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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
Coverpage
September-October 2019
Volume 30 | Issue 5
Page Nos. 1002-1189

Online since Monday, November 4, 2019

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REVIEW ARTICLE  

Vaccine-associated kidney diseases: A narrative review of the literature Highly accessed article p. 1002
Chinmay Patel, Hitesh H Shah
DOI:10.4103/1319-2442.270254  PMID:31696837
Immunization is one of the greatest public health achievements of the 20th century. Vaccines have enabled the eradication of deadly diseases and decreased the morbidity and mortality associated with various infections. Most vaccines are safe to administer and cause only minor side effects. Although very rare, various glomerular diseases and acute kidney injury have been reported following immunization with certain vaccines including influenza, pneumococcal, and hepatitis B vaccines. This review summarizes these rare renal complications that have been published in the literature. Physicians and other health-care providers administrating vaccines should be aware of these very rare but possible renal side effects.
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ORIGINAL ARTICLES Top

Serum fibroblast growth factor 23 levels do not correlate with carotid intima-media thickness in patients with chronic kidney disease Highly accessed article p. 1010
Bulent Kaya, Neslihan Seyrek, Saime Paydas, İbrahim Karayaylali, Mustafa Balal, Kairgeldy Aikimbaev
DOI:10.4103/1319-2442.270255  PMID:31696838
High levels of fibroblast growth factor 23 (FGF 23) are associated with mortality and cardiovascular events in patients with chronic kidney disease (CKD). Carotid intima-media thickness (CIMT) is a useful marker of subclinical atherosclerosis. This study aimed to investigate the relationship between serum FGF23 levels and CIMT of CKD patients. In this cross-sectional study, CIMT was measured in 162 patients with CKD Stage of 2–5 (age range 18–79 years, 61.7% males). Serum FGF23 levels were determined by enzyme-linked immunosorbent assay. CIMT was measured by ultrasonography. Serum FGF-23 levels were significantly higher (P = 0.046) in advanced CKD patients. CIMT was thicker in patients with advanced CKD patients (P = 0.01). CIMT was correlated with age (r = 0.486, P <0.001), smoking (r = 0.411, P <0.001), and 25-OH Vitamin D (r = −0.195, P= 0.045). There was no correlation between serum FGF23 and CIMT. Multivariate analysis showed that age (β = 0.373, P <0.001), smoking (β = 0.228, P = 0.004), and serum 25-hydroxyvitamin D levels (β = −0.164, P = 0.042) were associated with CIMT. There was no relationship between FGF23 and CIMT. The CIMT was found to be related to increased age, smoking, and 25-hydroxyvitamin D in CKD patients.
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Correlation between serum sclerostin level and bone density status in children on regular hemodialysis Highly accessed article p. 1022
Manal Abd Elsalam, Maha Zein El-Abden, Eman Mahmoud, Zakia Abo Zahab, Heba Ahmed
DOI:10.4103/1319-2442.270256  PMID:31696839
Bone disease is frequently observed in chronic kidney disease (CKD) and increases a patient’s risk for fracture. Sclerostin is an osteocyte-derived negative regulator of bone formation. We aimed to assess serum sclerostin level as a bone marker in children with CKD on regular hemodialysis (HD) and detect the association between this and bone density status. This cross-sectional comparative study was conducted on 25 children with CKD on HD and 25 age- and sex-matched healthy children, as controls. Their ages ranged from 4 to 18 years. Serum sclerostin levels were measured and dual-energy X-ray absorptiometry scan was performed in the same line with the traditional bone markers. There was a significant increase in serum sclerostin level in patients (1.754 ± 1.31 ng/mL) compared to controls (0.290 ± 0.074 ng/mL) with P = 0.001. Nine patients (36%) had low bone mineral density (BMD) with z score under -2.0, eight of whom had low BMD in both the neck of femur and lumbar spines. There was a significant increase in serum sclerostin levels in the patient-group with low BMD (2.38 ± 0.85 ng/mL) compared with patients with normal BMD (1.4 ± 0.98 ng/mL) (P = 0.001). A significant positive correlation was found between serum sclerostin level and alkaline phosphtase, parathormone with negative correlation with serum calcium. Sclerostin was 100% specific and sensitive in predicting CKD-mineral and bone disorder. Elevated sclerostin levels were consistent with low BMD and appear to be an independent predictor of reduced BMD in children on regular HD.
