This document discusses hepatitis C virus (HCV) infection in patients with kidney disease. It covers several topics:
1. HCV can cause a variety of systemic effects beyond liver disease, including cardiovascular disease, diabetes, renal disease, cryoglobulinemia vasculitis, and B-cell lymphomas.
2. Diagnostic tests for HCV have evolved from antibody tests to include RNA tests to detect active infection and genotype testing to determine the viral strain. Imaging and non-invasive markers of liver fibrosis are also used.
3. HCV infection is considered a systemic disease due to its many potential extrahepatic manifestations. Successful treatment of HCV has been shown to improve some of these associated conditions.
Hepatitis C virus & chronic kidney diseasesSamir Haffar
This document discusses hepatitis C virus (HCV) and its relationship to chronic kidney disease. It covers HCV diagnosis in chronic kidney disease patients, HCV-related glomerulonephritis, HCV in dialysis patients, and HCV and kidney transplantation. Key points include that HCV prevalence is higher in dialysis populations, HCV increases the risk of death in dialysis patients, and universal precautions can prevent HCV transmission in hemodialysis units. Cryoglobulinemia is also discussed as it relates to HCV infection and kidney involvement.
This document discusses guidelines for hemodialysis prescription. It provides details on various aspects of the dialysis prescription including modality, frequency, duration, dose, dialysate composition and temperature. It emphasizes the importance of achieving adequate dialysis as defined by fluid removal, normalized electrolytes and minerals, adequate dialysis dose and absence of symptoms. The criteria for optimal dialysis are more stringent and include normalization of blood pressure and minerals without medications, absence of symptoms during and between treatments, no interference with daily life and near-normal life expectancy.
This document discusses the prescription of peritoneal dialysis, including the choice of modality (CAPD vs APD), clearance targets, and measurement of clearance through Kt/V and creatinine clearance. It also covers factors that determine clearance like residual renal function, body size, and transport characteristics. For CAPD and APD, prescription factors include exchange frequency and volume, and dwell times. Nutritional monitoring for PD patients includes nPNA, serum albumin, subjective global assessment, and lean body mass. Treatment of malnutrition may include dietitian support, supplements, promotility agents, steroids, and amino acids.
This document summarizes a consensus document on hypertension in dialysis patients. It discusses how hypertension is common in dialysis patients and associated with shorter survival. The principal causes of hypertension include volume overload, arterial stiffness, sympathetic nervous system activation, and renin-angiotensin-aldosterone system activation. Treatment strategies should focus on correcting the primary causes of hypertension, which are sodium and volume excess. Non-pharmacological strategies like reducing salt intake, individualizing dialysate sodium, and increasing treatment length and frequency can help reduce blood pressure by managing volume status.
This document discusses hepatitis B virus (HBV) infection in patients undergoing dialysis or kidney transplantation. Some key points:
1) HBV infection is a concern for dialysis and transplant patients due to their immunosuppressed state, which increases susceptibility to infection and can cause HBV to take a more severe clinical course.
2) While HBV infection may seem relatively mild in dialysis patients, it poses significant risks if they undergo kidney transplantation, as HBV can reactivate or cause life-threatening complications after transplant.
3) Preventing HBV transmission in dialysis units is important through measures like vaccination, protective equipment, and regular screening. Prophylactic treatment is recommended for infected patients considering transplant
1. Dialysis adequacy refers to removing sufficient toxins and waste from the blood to prevent adverse health outcomes and is measured by urea clearance and nutritional intake.
2. Urea clearance is the standard measure and is expressed as Kt/V, with a target single pool Kt/V of at least 1.2 per session for patients receiving hemodialysis 3 times a week.
3. Other factors that determine adequacy include residual kidney function, nutrition as measured by normalized protein catabolic rate, and controlling symptoms like anemia, acidosis, and blood pressure.
Advanced in hemodialysis and biocompatbility chaken pmkCHAKEN MANIYAN
This document discusses advanced hemodialysis technologies and their role in improving outcomes for hemodialysis patients. It begins by outlining several challenges with hemodialysis including high mortality rates from cardiovascular causes and insufficient removal of toxins like phosphate, middle molecules, and protein-bound solutes. It then describes several modalities for advanced hemodialysis like super high flux membranes, hemodiafiltration, and adsorptive therapies that aim to remove more toxins. The document reviews landmark trials on high flux membranes and discusses how newer technologies may provide benefits like improved clearance of beta-2 microglobulin and phosphate.
Hepatitis C virus & chronic kidney diseasesSamir Haffar
This document discusses hepatitis C virus (HCV) and its relationship to chronic kidney disease. It covers HCV diagnosis in chronic kidney disease patients, HCV-related glomerulonephritis, HCV in dialysis patients, and HCV and kidney transplantation. Key points include that HCV prevalence is higher in dialysis populations, HCV increases the risk of death in dialysis patients, and universal precautions can prevent HCV transmission in hemodialysis units. Cryoglobulinemia is also discussed as it relates to HCV infection and kidney involvement.
This document discusses guidelines for hemodialysis prescription. It provides details on various aspects of the dialysis prescription including modality, frequency, duration, dose, dialysate composition and temperature. It emphasizes the importance of achieving adequate dialysis as defined by fluid removal, normalized electrolytes and minerals, adequate dialysis dose and absence of symptoms. The criteria for optimal dialysis are more stringent and include normalization of blood pressure and minerals without medications, absence of symptoms during and between treatments, no interference with daily life and near-normal life expectancy.
This document discusses the prescription of peritoneal dialysis, including the choice of modality (CAPD vs APD), clearance targets, and measurement of clearance through Kt/V and creatinine clearance. It also covers factors that determine clearance like residual renal function, body size, and transport characteristics. For CAPD and APD, prescription factors include exchange frequency and volume, and dwell times. Nutritional monitoring for PD patients includes nPNA, serum albumin, subjective global assessment, and lean body mass. Treatment of malnutrition may include dietitian support, supplements, promotility agents, steroids, and amino acids.
This document summarizes a consensus document on hypertension in dialysis patients. It discusses how hypertension is common in dialysis patients and associated with shorter survival. The principal causes of hypertension include volume overload, arterial stiffness, sympathetic nervous system activation, and renin-angiotensin-aldosterone system activation. Treatment strategies should focus on correcting the primary causes of hypertension, which are sodium and volume excess. Non-pharmacological strategies like reducing salt intake, individualizing dialysate sodium, and increasing treatment length and frequency can help reduce blood pressure by managing volume status.
This document discusses hepatitis B virus (HBV) infection in patients undergoing dialysis or kidney transplantation. Some key points:
1) HBV infection is a concern for dialysis and transplant patients due to their immunosuppressed state, which increases susceptibility to infection and can cause HBV to take a more severe clinical course.
2) While HBV infection may seem relatively mild in dialysis patients, it poses significant risks if they undergo kidney transplantation, as HBV can reactivate or cause life-threatening complications after transplant.
3) Preventing HBV transmission in dialysis units is important through measures like vaccination, protective equipment, and regular screening. Prophylactic treatment is recommended for infected patients considering transplant
1. Dialysis adequacy refers to removing sufficient toxins and waste from the blood to prevent adverse health outcomes and is measured by urea clearance and nutritional intake.
2. Urea clearance is the standard measure and is expressed as Kt/V, with a target single pool Kt/V of at least 1.2 per session for patients receiving hemodialysis 3 times a week.
3. Other factors that determine adequacy include residual kidney function, nutrition as measured by normalized protein catabolic rate, and controlling symptoms like anemia, acidosis, and blood pressure.
Advanced in hemodialysis and biocompatbility chaken pmkCHAKEN MANIYAN
This document discusses advanced hemodialysis technologies and their role in improving outcomes for hemodialysis patients. It begins by outlining several challenges with hemodialysis including high mortality rates from cardiovascular causes and insufficient removal of toxins like phosphate, middle molecules, and protein-bound solutes. It then describes several modalities for advanced hemodialysis like super high flux membranes, hemodiafiltration, and adsorptive therapies that aim to remove more toxins. The document reviews landmark trials on high flux membranes and discusses how newer technologies may provide benefits like improved clearance of beta-2 microglobulin and phosphate.
The document discusses several potential complications of hemodialysis, including intradialytic hypotension, dialyzer reactions, disequilibrium syndrome, cramping, air embolism, hemolysis, cardiac arrhythmias, hemorrhage, pruritus, febrile reactions, and hypokalemia. For each complication, the document outlines the etiology, diagnosis, treatment, and prevention strategies.
