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The increasing rate of cardiovascular disorders contributes to rising hospitalized patients receive chronic oral beta-blocker therapy. Beta-blockers remain one of the fundamental therapy for chronic heart failure. Still, their role in decompensated heart failure and severe sepsis during hospitalization is often debated and inconsistent in clinical practice. In recent years, evidence of the efficacy and clinical outcomes of beta-blockers in acute heart failure (AHF) have accumulated. Clinical research indicates that chronic beta-blockade withdrawals should be prevented, or as soon as hemodynamic stabilization and euvolemic condition are reached, it should be reinstituted. As a subset of AHF patients with low cardiac output required inotropes, the choice of proper agent is fundamental. Different inotropic agents such as inhibitors of the phosphodiesterase, levosimendan, and dobutamine also their associations with beta-blockers are discussed.

BACKGROUND: Chronic kidney disease (CKD) is often associated with an increased risk of cardiovascular disease. Cardiovascular disease in CKD can be affected by oxidative stress and inflammation. The oxidative stress can affect arterial stiffness, especially in patients with CKD, which will increase the risk of cardiovascular disease. This study aimed to explain the correlation between total antioxidant capacity (TAC) and 8-hydroxydeoxyguanosine (8-OHdG) with carotid-femoral pulse wave velocity (cf-PWV) in patients with CKD. METHODS: Forty-three CKD patients was included in this cross-sectional study. TAC was measured from serum samples by colorimetric method and 8-OHDG was measured from urine by enzyme-linked immunoassay method. cf-PWV was measured by Doppler ultrasound as a diagnostic tool for arterial stiffness. RESULTS: Significant correlations were found between age, estimated glomerular filtration rate (e-GFR), Hemoglobin A1C (HbA1C), serum creatinine, cystatin-C, and severity of CKD with urinary 8-OHdG levels. Serum creatinine, cystatin-C, severity of CKD, age, high-density lipoprotein (HDL), e-GFR, and HbA1C also had significant correlations with serum TAC levels. Other significant correlations between e-GFR, HbA1C, serum creatinine, cystatin-C, and severity of CKD with cf-PWV were also obtained. A significant negative correlation was obtained between serum TAC and cf-PWV with moderate levels of correlation coefficient (r=-0.504). CONCLUSION: There was a negative correlation between TAC and cf-PWV, but there was no significant correlation between 8-OHdG and cf-PWV in patients with CKD. KEYWORDS: chronic kidney disease, total antioxidant capacity, 8-hydroxydeoxyguanosine, carotid-femoral pulse wave velocity

BACKGROUND: Sleep deprivation is strongly associated with cardiovascular disease (CVD) via sympathetic overstimulation and systemic inflammation in general population. However, the significance of poor sleep quality in chronic kidney disease (CKD) is still underexplored. METHODS: This study assessed the sleep quality of 39 with non-dialysis CKD (ND CKD) patients and 25 hemodialysis CKD (HD CKD) patients using the Pittsburgh Sleep Quality Index (PSQI) questionnaire. Poor sleeper was defined as individual with PSQI > 5. RESULTS: The prevalence of poor sleeper (30% vs. 60%, p =0.029) and the cummulative PSQI (ND CKD 4.5±4.4, HD CKD 8±6, p =0.038) are different between ND CKD and HD CKD groups. Among the ND CKD, there are association between short sleep duration (< 5 hours per day) with elevated diastolic blood pressure groups (r=0.421, p

Background: Inflammation and oxidative stress are among the key contributing risk factors for cardiovascular disease (CVD) in chronic kidney disease (CKD). The human gut is the home for microbiota, of which some of the gram-negative gut bacteria are known to produce low-molecular-weight thiols including glutathione (GSH). GSH is used by mammals and eukaryotic cells as a substrate of glutathione peroxidase to eliminate reactive oxygen species. This study aims to investigate whether the presence of thiol-producing gut microbiota in CKD affects the level of oxidative stress and inflammation markers.Methods: This study examined the stool sample of 41 CKD patients at three hospitals in Surabaya, Indonesia to identify the gram-negative bacteria producing thiols. Based on Ellman's assay result, the study participants were grouped into patients with thiol-producing and non-thiol-producing gram-negative gut microbiota. The markers of inflammation, high sensitivity C-reactive protein (hs-CRP), total antioxidant capacity (TAC), and urinary oxidative stress marker 8-hydroxy-2' -deoxyguanosine (8-OHdG) were compared between the two groups.Results: The group with thiol-producing gut microbiota exhibited lower levels of plasma hs-CRP and urinary 8-OHdG compared to the group with non-thiol-producing gram-negative gut microbiota. In contrast, the group with thiol-producing gut microbiota has higher TAC compared to the group with non-thiol-producing gram-negative gut microbiota.Conclusion: This study emphasized that the phenotypical diversity regarding the ability to produce low-molecular-weight thiols might modulate inflammation and oxidative stress as CVD risk factors in CKD.

