Audit on data accuracy of the Malaysian Dialysis and Transplant Registry (MDTR)

Diabetes mellitus is the main aetiology of end stage kidney disease (ESKD) in Malaysia. However, there may be concerns of over-reporting of diabetes mellitus as the cause of ESKD in the Malaysian Dialysis and Transplant Registry (MDTR). The objective of this audit is to assess the accuracy of data collected in the MDTR. There were 151 centres/source data providers (SDP) with a total of 1977 patients included in this audit. The audit showed that 80.2% of doctors' records matched the MDTR data. The results were comparable with published validation studies in other countries.

Creatinine clearance in selection of living kidney donor among the Malaysian population: is it safe?

BACKGROUND

Assessment of donor renal function is made by the measurement of Glomerular Filtration Rate (GFR). Exogenous markers are preferred over creatinine clearance and are widely used for measuring GFR. However, they are difficult to obtain, costly and laborious. This is a study to look into the safety and accuracy of creatinine clearance for renal assessment among the living kidney donors in the Malaysian population.

METHODS

This is a retrospective, single-centre study comprising 105 living kidney donor candidates from the year 2007 to 2020. By comparing against 51-Chromium ethylenediamine-tetraacetic acid (51Cr-EDTA), we analysed creatinine clearance for correlation, bias, precision and accuracy.

RESULTS

The study group had a mean age of 45.68 ± 10.97 years with a mean serum creatinine of 64.43 ± 17.68 µmol/L and a urine volume of 2.06 ± 0.83 L. Mean measured GFR from 51Cr-EDTA was 124.37 ± 26.83 ml/min/1.73m2 whereas mean creatinine clearance was 132.35 ± 38.18 ml/min/1.73m2. Creatinine clearance overestimated 51Cr-EDTA significantly with a correlation coefficient of 0.48 (p < 0.001) and an accuracy of 78.10% and 64.0% within 30% and 20% respectively of 51Cr-EDTA.

CONCLUSION

Creatinine clearance is an acceptable and affordable alternative for donor renal assessment in the absence of exogenous markers with an emphasis on adequate urine collection followed by using measured GFR in selected cases.

Ultrasound shear wave elastography for the evaluation of renal pathological changes in adult patients

OBJECTIVE

Many studies have conflicting findings in using shear wave elastography (SWE) to assess renal fibrosis. This study reviews the use of SWE to evaluate pathological changes in native kidneys and renal allografts. It also tries to elucidate the confounding factors and care taken to ensure the results are consistent and reliable.

METHODS

The review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Literature search was conducted in Pubmed, Web of Science and Scopus database up to 23 October 2021. To evaluate risk and bias applicability, the Cochrane risk-of bias tool and GRADE was used. The review was registered under PROSPERO CRD42021265303.

RESULTS

A total of 2921 articles were identified. 104 full texts were examined and 26 studies included in systematic review. 11 studies performed on native kidneys and 15 studies on transplanted kidney. A wide range of impact factors was found that affect the accuracy of SWE of renal fibrosis in adult patients.

CONCLUSIONS

Compared to point SWE, two-dimensional SWE with elastogram could enable better selection of the region of interest in kidneys, leading to reproducible results. Tracking waves were attenuated as the depth from skin to region of interest increased, therefore, SWE is not recommended for overweight or obese patients. Variable transducer forces might also affect SWE reproducibility, thus, training of operators to ensure consistent operator-dependent transducer forces may be helpful.

ADVANCES IN KNOWLEDGE

This review provides a holistic insight on the efficiency of using SWE in evaluating pathological changes in native and transplanted kidneys, thereby contributing to the knowledge of its utilisation in clinical practice.

ABO-Incompatible Living-Donor Kidney Transplantation in a Developing Country: A Multicenter Experience in Malaysia