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Effects and association of pro-oxidants with magnesium in patients with diabetic nephropathy p. 1032
Kamal Kachhawa, Poonam Kachhawa, Divya Agrawal, Sanjay Kumar, Purnima Dey Sarkar
DOI:10.4103/1319-2442.270257  PMID:31696840
Diabetic nephropathy (DN) is the most common microvascular complication observed in patients with type-2 diabetes mellitus. Furthermore, magnesium (Mg) deficiency is a common problem in diabetic patients. In this study, we estimated the levels of Mg, which is an important trace element and pro-oxidant marker, and then evaluated the association between serum Mg and pro-oxidants in patients with DN. In the present study, 200 patients were enrolled and were divided into two groups. The control and DN groups consisted of 100 healthy individuals and 100 patients with DN, respectively. Serum Mg, total anti-oxidant capacity (TAC), and superoxide dismutase (SOD) levels were estimated using the Calmagite, Koracevic, and Marklund and Marklund methods, respectively. Glutathione (GSH) and malondialdehyde (MDA) levels were estimated using the Tietze F and Jean CD method, respectively. Mg levels were found to be significantly decreased in the DN group in comparison to the control group. Anti-oxidant markers were statistically significantly reduced (P <0.001), whereas MDA levels were statistically significantly elevated (P <0.001) in the DN group compared to the control group. There was a significant positive association of Mg with TAC, SOD, and GSH. A statistically significant negative association of Mg with MDA (r = −0.302, P <0.001, n = 100) was also observed. An apparent relationship was observed between hypomagnesemia and oxidative stress in patients with DN. Lower levels of Mg and oxidative stress were also strongly linked.
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Evaluation of blood pressure profile in chronic hemodialysis patients using two measurement methods: Home blood pressure measurement and conventional measurement p. 1038
Maria Faye, Moustapha Faye, Ahmed Tall Lemrabott, Mouhamadou Moustapha Cisse, Kodia Fall, Alex Rich Ismael Keita, Mansour Mbengue, Bacary Ba, Niakhaleen Keita, Seynabou Diagne, Abdou Niang, Boucar Diouf, El Hadji Fary Ka
DOI:10.4103/1319-2442.270258  PMID:31696841
The monitoring of hypertension (HTN) in dialysis is often delicate with potentially false measurements due to the white coat effect on the one hand and masked HTN (M-HTN) on the other hand. In this population, there is much controversy over the ideal moment for taking blood pressure (BP) and the target values. An answer to these questions is given by home BP measurement that can detect white coat HTN (WC-HTN) and M-HTN. The aim of this study was to determine the respective prevalence of permanent HTN (P-HTN), WC-HTN, M-HTN, and permanently normotensive (P-NTN) in this population and to analyze the risk factors of M-HTN and WC-HTN in hemodialysis (HD) centers in sub-Saharan Africa. This was a multicenter, descriptive, and analytical cross-sectional study conducted over a period of one month and 23 days. Data collection was performed using a home BP measurement form, conventional BP measurement form, and clinical and laboratory data collection form. The study included all patients who could take their BP at home using an electronic BP machine and record results on the BP forms. All analyses were performed using the Sphinx plus software version 5. The significance level for all statistical tests was set at 5%. The mean age of patients was 45.57 years ± 14.11, with a sex ratio of 1.42. The mean duration in dialysis was 57.96 months ± 34.86. Adherence to the home BP measurement was 100% in 71.7%. P-NTN patients were 15.2% (7 patients), WC-HTN patients were 13% (6 patients), M-HTN patients were 17.5% (8 patients), and P-HTN patients were 54.3% (25 patients). A statistically significant association was observed between WC-HTN and age (P = 0.01). In this work, we noted an important proportion of M-HTN and WC-HTN. This result confirms the need for home BP measurement in the follow-up of BP in HD patients.
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Prediction of mortality and need for renal replacement therapy in patients of acute kidney injury using fibroblast growth factor 23 p. 1044
Ahmed Fayed, Waheed Ahmed Radwan, Mohamed Amin, Ahmed Gamal
DOI:10.4103/1319-2442.270259  PMID:31696842
Acute kidney injury (AKI) occurs in up to 50% of patients admitted to the intensive care units. Fibroblast growth factor 23 (FGF23), which plays an important role in regulating phosphate, rises early in AKI. Few studies were conducted to correlate the level of FGF23 and adverse outcomes in AKI. The study was conducted on 30 participants with AKI, which was defined according to AKI network criteria, admitted to the Critical Care Department, Kasr El Aini Hospital, Cairo University between July 2016 and May 2017, and serum FGF23 was measured within 24 h of AKI onset to correlate the level of FGF23 with mortality and need for renal replacement therapy (RRT). Enrollment FGF23 levels were significantly higher among patients who died than in the survival group (mean level: 544.2 vs. 59.3 pg/mL, P = 0.004). Furthermore, FGF23 levels were significantly higher in patients who needed RRT than in other participants (mean level: 529.5 vs. 285.11 pg/mL, P = 0.04). There was a statistically significant positive relationship between FGF23 level and sequential organ failure assessment score (P = 0.03). In patients with AKI, higher FGF23 levels are associated with increased risk of mortality and need for RRT.