This document summarizes renal replacement therapy modalities. It discusses that acute kidney injury affects 5% of hospitalized patients and increases mortality. The main renal replacement therapies are hemodialysis, peritoneal dialysis, and continuous renal replacement therapies. Hemodialysis removes water and solutes across a semipermeable membrane via diffusion and convection. Peritoneal dialysis utilizes the peritoneal membrane for solute and fluid removal. Choice of modality depends on patient factors and available resources. The goal of renal replacement therapy is to control fluid, electrolyte, and acid-base disturbances while providing adequate solute clearance.
This document discusses evaluating the adequacy of hemodialysis treatment. It states that numerous studies have shown a correlation between the delivered dose of hemodialysis and patient mortality and morbidity. The urea reduction ratio (URR), which measures the percentage reduction of urea levels pre- and post-dialysis, is one way to evaluate adequacy, with a URR over 60% generally associated with better outcomes. Equilibrated Kt/V is also discussed as a standard measure of dialysis dose, with a minimum of 1.4 recommended. The document outlines factors that influence adequacy, including treatment time and frequency, dialyzer characteristics, blood and dialysate flow rates, and dialysis solution composition
The patient is a 49-year-old woman with end-stage renal disease and diabetes who presented with altered mental status. She receives hemodialysis three times per week for a few years. Recently, she has been increasingly tired, weak, and unable to perform daily activities with poor appetite and nausea. On examination, she was pale and swollen with low hemoglobin. Tests found elevated creatinine, BUN, and electrolyte abnormalities. The most probable diagnosis is inadequate hemodialysis, as her symptoms and labs are consistent with worsening uremia due to insufficient solute clearance from her dialysis sessions. Kt/V is a measure of dialysis adequacy that accounts for urea clearance and patient
This document discusses various modalities of renal replacement therapy in children including peritoneal dialysis, hemodialysis, and continuous renal replacement therapy. It provides details on the principles, procedures, indications, and complications of each modality. The key points are:
- Renal replacement therapy helps clear accumulated solutes, water, or toxins from the blood via diffusion or convection across a semipermeable membrane.
- Peritoneal dialysis can be performed manually or with a machine and involves exchanging dialysate fluid into the peritoneal cavity. Hemodialysis uses an artificial kidney to filter blood outside the body. Continuous renal replacement therapy provides prolonged dialysis without interruption that is better tolerated in critically ill
Crrt indications and modalities [autosaved]FAARRAG
The document discusses continuous renal replacement therapy (CRRT) modalities for acute kidney injury (AKI) patients in the intensive care unit (ICU). It provides details on different CRRT modalities including CVVH, CVVHD, and CVVHDF. CVVHDF is described as the safest combination as it utilizes both diffusion and convection. The document also discusses indications for specific CRRT therapies and notes that patient hemodynamic stability is the main determinant for choice of dialysis modality.
This document provides an overview of principles of haemodialysis. It describes the components of haemodialysis including the blood circuit, dialysate circuit and dialyzer. It explains how diffusion and convection work to remove solutes and fluid across the dialyzer membrane. High water purity standards are required for patient safety. Haemodiafiltration combines diffusive and convective clearances and may provide benefits over standard haemodialysis.
Anemia of renal disease is common and is associated with significant morbidity and death. It is mainly caused by a decrease in erythropoietin production in the kidneys and can be partially corrected with erythropoiesis-stimulating agents (ESAs). However, randomized controlled trials have shown that using ESAs to target normal hemoglobin levels can be harmful, and have called into question any benefits of ESA treatment other than avoidance of transfusions.
This document discusses the management of anemia in chronic kidney disease (CKD). It begins by defining anemia and its causes in CKD, which include reduced erythropoietin production and decreased red blood cell survival due to kidney failure. Left untreated, anemia in CKD can lead to deterioration in cardiac function, impaired cognition, and increased fatigue and mortality risk. The main therapeutic options for treating anemia in CKD are red blood cell transfusions, androgens, and erythropoiesis-stimulating agents (ESAs). ESAs such as epoetin alfa and darbepoetin alfa are now the standard treatment as they reduce transfusion needs and risks while helping to mobilize
Delayed Graft Function post kidney transplant, Moh'd sharshirMoh'd sharshir
Induction therapy with anti-thymocyte globulin (ATG) may decrease the risk of delayed graft function (DGF) in deceased donor kidney transplant recipients by ameliorating ischemia reperfusion injury. A retrospective study of 76 mated kidney transplants found a non-significant 35% decrease in the odds of DGF when ATG was used compared to basiliximab. Larger prospective studies are still needed to confirm ATG's potential protective effect against DGF.
- English version of this lecture is available at:
https://youtu.be/V3UGzJTwAWw
- Arabic version of this lecture is available at:
https://youtu.be/hGLaUde2ue4
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
This document discusses the history and physiology of peritoneal dialysis. It describes how peritoneal dialysis evolved from early experiments in the 19th century to the development of continuous ambulatory peritoneal dialysis in the late 20th century. It also summarizes the anatomy of the peritoneum and various models that have been used to describe solute and fluid transport across the peritoneal membrane during dialysis.
This document discusses diabetes management in patients receiving dialysis for end-stage renal disease. It covers alterations in glucose metabolism caused by kidney dysfunction, limitations of monitoring glycemic control in dialysis patients, glycemic targets and outcomes, and safety of diabetic medications in this population. Treatment approaches discussed include insulin regimens, non-insulin agents like sulfonylureas and DPP-4 inhibitors, and unique considerations for peritoneal dialysis patients. Guidelines recommend A1c monitoring along with home glucose testing, though optimal glycemic targets in dialysis are unclear due to limited evidence.
This document summarizes key information about anemia in chronic kidney disease (CKD). It defines CKD as kidney damage or decreased glomerular filtration rate (GFR) below 60 mL/min/1.73m2 for at least 3 months. Patients with CKD are more likely to die from cardiovascular causes than progress to end-stage renal disease. Anemia is common in CKD due to erythropoietin deficiency and has negative consequences if left untreated. The K/DOQI guidelines recommend evaluating hemoglobin levels when GFR is below 60 and treating anemia according to their guidelines if present. Intravenous iron is more effective than oral iron for treating anemia in CKD patients. Erythropoies
This document discusses peritonitis and exit site infections related to peritoneal dialysis. It provides statistics on the rates of these infections and their impact. Prevention is key and involves things like proper training, exit site care, antibiotic prophylaxis and monitoring infection rates. Symptoms, diagnosis, empirical antibiotic treatment and culture-specific treatment are outlined. Factors affecting exit site infections and appropriate pre-operative, operative and post-operative care are also covered.
This document discusses various aspects of renal replacement therapy for acute kidney injury. It begins by outlining the stage-based management of AKI, with increasing intervention and monitoring recommended as the stage progresses from risk to injury to failure. The document then addresses indications for starting renal replacement therapy, appropriate modalities including intermittent hemodialysis, slow continuous ultrafiltration, and continuous renal replacement therapy. Key factors like vascular access, solutions, membranes, anticoagulation, and dose are discussed. The overall conclusions are that while data from high-quality randomized controlled trials are still lacking, earlier initiation of renal replacement therapy may aid recovery, and continuous modalities are generally preferred over intermittent hemodialysis for unstable patients. Individualization of
This document discusses chronic kidney disease mineral and bone disorder (CKD-MBD). It begins by defining CKD-MBD and describing the pathogenesis involving abnormalities in calcium, phosphorus, PTH, and vitamin D metabolism. It then discusses the clinical features, investigations, and laboratory target levels. The final section covers treatment approaches including dietary phosphorus restriction, phosphate binders, vitamin D analogs, and calcimimetics to manage secondary hyperparathyroidism and hyperphosphatemia. It also addresses treating adynamic bone disease.
The document discusses hepatitis C virus (HCV) infection in patients with kidney disease. It covers several topics:
1) HCV is highly prevalent among patients undergoing dialysis, with rates ranging from 1.4-28.3% in developed countries and 4.7-41.9% in developing countries.
2) HCV can accelerate progression of chronic kidney disease and increase risk of end-stage renal disease. Successful treatment of HCV with antiviral therapy can improve kidney function and reduce dialysis risk.
3) Several direct-acting antiviral regimens, including paritaprevir/ritonavir/ombitasvir/dasabuvir, paritaprevir/
Presentation by Dr. Mishal Saleem on the topic of Extra hepatic manifestation of hep C, which is a grey area nut very important topic for FCPS Residents.
The document discusses several potential complications of hemodialysis, including intradialytic hypotension, dialyzer reactions, disequilibrium syndrome, cramping, air embolism, hemolysis, cardiac arrhythmias, hemorrhage, pruritus, febrile reactions, and hypokalemia. For each complication, the document outlines the etiology, diagnosis, treatment, and prevention strategies.
