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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
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January-February 2020
Volume 31 | Issue 1
Page Nos. 1-297

Online since Tuesday, March 3, 2020

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REVIEW ARTICLES  

Metabolome and microbiome in kidney diseases Highly accessed article p. 1
R Vairakkani, M Edwin Fernando, T Yashwanth Raj
DOI:10.4103/1319-2442.279927  PMID:32129192
Despite several decades of intensive research and hard work in nephrology, a void exists in the availability of markers for identifying at-risk individuals, diagnosing diseases at incipient stage, and predicting treatment response. Most of the current widely available diagnostic tools such as creatinine, urine analysis, and imaging studies are quite insensitive such that about half of the kidney function is lost before perceivable changes are observed with these tests. In addition, these parameters are affected by factors other than renal, questioning their specificity. Renal biopsy, though specific, is quite expensive, risky, and invasive. The recent surge in the knowledge of small molecules in the tissue and body fluids, “metabolomics,” thanks to the Human Metabolome Database created by the Human Metabolome Project, has opened a new avenue for better understanding the disease pathogenesis and, in parallel, to identify novel biomarkers and druggable targets. Kidney, by virtue of its metabolic machinery and also being a major handler of metabolites generated by other tissues, is very much amenable to the metabolomic approach of studying its various perturbations. The gut microbiome, characterized by the Human Microbiome Project, is one of the principal players in metabolomics. Changes in metabolite profile due to alterations in gut microbiome can occur either as a cause or consequence of renal diseases. Unmasking the renal–metabolome–microbiome link has a great potential to script a new era in the diagnosis and management of renal diseases.
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Pregnancy and lupus nephritis in developing countries: A systematic review Highly accessed article p. 10
Sukriti Bansal, Ogochukwu Okoye, Nilum Rajora
DOI:10.4103/1319-2442.279928  PMID:32129193
Systemic lupus erythematosus (SLE) and lupus nephritis (LN) have a significant impact on the course of pregnancy, as well as on maternal and fetal outcomes. LN in pregnancy can increase the maternal risks of SLE flare, acute kidney injury, preeclampsia, and even death. It also affects fetal outcomes by the increased risk of intrauterine growth retardation, premature delivery, and fetal loss. Successful pregnancy outcomes have been well documented in the developed world, but less is known about patients in developing nations. We searched PubMed and Google scholar for all articles published from 1999 to 2016 in developing countries. Twelve of 13 studies were included excluding only one. All studies were independently reviewed. Most of the studies reported a significant association between high flare rates of LN and higher rates of disease flare. Higher rates of active disease at conception were associated with lower live birth rates. Similarly, high flare rates of LN were associated with higher rates of fetal loss. With regard to geographic trends, Indian studies reported lower overall live birth rates and higher rates of active disease at conception. Interestingly, lower rates of preeclampsia were also noted in Indian studies. Higher rates of flare were observed in other Asian studies, but not the Indian studies. Although LN and active SLE at conception are associated with poor fetal outcomes, better outcomes are possible with proper management, even in low-resource settings. More research is necessary to fully understand the relationships between active disease at conception or LN and flare rates, live birth rates, and fetal loss rates in developing countries.
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ORIGINAL ARTICLES Top

Evaluation of safety and efficacy profile of Nigella sativa oil as an add-on therapy, in addition to alpha-keto analogue of essential amino acids in patients with chronic kidney disease p. 21
Mohd Ashraf Alam, Mohammad Nasiruddin, Shahzad F Haque, Rahat Ali Khan
DOI:10.4103/1319-2442.279943  PMID:32129194
Chronic kidney disease (CKD) encompasses a spectrum of different pathophysio- logic processes associated with abnormal kidney function. When it reaches end-stage renal disease (ESRD), the only option is dialysis and renal transplantation. This is unaffordable by most patients. Hence, newer treatment modalities are being looked for, which can slow down the progression of CKD and delay the development of ESRD. This study aimed to evaluate the efficacy and safety of Nigella sativa oil as an add-on therapy in addition to alpha-keto analogue of essential amino acids in patients with CKD Stages 3 and 4. The study was conducted at a tertiary care center in North India on patients with CKD Stages 3 and 4. It was a prospective, comparative, and open-labeled study. One hundred and fifty patients were enrolled and were randomly divided into two interventional groups. Fourteen patients were lost to follow-up. Group I (control) which had 66 patients received conservative management of CKD consisting of alpha-keto analogue (600 mg tablet three times a day), whereas Group II (test) which had 70 patients received conservative management along with alpha-keto analogue and N. sativa oil (2.5 mL, per orally, once daily) for 12 weeks. Hemogram, renal function, and serum electrolyte tests were done, and adverse events were recorded at baseline and at4, 8, and 12 weeks of treatment. After 12 weeks of treatment, there was a marked improvement in clinical features and biochemical parameters in both the control and test groups. There were a significant reduction in blood urea, serum creatinine, and 24-h total urine protein and a significant improvement in 24-h total urine volume and glomerular filtration rate. N. sativa oil supplementation along with alpha-keto analogue is more more efficacious and safe in delaying the progression of disease patients with CKD Stages 3 and 4.
