Severe Hyponatremia Associated With Terlipressin Use in Esophageal Variceal Bleeding.

Terlipressin is an analogue of vasopressin that is indicated as first-line therapy for variceal hemorrhage and hepatorenal syndrome. Hyponatremia is an uncommon complication of terlipressin because it has less effect on vasopressin V2 receptors located in the kidneys. Profound hyponatremia related to terlipressin use is a rare complication that needs to be aware of. We described a 35-year-old previously healthy man, who was admitted for esophageal variceal bleeding that was attributed to hepatitis B-related liver cirrhosis. He had a normal baseline sodium level (Na 139 mmol/L) and developed severe hyponatremia 119 mmol/L (euvolemic, hypo-osmolar) at 72 hours of terlipressin therapy. After holding the medication, the hyponatremia corrected rapidly to 135 mmol/L within 24 hrs. Terlipressin was given again as therapy for overcorrection of hyponatremia and the sodium level decreased before being stabilized without neurological consequences. Severe hyponatremia is an uncommon complication of terlipressin therapy; however, our case emphasizes the importance of sodium monitoring during terlipressin therapy in all patients to prevent this complication, and more importantly, to avoid rapid correction that could happen after holding it.

Gastrointestinal Bleeding in COVID-19 Infected Patients, and Management Outcomes.

Introduction: Gastrointestinal bleeding in COVID-19-infection poses unique challenges to patients owing to the high risk of concomitant respiratory failure. However, endoscopic care providers are prone to transmission. This study aimed to understand the risk and management outcomes of gastrointestinal bleeding in COVID-19-infected patients. Methods: Data were abstracted from electronic patient medical records, using ICD 10 codes, and demographic and clinical data were collected, for COVID-19-infected patients who developed gastrointestinal (GI) bleeding. Complications related to COVID-19 infection and management outcomes of GI bleeding were studied. Statistically, descriptive analysis was used because of the small sample size. Results: Eighteen COVID-19-infected patients developed episodes of GI bleeding, yielding a prevalence of 0.45%. Their mean age was 74.8 years, 55.5% were female, and 66.6% of patients (n=12) had upper GI bleeding symptoms, predominantly melena (55.5%), followed by coffee ground nasogastric aspirates (n=2). Only two patients (11.11%) had episodes of lower GI bleeding, and the remaining four patients (22.2%) had recurrent acute anemia requiring blood transfusion. The Glasgow-Blatchford score (GBS) at presentation ranged between 6 to 16 (mean 8.8) and seven patients (38.8%) underwent endoscopic evaluation for GI bleeding. The predominant comorbid conditions included hypertension (22.2%), diabetes mellitus (27.7%), chronic kidney disease (50%), ischemic heart disease (33%), atrial fibrillation (11.1%), and peripheral vascular disease (11.1%). The median hospitalization was 24.6 days (range: 3-54 days). The 30-day mortality rate in our cohort was 22.2%, (4/18) mainly noted in older patients aged> 60 years with comorbid conditions and severe COVID-19 infection. Conclusion: The prevalence of GI bleeding observed in our cohort was approximately 0.45%, significantly lower than the global prevalence observed, majority (66%) had upper GI bleeding. The exact reasons for the observed low prevalence of GI bleeding cannot be explained and will be the subject of future research.

Stomach bleeding in COVID-19-infected patients is a significant threat to the patients. This study aimed to understand the risk and management of stomach bleeding in patients infected with COVID-19. Medical records were retrospectively screened using appropriate disease codes to identify patients and collect information about their demographics and complications. Only 18 patients with stomach bleeding presented to the public hospitals in Al Ain from a total of 4000 COVID-19 patients during the peak of the pandemic. Majority of the patients had upper stomach bleeding (66%); the mean age of the patients was 78 years, majority of them being female (55.5%). The major comorbidity among the patients was chronic kidney disease (50%). The average duration of hospital stay was less than 25 days and the 30-day mortality was 22%. A higher mortality rate was observed in elderly patients with severe infections. The stomach bleeding observed in our patients was far less (0.45%) that in other COVID-19 patients globally, the reasons for which are not unknown.

New Onset Plaque Psoriasis in a Hemodialysis Patient: A Case Report and Review of Literature.

