Osmolar gap in hyponatraemia: An exploratory study.

Hyponatraemia has indeed been extensively studied from multiple angles, including volume status, tonicity, and aetiology; however, the specific consideration of the osmolar gap (OG) within the context of hyponatraemia and its potential impact on their overall outcomes received limited attention in research. The current study represents an effort to address this gap in our understanding. This prospective exploratory study was conducted on adults aged 14 years and older at the Indus Hospital, Karachi, from 2017 to 2020. The study involved categorising severity of hyponatraemia and volume status. The osmolar gap (OG) was calculated and categorised as either increased (OG>10) or normal (OG<10). Among the 262 patients included in the study, there were 139 females and 123 males. Elevated OG was observed in 141(53.8%) patients. There were 28 (10.7%) recorded fatalities and majority of these individuals had an elevated OG. These findings underscore the importance for clinicians to consider the osmolar gap when managing patients with hyponatraemia.

Nutritional vitamin D is efficacious for reducing intact parathyroid hormone in chronic kidney disease, a prospective interventional study.

OBJECTIVE: To see the efficacy of oral cholecalciferol administered to chronic kidney disease patients with vitamin D deficiency. Methods: The prospective interventional study was conducted at the Indus Hospital, Karachi, from January 11, 2017, to January 10, 2018, and comprised diagnosed pre-dialysis chronic kidney disease patients of either gender aged >14 years having vitamin D deficiency. Oral vitamin D 50,000IU was given weekly to those who had severe deficiency <10ng/ml, and every other week to those with less severe 10-25ng/ml deficiency for 3 months. Improvement in vitamin D level was checked along with other chronic kidney disease markers every month over the 3-month period. Data was analysed using SPSS 24. RESULTS: Of the 186 patients enrolled, 129(%) completed the study; 76(58.5%) males and 53(40.8%) females. Overall, 105(81.4%) patients achieved normal vitamin D levels after 3 months of treatment. Significant negative but weak correlation of phosphate, creatinine and intact parathyroid hormone levels was found with vitamin D (p<0.05). Significant positive but weak correlation was found between albumin and vitamin D levels (p<0.05). Conclusion: Significant efficacy of oral vitamin D in chronic kidney disease patients was seen.

Strategies for preventing end stage kidney disease: The impact of kidney stone disease on Chronic Kidney Disease in Pakistan.

Chronic Kidney Disease (CKD) is one of the major noncommunicable diseases that have social and economic impacts along with day-to-day health-related problems. Kidney stone disease is still one of the major causes of CKD in Pakistan. Kidney stone disease is a preventable cause of renal failure, if detected and treated early. Kidney stone is prevalent in the stone belt areas in our country which are located in rural areas. The treatment is very costly, and mostly available only in large cities. The treatment requires tertiary care setup and expertise. Therefore, there is a need to focus on the preventive strategies which are mainly dietary and lifestyle modifications, along with public awareness programmes. Nephrologists and urologists along with the government should take interest and give priority to CKD due to stone disease.

Status of chronic kidney disease of unknown aetiology in Pakistan.

The incidence of chronic kidney disease (CKD) is rising all over the world. Developing countries like Pakistan will be most affected due to the prevalence of risk factors associated with CKD, such as diabetes, hypertension, kidney stone, and infections. Chronic kidney disease of unknown aetiology (CKDu) is an emerging CKD recently recognised in agricultural communities all around the world. CKDu is recognised, mostly in men between 20 and 50 years of age, with no symptoms, having normal or borderline elevated blood pressure with normal blood glucose levels. Their ultrasonography manifests small kidneys. Urine examinations reveal no or minimal proteinuria, few red blood cells and leukocytes. The actual prevalence in Pakistan is unknown but it is not infrequent for nephrologists and physicians to see these patients in hospitals. There is a need to look into this entity at the community level.

Is haemodialysis the most feasible dialysis modality for Pakistan?

