Diagnostic role of urine specific gravity to detect kidney impairment on heat-exposed workers in a shoe factory in Indonesia: a cross-sectional study.

OBJECTIVES: Globally, there are increasing cases of chronic kidney disease of unknown origin among heat-exposed workers. We aimed to see the kidney damages of indoor heat-exposed workers and whether urine specific gravity can predict any kidney damages. DESIGN: A cross-sectional study. SETTING: A shoe-making factory in West Java, Indonesia. PARTICIPANTS: 119 subjects were included. Minimum total sample size was 62. Subjects were indoor heat-exposed workers who were exposed to occupational wet-bulb globe temperature (WBGT) of 28°C-30°C for 8 hours daily with 1 hour break, 5 days a week. The inclusion criterion was healthy subjects according to the result from annual medical check-up in 2019. The exclusion criteria were subjects who were taking vitamins and/or supplements that might cause disturbance in urine specific gravity and/or hydration status, pregnant and fasting. PRIMARY AND SECONDARY OUTCOME MEASURES: Area under the curve (AUC), sensitivity and specificity of urine specific gravity for the detection of urinary nephrin and urinary kidney injury molecule-1 (KIM-1) were analysed. Estimated glomerular filtration rate (eGFR) and quantitative albuminuria were also measured. RESULTS: WBGT in the work area of the subject was 28°C-30°C. There were 15 (12.6%) subjects who had eGFR <90 mL/min, but ≥60 mL/min. High serum vasopressin levels were found in 79 subjects with a mean of 6.54 (95% CI 5.94 to 7.14) ng/mL. Most subjects had nephrinuria (87.4%) with preserved renal function (87.4%). Several subjects had elevated urinary KIM-1 (10.9%) and albuminuria (7.6%). AUC of urine specific gravity for increased urinary nephrin was 81.7% (95% CI 68.8% to 94.6%) and statistically significant (p<0.001). Cut-off value of ≥1.018 for urine specific gravity has sensitivity of 71.2% and specificity of 80% for detecting elevation of urinary nephrin levels. CONCLUSION: Urine specific gravity with a cut-off value of ≥1.018 could be used to detect nephrinuria among heat-exposed workers.

Clinical Comparison of Renogen, a Biosimilar Epoetin-a, with the Originator, Eprex, in Chronic Kidney Disease Anemia in Indonesia: A Preliminary Study.

BACKGROUND: treatment of erythropoietin (EPO) is essential in chronic kidney disease (CKD) patients to maintain optimal hemoglobin (Hb) level. Renogen is a biosimilar epoetin-α, and Eprex is the originator epoetin-α. This study aimed to compare the efficacy and tolerance of Renogen with Eprex in CKD anemia. METHODS: Renogen and Eprex were compared in a randomized (2:1), open-label study for 8 weeks, proceeded by 4 weeks adjustment (maintenance) phase, in anemic CKD patients undergoing HD in Cipto Mangunkusumo General Hospital, Jakarta, from June 2017 to October 2018. RESULTS: a total of 45 patients (31 received biosimilar EPO and 14 received originator EPO) were included in the study.  At baseline, mean (SD) Hb levels were 10.9 (0.74) g/dL and 10.9 (0.61) g/dL in biosimilar and originator EPO groups, respectively. At end of study (8 weeks), mean (SD) Hb levels were 10.5 (1.28) g/dL and 11.0 (1.13) g/dL in biosimilar EPO and originator EPO groups, respectively.  The proportion of patients with Hb levels maintained within the target range (>10 g/dL) during 8 weeks randomization phase were 58.1% and 71.4% in biosimilar EPO and originator EPO, respectively (p=0.60; NS). There were no significant difference in epoetin dose between the 2 groups, and there was no drug-related adverse event in either group. CONCLUSION: Hb level at >10 g/dL could be maintained for 8 weeks of treatment with both originator and biosimilar EPO (more consistent with originator EPO and more fluctuations with biosimilar EPO), with similar epoetin dose and no drug-related adverse event.

Diagnostic Performance of Afternoon Urine Osmolality to Assess Optimal Hydration Status in an Adult Healthy Population.

