Recurrent Urinary Tract Infections in Renal Transplant Recipients: Risk Factors and Outcomes in Low-resource Settings.

Recurrent urinary tract infections (UTIs) after kidney transplantation are a common problem adversely affecting graft outcomes. This retrospective study aimed to report the frequency and risk factors of recurrent UTI and their impact on graft and patient outcomes in kidney transplant recipients at the Sindh Institute of Urology and Transplantation, Karachi, Pakistan, in January-December 2015. Five-year graft and patient survival rates were compared among different groups using Kaplan-Meier analysis. Of the 251 recipients, 67 developed one episode of UTI. Of these 67, 29 had 76 episodes of recurrent UTI. Out of the 76 episodes of recurrent UTI, Escherichia coli was the most common pathogen in 32 cases. Organisms causing recurrent UTI showed resistance to carbapenem in 19 cases versus 2 in the non-recurrent UTI group (P = 0.006). The estimated glomerular filtration rate at 1 year was 57.8 ± 16.23 mL/min/1.73 m2 in the recurrent UTI group vs. 61.9 ± 15.7 mL/min/1.73 m2 in the non-recurrent UTI group (P = 0.001). Graft survival in the recurrent UTI group at 5 years was significantly lower (76%) than in the non-recurrent UTI (95%) and no UTI groups (93%) (log-rank P = 0.006), with no significant effect on patient survival in these groups (P = 0.429). The presence of double-J stent (P = 0.036) and cytomegalovirus infections (P = 0.013) independently predicted recurrent UTI. Recurrent UTIs are common in low-resource settings and adversely affect graft outcomes. Appropriate prophylaxis and treatment are important to reduce recurrent UTI to improve graft outcomes.

Composition of urinary calculi in infants: a report from an endemic country.

Pediatric urolithiasis remains endemic in low-resource countries where infants constitute 17-40% of all children with urolithiasis. This study reports socio-economic factors, medical history and chemical composition of urinary stones in 976 infants of up to 2 years of age. Between 1992 and 2016, 976 infants presented to our institute with 1038 stones. Chemical composition of stones was analyzed by Fourier transformation infrared spectroscopy (FTIR). The mean age of infants was 19.5 ± 5.74 months with a M:F ratio of 5.5:1. Half (50%) of the infants were rural dwellers, 90% belonged to low socio-economic class and 70% were malnourished. A history of chronic diarrhoea was reported in 13% and urinary tract infections in 5%. The anatomic location was bladder in 487 (46.9%), kidney in 246 (23.6%), ureter in 142 (13.6%), urethra in 2 (0.2%) and 161 (15.5%) were passed spontaneously. Overall frequency of compounds in stones showed ammonium acid urate (AAU) in 772 (74.37%), calcium oxalate (CaOx) in 410 (39.5%). Uric acid (UA) in 119 (11.46%), calcium phosphate apatite (CaP) in 96 (9.25%), magnesium ammonium phosphate (Struvite) in 45 (4.34%), cystine in 12 (1.16%) and xanthine in 40 (3.85%). Frequency of compounds was similar in genders. Infants of age 0-6 months had higher frequency of UA (28%), CaOx (50%) and low AAU (61%) as compared to 11, 39 and 75%, respectively, in 7-24 months (p < 0.049) (p < 0.002) (p < 0.001). Nucleus of stones showed pure AAU in 63 and 43% on the surface due to addition of CaOx, struvite and CaP. Our study has shown that AAU is a major component of stones in infants where the main risk factors are poverty, malnutrition, diarrheal diseases and dehydration.

Cystatin C levels in healthy kidney donors and its correlation with GFR by creatinine clearance.

