Impact of vaccination on COVID-19 severity during the second wave in Brunei Darussalam, 2021.

Objective: Coronavirus disease (COVID-19) vaccinations have been shown to prevent infection with efficacies ranging from 50% to 95%. This study assesses the impact of vaccination on the clinical severity of COVID-19 during the second wave in Brunei Darussalam in 2021, which was due to the Delta variant. Methods: Patients included in this study were randomly selected from those who were admitted with COVID-19 to the National Isolation Centre between 7 August and 6 October 2021. Cases were categorized as asymptomatic, mild (symptomatic without pneumonia), moderate (pneumonia), severe (needing supplemental oxygen therapy) or critical (needing mechanical ventilation) but for statistical analysis purposes were dichotomized into asymptomatic/mild or moderate/severe/critical cases. Univariate and multivariable analyses were conducted to identify risk factors associated with moderate/severe/critical disease. Propensity score-matched analysis was also performed to evaluate the impact of vaccination on disease severity. Results: The study cohort of 788 cases (mean age: 42.1 ± 14.6 years; 400 males) comprised 471 (59.8%) asymptomatic/mild and 317 (40.2%) moderate/severe/critical cases. Multivariable logistic regression analysis showed older age group (≥ 45 years), diabetes mellitus, overweight/obesity and vaccination status to be associated with increased severity of disease. In propensity score-matched analysis, the relative risk of developing moderate/severe/critical COVID-19 for fully vaccinated (two doses) and partially vaccinated (one dose) cases was 0.33 (95% confidence interval [CI]: 0.16-0.69) and 0.62 (95% CI: 0.46-0.82), respectively, compared with a control group of non-vaccinated cases. The corresponding relative risk reduction (RRR) values were 66.5% and 38.4%, respectively. Vaccination was also protective against moderate/severe/critical disease in a subgroup of overweight/obese patients (RRR: 37.2%, P = 0.007). Discussion: Among those who contracted COVID-19, older age, having diabetes, being overweight/obese and being unvaccinated were significant risk factors for moderate/severe/critical disease. Vaccination, even partial, was protective against moderate/severe/critical disease.

Pros and cons of live kidney donation in prediabetics: A critical review and way forward.

There is shortage of organs, including kidneys, worldwide. Along with deceased kidney transplantation, there is a significant rise in live kidney donation. The prevalence of prediabetes (PD), including impaired fasting glucose and impaired glucose tolerance, is on the rise across the globe. Transplant teams frequently come across prediabetic kidney donors for evaluation. Prediabetics are at risk of diabetes, chronic kidney disease, cardiovascular events, stroke, neuropathy, retinopathy, dementia, depression and nonalcoholic liver disease along with increased risk of all-cause mortality. Unfortunately, most of the studies done in prediabetic kidney donors are retrospective in nature and have a short follow up period. There is lack of prospective long-term studies to know about the real risk of complications after donation. Furthermore, there are variations in recommendations from various guidelines across the globe for donations in prediabetics, leading to more confusion among clinicians. This increases the responsibility of transplant teams to take appropriate decisions in the best interest of both donors and recipients. This review focuses on pathophysiological changes of PD in kidneys, potential complications of PD, other risk factors for development of type 2 diabetes, a review of guidelines for kidney donation, the potential role of diabetes risk score and calculator in kidney donors and the way forward for the evaluation and selection of prediabetic kidney donors.

Deceased donor kidney transplant policies in Asia - implications on practice and recommendations for the future.

Deceased donor kidney transplantation (DDKT) is common in high income Western countries with high transplantation rates. However, the utilization of deceased organs is suboptimal in Asia, due to a multitude of factors. Coherent policies are integral to the development of DDKT programs and deterrence of commercialization, but most are still at an infancy and formative stage in Asia. This review article identifies the glass ceiling effects of social, cultural, religious, political, and technical factors hampering the progress of DDKT in Asia. Additionally, it reviews the history of policy development in different countries and describes their idiosyncratic barriers and challenges. Lastly, it discusses innovative policy measures that can be undertaken to proliferate DDKT practice and curtail commercialization. The long-term ideal is to achieve regional equity and self-sufficiency, through a shared ethos of social and ethical responsibility that transcends and resonates with the different segments of the Asian community.

Practice of dialysis access interventional nephrology procedures in the Asia-Pacific region: Getting lay of the land.

