chronic kidney disease Stage-5 (p-value&lt;0.05).&#x0D; Conclusion: Low levels of hemoglobin and ferritin were found in most patients suffering from chronic kidney disease Stage-5 and not undergoing hemodialysis. Therefore, special attention should be paid to female patients and patients with a longer duration of chronic kidney disease.

Evaluation of Homocysteine and Gamma-Glutamyl Transferase Concentrations As Markers of Chronic Kidney Disease: An Indian Perspective.

BackgroundChronic kidney disease (CKD) involves a gradual loss of kidney function over months to years. Oxidative stress plays a critical role in the pathogenesis of CKD. Homocysteine (Hcy), an amino acid derivative, is a known risk factor for oxidative stress and endothelial damage. Gamma-glutamyl transferase (GGT), an enzyme abundant on the cell surface of liver and kidney cells, is raised during oxidative stress. The objectives of this study were to estimate the concentrations of serum Hcy and GGT among CKD patients and healthy controls and to determine whether there is an association between serum Hcy and GGT levels in CKD.MethodologyA total of 246 participants were needed to meet the calculated sample size. A total of 123 CKD patients meeting the inclusion and exclusion criteria were recruited as cases from the Nephrology outpatient department of our institute. Equal numbers of age- and sex-matched healthy volunteers were recruited as controls. Biophysical profiling of participants was done. Baseline investigations were recorded. A blood sample was collected from each participant and analyzed for GGT and Hcy along with other routine parameters.ResultsHcy and GGT concentrations were significantly high in CKD patients compared to healthy controls. There was a significant positive correlation between serum GGT and Hcy levels (r = 0.357).ConclusionsElevated levels of GGT and Hcy in CKD patients compared to healthy controls demonstrated the oxidative stress associated with the disease. GGT and Hcy can be used as prognostic markers of the disease.

A Comparative Study of Acidosis in Diabetic Advanced Chronic Kidney Disease Patients on and off Metformin.

AimThe aim of the study is to assess the risk of acidosis in diabetic advanced chronic kidney disease (CKD) patients on and off metformin.MethodsThis retrospective descriptive study was conducted in the nephrology department in The Kidney Centre Post Graduate Training Institute (TKC PGTI) Karachi from February to April 2020. We reviewed the records of all patients over 18 years old who visited the nephrology outpatient department in three months in 2020 (from February 2020 to April 2020), who had CKD (stage 2-5), are not on dialysis, and had type 2 diabetes. These were divided into two groups: those on metformin for more than one year and those not on metformin. We looked at hospitalizations due to acidosis in the previous one-year period.ResultsA total of 524 CKD patients had diabetes; out of those, 268 patients were on metformin, and 256 were not on metformin. The male vs. female distribution was 52.1% vs. 47.9%. A total of 114 (21.8%) patients required admission in the previous one-year period, and only 12 hospitalized patients had acidosis, seven (58.3%) were on metformin, and five (41.7%) were not on metformin, which was statistically insignificant.ConclusionBiguanides, especially metformin, is a known oral hypoglycemic drug used for decades to treat type 2 diabetes mellitus (DM). Metformin use is related to a rare but serious adverse event, metformin-associated lactic acidosis (MALA), especially in renal failure patients. In our study, metformin use in CKD diabetic patients did not result in more admissions due to acidosis than non-metformin users.

Difference in Antihypertensive Medication Pattern in the First Year Compared to More than a Year of Maintenance Hemodialysis: A Northern India Tertiary Care Experience