Psoriasis is a common chronic skin condition characterized by erythematous plaques with silvery scales. Several small studies have shown the beneficial effects of peritoneal dialysis and hemodialysis on severe psoriasis cases that were refractory to different therapies even without renal impairment. On the other hand, new onset psoriasis after the initiation of hemodialysis or peritoneal dialysis in end-stage renal disease (ESRD) patients has been rarely reported. We describe a 37-year-old male ESRD patient who developed plaque psoriasis two months after starting hemodialysis. We reviewed the published cases of psoriasis in dialysis patients and the potential therapeutic options used.

Sodium-Glucose Cotransporter 2 Inhibitor (SGLT2i) Associated Diabetic Ketoacidosis in Oncology Patients: A Case Series and Literature Review.

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) use is associated with an increased risk of diabetic ketoacidosis (DKA). The clinical data regarding the use of SGLT2i and its potential side effects in oncology patients is limited. We are retrospectively reporting four oncology patients with type 2 diabetes mellitus using SGLT2i who were admitted with DKA. The mean age of the patients was 61.25 years, and male to female ratio was 1:1. The duration of type 2 diabetes ranged from 10 to 20 years (mean 15.75 years) and the types of SGLT2i used were empagliflozin 25 mg and dapagliflozin 10 mg. The types of malignancy in our case series included squamous cell carcinoma of the cheek, ovarian cancer, and two patients had laryngeal carcinoma (squamous cell carcinoma). Diabetic ketoacidosis was diagnosed in three patients following chemotherapy or concurrent chemo-radiotherapy. Poor oral intake and infections were the main risk factors in our patients. Mean blood glucose level, anion gap, and bicarbonate level were 11.7 mmol/l, 32.25, and 5 mmol/l, respectively. The majority had moderate DKA based on pH (mean 7.13). The hospital course was complicated by acute kidney injury (n=4), infections (n=4) (urinary tract infections, and pneumonia), and three patients required critical care. The mean length of hospitalization was 19.2 days and no mortality was reported among our patients. SGLT2i-related DKA is an emerging complication recognized in oncology patients. Some of the risk factors for this complication are starvation, poor oral intake, and infection which are quite prevalent in oncology patients. Temporary holding of SGLT2i medication during this period might have a potential preventive role.

Consensus recommendations on fasting during Ramadan for patients with kidney disease: review of available evidence and a call for action (RaK Initiative).

Ramadan fasting (RF) involves abstaining from food and drink during daylight hours; it is obligatory for all healthy Muslims from the age of puberty. Although sick individuals are exempt from fasting, many will fast anyway. This article explores the impact of RF on individuals with kidney diseases through a comprehensive review of existing literature and consensus recommendations. This study was conducted by a multidisciplinary panel of experts.The recommendations aim to provide a structured approach to assess and manage fasting during Ramadan for patients with kidney diseases, empowering both healthcare providers and patients to make informed decisions while considering their unique circumstances.

Rare Coexistence of Acute Intermittent Porphyria With Systemic Lupus Erythematous: Case Report and Literature Review.

Porphyrias, particularly acute intermittent porphyria (AIP), are rare, inherited disorders of heme synthesis. On the other hand, systemic lupus erythematosus (SLE) is an uncommon autoimmune disease that affects women predominantly. The coexistence of AIP and SLE is rare. We report a case of concomitant diagnosis of AIP and SLE in a 21-year-old woman who presented with recurrent acute abdominal, chest, and back pain associated with nausea and vomiting, followed by arthralgia, multiple joint pain, and rash. Investigations revealed severe hyponatremia related to SIADH (syndrome of inappropriate antidiuretic hormone secretion) with a positive SLE antibody panel and a positive urine screen for porphobilinogen. Molecular test confirmed the diagnosis of AIP with a pathogenic mutation in the HMBS gene.

Incidence of malignant pericardial effusion in pericardiocentesis patients and post-procedure care: an oncology center pilot study.

