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    Table of Contents - Current issue
Coverpage
September-October 2017
Volume 28 | Issue 5
Page Nos. 983-1214

Online since Thursday, September 21, 2017

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EDITORIAL  

The story of the first deceased donor kidney donation in Saudi Arabia – by a firsthand witness Highly accessed article p. 983
Abdulla Ahmed Al-Sayyari
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REVIEW ARTICLE Top

The importance of bone biopsy in chronic kidney disease–Mineral bone disorders p. 992
Periklis Dousdampanis, Kostantina Trigka
Renal osteodystrophy (ROD) is not a uniform bone disease; it is a heterogeneous group of metabolic bone diseases due to chronic kidney disease (CKD). The traditional term of ROD does not accurately include the wide spectrum of “CKD–mineral and bone disorder” (CKD–MBD) and has been restricted to define the several specific histologic disturbances of bone disease associated with CKD. Circulating parathyroid hormone (PTH) and total alkaline phosphatase levels do not always reflect bone turnover in CKD–MBD, whereas bone biopsy provides precise information regarding bone pathology. Given the lack of specificity of several biomarkers and noninvasive tools regarding ROD, bone biopsy is required for precise diagnosis and for the determination of therapeutic strategies. In clinical practice, bone biopsy is not performed due to lack of enthusiasm among nephrologists for several reasons including the invasiveness of the procedure, the potential pain, and lack of technical training. Since the application of bone biopsy in clinical practice is unrealistic, several biomarkers with specificity for bone disease should be studied.
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ORIGINAL ARTICLES Top

Association between apolipoprotein E polymorphism and nephropathy in Iranian diabetic patients p. 997
Mostafa Karimoei, Parvin Pasalar, Mohsen Mehrabzadeh, Maryam Daneshpour, Maryam Shojaee, Katayoun Forouzanfar, Farideh Razi
Approximately one-third of diabetic patients develop evidence of nephropathy. Pathogenesis of diabetic nephropathy (DN) remains unclear; however, some genetic and metabolic risk factors have been determined for the development and progression of DN. In the recent genetic studies, polymorphism of apolipoprotein E (ApoE) gene has been reported as a risk factor for the development of DN; however, the results are inconsistent. The aim of the present study was to evaluate the association between ApoE polymorphism and nephropathy in Iranian patient with type 2 diabetes. A total of 197 patients with type 2 diabetes in two groups with and without nephropathy (n = 99 and n = 98, respectively) participated in this case–control study. ApoE genotype was determined by restriction fragment length polymorphism analysis. Biochemical factors of all patients were measured. The frequency of Apo ε4 allele was significantly (P <0.05) lower in DN patients (10.6%) than in diabetic patients without nephropathy (20.4%). No significant difference was observed between the groups regarding Apo ε2 and Apo ε3 allele frequencies. Serum level of total and low-density lipoprotein cholesterol in Apo ε2 carriers was lower than Apo ε3 and Apo ε4 carriers, but this difference was not statistically significant. Frequency of Apo ε4 allele is higher in diabetic patients without nephropathy than DN participants. Given to the result, it seems that Apo ε4 has a protective effect in diabetic patients against nephropathy.
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Serum cystatin C as an earlier predictor of acute kidney injury than serum creatinine in preterm neonates with respiratory distress syndrome p. 1003
Noha Ahmed Abdelaal, Sherein Abdelhamid Shalaby, Abdelmoneim Kassem Khashana, Amina Mohamed Abdelwahab
In this study, we aimed to evaluate serum cystatin C (sCysC) as an early predictor of acute kidney injury (AKI) in preterm neonates with respiratory distress syndrome (RDS). Sixty preterm neonates diagnosed with RDS and 40 healthy controls (28–36 weeks) admitted to the neonatal Intensive Care Unit were investigated. AKI was defined on the 3rd day of life (DOL-3) as an increase in serum creatinine (sCr) of >0.3 mg/dL from baseline (the lowest previous sCr). sCysC levels were measured on DOL-1, -3 and -7. Of the 60 neonates with RDS, 24 (40%) developed AKI. Five patients (79.17%) were classified as AKI Network (AKIN-1) and 19 patients (20.83%), as AKIN-2. At DOL-3, the mean sCysC values were significantly higher among neonates with RDS and AKI (1.68 ± 0.37) compared with controls (0.79 ± 0.83) and those with RDS and no AKI (0.85 ± 0.20) (P <0.001). sCysC levels significantly increased among neonates with AKI from DOL-3 to DOL-7 (P = 0.002). The sCr values showed no significant difference between those with RDS with AKI, RDS, and no AKI or control groups at DOL-1 and -3. Only as late as DOL-7, the mean values of sCr were higher among neonates with AKI compared with no AKI and controls (P <0.001). The receiver operating characteristic curves area under the curve was 0.97 for predicting the development of AKI within 72 h (P = 0.001). With the best cutoff value of ≥1.28 mg/L, the sensitivity and specificity of sCysC for detecting AKI within 72 h were 100 and 83.3%, respectively. In conclusion, sCysC is an early marker for AKI in neonates with RDS.