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Study of the relationship between urinary level of uromodulin, renal involvement and disease activity in patients with systemic lupus erythrematosus p. 32
Rania Nabil Bedair, Marwa Mounir Amin Ismail, Eman Wagdy Gaber, Ragaa Abdel Kader Mahmoud, Mohamed Nader Mowafy
DOI:10.4103/1319-2442.279959  PMID:32129195
Systemic lupus erythematosus (SLE) is a multifactorial chronic inflammatory autoimmune connective tissue disease. Lupus nephritis (LN) is a common and serious complication of SLE which can progress to end-stage renal disease. Renal biopsy is the gold standard in the diagnosis and classification of LN, but since it is an invasive procedure, it is neither desirable nor applicable for all cases. This has led to the search for an alternative, noninvasive, site-specific, and immune process-related biomarkers. Uromodulin (Tamm-Horsfall glycoprotein) is the most abundant urinary protein expressed exclusively by the thick ascending limb cells and released into urine of healthy controls. Studies showed that it may act as a danger signaling molecule eliciting an inflammatory response following conditions that damage the nephron integrity and leading to uromodulin release into the interstitial space. This study aimed to assess uromodulin as a screening biomarker of tubulointerstitial involvement in patients with SLE and to elucidate its correlation with disease activity and progression. The study was conducted on 70 patients divided into two groups: control group (Group I) consisted of 20 apparently healthy volunteers of comparable age and sex to the patients’ group, and 50 SLE patients (Group II) diagnosed according to the 2012 Systemic Lupus Collaborating Clinics (SLICC) classification criteria. Group II was further subdivided into 23 patients without manifestations of LN (Group II A) and 27 patients with manifestations of LN (Group II B). Urinary uromodulin level showed statistically significant difference among the studied groups, being lowest among the LN patients with a mean value 5.6 ± 3.4, in SLE patients without nephritis 9.9 ± 5.2 and 12.9 ± 4.6 in the control group. Urinary uromodulin also correlated positively with estimated glome- rular filtration rate. A negative correlation was found between urinary uromodulin and serum creatinine, 24 h urinary proteins and SLICC renal activity score. No statistically significant correlation was found between urinary uromo- dulin and SLE disease activity index. Thus, decreasing urinary uromodulin levels can be a marker for renal involvement and tubulo- interstitial nephritis in active SLE patients and a marker for chronic kidney disease and nephron loss in the absence of activity markers.
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Comparison of the effect of linear and step-wise sodium and ultrafiltration profiling on dialysis adequacy in patients undergoing hemodialysis p. 44
Mehri Hamidi, Fariborz Roshangar, Hamid Tayebi Khosroshahi, Mansour Ghafourifard, Parvin Sarbakhsh
DOI:10.4103/1319-2442.279960  PMID:32129196
Patients with chronic renal failure undergoing hemodialysis (HD) need to receive adequate dialysis. Dialysis inadequacy leads to an increase in the side effects and even frequent hospitalizations as well as increased therapeutic costs. Considering the fact that improving the adequacy of dialysis is one of the goals of nursing care in these patients, this study aimed to compare the effect of linear and step-wise sodium-ultrafiltration (UF) profiling on HD adequacy. This study is a clinical trial; a total of 32 patients from two dialysis centers in East Azerbaijan province were selected and randomly divided into two groups. Each patient underwent HD for three sessions by routine method, three sessions by linear sodium profile and UF, and three sessions by the step-wise sodium profile and UF. At the end of each HD method, Kt/V was calculated to determine the adequacy of dialysis. Data analysis was performed using Statistical Package for the Social Sciences software version 13 with generalized estimating equation statistical test. According to the results of this study, there was a statistically significant difference between the mean of adequacy of dialysis (Kt/V) in the three treatment methods (P <0.05), in which the mean score of dialysis adequacy in step-wise method was 0.14 more than the routine method, and in the linear method, it was 0.21 more than the routine method. The mean Kt/V scores were 1.24, 1.31, and 1.10 in the step-wise method, linear method, and routine method, respectively(P <0.05). The results of this study indicate that simultaneous application of sodium and UF profiles is effective in the hemodynamic stability of patients, which reduces uncomfortable complications during dialysis. Therefore, in order to improve dialysis adequacy and prevent the complications, usage of sodium and UF profiles is recommended.
