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In Pakistan, patients with chronic kidney disease (CKD) are commonly diagnosed at a late stage. There is little information about the refusal of hemodialysis by hospitalized CKD patients who need hemodialysis (HD) and reasons for acceptance and refusal among these patients. All patients with Stage V CKD who had medical indications to undergo HD and were hospitalized at a tertiary care facility over a six-month period were invited to participate in this study. Patients were surveyed regarding acceptance or refusing of HD and reasons for their decisions. Demographic, socioeconomic, and clinical characteristics of patients were compared between patients who accepted or refused HD. A total of 125 patients were included in the study. The mean age of the patients was 47.9 ±12.1 years. The mean duration of diagnosis of CKD was 2.5 ± 0.6 months. Of all patients, 72 (57.6%) agreed to do HD and 53 (42.4%) refused HD. Patients with arteriovenous fistula in place (27.1 vs. 9.1%, P 0.02) and those in the middle- or higher-income group (64.4% vs. 38.6%, p = 0.03) were more willing to undergo HD. Trust in doctor's advice (86.1%) was the most common reason for acceptance of HD. Frequency of HD per week (52.8%), lifelong and permanent nature of HD (50.9%), advice by family members or friends (37.7%), perception of poor quality of life on HD (35.8%), and fear of HD needles and complications during HD (33.9%) were the most common reasons for refusal. Refusal of HD is common among hospitalized CKD patients with medical indications to undergo HD, especially in lower income group.

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OBJECTIVE: Tocompare frequency of anxiety and depression between pre-dialysis chronic kidney disease (CKD) and hemodialysis patients (ESRD) in Pakistan. METHODS: This study was conducted in an out-patient department and hemodialysis unit of Sharif Medical City Hospital. Inclusion criteria included age above 18 years and a diagnosis of CKD including both pre-dialysis CKD and ESRD patients. Patients were screened for anxiety and depression using hospital anxiety and depression scale (HADS). RESULTS: A total of 156 patients were included in the study. Out of these patients, 81 (51.9%) had ESRD and 75 (48.1%) had pre-dialysis CKD. Mean age of all patient was 47.3±18.3 years, 96 (61.5%) were males and 60 (38.5%) were females. Median duration of renal disease was 16 months (IQR 8-36 months). Anxiety and depression were present in 111 (71.2%) and 113 (72.4%) of all patients respectively. Moderate to severe anxiety and depression were present in 54 (34.6%) and 60 (38.5%) patients respectively. In multiple logistic regression model, after adjusting for other variables, ESRD vs. pre-dialysis CKD was significantly associated with moderate to severe depression (AOR 2.26 (1.1-5.1). CONCLUSION: Both anxiety and depression are common in pre-dialysis CKD and ESRD patients. Patients with ESRD have higher frequency of depression compared to pre-dialysis CKD patients.

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Few studies have compared quality of sleep between pre-dialysis chronic kidney disease (pre-dialysis CKD) patients and end-stage renal disease patients on dialysis (ESRD) and have found inconsistent results. Objective of this study is to compare quality of sleep between patients with pre-dialysis CKD and ESRD in a developing country. This study was conducted in an out-patient department and hemodialysis unit of a tertiary care facility. Patients included had either pre-dialysis CKD or ESRD. Assessment of quality of sleep was done using Pittsburgh sleep quality index (PSQI). A total of 152 patients were included in the study. Out of these patients, 79 (52%) had ESRD and 73 (48%) had pre-dialysis CKD. Median PSQI score was 6 (IQR 3-8.8). Poor sleep quality (PSQI ≥5) was present in 100 (65.8%) patients. Only hemoglobin (ß = -0.39, p < .01), depression (ß = 0.56, p < .01) and history of cardiovascular disease (ß = 0.22, p < .01) were associated with PSQI global score in a multiple linear regression analysis. There was no significant association between ESRD vs. pre-dialysis CKD and PSQI global scores and no significant co-relation between eGFR and global PSQI score (r = -0.34, p value .80) in pre-dialysis CKD patients. Poor sleep quality is common in patients with CKD including hemodialysis patients in a developing country, which is independent of kidney function in non-dialysis patients. There is no difference in quality of sleep between pre-dialysis CKD and ESRD patients.

