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Thrombotic Thrombocytopenic Purpura in Dengue Fever

Tee TY, Cader RA

Acta Med Indones, 2021 Apr;53(2):208-212.
PMID: 34251350

Thrombotic thrombocytopenic purpura is a rare but life threatening medical condition. Early recognition and treatment of thrombotic thrombocytopenic purpura is important especially in patients who do not present with the classic pentad to reduce the high mortality. Herein, we describe a case of a patient who does not fulfil the classic pentad features thrombotic thrombocytopenic purpura that was induced by dengue fever. The patients' initial full blood picture did not have all the typical features of microangiopathic haemolytic anaemia but there were fragmented red blood cells. However, even a small number of fragmented red blood cells in the peripheral blood should alert physicians of the possible diagnosis of thrombotic thrombocytopenic purpura together with other symptoms. Furthermore, signs and symptoms of thrombotic thrombocytopenic purpura and dengue fever can overlap such as fever, thrombocytopenia, neurological deficit mimicking dengue encephalopathy and dengue induced acute kidney injury.
Post transplant lymphoproliferative disorder: a case series and review of literature

Cader RA, Mohd R, Gafor HA, Kong NC

EXCLI J, 2013;12:144-9.
PMID: 26417223

Post-transplant lymphoproliferative disorder (PTLD) is a recognized complication exclusive to solid organ transplant recipients and carries a high mortality. We retrospectively reviewed records of all renal transplant recipients under follow up at our institution over the last seven years (2005-2011). We reviewed the patient characteristics, immunosuppression regimen and risk factors for the development of PTLD and its outcomes in our transplant cohort. Four out of 63 patients were diagnosed with PTLD. PTLD was incidentally diagnosed on a transplant biopsy that was performed for an unexplained rise in serum creatinine in three patients. The fourth patient presented with left submandibular lymphadenopathy. Majority presented within 18 months of renal transplantation. After the diagnosis of PTLD on graft biopsy, all patients were fully investigated and two patients had systemic involvement. In the patients with systemic involvement, reduction of immunosuppression and anti B cell therapy with Rituximab was used with good success. The patient with submandibular lymphadenopathy received chemotherapy in addition to reduction of immunosuppression. Three PTLD cases were polyclonal and diagnosed early whereas the fourth case was monoclonal. PTLD can sometimes be incidentally diagnosed on an allograft biopsy performed for rejection. The incidence of PTLD in our centre is higher than reports from other centres but our outcome is good if recognised and treated early.
Left ventricular hypertrophy and chronic fluid overload in peritoneal dialysis patients

Cader RA, Ibrahim OA, Paul S, Gafor HA, Mohd R

Int Urol Nephrol, 2014 Jun;46(6):1209-15.
PMID: 24307428 DOI: 10.1007/s11255-013-0615-8

PURPOSE: Cardiovascular disease is the leading cause of mortality in dialysis patients with left ventricular hypertrophy (LVH) being an important predictor of mortality. We wanted to determine the prevalence of LVH in peritoneal dialysis (PD) patients and factors contributing to it.
METHODS: This is a cross-sectional study assessing LVH using echocardiogram in PD patients. Left ventricular mass index (LVMI) was calculated to determine LVH. Chronic fluid overload (overhydration) was assessed using the body composition monitor, and blood pressure (BP) was measured using 24-h ambulatory BP monitoring.
RESULTS: Thirty-one patients (21 females:10 males, 48.97 ± 14.50 years and dialysis vintage 40.0 ± 28.9 months) were studied. More than two-thirds (77.4 %) were hypertensive, and a third (35.5 %) were diabetic. Baseline data included mean serum albumin (37.34 ± 4.43 g/l), weekly Kt/V (2.02 ± 0.23), residual renal function of 68 (0-880) ml and ultrafiltration of 1,606.9 ± 548.6 ml. Majority of patients (80.6 %) had LVH on echocardiogram with LVMI of 136.5 ± 37.8 g/m(2) and overhydration of 2.23 ± 1.77 l. Average systolic BP, diastolic BP and mean arterial pressure were 141.2 ± 23.3, 90.8 ± 19.7 and 107.6 ± 19.6 mmHg, respectively. Patients with LVH had a lower serum albumin (p = 0.003), were more overhydrated (p = 0.010) and were on higher number of anti-hypertensive agents (p ≤ 0.001). Predictors of LVMI were overhydration (p = 0.002), the presence of diabetes (p = 0.008) and the number of anti-hypertensive agents used (p = 0.026). However, overhydration (p = 0.007) was the main predictor of LVH on multivariate analysis.
CONCLUSION: Overhydration is strongly associated with LVH in PD patients.
Fulltext Low-dose cyclophosphamide-induced acute hepatotoxicity

