Maternal and fetal outcomes in pregnant patients with lupus nephritis

Background: Pregnancy in a woman with lupus nephritis (LN) carries a high risk of maternal and fetal morbidity and mortality. This study aims to analyze the effect of LN on maternal and fetal outcomes and lupus activity.Methods: In a single-center, cross-sectional observational study at national hospital Kandy, 32 pregnancies in 23 women with biopsy-proven LN between 2007 and 2019 were analyzed retrospectively.Results: Mean age at pregnancy was 28.4 years (SD=4.8, range 19–38 years). In six women, LN developed during pregnancy, 17 patients were already diagnosed with LN when they became pregnant. A renal biopsy performed 4.6 (SD=3.8) years before pregnancy, showed diffuse LN in 18 (78.3%) and focal LN in 5 (21.7%) cases. At conception, most patients were in complete (43.8%) or partial (21.9%) remission. Therapeutic abortion was performed in 8 pregnancies (indications: renal flares in 5, pre-eclampsia in 3) at a mean period of amenorrhea (POA) of 16.8 weeks (range 8-28 weeks). Spontaneous fetal loss occurred in one pregnancy. Among 23 live births, there were four pre-term deliveries (0.05) between LN histological type, initial clinical presentation and treated hypertension with fetal outcome. No case of neonatal lupus or congenital heart block was noted. During pregnancy, there were five (15.6%) renal flares and two acute kidney injury cases; all were reversible. Eight patients (25%) developed PIHConclusions: Pregnancy induced hypertension is a more commonly encountered complication in pregnancies with lupus nephritis. The fetal outcome is unfavorable in pregnancies with renal flares.

A study of lipid profile and glycemic status in patients with chronic kidney disease of unknown etiology in Sri Lanka

Background: Dyslipidemia and impaired glucose tolerance are common complications of chronic kidney disease (CKD) and are responsible for increased cardiovascular risk. Studies on lipid profile and glycemic status in CKD of unknown origin (CKDu) are scarce. The objective of this study was to evaluate the lipid profile and glycemic status of the patients with CKDu and to aid in preventing morbidity and mortality.Methods: The descriptive, cross sectional study was conducted in a rural CKDu endemic area, Girandurukotte.  Data was collected from February 2018 to June 2019. For the diagnosis of CKDu, history and clinical features with supportive biochemical, renal biopsy and radiological evidence were taken as criteria. Blood samples were taken for serum creatinine, lipid profile and HbA1C. Already diagnosed patients with diabetes mellitus and dyslipidemia were excluded.Results: A total of 168 patients within the age range of 32-66 years (mean 50.3±7.7) were participated. There were 106 males (63%) 46.4% were farmers. Majority of the patients (65.5%) had normal body mass index (BMI) (mean 22.9 kg/m2, normal range 18.5-23.5%) followed by overweight (23.5-30 kg/m2) in 55 (32.7%) patients. The prevalence of dyslipidemia in CKDu was found to be 55.9%.  Majority of the abnormality was seen in the HDL group with 68 (40.5%) patients having low HDL cholesterol (mean 44.7 mg/dl, SD=12.3).  There was a significant rise in the serum triglyceride concentration (>150 mg/dl) in 53 (31.5%) (mean 152.4 mg/dl, SD=73.5) and total cholesterol (>200 mg/dl) in 30 (18%) patients (mean 182 mg/dl, SD=36.9). LDL cholesterol abnormality (>130 mg/dl) was seen in only 9 patients (mean 88.7 7658mg/dl, SD=25.4). From the total, 144 (85.7%) patients had abnormal HbA1C levels; 27 (16.1%) patients had HbA1C levels between 5.7% and 6.4% (pre-diabetes), and 117 (69.6%) patients had HbA1C level more than 6.5% (diabetes mellitus). There was no statistically significant association between HbA1C levels and BMI (p=0.29) or HbA1C and lipid abnormalities (p=0.32)Conclusions: The high prevalence of dyslipidemia, pre-diabetes and diabetes mellitus in patients with CKDu may accelerate the progression of chronic kidney disease and increase the risk of cardiovascular disease. Early detection, initiation of appropriate medication and early referral to the expertise will ameliorate morbidity and mortality.

