Association of Anemia with Parathyroid Hormone Levels and Other Factors in Patients with End-Stage Renal Disease Undergoing Hemodialysis: A Cross-Sectional, Real-World Data Study in Pakistan

End-stage renal disease (ESRD) patients are mostly managed with maintenance hemodialysis (MHD). ESRD patients on MHD also present with many complications, such as anemia, hyperparathyroidism, and hepatitis prevalence. This study depicts the real-world scenario of anemia among MHD and end-stage renal disease patients in the Pakistani population. A retrospective, multicentric, and real-world data analytical study was conducted at 4 dialysis centers in Pakistan. The study had a sample size of n = 342 patients on maintenance hemodialysis. The data were gathered from the medical records of patients. Data analysis was performed using STATA Version 16. Statistical significance was gauged at a 0.05 level of significance. According to our results, the mean age of the patients was 45 (±15) years. Most of the patients were male (n = 234, 68.4%), whereas 58.1% of the patients were maintained on twice-weekly hemodialysis. The most commonly reported comorbidities were hypertension and diabetes mellitus. The frequency of dialysis (P < 0.01) and comorbidities (P = 0.009) had a significant association with anemia in MHD patients. The majority of the patients had hyperparathyroidism (52%) with anemia. Upon performing binary logistic regression, multivariate analysis displayed a similar odds value for having anemia in patients with every additional month in the duration of hemodialysis (OR 1.01, P = 0.001), the odds of anemic patients having a positive antihepatitis-C antibody (OR 2.22, P = 0.013), and the odds of having anemia in patients in the age category below 45 years (OR 1.93, P = 0.013). In conclusion, the study results depict that every additional month in the duration of hemodialysis, age (<45 years), and positive anti-HCV antibody status, these variables were more likely to have anemia in our study MHD patients. While in our final multivariate model, no statistically significant association was observed between hyperparathyroidism and anemia.

Renal Allograft Biopsy Findings in Live-related Renal Transplant Recipients

OBJECTIVE

 To determine the pattern of histopathology in living-related, kidney transplant recipients (KTRs) from a transplant centre in Khyber Pakhtunkhwa (KPK), Pakistan.

STUDY DESIGN

Descriptive, observational study.

PLACE AND DURATION OF STUDY

Institute of Kidney Diseases, Peshawar, from August 2008 to July 2018.

METHODOLOGY

A retrospective review of graft biopsy reports and clinical charts from living-related, kidney transplant recipients was carried out. Allograft biopsies were done for graft dysfunction with no apparent cause. The biopsy pathology was classified according to updated Banff classifications. The descriptive statistics were used to tabulate the results.

RESULTS

Out of the 55 biopsies, 51 (92.73%) were from males with mean age of 34.35±9.40 years. Out of 52 percutaneous biopsies, 10 (19.23%) belonged to the normal category. Category 2 (borderline rejection) and 3 (acute/active cellular rejection) were seen in three (5.7%) and one (1.9%) cases, respectively. Interstitial fibrosis/tubular atrophy (Banff Category 5) was observed in 18 (34.62%) cases. Banff Category 6 (others) was seen in 19 (36.5%) cases, in which calcineurin inhibitors (CNI) toxicity was commonest (17 [89.4%] of 19 cases). Mixed lesions were found in 19 (36.5%) cases. Out of the 19 mixed category cases, 12 (63.16%) showed both Category 3 and Category 5 changes with most of the cases showing mild to moderate IF/TA; while one case had severe IF/TA. Three graft nephrectomies were done, one each for recurrent oxalosis, nephroblastoma and fungal infection.

CONCLUSION

Among the studied specimens, mixed lesions were the predominant findings, followed by others (mostly CNI toxicity) and IFTA categories. The frequency of acute/active rejections was low and that of chronic changes higher, in keeping with delayed biopsies. Key Words: Allograft biopsy, Graft dysfunction, Rejection, Kidney.

