Refusal of hemodialysis by hospitalized chronic kidney disease patients in Pakistan.

In Pakistan, patients with chronic kidney disease (CKD) are commonly diagnosed at a late stage. There is little information about the refusal of hemodialysis by hospitalized CKD patients who need hemodialysis (HD) and reasons for acceptance and refusal among these patients. All patients with Stage V CKD who had medical indications to undergo HD and were hospitalized at a tertiary care facility over a six-month period were invited to participate in this study. Patients were surveyed regarding acceptance or refusing of HD and reasons for their decisions. Demographic, socioeconomic, and clinical characteristics of patients were compared between patients who accepted or refused HD. A total of 125 patients were included in the study. The mean age of the patients was 47.9 ±12.1 years. The mean duration of diagnosis of CKD was 2.5 ± 0.6 months. Of all patients, 72 (57.6%) agreed to do HD and 53 (42.4%) refused HD. Patients with arteriovenous fistula in place (27.1 vs. 9.1%, P 0.02) and those in the middle- or higher-income group (64.4% vs. 38.6%, p = 0.03) were more willing to undergo HD. Trust in doctor's advice (86.1%) was the most common reason for acceptance of HD. Frequency of HD per week (52.8%), lifelong and permanent nature of HD (50.9%), advice by family members or friends (37.7%), perception of poor quality of life on HD (35.8%), and fear of HD needles and complications during HD (33.9%) were the most common reasons for refusal. Refusal of HD is common among hospitalized CKD patients with medical indications to undergo HD, especially in lower income group.

A comparison of anxiety and depression between pre-dialysis chronic kidney disease patients and hemodialysis patients using hospital anxiety and depression scale.

OBJECTIVE: Tocompare frequency of anxiety and depression between pre-dialysis chronic kidney disease (CKD) and hemodialysis patients (ESRD) in Pakistan. METHODS: This study was conducted in an out-patient department and hemodialysis unit of Sharif Medical City Hospital. Inclusion criteria included age above 18 years and a diagnosis of CKD including both pre-dialysis CKD and ESRD patients. Patients were screened for anxiety and depression using hospital anxiety and depression scale (HADS). RESULTS: A total of 156 patients were included in the study. Out of these patients, 81 (51.9%) had ESRD and 75 (48.1%) had pre-dialysis CKD. Mean age of all patient was 47.3±18.3 years, 96 (61.5%) were males and 60 (38.5%) were females. Median duration of renal disease was 16 months (IQR 8-36 months). Anxiety and depression were present in 111 (71.2%) and 113 (72.4%) of all patients respectively. Moderate to severe anxiety and depression were present in 54 (34.6%) and 60 (38.5%) patients respectively. In multiple logistic regression model, after adjusting for other variables, ESRD vs. pre-dialysis CKD was significantly associated with moderate to severe depression (AOR 2.26 (1.1-5.1). CONCLUSION: Both anxiety and depression are common in pre-dialysis CKD and ESRD patients. Patients with ESRD have higher frequency of depression compared to pre-dialysis CKD patients.

A comparison of quality of sleep between patients with chronic kidney disease not on hemodialysis and end-stage renal disease on hemodialysis in a developing country.

Few studies have compared quality of sleep between pre-dialysis chronic kidney disease (pre-dialysis CKD) patients and end-stage renal disease patients on dialysis (ESRD) and have found inconsistent results. Objective of this study is to compare quality of sleep between patients with pre-dialysis CKD and ESRD in a developing country. This study was conducted in an out-patient department and hemodialysis unit of a tertiary care facility. Patients included had either pre-dialysis CKD or ESRD. Assessment of quality of sleep was done using Pittsburgh sleep quality index (PSQI). A total of 152 patients were included in the study. Out of these patients, 79 (52%) had ESRD and 73 (48%) had pre-dialysis CKD. Median PSQI score was 6 (IQR 3-8.8). Poor sleep quality (PSQI ≥5) was present in 100 (65.8%) patients. Only hemoglobin (ß = -0.39, p < .01), depression (ß = 0.56, p < .01) and history of cardiovascular disease (ß = 0.22, p < .01) were associated with PSQI global score in a multiple linear regression analysis. There was no significant association between ESRD vs. pre-dialysis CKD and PSQI global scores and no significant co-relation between eGFR and global PSQI score (r = -0.34, p value .80) in pre-dialysis CKD patients. Poor sleep quality is common in patients with CKD including hemodialysis patients in a developing country, which is independent of kidney function in non-dialysis patients. There is no difference in quality of sleep between pre-dialysis CKD and ESRD patients.

