The Correlation of MicroRNA-21 With the Nephrin, Podocin, and Urinary Albumin-Creatinine Ratio in Patients With Type 2 Diabetes and Albuminuria: A Cross-Sectional Study.

Background: Diabetic kidney disease (DKD) is the most common and deranging microvascular complication of diabetes mellitus (DM). Podocytopathy is a key component of glomerular damage in DKD. Micro RNA-21 (miRNA-21) is an epigenetic regulator that plays a role in podocyte damage; however, the results of previous studies have not resolved the controversy about the role of miRNA-21 in the pathogenesis of DKD. Objective: The objective was to investigate the correlation between miRNA-21 levels and urinary nephrin, podocin, and urinary albumin-creatinine ratio (UACR) in patients with type 2 DM and albuminuria. Design: This is a cross-sectional study. Setting: This study was carried out in internal medicine outpatient clinic of Cipto Mangunkusumo Hospital Jakarta, Indonesia. Patients: This study consisted of 42 adults with type 2 DM and albuminuria. Measurements: The measurements include (1) Serum miRNA-21; (2) urinary podocin, nephrin, and albumin-creatinine ratio; and (3) serum miRNA-21 correlated to urinary podocin, nephrin, and albumin-creatinine ratio. Methods: The Spearman bivariate analysis to assess the correlation of miRNA-21 with nephrin, podocin, and UACR. Results: The mean relative expression of miRNA-21 was 0.069 (0.024), the median for nephrin, podocin, and UACR was 35.5 (15.75-51.25) ng/mL, 0.516 (0.442-0.545) ng/mL, and 150 (94.56-335.75) ng/mL, respectively. A correlation between miRNA-21 and nephrin was observed (r = 0.598; P < .0001). There was a correlation between miRNA-21 and UACR (r = 0.604; P < .0001). No correlation was found between miRNA-21 and podocin. Limitations: A lack of non-DM and non-albuminuric control population and small sample size. We could not exclude concurrent disease, and all other potential confounding variables, particularly those related to inflammation. Conclusions: The miRNA-21 can be considered an early biomarker for podocytopathy and albuminuria in DM, highlighting its potential for early diagnostic and therapeutic interventions. Further research is required to confirm these findings and explore their clinical applications, which could significantly alter management strategies for DKD.

Contexte: La maladie rénale diabétique (MRD) est la complication microvasculaire la plus fréquente et une des plus inquiétantes du diabète (DB). La podocytose est une composante clé des lésions glomérulaires en contexte de MRD. Le micro-ARN-21 (miARN-21) est un régulateur épigénétique impliqué dans les lésions podocytaires, mais les résultats des études précédentes n'ont pas résolu la controverse sur le rôle du miARN-21 dans la pathogenèse de la MRD. Objectif: Étudier la corrélation entre le taux de miARN-21 et la néphrine, la podocine et le rapport albumine-créatinine (RAC) urinaires chez les patients atteints de diabète de type 2 et présentant une albuminurie. Type d'étude: Étude transversale. Cadre: La clinique ambulatoire de médecine interne de l'hôpital Cipto Mangunkusumo à Jakarta (Indonésie). Sujets: 42 adultes diabétiques de type 2 présentant une albuminurie. Mesures: (1) miARN-21 sérique; (2) podocine, néphrine et rapport albumine-créatinine urinaires; (3) le miARN-21 sérique corrélé à la podocine, à la néphrine et au rapport albumine-créatinine urinaires. Méthodologie: L'analyse bivariée de Spearman a servi à évaluer la corrélation entre le taux de miARN-21 et la néphrine, la podocine et le rapport albumine-créatinine urinaires. Résultats: L'expression relative moyenne du miARN-21 était de 0,069 ng/ml (0,024). La médiane s'établissait à 35,5 (15,75­51,25) ng/ml pour la néphrine, à 0,516 (0,442­0,545) ng/ml pour la podocine et à 150 (94,56­335,75) ng/ml pour le RAC. On a observé une corrélation entre le miARN-21 et la néphrine (r = 0,598; p = < 0,0001), de même qu'entre le miARN-21 et le RAC (r = 0,604; p = <0,0001). Aucune corrélation n'a été observée entre le miARN-21 et la podocine. Limites: L'étude ne comporte pas de population témoin (non-DB et sans albuminurie) et l'échantillon est de petite taille. Il n'a pas été possible d'exclure les maladies concomitantes, de même que toutes les autres variables confondantes potentielles, en particulier celles qui sont liées à l'inflammation. Conclusion: Chez les patients diabétiques, le miARN-21 peut être considéré comme un biomarqueur précoce de la podocytose et de l'albuminurie, ce qui met en évidence son potentiel à faire partie des interventions diagnostiques et thérapeutiques précoces. D'autres recherches sont nécessaires pour confirmer ces résultats et explorer leurs applications cliniques, ce qui pourrait modifier considérablement les stratégies de prise en charge de la maladie rénale diabétique.

