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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
Coverpage
July-August 2020
Volume 31 | Issue 4
Page Nos. 703-882

Online since Saturday, August 15, 2020

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REVIEW ARTICLES  

Risk Factors for the Development of Postoperative Acute Kidney Injury in Patients Undergoing Joint Replacement Surgery: A Meta-Analysis Highly accessed article p. 703
Parnandi Bhaskar Rao, Neha Singh, Sujit K Tripathy
DOI:10.4103/1319-2442.292304  PMID:32801231
A new-onset acute kidney injury (AKI) after arthroplasty impairs rehabilitation and outcome. A prior knowledge of risk factors contributes to a planned preventive management and prognostication. Although many studies have addressed the issue, our objective was to perform a meta-analysis to bring a consensus on the perioperative risk factors promoting AKI postoperatively. We conducted a systematic review and meta-analysis of observational studies reporting risk factors with odds of development of AKI according to the existing criteria after hip or knee replacement surgery. We searched the PubMed and Google Scholar databases for free English articles published until June 2018. Two authors independently screened the articles and extracted data. Discrepancies were resolved by consensus or consulting the third author. Methodological quality of the articles was assessed using the Newcastle-Ottawa Scale. A total of five studies were included in this meta-analysis. The following risk factors were found to contribute to new kidney injury: advanced age; male gender; preoperative liver, cardiac, or kidney diseases; presence of heart failure; American Society of Anesthesiologists grade ≥ 3; requirement of perioperative blood transfusion, revision arthroplasty, and knee arthroplasty; body mass index; and use of angiotensin-converting enzyme inhibitors. Diabetes, hypertension, duration of surgery, type of anesthesia, and preoperative serum creatinine were not found to be associated with renal injury. The key limitation was the availability of small number of studies. More longitudinal observational studies addressing the issue are the need of the hour, and, till then, a preventive strategy aimed at the identified risk factors should help.
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Birth Weight and Susceptibility to Chronic Kidney Disease p. 717
Issa Al Salmi, Suad Hannawi
DOI:10.4103/1319-2442.292305  PMID:32801232
The worldwide prevalence of noncommunicable diseases (NCDs) is projected to increase substantially over the next few decades. Chronic kidney disease (CKD) is a key determinant of poor health outcomes for major NCD. Genetic predisposition and environmental exposures are contributory factors, but increasingly, it is being recognized that fetal development is also an important modulator of the NCD risk. Low birth weight (LBW) and CKD affect more disadvantaged populations and ethnic minorities and, therefore, causes a disproportionate burden on the poor. Human nephron number is highly variable and may range from under half a million to almost over two million. Significant variability is already present at birth, highlighting the importance of early nephrogenesis. Nearly 60% of nephrons are developed in the third-trimester of pregnancy. Nephron numbers increase in proportion to birth weight and gestational age. This wide-variability probably contributes to individual susceptibility to develop CKD where individuals with nephron numbers on the lower side of the spectrum are those at higher risk of developing kidney dysfunction at higher rate and progress more toward end-stage CKD. This article aims at discussing LBW and the susceptibility to CKD. Furthermore, in postnatal environment, the weight gain or change at adult life increases the metabolic demand and determines the phenotypic expression of disease along with the spectrum of nephron number. Hence, a cycle of hyperfiltration mechanism of these nephrons leads to proteinuria, glomerulo- sclerosis, and progressive development of larger glomeruli, a greater risk of proteinuria and progressive CKD. Therefore, LBW offspring are at risk of developing CKD (defined as albuminuria, a reduced glomerular filtration rate, or renal failure) in later life. Furthermore, the impact of prenatal programming is expected to be compounded with age, and the association of LBW with the risk of CKD seen in younger adults may become greater with age. It would be prudent, to adopt policies of intensified life-long surveillance of LBW people, anticipating this risk.