Clinical predictors of an abnormal ultrasound in patients presenting with suspected nephrolithiasis.

OBJECTIVE: To determine any clinical features associated with an abnormal ultrasound in patients with suspected nephrolithiasis in an out-patient setting. METHODS: The study design was cross-sectional in nature. The study was conducted at an out-patient nephrology department of a tertiary care facility over a 3 month period. Patients included in the study were 18-80 years old, who presented with unilateral flank or costovertebral angle pain with or without other clinical features suggestive of renal or ureteric calculus based on clinician's judgement. Every patient's history was reviewed to obtain information on age, gender, location and radiation of pain, onset, severity and nature of pain, associated urinary and systemic symptoms and past history of nephrolithiasis. An ultrasound was considered to be abnormal if there was documented presence of renal or ureteric stone and/or unilateral hydronephrosis. RESULTS: A total of 209 patients were included in the study. Of these patients, 126 (60.3%) were males and 83 (39.7%) were females, 60 (28.7%) had prior history of nephrolithiasis. Ultrasound was abnormal in 110 patients (52.9%). On a multivariate logistic regression analysis, only past history of nephrolithiasis (OR 3.3, 95% CI 1.65-6.7) was associated with an abnormal ultrasound. CONCLUSION: In the absence of any significant clinical predictors use of ultrasound is justified in patients with suspected nephrolithiasis especially in those with prior history of stones.

ECG Abnormalities In Patients With Chronic Kidney Disease.

BACKGROUND: Chronic kidney disease (CKD) is associated with increased risk of cardiovascular disease. Electrocardiographic (ECG) abnormalities are common in CKD patients. However, there is variation in literature regarding frequency of ECG abnormalities in CKD patients and limited information in local population. METHODS: The study design was cross-sectional in nature. All patients between ages of 20-80 years with CKD not previously on renal replacement therapy who were admitted to nephrology ward at a tertiary care facility over a 6-month period were included. All patients underwent 12 lead electrocardiograms (ECG). ECG abnormalities were defined based on accepted standard criteria. RESULTS: Total number of patients included in the study was 124. Mean age of all patients was 49.9±13.8 years, 106 (84.8%) had hypertension, 84 (70%) had diabetes mellitus, and 35 (29.9%) had known cardiovascular disease. Mean serum creatinine was 7.2±3.4 mg/dl, mean eGFR was 10.6±9.2 ml/min/1.73 m2. Overall 78.4% of all CKD patients have one or more ECG abnormality. Left ventricular hypertrophy (40%), Q waves (27.2%), ST segment elevation or depression (23.4%), prolonged QRS duration (19.2%), tachycardia (17.6%) and left and right atrial enlargement (17.6%) were the most common abnormalities. CONCLUSIONS: ECG abnormalities are common in hospitalized CKD patients in local population. All hospitalized CKD patients should undergo ECG to screen for cardiovascular disease.

Frequency of Hepatitis C in hospitalized patients with chronic kidney disease.

BACKGROUND AND OBJECTIVES: Hepatitis C and chronic kidney disease (CKD) are major global health problems and are highly prevalent in Pakistan. There is limited information on prevalence of hepatitis C in patients with CKD not yet on dialysis. The objective of this study was to determine the frequency of hepatitis C in hospitalized chronic kidney disease patients at a tertiary care center in Pakistan. METHODS: The study design was cross-sectional in nature. Patients between ages of 20-80 years with CKD not previously on renal replacement therapy and who were admitted to nephrology ward at a tertiary care facility were included. Hepatitis C was tested using 3rd generation enzyme linked immunosorbent assay (ELISA). Hepatitis C RNA was tested by polymerase chain reaction (PCR) in patients with positive ELISA. RESULTS: A total of 180 patients were included in the study. Mean age of patients was 48.7±14.9 years. Of all patients, 105 (58.3%) were males and 75 (41.7%) were females, 152 (84.4%) had hypertension, 113 (62.8%) had diabetes mellitus and 26 (14.9%) had known cardiovascular disease. Mean eGFR of patients was 11.4±9.4 ml/min/1.73 m2. Of all patients with CKD, 49 (27.2%) had hepatitis C test positive by ELISA. Hepatitis C PCR testing was done in 39 patients with hepatitis C ELISA positive status and 29 (74.4%) tested positive. Risk factors and clinical characteristics of patients with and without positive hepatitis C antibody by ELISA were similar. CONCLUSION: A significant proportion of hospitalized CKD patients have hepatitis C. Strict universal infection control measures should be implemented in nephrology wards to prevent transmission of hepatitis C infection.

