Diuretics prescribing in chronic kidney disease patients: physician assessment versus bioimpedence spectroscopy.

INTRODUCTION: The relationship between hypertension and fluid overload in pre-dialysis CKD patients need to be elucidated. Current study aimed to find relationship between fluid overload and hypertension along with prescribed diuretic therapy using bioimpedance spectroscopy (BIS). METHODOLOGY: A prospective observational study was conducted by inviting pre-dialysis CKD patients. Fluid overload was assessed by BIS. RESULTS: A total of 312 CKD patients with mean eGFR 24.5 ± 11.2 ml/min/1.73 m2 were enrolled. Based on OH value ≥7 %, 135 (43.3 %) patients were hypervolemic while euvolemia was observed in 177 (56.7 %) patients. Patients were categorized in different regions of hydration reference plot (HRP) generated by BIS i.e., 5.1 % in region-N (normal BP and fluid status), 20.5 % in region I (hypertensive with severe fluid overload), 29.5 % in region I-II (hypertensive with mild fluid overload), 22 % in region II (hypertensive with normohydration), 10.2 % in region III (underhydration with normal/low BP) and 12.5 % in region IV (normal BP with severe fluid overload). A total of 144 (46 %) patients received diuretics on basis of physician assessment of BP and edema. Maximum diuretics 100 (69.4 %) were prescribed in patients belonging to regions I and I-II of HRP. Interestingly, a similar number of diuretic prescriptions were observed in region II (13 %) and region IV (12 %). Surprisingly, 7 (4.9 %) of patients in region III who were neither hypervolemic nor hypertensive were also prescribed with diuretics. CONCLUSION: BIS can aid clinicians to categorize CKD patients on basis of their fluid status and provide individualized pharmacotherapy to manage hypertensive CKD patients.

Outcomes of diuretic use in pre-dialysis CKD patients with moderate renal deterioration attending tertiary care referral center.

INTRODUCTION: Diuretic therapy has been the mainstay of treatment in chronic kidney disease (CKD) patients, primarily for hypertension and fluid overload. Apart from their beneficial effects, diuretic use is associated with adverse renal outcomes. The current study is aimed to determine the outcomes of diuretic therapy. METHODOLOGY: A prospective observational study was conducted by inviting pre-dialysis CKD patients. Fluid overload was assessed by Bioimpedance analysis (BIA). RESULTS: A total 312 patients (mean age 64.5 ± 6.43) were enrolled. Among 144 (46.1%) diuretic users, furosemide and hydrochlorothiazide (HCTZ) were prescribed in 69 (48%) and 39 (27%) patients, respectively, while 36 (25%) were prescribed with combination therapy (furosemide plus HCTZ). Changes in BP, fluid compartments, eGFR decline and progression to RRT were assessed over a follow-up period of 1 year. Maximum BP control was observed with combination therapy (-19.3 mmHg, p < 0.001) followed by furosemide [-10.6 mmHg with 80 mg thrice daily (p < 0.001)], -9.3 mmHg with 40-60 mg (p < 0.001) and -5.9 mmHg with 20-40 mg (p = 0.02) while HCTZ offered minimal SBP control [-3.7 mmHg with 12.5-25 mg (p = 0.04)]. Decline in extracellular water (ECW) ranged from -1.5 L(p = 0.01) with thiazide diuretics to -3.8 L(p < 0.001) with combination diuretics. Decline in eGFR was maximum (-3.4 ml/min/1.73 m2, p = 0.01) with combination diuretics and least with thiazide diuretics (-1.6 ml/min/1.73 m2, p = 0.04). Progression to RRT was observed in 36 patients. CONCLUSION: It is cautiously suggested to discourage the use of diuretic combination therapy and high doses of single diuretic therapy. Prescribing of diuretics should be done by keeping in view benefit versus harm for each patient.

Progression and outcomes of non-dialysis dependent chronic kidney disease patients: A single center longitudinal follow-up study.