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ORIGINAL ARTICLES Top

Angiotensin-Converting Enzyme Inhibitor Captopril: Does it Improve Renal Function in Lipopolysaccharide-induced Inflammation Model in Rats p. 727
Hamid Azizi-Malekabadi, Farimah Beheshti, Azam Abareshi, Fatemeh Norouzi, Majid Khazaei, Mohammad Soukhtanloo, Mahmoud Hosseini
DOI:10.4103/1319-2442.292306  PMID:32801233
Renin-angiotensin system as an important regulator of renal function has also a major role in inflammation. In the present study, the effects of captopril on renal dysfunction, renal cytokine levels, and renal tissue oxidative damage were investigated in lipopolysaccharide (LPS)-induced inflammation model in rats. Treatment of five groups of the rats was carried out as follows: (1) saline as a control, (2) LPS 1 mg/kg, and (3–5) 10, 50, or 100 mg/kg captopril 30 min, respectively, before LPS. The treatments were given for 12 days. Finally, the animals were deeply anesthetized, the blood samples were obtained, and the renal tissues were removed and kept for biochemical measurements. Administration of LPS increased serum blood urea nitrogen and creatinine (P < 0.001). Pretreatment with all doses of captopril decreased these parameters (P < 0.001). LPS also increased interleukin-6 (IL-6), malondialdehyde, and nitric oxide metabolites in the renal tissues (P<0.05 – P < 0.001), which was prevented by captopril (P < 0.05 – P < 0.001). The total thiol concentration and superoxide dismutase and catalase activities in the kidney of the LPS group were lower than the control (P < 0.001), while they were enhanced when the animals were cotreated by captopril (P <0.01 – P < 0.001). The results of the present study showed that captopril improved renal function and attenuated tissue oxidative stress in LPS-induced inflammation model in rats.
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Survey of Patient’s Experience of Altruistic Nondirected Kidney Donation p. 739
Katharina J Schumacher, Sarah Stacey, Jacob A Akoh
DOI:10.4103/1319-2442.292307  PMID:32801234
The scarcity of organs for donation is an ongoing issue. Change in legislative framework allows for altruistic donations in the UK, but, whereas the number of donations from deceased donors has increased, there has been a slow decline in altruistic living donors. The aim of this study was to review perspectives of altruistic nondirected kidney donors (ANDKD) at our center and outcome of all enquiries to inform service improvement and increase the numbers of donors. All enquiries by potential ANDKD at our center from September 2005 to September 2017 were analyzed. Donor assessment was performed as per the UK Guidelines, prior to obtaining Human Tissue Authority approval. The outcome of donation and results of questionnaires sent to 50 ANDKD were analyzed. During the period, 51 of the 180 enquiries (28.3%) resulted in kidney donation. Questionnaire responses were: 66% donors were retired; most heard about altruistic donation through media (60%); 72% thought psychological or psychiatric assessment was necessary; 95% found the information provided prior to donation adequate; 82% rated their overall experience as good/excellent; and 90% would recommend kidney donation to others. Thirteen of 50 donated kidneys were fed into the kidney exchange program. The mean ± standard error of the mean of the duration from human tissue authority approval to donation were 60.4 ± 5.4 and 131.2 ± 11.2 days, respectively (P = 0.00001). A significant proportion of enquiries for altruistic donation would result in donation but the assessment process needs to be quicker. ANDKD is useful way of priming the National Living Donor Kidney Sharing Scheme.
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Echocardiographic Evaluation of Left Atrial Volume Index in Patients with Chronic Kidney Disease p. 750
Syed Rizwan Bokhari, Abeera Mansur, Muhammad Zaman Khan Assir, Afshan Ittifaq, Shahbaz Sarwar
DOI:10.4103/1319-2442.292308  PMID:32801235
Chronic kidney disease (CKD) patients are at high risk of developing cardio vascular disease. Left atrial volume index (LAVi) is an indicator of left ventricular diastolic dysfunction. We conducted this study to find out the correlation of LAVi and other echocardio- graphic parameters with estimated glomerular filtration rate (eGFR). We prospectively enrolled 170 individuals: 69 patients with CKD and 101 controls. Echocardiographic parameters including systolic and diastolic volumes of left ventricle, LAVi, ejection fraction (EF), pulmonary artery systolic pressure (PASP), and E/e ratio were measured in all participants. The demographic, clinical, and echocardiographic parameters were examined. From the total of 170 individuals, 69 (40.5%) patients had CKD and 101 (59.5%) had normal renal profile. There were 38 (55.07%) males in the CKD group and 71 (70.29%) in the control group. Patients with CKD had higher median LAVi [33.33 mL/m2 ± 11.71 vs. 22.54 mL/m2 ± 5.82; P < 0.001], higher median E/e ratio [10.41 ± 6.28 vs. 7.48 ± 2.28; P < 0.001], higher median PASP [42.47 ± 13.64 vs. 33.59 ± 12.51; P < 0.001], and lower median EF [52.79% ± 14.37 vs. 60.7% ± 8; P < 0.001]. There was a statistically significant negative correlation of eGFR with LAVi (r = -0.515, P < 0.001), PASP (r = -0.44, P = 0.001), and E/e ratio (r = -0.331, P = 0.001). Patients with CKD have higher LAVi, PASP, and E/e ratio and lower EF as compared to individuals without CKD. There is a significant negative correlation between eGFR and LAVi.
