Renal biopsy: a much needed tool in patients with Systemic Lupus Erythematosis [SLE]

Background and Objective: Systemic lupus erythematosis [SLE] is an inflammatory disorder associated with significant morbidity and mortality. Kidneys are frequently affected in SLE and various stages of lupus nephritis have been identified based on severity of the disease. Treatment varies with the staging and correct diagnosis is essential for timely intervention as it can have significant impact on morbidity and mortality.The objective of the study was to determine whether laboratory parameters of lupus nephritis [LN]; including urinalysis, serum creatinine [S. Cr] and 24 hours urine protein can accurately predict histologic staging of the disease

Methods: This retrospective study was conducted in department of Nephrology, Liaquat National Hospital Karachi from January 2012 to December 2014. Fifty one patients of SLE who underwent renal biopsy were selected. Patients, urinalysis at the time of renal biopsy, serum creatinine and 24 hours urine collection for protein were noted. All patients renal biopsy was read by the same pathologist. Patients were clinically staged based on these parameters and their histologic staging based on biopsy findings were compared, to see their correlation. Data was analyzed using SPSS version 17. Chi-square test was used to analyze categorical data and p<0.05 was considered significant. Cohen's kappa [kappa] analysis was used to examine the agreement by comparing lupus nephritis staging done by laboratory and histological ground. P value <0.05 indicates that agreement was unlikely due to chance alone

Results: Among 51 patients analyzed, 37 patients were females [72.5%] and 14 patients were males [27.5%] with mean age of 32.51 + 16.91 years. In stage II, kappa [kappa] of 0.304 represented fair strength of agreement and a p value of 0.012 [p<0.05] which was statistically significant. In stage III, kappa was 0.209 indicating none to slight agreement and a p value of 0.131 [p>0.05]. In stage IV, kappa [kappa] was 0.141 [slight agreement] and p value 0.301 [p>0.05] in stage V; kappa [kappa] of 0.030 represented poor agreement and a p value of 0.828 [p>0.05]

Conclusion: Staging of lupus nephritis done on basis of laboratory findings did not correlate well with underlying histological staging. Therefore, renal biopsy is an essential tool in approach to lupus nephritis in order to provide timely and appropriate treatment to patients

Immune response to hepatitis B vaccination in hemodialysis patients

Background: Hemodialysis patients are vulnerable to infections with Hepatitis B Virus and hepatitis C virus [HCV]. Patients who are on maintenance hemodialysis are considered as high-risk group for acquiring hepatitis B virus, resulting in high morbidity and mortality. Therefore, to vaccinate them against the virus is mandatory. Compared to a response rate of over 90% in the normal population, only 50 to 60% of those with end-stage renal disease achieve adequate antibody levels following immunization and the objective of this study was to determine the antibody level after Hepatitis B vaccination in chronic hemodialysis patients

Methods: 118 patients, undergoing chronic hemodialysis [HD] at the dialysis unit of Liaquat National Hospital, fulfilling the inclusion and exclusion criteria were enrolled between April 2013 and September 2013, after taking informed consent and approval from ethical review committee. AntiHbs [Hepatitis B surface antibody] titers were measured. Patients were differentiated as Immune and non immune based on antibody titers, with levels of >10IU/l being considered as immune and levels of <10IU/las non immune. AntiHbs titer was measured by ELISA [Enzyme Linked Immunosorbant Assay]. Data was analyzed using SPSS version 14.0 for windows. Chi square test were used to ascertain the statistical significance. P value <0.05 was taken as statistically significant. In addition, the effect of age, gender and duration of Hemodialysis on antibody titer was also observed

Results: Out of 118 patients enrolled, 103 [87.3%] had an adequate antibody response and were considered immune while only 15 patients [12.7%] had an inadequate antibody response rendering them non immune. AntiHbs titers showed no significant co-relation with gender and duration of Hemodialysis therapy[p>0.05], while age was found to have significant correlation as younger age group [<60years] had more immune response [p<0.001]

Conclusion: Our study showed a very good antibody response to Hepatitis B vaccination among hemodialysis patients that correlated with age with younger age group having a better response but no correlation to gender and duration of dialysis

