The mechanisms of the damaging effects of endotoxin on renal function are complex but, in essence, involve dysregulated inflammation, oxidative stress, microvascular dysfunction and poor clearance of endotoxin burden. In both acute and chronic kidney dysfunction high levels of endotoxin are associated with a higher risk of mortality.
Measurement of endotoxin (lipopolysaccharide) in human whole blood has been difficult, in part due to the fact that the conserved active portion of the lipid A molecule is only amenable to binding by a single ligand. The endotoxin activity assay [EAA], is a bioassay based on neutrophil activation by complement opsonized immune complexes of lipopolysaccharide (LPS) and a high affinity IgM antibody. This assay permits detection of the lipid A epitope of LPS in a rapid whole blood assay format. The EAA is approved for use by Regulatory bodies in many regions including the US, Europe, Asia, and Japan. It can be performed in a unit dose format with result generation in 30 minutes and is suitable for patient triage and selection for anti-endotoxin therapy. The EAA has been used identify endotoxic septic shock (ESS) as a phenotype that is characterized by high endotoxin activity in addition to a high burden of organ failure; including hepatic dysfunction, acute kidney injury, and various forms of endothelial dysfunction. ESS is a subset of sepsis with a 28-day mortality that exceeds 40%.
While many drug development companies seek an endotoxin removal strategy, an alternative is via an extracorporeal hemoperfusion cartridge that selectively removes endotoxin from circulating blood. The PMX cartridge (TORAYMYXIN PMX-20R [adult], and TORAYMYXIN PMX-05R [pediatric]) utilizes the antibiotic polymyxin B, which is bound and immobilized to fibers within a cartridge and administered by veno-venous hemoadsorption. Studies using the EAA to identify patients with ESS and treating with polymyxin B hemoperfusion, have shown to be a safe and effective intervention in patients with acute kidney injury to improve survival.

Introduction: Arterial or venous thrombotic events in the fistula of hemodialysis patients is an important morbidity factor and complication of these patients. The purpose of this study is to demonstrate that patients with thrombotic events in the fistula in patients in hemodialysis have energy deficiency inside the five internal massive organs of the five elements theory of traditional Chinese medicine and the treatment of this condition can prevent the formation of thrombosis in all these patients in the arteriovenous fistula. Methods: one case report of a 53 years-old female patient with a history of doing hemodialysis for eight years. She changed the location of the fistula 6 times due to infection and local thrombosis. She went to do acupuncture due to her previous history of endometriosis and I measured the energy of her five internal massive organs of the five elements theory of traditional Chinese medicine. Results: all internal massive organs were in the lowest level of energy, rated one out of eight. The treatment of this condition rebalancing the energy using Chinese dietary counseling, auricular acupuncture with apex ear bloodletting, and replenishing the energy of these organs using highly diluted medications according to the theory of Constitutional Homeopathy of the Five Elements Based on Traditional Chinese Medicine and crystal-based medications. After beginning this treatment, she did not have thrombosis in the arteriovenous fistula and improved her self-esteem, increase her urine, and does not have any fatigue after hemodialysis anymore. The conclusion of this study is to demonstrate that hemodialysis patients have energy deficiency inside the five internal massive organs and the treatment of this condition can prevent the formation of thrombosis in the arteriovenous fistula and can reduce the complications in these patients.

