Subjective global assessment for nutritional assessment of hospitalized patients requiring haemodialysis: A prospective cohort study.

AIM: Evidence has validated that the nutritional status of hospitalized patients on haemodialysis could be compromised because of admission-related and hospital-associated morbidities on the background of their kidney disease. However, nutritional status is not assessed and monitored routinely during the hospitalization period. The aim of the present study was to assess the nutritional status of hospitalized patients requiring haemodialysis with the subjective global assessment (SGA) tool during the hospitalization period. METHODS: This is a prospective cohort study conducted in an acute tertiary general hospital. Patients aged 21-75 years old, admitted for various illnesses and requiring haemodialysis between November 2011 and May 2012 were enrolled into this study. A trained dietician assessed patients' nutritional status with the SGA tool, which included historical data on weight change, dietary intake, gastrointestinal symptoms, functional capacity, comorbidities and physical examination on subcutaneous fat loss, muscle wasting and presence of oedema and/or ascites. Patients were categorized under three groups: SGA-A (well-nourished), SGA-B (moderately malnourished) and SGA-C (severely malnourished). RESULTS: Eighty patients (mean ± SD age = 59 ± 10 years; 76% Chinese ethnicity) were assessed. Mean ± SD body mass index (BMI) was 25.1 ± 6.1 kg/m2 . SGA categories were 48% SGA-A, 46% SGA-B, and 6% SGA-C. Mean energy and protein intake (P < 0.001), length of hospitalization stay (P = 0.03) and BMI (P = 0.001) were significantly different across the three categories of nutritional status. CONCLUSIONS: More than half of the hospitalized patients requiring haemodialysis were malnourished. It is important to incorporate SGA in the care of hospitalized haemodialysis patients for early detection of malnutrition and for medical nutrition therapy to optimise patients' nutritional status for better outcomes.

Tolerance protocol of living kidney transplant for developing countries through basic strategy of lymphocyte depletion.

End-stage kidney failure (ESKD) is a global issue where kidney replacement therapy imposes enormous economic burden to people of developing countries, in addition to the severe limitations to the availability of hemodialysis and peritoneal dialysis technique. The best option of kidney transplantation also requires lifelong combination immunosuppressive medicines, the cost of which is equally comparable to lifelong dialysis. A strategy of achieving transplant tolerance that requires minimum immunosuppressive medicines, although in experimental stage, also requires state-of-art technology with costly medicines and interventions. This is evidently beyond the reach of ESKD patients of developing countries. Hence, globally in developing countries, a need for an innovative but cost-effective tolerance protocol is a burning need for a successful transplant program. In brief, transplant tolerance is defined as a state of donor-specific unresponsiveness to the allograft antigens without the need for ongoing pharmacologic immunosuppression or with a minimal need. Current state-of-art techniques involves: (1) A state of hematological chimera, for complete tolerance; (2) Prope or partial tolerance where immune-reactive T-lymphocytes are inhibited using monoclonal antibodies; and (3) Chimeric antigen receptor for T-regulatory (T-reg) cell therapy using genetically engineered T-reg cells targeting specific T-lymphocyte receptors for inducing anergy. From our real-world experience in transplant management in post-transplant lympho-proliferative disorders (PTLD), we noticed frequently a drastic reduction in the need of immunosuppressive medicines following lympho-ablative therapy for PTLD. We recently published a case study on a real-world experience transplant case where we explained a partial or prope tolerance that developed after lymphocyte ablation therapy, following which the allograft was maintained with low dose dual standard immunosuppressive medicines. Based on this publication, we propose here an innovative tolerance protocol for living related low risk kidney transplantation for developing countries, in this opinion review.

Could peak proteinuria determine whether patient with dengue fever develop dengue hemorrhagic/dengue shock syndrome?--a prospective cohort study.

BACKGROUND: Worldwide there is a need to develop simple effective predictors that can distinguish whether a patient will progress from dengue fever (DF) to life threatening dengue hemorrhagic (DHF) or dengue shock syndrome (DSS). We explored whether proteinuria could be used as such a marker. METHODS: We included patients admitted to hospital with suspected dengue fever. Starting at enrollment until discharge, each patient's daily spot urine protein creatinine ratio (UPCR) was measured. We classified those with confirmed dengue infection as DF or DHF (including DSS) based on WHO criteria. Peak and day of onset of proteinuria was compared between both groups. RESULTS: Compared to those with DF, patients with DHF had significantly higher median peak proteinuria levels (0.56 versus 0.08 g/day; p < 0.001). For patients with DHF, the median day of onset of proteinuria was at 6 days of defervescence, with a range of -2 to +3 days after defervescence. There were three patients with DF who did not have proteinuria during their illness; the five remaining patients with DF had a median day of onset of proteinuria of was at 6 days of defervescence with a range of 0 to +28 days. CONCLUSIONS: Peak UPCR could potentially predict DHF in patients with dengue requiring close monitoring and treatment.

Significance of urinary proteome pattern in renal allograft recipients.

Urinary proteomics is developing as a platform of urinary biomarkers of immense potential in recent years. The definition of urinary proteome in the context of renal allograft and characterization of different proteome patterns in various graft dysfunctions have led to the development of a distinct science of this noninvasive tool. Substantial numbers of studies have shown that different renal allograft disease states, both acute and chronic, could portray unique urinary proteome pattern enabling early diagnosis of graft dysfunction and proper manipulation of immunosuppressive strategy that could impact graft prognosis. The methodology of the urinary proteome is nonetheless not more complex than that of other sophisticated assays of conventional urinary protein analysis. Moreover, the need for a centralized database is also felt by the researchers as more and more studies have been presenting their results from different corners and as systems of organizing these newly emerging data being developed at international and national levels. In this context concept of urinary proteomics in renal allograft recipients would be of significant importance in clinical transplantation.

Sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) of urinary protein in acute kidney injury.

Recent experimental and clinical studies have shown the importance of urinary proteomics in acute kidney injury (AKI). We analyzed the protein in urine of patients with clinical AKI using sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) for its diagnostic value, and followed them up for 40 months to evaluate prognosis. Urine from 31 consecutive cases of AKI was analyzed with SDS-PAGE to determine the low, middle and high molecular weight proteins. Fractional excretion of sodium (FENa) was estimated from serum and urine creatinine and sodium (Na). The cases were followed-up for 40 months from the end of the recruitment of study cases. Glomerular protein was higher in the hematuria group when compared with the non-hematuria group (P <0.04) and in the AKI group than in the acute on chronic renal failure (AKI-on-CRF) group (P <0.002). Tubular protein was higher in the AKI-on-CRF group (P <0.003) than in the AKI group. Tubular protein correlated with FENa in groups with diabetes mellitus (DM), AKI-on-CRF, and without hematuria (P <0.03, P <0.02 and P <0.004, respectively). Pattern of protein did not differ between groups with and without DM and clinical acute tubular necrosis (ATN). At the end of 40 months follow-up, category with predominantly glomerular protein progressed to chronic renal failure (CRF) or end-stage renal failure in higher proportion (P <0.05). In clinical AKI, we observed that glomerular protein dominated in cases with glomerular insult, as indicated by hematuria. Tubular protein was common in the study cases with CRF, DM and cases without hematuria. This indicates tubulo-interstitial injury for AKI in these cases. Patients with predominantly glomerular protein had an adverse outcome.