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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
Coverpage
March-April 2020
Volume 31 | Issue 2
Page Nos. 298-572

Online since Saturday, May 9, 2020

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EDITORIAL  

Kidney health for everyone everywhere - from prevention to detection and equitable access to care Highly accessed article p. 298
Philip Kam-Tao Li, Guillermo Garcia-Garcia, Siu-Fai Lui, Sharon Andreoli, Winston Wing-Shing Fung, Anne Hradsky, Latha Kumaraswami, Vassilios Liakopoulos, Ziyoda Rakhimova, Gamal Saadi, Luisa Strani, Ifeoma Ulasi, Kamyar Kalantar-Zadeh,
DOI:10.4103/1319-2442.284004  PMID:32394902
The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions – be it primary, secondary or tertiary. This complementing article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management and treatment are often lacking. Hence, there is an urgent need to increase the awareness of the importance of preventive measures throughout populations, professionals and policy makers.
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REVIEW ARTICLES Top

Proton-pump inhibitors and chronic kidney disease: Hidden consequences of an inappropriate drug use? Highly accessed article p. 312
Helmut Schiffl, Emad Al-Nemnem, Susanne M Lang
DOI:10.4103/1319-2442.284005  PMID:32394903
Proton-pump inhibitors (PPIs) are the most effective therapy for gastric acid- related diseases. They are generally well tolerated with rare, often self-limiting adverse reactions. On the other hand, there is growing concern regarding the increased public access and inappropriate PPI use. This review aims to give a critical appraisal of current literature and to analyze a possible relationship between renal disorders and PPI use. A plethora of observational pharmacoepidemiological studies link PPI therapy to the development of acute interstitial nephritis (AIN). Most of these studies show a higher risk for acute kidney injury, de novo chronic kidney disease, and end-stage renal disease. However, current evidence is inadequate to establish a causal relationship between PPI use and many of the proposed renal syndromes. Residual confounding and bias related to study design and the over extrapolation of quantitatively small treatment effects contributed to the unnecessary controversy about PPI safety. Undoubtedly, PPI use may rarely induce AIN. Given the worldwide use of PPIs, the number of patients with biopsy- proven AIN is extremely small. However, more research is required to explore the underlying pathophysiological mechanisms and possible differences between commercially available PPIs regarding adverse renal effects. Till then, the PPIs should be used in the lowest effective dose, and inappropriate use should be avoided.
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Low serum albumin a predictor sign of the incidence of peritoneal dialysis-associated peritonitis? A quasi-systematic review Highly accessed article p. 320
Muneera Aiad Alharbi
DOI:10.4103/1319-2442.284006  PMID:32394904
Peritonitis is associated with an increasing morbidity and mortality rate in peritoneal dialysis patients. A number of peritonitis cases result in hypoalbuminemia, and in other cases, peritonitis follows a decline in the serum albumin level. However, it is not clear whether the level of serum albumin can be utilized to predict and prevent the incidence of peritonitis. A quasi-systematic search of the literature was conducted in the following databases: Cochrane, EBSCO, ProQuest, AHMED, CINHAL, MEDLINE, and EMBASE, from January 2008 to January 2018. The data was reviewed and extracted from each study. The quality of the studies was assessed using the Critical Appraisal Skills Programme and the Newcastle-Ottawa Scale. Six articles met the stated inclusion criteria of the quasi-systematic review. The study found a significant correlation between a low serum albumin level at the start of continuous ambulatory peritoneal dialysis (CAPD) and the development of peritonitis. Thus, hypoalbuminemia can be utilized as a warning sign of the occurrence of peritonitis in CAPD. Consequently, immediate intervention is required when the level of serum albumin declines in order to prevent peritonitis.
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ORIGINAL ARTICLES Top

Frequency and etiology of tubulo-interstitial nephritis in an adult renal biopsies in a tertiary renal care hospital: A single-center study p. 335
Ruqaya Qureshi, Salman Imtiaz, Murtaza Dhrolia, Aasim Ahmad
DOI:10.4103/1319-2442.284007  PMID:32394905
Tubulo-interstitial nephritis (TIN) is an important cause of acute renal failure which may progresses to chronic kidney disease (CKD). TIN is often under diagnosed with there are no specific signs and symptoms. As this entity has paramount importance, so we evaluated the frequency and etiological of TIN both acute TIN (ATIN) and chronic tububulo-interstitial nephritis (CTIN) in renal biopsies. This is a retrospective observational, descriptive study carried out in the Department of Nephrology at The Kidney Centre Post Graduate Training Institute from 2004 to 2016. A total of 1560 adult renal biopsies were done during this period with 125 biopsies of TIN, of which 70 (56%) cases were ATIN and 55 (44%), were CTIN. Thirty-eight (30%) patients had a history of taking proton-pump inhibitors, use of various antibiotics in 21 (16%) cases, and 11 (8%) patients had a history of taking Hakeemi (traditional healer using herbs and sometimes trace amounts of heavy metals) medications. The incidence of TIN is higher than suspected and can be caused by variety of etiological agents. Therefore, clinical awareness will help in the diagnosis and early identification of the disease.
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Anti-C1q antibodies in lupus nephritis and their correlation with the disease activity p. 342
George Emad, Said M Al-Barshomy
DOI:10.4103/1319-2442.284008  PMID:32394906
Systemic lupus erythematosus (SLE) is an autoimmune connective tissue disorder. Renal involvement usually develops in the first few years of illness and should be detected early by periodic urine analysis and quantitation of proteinuria. The aim of our work was to evaluate the biological marker [anti-complement 1q antibodies (anti-C1q Ab)] in lupus nephritis (LN) patients and its correlation to SLE disease activity. Sixty-five subjects were divided into four groups; Group I: SLE patients with LN (proteinuria >0.5 g/day), Group II: SLE patients without LN (all of them had a lupus flares rather than nephritis; active nonrenal), Group III: SLE patients without any activity (inactive disease), and Group IV: Control group. All subjects underwent urine analysis, complete blood picture, liver function tests, kidney function tests, albumin/ creatinine ratio, antinuclear antibody, anti-double stranded DNA (anti-dsDNA) antibody, C3, C4, and anti-C1q Ab. All patients in the first group underwent renal biopsy and pathological diagnosis showed: Class II in two patients, Class III and IV in nine patients, and Class V in four patients. Anti-C1q Ab were found in the serum of SLE patients and not in the control group and showed an association with active lupus with much higher concentration in active renal group, specifically those with severe renal histological lesions (proliferative form). There was significant statistical positive correlation between anti-C1q Ab with anti-dsDNA and SLE disease activity index in both active groups. There was statistically significant negative correlation between anti-C1q Ab with C3 and C4 in both active groups. Anti-C1q Ab could be used as useful marker for active lupus, especially with nephritis.