Comparison of the Discrimination Performance of AI Scoring and the Brixia Score in Predicting COVID-19 Severity on Chest X-Ray Imaging: Diagnostic Accuracy Study.

BACKGROUND: The artificial intelligence (AI) analysis of chest x-rays can increase the precision of binary COVID-19 diagnosis. However, it is unknown if AI-based chest x-rays can predict who will develop severe COVID-19, especially in low- and middle-income countries. OBJECTIVE: The study aims to compare the performance of human radiologist Brixia scores versus 2 AI scoring systems in predicting the severity of COVID-19 pneumonia. METHODS: We performed a cross-sectional study of 300 patients suspected with and with confirmed COVID-19 infection in Jakarta, Indonesia. A total of 2 AI scores were generated using CAD4COVID x-ray software. RESULTS: The AI probability score had slightly lower discrimination (area under the curve [AUC] 0.787, 95% CI 0.722-0.852). The AI score for the affected lung area (AUC 0.857, 95% CI 0.809-0.905) was almost as good as the human Brixia score (AUC 0.863, 95% CI 0.818-0.908). CONCLUSIONS: The AI score for the affected lung area and the human radiologist Brixia score had similar and good discrimination performance in predicting COVID-19 severity. Our study demonstrated that using AI-based diagnostic tools is possible, even in low-resource settings. However, before it is widely adopted in daily practice, more studies with a larger scale and that are prospective in nature are needed to confirm our findings.

The Etiology of Kidney Failure in Indonesia: A Multicenter Study in Tertiary-Care Centers in Jakarta.

Background: Despite a large number of patients requiring dialysis, the etiology of kidney failure is poorly documented in Indonesia. With the aim to reduce the disease burden, it is essential to obtain more insight in the etiology of chronic kidney disease (CKD). Objectives: In the present study, we attempted to investigate the primary renal disease of kidney failure patients from five tertiary-care centers in Jakarta. Methods: This is a multicenter, cross-sectional study of kidney failure patients receiving kidney replacement therapy (KRT), from December 2021 to July 2022. We recruited patients aged ≥18 years, had been receiving dialysis for at least three months or a kidney transplantation. Findings: This study included 1,152 patients treated with hemodialysis (68.1%), peritoneal dialysis (7.5%), and kidney transplantation (24.4%). At the start of KRT, the median (interquartile-range [IQR]) age was 48 [37-58] years with low eGFR (median [IQR]: 5.9 [4.0-8.34] ml/minute/1.73 m2). Hypertension was the main comorbidity (74.2%), followed by diabetes mellitus (30.1%). The major primary kidney disease was diabetic kidney disease (27.2%), followed by glomerulonephritis (13.0%), hypertension (11.5%), and urolithiasis (10.3%). Lupus nephritis was the common underlying etiology of secondary glomerulonephritis (91%). A high rate of unknown cause (31.1%) was also observed. Conclusions: Our results suggest that diabetic kidney disease is the leading cause of kidney failure in Jakarta, followed by glomerulonephritis. This study highlights the need for a better approach on primary prevention of diabetes mellitus as well as to better recognize glomerulonephritis at earlier stage might have a significant impact on reduction of the rate of kidney failure in Indonesia.

Practical considerations for the use of SGLT-2 inhibitors in the Asia-Pacific countries-An expert consensus statement.

