Problem to solution; from mammalian skin grafts to renal allograft rejection: a tale of 66 years of evolution of our understanding.

The first successful kidney transplant was done in 1954, and it remains the best option for those with failed kidneys. However, the recipient's immune system remains the most formidable barrier to transplantation, leading to rejection. Rejection continues to be the most important reason of graft malfunction and chronic renal allograft dysfunction and remains a challenge to date for successful transplant survival. The current narrative review was planned to find the best possible solution to the problem from among the different solutions presented in literature related to allograft rejection since 1954.

Development of Banff Classification from 1991 to 2019 for identifying renal allograft rejection: A narrative review for nephrologists.

Renal pathologists, nephrologists and transplant surgeons held a meeting in 1991 at Banff, Canada, and developed a classification scheme that standardised the international classification of renal allograft biopsies and called it the Banff Classification. Following the first meeting, 15 meetings were held, usually every two years, that revised the classification in the light of new evidence and techniques. The latest printed consensus was after the 2019 meeting in Pittsburgh in the United States of America. Several articles have been published in the last 30 years that have created ambiguities for nephrologists and have made things challenging for the expert pathologists. The current perspective review was planned to make it easy and clear for beginners and for practitioners how the Banff Classification has evolved since its inception.

The second wave of COVID-19 disease in haemodialysis patients: An experience of a dialysis center from Pakistan.

OBJECTIVE: To evaluate the characteristics and outcomes of second wave of coronavirus disease-2019 in haemodialysis patients. METHODS: The retrospective, observational cohort study was conducted at The Kidney Center Post-Graduate-Training-Institute, Karachi, Pakistan and comprised data of patients regardless of gender who contracted coronavirus disease-2019 during the second wave from November 3, 2020, till February 12, 2021. Epidemiological, clinical, laboratory, and radiological characteristics and outcomes of the patients were reviewed. Data was analysed using SPSS 21. RESULTS: Of 437 patients on haemodialysis, 46(10.5%) contracted coronavirus disease-2019; 29(63%) males and 17(37%) females. The overall median age was 61.5±13.02 years. Most patients developed mild disease 27(%). The most common symptom was fever 29(63%), and 6(13.1%) patients had patchy bilateral opacity on chest radiograph. Major complications were lymphocytopenia 29(63%), pneumonia 15(32.6%), thrombocytopenia 8(17.4%), and septic shock 5(10.9%). Overall, 15(32.6%) patients required hospitalisation, and 8(17.4%) required mechanical ventilation. There were 13(28.3%) deaths. Patients aged >60 years had 6.8 times more severe disease (p=0.023) and chances of death among them were 5.8 times higher (p=0.036) than in those aged <60 years. CONCLUSIONS: There was a high susceptibility of haemodialysis patients during the second wave of coronavirus disease compared to the general population. The most important determinants of death were advanced age, lower oxygen saturation and thrombocytopenia at presentation.

'Haemodialysis burden' overweighs the associations of demographic, social and clinical factors on quality of life: A single centre study from Pakistan.

OBJECTIVE: To assess health-related quality of life in haemodialysis patients, and the impact of various factors in this regard. METHODS: The retrospective observational cross-sectional study was conducted at The Kidney Centre Post-Graduate Training Institute, Karachi, and comprised data from June to December 2019 of patients on maintenance haemodialysis. The health-related quality of life was assessed using the self-administered Urdu version of the Kidney Disease Quality of Life-Short Form version 1.3. Data was analysed using SPSS 21. RESULTS: Of the 150 questionnaires distributed, 110(73.3%) were received fully completed. There were 64(58.2%) males, 46(41.8%) were females, 90(81.8%) were under <60 years age, 76(69%) were married, 54(49.1%) had income up to PKR50,000, 64(58.2%) had received education up to secondary school, and 56(50.9%) had been on haemodialysis for <5 years. The overall health-related quality of life mean score was 52.0±11.7, and it had no significant association with age, gender, haemodialysis duration, marital status, education level, and income of the subjects (p>0.05). CONCLUSIONS: The health-related quality of life in haemodialysis patients was not found to have significant association with age, gender, haemodialysis duration, marital status, education level, and income.

Frequency of iron deficiency anaemia in chronic kidney disease patient not on dialysis.