AIM: This cross-sectional survey aimed to determine the prevalence of Interventional Nephrology (IN) practice amongst nephrologists in the Asia-Pacific Region (APR), specifically related to dialysis access (DA). METHODS: The Association of VA and intervenTionAl Renal physicians (AVATAR) Foundation from India conducted a multinational online survey amongst nephrologists from the Asia-Pacific to determine the practice of IN in the planning, creation, and management of dialysis access. The treatment modalities, manpower and equipment availability, monthly cost of treatment, specifics of dialysis access interventions, and challenges in the training and practice of IN by nephrologists were included in the survey. RESULTS: Twenty-one countries from the APR participated in the survey. Nephrologists from 18 (85.7%) countries reported performing at least one of the basic dialysis access-related IN procedures, primarily the placement of non-tunnelled central catheters (n-TCC; 71.5%). Only 10 countries (47.6%) reported having an average of <4% of nephrologists performing any of the advanced IN access procedures, the most common being the placement of a peritoneal dialysis (PD) catheter (20%). Lack of formal training (57.14%), time (42.8%), incentive (38%), institutional support (38%), medico-legal protection (28.6%), and prohibitive cost (23.8%) were the main challenges to practice IN. The primary obstacles to implementing the IN training were a lack of funding and skilled personnel. CONCLUSION: The practice of dialysis access-related IN in APR is inadequate, mostly due to a lack of training, backup support, and economic constraints, whereas training in access-related IN is constrained by a lack of a skilled workforce and finances.

Factors Predictive of Development of Acute Kidney Injury in Patients With COVID-19 in Brunei Darussalam.

INTRODUCTION: Acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients affects their health outcomes. Incidence and outcomes varied in the literature, particularly with different population and epidemiological demographics. Data remain scarce in the Southeast Asia region. We report the incidence, outcomes, pattern, types of AKI, and factors that influence AKI patient outcomes in Brunei Darussalam. METHODS: All patients (N = 930) with COVID-19 who were admitted to the National Isolation Center (between 7th August 2021 and 30thSeptember 2021) were included in the study. The confirmation of AKI was based on the KDIGO (Kidney Disease Improving Global Outcomes) criteria. RESULTS: The mean age of the patients was 41.9 ± 14.4 years with diabetes mellitus (DM), hypertension (HT), and chronic kidney disease (CKD) accounting for 11.7%, 29.1%, and 4.8% of comorbidities, respectively. Overall, 109 (11.7%) had AKI (KDIGO Stage 1 [67.9%], 2 [13.8%], and 3 [18.3%]), while 75.2% of the cases occurred pre-admission and 26.6% were cases of acute exacerbation of CKD. Univariate analysis identified age (odd ratio [OR] 1.06), male gender (OR 1.63), local nationality (OR 8.03), DM (OR 4.44), HT (OR 5.29), vascular disease (OR 6.08), presence of gastrointestinal symptoms (OR 2.08), antibiotic (OR 3.70) and nephrotoxins exposures (OR 8.57) as significant variables. Multivariate analysis showed age (adjusted OR [AOR] 1.04), male gender (AOR 1.67), gastrointestinal symptoms (AOR 1.61), antibiotic (AOR 2.34), and nephrotoxins exposure (AOR 4.73) as significant. CONCLUSIONS: Our study showed that one in nine patients with COVID-19 developed AKI with almost a third having stages 2 and 3 AKI. Older age, male gender, presence of GI symptoms, and antibiotic and nephrotoxin exposures were significant predictors of AKI. Patients with these factors should be prioritized for admission and treatment. Even though manifestations are generally now less severe, findings from this study can guide the management of COVID-19 as the disease enters the endemic stage. Furthermore, lessons learned from the COVID-19 pandemic will provide useful information and knowledge for future viral outbreaks or pandemics.

Clinical outcomes and performance indicators of patients with kidney failure and acute kidney injuries in ASEAN countries.

