The Dilemma of Renal Involvement in COVID-19: A Systematic Review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), now known as coronavirus disease 2019 (COVID-19), has posed a serious threat to global health since December 2019. It has spread worldwide and is consuming healthcare resources rapidly. Published literature suggests that people with advanced age and comorbidities are affected more severely. It is crucial to uncover the underlying pathogenesis of acute kidney insufficiency in COVID-19 patients to understand better the reasoning behind the grave outcomes in these patients. In this review, we have included articles stating the prevalence and specific mortality rates of COVID-19 patients with acute kidney insufficiency. Our study included 1098 COVID-19 positive patients, of whom 66 (6%) developed acute kidney insufficiency and 62 patients died, showing a mortality rate of 94%. Patients with acute kidney insufficiency showed a more severe disease course, and these patients ended up more in intensive care units. Particular attention should be paid to those with already established kidney disease, such as chronic kidney disease, or renal transplant recipients, as these patients are already on immunosuppressive therapy. Our review focuses on the prevalence of acute kidney insufficiency in COVID-19 patients and mortality rates in this subset of patients.

Clinical Efficacy and Safety Profile of Lofexidine Hydrochloride in Treating Opioid Withdrawal Symptoms: A Review of Literature

Opioid use disorder (OUD) is a rapidly growing challenge worldwide and is characterized by an increase in dependence on opioids up to a point that a person loses control over the drug use. Multiple drugs are approved for its treatment, including methadone, buprenorphine, and diazepam. Although not approved, clonidine is also used for the treatment of OUD. On May 16, 2018, the United States Food and Drug Administration (FDA) approved a new drug lofexidine hydrochloride for the treatment of opioid withdrawal symptoms. Lofexidine is a centrally acting alpha two receptor agonist. It reduces the neurochemical surge by inhibiting the conversion of adenosine triphosphate (ATP) into cyclic adenosine monophosphate (cAMP) which in turn decrease the sympathetic outflow. This results in the improvement of withdrawal symptoms. When compared with methadone and buprenorphine, it is equally effective in controlling withdrawal symptoms. Its efficacy is also similar to clonidine with a better side effects profile. The adverse effects of lofexidine include bradycardia, hypotension, orthostasis, somnolence, sedation, dry mouth, and rebound elevations in blood pressure and prolongation of QT interval. Lofexidine is contraindicated in patients who are on beta-blockers and angiotensin converting enzyme inhibitors (ACE inhibitors). In our review, we have discussed the clinical efficacy and safety profile of lofexidine in treating opioid withdrawal symptoms and its comparison to other available treatment options.

Clinical Efficacy and Safety Profile of Prucalopride in Chronic Idiopathic Constipation

Chronic idiopathic constipation (CIC) can be defined as bowel movements that are difficult to pass, are not occurring frequently, or have incomplete evacuation during defecation. A high-fiber diet and laxatives are the commonly used treatments, but in many cases, they do not produce satisfactory results. The first line of treatment is osmotic laxatives. If there is no improvement, the second line is guanylate cyclase-C (GCC) agonists like linaclotide or prokinetic agents such as prucalopride. On December 14, 2018, the United States Food and Drug Administration (US FDA) approved prucalopride for treating chronic idiopathic constipation. Prucalopride is a prokinetic agent which works at the 5-hydroxytryptamine receptor 4 (5-HT4) as an agonist with greater receptor selectivity. Patients on prucalopride reported improved symptoms, quality of life and satisfaction. The most frequent adverse events were headaches and problems related to the gastrointestinal tract. Caution should be taken when using prucalopride in patients with impaired liver and renal function. In Canada, prucalopride has been approved for treatment of female patients with chronic idiopathic constipation who have failed therapy with at least two laxatives from different classes over a six-month period.

