Seroconversion and safety of Covid-19 vaccines in pa-tients with chronic liver disease and liver transplant: A systematic review.

BACKGROUND AND AIMS: As part of the COVID-19 control strategy, a growing number of vaccine portfolios evolved and got fast-tracked through regulatory agencies, with a limited examination of their efficacy and safety in vulnerable populations, such as patients with chronic conditions and immunocompromised states. Patients with chronic liver disease (CLD), and cohorts post liver transplant (LT) in particular, were underrepresented in the determinant trials of vaccine development, hence the paucity of data on their efficacy and safety in published literature. This systematic review aims to examine the available evidence and ascertain the effectiveness and safety of Covid-19 vaccination in patients with CLD and those with LT. METHODS: A systematic review of PubMed (Medline), Google Scholar, Cochrane Library, and ScienceDirect from inception until 1st March 2022 was conducted. We included observational studies and assessed vaccine efficacy regarding seroconversion or immunological rate, whereas serious or significant adverse effects have been considered safety outcomes when reported. RESULTS: Studies comprised 45275 patients, performed in 11 different countries. Seroconversion or immunological rate after Covid-19 vaccination was mostly the primary endpoint, whereas other endpoints like covid-19 related adverse effects were also reported. Twenty-four of the final analyzed studies are prospective cohort studies, while four are retrospective cohort studies. Twenty-one studies included patients who underwent LT and received the Covid vaccine; nine included patients who had CLD due to various etiologies. The median age range of all included patients varied from 43-69 years. All patients with LT who received at least two doses of Covid vaccine had a seroconversion rate of around 60%. Patients with CLD had a seroconversion rate of about 92% post two doses of Covid vaccination. The average seroconversion rate in post-transplant recipients was around 45% after two doses of the significant Covid vaccines: Pfizer, AstraZeneca, Moderna, and Jansen. Only two studies have reported a higher seroconversion rate of 75% and 73% after the third dose of Covid vaccine. No significant adverse effects were reported in all studies; the most commonly reported negative effect was local injection site pain. CONCLUSION: The present systematic review, comprising real-world observational data studies, concludes that Covid-19 vaccination was associated with 92% and 60% seroconversion rates in patients with CLD and LT, respectively. No significant side effects were reported in all studies. This finding helps to resolve the uncertainty associated with Covid-19 vaccination in this cohort of patients.

Effects of Nondipping Blood Pressure Changes: A Nephrologist Prospect.

Blood pressure (BP) variations depend on various internal, environmental, and behavioral factors. BP fluctuations occur both in normotensive and hypertensive people. Although it fluctuates over the 24-hr day and night, the morning BP increases after waking up and declines throughout sleep. It is typical for BP to decrease by 10% to 20%, while sleeping, known as dipping BP. However, if there is no decrease in nighttime mean systolic BP or a drop of less than 10 mmHg, it is called nondipping BP. Conversely, reverse dipping BP means an increase in mean systolic BP instead of a drop during the night. Reverse dipping is observed in hypertension (HTN), diabetes mellitus (DM), chronic kidney disease (CKD), and obstructive sleep apnea (OSA) syndrome. The introduction of ambulatory BP monitoring (ABPM) led to the emergence of identifying normal and elevated BP patterns. Non-dipping BP increases the risk of cardiovascular system (CVS) complications such as left ventricular hypertrophy, proteinuria, glomerular filtration rate (GFR) reduction, and CKD progression. A loss or blunting of the normal BP profile is recognized as a deleterious variant, and restoring abnormal BP patterns has been reported to significantly impact end-organ damage, morbidity, and mortality. In this non-systematic clinically-oriented, comprehensive review, we aim to update the BP variables and the pathophysiology of nondipping BP and point out the areas which need more investigation from a nephrology perspective because the nondipping BP increases the risk of proteinuria, GFR reduction, and CKD progression. A literature search of PubMed, Google, EMBASE, and Google Scholar was conducted. Checks of selected papers and relevant reviews complemented the electronic search. With improved BP measurement methods, the physiology of BP profile variations is readily detectable during the day and night. A nondipping BP profile is a distinct BP pattern that may have significant end-organ damage effects and therapeutic importance for nephrologists. The pathophysiology of the nondipping BP variant must be clarified to prevent complications, and further investigations are required. Furthermore, there is debate about the best BP index to utilize: systolic BP, diastolic BP, mean arterial pressure, or a mixture of all. All these areas are important and need new research projects.