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Serum cytokeratin 18 level is associated with dietary intake and serum triglycerides level in hemodialysis patients p. 353
Neda Haghighat, Morteza Zare, Nader Moein Vaziri, Babak Hosseini, Zahra Sohrabi, Hadi Bazyar, Meysam Alipour, Maryam Shafei
DOI:10.4103/1319-2442.284009  PMID:32394907
Cell death leads to increase serum cytokeratin 18 (CK-18) in chronic kidney disease. However, few studies have investigated the serum CK-18 level in relation to nutritional and metabolic biomarkers. We examined the association of dietary intake and lipid profile with serum CK18 level among hemodialysis (HD) patients. Ninety HD patients according to inclusion and exclusion criteria were included in the study. An analysis of clinical characteristics, anthropometric indices, dietary intake, and lipid profile revealed a significant association between serum CK-18 and diabetes, metabolic syndrome, body mass index (BMI), triglyceride (TG), aspartate aminotransferase (AST), alanine aminotransferase (ALT), energy intake (EI), protein intake (PI), and saturated fatty acid (SFA). In a multiple stepwise regression model, after adjusting for confounders in three models, the association between serum CK-18 and serum TG level, dietary SFA and EI remained significant. The model 3 adjusted for DM, Mets, BMI, ALT, AST, and PI; model 2 adjusted for model 1 + EI; and model 1 adjusted for model 2 + SFA. Our findings suggest that the development of hypertriglyceridemia and inadequate EI contribute to higher serum CK-18, which is a cell death biomarker.
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Novel biomarkers of acute kidney injury following living donor liver transplantation p. 360
Mohamed Sherif Mogawer, Mostafa Abd El-Rahman El-Shazly, Ahmed Yamany Ali, Ahmed Mohamed Abd El-Ghany, Samah Abd Elhamid
DOI:10.4103/1319-2442.284010  PMID:32394908
Urinary biomarkers such as neutrophil gelatinase-associated lipocalin (NGAL) and renalase were recently studied for their potential role in the early detection of acute kidney injury (AKI) in patients with cirrhosis. Our study was conducted on 50 patients with end-stage liver disease undergoing living donor liver transplantation. The patients were divided into two groups: Group I contained 23 patients with AKI who had undergone liver transplantation and Group II included 27 non-AKI patients who had undergone liver transplantation. Serum renalase and NGAL levels were measured by ELISA; renalase was measured on day 1, day 7, and three months after liver transplantation. NGAL was measured on day 1 postliver transplantation. There was an improvement in liver function, kidney functions, hemoglobin level, platelet count, and C- reactive protein levels in patients at three months posttransplantation when compared to day 1, day 3, and day 7 (P < 0.01). Comparison of the renalase level at day 1, day 7, and three months showed that there was a highly significant decline at three months in the AKI group compared to the non-AKI group (P < 0.01). Regarding the NGAL level at day 1, there was no significant difference between the AKI and non-AKI groups (P > 0.05). The receiver operating characteristic curve for the renalase biomarker showed a borderline significant change between the AKI and non-AKI groups at day 1 [area under the curve (AUC): 0.54, P = 0.08], day 7 (AUC: 0.605, P = 0.08), and three months (AUC: 0.605, P = 0.08). However, the NGAL biomarker level was not significantly different between the AKI and non-AKI groups. Our study suggests that renalase showed a better predictive value and a higher accuracy in identifying postliver transplantation patients with AKI than NGAL.
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Pregnancy-related acute kidney injury and urological comorbidities in morbidly adherent placenta: A potential challenge to AKI-0by25 p. 368
Harmandeep Singh Chahal, Sunil Kumar Juneja, Simran Kaur, Bakul Kochar, Sandeep Sharma, Vikas Makkar
DOI:10.4103/1319-2442.284011  PMID:32394909
Pregnancy-related acute kidney injury (PRAKI) and urological complications can significantly increase the maternal morbidity and mortality, and morbidly adherent placenta (MAP) has been found to increase the risk of both. This is a four-year prospective study, conducted on patients with MAP. Baseline parameters (demographic/antenatal/perinatal), operative details (obstetric/urological/hemostatic), peri-operative complications (AKI/urological), and maternal/fetal outcomes were studied till six weeks after delivery. Statistical analysis was done using IBM SPSS Statistics version 21.0, and P <0.05 was considered statistically significant. Out of the 5475 deliveries conducted in the study period, 64 had adherent placentation. AKI occurred in 39.1% of patients, with severe AKI (AKIN-2, 3) in 10.9%, and significantly higher incidence in placenta percreta (P = 0.021, relative risk [RR] - 2.34), urological injuries (P = 0.001, RR - 2.86), and high blood loss (P = 0.001) on univariate analysis, but placenta percreta was the most statistically significant factor P = 0.049) on multivariate analysis. Urological involvement/injuries requiring intervention were encountered in 22 patients, with statistically significantly high incidence in placenta previa (P = 0.023, RR - 1.62), placenta percreta (P = 0.000, RR - 17.18), and patients undergoing hysterectomy (P = 0.000, RR - 2.01) on univariate analysis, but placenta percreta was most statistically significantly implicated on multivariate analysis (P = 0.017). AKI and urological injuries significantly increased the need for intensive care and days of hospitalization. On six-week follow-up, all AKI patients recovered completely; no urinary leak or vesico-vaginal fistula was seen in urologically intervened patients and no maternal mortality occurred. There is an alarmingly high incidence of PRAKI and urological complications in MAP, posing a great threat to their worldwide improving statistics. Awareness of this condition among renal fraternity can significantly improve the maternal renal and overall prognosis.
