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

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

Predictors of Outcome of Cirrhotic Patients Requiring Invasive Mechanical Ventilation: Experience From a Non-Transplant Tertiary Care Hospital in Pakistan.

Background Patients with known liver cirrhosis, irrespective of the etiology, have poor outcomes when put on invasive mechanical ventilation in an intensive care unit (ICU) setting. The clinical situation becomes even more complicated when such patients are managed in a non-transplant center. Various factors are associated with poor outcomes, and hence, various scoring systems are available to help determine the prognosis in patients with liver cirrhosis. These scoring systems are broadly classified into two categories, namely, ICU-specific scoring systems and liver disease-specific scoring systems. There is a dearth of data from Pakistan regarding which score better determines the prognosis of patients with liver cirrhosis admitted to the ICU. In this study, we aimed to determine the outcome of cirrhotic patients requiring invasive mechanical ventilation in a non-transplant tertiary care hospital in Pakistan using ICU-specific and liver disease-specific scoring systems. Methodology A retrospective study design was applied to a record of 88 cirrhotic patients admitted to the medical ICU of a tertiary care teaching hospital in Karachi, Pakistan, from January 2016 to November 2016. Patients with acute hepatitis were excluded. Data on patients' characteristics, the reason for intubation, hepatic encephalopathy, the need for vasopressor support, and the duration of ICU and hospital stay were collected. Moreover, the first-day Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA), Child-Turcotte-Pugh (CTP), and Model for End-Stage Liver Disease (MELD) scores were calculated, with mortality being the primary outcome measure. Results The most common etiology was hepatitis C (52.3%, 46/88). The most common reason for intubation was airway protection (57.9%, 51/88). Overall mortality was 71.6% (63/88). On univariate analysis, CTP score >10, MELD score >18, hepatic encephalopathy, bilirubin, prothrombin time, presence of tense ascites, and APACHE II were significantly associated with mortality. On multivariate analysis, CTP score >10 (odd ratio = 21; 95% confidence interval (CI): 4-104; p < 0.001) was an independent predictor of mortality. Area under curve was 0.89 (95% CI = 0.82-0.96) for CTP, 0.86 (95% CI = 0.77-0.95) for MELD, 0.81 (95% CI = 0.69-0.92) for APACHE II, and 0.81 (95% CI = 0.71-0.91) for SOFA in predicting mortality. Conclusions CTP and MELD scores are better predictors of short-term mortality in patients with liver cirrhosis requiring invasive mechanical ventilation compared to APACHE II and SOFA scores. CTP score >10 was an independent predictor of mortality.

Frequency and risk factors of non-alcoholic fatty liver disease in Helicobacter pylori-infected dyspeptic patients: A cross-sectional study.

BACKGROUND: In dyspeptic patients with Helicobacter pylori contributes to non-alcoholic fatty liver disease. However, little evidence available from Pakistan. OBJECTIVE: The study aims to determine the frequency and risk factors of non-alcoholic fatty liver disease in dyspeptic patients with Helicobacter pylori. METHODS: This cross-sectional study was conducted between 22 November 2016 and 30 June 2018. Adults of age between 18 and 90 years who attended the out-patient department due to abdominal discomfort, pain, fullness, and bloating who underwent upper gastrointestinal tract endoscopy were enrolled after taking informed consent. Patients with celiac disease, inflammatory bowel disease, taking alcohol, pregnant women and lactating mothers, known cases of hepatitis B and C, and history of recent antibiotic use were excluded. Data on age, gender, smoking, alcohol use, dyslipidemia, hypertension, type 2 diabetes mellitus, and ischemic heart disease were collected. Non-alcoholic fatty liver disease was diagnosed through ultrasonography. Helicobacter pylori infection was detected using a carbon urea breath test. RESULTS: A total of 698 patients were screened for eligibility, and 399 (57.2%) had Helicobacter pylori infection and were enrolled in the study after consent. The median age was 50.1 (interquartile range = 14.5) years and 209 (52.4%) were males. Frequency of non-alcoholic fatty liver disease in patients with Helicobacter pylori dyspeptic patients was 153 (38.3%). Factors associated with non-alcoholic fatty liver disease in the presence of Helicobacter pylori were dyslipidemia 7.38 (95% confidence interval = 2.4-22.71), type 2 diabetes mellitus 5.96 (95% confidence interval = 1.86-19.07), hypertension 3.0 (95% confidence interval = 1.21-7.45), and moderate gastritis 2.81 (95% confidence interval = 1.2-6.59). CONCLUSION: The frequency of non-alcoholic fatty liver disease in Helicobacter Pylori dyspeptic patients was 38.3%. Male gender, dyslipidemia, hypertension, ischemic heart disease, and moderate gastritis were associated with non-alcoholic fatty liver disease.