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Evaluation of continuous renal replacement therapy and risk factors in the pediatric intensive care unit p. 53
Fatih Aygun
DOI:10.4103/1319-2442.279961  PMID:32129197
Acute kidney injury (AKI) is one of the most common causes of increased mortality and morbidity in the pediatric intensive care unit (PICU). Continuous renal replacement therapy (CRRT) is the mainstay treatment for AKI in children as it allows continuous and programmed removal of fluids, which is tolerated better hemodynamically. Defining the risk factors of CRRT related to mortality and morbidity will help improve the outcomes of patients in the PICU. In this study, we aimed to determine the prognostic factors and outcomes of patients who received CRRT. This was a single-center, retrospective study on PICU patients requiring CRRT. Patients with a history of chronic renal failure and PICU stay duration of <24 h and those who died on the 1st day of admission were excluded from the study. A total of 447 patients admitted between October 2016 and March 2018 were included in the study. Children who received CRRT for the management of AKI and/or other nonrenal indications, such as metabolic acidosis, poisoning, electrolyte imbalance, and congenital metabolic diseases, were also included in the study. Fifty patients underwent CRRT. There was a statistically significant relationship between CRRT support and prognostic factors, including age (P = 0.012), inotropic drug usage (P = 0.000), concomitant infection (P = 0.010), blood component transfusion (P = 0.005), pediatric risk of mortality score (P = 0.027), and mortality (P = 0.003). The odds ratio for mortality was 5.396 (95% confidence interval: 1.732-16.809). In conclusion, CRRT is associated with increased morbidity and mortality in the PICU.
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The relationship between body mass index and blood pressure in patients undergoing chronic hemodialysis: A reverse epidemiology in Jakarta, Indonesia p. 62
Lucky Aziza Abdullah Bawazir, Wicensius Sianipar, Stanley Buntaran, Aria Kekalih
DOI:10.4103/1319-2442.279962  PMID:32129198
In the general population, obesity is positively correlated with hypertension. On the other hand, there was hypothesis of “reverse epidemiology” in the relationship between body mass index (BMI) and blood pressure (BP) of hemodialysis (HD) patients. This study aimed to investigate the “reverse epidemiology” of the relationship between the two variables in Jakarta, Indonesia. Cross-sectional study was conducted at Cipto Mangunkusumo Hospital, Koja District Hospital, and Cengkareng District Hospital in July 2018. Total sampling was performed with a total of 525 HD patients aged >18 years. All data were analyzed from the medical records. Of 525 patients, 27.4% were obese. The post hoc analyses showed that obese patients had significantly lower post-HD systolic BP (P = 0.006) and diastolic BP (P = 0.004) than the normal-weight patients. The Chi-square analyses showed that the overweight group [odds ratio (OR) = 0.53; 95% confidence interval (CI) 0.31-0.87; P = 0.011] and the obese group (OR = 0. 63; 95% CI 0.400.97; P= 0.038) had significant protective effect (OR <1) on the post-HD hypertension. Being obese was a strong predictor for reduced BP (coefficient β = -0.02; P = 0.031). BMI is inversely associated with BP in patients undergoing chronic HD.
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Aldosterone renin ratio and chronic kidney disease p. 70
Wessam Osman, Hayam Al Dohani, Al Shaima Al Hinai, Suad Hannawi, Faissal A M. Shaheen, Issa Al Salmi
DOI:10.4103/1319-2442.279963  PMID:32129199
As a component of the metabolic syndrome, hypertension (HTN) is increasing throughout the world with variable percentages, but mostly among developing world. Aldosterone plays a role in the relationship between aldosterone and nephropathy. We aimed to evaluate the relationship between aldosterone renin ratio (ARR) and chronic kidney disease (CKD). Variables drawn from the computerized hospital information database were all patients who had an ARR above 35 (if aldosterone reading was above 300 pmol/L). A total of 1584 patients, of whom 777 were male and 807 were female, with a mean [standard deviation (SD)] of 43.3 (16.5) years were studied. The mean ARR was 210.1 (SD: 246.4) in males and 214.3 and 210.1 in females, P = 0.51. The mean estimated glomerular filtration rate (eGFR) was 50.2 (SD 12.6); in males, it was 49.99 (0.90) and in females, it was 50.48 (0.92), P = 0.70. The regression model revealed a negative relationship between ARR and GFR with a coefficient of -2.08, 95% confidence interval: -4.6, 0.21, P = 0.07. CKD population with HTN tends to have a very high level of ARR, and those with advanced CKD have higher ARR. However, high ARR could have low eGFR and kidney dysfunction on follow-up. In view of high prevalence of noncommunicable disease and high early CKD population, there is an important need to consider comprehensive management strategies that involve the blockage of high renin-angiotensin-aldosterone and the use of mineralocorticosteroid receptor blockers.