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Pulmonary hypertension – prevalence, risk factors, and its association with vascular calcification in chronic kidney disease and hemodialysis patients p. 380
N Nithiya, Elayaperumal Indhumathi, Dhakshinamoorty Jagadeswaran, Varadharajan Jayaprakash, Matcha Jayakumar
DOI:10.4103/1319-2442.284012  PMID:32394910
Pulmonary hypertension (PHTN) is a recently recognized complication in dialysis and it is associated with a poor outcome. We estimated the prevalence of PHTN and its association with vascular calcification in chronic kidney disease (CKD) and hemodialysis (HD) patients. One hundred and thirteen adult CKD patients were included in this study, of which 56 (49.6%) were on conservative treatment (nondialysis group) and 57 (50.4%) were on maintenance HD (dialysis group). Demographic, clinical, and biochemical parameters were collected and compared between the groups. Thirty-nine (69.6%) and 33 (57.8%) males were included in nondialysis and dialysis group, respectively. Mean age was 47.5 ± 13.7 in nondialysis group and 52.8 ± 13.9 in the dialysis group. PHTN was estimated using Doppler echocardiography and peripheral vascular calcification by lateral lumbar X-ray with aortic calcification scoring. Patients with and without PHTN and vascular calcification in dialysis and nondialysis group were compared. PHTN was found in 55 patients (48.7%) and it was high in patients on dialysis compared to nondialysis(59.6% vs. 37.5%, P <0.019). Abdominal aortic calcification was present in 35 patients (30.9%), dialysis versus nondialysis group was 22.8% and 39.3%. Increased left atrial diameter was significantly associated with PHTN (P <0.003), whereas peripheral artery calcification was not related to PHT (P = 0.248). The prevalence of PHTN in CKD was 48.7% which was higher in dialysis group than non dialysis group. Increased left atrial (LA) diameter was associated with PHTN but not peripheral arterial calcification.
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Endoscopic findings in hemodialysis patients upon workup for kidney transplantation p. 388
Maryam Pakfetrat, Leila Malekmakan, Jamshid Roozbeh, Taraneh Tadayon, Maryam Moini, Maryam Goodarzian
DOI:10.4103/1319-2442.284013  PMID:32394911
Upper gastrointestinal (GI) abnormality is believed to be higher in patients with end-stage renal disease (ESRD) which can make a big trouble for whom undergo kidney transplant. We conducted this study to assess upper GI findings of patients with ESRD. In the present retrospective study we recorded upper GI endoscopy results in hemodialysis patients who were candidate for renal transplantation during a 10-year period. We reviewed files of 1256 patients with a mean age of 37.6 ± 13.4 years. Half of patients (50.6%) had an abnormal endoscopy. Two most common abnormalities were mild gastritis (35.6%) and gastro-esophageal reflux disease (16.7%). GI ulcers were observed in 11% of patients. Duodenal ulcer was the most common ulcer which was seen in 6.8% of patients. Helicobacter pylori was positive in 32.9% of patients and correlated with GI lesions (P = 0.000, r = 0.371). Longer dialysis duration and older patients revealed more upper GI abnormality (P = 0 .032, <0.001). As long as more than half of our patients have at least one upper GI involvement, we recommended that endoscopy must be done as a pretransplantation evaluation for patients without symptoms who have risk factors for ulcers.
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Assessment of cognitive functions and adaptive behavior in children with end-stage renal disease on regular hemodialysis p. 395
Azza Kamal Al Shahawy, Mohamed Abdelaziz El-Gamasy, Mohammed Abd Elhakeem Seleem, Wegdan Mawlana, Amira Hassan El Sharkaway
DOI:10.4103/1319-2442.284014  PMID:32394912
Chronic kidney disease (CKD) is defined by the Kidney Disease and Outcome Quality Initiative as a child who has kidney damage lasting for at least three months with or without decreased glomerular filtration rate. Hemodialysis (HD) means removal of waste products and extra fluid directly from the blood when the kidneys do not work properly. Studies aimed at investigating neurocognitive impairment in children with CKD have identified a wide range of delays in cognitive development. The aim of this study was to assess the cognitive functions and adaptive behavior in children with end-stage renal disease (ESRD) on regular HD. This case-controlled study was conducted on 30 children suffering from ESRD who were on treatment at the Pediatric Nephrology Unit of Tanta University Hospital. Thirty apparently healthy children served as a control group, in the period from January 2017 to January 2018. All children were subjected to full history taking, careful physical and neurological examination, specific investigations including assessment of intelligence quotient (IQ) using Stanford Binet test 5th edition; assessment of adaptive behavior, assessment of executive functions by using Wisconsin Card Sorting Test; and continuous performance test. This study showed that mean values of IQ and the Vineland test were significantly lower among patients than controls. The study suggests that children with ESRD had lower IQ, adaptive behavior and executive functions than healthy control children.