AIM: Despite increase global prevalence of End stage renal disease (ESRD) and subsequent need for renal replacement therapy (RRT), relatively little is known about disease progression and prognosis of earlier stages of CKD. Current study was conducted to examine rate of CKD progression, predictors of ESRD and death. METHODS: A total 621 patients with estimated glomerular filtration rate (eGFR) of 15-59ml/min/1.73m2 (CKD stage 3 & 4) were selected and followed up for 10 years or until ESRD or death, whichever occurred first. Subjects who did not meet inclusion criteria were excluded (n=1474). RESULTS: Annual cumulative decline in eGFR was 3.01±0.40 ml/min/1.73m2 . Overall disease progression was observed in 60% patients while 18% died. Among patients with CKD stage 3, 21% progressed to stage 4, 10% to stage 5ND (non-dialysis) and 31% to RRT while mortality was observed in 16% patients. On the other hand, 8% patients with CKD stage 4 progressed to stage 5ND, 31% to RRT and mortality was observed in 24% cases. Patients with CVD, higher systolic blood pressure, elevated phosphate levels, heavy proteinuria, microscopic hematuria and use of diuretics were more likely to develop ESRD. Advancing age, low eGFR, low systolic blood pressure, low hemoglobin and baseline diabetes were found to be significant predictors of mortality while being female reduced risk of mortality. CONCLUSION: Our data suggest that, in this CKD cohort, patients were more likely to develop ESRD than death. Prime importance should be given to mild forms of CKD to retard and even reverse CKD progression.

Defining acute kidney injury in dengue viral infection by conventional and novel classification systems (AKIN and RIFLE): a comparative analysis.

BACKGROUND: Several criteria have been used to stratify acute kidney injury (AKI) in dengue infection and have resulted in variations in its incidence as well as clinic-laboratory characteristics. The current study was aimed to compare three commonly used criteria of AKI among patients with dengue. METHODS: 667 patients with dengue were defined and staged according to the conventional definition (CD), the Acute Kidney Injury Network (AKIN) and the Risk, Injury, Failure, Loss of function, End stage renal disease (RIFLE) criteria. Appropriate statistical methods were used to compare these three criteria. RESULTS: The incidence of AKI during dengue infection was 14.2% by AKIN criteria, 12.6% by RIFLE criteria and 4.2% by CD. AKIN and RIFLE criteria were comparable while AKIN-I identified 11 more patients with AKI than RIFLE-R (76.8% vs. 73.8%, p=0.023). CD was found to be less sensitive than AKIN and RIFLE due to stratification of only severe AKI cases with serum creatinine ≥176.8 µmol/L. Overall mortality was 1.2% and severe stages of AKI were associated with increased mortality (p<0.001). AKIN criteria identified seven risk factors, RIFLE identified six and CD identified three risk factors. Old age, severe dengue and the use of nephrotoxic drugs were found to be independent predictors identified by all criteria while hypertension was only identified by AKIN. CONCLUSIONS: The incidence of AKI in dengue infection, the risk factors for its development and clinico-laboratory characteristics vary significantly according to the diagnostic criteria used. In our analysis, AKIN and RIFLE were comparable to each other and superior to CD with regard to early diagnosis and sensitivity.

Clinico-laboratory spectrum of dengue viral infection and risk factors associated with dengue hemorrhagic fever: a retrospective study.

BACKGROUND: The incidence of dengue is rising steadily in Malaysia since the first major outbreak in 1973. Despite aggressive measures taken by the relevant authorities, Malaysia is still facing worsening dengue crisis over the past few years. There is an urgent need to evaluate dengue cases for better understanding of clinic-laboratory spectrum in order to combat this disease. METHODS: A retrospective analysis of dengue patients admitted to a tertiary care teaching hospital during the period of six years (2008 - 2013) was performed. Patient's demographics, clinical and laboratory findings were recorded via structured data collection form. Patients were categorized into dengue fever (DF) and dengue hemorrhagic fever (DHF). Appropriate statistical methods were used to compare these two groups in order to determine difference in clinico-laboratory characteristics and to identify independent risk factors of DHF. RESULTS: A total 667 dengue patients (30.69 ± 16.13 years; Male: 56.7 %) were reviewed. Typical manifestations of dengue like fever, myalgia, arthralgia, headache, vomiting, abdominal pain and skin rash were observed in more than 40 % patients. DHF was observed in 79 (11.8 %) cases. Skin rash, dehydration, shortness of breath, pleural effusion and thick gall bladder were more significantly (P < 0.05) associated with DHF than DF. Multivariate regression analysis demonstrated presence of age > 40 years (OR: 4.1, P < 0.001), secondary infection (OR: 2.7, P = 0.042), diabetes mellitus (OR: 2.8, P = 0.041), lethargy (OR: 3.1, P = 0.005), thick gallbladder (OR: 1.7, P = 0.029) and delayed hospitalization (OR: 2.3, P = 0.037) as independent predictors of DHF. Overall mortality was 1.2 % in our study. CONCLUSIONS: Current study demonstrated that DF and DHF present significantly different clinico-laboratory profile. Older age, secondary infection, diabetes mellitus, lethargy, thick gallbladder and delayed hospitalization significantly predict DHF. Prior knowledge of expected clinical profile and predictors of DHF/DSS development would provide information to identify individuals at higher risk and on the other hand, give sufficient time to clinicians for reducing dengue related morbidity and mortality.