Crescentic Glomerulonephritis in Association With Renal Cell Carcinoma: A Case Report

Clear renal cell carcinoma (RCC) is the most common primary renal tumor originating within the renal cortex. It is responsible for 75% to 85% of all primary renal neoplasms. Multiple risk factors are associated with the development of RCC, the most common being smoking. On some occasions, RCC has been linked to some autoimmune conditions, but data is limited. Especially, its association with glomerulonephritis (GN) is rare in literature and not fully understood. In this case report, we discuss a presentation of RCC associated with crescentic GN.

AB062. Investigating miR-21 as a non-invasive prognostic biomarker in glioma patients

BACKGROUND

Glioma prognosis remains a challenge due to its high recurrence and resistance to treatment. Diagnosis and follow-up in resource-constrained regions often lead to significant patient attrition. Serum microRNAs (miRNAs) are seen to be aberrantly expressed in malignancies can be found in tumor tissues and peripheral samples. This offers a pathway for non-invasive liquid biopsies. miR-21 is an established biomarker for glioma prognosis, which needs to be validated in our population.

METHODS

We collected 89 intraoperative tumor tissue samples, and 42 pre- and post-operative serum samples from glioma patients, ten control tissues, eight healthy serum samples and analysed for miR-21 expression through quantitative polymerase chain reaction (qPCR) analysis. Correlational analysis with molecular markers isocitrate dehydrogenase (IDH), Ki-67, ATRX, p53, and survival curves through the Kaplan-Meier method were calculated in high and low miR-21 expression groups. The hazard ratio was quantitatively determined using Cox regression analysis, considering both univariate associations and multivariate correlations with clinical parameters.

RESULTS

miR-21 expression in tissue was significantly upregulated with increase of glioma grades (P<0.001) and in patients above 50 years (P=0.003) age group. Whereas no gender bias was seen in its expression pattern. Its expression did not show any correlation with tumor volume (r=0.22, P=0.08). A similar expression pattern of miR-21 was observed in serum samples of glioma. IDH-wildtype (P=2.06e-03) and high Ki-67 (P=2.50e-03) patient group showed significant upregulation of miR-21 expression compared to IDH-mutant and low Ki-67 group. Patients with low miR-21 expression had significantly longer overall survival (OS) than patients with high miR-21 expression (P =0.006). Similarly, quantitative hazard analysis indicates that patients in the high expression group have 2.77 times higher risk of mortality [95% confidence interval (CI): 0.19-0.92], in comparison to patients in the low expression group (P=0.008).

CONCLUSIONS

Our findings validate the utility of miR-21 as a prognostic serum biomarker to help diagnose and assess treatment response in advancing glioma grades, within our population.

Effect of peri-operative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting on outcomes in a resource limited setting

INTRODUCTION

Intra-aortic balloon pump (IABP) insertion for diminished myocardial function is standard of care in cardiac surgery. Previous studies have suggested a possible benefit to IABP support before surgery with regards to outcomes and complications. However, there are conflicts with other studies suggesting no significant benefit. Optimal time of insertion, whether preoperative or perioperative (intra-operative and post-operative), has yet to be defined.

METHODOLOGY

A retrospective, hospital records-based chart review was conducted for patients admitted to our center from January 2015 to December 2019 for coronary bypass surgery necessitating IABP insertion. Cases were stratified according to the timing of insertion and analyzed according to surgical outcomes and complication rates.

RESULTS

Out of 97 patients, 84.5% underwent preoperative IABP insertion while 15.5% of patients received perioperative (Intra-operative or post-operative) insertion. In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003). However, there were no significant differences between 30-day readmission rates in the two groups (9.8% vs 6.7%, p = 1.000). Length of stay was also higher in patients with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107). Perioperative IABP patients had higher rates of arrhythmias (46.7%, p = 0.042) and reopening of patient (33.3%, p = 0.028).

CONCLUSION

Our study shows improved mortality in patients with preoperatively inserted IABP. This may be beneficial for high-risk patients undergoing CABG surgery. Expanding the use of IABP before CABG in third world countries such as Pakistan may improve overall survival for patients.