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Evaluation of the children with C3 glomerulopathy p. 79
Ayse Seda Pinarbasi, Ismail Dursun, Muammer Hakan Poyrazoglu, Hulya Akgun, Adil Bozpolat, Ruhan Dusunsel
DOI:10.4103/1319-2442.279964  PMID:32129200
C3 glomerulopathy (C3G) is a clinical spectrum that presents with a variety of symptoms, ranging from a mild disease with asymptomatic microhematuria and/or proteinuria to severe disease with nephritic or nephrotic syndrome and renal impairment. Herein, we aim to document the clinical and laboratory findings, response to immunosuppressive and supportive treatment and prognosis of the children with C3G. We retrospectively reviewed the medical records of patients diagnosed with membranoproliferative glomerulonephritis (MPGN). Kidney biopsy materials were reexamined for the diagnosis of C3G. The inclusion criteria for C3G are the dominant C3 staining with or without scanty immunoglobulins (Ig) deposition on immuno- fluorescence (IF) and MPGN patterns on light microscope. Twelve of 69 patients with MPGN were included in the study based on the definition criteria of C3G. Ten of them had only C3 staining and the rest of the patients had both C3 staining and a small amount of IgG/M staining on IF microscopy. One patient was on remission with only ACEI. The rest of the patients used immunosuppressive treatment and two of them needed eculizumab therapy. One of them did not respond to the treatment of eculizumab and progressed to end-stage renal failure. C3G is a disease characterized by a heterogeneous clinical presentation and outcome. Because of this broad spectrum of disease, treatment may vary widely. We think that complement-targeting therapy with eculizumab should be an alternative option for refractory cases, especially in the early stage of disease, if they did not respond to immunosuppressive treatment.
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Peripheral arterial disease diagnosed by ankle–brachial index: Predictor for early renal replacement therapy in chronic kidney disease p. 90
Yasemin Ozgur, Seydahmet Akin, Ergun Parmaksiz, Meral Meşe, Zerrin Bicik Bahcebasi, Ozcan Keskin
DOI:10.4103/1319-2442.279965  PMID:32129201
Our study aimed to investigate the relationship between ankle-brachial index (ABI) and need for early renal replacement therapy (RRT) in predialysis patients with chronic kidney disease (CKD). A total of 112 patients (62% men) with pre-dialysis CKD, seen in the outpatient clinic, were included, and ABI was obtained as per standard protocol. Peripheral arterial disease (PAD) was defined as ABI <0.9 or >1.3 in either leg. The clinical data were analyzed, and the risk factors for early RRT were determined by multivariate logistic regression analysis. The prevalence of PAD was 44% in predialysis CKD patients. Over three years’ follow- up, 14.2% required RRT; 11.3% developed major cardiovascular event (myocardial infarction, stroke, or death). A total of 26 events occurred. The incidence of all events was significantly higher in patients with abnormal ABI than in those with normal ABI (34.7% vs. 12.7%; log rank P = 0.02). PAD was associated with all events [hazard ratio (HR): 2.72; 95% CI: 1.04-7.17; P = 0.042] as also the need for RRT (HR 3.2; 95% Cl: 1.005-10.23; P = 0.049), on univariate cox proportional hazard analysis. Multivariate logistic regression analysis adjusted for other risk factors identified that PAD remained an independent predictor for the need for early RRT (HR: 12.2; 95%Cl: 2.2-66.5; P = 0.004) and all events (HR: 3.5; 95% Cl: 0.9-13.5; P = 0.032). PAD was an independent predictor for RRT requirement in predialysis CKD.
