Rozita Mohd

Immunoadsorption and plasmapheresis are equally efficacious as adjunctive therapies for severe lupus nephritis

This was a prospective randomized controlled trial to evaluate the effects of immunoadsorption (IA) versus conventional PP (PP) as adjunctive therapy in the treatment of severe lupus nephritis (LN). Of 28 patients with biopsy-proven severe LN (ISN/RPS classes III or IV ± V), 14 underwent 36 sessions of PP and the other 41 sessions of IA in addition to our centers standard LN treatment protocol. Three patients in the PP group and 2 in the IA group experienced a transient, marked drop in platelets with the second session. Except for a higher pre treatment mean SLEDAI score in the PP group 17.4 ± 2.0 vs. 13.5 ± 4.8; p = 0.009 and a serum creatinine of 163 ± 7.9 vs. 81.7 ± 10.2; p = 0.33, there were no other baseline differences. Some differences did exist between the two therapies in the immediate post-treatment phase, at 1 and 3 months. Three in IA relapsed, none of PP in third months, whereas two patients relapsed in the PP and none of IA cohorts at 6 months. However, most of these parameters did not differ by 6 months. The pre- and post-therapy SLEDAI scores remained different 12.4 ± 4.5 vs. 9 ± 4; p = 0.04 at 1 month, and at 3 month 13.5 ± 4.7 vs. 7.7 ± 1.1; p = 0.012 but not at 6 months. We conclude that IA and PP were equally well tolerated and efficacious as adjunctive therapy for severe LN.

Intravenous calcitriol versus paricalcitol in haemodialysis patients with severe secondary hyperparathyroidism

Aim:  Secondary hyperparathyroidism (SHPT) is common among haemodialysis patients. Intensive treatment with calcitriol is often complicated by hypercalcaemia, hyperphosphataemia and elevated calcium phosphorus (Ca X PO4) product. Paricalcitol is a vitamin D analogue developed to overcome some of the limitations of calcitriol therapy. The study objectives were to compare the response of intact parathyroid hormone (iPTH) and the incidence of hypercalcaemia, hyperphosphataemia and elevated Ca X PO4 product in patients with severe SHPT treated with either i.v. calcitriol or i.v. paricalcitol.

Assessment of fluid status in CAPD patients using the body composition monitor

AIMS AND OBJECTIVES To assess the degree of overhydration in our peritoneal dialysis patients and to examine the factors contributing to overhydration. BACKGROUND Volume control is critical for the success of peritoneal dialysis, but dry weight has been difficult to ascertain accurately. Chronic fluid overload and hypertension are among the leading causes of mortality in dialysis patients. DESIGN A cross-sectional observational study. METHODS The body composition monitor (Fresenius Medical Care, Bad Homburg, Germany) is a bioimpedance spectroscopy device that has been validated for the assessment of overhydration. We used this body composition monitor device on all patients on continuous ambulatory peritoneal dialysis at our institution who met the inclusion criteria to assess their degree of overhydration. RESULTS Thirty four (17 men, 17 women; mean age 44·5 ± 14·2 years) of a 45 continuous ambulatory peritoneal dialysis patients were enrolled. The mean overhydration was 2·4 ± 2·4 l. Fifty per cent of the patients were ≥2 l overhydrated. Overhydration correlated with male gender, low serum albumin, increasing number of antihypertensive agents and duration of dialysis. There was no difference in overhydration between diabetic and non-diabetic patients. Men were more overhydrated than women, had lower Kt/V and were older. Although, there was no difference in blood pressure between the genders, men had a trend towards a higher usage of antihypertensive agents. CONCLUSION Our study demonstrates that overhydration is common in peritoneal dialysis patients. Blood pressure should ideally be controlled with adherence to dry weight and low salt intake rather than adding antihypertensive agents even in the absence of clinical oedema. RELEVANCE TO CLINICAL PRACTICE Body composition monitor is a simple, reliable and inexpensive tool that can be routinely used in the outpatient clinic setting or home visit to adjust the dry weight and avoid chronic fluid overload in between nephrologists review.

The Effect of Calcium With or Without Calcitriol Supplementation on Renal Function in Patients With Hypovitaminosis D and Chronic Kidney Disease

