“Fleshy” Skin Cellulitis: A Triggering Factor for ANCA Associated Vasculitis

A 59-year-old lady with underlying hypothyroidism presented with acute contact dermatitis progressed to cellulitis with superimposed bacterial infection and acute kidney injury. She responded to initial management with antibiotics, but a week later, she had cutaneous and systemic vasculitis. Her skin biopsy consistent with immune-mediated leuko-cytoclastic vasculitis and her blood test was positive for cytoplasmic-anti-neutrophil cytoplasmic antibody (c-ANCA). A diagnosis of ANCA-associated vasculitis was made and she was treated with immunosuppressant with plasmapheresis and hemodialysis support for her kidney failure. Despite aggressive measures, the patient succumbed to her illness. This case report demonstrates that soft tissue infection could trigger the development of ANCA-associated vasculitis whilst a background of hypothyroidism serves as a predisposing factor as both condition were reported separately in a couple of case studies before

Intravenous Rituximab in Severe Refractory Primary Focal Segmental Glomerulosclerosis

Managing primary or even secondary glomerulonephritis remains a challenge to many nephrologists. In primary focal segmental glomerulosclerosis (FSGS) with heavy proteinuria, renin aldosterone system blockade and high dose of oral prednisolone is the mainstay of treatment. Other immunosuppressive medications like Cyclophosphamide, Cyclosporine A and Mycophenolate Mofetil (MMF) are warranted if a complete remission is not achieved. We illustrate a case of 21 year old gentleman with primary FSGS that was difficult to achieve remission despite on high dose steroid and oral Cyclophosphamide. He was also not responsive to a combination of MMF and Cyclosporine A (CSA) and even throughout the therapy he developed significant steroid and CSA toxicity. He presented to our center with severe nephrotic syndrome and acute kidney injury requiring acute haemodialysis. Despite re-challenged him again on high dose prednisolone, total of 2.4g of intravenous Cyclophosphamide, and MMF, he failed to achieve remission. He was subsequently given intravenous Rituximab 500mg/weekly for 4 doses and able to attained remission for 1 year. He relapsed again and a second course of Rituximab 500mg/weekly for 6 doses were given to attain remission. This case demonstrates the difficulty in managing refractory steroid dependent FSGS and we found that Rituximab is proven beneficial in this case to induce remission

"Fleshy" Skin Cellulitis: A Triggering Factor for ANCA Associated Vasculitis

A 59-year-old lady with underlying hypothyroidism presented with acute contact dermatitis progressed to cellulitis with superimposed bacterial infection and acute kidney injury. She responded to initial management with antibiotics, but a week later, she had cutaneous and systemic vasculitis. Her skin biopsy consistent with immune-mediated leuko-cytoclastic vasculitis and her blood test was positive for cytoplasmic-anti-neutrophil cytoplasmic antibody (c-ANCA). A diagnosis of ANCA-associated vasculitis was made and she was treated with immunosuppressant with plasmapheresis and hemodialysis support for her kidney failure. Despite aggressive measures, the patient succumbed to her illness. This case report demonstrates that soft tissue infection could trigger the development of ANCA-associated vasculitis whilst a background of hypothyroidism serves as a predisposing factor as both condition were reported separately in a couple of case studies before

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

The impact of educational intervention on attitude towards organ donation among healthcare workers in five hospitals in Malaysia

Introduction : The attitude of healthcare workers (HCW) are essential in influencing organ donation rates. Objective : The study aimed to assess the impact of educational intervention on attitudes towards organ donation among HCW. Methodology : A questionnaire-based interventional study was conducted among 458 HCW from five hospitals in Malaysia. A 26-item self-administered questionnaire was distributed online as a pre-intervention test. Afterwards, the respondents went through a website-based educative materials about organ donation and answered the same questionnaire again. Results : A total of 345 (75.3%) respondents completed the tests. Their attitude towards organ donation was positive pre-intervention. Following it, respondents expressed increase willingness to donate organs (P = 0.008) and their relatives’ organs (P <0.001); were more willing to adopt organ donation as part of the end-of-life care (P = 0.002) and were more comfortable to talk to relatives about organ donation (P = 0.001). There was increased willingness to admit patients to the Intensive Care unit for facilitating organ donation (P = 0.007); to employ the same resources to maintain a potential brain-dead donor (P <0.001); and to support organ donation if they or their relatives have end-stage organ failure (P = 0.008). However, there was increased negative attitude regarding association between organ donation with healthcare failure (P = 0.004), and with pain (P = 0.003). The positive attitude scores were higher following the intervention (P <0.001). Conclusion : An educational website-based intervention was able to improve HCW attitudes towards organ donation although some potential improvements are required

The Impact of educational intervention on attitude toward organ donation among health care workers in Malaysia

