Lifestyle Modifications and Nutritional and Therapeutic Interventions in Delaying the Progression of Chronic Kidney Disease: A Review.

Chronic kidney disease (CKD) is a debilitating progressive illness that affects more than 10% of the world's population. In this literature review, we discussed the roles of nutritional interventions, lifestyle modifications, hypertension (HTN) and diabetes mellitus (DM) control, and medications in delaying the progression of CKD. Walking, weight loss, low-protein diet (LPD), adherence to the alternate Mediterranean (aMed) diet, and Alternative Healthy Eating Index (AHEI)-2010 slow the progression of CKD. However, smoking and binge alcohol drinking increase the risk of CKD progression. In addition, hyperglycemia, altered lipid metabolism, low-grade inflammation, over-activation of the renin-angiotensin-aldosterone system (RAAS), and overhydration (OH) increase diabetic CKD progression. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend blood pressure (BP) control of <140/90 mmHg in patients without albuminuria and <130/80 mmHg in patients with albuminuria to prevent CKD progression. Medical therapies aim to target epigenetic alterations, fibrosis, and inflammation. Currently, RAAS blockade, sodium-glucose cotransporter-2 (SGLT2) inhibitors, pentoxifylline, and finerenone are approved for managing CKD. In addition, according to the completed Study of Diabetic Nephropathy with Atrasentan (SONAR), atrasentan, an endothelin receptor antagonist (ERA), decreased the risk of renal events in diabetic CKD patients. However, ongoing trials are studying the role of other agents in slowing the progression of CKD.

Impact of KRAS Mutation on Survival Outcome of Patients With Metastatic Colorectal Cancer in Jordan.

Background Colorectal cancer (CRC) is the most prevalent cancer in males, with an incidence rate (IR) of 13.1%, and the second most prevalent cancer in females, with an IR of 8.4%, coming after breast cancer in Jordan. The present study was motivated by conflicting clinical data regarding the prognostic impact of Kirsten rat sarcoma viral oncogene homolog (KRAS) mutation in patients with metastatic colorectal cancer (mCRC). Our study aimed to investigate if KRAS mutation conferred a negative prognostic value in Jordanian patients with mCRC. Materials and methods The current study is a retrospective study that collected data from a cohort of 135 mCRC patients diagnosed between 1 January 2017 and 1 January 2022 at our Oncology Department at the Jordanian Military Cancer Center (MCAC) using our patients' electronic medical records. The last follow-up date was 1 September 2022. From the cohort, we obtained data regarding age, sex, date of diagnosis, metastatic spread, KRAS status, either mutated KRAS or wild-type KRAS, and location of the primary tumor. All patients underwent tumor tissue biopsies to determine KRAS mutational status based on quantitative polymerase chain reaction and reverse hybridization from an accredited diagnostic laboratory at Jordan University Hospital. Statistical analysis was carried out to address the associations between KRAS mutation and the patients-tumor characteristics and their prognosis on survival. Results KRAS mutation was found in 40.3% of the participants in the study, and 56.7% had the wild type. There was a predilection of KRAS mutation, with 67% on the right side versus 33% on the left side (p = 0.018). Kaplan-Meier survival analysis showed worse survival outcomes in KRAS mutant patients (p = 0.002). The median overall survival in the KRAS mutant patients was 17 months (95% confidence interval (CI): 13.762-19.273) compared to 21 months (95% CI: 20.507-27.648) in patients with wild-type KRAS. Additionally, the Cox regression model identified that KRAS mutation carries a poorer prognosis on survival outcome hazard ratio (HR: 2.045, 95% CI: 1.291-3.237, p = 0.002). The test also showed statistical significance in the metastatic site (lung only). But this time, it was associated with a better survival outcome (HR: 0.383, 95% CI: 0.186-0.788, p = 0.009). Conclusion The present study shows that the presence of KRAS mutation has been found to negatively impact the prognosis and survival outcome of Jordanian patients with mCRC.

Hyperprogressive Disease In a Metastatic Renal Cell Carcinoma Patient After Receiving Immune Checkpoint Inhibitors: A Case Report.