Subramaniam SR, Cader RA, Mohd R, Yen KW, Ghafor HA

Am J Case Rep, 2013;14:345-9.
PMID: 24023976 DOI: 10.12659/AJCR.889401

Male, 48 FINAL DIAGNOSIS: Low dose cyclophosphamide-induced acute hepatotoxicity Symptoms: Epigastric pain Medication: Withdrawal of cyclophosphamide Clinical Procedure: - Specialty: Nephrology • Hepatology • Gastroenterology • Toxicology.
Fulltext An interesting case of systemic lupus erythematosus presenting with hypercalcemia: A diagnostic dilemma

Abdul Gafor AH, Cader RA, Das S, Masir N, Wahid FA

Am J Case Rep, 2013;14:1-3.
PMID: 23569551 DOI: 10.12659/AJCR.883849

BACKGROUND: Hypercalcemia is common in primary hyperparathyroidism malignancies and even in tuberculosis. Interestingly, systemic lupus erythematosus (SLE) rarely presents with hypercalcemia.
CASE REPORT: We describe an interesting case of SLE in a patient who was otherwise thought to have either tuberculosis or a malignancy. The patient initially presented with feeling unwell, with generalized lymphadenopathy, bilateral pleural effusion, and bilateral corneal calcium deposits secondary to severe hypercalcemia. The diagnosis of SLE was made based on positivity of antinuclear antibodies (ANA) and anti-dsDNA, the presence of serositis, lymphadenopathy, autoimmune hemolytic anemia, and constitutional symptoms. She was treated with steroids, with tremendous improvement in her general well-being, resolution of lymphadenopathy and pleural effusion, and normalization of her hemoglobin and serum calcium. The atypical presentation of SLE with hypercalcemia with pleural effusion is discussed.
CONCLUSIONS: SLE should be one of the differential diagnoses in patients presenting with severe hypercalcemia.
KEYWORDS: atypical presentation; hypercalcemia; systemic lupus erythematosus
Fulltext Systemic lupus erythematosus with a non functioning pituitary macroadenoma

Nadira U, Cader RA, Kong NC, Mohd R, Gafor HA

Am J Case Rep, 2012;13:160-2.
PMID: 23569517 DOI: 10.12659/AJCR.883248

BACKGROUND: Malignancies are more common in patients with systemic lupus erythematosus (SLE) than the general population. SLE patients are recognized to have higher prolactin levels. However, there are very few reported cases of SLE with pituitary adenomas.
CASE REPORT: We report the second case of a pituitary adenoma in a patient with underlying SLE. A 51 year old lady presented with blurred vision and magnetic resonance imaging of the brain demonstrated a pituitary macroadenoma with mildly elevated serum prolactin levels. The diagnosis of a non functioning pituitary macroadenoma was confirmed histologically. The diagnosis of SLE was made on the basis of thrombocytopenia, antinuclear antibodies, anti double stranded DNA antibodies and lupus nephritis (confirmed on renal biopsy). The patient initially received medical therapy with carbegoline, followed by transsphenoidal neurosurgery for the pituitary macroadenoma. SLE with lupus nephritis was treated with steroids and low dose intravenous cyclophosphamide.
CONCLUSIONS: Hyperprolactinaemia is prevalent in twenty to thirty percent of SLE patients but it is rarely due to a prolactinoma. The source of excessive circulating prolactin in SLE patients has not been fully determined.
KEYWORDS: pituitary macroadenoma; prolactin; systemic lupus erythematosus
Coupled Plasma Filtration Adsorption (CPFA) plus Continuous Veno-Venous Haemofiltration (CVVH) versus CVVH alone as an adjunctive therapy in the treatment of sepsis

Hassan J, Cader RA, Kong NC, Mohd M, Rahman AR, Hod R

EXCLI J, 2013;12:681-92.
PMID: 26600735

To compare the efficacy of Coupled Plasma Filtration and Adsorption (CPFA) plus Continuous Veno-Venous Haemofiltration (CVVH) versus CVVH alone as an adjunct treatment of sepsis in terms of haemodynamic stability, inotropic requirement and inflammatory mediators.
Fulltext Malignancy in systemic lupus erythematosus (SLE) patients

