Incidence and factors associated with chronic chikungunya arthritis following chikungunya virus infection.

OBJECTIVES: Chikungunya virus infection is a mosquito-borne illness. First-phase symptoms include fever, malaise, rash, and arthritis (self-limiting). Some patients can have chronic-phase symptoms, including chronic tenosynovitis, bursitis, and arthritis. This study aimed to determine the incidence and risk factors of chronic arthritis in patients with chikungunya infection. METHODS: This retrospective cohort study analysed all adults diagnosed with chikungunya infection between 2015 and 2020 at our centre. Baseline and follow-up symptoms were evaluated in serologically confirmed cases. Chronic chikungunya arthritis was persistent arthritis >3 months after the onset. Patients who had preexisting chronic inflammatory arthritis and were lost to follow-up before 3 months from diagnosis were excluded. RESULTS: This study enrolled 120 patients. The median age was 51 (IQR 14) years, and 78% were female. The median number of joints with arthritis was 4 (IQR 8). The initial visual analog scale (VAS) score was 50 mm (IQR 40). Small joints of the hands, wrist, and knee (44.2%, 43.3%, and 42.3%, respectively) were the most affected. The incidence of chronic chikungunya arthritis was 40.4%. From the multivariable logistic regression, the initial number of joints with arthritis, initial VAS scores, and female sex were independently associated with chronic chikungunya arthritis with odds ratios of 1.09 (95% confidence interval [CI] 1.01-1.18), 1.03 (95% CI 1.01-1.06), and 4.17 (95% CI, 1.05-16.67), respectively. CONCLUSIONS: Chronic chikungunya arthritis is common in patients with chikungunya virus infection. Its predictive factors include the initial number of joints with arthritis, initial VAS scores, and female sex.

Medium Cut-Off versus Low-Flux Dialyzers in Hemodialysis Patients with COVID-19: Clinical Outcomes and Reduction in Interleukin-6.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has caused extensive morbidity and mortality worldwide. Hemodialysis (HD) patients are both vulnerable to COVID-19 infection and tend to suffer greater disease severity and mortality. This retrospective study aimed to compare medium cut-off (MCO) and low-flux (LF) membrane dialyzers in terms of interleukin-6 (IL-6) reduction, change in inflammatory state, intradialytic complications, and mortality in chronic HD patients with COVID-19. METHOD: HD patients with a confirmed COVID-19 infection were admitted to the hospital for 10-14 days and underwent HD at the COVID-HD unit. Choice of dialyzer membrane used (MCO vs. LF) depended on the primary nephrologist(s). We collected data on demographics, baseline characteristics, laboratory results, diagnosis, treatments, HD prescription, hemodynamic status during HD, and mortality at 14 and 28 days after. RESULTS: IL-6 reduction ratio (RR) in the MCO group was 9.7 (interquartile range, 71.1) percent, which was significantly higher than that of the LF group (RR, -45.7 [interquartile range, 70.2] percent). The incidence rate of intradialytic hypotension in the MCO group was 3.846 events per 100 dialysis hours (95% confidence interval [CI], 1.954-6.856), which was significantly lower than that of the LF group (9.057; 95% CI, 5.592-13.170). Overall, mortality was not significantly different between the two groups. CONCLUSION: The MCO membrane was more effective in removing IL-6 and was better tolerated than the LF membrane. Large, randomized controlled trials are required to confirm the relative benefits of the MCO membrane, especially mortality. However, due to the COVID-19 pandemic, our results suggest that the MCO membrane may be beneficial in chronic HD patients with COVID-19.

Therapeutic plasma exchange with standard hemodialysis machine as an alternative to dedicated apheresis device: A 5-year experience.

Patients suffering from various diseases have been shown to benefit from therapeutic plasma exchange (TPE). However, in developing countries, there are many obstacles hindering the establishment and initiation of TPE programs. These include inadequate funding and lack of government healthcare coverage. Our center in Thailand practices a unique membrane plasma separator technique using a hemodialysis machine incorporated with a plasma separator. Over a 5 year period, there were 130 such sessions conducted in 24 patients. The indications for TPE treatment included neurological, hematological, and nephrological diseases. Overall, response to TPE was good. Some TPE-related adverse events did occur, but none were life-threatening. Unfortunately, infection remained a problem and was sometimes a cause of death. Future challenges include minimization of infection rates and making TPE treatment readily accessible to patients.

Early versus standard initiation of renal replacement therapy in furosemide stress test non-responsive acute kidney injury patients (the FST trial).

