Frequency of Hepatitis C in hospitalized patients with chronic kidney disease

Background and Objectives: Hepatitis C and chronic kidney disease [CKD] are major global health problems and are highly prevalent in Pakistan. There is limited information on prevalence of hepatitis C in patients with CKD not yet on dialysis. The objective of this study was to determine the frequency of hepatitis C in hospitalized chronic kidney disease patients at a tertiary care center in Pakistan

Methods: The study design was cross-sectional in nature. Patients between ages of 20-80 years with CKD not previously on renal replacement therapy and who were admitted to nephrology ward at a tertiary care facility were included. Hepatitis C was tested using 3[rd] generation enzyme linked immunosorbent assay [ELISA]. Hepatitis C RNA was tested by polymerase chain reaction [PCR] in patients with positive ELISA

Results: A total of 180 patients were included in the study. Mean age of patients was 48.7 +/- 14.9 years. Of all patients, 105 [58.3%] were males and 75 [41.7%] were females, 152 [84.4%] had hypertension, 113 [62.8%] had diabetes mellitus and 26 [14.9%] had known cardiovascular disease. Mean eGFR of patients was 11.4 +/- 9.4 ml/min/1.73 m2. Of all patients with CKD, 49 [27.2%] had hepatitis C test positive by ELISA. Hepatitis C PCR testing was done in 39 patients with hepatitis C ELISA positive status and 29 [74.4%] tested positive. Risk factors and clinical characteristics of patients with and without positive hepatitis C antibody by ELISA were similar

Conclusion: A significant proportion of hospitalized CKD patients have hepatitis C. Strict universal infection control measures should be implemented in nephrology wards to prevent transmission of hepatitis C infection

survey of hypertension prevalence, awareness, treatment, and control in health screening camps of rural central Punjab, Pakistan

Hypertension is a global public health problem with increasing prevalence. There is limited updated information on the prevalence of hypertension in the Pakistani population. This is a cross-sectional study based on data collected during multiple health screening camps held at multiple locations in rural central Punjab, Pakistan in the period between 2008 and 2015. A total of 13,722 patients were included in this study. Crude prevalence of hypertension was 35.1% and age-standardized prevalence was 34.4%. Among patients with hypertension, 62.3% were aware of having high blood pressure; among these patients, 75.3% were already on treatment for hypertension. Blood pressure was controlled in 22.3% of all patients with hypertension. Among those on treatment for hypertension, blood pressure was controlled in 32.3%. Nearly one-third of patients in health screening camps of rural central Punjab had hypertension. Blood pressure control rate was poor among these patients

Clinical predictors of an abnormal ultrasound in patients presenting with suspected nephrolithiasis

Objective: To determine any clinical features associated with an abnormal ultrasound in patients with suspected nephrolithiasis in an out-patient setting

Methods: The study design was cross-sectional in nature. The study was conducted at an out-patient nephrology department of a tertiary care facility over a 3 month period. Patients included in the study were 18-80 years old, who presented with unilateral flank or costovertebral angle pain with or without other clinical features suggestive of renal or ureteric calculus based on clinician's judgement. Every patient's history was reviewed to obtain information on age, gender, location and radiation of pain, onset, severity and nature of pain, associated urinary and systemic symptoms and past history of nephrolithiasis. An ultrasound was considered to be abnormal if there was documented presence of renal or ureteric stone and/or unilateral hydronephrosis

Results: A total of 209 patients were included in the study. Of these patients, 126 [60.3%] were males and 83 [39.7%] were females, 60 [28.7%] had prior history of nephrolithiasis. Ultrasound was abnormal in 110 patients [52.9%]. On a multivariate logistic regression analysis, only past history of nephrolithiasis [OR 3.3, 95% CI 1.65-6.7] was associated with an abnormal ultrasound

Conclusion: In the absence of any significant clinical predictors use of ultrasound is justified in patients with suspected nephrolithiasis especially in those with prior history of stones

Extracranial meningioma: an unusual presentation of a mass over inner canthus of left eye

Meningiomas are commonly encountered as intracranial brain tumours, but extracranial meningiomas do occur although seen rarely. Here we present a case of extracranial meningioma presenting as a mass over the medial canthus of left eye and the glabella with extension into the left ethmoid sinuses, without any neurological symptoms or signs. The patients underwent surgical excision, plastic surgical reconstruction and adjuvant radiotherapy after 3-dimensional conformal treatment planning

Referral pattern of end stage kidney failure patients at Shaikh Zayed Hospital, Lahore

