Sriwijaya Journal of Internal Medicine

Efficacy and Safety of Recombinant Activated Factor VII versus Activated Prothrombin Complex Concentrate for Bleeding Control in Acquired Haemophilia A: A Systematic Review and Meta-Analysis

I Made Bayu Indratama — 2026-05-15

Introduction: Acquired haemophilia A is a rare autoimmune coagulopathy with reported mortality of 3.3 to 22 per cent, in which uncontrolled haemorrhage is the principal cause of early death. International guidelines have endorsed both recombinant activated factor VII and activated prothrombin complex concentrate as first-line bypassing therapy without explicit preference, yet the comparative efficacy of these two agents has not previously been quantified by formal meta-analysis.

Methods: A systematic review and random-effects meta-analysis was conducted in line with the PRISMA 2020 guideline. PubMed/MEDLINE, Scopus, and Web of Science Core Collection were searched on 1 May 2026 for primary cohort, registry, and observational comparative studies of adults with acquired haemophilia A treated with recombinant activated factor VII (rFVIIa) or activated prothrombin complex concentrate (aPCC). Bleeding-control proportions per arm were converted to Hedges g via the Cox–Hasselblad–Hedges transformation, and were pooled under DerSimonian–Laird and restricted maximum-likelihood random-effects models. As co-primary metrics, pooled risk ratio and pooled risk difference were computed. Risk of bias was appraised with a modified Newcastle–Ottawa Scale, and certainty of evidence was rated with GRADE.

Results: Ten primary studies were retained for qualitative synthesis and nine of these were eligible for quantitative meta-analysis (916 patient-arm data points; rFVIIa arm n = 531; aPCC arm n = 385). Bleeding control was achieved in 474 of 531 patients (89.27 per cent) treated with rFVIIa and 343 of 385 patients (89.09 per cent) treated with aPCC. The pooled Hedges g was 0.026 (95 per cent confidence interval −0.232 to +0.285; p = 0.84). The pooled risk ratio was 1.00 (95 per cent confidence interval 0.95 to 1.06) and the pooled risk difference was +0.18 percentage points (95 per cent confidence interval −4.5 to +4.6). Heterogeneity was low (I² = 5.8 per cent; τ² = 0.009). Findings were robust across leave-one-out, EACH2-restricted, regional, design, and quality-stratified subgroup analyses. The certainty of evidence was rated low.

Conclusion: rFVIIa and aPCC produced clinically equivalent bleeding-control rates in adults with acquired haemophilia A. Selection should be informed by availability, acquisition cost, and individual safety profile rather than by presumed efficacy advantage of either agent.

Omalizumab in Reducing Exacerbation Rate and Oral Corticosteroid Burden in Allergic Bronchopulmonary Aspergillosis: A Systematic Review and Meta-Analysis

Harry Yuseptian — 2026-05-25

Introduction: Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity disorder complicating severe asthma and cystic fibrosis. Systemic corticosteroids, the mainstay of treatment, carry substantial cumulative toxicity, and the steroid-sparing role of the anti-immunoglobulin E (IgE) antibody omalizumab remained incompletely defined, particularly in South-East Asia where ABPA is under-recognised. We aimed to synthesise the most recent evidence on omalizumab in reducing exacerbations and oral corticosteroid (OCS) burden in adults with ABPA.

Methods: Following the PRISMA 2020 statement, six databases were searched for original studies enrolling at least ten ABPA patients treated with omalizumab. Standardised mean differences (Hedges' g) were pooled using a DerSimonian-Laird random-effects model with the Hartung-Knapp-Sidik-Jonkman correction. Risk of bias, subgroup, sensitivity and meta-regression analyses, and the GRADE certainty of evidence were assessed.

Results: Ten studies (n = 286) were qualitatively synthesised; eight (n = 241) entered the quantitative pool. Omalizumab produced a moderate-to-large favourable composite effect (Hedges' g = -0.69; 95% CI -1.12 to -0.25; p = 0.007). Outcome-specific pooling confirmed reduced exacerbations (g = -0.74), reduced OCS dose (g = -0.81), and improved FEV1 (g = +0.48) and asthma control (g = +0.69), corresponding to approximately 1.9 fewer exacerbations per year and 9 mg/day prednisolone equivalent. Heterogeneity was substantial (I-squared = 78.4%) but the effect was robust across leave-one-out and sensitivity analyses.

