The Relationship Between C-Reactive Protein (CRP) Concentrations and Erythropoietin Resistance, Hospital Admission Rate, Control of Mineral Metabolism, and Comorbidity in Hemodialysis Patients.

Background End-stage kidney disease patients undergoing hemodialysis are prone to develop inflammation detected by high serum C-reactive protein (CRP) levels. This study highlights the association between CRP and the erythropoietin resistance index, hospital admission rate, control of mineral metabolism, and comorbidities in a tertiary hospital and two dialysis centers in Saudi Arabia. Objectives The objective of the study is to assess the relationship between CRP levels and hemoglobin level, hospital admission rate, mineral metabolism, and comorbidity in hemodialysis patients. Materials and methods This was a cross-sectional study conducted at King Abdulaziz Medical City Dialysis Center and the South and North Dialysis Centers of King Abdullah Dialysis Program in Riyadh. All hemodialysis adult patients who have been on dialysis for over six months were included. Patients with acute illnesses and pediatric patients were excluded. The association between CRP and other variables was reported using the Pearson correlation test. The calculated sample size was 218 by using the Raosoft website; however, the final number we analyzed was 209 after exclusion. Results The prevalence of a high level of CRP was more common among patients with diabetes mellitus (p=0.008) and those who were using antihypertensives (p=0.044) while the prevalence of a high level of CRP was less common among underweight patients (p=0.031) and hepatitis C virus (HCV)-positive patients (p=<0.001). The mean value of Kt/V was significantly lower among patients with a high level of CRP (p=0.009). HCV negative was the only independent significant risk factor associated with high CRP concentration (p=0.006). Conclusions In conclusion, there was an association between CRP levels with BMI, diabetics, the use of antihypertensive medications, and negative or undetectable HCV test results with the latter being the only independent significant factor. These data suggest that patients meeting these characteristics are in an inflammatory state and more prone to develop complications; thus, implementing CPR testing in this population might be useful. Other reviews showing causations are needed to further elucidate.

Association between Hypertension and Atrial Fibrillation in Patients on Hemodialysis.

This study aimed to evaluate the prevalence and the association between hypertension (HTN) and atrial fibrillation (AF) in hemodialysis (HD) patients. A chart review-based, cross-sectional study was conducted on HD patients who had received HD for at least 6 months. Demographic, hemodynamic, and laboratory data were retrieved from the BestCare system, and the main outcomes were blood pressure before and after dialysis, and the presence of AF. Our sample consisted of 304 HD patients; 162 (53%) were male, and the mean age was 63 ± 18 years. Sixty-eight (20%) had AF, of whom 44 (64.7%) were male, with a mean age of 73 ± 12 years. The risk of AF increased by 0.4 [odds ratio: 1.04; 95% confidence interval (CI): 1.02-1.06; P <0.001] for every year of age. Almost the entire sample (66.45%, n = 202) was hypertensive, and those patients had a mean age of 64 ± 17 years, and nearly one-third had a body mass index in the obese category (28.7%, n = 58). In addition, with every increase in the Charlson comorbidity index score by two points, there was a 40% increased risk of developing HTN (OR: 2.47; 95% CI: 1.17-5.18; P = 0.017). The risk factors for the development of HTN and AF in HD patients were found to be increasing age for AF and female sex for HTN. The presence of HTN and diabetes increased the risk of developing AF seven-fold after HD.

Urinary Tract Infection as the Diagnosis for Admission Through the Emergency Department: Its Prevalence, Seasonality, Diagnostic Methods, and Diagnostic Decisions.