Severe Myocarditis in a Female Following mRNA-1273 Vaccine: A Case Report and Review of the Literature.

Myocarditis was recently described as one of the complications secondary to COVID-19 vaccination. We present a 38-year-old lady diagnosed with vaccine-related myocarditis a few days after receiving the mRNA-1273 vaccine. We also summarize what is reported in the literature about the association between COVID-19 vaccination and myocarditis. In conclusion, COVID-19 immunization appears to be associated with significantly fewer adverse outcomes than COVID-19 infection among all age groups.

Fasting Ramadan in Chronic Kidney Disease (CKD), Kidney Transplant and Dialysis Patients: Review and Update.

Chronic kidney disease (CKD) is a common disease in the Islamic regions. Dehydration occurs after prolonged fasting, particularly in hot and humid climates. In the Arabic months' calendar, Ramadan is a month of maximum given deeds, where Muslims are required to fast from dawn till sunset. Depending on where you live and when the Ramadan month falls, fasting might last anywhere from 10 to 20 hours or more. In certain circumstances, such as poorly controlled diabetes and advanced CKD patients who are allowed to break their fast, the Ramadan fasting amendment is viable. Some Muslims, however, continue fasting despite these circumstances, placing themselves at risk, which is not allowed in the Islamic religion. There are no medical recommendations that specify who should and should not fast. Nonetheless, the recommendations have been extracted from several published studies. The authors searched EMBASE, PubMed, Google Scholar, and Google for publications, research, and reviews. All authors debate and analyze the related articles. Each author was assigned a part or two of the topics to read, study, and summarize before creating the final draft of their given section. Then this comprehensive review was completed after discussion sessions. In conclusion, by the Islamic religion view, fasting Ramadan is mandatory for every wise adult person. People who have chronic diseases or that may deteriorate by fasting are exempted from fasting. It seems that fasting and the associated disease hours are determinant factors to fasting or not fasting. Up to our knowledge, there are no established guidelines for CKD patients and physicians to follow; however, the International Diabetes Federation and Diabetes and Ramadan (IDF-DAR) Practical Guidelines 2021 have been issued for CKD diabetic patients and fasting.

Blood Pressure and Chronic Kidney Disease Progression: An Updated Review.

Hypertension (HTN) is common in chronic kidney disease (CKD), and it may aggravate CKD progression. The optimal blood pressure (BP) value in CKD patients is not established yet, although systolic BP ≤130 mmHg is acceptable as a target. Continuous BP monitoring is essential to detect the different variants of high BP and monitor the treatment response. Various methods of BP measurement in the clinic office and at home are currently used. One of these methods is ambulatory BP monitoring (ABPM), by which BP can be closely assessed for even diurnal changes. We conducted a non-systematic literature review to explore and update the association between high BP and the course of CKD and to review various BP monitoring methods to determine the optimal method for BP recording in CKD patients. PubMed, EMBASE, Google, Google Scholar, and Web Science were searched for published reviews and original articles on BP and CKD by using various phrases and keywords such as "hypertension and CKD", "CKD progression and hypertension", "CKD stage and hypertension", "BP control in CKD", "BP measurement methods", "diurnal BP variation effect on CKD progression", and "types of hypertension." We evaluated and discussed published articles relevant to the review objective. Before preparing the final draft of this article, each author was assigned a section of the topic to read, research deeply, and write a summary about the assigned section. Then a summary of each author's contribution was collected and discussed in several group sessions. Early detection of high BP is essential to prevent CKD development and progression. Although the latest Kidney Disease Improving Global Outcomes (KDIGO) guidelines suggest that a systolic BP ≤120 mmHg is the target toprevent CKD progression, systolic BP ≤130 mmHg is universally recommended.ABPM is a promising method to diagnose and follow up on BP control; however, the high cost of the new devices and patient unfamiliarity with them have proven to be major disadvantages with regard to this method.

Gestational Thrombocytopenia: A Review on Recent Updates.