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Effects of graded exercise training on functional capacity, muscle strength, and fatigue after renal transplantation: a randomized controlled trial p. 100
Thillai Govindarajan Senthil Kumar, Periyasamy Soundararajan, Arun G Maiya, Annamalai Ravi
DOI:10.4103/1319-2442.279929  PMID:32129202
Successful renal transplantation (RT) recipients suffer residual muscle weakness, fatigue, and low functional capacity. A safe, feasible, structured, early graded exercise training to improve functional capacity, muscle strength, and fatigue is the need of the hour. The aim of the study is to assess the effectiveness of graded exercise training on the functional capacity, muscle strength, and fatigue after RT. It is a randomized controlled trial conducted at a tertiary care hospital from January 2012 to December 2016. This trial included 104 consented, stable renal transplant recipients without cardiopulmonary/neuromuscular impairment. They received either routine care (51) or graded exercise training (53) for 12 weeks after randomization. The functional capacity, isometric quadriceps muscle strength, and fatigue score were measured at baseline, six, and 12 weeks later to induction. The outcomes of the study and control groups were analyzed using the /-test, Wilcoxon signed-rank test, ANOVA, and Pearson’s correlation. For all analyses, P <0.05 was fixed acceptable. The functional capacity improved by 147 and 255 m, the muscle strength by 6.35 and 9.27 kg, and fatigue score by 0.784 and 1.781 in the control and the study group (SG), respectively, significantly more in the SG. Functional capacity had a positive and negative correlation with muscle strength and fatigue, respectively (P <0.05). The graded exercise training significantly improved the functional capacity, fatigue levels, and muscle strength after RT.
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Ribavirin as a beneficial treatment option for hepatitis C virusassociated glomerular disease p. 109
Fabrizio Fabrizi, Donata Cresseri, Gabriella Moroni, Patrizia Passerini, Francesco Pallotti, Francesca Maria Donato, Pietro Lampertico, Piergiorgio Messa
DOI:10.4103/1319-2442.279930  PMID:32129203
The management of hepatitis C virus (HCV)-induced glomerular disease remains unsatisfactory despite novel advances in antiviral and immunosuppressive therapy. Recent evidence highlighted the role of ribavirin, a drug provided with immunomodulatory properties, in the treatment of glomerular diseases associated with chronic HCV. We administered low-dose ribavirin (200 mg/day or 200 mg twice a week or 200 mg thrice weekly) in a prospective fashion to a group of patients with HCV-associated glomerular disease (n = 7). Ribavirin monotherapy was given in most (n = 6) patients and was accompanied by erythropoietin therapy in all. The primary endpoint was reduction of 24-h proteinuria after treatment ended; the secondary end-points were decrease in serum creatinine and amelioration of urinary abnormalities. We collected data on on-treatment adverse events (AEs), serious AEs, and laboratory abnormalities. Many patients (n = 6) had inactive HCV infection as they had shown HCV RNA clearance from serum after antiviral therapy with direct-acting antivirals. Some patients (n = 4) had membranoproliferative glomerulo- nephritis, the diagnosis being confirmed by kidney histology in three cases; others (n = 2) received diagnosis of diabetic glomerulosclerosis, confirmed in one by kidney biopsy. We observed consistent reduction of 24-h proteinuria in two individuals after ribavirin therapy; another patient reported disappearance of microscopic hematuria. We found severe AE (hemolytic anemia) in three patients which required discontinuation of ribavirin treatment in two patients, one required hospitalization. Other AEs were cutaneous rash (n = 1), dyspepsia (n = 1), and fatigue (n = 1). Low-dose ribavirin was able to give consistent reduction of 24-h proteinuria in two patients; tolerance to ribavirin was unsatisfactory. We need further studies aimed to expand our knowledge on ribavirin therapy of HCV-associated glomerular disease. The low incidence of the disease hampers the conduction of clinical trials on this aim.
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Educational needs of chronic kidney disease patients who presented to tengku ampuan afzan hospital: Preliminary findings p. 118
Siti Noorkhairina Sowtali, Sakinah Harith, Azarisman Shah Mohd. Shah, Nur Ain' Ishak, Dariah Mohd Yusoff, Che Rosle Draman, Ali Aminuddin Mohd Rasani, Norhasyima Ghazali
DOI:10.4103/1319-2442.279931  PMID:32129204
Knowledge limitation is a major cause of the increasing number of chronic kidney disease (CKD) patients in Malaysia and the world. Nurses are responsible for identifying the patients’ needs to come up with appropriate discharge plans which might include educational activities. The objective of this study was to determine the baseline information (socio- demographic background, as well as medical and lifestyle histories), along with educational needs of CKD patients. A total of 116 CKD patients who attended the Nephrology Clinic of Hospital Tengku Ampuan Afzan were recruited. Patients who fulfilled the inclusion criteria were selected between April and May 2017. Data were obtained via semi-guided questionnaires; the patients were given enough time to complete the required items. The CKD educational needs’ assessment consisted of seven domains: general information, chronic illness management, complications, self-management, medications, treatment, and financial status. Majority of the patients were men (53.4%), aged 54.65 ± 16.49 years, secondary school-finishers (49.1%), and jobless (48.3%). In terms of medical and life-style histories, most patients were diagnosed with end-stage renal disease (51.7%), hypertension (96.6%), diabetes (51.7%), and anemia (25.9%). The patients were interested to know the complications of kidney disease (57.8%), management of diseases like hypertension (58.6%), complications like edema (55.2%), indications for medication (73.3%), self-management or fluid control (37.9%), hemodialysis (37.1%), and financial status (21.6%). Thus, strengthening patient education strategies in the clinics, hospitals, and community settings should be given due attention by relevant healthcare professionals.