Effectiveness and safety profiling of zolpidem and acupressure in CKD associated pruritus: An interventional study

BACKGROUND

Chronic kidney disease (CKD)-associated pruritus (CKD-aP) contributes to poor quality of life, including reduced sleep quality and poor sleep quality is a source of patient stress and is linked to lower health-related quality of life. This study aimed to investigate the effectiveness of zolpidem 10 mg and acupressure therapy on foot acupoints to improve the sleep quality and overall quality of life among hemodialysis patients suffering from CKD-aP.

METHOD

A multicenter, prospective, randomized, parallel-design, open label interventional study to estimate the effectiveness of zolpidem (10 mg) oral tablets versus acupressure on sleep quality and quality of life in patients with CKD-aP on hemodialysis. A total of 58 hemodialysis patients having sleep disturbance due to CKD-aP completed the entire 8-week follow-up. The patients were divided into a control (acupressure) group of 28 patients and an intervention (zolpidem) group of 30 patients.

RESULTS

A total of 58 patients having CKD-aP and sleep disturbance were recruited. In the control group there was a reduction in the PSQI score with a mean ± SD from 12.28 ± 3.59 to 9.25 ± 3.99, while in the intervention group the reduction in PSQI score with a mean ± SD was from 14.73 ± 4.14 to 10.03 ± 4.04 from baseline to endpoint. However, the EQ5D index score and EQ-visual analogue scale (VAS) at baseline for the control group with a mean ± SD was 0.49 ± 0.30 and 50.17 ± 8.65, respectively, while for the intervention group the values were 0.62 ± 0.26 and 47.17 ± 5.82, respectively. The mean EQ5D index score in the control group improved from 0.49 ± 0.30 to 0.53 ± 0.30, but in the intervention group there was no statistical improvement in mean EQ5D index score from 0.62 ± 0.26 to 0.62 ± 0.27 from baseline to week 8. The EQ 5D improved in both groups and the EQ-VAS score was 2.67 points higher at week 8 as compared to baseline in the control group, while in the intervention group the score was 3.33 points higher at week 8 as compared to baseline. Comparing with baseline, the PSQI scores were significantly reduced after week 4 and week 8 (P =  < .001). Furthermore, at the end of the study, the PSQI scores were significantly higher in the control as compared to the intervention group (P = .012).

CONCLUSION

An improvement in sleep quality and quality of life among CKD-aP patients on hemodialysis has been observed in both the control and intervention groups. Zolpidem and acupressure safety profiling showed no severe adverse effect other that drowsiness, nausea and daytime sleeping already reported in literature of zolpidem.

The association between CKD-associated pruritus and quality of life in patients undergoing hemodialysis in Pakistan: A STROBE complaint cross-sectional study

Chronic kidney disease (CKD)-associated pruritus is one of the most common symptoms found in patients who undergo dialysis for CKD, leading to a compromised quality of life. This study aimed to investigate the association between CKD-associated pruritus and the quality of life in patients undergoing hemodialysis in Pakistan.A cross-sectional multicenter study was carried out from July 2016 to April 2017 in 2 tertiary care hospitals in Pakistan. Patients aged 18 years and above of both genders, undergoing hemodialysis, understood the Urdu language, and were willing to participate; were included.Of 354 recruited patients with a response rate of 100%, majority (66.1%) of the patients were males. The median (intra-quartile range [IQR]) age of patients was 42.0 [34.0-50.0] years. The prevalence of pruritus was 74%. The median [IQR] score for pruritus was 10.0 (out of possible 25) [8.0-12.0]. Multivariate linear regression revealed a statistically significant association between CKD-associated pruritus with age of patients (β = 0.031; 95% confidence interval [CI] = 0.002-0.061; P = .038), duration of CKD (β = -0.013; 95% CI = -0.023 --0.003; P = .014) and quality of life (β= -0.949; 95% CI = -1.450; -0.449). The median [IQR] score for health-related quality of life was 52.00 [43.00-58.00].Prevalence of CKD-associated pruritus was reported to be 74% and it negatively affected the patient's quality of life. Patients with moderate to severe CKD-associated pruritus have poor quality of life. With an increase in intensity of pruritus, the QOL score decreased among the patients undergoing hemodialysis.