This document summarizes renal replacement therapy modalities. It discusses that acute kidney injury affects 5% of hospitalized patients and increases mortality. The main renal replacement therapies are hemodialysis, peritoneal dialysis, and continuous renal replacement therapies. Hemodialysis removes water and solutes across a semipermeable membrane via diffusion and convection. Peritoneal dialysis utilizes the peritoneal membrane for solute and fluid removal. Choice of modality depends on patient factors and available resources. The goal of renal replacement therapy is to control fluid, electrolyte, and acid-base disturbances while providing adequate solute clearance.
This document discusses evaluating the adequacy of hemodialysis treatment. It states that numerous studies have shown a correlation between the delivered dose of hemodialysis and patient mortality and morbidity. The urea reduction ratio (URR), which measures the percentage reduction of urea levels pre- and post-dialysis, is one way to evaluate adequacy, with a URR over 60% generally associated with better outcomes. Equilibrated Kt/V is also discussed as a standard measure of dialysis dose, with a minimum of 1.4 recommended. The document outlines factors that influence adequacy, including treatment time and frequency, dialyzer characteristics, blood and dialysate flow rates, and dialysis solution composition
The patient is a 49-year-old woman with end-stage renal disease and diabetes who presented with altered mental status. She receives hemodialysis three times per week for a few years. Recently, she has been increasingly tired, weak, and unable to perform daily activities with poor appetite and nausea. On examination, she was pale and swollen with low hemoglobin. Tests found elevated creatinine, BUN, and electrolyte abnormalities. The most probable diagnosis is inadequate hemodialysis, as her symptoms and labs are consistent with worsening uremia due to insufficient solute clearance from her dialysis sessions. Kt/V is a measure of dialysis adequacy that accounts for urea clearance and patient
This document discusses various modalities of renal replacement therapy in children including peritoneal dialysis, hemodialysis, and continuous renal replacement therapy. It provides details on the principles, procedures, indications, and complications of each modality. The key points are:
- Renal replacement therapy helps clear accumulated solutes, water, or toxins from the blood via diffusion or convection across a semipermeable membrane.
- Peritoneal dialysis can be performed manually or with a machine and involves exchanging dialysate fluid into the peritoneal cavity. Hemodialysis uses an artificial kidney to filter blood outside the body. Continuous renal replacement therapy provides prolonged dialysis without interruption that is better tolerated in critically ill
Crrt indications and modalities [autosaved]FAARRAG
The document discusses continuous renal replacement therapy (CRRT) modalities for acute kidney injury (AKI) patients in the intensive care unit (ICU). It provides details on different CRRT modalities including CVVH, CVVHD, and CVVHDF. CVVHDF is described as the safest combination as it utilizes both diffusion and convection. The document also discusses indications for specific CRRT therapies and notes that patient hemodynamic stability is the main determinant for choice of dialysis modality.
This document provides an overview of principles of haemodialysis. It describes the components of haemodialysis including the blood circuit, dialysate circuit and dialyzer. It explains how diffusion and convection work to remove solutes and fluid across the dialyzer membrane. High water purity standards are required for patient safety. Haemodiafiltration combines diffusive and convective clearances and may provide benefits over standard haemodialysis.
Anemia of renal disease is common and is associated with significant morbidity and death. It is mainly caused by a decrease in erythropoietin production in the kidneys and can be partially corrected with erythropoiesis-stimulating agents (ESAs). However, randomized controlled trials have shown that using ESAs to target normal hemoglobin levels can be harmful, and have called into question any benefits of ESA treatment other than avoidance of transfusions.
This document discusses the management of anemia in chronic kidney disease (CKD). It begins by defining anemia and its causes in CKD, which include reduced erythropoietin production and decreased red blood cell survival due to kidney failure. Left untreated, anemia in CKD can lead to deterioration in cardiac function, impaired cognition, and increased fatigue and mortality risk. The main therapeutic options for treating anemia in CKD are red blood cell transfusions, androgens, and erythropoiesis-stimulating agents (ESAs). ESAs such as epoetin alfa and darbepoetin alfa are now the standard treatment as they reduce transfusion needs and risks while helping to mobilize
Delayed Graft Function post kidney transplant, Moh'd sharshirMoh'd sharshir
Induction therapy with anti-thymocyte globulin (ATG) may decrease the risk of delayed graft function (DGF) in deceased donor kidney transplant recipients by ameliorating ischemia reperfusion injury. A retrospective study of 76 mated kidney transplants found a non-significant 35% decrease in the odds of DGF when ATG was used compared to basiliximab. Larger prospective studies are still needed to confirm ATG's potential protective effect against DGF.
- English version of this lecture is available at:
https://youtu.be/V3UGzJTwAWw
- Arabic version of this lecture is available at:
https://youtu.be/hGLaUde2ue4
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
This document discusses the history and physiology of peritoneal dialysis. It describes how peritoneal dialysis evolved from early experiments in the 19th century to the development of continuous ambulatory peritoneal dialysis in the late 20th century. It also summarizes the anatomy of the peritoneum and various models that have been used to describe solute and fluid transport across the peritoneal membrane during dialysis.
This document discusses diabetes management in patients receiving dialysis for end-stage renal disease. It covers alterations in glucose metabolism caused by kidney dysfunction, limitations of monitoring glycemic control in dialysis patients, glycemic targets and outcomes, and safety of diabetic medications in this population. Treatment approaches discussed include insulin regimens, non-insulin agents like sulfonylureas and DPP-4 inhibitors, and unique considerations for peritoneal dialysis patients. Guidelines recommend A1c monitoring along with home glucose testing, though optimal glycemic targets in dialysis are unclear due to limited evidence.
This document summarizes key information about anemia in chronic kidney disease (CKD). It defines CKD as kidney damage or decreased glomerular filtration rate (GFR) below 60 mL/min/1.73m2 for at least 3 months. Patients with CKD are more likely to die from cardiovascular causes than progress to end-stage renal disease. Anemia is common in CKD due to erythropoietin deficiency and has negative consequences if left untreated. The K/DOQI guidelines recommend evaluating hemoglobin levels when GFR is below 60 and treating anemia according to their guidelines if present. Intravenous iron is more effective than oral iron for treating anemia in CKD patients. Erythropoies
This document discusses peritonitis and exit site infections related to peritoneal dialysis. It provides statistics on the rates of these infections and their impact. Prevention is key and involves things like proper training, exit site care, antibiotic prophylaxis and monitoring infection rates. Symptoms, diagnosis, empirical antibiotic treatment and culture-specific treatment are outlined. Factors affecting exit site infections and appropriate pre-operative, operative and post-operative care are also covered.
This document discusses various aspects of renal replacement therapy for acute kidney injury. It begins by outlining the stage-based management of AKI, with increasing intervention and monitoring recommended as the stage progresses from risk to injury to failure. The document then addresses indications for starting renal replacement therapy, appropriate modalities including intermittent hemodialysis, slow continuous ultrafiltration, and continuous renal replacement therapy. Key factors like vascular access, solutions, membranes, anticoagulation, and dose are discussed. The overall conclusions are that while data from high-quality randomized controlled trials are still lacking, earlier initiation of renal replacement therapy may aid recovery, and continuous modalities are generally preferred over intermittent hemodialysis for unstable patients. Individualization of
This document discusses chronic kidney disease mineral and bone disorder (CKD-MBD). It begins by defining CKD-MBD and describing the pathogenesis involving abnormalities in calcium, phosphorus, PTH, and vitamin D metabolism. It then discusses the clinical features, investigations, and laboratory target levels. The final section covers treatment approaches including dietary phosphorus restriction, phosphate binders, vitamin D analogs, and calcimimetics to manage secondary hyperparathyroidism and hyperphosphatemia. It also addresses treating adynamic bone disease.
The document discusses hepatitis C virus (HCV) infection in patients with kidney disease. It covers several topics:
1) HCV is highly prevalent among patients undergoing dialysis, with rates ranging from 1.4-28.3% in developed countries and 4.7-41.9% in developing countries.
2) HCV can accelerate progression of chronic kidney disease and increase risk of end-stage renal disease. Successful treatment of HCV with antiviral therapy can improve kidney function and reduce dialysis risk.
3) Several direct-acting antiviral regimens, including paritaprevir/ritonavir/ombitasvir/dasabuvir, paritaprevir/
Presentation by Dr. Mishal Saleem on the topic of Extra hepatic manifestation of hep C, which is a grey area nut very important topic for FCPS Residents.