KAP AMONG DOCTORS WORKING IN HOSPITALS, REGARDING HALAL PHARMACEUTICALS; A CROSS SECTIONAL ASSESSMENT.

There is a growing awareness amongst Muslims to avoid all items containing non-Halal ingredients. This sentiment has now progressed into the field of various medications. It therefore, required a study to assess the knowledge, attitude and perception (KAP) relating to pharmaceuticals containing non-Halal ingredients among doctors working in various hospitals of Malaysia. This was a cross sectional study, carried out in January 2013-February 2013 period, using a structured, self-administered questionnaires. Study settings included various government hospitals in Malaysia. Data were collected by distributing questionnaires through respective heads of the departments. Study was conducted on a sample of 243 participants. Inclusion criterion was a registered medical doctor working in a government hospital. Descriptive statistics (mean, standard deviation, frequency, percentage, median, inter quartile range) was applied to summarize the data, non-parametric tests were applied. χ2 Test and Fisher's Exact Test were applied to assess the association between demographic characteristics and knowledge, attitude and perception scores. Results revealed that the hospital doctors had a good and positive attitude and perception about Halal pharmaceuticals. Mean knowledge score out of maximum possible 9 score was 7.67 ± 1.68. Mean attitude score out of maximum possible 45 score was 34.10 ± 5.35 while mean perception score out of maximum possible 55 score was 45.73 ± 5.44. Mean overall KAP score out of maximum possible 109 was 87.60 ± 10.37. There was a significant, positive and weak correlation (0.20-0.29) between knowledge and attitude (r = 0.231, p < 0.001) as well as between knowledge and perception (r = 0.209, p = 0.001) while there was good correlation (0.5-0.75) between attitude and perception (r = 0.588, p < 0.001). It is concluded from the results that the better knowledge the respondents have on Halal pharmaceuticals the better is their perception and attitude towards Halal pharmaceuticals.

Pilot testing of a pharmacist led care program for asthma patients in Saudi Arabia.

This study aimed at evaluating the usefulness of a structured patient counseling program on clinical outcomes of asthma patients in Saudi Arabia. This cross sectional study enrolled 10 asthma patients and all were evaluated for their baseline knowledge on asthma, quality of life, compliance, patient satisfaction and drug related problems among randomly selected 5 (of the total 10) patients. The median (IQR) age of the patients was 46 (33.5-56.2) years. The baseline knowledge scores was 9 (8-11), the maximum possible scores to be 21. Cronbach alpha of the KQ was 0.65. The overall total median (IQR) compliance (Morisky) score was 4 (3-5), the maximum possible score was 5. The patient satisfaction median (IQR) score was 35.5 (32-46.25), the maximum possible score was 70. Of the total patients 3 (30%) had a history of allergy. There were total 18 allergens observed in these patients. There has been no drug-drug or drug-food interactions observed between among the prescribed drugs of the patients. Altogether 2 patients reported a total of 2 ADRs. The knowledge of the asthma patients was found to be poor. Missing the dose was the most commonly encountered drug taking behavior. The compliance was found to be good and the patient satisfaction was average.

Infective Endocarditis and Chronic Kidney Disease: How to Deal with Complications.

