Symptom burden, fatigue, sleep quality and perceived social support in hemodialysis patients with musculoskeletal discomfort: a single center experience from Egypt.

BACKGROUND AND AIMS: Musculoskeletal disorders (MSDs) are commonly encountered in hemodialysis (HD) patients. However, the causes linked to these disorders are still partially defined. The aim of this study was to determine the frequency of MSDs and their relationship to a variety of clinico-social characteristics such as sleep quality, mood disorders, fatigue, and social support, in addition to the patients' clinical and therapeutic profile. METHOD: The study included 94 patients on maintenance HD. Clinical and Sociodemographic data was gathered. To investigate the prevalence and trends of MSDs, the Nordic Musculoskeletal Questionnaire (NMQ-E) was employed. Patients completed the modified Edmonton Symptom Assessment System, Pittsburgh Sleep Quality Index (PSQI), multidimensional Fatigue Inventory (MFI-20), and Perceived Social Support from Family Scales. Univariate and multivariate regression analysis were used to assess the determinants of MSDs. RESULTS: The patients' mean age was 49.73 and 59.6% were males. Seventy-two percent of patients were afflicted by MSDs. Knee pain (48.9%), low back pain (43.6%), shoulder pain (41.6%), hip/thigh pain (35.1%), and neck pains (35.1%) were the most reported MSD domains. Pain (p = 0.001), fatigue (p = 0.01), depression (p = 0.015), and anxiety (p = 0.003) scores were substantially higher in patients with MSDs. Furthermore, patients with MSDs engaged in less physical activity (p = 0.02) and perceived less social support (p = 0.029). Patients with MSDs had lower subjective sleep quality, daytime dysfunction domains, and global PSQI scores (p = 0.02, 0.031, 0.036, respectively). Female gender (p = 0.013), fatigue (p = 0.012), depression (p = 0.014), anxiety (p = 0.004), lower activity (p = 0.029), and PSQI score (0.027), use of erythropoiesis-stimulating agents (ESAs), antihypertensive drugs, calcium and Iron supplementation were all significantly associated with MSDs. At the multivariable regression model, administration of ESAs (p = 0.017) and pain score (p = 0.040) were the only independent variables associated with the outcome. CONCLUSION: MSDs are quite common among HD patients. Female gender, pain, fatigue, depression, anxiety, reduced activity, poor sleep quality, and use of ESAs are all significantly associated with MSDs in HD patients. Patients with MSD perceived less social support compared to the other group. Patients treated with antihypertensive drugs, calcium and iron supplements were more likely to suffer MSDs.

Access to Nephrology Care for Pregnancy-Related Acute Kidney Injury in Low- and Lower-Middle-Income Countries: A Perspective.

Pregnancy-related acute kidney injury (AKI) is a major public health problem with substantial maternal and fetal morbidity and mortality. Women with pregnancy-related AKI require immediate access to nephrology care to prevent deleterious kidney and health outcomes. Patients with pregnancy-related AKI in low-income and lower-middle-income countries experience disparities in access to comprehensive nephrology care for many reasons. In this perspective, we highlight the burden of pregnancy-related AKI and explore the challenges among different low-income and lower-middle-income countries. The lack of adequate nephrology workforce and infrastructure for kidney health care represents a fundamental component of the problem. A shortage of nephrologists hampers the care of patients with pregnancy-related AKI leading to poor outcomes. The lack of diagnostic tools and therapeutic options, including kidney replacement therapy, impedes the implementation of effective management strategies. International efforts are warranted to empower women to get the right services and support at the right time. Dedicated preventive and early care programs are urgently needed to decrease the magnitude of pregnancy-related AKI, a complication under-represented in the literature.

Revisiting maintenance immunosuppression in patients with renal transplant failure: early weaning of immunosuppression versus prolonged maintenance-systematic review and meta-analysis.