Thrombocytopenia is a condition in which the blood platelet count is low. It is well established that the mild thrombocytopenia frequency is higher in normal pregnancy. This type of thrombocytopenia was named pregnancy-induced thrombocytopenia. However, recently, it has been widely known as gestational thrombocytopenia (GT). The rate is higher in women with a prior GT history and multiple pregnancies. However, it appears that GT is a physiological response to the pregnancy; placenta's peculiar structure and its unique blood flow pattern play major roles in GT development. There are no specific, precise, or known underlying pathophysiological mechanisms of GT, and no new specific management strategies are published yet. Therefore, we decided to do a non-systematic review of any recent updates that had been published in PubMed, EMBASE, and Web of Science about the pathophysiology of GT, its treatment, and other related topics.

Potential Predictors and Prevalence of Helicobacter pylori Infection Among Adult Patients With Dyspepsia: A Retrospective Study From Qatar.

Aim To study the prevalence of Helicobacter pylori (H. pylori) infection among dyspeptic patients of various ethnic origins in Qatar and determine the association between H. pylori infection and various demographic factors and endoscopic findings. Methods A retrospective data review was carried at Alkhor Hospital, Hamad Medical Corporation, Qatar. Adult patients who underwent endoscopy for the evaluation of dyspepsia between January 2011 to December 2017 were included. Patients who underwent endoscopy for reasons other than dyspepsia and those with incomplete data were excluded. Results Of the 638 subjects included, 58.9% were males, and the mean age of the subjects was 42.2 years (range 18-79 years). Epigastric pain (80.6%) was the most common symptom, followed by heartburn (26.2%). Forty point nine percent (40.9%) had a positive Campylobacter-like organism (CLO) test for H. pylori. A higher prevalence of H. pylori infection was observed among subjects between 31-50 years of age (43.6%) and 18-30 years (40.5%), and in Asian (42.2%) and Middle East and North African nationals (MENA) nationals (40%). Among the endoscopic findings, esophagitis (P=0.002) and gastritis (P=0.001) showed a statistically significant correlation with H. pylori positivity. Univariate regression analysis revealed an increased risk for H. pylori infection among all age groups except above 65 years, with an odds ratio (OR) of more than 2 in all the three age groups. Among various ethnicities, patients from Asia and MENA countries showed an increased risk of getting H. pylori infection (OR 1.16, 95% CI; 0.77,1.75 and OR 1.06, 95% CI 0.70,-1.61 respectively). The multivariable logistic regression analysis showed that subjects with endoscopic findings of esophagitis (adjusted OR 1.67, 95%CI 1.19, 2.34; P=0.003), gastritis (adjusted OR 1.79, 95%CI 1.27, 2.57; P=0.001), and duodenal ulcer (adjusted OR 2.41, 95%CI 1.24, 4.70; P=0.010) remained significantly associated with an increased risk of having H. pylori infection. Conclusion The burden of H. pylori infection in patients with dyspepsia undergoing endoscopy is not low in Qatar. Less than 65 years of age, Asian nationals, and being from the MENA region were the demographic predictors for H. pylori infection. The finding of esophagitis, gastritis, and duodenal ulcer on endoscopy were independent endoscopic predictors for having H. pylori infection.

Secondary Hyperparathyroidism in Chronic Kidney Disease: Pathophysiology and Management.

Serum calcium concentration is the main determinant of parathyroid hormone (PTH) release. Defect in the activation of vitamin D in the kidneys due to chronic kidney disease (CKD) leads to hypocalcemia and hyperphosphatemia, resulting in a compensatory increase in parathyroid gland cellularity and parathyroid hormone production and causing secondary hyperparathyroidism (SHP). Correction and maintenance of normal serum calcium and phosphate are essential to preventing SHP, hungry bone disease, cardiovascular events, and anemia development. Understanding the pathophysiology of PTH and possible therapeutic agents can reduce the development and associated complications of SHP in patients with CKD. Medical interventions to control serum calcium, phosphate, and PTH such as vitamin D analogs, calcium receptor blockers, and parathyroidectomy are needed in some CKD patients. In this review, we discuss the pathophysiology, clinical presentation, and management of SHP in CKD patients.