Prevalence of chronic kidney disease-associated pruritus, and association with sleep quality among hemodialysis patients in Pakistan

Background

The prevalence of chronic kidney disease-associated pruritus (CKD-aP) varies from 22% to 84% among patients receiving hemodialysis. It occurs more frequently at night, and often affects patient’s sleep quality. CKD-aP is often unreported by patients, and many do not receive effective treatment. There is, however, a paucity of available data on the prevalence and impact of CKD-aP on patients receiving hemodialysis in Pakistan.

Methods

A multicenter cross-sectional study was undertaken from July 2016 to April 2017 at a tertiary care hospitals in Pakistan.

Results

354 patients undergoing hemodialysis were studied. 35.6% had CKD for 1–2 years, and 42.4% were receiving hemodialysis for 1–2 years. The prevalence of pruritus was 74%. The median [interquartile range] score for pruritus was 10.0 (out of possible 25) [8.0–12.0]; while the median [interquartile range] Pittsburgh Sleep Quality Index (PSQI) score was 8.0 (out of possible 21) [7.0–10.0]'. Pruritus was significantly correlated with the sleep score (r = 0.423, p<0.001). The results of the multivariate linear regression revealed a positive association between pruritus and age of patients (β = 0.031; 95% CI = 0.002–0.061; p = 0.038) and duration of CKD (β = -0.013; 95% CI = -0.023 –-0.003; p = 0.014). Similarly there was a positive association between sleep score and duration of CKD (β = 0.010; 95% CI = 0.002–0.019; p = 0.012) and pruritus (β = 0.143; 95% CI = 0.056–0.230; p = 0.001).

Conclusions

Chronic kidney disease-associated pruritus is very common in patients receiving hemodialysis in Pakistan. Pruritus is significantly associated with poor sleep quality.

A randomized controlled trial for effectiveness of zolpidem versus acupressure on sleep in hemodialysis patients having chronic kidney disease-associated pruritus

BACKGROUND

Pruritus adds to the complications of chronic kidney disease (CKD) patient and a well-recognized complication among the CKD patients. Majority of the patients on hemodialysis experience a generalized pruritus and patients reported being moderately to extremely disturbed by at least one of the sleep-related condition. This study aim to investigate the effectiveness of zolpidem 10 mg and acupressure therapy on foot acupoints to improve the sleep quality and overall quality of life among hemodialysis patients suffering from CKD-associated pruritus.

METHODS

A multicentered, open-label, parallel group, prospective randomized controlled trial among patients suffering from CKD-associated pruritus with sleep disturbance, after randomization into control, and intervention group to be held at North West General Hospital and Research Center Peshawar, Pakistan and Institute of Kidney Diseases Peshawar, Pakistan.

RESULTS

The primary outcome is to investigate the effectiveness of zolpidem 10 mg and acupressure therapy on foot acupoints to improve the sleep quality and overall quality of life among hemodialysis patients suffering from CKD-associated pruritus. After baseline assessment by Urdu version of 5D itch scale and Urdu version of Pittsburgh Sleep Quality Index (PSQI) and Urdu EQ-5D 3L, the intervention group will be given zolpidem 10 mg oral tablets and control group with acupressure on both foots on KI-1 acupoints for total of 6 minutes. Assessment will be done at weeks 4 and 8 from baseline by using Urdu version of 5D itch scale and Urdu version of PSQI and Urdu EQ-5D 3L, whereas safety profiling of zolpidem 10 mg tablet at week 6 from baseline and acupressure acceptability at week 6 from baseline. Analysis of covariance will be used to examine the differences in treatment effects between the intervention and control groups.

CONCLUSION

Improvement of sleep quality and quality of life among patients with CKD-associated pruritus requires great importance. This study aims to improve the quality of sleep and quality of life among patients with hemodialysis suffering from CKD-associated pruritus.