Hepatitis C can have complicated relationships with renal disease. HCV is transmitted through blood and high risk behaviors. It can cause direct renal disease like MPGN from cryoglobulinemia or membranous glomerulonephritis. HCV also increases risk of CKD and worsens outcomes in dialysis patients. New direct acting antivirals provide opportunities to treat HCV in renal patients before and after transplant, but safety data is still emerging regarding drug interactions and dosing in kidney disease. Careful monitoring is needed with any HCV treatment in renal patients.
Management of patient with hepatic disorder in dental office (hepatitis, alco...Shankar Hemam
The document provides information on managing dental patients with hepatic disorders such as hepatitis and alcoholic liver disease. It discusses the various types of hepatitis (A, B, C, D, E), their causes, symptoms, and medical management. For dental management, it emphasizes identifying potential hepatitis carriers, minimizing aerosols for infected patients, using isolation techniques, and consulting physicians on medication and bleeding risks. The liver's role in metabolism requires special consideration of drugs and procedures for patients with hepatic impairment.
This document provides information on chronic liver disease, including the different patterns of liver injury, symptoms, risk factors, and definitions of chronic liver disease and cirrhosis. It discusses chronic hepatitis caused by hepatitis B and C viruses. Major complications of cirrhosis include portal hypertension, which can lead to variceal hemorrhage, ascites, and hypersplenism. Ascites is treated initially with diuretics and sodium restriction. Complications of ascites include spontaneous bacterial peritonitis.
Hepatitis C Virus Infection, a New Modifiable.pptxihabmahmoud10
Chronic hepatitis C virus (HCV) infection is associated with increased cardiovascular disease risk through direct and indirect mechanisms. Observational studies show higher rates of cardiovascular events in HCV-infected patients compared to uninfected controls. Eradicating HCV through antiviral therapy is associated with reduced cardiovascular risk, as treatment with direct-acting antivirals or pegylated interferon plus ribavirin was found to lower rates of cardiovascular events by 22-43% compared to untreated patients. Successful treatment of HCV infection through sustained virologic response is thus considered evidence that HCV is a modifiable and reversible cardiovascular risk factor.
This document provides an overview of hepatitis B virus (HBV) diagnosis and classification. It begins with basic concepts around HBV terminology, classification, and diagnosis. It then discusses a patient-based approach for evaluating those with acute hepatitis or elevated liver enzymes. The document reviews diagnosing resistance to treatment and new developments in diagnosis. It concludes with reminders about HBV co-infections and summarizes the key points.
This document discusses a case of Kaposi sarcoma involving the small intestine. CT and endoscopy showed jejunal thickening and lymphadenopathy. Biopsy showed spindle cell proliferation and immunohistochemical staining was positive for HHV-8, indicating Kaposi sarcoma. Kaposi sarcoma commonly involves the GI tract in AIDS patients and can cause bleeding, pain, weight loss, nausea or diarrhea. Treatment involves antiretroviral therapy and radiation or chemotherapy.
HCV/HIV co-infection is common, with prevalence rates as high as 60% in some groups. Coinfection may accelerate the progression of liver disease and increase the risk of complications like cirrhosis and liver cancer. Successful treatment of HCV has the potential benefits of reducing liver disease progression, improving tolerance of antiretroviral therapy, and decreasing the risk of liver-related death. However, HCV treatment can also cause side effects and drug interactions with antiretrovirals require careful management. Overall, treatment should be considered on a case by case basis for coinfected patients with stable HIV control and significant liver disease.
This lecture is about Spectrum of HCV infection presented by Dr. Muhammad Mostafa Abdel Ghaffar, Head of Tropical Medicine Department, Ahmed Maher Teaching Hospital.
The lecture was presented in the scientific meeting of Internal and Tropical Medicine departments, Ahmed Maher Teaching Hospital titled (Towards Eradication of HCV in Egypt) in celebration of World Hepatitis Day on July 28, 2016.
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Relation between Hepatitis C and Kidney disease.pdfAlfa Kidney Care
Discover the intricate relationship between Hepatitis C and Kidney Disease on Alpha Kidney Care's informative page. Learn about risk factors, symptoms, and treatments connecting these conditions. Gain valuable insights to promote kidney health and manage Hepatitis C effectively. Expert knowledge awaits on the link between these two significant health concerns. Stay informed and proactive in your healthcare journey. Visit now to access essential resources and guidance for Hepatitis C and Kidney Disease.
HIV-associated nephropathy (HIVAN) was once the most common cause of glomerular disease in HIV-infected patients but has been overtaken by focal segmental glomerulosclerosis (FSGS) associated with metabolic and cardiovascular risk factors. HIVAN remains strongly associated with severe renal failure, black race, and low CD4 counts. While renal biopsy is needed for definitive diagnosis, certain clinical factors such as black race, low CD4, and rapid renal progression suggest HIVAN. Treatment includes antiretroviral therapy and corticosteroids, with the latter showing benefit in slowing renal disease progression in some studies. Renal replacement therapy is an option for end-stage renal disease, with peritoneal dial
Haematological manifestations of HIV by Dr Senani Williams (FRCPath, MD), Consultant Haematologist, Faculty of Medicine, University of Kelaniya, Sri Lanka
This document discusses renal involvement and glomerulopathies secondary to HCV infection. Some key points:
- HCV infection increases the risk of chronic kidney disease, proteinuria, and end-stage renal disease. It is associated with various types of glomerulonephritis.
- HCV can directly infect renal cells and also cause immune-complex mediated glomerulonephritis through mixed cryoglobulinemia. Common pathologies include membranoproliferative glomerulonephritis and membranous nephropathy.
- Screening HCV patients for renal markers annually and kidney biopsy if indicated can help diagnose HCV-induced glomerular lesions. While antiviral therapy treats the underlying
kidney disease in HIV-positive patients, Moh'd sharshirMoh'd sharshir
Patients with HIV are at risk for both acute kidney injury and chronic kidney disease due to various factors like medication toxicity, HIV-associated nephropathy, and immune complex kidney diseases. The risk factors for acute kidney injury in HIV patients are similar to the general population but also include factors specific to HIV like low CD4 count and co-infection with hepatitis C virus. Timely screening for chronic kidney disease is important in HIV patients to monitor for decline in kidney function and proteinuria, in order to guide management and reduce risk of end-stage renal disease.
- Hepatitis C is a contagious liver disease caused by the Hepatitis C virus. It can range from mild to severe and lifelong.
- It is commonly spread through blood-to-blood contact, especially from intravenous drug use. Other potential sources of transmission include sexual contact, transfusions, and from mother to child.
- Diagnosis involves blood tests to detect HCV antibodies and the virus. Additional tests like liver function tests and biopsy may also be used. There is no vaccine but risk of transmission can be reduced through safe practices.
The document discusses surgical problems in HIV positive patients. It covers the epidemiology of HIV/AIDS, how HIV affects the body's immune system, common clinical manifestations including opportunistic infections, diagnostic tests for HIV, and various surgical presentations and considerations for HIV positive patients. Key points are that surgeons must take universal precautions for all patients, opportunistic infections can mimic surgical conditions, and HIV patients require careful pre-operative screening, intra-operative protocols, and post-operative management to prevent complications and transmission.
Liver biopsy remains the gold standard for diagnosing chronic liver disease and assessing inflammation and fibrosis. While non-invasive modalities are being developed and evaluated, liver biopsy provides valuable information for both diagnosis and management of many liver diseases. It allows quantification of necrosis, inflammation, fibrosis and fat content which is important for evaluating disease progression. Liver biopsy also provides adequate tissue for special staining and assessing other pathologies. While it carries some risk, liver biopsy has low mortality and morbidity when performed properly by an experienced practitioner.
This document describes a case of HIV-associated thrombocytopenia in a 38-year old male patient. He presented with frank hematuria and weakness. Laboratory tests showed thrombocytopenia with a platelet count of 6,000/μl. Further testing revealed the patient was HIV-positive. He was diagnosed with HIV-associated thrombocytopenia and started on oral steroids, antiretroviral therapy, and supplements. Within 4 days his symptoms resolved and his platelet count improved to 70,000, at which point he was discharged. The document then provides background information on HIV-associated thrombocytopenia, its pathophysiology and treatment.
