Incidence of COVID-19 and Identification of Possible Risk Factors Associated with COVID-19 in Acute Renal Transplant Recipients in Pakistan.

BACKGROUND Renal transplant recipients are susceptible to increased mortality with COVID-19 infection. There is insufficient data regarding risk factors for COVID-19 disease acquisition. We aimed to identify them here. MATERIAL AND METHODS We enrolled Pakistani renal transplant recipients from February 10, 2020, to March 18, 2021, and actively tracked their baseline health status, transplant characteristics, comorbidities, immunosuppressive therapies, and post-transplant follow-ups until September 2021. Furthermore, we formulated 2 questionnaires for their compliance assessment with COVID-19-preventive measures. We also identified COVID-19 disease acquisition, symptomatology, and management. RESULTS Among the 50 enrolled patients, 14 (28%) patients developed COVID-19, which is higher than the incidence observed in general Pakistani population (0.55%). Their mean age was 35.38 years ±11.69 SD years, and 82% of patients were males. The following factors were independently associated with COVID-19 disease: female gender (P value: 0.042), diabetes mellitus (P value: 0.002), anti-thymocyte globulin (ATG) induction (P value: 0.006), in-person follow-ups (P value: 0.000), prolonged immediate and late post-transplant hospital stays (P value: 0.019 and 0.000, respectively), raised post-transplant serum creatinine (P value: 0.019), and COVID-19 protective measures non-compliance (P value: 0.000). Out of 14 infected recipients, 92.85% required symptomatic management and overall mortality was 0%. CONCLUSIONS Female gender, diabetes mellitus, ATG induction, in-person follow-ups, prolonged hospital stays, raised post-transplant serum creatinine, and COVID-19-protective measures non-compliance were associated with the higher acquisition of SARS-CoV-2 infection. By taking concrete measures against these risk factors, we can continue renal transplants, as overall mortality was lower than in the general Pakistani population (2%).

Anti-Phospholipase A2 Receptor Antibodies in Biopsy-Proven Idiopathic Membranous Nephropathy: A Report from the Pakistani Population.

This study aimed to determine the percentage of anti-phospholipase A2 receptor (PLA2R) autoantibody positivity in a cross-section of 74 Pakistani patients with biopsy-proven idiopathic membranous nephropathy. It was an observational study conducted from December 2018 to June 2019. Seventy-four (n=74) consecutive biopsy-proven cases of membranous nephropathy, aged between 12-60 years, were included. Out of them, 63.5% (n=47) were males and 36.5% (n=27) were females. The mean age was 40.2±16.7 years. Anti-PLA2R antibodies were positive in 35 (47.3%) patients, negative in 38 (51.4%) patients, and borderline positive in 1(1.35%) patient. A significant difference (p ≤ 0.05) was noted among different levels of antibodies in both genders. Anti-PLA2R antibodies were detected in approximately half of the diagnosed idiopathic membranous nephropathy cases. However, this percentage was much lower than the studies conducted on other populations around the globe, indicating a possible pathogenic role of other antigens in our population. Key Words: Membranous nephropathy, Phospholipase A2 receptors, Renal biopsy.

Granulomatous Disorder With Pulmonary and Renal Involvement: A Diagnostic and Therapeutic Dilemma.

Granulomatosis with polyangiitis (GPA) can present with a wide array of clinical signs and symptoms; therefore, it should be differentiated from other mimicking clinicopathological entities. We report a case of a 66-year-old gentleman who was found to have a mediastinal mass and histopathological examination showed chronic necrotizing granulomatous inflammation. The patient was managed on lines of pulmonary tuberculosis for 12 months and remained in remission for two years. Later, workup showed cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA)-associated granuloma with marked renal impairment, which responded to immunosuppression. From this, we suggest that in a patient with radiological evidence of mediastinal mass, the remote possibility of GPA must be kept in mind.

Analysis of Clinical, Pathological and Prognostic Features of Coexistent Membranous and IgA Nephropathy in a Series of 13 Patients at a Tertiary Care Hospital.