Malaysia has a low deceased-donor donation rate and has not embarked on a paired kidney exchange program; therefore, ABO-incompatible and HLA-incompatible transplantation remain the main contributor to the sustainability of the national kidney transplantation (KT) program. There were 26 cases of ABO-incompatible KTs performed from 2011 to 2018 in 3 major transplant centers, namely, Hospital Kuala Lumpur, University Malaya Medical Centre, and Prince Court Medical Centre. We collected perioperative and follow-up data through June 2019. The desensitization protocol varies and is center specific: the localized Japanese protocol and Swedish protocol with a target anti-A/B isoagglutinin titer of 16 or 32 on the day of transplant. The induction and tacrolimus-based maintenance protocol was nearly identical. The median follow-up time was 62.3 months (interquartile range, 37.0-79.7). Fifteen subjects had the highest predesensitization anti-A/B titer of ≥32 (57.7%). The acute cellular rejection and antibody-mediated rejection incidence were 12.5% (3 cases) and 8.3% (2 cases), respectively. Patient, graft, and death-censored graft survival rates were 96.2%, 92.3%, and 96.0%, respectively, 1 year post-living-donor KT (LDKT) and 96.2%, 87.2%, and 90.7%, respectively, 5 years post-LDKT. Our experience shows that ABO-incompatible LDKT using a suitable desensitization technique could be a safe and feasible choice for LDKT even with varied desensitization regimens for recipients with relatively high baseline isoagglutinin titers.

Shear wave elastography accurately detects chronic changes in renal histopathology

AIM

Renal biopsy is the gold standard for the histological characterization of chronic kidney disease (CKD), of which renal fibrosis is a dominant component, affecting its stiffness. The aim of this study was to investigate the correlation between kidney stiffness obtained by shear wave elastography (SWE) and renal histological fibrosis.

METHODS

Shear wave elastography assessments were performed in 75 CKD patients who underwent renal biopsy. The SWE-derived estimates of the tissue Young's modulus (YM), given as kilopascals (kPa), were measured. YM was correlated to patients' renal histological scores, broadly categorized into glomerular, tubulointerstitial and vascular scores.

RESULTS

Young's modulus correlates significantly with tubulointerstitial score (ρ = 0.442, P < .001) and glomerular score (ρ = 0.375, P = .001). Patients with no glomerular sclerosis showed lower mean YM measurements compared to those with glomerular sclerosis. The mean YM increased as the percentage of interstitial fibrosis and tubular atrophy increased. The area under the receiver operating characteristic curve (ROC) for SWE in differentiating between mildly and moderately impaired kidneys was 0.702.

CONCLUSION

Shear wave elastography accurately detects chronic renal damage resulting from glomerular sclerosis, interstitial fibrosis and tubular atrophy, using the optimal cut-off YM value of ≥5.81 kPa.

P0590ADVERSE RENAL OUTCOME FOLLOWING ADMINISTRATION OF INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INHIBITORS IN A SINGLE TERTIARY CENTRE IN MALAYSIA

Background and Aims

Intravenous (IV) anti-vascular endothelial growth factor(VEGF) is a potent anti-angiogenic factor for the treatment of solid tumours. While, intravitreal anti-VEGF injection is used in the treatment for macular and retinal diseases. The effects of IV anti-VEGF agents are well documented to cause hypertension, renal impairment and proteinuria. However only few reports showed the significance of intravitreal anti-VEGF injection causing minimal change disease (MCD) and acute kidney injury (AKI). Hence, this study is to determine the outcome of renal function following intravitreal anti-VEGF injection.

Method

This is a prospective, cross sectional study recruiting patients from ophthalmology day-care operation theatre that were scheduled for intravitreal anti-VEGF injection in University Malaya Medical Centre (UMMC). On the day of the injection of anti-VEGF, patients’ demographic data (age, gender, medical background, medications), blood pressure, height, weight and investigations for serum creatinine and urine protein creatinine ratio (PCR) were collected. Following these, they will receive the intravitreal anti-VEGF as per schedule. All these patients were given a follow-up within 72hours to reassess blood pressure, serum creatinine and urine PCR.

Results

A total of 90 patients were recruited. However, 15 patients were subsequently excluded as there was no repeated serum creatinine at 72-hours post treatment. Their mean age was 67.25 ± 10.41. Among all, 3 patients had significance increased in serum creatinine (4%) with significance changed of urine PCR post treatment. Table 1 showed baseline parameters prior to treatment and table 2 was post treatment parameters.

Higher serum creatinine and proteinuria pre intravitreal anti-VEGF were identified to have higher OR of 1.018 (95% CI 1.001-1.035) (p=0.043) and OR 1.004 (1.000-1.007) (p=0.025) respectively among those who developed AKI. In assessing the association between higher pre-treatment creatinine and proteinuria (independent variable) and development of AKI (dependent variable) estimated by logistic regression with no AKI as a reference group we found that there were no significance.

Conclusion

Following intravitreal anti-VEGF administration, there were no significant changes in blood pressure. However, 4% from our cohort had AKI and worsening proteinuria at 72 hours post treatment. These patients had higher serum creatinine and proteinuria prior to treatment. However, our study is underpowered to establish the relationship between intravitreal anti-VEGF and development of AKI. Further study with larger sample size and longer-term outcome is needed.