Plasmapheresis is a medical procedure that separates blood components to remove plasma. There are three main types: autologous, therapeutic exchange, and donation. Autologous plasmapheresis removes a patient's own plasma, treats it, and returns it to remove antibodies, immune complexes, or toxins. It is used to treat various neurological, hematological, metabolic, dermatological, and renal diseases. Complications can include hypotension, allergic reactions, hemorrhage, hypocalcemia, and infections from replacement fluids. Plasmapheresis removes drugs and proteins from plasma like IVIG and monoclonal antibodies but not drugs like steroids that are widely distributed in tissues. It is used pre- and
immunomodulation either stimulation or suppression has a crucial role in clinical practice dealing with either malignancy or infection
organ transplantation also need
THIS is a PowerPoint presentation denoting different clinical picture and case report of atypical prese tation
the question is: is it coindenance or autiological relation
New microsoft power point presentationdrsalwa22000
This document provides recommendations for fasting during Ramadan for those with diabetes. It categorizes risk levels as very high, high, moderate, and low based on factors like blood sugar control and medical history. For each risk level, it recommends whether fasting is advised against or can be done with/without caution. It also reviews common diabetes medications and provides guidance on any dosage adjustments or precautions needed when taking them during Ramadan fasting. Finally, it outlines the religious opinion of the Egyptian Fatwa Authority, which is that fasting should avoid hardship and harm for all patients with diabetes.
This document discusses various topics related to immunosuppressive drugs used in renal transplantation. It begins by reviewing mTOR inhibitors used in combination with calcineurin inhibitors, noting their synergistic effect. It then discusses a study finding lower rates of discontinuation and better graft function with mTORi-CNI compared to MMF/MPA-CNI. Finally, it briefly touches on induction immunosuppression methods, tolerance without immunosuppression, and withdrawal of steroids and calcineurin inhibitors.
This document discusses immunosuppressive therapy for renal transplantation. It covers various types of immunosuppressive drugs used for induction and maintenance, including calcineurin inhibitors (CNIs), mTOR inhibitors, steroids, and antiproliferatives. It provides information on monitoring drug levels, drug toxicities, and strategies to improve graft survival like avoiding high intrapatient drug level variability. It also addresses the impact of immunosuppressive drugs on male reproduction and pregnancy.
This document discusses post-transplant diabetes mellitus (PTDM), covering its definition, risk factors, diagnostic criteria, management, and the effects of various immunosuppressive and antidiabetic drugs. It provides questions and answers on topics like the most common cause of end-stage kidney disease in the US, risk factors for PTDM, criteria for diagnosing diabetes and prediabetes, preferred tests for diagnosing diabetes after transplantation, and factors that affect immunosuppressant and antidiabetic drug levels.
New microsoft office power point 97 2003 presentationdrsalwa22000
Membranoproliferative glomerulonephritis (MPGN) is characterized by three histopathologic findings: proliferation of mesangial and endothelial cells, thickening of peripheral capillary walls, and mesangial interposition into capillary walls. It can present with asymptomatic proteinuria and hematuria, nephrotic syndrome, acute nephritic syndrome, or recurrent gross hematuria. Treatment involves immunosuppression, antiplatelet agents, anticoagulants, and anti-inflammatory drugs. Recurrent disease is common after kidney transplantation.
New microsoft office power point 97 2003 presentationdrsalwa22000
Membranoproliferative Glomerulonephritis (MPGN) is a type of glomerular disease characterized by three histological findings: proliferation of mesangial and endothelial cells, thickening of capillary walls, and mesangial interposition into capillary walls. It accounts for 6-12% of renal biopsies performed to evaluate glomerular disease. Presentations include asymptomatic proteinuria and hematuria, nephrotic syndrome, acute nephritic syndrome, and recurrent gross hematuria. Recurrence is common after kidney transplantation.
This document discusses the role of continuous renal replacement therapy (CRRT) in liver transplantation. It provides details on how to prescribe CRRT, including blood flow, dose, mode, substitution fluid, dialysate flow, fluid removal, fluid addition, and anticoagulation. It compares CRRT to intermittent hemodialysis. It then presents a case scenario of a patient undergoing liver transplantation who develops hepatorenal syndrome and requires CRRT intraoperatively and postoperatively based on their condition of massive blood loss, hypotension, and anuria. The CRRT prescription and monitoring of the patient over one week is described, showing recovering kidney function.
This document discusses the role of continuous renal replacement therapy (CRRT) in liver transplantation. It provides details on how to prescribe CRRT, including blood and dialysate flow rates, substitution fluid used, and anticoagulation. It notes CRRT is useful for hemodynamically unstable patients undergoing liver transplant due to complications like blood loss and hypotension. The case scenario describes using CRRT intraoperatively and postoperatively for a patient with liver and kidney failure undergoing liver transplant who experienced blood loss and hypotension.
This document discusses sexual and reproductive health issues after kidney transplantation. It notes that more than half of male patients with renal failure have biochemical hypogonadism, which is a risk factor for sexual dysfunction. Several medications commonly used after transplantation can negatively impact erectile function and fertility in men. Treatment with phosphodiesterase 5 inhibitors can help erectile dysfunction. Female patients may experience ovulatory and menstrual irregularities due to hypothalamic-pituitary changes from chronic kidney disease. Pregnancy is possible after transplantation if kidney function is good with no proteinuria or hypertension and at least one year post-transplant. Fertility preservation techniques before transplantation like ovum pickup and preservation are discussed.
This document discusses living kidney donors for transplantation. It notes that living donation is beneficial as it provides superior graft survival and reduces waiting lists compared to deceased donation. Potential living donors are screened based on health criteria like being over 21, having normal kidney function, and no uncontrolled medical issues. While criteria have been expanded, donors must be carefully monitored long term to ensure no excess mortality or health issues result from donation.
During a 6-year period, 499 patients with morbid obesity and either end-stage renal disease or chronic kidney disease were evaluated for possible sleeve gastrectomy surgery. A total of 243 patients, 198 with end-stage renal disease and 45 with chronic kidney disease, underwent sleeve gastrectomy from December 2011 through February 2018. Immunosuppressive drugs, graft biopsy, and median follow-up period of 5.8 years were examined.
1) The document discusses using ultrasound measurement of the inferior vena cava (IVC) diameter to assess volume status in patients.
2) Measuring the IVC is a fast, reliable, and non-invasive method to detect volume status changes compared to other methods like central venous pressure measurement.
3) The document reviews the technique for measuring IVC diameter using ultrasound and interpreting the results to help guide clinical decisions like fluid administration in patients with abnormal volume status.
A 23-year-old man with ESKD underwent a kidney transplant. On day 10, he developed sterile pyuria. On day 17, a biopsy showed acute rejection with glomerulitis, peritubular capillaritis and tubulitis. He received pulse steroids, plasma exchange and IVIG. His creatinine improved with treatment. A literature review discussed causes of sterile pyuria and outcomes of acute rejection treatment. The case will be followed to monitor for infection or ongoing rejection.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
1. Hepatitis C Virus Infection in
Patients with Kidney Disease:
a Roadmap for Nephrologists
By
Salwa Elwasif, MD Mohammed Elhadidy
Rasha Kamal Ahmed Yahiya
Nour Elbialy
2. • a bimonthly publication
• Edited by Prof. Richard A Sherman from
Rutgers University, New Jersey.
• It focuses exclusively on cutting-edge clinical
aspects of dialysis therapy.
• It publishes review articles by the most
respected names in the field of dialysis
5. Introduction
12 articles
Diagnostic test and
prognosis
HCV as a systemic
disease
HCV ttt in dialysis
Transmission
Coinfection with
HIV
Treatment , how,
when and why?
In advanced
kidney disease
Epidemiology
Pharmacokinetics
DAA
HCV ttt in tx
Management and
ttt
Donor with HCV
6. Introduction
12 articles
Diagnostic test and
prognosis
HCV as a systemic
disease
HCV ttt in dialysis
Transmission
Coinfection with
HIV
Treatment , how,
when and why?
In advanced
kidney disease
Epidemiology
Pharmacokinetics
DAA
HCV ttt in tx
Management and
ttt
Donor with HCV
7. Introduction
12 articles
Diagnostic test and
prognosis
HCV as a systemic
disease
HCV ttt in dialysis
Transmission
Coinfection with
HIV
Treatment , how,
when and why?
In advanced
kidney disease
Epidemiology
Pharmacokinetics
DAA
HCV ttt in tx
Management and
ttt
Donor with HCV
8. Introduction
12 articles
Diagnostic test and
prognosis
HCV as a systemic
disease
HCV ttt in dialysis
Transmission
Coinfection with
HIV
Treatment , how,
when and why?
In advanced
kidney disease
Epidemiology
Pharmacokinetics
DAA
HCV ttt in tx
Management and
ttt
Donor with HCV
9.