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Acute kidney injury in dengue among hospitalized children: A prospective view p. 407
Sanjukta Poddar, Shobha Sharma, Charanjeet Kaur, Harish Kumar Chellani
DOI:10.4103/1319-2442.284015  PMID:32394913
Dengue viral infection (DVI) has emerged as one of the most common arthropod borne diseases and is more prevalent in the tropical countries. It has varied clinical spectrum ranging from undifferentiated fever to severe hemorrhagic fever and shock with multi-organ dysfunction. Acute kidney injury (AKI) is lesser known complication in DVI. Although studies report varying reports of AKI in DVI among children, exact incidence is not known as most of the studies are retrospective. Hospital-based observational study in 105 children with DVI requiring admission was studied for the occurrence of AKI along with clinical course and outcome. AKI Network (AKIN) criteria were used to define AKI. The IBM SPSS Statistics software version 21.0 was used for the statistical analysis. Of 105 children with dengue, six (5.71%) cases developed AKI. All six cases had urine output <0.5 mL/kg/h for ≥12 h. Out of six cases with AKI, four had raised serum creatinine (SCr) ≥0.3 mg/dL at admission. One child had normal SCr level at admission which got deranged over the next 12 h, one child had oliguria ( <0.5 mL/kg/h) for about 24 h though the renal function was not deranged. Out of six children with AKI, three (50%) in Stage III and three had AKI Stage II as per the AKIN criteria. Children with AKI (Group A) differed significantly from those without AKI (Group B) in having blood pressure <3rd centile (P = 0.0023), tachycardia P = 0.008), hyponatremia and hypokalemia (P <0.001 and P = 0.029, respectively) and poor outcome 6% mortality in Group B compared to 66.67% in Group A) with P = 0.001. AKI is not a common complication of DVI but if develops it may lead to significant morbidity and mortality among pediatric age group.
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Biopsy-proven acute graft pyelonephritis: A retrospective study from sindh institute of urology and transplantation p. 415
Muhammad Khalid Idrees, Saima Sadiq, Tariq Ali, Iqbal Ur Rehman, Syed Fazal Akhtar
DOI:10.4103/1319-2442.284016  PMID:32394914
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Efficacy and outcome of intermittent peritoneal dialysis in patients with acute kidney injury: A single-center experience p. 423
Nitish Garg, Vipin Kumar, Preet Mohinder Sohal, Dinesh Jain, Aayush Jain, VikasMakkar , Sudhir Mehta
DOI:10.4103/1319-2442.284017  PMID:32394915
There are only a few reports on the role of peritoneal dialysis (PD) in critically ill patients requiring continuous renal replacement therapies (RRT). This study aimed to determine the efficacy and outcome of intermittent PD in acute kidney injury (AKI) patients in intensive care unit setting and to assess the procedure-related complications. This was a prospective, observational study conducted from March 1, 2015, to February 29, 2016, which included patients of either sex, aged ≥18 years, diagnosed with AKI, and undergoing RRT with intermittent PD sessions with more than 48 h of hospital stay. Patients were later shifted to sustained low- efficiency dialysis or hemodialysis, when they became hemodynamically stable. Hence, the patients who received at least 48 h of PD were included in the study. A total of 75 patients were enrolled. Overall, the mean age was 55.75 years, and around 64% were men. The most common indication to start PD was metabolic acidosis, and the most common cause of AKI was sepsis. A total of 21 patients survived, and the mortality rate was 72%. The average peritoneal urea clearance and creatinine clearance were 14.81 mL/min and 12.59 mL/min, respectively. Of the 66 patients on inotropes, 28 patients were tapered from inotropic support. Thirty-nine patients had hyperkalemia, and 27 patients had correction within 1 day of the start of PD. Forty-seven patients had correction of acidosis, and 33 of these achieved pH ≥7.25 within one day of PD. The most common complication that occurred was peri-catheter leaks followed by peritonitis. Acute PD can be an effective, simple, and safe bridge RRT in hemodynamically unstable patients until the achievement of hemodynamic stability to shift them to other modalities of RRT.
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Assessment of cognitive impairment and its correlation with vitamin D levels patients on maintenance hemodialysis p. 431
Babby Arvind Reddy, Manjusha Yadla
DOI:10.4103/1319-2442.284018  PMID:32394916
Cognitive impairment (CI) is common in patients with chronic kidney disease, and its prevalence increases in patients on hemodialysis (HD). Different factors were identified to be the cause of cognitive dysfunction, of which Vitamin D, which is known to have pleiotropic effects, has been implicated for the neurocognitive decline of functions. We assessed the prevalence of cognitive dysfunction in patients on HD in our center and also studied the deficiency of Vitamin D on CI.
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Risk factors for kidney disease among civil servants: Report of annual screening and medical evaluation p. 440
Samuel Ayokunle Dada, David Daisi Ajayi, Taiwo Hussean Raimi, Awolowo A Thomas, Bolade Dele-Ojo
DOI:10.4103/1319-2442.284019  PMID:32394917
The outlook of chronic kidney disease (CKD) is worse among the poor sub-Saharan Africa populace due to limited and unaffordable renal replacement therapy. Regular screening of at-risk population can contribute to delaying or even preventing the progression of the disease. This study was designed to evaluate prevalent risk factors for CKD among the urban dwelling civil servants in Ado Ekiti. This is a cross-sectional observational study involving healthy adults above 18 years old. Data on sociodemographic and relevant lifestyle pattern such as smoking, alcohol intake, personal and family history of hypertension, diabetes, and kidney disease were obtained. Clinical variables such as anthropometric measurements, blood pressure (BP), and blood samples for laboratory investigations were taken. There were 122 participants with a mean age of 47.26 ± 5.62 years. About half of them earn <$140/month. Fifty-two (42.6%) individuals admitted taking local herbs and/or Chinese medicines and about a third (36.1%) use unprescribed medi-cations including nonsteroidal anti-inflammatory drugs. Family history of high BP and diabetes mellitus was present in 15.6% and 11.5% of individuals, respectively. We found 45 (32.6%) individuals with body mass index ≥30 kg/m2, while 13.3% and 3.3% have at least 1+ of dipstick and microalbuminuria, respectively. About one-third (25.4%) were either found to be hypertensive or were on antihypertensives, while 12 (9.8%) were either diabetic or had hyperglycemia during the screening. There is a high prevalence of risk factors for CKD among these apparently well individuals. Regular screening, and treatment of the identified risk factors is recommended.
