Azreen Syazril Adnan

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.

Predictors of two months culture conversion in multidrug-resistant tuberculosis: findings from a retrospective cohort study.

Background Various studies have reported culture conversion at two months as a predictor of successful treatment outcome in multidrug-resistant tuberculosis (MDR-TB). Objectives The present study was conducted with the aim to evaluate the rate and predictors of culture conversion at two months in MDR-TB patients. Methods All confirmed pulmonary MDR-TB patients enrolled for treatment at Lady Reading Hospital Peshawar, Pakistan from 1 January to 31 December 2012 and met the inclusion criteria were reviewed retrospectively. Rate and predictors of culture conversion at two months were evaluated. Results Eighty seven (53.4%) out of 163 patients achieved culture conversion at two months. In a multivariate analysis lung cavitation at baseline chest X-ray (P = 0.006, OR = 0.349), resistance to ofloxacin (P = 0.041, OR = 0.193) and streptomycin (P = 0.017, OR = 0.295) had statistically significant (P<0.05) negative association with culture conversion at two months. Conclusion A reasonable proportion of patients achieved culture conversion at two months. Factors negatively associated with culture conversion at two months can be easily identified either before diagnosis or early in the course of MDR-TB treatment. This may help in better care of individual patients by identifying them early and treating them vigorously.

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.

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.

Management of Patient Care in Hemodialysis While Focusing on Cardiovascular Disease Events and the Atypical Role of Hyper- and/or Hypotension: A Systematic Review

Background. Hemodialysis related hemodynamic instability is a major but an underestimated issue. Moreover, cardiovascular events are the leading cause of morbidity and mortality associated with blood pressure in hemodialysis patients. However, there have been many controversies regarding the role and management of hyper- and/or hypotension during hemodialysis that needs to be addressed. Objective. To critically review the available published data on the atypical role of hyper- and/or hypotension in cardiovascular associated morbidity and mortality in patients on hemodialysis and to understand the discrepancies in this context. Methods. A comprehensive search of literature employing electronic as well as manual sources and screening 2783 papers published between Jan 1980 and Oct 2015 was conducted to collect, identify, and analyze relevant information through peer-reviewed research articles, systematic reviews, and other published works. The cardiovascular events, including accelerated atherosclerotic cardiovascular disease (ASCVD), stroke, heart failure, myocardial infarction, myocardial ischemia, and stress induced myocardial dysfunction, leading to death were considered relevant. Results. A total of 23 published articles met the inclusion criteria and were included for in-depth review and analysis to finalize a comprehensive systematic review article. All the studies showed a significant association between the blood pressure and cardiovascular disease events in hemodialysis patients. Conclusions. Both intradialytic hypertension/hypotension episodes are major risk factors for cardiovascular mortality with a high percentage of probable causality; however, clinicians are faced with a dilemma on how to evaluate blood pressure and treat this condition.

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,

A Study of Effectiveness of Medical Therapy in Benign Prostatic Hyperplasia Patients in HUSM.

Introduction : Benign prostate hyperplasia (BPH), a progressive disease, can cause various urinary complications if left untreated. Aims and Objective : The current study was desigined to compare international prostate symptom score (IPSS), urine flow rate (Qmax), Prostate specific antigen (PSA) in pre and post treatment among patients with Benign prostate hyperplasia and to asses their quality of life. Methodology : A cross sectional study was designed at Hospital Universiti Sains Malaysia, including all patients diagnosed as BPH from year 2007 to 2010. Based on inclusion and exclusion criteria 307 subjects were selected. New set of International Prostate Symptom Score (IPSS) and urine flow rate (Qmax) was obtained from all selected patients. SPSS version 19 was used for statistical analysis. Result : Out of the 307 patients currently treated at Hospital University Sains Malaysia (HUSM), 268(87.3%) were Malays, 38(12.4%) were Chinese and 1(0.3%) was Indian. Majority of the patients having BPH were above 50 years of age. One hundred and seven (34.9%) patients were associated with hypertension, followed by diabetes mellitus 12 (3.9%). urine peak flow rate (Qmax) had mean difference of 11.74 and 14.41ml/ sec, which shows the medical therapy do improve urine flow rate and benign prostatic hyperplasia (p<0.001). The prostate size also showed an increase having mean difference from 36.12 to 38.14cc 3 (p<0.001). There is significant relation between prostate gland volume and serum prostatic specific antigen (p<0.001). Conclusion : Benign prostatic hyperplasia although a benign condition, but still interferes with the normal life style of the patients. By initiating medical treatment this disease can not only be treated but also significantly improves the quality of life of the patients.

Efficacy of Losartan in the management of Post-Dialysis Euvolemic Hypertension (HELD-Trial): A Single-Blind Randomized Control Trial

To assess the effectiveness of losartan 50 mg on post dialysis euvolemic hypertensive patients against standard antihypertensive pharmacotherapy. A multicentre, prospective, randomized, single-blind trial was conducted to assess the effect of losartan 50 mg every other day (EOD), once a morning (OM) among post-dialysis euvolemic hypertensive patients. Covariate-adaptive randomization was used to allocate participants to a standard or treatment arm, and they were followed up for eight weeks. Pre-, intra- and post-dialysis session blood pressure (BP) measurements were recorded along with any adverse events. A total of 88 patients were randomized into standard (n = 44) and treatment arms (n = 44) and were followed for a period of 8 weeks. In the standard group, the mean post-dialysis blood pressure dropped by 0.3 mmHg by the end of the 8th week. However the treatment arm reported a drop of 2.4 mmHg of BP drop during the 8-week trial period. Analysis suggests that there was a significant difference in blood pressure readings at the end of 8 weeks among patients treated with losartan (P < 0.001). However, no such statistical association was observed in the standard arm (P 0.75). A slow, steady significant decline in post-dialysis BP was observed among euvolemic hypertensive patients that were treated with losartan 50 mg.

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.

Status epilepticus as the initial presentation of antibody-negative Goodpasture's syndrome

Goodpastures syndrome is a rare pulmonary-renal disease. It is characterised by presence of auto-antibodies directed against the glomerular basement membrane (GBM) antigen. These antibodies that bind to the GBM antigens cause rapidly progressive glomerulonephritis. The alveolar basement membrane also contains similar antigen, leading to pulmonary haemorrhage in active disease. We report a case of a young man who initially presented with status epilepticus and later was found to have rapidly progressive glomerulonephritis with pulmonary haemorrhage. Serum anti-GBM antibody was negative but the renal biopsy confirmed the diagnosis by showing typical linear IgG along the GBM on immunofluorescent study. He was treated with plasmapheresis and high-dose steroid in combination with oral cyclophosphamide. His renal function normalised after treatment.