Prevalence of Fibromyalgia in chronic kidney disease pre-dialysis patients: Experience from a Tertiary Care Renal unit in Pakistan

Background and Objective: Fibromyalgia syndrome (FMS) is a well-established medical problem which gives rise pain at various sites, fatigue, sleep disturbances, poor memory and definitely affects quality of life. Its prevalence in chronic kidney disease (CKD) is scarcely reported, thus we aimed to assess this condition and report its prevalence in our population. Methods: The current study was carried out in all adult CKD stage III and IV patients registered from January 2020 to July 2020 at outpatient department of a tertiary care renal institution in Karachi, Pakistan. This is a cross sectional study where prevalence of FMS was assessed by interviewing and examining patients according to established criteria for FMS. All data and laboratory parameters were recorded on a proforma and statistical analysis was done on SPSS version22.0. Results: During the study period of six months, 161 patients with CKD stage III and IV were registered. Among these 81 male and 80 were females. Mean age was 47.12±9.27 (range 21-60) years. There were 22 (13.66%) patients found to have FMS. Mean Widespread Pain Index (WPI) score was 5.68±4.36 (range 1-16), while severity scale (SS) 2a was 3.17±1.78 (range 1-9) and SS2b 2.04±0.96 (range 1-5) was recorded. Conclusion: From Pakistan prevalence of FMS has never been published. As this syndrome affects quality of life of patients, its recognition and proper management is immensely required. doi: https://doi.org/10.12669/pjms.37.7.4474 How to cite this:Khan Z, Naqvi R. Prevalence of Fibromyalgia in chronic kidney disease pre-dialysis patients: Experience from a Tertiary Care Renal unit in Pakistan. Pak J Med Sci. 2021;37(7):---------. doi: https://doi.org/10.12669/pjms.37.7.4474 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Surgical management in retroperitoneal fibrosis: beyond ureterolysis

Background Retroperitoneal fibrosis can be associated with bilateral dense and extensive periureteral adhesions. When ureterolysis could not be successfully performed due to disease extent and severity, elaborate ureteral reconstructive procedures will be required. Case presentation A young male with retroperitoneal fibrosis presented with bilateral hydroureteronephrosis. The ureteral involvement was extensive and adhesions were dense. He was managed by laparoscopic boari flap ureteroneocystostomy on one renal unit and laparoscopic nephrectomy with renal autotransplantation on the other renal unit. Conclusions Ureterolysis is not feasible in all cases of retroperitoneal fibrosis. Extensive bilateral ureteral reconstruction without using intestinal segments is feasible. Minimally invasive surgical reconstructive procedures can be successfully employed in such scenarios also.

High Dependency Renal Unit (HDRU) for the management of COVID-19 in patients with severe acute or chronic kidney disease

Background: COVID-19 in patients on dialysis for acute or chronic kidney disease is associated with high mortality. We evaluated the effect of high dependency renal unit (HDRU) with nephrologists as primary care physicians for management of these patients. Methods: This was an observational, cohort study conducted at a tertiary care teaching hospital in western India. Patients needing dialysis for COVID-19 associated Acute Kidney Injury (AKI-D) and patients with End-Stage-Renal-Disease (ESRD) hospitalized for COVID-19 were included in the study. After 2 months into the pandemic (28 March to 28 May 2020), HDRU was commissioned for management of these patients. With nephrologists as primary care physicians, the components of care included completion of care bundle focusing on key nephrology and COVID-19 related issues, checklist-based clinical monitoring, integration of multispecialty care, and training of nurses and doctors. Primary outcome of the study was in hospital mortality compared between pre-HDRU and HDRU cohorts. Secondary outcomes were- dialysis dependence in AKI-D, and predictors of death. Results: 238 of 4254 (5.59%) patients with COVID-19 admitted from 28th March to 30th September had severe renal impairment (116 AKI-D and 122 ESRD). 145 (62%) had severe COVID-19. HDRU care was delivered from 28th May to 30th August. Kaplan-Meier survival analysis showed significant improvement in survival after implementation of HDRU [19 of 52 (36.5%) in pre-HDRU versus 35 of 160 (21.9%) in HDRU died, p=<0.01]. 44 (67.7%) AKI-D survivors were dialysis dependent at discharge. Breathlessness and altered mental status at presentation, development of shock during hospital stay and leukocytosis predicted mortality. Conclusions: HDRU managed by nephrologists is a feasible and potentially effective approach to improve the outcomes of patients with COVID-19 and severe renal impairment.