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BRIEF COMMUNICATIONS Top

Changes in body mass index after pediatric renal transplantation p. 448
Seyed Seifollah Beladi Mousavi, Ehsan Valavi, Majid Aminzadeh, Heshmatollah Shahbazian, Hasan Otukesh, Rozita Hoseini, Bahman Cheraghian
DOI:10.4103/1319-2442.284020  PMID:32394918
Significant weight gain following renal transplantation is common in adult and pediatric recipients and mostly depends on receiving higher doses of steroids, changes in mood and feelings, as well as their level of physical activities. This study was performed to evaluate body weight and body mass index (BMI) before and after kidney transplantation in children and adolescents. In this cross-sectional study, 71 pediatric renal transplant recipients (42 boys and 29 girls) were included. World Health Organization criteria were used for comparing Z-score BMI for age in our cases. Overweight was defined as Z-score BMI >+1 SD (standard deviation) and obesity as >+2 SD. At the time of transplantation, the mean age was 10.8 ± 3 years (5-16 years) and based on BMIZ-score, the patients were found to be thin (BMIZs <-2 SD) in 16.9%, normal (BMIZs = -2 to +1 SD) in 67.6%, overweight (>+1 SD to +2 SD) in 9.9%, and obese (BMIZs >+2 SD) in 5.6%.The mean follow-up duration after transplantation was 3.57 ± 1.68 years (1-7 years) and at the time of reevaluation after transplant, their mean age was 14.4 years (6-18 years). The mean BMI was 22 ± 5.3 kg/m2, and for BMI grouping, the patients were thin in 7%, normal in 54.9%, overweight in 21.1%, and obese in 17%. Pretransplant thinness (BMIZs <-2 SD) was found in 12 patients (16.9%), equally in boys and girls, and in most of them (83.3%), BMIZs changed to normal or even >+1 SD after transplant. Chronic continuous decrease of glomerular filtration rate (CCD/GFR) was found in 27 cases (38%); 74.1% were male (P = 0.045), hypertriglyceridemia was found in 74.1% (P = 0.023%), hypercholesterolemia in 63% (P = 0.032),and obesity in 18.5% (p = 0.5). The incidence of obesity has tripled after kidney transplantation. It was not a risk factor for graft or patient survival in our experience, whereas pretransplant obesity had some effects on long-term graft outcome.
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A prospective study on prevalence and causes of insomnia among end-stage renal failure patients on hemodialysis in selected dialysis centers in Qassim, Saudi Arabia p. 454
Rand Suliman Alkhuwaiter, Raneem Ahmad Alsudais, Amal Ahmed Ismail
DOI:10.4103/1319-2442.284021  PMID:32394919
Studies directed toward improving the life quality of hemodialysis (HD) patients revealed different etiologies for insomnia. We aimed to assess the prevalence of insomnia and determine associated etiologies in the AL Qassim region. This interview-based questionnaire study was conducted in HD centers for assessment of insomnia and its related causes using a validated screening questionnaire, developed by the JPS health network. Accordingly, patients were classified as insomnia, insomnia for further evaluation and management and no insomnia. Of 111 patients, there were 55 males and 56 females. The prevalence of primary insomnia was 28.82%, compared to 44% for secondary insomnia. Significant correlations linked insomnia with apnea, night itching, and not using phosphate binder usage. Primary and secondary insomnia is frequent among dialysis patients and require an application of diagnostic tools and severity scales. The assessment of causes and treatment of the complaints of apnea, usage of phosphate binders, and itching should be considered to decrease complications and improve quality of life.
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RENAL DATA FROM THE ARAB WORLD Top

Quality of life and its determinants among hemodialysis patients: A single-center study p. 460
Ahmed F El-Habashi, Amgad E El-Agroudy, Ahmed Jaradat, Zahra H Alnasser, Hanoof H Almajrafi, Rayan H Alharbi, Asma Alanzy, Asma M Alqahtani
DOI:10.4103/1319-2442.284022  PMID:32394920
The purpose of this study was to investigate the relation between selected demographic and clinical characteristics and quality of life (QOL) scores in patients with end-stage renal disease who receive dialysis. We conducted the study at one hemodialysis (HD) unit in Bahrain from May 2018 to July 2018. We used standard QOL Index (QOLI) score instrument in Arabic form. This study included 100 patients (66 men and 34 women), aged 22 to 80 years on treatment with maintenance HD for four to 190 months. Inclusion criteria were as follows: those aged >18 years with no severe morbidities or psychological diseases and were on dialysis for at least three months. The following QOL scores were recorded: the health and functioning domain (64.8 ± 15.3), the social and economic domain (65.6 ± 14.1), the psychological/spiritual domain (74.9 ± 14.3), and the family subscale domain (75.9 ± 14.5). Male patients had reduced QOL though not statistically significant and younger patients had better QOL scores. The QOL scores revealed a decreasing trend with decreasing level of education, and they were higher among those who were not working and stayed at home. In addition, the family subclass scores were significantly higher among the married patients. Correlations between the demographic characteristics and QOL scores showed that there was a significant negative correlation between family domain and educational level and marital status, while there was a significant positive correlation between residence and psychological domain. Age, gender, marital status, residence, ethnicity, education level, employment status, income, and duration on HD nonsignificantly affected one or more domains of QOLI scores in such patients. Adequate management of these factors could influence patient outcomes.
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Quality of life for kidney transplant palestinian patients p. 473
Kholoud Dweib, Salma Jumaa, Maher Khdour, Hussein Hallak
DOI:10.4103/1319-2442.284023  PMID:32394921
The purpose of kidney transplantation is to improve the quality of life (QoL) for patients with end-stage renal disease. This study aims to measure QoL in renal transplant patients in Bethlehem and Hebron in Palestine. A descriptive, cross-sectional study was performed on 109 renal transplant patients referred to Palestinian Ministry of Health - primary health-care clinics of Bethlehem and Hebron in Palestine from December 2016 to April 2017, by using Kidney Transplant Questionnaire (KTQ-25) for the assessment of QoL and determining the effect of sociodemographic variables on QoL. The reliability of KTQ-25 was determined to be 0.74 by Cronbach’s alpha method. Data were analyzed by Statistical Package for Social Sciences version 19.0 and descriptive analytic statistics. The mean QoL for kidney transplant patients was 4.02 ± 0.84. The highest score of the KTQ was the appearance dimension (5.40 ± 1.23), whereas the lowest was related to the uncertainty/fear dimension (3.36 ± 1.23). The sample consisted of mostly males (79.8%), and their mean age was (41 ± 24) years. Most were married (81.7%), 45.9% were without work, and 66.1% of kidney donors’ type were biologically blood related. No statistically significant difference was observed (P ≥ 0.05) between the sociodemographic variables and QoL. Surprisingly, the majority of kidney transplant patients (83.3%) were on prednisone. The QoL for kidney transplant patients was moderate. The society, government, family, and medical staff need to support patients to alleviate fear and uncertainty they feel. Furthermore, high reliance on corticosteroids in treatment needs to be reconsidered.