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Influenza A (H1N1) Virus Infection Associated Acute Kidney Injury - A Study from a Tertiary Care Center in South India p. 759
Elayaperumal Indhumathi, Vamsi Krishna Makkena, Varun Mamidi, Varadharajan Jayaprakash, Matcha Jayakumar
DOI:10.4103/1319-2442.292309  PMID:32801236
Influenza A (H1N1) infection in 2009 spread rapidly all over the world. Mortality was high in patients with H1N1-associated acute kidney injury (AKI). We estimated the incidence, risk factors of AKI and mortality associated with H1N1 infection. This is a prospective observational study, including 158 adult patients with H1N1 infection confirmed with real-time reverse transcriptase-polymerase chain reaction conducted between August 2016 and September 2017. AKIN criteria were used to define AKI. Of 158 patients in this study, 112 were male and the mean age was 46.4. Fifteen patients (9.5%) were found to have AKI. The mean age was higher (56.13 ± 10.02) in the AKI group compared to non-AKI (45.48 ± 16.26) (P = 0.007). Presence of shock, multiple organ dysfunction syndrome (MODS), ventilatory support were observed more in the AKI group (P = 0.000). Among AKI patients, the requirement of dialysis was more than 50% (n = 8/15, 53.3%). Eighteen patients died following H1N1 infection (11.4%).Shock (n = 8/18, 44.4%, P = 0.000), MODS (n = 13/18, 72.2%, P = 0.000), intensive care unit (ICU) care (n = 17/18, 94.4%, P = 0.000), ventilatory support (n = 18/18, 100% P = 0.000), AKI (n = 11/18, 61.1%, P = 0.000), and requiring dialysis (n = 7/18, 38.9%, P = 0.000) were significantly associated with mortality compared to patients who survived. The incidence of H1N1 AKI was 9.5%, with > 50% requiring dialysis. Risk factors for AKI included older age, underlying chronic kidney disease, presentation with sepsis, shock, MODS, ICU care, and mechanical ventilation. Mortality was high in patients with AKI compared to non-AKI patients.
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The Prevalence of Frailty and its Association with Cognitive Dysfunction among Elderly Patients on Maintenance Hemodialysis: A Cross-Sectional Study from South India p. 767
Jyotish Chalil Gopinathan, Benil Hafeeq, Feroz Aziz, Sajith Narayanan, Ismail Naduvileparambil Aboobacker, NA Uvais
DOI:10.4103/1319-2442.292310  PMID:32801237
Data are scarce regarding the prevalence of frailty in elderly patients undergoing maintenance hemodialysis (HD) in India. We conducted a cross-sectional observational study aimed to study the prevalence of frailty and cognitive dysfunction in patients aged 75 years or more undergoing maintenance HD in three tertiary care hospitals and associated stand-alone dialysis centers in North Kerala. Frailty was ascertained by two methods. In method 1 (physical performance measurement based), dichotomous scoring (0 or 1) of five domains, namely weight loss, exhaustion, low physical activity, weak grip, and slow walking, was done, and a score of 3/5 was used to define frailty. In method 2 (self-report measure based), scores on the Medical Outcomes Study Short-Form 36-item Questionnaire (SF-36) physical function domain were used instead of hand grip strength and walking speed, and a score of <75 was defined as meeting the criteria for weakness and slow walking. Cognitive function was documented using the Montreal Cognitive Assessment Instrument. A total of 899 patients were screened, of whom 44 were aged 75 years or more and 39 met the criteria for inclusion. The majority (n = 31, 79.5%) had ages between 75 and 80 years and were male. Dialysis vintage was <1 year in 15.4%, 1–3 years in 51.3%, and >3 years in 33.3% of patients. Frailty was documented in 22 (56.4%) patients by method 1 and in 25 (64.1%) by method 2. There was a statistically significant difference between the two methods in documenting frailty (P < 0.001, Chi-square test). Cognitive impairment was present in 89.7% of patients and significantly associated with frailty (P < 0.001, Fisher’s exact test). Frailty and cognitive dysfunction are highly prevalent in elderly people undergoing maintenance HD in North Kerala. Physical performance and self-report measure-based methods correlate well in frailty documentation.