Infective endocarditis (IE) is the one of the most important causes of increased mortality and morbidity among haemodialysis patients. The reason for this increasing prevalence of infection among these patients is the use of haemodialysis catheters during dialysis, as these patients are highly susceptible to infections that are easily transmitted via blood access points. The present case was a geriatric end stage renal disease (ESRD) patient who was readmitted to the hospital two days after her scheduled haemodialysis session with symptoms of nosocomial endocarditis. Her concurrent medical complications were hypertension, non-insulin dependent diabetes mellitus, and ischemic heart disease. Based on her previous medical history and current examination, the patient was suspected to have IE due to catheter related infection. The goal of therapy is to manage the comorbidities and infection by provision of appropriate treatment based on close monitoring of the patient condition.

Exploring the halal status of cardiovascular, endocrine, and respiratory group of medications.

Muslim consumers have special needs in medical treatment that differ from non-Muslim consumers. In particular, there is a growing demand among Muslim consumers for Halal medications. This descriptive exploratory study aims to determine the Halal status of selected cardiovascular, endocrine, and respiratory medications stored in an out-patient pharmacy in a Malaysian governmental hospital. Sources of active ingredients and excipients for each product were assessed for Halal status based on available information obtained from product leaflets, the Medical Information Management System (MIMS) website, or manufacturers. Halal status was based on the products' sources and categorized into Halal, Mushbooh, or Haram. The proportions of Halal, Mushbooh, and Haram products were at 19.1%, 57.1%, and 23.8%, respectively. The percentage of active ingredients for cardiovascular/endocrine products that were assessed as Haram was 5.3%; for respiratory medications, it was only 1.1%. For excipients, 1.7% and 4.8% fall under the category of Haram for cardiovascular/endocrine products and respiratory products, respectively. Ethanol and magnesium stearate were found to be the common substances that were categorized as Haram and Mushbooh.

Addressing the standardisation of internal standards and preservative used in human bio fluids for NMR analysis: a method optimization.

OBJECTIVES: A database comprising multivariate data in developing a model from nuclear magnetic resonance (NMR) analysis using human bio fluids are necessary to have reproducibility and reliability of the data. To achieve reproducibility of the data, standardised experiments, including internal standard and preservative used should be attained, especially for samples such as human bio fluids to hinder the variation among samples. The aim of the study was to optimise in commonly used human bio fluids (serum and urine) for a suitable internal standard and preservative used in extended storage samples for NMR analysis. METHODS: Serum and urine samples were collected from healthy human subjects. The experiment was divided into two parts, part one to evaluate 2,2,2,2-tetradeutero-4,4-dimethyl-4-silapentanoic acid (TSP) and 4,4-dimethyl-4-silapentane-1-ammonium trifluoroacetate (DSA) as the optimal internal standard for the serum and urine samples. The second part investigated the effects of preservatives in the serum and urine samples on extended storage. RESULTS: Overall, TSP and DSA are suitable to be used as an internal standard in human urine samples. However, DSA is a superior internal standard in serum samples for NMR analysis. For the effect of preservative, the results indicated that human serum and urine samples could be stored without addition of preservative in -80 °C, as no changes in NMR fingerprinting have been observed during storage in the absence or presence of the preservative. CONCLUSIONS: The findings suggest the use of DSA and TSP as an internal standard in serum and urine samples, respectively. Storage of serum and urine samples without any addition of preservative for an extended period has no effect on the metabolites changes. By having a standardised method, it will offer a considerable saving in both operator and spectrometer time and most importantly produce reproducible and reliable data.

Addressing the standardisation of internal standards and preservative used in human bio fluids for NMR analysis: a method optimization.