OBJECTIVE: To determine Serum Cystatin C (S.CysC) levels in healthy potential kidney donors and its correlation with Serum Creatinine (S.Cr), Glomerular filtration rate (GFR) by 24 hour urinary Creatinine clearance (CCL) and GFR by formulae of Cockcroft Gault (CCG) and Modification of diet in Renal Disease (MDRD). METHODS: A Cross sectional study was conducted at Sindh Institute of Urology and Transplantation (SIUT), Karachi, between June and December 2012. One hundred and three potential healthy kidney donors were enrolled in the study to measure their S.CysC and correlate it with S.Cr, CCL and GFR by CCG and MDRD. Statistical analysis was done by SPSS 17. RESULTS: The mean age of the healthy kidney donors was 32.19 + 8.27 years with a M:F ratio of 1.86:1. The mean Serum Creatinine (S.Cr) was 0.86 + 0.18 mg/dl and mean S.CysC was 0.88 + 0.12 mg/dl. S.CysC showed significant correlation with S.Cr (r = 0.78, p < 0.001), CCL (r = 0.67, p < 0.001), GFR CCG (r = 0.54, p < 0.001) and GFR MDRD (r = 0.67, p < 0.001). Correlation of S.CysC was better than S.Cr for CCL, S.Cr (0.60) vs S.CysC (0.67) and GFR CCG, S.Cr (0.41) vs S.CysC (0.54). Correlation was comparable for MDRD, S.Cr (0.67) vs S.Cys (0.67). CONCLUSION: S.CysC is better marker of kidney function in potential healthy kidney donors. It is a reliable, convenient and economical marker that can be used especially in routine clinical practice.

Evaluation of renal function by cystatin C in renal transplant recipients.

OBJECTIVES: We evaluated cystatin C concentration as a marker of glomerular filtration rate in renal transplant recipients, and its correlation with creatinine-based glomerular filtration rate by urinary creatinine clearance, and the Cockroft-Gault and Modification of Diet in Renal Disease formulas. MATERIALS AND METHODS: In this cross-sectional study, we measured serum cystatin C levels and its correlation with serum creatinine, creatinine clearance, and glomerular filtration rate using the Cockroft-Gault formula and Modification of Diet in Renal Disease formulas. RESULTS: One hundred two recipients between June and December 2012, were examined. The mean subject age was 31.87 ± 8.37 years; the male:female ratio was 4.3:1. Mean serum creatinine concentration was 141.44 ± 43.31 mol/L (1.60 ± 0.49 mg/dL) and serum cystatin C 122.09 ± 38.95 nmol/L (1.63 ± 0.52 mg/L). Serum cystatin C was significantly correlated with serum creatinine (r=0.90; P<.001), creatinine clearance (r=0.77; P<.001), and the Cockroft-Gault (r=0.73; P<.001) and the Modification of Diet in Renal Disease formulas (r=0.82; P<.001). We assessed the correlation among serum cystatin C with serum creatinine, creatinine clearance, the Cockroft-Gault and Modification of Diet in Renal Disease at 1, 2-3, 4-5, and more than 5 years after transplant. The correlation between serum cystatin C and serum creatinine ranged from 0.8 to 1.0; cystatin C and creatinine clearance ranged from 0.8 to 0.85; serum cystatin C and the Cockroft-Gault Formula ranged from 0.7 to 0.8; and serum cystatin C and the Modification of Diet in Renal Disease formulas ranged from 0.8 to 0.84. CONCLUSIONS: Our results show that serum cystatin C is a reliable marker for estimating glomerular filtration rate among renal transplant recipients. This test can determine the glomerular filtration rate of renal transplant recipients on follow-up. Further studies are required to establish serum cystatin C as a standard test for monitoring glomerular filtration rate in transplanted patients.

Still births--eight years experience at Aga Khan University Hospital Karachi, Pakistan.

OBJECTIVES: To examine the possible etiological causes of still births during 8 years of clinical experience at a tertiary referral center, The Aga Khan University Hospital Karachi Pakistan. In addition, to compare demographic and medical risk factors along with analysis of cause of fetal death in different groups. MATERIAL AND METHODS: This was a retrospective cohort study, conducted at the Aga Khan University Karachi, Pakistan over a period of 8-year period between January 2000 and January 2008. We reviewed 287 medical records of all women who had intrauterine fetal demise during study time period. RESULTS: The prevalence of still births at our institution was 6.6 +/- 2.1 per 1000 total births. Congenital anomalies, maternal hypertension, and fetal growth restrictions were the three main causes of still births. About half of still births were among unbooked pregnant women. More than 90% of occurred during the ante natal period while 10% were intrapartum. Majority of stillborns were in macerated state when delivered. CONCLUSION: Most of still births were due to known causes such as hypertension, congenital anomalies, and fetal growth restriction. Improvement in the management of hypertension and diagnosis of congenital anomalies is necessary. Results of the analysis urge on the need for antenatal care and compliance for follow-ups.

