Azmi Sarriff

Incidence, Characteristics and Risk Factors of Acute Kidney Injury among Dengue Patients: A Retrospective Analysis

Background Dengue induced acute kidney injury (AKI) imposes heavy burden of illness in terms of morbidity and mortality. A retrospective study was conducted to investigate incidence, characteristics, risk factors and clinical outcomes of AKI among dengue patients. Methodology A total 667 dengue patients (2008–2013) were retrospectively evaluated and were stratified into AKI and non-AKI groups by using AKIN criteria. Two groups were compared by using appropriate statistical methods. Results There were 95 patients (14.2%) who had AKI, with AKIN-I, AKIN-II and AKIN-III in 76.8%, 16.8% and 6.4% patients, respectively. Significant differences (P<0.05) in demographics and clinico-laboratory characteristics were observed between patients with and without AKI. Presence of dengue hemorrhagic fever [OR (95% CI): 8.0 (3.64–17.59), P<0.001], rhabdomyolysis [OR (95% CI): 7.9 (3.04–20.49)], multiple organ dysfunction [OR (95% CI): 34.6 (14.14–84.73), P<0.001], diabetes mellitus [OR (95% CI): 4.7 (1.12–19.86), P = 0.034], late hospitalization [OR (95% CI): 2.1 (1.12–19.86), P = 0.033] and use of nephrotoxic drugs [OR (95% CI): 2.9 (1.12–19.86), P = 0.006] were associated with AKI. Longer hospital stay (>3 days) was also observed among AKI patients (OR = 1.3, P = 0.044). Additionally, 48.4% AKI patients had renal insufficiencies at discharge that were signicantly associated with severe dengue, secondary infection and diabetes mellitus. Overall mortality was 1.2% and all fatal cases had AKI. Conclusions The incidence of AKI is high at 14.2% among dengue patients, and those with AKI portended significant morbidity, mortality, longer hospital stay and poor renal outcomes. Our findings suggest that AKI in dengue is likely to increase healthcare burden that underscores the need of clinicians’ alertness to this highly morbid and potentially fatal complication for optimal prevention and management.

Defining acute kidney injury in dengue viral infection by conventional and novel classification systems (AKIN and RIFLE): a comparative analysis.

Background Several criteria have been used to stratify acute kidney injury (AKI) in dengue infection and have resulted in variations in its incidence as well as clinic-laboratory characteristics. The current study was aimed to compare three commonly used criteria of AKI among patients with dengue. Methods 667 patients with dengue were defined and staged according to the conventional definition (CD), the Acute Kidney Injury Network (AKIN) and the Risk, Injury, Failure, Loss of function, End stage renal disease (RIFLE) criteria. Appropriate statistical methods were used to compare these three criteria. Results The incidence of AKI during dengue infection was 14.2% by AKIN criteria, 12.6% by RIFLE criteria and 4.2% by CD. AKIN and RIFLE criteria were comparable while AKIN-I identified 11 more patients with AKI than RIFLE-R (76.8% vs 73.8%, p=0.023). CD was found to be less sensitive than AKIN and RIFLE due to stratification of only severe AKI cases with serum creatinine ≥176.8 µmol/L. Overall mortality was 1.2% and severe stages of AKI were associated with increased mortality (p<0.001). AKIN criteria identified seven risk factors, RIFLE identified six and CD identified three risk factors. Old age, severe dengue and the use of nephrotoxic drugs were found to be independent predictors identified by all criteria while hypertension was only identified by AKIN. Conclusions The incidence of AKI in dengue infection, the risk factors for its development and clinico-laboratory characteristics vary significantly according to the diagnostic criteria used. In our analysis, AKIN and RIFLE were comparable to each other and superior to CD with regard to early diagnosis and sensitivity.

Perceived Stress Scale Psychometric Validation for Malaysian Diabetic Patients

Aims: The purpose of this study was to provide factorial analytic findings, construct validation and normative data for the Malaysian diabetic patients. Gender difference was also examined with racial response to PSS-10. Study design: Population base cross sectional survey. Place and Duration of Study: Penang between Nov 2009 and March 2010. Methodology: Cluster random sampling technique was employed for the selection participants in the community. A total of 1924 diabetic patients with age ≥ 18 (mean age = 39.51) were approached; 992 of them were female and 932 of them were male. People rated how often they had experienced these feelings in the last week on a five-point Likert scale from 0 = never to 4 = very often. The scale was translated into Malay language independently by two psychological counselors who had at least a master’s degree and bilingual efficiency. The LISREL 8.30 program was used to assenting factor analysis. Chisquare ( χ 2 )/df (degree of freedom) ratio, GFI (goodness of fit index), AGFI (adjusted goodness of fit index) and root mean square error of approximation (RMSEA) were used to evaluate the fit of the model (two-factor). Results: Barlett’s test of sphericity was 1603.417 ( p< 0.001) and Kaiser-Meyer-Olkin measure of the sampling adequacy was 0.83. Varimax rotation was conducted with these two identified factors. Factor A integrated items 1, 2, 3, 6, 9 and 10, labeled as ‘Perceived Avoidance’ while Factor B containing items 4, 5, 7, 8 and labeled as ‘Perceived