OBJECTIVE: To determine the frequency of iron deficiency anaemia in non-dialysis chronic kidney disease patients. METHODS: The observational, cross-sectional study was conducted at the Department of Nephrology, The Kidney Centre Post-Graduate Training Institute, Karachi, from April 27 to October 26, 2018, and comprised adult patients of either gender diagnosed with anaemia and estimated glomerular filtration rate <90ml/min. Patient with transferrin saturation <20% were labelled as having iron deficiency anaemia. Data was analysed using SPSS 21. RESULTS: Of the 366 participants, 185(50.5%) were males and 181(49.5%) were females. The overall mean age was 54.47±14.93 years. The most prevalent comorbid was hypertension 263(71.9%), followed by diabetes mellitus 187(51.1%) and cardiovascular disease 54(14.8%). Besides, 192(52.5%) patients had CKD stage 5 followed by 115(31.4%) and 54(14.8%) with CKD stages 4 and 3, respectively. The mean haemoglobin was 9.17±1.57g/dL. Iron deficiency was found in 285(77.9%) patients. CONCLUSIONS: Iron deficiency anaemia was found to be highly prevalent and should be screened routinely and managed appropriately.

Preprints in times of COVID19: the time is ripe for agreeing on terminology and good practices.

Over recent years, the research community has been increasingly using preprint servers to share manuscripts that are not yet peer-reviewed. Even if it enables quick dissemination of research findings, this practice raises several challenges in publication ethics and integrity. In particular, preprints have become an important source of information for stakeholders interested in COVID19 research developments, including traditional media, social media, and policy makers. Despite caveats about their nature, many users can still confuse pre-prints with peer-reviewed manuscripts. If unconfirmed but already widely shared first-draft results later prove wrong or misinterpreted, it can be very difficult to "unlearn" what we thought was true. Complexity further increases if unconfirmed findings have been used to inform guidelines. To help achieve a balance between early access to research findings and its negative consequences, we formulated five recommendations: (a) consensus should be sought on a term clearer than 'pre-print', such as 'Unrefereed manuscript', "Manuscript awaiting peer review" or ''Non-reviewed manuscript"; (b) Caveats about unrefereed manuscripts should be prominent on their first page, and each page should include a red watermark stating 'Caution-Not Peer Reviewed'; (c) pre-print authors should certify that their manuscript will be submitted to a peer-review journal, and should regularly update the manuscript status; (d) high level consultations should be convened, to formulate clear principles and policies for the publication and dissemination of non-peer reviewed research results; (e) in the longer term, an international initiative to certify servers that comply with good practices could be envisaged.

Assessment of nutritional status of haemodialysis patients by subjective global assessment score: A single centre study from Karachi, Pakistan.

OBJECTIVE: To assess the nutritional status of patients on maintenance haemodialysis to determine the frequency and severity of malnutrition. METHOD: The cross-sectional study was conducted in November 2020, at the The Kidney Centre Post-Graduate Training Institute, Karachi, and comprised secondary data related to patients on maintenance haemodialysis which was collected from January to August 2016. A one-time subjective global assessment score was calculated based on the history and physical examinations. Data was analysed using SPSS 17. RESULTS: Of the 150 patients, 84(56%) were male and 66(44%) were female. The overall mean age of study participants was 52.21±12.5 years. Hypertension was the most frequent comorbid 130(86.7%), and normal body mass index was noted in 58(38.7%). Overall, 96(64%) patients had mild or moderate malnourishment, and 54(36%) were well-nourished. Females were 2.6 times more likely to be malnourished (p=0.009), and duration >5 years on haemodialysis increased the risk of malnourishment by 12.5 times (p<0.001), while overweight patients had significantly less chance of being malnourished (p=0.004). CONCLUSIONS: Malnutrition was found to be quite common in haemodialysis patients, which necessitates its regular assessment and monitoring.

Innovations in research ethics governance in humanitarian settings.