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Outcome of childhood lupus nephritis in Saudi children p. 1015
Sulaiman Mohammed Al-Mayouf, Ali AlAmeer, Areej Alfattani, Abdullah Alsonbul
Our aim in this study is to report the long-term renal outcome of a cohort of Saudi children with systemic lupus erythematosus (SLE). All patients with childhood lupus nephritis (cLN) proved by renal biopsy seen between January 2000 and June 2015 were reviewed. The renal outcome was assessed according to serum creatinine level, protein/creatinine ratio at the last follow-up visit, and/or evidence of renal impairment during follow-up period and end-stage renal disease (ESRD). Additional outcome measures include accrual damage measured by pediatric adaptation of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (pSDI), and death related to SLE was determined. A total of 84 (72 females) cLN patients with follow-up duration of 9.3 years (±5.2) were included in this study. The mean current age was 19.4 years (±5.5) and mean age at onset was 9.2 years (±2.4). The most frequent histopathological class was proliferative glomerulonephritis (64.3%) followed by membranous nephritis (27.4%). The mean activity and chronicity indices were 5.9 (±3.9) and 2.9 (±2.2), respectively. Renal microthrombosis was found in 9 (10.7%) patients. All patients treated with immunosuppressive medications; cyclophosphamide used in 64 followed by mycophenolate mofetil in 42, then azathioprine in 19 patients, while rituximab used in 24 patients. At the last follow-up visit, the mean serum creatinine was 147 umol/L (±197) and the mean protein/ creatinine ratio was 0.8 (± 1.1) while the mean total pSDI was 1.9 (±1.9) and mean renal SDI was 0.7 (±1.1). Sixteen (19%) patients had ESRD and eight of them had class IV nephritis. However, there was no significant difference in ESRD by histological class. The overall survival rates were five years: 94% and 10 years: 87%. Infection was the leading cause of mortality. Our patients had severe cLN and required intensive treatment. Despite the survival rate is comparable to other studies, ESRD is more frequent and this may be attributed to genetic or ethnic factors.
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Epidemiology of human leukocyte antigens among omani population p. 1021
Issa Al Salmi, Abdul Massiah Metry, Faisal Al Ismaili, Alan Hola, Faissal Shaheen, Hana Fakhoury, Suad Hannawi
Oman is located on the Southeastern coast of the Arabian Peninsula, and its population has high levels of consanguinity. Human leukocytic antigen (HLA) typing analysis in human population holds unexploited potential for elucidating the genetic causes of human disease and possibly leads to personalized medicine. This is a retrospective, descriptive study evaluating HLA frequencies of Omani individuals who underwent workup for kidney transplantation at the Royal Hospital (RH) from 2005 to 2016. Data on 870 subjects were collected from the Oman kidney transplant registry at RH as well from electronic medical record system. The mean age (standard deviation) years for the cohort were 33.2 (13.0). Males constituted 56.3% (490) while females constituted 43.7% (380). Seven HLA-A alleles accounted for more than 70% of the total alleles. Of which, HLA-A2 contributed the highest frequency (24%), followed by HLA A11 (9.4%), and A32 (8.1%). Ten alleles accounted for 70% of HLA-B alleles. Of which, HLA-B51 was the most common (18.9%), followed by HLA-B-35 (13.6%), and HLA-B8 (7.9%). Seven HLA-DRB1 alleles accounted for more than 70% of the total HLA DRB1 alleles, of which HLA- DRB1*16 contributed the highest frequency (29.56%). This was followed by HLA-DRB1*03 (14.57%) and HLA-DRB1*11 (9.48%). While three alleles accounted for more than 75% of the total HLA DQB1alleles. Of which, HLA-DQB1*05 contributed the highest frequency (37.56%). This was followed by allele HLA-DQB1*02 (26.48%) and HLA-DQB1*03 (17.18%). This study showed considerable heterogeneity in both HLA Class I and Class II antigens, which reflects admixture of our population with rest of old world countries. Despite the high levels of consanguinity, this population is genetically highly heterogeneous. These findings may be useful for transplantation programs, noncommunicable diseases, epidemiology of HLA linked diseases, pharmacogenomics, and anthropology.
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The effect of an educational program for vascular access care on nurses’ knowledge at dialysis centers in Khartoum State, Sudan p. 1027
Kalthoum Ibrahim Yousif, Hasan Abu-Aisha, Omar Ibrahim Abboud
End-stage renal disease is a worldwide problem that requires highly skilled nursing care. Hemodialysis (HD) is a corner-stone procedure in the management of most patients who require renal replacement therapy. Adequate vascular access is essential for the successful use of HD. Appropriate knowledge in taking care of vascular access is essential for minimizing complications and accurately recognizing vascular access-related problems. This study was to evaluate the effect of an educational program for vascular access care on nurses’ knowledge at nine dialysis centers in Khartoum State. This was a Quasi experimental study (pre-and post-test for the same group). Sixty-one nurses working in these HD centers were chosen by simple random sampling method. A structured face-to-face interview questionnaire based on the Kidney Dialysis Outcome Quality Initiative (K/DOQI) clinical practice guidelines for vascular access care was used. Instrument validity was determined through content validity by a panel of experts. Reliability of the instrument was tested by a pilot study to test the knowledge scores for 15 nurses. The Pearson correlation coefficient obtained was (r = 0.82). Data collection was taken before and after the educational intervention. A follow-up test was performed three month later, using the same data collection tools. Twenty-two individual variables assessing the knowledge levels in aspects related to the six K/DOQI guidelines showed improvement in all scores of the nurses’ knowledge after the educational intervention; and the differences from the preeducational scores were statistically significant (P < 0.001). The study showed that a structured educational program based on the K/DOQI clinical practice guidelines had a significant impact on the dialysis nurses knowledge in caring for vascular access in HD patients. The knowledge level attained was maintained for at least three months after the educational intervention.
