Sofosbuvir and Velpatasvir Regimen Outcome for Chronic Hepatitis C Patients With End-Stage Renal Disease Undergoing Hemodialysis.

Background Patients on hemodialysis (HD) are most likely to contract hepatitis C (HCV) infection, which is associated with significant morbidity and disease progression. Direct-acting antivirals (DAAs) are safe and tolerable in chronic kidney disease (CKD) with a 90-100% cure rate, and limited data exist regarding their efficacy in end-stage renal disease (ESRD), particularly for HD patients in South Asia. The study aimed to assess the outcome of a 12-week sofosbuvir (SOF) and velpatasvir (VEL) treatment regimen on ESRD patients with chronic HCV infection undergoing HD in the Pakistani Asian population. Methodology This prospective cohort study was conducted between January 2022 and January 2023 at the outpatient nephrology and gastroenterology clinic of Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, Pakistan. This study included a total of 220 ESRD patients fulfilling the inclusion criteria, aged 20-55 years, who had been undergoing weekly HD sessions for at least two years, with acquired HCV infection. Data on demographic and clinical characteristics were collected through patient interviews. Laboratory and dialysis profiling was executed to assess ESRD and discover the underlying cause by ultrasound abdomen, blood pressure measurement by sphygmomanometer, random blood sugar for diabetes, and taking note of the duration and frequency of dialysis. HCV RNA PCR was done at selected intervals to evaluate the virological response to treatment. Sustained virological response (SVR), liver cirrhosis status, and number of weekly HD sessions were compared at one year of SOF/VEL regimen. Results The mean age of patients with ESRD was 41.8 with a standard deviation (SD) of 9.3 years, and HCV diagnosis was 1.3 years with SD of 0.4 years; 52.7% (n=116) were males, 47.3% (n=104) were females, 75% (n=165) were urban dwellers, and 93.6% (n=206) were married. CKD that requires dialysis was caused mainly by hypertension (78, 35%), diabetes mellitus type 2 (52, 24%), bilateral small kidney disease (40, 18%), and others (34, 16%). One hundred and six (48.2%) received dialysis thrice weekly, 83 (37.7%) twice, and 31 (14.1%) once weekly. The study monitored the rapid virological response (RVR) at four weeks of SOF/VEL regimen in 89.5% of ESRD patients, observed end-of-treatment response (ETR) at 12 weeks in 93.2%, and noted 91.4% SVR response at one year. Only four (1.8%) relapses were observed in the study, which was statistically insignificant. The status of liver cirrhosis showed a 50% improvement, decreasing from 40% to 20%. The frequency of weekly HD sessions decreased from thrice to twice-thrice a week. Conclusion The prevalence of contracting HCV is high among CKD and dialysis ESRD patients. All-oral DAA therapy has revolutionized HCV treatment with co-morbidities. Renal functions improved after the SOF/VEL regimen for chronic HCV infection in ESRD patients undergoing HD, with the number of weekly dialysis sessions reduced and SVR reaching 91.4%. Thus, a single-tablet, pan-genotypic DAA regimen of SOF/VEL for 12 weeks is safe, effective, and tolerable regardless of the underlying etiology of ESRD, complications of cirrhosis, HCV genotype, or previous treatment exposure. The successful treatment of HCV and achieving SVR lowers the risk of ESRD complications, improves extra-hepatic manifestations, and greatly enhances survival. Further studies are warranted after the availability of other DAAs to confirm findings with no limitations.

Microalbuminuria as the Tip of Iceberg in Type 2 Diabetes Mellitus: Prevalence, Risk Factors, and Associated Diabetic Complications.