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The characteristics of patients returning to hemodialysis due to nonfunctioning graft in Turkey p. 1052
Ilkem Altun, N Yılmaz Selcuk, Ismail Baloglu, Kultigin Turkmen, H Zeki Tonbul
DOI:10.4103/1319-2442.270260  PMID:31696843
Renal transplantation is the most effective treatment modality for end-stage renal failure. According to the Ministry of Health Organ Transplant Registration System, despite the presence of 14,936 renal transplant recipients in Turkey, there are not enough data about the prognosis of these patients. Therefore, we aimed to ascertain the rate of patients returning to hemodialysis (HD) due to nonfunctioning graft in our country. One thousand four hundred and ninety-eight (males: 826, females: 672) HD patients who undergo HD at 22 HD centers in total, from different geographical regions to represent our country were examined retrospectively. The informations were obtained from patient registry files and anamnesis which were in HD centers. The number of patients returning to HD due to the loss of graft function was 77 (males: 56, females: 21). Eleven of the patients had transplantation from cadavers (14%) and 66 from living donors (86%). Prevelance of patients, who return to HD after the failure of renal transplantation, between HD patients was 5.1. The mean duration of return to HD after renal transplantation was 6.7 ± 5.9 years for all patients. There was no significant difference in the duration without HD after transplantation between two groups when cadaveric and living donor transplants were compared (P = 0.759). There was no statistically significant difference in duration without HD after transplantation between patients receiving HD treatment before transplantation and preemptive transplant (P = 0.212). The prevelance of patients, who return to HD due to nonfunctioning graft among HD patients was 5.1. The duration without HD were similar after transplantation from both cadavers and living donors. The duration without HD was found longer among those who were operated before 2000.
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Prediction model for successful radiocephalic arteriovenous fistula creation in patients with diabetic nephropathy p. 1058
J Suresh Kumar, KS Sajeev Kumar, ET Arun Thomas, KG Hareesh, Jacob George
DOI:10.4103/1319-2442.270261  PMID:31696844
Arteriovenous fistula (AVF) is the most appropriate vascular access for all chronic kidney disease patients for hemodialysis. However, patients with diabetic nephropathy are at increased risk for primary failure after AVF creation, mainly due to atherosclerosis and calcification of blood vessels. We conducted this study to find out the risk factors for primary failure of radiocephalic AVF in end-stage renal disease (ESRD) patients due to diabetic nephropathy and develop a risk predicting model. This study was conducted at a tertiary care teaching hospital of South India. Patients with ESRD due to diabetic nephropathy whom underwent left radiocephalic AVF at wrist were enrolled. Risk factors for primary failure were analyzed by univariate and multivariate logistic regression models. Sixty-six patients were included in the study. Thirty-one patients had a primary failure. Independent risk factors for primary failure were palpable vessel wall of the radial artery (P = 0.003, odds ratio [OR] = 15.317), smaller radial artery diameter (P = 0.001, OR = 16.526), radial artery peak systolic velocity (PSV) <45 cm/s (P = 0.005, OR = 8.494), and linear radial artery calcification (P = 0.006, OR = 7.942). The risk predicting model obtained by adding the score given for each risk factors (vessel wall not palpable = 0, palpable = 1, no linear calcification in digital X-ray = 0, linear calcification = 1, PSV ≥45 cm/s = 0, <45 cm/s = 1 and 2.5 - radial artery diameter in mm) had an area under receiver-operating characteristic curve of 0.886. Cutoff score of 1.5 had sensitivity of 83.9% and specificity of 80.0% for primary failure. Risk predicting model for primary failure based on condition of the vessel wall on palpation, radial artery diameter, flow velocity, and calcification may be helpful for suitable patient selection.
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Long-term renal outcome and survival of kidney transplant recipients admitted to the intensive care unit p. 1065
Amgad E El-Agroudy, Asma Mohamed Alqahtani, Balij Dandi, Eman Farid, Ali Alaradhi
DOI:10.4103/1319-2442.270262  PMID:31696845
The goal of this study was to evaluate the course and outcome of kidney transplant (KT) recipients admitted to the intensive care unit (ICU). We reviewed the data of all adult renal transplant recipients who are admitted to the ICU at our center, between 1997 and 2017. Data reviewed included the demographic features, causes of end-stage renal disease, causes of admission, time between transplantation and admission, and ICU course and outcome. Among 379 KT recipients followed up in our center, 60 patients were admitted to the ICU and were categorized to early (during first 90 days; n = 28); intermediate (3–12 months; n = 7); and late (12 months and later, n = 25). The rate of ICU admission was 15.9%, and the mean age was 48.3 ± 12.6 years. The main reason for ICU admission was surgical complications (71%) in early group and infection (57% and 80%) in the intermediate and late groups, respectively. Mortality was significantly higher in late admission (52%) (P = 0.0001) and the leading cause of death in all groups was sepsis (89%). Twenty patients required ventilator that was an independent risk factor for mortality (P < 0.05). There was statistically significant decrease in the overall 5-year and 10-year patient survival (P = 0.031) in KT patients admitted to the ICU. The study shows that the main reason for ICU admissions was infections, especially in late admission. Mortality rate was relatively high and was linked to need for ventilator. Admission to the ICU is usually associated with decrease in the graft and patient survival.