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The Effect of Nigella Sativa on Renal Oxidative Injury in Diabetic Rats p. 775
Reza Mohebbati, Abbasali Abbasnezhad, Shahrzad Havakhah, Mojtaba Mousavi
DOI:10.4103/1319-2442.292311  PMID:32801238
Oxidative stress plays a key role in the evolution of diabetes complications. The current study looked into the potential effects of the hydroalcoholic extract of Nigella sativa on the oxidative injury of the rat kidneys in diabetic animals. The animals were placed into five study groups in a random manner as follows: (1) control, (2) diabetic, (3 and 4) treatment with two doses of N. sativa extract (200 and 400 mg/kg), and (5) treatment with metformin (300 mg/kg). The time course of administration was six weeks. The malondialdehyde (MD A) and total thiol groups, as well as the superoxide dismutase and catalase activities, were also assessed in the renal tissue and lipid profile in serum. In the diabetic groups, the level of MDA significantly increased (P < 0.01) and antioxidant levels decreased compared to the control (P < 0.05). In treated rats with N. sativa, the antioxidant status of renal tissue was improved (P < 0.05 to P < 0.001). The lipid profile also improved in the rats treated with the extract (P < 0.001). Our findings suggest that long-term administration of N. sativa in diabetic rats induced by streptozotocin can improve the status of the oxidative stress in kidney tissue.
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Heat Shock Protein 70 Gene Polymorphism in Egyptian Patients with Type 2 Diabetes Mellitus, with and without Nephropathy p. 787
Osama Mohamady Elshahed, Olfat Gamil Shaker
DOI:10.4103/1319-2442.292312  PMID:32801239
Heat-shock proteins (HSPs) are a group of proteins that function to protect cells and tissues against different types of damage. The aim of this work was to study the relationship between the genetic variation in HSP70 genes and the risk for development of nephropathy in Egyptian patients with Type 2 diabetes mellitus (DM). This study was carried out on 90 patients divided into three groups: 30 patients of Type 2 DM with nephropathy (Group I), 30 patients of Type 2 DM without nephropathy (Group II) with duration of diabetes > 10 years in both patient groups, and 30 healthy persons, who served as controls (Group III). All the studied patients were submitted to full history taking, complete clinical examination, and laboratory investigations including fasting blood glucose, glycated hemoglobin, renal function tests, and urinary albumin- to-creatinine ratio. HSP70-1 -110 AC, +190 G/C, HSP70-2 +1267 A/G, and shock protein70- hom +2437 T/C gene polymorphism were determined using the polymerase chain reaction- restriction fragment length polymorphism technique (PCR-RFLP). The results of the present study showed a highly statistically significant difference between Group I and Group II regarding family history, systolic and diastolic blood pressure, and duration of diabetes. There was a significant difference in the distribution of C allele of HSP70-1 -110A/C and +190 G/C and G allele of HSP70-2+1267A/G with more frequent detection in nephropathy group versus other groups, while there was no significant difference in genotype and allele distributions among the three studied groups for the HSP70-hom. It can be concluded that the C allele distribution of (HSP70-1 -110 A/C and HSP70+190 C/G) and the G allele distribution of HSP70-2 +1267A/G are associated with the susceptibility to renal complications in Egyptian patients with Type 2 DM.
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Cognitive Dysfunction in Patients with Chronic Kidney Disease p. 796
HK Aggarwal, Deepak Jain, Aswvini Bhavikatti
DOI:10.4103/1319-2442.292313  PMID:32801240
Cognitive impairment is a common entity in patients with chronic kidney disease (CKD), which plays an important role in increasing the morbidity in these patients. This study was performed to evaluate cognitive dysfunction and its severity in different stages of CKD and identify the correlation with factors affecting this dysfunction. A cross-sectional design study was conducted on 100 patients with CKD Stage III to V-D fulfilling the eligibility criteria. Cognitive status was assessed using the mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA) tests. The patients were divided into four groups according to their estimated glomerular filtration rate (eGFR); Group A with eGFR ranging between 30 and 59 mL/min/1.73 m2, Group B with eGFR between 15 and 29 mL/min/1.73 m2, Group C with eGFR <15 mL/min/1.73 m2 not on hemodialysis (HD), and Group D with eGFR <15 mL/min/1.73 m2 and on HD for the past six months. Factors affecting MMSE and MoCA scores were assessed using univariate and multivariate linear regression analysis. Mean MMSE score was 28.72 ± 1.37 in Group A, 26.00 ± 3.67 in Group B, 20.76 ± 4.84 in Group C, and 17.28 ± 3.32 in Group D, which showed a statistically significant difference. The mean MoCA score also showed a statistically significant decline from Group A to Group D with values being 26.36 ± 1.91, 24.56 ± 1.94, 22.08 ± 2.12 and 20.12 ± 1.81, respectively (P < 0.05). The MMSE and MoCA scores were found to have a statistically significant positive correlation with hemoglobin; serum corrected calcium and eGFR (P < 0.01) and statistically significant negative correlation with blood urea, serum creatinine, serum uric acid, serum phosphate, serum potassium and stage of CKD (P < 0.01). By raising the clinician’s awareness about cognitive dysfunction in CKD patients and its potential effects on medication, fluid and, dietary compliance improved quality of care is expected. Early intervention will improve the patient’s quality of life.