A survey of hypertension prevalence, awareness, treatment, and control in health screening camps of rural central Punjab, Pakistan.

Hypertension is a global public health problem with increasing prevalence. There is limited updated information on the prevalence of hypertension in the Pakistani population. This is a cross-sectional study based on data collected during multiple health screening camps held at multiple locations in rural central Punjab, Pakistan in the period between 2008 and 2015. A total of 13,722 patients were included in this study. Crude prevalence of hypertension was 35.1% and age-standardized prevalence was 34.4%. Among patients with hypertension, 62.3% were aware of having high blood pressure; among these patients, 75.3% were already on treatment for hypertension. Blood pressure was controlled in 22.3% of all patients with hypertension. Among those on treatment for hypertension, blood pressure was controlled in 32.3%. Nearly one-third of patients in health screening camps of rural central Punjab had hypertension. Blood pressure control rate was poor among these patients.

Home blood pressure monitor use in patients with chronic kidney disease.

Home blood pressure monitoring (HBPM) is recommended in patients with chronic kidney disease (CKD) and hypertension (HTN). However, little is known about the use and pattern of HBPM in CKD patients. A cross-sectional study was conducted in an out-patient nephrology clinic. A total of 285 patients participated in the study. Of all patients, 66% reported using HBPM. Self-reported compliance with BP medications (93.9% vs. 85.1%, p 0.03), exercise >3 days/week (45.9 vs. 26.3%, p <0.001) and dietary sodium restriction (85.6% vs. 71.6%, p < 0.001) were more common in HBPM users vs. non-HBPM users. Most patients with HBPM used upper arm cuff (82.3%), reported receiving education on correct use of HBPM (82.5%), had perception that home BP was controlled (75.4%) and believed that HBPM is helpful in managing hypertension (85.4%). Most common reason for not using HBPM was lack of advice by a physician (43.4%). HBPM use is common in patients with CKD and HTN. HBPM users are more likely to follow life-style and dietary modifications for blood pressure control.

A case of dabigatran-associated acute renal failure.

Dabigatran is a direct thrombin inhibitor that reduces the risk of systemic embolism in patients with nonvalvular atrial fibrillation. We report a case of an elderly man who developed unexplained rapid decline in renal function 6 weeks after starting dabigatran. A renal biopsy was planned to find out the etiology of acute renal failure, but the patient has significantly prolonged coagulation parameters despite holding medication for 5 days per manufacturer's recommendation. He was started on hemodialysis due to worsening renal function and to ensure dabigatran clearance before renal biopsy. Renal biopsy showed renal atheroembolic disease, which was possibly induced by dabigatran. Although renal atheroembolic disease is a known rare complication following treatment with warfarin, heparin, and thrombolytic agents, this is the first reported case of renal atheroembolic disease potentially caused by dabigatran. This case also highlights the extended duration of prolonged coagulation parameters after holding dabigatran and its implication for timing of nonemergent invasive procedures.

Ambulatory blood pressure monitoring in patients with chronic kidney disease and resistant hypertension.

The role of ambulatory blood pressure (BP) monitoring (ABPM) has not been well-studied in patients with chronic kidney disease and resistant hypertension. In a retrospective study of the outpatient chronic kidney disease population, 156 patients with chronic kidney disease and resistant hypertension who had 24-hour ABPM and clinic BP measurements were identified. Resistant hypertension was defined as uncontrolled clinic BP while taking ≥ 3 medications including a diuretic or controlled BP while taking ≥ 4 medications. Within the study group, ambulatory BP <130/80 mm Hg was found in 35.9% of all patients. Only 6.4% had both ambulatory and clinic BP <130/80 mm Hg. Prevalence of white-coat hypertension, masked hypertension, and sustained hypertension were 29.5%, 5.8%, and 58.3%, respectively. Compared with patients with sustained hypertension, more patients in the white-coat hypertension group had low nocturnal average systolic BP (defined as nocturnal average systolic BP <100 mm Hg) (17.4% vs 0%) and low 24-hour average diastolic BP (defined as 24-hour average diastolic BP <60 mm Hg) (52.2% vs 22%, P<.01). ABPM provides more reliable assessment of BP in patients with chronic kidney disease and resistant hypertension.