The outcome in end stage kidney disease depends upon the presence of numbers and severity of complications like anemia, hypoalbumenemia, acidosis, hypertension and degree of uremia at the time of start of renal replacement therapy [RRT]. It has been observed that patient who are referred early to the nephrologist have lesser number of complications, get elective vascular access, have the choice to select the mode of RR T and their survival is much better as compared to those who are referred late and require emergency dialysis. In the present study, out of total 210 patients who were admitted for dialysis, only 46 [22%] were under the care of nephrologist. Their mean hemoglobin was 8.2gm/dl, Blood Urea Nitrogen [BUN] 121 mg/di, serum creatinine l 4.67mg/dl and serum Bicarbonate was 10.92meq/1. Systolic blood pressure was less than 140mmHg in only 20 patients [10%] and diastolic blood pressure was less than 90mmHg in only 23 patients [11%]. Only 14 patients [6.7%] had already created arterio venous fistula on hospitalization. One hundred and eighteen patients [56%] had fluid over load, 93 patients [44%] had Hyperkalemia, 96 patients [46%] had metabolic acidosis and 71 patients [34%] had uremic encephalopathy. Presence of these complications in such large number of patients and other bad prognostic factors as low mean hemoglobin, sever uremia, sever metabolic acidosis and hyperkalemia at the time of start of RRT indicates poor pre ESRD management in our patient and signifies the need for early referral of renal failure patients to Nephrologist

Correlation of vitamin C and E with lipid profile in hemodialysis patients

The present study was planned and carried out to see the level of vitamin C, vitamin E and lipid profile in ESRD patients on regular hemodialysis, and also the immediate effect of dialysis on vitamin C and E levels. Serum was tested from 50 ESRD patients on hemodialysis and 15 healthy control subjects matched for age and sex. No significant correlation could be elicited between the post dialysis fall of vitamin C level of [6 mg/l or more than 6 mg/l] in patient with abnormal triglyceride level. Similarly no significant correlation could be elicited between predialysis vitamin E level of [less than 6 mg/l] and triglyceride level. Lipid profile of patient and control showed no significant difference in total cholesterol, HDL, LDL level, but the triglyceride level was significantly higher in both male and female patients as compared with control subjects

Renal tubular acidosis

The clinical laboratory and X-Ray findings of 16 patients with distal [type-1] renal tubular acidosis diagnosed at Mayo and Sheikh Zayed Hospital, Lahore during an eight year period [1984 to 1992] are presented. Twelve patients [75%] were males and four females [25%]. Their ages ranged between 1.5 and 41 years [mean age 12.8 years]. Eight patients [50%] had radiologically evident bone disease in the form of rickets or osteomalacia. Two patients had pathological fractures. Growth retardation was noted in 10 patients [63%]. Polyuria and polydipsia were noted in 6 patients [31%]. Nephrocalcinosis and or nephrolithiasis was evident in 12 patients [75%]. Muscle weakness were noted in 7 patients [44%]. Biochemical derangements observed were hyperchloremic metabolic acidosis mean blood pH = 7.259 +/- 0.055, but urine pH remained alkaline in all patients during all grades of metabolic acidosis with a mean value of 6.69 [range 5.8 to 8.0]. Serum Chloride level was mean 111 +/- 5.288 mmol/l. Hypocalcemia, hyponatremia and hypokalemia was noted with mean values of 8.44 +/- 1.24 mg/dl, 134 +/- 3.56 mmol/l and 3.68 +/- 0.53. Treatment with alkali therapy resulted in general well being, reduced bone pains, muscle weakness and improved growth significantly

Prevalence of anti HCV in hemodialysis patients

Eighty two patients. 55 males and 27 females, aged 18 to 80 years [mean 42.32 +/- 14.95 years] on chronic hemodialysis were screened for sero- markers of hepatitis B and C and their Liver function was evaluated. Fifty one patients [62.2%] showed anti Hepatitis C antibodies [anti HCV] in their serum. Seven patients [8.5%] were Hepatitis B surface antigen positive; live of them were positive for both anti HCV and HBsAg. Liver functions tests were performed in 70 patients; 22 of them had abnormal liver function. Out of these, 18 patients [81.8%] were anti HCV positive and 4 cases [18.2%] were negative for anti HCV antibodies [P<0.05]. Eighteen of anti HCV positive [39.1%] and 4 of anti HCV negative [16.7%] had abnormal liver functions. Out of 51 Anti HCV Positive patients 43 had received blood transfusions [84.3%]while 8 patients [15.7%] did not have any transfusion [P<0.05]. The patients, who were Anti HCV positive, had more blood transfusions and were on hemodialysis for longer periods as compared to Anti HCV negative patient but the difference in our study was not statistically significant

Effectiveness of low-dose intradermally administered hepatitis B virus vaccine

Hepatitis B vaccine is underutilized due to high cost. A study was performed to see the effectiveness of yeast derived recombinant vaccine in low dose [0.1 ml; 2 micro g] given at 0, 1,2 and 6 months in 50 seronegative individuals. Out of them 39 subjects [78%] developed anti-hepatitis B surface antigen [anti HBs] in a concentration greater than 10 IU/L which is considered to be protective. None of them had any significant side effect except for minor local soreness at the site of injection

