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Treatment of focal segmental glomerulosclerosis (FSGS) is frustrating, especially for steroid-resistant FSGS. Different immunosuppressive agents have been used with inconsistent outcome. We analyzed the data in our FSGS patients who, in addition to steroid, were treated with cyclosporine (CYA), cyclophosphamide (CYP), and mycophenolate mofetil (MMF) along with the long-term follow-up. This is a retrospective analysis of 113 patients diagnosed to have FSGS with 11 years' follow-up carried out at The Kidney Center Post Graduate Training institute. Among 113 patients, 51.3% were male with a mean age of 34.4 ± 11.8 standard deviation. Patients who achieved complete remission with steroid alone and steroid with combination of CYA, CYP, and MMF were 38 (26%), 19 (16.8%), and six (5.3%), respectively, similarly those who got partial remission were three (3.6%), five (4.4%), three (2.6%), and eight (7.0%), respectively. The factors which affected the outcome were serum creatinine (SCr), tubulointerstitial fibrosis (TIF), and the treatment. In adjusted analysis, increase in 1 mg of SCr reduces the patient recovery by 56%, while the absence of TIF increases recovery by 80.75%. Taking steroid as reference category, steroid + CYA found 2.03 times more effective as compared with steroid alone. Seven patients developed end-stage renal disease (ESRD) and three died due to disease during the follow-up. CYA comes out as the most effective treatment for steroid-resistant FSGS followed by MMF and CYP. The long-term outcome of all modalities is the same in terms of mortality and developing ESRD. The degree of TIF and renal failure has strong influence on the course of the disease., Competing Interests: None

Much has now been learned about the coronavirus disease 2019 (COVID-19) in the general population, but data for hemodialysis (HD) patients are limited. This is the first study of COVID-19 disease in patients undergoing maintenance HD in Pakistan. We studied the epidemiological, clinical, laboratory, radiological characteristics, and outcomes of a cohort of HD patients that contracted COVID-19 in our HD center from the first confirmed case on May 12, 2020, until September 9, 2020. Out of the total 423 patients being dialyzed in our center, 87 were suspected and 50 (11.8%) were confirmed for COVID-19. Male:Female ratio was nearly equal. The median age was 59.5 ± 9.99 years. Most patients developed mild disease. The most common symptoms were fever (82%). Ten (20%) had patchy bilateral opacity (ground-glass opacity) on the chest radiograph. Major complications were lymphocytopenia (36%), thrombocytopenia (30%), pneumonia (28%), and septic shock (6%). Eleven (22%) patients were hospitalized. Five required mechanical ventilation. Ten (20%) patients died. The relative risk of death with COVID-19 in HD patient was 1.46 with 95% confidence interval 1.15-1.84, (P = 0.003). The patients aged ≥60 years had 4.3 times more severe disease (P = 0.044) and died 3.3 times (P = 0.164) more than patients aged <60 years. HD patients have a high susceptibility to COVID-19 compared to the general population with an increased mortality rate and prolonged recovery time. Patients with age >60 years, female gender, diabetics, and those presented with more severe symptoms and laboratory parameters, had a higher fatal outcome., Competing Interests: None

Recently the WHO Ad Hoc Expert Group proposed that it is ethical to continue placebo-controlled Covid-19 vaccine trials in countries where vaccines are not available even if this vaccine is marketed and being used elsewhere. The reason for this proposal is the usual scientific argument claiming that these trials are the most efficient method to obtain reliable results, and individuals in these countries will continue to get the local standard of care, meaning no vaccination, and thus participants are not being left worse off. We refute this argument on two counts. First the global equity and justice issue, that the scarcity of vaccines in most countries is created by the rich nations that have hoarded vaccines. Second, the science versus research ethics issue, that there are valid scientific methods like non-inferiority trials which can give reliable results, and that applying a standard of care imposed by rich nations is both unethical and possibly exploitative. Thus, we feel that the WHO Ad Hoc Expert Group is wrong in proposing to continue placebo-controlled Covid-19 vaccine trials.