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Chest Ultrasound as a New Tool for Assessment of Volume Status in Hemodialysis Patients p. 805
Walaa H Mohammad, Ahmad B Elden, Mohamed F Abdelghany
DOI:10.4103/1319-2442.292314  PMID:32801241
Accurate assessment of volume status (VS) in hemodialysis (HD) patients is challenging. The use of chest ultrasound (CUS) for detection of extravascular lung water has recently gained wide acceptance. The aim of this study was to evaluate the use of CUS in VS assessment in HD patients in comparison to clinical and inferior vena cava (IVC) indices and to assess their relation with volume displacement after ultrafiltration. This prospective cohort study was carried out on 38 patients on regular HD. VS was assessed using a 13-point clinical score, and IVC indices and CUS score were measured pre- and post-ultrafiltration. Correlation between these parameters and with ultrafiltration volume was tested. There was a statistically significant reduction in post-ultrafiltration CUS score and the 13-point clinical score (P < 0.01). Moreover, reduction in all the IVC indices (inspiratory and expiratory diameters and collapsing index) was detected, but did not reach statistical significance (P = 0.185, P = 0.296, and P = 0.194, respectively). CUS score had statistically significant correlations with ultrafiltration volume and New York Heart Association classes (P < 0.001 and <0.001, respectively). Neither clinical signs nor IVC indices can be used independently for the assessment of VS in HD patients. CUS is a useful guide in VS assessment, and we recommend its routine use in the management of HD patients. Concomitant use of bio- impedance analysis (BIA) may be needed in addition to CUS for more accurate assessment of VS in HD patients.
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BRIEF COMMUNICATION Top

Arterial Hypertension in Systemic Lupus Erythematosus: About 40 Cases p. 814
Imene Rachdi, Fatma Daoud, Hana Zoubeidi, Mehdi Somai, Yosra Fekih, Besma Ben Dhaou, Zohra Aydi, Fatma Boussema
DOI:10.4103/1319-2442.292315  PMID:32801242
The aim of this study was to determine the prevalence and the etiologic profile of hypertension (HTN) in systemic lupus erythematosus (SLE). A retrospective analysis was performed on 153 patients with SLE who attended our center for 16 years from January 2000 to December 2016. The diagnosis of SLE was established according to the classification criteria of the American College of Rheumatology in 1990. The prevalence of HTN in patients with SLE was 26.1% (40/153)' with an average delay of appearance of 21 months. There were 37 women and three men with a mean age of 46’ eight years (20–70). HTN was associated with lupus nephritis (n = 8)' other renal impairments (n = 6)' and corticosteroid treatment (n = 20). Essential HTN was found in six cases. Cardiovascular factors associated with HTN were: diabetes (n = 14)' sedentary life (n = 15)' obesity (n = 12)' and dyslipidemia (n = 8). Main clinical manifestations associated with HTN were: arthralgia/arthritis (24 cases)' cutaneous involvement (22 cases)' and hematological manifestations (16 cases). Anti-phospholipid syndrome was found in 12 cases. Coronary artery disease’ arteritis of lower limb’ and transient ischemic attacks complicated the course of HTN in six patients. Angiotensin-converting-enzyme inhibitors were the most commonly used drug for treatment in this group. HTN was frequently associated with corticosteroid treatment in this study. We feel that the use of corticosteroids should be avoided as far as possible in all patients with SLE.