Recurrent Urinary Tract Infections Risk Factors in Patients with Primary Vesicoureteral Reflux

Background: Knowing the risk of recurrence of urinary tract infection (UTI) in vesicoureteral reflux (VUR) can assist clinicians to sort therapeutic decisions. The current study's aim was to assess the association of UTI in VUR. Additionally, UTI recurrence might be predicted by the risk score. Materials and Methods: This case-control study was carried out on 123 children at department of Paediatric, Saidu Group of Teaching Hospitals, Swat for the duration of one year from 1st July 2020 to 30thJune 2021. Out of 123 children, the group-I had 57 children with documented previous UTIs history while group-II had 66 children with no previous UTIs and was referred to as a control group. All the patients were VUR diagnosed and were thoroughly followed up at a Renal Unit of single tertiary. UTI recurrence was referred to more than one follow-up episode. A regression model was used for independent variables identification regarding UTI recurrence. . A questionnaire on bowel habits was provided to the parents. The abdominal plain film was evaluated by the observer and recorded on the documented scoring system. The constipation history was compared with the radiological and symptomatic scores. Organism single species with > 105/ml count in a single midstream catch of urine sample was reflected as UTI evidence. Result: Out of 123 children, 88 (71.5%) were females while 35 (28.5%) were male. A total of 123 children had been investigated for UTI complaints. After the multivariable analysis adjustment, five recurrent UTIs predictor variables were the clinical presentation of UTI, female gender, reflux several grades, age less than 6 months, and syndrome dysfunction elimination. The UTIs recurrence risk factors were classified as high, medium, and low with prevalence 52 (42%), 41 (34%), and 30 (24%) respectively. The prevalence of UTIs rate per person-month was 10.9 (95% CI, 9.8, 12.7), 8.2 (95% CI, 6.7, 9.1) for medium, and 5.2 (95% CI, 3.3, 5.5) for the low-risk group. Conclusion: The formulation of therapeutic strategies can be done based on prediction model for UTIs recurrence besides early detection of morbidity long-term risk for the patients. Keywords: Vesicoureteral reflux, Urinary tract infection, Dysfunctional voiding, Constipation

Comparative study of renal drainage with different ureteral stents subject to extrinsic ureteral obstruction using an in vitro ureter-stent model

Background To compare the efficacy of different ureteral stents subject to extrinsic ureteral obstruction (EUO), in a controlled in vitro stented ureter experiment. Methods We employ an in vitro ureter-stent experimental set-up, with latex tubing simulating flexible ureters attached to vessels simulating renal units and bladders. The flow behavior of five ureteral stents—polymeric 8F, tandem 6F, tandem 7F, endopyelotomy and metal—was tested under a ureteral deformation configuration of 40°, with 2000 g external force over a 3.5 cm length of the ureter. A constant fluid flow was applied through the ureter-stent configurations, and pressure fluctuations in the renal unit were monitored. We considered a renal unit pressure of 10 cmH2O or flow discontinuation in the bladder as stent failure. Urine containing debris was mimicked by use of a colloidal solution. Results Of all assessed ureteral stents, under EUO conditions, only the single 8F stents remained patent throughout the length of the experiment. All other stents—tandem 6F and 7F, single 7F, metal and endopyelotomy—displayed limitations. Conclusions Tandem and metal stents show no superiority over large luminal polymeric stents for EUO treatment in this in vitro model. Larger luminal stents offer excellent resistance to external pressure and allow adequate colloidal flow. The need for frequent exchange and bladder irritation should also be considered in the choice of stent configuration for treatment of kidney drainage under EUO.