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OBJECTIVE: To determine any clinical features associated with an abnormal ultrasound in patients with suspected nephrolithiasis in an out-patient setting. METHODS: The study design was cross-sectional in nature. The study was conducted at an out-patient nephrology department of a tertiary care facility over a 3 month period. Patients included in the study were 18-80 years old, who presented with unilateral flank or costovertebral angle pain with or without other clinical features suggestive of renal or ureteric calculus based on clinician's judgement. Every patient's history was reviewed to obtain information on age, gender, location and radiation of pain, onset, severity and nature of pain, associated urinary and systemic symptoms and past history of nephrolithiasis. An ultrasound was considered to be abnormal if there was documented presence of renal or ureteric stone and/or unilateral hydronephrosis. RESULTS: A total of 209 patients were included in the study. Of these patients, 126 (60.3%) were males and 83 (39.7%) were females, 60 (28.7%) had prior history of nephrolithiasis. Ultrasound was abnormal in 110 patients (52.9%). On a multivariate logistic regression analysis, only past history of nephrolithiasis (OR 3.3, 95% CI 1.65-6.7) was associated with an abnormal ultrasound. CONCLUSION: In the absence of any significant clinical predictors use of ultrasound is justified in patients with suspected nephrolithiasis especially in those with prior history of stones.

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BACKGROUND: Chronic kidney disease (CKD) is associated with increased risk of cardiovascular disease. Electrocardiographic (ECG) abnormalities are common in CKD patients. However, there is variation in literature regarding frequency of ECG abnormalities in CKD patients and limited information in local population. METHODS: The study design was cross-sectional in nature. All patients between ages of 20-80 years with CKD not previously on renal replacement therapy who were admitted to nephrology ward at a tertiary care facility over a 6-month period were included. All patients underwent 12 lead electrocardiograms (ECG). ECG abnormalities were defined based on accepted standard criteria. RESULTS: Total number of patients included in the study was 124. Mean age of all patients was 49.9±13.8 years, 106 (84.8%) had hypertension, 84 (70%) had diabetes mellitus, and 35 (29.9%) had known cardiovascular disease. Mean serum creatinine was 7.2±3.4 mg/dl, mean eGFR was 10.6±9.2 ml/min/1.73 m2. Overall 78.4% of all CKD patients have one or more ECG abnormality. Left ventricular hypertrophy (40%), Q waves (27.2%), ST segment elevation or depression (23.4%), prolonged QRS duration (19.2%), tachycardia (17.6%) and left and right atrial enlargement (17.6%) were the most common abnormalities. CONCLUSIONS: ECG abnormalities are common in hospitalized CKD patients in local population. All hospitalized CKD patients should undergo ECG to screen for cardiovascular disease.

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BACKGROUND AND OBJECTIVES: Hepatitis C and chronic kidney disease (CKD) are major global health problems and are highly prevalent in Pakistan. There is limited information on prevalence of hepatitis C in patients with CKD not yet on dialysis. The objective of this study was to determine the frequency of hepatitis C in hospitalized chronic kidney disease patients at a tertiary care center in Pakistan. METHODS: The study design was cross-sectional in nature. Patients between ages of 20-80 years with CKD not previously on renal replacement therapy and who were admitted to nephrology ward at a tertiary care facility were included. Hepatitis C was tested using 3rd generation enzyme linked immunosorbent assay (ELISA). Hepatitis C RNA was tested by polymerase chain reaction (PCR) in patients with positive ELISA. RESULTS: A total of 180 patients were included in the study. Mean age of patients was 48.7±14.9 years. Of all patients, 105 (58.3%) were males and 75 (41.7%) were females, 152 (84.4%) had hypertension, 113 (62.8%) had diabetes mellitus and 26 (14.9%) had known cardiovascular disease. Mean eGFR of patients was 11.4±9.4 ml/min/1.73 m2. Of all patients with CKD, 49 (27.2%) had hepatitis C test positive by ELISA. Hepatitis C PCR testing was done in 39 patients with hepatitis C ELISA positive status and 29 (74.4%) tested positive. Risk factors and clinical characteristics of patients with and without positive hepatitis C antibody by ELISA were similar. CONCLUSION: A significant proportion of hospitalized CKD patients have hepatitis C. Strict universal infection control measures should be implemented in nephrology wards to prevent transmission of hepatitis C infection.