Background Microalbuminuria (MA) is an important clinical marker for the early detection of kidney damage in patients with type 2 diabetes (T2DM). Urine albumin-to-creatinine ratio (ACR), also known as urine microalbumin, is a sign of diabetic nephropathy (DN), which is a prevalent complication of diabetes and can result in end-stage renal disease (ESRD) if not managed. The prevalence of MA in T2DM has been steadily increasing worldwide, making it a significant public health concern. The goal of this study was to estimate the prevalence of MA and its relationship to hypertension and other diabetic complications among people with T2DM. Methodology This descriptive cross-sectional study was conducted from February 5, 2022, to February 10, 2023, to analyse data from T2DM patients who visited the outpatient diabetic clinic of Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, Pakistan. This study included a total of 640 patients, aged 35-60 years, who had been diagnosed with T2DM for at least five years and fulfilled the inclusion criteria. Data on demographic and clinical characteristics, blood pressure (BP) measurements, and laboratory investigations were collected. MA was assessed based on the ACR in a spot urine sample of more than 30 mg/l. Blood pressure greater than 140/90 or already taking anti-hypertensives was taken to constitute hypertension. Factors associated with MA like hypertension, gender, mode of diabetes treatment, duration of diabetes, glycosylated haemoglobin (HbA1c), dyslipidemia, and other diabetic complications such as retinopathy and neuropathy were also recorded. Results The prevalence of MA in this study of T2DM patients study was 39.1%. The mean age of the participants with MA was 53.9 with a standard deviation (SD) of 6.1 years, and the mean duration of diabetes was 10.1 years (SD 6.2 years); 101 (33.4%) males (n=302) and 103 (30.5%) females (n=338) had MA.  There was a statistically significant correlation between MA > 30mg/d and hypertension (p = <0.001), diabetes duration since diagnosis (p=0.04), HbA1C level (p = <0.001), dyslipidemia (p=0.001), therapy type (p = <0.001), triglyceridemia (p = 0.03), history of diabetes retinopathy (p= <0.002), and peripheral neuropathy (p= <0.001). However, there was no statistically significant correlation between MA and age (p = 0.56), female gender (p = 0.08), low- and high-density lipids, or statin use (p = 0.06). Conclusion The prevalence of microalbuminuria among T2DM patients is significantly high (39.1%) and is positively correlated with various factors such as male gender, hypertension, suboptimal control of diabetes mellitus, high HbA1c levels, longer disease duration, dyslipidemia with high triglycerides, treatment modalities of T2DM, and other diabetic complications like neuropathy and retinopathy. As diabetes is very prevalent in our country, the number of patients with diabetic kidney disease will rise significantly in the near future, leading to ESRD and other diabetic complications, and immediate intervention is needed to prevent this. Further research is warranted to explore potential interventions and evaluate their impact on patient outcomes.

Retraction: Small Intestinal Tumors: A Rare Case of Tubulovillous Adenoma in Duodenum.

[This retracts the article DOI: 10.7759/cureus.4671.].

Small Intestinal Tumors: A Rare Case of Tubulovillous Adenoma in Duodenum.

The small intestine is a relatively privileged organ; primary tumors are uncommon among malignancies of the gastrointestinal tract, with an average annual incidence rate of 9.9 per million people. Among these uncommon tumors, duodenal tumors are even rarer with an average incidence rate of 0.4% only. Histopathological examination mostly shows villous type. Tubulovillous histology is extremely rare with an incidence of less than 1% of all duodenal tumors. These tumors are either found incidentally or during screening for familial disorders such as familial adenomatous polyposis or Gardner's syndrome. Patients usually have symptoms such as diarrhea and abdominal pain along with weight loss over a period of months. Itching over the whole body and progressive yellow discoloration of sclera and skin (jaundice) can also be present when tumor compresses the common bile duct (CBD) and causes obstruction, especially in the region of ampulla of Vater. Examination of the abdomen may or may not reveal a mass lesion. Abdominal radiography and ultrasound show intra- and extra-hepatic biliary dilatation along with distention of CBD and growth at the lower end of CBD. Endoscopic retrograde cholangiopancreatography (ERCP) is, however, the investigation of choice as it not only allows direct visualization of a biliary tree but biopsy specimens can also be taken. Palliative procedures like placing a stent in the common bile duct to relieve obstruction can be done or a drain can be placed to drain bile. The definitive treatment is the Whipple procedure involving gastrojejunostomy, choledochojejunostomy, and cholecystectomy. Our case is unique as the patient had duodenal tubulovillous adenoma, a very rare tumor among the already uncommon duodenal tumors. The patient underwent Whipple procedure, T tube was placed, and feeding jejunostomy was done. An uneventful recovery occurred.

Gallbladder Perforation Secondary to Enteric Fever: An Interesting Case of Acute Abdomen.

Enteric fever is a common infectious disease, especially in countries with poor sanitation and in the tropics. It is caused mainly by Salmonella typhi and accounts for nearly 27 million cases worldwide and 200,000 deaths annually. Enteric fever involves the reticuloendothelial system such as bone marrow, spleen, and liver. As it mostly involves the Peyer's patches of the terminal ileum, enteric perforation occurs commonly. However, gallbladder perforation can also occur, though not very often. Ultrasound as well as computerized tomography (CT) abdomen and pelvis lack specificity for detecting gallbladder perforations in enteric fever. Diagnosis is usually confirmed intraoperatively when the gallbladder is visualized and perforation is seen. Gallbladder perforation is usually seen in acute cholecystitis when the gallbladder becomes necrotic and gangrenous. In acalculous cholecystitis, perforation is rare. Enteric fever is one of the rarest causes of acalculous cholecystitis, leading to perforation. Here, we present the case of a 20-year-old man who presented with fever for 10 days along with loose stools, vomiting, and acute abdomen. Labs showed leukopenia, positive Typhidot test but X-ray erect abdomen and ultrasound abdomen and pelvis were nonspecific. Only after resuscitation and exploration of the abdomen was it found that the gallbladder had multiple perforations. The patient was improved after eight days of postoperative intravenous antibiotics. This is a unique and rare presentation of such a common infectious disease.