Recent clinical studies have demonstrated the effectiveness of SGLT-2 inhibitors in reducing the risks of cardiovascular and renal events in both patients with and without type 2 diabetes mellitus. Consequently, many international guidelines have begun advocating for the use of SGLT-2 inhibitors for the purpose of organ protection rather than as simply a glucose-lowering agent. However, despite the consistent clinical benefits and available strong guideline recommendations, the utilization of SGLT-2 inhibitors have been unexpectedly low in many countries, a trend which is much more noticeable in low resource settings. Unfamiliarity with the recent focus in their organ protective role and clinical indications; concerns with potential adverse effects of SGLT-2 inhibitors, including acute kidney injury, genitourinary infections, euglycemic ketoacidosis; and their safety profile in elderly populations have been identified as deterring factors to their more widespread use. This review serves as a practical guide to clinicians managing patients who could benefit from SGLT-2 inhibitors treatment and instill greater confidence in the initiation of these drugs, with the aim of optimizing their utilization rates in high-risk populations.

Diagnostic performance of Mac-2-binding protein glycosylation isomer (M2BPGi) as a liver fibrosis marker in chronic hepatitis C patients with chronic kidney disease on hemodialysis.

BACKGROUND/AIM: Liver fibrosis assessment is essential to determine the initiation, duration, and evaluation of chronic hepatitis C treatment. Therefore, the study aimed to assess the role of Mac-2-binding protein glycosylation isomer (M2BPGi) as a biomarker to measure liver fibrosis in chronic hepatitis C patients with chronic kidney disease on hemodialysis. METHODS: This study used a cross-sectional design. Serum M2BPGi level and transient elastography results were evaluated in 102 chronic hepatitis C patients with CKD on HD, 36 CKD on HD patients, and 48 healthy controls. ROC analysis was conducted to identify the optimal cutoff values to assess significant fibrosis and cirrhosis among chronic hepatitis C patients with CKD on HD. RESULTS: In chronic hepatitis C patients with CKD on HD, the level of serum M2BPGi had a moderately significant correlation with transient elastography (r = 0.447, p < 0.001). The median serum M2BPGi was higher among CKD on HD patients compared to healthy controls (1.260 COI vs. 0.590 COI, p < 0.001) and was even higher in chronic hepatitis C patients with CKD on HD compared to CKD on HD group (2.190 COI vs. 1.260 COI, p < 0.001). It is also increased according to the severity of liver fibrosis: 1.670 COI, 2.020 COI, and 5.065 COI for F0-F1, significant fibrosis, and cirrhosis, respectively. The optimal cutoff values for diagnosing significant fibrosis and cirrhosis were 2.080 and 2.475 COI, respectively. CONCLUSION: Serum M2BPGi could be a simple and reliable diagnostic tool for evaluating cirrhosis in chronic hepatitis C patients with CKD on HD.

Effect of primary balloon angioplasty on draining vein diameter and volume flow in patients with arteriovenous fistula: A cohort study.

Background: Chronic kidney disease (CKD) and end-stage kidney disease (ESKD) cause major morbidity and mortality in 10% of the global population with CKD. The most common renal replacement therapy is hemodialysis with arteriovenous fistula (AVF) access. AVF often undergoes maturation failure due to feeding artery and draining vein inadequacy. Mechanical dilatation, such as primary balloon angioplasty (PBA), can overcome AVF maturation failure. The volume flow (VF) and diameter of the draining veins in AVF patients must be known to evaluate the effect of PBA on AVF maturation. This study aims to analyze the impact of PBA on VF and draining vein diameter in ESKD patients undergoing AVF surgery. Methods: A retrospective cohort clinical trial was conducted at our institution. A total of 75 participants had AVF with an arterial diameter >1.5 mm or vein diameter at the AVF creation site of 2-4 mm. The subjects were divided into 2 groups: the intervention group undergoing PBA (n = 36) and the control group, without PBA (n = 39). PBA was performed using a Mustang ballon (3-6 mm, Medtronic). Follow-ups were conducted at 1 week, 2 weeks, and 6 weeks after AVF creation. Results: Based on the data, the diameter and VF of the draining veins were significantly larger in the intervention group than in the control group (p < 0.001). Furthermore, we found significant differences in the mean diameter and VF of the draining veins between the control and intervention groups at all stages of examination, from preoperatively to 6 weeks postoperatively (p < 0.001). The strength of the analysis was more than 80%. Conclusion: PBA can increase the diameter and VF of the draining veins in patients with AVF.

The effects of synbiotics on indoxyl sulphate level, constipation, and quality of life associated with constipation in chronic haemodialysis patients: a randomized controlled trial.