Introduction There is a high prevalence of hypertension in maintenance hemodialysis patients. Information regarding prevalent pattern of antihypertensive medications will help modify it to prevent future cardiovascular morbidity and mortality. Materials and Methods In this cross-sectional study, patients on maintenance hemodialysis, aged ≥18 years visiting Nephrology outpatient department (OPD) from April 2019 to May 2020 were included. The patients were divided into two groups based on their dialysis vintage, ≤12 months and &gt;12 months. Their antihypertensive medication patterns and two-dimensional (2D) echocardiography (ECHO) findings were compared. Independent t-test was used to compare continuous variables. One-way analysis of variance was used to study the antihypertensive drug-dosing pattern in both the groups. Results Out of 250 patients, 131 had a dialysis vintage of ≤12 months, whereas 119 had a vintage of &gt;12 months. There was no significant difference in the number of antihypertensive agents used in either of the vintage groups. Calcium channel blockers (87.02 and 89.07%, respectively, in ≤12 and &gt;12 months' vintage groups) and β blockers (64.12 and 65.54%, respectively, in ≤12 and &gt;12 months' vintage groups) were the commonly used antihypertensive agents. Metoprolol use was higher in ≤12 months' group, whereas carvedilol usage was higher in &gt;12 months' group (p = 0.028). Mean pill burden was more than five in both the groups. Concentric left ventricular hypertrophy was significantly more common in &gt;12 months' group. Renin–angiotensin system (RAS) blocking agent use was limited to 3% of patients. Conclusion This study shows a high antihypertensive pill burden in dialysis patients likely due to underlying chronic volume overload in addition to the perceived efficacy of certain class of drug in a frequent dosing pattern. Low use of RAS blocking agent was also underlined. This study highlights the need to bring about changes in the antihypertensive prescription pattern in line with the existing evidence.

Association of fibroblast growth factor-23 among chronic kidney disease patients with mineral bone disease

Background: Chronic kidney disease (CKD) is characterized by slow and progressive loss of kidney function over years. Most of the time it goes undetected till severe irreparable damage has occurred. CKD is a worldwide public health problem.Methods: The present cross sectional study was conducted in nephrology outpatient department (OPD) and medicine wards of Government Medical College and Hospital, Ambikapur, Sarguja, Chhattisgarh, India from June 2020 to June 2021. The study involved 50 adult patients (&gt;18 years) of CKD who were on hemodialysis. Patients who are not willing to participate and comatose patients were excluded from the study.Results: Among the CKD patients, 10 (20%) had left ventricular hypertrophy, 5 (10%) patients had left ventricular dysfunction with ejection fraction (EF) less than 40. 98% of the study participants were undergoing twice weekly hemodialysis and 2% were on thrice weekly hemodialysis. No significant association was found between left ventricular hypertrophy (LVH), pulmonary arterial hypertension (PAH), left ventricular dysfunction (LVD) with fibroblast growth factor-23 (FGF-23) (p&gt;0.05) whereas there was a significant association between phosphate and FGF-23 (p&lt;0.05) and between calcium and FGF-23 (p&lt;0.05).Conclusions: CKD mineral and bone metabolism (MBD) is common in patients with CKD especially stage 5. They are also prone for cardiovascular manifestation. FGF23 levels were high in those with elevated phosphorous, left ventricular hypertrophy and left ventricular dysfunction. Levels of calcium, intact parathyroid hormone (iPTH) and ejection fraction did not correlate with FGF-23. Larger population in the study would have helped in actual identification of these patients and also helped in the knowing the predominant role of FGF-23.