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RENAL DATA FROM THE ARAB WORLDS Top

Attitudes, Knowledge, and Social Perceptions toward Organ Donation and Transplantation in Eastern Morocco p. 821
Intissar Haddiya, Hicham El Meghraoui, Yassamine Bentata, Mohammed Guedira
DOI:10.4103/1319-2442.292316  PMID:32801243
The study is aimed to assess attitudes, knowledge, and social perceptions toward organ donation and transplantation in Eastern Morocco and therefore understand what sets back this activity’s expansion and progression. We conducted a cross-sectional study involving three groups of persons that are theoretically involved in the process of organ donation (medical students, law students, and nurses). Data were collected using an anonymous questionnaire related to the cultural, religious, medical, and legal aspects of organ donation and transplantation. Six hundred questionnaires were distributed. The participation rate in the study was 71%, with female predominance and participants were mainly from an average socioeconomic level. Fifty- one percent of the participants were medical students. About 87.1% had already heard about organ transplantation in Morocco, but most of them felt that they were not sufficiently informed. 57.9% of the participants were favorable with some reluctance to organ donation, 28.7% were unconditionally favorable, and 5.9% were totally unfavorable. Only 46% of the participants accepted living organ donation, whereas 47.1% did not. Moreover, 64.7% of the participants accepted organ donation after their death, evoking the desire to help others and save lives. According to our survey, 55.1% of our participants considered that the decision to donate their organs after death belongs to them. About 44.9% think they should discuss this decision with their relatives and 50% said their culture and religion influence their decisions. Our work did reveal an insufficient level of awareness about various aspects of the topic. Moreover, a high pro-portion of the participants did not have positive attitudes toward donating, mainly driven by religious, cultural beliefs and perceived risks to the donor. The reasons of refusal should be analyzed carefully to improve acceptability toward organ donation and transplantation.
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Renal Data from the Arab World Dialysis in Kuwait: 2013-2019 p. 826
Ali AlSahow, Bassam AlHelal, Anas Alyousef, Ahmad AlQallaf, Ayman Marzouq, Hani Nawar, George Fanous, Mohammed Abdelaty, Yousif Bahbahani, Heba AlRajab, Aisha AlTerkait, Hamad Ali
DOI:10.4103/1319-2442.292317  PMID:32801244
The total number of end-stage kidney disease patients treated with dialysis in 2019 in Kuwait was 2230, with a 6% increase from the year before. Dialysis prevalence was 465 per million population (PMP) and dialysis incidence was100 PMP. Kuwaiti nationals represented 70% of the dialysis population and males represented 52%. Of the same population, 59% had diabetes. Hepatitis C virus affected <4% and hepatitis B virus affected <2% of the dialysis population. The annual mortality rate was stable at around 12%. Hemodialysis (HD) share was 89%, with 48% of HD patients getting HD via catheter, 54% on hemodiafiltration (HDF), and 50% dialyzing against a calcium bath of 1.75. Patients getting <3 times/week of HD constituted 10% and patients spending <3.5 h/session constituted 11%. We had only 20 dialysis patients under the age of 12 years (12 on HD). The major challenges faced included poor peritoneal dialysis penetration, the unacceptable high rates of catheters as primary HD vascular access, partly due to lack of chronic kidney disease (CKD) clinics and lack of vascular access coordinators, and the unexplained high rates of use of calcium bath of 1.75. There is also a need for a national campaign for early detection and prevention of CKD to reduce rates of end-stage renal disease.
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RENAL DATA FROM ASIA–AFRICAS Top

Prevalence of Nondiabetic Renal Disease in Patients with Type 2 Diabetes Mellitus with Clinicopathological Correlation: A Study from a Tertiary Care Center of Assam, India p. 831
Manjuri Sharma, Manzoor Ahmad Parry, Hamad Jeelani, Pranab Jyoti Mahanta, Prodip Kumar Doley, Gayatri Pegu
DOI:10.4103/1319-2442.292318  PMID:32801245
Diabetes mellitus is the most common cause of chronic kidney disease worldwide. The prevalence of nondiabetic renal disease (NDRD) among patients with type 2 diabetes mellitus (T2DM) varies widely. This study aimed to evaluate the renal biopsies performed on type 2 diabetic patients for suspicion of NDRD and to correlate clinicopathological findings. All T2DM patients aged > 18 years were included in this study, who had renal biopsy performed for the following reasons: recent-onset nephrotic syndrome, unexplained rapid deterioration of renal function, proteinuria not accompanied by retinopathy, and unexplained hematuria. Renal biopsy was analyzed by light microscopy and immunofluorescence. Based on biopsy findings, the patients were grouped into three: (i) isolated NDRD, (ii) NDRD ± diabetic nephropathy (DN), and (iii) isolated DN. A total of 140 patients were enrolled in this study. Recent-onset nephrotic syndrome was the most common indication for biopsy, followed by the presence of active urine sediment. Forty-two percent of the patients had isolated DN, while NDRD was seen in 34% and DN ± NDRD in 24%. Focal segmental glomerulosclerosis (FSGS) and IgA nephropathy were the most common causes of isolated NDRD, while chronic tubulointerstitial nephritis (CTIN) was common in NDRD plus DN. Short duration of diabetes, absence of diabetic retinopathy, and lower glycated hemoglobin were predictive of NDRD. NDRD was seen in 58% of the patients with atypical presentations. FSGS and CTIN were common in NDRD diseases. Judicious use of biopsy in diabetic patients with atypical presentation may help in the diagnosis of NDRD.
