Frequency of Pulmonary Hypertension and Its Associated Risk Factors in End-Stage Renal Disease (ESRD) Patients on Maintenance Hemodialysis.

Introduction Pulmonary hypertension (PH) is a recognized complication in patients with end-stage renal disease (ESRD undergoing maintenance hemodialysis (MHD). PH is commonly found in patients with chronic kidney disease (CKD) and ESRD. PH is associated with increased morbidity and mortality in patients with CKD. Methodology This cross-sectional study aimed to assess the prevalence of PH and its associated risk factors in MHD patients. A total of 220 ESRD patients on MHD patients at The Kidney Center, Karachi, Pakistan, aged 18-70 were included. Patients with chronic obstructive lung disease, valvular heart disease, and obstructive sleep apnea were excluded, as these conditions can be responsible for PH. PH was evaluated by echocardiography (ECHO), which was performed by a cardiologist. Results The mean age was 50.65 ± 14.4 years, with 131 (59.5%) males and 89 (40.5%) females. The average duration on hemodialysis was 5.3 ± 2.8 years. Hypertension (89.5%) and ischemic heart disease (24.1%) were prominent comorbidities. Hypertensive nephropathy (42.7%) was the leading cause of ESRD. Left ventricular hypertrophy was mild in most cases (85.5%), whereas regional wall motion abnormality (RWMA) was common (67.3%). The average pulmonary artery pressure was 35.2 ± 15.3 mmHg. Out of 220 patients, 109 patients (49.8%) of them had mild PH, nine patients (4.1%) had severe PH, and 72 patients (32.7%) had moderate PH. Associations between PH and various factors were examined. RWMA, left ventricular hypertrophy, and left ventricular ejection fraction were significantly associated with PH (p < 0.001). Serum calcium and albumin levels were also associated with PH severity (p < 0.05). Other demographic and laboratory parameters did not show a significant association. Conclusion This study highlights the prevalence of PH in MHD patients and identifies associated risk factors. Understanding these associations can aid in better managing PH in ESRD patients.

From Exhaustion to Empowerment: Investigating Fatigue and Its Associations in Patients With End-Stage Renal Disease on Maintenance Hemodialysis.

Introduction Patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis (MHD) frequently experience fatigue. This cross-sectional study examined the severity of fatigue and the demographic and clinical characteristics that may contribute to fatigue in ESRD patients on MHD. Methods The study included 250 ESRD patients on MHD. Age, gender, marital status, occupation, level of education, and information regarding dialysis and laboratory parameters were gathered. The Fatigue Assessment Scale (FAS) was used to quantify fatigue. The FAS consisted of 10 questions. Fatigue severity was categorized into three groups based on the total FAS score. Results The mean fatigue score using FAS in our study was 22.1 ± 4.1 (47.2%), indicating a moderate level of fatigue among the participants. Approximately 47.2% of the patients reported moderate fatigue, while severe fatigue was not observed in our study. Employment status showed a significant association with fatigue, with a higher prevalence among unemployed individuals 56 (47.5%) and those engaged in housework 40 (33.9%). The duration of hemodialysis was also significantly associated with fatigue in our study (p < 0.001), with patients undergoing treatment for more than 4 years experiencing a higher prevalence of 81 (68.7%). Among the demographic and clinical parameters analyzed, age, gender, residence, education, socioeconomic status, and comorbid conditions did not show a significant association with fatigue. However, phosphorus levels demonstrated a significant association (p = 0.014), with higher levels being associated with a decreased chance of experiencing fatigue. Conclusion These findings suggest that employment status and the duration of hemodialysis are potential factors influencing fatigue in ESRD patients on MHD. Furthermore, it is possible that phosphorus levels affect how tiredness manifests. Understanding these factors can contribute to improved management and timely interventions to address fatigue in this patient population. It is important to conduct more studies to understand the causes of fatigue in ESRD patients receiving MHD, as well as possible treatments.