INTRODUCTION: This review article reports clinical outcomes and performance indicators of patients with kidney failure (KF) and acute kidney injuries (AKI) in Association of South East Asian Nations (ASEAN) countries. METHODOLOGY: Association of South East Asian Nations data, segregated by income status, from national registries and literature were collated, compared and benchmarked against international references. RESULTS: The national incidence and prevalence of treated KF ranged from 172 to 479 per million population (pmp) and 36-2255 pmp, respectively. Brunei (79%), Malaysia (66%) and Singapore (66%) had world-leading proportions of diabetes-related KF. Hemodialysis (HD), Peritoneal Dialysis (PD) and transplant accounted for 68-100%, 0-27% and 0-18% of all KF replacement therapy, respectively. Transplant patient survival was superior with 90%-93% at 5 years and 71%-90% at 10 years, compared to PD (44%-54%) and HD (53-64%) at 5 years. Higher-income countries were able to achieve good anemia control, HD and PD adequacy targets, while usage of arteriovenous fistula in HD varied from 70% to 85%. Acute Kidney Injury rates ranged from 24.2% to 49.2% of high-dependency admissions. Lower incidences of PD peritonitis and HD catheter-related Bloodstream Infections; and PD-favouring quality-of-life were evident in higher-income countries. CONCLUSION: Association of South East Asian Nations has a challenging burden of kidney disease, with extremely high incidence, prevalence, DM-related KF and AKI rates. The magnitude of the prevailing problem calls for the creation of a regional society under the auspices of ASEAN with a shared perspective of universal, equitable and charitable access to quality renal care; consistent with the founding premises and healthcare initiatives of ASEAN.

Refractory Statin-Induced Immune-Mediated Necrotizing Myositis: Challenges and Perils in Its Management.

Statin or 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) inhibitor is widely used and plays a vital role in the management of cardiovascular and cerebrovascular diseases. Statin is generally safe and its side effects are mostly mild and self-limiting. Immune-mediated necrotizing myositis (IMNM) is a rare and serious side effect characterized by the presence of anti-HMGCR inhibitor and myositis. Long-term immunosuppressive therapy is often required to manage it, and in refractory cases, the treatment can be very challenging. We report the case of a 55-year-old female with underlying diabetes mellitus and hyperlipidemia who developed refractory statin-induced IMNM despite being administered prednisolone, methotrexate, azathioprine, and immunoglobulin. After the introduction of rituximab, steroids were able to be tapered down to the lowest maintenance dose. Unfortunately, the patient subsequently succumbed to severe coronary artery disease (CAD) likely caused by the long-term steroid therapy, highlighting the difficulty and complications associated with the treatment of IMNM, especially in patients with cardiovascular risk factors.

Mammalian Target of Rapamycin Inhibitors and Wound Healing Complications in Kidney Transplantation: Old Myths and New Realities.

Mammalian target of rapamycin inhibitors (mTOR-I) lacks nephrotoxicity, has antineoplastic effects, and reduces viral infections in kidney transplant recipients. Earlier studies reported a significant incidence of wound healing complications and lymphocele. This resulted in the uncomfortable willingness of transplant clinicians to use these agents in the immediate posttransplant period. As evidence and experience evolved over time, much useful information became available about the optimal use of these agents. Understandably, mTOR-I effects wound healing through their antiproliferative properties. However, there are a lot of other immunological and nonimmunological factors which can also contribute to wound healing complications. These risk factors include obesity, uremia, increasing age, diabetes, smoking, alcoholism, and protein-energy malnutrition. Except for age, the rest of all these risk factors are modifiable. At the same time, mycophenolic acid derivatives, steroids, and antithymocyte globulin (ATG) have also been implicated in wound healing complications. A lot has been learnt about the optimal dose of mTOR-I and their trough levels, its combinations with other immunosuppressive medications, and patients' profile, enabling clinicians to use these agents appropriately for maximum benefits. Recent randomized control trials have further increased the confidence of clinicians to use these agents in immediate posttransplant periods.

Isolated Renal Involvement by IG4-Related Disorder Mimicking Multiple Myeloma, a Diagnosis Not to Miss.