Conclusion: Omalizumab confers a clinically meaningful steroid-sparing benefit in adults with ABPA, supporting its adoption as maintenance therapy, pending adequately powered randomised trials in South-East Asian populations.

Vancomycin Plus Piperacillin–Tazobactam Versus Vancomycin Plus Cefepime and the Risk of Acute Kidney Injury in Hospitalised Adults: A Meta-Analysis

Putri Indah Permata — 2026-06-03

Introduction: Vancomycin with piperacillin–tazobactam is a common empirical regimen but may increase acute kidney injury (AKI) risk. Because vancomycin is common to most comparisons, the cleanest test of the piperacillin–tazobactam effect is a head-to-head comparison against vancomycin plus cefepime. This meta-analysis quantified the association between the two regimens and AKI in hospitalised adults.

Methods: PubMed/MEDLINE, Scopus and Web of Science were searched for comparative cohort studies and randomised trials in adults reporting AKI with vancomycin plus piperacillin–tazobactam versus vancomycin plus cefepime. Risk of bias was appraised with ROBINS-I and certainty with GRADE. Odds ratios (OR) were pooled using a DerSimonian–Laird random-effects model; heterogeneity (I²), a prediction interval, leave-one-out analysis and the Egger test were computed.

Results: Ten cohort studies were eligible and nine (>11,000 adults) were pooled. Piperacillin–tazobactam was associated with significantly higher odds of AKI (pooled OR 1.90, 95% CI 1.43–2.52; p<0.001; I²=81%). The prediction interval (0.77–4.69) was wide, and the result was robust to leave-one-out analysis (OR 1.71–2.06). The number needed to harm ranged from about 15 to about 8 across baseline incidences of 9% to 21%. The Egger test suggested small-study effects (p=0.04); certainty was graded low.

Conclusion: In hospitalised adults, vancomycin plus piperacillin–tazobactam was associated with roughly twofold higher odds of AKI than vancomycin plus cefepime; where both regimens are appropriate, cefepime may be the safer renal companion.

Platelet-to-Lymphocyte Ratio as a Predictor of Exacerbation Severity and Hospital Length of Stay in Acute Exacerbation of COPD: A Dual-Center Study in West Sumatra, Indonesia

Herry Saputra Yunior — 2026-06-17

Introduction: Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a leading driver of morbidity, mortality and health-care expenditure, and simple admission biomarkers that grade severity are needed in resource-limited settings. The platelet-lymphocyte ratio (PLR) integrates thrombo-inflammation and relative lymphopenia, yet Indonesian evidence linking it to exacerbation severity and length of stay (LOS) remains limited.

Methods: In this dual-center analytical cross-sectional study, 141 hospitalized AECOPD patients at Dr. M. Djamil General Hospital, Padang and RS Madina Bukittinggi (January-December 2024) were analyzed. Admission PLR was related to Anthonisen exacerbation severity and LOS (>7 days) using Kruskal-Wallis and Mann-Whitney tests, Spearman correlation, receiver-operating-characteristic (ROC) analysis and multivariable logistic regression (adjusted odds ratios, aOR).

Results: Most patients were male (86.5%), aged 40-70 years (56.0%) and heavy smokers (87.5%). Mean PLR increased across severity strata (mild 126.8±40.8, moderate 192.3±69.1, severe 444.9±241.7; p<0.001) and correlated moderately with severity (ρ=0.534, p<0.001) but weakly with LOS (ρ=0.295). PLR discriminated severe exacerbation with excellent accuracy (AUC 0.929, 95% CI 0.874-0.985; cut-off ≥216.3, sensitivity 100.0%, specificity 73.2%, accuracy 89.6%) but predicted LOS poorly (AUC 0.566, p=0.273). After adjustment, PLR independently predicted severe exacerbation (aOR 3.73 per 50 units, 95% CI 1.87-7.42, p<0.001; Nagelkerke R2=0.642), whereas prolonged stay was driven by pneumonia (aOR 6.40, 95% CI 2.50-16.37, p<0.001) rather than PLR (aOR 1.15, p=0.139).

Conclusion: Admission PLR is an inexpensive, widely available biomarker that accurately identifies severe AECOPD and may support early risk stratification, although it should not be used alone to predict length of stay, which is governed chiefly by comorbidity.