Problem to solution; from mammalian skin grafts to renal allograft rejection: a tale of 66 years of evolution of our understanding.

The first successful kidney transplant was done in 1954, and it remains the best option for those with failed kidneys. However, the recipient's immune system remains the most formidable barrier to transplantation, leading to rejection. Rejection continues to be the most important reason of graft malfunction and chronic renal allograft dysfunction and remains a challenge to date for successful transplant survival. The current narrative review was planned to find the best possible solution to the problem from among the different solutions presented in literature related to allograft rejection since 1954.

Association Of Bone Mineral Profile With Restless Leg Syndrome In Patients With End Stage Renal Disease.

Background: Restless leg syndrome (RLS) is one of the problem hemodialysis patients may encounter. This study was done to find out the association of restless legs syndrome (RLS) in end stage renal disease patients with serum calcium, phosphorus and parathyroid hormone levels. Methods: This cross-sectional observational study was done at The Kidney Centre, postgraduate Training Institute Karachi, Pakistan from Jan to June 2020. One hundred and twelve patients on three per week hemodialysis for more than three months at our hemodialysis centre were face to face interviewed as per International Restless Legs Syndrome Study Group criteria (IRLSSG) for the presence of RLS symptoms. Their demographic data and laboratory values were recorded from history chart and computer records. The bone mineral profile in this study includes serum calcium (corrected for albumin), serum phosphate levels and serum intact Parathyroid hormone (iPTH) levels. Statistical analyses were done by using SPSS-21. Results: In our study, 38.4% patients had RLS. Serum phosphorus levels were significantly higher in patients with RLS as compared to those who didn't have RLS. No significant association of serum calcium and Parathyroid hormone (PTH) levels with RLS was found. Conclusion: There is a high prevalence of RLS in ESRD patients as compared to general population. Serum phosphorus levels need to be observed and corrected along with maintenance of calcium and PTH levels to improve symptoms of RLS in these patients.

Development of Banff Classification from 1991 to 2019 for identifying renal allograft rejection: A narrative review for nephrologists.

Renal pathologists, nephrologists and transplant surgeons held a meeting in 1991 at Banff, Canada, and developed a classification scheme that standardised the international classification of renal allograft biopsies and called it the Banff Classification. Following the first meeting, 15 meetings were held, usually every two years, that revised the classification in the light of new evidence and techniques. The latest printed consensus was after the 2019 meeting in Pittsburgh in the United States of America. Several articles have been published in the last 30 years that have created ambiguities for nephrologists and have made things challenging for the expert pathologists. The current perspective review was planned to make it easy and clear for beginners and for practitioners how the Banff Classification has evolved since its inception.

The second wave of COVID-19 disease in haemodialysis patients: An experience of a dialysis center from Pakistan.

OBJECTIVE: To evaluate the characteristics and outcomes of second wave of coronavirus disease-2019 in haemodialysis patients. METHODS: The retrospective, observational cohort study was conducted at The Kidney Center Post-Graduate-Training-Institute, Karachi, Pakistan and comprised data of patients regardless of gender who contracted coronavirus disease-2019 during the second wave from November 3, 2020, till February 12, 2021. Epidemiological, clinical, laboratory, and radiological characteristics and outcomes of the patients were reviewed. Data was analysed using SPSS 21. RESULTS: Of 437 patients on haemodialysis, 46(10.5%) contracted coronavirus disease-2019; 29(63%) males and 17(37%) females. The overall median age was 61.5±13.02 years. Most patients developed mild disease 27(%). The most common symptom was fever 29(63%), and 6(13.1%) patients had patchy bilateral opacity on chest radiograph. Major complications were lymphocytopenia 29(63%), pneumonia 15(32.6%), thrombocytopenia 8(17.4%), and septic shock 5(10.9%). Overall, 15(32.6%) patients required hospitalisation, and 8(17.4%) required mechanical ventilation. There were 13(28.3%) deaths. Patients aged >60 years had 6.8 times more severe disease (p=0.023) and chances of death among them were 5.8 times higher (p=0.036) than in those aged <60 years. CONCLUSIONS: There was a high susceptibility of haemodialysis patients during the second wave of coronavirus disease compared to the general population. The most important determinants of death were advanced age, lower oxygen saturation and thrombocytopenia at presentation.