Endoscopic Findings in Patients With Uninvestigated Dyspepsia: A Retrospective Study From Qatar.

Background and objective Dyspepsia is a common complaint encountered in general clinical practice. The prevalence of clinically significant endoscopy findings in dyspeptic subjects of various age groups and ethnicities in Qatar is not well studied. This study aimed to evaluate the prevalence of endoscopic findings in previously uninvestigated patients with dyspepsia. Patients and methods We retrospectively studied subjects older than 18 years of age who underwent endoscopy for dyspeptic complaints from January 2011 to December 2017. Subjects who already had peptic ulcer disease (PUD), those who underwent endoscopy for reasons other than dyspepsia, and those with incomplete data were excluded. Results A total of 824 subjects were reviewed for eligibility and 733 were included for analysis. The mean ±SD age of the study subjects was 42.7 ±13.5 years, and 59.5% of the subjects were male. Epigastric pain was the predominant symptom (79.2%) followed by heartburn (26.1%). Abnormal endoscopic findings were noted in 91.8% of subjects. Gastritis (65.5%) and oesophagitis (33.1%) were the most common findings observed. The overall prevalence of gastric ulcers was 4.6%, and it was higher in subjects who were more than 60 years of age (14.1%, p=0.001). Gastric carcinoma was seen in only four (0.54%) subjects. Conclusion Gastritis was the most common endoscopic finding observed followed by oesophagitis. The most common presenting symptoms were epigastric pain and heartburn. The prevalence of gastric ulcers was significantly high in patients above 60 years of age, and the incidence of gastric carcinoma was low in the study population.

Autoimmune-like Drug-induced Liver Injury Caused by Atorvastatin and Demonstration of the Safety Profile of Pravastatin: A Case Report and Literature Review.

Statin-induced liver injury is a well-recognized but rare phenomenon with hepatocellular, cholestatic, and mixed phenotypes. Most studies do not recommend regular monitoring of liver function tests (LFTs) after starting statins unless clinically indicated. We report a case of autoimmune-like atorvastatin-induced liver injury (aminotransferases > 5 times the upper limit of normal) that was detected on routine follow-up after three months in an asymptomatic patient. In addition to elevation in transaminases, the patient had weakly positive ANAs. Anti-smooth muscle antibody (ASMA) was positive in titers of 1:680. Screening for viral hepatitis A-E was negative. Other diagnostic investigations showed complete blood examination, including eosinophils, renal function tests, electrolytes, total protein, albumin, prothrombin time, activated partial thromboplastin time (aPTT), international normalized ratio (INR), serum ferritin, and iron saturation to be in the normal range. Ultrasound and computed tomography (CT) abdomen showed normal liver, gall bladder, biliary tree, and pancreas. The patient was managed as a case of autoimmune-like drug-induced liver injury (DILI) caused by atorvastatin and the medication was discontinued. LFTs returned to completely normal 30 days after the discontinuation of atorvastatin. Furthermore, switching to pravastatin for dyslipidemia management four months after stopping atorvastatin did not lead to hepatotoxicity, illustrating the safety profile of pravastatin in patients who are unable to tolerate atorvastatin.

Subacute Thyroiditis: An Unusual Presentation of Fever of Unknown Origin Following Upper Respiratory Tract Infection.

BACKGROUND Fever of unknown origin (FUO) is a diagnosis that requires a demanding workup from physicians before confirming a diagnosis. Thyroid diseases are a rare cause of FUO. Subacute thyroiditis is an inflammatory disease that can lead to a wide spectrum of presentations. CASE REPORT We report a case of a previously healthy male who presented with persistent fever of 4 weeks following an upper respiratory tract infection associated with constitutional symptoms. His laboratory workup included complete blood counts (CBC), complete metabolic panel (blood urea and creatinine, liver function tests, and serum electrolytes), blood cultures, abdominal and pelvic ultrasound, and computed tomography abdomen and pelvis that were inconclusive. His thyroid function tests showed a hyperthyroid state and a thyroid scan confirmed a picture of thyroiditis. The patient was treated with Ibuprofen and then with prednisolone; he showed significant improvement over a few days and was discharged with treatment of tapering doses of prednisolone over 6 weeks. Two weeks after discharge the patient had a follow-up at an outpatient clinic and was found to be in good health with resolution of his symptoms. CONCLUSIONS Thyroid disorders are not a common cause of FUO, and even if the clinical assessment of the patient is not suggestive of thyroid disease, we should consider it a possible cause. and thyroid function test should be performed to exclude thyroid problems.