BACKGROUND: The timing of initiation of renal replacement therapy (RRT) in severe acute kidney injury (AKI) remains controversial, with early initiation resulting in unnecessary therapy for some patients while expectant therapy may delay RRT for other patients. The furosemide stress test (FST) has been shown to predict the need for RRT and therefore could be used to exclude low-risk patients from enrollment in trials of RRT timing. We conducted this multicenter pilot study to determine whether FST could be used to screen patients at high risk for RRT and to determine the feasibility of incorporating FST into a trial of early initiation of RRT. METHODS: FST was performed using intravenous furosemide (1 mg/kg in furosemide-naive patients or 1.5 mg/kg in previous furosemide users). FST-nonresponsive patients (urine output less than 200 mL in 2 h) were then randomized to early (initiation within 6 h) or standard (initiation by urgent indication) RRT. RESULTS: FST was completed in all patients (100%). Only 6/44 (13.6%) FST-responsive patients ultimately received RRT while 47/60 (78.3%) nonresponders randomized to standard RRT either received RRT or died (P <  0.001). Among 118 FST-nonresponsive patients, 98.3% in the early RRT arm and 75% in the standard RRT arm received RRT. The adherence to the protocol was 94.8% and 100% in the early and standard RRT group, respectively. We observed no differences in 28-day mortality (62.1 versus 58.3%, P = 0.68), 7-day fluid balance, or RRT dependence at day 28. However, hypophosphatemia occurred more frequently in the early RRT arm (P = 0.002). CONCLUSION: The furosemide stress test appears to be feasible and effective in identifying patients for randomization to different RRT initiation times. Our findings should guide implementation of large-scale randomized controlled trials for the timing of RRT initiation. TRIAL REGISTRATION: clinicaltrials.gov, NCT02730117 . Registered 6 April 2016.

Intra-abdominal hypertension among medical septic patients associated with worsening kidney outcomes (IAH-WK study).

High intra-abdominal pressure (IAP) is associated with acute kidney injury (AKI). However, the relationship between intra-abdominal hypertension (IAH) and AKI in medical septic patients is still inconclusive. This prospective cohort study enrolled patients admitted in the Medical Intensive Care Unit from April 2020 to February 2021. Demographic, therapeutic, and laboratory data were obtained upon admission. The evaluation of IAP was performed via the intra-vesical method during the first and second 24 hours of admission. Kidney function was evaluated on the first 3 days and at least on the 7th day of enrollment. Among 79 patients, 30 (38%) developed IAH, while 50 (63.3%) developed AKI within 7 days. On the first day, the mean IAP was 15.4 (interquartile range [IQR], 4) and 7.0 (IQR, 3.7) mm Hg in the IAH and non-IAH groups, respectively. A total of 52 patients (65.8%) developed the primary outcome (i.e., a composite outcome including AKI, treatment with kidney replacement therapy, or death). On Cox proportional-hazards model between IAH and outcomes, after adjustment for multiple covariates, IAH was associated with a composite outcome (hazard ratio [HR], 6.5; 95% confidence interval [CI], 2.3-18.6; P < .005) and the development of AKI (HR, 6.5; 95% CI, 2.3-18.8; P < .005). IAH was associated with a composite outcome of AKI, treatment with kidney replacement therapy, or death in medical septic patients. thaiclinicaltrial.org, Identifier: TCTR20200531001, Registered May 24, 2020.

Cranial versus Caudal Direction Technique of Native Percutaneous Kidney Biopsy: A Randomized Controlled Trial.

Background: Percutaneous kidney biopsy (PKB) is the gold standard for diagnosing various kidney diseases, but it can result in potential complications. This study aimed to compare kidney tissue adequacy and safety between the two biopsy techniques, including cranial direction (CN) and caudal direction (CD), of needle biopsy under real-time ultrasonogram guidance. Methods: This single-center, prospective, single-blinded, randomized trial included patients undergoing native PKB from July 5, 2017, to June 30, 2019. Patients were randomized to the CN and CD groups. Adequacy and complications between the two groups were analyzed. All PKBs were performed under real-time ultrasonogram guidance with a 16-gauge kidney biopsy needle. Results: A total of 107 participants were enrolled (53 in the CD group and 54 in the CN group). The CD group has more glomeruli than the CN group but with no statistical significance (16 versus 11, p = 0.0865). The CD group obtained more adequate kidney tissue samples than the CN group (69.8% versus 59.3%, p = 0.348). The number of inadequate glomeruli tissue sampling is similar in both groups (14 versus 15, respectively). Furthermore, the CN group had more adverse events, including Hb decline ≥10% after kidney biopsy, perinephric hematoma size ≥1 cm, hematuria, and the need for blood transfusion, than the CD group. Conclusion: The CD technique of the percutaneous kidney biopsy in the native kidney has fewer complications and was possibly more effective than the CN technique.

Early versus Late Allopurinol Initiation in Acute Gout Flare (ELAG): a randomized controlled trial.