BACKGROUND: Médecins Sans Frontières (MSF) is one of the world's leading humanitarian medical organizations. The increased emphasis in MSF on research led to the creation of an ethics review board (ERB) in 2001. The ERB has encouraged innovation in the review of proposals and the interaction between the ERB and the organization. This has led to some of the advances in ethics governance described in this paper. DISCUSSION: We first update our previous work from 2009 describing ERB performance and then highlight five innovative practices: • A new framework to guide ethics review • The introduction of a policy exempting a posteriori analysis of routinely collected data • The preapproval of "emergency" protocols • General ethical approval of "routine surveys" • Evaluating the impact of approved studies. The new framework encourages a conversation about ethical issues, rather than imposing quasi-legalistic rules, is more engaged with the specific MSF research context and gives greater prominence to certain values and principles. Some of the innovations implemented by the ERB, such as review exemption or approval of generic protocols, may run counter to many standard operating procedures. We argue that much standard practice in research ethics review ought to be open to challenge and revision. Continued interaction between MSF researchers and independent ERB members has allowed for progressive innovations based on a trustful and respectful partnership between the ERB and the researchers. In the future, three areas merit particular attention. First, the impact of the new framework should be assessed. Second, the impact of research needs to be defined more precisely as a first step towards being meaningfully assessed, including changes of impact over time. Finally, the dialogue between the MSF ERB and the ethics committees in the study countries should be enhanced. SUMMARY: We hope that the innovations in research ethics governance described may be relevant for other organisations carrying out research in fragile contexts and for ethics committees reviewing such research.

Type of immune and complement deposits and response of immunosuppressive treatment on Membranoproliferative Glomerulonephritis -- a single centre experience.

OBJECTIVE: To see the response of steroid and cyclophosphamide if membranoproliferative glomerulonephritis is classified by pattern of immune and complement deposits. METHODS: The retrospective study was conducted at The Kidney Centre, Karachi, and comprised patients treated for membranoproliferative glomerulonephritis between 1996 and 2013. Records of patients who were not treated with immunosuppressive medications were excluded. Patients were classified according to the types of immune deposits; one group had patients with only Complement factor 3 deposits, and the other with Complement factor 3 and immunoglobulin deposits. The effect of steroid alone and steroid with cyclophosphamide was observed on two histological patterns, according to the severity of kidney dysfunction and degree of interstitial fibrosis. SPSS 17 was used for statistical analysis. RESULTS: Of the 54 patients, 31(57%) were males and 23(42%) were females, with an overall mean age of 30.26±15.41 years. Group with Complement factor 3deposits had 17(31%) patients, while that with Complement factor 3 and immunoglobulin had 37(68%). Both groups were similar in terms of clinical and laboratory parameters (p>0.05). Both groups showed better response when treated with steroid and cyclophosphamide: 8/9(88.9%) vs. 3/8(37.5%) in Complement factor 3 only; and 10/15(66.7%) vs. 12/22(54.5%) in Complement factor 3 with immunoglobulin. Increasing severity of interstitial fibrosis (p=0.014) and presence of renal dysfunction (p=0.001) hampered the response. After adjusting the confounders, the odds ratio of response was 4.654(95%confidence interval: 0.957-22.63) in patients who received the treatment with steroid and cyclophosphamide compared to steroid alone. CONCLUSIONS: Steroids and cyclophosphamide together have a beneficial role if treatment is initiated early in the course of the disease.

Treatment of hyperkalemia in patients with chronic kidney disease: a comparison of calcium polystyrene sulphonate and sodium polystyrene sulphonate.

BACKGROUND: Hyperkalemia is one of the most dreadful complications of chronic kidney disease (CKD). Medical management includes use of cation exchange resins to reduce the amount of excessive potassium from the body. Sodium polystyrene sulphonate (SPS) and calcium polystyrene sulphonate (CPS) are currently used for hyperklemia of CKD all over the world. The objective was to compare the efficacy and safety of two different cation exchange resins (CPS and SPS) in patients of CKD with hyperkalemia. METHODS: This randomized control trial was done at the Kidney Centre, Post Graduate Training Institute (PGTi), Karachi, Pakistan between 15 January 2010 till 31st December 2010 to compare the efficacy and safety of, CPS and SPS in 97 CKD patients with hyperkalemia. The subjects were divided in two groups. Group-A received CPS while group-B received SPS. The data included symptoms, food recall, physical signs of volume overload and electrolytes. After receiving potassium binding resin for 3 days patients were evaluated for symptoms, weight gain, worsening of blood pressure and effect on electrolytes. Adverse events were recorded in an event reporting form. RESULTS: Average potassium level pre resin was 5.8_0.26 in group-A and 5.8±0.6 in group-B, which reduced to 4.8±0.5 in group-A and 4.3±0.53 in group-B suggesting the efficacy of both drugs for treatment of hyperkalemia in CKD patients. Systolic blood pressure remains stable in both the groups while an increase in diastolic blood pressure was noticed in group-B patients (p-value 0.004). No major adverse effect occurred in both the groups. CONCLUSION: Both CPS and SPS can be used effectively for reducing hyperkalemia of CKD. CPS showed fewer side effects as compared to SPS.