Background Membranous nephropathy (MN) and immunoglobulin A nephropathy (IgAN) are although two different entities, yet can rarely coexist. There is not much data available on this coexistent disorder, specifically with regard to the treatment modality and outcome. Here, we analyse in detail, retrospectively, 13 cases of coexistent IgA and membranous nephropathy (IgA-MN). Methods Renal biopsy data of 1084 diagnosed cases of either membranous or IgA nephropathy was obtained from March 2015 till March 2021. Out of 1084 patients, 19 diagnosed cases of the coexistent disorder were identified. Six out of 19 patients were excluded because of their unwillingness. From remaining 13 patients, data regarding clinical presentation, investigations, management and treatment response was collected from hospital database, files and via telephonic interview. Results The overall prevalence noted was 1.75%. Among them, 53.8% were females and 46.2% were males. Their median age was 40 years (range: 14-71 years). On workup, mean serum albumin was 2.64 g/dl (range: 1.6-3.8 g/dl), mean proteinuria was 5.5 g/24 hours (range: 1.55-11.48 g/24 hours) and mean creatinine was 0.98 mg/dl (range: 0.5-2.8 mg/dl). Anti-phospholipase A2 receptor antibody positivity was only 14.2%. The renal biopsy of all patients showed thickening of the glomerular basement membrane with granular IgG deposits and mesangial expansion with granular IgA deposits. A total of 80% patients showed complete remission with steroids, calcineurin inhibitors (CNIs) and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs). Conclusion IgA-MN is probably a separate disorder that can only be confirmed on immunofluorescence microscopy. The response to the combination of steroids, CNIs and ACEi/ARBs is found to be the most effective; hence, this combination must often be used for the management of this coexistent disorder.

Role of Anti-ganglioside Antibodies in the Diagnosis of Guillain-Barré Syndrome as an Alternate Investigation.

Objective The goal of the study was to see if anti-ganglioside antibodies have a role in the diagnosis of Guillain-Barré syndrome (GBS). Study design Between May 2016 to October 2017, we conducted a prospective pilot study of 15 patients with a clinical diagnosis of GBS with equivocal cerebrospinal fluid (CSF) analysis and/or nerve conduction studies (NCS) . Materials and methods All adult patients (age >18 years) whose clinical diagnosis was GBS but diagnostic tests (either NCS or CSF analysis or both) were not suggestive of GBS were included in the study and were tested for anti-gangliosides antibodies. Data was entered in SPSS, version 21.0 (IBM, Armonk, New York) and analyzed. Results Of the 15 patients fulfilling the inclusion criteria, 60% had a normal CSF analysis while 40% had normal NCS. The percentages of different GBS variants observed in sampled patients were acute inflammatory demyelinating polyradiculopathy (AIDP) 40%, acute motor axonal neuropathy (AMAN) 40%, acute motor and sensory axonal neuropathy (AMSAN) 13.3%, and Miller Fisher syndrome 6.7%. However, the anti-ganglioside antibodies were negative in all patients. Conclusion Anti-gangliosides antibodies cannot be used as an alternative diagnostic investigation in GBS patients as our study failed to show positive results in different GBS variants.

Overcoming the Immunological Barrier in Highly HLA Sensitized Renal Transplant Recipients - A Desensitization Experience from a Transplant Center in Pakistan.

Highly Human Leukocyte antigen sensitized patients have relatively fewer chances of being transplanted successfully and may remain dialysis dependent for a long time. In the last few years with the development of immunomodulatory therapies and advancements in immunological investigations, the chance s of transplantation in these sensitized patients have improved. Desensitization therapies in these patients include plasma exchange, intravenous immune globulins and immunomodulatory agents such as rituximab and bortezomib. These agents used together in desensitization protocols across the world have shown encouraging results in highly Human Leukocyte Antigen sensitized recipients awaiting renal transplant. We used a desensitization protocol using rituximab followed by bortezomib with concurrent plasma exchange sessions and Intravenous Immune Globulins. Our aim was to assess improvement in renal function and quality of life in these patients after desensitization and renal transplantation. To the best of our knowledge, this is the first account of desensitization prior to renal transplantation from Pakistan.

Early Diagnosis Of Acute Kidney Injury By Urinary Neutrophil Gelatinase Associated Lipocalin In Adult Critically Ill Patients.