MO654REAL LIFE EXPERIENCE AFTER 20 MONTHS USING SGLT2 INHIBITORS

Abstract Background and Aims Diabetic kidney disease (DKD) develops in almost half of diabetic patients and is the leading cause of chronic kidney disease (CKD). SGLT2 inhibitors (SGLT2i) have consistently shown to confer kidney protection in patients with type 2 diabetes (T2D). The recent KDIGO guidelines suggest their use as a first line medication along with metformin. After the study CREDENCE was published, in mid-2019, DKD patients at the Nephrology outpatient department of the Hospital of Braga were started on SGLT2i. We aimed at assessing these patients’ clinical and laboratory data after the introduction of the new drug. Method We collected data on age, gender, weight, blood pressure (BP) values, the use of renin-angiotension-aldosterone system inhibitors (RAASi), kidney function, glycated hemoglobin (HbA1c), glycosuria, proteinuria and albuminuria at baseline and during the two next patient assessments. Data was analyzed using SPSS®. Results Twenty-nine DKD patients who started SGLT2i between May 2019 and August 2020 were followed. Mean age was 71.2±13.5 years, 22 patients were male and their mean weight was 86.9±13.9 kg. They had had T2D for a mean of 15.9±10.3 years and a significant percent had end organ damage: 34% had diabetic retinopathy, 24% complaints suggestive of neuropathy, 51% had documented heart failure and 27% had cerebral vascular disease. Most were hypertensive with a mean BP of 156±19/83±11mmHg and 72.4% were taking RAASi. One third were treated with insulin. Most patients were started on canagliflozin (n=28) and one patient started empagliflozin. After starting the drug, patients were evaluated at a mean time of 141±55 days and had a second reevaluation at a mean time of 254±72 days. On the first evaluation they showed a significant reduction in the mean systolic BP to 140±15.1mmHg (p=0.001). Glycated hemoglobin decreased from a mean of 7.4±1.3% to 7.1±1.1% although this difference was not significant (p=0.4). Protein-creatinine urinary ratio was significantly reduced from a median value of 1.48 (IQR 0.24-1.85) to 0.93 (IQR 0.40-1.56). Mean serum creatinine increased significantly from baseline until the first evaluation at 1.96±0.49 to 2.27±0.66mg/dL (p=0.00) but remained stable on the second evaluation (2.29±0.79mg/dL). Seventy percent of the patients developed significant glycosuria (urinary concentration &amp;gt;500mg/dL) after starting SGLT2i. When asked about adherence, most non-glycosuric patients admitted not having started the drug. Conclusion Despite having a weak effect in the reduction of HbA1c, SGLT2i are an exciting drug for kidney protection in DKD. Patient adherence is easy to assess based on glycosuria. In our experience and based on this criterion drug compliance was acceptable (at least 70%) and we were able to reinforce instructions among non-compliant patients. Some of the benefits of SGLT2i were evident soon after they were started such as the improvement in BP and proteinuria. The initial increase in plasma creatinine was expected due to reduction in intraglomerular pressure and hyperfiltration and was noticeable only on the first assessment. We expect to continue SGLT2i use DKD patients.

Microbiological profile and antibiotic resistance pattern of urinary tract infection in a tertiary care hospital

Urinary tract infection (UTI), of varying severity is one of the most commonly encountered ailments in nephrology outpatient department (OPD). The commonest pathogens causing community acquired UTI (CAUTI) are E. Coli, Proteus mirabilis, Pseudomonas aeruginosa and Klebsiella pneumonia. There is a rapidly rising trend of antibiotic resistance among these uropathogens, may be due to indiscriminate antibiotic usage and poor patient compliance. We conducted a retrospective analysis of all culture proven UTI cases that attended the nephrology OPD of S. K. hospital, Trivandrum from August 2017 to July 2019 (24 months). 130 males and 121 females were included in the study. The mean age of the study group was 62.8 years with a male predominance in the age group above 50 years and a female predisposition in less than 50 years group. Commonest pathogen isolated in urine culture was E. coli (52.98%) followed by Klebsiella (39.09%), Citrobacter (8.76%), Pseudomonas (8.37%), Enterobacter (2.39%), Enterococci (1.99%), Candida (1.59%), Acinetobacter (1.2%), Proteus (1.2%), Streptococci (1.2%) and Serratia (0.4%).

POS-178 Prevalence of Ciprofloxacin Resistance Among UTI patients having Chronic Kidney Disease

