Post transplant lymphoproliferative disorder

Introduction: Post-transplant lymphoproliferative disorder (PTLD) is a recognized complication exclusive to solid organ transplant recipients and carries a high mortality. Methods: We retrospectively reviewed records of all renal transplant recipients under follow up at our institution over the last seven years (2005-2011). We reviewed the patient characteristics, immunosuppression regimen and risk factors for the development of PTLD and its outcomes in our transplant cohort. Results: Four out of 63 patients were diagnosed with PTLD. PTLD was incidentally diagnosed on a transplant biopsy that was performed for an unexplained rise in serum creatinine in three patients. The fourth patient presented with left submandibular lymphadenopathy. Majority presented within 18 months of renal transplantation. After the diagnosis of PTLD on graft biopsy, all patients were fully investigated and two patients had systemic involvement. In the patients with systemic involvement, reduction of immunosuppression and anti B cell therapy with Rituximab was used with good success. The patient with submandibular lymphadenopathy received chemotherapy in addition to reduction of immunosuppression. Three PTLD cases were polyclonal and diagnosed early whereas the fourth case was monoclonal. Conclusion: PTLD can sometimes be incidentally diagnosed on an allograft biopsy performed for rejection. The incidence of PTLD in our centre is higher than reports from other centres but our outcome is good if recognised and treated early

Vitamin K status in diabetic patients with chronic kidney disease stage 3-5 and its effects on chronic kidney disease - mineral bone disorder

Diabetic kidney disease (DKD) is common in Malaysia. Vitamin K deficiency among DKD patients may be associated with higher incidence of chronic kidney disease-mineral bone disorder (CKD-MBD). This study was conducted to determine the prevalence of vitamin K deficiency in diabetic patients with CKD stage 3-5. We also correlated vitamin K deficiency with baseline demographic, biochemical results and analysed the effects of vitamin K levels on CKD-MBD. This was a single centre cross-sectional study on diabetic patients with CKD stage 3-5. Demographic profiles were recorded, blood samples were measured for vitamin K level (phylloquinone, proteins induced by vitamin K absence II (PIVKA-II), prothrombin time) and bone markers (parathyroid hormone (PTH), alkaline phosphatase, corrected calcium and phosphate). This study was approved by UKM ethic and research committee (FF-2018-375). Forty-five patients with a median age of 70 (IQR:13) years were recruited. Majority were females (53.3%) and Malays (64.4%). Prevalence of patients with insufficient vitamin K was 28.9 % based on the low level of phylloquinone (0.66 ng/mL) and 2.2% based on prolonged prothrombin time (>14.5 s). PIVKA-II was found to be positively correlated with serum creatinine and PTH levels. There were positive correlations between phylloquinone with serum triglyceride and total cholesterol. Prothrombin time was found to be negatively correlated with corrected calcium and total cholesterol. Malay race (p = 0.039) and high serum PTH (p = 0.016) were significantly associated with higher PIVKA-II concentrations. Multivariable analysis showed serum triglyceride (OR 0.112; CI 95 % (0.02-0.66); p = 0.017) and serum PTH (OR 1.997; CI 95 % (1.01-3.95); p = 0.047) were independent predictors for abnormal phylloquinone and PIVKA-II levels, respectively. In conclusion, the prevalence of Vitamin K deficiency was high in diabetic patients with CKD stage 3-5. Serum triglyceride and serum PTH were independent predictor of Vitamin K deficiency

Association between health-related quality of life and psychological distress at different stages of chronic kidney disease

The prevalence of chronic kidney disease (CKD) have increased and become one of the major public health concerns worldwide including Malaysia. Previous studies on CKD generally focused on patients who were already undergoing dialysis treatment; however, studies investigating the stresses experienced by pre-dialysis CKD patients were limited. This study aimed to examine the prevalence of psychological distress and their association with the Health Related Quality of Life (HRQoL) during the different stages of CKD. This cross-sectional study involved 200 pre-dialysis patients from stages 3 to 5, who were recruited from the Nephrology Clinic at the National University of Malaysia Medical Centre (UKMMC). The instruments used in this study were the Short Form 36 (measuring HRQoL) and Hospital Anxiety and Depression Scale (HADS) to measure the psychological distress. The results showed that the prevalence of depression and anxiety increased proportionally with the CKD stages. The HRQoL sub-component scores declined as the CKD stages increased except for social functioning. An impaired HRQoL was associated with depression and anxiety in the CKD patients. The results suggested that it is very important to manage kidney disease at an early stage and that a healthier lifestyle is adopted