BACKGROUND: Acute kidney injury (AKI) is a major cause of mortality and morbidity in the hospitalized patients. It is also a risk factor for chronic kidney disease and advance renal failure. Early diagnosis with new biomarkers for AKI can prevent and/or reverse the process before rise in serum creatinine and symptomatic renal failure. This study is aimed at the accuracy of Urine neutrophil gelatinase associated lipocalin (NGAL) for detection of AKI at an early stage. METHODS: It is a descriptive, cross sectional study conducted in the Medical Intensive Care Unit of Shifa International Hospital, Islamabad. Total 97 patients admitted in intensive care unit, age from 18-75 years, fulfilling the inclusion criteria were included by non-probability, consecutive sampling technique. Duration of study was six months, from 1st February 2014 till 31st July 2014. Urine samples of study population were tested for NGAL and simultaneously serum creatinine levels were checked, which were repeated at 48 hours for diagnosis of AKI. Patients with AKI and positive values of NGAL were considered true positive while patients without AKI and negative values of NGAL were considered true negative. Accuracy of NGAL was then calculated and effect modifiers like age and gender checked by chi square testing.. RESULTS: Mean age of the participants was 57.76 years with the range of 26-74 years. Out of the total population of 97 patients, 48.5% were males and remainder 51.5% were females. The study found that the accuracy of the urinary NGAL in diagnosis of AKI when compared with serum creatinine was 90.7%.. CONCLUSIONS: Urine NGAL is an accurate marker of AKI in critically ill patients. Therefore, it should be included in the diagnostic workup of AKI in early stages..

Contrast-induced Acute Kidney Injury in Patients with Liver Cirrhosis: A Retrospective Analysis.

Contrast-induced acute kidney injury (CI-AKI) has been studied less extensively in patients with liver cirrhosis (LC). It is unclear whether the presence of severe liver disease is actually a predisposing factor for CI-AKI. Liver cirrhosis is extremely common in Pakistan and is attributed to the high prevalence of chronic viral hepatitis. Patients with LC often undergo contrast-enhanced computed tomograms (CECT) for various diagnostic and therapeutic purposes, and there have been concerns regarding them being at risk for CI-AKI. The available literature on this topic is scanty, and no study has been conducted in Pakistan. The purpose of this study, therefore, was to determine the frequency of CI-AKI in patients with LC undergoing CECT and to determine any significant predispositions. We retrospectively analyzed the records of 470 LC patients at our center. The frequency of CI-AKI in our study was 5.1%. A higher mean model for end-stage liver disease (MELD), MELD including sodium (MELD-Na), and Child-Pugh (CP) scores was significantly associated with developing CI-AKI (p<0.05). Patients with CI-AKI also had a significantly higher mean international normalized ratio (INR) and serum bilirubin levels, with lower mean venous bicarbonate and serum sodium levels (p<0.05). Our results show that patients with a more advanced liver disease and poorer synthetic function are increasingly susceptible to developing CI-AKI. Further studies can investigate the role of bicarbonate therapy in preventing CI-AKI in LC.

Quality of Sleep in CKD Patients on Chronic Hemodialysis and the Effect of Dialysis Shift.

OBJECTIVE: To determine the frequency of poor sleep quality in chronic kidney disease (CKD) patients on chronic haemodialysis and compare the quality of sleep amongst patients undergoing chronic haemodialysis in morning shift to other shifts (including afternoon, evening and night). STUDY DESIGN: Cross-sectional, descriptive study. PLACE AND DURATION OF STUDY: Dialysis Unit, Department of Nephrology, Shifa International Hospital Islamabad, Pakistan, from May to November 2016. METHODOLOGY: CKD patients who were dialysis dependant for a minimum of three months between ages of 20 years to 70 years were included. Participants were interviewed using a questionnaire measuring age, gender, time on haemodialysis, duration of each session and shift in which they were dialysed. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Using patient's responses to all questions in the PSQI, sleep quality score for each patient was calculated and they were classified as poor or good sleepers. RESULTS: A total of 113 patients were included. Out of these, 82 patients (72.6%) had poor quality of sleep and 31 (27.4%) patients had good sleep quality. Thirty three out of the 48 morning shift patients had poor sleep quality and 49 out of 65 patients in other shifts had poor sleep quality. This relationship was not statistically significant. CONCLUSION: The frequency of poor sleep quality amongst CKD patients receiving chronic haemodialysis is high. However, dialysis shift does not seem to have any statistically significant relationship with the occurrence of poor sleep quality in these patients.