The etiology of pericardial effusion can affect many important factors during and after pericardiocentesis. The frequency of etiologies varies among different patient populations. Pericardiocentesis is an important diagnostic and therapeutic intervention; however, data on the characteristics of malignant pericardial effusion are lacking in the United Arab Emirates (UAE). Thus, we conducted a pilot study on the incidence and post-procedure care of patients who underwent pericardiocentesis in our facility to enhance their management and treatment. This retrospective study included all cases of pericardiocentesis between 2011-2019. Epidemiological, clinical, and biochemical data were collected and analyzed. Pericardial fluid analysis, malignancy type, recurrence rate, need for a repeat procedure, and echocardiography findings were reviewed. Thirty-three patients (mean: 47.2 years) underwent pericardiocentesis, and 22 of these patients (66.7%) had malignancy. The predominant cancers were breast cancer (27.3%), lung cancer (27.3%), exudative pericardial effusion and malignant effusion (68%), and bloody fluid (73%). An average of 350 ml was drained from the patients, and the drain was retained for 4 days. Six patients (18.2%) had re-accumulation of pericardial effusion, and 4 patients required repeat procedures. All patients underwent post-procedure echocardiography, and 82% underwent follow-up echo within one week. More than two-thirds of our cancer patients had malignant pericardial effusion. The early diagnosis of the etiology of pericardial effusion may alter its management and prognosis. We would like to conduct further research to determine its influence on the prognosis of cancer patients in the UAE.

Clinical Characteristics and Outcomes of Diabetic Ketoacidosis in Patients With Type 2 Diabetes using SGLT2 Inhibitors.

Background: Sodium glucose cotransporter 2 inhibitors (SGLT2i) use is associated with an increased risk of diabetic ketoacidosis (DKA). Objective: This study evaluated and compared the DKA characteristics and outcomes of users and non-users of SGLT2i. Methods: We retrospectively studied patients with type 2 diabetes mellitus (T2DM) admitted with DKA to Tawam Hospital, Al Ain City, UAE between January 2017 and March 2021. Demographic data, clinical, and laboratory findings were extracted from the electronic medical records. Results: A total of 55 patients with T2DM (62% UAE nationals, 50% women) were admitted with DKA. The average age was 54.0 ± 18.9 years and average diabetes duration of 15.7 ± 15.1 years. Seventeen patients (31%) were using SGLT2i. Infection was the main precipitating factor for DKA in (8 out of 17) SGLT2i users. Compared to non-users, SGLT2i users had lower systolic blood pressure (119.9 vs 140 mmHg; P = .012) and serum glucose levels (16.2 vs 24.9 mmol/L; P < .001) and higher Na level (137.5 vs 132.6 mmol/L; P = .005). Additionally, 56.3% of SGLT2i users had euglycemic DKA compared to 2.6% of nonusers (P < .001). Acute kidney injury (AKI) occurred more in SGLT2i users compared to non-users (94.1% vs 67.6%, P = .043). Further analysis revealed that SGLT2i users were about five times more likely to have prolonged hospital length of stay (⩾14 days) when compared with non-users (adjusted OR: 4.84; P = .035). Overall, there was no difference between the two groups with regards to DKA complications and mortality. Conclusions: SGLT2i related DKA is associated with lower blood glucose levels, lower SBP, worse hypovolemia, increased risk of AKI, and longer hospital stay when compared to non SGLT2i related episodes. Since the benefits of SGLT2 inhibitors far outweigh potential risks, there is a need to raise healthcare professionals and patients' awareness about this potential association.

Prevalence of Latent Tuberculosis Infection Among Rheumatology Patients and Management Practices in the United Arab Emirates: A Single-Center Retrospective Cohort Study.