Background Urinary tract infections (UTIs) affect millions of people of all ages around the world. It constitutes one of the most common conditions encountered in emergency departments (EDs). In this study, we aimed to inquire into the prevalence of UTIs as the hospitalization primary diagnosis through the emergency department and to research the seasonal pattern, accuracy of the diagnostic methods used, and final diagnosis. Methods A retrospective cross-sectional study was undertaken that included all patients admitted with a primary diagnosis of UTIs through the ED over a four-month period (January, April, June, and September) in the emergency department of King Abdulaziz Medical City (KAMC) in Riyadh. The prevalence, diagnostics, and outcomes of UTIs were evaluated, and their association with seasonality was assessed after obtaining data from the Hospital Information System BestCare of King Abdullah National Guard Hospital. The variables that have been collected were analyzed using the Statistical Package for Social Sciences software version 26 (IBM Corp., Armonk, NY, USA). Results A total of 315 patients were admitted with a diagnosis of UTI. The prevalence of UTI among patients admitted through the ED was 10.5% with a significantly higher prevalence noted in January (13.3%) than in April (8.5%) or September (8.8%) (Fisher's exact test: 0.009 and 0.01, respectively). As would be expected, the cohort was made up of elderly individuals with a mean age of 70.6 years, and the male/female ratio was 1:2. UTI symptoms including dysuria, frequency, urgency, rigors, and loin pain were noted in only 41% of cases or less, and urinalysis was the basis of making the diagnosis (87.9% had positive leukocyte esterase (LE) and 90.5% had positive urine WBC/HPF). Furthermore, 4.4% required urgent treatment, and 3.1% required intensive care unit (ICU) admission. Urine culture was negative in 30.8% of the cases (30.8% false positives among those admitted with UTI). The commonest organisms isolated were Escherichia coli (33%), Klebsiella pneumoniae (14.3%), and Pseudomonas aeruginosa (5.1%). The median length of hospital stay (LOS) was 3.5 days, and the Charlson Comorbidity Index (CCI) score was 5.7. The mean hemoglobin (Hb), creatinine, C-reactive protein (CRP), procalcitonin, and lactic acid were 108 gm/L, 131.3 umol/L, 38.3 mg/L, 0.28 ng/mL, and 2.07 mmol/L, respectively. Conclusion This research found that the prevalence of UTI cases as an admission diagnosis through the emergency department was high, despite some cultures being negative or contaminated, thus probably indicating an increase in the rates of false positives. The admission rate is linked to factors such as oxygen saturation and RDW, but this is not entirely understood. In addition, the study also displayed a seasonal pattern linked to the highest number of confirmed cases in January, while the lowest was in April.

Saudi pediatric residents' confidence in handling ethical situations and factors influencing it.

BACKGROUND: During their residency program, pediatric residents frequently face ethical challenges. The aim of the study is to evaluate the pediatric residents' knowledge and confidence to handle common ethical dilemmas during their training. METHODS: This is a survey-based cross-sectional study on all pediatric residents in the largest pediatric training center in Saudi Arabia. The survey had six sections: a) Demographics and self-assessment of religiosity, b) Sources of ethics education, c) Degree of confidence in dealing with ethical challenges in clinical practice, d) Rating of the quality of ethics education during residency, e) Agreement or disagreement regarding ten ethical scenarios, and f) Confidence level in handling 21 different ethical situations.The response to the survey questions was based on a Likert scale; the survey was electronically distributed to all pediatrics residents. Mean knowledge scores and 95% confidence intervals (CI) were calculated for each independent variable to test for associations. Comparisons were made using an independent t-test or an ANOVA test when there were more than two groups. RESULT: Eighty residents responded to the study (85.1% response rate). Over 60% reported that the best source of ethical education for them was through discussions with a senior physician and it was through formal lecturers in 13.8%. One-fifth felt confident in dealing with ethical challenges. Only 2.5% rated the ethics education as "very good/excellent" and 12.5% rated the "support from residency program for ethics education" as being "very good/excellent." Agreement of more than 80% was only noted for 4 of 10 of the ethical scenarios. Overall, only 16.4% felt "confident/extremely confident" in handling different ethical situations while 38.5% felt "not confident/a little confident" with more confidence among male residents (35.3% versus 18.7% p = 0.01). Marital status, year of residency, religiosity, and source of ethics knowledge had no impact on the level of confidence. CONCLUSION: Overall, the ethics education was considered inadequate. Only one fifth had the confidence in dealing with ethical situations. Gender but not marital status, year of residency, religiosity, or source of ethics knowledge had an impact on the level of confidence in handling ethical situations.