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Metabolic syndrome, malnutrition, and its associations with cardiovascular and all-cause mortality in hemodialysis patients: Follow-up for three years p. 129
Zohra El Ati, Hanene Machfar, Hamza Boussafa, Nidhal Ati, Olfa Ben Omrane Sioud, Baha Zantour, Hassen Bouzidi, Mohamed Elati
DOI:10.4103/1319-2442.279932  PMID:32129205
Metabolic disorder contributes to the increase in the mortality rate of patients on hemodialysis (HD). The aim of this study was to estimate the prevalence of metabolic syndrome (MS) and malnutrition in patients on maintenance HD and to evaluate their influence on cardiovascular and all-cause mortality during the follow-up. We carried out a prospective cross- sectional study in which we enrolled 100 patients from a single center who had been followed up for three years. Collected data included demographic characteristics, detailed medical history, clinical variables, MS variables, nutritional status, and laboratory findings. The outcomes were the occurrence of a cardiovascular event and cardiovascular or all-cause mortality during the follow-up period. The Statistical Package for the Social Sciences software was used for statistical analysis. Whereas 50% of patients had MS, 23% showed evidence of malnutrition. Patients with MS were older and had more preexisting cardiovascular diseases (CVDs). All patients were followed for 36 months. During this time, 19 patients with MS and 14 patients without MS died (38% vs. 28%; P = 0.19), most frequently of CVD. Mean survival time was 71.52 ± 42.1 months for MS group versus 92.06 ± 65 months for non-MS group, but the difference was not significant. MS was related with a higher cardiovascular mortality, while malnutrition was significantly associated with all-cause mortality. Our data showed that MS was not related to cardiovascular or all-cause mortality in HD patients and did not influence survival. The independent risk factors for all-cause mortality were older age, preexisting CVD, and malnutrition.
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Evaluation of the relationship between blood cell parameters and vascular calcification in dialysis-dependent end-stage renal disease patients p. 136
Abhilash Chandra, Gaurav Raj, Namrata P Awasthi, Namrata Rao, Divya Srivastava
DOI:10.4103/1319-2442.279933  PMID:32129206
Coronary artery calcification is an acceptable tool for cardiovascular risk assessment in end-stage renal disease (ESRD) population. We aimed to identify the association and predictive value of components of blood cell parameters with coronary and thoracic aorta vascular calcification (VC) in ESRD population on dialysis. All ESRD patients receiving hemodialysis or peritoneal dialysis aged between 18 and 60 years were included in the study. Exclusion criteria comprised patients with active infection or inflammatory disease, autoimmune disease, congestive heart failure, angina pectoris and/or documented coronary artery disease, thyroid disease, and hepatic dysfunction. Agatston scoring was used for the evaluation of coronary aorta calcification (CAC) score (CACS) and thoracic aorta calcification (TAC) score (TACS). Compared to participants with no VC, those who had VC were statistically significantly older (P <0.001) and had higher neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) (P = 0.02 and <0.001, respectively). On multivariate logistic regression analysis, increasing age (P = 0.00) and higher PLR (P = 0.04) were associated with an increased likelihood of exhibiting VC (CAC or TAC). There was a positive correlation between CACS and age (rs = 0.495, P = 0.00). A statistically significant positive correlation existed between TACS and age (rs = 0.516, P = 0.00). Similarly, a positive correlation was found between NLR, PLR, and TACS (rs = 0.334, P = 0.001, and rs = 0.438, P = 0.00, respectively). On multivariate linear regression analysis, increased age and red cell distribution width were found to be significant predictors of log(n) TACS. PLR of 135 gave a sensitivity of 80% and a specificity of 50% for predicting VC. Being a cost-effective and easily available investigation, the utilization of the correlation of NLR and PLR with CAC and TAC appears promising, particularly in the age group of 30–60 years.