Introduction Prior to immunosuppression, rheumatology patients are routinely screened for latent tuberculosis (TB) infection using interferon-gamma release assays (IGRAs). Variability in the management of latent and indeterminate IGRA results across institutions limited long-term outcome data. A retrospective study was conducted at Tawam Hospital, United Arab Emirates, to investigate the incidence and management protocols associated with positive and indeterminate IGRA results, as well as TB infection, among patients with rheumatic conditions. Methods A single-center retrospective observational study was performed at Tawam Hospital, Abu Dhabi, UAE. Ethical approval for this study was obtained from the Tawam Human Research Ethics Committee. Laboratory records and the hospital's electronic medical system were used to obtain information about IGRA results over a 12-year period (April 2010-April 2022). The hospital's electronic medical system was used to obtain patient information and subsequent management approaches of positive and indeterminate IGRAs. Moreover, long-term follow-up data were collected to determine the risk of TB reactivation in the cohort. Results We found a total of 1,012 positive and 223 indeterminate IGRA test results within the 12-year period. Within the rheumatology department, 123 positive and 39 indeterminate IGRA results were identified. In the indeterminate IGRA group, the majority were women (n = 24, 61.5%) and UAE nationals (n = 22, 56.4%), and their mean age was 38.6 years. Systemic lupus erythematosus was the most prevalent rheumatologic condition (n = 21, 53.8%). Thirteen (33.3%) were on disease-modifying anti-rheumatic drugs (DMARDs) and 26 (66.7%) were on corticosteroids during IGRA testing. A total of eight patients (20.5%) received anti-TB medications. In the positive IGRA group, the mean age was 55.7 years and the female-to-male ratio was 3:1. The most common rheumatologic condition was rheumatoid arthritis (n = 69, 56%). Sixty-five (52.8%) patients were on conventional DMARDs, 43 (34.9%) were on corticosteroids during IGRA testing, and 74 (60%) received anti-TB medications. Two cases (1.6%) of active TB infections were detected among patients with positive IGRA tests, both of whom were receiving anti-tumor necrosis factor alpha inhibitor treatment in combination with methotrexate. No cases of active TB infection were observed in the indeterminate IGRA group. Conclusion Long-term data on the risk of TB activation in positive and indeterminate IGRA results for rheumatological conditions are low. It is recommended to reassess the choice of using anti-TNF-α, with a positive IGRA result if no other feasible alternatives can be offered. Our findings stress the importance of age, underlying diseases, and immunosuppressive treatments in interpreting IGRA results and guiding patient management. A large multicenter study is needed to understand the differences and outcomes of such patients in TB endemic and nonendemic geographical areas.

Severe Prolonged SGLT2i-induced Euglycemic Diabetic Ketoacidosis Refractory to Standard Therapy and Dialysis: Case Report and Literature Review.

Sodium-glucose cotransporter type 2 inhibitors (SGLT2i) are oral hypoglycemic agents that have insulin-independent glucose-lowering effects mediated by increasing the renal excretion of glucose by inhibiting the SGLT2-mediated renal glucose reabsorption. An increasingly recognized complication induced by SGLT2i is euglycemic diabetic ketoacidosis (eDKA). Here, we describe the case of a 26-year-old male patient with type 2 diabetes mellitus and morbid obesity. Prior to presentation he was on multiple oral hypoglycemic agents including SGLT2i. He developed life-threatening severe prolonged eDKA associated with SGLT2i (Canagliflozin), precipitated by adenovirus infection. The acidosis was not responding to standard DKA therapy and renal replacement therapy but was managed effectively with insulin titration based on capillary ketone measurements. After reviewing the literature on severe prolonged eDKA induced by SGLT2 and treatment modalities used, we present previously reported cases similar to ours.

Outcomes of SGLT2 Inhibitors Use in Diabetic Renal Transplant Patients.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are newly introduced hypoglycemic drugs that work by inhibiting glucose reabsorption at proximal renal tubules. The use of SGLT2 inhibitors in nontransplant diabetic patients with or without cardiovascular disease has well-established efficacy and safety. The risks of renal graft dysfunction and urinary tract infections might be the limiting factors for their use in renal transplant patients. Data regarding the safety and long-term efficacy of SGLT2 inhibitors use in diabetic renal transplant patients is scanty. The aim of the study is to report our experience with use of SGLT2 inhibitors in 8 diabetic renal transplant patients supported by literature review. Eight diabetic renal transplant patients were recruited from Tawam hospital during the period between June 2016 and January 2019. Demographic, clinical, and laboratory data were collected and analyzed. Adding SGLT2 resulted in significant decrease in hemoglobin A1c and body mass index after 12 months of treatment. There was significant negative correlation between the duration of treatment with SGLT2 and hemoglobin A1c. Diabetic renal transplant patients with stable kidney function had better glycemic control with use of SGLT2 inhibitors. There was no deterioration of kidney function and risk of recurrent urinary tract infection was low.