Cader RA, Mei Yee AK, Yassin A, Ahmad I, Haron SN

Asian Pac J Cancer Prev, 2018 Dec 25;19(12):3551-3555.
PMID: 30583682

Background: Malignancies are among the leading causes of death in Systemic Lupus Erythematosus (SLE)
patients with studies reporting a higher prevalence of malignancy in SLE patients compared to the general population.
We wanted to determine the frequency of cancer in a cohort of SLE patients and identify its associated risk factors.
Methods: Cross-sectional study involving SLE patients attending the nephrology outpatient clinic, Universiti
Kebangsaan Malaysia Medical Centre between January and June 2014. Results: We recruited 228 patients (207 female,
21 male), aged 40.48 ± 12.86 years with mean SLE duration of 11.65 ± 6.46 years. Majority (87%) had lupus nephritis
and were in remission with a median SLEDAI score 2 (0, 14). Majority (89%) were on corticosteroid with either a
steroid sparing agent like mycophenolate mofetil (15.4%), azathioprine (36.8%) or ciclosporin (15.4%). One hundred
and sixty (70.2%) patients were either receiving or had received intravenous cyclophosphamide with median dose
of 5,173.6 ± 3,242.4 mg. Seven female patients were diagnosed with cancer during the course of their SLE with 56
(34-78) years being median age at malignancy and SLE duration of 4 (0-12) years. Majority (5/7) had lupus nephritis
and all patients a median dose of prednisolone 10 (2.5, 10) mg with 10 (4-24) years of steroids. Two patients had a
family history of cancer with majority developing cancer after the diagnosis of SLE. Two patients received intravenous
cyclophosphamide prior to the development of cancer for their SLE compared to overall cohort of 160. Three patients
had colorectal cancer, 2 had cervical cancer, 1 had breast cancer, and one patient had germ cell tumour and one thyroid
cancer. All patients had their cancer successful treated with no signs of recurrence. Conclusion: We found a lower
occurrence of cancer in our SLE patients as compared with the reported literature.
Fulltext Community acquired multi drug resistant (MDR) Acinetobacter baumannii pneumonia in Malaysia - A case report

Mohd R, Nesam T, Kamaruzaman L, Cader RA, Mustafar R, Kong WY

Respir Med Case Rep, 2018;24:147-149.
PMID: 29977783 DOI: 10.1016/j.rmcr.2018.05.019

Acinetobacter baumannii is an aerobic Gram-negative coccobacillus that is associated with hospital acquired pneumonia. There is increased reporting of emergent cases of community acquired multidrug resistance (MDR) acinetobacter associated with a higher mortality due to antibiotic resistance. Community acquired MDR acinetobacter pneumonia has not been reported in Malaysia. Here we report a case of a 19-year-old army officer who presented with fever and respiratory symptoms for 5 days. He had no known medical illness before and no history of hospitalization. Upon arrival, he was in septicaemic shock, requiring invasive ventilator support and renal replacement therapy in intensive care unit. Chest radiograph showed bilateral lung consolidations and bronchoscopy revealed haemoserous and greenish bronchiole secretion. He was treated with broad spectrum antibiotics and oseltamivir. Unfortunately he died on day 3 of hospital admission. His bronchial lavage culture came back positive for MDR Acinetobacter baumannii. This case illustrates that clinicians need to be aware that MDR Acinetobacter baumannii can cause severe community acquired pneumonia. We may need to consider this diagnosis in patients who do not respond to standard therapy.
Intravenous Rituximab in Severe Refractory Primary Focal Segmental Glomerulosclerosis

Wee Leng G, Mustafar R, Kamaruzaman L, Mohd R, Cader RA, Wei Yen K, et al.

Acta Med Indones, 2018 Jul;50(3):237-243.
PMID: 30333274

Managing primary or even secondary glomerulonephritis remains a challenge to many nephrologists. In primary focal segmental glomerulosclerosis (FSGS) with heavy proteinuria, renin aldosterone system blockade and high dose of oral prednisolone is the mainstay of treatment. Other immunosuppressive medications like Cyclophosphamide, Cyclosporine A and Mycophenolate Mofetil (MMF) are warranted if a complete remission is not achieved. We illustrate a case of 21 year old gentleman with primary FSGS that was difficult to achieve remission despite on high dose steroid and oral Cyclophosphamide. He was also not responsive to a combination of MMF and Cyclosporine A (CSA) and even throughout the therapy he developed significant steroid and CSA toxicity. He presented to our center with severe nephrotic syndrome and acute kidney injury requiring acute haemodialysis. Despite re-challenged him again on high dose prednisolone, total of 2.4g of intravenous Cyclophosphamide, and MMF, he failed to achieve remission. He was subsequently given intravenous Rituximab 500mg/weekly for 4 doses and able to attained remission for 1 year. He relapsed again and a second course of Rituximab 500mg/weekly for 6 doses were given to attain remission. This case demonstrates the difficulty in managing refractory steroid dependent FSGS and we found that Rituximab is proven beneficial in this case to induce remission.
Fulltext Breathlessness worsened by haemodialysis