10. hepatitis C virus infection as a systemic disease
• Cardiovascular disease:
• Metabolic diseases:
• Renal Insufficiency:
• Cryoglobulinemia vasculitis:
• B‐cell lymphoproliferative diseases
• Arthralgia and myalgia:
• Sicca syndrome
11. hepatitis C virus infection as a systemic disease
Cardiovascular disease:
• Major adverse cardiovascular events (MACE)
(stroke, coronary artery disease, heart failure,
peripheral arterial disease) are currently recognized
as important comorbidities in patients with chronic
HCV infection.
(Negro et al, 2014)
12. hepatitis C virus infection as a systemic disease
Cardiovascular disease:
• HCV seropositivity is associated with high
rates of carotid artery plaques, increasing
cerebrovascular disease risk.
• Patients with sustained virological response
showed an improvement in myocardial
perfusion defects whereas relapsing patients
exhibited a worsening following a transient
improvement
13. hepatitis C virus infection as a systemic disease
• Cardiovascular disease:
• Metabolic diseases:
• Renal Insufficiency:
• Cryoglobulinemia vasculitis:
• B‐cell lymphoproliferative diseases
• Arthralgia and myalgia:
• Sicca syndrome
14. hepatitis C virus infection as a systemic disease
Metabolic diseases:
Diabetes and insulin resistance occur with an
increased incidence in patients with chronic
HCV infection.
(Taskoparan et al, 2011)
15. hepatitis C virus infection as a systemic disease
Metabolic diseases:
• The mechanisms through which hepatitis C
induces type 2 diabetes involve direct viral effects,
insulin resistance, release of proinflammatory
cytokines and other immunemediated processes.
(Serfaty et al, 2009)
16. hepatitis C virus infection as a systemic disease
• Cardiovascular disease:
• Metabolic diseases:
• Renal Insufficiency:
• Cryoglobulinemia vasculitis:
• B‐cell lymphoproliferative diseases
• Arthralgia and myalgia:
• Sicca syndrome
17. hepatitis C virus infection as a systemic disease
Renal Insufficiency:
• Cryoglobulinemic vasculitis
• Membranoproliferative glomerulonephritis
(MPGN) .
(Cacoub and Comarmond, 2019)
18. hepatitis C virus infection as a systemic disease
Renal Insufficiency:
• patients with chronic HCV infection appear
to have more rapid progression of CKD and
an almost twofold increased risk of
developing end‐stage renal disease
(Molnar et al, 2015)
19. hepatitis C virus infection as a systemic disease
Renal biopsy
• Type I MPGN in more than 70% of patients
• (Less frequent)
– focal segmental glomerulosclerosis
– Membranous glomerulopathy.
– crescentic GN, necrotizing vasculitis, interstitial inflammation,
– capillary luminal cryoglobulin thrombi
• Immunofluorescence study:
– IgG, IgM, and C3 within most of the cryoglobulin deposits present
in capillary loops;
– C1q was present in about one‐third of the patients.
(Cacoub and Comarmond, 2019)
20. hepatitis C virus infection as a systemic disease
• Cardiovascular disease:
• Metabolic diseases:
• Renal Insufficiency:
• Cryoglobulinemia vasculitis:
• B‐cell lymphoproliferative diseases
• Arthralgia and myalgia:
• Sicca syndrome
21. hepatitis C virus infection as a systemic disease
Cryoglobulinemia vasculitis:
• Circulating mixed cryoglobulins in 40%‐60% of patients
chronically infected with HCV
• Overt CryoVas develops in only approximately 15% of
patients. (dermatologic, neurologic, and renal
involvement)
(Serfaty et al, 2009)
22. hepatitis C virus infection as a systemic disease
Cryoglobulinemia vasculitis:
1) Dermatologic manifestations:
• Purpura, chronic cutaneous ulcers, Raynaud's
phenomenon, acrocyanosis, and digital ulcerations)
2) Neurologic manifestations:
• distal sensory or sensory‐motor polyneuropathy
• painful asymmetric paresthesia.
• Multiple mononeuropathy (less frequent)
(Cacoub et al, 2015)
23. hepatitis C virus infection as a systemic disease
Cryoglobulinemia vasculitis:
treatment
• Initial control of disease with rituximab, with or without
plasmapheresis, is recommended along with DAA treatment.
• Low‐dose corticosteroids for inflammatory findings but are
not adequate alone in cases of major organ involvement.
• Immunosuppressants should be given only in cases of
refractory forms of CryoVas, which are frequently associated
with underlying B‐cell lymphoma.
(Saadoun et al, 2009)
24. hepatitis C virus infection as a systemic disease
• Cardiovascular disease:
• Metabolic diseases:
• Renal Insufficiency:
• Cryoglobulinemia vasculitis:
• B‐cell lymphoproliferative diseases
• Arthralgia and myalgia:
• Sicca syndrome
25. hepatitis C virus infection as a systemic disease
B‐cell lymphoproliferative diseases
• HCV‐related lymphoproliferative diseases appear to
be the result of multiple events, including sustained
B‐cells activation, an aberrant B‐cell survival,
genetic/epigenetic, and environmental factors.
(Zignego et al, 2012)
26. hepatitis C virus infection as a systemic disease
B‐cell lymphoproliferative diseases
• Patients with SVR, low incidence of B-NHL and
regression of already diagnosed one.
• Patients with recurrent viremia , , relapse of B-NHL.
(Kawamura et al, 2007)
27. hepatitis C virus infection as a systemic disease
• Cardiovascular disease:
• Metabolic diseases:
• Renal Insufficiency:
• Cryoglobulinemia vasculitis:
• B‐cell lymphoproliferative diseases
• Arthralgia and myalgia:
• Sicca syndrome
28. hepatitis C virus infection as a systemic disease
Arthralgia and myalgia:
• in 30%‐70% with mixed cryoglobulin
syndrome.
• O/E:
bilateral, symmetric, nondeforming joint
pains involving mainly the knees and
hands.
(Cacoub et al, 2015)
29. hepatitis C virus infection as a systemic disease
• Cardiovascular disease:
• Metabolic diseases:
• Renal Insufficiency:
• Cryoglobulinemia vasculitis:
• B‐cell lymphoproliferative diseases
• Arthralgia and myalgia:
• Sicca syndrome
30. hepatitis C virus infection as a systemic disease
Sicca syndrome
• in 20%‐ 30% of HCV‐infected patients
• Sjögren's syndrome (less than 5% ).
(Verbaanet al, 1999)
31.
32. Evolution of diagnostic tests in HCV
Laboratory blood tests:
General testing for liver disease:
LFT
HCV‐specific tests:
HCV Antibody (Ab), not protective
• can also be performed using oral fluid or
buccal swab and the sensitivity is slightly
lower at 98.1%.
33. Evolution of diagnostic tests in HCV
• if HCV antibody is positive, the presence of
active infection should be confirmed using HCV
Ribonucleic acid (HCV RNA)
34. Evolution of diagnostic tests in HCV
• HCV RNA test needs to be performed even if
HCV antibody is negative, In immunosuppressed
patients or those with HCV infection during the
“window” period.
• A study on 2796 HD patients, reported an overall
prevalence of 0.8% of HCV RNA positive
subjects although HCV antibody was negative
35. Evolution of diagnostic tests in HCV
Laboratory blood tests:
HCV has seven different genotypes 1 to 7 and
67 subtypes
HCV virus is capable of mutating within the
same host, with the production of different
genetic variants and quasispecies.
36. Evolution of diagnostic tests in HCV
• HCV genotype testing
is recommended if the patient has detectable
HCV viremia to personalize the treatment
options.
• HIV and HBV infection:
should be ruled out in all HCV positive patients
before starting DAAs
37. Evolution of diagnostic tests in HCV
IMAGING STUDIES:
• Ultrasound (US): liver architecture, spleen size,
• Doppler US: portal vein diameter and flow
• Computed tomography(CT) & magnetic
resonance imaging(MRI): iron deposition, liver
lesions and concomitant biliary diseases.
38.
39. Evolution of diagnostic tests in HCV
Liver fibrosis assessment:
Liver biopsy
• KDIGO-2008: liver biopsy as clinical standard to
assess liver fibrosis
• KDIGO-2018: use non‐invasive markers of liver
fibrosis as first line, and liver biopsy only if non
invasive markers are not concordant or to rule out
other liver‐related comorbidities
41. Evolution of diagnostic tests in HCV
Liver fibrosis assessment:
Serum markers of liver fibrosis:
• Directly involved in the remodeling and
turnover of the liver matrix
– hyaluronic acid, human cartilage glycoprotein
• indirect biomarkers that reflect the liver cell
damage
– AST, ALT, albumin, bilirubin,
42. Evolution of diagnostic tests in HCV
Liver fibrosis assessment:
Serum markers of liver fibrosis:
• The aminotransferase‐to‐platelet ratio index
(APRI) is an indirect score system calculated
as [(AST level/ULN)/PLT] × 100.