Effectiveness of recombinant hepatitis B vaccine

The study was carried out to see the efficacy of recombinant hepatitis B vaccine in two high risk groups viz; chronic renal failure patients on maintenance haemodialysis [n = 20] and medical staff [n = 25]. The pre-vaccination status of these individuals was assessed by HBsAg, Anti-HBs and LFTs. Only those subjects were included in this study who were negative for HBsAg and Anti-HBs. The patients were given 2cc while the staff 1cc dose of the vaccine intramuscularly at the schedule of 0,1 and 6 months. Quantitative estimation of antibody titre [seroconversion] was noted by ELISA method 15 days after the last dose. This became positive in 84% of the medical staff members and 65% of the patients in a concentration of >/= 10 IU/L. No significant side effects were noted in any of the subject

Paroxysmal nocturnal hemoglubinuria

Three cases with Paroxysmal Nocturnal Hematuria [PNH] with different presentations are reported. The first case presented as chronic hemolytic anemia, the second as acute renal failure and third as hepatic vein thrombosis. Their diagnosis and management is discussed

Hospital associated hyponatremia

Out of 7843 hospitalized patients 342 [4.36%] have serum electrolytes abnormalities. Hyponatremia was the most common which was seen in 3.45% of all patients and 79.2% of 342 patients with serum electrolyte abnormalities. 73.4% had mild hyponatremia [serum sodium concentration 121-130 mE[q]/L] 53 patients [9.6%] had moderate hyponatremia, [serum sodium concentration 111-120 mE[q]/L] and 19 patients [7%] had severe hyponatremia [serum sodium 110 mE[q]/L or less]. Advanced renal failure was the most common cause while gastrointestinal problems with vomiting diarrhea, congestive heart failure, liver disease, post-operative states, and i.v. fluid administration were other frequent causes. Mildly hyponatremic patients were usually asymptomatic but progressive symptomatology appeared with further decline of serum sodium concentration. Cerebral symptoms were seen in 8% of patients with mild hyponatremia 53% of cases with moderate and 84% of cases with severe hyponatremia. 9 patients with hyponatremia died, mortality being 3.3%

Effect of dialysis on bleeding time in chronic renal failure

Renal failure is associated with severe hemorrhagic complications. Platelets play an important role in coagulation and their dysfunction may be responsible for the bleeding tendency in these patients. 60 patients with advanced failure were investigated for bleeding tendency due to platelet dysfunction. The pre-dialysis platelet count was 46 to 325x10[9]/L [mean 166x10[9]/L]. Post-dialysis platelet count was 60 to 310x10[9]/L [mean172x109/L]. Pre-dialysis mean bleeding time [BT] was 4.95 +/- 0.27 minutes [range 1.30 to 20 minutes]. Thirty three patients [55%] had prolonged BT before dialysis. Mean BT in all patients after dialysis was 3.46 +/- 0.24 minutes [range 1.15 to 10 minutes]. BT was corrected in 27 [81.8%] out of 33 patients with prolonged BT before dialysis. In 6 patients [10%] it remained prolonged. This improvement in BT after dialysis was statistically significant [p value< 0.001]. Both peritoneal and hemodialysis resulted in significant improvement in bleeding time

Effectiveness of recombinant hepatitis B vaccine

The study was carried out to see the efficacy of recombinant hepatitis B vaccine [Engerix 'B' by SK and F] in two high risk groups viz; chronic renal failure patients on maintenance haemodialysis [n=20] and medical staff [n-25]. The prevaccination status of these individuals was assessed by HB[s]A[g], Anti-HB[s] and LFT[s]. Only those subjects were included in this study who were negative for HB[s]A[g] and Anti-HB[s]. The patients were given 2cc while the staff 1cc dose of the vaccine intramuscularly at the schedule of 0, 1 and 6 months. Quantitative estimation of antibody titre [seroconversion] was noted by ELISA method 15 days after the last dose. This become positive in 84% of the medical staff members and 65% of the patients in a concentration of >/= 10IU/L

Hospital associated hyponatremia

Out of 7843 hospitalized patients admitted in Shaikh Zayed Hospital between April to August, 1988, 342 [4.36%] [had serum electrolytes abnormalities. Hyponatremia was the most common and was seen in 3.45% of all patients and 79.2% of 34.2 patients, with serum electrolyte abnormalities. 73.4% had mild hyponatremia [serum concentration 121-130 mEq/I] 19.6% patients had moderate hyponatremia, [serum sodium concentration 111-120mEq/L] and 7% had severe hyponatremia [serum sodium 110 mEg/L or less]. Advanced renal failure was the most common cause while gastrointestinal problems with vomiting, diarrhoea, congestive heart failure, liver diseases, postoperative states, and i. v. fluid administration were other frequent causes. Mildly hyponatremic patients were usually asyrnptomatic but progressive symptomatology appeared with further decline of serum sodium concentration. Cererbral symptoms were seen in 8% of patients with mild hypomatremia, 53% of cases with moderate and 84% of cases with severe hyponatremia. Nine patients with hyponatremia died, mortality being 3.3%

Fungal infections in renal transplant patients

Three cases of systemic fungal infections in renal transplant patient are described here. One patient had mucormycosis. The second patient had aspergillosis and the patient had candidiasis. All three patients died inspite of treatment. These fungal infections and their treatment is discussed