Frequency of Pulmonary Hypertension and Its Associated Risk Factors in End-Stage Renal Disease (ESRD) Patients on Maintenance Hemodialysis.

Introduction Pulmonary hypertension (PH) is a recognized complication in patients with end-stage renal disease (ESRD undergoing maintenance hemodialysis (MHD). PH is commonly found in patients with chronic kidney disease (CKD) and ESRD. PH is associated with increased morbidity and mortality in patients with CKD. Methodology This cross-sectional study aimed to assess the prevalence of PH and its associated risk factors in MHD patients. A total of 220 ESRD patients on MHD patients at The Kidney Center, Karachi, Pakistan, aged 18-70 were included. Patients with chronic obstructive lung disease, valvular heart disease, and obstructive sleep apnea were excluded, as these conditions can be responsible for PH. PH was evaluated by echocardiography (ECHO), which was performed by a cardiologist. Results The mean age was 50.65 ± 14.4 years, with 131 (59.5%) males and 89 (40.5%) females. The average duration on hemodialysis was 5.3 ± 2.8 years. Hypertension (89.5%) and ischemic heart disease (24.1%) were prominent comorbidities. Hypertensive nephropathy (42.7%) was the leading cause of ESRD. Left ventricular hypertrophy was mild in most cases (85.5%), whereas regional wall motion abnormality (RWMA) was common (67.3%). The average pulmonary artery pressure was 35.2 ± 15.3 mmHg. Out of 220 patients, 109 patients (49.8%) of them had mild PH, nine patients (4.1%) had severe PH, and 72 patients (32.7%) had moderate PH. Associations between PH and various factors were examined. RWMA, left ventricular hypertrophy, and left ventricular ejection fraction were significantly associated with PH (p < 0.001). Serum calcium and albumin levels were also associated with PH severity (p < 0.05). Other demographic and laboratory parameters did not show a significant association. Conclusion This study highlights the prevalence of PH in MHD patients and identifies associated risk factors. Understanding these associations can aid in better managing PH in ESRD patients.

Plasma Levels of Secreted Cytokines in Virologically Controlled HIV-Infected Aging Adult Individuals on Long-Term Antiretroviral Therapy.

HIV-infected (HIV+) aging adult individuals who have achieved undetectable viral load and improved CD4 T cell counts due to long-term antiretroviral therapy (ART) may continue to experience inflammation and immunosenescence. Therefore, we evaluated the plasma levels of proinflammatory and anti-inflammatory cytokines in 173 HIV+ aging adult individuals with age ranging from 22 to 81 years on long-term ART with viral load mostly <20 HIV RNA copies/mL and compared with 92 HIV-uninfected (HIV- or healthy controls) aging individuals. We found that the median levels of TNF-α, IFN-γ, IL-1ß, IL-6, and IL-10 were higher (p < 0.001 to <0.0001) and IL-17 trended lower in HIV+ individuals than healthy controls. Increasing CD4 T cell counts in the HIV+ cohort did not significantly change the circulating cytokine levels, although levels of IL-1ß increased. However, IL-17 levels significantly decreased with increasing CD4 counts in the healthy controls and yet unchanged in the HIV+ cohort. Of note, the levels of circulating IL-17 were significantly reduced comparatively in the healthy controls where the CD4 count was below 500, yet once above 500 the levels of CD4, IL-17 levels were comparable with the HIV+ cohort. With increasing CD8 T cell counts, the levels of these cytokines were not significantly altered, although levels of TNF-α, IFN-γ, and IL-6 declined, whereas IL-1ß and IL-17 were slightly elevated. Furthermore, increasing age of the HIV+ cohort did not significantly impact the cytokine levels although a slight increase in TNF-α, IL-6, IL-10, and IL-17 was observed. Similarly, these cytokines were not significantly modulated with increasing levels of undetectable viral loads, whereas some of the HIV+ individuals had higher levels of TNF-α, IFN-γ, and IL-1ß. In summary, our findings show that HIV+ aging adult individuals with undetectable viral load and restored CD4 T cell counts due to long-term ART still produce higher levels of both proinflammatory and anti-inflammatory cytokines compared with healthy controls, suggesting some level of inflammation.