Uremic pruritus is a common discomfort in end- stage renal disease patients on long-term hemodialysis. It negatively affects patients’ quality of life and is associated with increased mortality. The pathogenesis of uremic pruritus is complex. Aluminum is a toxic metal and common human allergen that causes an immune reaction in patients on hemodialysis. Aluminum is hypothesized to play a vital role in the pathogenesis of uremic pruritus. Controlling serum aluminum levels is still critical for patients on long-term hemodialysis. our Objectives was to determine the prevalence of hyperaluminemia and assess its correlation with uremic pruritus in patients on long-term hemodialysis.
We conducted a case-control study on 90 patients on long-term hemodialysis at the dialysis units of Ain Shams university hospitals. We used the 5-D itch scale numerical rating system to determine the presence and severity of pruritus in our study participants. We collected blood samples to estimate blood urea nitrogen levels pre- and post- dialysis, as well as the measured urea reduction ratio, serum creatinine, hemoglobin level, intact parathyroid hormone, ionized calcium, serum phosphate levels, iron study and serum aluminum levels.
Our study showed no statistically significant differences between the pruritic and nonpruritic study groups (median values 9.78 [6.48–11.72] and 9.13 [6.3–10.4] for the pruritic and non-pruritic groups, respectively; P = 0.32). We concluded that The serum aluminum levels of our study participants were higher than the normal levels in humans. Patients in the pruritic group had higher levels than those in the non- pruritic group. However, aluminum levels were not significantly associated with either the presence or severity of pruritus in patients on long-term hemodialysis.

The human gut microbiota is a complex and diverse community of microorganisms that various factors such as diet, metabolism, age, geography, stress, seasons, temperature, sleep, and medication can influence. Recent research has suggested a strong and reciprocal relationship between the gut microbiota and the brain, indicating that an imbalance in the gut may play a crucial role in the development, function, and disorders of the central nervous system.
Various mechanisms explain how gut-microbiota interactions affect neuronal activity. The vagus nerve, endocrine, immune, and biochemical pathways mediate the brain-gut-microbiota axis. Dysbiosis of the gut microbiota has been linked to neurological disorders through activation of the hypothalamic-pituitary-adrenal axis, neurotransmitter imbalance, systemic inflammation, and increased intestinal and blood- brain barrier permeability.
With the COVID-19 pandemic, the prevalence of mental and neurological diseases has increased globally, including among patients with chronic kidney disease (CKD), making it an essential public health issue. Since an imbalance in the gut microbiota is a significant risk factor for neurological disorders, it is crucial to understand the importance of diagnosing, preventing, and treating dysbiosis, which is commom in CKD. This review provides a summary of evidence demonstrating the influence of gut dysbiosis on mental and neurological disorders.

In the past thirty years, the Kingdom of Saudi Arabia (KSA) has experienced a dramatic shift in its epidemiology and nutrition, leading to a widespread outbreak of non-communicable diseases and a notable rise in illness and death caused by diabetes. In addition to nephropathy, diabetic retinopathy is the most common microvascular complication of diabetes. The study investigated the correlation between diabetic retinopathy (DR) and nephropathy, considering their interconnection. Chronic elevation of blood sugar levels and widespread inflammation in the body increase the likelihood of developing diabetic retinopathy (DR) and nephropathy. Individuals with diabetes may experience concurrent renal and ocular microvascular impairment. In addition, a study carried out in Saudi Arabia on patients with diabetes found that nephropathy significantly influenced the probability of diabetic retinopathy in type 1 diabetes mellitus. Therefore, gaining knowledge and properly predicting the concurrent progression of these problems should improve the management and comprehension of diabetes' systemic influence on several organ systems. Hence, the aim of this study is to develop inclusive prognostic models that consider both diabetic retinopathy (DR) and nephropathy in individuals diagnosed with type 1 diabetes mellitus (T1DM), with the objective of improving the precision of clinical progression forecasts. This research topic encompasses several components, including multimodal data fusion, sophisticated machine learning, longitudinal analysis, and risk stratification, in order to accomplish its objective. This Integrative Predictive Models ensures that the research is thorough and has a significant impact. The Multimodal Data Fusion study aims to explore techniques for combining several forms of data, including retinal pictures, electronic health records, and genetic information, in order to provide a comprehensive dataset for the purposes of training and validating models. The study will evaluate and analyse the effectiveness of cutting-edge machine learning algorithms, including deep learning models, ensemble approaches, and explainable AI techniques, in forecasting the advancement of both diabetic retinopathy and nephropathy. Create risk stratification models to identify certain subgroups with an elevated risk of concurrent progression of diabetic retinopathy and nephropathy. This will enable the implementation of individualized interventions and treatment strategies. Longitudinal research will be done at two diabetic centers in Riyadh to capture temporal patterns and trends in disease progression, so facilitating more precise predictions over time. The patients' data will consist of demographic information and clinical features, including hypertension, Hemoglobin A1c (HbA1c), nephropathy (Serum Creatinine Levels, Estimated Glomerular Filtration Rate (eGFR), and Urinary Albumin-to-Creatinine Ratio (UACR), recorded in their electronic medical records. The retinal data is assessed by fundus photography and classified 24, Dec 2023 into five categories: No diabetic retinopathy, nonproliferative retinopathy, Mild nonproliferative retinopathy, severe nonproliferative retinopathy, and proliferative retinopathy.
Keywords: Diabetes, Diabetic Retinopathy, Nephropathy , Multimodal Data Fusion, Machine Learning, Longitudinal Analysis, Risk Stratification, Integrative Predictive Models.

