De Novo Focal Segmental Glomerulosclerosis (FSGS) Post Covid 19 Vaccination: Case Series in A Single Centre in Malaysia

@#Introduction: Mass COVID-19 vaccination has been pivotal in the fight against this pandemic. The occurrence of glomerular disease following COVID-19 vaccinations particularly mRNA vaccine has been reported. The reported cases in the region are limited and number of cases reported are low in contrast to the total number of vaccine doses given worldwide, the healthcare providers should be alerted about such issues to provide swift and proper management. Case Series: Here, we report 3 cases of Focal segmental glomerulosclerosis (FSGS) following COVID-19 vaccination and their outcomes. Two of the patients received BNT162b2 vaccination and one received CoronaVac vaccination. The mean age of the patients was 33+/-7 years old. The mean duration onset of FSGS was 23+/-19 days post vaccinations. Two of the patients (BNT162b2 vaccination and CoronaVac vaccination) achieved complete remission after corticosteroid therapy. This is the first reported case of De Novo FSGS following CoronaVac vaccination in the literature. The third patient, who received BNT162b2 vaccination and presented late (42 days post vaccination) was not in remission despite three months of immunosuppressive treatment. Conclusion: The treating physician needs to be aware of the possibility of the development of FSGS associated with COVID-19 vaccination and how to proceed with vaccination schedule in these populations. Overall, the advantage of COVID-19 vaccination far outweighs the possibility of COVID-19 vaccine-associated glomerular disease.

A Rare Case of Factor Xii Deficiency in a Pregnant Woman

@#Factor XII deficiency, also known as the Hageman factor, is a rare disorder that has not been associated with any adverse outcomes. It is an interesting blood disorder whereby in the state of deficiency, it causes prolongation activated partial thromboplastin time (aPTT) which is correctable with mixing test. Although there have been case reports that have mentioned events of thrombosis and bleeding, however, no clear causal relationship has been established. Evidence for adverse events occurring in patients with Factor XII deficiency is sparse. We report here a case of a lady with a history of miscarriages who was incidentally found to have Factor XII deficiency during a routine workup for prolonged aPTT.

Streptococcus plurianimalium Peritonitis in a Patient on Continuous Ambulatory Peritoneal Dialysis: A Case Report

@#Streptoccoccus plurianimalium is a rare pathogen that has recently made a crossover from its common host, animals to humans. As reports start to emerge from this pathogen, it has come to light that it can cause clinically significant infections in a broad spectrum of systems. However, the mode of transmission of this pathogen has not yet been fully established. We report here a case of Streptoccoccus plurianimalium peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis in our centre. To the best of our knowledge, this is the first case report of a Streptoccoccus plurianimalium peritonitis in an end-stage kidney disease patient.

Diabetic Ketoacidosis in End Stage Renal Failure Patient On Maintenance Dialysis – Key Challenges in Management

@#Diabetic ketoacidosis (DKA) is a medical emergency which requires prompt management to prevent mortality. Treatment is complicated in end stage renal failure (ESRF) patients due to their altered physiology in sugar metabolism and fluid haemodynamics. To date, there are only a few case reports illustrating the presentation and management of DKA in ESRF patients and a definite guideline on treatment of DKA in ESRF is seriously lacking. We report here a case of an ESRF patient on maintenance haemodialysis, who develops DKA due to missed insulin, and outline our successful treatment plan. We hope our reported case report research can further contribute to the knowledge of DKA management in ESRF.

Ochrobactrum anthropi Bacteremia with Variable Clinical Course: Report of Two Cases

@#Ochrobactrum anthropi is a rare nosocomial pathogen that is manifesting itself mostly in immunocompromised patients and those with indwelling catheters. Identification of the microorganism is challenging and the ability to survive in aquatic surroundings have made it a clinically significant pathogen. Furthermore, the clinical picture of O. anthropi infection, is not well described. It may manifest in any form of clinical infections though bacteremia is the most common mode of presentation reported in the limited literature. We report here two cases of O. anthropi bacteremia presenting in an immunocompetent and an immunocompromised host respectively with different clinical manifestation and response. In view of the highly variable presentation of O.anthropi, a high index of suspicion must be given to at risks patients to ensure the timely diagnosis and optimal clinical outcome.

Enterobacter Gergoviae Peritonitis In A Patient On Chronic Ambulatory Peritoneal Dialysis - First Reported Case

Enterobacter gergoviae is a gram negative rod-shaped opportunistic organism reported to cause urinary and respiratory tract infections, but peritonitis caused by this organism is unknown. We report a case of 50-year-old patient on peritoneal dialysis (PD) presented with Enterobacter gergoviae peritonitis with septic shock. Despite Intraperitoneal (IP) cloxacillin 250mg qid and IP ceftazidime 1gram q24h and subsequent escalation with IP amikacin 2mg/kg q24h and IP vancomycin 15mg/kg q24h within the next 48 hours, his peritonitis remained refractory and required catheter removal. Although Enterobacter gergoviae is naturally sensitive to aminoglycosides, carbapenems and quinolones, it reacts differently to the beta lactam antibiotics. Their resistance to third-generation cephalosporins is fast emerging and treatment with third-generation cephalosporins may cause AmpC-overproducing mutants. The majority of Enterobacteriaceae, including Extended-spectrum beta-lactamases producers, remain susceptible to carbapenems. Our report provides an unfavourable course of E. gergoviae peritonitis likely due to acquired secondary drug resistance during the therapy period.