Chronic kidney disease (CKD) is progressive disease that closely related to the chronic inflammatory process.Angiotensin-Converting Enzyme Inhibitor (ACE-I)/Angiotensin Receptor Blockers (ARBs) is the main therapy in the management of CKD, based on the recent sudies stated that this drug have pleiotropic effects as anti-inflammation.The aim of this study is tosee the interaction of hs-CRP and HDL-Cholesterol to prove the role of ACE-I/ARBs as an anti-inflammatory treatment for CKD patient. In this study we compared hs CRP, HDL Cholesterol and HDL Cholesterol /hs-CRP ratio levels in CKD patients who consumeand do not consumeACE-I/ARBs. Forty eight samples of CKD patients were taken randomly and then separated into two group based on their consumption of ACE-I/ARBs, each group have 24 samples.There were significantly different of mean of hs-CRP, HDL Cholesterol, and HDL Cholesterol/hs-CRP ratio between group, the mean concentration of hs-CRP in the ACE-I/ARBs group was significantly lower than in non-ACE-I/ARBs group (1,48±0,81 vs 4,19±4,02; P= 0.038),the mean of HDL (48,95±13,05vs 41,50±12,31; P= 0,048).There were negative correlation between HDL Cholesterol and hs-CRP, positive correlation between HDL Cholesterol/hs-CRP ratio and eGFR.This result indicate that hs-CRP and HDL-Cholesterol monitoring very important in CKD patient.

Severe COVID-19 infection management for a recipient of kidney transplant has debatable prognosis and treatment. We described the case of a COVID-19 infected 70 year old female, previously had renal transplantation in 2017. The patient took immunosuppressive agents as routine drugs for transplant recipient status and received lopinavir/ritonavir, hydroxychloroquine, and dexamethasone daily at the hospitalization. Specific question arises about renal transplant recipients being infected by COVID-19 – whether the infection will get worse compared to those without immunosuppresive agent. In this case, author decided to stop the immunosuppressive agent followed administration of combination lopinavir/ritonavir, hydroxychloroquine, and dexamethasone that gives a good clinical impact change to patient’s condition after once getting worsened and mechanically ventilated. Nevertheless, the assessment of risk and benefit in continuing immunosuppressive drugs is concurrently essential due to the prevention of transplant rejection.

Background: Activation of renin-Angiotensin system in hypertension was believed to be major determinant in endothelial dysfunction, micro-inflammation, and reactive oxygen species generation. This study aimed to investigate the interaction of increased blood pressure with cardiovascular risk factors in chronic kidney disease (CKD). Materials & methods: The study was an observational study with cross-sectional design that consecutively enrolled CKD patients in Universitas Airlangga Hospital and two other hospitals in Surabaya, Indonesia. The resting blood pressure and kidney functions of the participants were examined. Malondialdehyde (MDA) and total antioxidant capacity (TAC) was measured in serum and used as oxidative stress markers. Serum hs-C-reactive protein (CRP), lymphocyte-to-monocyte ratio and platelet-to-lymphocyte ratio were utilized as inflammatory markers, while urine albumin-to-creatinine ratio (ACR) was used as renal disease marker. The participants were grouped based on their systolic and diastolic blood pressure (SBP and DBP). The difference of marker levels between groups was tested using Mann-Whitney test. The correlation between SBP and DBP with inflammation, oxidative stress, and albuminuria was determined using Spearman’s test. Results: As many as 71 patients with CKD were enrolled in this study. As much as 37% of the participants had high SBP and 14% had high DBP. High SBP positively associated with MDA (P