Malnutrition is a common condition in patients undergoing hemodialysis (HD), and it is associated with increased morbidity and mortality. The main objective of the study was to evaluate the nutritional status of patients on maintenance HD. After applying eligibility criteria, 141 HD patients attending major governmental dialysis centers were randomly recruited in this cross-sectional study and assessed for nutritional status using the Patient-Generated Subjective Global Assessment (PG-SGA) tool. The PG-SGA categorizes patients as well-nourished, moderately malnourished, and severely malnourished. Different anthropometric measurements, laboratory investigations, blood pressure measurements, and 24-h dietary recall were collected from each patient. According to PG- SGA results, 78% of patients were moderately malnourished and 22% of patients were severely malnourished. The mean body mass index was 27.8 kg/m2, and 5.7% of patients were underweight. There were significant differences in the mid-upper arm muscle circumference (P = 0.020) between the PG-SGA groups. The total energy and protein intake were significantly (P <0.001) less than the recommended dietary intake by 1268.9 kcal and 41.4 g, respectively. The albumin level in 37.6% of patients was less than the normal level, and the results indicated that there were significant differences in serum iron (P = 0.022) between the moderately and severely malnourished patients. The results of this study indicated that all HD patients were suffering from different degrees of malnutrition and, unfortunately, most of their energy and nutrient intake was far less than the requirements, which might be the reason why they face nutritional and health risks.

Background : Cryoglobulinemia is defined as the presence of an abnormal immunoglobulin that may be responsible for vasculitis of small-caliber vessels.

Apheresis can be used in order to temporarily eliminate circulating cryoglobulins. The aim of this study was to assess the effectiveness of apheresis (double-filtration plasmapheresis-DFPP) in symptomatic and/or severe cryoglobulinemias.

Methods : Four male patients presenting cryoglobulinemic vasculitis and who received DFPP sessions were included.

Results : Their mean age was 57 ± 15 years. One patient had hepatitis-C virus (HCV)-related cryoglobulinemia and the other three patients were carriers of an IgM Kappa monoclonal gammopathy. Mean duration of follow-up was 15 ± 2 months. DFPP allowed healing of ulcerative skin lesions in the first patient and remission of nephrotic syndrome in the other patients after a median of 6(5–10) sessions.

Conclusion : DFPP can be used safely in cryoglobulinemic-vasculitis and can be considered early to achieve a faster and sustained clinical-biological response.

KEYWORDS : chronic hepatitis C, cryoglobulinemia, double-filtration plasmapheresis, membranoproliferative glomerulonephritis, rituximab, Waldenström disease