Evaluation of knowledge, attitude, and perception regarding Halal pharmaceuticals, among general medical practitioners in Malaysia

Objective: To evaluate the knowledge, attitude, and perception (KAP) regarding Halal pharmaceuticals, among general medical practitioners in Malaysia. Materials and Methods: This was a cross-sectional study, carried out between September 2012 and November 2012 period, using a structured, self-administered questionnaire. Clinics were chosen based on systematic random sampling technique across Malaysia. Descriptive statistics (mean, standard deviation, frequency, percentage, median, and interquartile range) were used to summarize the data. Chi-square and Fishers exact tests were used as appropriate to assess the association between demographic characteristics, and KAP scores. Results: Results revealed that general medical practitioners have a good knowledge and positive attitude and perception towards Halal pharmaceuticals. Mean knowledge score was 7.72 ± 1.65, out of maximum possible score of 9. Mean attitude score was 34.24 ± 6.77 out of maximum score of 45 and mean perception score was 46.98 ± 5.84 out of maximum possible score of 55. Mean overall KAP score out of maximum possible 109 was 88.90 ± 12.75. There was a significant, positive, and fair correlation (0.25-0.5) between knowledge and attitude (r = 0.443, P Conclusion: It can be concluded that better knowledge of Halal pharmaceuticals is associated with positive attitude towards the use of Halal pharmaceutical products. However, it still remains unknown how this positive attitude influence prescribing practices of general practitioners.

Progression and outcomes of non-dialysis dependent chronic kidney disease patients: A single center longitudinal follow-up study.

Despite increase global prevalence of End stage renal disease (ESRD) and subsequent need for renal replacement therapy (RRT), relatively little is known about disease progression and prognosis of earlier stages of CKD. Current study was conducted to examine rate of CKD progression, predictors of ESRD and death.

Association of Ward Acquired, On-admission, Progressive and Non-progressive AKI with Death among Dengue Patients: A Hidden Relationship

Respected Editor, We retrospectively investigated 7 894 patients admitted during the period of 15 years (2000–2014) and identified 57 fatal cases. By defining mortality as death resulted from or as a consequence of dengue infection, 44 fatal cases were selected. A case-control study was designed by taking five non-fatal controls for every dengue associated death case (study/control group: 44/220 patients). All the confounders i.e. age, gender, baseline kidney disease, co-morbidities and type of dengue infection were matched with control group. Characteristics of patients in study and control group are shown in Table 1. Out of 44 fatal cases, acute kidney injury (AKI) was diagnosed in 35 (79.5%) patients by using Acute Kidney Injury Network (AKIN) criteria: 11.4% with AKIN-I, 22.7% with AKIN-II and 45.5% with AKIN-III. AKI occurred in 24 (10.9%) cases among control group: 5% with AKIN-I, 3.6% with AKIN-II and 2.3% with AKINIII. In case of disease progression, we classified the worst stage of AKI during hospital stay. Out of 21 fatal cases without AKI on hospital admission, 12 (57.1%) patients developed AKI later during their stay (ward-acquired AKI), including two patients with AKIN-I, three with AKINII and seven with AKIN-III. On the other hand, 23 fatal cases had AKI on hospital admission (on-admission AKI) with varying severity. Some of the patients with wardacquired and on-admission AKI progressed to severe AKI (progressive AKI) i.e. three and five patient respectively. Patients with ward-acquired AKIN-I were associated with greater than two times odds of deteriorating into AKINII and AKIN-III. Cox proportional hazards regression analysis suggested AKI as an independent predictor of inhospital mortality, with HR 5.781 (p < 0.001). Furthermore,

Chronic Kidney Disease, Fluid Overload and Diuretics: A Complicated Triangle

Background Despite promising role of diuretics to manage fluid overload among chronic kidney disease (CKD) patients, their use is associated with adverse renal outcomes. Current study aimed to determine the extent of renal deterioration with diuretic therapy. Methods A total 312 non-dialysis dependent CKD (NDD-CKD) patients were prospectively followed-up for one year. Fluid overload was assessed via bioimpedance spectroscopy. Estimated GFR (eGFR) was calculated from serum creatinine values by using Chronic Kidney Disease- Epidemiology Collaboration (CKD-EPI) equation. Results Out of 312 patients, 64 (20.5%) were hypovolemic while euvolemia and hypervolemia were observed in 113 (36.1%) and 135 (43.4%) patients. Overall 144 patients were using diuretics among which 98 (72.6%) were hypervolemic, 35 (30.9%) euvolemic and 11 (17.2%) were hypovolemic. The mean decline in estimated GFR of entire cohort was -2.5 ± 1.4 ml/min/1.73m2 at the end of follow up. The use of diuretics was significantly associated with decline in eGFR. A total of 36 (11.5%) patients initiated renal replacement therapy (RRT) and need of RRT was more profound among diuretic users. Conclusions The use of diuretics was associated with adverse renal outcomes indicated by decline in eGFR and increasing risk of RRT initiation in our cohort of NDD-CKD patients. Therefore, it is cautiously suggested to carefully prescribe diuretics by keeping in view benefit versus harm for each patient.