BACKGROUND: Establishment of inexpensive clinical laboratory tests to evaluate inflammation and oxidative stress is urgently needed in the limited resources settings. This study aims to investigate the potential of complete blood count (CBC) parameters and non-fasting cholesterol profile parameters to describe inflammation and oxidative stress in chronic kidney disease (CKD) patients. METHODS: Measurement of CBC, non-fasting cholesterol profile, high sensitivity C-reactive protein (hs-CRP) and malondialdehyde (MDA) were performed in 71 CKD patients grouped into hemodialysis (HD) and non-hemodialysis (non-HD). Correlation analysis were performed to assess the potential of CBC and cholesterol profile to describe the level of hs-CRP and MDA. RESULTS: In the HD group, total cholesterol was moderately associated with hs-CRP while total cholesterol/HDL-C ratio, monocyte/HDL-C ratio, monocyte/LDL-C ratio, neutrophil/HDL-C ratio, neutrophil/LDL-C ratio, platelet/HDL-C ratio and platelet/LDL-C ratio were strongly associated with hs-CRP. In the non-HD group, only neutrophil/total cholesterol ratio and platelet/total cholesterol ratio that were associated with hs-CRP. Total cholesterol, monocyte/LDL-C ratio, neutrophil/LDL-C ratio and platelet/LDL-C ratio were moderately associated with MDA while total cholesterol/HDL-C ratio, monocyte/HDL-C ratio, neutrophil/HDL-C ratio and platelet/HDL-C ratio were strongly associated respectively with MDA in HD group. In the non-HD group, total cholesterol/HDL-C ratio, neutrophil/HDL-C ratio and platelet/HDL-C ratio were moderately associated with MDA in non-HD group while monocyte/HDL-C ratio was weakly associated with MDA. CONCLUSION: Some CBC parameters and non-fasting cholesterol profile such as cholesterol/HDL-C, monocyte/HDL-C, neutrophil/HDL-C and platelet/HDL-C ratio showed a potential to describe the inflammation and stress oxidative markers, given some strong associations with the level of hs-CRP and MDA. Further study is needed to assess whether this parameter represent long-term prognostic value among CKD patients. KEYWORDS: inflammation, oxidative stress, CRP, MDA, TAC, 8-OHdG, CBC, cholesterol

BACKGROUND: Obesity is an important cardiovascular risk factor and associated with low grade inflammation in chronic kidney disease (CKD) patients. This study aims to assess the association between body fat with serum high sensitivity C-reactive protein (hs-CRP) level in CKD patients.METHODS: A cross-sectional study was performed in 71 CKD patients. Anthropometric measurements included body weight, height, body mass index (BMI), body fat percentage (BFP), skinfold thickness (SKF) of triceps and biceps were performed by trained physician. BFP was calculated using Kwok’s Formula and hs-CRP was measured by Particle enhanced Turbidimetry.RESULTS: The averaged BMI of our subjects was 25.8±4.4. There was no significant difference in BMI between pre-dialysis and hemodialysis CKD patients. Positive correlation was found between BFP and hs-CRP (r=0.266; p

Anti-Human Immunodeficiency Virus (Anti-HIV) was performed from 100 plasma Chronic Kidney Disease (CKD) stage 5 patientswith continuous hemodialysis (HD) at the Hemodialysis Instalation Dr Soetomo hospital, Surabaya, Indonesia, using three (3) kind ofreagents: Tri-line HIV Rapid test Device from Acon for HIV 1/2/O as strips form, Foresight HIV 1/2/O Antibody EIA Test Kit from Aconand Anti-HIV 1+2/Subtype O ELISA from Axiom. HIV RNA and HIV subtype were detected by Reverse Transcription Polymerase ChainReaction (RT-PCR) based on HIV gag region and analysis of DNA result. Seventy three % patients were hemodialysed twice in a week andonly 14% with duration more than five (5) years. Most of the patients (43%) were hemodialysed between 100−300 times. From the 100plasma samples was obtained only one (1%) man patient plasma sample with positive anti-HIV. A weak positive of RT-PCR result wasnot succeed to be sequenced for determining the HIV subtype. This cause was suspected due to low levels of HIV RNA in blood. The resultsof this study was expected can be used as an additional management consideration of hemodialysis patients at the Hemodialysis Unit.