Frequency of pulmonary hypertension in hemodialysis patients

Pulmonary hypertension [PH] has been described in hemodialysis [HD] patients and has been associated with increased morbidity and mortality. Our objective was to determine the prevalence of pulmonary hypertension in patients on regular hemodialysis. This cross sectional study was conducted in Department of Nephrology, Liaquat National Hospital Karachi from April 2013 to March 2014. Eighty patients of end stage renal disease [ESRD], on maintenance hemodialysis [HD]; underwent Trans thoracic Echocardiography were selected. Systolic pulmonary arterial pressure [SPAP] was recorded. Pulmonary hypertension was defined as, pulmonary artery pressure [PAP] greater than 30 mm Hg at rest. Pulmonary hypertension was further divided into mild [PAP b/w 30-45mmHg], moderate [PAP b/w 45-65mmHg] and severe pulmonary hypertension [PAP > 65mmHg]. The effect of different vascular accesses, age, gender, dialysis vintage on the development of pulmonary hypertension was observed. Out of 80 patients, 45 patients [56%] had pulmonary hypertension [PH]; 25 [55.5%] had moderate, 13 [29%] had mild, and 7 [15.5%] patients had severe pulmonary hypertension [PH]. Pulmonary hypertension was present in 41 [60%] patients with AVF, 3 [27%] patients with tunnel cuffed catheter and 1 patient had AV bridge graft. Pulmonary hypertension was more common in females; present in 28 females [67%] and 17 males [45%], that was statistically significant [p<0.05]. Mean duration of hemodialysis in [months] of patients with PH was 20.93 +/- 12 vs. 10.29 +/- 10 in patients without PH [p<0.05]. Age had no relation to development of PH. ESRD patients on HD have strong tendency to develop PH. Our study demonstrated that PH is more common among females. Duration of hemodialysis and AV access has strong relation to the development of PH

Pre dialysis care and types of vascular access employed in incident hemodialysis patients: a study from Pakistan

To determine frequency of different vascular access use in Incident hemodialysis [HD] patients and determine whether predialysis care in terms of timely advice for vascular access placement was better in the hands of nephrologist. A cross sectional study was conducted. Data was collected on the type of access used for first HD, including temporary Central venous catheters [CVC], permanent CVC [Permacath], arteriovenous fistula [AVF], or arteriovenous graft [AVG]. In addition, information was also gathered if patients were aware of their renal disease and was followed by other physicians or nephrologist. A total of 120 patients were enrolled in the study, 80% required CVC as their first access for HD [96/120 patients] out of which 74.2% were dialyzed through temporary catheter and 5.8% through Permacath. About 20% of patients were dialyzed through mature Arteriovenous [AV] access. Majority [95.8%] of patients were being followed by any health care provider. 68% of them were aware of their renal disease. About 55.8% were referred to nephrologist and 40% were followed by other physicians. About 83.5% of patients followed by nephrologist were advised AV access prior to commencing HD, compared to only 10.4% followed by other physicians [p < 0.05]. 24/61 [39.3%] patients that were advised AV access by both groups had timely made AV access and underwent HD by it. Very high incidence of temporary HD catheter was used in Incident HD patients. Moreover, pre dialysis care in terms of placement of AV access prior to initiating HD is better in the hands of nephrologist and patients should be timely referred to nephrologist especially when they have Stage 4 chronic kidney disease [CKD]

CT guided renal biopsy: Safety and efficacy, a study in Pakistan

Percutaneous renal biopsy [PRB] of native kidney with automated spring loaded device is performed with various techniques to improve efficacy and safety .This study was performed to evaluate[1] the safety and efficacy of PRB performed under CT guidance[2] time to develop complications to see whether this procedure can be performed as outpatient[3] diagnostic yield of the specimen. The study was conducted at the Department of Nephrology of Dr. Ziauddin Hospital, on all patients admitted for renal biopsy between 1[st] January 2009 to 31[st] December 2011. PRB was performed on native kidneys by experienced nephrologist under CT guidance with a 18 guage automated spring loaded biopsy gun. Patients were included if they fulfilled the inclusion criteria. All patients were observed for 24 hours post biopsy for major complications like gross hematuria, drop in hemoglobin requiring transfusion, or requiring surgical or radiological intervention and minor complications like transient hematuria, spontaneously resolving perinephric hematoma and their timing of development. In addition, information was gathered regarding diagnostic yield of the specimen. 100 consecutive biopsies were performed. There were no major complications in 98% of the biopsies. 2% patients developed gross hematuria and significant hematoma with a drop in hemoglobin that required blood transfusion. 2% of patients developed minor complications. 100% of the specimen had adequate tissue for making the diagnosis. All major complications developed within 12 hours of procedure. The minor complication occurred at 18 hrs. PRB under CT guidance is a safe and effective procedure; however recommendations can not be made to perform it on outpatient basis