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Repercussions of eosinophils in a renal allograft - Predictor of early graft loss! p. 1034
Aruna V Vanikar, Kamal V Kanodia, Rashmi D Patel, Kamlesh S Suthar, Lovelesh A Nigam, Umang G Thakkar, Himanshu V Patel, Vivek B Kute, Hargovind L Trivedi
We present 5-year experience of renal transplantation (RT) with tissue eosinophilia (TE) in renal allograft biopsy (RAB) and its repercussions on the outcome. In total, 1217 recipients underwent RT from 2011 to 2015, and they were evaluated for the presence of ≥4% TE. Group 1 consisted of RT with RAB showing TE, Group 2 consisted of RT with RAB with rejections without TE, and Group 3 consisted of RT without rejections. Group 1 had 27 recipients, Group 2 had 395, and Group 3 had 795 recipients. The outcome in terms of graft function, patient and graft survival were evaluated and compared between three groups. All recipients received standard triple immunosuppression. One-year patient and death-censored graft survival were 80.7% and 82.7% in Group 1, 87.2% and 95.1% in Group 2, and 92.6% and 99.6%, respectively in Group 3 and corresponding mean serum creatinine (SCr, mg/dL) was 1.60 ± 0.45 in Group 1, 1.63 ± 0.58 in Group 2, and 1.19 ± 0.39 Group three, respectively. Five-year patient and death-censored graft survival were 72.9 % and 71.1% for Group 2 and 87% and 98.2% for Group 3 with SCr of 1.63 ± 0.38 and 1.25 ± 0.4, respectively. Group 1 recipients did not appear at five years. At four years posttransplant, patient and death-censored graft survival were 71.7% and 59.5% in Group 1 with SCr of 1.55 ± 0.65 mg/dL. In conclusion, the presence of eosino-phils in a renal allograft is an impending sign of graft damage and eventual graft loss.
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Long-term evaluation of kidney function in live-related kidney donors Highly accessed article p. 1041
Kalpana S Mehta, Rudramani Swami, Atim Pajai, Sandip Bhurke, Abhishek Shirkande, Sunil Jawle
The consequences of live kidney donation on the donor health with main emphasis on postdonation blood pressure (BP), proteinuria, kidney size, and glomerular filtration rate (GFR) were evaluated. Twenty-five donors with minimum of six months postdonation duration were included in the study. Donor age at nephrectomy, duration postnephrectomy, systolic and diastolic BP measurement pre-and post-donation, postdonation, blood urea nitrogen, serum creatinine and 24-h proteinuria, blood sugar, two-dimensional echocardiogram were recorded. Kidney sizes pre-and post-donation were noted. GFR was calculated by chronic kidney disease epidemiology collaboration and modification of diet in renal disease formula and measured by diethylene triamine pentaacetic acid renogram in all donors pre-and post-donation. Twenty-one (84%) were female, and four (16%) were male. The mean age at donation was 46.24 ± 9.62 (28–65) years. Median duration postdonor nephrectomy was 26 (minimum 7 and maximum 228) months. There was a mean rise of 6.24 mm Hg in systolic and 4.20 mm Hg diastolic BP (P = 0.001). Remnant kidney size increased from 35.12 ± 6.80 to 42.32 ± 8.59 sq cm (P <0.0001). There was reduction of postdonation GFR from 94.50 ± 18.12 mL/min to 60.48 ± 14.32 mL/min after nephrectomy (P <0.0001). There was significant increase in remnant kidney GFR from 48.83 ± 7.79 mL/min to 60.48 ± 14.32 mL/min (P <0.0001). Two donors had hypertension postdonation while 23 did not. No donor developed postdonation proteinuria. A significant increase in the kidney size and GFR was evident in remnant native kidney in all. No mortality was observed.
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Cryotherapy intervention in relieving arteriovenous fistula cannulation-related pain among hemodialysis patients at the King Khalid Hospital, Tabuk, Kingdom of Saudi Arabia p. 1050
Hamad S Al Amer, Wireen Leila Dator, Hamzeh Y Abunab, Mohammad Mari
Pain during arteriovenous fistula (AVF) cannulation remains a common problem in hemodialysis (HD) patients that leads to noncompliance to lifetime maintenance HD. This study was performed to determine the effect of cryotherapy on reducing pain during AVF cannulation among HD patients in the King Khalid Hospital, Tabuk, Kingdom of Saudi Arabia. This is an experimental study which included 62 patients undergoing HD through an AVF. Randomization was used to assign the patients into the experimental (received cryotherapy) and control (no cryotherapy) groups. The Arabic version of Wong-Baker pain rating scale was used to determine the pain score. There was a significant difference in the pre-and post-intervention pain scores among the experimental group, while there was no such difference in the control group. The null hypothesis was rejected based on a P <0.05. Our study suggests that cryotherapy intervention to relieve AVF cannulation-related pain among adult patients undergoing HD is effective. Therefore, it is recommended that cryotherapy should be considered as a complementary intervention to reduce pain related to AVF cannulation.
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A “Mini-Epidemic” of anti-glomerular basement membrane disease: Clinical and epidemiological study p. 1057
Umesh Lingaraj, Shivaprasad Sasivehalli Mallappa, Rajiv Elkal Neminah, Satishkumar Madakala Mohan, Leelavathi Venkatesh, Sreedhara Chikkanayakanahalli Gurusiddaiah, Niranjan Manibally Rachaiah
Acute glomerulonephritis due to anti-glomerular basement membrane (anti-GBM) antibody disease is rare, estimated to occur in fewer than one case per million population and accounts for less than 20% of rapidly progressive glomerulonephritis. The prevalence among patients evaluated for potential glomerular disease is lower. It accounts for fewer than 3% of all kidney biopsies done with crescentic glomerulonephritis. Cases of anti-GBM disease occurring in a cluster have rarely been reported. All biopsy proven anti-GBM disease cases were collected from January 2015 to March 2015 at our Institute. All cases were analyzed for demographic and clinical profile, pathological findings, treatment received and for any common environmental antigenic source. A total of 11 new biopsy proven anti-GBM cases were seen within a span of three months. Age group varied from 17–80 years. Seven were males and four were females. All were dialysis dependent at presentation. Seven had active cellular crescents, and four had fibrocellular. Only one patient was a smoker and none had a history of exposure to any forms of hydrocarbons. The peak seen from January 2015 to March 2015 does not correlate with any of seasonal occurrence of infections in southern India. Although there was clustering of cases to southern territories of Karnataka state, no common etiological agents could be identified. No patient had any previous urological surgeries. All patients received methylprednisolone with plasmapheresis 5–7 sessions and cyclophosphamide. All 11 patients were dialysis dependent at the end of three months. We conclude anti-GBM disease cannot be regarded as a rare cause of renal failure and lung hemorrhage. The occurrence of such epidemic within a short period suggests a possible unidentified environmental factor like infection or occupational agents as inciting agents. Identification of such inciting agents could help us in instituting appropriate preventing measures.