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Hemodialysis at Doorstep - “Hub-and-Spoke” Model of Dialysis in a Developing Country p. 840
Manisha Sahay, Kiranmai Ismal, P Sharmas Vali
DOI:10.4103/1319-2442.292319  PMID:32801246
End-stage kidney disease has become a huge burden in our country. There has been an increase in dialysis centers across the country. State-funded dialysis has been initiated in many states of India. However, most of the centers are concentrated in the cities. Patients living in the peripheral districts have to travel long distance to reach the dialysis centers. In addition, there is a dearth of nephrology services in the peripheral areas. To address this problem, the hub-and- spoke model of dialysis has been initiated in Telangana state in South India, which has brought dialysis at the doorstep for people residing in remote districts. This study highlights the important features of this model.
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Biopsy-proven Renal Pathologies: Experience from Multan Institute of Kidney Diseases p. 850
Muhammad Nauman Hashmi, Rashid Asghar, Tanzeel Abbasi, Khurram Bashir, Ruqayya Basharat, Sadia Majeed
DOI:10.4103/1319-2442.292320  PMID:32801247
In this part of world, nephrology data lack as there is no renal registry, and nephrology is still in its primitive stage. Multan Institute of kidney diseases started tertiary care renal services. We carried out an analysis of our renal biopsies performed here from August 2017 to May 2019. This was carried out to see the spectrum of renal diseases in this area. This is a retrospective analysis of renal biopsies performed at the Multan Institute of Kidney Diseases from August 2017 to May 2019. Renal biopsy was performed using real-time ultrasound. One hundred and seventy-five native renal biopsies were performed during this study period. One hundred and three male (59%) and 72 female (41%) patients underwent renal biopsy. The average age was 36 years, with a range of 16–70 years. Results from our study showed membranous glomerulo- nephritis (36%) as a leading cause of primary glomerular disease in this region. Lupus nephritis (30.3%) was a leading cause in secondary glomerular disease. Reviewing our study and published literature it’s pellucid that lupus nephritis is a leading cause of secondary glomerulonephritis worldwide. In terms of primary glomerular disease, spectrum is different globally. This study sets alight to explore membranous nephropathy, which is the leading primary glomerular disease in our studied population.
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CASE REPORTS Top

Granulomatous Interstitial Nephritis Due to Renal-limited Sarcoidosis p. 856
Fatima S Alangari, Salih A Binsalih, Basel Heijani, Nourah Aloudah
DOI:10.4103/1319-2442.292321  PMID:32801248
Sarcoidosis can present as acute kidney injury (AKI) due to granulomatous interstitial nephritis (GIN). AKI caused by sarcoid GIN without extra-renal manifestations is extremely rare. We report a case of a 42-year-old man with a history of unexplained weight loss admitted with progressively worsening kidney function. Physical examination did not show any abnormality. Laboratory investigations were normal except for high calcium level with no evidence of organ involvement of sarcoidosis. A renal biopsy showed GIN with non-caseating granulomata. Prednisolone was initiated and renal function improved. This is a case of an extremely rare AKI caused by sarcoid GIN without extra-renal manifestations which responded to prednisolone.
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Primary Anti-phospholipid Antibody Syndrome Presenting as Acute Nephritic Syndrome p. 860
Binu Upendran, Varadha Retna Kumar, Punnoose Thomas
DOI:10.4103/1319-2442.292322  PMID:32801249
Primary anti-phospholipid antibody (APLA) syndrome in males most commonly presents with clinical manifestations of venous thrombosis, thrombocytopenia, and pulmonary embolism. Although most present with acute symptoms following arterial thrombosis, diagnosis following evaluation for elevated renal function tests and hypertension is less common. We report here a case of a 22-year-old man who presented with acute nephritic syndrome following an acute febrile illness. He was detected to have altered renal function tests with serum creatinine of 1.6 mg/dL (141.4 μmol/L), microscopic hematuria, and proteinuria along with hypertension. His 24-h urine protein was 1700 g/day. He was planned for a kidney biopsy. Subsequent evaluations revealed an isolated elevation of activated partial thromboplastin time. Further evaluation revealed positive APLA syndrome. He underwent kidney biopsy later which showed mesangial hypercellularity with no involvement of the renal parenchymal vasculature. The reported case is an unusual presentation of primary APLA syndrome with acute nephritic syndrome.