A very low incidence of acute kidney injury (AKI) has been observed in COVID-19 patients purposefully treated with early pressure support ventilation (PSV) compared to those receiving mainly controlled ventilation. The prevention of subdiaphragmatic venous congestion through limited fluid intake and the lowering of intrathoracic pressure is a possible and attractive explanation for this observed phenomenon. Both venous congestion, or “venous bagging”, and a positive fluid balance correlate with the occurrence of AKI. The impact of PSV on venous return, in addition to the effects of limiting intravenous fluids, may, at least in part, explain this even more clearly when there is no primary kidney disease or the presence of nephrotoxins. Optimizing the patient–ventilator interaction in PSV is challenging, in part because of the need for the ongoing titration of sedatives and opioids. The known benefits include improved ventilation/perfusion matching and reduced ventilator time. Furthermore, conservative fluid management positively influences cognitive and psychiatric morbidities in ICU patients and survivors. Here, it is hypothesized that cranial lymphatic congestion in relation to a more positive intrathoracic pressure, i.e., in patients predominantly treated with controlled mechanical ventilation (CMV), is a contributing risk factor for ICU delirium. No studies have addressed the question of how PSV can limit AKI, nor are there studies providing high-level evidence relating controlled mechanical ventilation to AKI. For this perspective article, we discuss studies in the literature demonstrating the effects of venous congestion leading to AKI. We aim to shed light on early PSV as a preventive measure, especially for the development of AKI and ICU delirium and emphasize the need for further research in this domain.

An accurate assessment of intravascular volume status in haemodialysis patients presents a significant challenge. Current clinical practice to determine  dry weight is flawed due to interobserver variability and non-reproducibility. This miscalculation results in either  chronic hypervolemia or hypovolemia with intra or interdialytic hypertension and hypotension respectively. The quest for non-invasive volume assessment tools to aid in  estimation of dry weight still continues. Current study was aimed at goal directed ultrafiltration removal compared with clinical dry weight assessment in achieving euvolemic status of patients on chronic haemodialysis.

It was a prospective single centre non-randomised, non-invasive interventional study on haemodialysis patients, for 12 months. Patients enrolled in study were advised to follow prescription of thrice per week hemodialysis with 4 hours duration per session. At the time of enrolment at day 0 and during the run in phase of 1 month we considered those patients to be our clinical standard dry weight control group. After one month the same population served as the test population. At zero month, pre and post dialysis IVCCI, B lines was checked. Again post dialysis B lines were checked at 6th and 12th month. Post dialysis IVCCI was assessed again at 3rd, 9^th and 12th month.

Fifty two patients participated and  46 completed the study. Ultrasound guided Inferior Ven cava collapsing index(IVCCI) and B lines were measured at intervals at 0,3,6along with cardiac parameters. Dry weight was estimated first clinically by trial and error. New dry weight target was set when B-lines were less than 4 in the eight site Lung Ultrasound and IVCCI  between 50%–75%, after 30 minutes post dialysis. The mean age of our study population is 57 years with slightly male preponderance (58%). Majority of our study population has had Diabetes(73.1%) and Hypertension (75%) as comorbidities. At zero month Pre HD IVCCI >50% was observed in 28.8 % of patients. At 12th month post HD IVCCI > 50% was observed in 82.6% patients showing statistically  significant  value. At zero month pre and post HD USG chest was done. About 69.2% patients had Pre HD B lines >4 and Post HD B lines > 4 was observed in 38.5% patients. At 12th month post HD B lines > 4 was observed in 17.4 % patients showing statistically significant value. Approximately 23.91% patients did not require dry weight modification throughout study. Nineteen percent patients did not achieve dry weight in spite of all interventions.. Overall 56.5% patients achieved dry weight during study period. There were 46.3% of patients with NYHA grade 3 dyspnoea observed at the start of study which was reduced to 2.2% showing statistical  significance.

Clinical assessment when bundled with non-invasive technology of assessment of dry weight showed encouraging result. B-lines and IVCCI estimation could be additional tools to achieve target weight goals reducing complications and increasing compliance.

OBJECTIVE :1. To study the incidence of  pulmonary hypertension (PH) in chronic kidney disease (CKD) stage V patients on maintenance hemodialysis (HD) at our center.2. To compare clinical and metabolic variables among CKD patients with and without PH to search for possible etiologic factors. 3.Comparison of  PH in CKD patients at baseline and after 3 months of  sildenafil therapy.