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Nephrocalcinosis among children at king hussein medical center: Causes and outcome p. 1064
Jwaher T Al-Bderat, Reham I Mardinie, Ghazi M Salaita, Amer T Al-Bderat, Mahdi K Farrah
Nephrocalcinosis (NC) is defined as deposition of calcium crystals in the renal parenchyma and tubules. This is a retrospective review of all the data of 63 children presented to Pediatric Nephrology Clinic at King Hussein Medical Center (KHMC) over a 15-year period with bilateral NC. We determine their causes, clinical presentation and evaluate their growth and renal function during their follow-up. Thirty-five (55.5%) cases were males and 28 (44.5%) were females. The median (range) age at presentation was four (2–192) months. The most common leading cause to NC was hereditary tubulopathy in 48% followed by hyperoxaluria in 35%. The cause of NC remained unknown in 3% and Vitamin D excess accounts for 5% of the cases. The most presenting symptom was a failure to thrive (68%) and the second most common symptom was abdominal pain and recurrent urinary tract infection was found in 40%, polyuria and polydipsia were found in 32% of cases, and 16% of cases were diagnosed incidentally. At a median follow-up of 38 (14–200) months, estimated glomerular filtration rate had decreased from 84.0 (42–110) mL/min per 1.73 m2 body surface area to 68.2 (10–110) mL/min/1.73 m2 body surface (P = 0.001). This study illustrated the need for a national registry of rare renal diseases to help understand the causes of these conditions in our populations and provide support to affected patients and their families.
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Mycophenolate mofetil or cyclophosphamide in indian patients with lupus nephritis: Which is better? A single-center experience p. 1069
Satish Mendonca, Devika Gupta, Sofia Ali, Pooja Gupta
Mycophenolate mofetil (MMF) is used extensively for the induction therapy of lupus nephritis (LN) and has even outpaced intravenous (i.v.) cyclophosphamide (CyP) as the initial choice of therapy. There are no studies comparing the response of MMF with standard dose i.v. CyP in Indian patients with LN. We conducted a 24-week prospective, randomized, open-label trial comparing oral MMF with monthly i.v. CyP as induction therapy for active biopsy proven Class III and IV LN. The primary end-point was response to treatment at 24 weeks, and the secondary end-points were complete remission, Systemic Lupus Erythematosus Disease Activity Index scores (SLEDAI) and adverse reactions. Of the 40 patients, 17 were randomized to the MMF group and 23 to the i.v. CyP group. Complete remission was seen in nine (52.94%) patients in the MMF group and 11 (47.82%) in the i.v. CyP group. Partial remission was seen in six (35.30%) in the MMF group and nine (39.13%) in the i.v. CyP group. At six months, the cumulative probability of response was not statistically significant between the two groups (P = 1.000). MMF is comparable to i.v. CyP in the management of LN in Indian patients having an equal safety profile. The dose of MMF required was lower than the conventional doses used in other studies suggesting genetic or environmental factors in the Indian population influencing the metabolism of MMF, which requires further evaluation. The cost of MMF is a limiting factor in its use. The use of i.v. CyP is favorable as the monthly doses ensure compliance and is also cost-effective.
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BRIEF COMMUNICATIONS Top

Relationship of insulin resistance to vitamin d status in children with nondiabetic chronic kidney disease p. 1078
Seçil Conkar, Sevgi Mir
Insulin Resistance is common in patients with mild-to-moderate stage chronic kidney disease (CKD), even when the glomerular filtration rate is within the normal range. This study aimed to investigate the association of IR and 25-hydroxyvitamin D levels. In this study, we evaluated the frequency of IR in predialysis patients and the association with 25-hydroxyvitamin (OH)D levels. A total of 32 non-diabetic patients with predialysis were included in the study. Homeostasis model assessment for insulin resistance (HOMA-IR) index was calculated to show presence of IR. Data were analyzed with the Statistical Package for the Social Sciences (SPSS) program version 13.0 (SPSS Inc, Chicago, Ill, USA) using the Chi-square, Student t-test, and logistic regression analysis. Nineteen of 32 subjects (59.4%) were detected to have IR. There was no consistent relationship was detected between IR and glomerular filtration rate, body mass index, and blood pressure in chronic kidney disease (CKD). However; significant difference was detected in 25(OH)D levels with IR in CKD (P = 0.49). The regression analysis showed that 25(OH)D was an independent predictor of IR with an odds ratio of 1.2. In our study, we demonstrated that IR was high in different stages of CKD. Insulin-resistance in non-diabetic CKD was correlated with 25(OH)D levels. 25(OH) vitamin D levels can play a significant role in the development of IR in pediatric patients with CKD. This is important for the early detection and intervention of vitamin D deficiency thereby preventing potentially future complications related to IR.