BACKGROUND: optimal hydration represents adequate total daily fluid intake to compensate for daily water losses, ensure adequate urine output to reduce the risk of urolithiasis and renal function decline, and also avoid the production of arginine vasopressin (AVP). Twenty-four-hour urine osmolality has been used to assess hydration status, but it is challenging because of the possibility of spilling urine and limitation of daily activities. This study is aimed to determine the performance of the afternoon urine osmolality to assess the optimal hydration status compared with 24-hour urine osmolality. METHODS: a cross sectional study was conducted on healthy employees aged 18-59 years at Universitas Indonesia Medical Faculty/Cipto Mangunkusumo Hospital, with consecutive sampling method. The ROC curve was analyzed to obtain the optimal cut off point and the accuracy of the afternoon urine osmolality in assessing the optimal hydration status. RESULTS: between August-September 2016 there were 120 subjects (73.8% female, median age 32 years) who met the study criteria with a median 24-hour urine osmolality 463.5 (95% CI, 136-1427) mOsm/kg H2O and median afternoon urine osmolality 513 (95% CI, 73-1267). We found moderate correlation (r=0.59; p<0.001) between afternoon urine osmolality and a 24-hour urine osmolality. Using ROC curve, the AUC value was 0.792 (95% CI, 0.708-0.875) with the cut off 528 mOsm/kg H2O. To assess the optimal hydration status, the afternoon urine osmolality had the sensitivity of 0.7 (95% CI, 0.585-0.795) and the specificity of 0.76 (95% CI, 0.626-0.857), Likelihood Ratio (LR) (+) 2.917 (95% CI, 1.74-4.889) and LR (-) 0.395 (95% CI, 0.267-0.583). CONCLUSION: afternoon urine osmolality can be used as a diagnostic tool to assess the optimal hydration status in healthy population with cut off 528 mOsm/kg H2O, sensitivity of 0.7, and specificity of 0.76.

Plasma Potassium Levels in Healthy Prehypertension Subjects and the Role of A High Potassium Drink.

BACKGROUND: Most populations around the world consume less than the recommended levels of potassium. Long term low potassium intake could lead to decreased plasma potassium levels and induce hypokalemia. The increasing of plasma potassium levels 0,2-0,4 mmol/L by improving potassium intake decreased significantly blood pressure (BP). Assessing plasma potassium levels in healthy people related to potassium intake have not been studied. OBJECTIVE: In this study, we analysed plasma potassium levels in prehypertension (PHT) subjects to evaluate the effect of tender coconut water (TCW) as a high potassium drink on plasma potassium levels in PHT adults. MATERIALS AND METHODS: Thirthy-two female aged 25-44 years were randomly allocated to 14 days on TCW or water in a parallel randomized clinical trial. The treatment (T) group received TCW 300 ml twice daily and the control (C) group received water 300 ml twice daily too. RESULTS: At baseline, plasma potassium levels was 3.71±0.41 mmol/L, and 22.58% were categorized as hypokalemia. After 14 days treatment, potassium plasma level between T and C groups were not significantly different (p=0,247). The change of plasma potassium levels in both groups showed tendency to increase but not statistically significant difference was observed (p=0.166). CONCLUSION: In healthy prehypertension women, the low levels of potassium plasma may be caused by low potassium intake for long time and intervension with TCW 300 ml twice daily for 14 consecutive days has not proven yet to increase plasma potassium levels. It is necessary to give higher dose and longer time to increase potassium plasma in low potassium plasma level subjects.

Plasma sodium in relation with the extracellular fluid volume in chronic hemodialysis patients.

AIM: To obtain a causal relationship between changes in plasma sodium levels and increased extracellular fluid volume between post-hemodialysis and pre-hemodialysis on the following day or plasma sodium serves as a predictor of extracellular fluid volume. METHODS: The study was conducted on 40 subjects randomly selected from the 247 chronic hemodialysis patients in Hemodialysis Unit of Nephrology and Hypertension Division, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia--Cipto Mangunkusumo Hospital that met the inclusion and exclusion criteria. Their plasma sodium levels, post-hemodialysis weight and pre-hemodialysis weight on the following day were examined. RESULTS: There was no significant difference in the plasma sodium levels between post-hemodialysis and pre-hemodialysis on the following day. However, there was a considerable differences between post-hemodialysis weight and pre-hemodialysis weight on the following day (p=0.0000). In regression analysis that were conducted on the relationship between the difference in pre-hemodialysis sodium levels subtracted by previous post-hemodiaysis sodium levels (Y) and the difference in pre-hemodialysis weight subtractted by previous post-hemodialysis weight (X), a significant causal relationship was found with the regression formula of Y=-2.205+0.937 X. CONCLUSION: Plasma sodium levels in chronic hemodialysis patients can be used as predictors of body fluid volume or extracellular fluid volume. At each dialysis unit, the recommended weight gain for the patients are 2.5 kg-2.9 kg, in order to prevent a significant decrease in plasma sodium levels that could lead to mortality.

