Fasting during Ramadan and acute kidney injury (AKI): a retrospective, propensity matched cohort study.

BACKGROUND: During the month of Ramadan, Muslims abstain from daytime consumption of fluids and foods, although some high-risk individuals are exempt. Because fasting's effects on the risk of acute kidney injury (AKI) have not been established, this study assesses the relationship between fasting and risk of AKI and identifies patients at high risk. METHODS: A single-center, retrospective, propensity-score matched, cohort study was conducted with data collected from adult patients admitted to the emergency room during Ramadan and the following month over two consecutive years (2016 and 2017). AKI was diagnosed based on the 2012 definition from the Kidney Disease: Improving Global Outcomes clinical practice guideline. Multivariable logistic regression analyses were used to examine the correlation and measure the effect of fasting on the incidence of AKI, and assess the effect of different variables on the incidence of AKI between the matching cohorts. RESULTS: A total of 1199 patients were included; after matching, each cohort had 499 patients. In the fasting cohort, the incidence of AKI and the risk of developing AKI were significantly lower (adjusted odds ratio (AOR) 0.65;95% confidence interval (CI) 0.44-0.98). The most indicative risk factors for AKI were hypertension (AOR 2.17; 95% CI 1.48-3.18), history of AKI (AOR 5.05; 95% CI 3.46-7.39), and liver cirrhosis (AOR 3.01; 95% CI 1.04-8.70). Patients with these factors or most other comorbidities in the fasting cohort had a lower risk of AKI as compared with their nonfasting counterparts. CONCLUSION: The data show a strong reduction in the risk of developing AKI as a benefit of fasting, particularly in patients with comorbid conditions. Therefore, most patients with comorbid conditions are not harmed from fasting during Ramadan. However, larger prospective studies are needed to investigate the benefit of fasting in reducing the risk of developing AKI.

Hyperkalemia Management with Intravenous Insulin in Patients with Reduced Kidney Function.

Background: Insufficient kidney function increases the risk of hyperkalemia and hypoglycemia, particularly in hemodialysis-dependent patients. Hypoglycemia is a common complication of insulin-based hyperkalemia treatment. This study aims to evaluate the efficacy and safety of hyperkalemia treatment in hemodialysis-dependent and -non-dependent patients and identify risk factors associated with hypoglycemia. Methods: A retrospective observational cohort study was conducted to assess the efficacy and safety of hyperkalemia treatment including patients with reduced kidney function and hyperkalemia treated with intravenous insulin. The decline rate of potassium and glucose levels were compared between hemodialysis-dependent and non-dependent patients. In addition, univariate and multivariable logistic regression analyses were performed to identify risk factors associated with hypoglycemia. Results: A total of 172 patients with hyperkalemia and reduced kidney function were included. The steepest reduction of serum potassium levels happened within the first 6 h after insulin administration, at 1.1 and 0.9 mmol/L for hemodialysis-dependent and non-dependent patients, respectively. The incidence of hypoglycemia was 18%, and no significant difference was found between cohorts. Hemodialysis-dependent patients were more likely to be readmitted within one month with hyperkalemia, while all-cause ICU admission was more likely for non-dependent patients. Older patients, and those who had heart failure or received a second dose of insulin to treat hyperkalemia, were more likely to experience hypoglycemia. Conclusions: Monitoring blood glucose levels following insulin administration is essential given the complexity of patients' factors associated with hypoglycemia resulting from hyperkalemia treatment in patients with insufficient kidney function.

The impact of child-specific characteristics on warfarin dosing requirements.