Blood pressure profile in contiuous ambulatory peritoneal dialysis patients

Background: Cardiovascular mortality is the leading cause of death in end stage renal disease. Despite being on continuous ambulatory peritoneal dialysis (CAPD), blood pressure (BP) remains poorly controlled. A higher pulse pressure and non dipping are associated with increased cardiovascular mortality. We studied BP control and the prevalence of non dipping in CAPD patients. Methods: All patients undergoing CAPD at our institution who met the inclusion criteria were recruited. We compared BP control and dipping status in diabetic and non diabetic pa-tients on CAPD. We also determined whether BP and peritoneal membrane permeability were associated. Results: Forty six patients with a mean age 45 ± 13 years were enrolled. Diabetic patients were older (mean age 54 ± 13 vs. 40 ± 11 yrs, p <0.001), had a lower mean diastolic BP (80 ± 14 vs. 90 ± 14 mmHg, p = 0.025) and a higher mean pulse pressure (59 ± 17 vs. 49 ± 14 mmHg, p = 0.035). They were also non dippers (n = 15 vs. n = 1, p = 0.007). The low and low average transporters tended to have a higher systolic BP (p = 0.054) and a higher pulse pressure (p = 0.058). On multivariate analysis, age was the main predictor of pulse pressure. Conclusion: Despite being on chronic maintenance PD, BP was not well controlled. Diabetic patients had a higher pulse pressure and were non dippers thereby increasing their cardiovascular risk. We should therefore optimize BP control and aim to restore the nocturnal dip in these patients

Current clinical practice in adapted automated peritoneal dialysis (aAPD)-A prospective, non-interventional study

Insuficiència renal crònica; Diàlisi peritonealFallo renal crónico; Diálisis peritonealChronic Kidney Failure; Peritoneal DialysisAdapted automated peritoneal dialysis (aAPD), comprising a sequence of dwells with different durations and fill volumes, has been shown to enhance both ultrafiltration and solute clearance compared to standard peritoneal dialysis with constant time and volume dwells. The aim of this non-interventional study was to describe the different prescription patterns used in aAPD in clinical practice and to observe outcomes characterizing volume status, dialysis efficiency, and residual renal function over 1 year. Prevalent and incident, adult aAPD patients were recruited during routine clinic visits, and aAPD prescription, volume status, residual renal function and laboratory data were documented at baseline and every quarter thereafter for 1 year. Treatments were prescribed according to the nephrologist's medical judgement in accordance with each center's clinical routine. Of 180 recruited patients, 160 were analyzed. 27 different aAPD prescription patterns were identified. 79 patients (49.4%) received 2 small, short dwells followed by 3 long, large dwells. During follow-up, volume status changed only marginally, with visit mean values ranging between 1.59 (95% confidence interval: 1.19; 1.99) and 1.97 (1.33; 2.61) L. Urine output and creatinine clearance decreased significantly, accompanied by reductions in ultrafiltration and Kt/V. 25 patients (15.6%) received a renal transplant and 15 (9.4%) were changed to hemodialysis. Options for individualization offered by aAPD are actually used in practice for optimized treatment. Changes observed in renal function and dialysis efficiency measures reflect the natural course of chronic kidney disease. No safety events were observed during the study period.The study has been funded by Fresenius Medical Care. The funder was involved in the design, analysis, decision to publish and preparation of the manuscript

Role of febuxostat in retarding progression of diabetic kidney disease with asymptomatic hyperuricemia

Introduction: Hyperuricemia is associated with chronic kidney disease (CKD) progression and poor cardiovascular outcomes. We studied the effect of febuxostat on estimated glomerular filtration rate (eGFR), proteinuria and monitored the safety profile of the medication. Material and Methods: This is a prospective open-label, randomized study in CKD stage 3 and 4 patients with diabetic nephropathy and asymptomatic hyperuricemia. Patients were randomized into febuxostat 40 mg daily and no treatment group using block randomization method and were followed up for 6 months. Their usual care for diabetes mellitus, hypertension and dyslipidemia were continued in the study. Blood and urine investigations were monitored at baseline, 3 months and 6 months. Results: The eGFR in febuxostat group was stabilized at 6 months with no significant reduction [26.2 (IQR 14.30) at baseline to 26.3 (IQR 15.2) ml/min/1.73 m2]. Whereas, there was a significant reduction of the eGFR in no treatment group from 28.2 (IQR 17.9) to 27.6 (IQR 19.3) ml/min/1.73 m2 (p value < 0.01). We found the HbA1c (glycosylated hemoglobin) was significantly increased in febuxostat group from 7.2 ± 0.5 % at baseline to 7.6 ± 1.4 at 6 months (p value 0.04) but no significant change of HbA1c in the no treatment group. Proteinuria level was unchanged in both groups. The commonest adverse event was joint pain. Conclusions: Febuxostat was able to preserve eGFR in CKD patients with diabetic nephropathy and this effect was beyond glycemic control. Increment of HbA1c level in febuxostat group needs further larger trials

Evaluating cardiovascular risk in chronic kidney disease patients: a biomarker approach

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in chronic kidney disease (CKD) patients. This study aimed to determine the roles of CVD biomarkers in CKD patients. This was a case-control study which recruited consecutive patients with stage 2-4 CKD patients with and without CVD. Serum levels of highly-sensitive C reactive protein (hs-CRP), cystatin C (CysC), asymmetrical dimetylarginine (ADMA) and symmetrical dimethylarginine (SDMA) were measured. Sixty two stage 2-4 CKD patients with a mean age of 60.3 ± 10.4 years were recruited. Twenty three (37.1%) of them had CVD. Those CKD patients with CVD were older (64.1±8.0 vs 58.1± 1.1, p0.05). There were no differences in their mean serum levels of hs-CRP, CysC, ADMA and SDMA. Risk factors including age, diabetes mellitus, hypertension and renal functions were still the most important CVD risk factors in CKD patients

