Bilateral Pleural Effusion in Continuous Ambulatory Peritoneal Dialysis Managed by Vats Pleurodesis.

Pleuroperitoneal leak as a cause of pleural effusions in peritoneal dialysis is a rare but important complication to consider in continuous ambulatory peritoneal dialysis (CAPD) patients presenting with recurrent progressive dyspnoea. Generally, these effusions are unilateral and right-sided, resulting in shortness of breath and reduced ultrafiltration volume, which are initially managed by peritoneal rest. We describe a case of bilateral pleural effusions in a 57-year-old female on chronic CAPD who developed recurrent progressive dyspnoea but maintained adequate dialysis output. A chest radiograph revealed bilateral pleural effusions with high glucose content, and scintigraphy confirmed the existence of a definite pleuroperitoneal communication. She was managed by temporary substitution to haemodialysis, followed by suturing of the shunt and successful video-assisted thoracoscopic surgery (VATS) pleurodesis with an aldehyde-based surgical glue. Unexplained recurring dyspnoea in chronic CAPD should raise the suspicion of a possible pleuroperitoneal leak, even in patients without an apparent loss of ultrafiltration. Pleurodesis using an aldehyde-based adhesive was effective and tolerated well by our patient and may be considered in managing cases of recurrent pleural effusion. LEARNING POINTS: Recurrent dyspnoea in a chronic peritoneal dialysis patient should raise the diagnosis of a possible pleuroperitoneal leak, even if no apparent loss of ultrafiltration was observed.Minimally invasive surgical pleurodesis using surgical adhesive can be considered in cases of refractory pleuroperitoneal leak.

Circulating Biomarkers to Predict Diabetic Retinopathy in Patients with Diabetic Kidney Disease.

The purpose of this review is to outline the currently available circulating biomarkers to predict diabetic retinopathy (DR) in patients with diabetic kidney disease (DKD). Studies have extensively reported the association between DR and DKD, suggesting the presence of common pathways of microangiopathy. The presence of other ocular complications including diabetic cataracts may hinder the detection of retinopathy, which may affect the visual outcome after surgery. Unlike DKD screening, the detection of DR requires complex, costly machines and trained technicians. Recognizing potential biological markers related to glycation and oxidative stress, inflammation and endothelial dysfunction, basement membrane thickening, angiogenesis, and thrombosis as well as novel molecular markers involved in the microangiopathy process may be useful as predictors of retinopathy and identify those at risk of DR progression, especially in cases where retinal visualization becomes a clinical challenge. Further investigations could assist in deciding which biomarkers possess the highest predictive power to predict retinopathy in clinical settings.

Peritoneal dialysis in Indonesia: Current status, challenges and prospects.

Despite an increase in incident peritoneal dialysis (PD) use of 20% per year, the overall PD prevalence in Indonesia is only 1-2%, with the goal of 30% yet to be reached by 2019. In the absence of contraindications, increasing continuous ambulatory PD (CAPD) use may be an attractive option for Indonesia to reduce the high costs of end-stage kidney disease (ESKD) treatment. The implementation of CAPD in Indonesia faces several challenges, including the cost of PD, the unique archipelagic geography, limited facilities and trained medical personnel in rural areas, inadequate reimbursement rates and incentive fees, high rates of PD discontinuation, as well as insufficient knowledge regarding CAPD by the general public and health professionals. Changes in the policy of medical service incentive fees and improvements in the national health insurance system regulation over CAPD may improve the utilization of PD for ESKD patients in Indonesia. Nationwide promotional and preventive efforts on chronic kidney disease, dialysis modality education and establishment of PD training programs for medical professionals are necessary.

Pars-plana vitrectomy combined with retinectomy in severe open-globe injuries: A systematic review and meta-analysis.

BACKGROUND: This review summarized prophylactic retinectomy technique and its effect on anatomic and functional outcomes in severe open globe injuries (OGIs). METHODS: A comprehensive search in PubMed (MEDLINE), Embase, Scopus, and EuropePMC databases was performed up until 8 January 2020. Enrolled studies include case series, studies involving pars plana vitrectomy (PPV) combined with retinectomy in severe penetrating injuries with or without IOFB, perforating injuries, and globe ruptures. Primary outcome was best-corrected visual acuity (BCVA) ⩾20/200 at the end of the study. Secondary outcomes were the rate of proliferative retinopathy (PVR), globe survival rate and retinal reattachment rate. RESULTS: A total of seven studies, involving 275 eyes with severe OGIs, is included in this study. Meta-analysis indicates that final BCVA ⩾20/200 was achieved in 61% (95% CI 49%-73%). Meta-regression analysis showed that improvement was inversely affected by the presence of pre-operative direct macular injury (p = 0.001) and corneal scar (p = 0.015). The proportion of pre-operative BCVA <20/200 was statistically insignificant to the final BCVA ⩾20/200 (p = 0.569). One study showed that the rate is higher in the retinectomy group than the non-retinectomy group (54% vs 11%). Meta-analysis showed that anatomical success can be achieved in 85% (95% CI 78%-91%) of the patients. Meta-regression analysis indicates that the anatomical success did not vary with age (p = 0.653), retinal detachment (p = 0.525), corneal scar (p = 0.596), and lens involvement (p = 0.450). CONCLUSION: Early PPV combined with retinectomy was associated with acceptable visual improvement and anatomical success.