Association of Hemodialysis Inadequacy and Duration with Restless Legs Syndrome: A Cross-sectional Study.

Restless legs syndrome (RLS) is a common neurological disorder in hemodialysis (HD) patients. It is associated with poor sleep and decreased quality of life. The precipitants for the disorder are still poorly understood. The condition has not been studied extensively in Pakistan, which has a vast majority of end-stage renal disease patients on maintenance HD. We aimed to determine the prevalence of this condition in patients attending HD units of the largest renal dialysis center in Northern Pakistan. We also strived to determine any associations with dialysis inadequacy and the total duration of HD. This was an observational study comprising 279 patients. RLS was diagnosed using the International Restless Leg Syndrome Study Group criteria. Dialysis adequacy was determined using the Urea Reduction Ratio and the Kt/V technique. The prevalence of RLS in this large HD population was 24%. Our results show that a longer duration and greater number of HD sessions were significantly associated with the development of RLS (p<0.05). Dialysis inadequacy was not associated with the development of the disorder. These results may indicate that the pro-inflammatory nature of hemodialysis may have a role in the pathophysiology of RLS in HD patients and prolonged exposure to it may make them more prone to developing the disorder.

Central Diabetes Insipidus and Hyperglycemic Hyperosmolar State Following Accidental Carbon Monoxide Poisoning.

Carbon monoxide poisoning is common and carries significant morbidity and mortality. The nervous system, particularly the brain, is frequently affected by it, owing to its high metabolic activity and oxygen requirements. Carbon monoxide damages the nervous system by both hypoxic and inflammatory mechanisms. Central diabetes insipidus is an extremely rare complication of carbon monoxide poisoning. Herein, we report the case of a young lady, who developed this complication and severe hypernatremia after accidental carbon monoxide poisoning. She also developed a hyperglycemic hyperosmolar state during the treatment for hypernatremia. To the best of our knowledge, both these entities have not been reported together in association with carbon monoxide poisoning. The purpose of this article is to emphasize the anticipation and early recognition of central diabetes insipidus in carbon monoxide poisoning. This can prevent severe hypernatremia and complications associated with its presence and treatment.

Renal Infiltration by Diffuse Large B-Cell Lymphoma as a Rare Cause of Fanconi's Syndrome: A Case Report.

We report the case of a 16-year-old female patient with a known history of coeliac disease, who presented with the complaints of diarrhea, vomiting and generalized body weakness. On examination, she was found to have dehydration, decreased power in all her limbs, cervical lymphadenopathy and hepatosplenomegaly. Investigations showed severe hypokalemia, hyponatremia, hypomagnesemia, hypoglycemia and mildly enlarged kidneys on ultrasonography. Biopsy of the duodenum confirmed the flare up of coeliac disease, while cervical lymph node biopsy was positive for atypical lymphoid infiltrate and a morphology suggestive of non-Hodgkin's lymphoma. The immune profile performed on this sample confirmed the presence of activated/non-germinal center type of diffuse large B cell lymphoma (DLBCL), which was morphologically aggressive in type. The bone marrow biopsy was hypocellular and was negative for any infiltration. The patient was suspected to have developed infiltration of one or both kidneys leading to a rare presentation of Fanconi's syndrome. She was given first dose of rituximab on the 14th day of her admission. Unfortunately, she developed cardiopulmonary arrest and expired on the next day. We recommend screening for a possible renal involvement in patients with DLBCL and in patients with unusually deranged serum electrolytes as seen in Fanconi's syndrome. Renal biopsy is considered the gold standard modality for diagnosis and if possible, an earlier sample in a patient with newly developed acute kidney injury can save future complications.

Spontaneous Rupture and Dissection of Aspergillus Infected Arteriovenous Fistula.

Patients with end stage renal disease need a vascular access like arteriovenous (AV) fistula, AV graft or central venous catheter for hemodialysis. However, AV fistula can be complicated due to infection, stenosis, ulceration etc. Among these, spontaneous rupture of AV fistula is rare and can be due to stenosis or infection. Fungal infection of AV fistula is very rare and the most common organism involved is Candida. Infection of native AV fistula with Aspergillusis not reported in the literature. This case discusses the spontaneous rupture and dissection of an Aspergillusinfected arteriovenous fistula, requiring urgent closure and repairing of vessel.