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NPHS2 gene mutations in azerbaijani children with steroid-resistant nephrotic syndrome p. 144
Rauf Baylarov, Ozgur Senol, Merve Atan, Afig Berdeli
DOI:10.4103/1319-2442.279934  PMID:32129207
Nephrotic syndrome (NS) is characterized by proteinuria in children. Steroid- resistant NS (SRNS) is defined by resistance to standard steroid therapy, and it continues to be one of the most common causes of chronic renal failure. Molecular studies have revealed specialized molecules in different regions of the podocytes that play a role in proteinuria. Mutations in NPHS2 that encode for podocin constitute a frequent cause of SRNS worldwide. This study aimed to screen for podocin mutations in Azerbaijani patients with SRNS. Our study included 21 pediatric patients with SRNS aged between 0 and 18 years and the same number of healthy control groups. Mutational analysis of the NPHS2 gene was performed using direct sequencing methods. Disease-causing mutations in the NPHS2 gene were detected in eight patients (38%). Thirteen patients (62%) had NPHS2 mutations without causing the disease. Two patients had p.Val290Met homozygous mutation; two had p.Arg229Gln homozygous mutations; and one each had p.Pro20Leu homozygote, p.Leu169Pro homozygote, p.Arg138Gln homozygote, and p.Arg168His homozygous mutations. When we correlated the NPHS2 mutation status with disease progression, there was a statistically significant increase in serum creatinine, proteinuria, and serum albumin values in patients with NPHS2 gene mutations compared to the group without mutation (P <0.05). Our study concludes that mutations of the NPHS2 gene (38%) are heterogeneous in Azerbaijani SRNS patients. Based on our results, we support a model in which ethnicity plays an important role in certain NPHS2 mutations. NPHS2 mutation analysis may help to better predict the course of the disease, remove unnecessary long-term immunosuppressive therapy, and develop specific treatment.
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BRIEF COMMUNICATIONS Top

Effectiveness of interventions based on lazarus and folkman transactional model on improving stress appraisal for hemodialysis patients in Tehran p. 150
Mohammad Ali Morrowati Sharifabad, Mohtasham Ghaffari, Yadollah Mehrabi, Jafar Askari, Samad Zare, Somayeh Alizadeh
DOI:10.4103/1319-2442.279935  PMID:32129208
Today, we witness an increase in the prevalence of chronic kidney disease, which is a very stressful process. In order to cope with the stress caused by this disease, the first step is to appraise the stressful situation correctly. Therefore, the present study was conducted with the aim of investigating the effect of training on the basis of Lazarus and Folkman transactional model on stress appraisal for hemodialysis (HD) patients. The present quasi-experimental study was conducted on 116 filed HD patients in two dialysis centers in Tehran. The patients were randomly divided into two groups: experimental and control groups. The data were collected using a researcher-made questionnaire whose validity and reliability were confirmed. After performing the intervention, the primary and secondary appraisals’ scores were investigated before and three months after the intervention. The data were analyzed using independent /?-test, paired /-test, and covariance at a significant level of 0.05 using software Statistical Package for the Social Sciences version 16.0. The mean age of participants in the study was 52.86 years. In this study, the difference between the mean score of the primary appraisal and substructure of perceived susceptibility, motivational relevance, self-blame (casual focus), and secondary appraisal and self-efficacy substructure after the intervention was significant in the experimental group. However, these differences were not significant in the control group. According to the study results, it can be concluded that the use of training based on Lazarus and Folkman tran- sactional model can be useful for improving the correct appraisal of individuals for stressful situations.
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Clinical profile and outcomes of De novo posttransplant thrombotic microangiopathy p. 160
LP Saikumar Doradla, H Lal, Anupma Kaul, D Bhaduaria, M Jain, N Prasad, V Thammishetti, A Gupta, M Patel, RK Sharma
DOI:10.4103/1319-2442.279936  PMID:32129209
Thrombotic microangiopathy (TMA) after kidney transplant is rather uncommon but an important reversible cause of graft loss. This retrospective study of biopsy-proven posttransplant TMA was done to identify the important etiological factors, clinical features, and outcomes of post transplant TMA in a tertiary care referral hospital in northern India. This retrospective study was conducted among all renal transplant recipients who presented with graft dysfunction between 1989 and 2015. All the cases were looked for their etiology, clinical course, treatment modalities, and renal outcomes. The study was conducted in accord with prevailing ethical principles and reviewed by our own institutional review board. Seventeen patients out of 2000 (0.008%) transplants done during the study period had posttransplant TMA, out of which all the patients had de novo TMA, and the median time of presentation after transplantation was four months. Systemic TMA was noted in only four patients. Biopsy revealed associated rejection in five patients and associated calcineurin inhibitor (CNI) toxicity in 12 patients. Patients with TMA due to CNI toxicity were managed with CNI reduction or switching to alternate CNI or mammalian target of rapamycin inhibitors. In addition, antithymocyte globulin and plasma exchange were used in rejection-associated TMA. While four out of 12 patients (33%) in CNI-related TMA developed end-stage renal disease (ESRD), all patients in rejection-associated TMA developed ESRD. The overall one-year graft survival was 47%, whereas five- and 10-year survival was 35%. There was no significant difference in graft survival between localized and systemic TMAs (P = 0.4). Posttransplant TMA should be suspected even if there are no systemic features of hemolysis and early graft biopsy and prompt action is needed. The occurrence of TMA in the setting of rejection is associated with grave prognosis.