OBJECTIVES: A database comprising multivariate data in developing a model from nuclear magnetic resonance (NMR) analysis using human bio fluids are necessary to have reproducibility and reliability of the data. To achieve reproducibility of the data, standardised experiments, including internal standard and preservative used should be attained, especially for samples such as human bio fluids to hinder the variation among samples. The aim of the study was to optimise in commonly used human bio fluids (serum and urine) for a suitable internal standard and preservative used in extended storage samples for NMR analysis. METHODS: Serum and urine samples were collected from healthy human subjects. The experiment was divided into two parts, part one to evaluate 2,2,2,2-tetradeutero-4,4-dimethyl-4-silapentanoic acid (TSP) and 4,4-dimethyl-4-silapentane-1-ammonium trifluoroacetate (DSA) as the optimal internal standard for the serum and urine samples. The second part investigated the effects of preservatives in the serum and urine samples on extended storage. RESULTS: Overall, TSP and DSA are suitable to be used as an internal standard in human urine samples. However, DSA is a superior internal standard in serum samples for NMR analysis. For the effect of preservative, the results indicated that human serum and urine samples could be stored without addition of preservative in -80 °C, as no changes in NMR fingerprinting have been observed during storage in the absence or presence of the preservative. CONCLUSIONS: The findings suggest the use of DSA and TSP as an internal standard in serum and urine samples, respectively. Storage of serum and urine samples without any addition of preservative for an extended period has no effect on the metabolites changes. By having a standardised method, it will offer a considerable saving in both operator and spectrometer time and most importantly produce reproducible and reliable data.

Incidence of risk factors for developing hyperkalemia when using ACE inhibitors in cardiovascular diseases.

STUDY OBJECTIVE: To determine the incidence of and the risk factors associated with hyperkalemia, induced by ACEI-drug interactions among cardiac patients. SETTING: Five medical and cardiology wards of a tertiary care center in Malaysia. SUBJECTS: Five hundred cardiac inpatients, who received ACEIs concomitantly with other interacting drugs. METHOD: This was a prospective cohort study of 500 patients with cardiovascular diseases admitted to Penang Hospital between January to August 2006, who received ACEIs concomitantly with other interacting drugs. ACEI-drug interactions of clinical significance were identified using available drug information resources. Drug Interaction Probability Scale (DIPS) was used to assess the causality of association between ACEI-drug interactions and the adverse outcome (hyperkalemia). MAIN OUTCOME MEASURE: Hyperkalemia as an adverse clinical outcome of the interaction was identified from laboratory investigations. RESULTS: Of the 489 patients included in the analysis, 48 (9.8%) had hyperkalemia thought to be associated with ACEI-drug interactions. Univariate analysis using binary logistic regression revealed that advanced age (60 years or more), and taking more than 15 medications were independent risk factors significantly associated with hyperkalemia. However, current and previous smoking history appeared to be a protective factor. Risk factors identified as predictors of hyperkalemia secondary to ACEI-drug interactions by multi-logistic regression were: advanced age (adjusted OR 2.3, CI 1.07-5.01); renal disease (adjusted OR 4.7, CI 2.37-9.39); hepatic disease (adjusted OR 5.2, CI 1.08-25.03); taking 15-20 medications (adjusted OR 4.4, CI 2.08-9.19); and taking 21-26 medications (adjusted OR 9.0, CI 1.64-49.74). CONCLUSION: Cardiac patients receiving ACEIs concomitantly with potentially interacting drugs are at high risk of experiencing hyperkalemia. Old age, renal disease, hepatic disease, and receiving large number of medications are factors that may significantly increase their vulnerability towards this adverse outcome; thus, frequent monitoring is advocated.

Knowledge, attitude and practice of pharmacists on medication therapy management: a survey in Hospital Pulau Pinang, Penang, Malaysia.

BACKGROUND: Medication therapy management (MTM) service provides set of clinical activities to optimize therapeutic outcomes for patients. It requires the collaboration between patient, pharmacist and other healthcare providers to ensure safe and effective use of medicines. The objective of the current study was to assess Hospital Pulau Pinang pharmacists' knowledge, attitude and practice on MTM service. METHODS: A self-administrated validated survey was carried out among all pharmacists working at Hospital Pulau Pinang. RESULTS: A total of 93 pharmacists out of 130 (71.5%) were included in the study (61.3% between the age of 20-30 years old, 74.2% female, 68.8% Chinese, 88.2% holding bachelor's degree and 48.4% working in medication therapy adherence clinic and outpatient pharmacy). Majority of pharmacists had a high level of knowledge and positive attitudes regarding MTM service. All pharmacists agreed that MTM service could improve the quality of health services and most pharmacists were interested in providing MTM service (92.5%). Moreover, 95.7% were interested in acquiring more information about MTM service. About the barriers that might affect MTM service implementation, the most common barriers identified by pharmacists were lack of training (88.2%), need of high budget to implement MTM service (51.6%) and lack of time (46.2%). CONCLUSIONS: Overall, the research findings provide some insights about the Hospital Pulau Pinang pharmacists' knowledge, attitude and practice regarding MTM service. Majority of pharmacists agreed and showed their interest towards the implementation of MTM service.