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Intensive monitoring of adverse drug reactions in nephrology unit of tertiary care teaching hospital p. 1075
Shoukath Ali Kareem, Sathvik Belagodu Sridhar, Manjunath S Shetty
DOI:10.4103/1319-2442.270263  PMID:31696846
Adverse drug reactions (ADRs) are one of the common causes of morbidity and mortality. Renal insufficiency is considered as one of the risk factors for the development of ADR. The study determined the occurrence of ADRs in patients with renal failure and their incidence of hospital admission. The study also evaluated the nature and severity of ADRs. This was a prospective study conducted in the nephrology unit at a tertiary care teaching hospital for a period of nine months. Patients receiving regular hemodialysis and those either referred or admitted to the nephrology ward were included. ADRs were intensively monitored throughout the study. The causality of suspected ADRs was assessed with the WHO probability scale, Naranjo algorithm, and Karch and Lasagna’s scale. The predictability and preventability of ADRs were also determined. A total of 45 ADRs were identified in 369 patients; incidence was 12.19%. Nine ADRs (20%) needed hospitalization. A total of 27 (60%) and 17 (37.8%) ADRs were found to be probable and possible, respectively when assessed by the WHO probability scale. On the contrary, 33 (73.3%) and 26 (57.8%) ADRs were possible in causality when assessed by Karch and Lasagna’s scale and Naranjo scale, respectively. Most of the ADRs [26 (57.8%)] were predictable in nature. A wide range of ADRs was noticed in patients with renal impairment, and our study has systematically assessed the nature and severity of ADRs.
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A narrative review of the impacts of income, education, and ethnicity on arterial hypertension, diabetes mellitus, and chronic kidney disease in the world p. 1084
Luciana dos Santos Tirapani, Natália Maria da Silva Fernandes
DOI:10.4103/1319-2442.270264  PMID:31696847
Nontransmissible chronic diseases (NTCDs) are the leading causes of death worldwide, causing serious social and economic consequences in all societies and economies and emerging as a major public health problem. One of the ways of coping the social and economic impact caused by the NTCDs is the elaboration of effective public policies; one of the instruments used for the elaboration of public policies is the social indicators. The most popular indicator at present is the Human Development Index (HDI), which covers the dimensions of longevity, education, and income. The Inequality-adjusted HDI (IHDI) was implemented that quantifies the effects of inequality in development, measured in terms of HDI. The objective of the present study was to analyze the impact of income, education, and ethnicity in hypertension, diabetes mellitus (DM), and chronic kidney disease (CKD) in the world, through the narrative review of the literature and analyzing the social indicators HDI and IHDI of the countries analyzed. After analyzing 161 studies from 96 countries, we identified that income, education, and color impact on the prevalence, incidence, diagnosis, treatment, progression, and mortality of hypertension, DM, and CKD in both low- and middle-income countries’ development, as well as high and very high human development. The HDI data for all countries change when adjusted for inequality. The theme related to social factors needs to be a constant in the elaboration of health policies, as well as present in the professional doing.
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Risk of obstructive sleep apnea among senegalese dialysis patients p. 1097
Sidy Mohamed Seck, Zeinabou Maiga Moussa Tondi, Samba Niang, Ahmed Tall Ould Lemraboot, Elhadj Fary Ka
DOI:10.4103/1319-2442.270265  PMID:31696848
Obstructive sleep apnea syndrome (OSAS) is a common condition in patients undergoing chronic dialysis and is associated with increased cardiovascular morbidity and mortality. This study aimed to determine the prevalence and risk factors of OSAS in Senegalese dialysis patients. In a cross-sectional study including 128 patients (75 men and 53 women) dialyzed since ≥6 months in four dialysis units. Data were collected during the dialysis session in the units. OSAS was assessed with the Berlin Questionnaire. Factors associated with OSAS risk were identified by multivariate logistic regression. The mean age of patients was 46.8 ± 16.9 ¥16–85 years). OSAS was found in 53 patients (overall prevalence of 41.4%) with predominance among individuals aged ≥50 years (52.6%). Hypertension and diabetes were more frequent in patients with OSAS, while the prevalence of obesity and sedentary was not different. The majority of patients were not aware of their disease before the survey, and none was treated. After multivariate regression analysis, age >50 years [odds ratio (OR) = 1.09, P = 0.02], neck circumference >45 cm (OR= 1.25, P= 0.03), and daytime hypersomnia (OR = 1.18, P= 0.02) were significantly associated with OSAS. This study showed that OSAS is frequent among Senegalese dialysis patients but is usually under-diagnosed. Older age, excessive daytime sleepiness, and neck circumference are the main associated factors.