Frequency Of Different Risk Factors Associated With Recurrent Urinary Tract Infection Among Postmenopausal Women.

BACKGROUND: Urinary Tract Infection is one of the most common infections encountered by women. These infections have the tendency to recur. In order to identify women at risk of recurrence there is a need to identify risk factors associated with it. Among women, factors predisposing to recurrent infections are not much explored. The study was done with an objective to determine different risk factors associated with recurrent UTI among postmenopausal women. METHODS: This was a cross sectional study conducted at the Out Patient Department of Nephrology in Shifa International Hospital Islamabad over a period of six months, June 6th to December 5th 2012. Information regarding demographics and risk factors were recorded on a predesigned pro forma. A descriptive analysis was done for quantitative variables like age and qualitative variables like marital status and frequency of different risk factors. Stratification of risk factors according to age was also done. RESULTS: Hundred females were enrolled into the study after informed consent. The mean age of the study population was 64.4±9.48. 97% of the population was married. Out of 100 patients, 42 had high post-void volume, 35 had urinary incontinence and 17 patients were having cystocele. According to age stratification, most frequently affected age group was between 51-60 years (38%), followed by 61-70 years (36%), then 25% in more than 70 years, whereas only 1% was between 41-50 years. CONCLUSIONS: Recurrent UTI in postmenopausal females is most frequently associated with high post void volume and most frequently affected age group is between 51-60 years.

Experience with a theme-based integrated renal module for a second-year MBBS class.

Integrated learning is the need of the hour. We at Shifa College of Medicine switched to an integrated modular curriculum last year. In the present article, we describe our experience with the renal module in year 2 of a 5-yr undergraduate medical curriculum. A multidisciplinary renal modular team developed the relevant objectives, themes, and clinical cases. The learning strategies used were large-group interactive sessions, small-group learning, problem-based learning, practicals, and self-directed learning. Assessment was both formative and summative. Student and faculty feedback questionnaires were administered at the end of the module. Forty-four percent of the students agreed that the basic science and clinical concepts were well balanced and integrated. Fifty-seven percent of the students believed that important learning issues could be identified and that participation and critical thinking were encouraged during the small-group sessions. Eighty-five percent of the facilitators agreed that they were able to motivate students for critical thinking and better learning through integrating various disciplines. In conclusion, the integrated method of curricular delivery was well received by students and faculty members, and it can be used successfully in undergraduate medical education in developing countries.

Risk factors for hepatitis C virus infection in patients on long-term hemodialysis.

OBJECTIVE: To estimate the frequency of hepatitis C virus (HCV) infection in patients on hemodialysis at Shifa International Hospital and determine the association of various risk factors in the acquisition of hepatitis C infection. DESIGN: A cross-sectional analytical study. PLACE AND DURATION OF STUDY: Shifa International Hospital from January 2002 to June 2003. patients and METHODS: All patients on long-term hemodialysis in Nephrology Unit of Shifa International Hospital were studied. Their medical records were reviewed for the presence of anti-HCV in all patients. Any risk factors were noted from the patient's records and from the history of those patients who were regularly attending the dialysis unit. RESULTS: A total of 97 patients on hemodialysis were included. Out of these, 23 (23.7%) were found to be anti-HCV positive. The mean age of HCV positive patients was 55.2+/-15.5 years while for the anti-HCV negative patients it was 54.9+/-15.1 years. There were 18 (78.3%) males in the HCV positive group while 46 (62.2%) males in the HCV negative group. The mean duration of dialysis among HCV positive patients was 2.9+/-2.7 years while the mean duration of dialysis in HCV negative patients was 1.51+/-0.86 years (p-value 0.000). Anti-HCV positive group had significantly greater proportion of patients with a history of dialysis more than 2 years (43.5% vs 9.5%), adjusted odds ratio being 0.45 (95% CI 0.27-0.75). No significant difference in other risk factors between the two groups was found. When years of dialysis were treated as categorical variable, significant difference between the anti-HCV positive and negative groups was found. The risk of getting HCV was found to be significantly associated with increasing years of dialysis, (adjusted p-value 0.002). CONCLUSION: Patients on hemodialysis in our unit had 23.7% positivity of anti-HCV and history of dialysis over more than 2 years was noted to be a significant risk factor for acquisition of infection in these patients.