Frequency of iron deficiency anaemia in chronic kidney disease patient not on dialysis.

OBJECTIVE: To determine the frequency of iron deficiency anaemia in non-dialysis chronic kidney disease patients. METHODS: The observational, cross-sectional study was conducted at the Department of Nephrology, The Kidney Centre Post-Graduate Training Institute, Karachi, from April 27 to October 26, 2018, and comprised adult patients of either gender diagnosed with anaemia and estimated glomerular filtration rate <90ml/min. Patient with transferrin saturation <20% were labelled as having iron deficiency anaemia. Data was analysed using SPSS 21. RESULTS: Of the 366 participants, 185(50.5%) were males and 181(49.5%) were females. The overall mean age was 54.47±14.93 years. The most prevalent comorbid was hypertension 263(71.9%), followed by diabetes mellitus 187(51.1%) and cardiovascular disease 54(14.8%). Besides, 192(52.5%) patients had CKD stage 5 followed by 115(31.4%) and 54(14.8%) with CKD stages 4 and 3, respectively. The mean haemoglobin was 9.17±1.57g/dL. Iron deficiency was found in 285(77.9%) patients. CONCLUSIONS: Iron deficiency anaemia was found to be highly prevalent and should be screened routinely and managed appropriately.

Genetic Analysis of HIV-1 vpr Sequences from HIV-Infected Older Patients on Long-Term Antiretroviral Therapy.

BACKGROUND: Many HIV-infected individuals have achieved undetectable viral load and increased CD4 T cell counts due to the success of Antiretroviral Therapy (ART). However, HIV persists in resting T cells, monocytes/macrophages and other quiescent cells. Furthermore, the HIV- 1 vpr accessory gene may play an important role in the persistence of HIV in these infected patients. OBJECTIVES: Therefore, we characterized the HIV-1 vpr gene from PBMC DNA of 14 HIV-infected older patients on long-term ART with mostly undetectable viral load and increased CD4 T cell counts. METHODS: Peripheral Blood Mononuclear Cells (PBMC) were isolated from 14 HIV-infected individuals, followed by extraction of genomic DNA, amplification of HIV-1 vpr gene by polymerase chain reaction (PCR), cloning of vpr gene in TOPO vector and characterization of correct size recombinant inserts containing vpr genes. An average of 13 clones were sequenced from each patient, followed by sequence analysis by bioinformatic tools. RESULTS: Phylogenetic analysis of 182 vpr sequences demonstrated that the vpr sequences of each patient were well separated and discriminated from other patients' sequences and formed distinct clusters. The vpr sequences showed a low degree of viral heterogeneity, lower estimates of genetic diversity and about half of the patients' sequences were under positive selection pressure. While the majority of the vpr deduced amino acid sequences from most patients contained intact open reading frames, several sequences, mostly from two patients, had stop codons. Numerous patient-specific and common amino acid motifs were found in deduced vpr sequences. The functional domains required for vpr activity, including virion incorporation, nuclear import of pre-integration complex and cell cycle arrest, were generally conserved in most vpr sequences. Several of the known Cytotoxic T-lymphocytes (CTL) epitopes in vpr showed variation in our patients' sequences. CONCLUSION: In summary, a low degree of genetic variability, conservation of functional domains and variations in CTL epitopes were the features of vpr sequences from the 14 HIV-infected older patients with controlled viremia on long-term ART.

'Haemodialysis burden' overweighs the associations of demographic, social and clinical factors on quality of life: A single centre study from Pakistan.