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BRIEF COMMUNICATION Top

Predialysis nephrology care and its impact on initial vascular access type in hemodialysis patients in Jordan p. 1103
Abdurrahman M Hamadah, Kamel Gharaibeh
DOI:10.4103/1319-2442.270266  PMID:31696849
Chronic kidney disease (CKD) patients who reach end-stage renal disease (ESRD) require early nephrology referral and appropriate vascular access. Arteriovenous fistula (AVF) is the preferred access for hemodialysis (HD). Referral to nephrology of CKD patients starting HD in Jordan and its impact on AVF utilization is unknown. Patients on in-center HD in a large Jordan Ministry of Health dialysis unit were interviewed, and medical records reviewed to assess prior nephrology care and AVF use. Of 104 total patients, 93 met the inclusion criteria. The mean age was 50 ± 16 years, with 44% being females. The average body mass index was 25 ± 5. The cause of ESRD was diabetes mellitus in 28 (30%), hypertension in 28 (30%), and polycystic kidney disease in three (3%). Type of HD access at the initiation of dialysis was central venous catheter (CVC) in 80 (86%) and AVF in 12 (13%). Of the overall group, 50 (54%) were seen by nephrology before initiating dialysis, and of these, 39 patients (78%) were seen >1 year before HD initiation. Of the patients who initiated dialysis with a CVC, 38 (48%) had received prior nephrology care. All 12 patients who initiated dialysis with AVF had received prior nephrology care. Of the 50 patients who received nephrology care before dialysis initiation, 12 patients (24%) had started dialysis with an AVF; in patients without prior nephrology care, all were started with a CVC. In conclusion, our study suggests that a large percentage did not have nephrology care before initiating dialysis. The ones who were seen by nephrology before dialysis were significantly more likely to initiate dialysis using an AVF. A national focus on improving nephrology referral in advanced CKD may allow better utilization of AVF as the method of access at dialysis initiation.
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SHORT REVIEW ARTICLE Top

Living-unrelated kidney donor transplantation: Legalization in exceptional circumstances? p. 1111
Rashid bin Hamid, Muhammad Tassaduq Khan
DOI:10.4103/1319-2442.270267  PMID:31696850
The prevalence of end-stage renal disease (ESRD) morbidity and mortality is mounting. Kidney transplantation offers a good means of survival and improves longevity of patients with ESRD. However, not everyone is fortunate to benefit from this lifesaving renal replacement therapy due to the lack of available kidneys, one of the many reasons. It eventually expands the number of patients on waiting list of kidney transplantation. At present, deceased and living-related kidney donor transplantation models are widely used, but with limited success to keep up with the pace of burgeoning ESRD. A debate over the legalization of unrelated living kidney donor transplantation has erupted lately. This short review articles focuses on issues surrounding kidney transplantation in Pakistan and draws an informed conclusion regarding pragmatic legalization of unrelated living kidney donor transplantation in exceptional circumstances. Finally, this article also offers a food for thought for countries facing analogous picture in the field of kidney transplantation.
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RENAL DATA FROM ASIA–AFRICA Top

Changing epidemiology of acute kidney injury in pregnancy: A journey of four decades from a developing country p. 1118
Jai Prakash, Suraj Prakash, Vivek C Ganiger
DOI:10.4103/1319-2442.270268  PMID:31696851
The incidence of acute kidney injury in pregnancy (P-AKI) has markedly decreased over the last three decades in India, particularly due to decreased incidence of postabortion AKI. However, P-AKI still accounts for 3%–5% of cases of total AKI. Postabortion sepsis has decreased to between 0.9% and 1.5% in 2014 from 9.4% in 1980–1990 in the new millennium. Currently, in India, majority of P-AKI (70%–90%) occurs in the postpartum period and in late 3rd trimester similar to the developed countries, but causes are different. We observed that preeclampsia/eclampsia is the most common cause of P-AKI in the late 3rd trimester and postpartum period followed by puerperal sepsis and postpartum hemorrhage (PPH). Both puerperal sepsis and PPH are treatable and preventable etiologies of P-AKI. Timely and aggressive management of antepartum hemorrhage (APH/PPH) and puerperal sepsis are required to reduce the burden of P-AKI in developing countries. Specific-pregnancy disorders such as P-aHUS/thrombotic thrombocytopenic purpura, pregnancy-associated thrombotic microangiopathy, and acute fatty liver of pregnancy are the uncommon/rare causes of P-AKI in India and possibly also because of the lack of awareness toward diagnosis. Despite decreasing incidence of P-AKI, fetal mortality remained high and unchanged. However, maternal mortality has decreased to 5% from initial high mortality of 20%–25%. The incidence and severity of renal cortical necrosis have significantly decreased at our center.