Objective: To compare adequacy of dialysis between single-use and reused dialyzer in order to ascertain whether reuse of dialyzers provides adequate dialysis and thereby enable provision of effective yet affordable renal replacement therapy in resource-limited countries., Study Design: Observational cross-sectional study., Place and Duration of Study: Department of Nephrology, The Kidney Centre, Postgraduate Training Institute (TKC-PGTI), Karachi, from December 2017 to February 2018., Methodology: Equal number of patients on thrice weekly hemodialysis with either single-use (group A; n=33) or reuse (group B; n=33) dialyzer for at least six months were reviewed. Both groups were compared for dialysis adequacy measured as urea reduction ratio (URR); as well as adequacy of patient care in terms of anemia, bone-mineral control and nutritional status. Serum hemoglobin and erythropoietin stimulating agent (ESA) dose were taken as markers for anemia management, serum calcium, phosphate and intact parathyroid hormone (iPTH) for bone-mineral control and serum albumin as index for nutritional status., Results: The mean age of patients in Group A was 51.36 +13.9 years and in Group B was 54.78 +15.4 years. Female to male ratio was 1.75:1. The mean number of dialyzer reused in group B was 47.5±27.8. There was no significant difference between the study groups in terms of URR (p=0.362), hemoglobin (p=0.347), ESA dose (p-=0.556), serum calcium, phosphorus and iPTH (p=0.868, p=0.138 and p=0.323, respectively), and serum albumin (p=0.777). All the parameters were in accordance with KDOQI guidelines., Conclusion: Reuse of dialyzer does not affect dialysis efficiency. Adequate dialysis therapy can be provided economically through reprocessed dialyzers in at least resource-poor countries.

Objective: To study the clinical characteristics of patients on hemodialysis for more than ten years in order to highlight the modifiable factors that may improve survival in low socioeconomic status., Study Design: Observational cross-sectional study., Place and Duration of Study: Department of Nephrology, The Kidney Centre Postgraduate Training Institute (TKCPGTI), Karachi, from November 2017 to January 2018., Methodology: Clinical records of 38 patients, who have been on thrice weekly hemodialysis for more than ten years at the study centre with registration period from 1989 to 2018, were reviewed. The participants were placed in three groups according to duration of hemodialysis: 10 to 15 years; 15 to 20 years, and >20 years. Background information (age, gender, age at initiation of hemodialysis, cause of renal failure), dialysis dose (urea reduction ratio), anemia (hemoglobin), bone-mineral metabolism (calcium, phosphate and iPTH), and nutrition (albumin) were evaluated. The parameters were compared among the groups and with respect to K/DOQI and EBPG guidelines., Results: Mean age at institution of hemodialysis was 33.5 years. The most common cause of End Stage Renal Disease (ESRD) was of unknown etiology (bilateral small shrunken kidneys). Chronic sclerosing glomerulonephritis was the second most common cause. The mean hemoglobin level was 10.98 +1.4 g/dL. Mean phosphate, calcium and iPTH were 4.75 ±1.34 mg/dL, 9.62 ±0.64 mg/dL and 281.5 pg/ml, respectively. Serum albumin was 3.66 ±0.39 mg/dL. These indexes were comparable to recommended guidelines., Conclusion: Clinical characteristics and other profiles of patients on hemodialysis for more than 10 years are comparable to the standard K/DOQI and EPBG guidelines. We believe that complying the standard guidelines for management of patients on chronic hemodialysis can result in better long-term outcome and survival in our population.