Chronic kidney disease (CKD) has shown a rising trend in the last two decades. It is one of the most devastating diseases which has an enormous psychosocial and economic burden. The treatment available includes haemodialysis, peritoneal dialysis and kidney transplantation. All treatment options have their pros and cons, needs and preferences, though haemodialysis is one of the most available entity in Pakistan. There are a few intrinsic problems associated with haemodialysis which has significant environmental as well as economic impact. One of the most important is the need of huge quantity of water to carry out the haemodialysis procedure along with production of solid waste in the form of disposables and electricity consumption. Peritoneal dialysis on the other hand is more environment-friendly and cost-effective and it should be one of the preferred options for our CKD patients.

The frequency of vitamin D deficiency in chronic kidney disease and its relation with baseline mineral bone markers.

OBJECTIVE: To assess the frequency of Vitamin D deficiency in chronic kidney disease and its association with baseline mineral bone markers in patients visiting nephrology clinics. METHODS: The observational study was conducted at the Indus Hospital, Karachi, from January 2017 to January 2018, and comprised patients of either gender aged >16 years diagnosed with chronic kidney disease stage I-V. The patients were divided into two groups on the basis of severity of vitamin D deficiency. Severe vitamin D deficiency was defined as <10ng/ml, and moderate deficiency ad 10- 25ng/ml. Data was analysed using SPSS 21. RESULTS: Of the 267 patients, 146(54.7%) were males and 189(70.8%) had vitamin D deficiency. Vitamin D-deficient patients were younger than those with normal levels (p=0.044). Serum creatinine was raised in the deficient patients compared to those with normal vitamin D level (p=0.042). Females and currently employed patients were at a higher risk of having vitamin D deficiency (p=0.048, 0.009). There was no si gn ific ant as s ociation between disease stage a nd vitamin D defic ienc y ( p= 0.311). CONCLUSIONS: Vitamin D deficiency was found in a significant proportion of chronic kidney disease patients irrespective of the disease stage. Females, currently employed and young patients were more prone to having vitamin D deficiency.

The role of the poultry industry on kidney and genitourinary health in Pakistan.

Pakistan is experiencing a "double burden'' of disease. Under-development is associated with illnesses like infections and nutritional deficiency, and is accompanied with diseases linked with development, such as diabetes, hypertension, cancer and chronic kidney disease. In Pakistan, renal and genitourinary diseases are an important, unaddressed health issues. Chronic kidney disease of unknown etiology (CKDu) is a recognized form of renal failure in Pakistan. A possible cause of CKDu is toxins such as arsenic, cadmium, lead and other heavy metals associated with renal and genitourinary diseases. The poultry industry is an important source of both heavy metal toxins and also mycotoxins spread in the process of farming. Of the numerous mycotoxins, zearalenone and ochratoxin are well-known for their hazardous effects on genitourinary and renal parenchyma respectively. We reviewed the literature using PubMed and Google Scholar databases for levels of these toxins in various constituents of chicken farming like chicken feed, meat, litter and human drinking water contamination in various parts of the country. We found that these toxins are in higher levels than recommended.

Inter-hospital communication and transfer practices during COVID-19 Pandemic in Karachi, Pakistan. A brief overview.

OBJECTIVE: To discuss the referral mechanisms established for safe and expeditious inter-facility transfer of COVID 19 positive patients to ensure their referrals through establishing proper communication channels. METHODS: Mobile phone and WhatsApp based groups, administrated by The Indus Hospital were established in April 2020. Through detailed reports and frequent communication, factors like bed and ventilator availability across these facilities are shared. Weekly reports through zoom meetings updating the key stake holders, discussion of problems faced and planning for the week ahead are also done. RESULT: The establishment of these groups has been successful in ensuring referral to and from The Indus Hospital to various healthcare facilities across Karachi using appropriate ambulance services. CONCLUSION: The development of referral mechanisms is the need of the day that has been highlighted through the COVID 19 pandemic. It is our hope that these mechanisms are sustained after the pandemic and result in improvement in patient outcome through proper referrals.

Reflections on the process of adapting hospital performance measures for an LMIC tertiary care setup.