Effect of folic acid, vitamin B6 and vitamin B12 supplementation on mortality and cardiovascular complication among patients with chronic kidney disease: an evidence-based case report.

AIM: to determine whether the administration of folic acid, vitamin B6 and vitamin B12 would lead to reduction of cardiovascular complication and mortality among CKD patients. METHODS: a search was conducted on PubMed and Google. The selection of title and abstract was conducted using inclusion and exclusion criterias, which led to six relevant articles. The selected studies were critically appraised for its validity, importance and applicability. RESULTS: the administration of folic acid and vitamin B reduce homocysteine level among CKD patients. Despite homocysteine level reduction, all six studies reported similar findings that folic acid and vitamin B supplementation did not significantly reduce cardiovascular complication and mortality. CONCLUSION: treatment with folic acid, vitamin B6 and vitamin B12 did not reduce cardiovascular complication and mortality among CKD patients.

Hypertensive crises in the adolescent: evaluation of suspected renovascular hypertension.

Hypertensive crises can be divided into two categories as hypertensive emergency and hypertensive urgency. Most authorities have defined hypertensive emergency as a situation that requires immediate reduction in blood pressure (BP) with parenteral agents because of acute or progressive target organ damage, whereas hypertensive urgency is a situation with markedly elevated BP but without severe symptoms or progressive target organ damage, wherein the BP should be reduced within hours, often with oral agents. Adolescent with hypertension should be suspected of having renovascular hypertension in spite of other causes. This case is presenting a 16-year-old boy with hypertensive crises due to suspected renovascular hypertension. His blood pressure was 240/120 at admission with hypertensive retinopathy grade III and there was increase in creatinine after administering ACE-inhibitor but his renal arteriography revealed normal, other physical examination and laboratory findings was normal. Regarding these findings, the conclusion was this patient got essential hypertension. As many hypertensive crises occur in any ages, clinicians should aware the possibility of renovascular hypertension in young patients with hypertensive crises. An early detection and urgent treatment are needed to prevent the implication of progressive target organ damage.

Abdominal circumference in relation to body weight gain/loss in patients on chronic hemodialysis.

AIM: to determine a constant relationship between changes in abdominal circumference (in centimeter) and body weight (in kilogram) in chronic kidney disease (CKD) patients undergoing chronic hemodialysis. METHODS: experimental-analytical study in patients with CKD on hemodialysis, using before and after treatment design at the Dialysis Unit of Cipto Mangunkusumo Hospital, Jakarta. The sample were selected consecutively. Weighing and abdominal circumference measurements were done at the time of before and after hemodialysis session on the same day. Repeated measurements were performed on different days in 104 subjects to achieve the target sample size of 676. Serum albumin level were also measured on the patients. RESULTS: there was a strong (r=0.838) and significant (p=0.000) correlation between mean body weight and mean abdominal circumferences before and after hemodialysis. In the calculation of the regression between the mean body weight before and after hemodialysis (X) with a mean abdominal circumference before and after hemodialysis (Y), regression formula: Y=34.94 + 0.84 X was obtained. There was no significant correlation between serum albumin levels (3.93±0.40 g/dL) and abdominal circumference before hemodialysis, abdominal circumference after hemodialysis, and the mean abdominal circumference before and after hemodialysis. CONCLUSION: prediction of weight changes in patients with CKD on chronic hemodialysis, can be measured through the abdominal circumference measurement before and after hemodialysis.

Sixteen years experience in six cases of Conn syndrome in Jakarta.

Primary hyperaldosteronism or Conn syndrome is the syndrome formed from the triad of hypertension, hypokalemia, and metabolic alkalosis. Six patients of Conn syndrome, two females (21 and 50 years) and 4 males (30, 33, 46, dan 51 years), were reported. All of the cases came with the symptoms of weakness of the lower extremities in conjunction with hypertension. The plasma aldosterone level was high with the very low plasma renin activity in all of the cases. All of the patients in this case had metabolic alkalosis. Unilateral adrenal mass was found on CT-Scan or MRI imaging. Following adrenalectomy, three patients (one female and two males) still needed one type of anti hypertension drug. All of the patients did not require anti aldosterone anymore. The plasma aldosterone returned to normal value in three patients while in three other patients were not checked. The histopathology of the adrenal revealed the adenoma of the adrenal cortex in all of the six cases.