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RENAL DATA FROM ASIA–AFRICA Top

Ten-year appraisal of pediatric renal allograft biopsies: Points to ponder p. 482
Aruna V Vanikar, Lovelesh A Nigam, Kamal V Kanodia, Rashmi D Patel, Kamlesh S Suthar, Aanal H Mehta
DOI:10.4103/1319-2442.284024  PMID:32394922
There is paucity of literature on pediatric renal allograft biopsy (RAB) evaluation. We present RAB findings of pediatric renal transplantation (RT) and correlate with outcome. This is a 10-year retrospective study of diagnostic RAB of children <12 years divided in to three groups: Group 1 (n = 9): less than haplo-match living donor RT (LDRT), Group 2 (n = 32): greater than or equal to haplo-match LDRT, and Group 3 (n = 7): deceased donor RT. Demographics, biopsy findings, survival, and serum creatinine (SCr) were evaluated. Statistical analysis was performed using IBM SPSS Statistics version 20.0. The most common findings were antibody-mediated rejection (ABMR) observed in 77.7%, 45%, and 71.5% and T-cell-mediated rejections (TCMRs) in 33.3%, 52.5%, and 42.9% in Groups 1, 2, and 3, respectively. Recurrent oxalosis was seen in 5% in Group 2. Death-censored graft survival was 100% at 1 year and 43.8% from 5 to 9 years in Group 1; 93.5%, 76.6%, 56.5%, and 14.4% at 1, 5, 10, and 15 years in Group 2; 100% at one year; and 71.4% from 5 to 12 years in Group 3. No patient appeared after 9 years in Group 1 and after 12 years in Group 3. In Group 1, the mean SCr (mg/dL) was 1.06 ± 0.45, 2.12 ± 1.87, and 1.39 at 1, 5, and 9 years; 1.35 ± 0.97, 1.73 ± 1.15, and 2.49 ± 1.64 in Group 2; and 1.15 ± 1.24, 1.43 ± 0.1, and 1.18 ± 0.06, respectively, in Group 3 at 1, 5, and 10 years posttransplant. ABMR followed by TCMR was the most common injury in all the groups. Group 1 had more rejections than others.
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The changing face of pregnancy-related acute kidney injury from eastern part of India: A hospital-based, prospective, observational study p. 493
Sandeep Saini, Arpita Ray Chaudhury, Smita Divyaveer, Pratima Maurya, Dipankar Sircar, Sanjay Dasgupta, Debabrata Sen, Sambhunath Bandyopadhyay, Rajendra Pandey
DOI:10.4103/1319-2442.284025  PMID:32394923
This study was initiated to look into the etiologies, prevalence, and outcome of pregnancy-related acute kidney injury (PRAKI) in a tertiary care hospital. Women admitted with PRAKI from January 2015 to December 2016 were included in the study. All patients were investigated and treated and followed up for the next six months.. For statistical analysis, Chi- square test and analysis of variance were performed to analyze the data. Multivariate analysis was applied to compare the risk of nonrecovery of renal function in different etiologies of PRAKI. During the study period, 81 patients were admitted with PRAKI, of whom 68 (84%) received hemodialysis (HD). A total of 449 patients including all cases of AKI underwent HD from January 2015 to June 2016. The incidence of dialysis requiring PRAKI was 68 out of the 449 patients (15%). Sixty-eight (84%) patients required dialysis support while the most common cause was sepsis (49%), with the second being pregnancy-associated atypical hemolytic-uremic syndrome (P-aHUS) (17%) followed by obstetric hemorrhages (16%). There was a significant reduction of first-trimester AKI (8.6%) compared to a previous study published from this institute (19.3%). The maternal mortality (25%) and fetal mortality (23.5%) were high. Nearly 39% of the patients had complete recovery of renal function. This study revealed significant PRAKI burden due to a largely preventable cause, puerperal sepsis. Renal survival was poor in P- aHUS. The gaps in the obstetric care may be identified for the improvement of fetomaternal outcome.
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SPECIAL ARTICLE Top

Is altruism always sufficient for organ donation? vroom's expectancy theory, for expanding the organ donor pool p. 503
Osebor Ikechukwu Monday
DOI:10.4103/1319-2442.284026  PMID:32394924
Organ transplantation is perhaps one area in which scientists have accomplished stunning outcomes in the 21st century. Nonetheless, the shortage of organs remains a major challenge of medical science, and worldwide, thousands of human organs are buried every day, especially from cerebrum-dead-injury victims. Using a method of philosophical analysis, this viewpoint study contends that the root cause of organ shortage is the dependence solely on altruistic organ donations. The unselfish organ donation is good, yet it is not enough. To close the gap between the demand and supply of organs, steps need to be taken to improve the organ donation pool. The Victor Vroom’s expectancy theory, if applied, could expand the organ donor pool for transplantation.