The hospital performance measurement is critical for any institute to identify its areas of improvement and take appropriate corrective and preventive actions. However, to design a framework that is globally acceptable has always been a challenging task. The developed countries have formulated a few models but that cannot be implemented in the developing world without understanding their context. In this paper, we are sharing our process of sifting through the numerous frameworks and models to come up with an approach that works for Indus Hospital and Health Network. We also intend to highlight the leadership thought process and challenges in coming up with and implementing our approach. Our framework is based on including volume measures to the traditional value in healthcare measures of cost-effectiveness and quality. Moreover, our measurements were done at specialty or medical condition level in various types of services offered at our hospital. We have implemented this framework in our tertiary care hospital and deem that this model has given us the liberty to design key performance indicators according to specialties, services and medical conditions being dealt in our various facilities. We hope our experience will give healthcare leaders in similar settings ideas of how best to implement hospital performance indicators based on their own circumstances.

Clinical Course and Outcome of ESRD Patients on Maintenance Hemodialysis Infected with COVID-19: A Single-Center Study.

BACKGROUND: In an ESRD subset of patients, COVID-19 infection is associated with increased disease burden and higher mortality rates. METHODS: We conducted a retrospective single-center cohort study in which 43 ESRD patients had a diagnosis of COVID-19. Association of risk factors with mortality was assessed by chi-square test and logistic regression analysis. Data were collected on a structured performa which included variables like age, gender, comorbid conditions, drug history, clinical presentation, hemodynamic status and laboratory parameters. Outcome variables were recovery and death. All patients received standard treatment for COVID-19 according to hospital protocols, along with hemodialysis and continuous renal replacement therapy (CRRT) when needed. RESULTS: Those most affected were found to be male, 25 (58.1%), while the number of females affected was 18 (41.9%). The most frequent comorbid condition was hypertension (HTN), seen in 35 (81.4%) patients; however, thromboembolic complications were very few in these patients. The mortality rate in our study was 25.6%, and the population most susceptible to poor outcomes in the ESRD subgroup was elderly people (45.5%), while younger patients recovered the most from COVID-19 (53.1%). Hypoalbuminemia, leukocytosis, lymphopenia and raised LDH were also found to be associated with death in ESRD patients suffering from COVID-19 (81.8, 72.7, 100 and 100%, respectively). In multivariate logistic regression analysis, we found that the odds ratio of dying from COVID-19 was 19.5 times higher in patients aged >65 years as compared to patients aged 18-50 years (p=0.039). Similarly, patients with a high TLC were 24.1 times more likely to die than patients with a normal TLC (p=0.008). CONCLUSION: In our center, the mortality rate of ESRD patients affected with COVID-19 disease was 25.6%, and older age, leukocytosis, lymphopenia, hypoalbuminemia and high LDH were significantly associated with mortality.

Prevalence and risk factors of kidney disease in urban Karachi: baseline findings from a community cohort study.

BACKGROUND: Chronic kidney disease (CKD) is being increasingly recognized as a leading public health problem. However, there are limited data available with respect to prevalence of CKD in Pakistan, a developing South Asian country. The study presents the baseline findings of prevalence and risk factors for adult kidney disease in a Pakistani community cohort. METHODS: A total of 667 households were enrolled between March 2010 and August 2011 including 461 adults, aged 15 and older. Mild kidney disease was defined as estimated Glomerular Filtration Rate (eGFR) ≥60 ml/min with microalbuminuria ≥ 30 mg/dl and moderate kidney disease was defined as eGFR <60 ml/min (with or without microalbuminuria). RESULTS: The overall prevalence of kidney disease was 16.6% with 8.6% participants having mild kidney disease and 8% having moderate kidney disease. Age was significantly associated with kidney disease (p < 0.0001). The frequency of diabetes, hypertension and smoking differed significantly among the three groups, i.e., no kidney disease, mild kidney disease and moderate kidney disease. CONCLUSION: Our study results suggest that the burden of kidney disease in this population is found considerable and comparable to neighboring developing countries. We believe that these results have critical implications on health and economics of these countries and due to the epidemic of diabetes, hypertension, cardiovascular disease, smoking and association with worsening poverty, further rapid growth is expected. There is an urgent need for early recognition and prevention strategies based on risk factors and disease trends determined through longitudinal research.