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Hypertension is a global public health problem with increasing prevalence. There is limited updated information on the prevalence of hypertension in the Pakistani population. This is a cross-sectional study based on data collected during multiple health screening camps held at multiple locations in rural central Punjab, Pakistan in the period between 2008 and 2015. A total of 13,722 patients were included in this study. Crude prevalence of hypertension was 35.1% and age-standardized prevalence was 34.4%. Among patients with hypertension, 62.3% were aware of having high blood pressure; among these patients, 75.3% were already on treatment for hypertension. Blood pressure was controlled in 22.3% of all patients with hypertension. Among those on treatment for hypertension, blood pressure was controlled in 32.3%. Nearly one-third of patients in health screening camps of rural central Punjab had hypertension. Blood pressure control rate was poor among these patients.

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To determine the efficacy of antiviral therapy in hepatitis C virus associated glomerulopathy, we studied 30 patients with HCV-associated glomerulopathy at Sheikh Zayed Hospital, Lahore, Pakistan from June 2004 to February 2007. Membranoproliferative glomerulonephritis (MPGN) was the commonest kidney lesion, being reported in 25/30 (83%), followed by membranous glomerulonephritis (MGN) in 3/30 (10%) and mesangioproliferative glomerulonephritis (MesGN) in 2/30 (7%). Cryoglobulinaemia was positive in 8/20 (40%) cases. Most common HCV genotype was 3a. All the patients received interferon alpha combined with ribavirin therapy for 6-12 months based on viral genotypes and doses were adjusted according to renal function. Anti-viral response was achieved in the form of aviremia at completion of 6 months treatment in 8/30 (26.6%), decreased transaminases levels from a mean of 96.4 +/- 72.2 to 60.1 +/- 44.3 IU/L, p= 0.005, 24-hour proteinuria decreased significantly from a mean of 4.8 g to 1.20 g, p= 0.001, and complement C3 and C4 concentrations returned to normal in those subjects who responded to treatment. The rate of relapse was 50%. We conclude that though the overall antiviral response of HCV was not high, there was a significant reduction in proteinuria suggesting indirectly an improvement in renal pathology. Further studies with large number of patients with follow-up renal biopsies are warranted.

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OBJECTIVE: To compare arteriovenous fistula recirculation by thermodilution technique and urea based two needle slow flow method. DESIGN: Comparative cross-sectional study. PLACE AND DURATION OF STUDY: Hemodialysis Unit of Nephrology Department of Shaikh Zayed Hospital, Lahore, from October 2005 to December 2005. PATIENTS AND METHODS: Thirty one patients with end stage renal disease on maintenance hemodialysis through arteriovenous fistula were selected on purposive design. Hemodialysis was done on Fresenius 4008 S machines with in-built blood temperature monitoring module to measure recirculation by thermodilution method. Recirculation by the thermodilution method was calculated with the blood flow rate of 300 milliliter /minute and dialysate flow of 500ml /minute. Access recirculation by urea based method was calculated by taking three blood samples for blood urea nitrogen. Two samples were taken simultaneously from the arterial and venous ports respectively. Third sample was taken from the arterial port after slowing the blood flow pump to 50 milliliter/minute and waiting for 30 seconds. Relationship of thermodilution and urea based method was assessed by calculating Pearson correlation coefficient (r). RESULTS: Out of 31 patients, 18 (58.1%) were males, whereas 13 (41.9%) were females. Their mean age was 47.29 +/- 13.42 years. Mean access recirculation by thermodilution method was 7.31 +/- 3.03 and by urea based method was 9.55 +/- 6.64. Correlation coefficient (r) was 0.706 with p-value of < 0.001, which was highly significant. CONCLUSION: Arteriovenous fistula recirculation calculated by thermo-dilution technique has a strong correlation with the recirculation calculated by the two-needle urea based method.