P1718COMPARISON OF MEASURED GLOMERULAR FILTRATION RATE USING 24-HOUR URINE CREATININE CLEARANCE WITH 51-CHROMIUM EDTA IN A MALAYSIAN COHORT OF LIVING KIDNEY DONOR CANDIDATES

Background and Aims

All living kidney donors undergo assessment of renal function by evaluation of Glomerular Filtration Rate (GFR). 51Cr-EDTA is one of the most widely used marker for measuring GFR but it is hampered by cost and laboriousness as well as not being widely available in Malaysia. Measuring 24-hour urine for creatinine clearance (Ccr) is a common alternative when exogenous filtration markers are not available. Ccr suffers from over/underestimation of measured GFR (mGFR) due to errors in urine collection and tubular secretion of creatinine. This is a study to compare the correlation of Ccr against 51Cr-EDTA in measuring GFR among the living donors in Malaysian population.

Method

This is a cross-sectional, single-centre study of a cohort of living kidney donor candidates from January 2007 to March 2019. All candidates who had mGFR done with both 51Cr-EDTA and Ccr in University Malaya Medical Centre were enrolled. Special consideration was taken to account for adequate urine sampling for Ccr. Clinical data was analysed for correlation, bias, precision and accuracy between Ccr and 51Cr-EDTA.

Results

A total of 83 living kidney donors with a mean age of 45.60 ± 11.06 years and body mass index (BMI) of 24.36 ± 4.03 were enrolled. Female comprised 74.7% of the donors while Chinese, Malay and Indian accounted for 67.5%, 20.5% and 7.2% of the donors respectively. The study group had a mean serum creatinine of 63.37 ± 16.00 umol/L with a urine volume of 2.03 ± 0.81 L (range 0.70 – 3.82). mGFR from 51Cr-EDTA was 125.56 ± 27.64 ml/min/1.73m2 (range 77.0 – 194.3) whereas calculated Ccr was 136.05 ± 36.15 ml/min/1.73m2 (range 75.32 – 280.06). The correlation coefficient between Ccr and 51Cr-EDTA is moderate (r = 0.43) (p &lt; 0.01). Mean absolute bias between Ccr and 51Cr-EDTA was 10.59 ± 37.99 ml/min/1.73m2 (p &lt; 0.05). The accuracy of Ccr within 30% of 51Cr-EDTA was 77.11%.

Conclusion

Our study showed that Ccr significantly overestimates mGFR compared to 51Cr-EDTA. However, there is a significantly moderate positive correlation between Ccr and 51Cr-EDTA. Thus, in the absence of 51Cr-EDTA, Ccr is a clinically acceptable alternative if utilized with care and understanding its limitations.

Low Immunologic Risk Living Related Renal Transplant Using Very Low-Dose Antithymocyte Globulin as Induction Therapy: A Single Tertiary Hospital Experience

The aim of induction therapy in the management of kidney transplant is to reduce the incidence of acute rejection and delayed graft function after kidney transplant. The agent for induction therapy differs depending on the recipient risks. The regimen can be either polyclonal (rabbit antithymocyte globulin [rATG]) or monoclonal antibody (basiliximab). Basiliximab is commonly used in patients with low immunologic risk. However, to date we know that the use of rATG on T cell depletion is dose dependent and more potent antirejection therapy. Therefore, we would like to look at 1-year graft function of very low-dose rATG in low immunologic risk recipients. All low immunologic risk patients who received low-dose rATG (0.5 mg/kg of body weight daily) during transplant (day 0) and on days 1 and 2 were recruited. Their renal function, HLA donor-specific antibodies, lymphocyte counts, protocol biopsy results, and cytomegalovirus (CMV) polymerase chain reaction were monitored as per clinical practice. All 10 patients had immediate graft function. Low-dose rATG caused lymphocyte counts to deplete immediately on day 0, and the effect lasted about 1 month post-transplant. All the patients had stable graft function without any significance episode of rejection. Only one patient had de novo HLA-DQ antibody. It is good to know that without prophylaxis antiviral in CMV⁺ donor to CMV⁺ recipient, the incidence of CMV viremia is considerably low in our cohort. Very low-dose rATG is an effective induction immunosuppression in low immunologic risk patients with acceptable infection risk.