OBJECTIVE: To assess health-related quality of life in haemodialysis patients, and the impact of various factors in this regard. METHODS: The retrospective observational cross-sectional study was conducted at The Kidney Centre Post-Graduate Training Institute, Karachi, and comprised data from June to December 2019 of patients on maintenance haemodialysis. The health-related quality of life was assessed using the self-administered Urdu version of the Kidney Disease Quality of Life-Short Form version 1.3. Data was analysed using SPSS 21. RESULTS: Of the 150 questionnaires distributed, 110(73.3%) were received fully completed. There were 64(58.2%) males, 46(41.8%) were females, 90(81.8%) were under <60 years age, 76(69%) were married, 54(49.1%) had income up to PKR50,000, 64(58.2%) had received education up to secondary school, and 56(50.9%) had been on haemodialysis for <5 years. The overall health-related quality of life mean score was 52.0±11.7, and it had no significant association with age, gender, haemodialysis duration, marital status, education level, and income of the subjects (p>0.05). CONCLUSIONS: The health-related quality of life in haemodialysis patients was not found to have significant association with age, gender, haemodialysis duration, marital status, education level, and income.

Comparison of the Quality of Sleep in Patients With Chronic Kidney Disease and End-Stage Renal Disease.

Objective In this study, we aimed to compare the quality of sleep between patients with (CKD) and those with end-stage renal disease (ESRD). Methodology We performed a cross-sectional study between August 2020 and January 2021. We included 240 patients, among which 178 (74.2%) were CKD patients and 62 (25.8%) were ESRD patients on maintenance hemodialysis (MHD). Demographic data were collected on a pre-designed proforma. The quality of sleep was evaluated using the Pittsburgh Sleep Quality Index (PSQI). PSQI assesses subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. A PSQI score >5 indicates poor sleep quality. Results Out of the 240 patients, 159 (66%) had poor sleep quality. We found a significant difference in mean PSQI scores between CKD and ESRD patients (9.6 ± 12.4 vs. 11.4 ± 3.9 respectively), indicating poorer sleep quality in ESRD patients as compared to those with CKD (p<0.001). In our study, among all comorbidities, poor sleep was significantly associated with ischemic heart disease (IHD) (p = 0.025), after adjusting for confounding factors. Conclusions Our study showed that two-thirds of the study population had poor sleep quality. ESRD patients suffered from more disturbed sleep as compared to CKD patients.

Comparison of COVID-19 Inactivated Virus Vaccine Immunogenicity Between Healthy Individuals and Patients on Hemodialysis: A Single-Center Study From Pakistan.

Introduction This study compares the immune response after coronavirus disease 2019 (COVID-19) inactivated virus vaccine between healthy individuals (HI) and patients on hemodialysis (HD). Methods In this cross-sectional, comparative study, the presence or absence of immunoglobulin G (IgG) anti-S antibody and IgG anti-S antibody titer was compared between HI, and patients on HD after two doses of COVID-19 vaccine. Results A total of 81 participants, 50 (61.7%) HD patients and 31 (38.3%) HI, were studied. The mean age was 52.9±12 in HD patients and 42±12.4 in HI. Vaccination responder rates were 80.6% in HI and 72% in HD patients after the first dose (p=0.38) and 93.5% in HI and 94% in HD at the third week of the second dose of the vaccine (p=0.93). The mean IgG antibody titer was 156.3±113.8 in HI and 143.4 ± 117.8 in HD patients (p=0.538) after the first dose and 186.7 ± 97.9 in HI and 180.6 ± 105.8 in HD patients (p=0.552) at three weeks of the second dose. No statistically significant difference was found in antibody titer with respect to gender, age, vaccine (BBIBP-CorV or Conovac), and hypertension. Diabetic HD patients had a lower antibody titer than non-diabetic HD patients (p=0.03) while participants who had a history of COVID-19 infection had a higher IgG titer (p = 0.001). The levels of IgG titer in the same patient increased, corresponding to the doses of vaccine (p <0.001). No HD patient developed COVID-19 infection till the third week of vaccination. Conclusion This study demonstrates a similar humoral response after COVID-19 inactivated virus vaccination in HD patients and HI. The response was lower among diabetic patients on HD and better in those with previous COVID-19 infection.