BACKGROUND: Gut microbiota dysbiosis in patients with chronic kidney disease on haemodialysis (CKD-HD) creates an increase in proteolytic bacteria activity, leading to an increase in the production of uraemic toxins, such as indoxyl sulphate, worsening of constipation symptoms and reducing patients' quality of life. Improving gut microbiota dysbiosis is expected to improve this condition. This study aimed to evaluate the effect of synbiotics on indoxyl sulphate levels, constipation symptoms, and constipation-related quality of life in haemodialysis patients. METHODS: This was a double-blinded randomized controlled clinical trial with a parallel design involving haemodialysis patients. We included chronic haemodialysis patients with gastrointestinal complaints, difficulty defecating, faeces with hard consistency, or a bowel movement frequency of fewer than three times per week. Patients were randomly divided into two groups (synbiotics (Lactobacillus acidophilus and Bifidobacterium longum 5x109 CFU) and placebo) for 60 days of oral intervention. All participants, caregivers, and outcome assessors were blinded to group assignment. The primary outcome was a decrease in indoxyl sulphate toxin levels. Meanwhile, improvement in constipation symptoms (measured using the Patient Assessment of Constipation: Symptoms (PAC-SYM) questionnaire) and improvement in constipation-related quality of life (measured using the Patient Assessment of Constipation Quality of Life (PAC-QOL) questionnaire) were assessed as secondary outcomes. RESULTS: We included 60 patients (30 intervention; median age of 51.23 (13.57) years, 33.3% male; 30 control; median age of 52.33 (11.29) years, 36.7% male). There was no significant difference in terms of pre- and postintervention indoxyl sulphate toxin levels in the synbiotics group compared to the placebo group (p=0.438). This study found an improvement in constipation symptoms (p = 0.006) and constipation-related quality of life (p=0.001) after synbiotic administration. CONCLUSION: Two months of synbiotic supplementation did not lower indoxyl sulphate toxin levels. Nevertheless, it had a major effect in improving constipation and quality of life affected by constipation in patients undergoing chronic haemodialysis. TRIAL REGISTRATION: NCT04527640 (date of first registration: 26/08/2020).

Early Recognition of Type 2 Diabetes Complications and Use of SGLT2i in Multidisciplinary Approach: Indonesian Perspective - An Expert Opinion.

Indonesia ranks seventh with the highest number of cases of type 2 diabetes mellitus (T2DM). T2DM is associated with major undesirable complications including cardiovascular disease and chronic kidney disease. Kidneys play a major role in maintaining glucose homeostasis, leading the development of sodium glucose transporter inhibitors (SGLT2i). These inhibitors block renal sodium and glucose reabsorption. Several cardiovascular trials proved that SGLT2i have cardioprotective and renoprotective roles and have been suggested  as a drug of choice in primary and secondary prevention and management of cardiorenal complications associated with T2DM. This review highlights the need for a multidisciplinary recommendation for T2DM management in Indonesian population. Additionally, it is vital to provide the perspective of Indonesian medical experts in terms of screening, diagnosis and treatment as the outcome differs geographically. An expert panel of 6 members from Indonesia was convened to review the existing literature and develop an expert-based review/ summary on this topic. Members were chosen for their proficiency in diabetes, kidney disease and cardiovascular disease. The experts opined that the early use of SGLT2i will be effective in preventing and minimising the progression of cardiorenal complications. Moreover, a consistent multidimensional approach is necessary for improved outcomes.

Raising Awareness of Acute Kidney Injury: Unfolding the Truth.

AKI is rarely being recognized as it may take place without any apparent symptoms. Severe AKI is commonly found in intensive care unit (ICU) patients. AKI in the ICU is an independent risk factor for death, as it may cause systemic effects on other vital organs including the lung, heart, liver, brain and immune system. Some studies have reported that AKI increases susceptibility to infection, doubles the rate of respiratory failure and impairs cardiac function. Considering the substantial impacts of AKI in ICU patients, early implementation of preventive measures should be an essential program which consists of developing AKI risk stratification in the ICU and encouraging the use of novel AKI biomarkers (TIMP-2, IGFBP-7, Cystatin C, IL-18,  KIM-1 and NGAL) as well as other risk stratification tools (clinical risk prediction scores, computer algorithms, furosemide stress test). Furthermore, after ICU patients have recovered, AKI survivors are more likely to develop chronic kidney disease (CKD) and end-stage kidney disease (ESKD), imposing significant morbidity in the future. Recent study has shown that nephrologist intervention was associated with lower risk of starting KRT and progression of AKI.     The coronavirus disease 2019 (COVID-19) pandemic has caused more than 800,000 deaths worldwide. Kidney involvement in patients with COVID-19 may present as proteinuria or hematuria and may lead to acute kidney injury (AKI). Some initial reports showed that the incidence of AKI in COVID cases was negligible. However, later reports suggested that AKI is actually prevalent in patients with COVID-19, particularly in ICU patients. AKI is now considered as a common complication of COVID-19 and it is also associated with adverse outcomes, including development or worsening of comorbidities, yet little is known about the pathogenesis or optimal management of COVID-19-associated AKI.