Background: Hypertension, as the comorbidity accompanying COVID-19, is related to angiotensin-converting enzyme 2 receptor (ACE-2R) and endothelial dysregulation which have an important role in blood pressure regulation. Other anti-hypertensive agents are believed to trigger the hyperinflammation process. We aimed to figure out the association between the use of anti-hypertensive drugs and the disease progression of COVID-19 patients. Methods: This study is an observational cohort study among COVID-19 adult patients from moderate to critically ill admitted to Universitas Airlangga Hospital (UAH) Surabaya with history of hypertension and receiving anti-hypertensive drugs. Results: Patients receiving beta blockers only had a longer length of stay than angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ACEI/ARB) or calcium channel blockers alone (17, 13.36, and 13.73 respectively), had the higher rate of intensive care unit (ICU) admission than ACEi/ARB (p 0.04), and had the highest mortality rate (54.55%). There were no significant differences in length of stay, ICU admission, mortality rate, and days of death among the single, double, and triple anti-hypertensive groups. The mortality rate in groups taking ACEi/ARB was lower than other combination. Conclusions: Hypertension can increase the severity of COVID-19. The use of ACEI/ARBs in ACE-2 receptor regulation which is thought to aggravate the condition of COVID-19 patients has not yet been proven. This is consistent with findings in other anti-hypertensive groups.

Introduction: The morbidity and mortality rate of patients with chronic kidney disease (CKD) remain high despite progressive development in CKD management. Microinflammation is an important component of CKD, and has an important role in the pathophysiology of cardiovascular disease (CVD) complications, as well as protein energy deficiency (PED) and mortality. Various factors contributes to the inflammatory state of CKD, including increased production and decreased excretion of pro-inflammatory cytokines, oxidative stress, acidosis, chronic vascular access infection, fat metabolism dysregulation, and intestinal dysbiosis. The inflammatory process has been shown to be directly correlated with glomerular filtration rate (GFR) in CKD and reaches its peak in end-stage renal disease (ESRD). A number of dialysis-related factors such as bioincompatible membranes and dialysate quality also have important roles in the inflammatory process. Meanwhile, the role of genetic and epigenetic factors is being widely studied. Efforts in reducing inflammation such as lifestyle modification, medication, and dialysis optimization have been performed and tested into a controlled clinical trial.

Background: Total antioxidant capacity (TAC) is one of the biomarkers to determine a person's health condition through antioxidant and oxidant activity or oxidative stress so that it can help in determining the therapy needed. However, currently, TAC levels in patients with chronic kidney disease (CKD) undergoing hemodialysis (HD) and non-hemodialysis (non-HD) are still controversial, so further research is needed. Objective: To analyze the comparison of TAC in HD and non-HD CKD patient. Materials and Methods: This was an analytical cross-sectional study with clinical observation in CKD patient. A total of 71 CKD patients consisting of 28 CKD HD patients and 43 non-HD CKD patients were enrolled in this study. Data about the characteristics of the subjects were taken using the anamnesis method, while data about TAC were taken using the colorimetric method with COBAS C-501 0837-19 series and 0835-13 series to measure TAC levels in the serum of CKD patients. The data that has been obtained were analyzed using independent sample t-tests. Results: TAC levels were significantly higher in CKD patients undergoing HD compared to non-HD CKD patients (p