 METHODS :  The study was conducted in the Department of  Nephrology, Sri Aurobindo Institute of  Medical Sciences, Indore, for a period of  1 year from December 2021 to November 2022. All CKD patients on maintenance HD at our center were included in the study. A pre-structured proforma was used to record patient data. Detailed clinical examination, 2DECHO, and Biochemical tests were done. All patients with mean pulmonary artery pressure (mPAP) > 25 mmHg on 2D echocardiography were considered to have PH and were started on sildenafil therapy 20 mg three times a day for 3 months. PH was classified as mild PH (mPAP > 25 up to 40 mmHg), moderate PH (mPAP > 40 mmHg to 60 mmHg), and severe PH (mPAP > 60 mmHg). Patients were then followed for 3 months to look for episodes of   dyspnea  and  emergency  admissions  and  reassessed  after  3  months  by  repeat  2D  echocardiography  to  find  improvement  in  PH.

 RESULT : A  total  of   102  patients were analyzed during the study period; among them, 40 patients (39.2%) had PH. Out of  them, 18 patients (45%) had mild PH, 14 patients (35%) had moderate PH, and 8 patients (20%) patients had severe PH. Average age of  our patients was 48.8 ± 9.4 years, the majority being men. On comparing the clinical features between patients with and without PH, none of  the clinical parameters had any statistically significant impact on PH. Also, none of  the laboratory parameters had statistical significance among PH and non-PH groups. Among the patients with PH, 25 patients (62.5%) had Arteriovenous (AV) fistula, 10 patients (25%) had temporary dialysis catheters,8 patients (20%) had jugular catheters, 2 patients (5%) had femoral catheters, and 5 (12.5%) patients had tunneled jugular catheters. Initially, 102 patients were enrolled in the study. Of  these, 40 (39.2%) had PH and 62 (60.7%) did not. Patients who had PH started sildenafil 20 mg three times a day. Of  these 40 patients, at 3 months, eight patients were lost to follow-up, and 32 patients with PH remained in the study. The mean PH at baseline was 47.8 ± 8.9 mmHg and at 3 months the mean PH was 44.4 ± 7.8 mmHg. mPAP at baseline and at 3 months was compared with the severity of  PH. After 3 months, there were 14 patients with mild PH, 11 patients with moderate PH, and 7 patients with severe PH. After treatment, five patients downgraded from mild to no PH, four patients from moderate to mild PH, and three patients from severe to moderate PH. Emergency admissions in each group of  PH declined after 3 months, and the result was statistically significant. Echocardiographic findings were compared in patients with PH and without PH, but the difference in patients on HD with PH and without PH was not statistically significant.

CONCLUSION :  PH is a significant problem in CKD patients on HD. This issue needs to be evaluated in a timely manner to avoid the risk of  morbidity and mortality. It is vital to treat them at the earliest to prevent life-threatening complications.

Background: Continuous renal replacement therapy (CRRT) is frequently used for patients with critical acute kidney injury. However, its effect on inflammation-related anemia, iron metabolism and short-term prognosis remains largely unknown.

Methods: In this single-center retrospective observational study, data from a total of 193 cases of critical acute kidney injury were collected and analyzed. Comparisons were made between those treated with CRRT (CRRT group) and without CRRT (non-CRRT group) at day 3, 7 and 14 after intensive care unit admission. Iron metabolism biomarkers assessed included iron, ferritin, transferrin saturation rate, and soluble transferrin receptor. Short-term prognosis is defined as 28-dya mortality.

Results: Of the 193 cases included, 112 patients (58.03%) received CRRT treatment. The most common causes for acute kidney injury in this study were sepsis (69.43%), followed by ischemia reperfusion injury (18.65%) and nephrotoxicity (6.22%). Compared with the non-CRRT group, patients in the CRRT group were associated with significantly higher sequential organ failure assessment score (P<0.001). Hemoglobin levels between the 2 groups were statistically insignificant at all time points. However, levels of iron, ferritin and transferrin saturation rate in the CRRT group were significantly higher than those in the non-CRRT group at day 14, despite the soluble transferrin receptor level showed no statistical significance. The 28-day mortality rate between the CRRT and non-CRRT group were similar (39.29% vs , 24.69%, P=0.26).

Conclusion: CRRT treatment in patients with critical acute kidney injury improves iron metabolism but has limited effect on inflammation-related anemia and short-term mortality.