Re-Hospitalization in First Six Months After Live Related Renal Transplantation: Risk Factors, Burden, Causes and Outcomes.

Objective The aim of our study was to evaluate the incidence, causes, risk factors, outcomes, and cost of hospital readmission after live related renal transplantation (LRRT). Methods We conducted a cross-sectional study and followed patients' re-admissions for six months whose LRRT was done in our center between September 2019 and June 2020. Results We recruited 53 patients, 40 (75.5%) were male. The mean age was 36.9 ± 11.9 years. Donor gender was similar, and their mean age was 31.6 ± 9.2 years. The mean length of hospital stay after LRRT was 14 ± 2.2 days. A total of 81.1% were readmitted after LRRT within the first six months, with a total of 113 readmissions. The median time of readmission after LRRT was 66 days. The median readmission hospital stay was four days. The causes of readmission were surgical in 11 (9.7%), medical in 89 (78.8%), and combined medical and surgical in 13 (11.5%). Infection was the most common medical cause, followed by rejection. Statistically significant difference between readmission and non-readmission groups was found in estimated glomerular filtration rate (eGFR) at six month 61.3 ± 25.9 vs. 84.3 ± 36.1 mL/min/1.73 m2 respectively (p = 0.02). The median cost of readmission was PKR 40629, equivalent to USD 261. Conclusion Over three-fourths of the patients were readmitted after LRRT within the first six months. The most common causes were infection and rejection. Readmissions after LRRT are associated with lower graft function at six months and a significant cost burden on the health system.

A Comparative Study of the First and Second Waves of COVID-19 in Hemodialysis Patients From Pakistan.

INTRODUCTION: This study aims to compare the characteristics and outcomes of the first and second waves of coronavirus disease 2019 (COVID-19) in hemodialysis (HD) patients. METHOD: We compared the epidemiological, clinical, laboratory, and radiological characteristics and outcomes of a cohort of HD patients who contracted COVID-19 in our HD center during the first wave from May 2020 to September 2020 and the second wave from November 2020 to February 2021. RESULTS: A total of 50 (11.8%) of 423 patients during the first wave and 46 (10.5%) of 437 patients during the second wave contracted COVID-19. The median age was 59.5 ± 9.99 years (first wave) and 60.3 ± 13.02 years (second wave). Most patients developed the mild disease. Patients requiring hospitalization (22% vs. 32.6%) and mechanical ventilation (10% vs. 17.4%) were more in the second wave. The most common symptom was fever (82% and 63%) in both waves. Patchy bilateral opacity was the most common radiological finding. Major complications including lymphocytopenia (36% and 63%), pneumonia (28% and 32.6%), thrombocytopenia (30% and 17.4%), and septic shock (6% and 10.9%) were shared. Ten (20%) patients died in the first wave and 13 (28.3%) in the second wave. Patients aged > 60 years had more severe disease and died more than patients aged < 60 years in both waves. CONCLUSION: There is a high susceptibility and mortality of HD patients in both the first and second waves of COVID-19 as compared to the general population. Disease symptoms, radiological findings, and laboratory tests were similar in both waves. Patients developing critical disease and requiring hospitalization and mechanical ventilation were more in the second wave.

A Comparative Study of Acidosis in Diabetic Advanced Chronic Kidney Disease Patients on and off Metformin.