Frequency of bloodstream infection in febrile neutropenic patients, experience from a developing country.

INTRODUCTION: About 20% of febrile neutropenic patients are presented with bloodstream infection which is a leading cause of mortality among these patients. Awareness of the locally prevalent pathogens and their susceptibility pattern is important for proper treatment of infection which improves survival in these patients. The objective of this study was to determine the frequency of bloodstream infection in patients with febrile neutropenia admitted in Abbasi Shaheed Hospital. METHODS: This cross-sectional study was conducted in the Medical wards in Abbasi Shaheed Hospital, Karachi from 21-2-2016 to 20-8-2017. Patients of over 15 years of age of either gender with severe neutropenia were included in this study. Patients with noninfectious cause of fever, or fever prior to neutropenia were excluded. Patients meeting inclusion criteria were enrolled after taking informed consent. About 2-5 ml blood was collected under aseptic measures in Bactac culture bottles. Blood samples were sent to lab within 30 min of collection. Antimicrobial sensitivity testing of all isolates was performed on diagnostic Sensitivity test plates by Kerby - Bauer Method. Patients were referred back to treating physician if blood culture is positive. The data was analyzed using SPSS version 20. RESULTS: Of 200 patients, the mean age was 25.8 ±â€¯5.7 years, 120 (60%) were male with male to female ratio of 1.5:1, 89 (44.5%) had low grade fever (Temp. ≤102 °C) and 111 (55.5%) had high grade fever(Temp. >102 °C). The frequency of staphylococcus aureus was 16%, E. coli was 14.5%, Pseudomonas 8.5% and Klebsiella 15.5. CONCLUSIONS: It is concluded that the frequency of staphylococcus aureus was 16%, E. coli was 14.5%, Pseudomonas 8.5% and Klebsiella 15.5.

Factors Affecting Inpatient Mortality in Elderly People with Acute Kidney Injury.

BACKGROUND: Acute Kidney Injury (AKI) is common in elderly people (EP). There is paucity of data on predictor of mortality in EP with AKI. OBJECTIVE: This study was done to know more about factors associated with inpatient mortality in EP with AKI. METHODS: We retrospectively reviewed medical records of patients aged 65 years or above hospitalized with a diagnosis of AKI at Aga Khan University Hospital, Karachi, between January 2005 and December 2010. Binary logistic regression models were constructed to identify factors associated with mortality in EP with AKI. RESULTS: 431 patients had AKI, with 341 (79.1%) having stage I AKI, 56 (13%) having stage II AKI, and 34 (7.9%) having stage III AKI. Out of 431 patients, 142 (32.9%) died. Mortality increased with increasing severity of AKI. Mortality was 50% (17/34) in AKI stage III, 44.6% (25/56) in AKI stage II, and 29.3% (100/341) in AKI stage I. Factors associated with increased inpatients mortality were presence of stage III AKI (OR: 3.20, P = 0.04, 95% CI: 1.05-9.72), presence of oliguria (OR: 3.42, P = 0.006, 95% CI: 1.42-8.22), and need for vasopressors (OR: 6.90, P < 0.001, 95% CI: 2.42-19.65). Median bicarbonate 18 versus 17 between those who survived and those who died was associated with less mortality (OR: 0.94, P = 0.02, 95% CI: 0.89-0.99). History of hypertension (OR: 0.49, P = 0.03, 95% CI: 0.25-0.95) and high admission creatinine (OR: 0.68, P = 0.01, 95% CI: 0.50-0.91) were also associated with less mortality. CONCLUSION: Mortality in EP increases with increasing severity of AKI. Presence of stage III AKI, oliguria, and hemodynamic instability needing vasopressor are associated with increased mortality. Increased median bicarbonate, presence of hypertension, and high admission creatinine were various factors associated with decreased inpatient mortality. Increasing age and need for dialysis did not increase mortality in elderly population.

Distribution of Helicobacter pylori infection and abnormal body- mass index (BMI) in a developing country.