One-Year Outcomes of Living Related Kidney Transplant in Patients With Preformed HLA Donor-Specific Antibodies: A Single-Center Experience in Malaysia

The shortage of deceased donors led to an increase of living related renal transplant performed in the presence of donor-specific antibodies (DSAs) or ABO incompatibilities. There are various desensitization protocols that have been proposed. Here, we describe the outcome of these sensitized patients. This is a prospective cohort study recruiting all kidney transplant recipients from August 2016 until June 2018. Deceased donations, ABO incompatible patients, and sensitized patients who were not prescribed on our desensitization protocol were excluded. Recipients were screened for the presence of HLA-antibodies 1 month before transplant. Those with positive DSA will undergo flow cytometry (risk stratification). We are using a protocol that consisted of intravenous rituximab 200 mg (day -14), intravenous antithymocyte globulin 5mg/kg (day 0-4), plasma exchange post transplant for patients with mean fluorescent intensity (MFI) < 3000, and negative flow cytometry. Those patients with MFI ≥ 3000 or positive flow cytometry need extra cycles pretransplant. A total of 40 patients were recruited, and 20 were sensitized patients. Among the sensitized group 4 of 20 had flow cytometry crossmatch positive, while all had preformed HLA-DSA. A total of 8 of 20 had class I HLA-DSA, 11 of 20 had class II HLA-DSA, and 1of 20 was positive for both class I and II HLA-DSA. Mean immunodominant MFI was 2133.4 (standard deviation [SD], 4451.24) and 1383.7 (SD, 2979.02) for class I and class II, respectively. At 1 year, mean serum creatinine was 108.90 (SD, 25.95) and 118.42 (SD, 31.68) in sensitized and unsensitized patients, respectively. One of 20 unsensitized patients had Banff 1B rejection at 3 months, and there was no significant rejection in sensitized patients at 6 months and 1 year. There was no difference in the occurrence of de novo HLA-DSA between the groups. Desensitization protocols may help to overcome incompatibility barriers in living donor renal transplant. The combination of low-dose rituximab, antithymocyte globulin, and judicious use of plasma exchange has worked well for our cohort.

Development of de novo HLA donor specific antibodies (HLA-DSA), HLA antibodies (HLA-Ab) and allograft rejection post blood transfusion in kidney transplant recipients

BACKGROUND

Blood transfusion during the post-operative period of kidney transplantation is common as part of a life-saving procedure, especially in the event of acute blood loss. However, there have been conflicting opinions since the pre-cyclosporine era. The risk of sensitization post-transfusion remains the main limiting factor following transfusion in kidney transplant recipients. Thus, the objective of this study is to assess the development of de novo HLA-DSA, HLA-Ab and allograft rejection post blood transfusion.

METHODOLOGY

This is a retrospective cohort study recruiting all kidney transplant recipients in South Australia from January 2010 till December 2018. Following that, the incidence of blood transfusion within one week post-operatively were traced (transfusion group). The outcomes were compared with all other transplant recipients (non-transfusion group). Recipient's demographic, donor characteristics and immunological risk profiles were obtained from the transplant unit database, while the biopsy report, history of blood transfusion, latest serum creatinine and follow-up status was gathered from the electronic medical system (OASIS). The HLA-DSA and HLA-Ab results were collected from the NOMS database. Finally, the survival data were merged with the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry for South Australia recipients graft survival.

RESULTS

A total of 699 patients were eligible for analysis. The mean age was 50.64 ± 13.23 years old. There were more elderly (>65 years old) and females who needed transfusion. The majority had glomerulonephritis as the primary disease. There was no statistical difference in donor characteristics, cold ischemic time and immunological risk between the transfusion and non-transfusion group. There was no difference in the development of de novo HLA-DSA, HLA-Ab and rejection episodes between the group and the results were consistent in a model adjusted for all potential confounders. Median graft survival in days between the transfusion vs non-transfusion group was 1845 IQR (961,2430) and 1250 IQR (672,2013).

CONCLUSION

Blood transfusion under strong immunosuppressive cover within a one-week post-operative period is safe with no significant association with the development of de novo HLA-DSA, HLA-Ab or clinical rejection.

