Factors Predictive of Development of Acute Kidney Injury in Patients With COVID-19 in Brunei Darussalam

INTRODUCTION

Acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients affects their health outcomes. Incidence and outcomes varied in the literature, particularly with different population and epidemiological demographics. Data remain scarce in the Southeast Asia region. We report the incidence, outcomes, pattern, types of AKI, and factors that influence AKI patient outcomes in Brunei Darussalam.

METHODS

All patients (N = 930) with COVID-19 who were admitted to the National Isolation Center (between 7th August 2021 and 30thSeptember 2021) were included in the study. The confirmation of AKI was based on the KDIGO (Kidney Disease Improving Global Outcomes) criteria.

RESULTS

The mean age of the patients was 41.9 ± 14.4 years with diabetes mellitus (DM), hypertension (HT), and chronic kidney disease (CKD) accounting for 11.7%, 29.1%, and 4.8% of comorbidities, respectively. Overall, 109 (11.7%) had AKI (KDIGO Stage 1 [67.9%], 2 [13.8%], and 3 [18.3%]), while 75.2% of the cases occurred pre-admission and 26.6% were cases of acute exacerbation of CKD. Univariate analysis identified age (odd ratio [OR] 1.06), male gender (OR 1.63), local nationality (OR 8.03), DM (OR 4.44), HT (OR 5.29), vascular disease (OR 6.08), presence of gastrointestinal symptoms (OR 2.08), antibiotic (OR 3.70) and nephrotoxins exposures (OR 8.57) as significant variables. Multivariate analysis showed age (adjusted OR [AOR] 1.04), male gender (AOR 1.67), gastrointestinal symptoms (AOR 1.61), antibiotic (AOR 2.34), and nephrotoxins exposure (AOR 4.73) as significant.

CONCLUSIONS

Our study showed that one in nine patients with COVID-19 developed AKI with almost a third having stages 2 and 3 AKI. Older age, male gender, presence of GI symptoms, and antibiotic and nephrotoxin exposures were significant predictors of AKI. Patients with these factors should be prioritized for admission and treatment. Even though manifestations are generally now less severe, findings from this study can guide the management of COVID-19 as the disease enters the endemic stage. Furthermore, lessons learned from the COVID-19 pandemic will provide useful information and knowledge for future viral outbreaks or pandemics.

The Living-Related Kidney Transplant Program in Brunei Darussalam: Lessons Learnt from a Nascent National Program in a Small, Muslim, and Asian Country

Brunei Darussalam commenced its living-related renal transplant program in 2013, with subsequent attainment of independent local capacity and proficiency in 2019. The preliminary outcome from the program has already begun to shape the national nephrology landscape with a 36% increment in transplant rate and mitigation of commercialized transplantations. The blueprint for the program was first laid out in 2010 and thereupon executed in four phases. The first phase involved the gathering of evidence to support the establishment of the national program, through researches investigating feasibility, public opinion, quality of life, graft survival, and cost-effectiveness. The second phase focused on laying the foundation of the program through grooming of local expertise, implementation of legal-ethical frameworks, religious legitimization, and propagation of awareness. The third phase worked on facilitating experiential exposure and strengthening local infrastructure through the upgrading of facilities and the introduction of subsidiary services. The fourth phase was implemented in Brunei in 2013 when foreign personnel worked together with the local team to perform the transplants. Between 2013 and 2019, ten kidney transplants were performed, with two being done in 2018 and three in 2019. We hope to inspire other similar countries to develop their own self-sustainable and independent local program.

Barriers to Kidney Transplantation as a Choice of Renal Replacement Therapy

Brunei Darussalam has a live related kidney transplant program since 2013. Uptake of transplant remains poor in the country despite full government subsidy for health care. This study aims to assess barriers and factors affecting patients' preference toward dialysis over transplant as their choice of renal replacement therapy. It is hoped that the study can provide a better insight into the poor uptake of transplant in the country.

METHODS

The target population was all patients with end-stage renal disease undergoing dialysis in Brunei Darussalam who are fit enough to undergo kidney transplant. The shortlisted patients were approached during their hemodialysis sessions or while waiting for clinical reviews in peritoneal dialysis clinics and were given self-administered structured questionnaires.