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CASE REPORTS Top

A case of renal and splenic LECT 2 amyloidosis: A recently recognized cause of renal and systemic amyloidosis p. 508
Michael Shye, Anthony Sisk, Carl Schulze, Marina Barsoum, Mira Mikhail, Farid Arman, Anjay Rastogi, Ramy M Hanna
DOI:10.4103/1319-2442.284027  PMID:32394925
Amyloidosis has traditionally been of a few defined varieties, most commonly including light-chain amyloidosis (AL amyloidosis) and secondary amyloidosis due to chronic inflammation (AA amyloidosis). Apolipoprotein A-I/A-II cystatin C, gelsolin, lysozyme, fibrinogen alpha chain, beta 2 microglobulin, and transthyretin familial amyloidosis represent rarer but reported varieties. Ten years ago, the first reports linked leukocyte chemotactic factor 2 (LECT2) amyloidosis as a pathological agent identified as a novel class of amyloid-generating protein. Epidemiology suggested that this was a new cause of amyloidosis that is especially common in Hispanic patients and somewhat common among patients from the Middle East-North Africa (MENA) region. We report a case of splenic and renal LECT 2 amyloidosis in a 62-year- old Hispanic male with diabetes mellitus. After an unremarkable serological workup, LECT 2 amyloidosis was diagnosed on renal biopsy. The case presentation is reviewed as a typical presentation, and the literature is reviewed regarding this newly reported entity, resulting in infiltrative renal amyloidosis and chronic renal disease.
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Severe hyponatremia after donor nephrectomy p. 515
Ihab A Ibrahim, Ehab A Hassan, Tariq Z Ali, Jens G Brockmann, Hassan A Aleid
DOI:10.4103/1319-2442.284028  PMID:32394926
Living kidney donation is safe and established but can lead to short- and long-term complications. Hyponatremia is the most common disorder of body fluid and electrolyte balance in clinical practice, associated with increased morbidity, mortality, and the length of hospital stay. A correct diagnosis of the etiology of hyponatremia is critical, both to determine correct management and prognosis. Here, we present a case of a severe hyponatremia following left- sided donor nephrectomy with a physical examination suggestive of mild hypovolemia. Laboratory tests revealed high urine osmolality and sodium concentration mimicking syndrome of inappropriate antidiuretic hormone secretion (SIADH), in the setting of abnormally blunted response to Synacthen. The patient responded well to hydrocortisone replacement. Differentiating between primary adrenal insufficiency and SIADH as a cause of severe hyponatremia was the key to successfully treating this patient. Hyponatremia following donor nephrectomy is unusual and could be explained in this case by hypocortisolism.
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Successful treatment of a patient with posttransplant IgA nephropathy with targeted release formulation of budesonide p. 521
Umesh Lingaraj, Kishan Aralapuram, Sreedhara Chikkanayakanhalli, Akila Vishwanathan, Mahesha Vankalakunti
DOI:10.4103/1319-2442.284029  PMID:32394927
Recurrence of glomerulonephritis is the third-leading cause of allograft loss. Graft loss due to IgA nephropathy occurs in 10% at 10-year follow-up. The NEFIGAN trial demonstrated that Target Release Formulation (TRF) of budesonide is a specific treatment for IgA nephropathy targeting intestinal mucosal immunity upstream of disease manifestation with favorable safety profile. We are reporting a case of successful treatment of a patient with posttransplant IgA nephropathy with TRF of budesonide.
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Hyperkalemia mimicking brugada pattern in electrocardiogram: A rare case report from Nepal p. 524
Kashyap Dahal, Dineshowri Shrestha, Rajani Hada, Anil Baral, Kunjang Sherpa
DOI:10.4103/1319-2442.284030  PMID:32394928
Hyperkalemia is one of the dangerous complications of renal impairment (acute kidney injury or chronic kidney disease). Hyperkalemia may present with the electrocardiogram (ECG) changes as nonspecific repolarization abnormalities. Here, we report a case of AKI with hyperkalemia and the Brugada pattern of ECG, which reverted to normal after effective management of hyperkalemia. A 55-year-old male reported to the Emergency Department of National Academy of Medical Sciences (Bir Hospital) with injuries in his lower limbs and spine after he had met an accident two days back. He also had decreased urine output for the last one day. On physical examination, he had injuries in the spine and lower limbs. His laboratory investigations showed impaired renal function parameters with serum sodium 130 mEq/L and serum potassium of 7.3 mEq/L. His ECG was consistent with Brugada pattern. Patient was treated with 10% calcium gluconate, insulin and dextrose, salbutamol nebulization, and sodium polystyrene sulfonate till hemodialysis was initiated. Hyperkalemia and acidosis can manifest with the Brugada pattern in ECG. Thus, a careful evaluation of hyperkalemia and its treatment must be instituted in such an ECG pattern.
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Mesalazine induced focal segmental glomerulosclerosis in a patient with ulcerative colitis p. 528
Fatih Yilmaz, Bora Uslu, Bahar Akkaya, Ramazan Cetinkaya
DOI:10.4103/1319-2442.284031  PMID:32394929
Focal segmental glomerulosclerosis (FSGS) and other glomerulonephritis due to the use of 5-aminosalicylic acid derivatives have been reported in the literature. A 38-year-old male who had been using mesalazine for four years because of ulcerative colitis applied to doctor due to swelling in the lower extremities. The patient was diagnosed with nephrotic syndrome (NS). Renal biopsy was performed, and FSGS was diagnosed. Antiproteinuric treatments were initiated with steroid therapy. The patient has been followed with the normal renal function of the after treatment. 5-aminosalicylic acid derivatives affect renal functions at different levels and caused in NS.
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A complicated chinese herbal medicine nephrotoxicity p. 533
Haider Ali Omer Mohamed, Osama Mirghani Osman, Husaam Haider Ali, Mohammed Nasser Asiri, Abdulrhman Ali Hassan, Ibrahim Mohammed Almangah, Abbas Omer Elkarib, Ali AbBshabshe
DOI:10.4103/1319-2442.284032  PMID:32394930
Chinese herbal medicine is widely used globally. In many instances, it is associated with severe adverse outcomes. We report case of a Chinese herbal nephropathy occurring in a 43-year-old woman showing renal impairment, metabolic acidosis, Stokes - Adams syndrome, hypernatremia, and hypokalemia, characteristics not usually encountered in published cases.
