Aggressive posterior paraganglioma presenting with generalized weakness, anemia, hypertension, and weight loss: A case report.

Paragangliomas (PGLs) are rare neuroendocrine tumors that originate from chromaffin cells in the extra-adrenal autonomic nervous system's ganglia. The diagnosis of PGL is made based on clinical characteristics, biochemical tests, imaging, functional studies, and pathology reports. Catecholamines and chromogranin A levels should be evaluated prior to biopsy or surgical excision. We present a case of aggressive PGL in a 55-year-old woman presented with weakness, blurred vision, hypertension, and weight loss.

Seroconversion rates in kidney transplant recipients following SARS-CoV-2 vaccination and its association with immunosuppressive agents: a systematic review and meta-analysis.

This systematic and meta-analysis aims to evaluate humoral and cellular responses to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine among kidney transplant recipients (KTRs). We conducted a systematic literature search across databases to evaluate seroconversion and cellular response rates in KTRs receiving SARS-CoV-2 vaccines. We extracted studies that assessed seroconversion rates described as the presence of antibody de novo positivity in KTRs following SARS-CoV-2 vaccination published up to January 23rd, 2022. We also performed meta-regression based on immunosuppression therapy used. A total of 44 studies involving 5,892 KTRs were included in this meta-analysis. The overall seroconversion rate following complete dose of vaccines was 39.2% (95% confidence interval [CI], 33.3%-45.3%) and cellular response rate was 41.6% (95% CI, 30.0%-53.6%). Meta-regression revealed that low antibody response rate was significantly associated with the high prevalence of mycophenolate mofetil/mycophenolic acid (p=0.04), belatacept (p=0.02), and anti-CD25 induction therapy uses (p=0.04). Conversely, tacrolimus use was associated with higher antibody response (p=0.01). This meta-analysis suggests that postvaccination seroconversion and cellular response rates in KTRs are still low. And seroconversion rate was correlated with the type of immunosuppressive agent and induction therapy used. Additional doses of the SARS-CoV-2 vaccine for this population using a different type of vaccine are considered.

The Association of Kidney Function Monitoring Adherence and Estimated Glomerular Filtration Rate Changes Among Patients At-Risk for Chronic Kidney Disease.

BACKGROUND: Kidney Disease: Improving Global Outcome in 2012 has provided recommendations to prevent CKD progression by monitoring kidney function periodically according to the CKD stage and the clinician's adherence to these guidelines is important. This is the first study on the relationship between adherence to monitoring renal function and changes in estimated glomerular filtration rate (eGFR) in patients at risk for CKD in Indonesia. METHODS: This study was a comparative observational study with a cross-sectional approach. Research subjects were electronic medical record data from the Hasan Sadikin General Hospital information system (SIRS) data collected with the SQL Server Report Builder and "HCLAB" applications on patients at risk for CKD at the Hasan Sadikin General Hospital's Outpatient Clinic from January 2018 to March 2020. The patients' data were taken by the total sampling technique and then processed with the Chi-Square test. RESULTS: From 376 subjects, the results showed that poor adherence in renal function monitoring would increase the risk of decreasing eGFR by 1.51 times compared to good monitoring adherence (PR 1.51 95% CI (1.172 - 1.935); p-value 0.007). The eGFR changes were significant (p-value 0.002) with mean 10.84 ml/min/1.73m2 (95% CI: 4.17 - 17.50). CONCLUSION: The study demonstrated that poor renal function monitoring adherence had an association with a decrease in eGFR in a group of patients at risk for CKD.

Risk factors of latent tuberculosis among chronic kidney disease with routine haemodialysis patients.

INTRODUCTION: Since immune system alteration occurs, chronic kidney disease (CKD) on routine haemodialysis (HD) patients have a greater risk for latent tuberculosis (LTB). LTB needs special attention so that it does not develop into an active form, because infection in CKD patients increases the mortality. This study aims to determine the risk factors that associated with LTB among CKD on routine HD patients. METHODS: This was a cross-sectional study conducted in Haemodialysis Unit, Hasan Sadikin General Hospital, Bandung. The subjects were recruited from March-May 2020. Subjects aged > 18 years at least have undergoing HD in 3 months and twice a week HD were included in this study. Patients with active tuberculosis (TB) suspected, malignancy, or immunocompromised were excluded. LTB was diagnosed using interferon-γ release assays (IGRA). All data including age, sex, CKD etiologies, smoking status, HD adequacy that assessed using KT/V and urea reduction ratio (URR), and contact status with TB patients were obtained and recorded in case report form. RESULTS: A total of 120 subjects were involved. LTB based on IGRA was occurred in 39.2% subjects, while 56.7% and 4.1% subjects had negative and indeterminate IGRA, respectively. Adequacy of HD based on KT/V value was not significantly different between positive and negative IGRA subjects. Positive IGRA subjects had lower URR (p = 0.042). Smoking status had significant association with LTB (OR = 2.5[95%CI 1.2-5.4, p = 0.017). Furthermore, URR < 73% also had significant association with LTB (OR = 2.6[1.2-5.6, p = 0.013). CONCLUSION: Smoking status and HD adequacy based on URR < 73% are associated factors that contribute to LTB among CKD on HD patients.

Impaired glucose tolerance among adolescents with low birth weight history: The Tanjungsari Cohort Study in Indonesia.