Stiffness and Anisotropy Effect on Shear Wave Elastography: A Phantom and in Vivo Renal Study

Tissue elasticity is related to the pathologic state of kidneys and can be measured using shear wave elastography (SWE). However, SWE quantification has not been rigorously validated. The aim of this study was to evaluate the accuracy of SWE-measured stiffness and the effect of tissue anisotropy on SWE measurements. Point SWE (pSWE), 2-D SWE and dynamic mechanical analysis (DMA) were used to measure stiffness and evaluate the effect of tissue anisotropy on the measurements. SWE and DMA were performed on phantoms of different gelatin concentrations. In the tissue anisotropy study, SWE and DMA were performed on the outer cortex of sheep kidneys. In the in vivo study, 15 patients with different levels of interstitial fibrosis were recruited for pSWE measurements. Another 10 healthy volunteers were recruited for tissue anisotropy studies. SWE imaging revealed a non-linear increase with gelatin concentration. There was a significant correlation between pSWE and 2-D SWE, leading to the establishment of a linear regression equation between the two SWE ultrasound measurements. In the anisotropy study, the median difference in stiffness between shear waves oriented at 0° and 90° towards the pyramid axis was significant. In the in vivo study, there was a strong positive linear correlation between pSWE and the percentage of interstitial fibrosis. There was a significant difference in the Young's modulus (YM) between severities of fibrosis. The mean YM values were lower in control patients than in patients with mild, moderate and severe fibrosis. YM values were also significantly higher when shear waves were oriented at 0° toward the pyramid axis. Tissue stiffness and anisotropy affects SWE measurements. These factors should be recognized before applying SWE for the interpretation of measured values.

Comparison of Shear Wave Elastography and Conventional Ultrasound in Assessing Kidney Function as Measured Using 51Cr-ethylenediaminetetraacetic Acid and 99Tc-Dimercaptosuccinic Acid

The purpose of this study was to assess the potential of shear wave elastography (SWE) as an indicator of abnormal kidney function defined by radiolabeled glomerular filtration rate (GFR). Fifty-seven patients referred for ⁵¹Cr-ethylenediaminetetraacetic acid GFR and ^99mTc-dimercaptosuccinic acid renal scintigraphy were included. Young's modulus (YM) measured with SWE and kidney length, volume, cortical thickness and parenchymal echogenicity measured with conventional ultrasound were correlated with patients' GFR and renal scintigraphy results. Spearman correlation coefficients between SWE and GFR were negative for the right (r = -0.635, p < 0.0001) and left (r = -0.817, p < 0.0001) kidneys. Positive correlations between left renal cortical thickness (r = 0.381, p = 0.04) and left kidney volume (r = 0.356, p = 0.019) with GFR were reported. SWE correctly predicted the dominant functioning kidney in 94.7% of cases. The area under the receiver operating characteristic curve for SWE (0.800) was superior to that for conventional ultrasound (0.252-0.415). The cutoff value of ≥5.52 kPa suggested a kidney function ≤60 mL/min/1.73 m² (82.4% sensitivity and 76.2% specificity). SWE has advantages over conventional ultrasound in assessing kidney function and distinguishing the dominant functioning kidney.

Outcomes of STEMI patients with chronic kidney disease treated with percutaneous coronary intervention: the Malaysian National Cardiovascular Disease Database - Percutaneous Coronary Intervention (NCVD-PCI) registry data from 2007 to 2014

Background

Patients with renal impairment often left out from most major clinical trials assessing the optimal treatment for ST-elevation myocardial infarction (STEMI). Large body of evidence from various cardiovascular registries reflecting more ‘real-world’ experience might contribute to the knowledge on how best to treat this special cohort. We aim to analyze the outcomes of Malaysian STEMI patients with renal impairment treated with coronary angioplasty.

Methods

Utilizing the Malaysian National Cardiovascular Disease Database-Percutaneous Coronary Intervention (NCVD-PCI) registry data from 2007 to 2014, STEMI patients treated with percutaneous coronary intervention (PCI) were stratified into presence (GFR < 60 mls/min/1.73m²) or absence (GFR ≥ 60 mls/min/1.73m²) of chronic kidney disease (CKD). Patient’s demographics, extent of coronary artery disease, procedural data, discharge medications, short (in-hospital) and long (1 year) term outcomes were critically assessed.

Results

A total of 6563 patients were included in the final analysis. STEMI CKD cohort was predominantly male (80%) with mean age of 61.02 ± 9.95 years. They had higher cardiovascular risk factors namely diabetes mellitus (54.6%), hypertension (79.2%) and dyslipidemia (68.8%) in contrast to those without CKD. There were notably higher percentage of CKD patients presented with Killip class 3 and 4; 24.9 vs 8.7%. Thrombolytic therapy remained the most commonly instituted treatment regardless the status of kidney function. Furthermore, our STEMI CKD cohort also was more likely to receive less of evidence-based treatment upon discharge. In terms of outcomes, patients with CKD were more likely to develop in-hospital death (OR: 4.55, 95% CI 3.11–6.65), MACE (OR: 3.42, 95% CI 2.39–4.90) and vascular complications (OR: 1.88, 95% CI 0.95–3.7) compared to the non-CKD patients. The risk of death at 1-year post PCI in STEMI CKD patients was also reported to be high (HR: 3.79, 95% CI 2.84–5.07).