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Epstein Syndrome p. 865
Sana Barrah, Rania Kheder, Hela Jebali, Madiha Krid, Wided Smaoui, Soumaya Beji, Fathi Ben Hmida, Lilia Ben Fatma, Lamia Rais, Mohamed Karim Zouaghi
DOI:10.4103/1319-2442.292323  PMID:32801250
Epstein syndrome is characterized by sensorineural hearing impairment, macro- thrombocytopenia without neutrophil inclusion bodies, and hereditary nephritis which can progress to end-stage renal disease (ESRD) in adolescence. The prognosis of Epstein’s syndrome depends on the severity of the hematological disorders and renal involvement that can lead to ESRD at an early age. Thrombocytopenia in Epstein syndrome is not an absolute contraindication for major surgical procedures like arteriovenous fistula formation or kidney transplantation. There are no set guidelines for preoperative prophylaxis in a patient with this pathology.
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Disseminated Histoplasmosis Masquerading as Significant Weight Loss Eight Years Post Renal Transplant p. 868
Vijoy Kumar Jha, Debasish Mahapatra
DOI:10.4103/1319-2442.292324  PMID:32801251
With the advent of potent immunosuppressive therapies, renal transplant recipients are more susceptible to a variety of infections with atypical pathogens and presentations. In the setting of many years post-renal transplant, weight loss may be due to occult systemic fungal infection and if left untreated it may evolve with multisystem involvement. We describe a case with significant weight loss who got admitted for the evaluation for post-transplant lympho- proliferative disorder. The 30-year-old male patient presented with weight loss eight years post- renal transplant and detailed evaluation revealed systemic fungal infection involving cutaneous, pulmonary, and hematopoietic systems.
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Pellagra Disease in a Hemodialysis Patient p. 874
Sana Barrah, Hela Jebali, Rania Kheder, Madiha Krid, Wided Smaoui, Soumaya Beji, Fathi Ben Hmida, Lilia Ben Fatma, Lamia Rais, Mohamed Karim Zouaghi
DOI:10.4103/1319-2442.292325  PMID:32801252
Pellagra usually results from niacin deficiency and presents with the classic triad of dermatitis, diarrhea, and dementia. It is most commonly associated with malnutrition and poverty. We report a case of pellagra in a hemodialysis (HD) patient with breast neoplasia, aged 68-years, female, on HD unit for seven years. Her original nephropathy was indeterminate. The patient was followed up for homozygous beta-thalassemia and breast neoplasia with hepatic metastases on chemotherapy. The body mass index of the patient was 18.5 kg/m2. Physical examination showed a thickening of the epidermis with a scaly surface, pigmented, and atrophied areas. We noted neuropsychiatric signs (apathy, irritability, anorexia, and depression) and digestive symptomatology (diarrhea). The laboratory tests revealed hypoproteinemia at 55 g/L, hypoalbuminemia at 21 g/L, and hypocholesterolemia at 0.8 g/L. The diagnosis of pellagra disease was made. Vitamin and protein supplementation was initiated, but the patient committed suicide by puncture of her arteriovenous fistula, causing hemorrhagic shock. Pellagra is usually reported to be associated with malnutrition, chronic alcoholism, and some chemotherapeutic agents. In our patient, pellagra was caused by malnutrition and co-morbidities. Pellagra disease requires multidisciplinary care and can be frequently seen in HD patients due to the associated malnutrition.
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Rhabdomyolysis Induced Acute Kidney Injury in Acute Myeloid Leukemia: An Unusual Association p. 877
Archana Chiniwalar, M Edwin Fernando, Suren Sujit, ND Srinivasa Prasad, K Thirumal Valavan
DOI:10.4103/1319-2442.292326  PMID:32801253
Rhabdomyolysis is a potentially life-threatening syndrome that causes acute kidney injury. Association of acute myeloid leukemia (AML) and myoglobin induced acute tubular necrosis (ATN) is rarely reported in the literature. Here, we report a young male who was admitted with fever of unknown origin. Diagnosed to have AML with renal failure and subsequently succumbed to illness, whose post mortem renal biopsy confirmed myoglobin induced ATN.
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LETTER TO THE EDITOR Top

Neurocysticercosis and Adult-Onset Epilepsy p. 881
Jamir Pitton Rissardo, Ana LetÍcia Fornari Caprara
DOI:10.4103/1319-2442.292327  PMID:32801254
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