Background: The influence of child characteristics on warfarin dosing has been reported; however, there is no consensus on the nature and extent of this effect. Objectives: To investigate the impacts of the demographic and clinical characteristics of children on the warfarin dose required to achieve a therapeutic international normalization ratio (INR). Methods: This retrospective cohort study included children aged 3 months to 14 years old who were prescribed warfarin for 3 months or longer with a "stable INR." The primary outcome was the total daily dose (TDD) and total weekly dose of warfarin required to achieve a therapeutic INR target. Results: We included 127 patients with a mean age of 7.7 ± 3.7 years and a median weight of 22 (IQR, 16-33) kg. Of the sample, 55 patients (43.3%) required a TDD of ≤0.1 mg/kg. The TDD for children younger than 5 years, 5 to 10 years, and older than 10 years were 0.14 ± 0.06 mg/kg, 0.12 ± 0.05 mg/kg, and 0.096 ± 0.04 mg/kg, respectively (P = .002). Overweight and obese children required a smaller TDD than normal-weight children: 0.09 ± 0.05 vs 0.13 ± 0.05 mg/kg (P = .004), which was similar for underweight children. A lower body surface area (<0.5 m2) required a higher dose. All the other variables did not affect warfarin doses. The incidence of a subtherapeutic or supratherapeutic INR was independent of demographic or clinical variables. Conclusion: The study confirmed that the patient demographics affect the daily warfarin dose required to achieve the INR target. However, they do not have any predictive value for the incidence of out-of-range-INR.

Validity and reliability of the Arabic-translated kidney disease quality of life survey among long-term dialysis patients in Saudi Arabia.

One of the tools used to measure the quality of life in hemodialysis (HD) patients is the Kidney Disease Quality of Life (KDQOL) survey. The KDQOL has been through several developmental processes, with the most recent one being the KDQOL-36™. Our study evaluated the validity and reliability of the Arabic-translated KDQOL-36™ survey in Saudi chronic dialysis patients. This cross-sectional study was conducted at four HD centers in Saudi Arabia. The KDQOL-36™ survey was translated into Arabic according to the RAND Corporation's basic guidelines for translating surveys. The validation process was achieved by assessing reliability and validity. The reliability of the translated survey was established by Cronbach's alpha to measure internal consistency and the intra-class correlation coefficient (ICC) to measure the test-retest reliability. The validity of the translated survey was established based on content validity and convergent validity. The study included 184 patients (36-65 years; 60.9% of men). Regarding reliability, Cronbach's alpha for the subscales ranged from 0.63 to 0.89, and ICCs ranged from 0.60 to 0.88. For content validity, an expert panel reviewed the questions in depth. In addition, we found a positive relationship between all sub- and overall health-rated scores (P <0.01). The Arabic-translated version of the KDQOL-36™ survey is reliable and valid for evaluating the quality of life in Saudi chronic dialysis patients.

Evaluation of warfarin dose requirements in patients with chronic kidney disease and end-stage renal disease.

STUDY OBJECTIVES: The effect of chronic kidney disease (CKD) on warfarin has gained attention because of an increased risk of thromboembolism and an increased risk of bleeding associated with warfarin treatment in these patients. Data suggest that patients with reduced kidney function require lower warfarin doses; however, relatively few patients with end-stage renal disease (ESRD) were included in previous studies. The goal of this study was to evaluate warfarin dosing requirements and time to reach therapeutic international normalized ratio (INR) in patients with CKD stages 3-5 and ESRD compared with patients with normal kidney function (NKF). METHODS: A historical cohort was identified to evaluate warfarin response in 210 hospitalized adults with varying degrees of kidney function initiated or maintained on warfarin for 4 or more consecutive days including 49 patients with NKF (glomerular filtration rate [GFR] higher than 60 ml/min/1.73 m(2) ), 44 with CKD stage 3, 27 with CKD stage 4/5, and 90 with ESRD. The average daily dose (ADD), time to achieve a therapeutic INR, and adverse effects were compared. MEASUREMENTS AND MAIN RESULTS: The ADD to maintain a therapeutic INR was 5.6 ± 1.7 mg in the NKF group, 4.3 ± 1.6 mg in CKD stage 3, 4.6 ± 1.9 mg in CKD stage 4/5, and 4.8 ± 1.9 mg in ESRD. The ADD was lower in CKD/ESRD patients compared with NKF patients (p=0.001), especially among whites. The time to reach a therapeutic INR in patients newly initiated on warfarin was significantly lower in the CKD/ESRD group when compared with the NKF group (p=0.02). No differences in bleeding episodes were observed during hospitalization or within 30 days of discharge in patients with CKD stage 3 or higher compared with patients with NKF. CONCLUSIONS: Our findings suggest that CKD and ESRD patients require ~20% lower warfarin doses to maintain a therapeutic INR and may require less time to achieve a therapeutic INR compared with patients with NKF.