Blood Pressure and Mortality in Hemodialysis Patients: A Systematic Review of an Ongoing Debate

Hypertension is prevalent in 75–80% of hemodialysis patients and remains the most controversial prognostic marker in end stage kidney disease patients. In contrast to the general population where systolic blood pressure of ≤120 mm Hg is considered normal, a debate remains regarding the ideal target blood pressure in hemodialysis patients. Using the PUBMED and EMBASE databases, the research studies that evaluated the relationship between blood pressure measurements and mortality in hemodialysis patients were searched. Thirteen studies were identified from different regions of the world. Five studies reported low predialysis systolic blood pressure as a prognostic marker of mortality. Other studies showed varying results and reported postdialysis systolic blood pressure as well as ambulatory blood pressure as better predictors of mortality and emphasized their optimized control. One study in this review concluded that there is no direct relationship between mortality and blood pressure if the patients are on anti‐hypertensive medications. The observed all‐cause mortality varied from 12% to 36%, whereas the cardiovascular mortality varied from 16% to 60%. On the basis of studies included in the current review, a low predialysis systolic blood pressure (<120 mm Hg) is shown to be a widely accepted prognostic marker of mortality while ambulatory blood pressure best predicts CV mortality. Therefore, we recommend that apart from routine BP (pre, post and intradialysis) monitoring in centers, assessment of ambulatory BP must be mandatory for all patients to reduce CV mortality in hemodialysis patients.

Factors Associated With the General Public Knowledge and Awareness of Cardiovascular Diseases and its Risk Factors in Penang – Malaysia

Background: Cardiovascular diseases(CVDs) are the top of the ten causes of hospital deaths in Malaysia. Increasing knowledge and awareness on CVDs and its risk factors is crucial for the prevention of CVDs. Identification of factors which are associated with the knowledge and awareness is important for the proper design of future awareness programs. Objectives: This study was carried out to find out factors which are associated with the current knowledge and awareness of cardiovascular diseases (CVDs) and its risk factors among the general public in PenangMalaysia. Method: Four hundred and fifty-six (456) from the general public participated in the study by filling a structured questionnaire offered in three languages, English, Malay and Chinese. The knowledge and the awareness scores were computed as continuous variables then simple liner regression (SLR) followed by general linear regression (GLR) were used to find factors associated with the levels of knowledge and awareness. Findings: The GLR final model revealed that the knowledge and awareness of CVDs and its risk factors was associated with the level of education, the previous attendance of health campaign on CVDs and having any CVDs or family history of CVDs. Conclusion: The study provides insights into factors associated with the knowledge and awareness of CVDs and its risk factors among the general public. Tailored awareness programs are required to address specific demographic groups of the general public.

Public Knowledge and Awareness of Cardiovascular Diseases and the Expected Role of Community Pharmacists in the Prevention and Management of Cardiovascular Diseases in Penang, Malaysia

This study was carried out to estimate the current knowledge and awareness of cardiovascular diseases (CVDs) and its risk factors among the general public in Penang, Malaysia and to explore public perception of the role of commu- nity pharmacists in the prevention and management of CVDs. Four hundred and fifty-six members of the public were given a self-administered, structured questionnaire. The questionnaire was in three languages (English, Malay and Chinese). Those who were illiterate or with prior experience/knowledge in the medical field were excluded from the study. The knowledge and the awareness scores were computed as continuous variables, and then categorized into three levels (poor, moderate and high). The analysis of the results revealed that 46%, 43% and 9% of the respondents had poor, moderate and good knowledge of CVDs and its warning symptoms, respectively. Public awareness of CVD risk factors was better than their knowledge of CVDs and its warning symptoms; in which 37%, 35% and 28% had poor, moderate and good awareness, respectively. Males were more knowledgeable than females. Education level also associated, positively, with knowledge. The majority of respondents gave favorable responses on the role of community pharmacists in identifying and preventing CVD risk factors in the community. This study provides insights into the limited knowl- edge and awareness of CVDs and its risk factors among the public in Penang, Malaysia and it shows the extended clinical role of community pharmacists in public health and preventing non-communicable diseases. Extensive awareness programs targeting those with limited knowledge are required.