Associations between Body Mass Index in Hemodialysis Patients and Comorbidity, Dialysis Adequacy, Blood Pressure Control, Vascular Access Type, and Hospital Admission Rate.

Higher body mass index (BMI) is associated with various comorbidities. In hemodialysis (HD) patients, BMI affects dialysis adequacy and blood pressure (BP) control and is associated with serious comorbidities. This is a cross-sectional observational study that took place at King Abdulaziz Medical City, Riyadh, Saudi Arabia. A total of 262 adult patients on HD for at least six months were recruited to this study. Chart review was used to retrospectively collect patients' data. Categorical variables were compared using Chi-square test of proportions, whereas analysis of variance was used between categorical and continuous variables. P <0.05 was considered statistically significant. Only 17 (6.5%) patients were underweight, 90 (34.4%) had normal weight, 65 (24.8%) were overweight, and 90 (34.4%) were obese. Diabetes mellitus was the most common cause of chronic kidney disease. A significant relationship was found between BMI and dialysis adequacy (P = 0.004) with 54 (60%) obese patients having inadequate dialysis. The mean postdialysis systolic BP was the lowest in the obese BMI category (129.71 ± 18.38 mmHg, P = 0.037). The obese category scored least on the Charlson Comorbidity Index (CCI) reflecting lower risk of mortality than the other three BMI categories. Despite having the lowest overall rate of hospitalization in the previous 12 months, obese patients had higher rates of hospitalization from sepsis compared to the other three groups (P = 0.048). Despite having reduced dialysis adequacy, obese HD patients scored less on CCI, had better postdialysis BP, and had fewer hospital admissions in the previous 12 months compared to the other BMI groups. These findings distinctly contrast with what is seen among obese persons in the general population.

Validity and reliability of the Arabic-translated kidney disease quality of life survey among long-term dialysis patients in Saudi Arabia.

One of the tools used to measure the quality of life in hemodialysis (HD) patients is the Kidney Disease Quality of Life (KDQOL) survey. The KDQOL has been through several developmental processes, with the most recent one being the KDQOL-36™. Our study evaluated the validity and reliability of the Arabic-translated KDQOL-36™ survey in Saudi chronic dialysis patients. This cross-sectional study was conducted at four HD centers in Saudi Arabia. The KDQOL-36™ survey was translated into Arabic according to the RAND Corporation's basic guidelines for translating surveys. The validation process was achieved by assessing reliability and validity. The reliability of the translated survey was established by Cronbach's alpha to measure internal consistency and the intra-class correlation coefficient (ICC) to measure the test-retest reliability. The validity of the translated survey was established based on content validity and convergent validity. The study included 184 patients (36-65 years; 60.9% of men). Regarding reliability, Cronbach's alpha for the subscales ranged from 0.63 to 0.89, and ICCs ranged from 0.60 to 0.88. For content validity, an expert panel reviewed the questions in depth. In addition, we found a positive relationship between all sub- and overall health-rated scores (P <0.01). The Arabic-translated version of the KDQOL-36™ survey is reliable and valid for evaluating the quality of life in Saudi chronic dialysis patients.

Patient reluctance to accept Do Not Resuscitate order: impact on clinical care.

BACKGROUND: A Do Not Resuscitate (DNR) order should only impede the performance of cardiopulmonary resuscitation in case of cardiac or respiratory arrest; it should not interfere with any other treatment decisions. AIMS: To study the impact of DNR order placement on daily clinical care of patients. METHODS: This was a retrospective cohort study of 72 patients in a tertiary care centre in Saudi Arabia. Daily clinical care measures were collected for 2 weeks prior and 2 weeks after DNR order placement and included vital signs, nursing care, comfort measures, documentation, visits by senior and junior physicians, and tests completed. RESULTS: Malignancy was the most common diagnostic category (43.1%). There was a significant reduction in vital signs documentation, tests completed, documentation, and visits by physicians after DNR orders, with no change in nursing care and comfort measures. No differences were seen for place of DNR order (intensive care unit vs medical ward), category of disease, or sex, but there were differences for documentation (more in females) and vital signs (more in males). More vital signs were documented and more tests were done in patients who survived compared to those who died. Regression analysis showed that the frequency of post-DNR order vital signs measurements and investigations done was not related to sex, age, diagnosis, time from admission to DNR order, or location of patients. Time to death was only related to sex and post-DNR order summary documentation. CONCLUSIONS: Placement of DNR orders significantly reduced vital signs measurements, investigations done, documentation and visits by physicians but not nursing care and comfort measures.