Conclusion

STEMI and CKD is a deadly combination, proven in our cohort, adding on to the current evidence in the literature. We noted that our STEMI CKD patients tend to be younger than the Caucasian with extremely high prevalence of diabetes mellitus. The poor outcome mainly driven by immediate or short term adverse events peri-procedural, therefore suggesting that more efficient treatment in this special group is imperative.

Shear wave elastography in the evaluation of renal parenchymal stiffness in patients with chronic kidney disease

OBJECTIVE

To investigate the use of shear wave elastography (SWE)-derived estimates of Young's modulus (YM) as an indicator to detect abnormal renal tissue diagnosed by estimated glomerular filtration rate (eGFR).

METHODS

The study comprised 106 chronic kidney disease (CKD) patients and 203 control subjects. Conventional ultrasound was performed to measure the kidney length and cortical thickness. SWE imaging was performed to measure renal parenchymal stiffness. Diagnostic performance of SWE and conventional ultrasound were correlated with serum creatinine, urea levels and eGFR.

RESULTS

Pearson's correlation coefficient revealed a negative correlation between YM measurements and eGFR (r = -0.576, p < 0.0001). Positive correlations between YM measurements and age (r = 0.321, p < 0.05), serum creatinine (r = 0.375, p < 0.0001) and urea (r = 0.287, p < 0.0001) were also observed. The area under the receiver operating characteristic curve for SWE (0.87) was superior to conventional ultrasound alone (0.35-0.37). The cut-off value of less or equal to 4.31 kPa suggested a non-diseased kidney (80.3% sensitivity, 79.5% specificity).

CONCLUSION

SWE was superior to renal length and cortical thickness in detecting CKD. A value of 4.31 kPa or less showed good accuracy in determining whether a kidney was diseased or not. Advances in knowledge: On SWE, CKD patients show greater renal parenchymal stiffness than non-CKD patients. Determining a cut-off value between normal and diseased renal parenchyma may help in early non-invasive detection and management of CKD.

MDRD vs. CKD-EPI in comparison to 51Chromium EDTA: a cross sectional study of Malaysian CKD cohort

Background

Accurate measurement of renal function is important: however, radiolabelled gold standard measurement of GFR is highly expensive and can only be used on a very limited scale. We aim to compare the performance of Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equations in the multi-ethnic population attending University Malaya Medical Centre (UMMC).

Methods

This is a cross-sectional study recruiting patients, who attend UMMC Nephrology clinics on voluntary basis. 51-Chromium EDTA (⁵¹Cr-EDTA) plasma level was used to measure the reference GFR. The serum creatinine was determined by IDMS reference modified Jaffe kinetic assay (Cr_Jaffe). The predictive capabilities of MDRD and CKD-EPI based equations were calculated. Data was analysed using SPSS version 20 and correlation, bias, precision and accuracy were determined.

Results

A total of 113 subjects with mean age of 58.12 ± 14.76 years and BMI of 25.99 ± 4.29 kg/m² were recruited. The mean reference GFR was 66.98 ± 40.65 ml/min/1.73m², while the estimated GFR based on MDRD and CKD-EPI formula were 62.17 ± 40.40, and 60.44 ± 34.59, respectively. Both MDRD and CKD-EPI were well-correlated with reference GFR (0.806 and 0.867 respectively) and statistically significant with p < 0.001. In the overall cohort, although MDRD had smaller bias than CKD-EPI (4.81 vs. 6.54), CKD-EPI was more precise (25.22 vs. 20.29) with higher accuracy within 30% of measured GFR (79.65 vs. 86.73%).

Conclusion

The CKD-EPI equation appeared to be more precise and accurate than the MDRD equation in estimating GFR in our cohort of multi-ethnic populations in Malaysia.

Severe Plasmodium falciparum infection mimicking acute myocardial infarction

This case report describes a case of presumed acute myocardial infarction in a returned traveler who was later diagnosed to have severe malaria. Emergency coronary angiography was normal and subsequent peripheral blood film was positive for Plasmodium falciparum.