Aim The aim of the study is to assess the risk of acidosis in diabetic advanced chronic kidney disease (CKD) patients on and off metformin. Methods This retrospective descriptive study was conducted in the nephrology department in The Kidney Centre Post Graduate Training Institute (TKC PGTI) Karachi from February to April 2020. We reviewed the records of all patients over 18 years old who visited the nephrology outpatient department in three months in 2020 (from February 2020 to April 2020), who had CKD (stage 2-5), are not on dialysis, and had type 2 diabetes. These were divided into two groups: those on metformin for more than one year and those not on metformin. We looked at hospitalizations due to acidosis in the previous one-year period. Results A total of 524 CKD patients had diabetes; out of those, 268 patients were on metformin, and 256 were not on metformin. The male vs. female distribution was 52.1% vs. 47.9%. A total of 114 (21.8%) patients required admission in the previous one-year period, and only 12 hospitalized patients had acidosis, seven (58.3%) were on metformin, and five (41.7%) were not on metformin, which was statistically insignificant. Conclusion Biguanides, especially metformin, is a known oral hypoglycemic drug used for decades to treat type 2 diabetes mellitus (DM). Metformin use is related to a rare but serious adverse event, metformin-associated lactic acidosis (MALA), especially in renal failure patients. In our study, metformin use in CKD diabetic patients did not result in more admissions due to acidosis than non-metformin users.

Mini Nutritional Assessment (MNA) as a Reliable Tool for Nutritional Assessment of Hemodialysis Patients: A Single-Center Observation.

Objective In this study, we evaluated mini nutritional assessment (MNA) as a tool for the assessment of the nutritional status of end-stage renal disease (ESRD) patients on maintenance hemodialysis (MHD). Methods This prospective cross-sectional study was done from February 2021 till August 2021 on ESRD patients on MHD at our center. Nutritional status was assessed by using MNA score which evaluates four different aspects: anthropometric measures (body mass index [BMI], weight loss, mid-arm and mid-calf circumferences); general assessment (lifestyle, medications, mobility, and signs of depression); short dietary assessment (number of meals, food, and fluid intake) and subjective assessment (self-perception of food and nutrition). Results Out of 195 study subjects, 127 (65.1%) were males and 68 (34.9%) were females. Most women were stay-at-home mothers (57, 29.2% overall and 83.8% among all women), while most men owned their own businesses (44, 22.6% overall). The mean age was 51.2±14 years and the mean duration of hemodialysis was 4.6±4.1 years. Most of our patients belonged to the middle socioeconomic group (110, 56.6%). By using MNA, we found that most are at risk of developing malnutrition (112, 57.4%); however, only 9 (4.6%) patients are malnourished. In our study group, most malnourished patients belonged to the age group of >65 years (5, 56.6%). BMI was found to be significantly associated with MNA (p <0.001). Conclusion MNA is an easy and reliable bedside tool that can be used in ESRD patients on MHD for nutritional assessment. This is helpful in nutritional planning and the prevention of malnutrition.

Outcomes of Different Immunosuppressive Regimen in Adult Biopsy Proven Idiopathic Focal Segmental Glomerulosclerosis: A Retrospective Analysis at a Single Center.

Treatment of focal segmental glomerulosclerosis (FSGS) is frustrating, especially for steroid-resistant FSGS. Different immunosuppressive agents have been used with inconsistent outcome. We analyzed the data in our FSGS patients who, in addition to steroid, were treated with cyclosporine (CYA), cyclophosphamide (CYP), and mycophenolate mofetil (MMF) along with the long-term follow-up. This is a retrospective analysis of 113 patients diagnosed to have FSGS with 11 years' follow-up carried out at The Kidney Center Post Graduate Training institute. Among 113 patients, 51.3% were male with a mean age of 34.4 ± 11.8 standard deviation. Patients who achieved complete remission with steroid alone and steroid with combination of CYA, CYP, and MMF were 38 (26%), 19 (16.8%), and six (5.3%), respectively, similarly those who got partial remission were three (3.6%), five (4.4%), three (2.6%), and eight (7.0%), respectively. The factors which affected the outcome were serum creatinine (SCr), tubulointerstitial fibrosis (TIF), and the treatment. In adjusted analysis, increase in 1 mg of SCr reduces the patient recovery by 56%, while the absence of TIF increases recovery by 80.75%. Taking steroid as reference category, steroid + CYA found 2.03 times more effective as compared with steroid alone. Seven patients developed end-stage renal disease (ESRD) and three died due to disease during the follow-up. CYA comes out as the most effective treatment for steroid-resistant FSGS followed by MMF and CYP. The long-term outcome of all modalities is the same in terms of mortality and developing ESRD. The degree of TIF and renal failure has strong influence on the course of the disease.