A study of quality of life among hemodialysis patients and its associated factors using kidney disease quality of life instrument-SF36 in Riyadh, Saudi Arabia.

We aimed in this study to assess the quality of life for kidney-ill patients using Kidney Disease Quality of Life Instrument-SF36 (KDQOL-SF36) and the impact of other demographic, clinical, and social factors on patients' QOL. The quality of life was assessed using an Arabic version of KDQOL-36. The KDQOL-36 subscales Physical Component Summary (PCS), Mental Component Summary (MCS), Burden of Kidney Disease, and Effects of Kidney Disease were calculated. The effect of sex, diabetic status, diabetes mellitus, marital and status employment status, etc. on these subscales was evaluated. Reliability was determined by calculating Cronbach's alpha. A total of 254 patients were enrolled. The mean age was 58.2 (standard deviation 18.2) years; 61% were male, 56.7% diabetic and 20.1% were employed. The mean domain scores on the PCS, MCS, burden of kidney disease, and effects of kidney disease subscales were 49.4, 38.7, 52.6, and 37.2, respectively. Afternoon shift patients score highest among all shifts in MCS and PCS (P = 0.0001). The MCS score (38.7 ± 28.7) was significantly lower than PCS (49.4 ± 16.5) (P = 0.0001). The "effect of kidney disease" subscale was higher in males (P = 0.02), employed patients (P = 0.02), in the afternoon dialysis shift (0.0001). For PCS higher scores were seen in males (P = 0.0001), in non-diabetics (compared to diabetics) (P = 0,006), in the employed patients (P = 0.02). The highest score was seen in the "burden of kidney disease" subscale and the lowest in the "effects of kidney disease" subscale. Higher scores were seen in males, in nondiabetics, in the employed patients.

Acute Cellular Rejection With Severe Interstitial Lymphoplasmacytic Infiltrate and Edema Associated With Minimal Change Disease.

We describe a case of a 24-year-old female renal transplant recipient who, 10 years after receiving a deceased-donor kidney, presented with acute and massive increases in serum creatinine and proteinuria levels of 13 g over 24 hours. At a previous outpatient clinic visit, her baseline serum creatinine was noted to be 87 µmol/L; on admission, serum creatinine was 1377 µmol/L. Renal biopsy results were consistent with acute cellular rejection with severe interstitial lymphoplasmacytic infiltrates and edema with no evidence of glomerular pathology, including transplant glomerulopathy. The immunofluorescence test results were negative, and the ultrastructural features were consistent with podocytopathy with no immune deposits present. We believe thatthis is the first case of acute cellular rejection typified by severe interstitial lymphoplasmacytic infiltrates and edema with severe proteinuria secondary to minimal change disease (or podocytopathy).

Effect of Fasting the Whole Month of Ramadan on Renal Function Among Muslim Patients With Kidney Transplant: A Meta-Analysis.