IG4-related disorder (IgG4-RD) with isolated kidney involvement is rare. IG4-RD is a fibroinflammatory disorder leading to polyclonal activation of plasma cell and can affect kidney, orbital tissues, salivary glands, pancreas, bile duct, lymph nodes, and can cause inflammatory mass in any organ. Isolated kidney involvement is rare in this order. We share a case of isolated kidney involvement by this order presenting as enlarged kidneys with renal impairment. Kidney biopsy showed CD138 plasma cell interstitial nephritis. The biopsy also showed kappa light chain along IgG on immunofluorescence and was reported as light chain deposition disease initially. In view of hyperproteinemia and initial renal biopsy finding, workup was done for myeloma. Bone marrow biopsy showed around 20% of plasma cell infiltration. Skeletal survey did not show any lytic lesions and immunofixation did not reveal any paraprotein. Flowcytometry of the bone marrow showed nonclonal plasma cell. In view of negative workup for myeloma and nonclonal cells, re-evaluation of the kidney biopsy was done. Biopsy was reanalyzed for both IgG and IgG4. It showed 30 IgG4 cells per high-power field with a ratio of IgG4 / IgG of 40%. The staining for IgM, IgA C3, and C1q was negative. The patient was labeled as having plasma cell interstitial nephritis due toIgG4-RD. The patient responded well to oral prednisolone. It is important not to miss this potentially treatable and reversible condition by staining the biopsy sample for both IgG and IgG4 in clinically suspected cases.

The Living-Related Kidney Transplant Program in Brunei Darussalam: Lessons Learnt from a Nascent National Program in a Small, Muslim, and Asian Country.

Brunei Darussalam commenced its living-related renal transplant program in 2013, with subsequent attainment of independent local capacity and proficiency in 2019. The preliminary outcome from the program has already begun to shape the national nephrology landscape with a 36% increment in transplant rate and mitigation of commercialized transplantations. The blueprint for the program was first laid out in 2010 and thereupon executed in four phases. The first phase involved the gathering of evidence to support the establishment of the national program, through researches investigating feasibility, public opinion, quality of life, graft survival, and cost-effectiveness. The second phase focused on laying the foundation of the program through grooming of local expertise, implementation of legal-ethical frameworks, religious legitimization, and propagation of awareness. The third phase worked on facilitating experiential exposure and strengthening local infrastructure through the upgrading of facilities and the introduction of subsidiary services. The fourth phase was implemented in Brunei in 2013 when foreign personnel worked together with the local team to perform the transplants. Between 2013 and 2019, ten kidney transplants were performed, with two being done in 2018 and three in 2019. We hope to inspire other similar countries to develop their own self-sustainable and independent local program.

Knowledge Attitude and Practice of traditional and complementary / alternative medicines amongst End Stage Renal Disease patients in Brunei Darussalam.

OBJECTIVE: A limited study was found in regards to knowledge, attitudes, and practices (KAP) of traditional and complementary/alternative medicines (TCAM) amongst end-stage renal disease (ESRD) in South East Asian region including Brunei Darussalam. This study explored TCAM use amongst ESRD patients in Brunei Darussalam. METHODS: This was a cross-sectional study in a local Dialysis Centre using a bilingual self-structured questionnaire. Recruitment was done using systematic random sampling with certain inclusion criteria. All collected data were entered into Microsoft Excel 2016, and inferential statistics were carried out using R studio version 1.1.383. RESULTS: About 40.2% were TCAM users, and this was not predictable by any sociodemographic background. Nevertheless, compliance with conventional medicine (CM) was very high (94.1%). Users had a more positive disease perception, which was not affected by length on dialysis treatment or the presence of comorbidities. TCAM was perceived to be less effective and unsafe compared to CM, and patients agreed that its use should be monitored and notified. Health supplement (70.7%) was mainly used to improve general wellness (48.5%) or to relieve fatigue (42.4%), and most practices were influenced by family (43.9%). Only a minority of users (19.5%) reported side effects as majority (80.5%) consumed TCAM and CM separately. CONCLUSIONS: High TCAM practice showed that there are still needs that are not fulfilled. The health care professionals should always remain vigilant of its use and be attentive to attend to patients' needs.

PPDIST, global 0.1° daily and 3-hourly precipitation probability distribution climatologies for 1979-2018.

We introduce the Precipitation Probability DISTribution (PPDIST) dataset, a collection of global high-resolution (0.1°) observation-based climatologies (1979-2018) of the occurrence and peak intensity of precipitation (P) at daily and 3-hourly time-scales. The climatologies were produced using neural networks trained with daily P observations from 93,138 gauges and hourly P observations (resampled to 3-hourly) from 11,881 gauges worldwide. Mean validation coefficient of determination (R2) values ranged from 0.76 to 0.80 for the daily P occurrence indices, and from 0.44 to 0.84 for the daily peak P intensity indices. The neural networks performed significantly better than current state-of-the-art reanalysis (ERA5) and satellite (IMERG) products for all P indices. Using a 0.1 mm 3 h-1 threshold, P was estimated to occur 12.2%, 7.4%, and 14.3% of the time, on average, over the global, land, and ocean domains, respectively. The highest P intensities were found over parts of Central America, India, and Southeast Asia, along the western equatorial coast of Africa, and in the intertropical convergence zone. The PPDIST dataset is available via www.gloh2o.org/ppdist .