Body composition in lupus nephritis patients

Background: The assessment of body fat distribution is an important evaluation in patients with lupus nephritis (LN), which does not practice routinely. The objectives of this study were to determine the body composition by using bioelectrical impedance analysis and to identify the effects of age, body mass index, disease activity, and corticosteroid therapy on body composition.Methods: This was a single-centered, cross-sectional, and observational study conducted at the nephrology unit, National Hospital Kandy, Sri Lanka. Seventy-nine patients with biopsy-proven LN have participated in the study.Results: There were 79 lupus nephritis patients enrolled in this study. The duration of LN ranged from 8 months to 32 years. The main non-renal clinical manifestations included skin lesions (59%), arthritis (54%), and oral ulcers (48%). The disease activity was low with a mean SLEDAI score of 1.01 (SD=2.3). The body fat (BF) percentage (p=0.002) and subcutaneous fat (SF) percentage (p<0.001) were significantly low in males compared to females. And, BF percentage was significantly low among patients with SLEDAI-2K 6 (p=0.03). Moreover, there were positive correlations found between SLE disease activity with the BMI (p=0.004), body fat percentage (p=0.001), and visceral fat percentage (p=0.001).Conclusions: Females are more prone to have a high mean value of body composition parameters than males in this study. There is a negative influence of the body composition parameters reported against the disease activity among LN patients in Sri Lanka.

Early ultrasound surveillance of newly-created haemodialysis arteriovenous fistula

IntroductionWe assess if ultrasound surveillance of newly-created arteriovenous fistulas (AVFs) can predict nonmaturation sufficiently reliably to justify randomized controlled trial (RCT) evaluation of ultrasound-directed salvage intervention.MethodsConsenting adults underwent blinded fortnightly ultrasound scanning of their AVF after creation, with scan characteristics that predicted AVF nonmaturation identified by logistic regression modeling.ResultsOf 333 AVFs created, 65.8% matured by 10 weeks. Serial scanning revealed that maturation occurred rapidly, whereas consistently lower fistula flow rates and venous diameters were observed in those that did not mature. Wrist and elbow AVF nonmaturation could be optimally modeled from week 4 ultrasound parameters alone, but with only moderate positive predictive values (PPVs) (wrist, 60.6% [95% confidence interval, CI: 43.9–77.3]; elbow, 66.7% [48.9–84.4]). Moreover, 40 (70.2%) of the 57 AVFs that thrombosed by week 10 had already failed by the week 4 scan, thus limiting the potential of salvage procedures initiated by that scan’s findings to alter overall maturation rates. Modeling of the early ultrasound characteristics could also predict primary patency failure at 6 months; however, that model performed poorly at predicting assisted primary failure (those AVFs that failed despite a salvage attempt), partly because patency of at-risk AVFs was maintained by successful salvage performed without recourse to the early scan data.ConclusionEarly ultrasound surveillance may predict fistula maturation, but is likely, at best, to result in only very modest improvements in fistula patency. Power calculations suggest that an impractically large number of participants (>1700) would be required for formal RCT evaluation

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Fever of unknown origin in a male patient with systemic lupus erythematosus

Background: Systemic lupus erythematosus (SLE) is an inflammatory autoimmune disorder which is uncommon in men. It has a wide variety of clinical presentations. Case Report: We report a 21-year-old male presented with one month history of fever, loss of appetite, weight loss and reduced hair growth with an examination revealing an oral ulcer, cervical and axillary lymphadenopathy simulating hematological malignancy. Investigations showed pancytopenia, positive anti-nuclear factor and double-stranded DNA, high erythrocyte sedimentation rate with normal C-reactive protein levels and hypocomplementemia. The diagnosis of systemic lupus erythematosus was made and treatment with oral prednisolone conferred a dramatic clinical and biochemical improvement within one week. Conclusion: In the evaluation of fever of unknown origin, one should be guided by the presenting symptoms and signs of a patient and even though uncommon, SLE is a worthwhile diagnosis to investigate even in a male patient if the clinical picture is suggestive

Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study an international prospective cohort study

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care. We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care