Every nephron deserves a second chance before nephrectomy in obstructed uropathy due to urolithiasis

Objective: In this case report, we aimed to present our clinical experience in a patient with hydronephrotic and atrophic kidney due to impacted lower ureteral stone. Case description: A 56-year-old male was admitted to our emergency department with flank pain and nausea. A computed tomography scan revealed a 3 cm stone at the distal ureter, causing severe hydroureteronephrosis. Right kidney parenchyma was extremely thin at the medial zone, and some parenchyma was apparent at the upper and lower poles. We planned renal scintigraphy, but it was impossible to perform quickly due to the active appointment list. The patient’s kidney was assumed to be atrophic/non-functioning; however, given the long waiting list for renal scintigraphy and the patient’s intractable pain, we decided to relieve the patient’s pain with urinary drainage. Nephrostomy insertion was denied because of the extra thin parenchyma. About 40 days later, the patient underwent semi-rigid ureterorenoscopy under spinal anesthesia. It was impossible to place a double J stent to the ureter because of the kinked and extremely dilated ureter. So, we decided to place an open-end 6Fr ureter catheter. DMSA renal scintigraphy showed 33% right kidney and 67% left kidney function. Conclusion: Intractable flank pain might be a predictor of functioning renal parenchyma in hydronephrotic/atrophic kidneys. Renal split function lower than 10% on DMSA scintigraphy might not be an absolute indication of nephrectomy, especially in the obstructed renal unit. Evaluation of renal function after eliminating obstruction might be more reliable.

Renal functional improvement after pediatric pyeloplasty in kidneys with split renal function less than 20%: a single institute experience

Background Pediatric pyeloplasty in ureteropelvic junction obstruction (UPJO) is indicated in renal impaired drainage or renal function deterioration. The improvement of renal function after pediatric pyeloplasty is still controversial in poorly functioning kidneys. Past studies on poorly functioning kidneys had a variable SRF specification, and these studies often had a limited number of patients so that they did not achieve statistical significance. The study aims to detect the renal functional improvement after pediatric Anderson-Hynes pyeloplasty (AHP) with split renal function (SRF) less than 20% (poor renal function). Results A retrospective study included 46 pediatric patients with unilateral UPJO who underwent open AHP with SRF < 20% on a renal isotope scan from August 2012 to October 2018. Success was defined based on either improvement in symptoms, improvement in drainage on postoperative renography, and/or improvement or stability in SRF on the renal scan done 6 months postoperatively and yearly thereafter. Deterioration of SRF by more than 5% was deemed to be deterioration. An increase in SRF of more than 5% was deemed to be an improvement. A total of 46 patients with a mean age of 32 months with poor renal function on isotope renogram (SRF < 20%) were included. All patients had an obstructive pattern on the preoperative radionuclide scans. The median preoperative SRF was 9.26%. The mean (range) follow-up was 30 months. The success rate was 91.3%. Three patients underwent redo pyeloplasty, whereas a secondary nephrectomy was necessary for one. The remaining (42) patients showed stability or improvement of SRF with no further symptoms. Renal scintigraphy at 6 and 12 months after surgery revealed significantly increased SRF compared to preoperative one. Conclusion Poorly functioning renal unit with SRF < 20% can show functional improvement and recoverability after pediatric pyeloplasty.