Effect of dark chocolate on nitric oxide serum levels and blood pressure in prehypertension subjects.

AIM: to investigate the effect of consumption of dark chocolate 30 g/day for fifteen days on Nitric oxide (NO) serum levels and blood pressure in male and female employees with prehypertension. METHODS: the study was a parallel randomized clinical trial. A total of thirty-two subjects was divided into two groups using block randomization. Sixteen subjects received 30 g/day dark chocolate and dietary counseling (treatment group) and the other 16 subjects received white chocolate 25 g/day and dietary counseling (control group) for fifteen days. Data collected in this study consisted of age, physical activity, body massa index, intake of energy, intake of sodium, and intake of polyphenol, NO serum levels and blood pressure. The measurement of NO serum levels was done in pre- and after- treatment, while blood pressure was assessed in pre- , during- and after- treatment. Statistical analysis was performed using independent t-test for normal distribution data and Mann-Whitney test for not normal distribution data, with the level of significancy of 5%. RESULTS: after 15 days treatment, NO serum level between treatment and control groups were significantly different 7.70 ± 3.84 vs 1.92(-0.79 ± 17.78) (p=0.001). Both groups had decreased systolic and diastolic blood pressure. Systolic blood pressure was different significantly between groups after treatment 120.64 ± 8.47 vs 131.19 ± 7.45 (p=0.001), while diastolic blood pressure was not significant 74.14 ± 6.30 vs 77.44 ± 10.29 (p=0.308). CONCLUSION: in prehypertension subjects, dark chocolate 30 g/day increased NOx serum levels and decreased systolic blood pressure after 15 days of treatment.

The risk of hyponatremia in the elderly compared with younger in the hospital inpatient and outpatient.

AIM: to comparise the prevalences of hyponatremia between elderly and younger patients in hospital inpatients and outpatients setting. METHODS: this study was done using cross-sectional design. Medical records of all adult patients (age of more than 13 years) from March 2008 to March 2009 in Siloam Hospital Lippo-Village whose sodium plasma level data were recorded. The patients were divided into two main groups according to their age, that were elderly and younger. These two main groups were then divided into 4 sub-groups that were general inpatient, special inpatient, general outpatient, and emergency outpatient. The prevalence ratio of the proportion of hyponatremia between the elderly and the younger in the four sub-groups were then analyzed. Independency between the 4 sub-groups and frequency of hyponatremia in each of the two main group were tested by Chi-Square test, using SPSS statistics version 17. RESULTS: in the general inpatient, the prevalence of hyponatremia in the elderly group and the young group were 26.32% and 10.85% respectively, with the Prevalence Ratio of 2,43 (95% CI, 0,11-0,19). In the general outpatient, the prevalence of hyponatremia in the elderly group and the young group were 7.18% and 2.98% respectively, with the Prevalence Ratio of 2,40 (95% CI, 0,02-0,06). In the emergency outpatient, the prevalence of hyponatremia in the elderly group and the young group were 18.28% and 7.71% respectively, with the Prevalence Ratio of 2,37 (95% CI, 0,08-0,14). In the special inpatient, the prevalence of hyponatremia in the elderly group and the young group were 14.98% and 5.58% respectively, with the Prevalence Ratio of 2,69 (95% CI, 0,05-0,13). The risk to get hyponatremia during inpatient was significantly higher in the elderly with the Prevalence Ratio of 2.79 (95% CI, 0,03-0,07). Chi Square analysis which was done in both the elderly and the younger group revealed that the place of the services will influence the frequency of hyponatremia significantly (p = 0.000). CONCLUSION: compared with the younger group, the mean of the risk for the elderly group to get hyponatremia in the hospital inpatient and outpatient is 2.54 times higher.

Diagnosis and clinical approach in Gitelman's syndrome.