INTRODUCTION: Prolonged immunosuppression after dialysis start has been assumed to reduce sensitization, need for graft nephrectomy, and to favor re-transplantation. In contrast, immunosuppression is considered to increase the risk of mortality, infection, and malignancy. We aimed to assess the evidence regarding superiority of early or late withdrawal of maintenance immunosuppression post renal transplant failure. METHODS: A literature search of the PubMed, WOS, Ovid, and Scopus databases was conducted. Combined relative risks, (RRs), mean differences, and 95% confidence intervals (CIs) were calculated by using a random-effect model. RESULTS: Ten studies involving 1187 patients with kidney transplant failure were included. No difference could be detected between patients with early withdrawal of  immunosuppressive drugs (≤ 3 months) or prolonged immunosuppressive treatment (> 3 months) regarding mortality (95% CI 0.91-2.28), panel reactive antibodies (PRAs) (95% CI - 0.75-30.10), re-transplantation rate (95% CI 0.55-1.35), infectious episodes (95% CI 0.67, 1.17), cancer (95% CI 0.26-1.54), and graft nephrectomy (95% CI 0.82-1.63). Similarly, no difference was found between immunosuppressive drug withdrawal over < 6 or ≥ 6 months regarding mortality (95% CI 0.16, 2.89), re-transplantation rate (95% CI 0.85-1.55), cancer (95% CI 0.37-1.63), and allograft nephrectomy (95% CI 0.87-4.33). CONCLUSION: Prolonged maintenance immunosuppression post kidney transplant failure is not associated with increased risk of mortality, infection, or malignancy, or reduced risk of sensitization or allograft nephrectomy compared with early withdrawal.

Pregnancy-related acute kidney injury in the African continent: where do we stand? A systematic review.

BACKGROUND: Pregnancy-Related Acute kidney injury (PR-AKI) is a global health problem with substantial maternal and fetal morbidity and mortality. However, little is known about the current situation in the developing world including African countries. Africa is the poorest continent per capita, and women from Sub-Saharan Africa alone account for 66% of the estimated global maternal deaths from preventable obstetric causes. METHODS: OBJECTIVE: To review the literature on the clinical profile, maternal and renal outcomes of women with PR-AKI in the African continent. SEARCH STRATEGY: Medline, ISI Web of Science, Scopus, and Cochrane library were searched in February 2022, using the MeSH terms and text key words: "pregnancy", "pregnant", "acute kidney injury", "acute renal insufficiency", "acute renal injury", "acute renal failure", and "Africa". SELECTION CRITERIA AND DATA COLLECTION: Studies from African countries which reported maternal and renal outcomes in women with PR-AKI during pregnancy or postpartum were included. Editorials, short communications, and case reports were excluded. The study quality was assessed using the NHLBI tool. Data extraction was done using predefined data fields. RESULTS: A total of 167 studies were evaluated, of which 14 studies from seven African countries met the inclusion criteria. Preeclampsia, obstetric hemorrhage, and sepsis represented the main causes of PR-AKI. Maternal mortality ranged between 0 and 34.4%. Although the majority of women needed ICU admission and hemodialysis, renal recovery occurred in 53.1-90% of patients. Perinatal mortality has been reported to be 1.5-60.5% in the included studies. AUTHORS' CONCLUSIONS: PR-AKI in Africa represents the second leading cause of AKI. Limited access to obstetric care, late referral, and late diagnosis of women with risks for PR-AKI hinder the curtailment of the problem. Provision of health care facilities with adequately trained personnel and implementation of preventive strategies will be of great value in decreasing the magnitude of the problem.

Amenorrhea, premenstrual tension syndrome, and dysmenorrhea among women of reproductive age on hemodialysis: A national study in Egypt.

BACKGROUND AND AIM: The current literature concerning the reproductive health of end stage renal disease (ESRD) females is scarce, outdated, and largely unknown in women living in developing countries. This study aims to estimate the prevalence of menstrual abnormalities and their associated factors among ESRD women in reproductive age undergoing chronic hemodialysis (HD) in Egypt. METHODS: Thirty-five dialysis centers were selected by simple random sampling to represent the different regions of Egypt. Non-pregnant women in the reproductive age (15-50 years) receiving dialysis at the participating centers completed a questionnaire about their menstrual health during a routine hemodialysis session. Their responses were verified by reviewing the medical records and assessing their clinical data. RESULTS: Out of the 472 women, 32.6% had amenorrhea. Menstrual irregularities were reported in 37% of the menstruating women. Premenstrual tension syndrome (PMS) was reported in 70% while dysmenorrhea in 58%. Amenorrhea was more prevalent in non-working women who started hemodialysis after the age of 30. PMS was more encountered in women with hypertension or in those with obstructive uropathy or autoimmune disease as a cause of ESRD. Dysmenorrhea was more prevalent among patients with autoimmune disease or chronic hepatitis C virus and those who started dialysis after the age of 30. CONCLUSION: Secondary amenorrhea, dysmenorrhea, and PMS are common among premenopausal women with ESRD on dialysis. Several factors including socio-economic factors, cause of ESRD, and hypertension contribute to these disorders. Future studies are needed to understand the underlying pathophysiologic mechanisms and management of these abnormalities.