Background: Hypovitaminosis D (serum 25-OHD < 30 ng/mL) is common in patients with chronic kidney disease (CKD). Vitamin D is believed to involve in the regulation of renin-angiotensin system and may be renoprotective. Objectives: To compare the effects of calcium with or without calcitriol on renal function in patients with CKD. Patients and Methods: A prospective randomized trial was performed involving patients with stages 2-4 CKD and hypovitaminosis D. Baseline demographics data were taken at baseline. Patients were randomized equally into oral calcitriol plus calcium carbonate (calcitriol group) or calcium carbonate alone (non-calcitriol group). Serum levels of 25-hydroxyvitamin D (25-OHD), 1,25-dihydroxyvitamin D3 (1,25-(OH)2D), creatinine, calcium and urine protein creatinine index (uPCI) were measured at 6 and 12 weeks. Results: Fifty (21 Female: 29 Male) patients with CKD with a median age of 53 (22-65) years were recruited. Their median MDRD eGFR (modification of diet in renal disease, estimation of glomerular filtration rate) was 36.0 (15-89) mL/min/1.73 m2 with the CKD stage 2 (n = 8, 16%), stage 3 (n = 29, 58%), and stage 4 (n = 13, 26%) respectively. In both study groups serum 25-OHD levels were increased at 12 weeks (P = 0.001), in contrast to serum 1,25-(OH)2D levels which remained unchanged (P > 0.05), serum creatinine and uPCI were also remained unchanged until the end of study (P > 0.05 each). Patients with diabetes had higher serum creatinine (P = 0.01) and lower serum 1,25-(OH)2D (P = 0.02) at baseline. Regardless of the diabetics status, the serum 25-OHD was increased, and 1,25-(OH)2D remained unchanged at 12 weeks in both study groups. At 12 weeks, serum creatinine was decreased in patients with diabetes in the noncalcitriol group (P = 0.03) compared to stabilization of creatinine in the calcitriol group (P > 0.05). Serum calcium was increased, though it was still within the normal range in the calcitriol group (P < 0.001); whereas, in the noncalcitriol group, there was an initial reduction but increased back to baseline (P = 0.007). Urine PCI remained unchanged in both groups. Conclusions: We have demonstrated that calcitriol supplementation did not offer any additional benefit to reduce 25-OHD and 1,25-(OH)2D levels over calcium carbonate alone in patients with CKD in this short term study. Overall renal function remained unchanged. However, we found that calcitriol at 0.5 mg daily plus calcium carbonate 500 mg daily could be reno-protective in diabetic nephropathy regardless of their serum 25-OHD levels.

Damage in the multiethnic Malaysian systemic lupus erythematosus (SLE) cohort: Comparison with other cohorts worldwide

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease and despite the improvement in the survival in the past few decades, the morbidity due to disease damage remains significant. The objectives of this study were to investigate the disease damagepattern and determine the associated factors of damage in the multi-ethnic Malaysian SLE patients. We consecutively 424SLE patients who attended a consistent follow-up at the National University of Malaysia Medical Centre and Putrajaya Hospital were recruited. Disease damage was assessed using the SLICC/ACR (Systemic Lupus International Collaborating Clinics/American College of Rheumatology) Damage Index (SDI) scores. Information on their demographics and disease characteristics were obtained from the clinical record. Univariate analysis was performed and the best model of independent predictors of disease damage was determined by multivariate logistic regression analysis. A total of 182 patients (42.9%) had disease damage (SDI ≥1). A significantly higher number of Indian patients had disease/organ damage and they predominantly developed steroid-induced diabetes mellitus (SDM). Patients with corticosteroid-induced osteoporosis (CIOP) were more likely to be Malayswhile majority of patients who developed malignancy were Chinese (p<0.05). In the univariate and multivariate analyses, disease damage was significantly associated with age, Indian ethnicity, lower mean cumulative C3 level, neuropsychiatry lupus (NPSLE), and antiphospholipid syndrome (APLS). Patients who had ever and early treatment with hydroxychloroquine(HCQ)were less likely to develop disease damage while more patients who had received oral prednisolone ≥1mg/kg daily over 2 weeks had disease damage (p<0.05). In conclusion, there were inter-ethnic differences in the damage pattern and risks among SLE patients.

Systemic lupus erythematosus with a non functioning pituitary macroadenoma

Summary Background: Malignancies are more common in patients with systemic lupus erythematosus (SLE) than the general population. SLE patients are recognized to have higher prolactin levels. However, there are very few reported cases of SLE with pituitary adenomas. Case Report: We report the second case of a pituitary adenoma in a patient with underlying SLE. A 51 year old lady presented with blurred vision and magnetic resonance imaging of the brain demonstrated a pituitary macroadenoma with mildly elevated serum prolactin levels. The diagnosis of a non functioning pituitary macroadenoma was confirmed histologically. The diagnosis of SLE was made on the basis of thrombocytopenia, antinuclear antibodies, anti double stranded DNA antibodies and lupus nephritis (confirmed on renal biopsy). The patient initially received medical therapy with carbegoline, followed by transsphenoidal neurosurgery for the pituitary macroadenoma. SLE with lupus nephritis was treated with steroids and low dose intravenous cyclophosphamide. Conclusions: Hyperprolactinaemia is prevalent in twenty to thirty percent of SLE patients but it is rarely due to a prolactinoma. The source of excessive circulating prolactin in SLE patients has not been fully determined.

The effects of calcitriol with calcium carbonate supplementation on inflammatory biomarkers in chronic kidney disease patients' with low vitamin D.