Owing to their survival benefits, immune checkpoint inhibitors (ICIs) have emerged as the mainstay treatment for several types of malignant tumors including renal cell carcinoma (RCC). However, the usage of ICIs such as nivolumab, ipilimumab, and atezolizumab can be complicated by unexpected rapid clinical deterioration and acceleration of tumor growth. This adverse event is called hyperprogressive disease (HPD) with an incidence rate of 10-20%. Since its first description in 2016, efforts have been made to identify and predict this phenomenon. We report a case of a 34-year-old female patient diagnosed with metastatic renal cell carcinoma (mRCC) with sarcomatoid features. She underwent a left radical nephrectomy followed by combination ICIs (nivolumab/ipilimumab) therapy. However, she presented with a rapid clinical deterioration shortly after receiving her second cycle of ICIs. The radiological assessment showed new multiple bilateral lung nodules, new multiple mediastinal and left hilar lymph node involvement, and two focal areas of new appearance involving the left aspect of L3 lumbar vertebrae and left ischial bone. The diagnosis of HPD was made. Unfortunately, the patient died soon following her second infusion of the nivolumab/ipilimumab combination.

Post Kidney Transplant Cyclosporine-Induced Acute Pancreatitis.

Drug-induced pancreatitis (DIP) is a rare cause of acute pancreatitis. Efforts have been made to assess the relationship between many drugs and acute pancreatitis. Also, studies have been held to investigate the possible mechanisms of DIP. Cyclosporine is one of the immunosuppressive agents that is still under investigation regarding its association with acute pancreatitis. We report a case of a 21-year-old male patient post kidney transplant who presented with a picture of acute pancreatitis; upon further investigation, the diagnosis of cyclosporine-induced pancreatitis was made by ruling out all other possible causes of acute pancreatitis. Furthermore, he showed significant improvement and was discharged home upon stopping cyclosporine and replacing it with sirolimus, and there was no relapse of pancreatitis in three months of follow-up.  Our case provides evidence that cyclosporine can be a possible cause of pancreatitis in post kidney transplant patients receiving cyclosporine, and how early detection of cyclosporine-induced pancreatitis can significantly improve the patient's condition.

Assessment of final-year medical students' performance in diagnosing critical findings on chest X-ray.

PURPOSE: Due to the recently emerging shortage in medical staff during the novel corona virus pandemic, several countries have rushed their undergraduate medical students into the emergency department. The accuracy of diagnosing critical findings on X-rays by senior medical students is not well assessed. In this study, we aim to assess the knowledge and accuracy of undergraduate final-year medical students in diagnosing life-threatening emergency conditions on chest x-ray. METHOD: This is a cross-sectional nationwide survey across all medical schools in Jordan. Through an electronic questionnaire, participants were sequentially shown a total of six abnormal X-rays and one normal. For each X-ray, participants were asked to choose the most likely diagnosis, and to grade the degree of self-confidence regarding the accuracy of their answer in a score from 0 (not confident) to 10 (very confident). RESULTS: We included a total of 530 participants. All participants answered at least six out of seven questions correctly, out of them, 139 (26.2%) participants answered all questions correctly. Pneumoperitoneum was the highest correct answer (93.8%), whereas flail chest was the least correctly answered case with only 310 (58.5%) correct answers. Regarding self-confidence for each question, 338 participants (63.8%) reported very high overall self-confidence level. Answers related to tension pneumothorax had the highest confidence level. CONCLUSION: Senior Jordanian medical students showed good knowledge with high confidence levels in diagnosing life-threatening conditions on chest x-rays, supporting their incorporation in the emergency department during pandemics and confirming the reliability of information they can extract.

Cardiac Tamponade as a Rare Presentation of Adult-Onset Still's Disease.

Adult-onset Still's disease (AOSD) is a rare inflammatory disease that affects multiple organ systems. Efforts have been made to study the course of the illness and possible treatment options. Cardiac tamponade is a rare and life-threatening complication of AOSD that can be the initial presentation of the disease. We report a 34-year-old patient who presented with a picture of cardiac tamponade and underwent emergency pericardiocentesis. Upon further investigations, the diagnosis of AOSD was made based on Yamaguchi criteria. Furthermore, he showed significant improvement following treatment with prednisolone, methotrexate, and tocilizumab. Our case provides evidence that AOSD should be considered in the differential diagnosis of cardiac tamponade and how prompt treatment of AOSD can effectively prevent potentially fatal complications.