Kidneys in SARS-CoV-2 era: A challenge of multiple faces.

INTRODUCTION: With the evolution of SARS-CoV-2 pandemic, it was believed to be a direct respiratory virus. But, its deleterious effects were observed on different body systems, including kidneys. AIM OF WORK: In this review, we tried as much as we can to summarize what has been discussed in the literature about the relation between SARS-CoV-2 infection and kidneys since December, 2019. METHODS: Each part of the review was assigned to one or two authors to search for relevant articles in three databases (Pubmed, Scopus, and Google scholar) and collected data were summarized and revised by two independent researchers. CONCLUSION: The complexity of COVID-19 pandemic and kidney could be attributed to the direct effect of SARS-CoV-2 infection on the kidneys, different clinical presentation, difficulties confronting dialysis patients, restrictions of the organ transplant programs, poor outcomes and bad prognosis in patients with known history of kidney diseases who got infected with SARS-CoV-2.

The Relation of Serum Dehydroepiandrosterone Sulfate Level to Protein Energy Wasting in Hemodialysis Patients.

Protein-energy wasting (PEW) is a major risk for morbidity and mortality in hemodialysis (HD) patients. The change in the concentration of dehydroepiandrosterone sulfate (DHEA-S) may play a role in PEW. The aim of this work was to study the possible relationship between serum DHEA-S levels and various nutritional and inflammatory parameters in a cohort of HD patients. In total, 78 HD patients (47 males and 31 females) were included in this crosssectional observational study. In addition to taking their history, clinical examinations, and routine laboratory investigations, the nutritional status was assessed, and their serum DHEA-S was measured. Nutritional status was assessed by anthropometric measures, bioelectrical impedance analysis, malnutrition inflammation scores, and subjective global assessments. A diagnosis of malnutrition was made based on the recommendations of the International Society of Renal Nutrition and Metabolism. The relationship between DHEA-S and various nutritional parameters was analyzed. Eighteen patients (23.1%) suffered from PEW. Those with PEW had a longer duration of HD (P = 0.04), and lower serum levels of creatinine (P = 0.003), hemoglobin (P = 0.01), albumin (P <0.0001), cholesterol (P = 0.02), and DHEA-S (P = 0.01). Among the variables, serum DHEA-S levels were significant predictors of PEW in this cohort (odds ratio: 0.976; 95% confidence interval: 0.954-1.0; P = 0.04). PEW is frequently encountered in HD patients. Decreased serum DHEA-S levels were associated with PEW in male HD patients. Further studies are needed to assess the effect of hormone supplementation on this serious disorder in HD patients.

Angiogenic markers predict kidney injury and obstetric complications in women with preeclampsia and pregnancy-related acute kidney injury.

Pregnancy-related acute kidney injury (PRAKI) particularly on top of preeclampsia (PE) represents a major cause of maternal and fetal morbidity and mortality. Reliable diagnostic tools are needed to further evaluate the diagnosis and prognosis of PRAKI. Our objective was to study the diagnostic and prognostic value of angiogenic markers (e.g., stromal cell-derived factor 1 (SDF-1), vascular endothelial growth factor (VEGF), alarmins as uric acid) in women with PE and PRAKI. This prospective study included three groups; PRAKI, PE patients, and healthy controls that were compared regarding serum levels of the studied markers correlated to renal, maternal, and fetal outcomes. SDF-1, VEGF, and uric acid levels were significantly different between the three included groups and predicted PRAKI diagnosis. Patients with hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome exhibited the highest titers of SDF-1 and VEGF. A positive correlation was found between SDF-1 and renal recovery. Conclusively, serum assays of SDF-1, VEGF, and uric acid may add a diagnostic value in PRAKI and PE.

