Chlorhexidine – a commonly used but often neglected culprit of dialysis associated anaphylactic reactions (case report)

Background Hemodialysis-associated anaphylactic reactions are rare and frequently complex in nature due to the sheer number of possible culprit agents. Unfortunately, dialysis is often unavoidable or strictly essential for life-saving solute clearance or fluid removal in patients with end stage kidney failure and those with severe acute kidney injury. It is of utmost importance that the culprit agent is identified and avoided to allow continuation of dialysis treatment as needed. Case presentation We present 2 cases of hemodialysis-associated anaphylactic reactions. These patients developed anaphylactic reactions peri-dialysis and were initially suspected to have dialyser reactions. They were investigated in a controlled healthcare setting and possible culprit agents were systemically identified and eliminated. They both underwent allergy testing and were diagnosed with chlorhexidine allergy. Of note, Case 1 was an incident dialysis patient at the time of presentation and Case 2 was a prevalent dialysis patient. This suggests that the time from initial sensitization to reaction may not always be helpful in determining if a particular agent is the culprit of an anaphylactic reaction. In both cases, the patients were dialysed through a tunnelled dialysis catheter. We postulate that the presence of an exit site, which represents a compromise to the integrity of the skin’s epidermal barrier, may have a significant role in the development of these reactions. As chlorhexidine is a widely used disinfectant in hemodialysis, it is imperative that we consider it as a possible culprit agent when these reactions arise. To our knowledge, there are no other reported cases of anaphylaxis secondary to chlorhexidine use in dialysis patients other than a previous report in 2017. Our report also highlights the possibility of these reactions occurring more frequently in patients with damaged epidermal barriers and in patients exposed to higher environmental concentrations of chlorhexidine. These are novel concepts that can be explored with further research. Conclusion Chlorhexidine associated anaphylactic reactions can occur in the peri-dialysis setting and a high index of suspicion is paramount to diagnosis.

Evaluation of Clinical and Follow-up Results of Patients with Congenital Nephrotic Syndrome

Congenital nephrotic syndrome (CNS) is characterized by severe proteinuria, hypoalbuminemia, and edema within the first three months of life. Congenital nephrotic syndrome can occur due to perinatal infections or mutation of genes encoding structural or regulatory proteins of the glomerular filtration barrier. Treatment includes albumin infusions, nephrectomy, dialysis, and transplantation. In this study, we aimed to evaluate the demographic, clinical, and follow-up results of patients with CNS followed up in our center between 2010 and 2020. Demographic, clinical, laboratory values of 8 patients diagnosed with CNS between 2010 and 2020, kidney biopsy results, genetic examinations, and follow-up results were retrospectively evaluated. A total of 8 patients (4 girls) were included in this study. The median age at diagnosis was 36 days (3 days-8 months) and the follow-up period was 34 months (7-114 months). There was a history of prematurity and consanguinity in 5 patients. Edema was detected at the admission of all patients. Albumin infusion and captopril therapy were started from the diagnosis. No pathology was seen in the tests for perinatal infection, and ultrasonographic examinations were normal. In the genetic analysis, NPHS1 (Nephrin) homozygous mutation was detected in six patients, and coenzyme Q2 mutation was detected in one patient. Peritoneal dialysis treatment was performed in four patients during the follow-up, and unilateral nephrectomy was completed in one patient. During the follow-up, four of eight patients (three due to sepsis while on dialysis, one on the postoperative after the first day of transplantation) died. Three patients are followed up with kidney transplantation and one with supportive treatment. According to our results, most CNS cases are genetic, and nephrin mutation is the most common cause. Management of complications in CNS is crucial for patient surviva