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Histopathological patterns of renal diseases in egyptian children: A single-center experience p. 1085
Maher Ahmed Abdel-Hafez, Hend Abdel-Nabi, Mohamed El-Gamasy, Hossam Zayton, Ibrahim Nassar
The present cross-sectional, retrospective study was aimed to determine the histopathological spectrum of renal diseases in Egyptian children and to evaluate the indications, safety, and efficacy of percutaneous renal biopsy (PRB) in a large tertiary center in Egypt. PRBs performed at the Department of Pediatrics, Tanta University Hospital over a period of nine years (from January 2007 to December 2015) were included. Light microscopic (LM) examination was performed in all cases while immunofluorescence and electron microscopic examination were performed in selected cases. Two hundred and thirty renal biopsies were performed during the study duration. Nine biopsies were excluded from the study due to insufficient sample (<7 glomeruli per specimen) giving a PRB efficacy rate of 96.1%. Results of 221 renal biopsies performed on 210 patients from native kidneys were described. Ninety-seven patients were male (46.19%) and 113 were female (53.81%) with age ranging from three months to 18 years (mean 10.51 ± 3.81 years). The main indications of renal biopsy were nephrotic syndrome (NS) (43.89%), lupus nephritis (23.53%), and recurrent or persistent hematuria (10.41%). The most common finding on LM examination of renal biopsies from children with NS was minimal change disease (22.17%). Secondary nephropathies were mostly due to lupus (23.53%). IgA nephropathy was found in eight patients (3.62%). Local pain at the site of biopsy was the most common minor complication seen postbiopsy (60.58%). Transient gross hematuria was seen in 13 patients (5.88%) without urinary retention. Major complications that required surgical intervention or blood transfusion did not occur. NS was the main indication and minimal change disease was the most common histological finding of renal biopsies from Egyptian children. Complications and efficacy of renal biopsy procedure were comparable to that reported from developed countries.
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Knowledge of acute kidney injury among nurses in two government hospitals in Ondo City, Southwest Nigeria p. 1092
Oluseyi A Adejumo, Ayodeji A Akinbodewa, Oladimeji E Alli, Olufemi B Pirisola, Olatunji S Abolarin
Adequate knowledge of acute kidney injury (AKI) among all health-care providers is essential for early diagnosis and management to reduce the associated burden. This study determined the knowledge of AKI among nurses in two government hospitals in Ondo City, Southwest Nigeria. This cross-sectional descriptive study was carried out in two government hospitals in Ondo City using a self-administered pretested questionnaire that assessed knowledge of AKI and associated factors. A total of 156 respondents participated in the study. Majority were between 20 and 40 years of age and were females. Ninety-nine (63.5%) had ≤10 years of nursing experience. A total of 106 (67.5%) respondents had received formal lectures on AKI in the past. Only 12 (7.7%) respondents had good knowledge of AKI, 98 (62.8%) had fair knowledge, and the remaining 46 (29.5%) had poor knowledge of AKI. There was a significant association between the knowledge of AKI and having received previous AKI lectures (P = 0.03), but knowledge was not associated with the years of nursing experience (P = 0.37). There was a significant association between having received previous AKI lecture and knowledge of AKI. We, therefore, recommend regular in-service training on AKI for practicing nurses.
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Oral health in diabetic and nondiabetic patients with chronic kidney disease p. 1099
Lingam Amara Swapna, Pradeep Koppolu, Jyothi Prince
The objective of our study is to assess the subjective and objective oral manifestations and salivary pH in diabetic and nondiabetic uremic patients at a nephrology clinic. A total of 194 diabetic and nondiabetic patients with chronic kidney disease (CKD), who were divided into four groups, Group A, B, C, D, and who were attending a nephrology clinic were included in the study. Predialytic unstimulated whole salivary pH was recorded using pH- measuring strips. Subjective and objective findings were evaluated and recorded in the specially designed pro forma. Dental health assessment consisted of decayed, missing, and filled teeth index and community periodontal index (CPI). Dysgeusia was found to be significantly more prevalent in nondiabetic patients on dialysis. Uremic odor showed high significance (P <0.05) with 75% patients being positive in diabetic dialysis. There was no significant difference in the incidence of tongue coating between the four groups. A statistically high significance was observed with the objective oral manifestation of mucosal petechiae, with P = 0.01. There was an increased periodontal pocket depth among diabetic CKD patients as compared to that in nondiabetic patients. A moderate significance was found, with a CPI score showing P <0.05. Increased prevalence of caries was noticed among the diabetic CKD patients (Groups A, B). Recorded salivary pH showed no significant difference among diabetic and nondiabetic CKD patients. Findings suggest that these patients are at risk of developing complications, related to systemic health causing morbidity and mortality. Hence, these patients are to be motivated for comprehensive professional oral care and self oral hygiene instructions. Additional research is necessary to elucidate and correlate the combined influence of diabetes, CKD, and dialysis on oral health.
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Renal transplantation in HIV-positive patients – No more a scare! p. 1106
Eswarappa Mahesh, Manns Manohar John, Gurudev Channabasappa Konana, Rakesh Madhyastha Parampalli, Sujeeth Reddy Bande, Sarita Suryadevara
Human immunodeficiency virus (HIV) infection has posed as a major global health epidemic for almost three decades. With the advent of highly active antiretroviral therapy in 1996 and the application of prophylaxis and management of opportunistic infections, acquired immunodeficiency syndrome mortality has decreased markedly. The most aggressive HIV-related renal disease is end-stage renal disease due to HIV-associated nephropathy. Presence of HIV infection used to be viewed as a contraindication to renal transplantation for multiple reasons; concerns for exacerbation of an already immunocompromised state by administration of additional immunosuppressants; the use of a limited supply of donor organs with unknown long-term outcomes. Multiple studies have reported promising outcomes at three to five years after kidney transplantations in patients treated with highly active antiretroviral therapy, and HIV is no longer a contraindication for renal transplant. Hence, we present eight HIV-positive patients who received live-related renal transplantation at our center and their follow-up.