Renal replacement therapy for critically ill patients with COVID-19-associated acute kidney injury: A review of current knowledge.

The outbreak of coronavirus disease 2019 (COVID-19) has rapidly evolved into a global pandemic. A significant proportion of COVID-19 patients develops severe symptoms, which may include acute respiratory distress syndrome and acute kidney injury as manifestations of multi-organ failure. Acute kidney injury (AKI) necessitating renal replacement therapy (RRT) is increasingly prevalent among critically ill patients with COVID-19. However, few studies have focused on AKI treated with RRT. Many questions are awaiting answers as regards AKI in the setting of COVID-19; whether patients with COVID-19 commonly develop AKI, what are the underlying pathophysiologic mechanisms? What is the best evidence regarding treatment approaches? Identification of the potential indications and the preferred modalities of RRT in this context, is based mainly on clinical experience. Here, we review the current approaches of RRT, required for management of critically ill patients with COVID-19 complicated by severe AKI as well as the precautions that should be adopted by health care providers in dealing with these cases. Electronic search was conducted in MEDLINE, PubMed, ISI Web of Science, and Scopus scientific databases. We searched the terms relevant to this review to identify the relevant studies. We also searched the conference proceedings and ClinicalTrials.gov database.

Fetal proximal and distal limb anomalies following exposure to mycophenolate mofetil during pregnancy: A case report and review of the literature.

BACKGROUND: Mycophenolate mofetil (MMF) is currently used in a wide spectrum of autoimmune diseases and has been rendered very effective in the management of systemic lupus erythematosus and lupus nephritis. MMF is known to be teratogenic (FDA category D) and therefore, women in childbearing period receiving MMF should be counselled to use effective contraceptive methods to avoid an unplanned pregnancy. CASE: A 22-year-old lady accidentally discovered to be pregnant while using MMF as a treatment of lupus nephritis which was replaced later on by azathioprine. After maternal and fetal evaluation, maternal lupus flare was confirmed and multiple fetal skeletal deformities associated with intrauterine growth restriction (IUGR) were diagnosed by 4-dimensional ultrasound. Termination of pregnancy was decided after shared decision making. CONCLUSION: Women in childbearing period should be advised to postpone pregnancy for at least six weeks after stoppage of MMF therapy because of its potential teratogenic effects during pregnancy.

Association between Plasma Dehydroepiandrosterone Sulfate and Carotid Intima-Media Thickness among Male and Female Patients with End-Stage Renal Disease on Hemodialysis.

BACKGROUND AND AIM: Serum dehydroepiandrosterone sulfate (DHEA-S) is known to be lower in chronic kidney disease (CKD) patients and in those with cardiac disease, and correlates with a poor cardiovascular outcome. This study aimed to assess the correlation between DHEA-S and carotid intima-media thickness (CIMT) as a predictor of cardiovascular disease in hemodialysis (HD) patients. METHODS: A total of 88 HD patients were included in this cross-sectional study. They included 53 male (group I) and 35 female patients (group II). In addition to conventional history taking, clinical examination, and routine laboratory investigations, serum DHEA-S and CIMT were measured for all patients. CIMT was measured using B-mode ultrasonography, and the mean of maximum CIMT was recorded. The 2 patient groups were further classified according to the level of DHEA-S. The correlation between serum DHEA-S and CIMT was studied. RESULTS: In male patients, CIMT and age were significantly higher in the group with low DHEA-S level (p = 0.003 and 0.001, respectively), while there was no significant difference in both parameters in females. A higher percentage of HCV-positive patients is present in the male group with low DHEA-S level (p = 0.009). Serum DHEA-S is significantly negatively correlated with CIMT in males (p = 0.003) but not in females, and has a significant negative correlation to age in both genders (p = 0.001 and 0.04, respectively). CONCLUSION: Endocrinal disturbance representing as lower serum DHEA-S is associated with increased CIMT, which is considered a predictor of cardiovascular disease in male HD patients, although it is largely explained by advancing age.