Role of Soluble Transferrin Receptor - An Iron Marker in Hemodialysis Patients.

Background: Iron status assessment is crucial in end-stage renal disease hemodialysis (ESRD-HD) patients because iron deficiency may cause unresponsiveness to erythropoiesis-stimulating agent. Soluble transferrin receptor (sTfR) is a potential iron marker that is not influenced by inflammation, and the results among studies are still conflicting. This study evaluated the role of sTfR in determining iron deficiency in ESRD-HD patients. Methods: This cross-sectional study was conducted at the Hemodialysis Unit in Cipto Mangunkusumo Hospital, Indonesia, from August to September 2018 and included 127 ESRD-HD patients. The sTfR level, sTfR index (sTfR/log ferritin), iron status, ferritin level, and complete blood count were assessed. Transferrin saturation (TSAT) was used as a reference. The role of sTfR was analyzed using the Chi-square test and receiver operating characteristic curve analysis. Results: The median sTfR was 3.0 (range, 1.0-8.5) mg/l, and the median TSAT was 23% (4.0%-100%). The sTfR level in ESRD-HD patients with absolute iron deficiency was 3.9 (1.9-8.5) mg/l, in those with functional iron deficiency was 3.5 (1.9-5.4) mg/l, and in those with no iron deficiency was 2.6 (1.0-6.4) mg/l. The previous sTfR cut-off value of 2.5 mg/l had a sensitivity of 83.3%, specificity of 48.2%, positive predictive value (PPV) of 44.3%, and negative predictive value (NPV) of 85.4%, whereas the new sTfR cut-off value of 2.71 mg/l had a sensitivity of 83.3%, specificity of 56.5%, PPV of 48.6%, and NPV of 87.3%. TSAT and index TSAT were not influenced by inflammation. Conclusion: The cut-off sTfR value of 2.71 mg/l is better than 2.5 mg/l to determine the iron status in ESRD-HD patients.

The Relationship between Folic Acid and Vitamin B12 Serum Levels with High Sensitivity C-reactive Protein and Homocysteine in Chronic Hemodialysis Patients: A Cross-sectional Study.

BACKGROUND: Folic acid (FA) and vitamin B12 treatment have been routinely prescribed to lower serum homocysteine levels and to reduce inflammation. However, no study has been conducted to determine serum folic acid (SFA) and vitamin B12 (B12) levels in patients who have twice-weekly hemodialysis. The aim of our study was to assess serum folate and B12  levels in chronic hemodialysis patients and their relationship with hsCRP and homocysteine levels. METHODS: Our study was a cross-sectional study involcing patients who had twice-weekly hemodialysis in Dr Cipto Mangunkusumo National Hospital Jakarta, Indonesia. Predialysis blood samples were taken to measure SFA, B12, homocysteine and hsCRP levels. Patients with medical conditions affecting the assays were excluded. Spearman correlation was used to compare variables. RESULTS: Eighty subjects enrolled in this study. Among those of non-given folic acid and vitamin B-12 supplementation, only 3.85% of subjects had low folic acid levels, and none had low vitamin B12 levels. A moderate negative correlation between serum folic acid and homocysteine level (p≤0.001; r=-0.42) and a weak correlation between serum vitamin B12 and homocysteine level (p=0.009; r=-0.29) was found. Among the high-risk cardiovascular group (CRP>3, n=49), there is a moderate negative correlation between serum folic acid and homocysteine level (p≤0.001; r=-0.561) and a weak negative correlation between vitamin B12 and homocysteine level (p=0.018; r=-0.338). CONCLUSION: There is a significant negative correlation between serum vitamin B12 and folic acid with homocysteine levels, especially in high-risk cardiovascular group.