Prevalence of Chronic Kidney Disease in Asia: A Systematic Review of Population-Based Studies.

Chronic kidney disease (CKD) is an asymptomatic disease associated with high morbidity and life-threatening complications that lead to decreased life expectancy. Worldwide prevalence of CKD is escalating at an alarming rate. Large population-based representative surveys have been reported in Western countries to estimate the prevalence of the disease. However, there is paucity of data as far as developing nations are concerned. Asia is the world's largest continent accommodating maximum number of under-developed and developing countries with an unclear picture of prevalence of CKD. Current review attempts to give an insight to the prevalence of CKD in this region by combining population-based surveys. This review will assist in estimating the burden of CKD in Asia, so that appropriate control measures could be designed.

Short-term renal outcomes following acute kidney injury among dengue patients: A follow-up analysis from large prospective cohort.

BACKGROUND: Despite myriad improvements in the care of dengue patients, acute kidney injury (AKI) remained least appreciated intricacy of dengue infection. Exiting literature does not provide any information on renal outcomes among dengue patients surviving an episode of AKI. METHODS: Dengue patients who developed AKI were followed up for post-discharge period of three months and renal recovery was assessed by using recovery criteria based on different thresholds of serum creatinine (SCr) and estimated glomerular filtration rates (eGFR). RESULTS: Out of the 526 dengue participants, AKI was developed in 72 (13.7%) patients. Renal recovery was assessed among AKI survivors (n = 71). The use of less (±50% recovery to baseline) to more (±5% recovery to baseline) stringent definitions of renal recovery yielded recovery rates from 88.9% to 2.8% by SCr and 94.4% to 5.6% by eGFR, as renal function biomarkers. At the end of study, eight patients had AKI with AKIN-II (n = 7) and AKIN-III (n = 1). Approximately 50% patients (n = 36/71) with AKI had eGFR primitive to CKD stage 2, while 18.3% (n = 13/71) and 4.2% (n = 3/71) patients had eGFR corresponding to advanced stages of CKD (stage 3 & 4). Factors such as renal insufficiencies at hospital discharge, multiple organ involvements, advance age, female gender and diabetes mellitus were associated with poor renal outcomes. CONCLUSIONS: We conclude that dengue patients with AKI portend unsatisfactory short-term renal outcomes and deserve a careful and longer follow-up, especially under nephrology care.

Determinants of mortality and prolonged hospital stay among dengue patients attending tertiary care hospital: a cross-sectional retrospective analysis.

OBJECTIVES: Dengue imposes substantial economic, societal and personal burden in terms of hospital stay, morbidity and mortality. Early identification of dengue cases with high propensity of increased hospital stay and death could be of value in isolating patients in need of early interventions. The current study was aimed to determine the significant factors associated with dengue-related prolonged hospitalisation and death. DESIGN: Cross-sectional retrospective study. SETTING: Tertiary care teaching hospital. PARTICIPANTS: Patients with confirmed dengue diagnosis were stratified into two categories on the basis of prolonged hospitalisation (≤3 days and >3 days) and mortality (fatal cases and non-fatal cases). Clinico-laboratory characteristics between these categories were compared by using appropriate statistical methods. RESULTS: Of 667 patients enrolled, 328 (49.2%) had prolonged hospitalisation. The mean hospital stay was 4.88±2.74 days. Multivariate analysis showed that dengue haemorrhagic fever (OR 2.3), elevated alkaline phosphatase (ALP) (OR 2.3), prolonged prothrombin time (PT) (OR 1.7), activated partial thromboplastin time (aPTT) (OR 1.9) and multiple-organ dysfunctions (OR 2.1) were independently associated with prolonged hospitalisation. Overall case fatality rate was 1.1%. Factors associated with dengue mortality were age >40 years (p=0.004), secondary infection (p=0.040), comorbidities (p<0.05), acute kidney injury (p<0.001), prolonged PT (p=0.022), multiple-organ dysfunctions (p<0.001), haematocrit >20% (p=0.001), rhabdomyolosis (p<0.001) and respiratory failure (p=0.007). Approximately half of the fatal cases in our study had prolonged hospital stay of greater than three days. CONCLUSIONS: The results underscore the high proportion of dengue patients with prolonged hospital stay. Early identification of factors relating to prolonged hospitalisation and death will have obvious advantages in terms of appropriate decisions about treatment and management in high dependency units.