Fatal Severe Community-Acquired Pneumonia with Sputum Retention in a 19-Year-Old Woman with Post-Poliomyelitis Syndrome: A Case Report

Thanisya Nabila Muthiarifa — 2026-06-22

Introduction: Post-poliomyelitis syndrome (PPS) is a late complication of paralytic poliomyelitis in which progressive failure of enlarged motor units extends to the respiratory muscles, eroding ventilatory reserve and the capacity to clear airway secretions. Fatal pneumonia in a young adult with PPS is rarely documented; we describe such a case to highlight the role of diminished respiratory reserve and sputum retention.

Case presentation: A 19-year-old Indonesian woman with childhood paralytic poliomyelitis, generalized atrophy, thoracolumbar scoliosis, and pectus carinatum presented with one hour of acute dyspnoea preceded by three days of productive cough and fever. She was febrile (38.8 C), tachypnoeic, and hypoxaemic (PaO2 58 mmHg; SpO2 93% on room air), with bilateral crackles, severe leukocytosis (30,100/microL), mild anaemia (haemoglobin 9.0 g/dL), and Gram-positive cocci on sputum microscopy. Despite empirical antibiotics, bronchodilators, mucolytics, fluids, and oxygen, she deteriorated within 24 hours, requiring intubation and mechanical ventilation; repeat blood gas showed a profound metabolic acidosis (pH 6.914, base excess -26.5 mmol/L). She developed vasopressor-dependent septic shock with multi-organ failure and died on the sixth hospital day.

Conclusion: The diminished respiratory reserve, ineffective cough, and impaired airway clearance intrinsic to PPS can convert an otherwise moderate community-acquired pneumonia into rapidly fatal respiratory failure and septic shock; such pneumonia warrants early severity stratification, aggressive airway clearance, and a low threshold for ventilatory support.

Severe Thalassemia Bone Disease in a Young Woman with Transfusion-Dependent β-Thalassemia Major: Erlenmeyer Flask Deformity, Muscular Hemosiderin Deposition, and Profound Osteoporosis — A Case Report

Putu Arya Nugraha — 2026-06-24

Introduction: Beta-thalassemia major (β-TM) is a chronic transfusion-dependent hemolytic disorder in which thalassemia bone disease (TBD) is among the most frequent and least resolved long-term complications, driven by ineffective erythropoiesis with marrow expansion, iron-overload toxicity, and endocrine and nutritional deficiencies.

Case Presentation: We report a 27-year-old woman with β-TM diagnosed at the age of two years and a long history of iron overload, who presented with severe, movement-limiting pain of the right lower limb that had been intermittent since 2019 and acutely worsened over the preceding month. She had a documented hypersensitivity to deferasirox and was maintained on deferiprone. Examination revealed clinical anemia, hepatosplenomegaly, and a spontaneously painful, immobile right lower limb. Investigations confirmed hypochromic microcytic anemia (hemoglobin 5 g/dL), elevated ferritin, and low calcium and vitamin D levels. Pelvic radiography showed diffuse osteopenia; femoral radiography showed widening of the medullary cavity with an Erlenmeyer flask deformity; and magnetic resonance imaging revealed extensive hemosiderin deposition throughout the visualized bone and within the right rectus femoris muscle. Dual-energy X-ray absorptiometry showed a lowest Z-score of −3.5 at the left forearm, confirming profound, below-expected bone mineral density for age.

Conclusion: This case highlights the diagnostic and therapeutic complexity of advanced TBD — structural deformity, soft-tissue iron deposition, and profound osteoporosis compounded by chelation-limited iron control — and underscores the necessity of an urgent, individualized, multidisciplinary approach.

Corticosteroid Therapy and the Risk of Kidney Failure in IgA Nephropathy: A Dose- and Ethnicity-Stratified Meta-Analysis of Randomised Controlled Trials

Festi Eliza — 2026-07-09

Introduction. Corticosteroids are widely used in IgA nephropathy, but their net benefit is contested because the largest trials show both protection against kidney-function decline and excess serious infection; the optimal dose and consistency across ethnic groups are uncertain. This study was aimed to quantify the effect of systemic corticosteroids on the risk of kidney failure in IgA nephropathy and to explore modification by dose and ethnicity (PICO: biopsy-proven IgA nephropathy; systemic corticosteroids with or without renin-angiotensin system blockade; supportive care or placebo; kidney failure and proteinuria).

Methods. Four databases were searched from inception for randomised controlled trials. Risk ratios (RR) were pooled with a DerSimonian-Laird random-effects model and proteinuria as Hedges’ g; heterogeneity was assessed with I² and a prediction interval, bias with RoB 2 and the Egger test, and certainty with GRADE. The review was not registered.