Background. The attitudes of the health care workers (HCWs) are essential in influencing organ donation rate. The aim of this study was to assess the effects of an educational intervention on attitudes toward organ donation among HCWs. Methods. A questionnaire-based interventional study was conducted with 458 HCW from 5 hospitals in Malaysia. A 26-item self-administered questionnaire was distributed online as a pre- intervention test. Respondents then went through website-based educational materials followed by a post-intervention questionnaire. Results. A total of 345 (75.3%) respondents completed the tests. Their attitude toward organ dona- tion was positive preintervention. After the intervention, respondents expressed an increase willingness to donate their own organs (P = .008) and their relatives’ organs (P < .001) after death; were more willing to adopt organ donation as part of end-of-life care (P =.002); were more comfortable talking to relatives about organ donation (P =.001); and expressed an increase consideration to execute the action at any time (P =.001). There was increased willingness to admit to the intensive care unit for facilitating organ donation (P =.007); to employ the same resources to maintain a potential brain-dead donor (P < .001); and to support organ donation in case they or their relatives were diagnosed with end-stage organ failure (P =.008). However, there was an increase in negative attitudes regarding the association between organ donation with health care failure (P =.004) and with pain (P =.003). Posi- tive attitude scores were higher after the intervention (P < .001). Conclusion. An educational website-based intervention was able to improve the attitudes of HCWs toward organ donation

Catheter-Related Bloodstream Infections and Catheter Colonization among Haemodialysis Patients: Prevalence, Risk Factors, and Outcomes

Introduction. Catheter-related bloodstream infection (CRBSI) and catheter colonization (CC) are two complications among haemodialysis (HD) patients that lead to increased morbidity and mortality. This study aims to evaluate the prevalence of CRBSI and CC among HD patients registered at Universiti Kebangsaan Malaysia Medical Centre and to identify the factors involved by focusing on the demographic profile of the patients as well as their clinical characteristics and outcomes. Method. This is a retrospective study of end-stage renal disease patients with suspected CRBSI during the period from 1 January 2016 to 31 December 2018. Data on patients who fulfilled the blood culture criteria for CRBSI and CC diagnosis were further analysed for clinical manifestations, comorbidities, history of dialysis, catheter characteristics, and microbiological culture results. The outcomes of CRBSI and CC were also assessed. Findings. In the 3-year period under study, there were 496 suspected CRBSI cases with a total of 175 events in 119 patients who fulfilled the inclusion criteria. During that time, the percentage of patients who experienced CRBSI and CC was 4.2% and 4.8%, respectively. The majority of the cohort consisted of male (59.4%), Malay ethnicity (75%), and patients on a tunnelled dialysis catheter (83%). Patients who were fistula naïve and had an internal jugular catheter were more common in the CRBSI group than in the CC group. The predominant microorganisms that were isolated were Gram-positive organisms. In terms of clinical presentation and outcome, no differences were found between the CRBSI and CC groups. Patients with Gram-negative bacteraemia, high initial c-reactive protein, and catheter salvation were likely to have poor outcomes. Recurrence of CRBSI occurred in 31% of the cohort. Neither catheter salvation nor antibiotic-lock therapy were associated with the recurrence of CRBSI. On the other hand, the femoral vein catheter site was associated with risk of recurrence. The overall mortality rate was 1.1%. Discussion. From the analysis, it was concluded that clinical assessment and positive culture are crucial in diagnosing CRBSI with or without peripheral culture. This study provides essential information for the local setting which will enable healthcare providers to implement measures for the better management of CRBSI

Community acquired multi drug resistant (MDR) Acinetobacter baumannii pneumonia in Malaysia – A case report

Acinetobacter baumannii is an aerobic Gram-negative coccobacillus that is associated with hospital acquired pneumonia. There is increased reporting of emergent cases of community acquired multidrug resistance (MDR) acinetobacter associated with a higher mortality due to antibiotic resistance. Community acquired MDR acinetobacter pneumonia has not been reported in Malaysia. Here we report a case of a 19-year-old army officer who presented with fever and respiratory symptoms for 5 days. He had no known medical illness before and no history of hospitalization. Upon arrival, he was in septicaemic shock, requiring invasive ventilator support and renal replacement therapy in intensive care unit. Chest radiograph showed bilateral lung consolidations and bronchoscopy revealed haemoserous and greenish bronchiole secretion. He was treated with broad spectrum antibiotics and oseltamivir. Unfortunately he died on day 3 of hospital admission. His bronchial lavage culture came back positive for MDR Acinetobacter baumannii. This case illustrates that clinicians need to be aware that MDR Acinetobacter baumannii can cause severe community acquired pneumonia. We may need to consider this diagnosis in patients who do not respond to standard therapy. Keywords: Acinetobacter baumannii, Multi drug resistance, Community acquired pneumoni

Breathlessness worsened by haemodialysis

A 54 year old lady with underlying chronic lung disease on long term oxygen therapy and end stage renal disease of unknown aetiology on regular haemodialysis for two years started developing progressive shortness of breath during her routine haemodialysis. She was unable to tolerate her haemodialysis sessions which had to be terminated prematurely in view of her symptoms despite adjustment of her dry weight and treatment of anaemia. She was not in chronic fluid overload and her symptoms always worsened after initiation of haemodialysis and improved after termination of haemodialysis. She was admitted to hospital for further investigations and initially treated for a lung infection but her symptoms did not improve. A computed tomography pulmonary angiography did not reveal any evidence of pulmonary embolism, and was consistent with chronic fibrotic changes. Her hypoxemia was concluded to be due to her underlying chronic lung disease, worsened by alveolar hypoventilation during haemodialysis. Her symptoms improved slightly with supplemental oxygen during her routine haemodialysis but we had to shorten her haemodialysis duration to 3 hours. Keywords: Chronic lung disease, End stage renal disease, Haemodialysis, Hypoxemia, Hypoventilatio