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RENAL DATA FROM THE ARAB WORLD Top

Insomnia in hemodialysis patients: A multicenter study from morocco p. 1112
Mohamed Amine Hamzi, Kawtar Hassani, Mohamed Asseraji, Driss El Kabbaj
Previous studies have shown that insomnia is a common sleep disorder in patients with end-stage renal disease. This study aims to determine the prevalence and risk factors of insomnia in our chronic hemodialysis (HD) patients. This is a cross-sectional study conducted in three HD units in Morocco. To assess the prevalence of insomnia, we used a specific questionnaire. Patients complaining of difficulty in falling asleep and/or nocturnal awakenings occurring seven nights a week during the last month were included in the group “insomnia;” the other patients were used as controls. Clinical, biological, and dialysis data were recorded for each patient. Sleep disorders and their subjective causes were also identified. Eighty-nine percent of questioned patients admitted to having sleep disturbances of different degrees. Insomnia was significantly associated with female gender and time of dialysis. Age, body mass index, inter-dialytic weight gain, and blood pressure were similar between the two groups, as well as dialytic parameters and drug use. There was no significant difference in the values of plasma creatinine, urea, hemoglobin, parathyroid hormone, calcium, phosphorus, C-reactive protein, and albumin between the groups. Disorders most frequently encountered in patients with insomnia were waking up at night (90%), difficulty falling asleep (60%), and daytime sleepiness (60%). The restless legs syndrome was seen in half of these patients. The main reported causes of insomnia were anxiety and/or depression (70%) and bone pain (67%). Insomnia is common in HD patients and is frequently associated with other disorders of sleep. Female sex and duration on dialysis are the two risk factors found in our study. Insomnia does not appear related to any biochemical or dialysis parameters. Increased attention should be given to the management of dialysis patients regarding the diagnosis and management of insomnia and associated sleep disorders.
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Epidemiology of end-stage renal disease in Dubai: Single-center data p. 1119
Fakhriya Alalawi, Maseer Ahmed, Hind AlNour, Malaz Noralla, Amna Alhadari
Hemodialysis (HD) was first established in Dubai in the year 1980 and was in its full capacity by the year 1983. Since then, the HD population has been growing rapidly. This report represents the demographic data and clinical characteristics of our HD patients during the period between January 2012 and October 2016. Diabetic nephropathy (57%) and hypertension (12.4%) are emerging as the most common causes of end-stage renal disease (ESRD) in our data, followed by undetermined causes in those who presented as ESRD (10.9%), and then by rejected transplant in 4.6%. Obstructive uropathy in our data was 4.37% among all causes. The causes were primary glomerulonephritis (only proven cases in kidney biopsy were counted) in 3.6%, adult polycystic kidney disease in 2.43%, and lupus nephritis in 1.45% of cases. The prevalence of ESRD in the current study was 152 patients per million population per year.
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Hepatitis C virus status in hemodialysis patients in Menoufia Government, Egypt, five years apart: Do we have any improvement? p. 1126
Khaled Mohamed Amin Elzorkany, Ahmed Zahran
There is a high prevalence of hepatitis C virus (HCV) infection in hemodialysis (HD) patients in Menoufia Governorate, Egypt. The aim of this cross-sectional study was to assess current HCV status and its seroconversion in HD patients after implementing preventative measures to limit transmission of HCV. All data were compared with our previous data collected in 2011 before implementation of isolation policy. There was a significant decrease in HCV infection in HD patients from 49.6% in year 2011 to 41.9% in year 2016 (P = 0.001). The seroconversion rate was significantly reduced from 14.5% in year 2011 to 4.9% in year 2016 (P = 0.001). Age, gender, body mass index, hemoglobin, and calcium did not show any significant difference whereas blood transfusion, serum phosphate, and urea reduction ratio showed a significant difference with much improvement in year 2016. When comparing seroconversion group with HCV-negative patients, blood transfusion did not show significant difference whereas seroconverted group showed significantly longer duration of dialysis (94.94 ± 82.87 months vs. 38.21 ± 31.55 months). Same result was obtained in year 2011; however, when all data analyzed the duration of dialysis and blood transfusion were higher significantly in seroconverted group. Binary logistic regression analysis for all data demonstrated that isolation reduced the likelihood of seroconversion while longer duration of dialysis increased the risk for seroconversion. HCV infection and its seroconversion in HD patients were significantly reduced in year 2016 compared to year 2011. Isolation policy is recommended for HD patients with HCV in dialysis units with high HCV prevalence in developing countries.
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RENAL DATA FROM ASIA AFRICA Top

Clinicoepidemiological profile of peritonitis complicating acute peritoneal dialysis: A single-center experience p. 1133
Kunal Gandhi, Dharmendra Prasad, Vinay Malhotra, Dhananjai Agrawal, Pankaj Beniwal, Amith Vijay Leon Dsouza
A prospective observational study examining the incidence and microbiological aspects of peritonitis complicating acute intermittent peritoneal dialysis (IPD) was performed. A total of 145 acute IPD treatments were included involving 112 patients. The majority of patients suffered from acute kidney injury (72.3%) secondary to sepsis. Peritonitis occurred in 31 treatment sessions, giving a frequency of 21.4% of procedures performed. The mean interval between starting dialysis and the first sign of peritonitis was 2.9 days, with 58% of cases occurring in the Intensive Care Unit. Frequent catheter manipulation/repositioning and leakages were identified as significant predisposing factors for peritonitis, and the risk of peritonitis was increased with longer duration of IPD. Gram-negative infections were more common than Grampositive infections. The use of systemic antibiotics did not prevent the development of peritonitis.
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A comparison of socioeconomic level among hemodialysis patients and normal controls in the fars province, Iran p. 1138
Leila Malekmakan, Maryam Pakfetrat, Arghavan Daneshian, Mehrab Sayadi
Chronic kidney disease (CKD) is a public health problem and it is suggested that low socioeconomic status (SES) may increase the risk of renal failure. The aim of this study was to report and compare the SES of hemodialysis patients (HD) and normal population in Shiraz, Iran. In this cross-sectional study, we evaluated 519 HD patients and 900 normal controls. We asked about SES using a questionnaire. The participants were categorized into three groups according to their SES as low, medium, and high SES. Of the 1419 participants, 454 (31.7%), 581 (40.6%), and 395 (27.6%) were grouped in low, medium, and high SES, respectively. Most of our normal controls (43.5%) were in the medium SES group and most of the HD patients (61.3%) were in the low SES group. HD patients had a significantly lower SES score than the normal population (P <0.001). A pattern of decrease in the child number and increase in the marital age was seen associated with a rise in SES status among the two groups. In contrast with the control population, a pattern of increasing age was seen in the HD patients with a higher SES status (P = 0.038). In conclusion, SES was significantly lower in HD patients than the normal population. People with CKD and limited education or lower income should be targeted for early intervention.