OBJECTIVES: Muslim renal transplant patients often ask whether fasting during Ramadan would be harmful to their kidneys. We performed a meta-analysis on relevant studies to answer this question. MATERIALS AND METHODS: We searched 4 databases using comprehensive search terms with predefined eligibility criteria. Two reviewers (FH and RA) independently assessed the relevance of studies obtained during the search. If disagreement occurred, a consensus would be sought; if disagreement persisted, the arbitration would be left to a third author (AAS). RESULTS: Eight studies (549 patients) were identified as eligible; these studies measured renal function before and after Ramadan with patients acting as their own controls in 5 studies. Our pooled analyses showed no significant changes after fasting with regard to estimated glomerular filtration rate (70.1 ± 9.1 vs 68.5 ± 7.5 mL/min, respectively; P = .6) or in serum creatinine levels (105.3 ± 8.8 and 106.1 ± 6.0 µmol/L, respectively; P = .47). In 4 self-controlled studies (148 patients) that had analyzed changes in systolic and diastolic blood pressure before versus after fasting, no significant differences were shown. However, in 3 studies that assessed changes in glomerular filtration rate in fasting (n = 358) versus nonfasting patients (n = 355), there was a significant difference in change in glomerular filtration rate following Ramadan fasting (-0.13 ± 1.2 mL/min in those who fasted versus 4.2 ± 4.6 mL/min in those who did not fast; P = .039); however, these results were associated with significant publication bias (systematic heterogeneity). CONCLUSIONS: Fasting during Ramadan did not result in significant changes in kidney function or blood pressure in posttransplant patients with good baseline kidney function when patients acted as their own controls.

Attendees' feedback on king abdulaziz medical city pilot chronic kidney disease education class.

Despite similar or better patient outcomes, peritoneal dialysis and pre-emptive kidney transplantation are underutilized in Saudi Arabia. Moreover, most patients with end-stage renal disease begin dialysis in unplanned fashion necessitating the commencement of dialysis using central venous catheter access. We aimed to investigate if early patient education can help in overcoming these barriers. The study is a survey-based study at King Abdulaziz Medical City, Riyadh Dialysis Center. In January 2017, we started a monthly Chronic Kidney Disease Education Class in our center. Since then, 14 classes have taken place attended by 54 patients referred from outpatient nephrology clinics with chronic kidney disease (CKD) stages IV and V. The mean age was 51.6 years (16-85); 32 of the attendees were male and 22 were female. The class consisted of a slide informative presentation, a display of educational materials, and interactions with a multidisciplinary team from dialysis, transplantation, vascular access, and dietician services. A feedback survey was given to attendees at the conclusion of the class covering three domains; speakers, the program, and their personal reflections. Feedback options were laid out as "excellent, very good, good, fair, and poor." All class attendees responded to the questionnaire (100% response rate). The overall class evaluation was positive with the majority of attendees giving "excellent" rating for the speakers and the educational materials covered. Most thought that the class made them understand CKD nature better and helped them choose the right modality of renal replacement therapy. This initiative proves the feasibility of a sustained and attendee-gratifying education class to inform patients with advanced CKD about different options of renal replacement therapy and the need for timely preparation. To objectively measure the class's effect, the next phase of this review will define the ultimate outcome of each of its attendees.

Immediately Functioning Grafts from Brain-Dead Donors Treated with Extracorporeal Membrane Oxygenation.

A brain-dead donor experienced repeated cardiac arrests followed by severe hypotension requiring multiple vasoactive agents. These events were associated with severe lactic acidosis and dysregulated kidney function in the donor. A 10-hour treatment with extracorporeal membranous oxygenation was instituted, which was able to hemodynamically stabilize the donor. This treatment protocol resulted in the procurement of 2 viable kidney grafts transplanted into 2 recipients, who had immediate kidney graft function and excellent serum creatinine levels upon hospital discharge. These results are all the more significant considering that both cases involved long cold ischemia times, and one of the recipients had diabetes and was receiving his second kidney graft.

Nonadherence to dialysis among saudi patients - Its prevalence, causes, and consequences.