Hypokalemia, defined as a plasma potassium concentration <3.5 mmol/l, is the most common electrolyte abnormality encountered in our clinical practice. Unfortunately, in many cases, the etiologies were unclear and resulted in a wrong treatment. Indeed, the true etiology could be such a 'rare' one and could be found by doing a comprehensive work up. One of this is Gitelman's syndrome, a rare genetic disorder characterized by hypokalemic alkalosis, hypomagnesemia, hypocalciuria, and secondary aldosteronism without hypertension. Since this disorder is found in 1% Caucasian populations, this is one of the most frequently inherited renal tubular disorders. A 27 year old man came to emergency room with weakness and generalised muscle cramps. He was investigated three months before for a similar electrolyte disturbance which was found to be inconclusive. The routine laboratory data in emergency room revealed a potassium concentration of 2.3 mmol/l. He had never used diuretics or hormonal therapy nor had history of vomiting or diarrhea. He had normal blood pressure and the blood gas analysis revealed metabolic alkalosis. On his ECG (electrocardiography), we found the prominent U wave. Despite his low concentration of serum potassium and cloride, the concentration of these electrolytes in urine were extremely high. We also found hipomagnesemia. The calcium concentration in serum was normal with slightly hypocalciuria. Even with aggressive oral and intravenous potassium suplementation, the patient remained hypokalemic. In cases when the etiology of hypokalemia is unclear, we should perform some investigations to confirm the diagnosis and give the proper treatment. In Gitelman's syndrome, where the defect in the distal tubule cannot be corrected, the treatment must be a life-long. Most patients require oral potassium and magnesium supplementation, since drug therapy is usually incompletely effective.

Urine osmolality in the elderly.

AIM: Investigation was done in the institutionalized elderly in order to know the value of urine osmolality in this population. METHODS: Cross sectional study was done in the government institutionalized elderly that localized in South Jakarta. By using simple random sampling, 50 elderly people were chosen from all of the residents in this institutionalized elderly aged more than 60 years. They were excluded if they had diabetes mellitus, abnormal cortisol (reference range of morning cortisol, 5-25 ug/dL), potassium less than 3 meq/L, chronic diarrhoe, congestive heart failure, nephrotic syndrome, and cirrhosis of the liver, and also if they were in manitol or diuretic treatment, and not cooperative. All of these data were analyzed with descriptive analysis and comparative T-test of two non-related groups. RESULTS: There were 28 elderly peoples consisted of 13 males and 15 females participated in this study. The mean of the urine osmolality was 581 +/- 174 mosmol/Kg. The mean of the urine osmolality in the female group (657.33 +/- 126.54 mosmol/kg) was significantly higher than in the male group (p = 0.01). CONCLUSION: The urine osmolality in the elderly is high and the so-called normal value is 407-755 mosmol/Kg. Further study is needed to investigate the lowest urine osmolality value as the diagnostic tool of hyponatremia due to water excretion disorder in the elderly.

Correlation between vitamin D concentration and basic functional mobility in elderly women.

AIM: to determine vitamin D serum concentration, the timed up and go (TUG) test score, and the correlation between vitamin D serum concentration and TUG test score of elderly women. METHODS: a correlative cross-sectional study of elderly women aged 60 years old or above was carried out in three nursing homes in DKI Jakarta and one elderly nursing home in Bekasi, in January 2005. TUG test was performed to evaluate basic functional mobility by measuring the time in seconds to stand from 46 cm height armchair, walk three meters, turn around, and return to full sitting in chair. Vitamin D serum concentration was measured by ELISA method. Calcium ion serum concentration that was measured by NOVA method, age and body mass index (BMI) were confounding variables. RESULTS: of forty-two elderly women who met the inclusion and exclusion criteria, thirty subjects which proportional randomly assigned participated in this study. Mean (+SD) vitamin D serum concentration was 68.0 (21.1) nmol/L, with concentration < 50 nmol/L was 23.3%, TUG score was 10.7 (2.1) seconds, BMI was 22.3 (3.7) kg/m2, age was 70.2 (6.4) years, and median (minimum-maximum) ionized calcium serum concentration was 1.095 (1.030-1.230) mmol/L. Vitamin D serum concentration did not show significant correlation with TUG (r = -0.008; P = 0.968). There were also no significant correlations among the confounding variables and TUG. The correlation with TUG for BMI r = 0.014; P = 0.942, ionized calcium serum concentration r = 0.287; P = 0.124, and age r = 0.315; P = 0.09. CONCLUSION: vitamin D serum concentration has not show significant correlation with basic functional mobility of elderly women, the higher vitamin D serum concentration was not followed by lesser time to perform TUG test; the proportion of subjects with TUG score < 10 seconds (freely mobile in functional mobility) were lesser in vitamin D deficiency respondents.