Acute kidney injury (AKI) in pregnancy is associated with significant maternal morbidity and mortality. Several studies from worldwide have shown different frequencies of the causes of pregnancy-related AKI (PRAKI). The present study aimed to provide local data on frequency of causes of PRAKI. A total of 111 pregnant women using nonprobability consecutive sampling technique, with the age group of 18-45 years, admitted with the diagnosis of PRAKI were included in the study. The information regarding age, duration of pregnancies, serum creatinine levels, and outcome variables (complications) were collected from each patient. Effect modifiers were controlled by stratification. The mean age was 29.90 ± 5.40 years. Out of 111 cases, 10 (9%) developed AKI in the 1 st trimester, 12 (10.8%) in the 2 nd trimester, 13 (11.7%) cases in the 3 rd trimester, and rest of the 76 (68.4%) cases were of the postpartum period. The etiology of PRAKI was multifactorial in several patients. The frequencies of complication leading to AKI were observed individually. The results showed that 21 (18.9%) had antepartum hemorrhage, 41 (36.9%) postpartum hemorrhage, 33 (29.7%) puerperal sepsis, 11 (9.9%) preeclampsia, 13 (11.7%) eclampsia, 11 (9.9%) hemolysis, elevated liver enzymes, and low-platelet count syndrome, 7 (6.3%) hemolytic uremic syndrome, and 5 (4.5%) had hyperemesis gravidarum. The results of the present study showed no statistically significant association of age with the individual complications with P >0.05. AKI during pregnancy was mostly due to prerenal causes. The most common cause was postpartum hemorrhage followed by puerperal sepsis and antepartum hemorrhage.

Chronic kidney disease (CKD) affects health and life of patients. They confront anemia, hypertension, infections and cardiovascular disease. Due to these health issues, they are at risk of repeated hospitalizations. The risk factors which propel them to hospitalize are important to know, and by controlling these factors, we can impede preventable hospitalization. This case-control study included 1050 adult CKD patients, conducted in two tertiary care hospitals of Karachi. Variables included were age, gender, ethnicity, area of residence, marital status, education smoking status, comorbids, blood pressure, type of angioaccess, hemodialysis (HD) status, stage of CKD, activity level, and laboratory parameters. Two predicted models using multivariable logistic regression analysis were established to evaluate the effect of factors leading toward hospitalization. Patients with ischemic heart disease had 3.56 [95% confidence interval (CI): 2.14-5.9] times higher rate of admission. The nonactive and moderately active patients were admitted 3.8 and 2.26 times more respectively as compared to the active patients (P <0.001). Patients with HD venous catheter were admitted 33.43 (95% CI: 12.45-89.81) times more than patients without any angioaccess. All laboratory parameters had highly significant effect on admission (P <0.001), odds ratio for low albumin, low hemoglobin, and high total leukocyte count were 6.87(95% CI: 4.45-10.6), 4.2 (95% CI: 2.73-6.57) and 7.9 (95% CI: 4.93-12.66) respectively. In conclusion, cardiovascular disease was observed as the most important risk factor of hospitalization for CKD patients. The other plausible risk factors were late referral to nephrologist, low activity level anemia, and hypoalbuminemia., Competing Interests: None declared.

The prevalence of subclinical hypothyroidism (SHT) has been reported to be much higher in patients with chronic kidney disease (CKD) than in the general population. SHT has been identified as a strong predictor of mortality and a risk factor for cardiovascular disease in CKD. The study aimed to provide local data on the prevalence of SHT in CKD patients on maintenance hemodialysis (MHD). A total of 72 patients with CKD on MHD were enrolled. Nonprobability consecutive sampling was performed on patients of either gender aged 14-50 years who met the inclusion and exclusion criteria. Thyroid-stimulating hormone and free thyroxine four levels were obtained and interpreted for the presence of SHT. SHT was present in 22 patients (30.6%). When stratified according to age, 22.7% of patients were younger than 30 years, 20.8% between 30 and 40 years and 46.2% were above 40 years. The percentage of patients above 40 years with SHT was much higher, but not statistically significant (P = 0.096). When stratified according to gender, 21.6% were male, and 46.2% were female (P = 0.03). When stratified according to duration on hemodialysis (HD), 4.5% of patients on HD for two years or less had SHT; 25.9% on HD for three to five years and, 60.9% on HD for more than five years had SHT (P <0.01). The study shows a considerably high prevalence of SHT in CKD patients on HD. Routine screening of thyroid functions in these patients, especially in females and those on HD for >5 years, may help in reducing the morbidity and mortality associated with SHT through early detection and timely intervention., Competing Interests: None declared

Chikungunya fever is an arthropod-borne viral illness characterised by high grade fever and incapacitating arthralgias. It is considered benign; however, in the recent outbreaks, several complications have been reported worldwide. We report a case of male patient with Chikungunya fever, possibly contracted from infected mosquitoes endemic in Karachi, Pakistan. The clinical presentation included fever, myalgias and anuria. Investigations revealed renal failure and significantly raised creatinine phosphokinase (CPK), suggesting rhabdomyolysis to be the cause of acute kidney injury (AKI). Rhabdomyolysisis likely occurred due to virus-induced myositis; a rare presentation of Chikungunya fever. The patient gradually recovered from renal failure following supportive care and renal replacement therapy.