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Prevalence and risk factors of chronic kidney disease in newly diagnosed and untreated hypertensive patients in cameroon: A cross-sectional study p. 1144
Félicite Kamdem, Fernando Kemta Lekpa, Marie Solange Doualla, Yvette Ngo Nouga, Olivier Donfack Sontsa, Elvis Temfack, Samuel Kingue
Chronic kidney disease (CKD) has emerged as a worldwide problem and is a major cause for comorbidity in hypertensive patients. In an attempt to enhance awareness and to help in establishing preventive measures and care, it is necessary to describe CKD among newly diagnosed and untreated hypertensive patients. We conducted a cross-sectional study to describe the characteristics of CKD among newly diagnosed, treatment naïve, hypertensive patients in four health-care centers in the city of Douala, Cameroon. Sociodemographic and biological data were collected and serum creatinine was measured by enzymatic – colorimetric methods. We calculated estimated glomerular filtration rate (eGFR) by the Modification of Diet in Renal Disease equation and described CKD as eGFR <60 mL/min/1.73 m2. Logistic regression was further used to develop early clues of association. We included 839 newly diagnosed hypertensive treatment naïve patients, among which 412 (49.1%) men. The mean [±standard deviation (SD)] age was 51 (±11) years and was higher among those with CKD. Seventy-six had a family history of hypertension and 65 were known diabetic patients. Mean (±SD) eGFR was 94.4 (±33.3) mL/min and the prevalence of CKD was 12.4% (104/839). From multivariate logistic regression, age >55 years [OR: 5.29 (3.33–8.42)], obesity [OR: 0.15 (0.10–0.26)], kalemia [OR: 1.33 (1.03–1.72)] were independently associated to CKD. CKD is a common condition in newly diagnosed and untreated hypertensive patients in Cameroon. Individuals with hypertension should be carefully evaluated for the presence of CKD, especially those with decreased GFR.
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Practice pattern of hemodialysis among end-stage renal disease patients in Rural South India: A single-center experience p. 1150
R Hemachandar
Hemodialysis (HD) is the most common mode of renal replacement therapy for end-stage renal disease (ESRD) patients in India. However, the practice and pattern of dialysis in a hospital serving rural population is largely unknown. A prospective study of 127 ESRD patients initiated on HD between January 2013 and December 2014 was done. The study included 101 males and 26 females, with a mean age of 50.05 ± 13.80 years. Native kidney disease was unknown in 45.67% of patients as they presented very late in their disease course. Nearly 87.4% of patients had emergency dialysis. Only 6.30% of patients had started dialysis with an arteriovenous fistula while 93.70% with a temporary catheter. The mean creatinine and hemoglobin at the initiation of dialysis were 11.18 mg/dL and 6.8 g/dL, respectively. All patients underwent twice weekly HD of 4 h duration with achieved average single-pool Kt/V of 1.52. The hospitalization rate was 3.25 per patient-year. The outcomes in our cohort were as follows: 3.94% transferred to other centers, 16.54% died, 0.79% underwent transplantation, 33.07% continued on HD, and majority 45.67% stopped dialysis. The most common cause of death was sepsis. The Kaplan–Meier analysis showed median survival time on dialysis to be 64 days. Patients initiated on HD in rural area often present late with poor predialysis care leading to high morbidity. Prognosis is generally poor with majority of the patients stopping dialysis within few weeks.
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CASE REPORTS Top

Acute kidney injury with granulomatous interstitial nephritis and vasculitis revealing sarcoidosis p. 1157
Amel Harzallah, Hayet Kaaroud, Karima Boubaker, Samia Barbouch, Rim Goucha, Fethi Ben Hamida, Taieb Ben Abdallah
Sarcoidosis is an inflammatory disease that affects mostly the lungs and lymph glands. Renal involvement is rare and especially vasculitis. We report a case who presented an acute kidney failure and had sarcoidosis with vasculitis and nodular splenic involvement. A 35-year-old woman presenting a Lofgren syndrome was hospitalized for acute renal failure with cervical lymphadenopathy without other clinical findings. Laboratory data disclosed elevated angiotensin converting enzyme serum level. Abdominal ultrasound showed a multinodular spleen. Renal histology revealed granulomatous interstitial nephritis with necrotizing vasculitis. Outcome was favorable after the institution of high dose corticosteroids along with cyclophosphamide. Renal involvement is rare in sarcoidosis. However, the diagnostic delay should be avoided to improve the outcome.
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Neonatal bartter syndrome in an extremely low birth weight baby p. 1162
Deeparaj Hegde, Jayashree Mondkar, Nitinkumar Abdagire
Early diagnosis of Bartter syndrome (BS) in the neonatal period is a clinical challenge, more so in an extremely low birth weight (ELBW) baby because of the inherent renal immaturity and the associated difficulty in fluid management. However, once a diagnosis is made, the disorder is known to respond well to fluid and electrolyte management, prostaglandin inhibitors, and potassium-sparing diuretics. Herein, we report a case of neonatal BS in a very premature ELBW infant.
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Branchio-oto-renal syndrome presenting with syndrome of hyporeninemic hypoaldosteronism p. 1165
Jane Jackie David, Preeti Shanbag
Branchio-oto-renal (BOR) syndrome is an autosomal dominant, clinically heterogeneous disorder characterized by branchial arch anomalies, hearing impairment, and renal malformations. We report the case of a 10-year-old boy with BOR syndrome who presented with hyperkalemic hyperchloremic metabolic acidosis due to hyporeninemic hypoaldosteronism. The child also had mental retardation and spastic diplegia which have hitherto not been described in BOR syndrome.