Results. Ten non-overlapping trials (1,153 participants; 104 vs 165 events) were included. Corticosteroids reduced the risk of kidney failure (RR 0.61, 95% CI 0.42–0.90; I² = 21%; p = 0.012), remaining significant under the Hartung-Knapp correction (0.39–0.97); a dose subgroup difference was significant (p = 0.010, larger effect with high-dose regimens). Proteinuria fell moderately (Hedges’ g −0.68, −1.00 to −0.35). Serious infection was more frequent with corticosteroids.

Conclusion. Corticosteroids reduce kidney failure and proteinuria but increase serious infection; a reduced-dose strategy preserves benefit while improving safety, supporting individualised, risk-stratified use.

Calcineurin Inhibitor–Based versus Cyclophosphamide-Based Immunosuppression for Primary Membranous Nephropathy: A Meta-Analysis of Remission and Relapse

Ligat Pribadi Sembiring — 2026-07-09

Introduction. Primary membranous nephropathy (MN) is a leading cause of the nephrotic syndrome in adults. Calcineurin inhibitor (CNI)-based and cyclophosphamide-based regimens are both endorsed as first-line therapy, but their comparative efficacy and the durability of the remission they induce remain uncertain. This study was aimed to compare CNI-based versus cyclophosphamide-based regimens for total remission, complete remission and relapse in adults with primary MN.

Methods. PubMed/MEDLINE, with Scopus and Web of Science indexing checks and manual reference screening, was searched for randomised controlled trials (RCTs) comparing a CNI-based regimen (tacrolimus or cyclosporine) with a cyclophosphamide-based regimen. Risk ratios (RRs) were pooled with a DerSimonian–Laird random-effects model; heterogeneity was quantified with I². Risk of bias used the Cochrane RoB 2 tool. The review was not registered.

Results. Nine RCTs (eleven articles; 599 participants) were included. Total remission did not differ between strategies (RR 1.02, 95% CI 0.86-1.20; I²=67%; 95% prediction interval 0.61-1.72; CNI 222/297 versus cyclophosphamide 215/302). Complete remission did not differ (RR 0.84, 95% CI 0.34-2.04). Relapse tended to be more frequent after CNI-based therapy (RR 1.76, 95% CI 0.95-3.24; I²=0%) without reaching significance. Estimates were stable across all sensitivity analyses (RR 0.91-1.11) and no small-study effect was detected (Egger p=0.87).

Conclusion. CNI-based and cyclophosphamide-based regimens produced comparable remission in primary MN; a non-significant signal towards more frequent relapse after CNI therapy supports individualised, durability- and toxicity-aware treatment selection.

The Many Faces of Expanded Dengue Syndrome: A Two-Case Series of Renal and Hepatic–Neurological Organ Involvement in Adult Patients

Putu Nindya Ayu Ningrum Subadra — 2026-07-10

Introduction: The rising global incidence of dengue has been accompanied by increasing recognition of atypical, organ-dominant presentations collectively termed expanded dengue syndrome (EDS), in which severe involvement of the liver, kidney, heart, lung or central nervous system dominates the clinical picture and drives mortality. We describe two adult men who illustrate contrasting EDS phenotypes.

Case presentation: Case I, a 30-year-old man with serologically confirmed secondary dengue infection (IgM-negative, IgG-positive), presented with gross haematuria, dysuria and warning signs and developed acute kidney injury (oliguria, rising creatinine, proteinuria, marked erythrocyturia) superimposed on leucopenia, severe thrombocytopenia and haemoconcentration; he recovered fully with carefully titrated crystalloid and renoprotective measures. Case II, a 23-year-old man with a primary infection, deteriorated on the sixth day with agitated delirium and acute liver failure (transaminases exceeding 100 times the upper limit, hyperbilirubinaemia, coagulopathy, hypoalbuminaemia) complicated by hepatic encephalopathy; he improved with supportive care, electrolyte correction and multidisciplinary management.

Conclusion: EDS may arise from either secondary or primary infection, and organ dysfunction tends to resolve in step with the natural history of dengue. Meticulous fluid stewardship stratified by clinical group, with systematic evaluation for intensive-care needs using clinical, laboratory and imaging parameters, is the cornerstone of management. Early recognition of organ-specific complications is essential to reduce preventable morbidity and mortality.