Despite almost universal practice of dialyzer reuse from the earliest days of haemodialysis, reusing dialyzer always remains a controversial issue and several ethical concerns have been raised. Some of the important are safety of reuse over single use, informed consent of the patient, conflict of interest on the part of physician or manufacturer, fiscal responsibility and environmental stewardship. Indeed, at the beginning of this century, there was a drastic shift of practice in favour of single use in developed countries due to availability of biocompatible haemodialyzers, at favourable price. Despite this mega shift, dialyzer reuse is still widely practised in low-income countries. Considering cost inflation and limited medical resources in such countries, dialyzer reuse may be justified as a cost-saving strategy for this part of world. However, it poses the same ethical questions to us which were a matter of debate for the western world in the 1980s and 1990s. This review of literature was planned to revisit and highlight these concerns.

Objective: To study the pattern of dyslipidaemia in patients with stage-V chronic kidney disease on conservative management and those on maintenance haemodialysis., Methods: This comparative observational study was conducted at the Jinnah Postgraduate Medical Centre, Karachi, from February to July, 2008, and comprised stage-V chronic kidney disease patients. The patients were divided in two groups. Those who were on conservative management were placed in Group A, and those who were on maintenance haemodialysis were in Group B. Serum total lipid, cholesterol, triglycerides and high-density lipoprotein for both groups were assayed on chemical analyser and low-density lipoprotein was calculated by Friedwald equation. SPSS 17 was used for data analysis., Results: Of the 120 patients, there were 60(50%) in each group. The mean age of patients in Group A was 46.33±14.56 years and in Group B was 43.4±14.1years. Of all, 64(53.3%) were men and 56(46.7%) were women. Mean systolic and diastolic blood pressure was 134±19.58mmHg and 83.6±14.14mmHg in Group A and 129±19.7mmHg and 79.7±12.1mmHg in Group B. Mean serum total lipid was significantly higher (p<0.01) whereas mean serum cholesterol was significantly lower (p<0.01) in Group B. Comparison of mean serum triglycerides between the groups was also statistically significant (p<0.01) and was high in Group B. Mean serum high-density lipoprotein was lower in Group B (p<0.01). The difference between serum low-density lipoprotein levels was statistically insignificant between the groups (p=0.11)., Conclusions: Pattern of dyslipidaemia in patients on maintenance haemodialysis was more hostile than those on conservative management, and posed increased risk of coronary heart disease.

Reusing dialyzers is almost universal in developing countries to reduce the cost of hemodialysis (HD). Economic benefits of dialyzer reuse, when estimated only on the basis of the dialyzer and its consumables are very significant and attractive. In this study, we compared the cost of mechanical reuse of dialyzer considering all of the direct costs (medications, dialyzer, and its consumables, disinfection fluid, and hospitalization if any) in HD treatment, which if significantly different between single use and reuse, can nullify the obvious cost benefits. A total of 70 adult patients of any gender on maintenance HD at The Kidney Centre Post Graduate Training Institute for more than three months were included. Equal numbers of patients were on single use (Group A) and reuse of dialyzer (Group B). Both groups were compared for total direct costs of HD over a six months period. Average six monthly total direct cost per patient of Group A was significantly high as compared to Group B, the United States Dollar (USD) 1750.67 ± 135.31$ vs. USD 1488.50 ± 132.23$); difference USD 262.18$ (P <0.001). The total cost saving being 14.97% in Group B. Our study shows that dialyzer reuse provides a significant economic benefit and remains a means of reducing the cost of HD.