MO156THE ‘WITHIN-DAY’ VARIABILITY OF ALBUMINURIA INFLUENCES THE MONITORING OF NEPHROPROTECTIVE TREATMENT EFFECT

Background and Aims Measurement of urine proteins, mainly through the 24-hour excretion or the albumin-to-creatinine ratio (ACR) has become crucial in current clinical practice in Nephrology. Besides being a biomarker of injury, albuminuria also exerts direct pro-inflammatory and pro-fibrotic effects on renal tubules. Hence, a large number of intervention studies have been aimed at lowering albuminuria levels in patients with Chronic Kidney Disease (CKD). However, albuminuria is a measure characterized by a random variability that has been evaluated in several mechanistic and experimental studies and may be influenced by several factors, such as posture, exercise and dietary factors. The aim of the present study was to evaluate the within-day variability, specifically in a cohort of CKD outpatients who were on Renin-Angiotensin-Aldosterone-System inhibitors (RAASi) therapy. Method We enrolled consecutive CKD patients referred to the Nephrology Unit at Magna Graecia University Hospital of Catanzaro between January 1st and March 30th 2020. Inclusion criteria were: age &gt; 18 years, diagnosis of CKD from any cause, presence of albuminuria in the range 150-3500 mg/g at screening. Patients already treated with RAASi, patients with active malignancy/signs of glomerulonephritis requiring immunosuppressive therapies, were excluded. At screening visit, patients with increased albuminuria were started with an Angiotensin Converting Enzyme inhibitor (ACEi) or an Angiotensin II Receptor Blocker (ARB). A second ambulatory visit was scheduled 1 month after start of RAASi therapy. During this visit, patients were asked to stay in the Renal Unit for 12 hours. They collected urine void for ACR, protein-to-creatinine ratio (PCR) and urine creatinine (Ucreat) assessment at 8am,1pm and 6pm. For each patient, comparisons between ACR, PCR and Ucreat were assessed by Kruskal-Wallis test and Friedman post-hoc, using the Benjamini-Hochberg as adjustment method. Coefficients of variation (CV,standard deviation/mean) were also computed. Results Final analysis included 43 patients (46.5% of males). Mean age was 59.6±16.7 years and median eGFR 41 [21-74] mL/min/1.73m2. A high cardiovascular (CV) risk profile was testified by the prevalence of type 2 diabetes (30.2%) and previous CV disease (34.8%). When patient characteristics were compared across ACR categories (&lt;30, 30-300, &gt;300 mg/g), systolic blood pressure was increased (p=0.020) and mean age decreased from 68.0 to 54.8 years on average (p=0.038). ACR values collected were 189 [38-759], 252 [51-1685] and 229 [56-1185] mg/g at 8am, 1pm and 6pm, respectively, with a CV of 24.6% (95%CI 12.4-39.1). 8am ACR was significantly different from 1pm ACR (p&lt;0.001) and from 6pm ACR (p&lt;0.001). 1 pm ACR was significantly different from 6pm ACR (p=0.002). Median PCR were 335 [115-932], 429 [146-1811] and 447 [151-1465] mg/g respectively at 8am, 1pm and 6pm, with CV being 17.8% (95%CI 9.0-26.6). 8am PCR differed significantly from 1pm and 6pm PCR (p&lt;0.001 for both), while 1pm ACR was lower than 6pm ACR (p&lt;0.001). Ucreat was 66 [53-103], 63 [47-96] and 69 [50-90] mg/dL respectively at 8am, 1pm and 6pm with no significant variation trend. Individual within-day ACR and PCR trends are depicted in the Figure . Conclusion The present analysis showed a significant individual within-day variability of albuminuria, measured as both ACR and PCR, suggesting that another parameter, in addition to those already known, may be responsible for the day-by-day albuminuria variation. Moreover, the absence of variability in Ucreat, namely the denominator of the ACR/PCR formula, suggests that the true variation is likely dependent on the urine protein values. Thus, albuminuria reduction in response to RAASi treatment should be carefully evaluated by measuring ACR/PCR preferentially at a similar time of the day for each patient. This would allow to avoid under- or overestimation of the actual treatment effect.