Aim : This research is to evaluate the hs-CRP level comparison between CKD stages in Dr. Soetomo General Hospital Surabaya. Methods : An analytic observational cross-sectional study, evaluating the differences of hs-CRP level between CKD stages in 72 patients (mean age 55.49±7.62 years, the ratio between male:female was 1:1.48, mean BMI 24.18±3.64 kg/m2, 36.11% diabetics, 43.05% on ACEI/ARB, 29.16% on statin), recruited from Nephrology Outpatient Clinic, Dr Soetomo General Hospital, Surabaya, from January to May 2014. The stages were stratified according to the MDRD formula. Results : The mean hs-CRP of CKD stage 3 was 2.29±2.86, stage 4 was 2.48 ± 2.19, and non-dialysis stage 5 was 2.09 ± 2.54. The analysis using Kruskal-Wallis test showed no significant differences among patients with CKD stage 3, stage 4, and non-dialysis stage 5 (median 1.25 vs 1.80 vs 1.05 mg/L; p=0.430). No significant differences of the serum hs-CRP level were detected between diabetics and non diabetics in stage 3, 4, and non-dialysis stage 5 (p=0.673 vs 0.666 vs 0.138); between patients with and without ACEI/ARB treatment (p=0.610 vs 0.649 vs 0.671); and between patients with and without statin treatment (p=0.852 vs 0.341 vs 0.309). Conclusion: The elevation of serum hs-CRP level can not indicate the decline of kidney function, but it still needs further investigations.

Introduction:Patients with CKD have elevated plasma levels of Asymmetrical Dimethyl Arginine (ADMA), impaired EDRF/NO responses in isolated resistance vessels, and a marked increase in the frequency of cardiovascular events that are predicated by plasma levels of ADMA. ADMA is considered as a risk factor for endothelial dysfunction, progression of chronic kidney disease and a marked increase in the frequency of cardiovascular events that are predicated by plasma levels of ADMA. Elevated ADMA in CKD have been related to a combination of a reduced renal ADMA excretion and a reduced catabolism of ADMA by dimethylarginine dimethylaminohydrolase (DDAH). The current study was undertaken to determine whether there is a correlation between ADMA and SNPs at -449 DDAH 2.Subjects and Methods :It was a cross sectional analytic study, 56 hemodialysis patients and 30 healthy individuals were enrolled. Based on its etiology, HD patients group was further divided in to hypertension (HT) subgroup and non-HT subgroup. Genotyping of the polymorphisms was performed using PCR-based SNP detection methods based on 5’-exonuclease activity assays for rs805305.Results :Heterozygotes were observed as the most abundant genotypes in both groups, followed by GG genotype in the HD patients (30%) and CC (27%) healthy individuals. Among the HT subgroup, the mean plasma levels of ADMA were sequentially higher from genotypes CC, G/C and GG (p = 0.037). Further multiple comparisons between groups using post hoc test showed results that genotype GG and CC were different at 0.05 level of significance. These findings were not found among non HT subgroup.Conclusion: Genetic variation in the DDAH 2 genes is significantly associated with serum ADMA levels in hypertensive HD patients. We observed that carriage of a G at position -449 in the promoter region of the DDAH 2 gene is associated with higher ADMA levels.

The prevalence of hepatitis C virus (HCV) infection has been as high as approximately 80% in patients with maintenance hemodialysis in public hospitals in Indonesia. However, the prevalence in private hospitals has not been examined yet. The aim of this study was to investigate the prevalence of anti-HCV antibody and the subtype distribution in patients with hemodialysis in a private hospital in Surabaya, Indonesia. Sera were obtained from 41 hemodialysis patients in a private hospital in Surabaya. The positive prevalence of anti-HCV antibody was carried out by the enzyme-linked immunosorbent assay (ELISA). Anti-HCV-positive sera were subjected to reverse transcription-PCR (RT-PCR) to detect HCV RNA and then direct sequencing. The HCV subtype was examined by phylogenetic analysis. Twenty five patients (61%) out of 41 were positive for anti-HCV antibody, and HCV-RNA was detected in 19 patients. The positive prevalence of anti-HCV antibody was 7.7% (one out of 13 patients) among patients who had undergone hemodialysis for less than one year, whereas it was 85.7% (24 out of 28 patients) among patients who had undergone hemodialysis for over one year. Phylogenetic analysis revealed HCV-1a (52.6%) was the most common subtype, followed by 1b (15.8%), 1c (15.8%), 2a (5.3%), and 3k (5.3%). In conclusion, the prevalence of HCV infection among hemodialysis patients in a private hospital was as high as that in general hospitals. The predominant subtype was HCV-1a, which is in accordance with the previous studies in general hospitals in Surabaya, Indonesia.