Dialysis nonadherence among Saudi hemodialysis (HD) patients has not been studied previously. We study its prevalence, causes, and consequences. All chronic HD patients at our center were enrolled. Their demographics as well as levels of hemoglobin (Hb), Kt/v, potassium, and phosphate; dialysis type; dialysis vintage; duration; and shift were recorded. Nonadherence, defined as missed dialysis session or patient-derived shortening of the dialysis session by >10 min at least once over a month's period, was recorded. We analyzed the relationship of nonadherence to emergency room visits, hospitalizations, interdialytic weight gain (IDWG), intradialytic symptoms, home-to-hospital distance, and smoking habits. Two hundred and sixty-five patients were included; their mean age was 61.8 ± 18.2 years, 47.3% were male, dialysis vintage was 3.8 ± 3.3 years, 5.9% were on HD, and 34.1% were on hemodiafiltration. During the study period, the nonadherence rate was 25% for missed dialysis sessions and 72% for shortened dialysis on at least one occasion. Nonadherence was more likely to occur in males than females (75% and 66%, respectively, P = 0.05), in smokers (57.1% vs. 21.7%, P = 0.0003), and in night shifts rather than day shifts (33.6% vs. 20.6%, P = 0.042). Nonadherent patients had lower Kt/V than adherent patients (1.22 ± 0.2 and 1.31 ± 0.2, respectively P = 0.01), had higher mean IDWG (2.7 ± 1.0 and 2.4 ± 1.0 kg, respectively, P = 0.02), and are more likely to be hospitalized (50% vs. 32%, P = 0.01). On the other hand, no differences were observed in serum phosphate, potassium, or Hb levels; intradialytic symptoms; education; employment; the distance between the dialysis unit and home; type of dialysis; Charlson Comorbidity Index; or the dialysis vintage. The prevalence of nonadherence in our group was comparable to that of other reports and is more likely to occur in male patients, smokers, and those in night shifts. It is associated with lower dialysis adequacy, higher mean IDWG, and higher hospitalization rate.

Effect of thyroid function status in hemodialysis patients on erythropoietin resistance and interdialytic weight gain.

Thyroid function abnormalities are common in hemodialysis (HD) patients. Here, we investigated their frequency and impact on intradialytic hemodynamics and erythropoietin resistance index (ERI). Demographic and laboratory data including thyroid-stimulating hormone (TSH), interdialytic weight gain, and intradialytic blood pressure (BP) changes were measured, and ERI was calculated. The prevalence and causes of abnormities in TSH and free thyroxine (FT4) and their effects on ERI and intradialytic hemodynamics were then assessed. One hundred and thirty patients (mean age, 57.1 ± 19.2 years; 66.4% diabetic, 86.7% hypertensive) were enrolled. Among them, 16.7% had hypothyroidism, 2.3% had hyperthyroidism, and 10.9% had subclinical hypothyroidism. TSH level was significantly associated with higher BP (P <0.05), lower albumin (3.6 ± 4.4 and 2.6 ± 1.8, respectively; P = 0.05), lower dialysis hours (3.9 ± 5.3 and 2.6 ± 1.8, respectively), and lower ERI (3.7 ± 4.4 and 2.4 ± 1.9, respectively; P = 0.05). FT4 was significantly associated with higher interdialytic weight gain (13.4 ± 4.3 and 11.8 ± 2.2 pmol/L, respectively; P = 0.009) and higher pre-HD diastolic BP (13.2 ± 4.0 and 12.0 ± 2.9 pmol/L, respectively; P = 0.05). A negative correlation was seen between TSH level and urea reduction ratio (r = 0.29, P = 0.002), serum albumin (r = 0.304, P = 0.001), hemoglobin level (r = 0.26, P = 0.005), and ERI (r = 0.2, P = 0.002). A higher TSH level was associated with hypertension, lower albumin level, fewer dialysis hours, and increased resistance to erythropoietin. TSH level was negatively correlated with dialytic adequacy, serum albumin level, hemoglobin level, and ERI.

Scores of awareness and altruism in organ transplantation among Saudi health colleges students-impact of gender, year of study, and field of specialization.