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Associated factors of dialysis-dependence among acute kidney injury patients in intensive care unit p. 1131
Mardhiah Kamaruddin, Siti-Azrin Ab Hamid, Azreen Syazril Adnan, Nyi Nyi Naing, Wan-Nor-Asyikeen Wan Adnan
DOI:10.4103/1319-2442.270269  PMID:31696852
Acute kidney injury (AKI) is a common problem in hospitals and many end up requiring dialysis. The aim was to identify the associated factors of dialysis-dependent of AKI patients admitted to the intensive care units (ICUs). A retrospective cohort study was conducted where a list of 121 AKI patients admitted to ICU in Hospital Universiti Sains Malaysia was retrospectively reviewed. AKI patients aged below 18 years old, had kidney transplantation or chronic dialysis before ICU admission and had incomplete medical record were excluded from the study. Simple and multiple logistic regression analysis were used. The mean [standard deviation (SD)] age of patients was 56 (17.15) years. Majority of patients were males (63.2%) and Malay ethnic (54.1%). 49.3% of patients were in stage I, 48.3% in stage II and 76.2% in stage III. The mean (SD) duration of patients stayed in ICU was 7 days (6.92) for non-dialysis dependent and 12 days (8.37) for dialysis-dependent. The associated factors were male gender [adjusted odds ratio (OR): 3.68; 95% confidence interval [CI]: 1.53, 8.86; P = 0.004], AKI Stage III (adjusted OR: 4.51; 95% CI: 1.28, 15.91; P = 0.019), admitted in ICU (adjusted OR: 3.05; 95% CI: 1.28, 7.29; P = 0.012), and longer length of stay (adjusted OR: 1.10; 95% CI: 1.03, 1.18; P = 0.003). The factors influence of dialysis-requiring AKI were observed to be dependent on the male male gender, suffer from the advanced stage (Stage III), admitted to the ICU and had a longer length of stay in ICU. Therefore, it is important for physicians to identify patients who are at high risk of developing AKI and implement preventive strategies.
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Prevalence and outcome of systemic fungal infections in renal transplant recipients - A tertiary care experience p. 1137
Manikantan Shekar, Ramprasad Elumalai, Indhumathi Elayaperumal, Renuka Prasad Yelahanka, Deepashree G Anandkumar, Varun Kumar Bandi, Jayakumar Matcha
DOI:10.4103/1319-2442.270270  PMID:31696853
Fungal infections are an important cause of morbidity and mortality in renal transplant recipients. These infections account for 5% of all infections in renal transplant recipients. The symptoms of systemic fungal infections are nonspecific, particularly in their early stages, and this can lead to delay in diagnosis. Retrospective analysis was conducted on all renal transplants that were performed at our center over a 20-year period from 1996–2016. Cases of invasive fungal infections (IFIs) that occurred among renal transplant recipients were identified to describe the epidmeiology of these infections. A total of 67 (9.2%) IFI cases were identified among 725 renal transplant recipients. Of the 67 patients (9.24%) with IFI, 31 (46.2%) cases were seen in deceased donor transplant recipients. Of 67 cases with IFI, 42 (62.7%) had received induction therapy. The incidence of fungal infections according to the induction agent used was, 14.3% with basiliximab, 12.3% each with daclizumab and rabbit antithymocyte globulin, and 6.3% among patients not given any induction. Invasive candidiasis was the most common IFI overall, followed by mucormycosis, invasive aspergillosis, and cryptococcosis. Median time to onset of IFI was 117.9 days. Majority of infections occurred within 180 days after transplantation. Late posttransplant (>180 days after transplantation) IFI’s were predominantly caused by Candida, followed by Cryptococcus. The longest time to infection was a case of histoplasma, occurring seven years posttransplant. The overall 12-month cumulative incidence (CI) for any IFI was 9.1%. The 12-month CI of the first IFI increased from 7.3% between 1996 and 2001 to 10.5% between 2010 and 2016. The overall mortality rate was 38.8%. The use of newer and more-effective immunosuppressive agents in recent years are associated with increased rates of fungal infections in renal transplant recipients. Therefore, early detection of fungal infections and proper therapy are important in improving survival and reducing mortality.