Urinary Tract Infection is a common disease in the Nephrology outpatient Department We evaluated 26 Urinary Tract Infection (UTI) who had growth of E.coli in their Urinary Culture and Sensitivity specimens. Drug Resistance is a common problem encountering UTI. We evaluated prevalence of Ciprofloxacin resistance among CKD patients. The patients attending the Nephrology Outpatient Department of Mount Adora Hospital, Nayasarak. Sylhet Bangladesh were evaluated. From them consecutive 26 E.coli positive Culture and Sensitivity of Urinary samples done in the Microbiology Laboratory of Mount Adora Hospital Nayasarak, Sylhet, Bangladesh were evaluated. All the patients were suffering CKD stage I-IV. Informed consent was obtained from the patients. As Ciprofloxacin is a common and effective drug in the treatment of UTI we evaluated the resistance of Ciprofloxacin among the samples. Among the 26 patients 6 were male (23%). 14 patients were hypertensive (53.8%) and 16 were diabetics (61.5%). After Culture and Sensitivity of Urinary Samples having E.coli growth 12 patients (46.1%) had resistance to Ciprofloxacin. Ciprofloxacin is a cheap drug in Bangladesh. But its ongoing resistance to E.coli is a current problem here. In the veterinary sector of Bangladesh, Ciprofloxacin is used widely. Bangladeshi people are used to eat beef and goat meat. So they ingest Ciprofloxacin along with meat. Easy availability of antibiotics is an issue. Drug compliance during antibiotic treatment is another factor which may contribute. Ciprofloxacin resistance in UTI caused by E.coli is a burning problem in Bangladesh. Implication of One Health , creating awareness on drug compliance during antibiotic therapy and strict regulation of drug authority on antibiotic availability are necessary to combat this problem.

Telemedicine Underutilized in Post COVID Lockdown Period

COVID-19 (Coronavirus disease) pandemic has put tremendous pressure on healthcare providers to seek for ways to provide a sustainable model of healthcare to the distantly located patients. The desired model needs to be easily accessible, affordable and effective enough to address the needs of the patients. Telehealth is one such way which can help a medical expert reach to the remotely located population. State government has taken multiple initiatives to start telehealth services in its tertiary care hospitals. Ours being a tertiary care hospital, telemedicine services were started in May 2020 and have continued till date. The response to this new service was good in the initial months when lockdown due to COVID-19 was in place and was expected to improve as its awareness spreads across the region. However, post lockdown the trend has not been very encouraging. In nephrology, from catering to 20-25 patients per session it went down to 4-5 patients per session. This called for an active search of possible elements operating behind this development and take remedial measures. A detailed discussion with the service providers was held. The physicians were quick to respond to the need of the system and were able to converse and write prescriptions to be uploaded in the pdf format. One resident and one consultant were present in each session. The frequency of the nephrology consultation sessions stood at once per week with provision of an increment as per response from the patients. Confidentiality related issues were well taken care by the trained manpower recruited by the hospital authorities. Internet connectivity issue rarely surfaced from the hospital side as the provided band width was usually 20-30 mbps. Though there were some poor bandwidth and connectivity issues at patients’ end, mostly from the rural areas. Limited internet access is a significant hurdle in preventing telemedicine usage by the rural population. [1,2]. A small survey among 106 patients visiting Nephrology OPD (Outpatient Department) revealed that only 15% of them were aware about the telemedicine services being offered by the hospital. This highlighted the need to relook into the effectiveness of the means of communication used to spread the information about this new service. The news was circulated primarily via newspapers and website of the hospital. The frequency of its publication was high in the initial months but declined later. In order to achieve a wider coverage, use of SMS (Short Message Service), e-mails and telephonic conversation giving details of tele-outpatient services may be of great help. Radio and television broadcast may further enhance awareness. Even after restoration of the regular physical OPD services, it may be useful to continue educating patients about this relatively new virtual service which is particularly useful in later follow-ups. Careful monitoring of the telemedicine programme with a watch on its smooth functioning and effectiveness in terms of patient numbers and their satisfaction scores can help improve the services. Goal oriented telemedicine programs are need of the hour. Our hospital didn’t have a running telemedicine department. The whole team worked in close collaboration with the personnel responsible for running the hospital information system. Setting a separate department or section to deal with telemedicine services can go a long way in its effective operation. Such departments can aid in laying down policies and plans to improve the utilization of the services. With the kind of impetus from the government in terms of manpower, hardware, software and electricity, an extra effort in spreading the awareness can provide the vital thrust the program needs. A change in mindset of the physicians about prescriptions sans physical examination will also be of help. A multidirectional and constant effort is required by physicians, administrators and policy holders to make the vision of providing telehealth to all, a success.