A case of idiopathic nephrotic syndrome treated with the homeopathic therapeutic

Nephrotic syndrome is a chronic clinical condition and drugs used in its treatment may result in severe side-effects. Renal transplantation or renal ablation and subsequent chronic dialysis treatment may be the only feasible way to patients. The present article reports the case of a 23-years-old white woman that presented nephrotic syndrome and was successfully treated with homeopathic medicines. Six kind of homeopathic diagnoses were made to build the clinical homeopathic picture of the patient and to determine the appropriate medicines, according to the clinical protocol used. Apis mellifica was the main medicine used to treat the diathesis sycosis. The satisfactory treatment outcome shows that the judicious homeopathic therapeutic may be a valuable resource in the treatment of nephrotic syndrome. Keywords: Nephrotic syndrome; Clinical protocol; Diathesis; Sycosis; Homeopathy  Um caso de síndrome nefrótica idiopática tratada com terapéutica homeopática. Resumo A síndrome nefrótica é uma condição clínica crônica. Os fármacos utilizados em seu tratamento podem produzir severos efeitos colaterais. O transplante ou a ablação renal, com a necessidade posterior de diálise, as vezes é a única alternativa real de tratamento. Este artigo descreve o caso de um paciente de 23 anos de idade portador de síndrome nefrótica. Foram realizados 6 diagnósticos homeopáticos para construir um quadro clínico homeopático do paciente e determinar os medicamentos homeopáticos, bem como o protocolo terapéutico. Apis mellifica foi o principal medicamento utilizado para tratar a diástesis sicótica. Os resultados terapéuticos foram satisfatórios e indicam que uma terapéutica homeopática racional pode ser um valioso recurso no tratamento da síndrome nefrótica. Palavras-chave: Síndrome nefrótica; Protocolo clínico; Diatese; Sicose; Homeopatia.  Un caso de síndrome nefrotico idiopatico tratado con terapeutica homeopatica Resumen El síndrome nefrótico es una condición clínica crónica; los fármacos utilizados en su tratamiento pueden producir severos efectos colaterales. El trasplante o ablación renal, con la necesidad posterior de diálisis, a veces es la única alternativa real de tratamiento. Este artículo describe el caso de una paciente de 23 años de edad portadora de síndrome nefrótico; 6 diagnósticos homeopáticos fueron realizados para construir el cuadro clínico homeopático de la paciente y determinar los medicamentos homeopáticos, como prescripto por el protocolo terapéutico utilizado. Apis mellifica fue el principal medicamento utilizado para tratar la diátesis sicótica. Los resultados terapéuticos favorables muestran que una terapéutica homeopática racional puede ser un recurso valioso en el tratamiento del síndrome nefrótico. Palabras-clave: Síndrome nefrótico; Protocolo clínico; Diatese; Sicose; Homeopatia  Correspondence author: Luiz Figueira Pinto, [email protected] How to cite this article: Pinto LF. A case of idiopathic nephrotic syndrome treated with the homeopathic therapeutic. Int J High Dilution Res [online]. 2009 [cited YYYY Mmm dd]; 8(26):26-32. Available from: http://journal.giri-society.org/index.php/ijhdr/article/view/302/382. ÂÂÂ

Prediction of hemodynamic tolerance of intermittent hemodialysis in critically ill patients: a cohort study

The evaluation and management of fluid balance are key challenges when caring for critically ill patients requiring renal replacement therapy. The aim of this study was to assess the ability of clinical judgment and other variables to predict the occurrence of hypotension during intermittent hemodialysis (IHD) in critically ill patients. This was a prospective, observational, single-center study involving critically ill patients undergoing IHD. The clinical judgment of hypervolemia was determined by the managing nephrologists and critical care physicians in charge of the patients on the basis of the clinical data used to calculate the ultrafiltration volume and rate for each dialysis treatment. Seventy-nine (31.9%) patients presented with hypotension during IHD. Patients were perceived as being hypervolemic in 109 (43.9%) of the cases by nephrologists and in 107 (43.1%) by intensivists. The agreement between nephrologists and intensivists was weak (kappa = 0.561). Receiver operating characteristic curve analysis yielded an AUC of 0.81 (95% CI 0.75 to 0.84; P < 0.0001), and a cutoff value of 70 mm for the vascular pedicle width (VPW) had the highest accuracy for the prediction of the absence of hypotension. The clinical judgment of hypervolemia did not predict hypotension during IHD. The high predictive ability of the VPW may assist clinicians with critical thinking.

Concept of Asnaf Al-Gharimin: Application at Lembaga Zakat Selangor

Each state in Malaysia interprets asnaf al gharimin differently due to the different ijtihad from the mufti. This study aims to analyze the application of asnaf al gharimin based on Lembaga Zakat Selangor (LZS). Qualitative method based on interview is used in this article and supported by library research. The finding shows that LZS has focused on four categories of debt to be given zakat aid in the types of asnaf gharimin, including medical/ dialysis treatment assistance, life necessities assistance, management of the corpse without the heir, and debt association due to public concern. Keywords: asnaf al- gharimin, debt; gharimin; zakat eISSN: 2398-4287 © 2021. The Authors. Published for AMER ABRA cE-Bs by e-International Publishing House, Ltd., UK. This is an open access article under the CC BYNC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer–review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers), ABRA (Association of Behavioural Researchers on Asians) and cE-Bs (Centre for Environment-Behaviour Studies), Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. DOI: https://doi.org/10.21834/ebpj.v6iSI6.3038

Discovery of Novel Proteomic Biomarkers for the Prediction of Kidney Recovery from Dialysis-Dependent AKI Patients

