Hypertension is prevalent in 75-80% of hemodialysis patients and remains the most controversial prognostic marker in end stage kidney disease patients. In contrast to the general population where systolic blood pressure of ≤120 mm Hg is considered normal, a debate remains regarding the ideal target blood pressure in hemodialysis patients. Using the PUBMED and EMBASE databases, the research studies that evaluated the relationship between blood pressure measurements and mortality in hemodialysis patients were searched. Thirteen studies were identified from different regions of the world. Five studies reported low predialysis systolic blood pressure as a prognostic marker of mortality. Other studies showed varying results and reported postdialysis systolic blood pressure as well as ambulatory blood pressure as better predictors of mortality and emphasized their optimized control. One study in this review concluded that there is no direct relationship between mortality and blood pressure if the patients are on anti-hypertensive medications. The observed all-cause mortality varied from 12% to 36%, whereas the cardiovascular mortality varied from 16% to 60%. On the basis of studies included in the current review, a low predialysis systolic blood pressure (<120 mm Hg) is shown to be a widely accepted prognostic marker of mortality while ambulatory blood pressure best predicts CV mortality. Therefore, we recommend that apart from routine BP (pre, post and intradialysis) monitoring in centers, assessment of ambulatory BP must be mandatory for all patients to reduce CV mortality in hemodialysis patients.
We evaluated therapeutic plasma exchange (TPE) efficiency in treatment of a single relapse in steroid-refractory patients with neuromyelitis optica spectrum disorders (NMOSD) in a multi-ethnic resource-limited setting. This was a historical cohort study on the clinical outcomes post-TPE in a multiethnic cohort of 53 steroid-refractory NMOSD patients at a single Malaysian tertiary center. Primary outcomes, assessed both pre- and post-TPE, were Medical Research Council scale of muscle power, Modified Rankin Scale, Expanded Disability Status Scale (EDSS), and visual acuity. Secondary outcomes were ambulatory status and target neurological deficit (TND)-based TPE response. Significant improvements in Medical Research Council, Modified Rankin Scale, EDSS, and visual acuity (P 14 days (P = 0.047) were significantly associated with improved EDSSΔ6. TND-based TPE response was significant in absence of cord atrophy (P = 0.030). TPE is an effective treatment for steroid-refractory acute relapses of NMOSD in a multiethnic Malaysian population despite its resource-limited setting. The predictive factors of EDSSΔ6 improvement were anti-aquaporin 4 seronegativity, longer cord lesions, and higher pre-TPE EDSS. Absence of cord atrophy was predictive of better TND-based TPE response. Unexpectedly, our study showed that delayed TPE initiation of more than 14 days and up to 60 days may also be beneficial.
Evidence on the benefits of intermittent therapeutic plasma exchange (TPE) as maintenance therapy in neuromyelitis optica spectrum disorder (NMOSD) is limited. This study explores the possible effectiveness of sequential intermittent therapeutic plasma exchange (SITPE), a novel TPE protocol in the management of adult NMOSD patients. Through retrospective review of medical records in Kuala Lumpur Hospital, Malaysia, NMOSD patients who underwent SITPE, namely, an induction phase of monthly cycle of TPE (1 cycle = five exchange sessions) for three cycles with or without a subsequent maintenance phase of three-monthly cycle of TPE for three cycles, were included in this controlled historical cohort study. We explored their serial improvements in Expanded Disability Status Scale (EDSS), limb power, visual acuity, and annualized relapse rate following SITPE initiation. Statistical significance was set at P
TRK-100STP, a sustained-release preparation of the orally active prostacyclin analogue beraprost sodium, targets renal hypoxia. This study aimed to show the superiority of TRK-100STP over placebos in patients with chronic kidney disease (with either primary glomerular disease or nephrosclerosis) to determine the recommended dose. CASSIOPEIR (Chronic Renal Failure Asian Study with Oral PGI2 Derivative for Evaluating Improvement of Renal Function) was a randomized, double-blind, placebo-controlled study conducted at 160 sites in seven Asia-Pacific countries and regions. Eligible patients (n = 892) were randomized to TRK-100STP 120, 240 μg, or placebo for a treatment period of up to 4 years. The primary efficacy endpoint was time to first occurrence of a renal composite: doubling of serum creatinine or occurrence of end-stage renal disease. No significant differences were observed in composite endpoints between TRK-100STP and placebo (P = 0.5674). Hazard ratios (95% CI) in the TRK-100STP 120 and 240 μg vs. placebo groups were 0.98 (0.78, 1.22) and 0.91 (0.72, 1.14), respectively. The overall incidence of adverse events and adverse drug reactions was comparable between treatment arms.
In conjunction with the third regional Southeast Asian (SEA) therapeutic plasma exchange (TPE) conference in Kuala Lumpur, Malaysia, 25 clinicians and researchers from SEA and South Asian countries attended the inaugural strategy meeting for the establishment of a regional TPE consortium for neurological disorders. The primary objective was to establish regional collaboration to improve delivery of TPE services in SEA. A pre-meeting survey was conducted to gather insights on disease spectrum, contextual practice challenges, and the need for a regional TPE consensus. Challenges identified include limited healthcare funding in support of diagnostic workup, TPE therapy, as well as development of clinical infrastructure and expertise capacity building. There was favorable interest in developing a working plan contextualized to this region. Strategies to overcome challenges were discussed. This included the need for a comprehensive referral system and network of regional TPE centers suited to local needs, supported by innovative TPE delivery programs.
CKD-associated pruritus is one of the common symptoms in patients undergoing dialysis, thus contributing to the diminished and compromised quality of life. This study aimed to explore the association between the CKD-associated pruritus on quality of life of patients undergoing hemodialysis in Malaysia. A cross-sectional multicenter study, carried out from February to September 2017 at tertiary care settings in Kuala Lumpur, Malaysia. Patients aged 18 years and above, undergoing hemodialysis, understanding Malay language and willing to participate were included. The CKD-associated pruritus was assessed by using Malay 5D-itch scale and Malay FANLTC questionaiare. To determine the factors associated with pruritus and quality of life, multivariate logistic regression analysis was used having P value < 0.05 as statistically significant. Among n = 334 recruited patients with a response rate of 100%, 59.6% were males and total of 61.3% were having CKD-associated pruritus. The results showed a statistically significant weak negative correlation between CKD-associated pruritus and quality of life. Multivariate linear regression revealed none of these factors were found to be associated with pruritus; however, CKD-associated prurtius was found to be associated with quality of life score. CKD-associated pruritus is have a negative impact on the patient's quality of life including physical, social, mental/emotional, and functional well-being. Despite the high prevalence and negative impact of CKD-associated pruritus on quality of life, it is disregarded by most health care professionals. It is thus pertinent to monitor the potential risk factors and consider providing timely treatment implications for CKD-associated pruritus in hemodialysis patients, in order to improve their quality of life.