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Direct-acting antiviral drugs against hepatitis C virus in renal transplant recipients: Is it the dawn of an interferon-free Era? p. 1169
Dharshan Rangaswamy, Shankar P Nagaraju, Ravindra P Attur
Hepatitis C virus (HCV) is a significant problem among hemodialysis population, especially in India where renal transplant often gets delayed in the presence of live-related donors. An acceleration of liver cirrhosis and poor renal allograft outcomes are often witnessed in allograft recipients with high viral load. Use of interferon in the postrenal transplant setting for the treatment of hepatitis C viral infection was limited to a few grave situations, fearing the precipitation of allograft rejection and poor efficacy for sustained virological remission. However, the availability of newer direct-acting antivirals has opened a new tool box in the management of HCV in the postrenal transplant setting and in reducing the pretransplant waiting period.
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Treatment of steroid-resistant focal segmental glomerulosclerosis with rituximab: A case report and review of literature p. 1175
Mohamed Hasham Varwani, Ahmed Sokwala
Various immunomodulating agents have been tried for the treatment of steroid-resistant focal segmental glomerulosclerosis (FSGS) in the native kidney. A few case series and small studies have reported mixed results with the use of Rituximab for this indication. We report on the case of a 76-year-old male with steroid-resistant FSGS successfully treated with rituximab and remained in remission at the end of six months. A review of the literature highlights the paucity of data on this subject. We conclude that rituximab is a potentially useful treatment for steroid resistant FSGS and larger controlled studies are needed to further define its role in this setting.
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Infantile cystinosis: From dialysis to renal transplantation p. 1180
Manel Jellouli, Meriem Ferjani, Kamel Abidi, Chokri Zarrouk, Jaouida Abdelmoula, Tahar Gargah
Cystinosis is an autosomal recessive, lysosomal storage disease characterised by the accumulation of the amino acid cystine in different organs and tissues. It is a multisystemic disease that can present with renal and extra-renal manifestations. In this report, we present the first case of transplanted nephropathic cystinosis in a Tunisian child. A 4-year-old Tunisian boy born to nonconsanguineous parents, was treated in our medical services in 1990 for cystinosis. Since the age of five months, he developed symptoms of severe weight loss, vomiting, dehydration, and polyuria. He manifested the Toni Debré Fanconi syndrome. Slit lamp examination of the anterior segment of both eyes revealed fine, shiny crystal-like deposits diffusely distributed in the corneal epithelium and the stroma. Our patient had renal failure. At the age of seven, he reached terminal chronic renal failure and was treated with peritoneal dialysis. Hemodialysis was started at the age of nine years. At the age of 13 years, he received a renal transplantation and was started on cysteamine 1999, five months after the renal transplantation. Currently, the patient is 28-year-old. The graft has survived 15 years after the transplantation. Renal functions were stable with a serum creatinine of 123 μmol/L at last follow-up.
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Primary Sjögren’s syndrome complicated by anti-neutrophil cytoplasmic antibody-mediated crescentic glomerulonephritis p. 1184
Imed Ben Ghorbel, Nabil Belfeki, Thouraya Ben Salem, Mohamed Habib Houman
Ocular and oral dryness are the hallmark of Sjögren’s syndrome (SS). However, SS can be associated with a variety of complications, affecting organs such as the liver, kidneys, lungs, muscle, and nervous system. Renal involvement has been usually in the form of tubulointerstitial nephritis. However, glomerulonephritis is rare in primary SS. We report three clinical cases of SS with anti-neutrophil cytoplasmic antibody-mediated crescentic glomerulo-nephritis treated with prednisone and cyclophosphamide, with favorable outcome.
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Galloway-mowat syndrome - unusual form of nephrotic syndrome in adolescent p. 1188
G Diwakar Naidu, Pathapati Deepthi, K RajaKarthik, S Sriram, G Swarnalatha, T Gangadhar
Galloway–Mowat syndrome (GMS), also acknowledged as Microcephaly-Hiatal hernia nephrotic syndrome, is an uncommon genetic disorder inherited as an autosomal recessive trait usually seen before two years of life. It is an exceptional multisystem genetic disorder with a collection of skeletal, neurological, facial, gastrointestinal, growth, and renal abnormalities. This case report describes GMS in a girl, suffering from developmental delay, stunted growth, and various dysmorphic features, in whom nephrotic syndrome became apparent at adolescent age.
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Pulmonary thromboembolism as first presentation of childhood membranous nephropathy p. 1192
Mohit Madken, Shankar Prasad Nagaraju, Ravindra Prabhu Attur, Mahesha Vankalakunti
Nephrotic syndrome is associated with an increased risk of thromboembolism. Pulmonary thromboembolism has been described in nephrotic syndrome with or without deep vein thrombosis. In this case report, we describe an unusual first presentation of childhood membranous nephropathy with massive pulmonary thrombus with pulmonary infarction with right renal vein thrombosis.
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LETTERS TO THE EDITOR Top

Urinary interleukin-10 in renal transplant recipients: Does it predict a state of tolerance or rejection p. 1196
Mahmoud M Elnokeety, Amr M Shaker, Ahmed M Fayed
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Mild renal pyelectasis: A practical and simple approach in neonate and infant p. 1201
Majid Malaki
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Usefulness of organoid technology and kidney transplantation p. 1203
Viroj Wiwanitkit
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Renal failure due to important arbovirus infection: A short summary p. 1206
Somsri Wiwanitkit, Viroj Wiwanitkit
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SCOT DATA Top

Organ Donation and Transplantation in the Kingdom of Saudi Arabia 2016 p. 1209
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