• APRI score is by far the most reliable and
accurate in identifying advanced liver fibrosis
43. Evolution of diagnostic tests in HCV
Liver fibrosis assessment:
Serum markers of liver fibrosis:
• Fib‐4 is a biomarker panel calculated as [age
(years) x AST]/PLT X
ALT
44. Evolution of diagnostic tests in HCV
Liver fibrosis assessment:
Serum markers of liver fibrosis:
• Fibrosure/Fibrotest gender, age, total bilirubin,
haptoglobin, ALT, GGT, alfa2‐macroglobulin,
and apolipoproteinA1.
• no data are available for the ESRD patients.
45. Evolution of diagnostic tests in HCV
Serum markers of liver fibrosis:
Limitations:
• AST levels are usually normal or mildly
elevated in HD patients and both APRI and
Fib‐4
• Heparin use during HD sessions may cause
possible thrombocytopenia, negatively
affecting the accuracy of APRI and Fib‐4.
46. Evolution of diagnostic tests in HCV
Liver fibrosis assessment:
Elastography techniques for assessment of liver
fibrosis (fibroscan):
• Diagnostic accuracy of TE was better than
APRI for fibrosis.
50. HCV and progression of ESRD
• HCV infection accelerate the progression of
CKD and the development of ESRD. even in
other renal diseases, including diabetic
nephropathy, HIV, and chronic GN
51. HCV and progression of ESRD
• treatment with interferon‐based therapy resulted
in a 58% reduction in incident CKD and an 84%
decreased risk of ESRD.
• HCV‐infected liver transplant recipients, antiviral
treatment, and SVR improved kidney function in
those with mild CKD.
52.
53. • The incidence of chronic HCV infection is between
64 and 103 million among people worldwide.
• Globally, HCV infection is still common in CKD
patients despite the advent of serologic screening and
better adherence to infection control.
54. • Evidence regarding the epidemiology of HCV in
CKD patients predialysis is much less abundant.
HCV is considered now a systemic disease associated
with both hepatic and extrahepatic manifestations.
55. • A large body of epidemiological evidence
regarding HCV infection among patients
undergoing maintenance dialysis in the
developed countries, prevalence rates have
been shown to range between 1.4% and 28.3%.
56.
57. • the epidemiology of HCV infection among
patients on chronic dialysis in developing
countries is partly explained by fewer studies ,
most of which have limited sample sizes .
prevalence rates between 4.7% and 41.9%
58.
59. • The adoption of several preventive measures has given way to
the possibility of reducing the prevalence of HCV infection
among patients on maintenance hemodialysis in the developed
world.
• HCV remains prevalent in the dialysis population, and
outbreaks of HCV infection continue to occur within dialysis
units.
• antiviral therapy of HCV is able to improve patient survival
and reduce the risk of dialysis in patients with advanced CKD.
60.
61. • There are currently 13 (FDA) approved DAAs
products for the treatment of HCV either as a single
agent or in combination with each other.
• Patients with CKD and an estimated GFR (eGFR) >
30 mL/min/1.73 m2 can be treated with any of these
regimens.
62. There are Four regimens used in patients with GFR
≤ 30 mL/min.:
• paritaprevir/ritonavir/ombitasvir/dasabuvir (PrOD)
• paritaprevir/ritonavir/ombitasvir (PRO)
• grazoprevir/ elbasvir (GZR/ELB)
• glecaprevir/pibrentasvir (G/P)
63.
64.
65.
66.
67.
68. SOFOSBUVIR‐BASED STUDIES IN CKD
• The low GFR group had a significantly higher rate of
cirrhosis, anemia and renal dysfunction.
• Viral response was high irrespective of eGFR, and
notably patients on hemodialysis had a sustained
virologic response (SVR12) also.
69. SOFOSBUVIR‐BASED STUDIES IN CKD
• The current AASLD and recently published KDIGO
guidelines: sofosbuvir‐based regimens are not
recommended in patients with an eGFR below 30
mL/min/1.73 m2.
70. PROD‐BASED (PARITAPREVIR/RITONAVIR/OMBITASVIR
+ DASABUVIR)STUDIES IN CKD
In stage 4 or 5 CKD, including those on hemodialysis.
• . The sustained virologic response rate was 90%.
• The SVR rate without RBV was also high, even in
genotype 1a patients.
• data from the ERCHIVES study demonstrating high SVR
rates, lower incidence of GFR decline with PrOD
regimen as compared with sofusbuvir‐based treatment.
71. GRAZOPREVIR AND ELBASVIR COMBINATION THERAPY
FOR HCVINFECTED CKD PATIENTS
• data using EBR/GZR for 12 weeks in a nonrandomized,
multicenter, nationwide observational survey in France
demonstrated high efficacy in HCV genotype‐1 or ‐4
infected patients with stage 4/5 CKD.
72. GLECAPREVIR AND PIBRENTASVIRCOMBINATION
TREATMENT IN CKD
• the EXPEDITION‐4 open label, single‐arm study the
clinical efficacy and safety of the pan‐genotypic
combination glecaprevir and pibrentasvir. for 12 weeks
was investigated in 104 treatment‐naïve and ‐experienced
patients HCV‐infected stage 4‐5 CKD patients.
• This regimen achieved an SVR12 rate of 98%.29 Adverse
events included fatigue (14%), and nausea (12%) which
was similar to the C‐SURFER trial.
73. • For advanced stage CKD patients with HCV strains
with viral resistance who do not achieve SVR12,
treatment options are currently limited. However, a
recent report suggested that the recently approved
pangenotypic glecaprevir/pibrentasvir combination is
a potentially useful salvage treatment for patients who
have failed prior DAA regimens.
74.
75. Epidemiology Of HCV Transmission Among HD Patients:
HD setting facilitates transmission of HCV through risk of blood
contamination of surfaces, objects and devices, treatment
simultaneously in a shared space.
The reported seroconversion rates are between 1.1% and 3.6%
per 100 patient‐years.
For all outbreaks, epidemiologic investigations must be
performed.
Investigations include (Usually, multiple findings are present):
interviews of dialysis facility staff.
Interviews of patients for HCV risk factors.
Review of patient charts.
Review and observation of infection control practices at the facilities
77. Recommendations For Prevention Of HCV Transmission
In Dialysis Facilities
Screening all patients for HCV AB upon admission.
HCV PCR for positive anti-body patients.
Positive HCV PCR to be referred for treatment.
Negative HCV AB to be screened every 6 months.
Negative HCV AB to be monitored for ALT monthly
and any unexplained rise should warrant HCV testing.
Any new HCV infections should be reported to local
public health agencies and steps be taken to prevent
further transmission of the virus.
78.
79. DAAs STUDIED IN ESRD PATIENTS
1. Sofosbuvir‐based regimens:
• Desnoyer et al.,: neither the parent drug nor its main
metabolite accumulated in patients treated with either daily
or three times a week dosing schedules; however, they did
find that the half‐life of the primary metabolite was
increased (38 vs 27 hours).
Nazario et al.,HCV-TARGET study
15 hemodialysis patients82 patients (Crcl: <45
ml/min)
Sample size
Sofosbuvir-based+ RBVSofosbuvir-based+ RBVTreatment used
100%85-90%SVR-12
015%Rise of serum creatinine
MinorCommonAnemia
80. • Simprevir/ Ledipasvir/ Velpatasvir :
Should be combined with sofosvubir.
Limited data.
Several case series (Effective, minimal adverse events).
More deterioration of kidney function with Ledipasvir.
• Daclatasvir:
Common combination with sofosbuvir.
Hepatic metabolism.
• Because sofosbuvir is cleared by the kidneys,
it is contraindicated in hemodialysis.
81. • 2. Ombitasvir‐paritaprevir‐ritonavir and dasabuvir:
• 3. Grazoprevir and elbasvir:
Less than 1% is renal excretion.
C‐SURFER trial: 235 (multi-center, double blinded), GT 1
The combination of grazoprevir/elbasvir to treat HCV GT 1
infected advanced CKD patients has minimal side effects, high
SVR rates and excellent quality‐of‐life outcomes.
RUBY IIRUBY I
18 CKD patients20 CKD patientsSample size
OMV/PTV/RTV/DOMV/PTV/RTV/D+RTreatment used
1, 4, 51, 4, 5Genotype
100%90%SVR-12
UncommonUncommonRise of serum creatinine
UncommonCommon with RBVAnemia
82. • 4. Glecaprevir/pibrentasvir:
EXPEDITION‐4 trial (multicenter, open-label, single arm)
proved the efficacy and safety of this combinations.