Giant Renal Angiomyolipomas and Pulmonary Lymphangioleiomyomatosis: Follow-up Report after More than a Decade.

Renal angiomyolipomas (AMLs) and pulmonary lymphangioleiomyomatosis (LAM) are two major presentations of tuberous sclerosis (TS), an autosomal dominant multisystem disorder. Renal AMLs can lead to life-threatening complications like hemorrhage and cause progressive renal failure requiring dialysis and kidney transplant. mTOR inhibitors showed promising results in TS patients with renal AMLs, LAM, and subependymal giant cell astrocytomas. This case report is a follow-up of a patient we reported in 2010 with giant AMLs and LAM who required an emergency nephrectomy for massive hemorrhage from giant left-sided AMLs.

From Exhaustion to Empowerment: Investigating Fatigue and Its Associations in Patients With End-Stage Renal Disease on Maintenance Hemodialysis.

Introduction Patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis (MHD) frequently experience fatigue. This cross-sectional study examined the severity of fatigue and the demographic and clinical characteristics that may contribute to fatigue in ESRD patients on MHD. Methods The study included 250 ESRD patients on MHD. Age, gender, marital status, occupation, level of education, and information regarding dialysis and laboratory parameters were gathered. The Fatigue Assessment Scale (FAS) was used to quantify fatigue. The FAS consisted of 10 questions. Fatigue severity was categorized into three groups based on the total FAS score. Results The mean fatigue score using FAS in our study was 22.1 ± 4.1 (47.2%), indicating a moderate level of fatigue among the participants. Approximately 47.2% of the patients reported moderate fatigue, while severe fatigue was not observed in our study. Employment status showed a significant association with fatigue, with a higher prevalence among unemployed individuals 56 (47.5%) and those engaged in housework 40 (33.9%). The duration of hemodialysis was also significantly associated with fatigue in our study (p < 0.001), with patients undergoing treatment for more than 4 years experiencing a higher prevalence of 81 (68.7%). Among the demographic and clinical parameters analyzed, age, gender, residence, education, socioeconomic status, and comorbid conditions did not show a significant association with fatigue. However, phosphorus levels demonstrated a significant association (p = 0.014), with higher levels being associated with a decreased chance of experiencing fatigue. Conclusion These findings suggest that employment status and the duration of hemodialysis are potential factors influencing fatigue in ESRD patients on MHD. Furthermore, it is possible that phosphorus levels affect how tiredness manifests. Understanding these factors can contribute to improved management and timely interventions to address fatigue in this patient population. It is important to conduct more studies to understand the causes of fatigue in ESRD patients receiving MHD, as well as possible treatments.

A Comparative Study of Acidosis in Diabetic Advanced Chronic Kidney Disease Patients on and off Metformin.

Aim The aim of the study is to assess the risk of acidosis in diabetic advanced chronic kidney disease (CKD) patients on and off metformin. Methods This retrospective descriptive study was conducted in the nephrology department in The Kidney Centre Post Graduate Training Institute (TKC PGTI) Karachi from February to April 2020. We reviewed the records of all patients over 18 years old who visited the nephrology outpatient department in three months in 2020 (from February 2020 to April 2020), who had CKD (stage 2-5), are not on dialysis, and had type 2 diabetes. These were divided into two groups: those on metformin for more than one year and those not on metformin. We looked at hospitalizations due to acidosis in the previous one-year period. Results A total of 524 CKD patients had diabetes; out of those, 268 patients were on metformin, and 256 were not on metformin. The male vs. female distribution was 52.1% vs. 47.9%. A total of 114 (21.8%) patients required admission in the previous one-year period, and only 12 hospitalized patients had acidosis, seven (58.3%) were on metformin, and five (41.7%) were not on metformin, which was statistically insignificant. Conclusion Biguanides, especially metformin, is a known oral hypoglycemic drug used for decades to treat type 2 diabetes mellitus (DM). Metformin use is related to a rare but serious adverse event, metformin-associated lactic acidosis (MALA), especially in renal failure patients. In our study, metformin use in CKD diabetic patients did not result in more admissions due to acidosis than non-metformin users.