Chronic Kidney Disease, Fluid Overload and Diuretics: A Complicated Triangle.

BACKGROUND: Despite promising role of diuretics to manage fluid overload among chronic kidney disease (CKD) patients, their use is associated with adverse renal outcomes. Current study aimed to determine the extent of renal deterioration with diuretic therapy. METHODS: A total 312 non-dialysis dependent CKD (NDD-CKD) patients were prospectively followed-up for one year. Fluid overload was assessed via bioimpedance spectroscopy. Estimated GFR (eGFR) was calculated from serum creatinine values by using Chronic Kidney Disease- Epidemiology Collaboration (CKD-EPI) equation. RESULTS: Out of 312 patients, 64 (20.5%) were hypovolemic while euvolemia and hypervolemia were observed in 113 (36.1%) and 135 (43.4%) patients. Overall 144 patients were using diuretics among which 98 (72.6%) were hypervolemic, 35 (30.9%) euvolemic and 11 (17.2%) were hypovolemic. The mean decline in estimated GFR of entire cohort was -2.5 ± 1.4 ml/min/1.73m2 at the end of follow up. The use of diuretics was significantly associated with decline in eGFR. A total of 36 (11.5%) patients initiated renal replacement therapy (RRT) and need of RRT was more profound among diuretic users. CONCLUSIONS: The use of diuretics was associated with adverse renal outcomes indicated by decline in eGFR and increasing risk of RRT initiation in our cohort of NDD-CKD patients. Therefore, it is cautiously suggested to carefully prescribe diuretics by keeping in view benefit versus harm for each patient.

Blood Pressure and Mortality in Hemodialysis Patients: A Systematic Review of an Ongoing Debate.

Hypertension is prevalent in 75-80% of hemodialysis patients and remains the most controversial prognostic marker in end stage kidney disease patients. In contrast to the general population where systolic blood pressure of ≤120 mm Hg is considered normal, a debate remains regarding the ideal target blood pressure in hemodialysis patients. Using the PUBMED and EMBASE databases, the research studies that evaluated the relationship between blood pressure measurements and mortality in hemodialysis patients were searched. Thirteen studies were identified from different regions of the world. Five studies reported low predialysis systolic blood pressure as a prognostic marker of mortality. Other studies showed varying results and reported postdialysis systolic blood pressure as well as ambulatory blood pressure as better predictors of mortality and emphasized their optimized control. One study in this review concluded that there is no direct relationship between mortality and blood pressure if the patients are on anti-hypertensive medications. The observed all-cause mortality varied from 12% to 36%, whereas the cardiovascular mortality varied from 16% to 60%. On the basis of studies included in the current review, a low predialysis systolic blood pressure (<120 mm Hg) is shown to be a widely accepted prognostic marker of mortality while ambulatory blood pressure best predicts CV mortality. Therefore, we recommend that apart from routine BP (pre, post and intradialysis) monitoring in centers, assessment of ambulatory BP must be mandatory for all patients to reduce CV mortality in hemodialysis patients.

Incidence, Characteristics and Risk Factors of Acute Kidney Injury among Dengue Patients: A Retrospective Analysis.