Frequency of Intradialytic Hypertension Using Kidney Disease: Improving Global Outcomes (KDIGO) Suggested Definition in a Single Hemodialysis Centre in Pakistan.

OBJECTIVES:  To estimate the frequency of intradialytic hypertension (IDH) in our centre as per the definition suggested by Kidney Disease: Improving Global Outcomes (KDIGO). METHODS:  A cross-sectional study was conducted at the dialysis department of The Kidney Centre Post Graduate Training Institute (PGTI) Karachi, Pakistan from August 2021 to October 2021 among 263 end-stage kidney disease (ESKD) patients on maintenance hemodialysis (MHD) aged ≥ 18 years of both genders. The study outcome was the frequency of IDH as per the latest KDIGO suggested definition i.e., systolic blood pressure (SBP) rise of > 10 mm Hg from pre- to post-dialysis within the hypertensive range in at least four out of six consecutive dialysis treatments. Frequencies (%) and mean (±SD) were calculated for categorical and continuous variables respectively, using SPSS version 21 (IBM Corp., Armonk, NY, USA). RESULTS:  Among 263 patients, the mean age was 51.02 (±14.1) years and 56.3% were males. Around 30.8% of patients were dialysis-dependent for 1.1 to three years. The most common comorbidity was hypertension (88.6%). Standard dialysate calcium of 3mEq/l was received by 91.6% of study participants. About 78.7% of patients were using antihypertensive(s), out of which 85.5% were compliant and 37.6% were using a single antihypertensive. The most common antihypertensive in use was beta-blockers (78.3%). Around 16% of patients were found to have IDH. Age of the patients was significantly associated with IDH (p=0.038). The majority of the patients with IDH were those who were taking anti-hypertension medications as compared to the patients who were not taking them (p <0.004). Interdialytic weight gain was not a significant predictor for IDH. CONCLUSION:  The frequency of IDH was 16% according to the latest suggested KDIGO definition. This is much lower than regional and global estimates according to earlier definitions. There is a dire need to establish a standardized definition of IDH in guidelines to diagnose, manage and compare data. Also, the association of IDH with fluid overload is not found in our study which emphasizes the need to evaluate other causative factors.

Causes of Emergency Department Visits Among End-Stage Kidney Disease Patients on Maintenance Hemodialysis in Pakistan: A Single-Center Study.

Background In this study, we aimed to determine the causes of emergency department (ED) visits by end-stage kidney disease (ESKD) patients on maintenance hemodialysis (MHD) in Karachi, Pakistan. Methodology We conducted a cross-sectional study that included 194 visits of ESKD patients on MHD aged ≥18 years of both genders presenting at the ED of The Kidney Centre Postgraduate Training Institute, Karachi, Pakistan between February 2021 and May 2021. The study investigated the causes behind ED visits. Frequencies were calculated for categorical variables, and a bar graph was used for the graphical representation of the causes. Results In total, 194 visits included 151 patients of whom 88 (58.3%) were males while 63 (41.7%) were females, with a mean age of 51.68 ± 15.8 years. The most common comorbidity among the ED visits was hypertension 182 (93.8%). The majority of the visits 129 (66.5%) were undergoing regular three dialysis sessions per week, 101 (52.1%) were registered for MHD at our Institute, and 69.1% of visits reported arteriovenous fistula (AVF) as the current access for hemodialysis. Around 111 (57.2%) of the visits had infection-related complications, followed by electrolyte abnormalities 74 (38.1%), cardiovascular 53 (27.3%), and pulmonary complications 41 (21.1%). Overall, 19 (9.8%), 16 (8.2%), and 14 (7.2%) patients reported access-related, neurological, and gastrointestinal complications, respectively. Conclusions Infection-related complications are a significant cause of ED visits among ESKD patients, followed by electrolyte abnormalities and systemic complications, many of which are related to the existing comorbid conditions. Risk identification of preventable causes and surveillance of existing comorbidities would help mitigate ED visits among ESKD patients.