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Familial mediterranean fever and immunoglobulin A nephropathy: A case report and review of the literature p. 537
Fatih Yılmaz, Meryem Keleş
DOI:10.4103/1319-2442.284033  PMID:32394931
Familial Mediterranean fever (FMF) is an autosomal recessive disease charac-terized by recurrent fever episodes and polyserositis. The most important complication is amyloidosis. Nonamyloidotic nephropathy in FMF is poorly documented. Besides amyloidosis, different types of glomerulonephritis may rarely be seen in FMF patients. A 24-year-old male patient followed up due to FMF was evaluated for macroscopic hematuria and acute kidney injury. The patient was diagnosed as immunoglobulin A nephropathy with renal biopsy. The patient gave a good response to colchicine and steroid treatment. The case reports in the literature about the treatment of the patients with association of FMF and glomerulonephritis are insufficient, and there are no satisfactory epidemiological and treatment outcome reports.
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Persistence of left superior vena cava detected during cuffed dialysis catheter insertion p. 542
Rashmi Yadav, Urmila Anandh, Ritesh Kumar, Sapna Marda
DOI:10.4103/1319-2442.284034  PMID:32394932
Persistent left superior vena cava is a rare finding seen only in 0.3%-0.5% population. It is generally asymptomatic and is often discovered after central venous catheterization done for various indications. We present a case where we demonstrate persistent left superior vena cava/left cardinal vein remnant discovered during left-sided cuffed catheter insertion for hemodialysis in a 65-year-old chronic kidney disease patient. Findings were confirmed with computed tomography venogram. This anomaly poses iatrogenic risks to the patient if not detected early. A catheter along the left mediastinal border can be dangerously close to descending aorta and could also be indicative of its placement in the internal thoracic vein or, pericardiophrenic vein. It can also perforate the persistent/remnant vessel and enter the pleura, pericardium, or mediastinum. This case emphasizes the importance of familiarity with this entity and its role in determining the appropriate venous access for patient therapy when faced with this clinical situation.
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Coagulopathy in the nephrotic syndrome p. 545
Sneha P Simon, Jose Thomas
DOI:10.4103/1319-2442.284035  PMID:32394933
Coagulopathy in the nephrotic syndrome (NS) is very rare. Simultaneous prolongation of both prothrombin time and activated partial thromboplastin time suggests common coagulation pathway abnormality such as liver dysfunction, Vitamin K deficiency, disseminated intravascular coagulation, or primary fibrinolysis. This results in difficulty in proceeding with renal biopsy and tissue diagnosis. We report one such case of NS with coagulopathy and refractoriness to correction with blood products, which led us to make a diagnosis of AL amyloidosis, which was confirmed with abdominal fat pad biopsy and other work-up.
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A rare case of sarcoidosis causing granulomatous interstitial nephritis presenting as non oliguric acute renal failure in the Indian subcontinent p. 549
Chinmaye Sapre, Praveen Kumar Kolla, K Varaprasad Rao, Raghavendra Sadineni, Bhargav Reddy, Sreedhar Sharma, V Viswanath, Mahaboob V Shaik
DOI:10.4103/1319-2442.284036  PMID:32394934
Sarcoidosis is a systemic disease characterized by non caseating granulomatous inflammation. Sarcoidosis can affect any organ, but it most commonly involves the lungs and lymph nodes. The exact incidence of renal involvement in sarcoidosis remains unclear, but it is found to be rare. Granulomatous interstitial nephritis is the most common histological pattern, but its presentation with renal insufficiency is rare. Here, we present a case of sarcoidosis causing granulomatous interstitial nephritis presenting as isolated non oliguric acute renal failure.
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Bullous lesions in a young adolescent postrenal transplant p. 553
Gurinder Kumar, Hanan Khalid AlHadhrami
DOI:10.4103/1319-2442.284037  PMID:32394935
Kidney transplant recipients frequently suffer from skin infections and malignancies. New dermatosis can appear after transplantation. Although children are maintained on varying degrees of chronic immunosuppression, there is still a possibility of autoimmune blistering skin conditions, which can pose a diagnostic challenge in terms of clinical presentation. Histopathology of skin lesions is very important which helps in correct diagnosis and prompt treatment. We report an extremely rare case of linear IgA dermatosis in a child who was postrenal transplant and treated successfully with dapsone and steroids.
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Nonuremic calciphylaxis in a patient with multiple myeloma and rheumatoid arthritis p. 556
Nadia Bouchemla, Abdelatif Laamani, Mariam Chettati, Wafaa Fadili, Inass Laouad
DOI:10.4103/1319-2442.284038  PMID:32394936
Calciphylaxis is a rare and highly morbid condition that has continued to challenge the medical community since its early descriptions in the scientific literature many decades ago. Calciphylaxis predominantly affects patients with chronic kidney disease treated by dialysis but is also described in patients with normal kidney function. We report a rare case of a patient who presented with calciphylaxis associated with multiple myeloma and rheumatoid arthritis. With a better understanding of its pathophysiology, more effective therapies are being developed.
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LETTER TO THE EDITORS Top

Remarks about the study on infection-associated relapses in children with nephrotic syndrome: A short-term outcome study p. 561
Akbar Shoukat, Raheel Allana, Rahim Jandani
DOI:10.4103/1319-2442.284039  PMID:32394937
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Author's reply p. 562
Mukta Mantan
DOI:10.4103/1319-2442.284040  PMID:32394938
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Unrelated donors in kidney transplantation: Myths and the gruesome reality p. 563
Taqi F Toufeeq Khan, Irfan Mirza, Tahir Rashid, Nisar Anwar
DOI:10.4103/1319-2442.284041  PMID:32394939
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Author's reply p. 566
Muhammad Tassaduq Khan
DOI:10.4103/1319-2442.284042  PMID:32394940
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Risk for renal carcinogenesis due to exposure to ochratoxin A contaminated roasted coffee: An assessment from Thailand p. 568
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/1319-2442.284043  PMID:32394941
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Multimedia training, a good method to reduce fatigue in patients undergoing hemodialysis p. 571
Nader Aghakhani, Miss Sara Fooladi
DOI:10.4103/1319-2442.284044  PMID:32394942
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