Background: Acute kidney injury requiring dialysis (AKI-D) is associated with prolonged hospitalization, mortality, and progressive chronic kidney disease (CKD) among survivors. Previous studies have examined only select urine or serum biomarkers for predicting kidney recovery from AKI. Methods: Serum samples collected on day 8 of randomized renal replacement therapy from 72 patients enrolled in the Veteran's Affairs/National Institutes of Health Acute Renal Failure Trial Network study were analyzed by the SOMAscan proteomic platform to profile 1305 proteins in each sample. Of these patients, 38 recovered kidney function and dialysis was discontinued, while another 34 patients remained on dialysis by day 28. Results: Differential serum levels of 119 proteins, with 53 higher and 66 lower, were detected in samples from patients who discontinued dialysis compared to patients who remained on dialysis by day 28. Patients were classified into tertiles based on SOMAscan protein measurements for the 25 proteins most differentially expressed. The association of serum levels of each protein with kidney recovery was further evaluated using logistic regression analysis. Higher serum levels of CXCL11, CXCL2/CXCL3, CD86, Wnt-7a, BTK, c-Myc, TIMP-3, CCL5, ghrelin, PDGF-C, survivin, CA2, IL-9, EGF, and neuregulin-1, and lower levels of soluble CXCL16, IL1RL1, stanniocalcin-1, IL-6, and FGF23 when classified in tertiles, were significantly associated with better kidney recovery. This significant association persisted for each of these proteins after adjusting for potential confounding risk factors including age, gender, cardiovascular SOFA score, congestive heart failure, diabetes, modality of intensive dialysis treatment, cause of AKI, baseline serum creatinine, day-8 urine volume, and estimated 60-day mortality risk. Conclusions: These results suggest concerted changes between survival-related proteins and immune-regulatory chemokines in regulating angiogenesis, endothelial and epithelial remodeling, and kidney cell regeneration, illustrating potential mechanisms of kidney recovery. Thus, this study identifies potential novel predictive biomarkers of kidney recovery in AKI-D patients.

Oral findings in patients with chronic kidney disease: A cross-sectional descriptive study in Cuenca, Ecuador

Objective: To determine the different oral findings in patients with renal insufficiency, chronic. Methods: A descriptive cross-sectional study was carried out that included 123 individuals who were diagnosed with renal insufficiency, chronic and underwent dialysis treatment at the Renal Services Unit of the Austro of the city of Cuenca-Ecuador. Once the study was approved by the Research Directorate of the Faculty of Dentistry (DIFO) of the University of Cuenca (code UC-DIFO-PROY-17-010), the oral cavity of the patients was examined to detect gingival enlargement non-inflammatory, hemorrhagic lesions (purpura and ecchymosis), uremic stomatitis and oral candidiasis. Data analysis was performed using the IBM-SPSS Statistics 20.0 program for Windows software (IBM Corporation, Armonk, NY, USA); the results were presented in simple distribution tables by calculating their percentage frequency. Results: Of the 123 subjects who participated in this study, 52% (n=64) were women, while 48% (n=59) were men. The mean age of the study population was 60.2 (SD: 14.6) years. Oral findings were described in 74% (n= 91) of patient’s with renal insufficiency, chronic. Among them were: non-inflammatory gingival enlargement (64.7%) (n=57), hemorrhagic lesions such as purpura and ecchymosis (57.7%) (n=71), uremic stomatitis (10.6%) (n=13) and oral candidiasis (8.1%) (n=10). Conclusion: Patients with renal insufficiency, chronic present important oral findings that should be identified and treated during dental practice.

Association of dialysis-related amyloidosis with lower quality of life in patients undergoing hemodialysis for more than 10 years: The Kyushu Dialysis-Related Amyloidosis Study

Background Dialysis-related amyloidosis (DRA) commonly develops in patients undergoing long-term dialysis and can lead to a decline in activities of daily living and quality of life (QOL), mainly owing to orthopedic complications. Methods First, we determined utility scores of the EuroQol 5-Dimensions 3-Levels (EQ-5D-3L) questionnaire in 1,323 patients with DRA who had undergone dialysis for more than 10 years and compared the score between those with and without DRA. Second, a 2-year follow-up was also performed, in which patients were divided into three groups: those complicated by DRA from the beginning, those with newly developed DRA within the 2-year period, and those not complicated by DRA throughout the survey period; changes in the EQ-5D-3L utility score were compared. In the group already complicated by DRA at the survey baseline, changes in the EQ-5D-3L utility score were compared according to the dialysis treatment method. Results A total of 1,314 and 931 patients were included in the first and second studies, respectively. EQ-5D-3L utility scores among patients diagnosed with DRA were significantly lower than scores in those not diagnosed with DRA. The reduction in the EQ-5D-3L utility score over the 2-year follow-up was significantly greater in patients newly complicated by DRA during the follow-up period after enrollment but not in those complicated by DRA from the beginning, as compared with patients not complicated by DRA throughout the survey period. The reduction in utility score tended to be lower in patients routinely treated with a β2-microglobulin adsorption column than in untreated patients with DRA. Conclusion Complication by DRA in patients undergoing long-term hemodialysis was significantly associated with a decline in QOL.