Factors Associated with Participation in Stool Based Colorectal Screening in Brunei Darussalam.

INTRODUCTION: Colorectal cancers (CRC) continues to increase worldwide and is associated with significant morbidity and mortality. CRC can be prevented through early detection using several modalities. However, like any screening program participation remains suboptimal. This study assessed the factors associated with participation in a stool based CRC screening that was carried out as part of an Integrated Health Screening Survey for civil servants. MATERIALS AND METHODS: Civil servants who participated in a health survey (N=10,756, mean age 48.08 ± 5.26 years old) were studied. Demographic factors (gender, age groups, marital status, employment status, body mass index [BMI] categories, smoking status, personal and family history of cancers) were analyzed to assess for features associated with willingness to participate in this fecal immunohistochemistry test (FIT) screening for CRC. Comorbid conditions studied were cardiac disease, diabetes mellitus, dyslipidemia, hypertension and stroke. Multivariate analysis was performed to evaluate variables associated with participation in CRC screening programme. RESULTS: Of the invited 10,756 participants, 7,360 returned a stool specimen giving a participation rate of 68.4%. Those who participated were significantly older (60 years [77.8%], p0.05). Multivariate analyses showed that older age (45-49, 50-54, 55-59 and >60) and employment status (professional) remained significant factors associated with participation in a stool based CRC screening. CONCLUSIONS: Our study showed that older age and professional employment status were significantly associated with willingness to participate in a stool based CRC screening.

Chylous nephrogenic ascites in a hemodialysis patient.

Chylous nephrogenic ascites is rare in hemodialysis (HD) patients. We would like to share a rare case of chylous nephrogenic ascites in a HD patient. The patient has a history of straw-colored nephrogenic ascites which was drained through pigtail five times in the past. Later on, the ascites became turbid and milky. The chloroform test of the ascitic fluid showed fat globules with Oil Red-O stain, and the triglyceride concentration of ascitic fluid was 168.14 mg/dL (1.93 mmol/L) satisfying the criteria of chylous ascites. We believe that this may be caused by microtrauma from repeated pigtail insertions for ascites which was compounded by inadequate HD and noncompliance with fluids. Routine investigations including screening for malignancy, tuberculosis, cirrhosis, and heart failure did not reveal any other possible causes. Although there are few case reports of chylous ascites in peritoneal dialysis patients, it has never been reported in patients on HD.

Large-scale Characteristics of Tropical Convective Systems through the Prism of Cloud Regime.

We employ the Cloud Regime (CR) concept to identify large-scale tropical convective systems and investigate their characteristics in terms of organization and precipitation. The tropical CRs (TCRs) are derived from Moderate Resolution Imaging Spectroradiometer (MODIS) Cloud Optical Thickness (COT) and Cloud Top Pressure (CTP) two-dimensional joint histograms. We focus on the TCRs that have relatively low CTPs and high COTs, as well as heavy precipitation, namely TCR1 (convective core-dominant), TCR2 (various high clouds), and TCR3 (anvils). The horizontal size of aggregates of TCR1, 2, or 3 occurrences (TCR123) is identified as the number of contiguous 1°×1° grid cells occupied by either of these three TCRs. For the small to intermediate size aggregates (TCR123 size 20 to 160 one-degree grid cells), there is large variability in the fraction of the aggregate each TCR occupies, but generally TCR2 exhibits the highest fraction. As the total system size grows, the variability shrinks and for the largest systems ratios eventually converge to 0.3, 0.2, and 0.5 for TCR1, 2, and 3, respectively. The mean precipitation of convective core-rich TCR1 is generally high for the systems of intermediate size (80-160 one-degree grid cells), but with the highest mean coming from smaller systems of 20-40 grid cells. For the largest systems, their mean precipitation in areas containing cores (TCR1) are relatively low with suppressed variation. The mean precipitation rates of TCR2 and TCR3 in a TCR123 aggregate tend to be stronger when accompanying TCR1 mean precipitation rate is also high.