Myeloma Kidney – A Treatable Yet Often Forgotten Disease

Multiple myeloma is a blood dyscrasias that accounts of almost 10% of all hematological malignancy. The presentation of myeloma kidney is highly variable and it often presents as renal insufficiency, renal tubular dysfunction and proteinuria of various types. In Malaysia the true incidence of myeloma kidney is unknown. Often the diagnosis of myeloma kidney was missed out despite the patient has sought medical treatment early. A high index of suspicion is required when the middle to elderly age patients present with unexplained renal impairment and enlarged kidneys. We present here the presentation of a rare subtype of myeloma in a relatively young patient whereby the patient presented with nephrotic syndrome and azotemia.

rare case of Ralstonia mannitolilytica infection in an end stage renal patient on maintenance dialysis during municipal water contamination

Ralstonia mannitolilytica is a gram negative soil bacterium. Ralstonia infection though rare, has become the emerging nosocomial pathogens in hospital settings. Various clinical manifestations had been described as well as the mode of transmission

Despite its low virulence factor, it is able to survive under harsh condition and this may potentially cause significant morbidity and mortality especially in immunocompromised patients. Outbreak of Ralstonia mannitolilytica infections in the hospital are typically associated with contaminated medical supplies or instruments. We described here a case of Ralstonia mannitolilytica infection in a dialysis patient that occurred during the municipal reservoir water contamination crisis. In this report, we will also describe the behaviour of Ralstonia genus and its 4 main species, namely R. pickettii, R. solanacearum, R. insidiosa, and R. mannitolilytica and the choices of antibiotic therapy based on literature review

Risk profiles of referred chronic kidney disease patients in a tertiary nephrology centre

Objective: To determine the risk profile of chronic kidney disease [CKD] patients

Methods: This is an observational cross sectional study involving 130 patients for which data was collected prospectively. Sixty five subjects with an estimated glomerular filtration rate [eGFR] below 120 ml/ min/1.73 m2 were recruited via random sampling technique from nephrology clinic in a tertiary nephrology referral center. Medical history, demographic data, urinary and serum biochemistry tests were obtained

Results: Most of the CKD patients who were referred to the nephrology clinic were asymptomatic. The most common laboratory abnormalities noted among CKD patients were proteinuria, anaemia and hyperkalaemia. Advancing age, pre-existing morbidities such as diabetes mellitus, hypertension and overweight are characteristics that are strongly associated with the referred CKD patients

Conclusions: Most of the referred CKD patients are in advanced age with diabetes, hypertension and overweight. Majority of the CKD remained asymptomatic despite in the advance stage of CKD. This strongly calls for cost effective screening for population at risk

Predictor of cardiovascular risks in end stage renal failure patients on maintenance dialysis

Objective: Cardiovascular disease [CVD] is the main cause of morbidity and premature mortality in end stage renal failure patients [ESRD] receiving dialysis. The aim of our study was to evaluate the impact of various risk factors in this group of high CVD risk patients in local population

Methods: We carried out a cross-sectional retrospective study in a single hospital. A total of 136 ESRF patients, consisted of 43 haemodialysis [HD] and 93 continuous ambulatory peritoneal dialysis [CAPD] patients, were recruited and followed up for 36 months duration. Midweek clinical and laboratory data were collected. The occurrence of existing and new CVD events was recorded

Results: Multiple Logistic Regression showed pre-existing cardiovascular event [odds ratio, 4.124, 95% confidence interval [CI], 0.990 to 17.187], elevated total cholesterol level [odds ratio, 0.550, 95% CI, 0.315 to 0.963], elevated serum phosphate level [odds ratio, 5.862, 95% CI, 1.041 to 33.024] and elevated random blood glucose level [odds ratio, 1.193, 95% CI, 1.012 to 1.406] were significantly associated with occurrence of CVD events

Conclusions: History of cardiovascular event before the initiation of dialysis, elevated level of serum phosphate and random blood glucose levels are the risk factors of CVD whereas paradoxically a high total cholesterol level has CVD protective effect towards the ESRF patients

significance of tubular and glomerular proteinuria in critically ill patients with severe acute kidney injury

Critically ill patients with acute kidney injury [AKI] frequently need acute renal replacement therapy [aRRT]. We evaluated an inexpensive, rapid quantitative and qualitative analysis of proteinuria on the course of AKI patients requiring aRRT in intensive care. This was a prospective, observational study of critically ill patients with severe established AKI or Acute on Chronic Kidney Injury [AoCKI] requiring aRRT. Urine samples were analyzed using Sodium-Dodecyl-Sulphate-Polyacryamide Gel Electrophoresis [SDS-PAGE]. A total of 30 critically ill patients were studied. Those who died have higher APACHE II [29 +/- 6 vs. 20 +/- 5, p<0.001], multi-organ failure [0.7 +/- 0.5 vs. 0.2 +/- 0.4, p < 0.02] and Tubular/Glomerular ratio [114 +/- 60 vs. 75 +/- 37, p < 0.05]. The renal non-recoverers have higher baseline creatinine [415 +/- 328 vs. 125 +/- 19 umol/l, p < 0.01], urinary Dipstick value [1.8 +/- 0.8 vs. 0.5 +/- 0, p <0.05] and Glomerular score [3.0 +/- 1.8 vs. 0.6 +/- 0.2, p < 0.02]. Heavy tubular proteinuria also predicts a longer duration of interim dialysis support and mortality whereas glomerular proteinuria correlates with development of chronicity and End Stage Renal Disease [ESRD]. The dominant presence of tubular proteinuria is associated with poor survival in patients who have high APACHE II score and multi-organ failure. It also correlates with a longer duration of dialysis support in survivals. Renal Non-recoverers had heavy dominant presence of glomerular proteinuria. SDS-PAGE proteinuria analysis offers a reliable and inexpensive method to prognosticate proteinuria in this group of critically ill patients