OBJECTIVE: This cross-sectional study explored the association between carotid intima—media thickness (CIMT) and the oxidative stress markers asymmetric dimethylarginine (ADMA) and homocysteine in patients with end-stage renal disease who were on haemodialysis. METHODS: A total of 30 patients undergoing chronic haemodialysis treatment were recruited to this study. Homocysteine and ADMA levels were determined using a fluorescence polarization immunoassay and an enzyme-linked immunosorbent assay, respectively. CIMT was measured as a marker of atherosclerosis using high-resolution ultrasonography and was performed after haemodialysis. RESULTS: Significant positive correlations were found between CIMT and ADMA, and CIMT and duration of haemodialysis. Linear regression analysis showed that ADMA level and age were significant independent determinants of CIMT, whereas homocysteine was not. CONCLUSIONS: The relationship demonstrated between plasma ADMA and carotid artery thickening suggests that ADMA may be a novel marker of atherosclerosis in patients on haemodialysis.

Background: Hyperhomocysteinaemia is an independent cardiovascular risk factor in patients with renal disease. The current study aimed to determine the effect of intravenous N-acetylcysteine on plasma homocysteine levels when administered during haemodialysis in patients with end-stage renal failure. Patients and methods: Sixty patients with end-stage renal failure were randomised to receive a 4-hour intravenous infusion of N-acetylcysteine or placebo during a 4-hour haemodialysis session. Plasma homocysteine levels were measured before and after haemodialysis. Haemodynamic parameters, including pulse pressure, were also measured. Results: After haemodialysis in the placebo treatment group, plasma homocysteine was reduced by 23.7% from the pre-dialysis level, whereas patients treated with N-acetylcysteine exhibited an 88.3% decrease (p < 0.001). Reduction of plasma homocysteine concentration was significantly correlated with a reduction of pulse pressure (p = 0.001). A 10% decrease in plasma homocysteine concentration was associated with a 1.45mm Hg decrease in pulse pressure. Conclusions: Intravenous administration of N-acetylcysteine during haemodialysis normalises plasma homocysteine concentration, and this is associated with improved pulse pressure in patients with end-stage renal failure. Intravenous administration of N-acetylcysteine during haemodialysis may be a promising approach to help reduce cardiovascular risk in this vulnerable group of patients.

Background: Uremic patients are in a pro-oxidant state and show an increased level of asymmetric dimethylarginine (ADMA), which is due to increased PRMT1 activity and reduced dimethylarginine dimethylaminohydrolase (DDAH) as degradation enzymes. Reactive oxidant species may play an important role in increasing the action of PRMT1 and in inhibiting the action of DDAH. Albuminuria and ADMA are closely correlated with progression of cardiovascular disease in chronic kidney disease (CKD) patients as well as indicators for decreasing renal function. Although ACEIs and/or ARBs reduced albuminuria in CKD patients, the results are still conflicting. Several factors in these patients may play important roles in the mechanism of albuminuria such as oxidative stress. The antioxidant N-acetylcysteine may prove to have beneficial therapeutic effect, because it can reduce oxidative stress as shown by evidence in humans, and subsequently increase ADMA. The objective of the present study is to explore the contribution of the antioxidant N-acetylcysteine (NAC) to the decrease of ADMA and albuminuria in non-diabetic CKD patients. Material and Methods: Patients with non-DM CKD stage 1–4 with albuminuria were randomized to receive ACEI and/or ARB alone (control group) or with antioxidant NAC 600 mg orally twice a day (treatment group). Observations were performed for 3 months to measure ADMA and albuminuria before and after-treatment. 80 patients in total 40 in the control group and 40 in the treatment group were used. Results: After oral treatment with NAC, the plasma level of ADMA in the treatment group increased from 0.604 µmol/l to 0.689 µmol/l, whereas ADMA level in the control group exhibited a higher increase from 0.561 µmol/l to 0.743 µmol/l. The increases in these groups were significantly different (p < 0.02). Moreover, the level of albuminuria was reduced from 148.12 µg/mg • cr to 132.7 µg/mg • cr in the treatment group, and from 75.25 µg/mg • cr to 71.85 µg/mg • cr in the control group. The difference was significant (p < 0.001). Conclusion: The anti-oxidant N-acetylcysteine can be used as adjuvant therapy to inhibit the progression of CKD in patients by decreasing the ADMA level and albuminuria.