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OBJECTIVE: To assess the relationship of postdialysis serum sodium level and interdialytic weight gain in patients on maintenance hemodialysis. DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Hemodialysis Department, Shaikh Zayed Hospital, Lahore, from May to October 2006. PATIENTS AND METHODS: A total of 50 adult patients with end-stage renal disease on maintenance hemodialysis were enrolled for the study with nonprobability convenience sampling technique. Pre-, post- and pre-next dialysis serum sodium were measured in each patient and their weights were recorded. Intradialytic sodium gains (delta Na1=postdialysis minus pre-dialysis sodium), interdialytic sodium fall (delta Na2 = previous postdialysis sodium minus pre subsequent dialysis sodium), and interdialytic weight gain (IDWG) (IDWG = weight, pre subsequent dialysis weight minus previous postdialysis weight) were computed. The relationship between delta Na1 and delta Na 2 with interdialytic weight gain was assessed by Pearson's correlation coefficient. RESULTS: There were 26 males and 24 females. The mean age of the patients was 49.6+/-14.5 years, and mean duration of HD was 40.9+/-40.8 months. The mean sodium gain during the session (delta Na1) was 4.0+/-3.1 and mean sodium fall in interdialytic period (delta Na2) was 4.2+/-2.7. The mean interdialytic weight gain was 2+/-0.8 Kg. The relationship between deltaNa1 and delta Na2 with interdialytic weight gain was statistically non-significant (r - .048, p = 0.739 and r = .019, P = 0 .897 respectively). CONCLUSION: The trend towards higher post dialysis serum sodium level and interdialytic weight gain was not statistically significant. Studies are needed with measurement of serum osmolality and investigation of other factors affecting interdialytic weight gain like dietary habits and medication etc.

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OBJECTIVE: To compare the three different protocols i.e. 1-litre 1-hour, 2-litre 1/2 hour and 1-litre 1/2 hour of acute peritoneal dialysis in terms of cost effectiveness and efficacy per one dialysis session. DESIGN: A comparative study. PLACE AND DURATION OF STUDY: Nephrology Department, Shaikh Zayed Hospital, Lahore, from August 2006 to February 2007. PATIENTS AND METHODS: Ninety patients with advanced renal failure underwent acute peritoneal dialysis according to three different protocols: Group 1 undergoing 1-litre 1-hour, Group 2 with 2-litre over 1/2 hour, and Group 3 having 1-litre 1/2 hour, approach, each for 30 patients. Pre- and postdialysis serum urea and creatinine were measured in each patient. Total cost of dialysate used for each treatment session was calculated. RESULTS: Mean pre-dialysis serum creatinine was 16.18 +/- 5.8, 14.72 +/- 5.9, 15.10 +/- 4.9 for group 1, 2 and 3 respectively. Mean postdialysis serum creatinine was 10.82 +/- 3.8, 8.72 +/- 3.5, 9.51 +/- 3.2 for group 1, 2 and 3 respectively. Mean pre- dialysis blood urea nitrogen (Bun )was 118.07 +/- 42.3, 126.73 +/- 38.8, 101.21 +/- 33.3 for group 1, 2 and 3 respectively. Mean postdialysis blood urea nitrogen was 68.70 +/- 28.8, 54.53 +/- 15.6, 62.83 +/- 22.5 for group 1, 2 and 3 respectively. Delta creatinine change (pre-dialysis creatinine - postdialysis creatinine) was 5.35 +/- 3.1, 5.99 +/- 3.42, 5.52 +/- 2.9 for group 1, 2 and 3 respectively (p =0.719) between the groups. Delta BUN change (pre-dialysis BUN - postdialysis BUN) was 49.37 +/- 22.2, 72.20 +/- 31.2, 39.40 +/- 21 for group 1, 2 and 3 respectively (p=0.00001). Average number of exchanges per treatment was 34 +/- 2, 44 +/- 2, and 43 +/- 2.5 for group 1, 2 and 3 respectively. Total cost per treatment session was Rs. 1368 +/- 87.5, Rs. 3458 +/- 371.8, and Rs. 1725 +/- 98 respectively (p< value 0.000). CONCLUSION: Urea reduction was better and statistically significant with 2-litre 1/2 hour protocol, while there was no difference in creatinine reduction among three groups.This higher urea reduction with 2-litre -1/2 hour protocol was at the expense of 2.4 times extra cost, therefore, 1-litre 1-hour protocol was more cost effective.

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