OBJECTIVE: Currently available guidelines on urate-lowering therapy (ULT) initiation in acute gout flare are conflicting. We compared the time to complete resolution of acute gout flare between early and late allopurinol initiation. METHODS: This 28-day, randomized controlled, open-label trial included patients with crystal-proven gout who were presented with acute gout flare within 72 h of arthritis onset. Exclusion criteria were advanced renal failure, ongoing ULT, and presence of the HLA-B*5801 allele. Allopurinol was used on days 1 and 14 in early and late groups, respectively. Primary outcome was time to complete arthritis resolution, and secondary outcomes were time to clinical resolution; arthritis relapse; laboratory parameters; and adverse events. RESULTS: One hundred seventeen patients were randomized to early and late allopurinol groups (n = 59 and 58, respectively). One patient in each group was lost to follow-up; therefore, 115 patients were included in the modified intention-to-treat analysis. Baseline characteristics were comparable between the groups. The median time to complete resolution was not significantly different between the early and late allopurinol groups (6 [5-14] and 6 [5-7] days, respectively; p = 0.14). The median time to clinical resolution was 4 [3-6] days in both groups (p = 0.12). Other secondary outcomes were not significantly different. Serious adverse events did not occur in either group. CONCLUSIONS: Early allopurinol initiation during an acute gout flare did not lead to significant changes in time to resolution, flare recurrence, and inflammatory markers. Key Points • Allopurinol Initiation in Gout.

Acute Kidney Injury Outcomes of Elderly and Nonelderly Patients in the Medical Intensive Care Unit of a University Hospital in a Developing Country.

BACKGROUND: Aging is associated with a high risk of acute kidney injury (AKI), and the elderly with AKI show a higher mortality rate than those without AKI. In this study, we compared AKI outcomes between elderly and nonelderly patients in a university hospital in a developing country. MATERIALS AND METHODS: This retrospective cohort study included patients with AKI who were admitted to the medical intensive care unit (ICU) between January 1, 2012, and December 31, 2017. The patients were divided into the elderly (eAKI; age ≥65 years; n = 158) and nonelderly (nAKI; n = 142) groups. Baseline characteristics, comorbidities, principle diagnosis, renal replacement therapy (RRT) requirement, hospital course, and in-hospital mortality were recorded. The primary outcome was in-hospital mortality. RESULTS: The eAKI group included more females, patients with higher Acute Physiology and Chronic Health Evaluation II scores, and patients with more comorbidities than the nAKI group. The etiology and staging of AKI were similar between the two groups. There were no significant differences in in-hospital mortality (p=0.338) and RRT requirement (p=0.802) between the two groups. After adjusting for covariates, the 28-day mortality rate was similar between the two groups (p=0.654), but the 28-day RRT requirement was higher in the eAKI group than in the nAKI group (p=0.042). CONCLUSION: Elderly and nonelderly ICU patients showed similar survival outcomes of AKI, although the elderly were at a higher risk of requiring RRT.

The efficacy of blind versus real-time ultrasound-guided percutaneous renal biopsy in developing country.

INTRODUCTION: Renal biopsy is a useful diagnostic procedure. In developing countries, two techniques of renal biopsy, blind percutaneous renal biopsy and real-time ultrasound-guided percutaneous renal biopsy, have been performed. The majority of studies compared these using different types and sizes of biopsy needle. The aim of this study was to compare both techniques in resource constraint country. METHOD: We reviewed renal biopsy database, between 1 January 2014 to 30 June 2017. The primary outcome was the total number of glomeruli. The other outcomes were tissue adequacy and bleeding complications. We also analyzed multivariable logistic regression to find factors associated with tissue adequacy and bleeding complications. RESULT: Of the 204 renal biopsies, 100 were blind percutaneous renal biopsy and 104 real-time ultrasound-guided percutaneous renal biopsy. The number of native renal biopsies was 169 (82.8%). Baseline characteristics of two groups were comparable. The mean number of total glomeruli from real-time ultrasound-guided percutaneous renal biopsy was significantly more than blind percutaneous renal biopsy (20.8 ± 12.1 vs 16.0 ± 13.0, p = 0.001). The real-time ultrasound-guided percutaneous renal biopsy obtained more adequate tissues than blind percutaneous renal biopsy (45.2% vs 16%, p < 0.001) and was the only factor associated with adequate tissue. Moreover, 16 renal biopsies from blind percutaneous renal biopsy obtained inadequate tissue. The overall bleeding complications were not statistically different. We found being female, lower eGFR and lower hematocrit were associated with bleeding complications. CONCLUSION: In comparison with blind percutaneous renal biopsy, real-time ultrasound-guided percutaneous renal biopsy obtained more adequate tissue and number of glomeruli. While the complications of both were comparable. We encourage to practice and perform real-time ultrasound-guided percutaneous renal biopsy in resource constraint countries.