Trainees' perceptions and expectations of formal academic mentoring during the COVID-19 pandemic in Indonesian cardiology residency programs.

PURPOSE: During medical residency programs, physicians develop their professional identities as specialists and encounter high expectations in terms of achieving competencies. The responsibilities of medical trainees include caring for patients, balancing work with personal life, and weathering stress, depression, and burnout. Formal academic mentoring programs strive to ease these burdens. The coronavirus disease 2019 (COVID-19) pandemic has altered the trainee­academic mentor relationship, and solutions are needed to address these challenges. The present study aimed to evaluate the formal academic mentoring process through trainees' perceptions and expectations of formal mentoring programs during COVID-19 in Indonesian cardiology residency programs. METHODS: This cross-sectional study used a self-administered online questionnaire to capture trainees' perceptions and expectations regarding academic mentoring programs in 3 cardiology residency programs in Indonesia from October to November 2020. The questionnaire was developed before data collection. Perceptions of the existing mentoring programs were compared with expectations. RESULTS: Responses were gathered from 169 out of 174 residents (response rate, 97.3%). Most trainees reported having direct contact with COVID-19 patients (88.82%). They stated that changes had taken place in the mode and frequency of communication with their academic advisors during the pandemic. Significant differences were found between trainees' perceptions of the existing mentoring programs and their expectations for academic mentoring programs (P<0.001). CONCLUSION: Despite the challenges of interacting with their academic mentors, trainees still perceived academic mentors as a vital resource. Study programs need to consider trainees' expectations when designing academic mentoring programs.

Association of BsmI Polymorphisms in the Vitamin D Receptor Gene Among Indonesian Population with Diabetic Kidney Disease.

BACKGROUND: Diabetic kidney disease (DKD), as a common cause of end-stage renal disease (ESRD), is a chronic complication of diabetes mellitus (DM). It has been established that vitamin D deficiency is one of DKD risk factors, which may be related to vitamin D receptor (VDR) polymorphisms. This study aimed to analyze the association between VDR polymorphisms and DKD in Indonesian population, also risk factors that influence it. METHODS: a cross-sectional study was conducted in Type 2 DM patients  who visited internal medicine outpatient clinic at Dr. Cipto Mangunkusumo Hospital, Jakarta, from November 2014 until March 2015.  Data collection includes characteristics of subjects and laboratory examination, including BsmI polymorphisms in the vitamin D receptor gene. Patients with acute and severe disease were excluded from the study. Bivariate and multivariate analyses were done. RESULTS: of 93 DM subjects, 42 (45.2%) subjects were without DKD and 51 (54.8%) subjects had DKD. Most of the subjects had the Bb genotype (89.2%), with no subject having the BB genotype. The proportions of the B and b alleles were 44.6% and 55.4%, respectively. There is no association between BsmI polymorphisms in the vitamin D receptor gene and DKD (OR = 1.243; CI 95% 0.334-4.621; p value = 0.751). CONCLUSION: the profile of BsmI polymorphisms in the vitamin D receptor gene in the Indonesian population were genotypes Bb (89.2%) and bb (10.8%). There was no association between BsmI polymorphisms in the vitamin D receptor gene and DKD. Duration of DM more than five years influenced the association between those variables.

Peritoneal dialysis: Status report in South and South East Asia.

BACKGROUND: Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region. METHODS: The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups. RESULTS: Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization. CONCLUSION: Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability.

Impact of National Economy and Policies on End-Stage Kidney Care in South Asia and Southeast Asia.