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Pattern of biopsy-proven kidney diseases: experience of a teaching hospital in Bahawalpur, Pakistan p. 1144
Suhail Iqbal Malik, Muhammad Khalid Idrees, Kamran Naseem, Saima Sadiq, Syed Hashim Raza, Farid-ud-din Ahmad
DOI:10.4103/1319-2442.270271  PMID:31696854
This descriptive observational study was conducted at the Department of Nephrology, Bahawal Victoria Hospital, Bahawalpur, Pakistan, from January 2012 to April 2018, to study the pattern of biopsy-proven kidney diseases in that region as a part to establish a national renal biopsy registry. All adult patients who underwent renal biopsy at the Bahawal Victoria Hospital, Bahawalpur, Pakistan, from January 2012 to April 2018, were included in the study. All the biopsies were evaluated by light microscopy and immunofluorescence. All the patients underwent urine dipstick, microscopic examination, and quantification of proteinuria. Hepatitis B surface antigen, anti-hepatitis C virus, human immunodeficiency virus, and serology (antinuclear antibody, anti-ds DNA, and C3 and C4) were checked in all the patients. There were a total of 195 patients, with a mean age of 30.5 ± 12.8 years. Females were comparatively younger than males (P = 0.0154). Primary glomerulonephritis (GN) accounted for 77% (155) of all the patients, whereas secondary GN contributed 15.8%. Focal and segmental glomerulosclerosis (FSGS) was the most common diagnosis (28.2%) followed by membranous nephropathy (MN) (18.9%). Lupus nephritis was the third-most common pathology, and it predominated among females (P= 0.0026). Out of the eight diabetic patients, one each had FSGS and crescentic GN. In conclusion, primary glomerular diseases were the predominant biopsy-proven kidney diseases, and FSGS and MN were the most common glomerular diseases. This pattern in South Punjab closely resembles that in southern and northern parts of the country.
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Profile of renal diseases in North-East Indian children p. 1151
Rimjhim Sonowal
DOI:10.4103/1319-2442.270272  PMID:31696855
The pattern of kidney diseases varies in different places due to differences in genetic status, socioeconomic status, access to health care, and presence of background infection. In spite of nephrology as a specialty since 1970s, there are still limited data regarding the spectrum of renal diseases in India. Our study was conducted in a tertiary care institute and referral center in northeast India. It provides insight into profile of renal diseases in hospitalized children. It is a cross-sectional study conducted in a government medical college in Assam. All children who were admitted in this department during one year period were examined for the presence of renal disease on the basis of history, clinical examination, and laboratory investigation. Of total admission, 7.17% of children had renal diseases. Nephrotic syndrome was the most common renal disease followed by glomerulonephritis in this study. Acute post infectious glomerulonephritis was the most common cause of glomerulonephritis. Septicemia was the most common cause of AKI. We have seen that a huge burden of pediatric morbidity is due to renal diseases. Majority of the renal diseases are curable with proper and adequate treatment. A large pool of renal diseases are still due to infective etiology and thus preventable.
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CASE REPORTS Top

Membranous nephropathy in a child with crescentic glomerulonephritis: Coincidence or comorbidity? p. 1156
Ilknur Girisgen, Seçil Conkar, İpek Kaplan Bulut, Sait Şen, Sevgi Mir
DOI:10.4103/1319-2442.270273  PMID:31696856
Rapidly progressive glomerulonephritis (RPGN) is rare syndrome in children, characterized by clinical features of glomerulonephritis and rapid loss of renal function, and is associated with crescentic glomerulonephritis. Primary membranous nephropathy (MN) is an immune-complex-mediated cause of the adult nephrotic syndrome but occurs less frequently in children. RPGN is rarely observed in adults with primary MN. In this article, we report a case of MN, which developed during long-term follow-up of previously treated RPGN. Our case may be the first to demonstrate primary MN and crescentic glomerulonephritis in a child. We would like to underline the importance of not dropping the long-term follow-up of cases with primary RPGN (not accompanied by other glomerulonephritis and vasculitis symptoms) who had improved with treatment.
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Monoclonal gammopathy of renal significance with light-chain deposition disease in kidney transplantation p. 1161
Raja Aoudia, Mohamed Mongi Bacha, Mondher Ounissi, Hanene Gaied, Mouna Jerbi, Ezzedine Abderrahim, Taieb Ben Abdallah, Rim Goucha
DOI:10.4103/1319-2442.270274  PMID:31696857
Light-chain deposition disease (LCDD) reoccurs almost invariably after renal transplantation, leading to early graft loss. We report a case of LCDD with monoclonal gammopathy of renal significance diagnosed in the post-transplant period in a 28-year-old male and we discuss the diagnostic and therapeutic challenges in the clinical course.