Introduction: Month of Ramadan bring many changes in life style, especially the diet of Muslims all over the world among both fasting and nonfasting individuals. Hemodialysis patients are kept on restricted diet because of fluid and electrolytes imbalance. The aim of this study was to compare changes in the clinical and biochemical parameters in fasting and nonfasting hemodialysis patients during the Ramadan., Materials and Methods: In a longitudinal study, we recruited 282 patients who were on maintenance dialysis for more than 3 months. Measurements included body weight, blood pressure, serum potassium, serum albumin, and serum phosphorus at the beginning and during the last week of Ramadan., Results: There were 252 patients who were not fasted while 34 patients were those who fasted during the Ramadan. In the nonfasting hemodialysis patients, serum albumin significantly increased at the end of Ramadan (P < .001), while serum phosphorus levels (P = .004) and diastolic blood pressure (P = .002) showed a decrease as compared with the measurements before Ramadan. In the fasting group, only serum albumin had a significant increase (P < .001) during Ramadan, while other parameters were not significantly different between the two measurements., Conclusions: Changes in dietary pattern and content during the Ramadan is safe in terms of electrolyte balance and blood pressure changes for patients on hemodialysis. It is also safe for those patients who want to fast during this month.

Objective: To see the response of steroid and cyclophosphamide if membranoproliferative glomerulonephritis is classified by pattern of immune and complement deposits., Methods: The retrospective study was conducted at The Kidney Centre, Karachi, and comprised patients treated for membranoproliferative glomerulonephritis between 1996 and 2013. Records of patients who were not treated with immunosuppressive medications were excluded. Patients were classified according to the types of immune deposits; one group had patients with only Complement factor 3 deposits, and the other with Complement factor 3 and immunoglobulin deposits. The effect of steroid alone and steroid with cyclophosphamide was observed on two histological patterns, according to the severity of kidney dysfunction and degree of interstitial fibrosis. SPSS 17 was used for statistical analysis., Results: Of the 54 patients, 31(57%) were males and 23(42%) were females, with an overall mean age of 30.26±15.41 years. Group with Complement factor 3deposits had 17(31%) patients, while that with Complement factor 3 and immunoglobulin had 37(68%). Both groups were similar in terms of clinical and laboratory parameters (p>0.05). Both groups showed better response when treated with steroid and cyclophosphamide: 8/9(88.9%) vs. 3/8(37.5%) in Complement factor 3 only; and 10/15(66.7%) vs. 12/22(54.5%) in Complement factor 3 with immunoglobulin. Increasing severity of interstitial fibrosis (p=0.014) and presence of renal dysfunction (p=0.001) hampered the response. After adjusting the confounders, the odds ratio of response was 4.654(95%confidence interval: 0.957-22.63) in patients who received the treatment with steroid and cyclophosphamide compared to steroid alone., Conclusions: Steroids and cyclophosphamide together have a beneficial role if treatment is initiated early in the course of the disease.

Objective: The effect of month of Ramadan on the mortality in hemodialysis patients, and to compare it with that in all other Islamic months., Study Design: A descriptive study., Place and Duration of Study: Hemodialysis Unit, The Kidney Center, Karachi, from January 1989 to December 2012., Methodology: All those patients who were diagnosed to have end stage kidney disease and on maintenance hemodialysis for more than 3 months, regardless of underlying cause of kidney failure were included. Patients with acute kidney injury were excluded. Status of the patients was recorded at the end of the study period. The fasting status of the patients was not mentioned. The deaths of the patients were further evaluated and frequencies of death in all twelve Islamic months were calculated., Results: A total of 1,841 patients were registered, out of whom 897 (48.7%) died, and 269 (14.6%) survived till the end of the study. One thousand and fifty six (57.3%) were males, 651 (35.4%) were diabetic. Total number of 143 (7.76%) events occurred in Ramadan, out of which 94 patients died which make nearly 11% of the total deaths distributed in 12 Islamic months. Frequency of death was higher in Ramadan when compared with other months., Conclusion: Ramadan reflected a higher frequency of death. Therefore, there is a need to evaluate the risk factors in a prospective study so that the dialysis patients can be better managed during this period.