BACKGROUND: Dengue induced acute kidney injury (AKI) imposes heavy burden of illness in terms of morbidity and mortality. A retrospective study was conducted to investigate incidence, characteristics, risk factors and clinical outcomes of AKI among dengue patients. METHODOLOGY: A total 667 dengue patients (2008-2013) were retrospectively evaluated and were stratified into AKI and non-AKI groups by using AKIN criteria. Two groups were compared by using appropriate statistical methods. RESULTS: There were 95 patients (14.2%) who had AKI, with AKIN-I, AKIN-II and AKIN-III in 76.8%, 16.8% and 6.4% patients, respectively. Significant differences (P<0.05) in demographics and clinico-laboratory characteristics were observed between patients with and without AKI. Presence of dengue hemorrhagic fever [OR (95% CI): 8.0 (3.64­17.59), P<0.001],rhabdomyolysis [OR (95% CI): 7.9 (3.04­20.49)], multiple organ dysfunction OR (95% CI):17.9 (9.14­35.12), P<0.001], diabetes mellitus [OR (95% CI): 4.7 (1.12­19.86), P = 0.034], late hospitalization [OR (95% CI): 2.1 (1.12­19.86), P = 0.033] and use of nephrotoxic drugs [OR(95% CI): 2.9 (1.12­19.86), P = 0.006] were associated with AKI. Longer hospital stay (>3days) was also observed among AKI patients (OR = 1.3, P = 0.044) [corrected].Additionally, 48.4% AKI patients had renal insufficiencies at discharge that were signicantly associated with severe dengue, secondary infection and diabetes mellitus. Overall mortality was 1.2% and all fatal cases had AKI. CONCLUSIONS: The incidence of AKI is high at 14.2% among dengue patients, and those with AKI portended significant morbidity, mortality, longer hospital stay and poor renal outcomes. Our findings suggest that AKI in dengue is likely to increase healthcare burden that underscores the need of clinicians' alertness to this highly morbid and potentially fatal complication for optimal prevention and management.

A Comparative Study of Piperacillin-Tazobactam With and Without Vancomycin as Empirical Therapy for Febrile Neutropenic Patients With Solid Tumor Malignancies.

BACKGROUND: The objective of this study was to evaluate the outcomes, mortality and toxicity associated with piperacillin-tazobactam (PT) and the addition of vancomycin (VM) to the empirical treatment of febrile neutropenic cancer patients. METHOD: A retrospective study on adult febrile neutropenic patients who were admitted between September 2008 and May 2013 with solid tumor malignancies was conducted at King Fahad Specialist Hospital Dammam, Saudi Arabia. RESULTS: Out of 86 febrile neutropenic patients, 60 patients were treated with PT group and 26 patients were with PT + VM group. The two groups were comparable in terms of outcome, mortality, nephrotoxicities and hepatotoxicities. The median duration of neutropenia in PT treatment group was 4 days (range 1 - 10) in the female and 7 days (range 1 - 13) in males while in PT + VM 6 days (range 1 - 5) in female and 7.5 days (range 1 - 6) in male with significance P = 0.007. There was no significant difference in terms of duration of fever and length of stay between the two treatment groups. There were no deaths reported during treatment in both groups. In PT, the microbial eradication was 27/40 (67.5%) patients (14/27 (51.9%) of female and 13/27 (48.1%) of male)), whereas it was 13/40 (32.5%) patients (9/13 (69.2%) of female and 4/13 (30.8%) of male)) in PT + VM group. Overall, there was no significant difference in terms of microbiological eradication between the two groups (OR: 1.22; 95% CI: 0.486 - 3.072; X2 stat: 0.182; P = 0.67). Response to therapy in clinically defined infections was higher 16/23 (69.56%) in PT treatment group than 7/23 (30.44%) in PT + VM group. But there was no significant difference between the two treatment groups in terms of clinically defined infections (OR: 1.013; 95% CI: 0.359 - 2.862; X2 stat: 0.001; P = 0.98). There was no significant difference in renal and liver functions between the two groups in terms of serum creatinine level and clearance, alkaline phosphate and alanine tranferase and gama glutamyl tranferase. The most commonly isolated organisms were Escherichais coli (eighteen isolates), Staphylococcus aureus (seven isolates), Streptococcus spp (six isolates) and Klebsiella pneumonia (four isolates). The overall success rate was similar in both treatment arms and treatment was well tolerated, with no severe adverse reactions reported. CONCLUSION: Although the addition of VM might provide an additional value for coverage of gram-positive pathogens. This study demonstrates that there was no significant difference in terms of response rate in both treatment groups, which could be due to the low local methicillin-resistant Staphylococcus aureus (MRSA) rates and other resistant gram-positive organisms at our institution, stressing the importance of local antibiograms in developing empirical neutropenic fever protocols.