Blood fatty acid status and clinical outcomes in dialysis patients: a systematic review

Blood fatty acids (FAs) are derived from endogenous and dietary routes. Metabolic abnormalities from kidney dysfunction, as well as cross-cultural dietary habits, may alter the FA profile of dialysis patients (DP), leading to detrimental clinical outcomes. Therefore, we aimed to (i) summarize FA status of DP from different countries, (ii) compare blood FA composition between healthy controls and DP, and (iii) evaluate FA profile and clinical endpoints in DP. Fifty-three articles from 1980 onwards, reporting FA profile in hemodialysis and peritoneal DP, were identified from PubMed, Embase, and the Cochrane library. Studies on pediatric, predialysis chronic kidney disease, acute kidney injury, and transplant patients were excluded. Moderate to high levels of n-3 polyunsaturated fatty acids (PUFA) were reported in Japan, Korea, Denmark, and Sweden. Compared to healthy adults, DP had lower proportions of n-3 and n-6 PUFA, but higher proportion of monounsaturated fatty acids. Two studies reported inverse associations between n-3 PUFAs and risks of sudden cardiac death, while one reported eicosapentaenoic acid + docosahexaenoic acid)/arachidonic acid ratio was inversely associated with cardiovascular events. The relationship between all-cause mortality and blood FA composition in DP remained inconclusive. The current evidence highlights a critical role for essential FA in nutritional management of DP

Efficacy of nutritional interventions on inflammatory markers in haemodialysis patients: a systematic review and limited meta-analysis

Low-grade chronic inflammation is prevalent in patients undergoing haemodialysis (HD) treatment and is linked to the development of premature atherosclerosis and mortality. The non-pharmacological approach to treat inflammation in HD patients through nutritional intervention is well cited. We aimed to assess the efficacy of different nutritional interventions at improving inflammatory outcomes in HD patients, based on markers such as C-reactive protein (CRP), interleukin-6 (IL-6), and tumour necrosis factor-α (TNF-α). We searched PubMed, Cochrane Library, and Embase for randomized controlled trials (RCT) published before June 2017. Inclusion criteria included RCTs on adult patients on maintenance HD treatment with duration of nutritional interventions for a minimum 4 weeks. Risk of bias was assessed using the Jadad score. In total, 46 RCTs experimenting different nutritional interventions were included in the review and categorized into polyphenols rich foods, omega-3 fatty acids, antioxidants, vitamin D, fibres, and probiotics. Meta-analyses indicated significant reduction in CRP levels by omega-3 fatty acids (Random model effect: −0.667 mg/L, p < 0.001) and vitamin E (fixed model effect: −0.257 mg/L, p = 0.005). Evidence for other groups of nutritional interventions was inconclusive. In conclusion, our meta-analysis provided evidence that omega-3 fatty acids and vitamin E could improve inflammatory outcomes in HD patients

Investigating physical and nutritional changes during prolonged intermittent fasting in hemodialysis patients: a prospective cohort study

Objective: Studies investigating the health effects of prolonged intermittent fasting during Ramadan among Muslim patients on hemodialysis (HD) are limited and reported heterogeneous findings. This study aimed to evaluate the effects of intermittent fasting during Ramadan on nutritional and functional status of patients on maintenance HD. Design and methods: This was a 12-week, multicenter, prospective observational study. The study setting included three HD centers. Adult Muslim patients, who were undergoing HD session thrice weekly and planned to fast during Ramadan, were screened for eligibility and recruited. Nutritional and functional status assessments were carried out 2 weeks before (V0), at the fourth week of Ramadan (V1), and 4 weeks after Ramadan (V2). Nutritional status parameters included anthropometry (body mass index, interdialytic weight gain, waist circumference), body composition (mid-arm circumference, triceps skinfold, body fat percentage), blood biochemistry (albumin, renal profile, lipid profile, and inflammatory markers), blood pressure, dietary intake, and handgrip strength. Changes in nutritional and functional status parameters across study timepoints were analyzed using repeated-measures analysis of variance. Results: A total of 87 patients completed the study, with 68 patients (78.2%) reporting fasting ≥20 days. Ramadan fasting led to significant reductions (all P .05). Significant improvement was observed in serum phosphate levels, but serum albumin, urea, and creatinine were also reduced significantly during Ramadan (P < .05). There were no significant changes in lipid profile and inflammatory markers. Interestingly, energy and protein intakes remain unchanged during Ramadan. Handgrip strength improved significantly during Ramadan and further improved after Ramadan. Conclusion: Intermittent Ramadan fasting leads to temporary changes in nutritional status parameters and poses nondetrimental nutritional risk for patients on maintenance HD