This study aimed to evaluate the awareness of organ transplantation and willingness to donate among Saudi Health Colleges students and the impact of gender, year of study, and field of specialization on this. This is a cross-sectional survey-based study. The survey was distributed to all the students attending the annual national conference of Saudi Health Colleges students held in 2018. The survey had two parts. The first part collected the information about gender, university, college of specialization, and year of study. The second part asked 10 questions, seven of which were about the types, causes, treatment of organ failure (awareness questions), and three of which were about their willingness to donate (altruism questions). The participants had three response options: "Yes", "No" and "I don't know. Descriptive statistics (mean, standard) and the frequencies were generated for each parameter. Categorical data were compared using Chi-square and continuous data using an independent t-test or paired t-test. A total of 821 respondents completed the questionnaire; 58.1% were female, 41.3% studying medicine, 25.1% applied medical sciences, 12.7% pharmacy, 9.6% dentistry, and 4.5% nursing 4.5%. The overall awareness of the correct responses constituted 60.4% while 12.3 % gave incorrect responses and 27.3% did not know what the answers were. The highest awareness score was about the concept of brain death (86.4%). The overall awareness score was significantly higher than the altruism score (62.7% and 45.7% respectively (P = 0.0001). Female respondents proved more aware than the male respondents in all the questions did. However, the differences reached the significant levels in four of the ten questions. If we split and summate the responses into "awareness" questions and "altruism" questions, we find that, although female students score higher in both categories, this reaches the significant level for the altruism score (59.90% vs. 45.60% (P = 0.0001). Final year students were significantly more aware than the freshmen in seven of the 10 questions posed with the biggest gap seen in the awareness that Islamic Sharia permits donating organs after death (82.3% vs. 49.6% (P = 0.0001). When we compare of responses by the college, we find that significant differences between the College of Medicine students and applied medical sciences in two questions with the former having a higher awareness score. The overall awareness score was significantly higher than the altruism score (62.7% and 45.7% respectively). Female students have higher altruistic score than male students. The scores are significantly higher in the senior students than in the junior ones.

Improvement in dialysis-related adverse events with use of body composition monitoring.

This study aims to utilize body composition monitor (BCM) device to achieve euvolemic status in problematic dialysis patients and to evaluate its clinical outcome. One hundred and five hemodialysis (HD) patients were enrolled based on difficulty in achieving dry weight. The reasons for enrollment in the study were (a) recurrent intradialytic hypotension, (b) intradialytic hypertension, (c) intradialytic muscle cramps, or (d) the presence of comorbid conditions that make clinical assessment of dry weight difficult (e.g., cirrhosis of liver, heart failure, severe malnutrition, or morbid obesity). Following initial assessment of hydration status using BCM device, dry weight for each patient was adjusted accordingly (upward, downward, or unchanged). The patients were, thereafter, monitored over a 15-week period for possible resultant change in the clinical and hemodynamic parameters. Forty-two patients were monitored due to hypertension, 18 due to hypotension, 10 due to hypotension and cramps, and 35 due to comorbid conditions that make clinical assessment of dry weight difficult. At the conclusion of study period, there was improvement in the monitored parameters. Hypertension improved in 79% of the patient with hypertension, hypotension in 90%, and hypotension with cramps in 90%. In the comorbid group, BCM monitoring provided better insight to clinical problem management in 80% cases. Overall quality of BCM assessments was 96.1%. In the hypertension group, mean blood pressure decreased by 10.9 mm Hg in the whole group (P = 0.0006), the drop was 3 mm Hg in the patients dialyzing with HD (P = 0.0006) and 8.6 mm Hg in those on hemodiafiltration (HDF) (P = 0.08). In the comorbid conditions group, the mean blood pressure rose by 22.5 mm Hg in the whole group (P 0.00001), 21.5 mm Hg in the patients dialyzing with HD (P = 0.00001) and 21.5 mm Hg in those on HDF (P = 0.0004). BCM monitoring together with clinical assessment is a useful tool which when appropriately applied reduces the incidence of dialysis-related complications.

Awareness of acute kidney injury risk factors and perspectives on its practice guidelines.