BACKGROUND AND OBJECTIVES: Diabetes prevalence has been increasing overtime in Indonesia along with its complications and morbidities. Diabetes prevention program is still a challenge. Previous study concluded poor intrauterine nutritional status, low birth weight (LBW), and nutrition status early in life were risk factors for impaired glucose tolerance (IGT) or type 2 diabetes mellitus in adulthood. This study aimed to evaluate the association between both LBW and intrauterine growth restriction (IUGR) with IGT in adolescents. METHODS AND STUDY DESIGN: Total of 536 subjects from Tanjungsari Cohort Study were included in this study. Subjects were in their early adolescence age (12-14 years). Anthropometric data were collected and IGT was determined by using 2- hour postprandial plasma glucose level, then it was assessed based on their birth weight and intrauterine nutritional status. RESULTS: Subjects with LBW history were shorter, had lower body weight and body mass index (p<0.05, respectively). The proportion of IGT is significantly higher among subject with LBW (RR 1.692 [1.079- 2.653]). There was no difference on proportion of IGT among subjects with IUGR compared with subjects who were not IUGR or born preterm (p=0.286). Multiple regression analysis showed the effect of LBW remain independent after adjusted with sex and socioeconomic variables (RR 1.650 [1.054-2.584]). CONCLUSIONS: Significant association was found between LBW and IGT in comparison to those who were born with normal birth weight. Hence, diabetes should be prevented as early as possible, even since in the pregnancy.

Role of statin as inducer of Hmox-1 system in treatment of preeclampsia.

Preeclampsia is the major cause of both maternal and neonatal morbidity and mortality. Its insidence remains high and the management has not been established yet because its etiology and pathophysiological are still poorly understood. Theories regarding etiopathogenesis and management of preeclampsia have been postulated yet it remains controversial. Placental ischemic and angiogenic imbalance are suggested to be predisposing factors of preeclampsia. It is thereby targeted in prevention of preeclampsia. Unfortunately, both primary and secondary prevention using various supplements and drugs fails to exhibit good outcome. Overall, these efforts are considered useless. In recent years, researchers have been using statin derivative in management of preclampsia. It has been reported that statin provides protective effect in endothelial cells by inducing expression of Hmox-1 and inihibiting release of sFlt-1 as well as potent antioxidant properties. Thus, statin has been proposed as promising agent to significantly reduce anti-angiogenic in preeclamptic patients which is overviewed in this review based on recent studies.

Cerebral Venous Sinus Thrombosis in Systemic Lupus Erythematosus.

A 38-year-old woman presented with general weakness and vaginal bleeding. One month prior, she had been diagnosed with Evans syndrome (haemolytic anemia with positive Coombs test and thrombocytopenia) and was given oral steroid as maintenance therapy. Her serology examination was negative for hepatitis B, hepatitis C, and human immunodeficiency virus (HIV). Her obstetrical history was marked by miscarriage in second pregnancy and preeclampsia in third pregnancy. She used hormonal contraceptives until 5 months prior to admission. On physical examination, she had anemic conjunctiva and no organomegaly. Blood tests were significant for anemia (3.4 g/dl) and thrombocytopenia (28,000/µl). Her vaginal bleeding had ceased, however her platelet continued decreasing to 12,000/µl during first several days of hospitalization despite receiving platelet transfusion. On the tenth hospital day, she suddenly complained of severe headache and blurred vision. She had bilateral edema and erythema of palpebral, chemosis, decreased in visual acuity, and reduced ocular motility. Ear and nose examination were normal. Peripheral blood smear showed no blast. Prothrombine time (PT), INR, APTT tests were normal and D Dimer was slightly increased (3.3 mg/l; NV ≤0.5 mg/l). Urine examination revealed proteinuria with 24 hour urine protein was 1,863 mg (NV <150 mg/day). We assessed her as cavernous sinus thrombosis and treated her empirically with intravenous broad-spectrum antibiotics, morphine drip. Either digital subtraction angiography or anticoagulant was deferred due to low platelet. Further examination revealed positive for ANA, anti-SSA, and diagnosis of SLE was established. Anticardiolipin antibodies of IgG and IgM and anti-beta2 glycoprotein antibodies of IgM and IgG tests were non reactive. Methylprednisolone pulse therapy (1g/day) was given for 3 consecutive days, and then tapered to oral methylprednisolone. She additionally received azathioprine 50 mg tab BID. Meanwhile her clinical symptoms alleviated and platelet count was increased, brain MRI and MR venography finally performed suggesting cerebral venous sinus thrombosis. She got additional oral anticoagulant rivaroxaban 15 mg tab BID and eventually discharged. Cerebral venous sinus thrombosis may be the presenting symptoms or occur concomitantly within the onset of SLE. Our patient had SLE, meeting 4 of the Systemic Lupus International Collaborating Clinic classification criteria (hemolytic anemia, thrombocytopenia, renal involvement, and positive for ANA test). Vasculitis due to endothelial cell injury mediated by immune-complex deposition is proposed to be the pathogenesis of CVST in SLE. Hypercoagulable state could be other etiology factor. Antiphospholipid antibodies were absent in our case as reported in some cases, emphasizing vasculitis as the underlying mechanism. Treatment of CVST in SLE consisting of anticoagulant, steroid, and immunosuppressant. This case elicits intriguing problem: CVST and thrombocytopenia. Anticoagulant treatment is proposed as the cornerstone treatment for CVST, however it was deferred due to risk of bleeding in thrombocytopenia. Steroid plays role in treatment of CVST in SLE, owing to its anti-inflammatory property. As shown in previous cases, the patient had remarkable response to high dose steroid treatment and eventually got anticoagulant after her platelet had increased. In summary, prompt diagnosis and treatment of CVST are important for a favorable prognosis.