INTRODUCTION: Helicobacter pylori is prevalent in developing nations. We determined the prevalence of H. pylori infection in relation to body-mass index (BMI) of dyspeptic patients and related comorbid conditions. METHODOLOGY: In a cross-sectional study, dyspeptic patients were enrolled and tested for H. pylori infection. "Underweight" was defined as BMI lower than 18.4; "Healthy" 18.5 to 23; "Overweight" 23.1-27.9; and "Obese" greater than 28. RESULTS: Six hundred and ninety-eight patients were included, with a mean age of 44 ± 16 years. Males were 373/698, 53%. H. pylori was positive in 399/698, 57%. Underweight were 36 (5%); BMI-healthy 168 (24%); overweight 236 (34%) and obese 258 (37%). H. pylori infection was present in 65/273 BMI-healthy patients ; 24% compared to obese 208/273; 76% (P < 0.001). In the H. pylori- positive with a "healthy" BMI, dyslipidemia was seen in 6/65; 8% compared to obese 53/208; 25% (P = 0.005); type 2 diabetes in 8/65; 12% with a "healthy" BMI compared to obese 54/208; 26% (P = 0.022) and coronary artery disease in 4/65; 6% of BMI-healthy compared to obese 38/208; 18% patients (P = 0.018). Multivariate analysis showed that age 31-50 years (OR 1.77, 95% CI 1.13-2.77), BMI > 23.1 (OR 2.91, 95% CI infection. 2.01-4.20), and type 2 diabetes (OR 2.41, 95% CI 1.43-4.06) were risk factors for H. pylori. CONCLUSIONS: H. pylori infection was prevalent in the 31-50-year age group. Abnormal BMI was associated with H. pylori infection.

Bleeding complications post ultrasound guided renal biopsy - A single centre experience from Pakistan.

INTRODUCTION: Renal biopsy is the diagnostic modality of choice for the diagnosis of renal parenchymal diseases. The advent of improved imaging techniques and biopsy needles over the years has increased the safety of the procedure and the ability to obtain adequate renal tissue for diagnosis. However, there is paucity of data in this regard from Pakistan. This study shall help in establishing the local perspective of the frequency of bleeding complications in percutaneous ultrasound guided renal biopsy. MATERIALS AND METHODS: This is a prospective case series of hospitalized patients from January till December 2015 at Nephrology Department, Aga Khan University Hospital, Karachi, Pakistan. After enrolment, each participant was followed for 24 h after renal biopsy. RESULTS: A total of 220 patients were included. Mean age was 41.65 ± 8.627 years, 82 (37.2%) were male and 138 (62.8%) were female. Pre and post biopsy haemoglobin, pre and post biopsy haematocrit were 10.92 ± 1.25 and 10.60 ± 1.22, and 30.82 ± 4.73 and 30.49 ± 4.68 respectively. Out of 220 patients, 16 (7.27%) developed major complications and 26 (11.8%) developed minor complications in 24 h after renal biopsy. CONCLUSIONS: Percutaneous kidney biopsy is a relatively safe procedure. Complication rates following the procedure are minimal. It is important that all nephrology programs train the trainees in performing biopsies, so that there is a wider clinical use of this important investigation even in underprivileged & developing countries.

Cigarette Smoking and Its Hazards in Kidney Transplantation.

Cigarette smoking affects many organs. It causes vasoconstriction through activation of sympathetic nervous system which leads to elevation of blood pressure and reduction in glomerular filtration rate and filtration pressure. It also causes thickening of renal arterioles. Cigarette smoking increases the risk of microalbuminuria and accelerates progression of microalbuminuria to macroalbuminuria. Furthermore, it causes rapid loss of glomerular filtration rate in chronic kidney disease patients. After kidney donation, these factors may be injurious to the solitary kidney. Kidney donors with history of cigarette smoking are prone to develop perioperative complications, pneumonia, and wound infection. Postkidney transplantation various stressors including warm and cold ischemia time, delayed graft function, and exposure to calcineurin inhibitors may result in poor graft function. Continuation of cigarette smoking in kidney transplant recipients will add further risk. In this review, we will specifically discuss the effects of cigarette smoking on normal kidneys, live kidney donors, and kidney transplant recipients. This will include adverse effects of cigarette smoking on graft and patient survival, cardiovascular events, rejection, infections, and cancers in kidney transplant recipients. Lastly, the impact of kidney transplantation on behavior and smoking cessation will also be discussed.

Dual Kidney Transplantation: A Review of Past and Prospect for Future.

Kidney transplantation (KT) is one of the treatment options for patients with chronic kidney disease. The number of patients waiting for kidney transplantation is growing day by day. Various strategies have been put in place to expand the donor pool. Extended criteria donors are now accepted more frequently. Increasing number of elderly donors with age > 60 years, history of diabetes or hypertension, and clinical proteinuria are accepted as donor. Dual kidney transplantation (DKT) is also more frequently done and experience with this technique is slowly building up. DKT not only helps to reduce the number of patients on waiting list but also limits unnecessary discard of viable organs. Surgical complications of DKT are comparable to single kidney transplantation (SKT). Patient and graft survivals are also promising. This review article provides a summary of evidence available in the literature.