OBJECTIVES: Identifying and assessing risk factors for acute kidney injury (AKI) are crucial for its early detection and possible intervention to prevent AKI and associated adverse outcomes. This study aimed to investigate AKI risk factor awareness and risk assessment by healthcare professionals and to evaluate perspectives on the Kidney Disease Improving Global Outcomes AKI guidelines. METHODS: This cross-sectional survey-based study was conducted among healthcare professionals (physicians and pharmacists) at XXX from December 2016 to February 2017. RESULTS: Among the respondents (117 physicians and 135 pharmacists), 78% were aged ≤38 years, 57% were men, and 70% had <9 years of experience. Respondents varied in their knowledge of the 25 risk factors for AKI and 15 nephrotoxic drugs: 96% were aware of nephrotoxic medication, whereas 20% acknowledged female sex as an AKI risk factor, and 92% agreed with aminoglycoside, while 47% agreed with ciprofloxacin as nephrotoxic drugs. A significantly higher percentage of physicians identified individual AKI risk factors than pharmacists; however, a significantly higher percentage of pharmacists identified individual AKI-causing drugs than physicians. Although 77% of respondents encountered AKI cases in their practice, only half of them performed AKI risk assessment, and 42% stratified patients' AKI risk according to their presenting risk factors or documented AKI in previous medical history. Seventy-one percent of respondents agreed that practice guidelines improve patient outcome, and 69% thought these guidelines help standardize care and ensure that patients are treated in consistently. CONCLUSION: While the majority of the respondents had a positive perspective toward AKI guidelines, a large variation in their knowledge of AKI risk factors, risk assessment, and nephrotoxic drugs was found. Educational efforts are needed to raise awareness and thereby reduce this variation.

Shifting paradigm: From "No Code" and "Do-Not-Resuscitate" to "Goals of Care" policies.

Policies addressing limitations of medical therapy in patients with advanced medical conditions are typically referred to as Code Status (No Code) policies or Do-Not-Resuscitate (DNR) status polices. Inconsistencies in implementation, understanding, decision-making, communication and management of No Code or DNR orders have led to delivery of poorer care to some patients. Several experts have called for a change in the current approach. The new approach, Goals of Care paradigm, aims to contextualize the decisions about resuscitation and advanced life support within the overall plan of care, focusing on choices of treatments to be given rather than specifically on treatments not to be given. Adopting "Goals of Care" paradigm is a big step forward on the journey for optimizing the care for patients with advanced medical conditions; a journey that requires collaborative approach and is of high importance for patients, community and healthcare systems.

The Role of Urinary Neutrophil Gelatinase-Associated Lipocalin in Predicting Acute Kidney Dysfunction in Patients With Liver Cirrhosis.

BACKGROUND: Early detection of acute kidney dysfunction (AKD) in cirrhotic patients is crucial. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) has been identified as an early marker of AKD. The aim of the study was to evaluate serial uNGAL as a marker and predictor of AKD in liver cirrhosis patients. METHODS: Serial uNGAL and serum creatinine (sCr) levels were measured daily during the first 6 days of admission. Furthermore, sCr levels and the estimated glomerular filtration rate (eGFR) were measured after 3 - 6 weeks. The uNGAL levels in patients with and without abnormal sCr were compared. RESULTS: Fifty-seven consecutive cirrhotic patients were enrolled in the study. Eight of 14 patients (57%) who developed abnormal uNGAL level also had abnormal sCr level (odds ratio (OR) = 3.4, 95% CI: 0.99 - 12.03, P = 0.05). After 6 weeks, 41% of patients exhibited an abnormal uNGAL level and abnormal sCr (OR = 6.7, 95% CI: 1.55 - 28.85, P = 0.01). Area under the curve (AUROC) and the best cut-off point for highest NGAL in 6 days were 0.64 and 72.55 ng/mL, respectively. CONCLUSIONS: There is a modest association between highest uNGAL in the first 6 days of admission and sCr at week 6 in all participants. This may indicate that in cirrhotic patients, uNGAL level during the first 6 days of admission has a potential predictability for the development of high sCr and low eGFR 6 weeks later. The AUROC of 0.64 quantifies the overall ability of uNGAL to discriminate between those individuals who will have a raised sCr levels and those who will not.