Introduction Chronic kidney disease (CKD) patients’ are at risk of low vitamin D and chronic inflammation. We studied the effect of 12 weeks calcitriol and calcium carbonate supplementation on inflammatory mediators serum; interleukin-6 (IL-6), interleukin-10 (IL-10) and highly sensitive C-reactive protein (hs-CRP). Material and methods A prospective randomized study in CKD stages 2-4 with serum 25-hydroxyvitamin D (25-OHD) levels < 30 ng/ml. Patients were randomized into the Vitamin D + Calcium (Vitamin D + C) or Calcium group. Serums were analyzed at baseline, week 6 and 12. Results Fifty patients, median age of 53 (13.5) years were recruited. Their median IL-10 was 13.35 (25.22) pg/ml. At week 12, serum IL-6 was reduced in both groups (p = 0.001), serum IL-10 was maintained in the Vitamin D + C group (p = 0.06) and was reduced in the Calcium group (p = 0.001). CKD-diabetic patients had reduced serum IL-6 in both study groups (p = 0.001) and a reduction was seen in the Vitamin D + C group of the non-diabetics counterparts (p = 0.005). Serum IL-10 was reduced in the Calcium group (p < 0.05) whereas serum 25-OHD rose in both groups, regardless of their diabetic status (p < 0.05). Conclusions Twelve weeks, calcitriol supplementation maintained IL-10, had no effects on hs- CRP and had no additional benefit compared to calcium carbonate in reducing serum IL-6 except in non-diabetics.

Blood pressure profile in continuous ambulatory peritoneal dialysis patients

Background: Cardiovascular mortality is the leading cause of death in end stage renal disease. Despite being on continuous ambulatory peritoneal dialysis (CAPD), blood pressure (BP) remains poorly controlled. A higher pulse pressure and non dipping are associated with increased cardiovascular mortality. We studied BP control and the prevalence of non dipping in CAPD patients. Methods: All patients undergoing CAPD at our institution who met the inclusion criteria were recruited. We compared BP control and dipping status in diabetic and non diabetic patients on CAPD. We also determined whether BP and peritoneal membrane permeability were associated. Results: Forty six patients with a mean age 45 ± 13 years were enrolled. Diabetic patients were older (mean age 54 ± 13 vs. 40 ± 11 yrs, p <0.001), had a lower mean diastolic BP (80 ± 14 vs. 90 ± 14 mmHg, p = 0.025) and a higher mean pulse pressure (59 ± 17 vs. 49 ± 14 mmHg, p = 0.035). They were also non dippers (n = 15 vs. n = 1, p = 0.007). The low and low average transporters tended to have a higher systolic BP (p = 0.054) and a higher pulse pressure (p = 0.058). On multivariate analysis, age was the main predictor of pulse pressure. Conclusion: Despite being on chronic maintenance PD, BP was not well controlled. Diabetic patients had a higher pulse pressure and were non dippers thereby increasing their cardiovascular risk. We should therefore optimize BP control and aim to restore the nocturnal dip in these patients.

Community acquired multi drug resistant (MDR) Acinetobacter baumannii pneumonia in Malaysia – A case report

Acinetobacter baumannii is an aerobic Gram-negative coccobacillus that is associated with hospital acquired pneumonia. There is increased reporting of emergent cases of community acquired multidrug resistance (MDR) acinetobacter associated with a higher mortality due to antibiotic resistance. Community acquired MDR acinetobacter pneumonia has not been reported in Malaysia. Here we report a case of a 19-year-old army officer who presented with fever and respiratory symptoms for 5 days. He had no known medical illness before and no history of hospitalization. Upon arrival, he was in septicaemic shock, requiring invasive ventilator support and renal replacement therapy in intensive care unit. Chest radiograph showed bilateral lung consolidations and bronchoscopy revealed haemoserous and greenish bronchiole secretion. He was treated with broad spectrum antibiotics and oseltamivir. Unfortunately he died on day 3 of hospital admission. His bronchial lavage culture came back positive for MDR Acinetobacter baumannii. This case illustrates that clinicians need to be aware that MDR Acinetobacter baumannii can cause severe community acquired pneumonia. We may need to consider this diagnosis in patients who do not respond to standard therapy.

Chronic Inflammatory Demyelinating Polyneuropathy in Systemic Lupus Erythematosus: A Rare Entity

Received: August 1, 2018 Revised: September 6, 2018 Accepted: September 19, 2018 Abstract: Background: Neurological manifestations in Systemic Lupus Erythematous (SLE) varies and commonly affects the Central Nervous System (CNS) rather than the peripheral nervous system. Neuropsychiatric or CNS manifestation can be as high as 24-54%, whereas the peripheral nervous system involvement is lower around 5-27%. Chronic Inflammatory Demyelinating Polyradiculopathy (CIDP) is one of the three commonest peripheral nervous system involvements in SLE patients and results with severe debilitating effects. However, it is rarely reported.