Comparison of the Quality of Sleep in Patients With Chronic Kidney Disease and End-Stage Renal Disease.

Objective In this study, we aimed to compare the quality of sleep between patients with (CKD) and those with end-stage renal disease (ESRD). Methodology We performed a cross-sectional study between August 2020 and January 2021. We included 240 patients, among which 178 (74.2%) were CKD patients and 62 (25.8%) were ESRD patients on maintenance hemodialysis (MHD). Demographic data were collected on a pre-designed proforma. The quality of sleep was evaluated using the Pittsburgh Sleep Quality Index (PSQI). PSQI assesses subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. A PSQI score >5 indicates poor sleep quality. Results Out of the 240 patients, 159 (66%) had poor sleep quality. We found a significant difference in mean PSQI scores between CKD and ESRD patients (9.6 ± 12.4 vs. 11.4 ± 3.9 respectively), indicating poorer sleep quality in ESRD patients as compared to those with CKD (p<0.001). In our study, among all comorbidities, poor sleep was significantly associated with ischemic heart disease (IHD) (p = 0.025), after adjusting for confounding factors. Conclusions Our study showed that two-thirds of the study population had poor sleep quality. ESRD patients suffered from more disturbed sleep as compared to CKD patients.

Causes of Emergency Department Visits Among End-Stage Kidney Disease Patients on Maintenance Hemodialysis in Pakistan: A Single-Center Study.

Background In this study, we aimed to determine the causes of emergency department (ED) visits by end-stage kidney disease (ESKD) patients on maintenance hemodialysis (MHD) in Karachi, Pakistan. Methodology We conducted a cross-sectional study that included 194 visits of ESKD patients on MHD aged ≥18 years of both genders presenting at the ED of The Kidney Centre Postgraduate Training Institute, Karachi, Pakistan between February 2021 and May 2021. The study investigated the causes behind ED visits. Frequencies were calculated for categorical variables, and a bar graph was used for the graphical representation of the causes. Results In total, 194 visits included 151 patients of whom 88 (58.3%) were males while 63 (41.7%) were females, with a mean age of 51.68 ± 15.8 years. The most common comorbidity among the ED visits was hypertension 182 (93.8%). The majority of the visits 129 (66.5%) were undergoing regular three dialysis sessions per week, 101 (52.1%) were registered for MHD at our Institute, and 69.1% of visits reported arteriovenous fistula (AVF) as the current access for hemodialysis. Around 111 (57.2%) of the visits had infection-related complications, followed by electrolyte abnormalities 74 (38.1%), cardiovascular 53 (27.3%), and pulmonary complications 41 (21.1%). Overall, 19 (9.8%), 16 (8.2%), and 14 (7.2%) patients reported access-related, neurological, and gastrointestinal complications, respectively. Conclusions Infection-related complications are a significant cause of ED visits among ESKD patients, followed by electrolyte abnormalities and systemic complications, many of which are related to the existing comorbid conditions. Risk identification of preventable causes and surveillance of existing comorbidities would help mitigate ED visits among ESKD patients.

Frequency of Intradialytic Hypertension Using Kidney Disease: Improving Global Outcomes (KDIGO) Suggested Definition in a Single Hemodialysis Centre in Pakistan.