Cader RA, Thoriappa K, Mohd R, Kong WY, Mustafar R, Kamaruzaman L

Respir Med Case Rep, 2019;26:6-8.
PMID: 30416956 DOI: 10.1016/j.rmcr.2018.10.022

A 54 year old lady with underlying chronic lung disease on long term oxygen therapy and end stage renal disease of unknown aetiology on regular haemodialysis for two years started developing progressive shortness of breath during her routine haemodialysis. She was unable to tolerate her haemodialysis sessions which had to be terminated prematurely in view of her symptoms despite adjustment of her dry weight and treatment of anaemia. She was not in chronic fluid overload and her symptoms always worsened after initiation of haemodialysis and improved after termination of haemodialysis. She was admitted to hospital for further investigations and initially treated for a lung infection but her symptoms did not improve. A computed tomography pulmonary angiography did not reveal any evidence of pulmonary embolism, and was consistent with chronic fibrotic changes. Her hypoxemia was concluded to be due to her underlying chronic lung disease, worsened by alveolar hypoventilation during haemodialysis. Her symptoms improved slightly with supplemental oxygen during her routine haemodialysis but we had to shorten her haemodialysis duration to 3 hours.
Fulltext Exacerbation of systemic lupus erythematosus in a patient with concomitant chronic plaque psoriasis treated with ustekinumab

Goh SW, Jamil A, Nor NM, Cader RA, Shaharir SS

Indian J Dermatol Venereol Leprol, 2019 12 12;86(1):68-70.
PMID: 31823905 DOI: 10.4103/ijdvl.IJDVL_961_18
Fulltext Gut microbiota in Immunoglobulin A Nephropathy: a Malaysian Perspective

Sugurmar ANK, Mohd R, Shah SA, Neoh HM, Cader RA

BMC Nephrol, 2021 04 22;22(1):145.
PMID: 33882859 DOI: 10.1186/s12882-021-02315-z

INTRODUCTION: The alteration of the gut microbiome in the gut-kidney axis has been associated with a pro-inflammatory state and chronic kidney disease (CKD). A small-scaled Italian study has shown an association between the gut microbiome and Immunoglobulin A Nephropathy (IgAN). However, there is no data on gut microbiota in IgAN in the Asian population. This study compares the gut microbial abundance and diversity between healthy volunteers and Malaysian IgAN cohort.
METHODS: A comparative cross-sectional study was conducted involving biopsy-proven IgAN patients in clinical remission with matched controls in a Malaysian tertiary centre. Demographic data, routine blood and urine results were recorded. Stool samples were collected and their DNA was extracted by 16S rRNA gene sequencing to profile their gut microbiota.
RESULTS: Thirty-six IgAN patients (13 male; 23 female) with the mean age of 45.5 ± 13.4 years and median estimated glomerular filtration rate (eGFR) of 79.0 (62.1-92.2) mls/min/1.73m2 with median remission of 7 years were analysed and compared with 12 healthy controls (4 male; 8 female) with the mean age of 46.5 ± 13.5 years and eGFR of 86.5 (74.2-93.7) mls/min/1.73m2. Other demographic and laboratory parameters such as gender, ethnicity, body mass index (BMI), haemoglobin, serum urea and serum albumin were comparable between the two groups. There were no significant differences seen in the Operational Taxonomic Unit (OTU) and alpha diversity (Shannon index) between IgAN and healthy controls. Alpha diversity increased with increasing CKD stage (p = 0.025). Firmicutes/Bacteroidetes (F/B) ratio was low in both IgAN and healthy cohort. Fusobacteria phylum was significantly increased (p = 0.005) whereas Euryarchaoeota phylum was reduced (p = 0.016) in the IgAN group as compared to the control cohort.
CONCLUSION: Although we found no differences in OTU and alpha diversity between IgAN in remission and control cohort, there were some differences between the two groups at phylum level.
Blood pressure profile in continuous ambulatory peritoneal dialysis patients

Cader RA, Gafor HA, Mohd R, Ibrahim S, Wan Haslina WH, Bain A, et al.

EXCLI J, 2012;11:116-24.
PMID: 27366136

Cardiovascular mortality is the leading cause of death in end stage renal disease. Despite being on continuous ambulatory peritoneal dialysis (CAPD), blood pressure (BP) remains poorly controlled. A higher pulse pressure and non dipping are associated with increased cardiovascular mortality. We studied BP control and the prevalence of non dipping in CAPD patients.
Assessment of fluid status in CAPD patients using the body composition monitor

Cader RA, Gafor HA, Mohd R, Kong NC, Ibrahim S, Wan Hassan WH, et al.

J Clin Nurs, 2013 Mar;22(5-6):741-8.
PMID: 23039369 DOI: 10.1111/j.1365-2702.2012.04298.x

To assess the degree of overhydration in our peritoneal dialysis patients and to examine the factors contributing to overhydration.

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