Pharmacological Treatment Options for Coronavirus Disease-19 in Renal Patients.

Patients with chronic kidney disease (CKD), including dialysis and transplant patients, are at greater risk of contracting SARS-CoV-2 due to kidney dysfunction and preexisting comorbidities. To date, a specific guideline on managing these high-risk patients infected with COVID-19 has not been established. As the current management of COVID-19 comprises mainly experimental drugs, the authors aim to provide information on dosing adjustments at different stages of kidney dysfunction and notable renal side effects. We performed a nonsystematical review of currently available COVID-19 drugs exploring several different clinical trial databases and search browsers. Several antivirals and monoclonal antibodies used in COVID-19 treatment require dosage adjustments in kidney dysfunction. In a global pandemic setting, nephrologists need to consider the appropriate dosage according to the renal function and closely monitor the side effects of different drug combinations to obtain the optimum therapeutic effect while avoiding further renal damage. Further studies are required to determine the safety and efficacy of these drugs in renal patients.

Acute Kidney Injury and Jaundice in a Patient With Concurrent Severe Malaria and Acute Exacerbation of Hepatitis B.

Patients chronically infected with hepatitis B virus (HBV) may travel to areas with high endemicity of malaria. The overlap between malaria and HBV infection can be clinically severe and present a diagnostic challenge as both diseases manifest similar symptoms. This case describes a fatal case of a 43-year-old man with chronic HBV infected with Plasmodium falciparum malaria that presents as acute kidney injury (AKI) and jaundice following a trip to malaria-endemic region. Despite administering antimalarial and 6 courses of renal replacement therapy, the patient's clinical condition did not improve, leading to septic shock, multi-organ dysfunction, and eventually, death. AKI and jaundice are commonly seen in severe P. falciparum malaria, as well as acute exacerbation of chronic HBV. This case emphasizes the importance to consider malarial screening when evaluating sick returning travelers, even in those with underlying chronic HBV. Given the severity of coinfection, prompt identification of this overlap can avert the rapid deterioration of severe malaria by early administration of intravenous artesunate and renal replacement therapy.

Combination of HSP90 and autophagy inhibitors promotes hepatocellular carcinoma apoptosis following incomplete thermal ablation.

The present study evaluated the effect of combining inhibitors (17­AAG) of heat shock protein 90 (HSP90) and autophagy (3­MA) on apoptosis using an incomplete thermal ablation animal model. A total of 28 orthotopic mice with hepatocellular carcinoma were randomly divided into 4 groups to receive different drug interventions. Following palliative laser ablation, changes in autophagy, apoptosis and Akt/mTOR expression levels were assessed in tumors. Compared with the controls, the 17­AAG­treated mice exhibited significantly decreased expression levels of phosphorylated (p)­Akt and p­mTOR with enhanced autophagy and apoptosis; no marked increases in the expression levels of p­Akt and p­mTOR were observed in the 3­MA­treated mice, with no significant changes in autophagy; however, apoptosis was enhanced. No significant decreases in p­Akt and p­mTOR or any increase in autophagy were observed in the mice receiving a combination of 17­AAG and 3­MA, but they did exhibit a marked increase in apoptosis. Compared with 17­AAG alone, the combination of 17­AAG and 3­MA resulted in a marked increase in apoptosis without enhanced autophagy. In the incomplete ablation model, the effects of autophagy and apoptosis are antagonistic. The combined use of 17­AAG and 3­MA can significantly promote apoptosis and is worthy of further study.

A prognostic model for hepatitis B acute-on-chronic liver failure patients treated using a plasma exchange-centered liver support system.

AIM: To determine the prognostic risk factors of patients with hepatitis B virus related acute-on-chronic liver failure (HBV-ACLF) treated with plasma exchange (PE)-based artificial liver support system (ALSS), and create a prognostic predictive model. METHODS: A total of 304 HBV-ACLF patients who received PE-based ALSS were retrospectively analyzed. Potential prognostic factors on admission associated with survival were investigated. Of note, 101 additional patients were analyzed to validate the performance of the prognostic models. RESULTS: According to 28-day survival, a total of 207 patients who survived and 97 non-survivors were identified in the derivation group. Overall, 268 (88.2%) ACLF cases were caused by reactivation of HBV. Cox proportional hazards regression model revealed that age, total bilirubin, ln (alpha-fetoprotein [AFP]), encephalopathy (HE) score, sodium level, and international normalized ratio (INR) were independent risk factors of short-term prognosis. We built a model named ALSS-prognosis model (APM) to predict the 28-day survival of HBV-ACLF patients with ALSS; the model APM showed potentially better predictive performance for both the derivation and validation groups than MELD, MELD-Na, and CLIF-C ACLF score. CONCLUSIONS: Low AFP was found to be an independent risk factor for high mortality in HBV-ACLF patients treated with PE-based ALSS. We generated a new model containing AFP, namely APM, which showed potentially better prediction performance than MELD, MELD-Na, and CLIF-C ACLF score for short-term outcomes, and could aid physicians in making optimal therapeutic decisions.