BACKGROUND: The association between economic status and kidney disease is incompletely explored even in countries with higher economy (HE); the situation is complex in lower economies (LE) of South Asia and Southeast Asia (SA and SEA). METHODS: Fifteen countries of SA and SEA categorized as HE and LE, represented by the representatives of the national nephrology societies, participated in this questionnaire and interview-based assessment of the impact of economic status on renal care. RESULTS: Average incidence and prevalence of end-stage kidney disease (ESKD) per million population (pmp) are 1.8 times and 3.3 times higher in HE. Hemodialysis is the main renal replacement therapy (RRT) (HE-68%, LE-63%). Funding of dialysis in HE is mainly by state (65%) or insurance bodies (30%); out of pocket expenses (OOPE) are high in LE (41%). Highest cost for hemodialysis is in Brunei and Singapore, and lowest in Myanmar and Nepal. Median number of dialysis machines/1000 ESKD population is 110 in HE and 53 in LE. Average number of machines/dialysis units in HE is 2.7 times higher than LE. The HE countries have 9 times more dialysis centers pmp (median HE-17, LE-02) and 16 times more nephrologist density (median HE-14.8 ppm, LE-0.94 ppm). Dialysis sessions >2/week is frequently followed in HE (84%) and <2/week in LE (64%). "On-demand" hemodialysis (<2 sessions/week) is prevalent in LE. Hemodialysis dropout rates at one year are lower in HE (12.3%; LE 53.4%), death being the major cause (HE-93.6%; LE-43.8%); renal transplants constitute 4% (Brunei) to 39% (Hong Kong) of the RRT in HE. ESKD burden is expected to increase >10% in all the HE countries except Taiwan, 10%-20% in the majority of LE countries. CONCLUSION: Economic disparity in SA and SEA is reflected by poor dialysis infrastructure and penetration, inadequate manpower, higher OOPE, higher dialysis dropout rates, and lesser renal transplantations in LE countries. Utility of RRT can be improved by state funding and better insurance coverage.

The Association of ß2-Microglobulin and Fibroblast Growth Factor 23 with Major Adverse Cardiac Event in Acute Coronary Syndrome Patients with Chronic Kidney Disease.

BACKGROUND: chronic kidney disease (CKD) increases the severity and risk of mortality in acute coronary syndrome (ACS) patients. The role of ß2-M as a filtration and inflammation marker and FGF23 as a CKD-MBD process marker might be significant in the pathophysiology in ACS with CKD patients. This study aims to determine the association of ß2-M and FGF23 with major adverse cardiac event (MACE) in ACS patients with CKD. METHODS: we used cross sectional and retrospective cohort analysis for MACE. We collected ACS patients with CKD consecutively from January until October 2018 at Dr. Cipto Mangunkusumo General Hospital. Data were analyzed using logistic regression and Cox's Proportional Hazard Regression. RESULTS: a total of 117 patients were selected according to the study criteria. In bivariate analysis, ß2-M, FGF23, and stage of CKD had significant association with MACE (p = 0.014, p = 0.026, p = 0.014, respectively). In multivariate analysis, ß2-M - but not FGF 23- was significantly associated with MACE (adjusted HR 2.16; CI95% 1.15-4.05; p = 0.017). CONCLUSION: ß2-M was significantly associated with MACE, while FGF23 was not so. This finding supports the role of inflammation in cardiovascular outcomes in ACS with CKD patient through acute on chronic effect.

Biofilm-Producing Bacteria and Risk Factors (Gender and Duration of Catheterization) Characterized as Catheter-Associated Biofilm Formation.

BACKGROUND: A catheter-associated urinary tract infection (CA-UTI) is preceded by biofilm formation, which is related to several risk factors such as gender, age, diabetic status, duration of catheterization, bacteriuria before catheterization, virulence gene factor, and antibiotic usage. AIMS: This study aims to identify the microbial composition of catheter samples, including its corresponding comparison with urine samples, to determine the most important risk factors of biofilm formation and characterize the virulence gene factors that correlate with biofilm formation. METHODS: A longitudinal cross-sectional study was conducted on 109 catheterized patients from September 2017 to January 2018. The risk factors were obtained from the patients' medical records. All catheter and urine samples were cultured after removal, followed by biomass quantification. Isolate identification and antimicrobial susceptibility testing were performed using the Vitex2 system. Biofilm-producing bacteria were identified by the Congo Red Agar (CRA) method. A PCR test characterized the virulence genes of dominant bacteria (E. coli). All data were collected and processed for statistical analysis. RESULTS: Out of 109 catheterized patients, 78% of the catheters were culture positive, which was higher than those of the urine samples (37.62%). The most common species isolated from the catheter cultures were Escherichia coli (28.1%), Candida sp. (17.8%), Klebsiella pneumoniae (15.9%), and Enterococcus faecalis (13.1%). E. coli (83.3%) and E. faecalis (78.6%) were the main isolates with a positive CRA. A statistical analysis showed that gender and duration prior to catheterization were associated with an increased risk of biofilm formation (p < 0.05). CONCLUSION: E. coli and E. faecalis were the most common biofilm-producing bacteria isolated from the urinary catheter. Gender and duration are two risk factors associated with biofilm formation, therefore determining the risk of CAUTI. The presence of PapC as a virulence gene encoding pili correlates with the biofilm formation. Biofilm-producing bacteria, female gender, duration of catheterization (more than five days), and PapC gene presence have strong correlation with the biofilm formation. To prevent CAUTI, patients with risk factors should be monitored by urinalysis tests to detect earlier the risk of biofilm formation.