OBJECTIVES:  To estimate the frequency of intradialytic hypertension (IDH) in our centre as per the definition suggested by Kidney Disease: Improving Global Outcomes (KDIGO). METHODS:  A cross-sectional study was conducted at the dialysis department of The Kidney Centre Post Graduate Training Institute (PGTI) Karachi, Pakistan from August 2021 to October 2021 among 263 end-stage kidney disease (ESKD) patients on maintenance hemodialysis (MHD) aged ≥ 18 years of both genders. The study outcome was the frequency of IDH as per the latest KDIGO suggested definition i.e., systolic blood pressure (SBP) rise of > 10 mm Hg from pre- to post-dialysis within the hypertensive range in at least four out of six consecutive dialysis treatments. Frequencies (%) and mean (±SD) were calculated for categorical and continuous variables respectively, using SPSS version 21 (IBM Corp., Armonk, NY, USA). RESULTS:  Among 263 patients, the mean age was 51.02 (±14.1) years and 56.3% were males. Around 30.8% of patients were dialysis-dependent for 1.1 to three years. The most common comorbidity was hypertension (88.6%). Standard dialysate calcium of 3mEq/l was received by 91.6% of study participants. About 78.7% of patients were using antihypertensive(s), out of which 85.5% were compliant and 37.6% were using a single antihypertensive. The most common antihypertensive in use was beta-blockers (78.3%). Around 16% of patients were found to have IDH. Age of the patients was significantly associated with IDH (p=0.038). The majority of the patients with IDH were those who were taking anti-hypertension medications as compared to the patients who were not taking them (p <0.004). Interdialytic weight gain was not a significant predictor for IDH. CONCLUSION:  The frequency of IDH was 16% according to the latest suggested KDIGO definition. This is much lower than regional and global estimates according to earlier definitions. There is a dire need to establish a standardized definition of IDH in guidelines to diagnose, manage and compare data. Also, the association of IDH with fluid overload is not found in our study which emphasizes the need to evaluate other causative factors.

A Comparative Study of the First and Second Waves of COVID-19 in Hemodialysis Patients From Pakistan.

INTRODUCTION: This study aims to compare the characteristics and outcomes of the first and second waves of coronavirus disease 2019 (COVID-19) in hemodialysis (HD) patients. METHOD: We compared the epidemiological, clinical, laboratory, and radiological characteristics and outcomes of a cohort of HD patients who contracted COVID-19 in our HD center during the first wave from May 2020 to September 2020 and the second wave from November 2020 to February 2021. RESULTS: A total of 50 (11.8%) of 423 patients during the first wave and 46 (10.5%) of 437 patients during the second wave contracted COVID-19. The median age was 59.5 ± 9.99 years (first wave) and 60.3 ± 13.02 years (second wave). Most patients developed the mild disease. Patients requiring hospitalization (22% vs. 32.6%) and mechanical ventilation (10% vs. 17.4%) were more in the second wave. The most common symptom was fever (82% and 63%) in both waves. Patchy bilateral opacity was the most common radiological finding. Major complications including lymphocytopenia (36% and 63%), pneumonia (28% and 32.6%), thrombocytopenia (30% and 17.4%), and septic shock (6% and 10.9%) were shared. Ten (20%) patients died in the first wave and 13 (28.3%) in the second wave. Patients aged > 60 years had more severe disease and died more than patients aged < 60 years in both waves. CONCLUSION: There is a high susceptibility and mortality of HD patients in both the first and second waves of COVID-19 as compared to the general population. Disease symptoms, radiological findings, and laboratory tests were similar in both waves. Patients developing critical disease and requiring hospitalization and mechanical ventilation were more in the second wave.

Re-Hospitalization in First Six Months After Live Related Renal Transplantation: Risk Factors, Burden, Causes and Outcomes.

Objective The aim of our study was to evaluate the incidence, causes, risk factors, outcomes, and cost of hospital readmission after live related renal transplantation (LRRT). Methods We conducted a cross-sectional study and followed patients' re-admissions for six months whose LRRT was done in our center between September 2019 and June 2020. Results We recruited 53 patients, 40 (75.5%) were male. The mean age was 36.9 ± 11.9 years. Donor gender was similar, and their mean age was 31.6 ± 9.2 years. The mean length of hospital stay after LRRT was 14 ± 2.2 days. A total of 81.1% were readmitted after LRRT within the first six months, with a total of 113 readmissions. The median time of readmission after LRRT was 66 days. The median readmission hospital stay was four days. The causes of readmission were surgical in 11 (9.7%), medical in 89 (78.8%), and combined medical and surgical in 13 (11.5%). Infection was the most common medical cause, followed by rejection. Statistically significant difference between readmission and non-readmission groups was found in estimated glomerular filtration rate (eGFR) at six month 61.3 ± 25.9 vs. 84.3 ± 36.1 mL/min/1.73 m2 respectively (p = 0.02). The median cost of readmission was PKR 40629, equivalent to USD 261. Conclusion Over three-fourths of the patients were readmitted after LRRT within the first six months. The most common causes were infection and rejection. Readmissions after LRRT are associated with lower graft function at six months and a significant cost burden on the health system.