• AASLD and IDSA guidelines recommend one of the
following regimen to advanced renal impairment and
hemodialysis patients:
• Ombitasvir‐paritaprevir‐ritonavir and dasabuvir.
• Grazoprevir and elbasvir.
• Glecaprevir/pibrentasvir.
85. Epidemiology:
• >36 million world wide, 1.1 million American
residents.
• Increasing incidence among CKD, less than 1%
among HD.
• Co-infection with HCV among HIV, CKD
patients is common.
86. Risk factors for development of CKD among
HIV patients:
• Common with general population:
– African American race.
– Diabetes, hypertension, cardiovascular disease.
– Lower baseline GFR, and older age.
• Special for HIV patients:
– Unsuppressed HIV viral loads.
– Lower nadir CD4 count.
– Use of potentially nephrotoxic medications, such as
tenofovir.
87. HIV dialysis outcome
• American reports (Rodriguez et al., 2003) found short
survival of HIV patients especially if co-infected with
HCV.
• European reports (Tourret et al., 2006) and (Trullas t al.,
2011) showed better survival.
• The difference was explained by lower Africans among
European reports.
• Better outcome after the era of ART (Ahuja et al., 2011).
• Mono-infection is associated with better outcome than
combined infection (Swainski et al., 2018)
88. HIV kidney transplantation outcome
• The introduction of ART improved TX outcome (Kumar et
al., 2005).
• One-year graft and patient survival was the same among
HIV infected and HIV-free groups (Poland et al., 2008).
• Xia et al., performed “mate kidney” analysis: HIV/HCV
infection is associated with higher mortality than mono or
no infection.
• Despite inferior long‐term patient and allograft survival
among HIV/HCV coinfected recipients, when compared
with patients with HIV or HCV alone, kidney
transplantation provides a survival benefit over dialysis
(Locke et al., 2017)
89. HCV/HIV co-infection and liver disease:
• In HCV mono‐infected patients it takes several decades
for liver disease to progress to cirrhosis and end‐stage
liver disease (ESLD), but the time course is accelerated
in patients who have both HIV and HCV infection
(Thomson et al., 2011).
91. Treatment options for co-infection among hemodialysis
Timing for HIV treatmentHIV treatment optionHCV treatment option
After 3D completingRitonavir3D regimen
The same timeAtazanavir
Contraindicated (GIT upsets)Lopinavir
Contraindicated (prolonged QT interval)Rilpivirine
Drug interaction (CI)Any of the aboveElbasvir/grazoprevir
Contraindicated combinationsRitonavir, LopinavirGlecaprevir/pibrentasvir
HLEAtazanavir
92. Treatment options for co-infection among transplants
Timing for HIV treatmentHIV treatment optionHCV treatment option
Drug interaction with IS
(CI)
Any of them3D regimen
Increase Sof level (CI)RitonavirSofosbuvir
Increase Tenofovir level
(CI)
TenofovirSofosbuvir/velpatasvir
Monitor kidney functionTenofovirSofosbuvir/velpatasvir/voxilaprevir
Reduced Sof/Vel level (CI)Ritonavir
Dac dose adjustment
according to ART type
Any of themDaclatasvir
93.
94.
95.
96.
97. Summery and Guidelines
• The workgroup formulated guideline statements
that were rated as strong (level 1) or weak (level
2) based on the strength of evidence and other
considerations.
• The strength of the overall evidence that supports
each guideline statement was rated from high to
very low quality (A to D).
98. Summery and Guidelines
• Ungraded statements were used for statements
that provided guidance based on common sense,
standards of care, reminders of the obvious, or
were otherwise not sufficiently specific to allow
for application of evidence to the issue and
therefore were not based on systematic evidence
review.
99. Guideline 1: Detection and Evaluation of HCV in CKD
1.1: Screening patients with CKD for HCV infection
• 1.1.1: We recommend screening all patients for
HCV infection at the time of initial evaluation of
CKD (1C).
• 1.1.1.1: We recommend using an immunoassay
followed by nucleic acid testing (NAT) if
immunoassay is positive (1A).
• 1.1.2: We recommend screening all patients for
HCV infection upon initiation of in‐center
hemodialysis (HD) or upon transfer from another
dialysis facility or modality (1A).
100. Guideline 1: Detection and Evaluation of HCV in CKD
1.1: Screening patients with CKD for HCV infection
• 1.1.2.1: We recommend using NAT alone or an
immunoassay followed by NAT if immunoassay is
positive (1A).
• 1.1.3: We suggest screening all patients for HCV
infection upon initiation of peritoneal dialysis or
home HD (2D).
• 1.1.4: We recommend screening all patients for
HCV infection at the time of evaluation for kidney
transplantation (1A).
101. Guideline 1: Detection and Evaluation of HCV in CKD
1.2: Follow‐up HCV screening of in‐center HD patients
• 1.2.1: We recommend screening for HCV infection with
immunoassay or NAT in in‐center HD patients every 6
months (1B).
• 1.2.1.1: Report any new HCV infection identified in a HD
patient to the appropriate public health authority (Not
Graded).
• 1.2.1.2: In units with a new HCV infection, we recommend
that all patients be tested for HCV infection and the
frequency of subsequent HCV testing is increased (1A).
• 1.2.1.3: We recommend that HD patients with resolved
HCV infection undergo repeated testing every 6 months
using NAT todetect possible reinfection (1B).
102. Guideline 1: Detection and Evaluation of HCV in CKD
1.2: Follow‐up HCV screening of in‐center HD
patients
• 1.2.2: We suggest that patients have serum alanine
aminotransferase (ALT) level checked upon
initiation of in‐center HD or upon transfer from
another facility (2B).
• 1.2.2.1: We suggest that HD patients have ALT
level checked monthly (2B).
103. Guideline 2: Treatment of HCV infection in
patients with CKD
• 2.1: We recommend that all CKD patients infected
with HCV be evaluated for antiviral therapy (1A).
• 2.1.1: We recommend an interferon‐free regimen
(1A).
• 2.1.2: We recommend that the choice of specific
regimen be based on HCV genotype (and subtype),
viral load, prior treatment history, drug‐drug
interactions, glomerular filtration rate (GFR), stage
of hepatic fibrosis, kidney and liver transplant
candidacy, and comorbidities (1A).
• 2.1.3: Treat kidney transplant candidates in
collaboration with the transplant center to optimize
timing of therapy (Not Graded).
104. Guideline 2: Treatment of HCV infection in patients
with CKD
• 2.2: We recommend that patients with GFR ≥ 30
ml/min/1.73 m2 (CKD G1‐G3b) be treated with
any licensed direct‐acting antiviral (DAA)‐based
regimen (1A).
• 2.3: Patients with GFR < 30 ml/min/1.73 m2
(CKD G4‐G5D) should be treated with a
ribavirin‐free DAA‐based regimen
105. Guideline 2: Treatment of HCV infection in patients
with CKD
• 2.4: We recommend that all kidney transplant
recipients infected with HCV be evaluated for
treatment (1A).
• 2.4.1: We recommend treatment with a DAA‐based
regimen (1A).
• 2.4.2: We recommend that the choice of regimen be
based on HCV genotype (and subtype), viral load,
prior treatment history, drug-drug interactions, GFR,
stage of hepatic fibrosis, liver transplant candidacy,
and comorbidities (1A).
• 2.4.3: We recommend avoiding treatment with
interferon (1A).
106. Guideline 2: Treatment of HCV infection in patients
with CKD
• 2.4.4: We recommend pretreatment assessment for
drug‐drug interactions between the DAA‐based
regimen and other concomitant medications
including immunosuppressive drugs in kidney
transplant recipients (1A).
• 2.4.4.1: We recommend that calcineurin inhibitor
levels be monitored during and after DAA
treatment (1B).
107. Guideline 2: Treatment of HCV infection in patients
with CKD
• 2.5: All treatment candidates should undergo
testing for HBV infection prior to therapy (Not
Graded).
• 2.5.1: If hepatitis B surface antigen [HBsAg] is
present, the patient should undergo assessment for
HBV therapy (Not Graded).
• 2.5.2: If HBsAg is absent but markers of prior
HBV infection (HBcAb‐positive with or without
HBsAb) are detected, monitor for HBV
reactivation with serial HBV DNA and liver
function tests during DAA therapy (Not Graded).
Editor's Notes
Aasld… american association for the study of liver disease
Erchives:electronically retrieved cohort of hcv infected veterans
Aasld… american association for the study of liver disease
Erchives:electronically retrieved cohort of hcv infected veterans