Prevalence of prehypertension and its risk factors in midlife and late life: Indonesian family life survey 2014-2015.

BACKGROUND: Early detection of prehypertension is important to prevent hypertension-related complications, such as cardiovascular disease, cerebrovascular disease and all-cause mortality. Data regarding the prevalence of prehypertension among mid- and late-life population in Indonesia were lacking. It is crucial to obtain the prevalence data and identify the risk factors for prehypertension in Indonesia, which may differ from that of other countries. METHODS: The cross-sectional analysis utilized multicenter data from Indonesian Family Life Survey-5 (IFLS-5) from 13 provinces in 2014-2015. We included all subjects at mid-and late-life (aged ≥40 years old) from IFLS-5 with complete blood pressure data and excluded those with prior diagnosis of hypertension. Prehypertension was defined as high-normal blood pressure according to International Society of Hypertension (ISH) 2020 guideline (systolic 130-139 mmHg and/or diastolic 85-89 mmHg). Sociodemographic factors, chronic medical conditions, physical activity, waist circumference and nutritional status were taken into account. Statistical analyses included bivariate and multivariate analyses. RESULTS: There were 5874 subjects included. The prevalence of prehypertension among Indonesian adults aged > 40 years old was 32.5%. Age ≥ 60 years (adjusted OR 1.68, 95% CI 1.41-2.01, p <  0.001), male sex (adjusted OR 1.65, 95% CI 1.45-1.88, p <  0.001), overweight (adjusted OR 1.44, 95% CI 1.22-1.70, p <  0.001), obesity (adjusted OR 1.77, 95% CI 1.48-2.12, p <  0.001), and raised waist circumference (adjusted OR 1.32, 95% CI 1.11-1.56, p = 0.002) were the significant risk factors associated with prehypertension. Prehypertension was inversely associated with being underweight (adjusted OR 0.74, 95% CI 0.59-0.93, p = 0.009). CONCLUSIONS: The prevalence of prehypertension in Indonesian mid- and late-life populations is 32.5%. Age ≥ 60 years, male sex, overweight, obesity, and raised waist circumference are risk factors for prehypertension.

Chronic kidney disease in Hepatitis C and its association with liver cirrhosis and viral load: Revealing the importance of hematuria.

Hepatitis C virus (HCV) contributed as a risk factor for chronic kidney disease (CKD). Many studies only showed it associated with estimated glomerular filtration rate (eGFR) reduction and albuminuria, but none revealed hematuria data. Besides, liver cirrhosis and viral load as risks for CKD are still yet to be established. This study aimed to assess the prevalence of CKD and its component in hepatitis C and to associate it with liver cirrhosis and viral load. A cross-sectional study using consecutive recruitment on the basis of anti-HCV positivity was done from August 2018 until January 2019. The participants with any renal abnormality on the first meeting were followed prospectively for at least three months. The study was done in Hepatology Clinic Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Liver cirrhosis was defined using transient elastography (>11 kPa). A baseline viral load >100,000 IU/mL was considered as high. CKD was defined as persistence of decreased eGFR and/or albuminuria and/or hematuria for three months. Logistic regression models were used to evaluate adjusted odds ratio (aOR) with adjustment for age, sex, diabetes mellitus, and hypertension. Of the 185 participants, prevalence of CKD was 23.2% [confidence interval (CI) 95% 17.1%-29.3%]. Decreased eGFR was present in 22 (11.9%), albuminuria in 29 (15.7%), and hematuria in 13 (7%). Liver cirrhosis was associated with CKD (aOR 2.948, CI 95%: 1.218-7.136) but not viral load (aOR: 0.93, CI 95%: 0.396-2.185). Renal examination is recommended in all patients with hepatitis C, particularly in patient with liver cirrhosis.