Demographic and clinical features of dengue fever in Pakistan from 2003-2007: a retrospective cross-sectional study.

BACKGROUND: Demographic features of dengue fever have changed tremendously in Pakistan over the past two decades. Small scale studies from all over the country have reported different aspects of individual outbreaks during this time. However, there is scarcity of data looking at the overall trend of dengue virus infection in the country. In this study, we examined annual trends, seasonality, and clinical features of dengue fever in the Pakistani population. METHODS: Demographic information and dengue IgM status of all patients tested for dengue IgM antibody at Aga Khan University Hospital from January 2003 to December 2007 were analyzed to look for trends of IgM-positive cases in Pakistan. In addition, clinical and biochemical parameters were abstracted retrospectively from medical records of all patients hospitalized with IgM-proven dengue fever between January 2006 and December 2007. These patients were categorized into dengue fever and dengue hemorrhagic fever according to the WHO severity grading scale. RESULTS: Out of a total of 15,040 patients (63.2% male and 36.8% female), 3952 (26.3%) tested positive for dengue IgM antibody. 209 IgM proven dengue patients were hospitalized during the study period. During 2003, IgM positive cases were seen only during the months of July-December. In contrast, such cases were detected throughout the year from the 2004-2007. The median age of IgM positive patients decreased every year from 32.0 years in 2003 to 24.0 years in 2007 (p<0.001). Among hospitalized patients, nausea was the most common presenting feature found in 124/209 (59.3%) patients. Children presented with a higher median body temperature than adults (p = 0.010). In addition, neutropenia was seen more commonly in children while raised serum ALT levels were seen more commonly in adults (both p = 0.006). While a low total white cell count was more common in patients with dengue fever as compared to Dengue Hemorrhagic Fever (p = 0.020), neutropenia (p = 0.019), monocytosis (p = 0.001) and raised serum ALT level (p = 0.005) were observed more commonly in the latter group. CONCLUSIONS: Dengue virus is now endemic in Pakistan, circulating throughout the year with a peak incidence in the post monsoon period. Median age of dengue patients has decreased and younger patients may be more susceptible. Total and differential leukocyte counts may help identify patients at risk of hemorrhage.

Healing during physician-patient consultation.

OBJECTIVE: To determine the patient perceptions regarding healing during a physician-patient consultation. DESIGN: A questionnaire-based survey. PLACE AND DURATION OF STUDY: Family Practice Center of the Aga Khan University Hospital, Karachi, Pakistan, in June 2004. PATIENTS AND METHODS: A questionnaire was designed that included the demographic profile of patients comprising age, gender, education and occupation as well as questions in line with the study objective. It was administered to 111 patients, visiting outpatient department of the hospital. Participants were explained the study objective, a written consent was taken and full confidentiality was assured. RESULTS: The mean age of the study population was 27.86 years. Majority of the subjects were males with 68% having graduate or more education. A physician-patient consultation has healing properties for patients and physicians, according to 99 (89%) and 67 (65%) respondents respectively, with 65 (58%) having had experienced healing during the consultation process. The competence of a physician, individual attention given by a physician and a cool and calm attitude of a physician, were reported to increase healing in a physician-patient consultation according to 34 (30%), 32 (29%) and 13 (11%) respondents respectively. The unhelpful physician behavior, incorrect diagnosis and physician's rude and arrogant attitude were reported to decrease healing according to 42 (37%), 15 (14%) and 14 (13%) respondents respectively. CONCLUSION: The study shows that a majority of the patients believe a physician-patient consultation has healing properties on its own, based on healing potential in the consultation process itself. Physicians must try to find ways to improve their ability to act as healers during consultation with patients.