Impact of hepatitis C infection on renal transplant patients: a single-center experience in Libya.

The objective of this study was to assess the effect of hepatitis C virus (HCV) infection on graft and patient survival in a cohort of Libyan renal transplant recipients. Medical records of 241 renal transplant (RT) patients who have been followed-up at the Benghazi Nephrology Center up to February 2010 were reviewed. Based on the presence or absence of anti-HCV antibodies and HCV-RNA in the serum, patients were divided into two groups: HCV-positives and HCV-negatives. Anti-HCV antibodies were detected by the enzyme-linked immunosorbent assay technique and HCV-RNA by the polymerase chain reaction. Of the 241 RT patients, 162 were male and 79 were female. One hundred and ten patients (45.6%) were HCV-positives and 131 (54.4%) were HCV-negatives. Acute graft rejection was significantly higher among HCV-negative than HCV-positive patients (42 patients versus 28 patients, respectively; P<0.001). Conversely, chronic graft rejection was higher among HCV-positives than that among HCV-negative patients (35 patients versus 24 patients, respectively; P<0.05), and this difference became more significant after a 12-month period of transplantation (P<0.01). Seventeen patients died during the follow-up: Seven HCV-positives (6.3%) and 10 HCV-negatives (7.6%), and there was no significant difference in the death rate following RT between the two groups (P=0.08). Among the seven deaths of HCV-positives, liver disease-related complications were the main cause of death in three (42.8%) HCV-positive patients compared with none in the HCV-negative patients. The presence of HCV infection influenced chronic graft survival in RT patients and a higher proportion of HCV-infected patients had hepatic dysfunctions after RT. An increase in fatal liver complications was noted in HCV-positive patients with RT. In addition to pre-RT-specific therapy of HCV infection, all measures should be taken to prevent HCV infection pre- and post-RT. HCV-infected RT recipients need close monitoring for graft and liver function to prolong allograft and patient survival.

Gastric cancer and Helicobacter pylori infection in the eastern Libya: a descriptive epidemiological study.

BACKGROUND AND STUDY AIMS: The aim of this study was to determine the pattern of histologically-proven gastric cancer in Eastern Libya and explore its association with Helicobacter pylori infection. PATIENTS AND METHODS: The registries of the Departments of Histopathology, Faculty of Medicine, Benghazi University and Oncology, Al-Jomhoria Hospital, Benghazi, were reviewed for cases with primary gastrointestinal cancer from January 2000 to December 2002 (sole Histopathology and Oncology Departments in Eastern Libya). Slides of hematoxylin and eosin stain of gastric cancer patients were re-stained to detect H. pylori. The American Joint Committee on Cancer Tumor, Node, Metastasis staging was used for clinical and pathologic staging. Gastric cancer biopsy materials were classified into intestinal or diffuse type according to Lauren criteria. RESULTS: One hundred and fourteen cases of gastric cancer were diagnosed. Tumor stages were: 2 (14%), 3 (21%), 4 (57%) and unknown (8%). Most common site of involvement was the antrum (48%). Diffuse adenocarcinoma occurred in 56 patients (49.1%), intestinal adenocarcinoma in 46 (40.4%) and malignant gastric lymphoma in 12 (10.5%). The overall frequency of H. pylori infection was 63.2% (72/114), more frequent in intestinal adenocarcinoma (71.7%) and malignant lymphoma (66.6%) than diffuse adenocarcinoma (55.3%). The frequency of gastric cancer increased throughout the three years of study. CONCLUSION: The majority of the patients were diagnosed in locally advanced or metastatic stage. Clearly more efforts need to be given to early detection. We showed a stronger association of H. pylori infection with intestinal type gastric adenocarcinoma and malignant lymphoma than diffuse adenocarcinoma suggesting that H. pylori infection is the most probable causal factor of gastric cancer in this part of Libya.