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A case of advanced chronic kidney disease with severe hypocalcemia, how to safely manage and dialyze? p. 1166
Turki Al-Shebani, Mubashar Azeem, Elwaleed A Elhassan
DOI:10.4103/1319-2442.270275  PMID:31696858
Patients often present with advanced chronic kidney disease (CKD) complicated with severe hypocalcemia that may be accompanied by electrocardiographic changes. The management of this kind of patients may require hemodialysis (HD). However, initiation of renal replacement therapy in this scenario needs special attention to avoid complications such as cardiac arrhythmias. A 22-year-old male presented to our emergency department with severe renal failure, hypocalcemia, hyperphosphatemia, severe acidosis, and QT prolongation on electrocardiography. The patient was kept in the emergency department under cardiac monitoring. He was started on IV calcium gluconate 1 g every 6 h aiming to increase his adjusted calcium level to 1.8 mmol/L. He subsequently received the first HD session with low blood flow, increased calcium, and decreased bicarbonate dialysate bath. There were no arrhythmias or hemodynamic instability. Intravenous calcium was discontinued; adjusted calcium improved progressively after dialysis and reached 1.9 mmol/L by the time of discharge and after receiving three sessions of HD. This case describes a not so infrequent presentation of advanced renal impairment with profound hypocalcemia, hyperphosphatemia in the setting of CKD-associated mineral bone disorder. Intravenous calcium administration may promote vascular and metastatic calcification, particularly with the coexistence of hyperphosphatemia, and hence, it is best avoided. There are no guidelines to direct initiating HD in this context. However, it appears that using a high calcium bath is prudent to minimize cardiovascular complications, particularly if there is the prolongation of the corrected QT interval on electrocardiography.
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Congenital factor VII deficiency presenting first time as isolated recurrent hematuria at late age p. 1171
Suman Sethi, Sudhir Mehta, Nitin Sethi, Vikas Makkar, Simran Kaur, Manpreet Kaur Jhingar
DOI:10.4103/1319-2442.270276  PMID:31696859
Hematological conditions rarely present as isolated hematuria. Factor VII deficiency is a rare congenital coagulopathy inherited as autosomal recessive pattern. It usually presents a severe life-threatening bleeding at an early age. The presentation of congenital factor VII factor deficiency for the first time as recurrent hematuria at a later age is a rare presentation. We report a case of a 23-year-old male, who presented to us with recurrent episodes of painless hematuria for the past three months due to congenital factor VII deficiency.
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An unusual clinical presentation of tuberculous pyomyositis in a renal allograft recipient p. 1175
Pradeep Khandalvalli, Shabana Nazneen, Manjusha Yadla
DOI:10.4103/1319-2442.270277  PMID:31696860
We present a renal allograft recipient with pulmonary tuberculosis presenting with multiple subcutaneous abscesses involving left forearm, left thigh, suture site and left loin, which on later evaluation revealed to be due to Mycobacterium tuberculosis.
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Cryptococcosis masquerading as disseminated tuberculosis in a patient on chronic hemodialysis p. 1179
Priti Meena, Anurag Gupta, Lovy Gaur, Aakash Shingada, Pallav Gupta, Vinant Bhargava, Devender S Rana
DOI:10.4103/1319-2442.270278  PMID:31696861
Chronic hemodialysis (HD) recipients are nearly ten times more prone to fungal infections compared to the general population. However, infections such as cryptococcosis usually affect immunocompromised patients, unusual in otherwise immunocompetent patients. Here, we describe a unique case of cryptococcosis in a human immunodeficiency virus negative end-stage renal disease (ESRD) patient. A 26-year-old female patient, diagnosed with ESRD, on maintenance HD for the past six months, presented with pyrexia of unknown origin associated with cervical lymphadenopathy, biopsy of which showed granulomatous inflammation. The patient was initiated on anti-tubercular treatment but did not respond to treatment. A month later, she developed skin lesions; biopsy and culture from scrapings of the lesions were suggestive of infection with Cryptococcus neoformans. She responded to antifungal therapy very well, with a resolution of fever and skin lesions within a month. This is a unique case report, in which cryptococcosis mimicked tuberculosis in an otherwise immunocompetent patient with ESRD.
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LETTER TO THE EDITORS Top

Severe hepatotoxicity of ritonavir, ombitasvir, paritaprevir, and dasabuvir in a kidney transplant recipient p. 1184
Nikolina Bukal, Vesna Furic-Cunko, Ivana Juric, Lea Katalinic, Antonia Dedo, Nikolina Basic-Jukic
DOI:10.4103/1319-2442.270279  PMID:31696862
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Hemodialysis tunneled catheter-related infection in a tertiary care center: A changing trend p. 1187
Navin Pattanashetti, Raja Ramachandran, HS Kohli, KL Gupta
DOI:10.4103/1319-2442.270280  PMID:31696863
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