RESULTS

Out of 348 eligible patients in the country, 226 (64.9%) agreed to participate in the study. The majority of patients (71.2%), especially the unmarried patients (81.5%), cited "lack of donor" as their main reason for not choosing transplant. "Happy with dialysis" (31.9%), "inadequate information" (21.2%), "unwilling to take risk" (26.5%), and "financial problems" (18.1%) were the other common factors identified. A total of 51.8% of the respondents had considered transplant, and 42.5 % of patients had considered the option of commercialization through foreign black market channels. Younger patients (<40 years) on dialysis for less than 5 years with higher education were more likely to consider transplant (P < .05). Likewise, patients who were younger, highly educated, and employed were more likely to choose commercialization (P < .05).

CONCLUSION

Lack of donor and poor knowledge were the main barriers to patients receiving kidney transplant in the country. Religio-cultural barriers, lack of reimbursement, poor knowledge, and stringent donor criteria contributed to the limited donor pool. Despite universal health coverage for the population, financial and social security factors were still important determinants that influenced recipients' and donors' decisions to reject transplant.

Chronic kidney disease in children and adolescents in Brunei Darussalam

AIM: To determine epidemiology of Bruneian paediatric chronic kidney disease (CKD) patients and factors that affect growth and progression of disease.

METHODS: A cross-sectional study conducted on all children below 18 years old who were diagnosed with CKD over a ten year period (2004 to 2013). The reference population was all children (< 18 years old) suffering from CKD and attending the tertiary paediatric nephrology clinic in Brunei Darussalam. Demographic (current age, age of diagnosis, gender, ethnicity), anthropometric (weight and height), diagnosis, laboratory data (serum creatinine and haemoglobin, urinalysis) and blood pressure were extracted from the patients’ clinical case notes and recorded using a data collection form.

RESULTS: The study revealed a high national prevalence [736 per million child population (pmcp)] and incidence (91 pcmp) of CKD. If CKD was defined at Stage 1, 2, 3, 4 or 5, the associated prevalence figures were 736, 132, 83, 50 and 33 pmcp. Glomerulonephritis accounted for 69% of all prevalent cases, followed by congenital abnormalities of kidney and urinary tract (20%) and tubulointerstitial diseases (8%). Minimal change disease being the most common histological diagnosis. The median age of diagnosis was 4.5 years, with congenital disease patients experiencing an earlier onset of diagnosis. A large proportion of patients were below the 5% percentile for height and weight. Non-glomerular diseases, adolescent and female patients were significantly associated with poor growth, but not glomerular filtration rate, age of diagnosis or steroid usage.

CONCLUSION: Brunei has a high prevalence of chronic kidney disease in the paediatric population with glomerulonephritis being the most common disease.

Outcomes of Renal Transplantation in Brunei Darussalam over a Twenty-Year Period (1993-2012)

Objectives. Brunei Darussalam has a high prevalence and incidence of end stage renal disease (ESRD). Up until 2012, all renal transplantations were performed in overseas centres, either as government-sponsored (living-related transplantation) or as self-sponsored (commercialized transplantation) ones. We hypothesize that graft and patient survival of Brunei renal transplant patients are on a par with international standards. Materials and Methods. Data of all renal transplant patients in Brunei were analysed over a twenty-year period from registry records and case notes. Comparative survival data from other countries were obtained from PubMed-listed literature. Results. A total of 49 transplantation procedures were performed in foreign centres between 1993 and 2012. 29 were government-sponsored and 20 were self-sponsored transplantations. The 5- and 10-year overall patient survival rates were 93.3% and 90.1%, respectively. The 5- and 10-year overall graft survival rates were 91.1% and 81.2%. There is no difference in the survival outcomes of government-sponsored and self-sponsored patients. Living-related (government-sponsored) and commercialised (self-sponsored) grafts had equivalent survival to those reported in the literature. Conclusion. Our survival data was on par with those achieved in many countries. We hope to use this information to convince local stakeholders and patients to favour transplantation as the preferred modality of RRT.