Co-relation Between Calcium-Phosphorus Product and Hypertension in End-Stage Renal Disease Patients.

Objective In our study, we evaluated the relation between calcium-phosphorus (Ca-P) product and various measurements of pre and post-dialysis blood pressure (BP) in hemodialysis (HD) patients. Methods This is a prospective, observational, cross-sectional study in which patients undergoing maintenance HD for > six months were enrolled through non-probability consecutive sampling during a six-month period from October 2020 to March 2021. Linear regression analysis was done to study the effect of the Ca-P product for each parameter of BP and regression coefficients were acquired. Results There was a total of 111 patients in our study, of which 59 (53.2%) were male. The mean age was 50.1± 14.4. The most common comorbid was hypertension (98.2%). The mean HD vintage of patients was 5.7 ± 5.8 years. On linear regression analysis, the Ca-P product was strongly correlated with pre-HD diastolic BP (DBP) (0.7) and post-HD mean arterial pressure (MAP) (0.7) while a moderate correlation was present with pre (0.59) and post (0.64) HD systolic BP (SBP), post-HD diastolic BP (0.68), and pre-HD MAP (0.68). On the other hand, the Ca-P product was not correlated with pre and post-HD pulse pressure (0.06 and 0.1, respectively). When the independent effect of serum calcium (Ca), phosphorus (P), and parathyroid hormone on BP was studied, P had a significant correlation with pre and post-HD SBP, DBP, and MAP. Conclusion Our study demonstrates a significant association of the Ca-P product and an independent high P level with pre and post-dialysis SBP, DBP, and MAP while no association was found with pulse pressure.

Bone Marrow Findings in Renal Patients: A Single Renal Specialist Center Experience.

Objective This study evaluated the importance of bone marrow aspiration and trephine biopsy (BM) for the diagnosis of underlying hematological abnormalities in renal patients. Methods This cross-sectional study on BM was carried out between August 2010 and April 2019, in our specialist renal center for various unexplained hematological abnormalities in patients with renal diseases [chronic kidney disease (CKD), end-stage renal disease (ESRD) requiring maintenance hemodialysis (MHD), patients with normal renal function but other nephrology and urology issues like stone disease and nephrotic syndrome]. Results Out of 176 reported BM examinations, 48 (27.3%) were done on ESRD patients on MHD (CKD-D), and 69 (39.2%) on CKD patients not on MHD (CKD-nD). Fifty-nine (33.5%) BM were done on patients with normal renal function (n-CKD). The indication for BM was pancytopenia 50 (28.4%), unexplained anemia 39 (22.2%), and unexplained thrombocytopenia 43 (24.4%). In 91 (51.7%) patients BM was normal. In 30 (17%) patients multiple myeloma (MM) was diagnosed on BM, out of which 18 (26.1%), nine (18%), three (5.3%) were CKD-nD, CKD-D, and n-CKD patients, respectively. In 11 (6.3%) patients BM was suggestive of myelodysplasia (MD), out of these 11 patients, five (10%) were CKD-D patients. Conclusion BM is an underutilized method of diagnosis of hematological abnormalities in renal patients. Our study revealed the importance of BM examination, especially in patients with CKD.