Microscopic polyangiitis complicated by intracerebral hemorrhage and pulmonary hemorrhage in a pediatric patient

Patient: Female, 10

Final Diagnosis: Polyangiitis

Symptoms: Intracranial hemorrhage • swelling • oliguria

Medication: Cyclophosphamide • prednisolone

Clinical Procedure: Plasmapheresis

Specialty: Paediatric nephrology • nephrology • paediatrics

End stage renal disease in Brunei Darussalam - report from the first Brunei Dialysis Transplant Registry (BDTR)

The Brunei Dialysis and Transplant Registry (BDTR) was established in 2011 to collect data from patients undergoing renal replacement therapy (RRT) in Brunei Darussalam. The chief aims of the registry are to obtain general demographic data for RRT patients and to determine disease burden attributable to End Stage Renal Disease (ESRD). The registry population comprises of all ESRD patients treated in Brunei Darussalam. Data domains include general demographic data, medical history, ESRD etiological causes, laboratory investigations, dialysis treatment and outcomes. There were 545 prevalent RRT patients in Brunei at the end of 2011. The incidence and prevalence of ESRD were 265 and 1250 per million population. Hemodialysis (HD), Peritoneal Dialysis (PD) and Transplant comprised of 83%, 11% and 6% of the RRT population, respectively. Diabetes mellitus accounted for 57% of all new incident cases. The mean serum hemoglobin, phosphate, calcium and iPTH were 11.0 ± 1.6 g/dL, 1.9 ± 0.5 mmol/L, 2.3 ± 0.2 mmol/L and 202.5 ± 323.4 ng/mL. Dialysis adequacy for HD and PD were 65.1 (urea reduction ratio) and 2.0 ± 0.3 (Kt/v). 71 % of all prevalent HD had functioning AV fistulae and the peritonitis incidence was one in 24.5 patient-month/episode. The first BDTR has identified some deficiencies in the renal services in Brunei. However, it signals an important milestone for the establishment of benchmarked renal practice in the country. We hoped to maintain and improve our registry for years to come and will strive to align our standards to acceptable international practice.

Co-incidental Plasmodium Knowlesi and Mucormycosis infections presenting with acute kidney injury and lower gastrointestinal bleeding

Background

Plasmodium knowlesi is frequently reported in Southeast Asian countries and is now widely regarded as the fifth malarial parasite. Mucormycosis is a rare fungal infection that can occur in patients with a weakened immune system.

Case Report:

We report a case of acute kidney injury secondary to Plasmodium knowlesi malaria infection and mucormycosis fungal infection. In addition, the patient also had lower gastrointestinal bleeding from invasive gastrointestinal mucormycosis. P. knowlesi infection was diagnosed by blood film and mucormycosis was diagnosed by histopathological examination of biopsy specimen of the colon. The patient recovered with antimalarial treatment (Quinine), antifungal treatment (Lipophilic Amphotericin), and supportive hemodialysis treatment.

Conclusions:

We hypothesize that P. knowlesi malarial infection can lower the immunologic threshold and predisposes vulnerable individuals to rare disseminated fungal infections. To the best of our knowledge, this is the first P. Knowlesi malaria-associated invasive fungal infection reported in the literature.

Side effects of oseltamivir in end-stage renal failure patients

BACKGROUND

Patients with end-stage renal disease who developed H1N1 infections have an increased risk of morbidity and mortality. In light of the high incidence of H1N1 infections in renal replacement therapy patients in Brunei Darussalam, an Oseltamivir (Tamiflu) prophylactic dosing regimen of 75 mg every 5 days for renal replacement therapy patients was initiated by the Ministry of Health in August 2009. The regime was used to serve as a bridge towards an anticipated nationwide vaccination programme that was due in September 2009. This study aimed to evaluate the side effects, factors that might influence the side effects profile and compliance of the dialysis patients that had undergone the month-long chemoprophylactic regime.

METHODS

A cross-sectional study was carried out on the dialysis patients that had undergone the oseltamivir prophylactic regime, which involved distribution of questionnaires to participants after the regime was completed.

RESULTS

Three hundred and thirty-three patients participated in this study. 25.7% of sample participants reported at least one side effect (experienced during the regime). 97% of participants were found to have reported three side effect types or less. The most frequent side effects reported were nausea (9.4%), abdominal pain (9.1%) and dizziness (9.1%). Age, gender, dialysis types, serum haemoglobin, serum albumin and dialysis clearance measurements were found to have no significant associations with the frequency of participants that had reported side effects. 11.2% of sample participants made up the non-compliant group. The top two reasons for not completing the medication were participants' perceived side effects (24.3%) and forgetting to take their medications (56.8%).

CONCLUSIONS

Side effects were found to be mild and tolerable by participants, with no life-threatening events. The study showed that high compliance of this regime can be achieved. These results, together with no incidence of H1N1 cases in the sample participants, showed that the dosing regimen of 75 mg every 5 days in both haemodialysis and continuous ambulatory peritoneal dialysis patients is both tolerable and effective and should be considered for future prophylactic regimes.