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Retroperitoneal fibrosis in the military hospital of Morocco p. 169
Mounia Azizi, Yassir Zajjari, Hicham Rafik, Driss El Kabbaj
DOI:10.4103/1319-2442.279937  PMID:32129210
Retroperitoneal fibrosis (RPF) is a rare disease. It is characterized by the presence of fibro-inflammatory tissue involving retroperitoneal structures. The usual mode of presentation of this disease is with lumbar pain, kidney failure, and a biological inflammatory syndrome. The aim of our study is to describe the diagnostic, etiologic, therapeutic aspects and outcomes of RPF in a nephrology unit in Morocco. Twelve cases of RPF were included in our study. The mean age was 57 ± 10 years (32.70). Nine patients were male and three were female. Symptoms were highly variable, dominated by pain that was present in all patients. Venous compressive signs were described in four patients (33.3%), anuria in one patient (8.3%), and hematuria in two patients (16.6%). Laboratory examinations found an inflammatory syndrome in all patients and renal failure in nine patients (75%), with a mean serum creatinine at 35 mg/L ± 8.5. Diagnosis was suspected on the ultrasound data and confirmed by computed tomography or magnetic resonance imaging. RPF was idiopathic in nine patients (75%). It was secondary to aortic aneurysm in one patient (8.3%), Riedel’s thyroiditis in one patient (8.3%), and drug induced in another patient (8.3%). All patients received surgical treatment along with corticosteroids. At six months, remission was achieved in nine patients, whereas three others had steroid resistance. These patients were treated by mycophenolate mofetil (MMF) at a dose of 2 g/day; two of them had intestinal intolerance to MMF and thus were treated by tamoxifen at a dose of 40 mg/day. At 24 months, they stabilized their renal function with incomplete regression of the fibrotic plate. No cases of recurrence were observed during the study period.
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Spectrum of pediatricbiopsy-proven renal diseases: A single center experience p. 176
Ebtisam Ibraheem Al-Sadoon, Khawla A Rahim, Abdulkarim AlAnazi, Hassan Faqeehi, Sawsan AlBatati
DOI:10.4103/1319-2442.279938  PMID:32129211
Glomerular diseases are considered to be a significant cause of chronic kidney disease. Kidney biopsy continues to be an essential diagnostic tool. We review the renal biopsies which were done on children below the age of 14 years in the past 10 years (from January 2008 to September 2018) in a single tertiary pediatric hospital in Saudi Arabia to determine the patterns of renal disease among Saudi children as well-correlating clinical presentation with histopathological diagnosis. A total of 203 pediatric kidney biopsies were performed. The mean age was 7.3 ± 3.9 years (3 months to 14 years). There were 105 males and 98 females. The most frequent indication for renal biopsy was nephrotic syndrome in 58.9% of patients, followed by acute glomerulo- nephritis in 20.8%. Other indications included significant proteinuria, persistent microscopic hematuria, acute kidney injury of uncertain etiology, in the remaining 20% of biopsies. Clinical diagnosis was consistent with histopathological diagnosis in 92% of the cases. Minimal change disease was the most common cause of primary glomerular diseases in 37.4%, followed by focal segmental glomerulosclerosis in 20.2%. Lupus nephritis represents the most common cause of the secondary renal disease (8.4%). Complications of kidney biopsy were observed in only 16.3% of patients, of whom 9.9% had perirenal hematomas and 6.4% of the patients developed either microscopic hematuria or macroscopic hematuria.
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Predictors of renal outcomes in anti-neutrophil cytoplasmic antibody glomerulonephritis p. 182
Hela Jebali, Meriem Khadhar, Ikram Mami, Soumaya Beji, Meriem Sellami, Mohaned Hassen, Fethi Ben Hmida, Mohamed Chermiti, Hiba Ghabi, Thouraya Ben Salem, Hbib Houman, Lamia Raies, Mohamed Karim Zouaghi
DOI:10.4103/1319-2442.279939  PMID:32129212
Glomerulonephritis associated with anti-neutrophil cytoplasmic antibody (ANCA) vasculitis still has a high prevalence of end-stage renal disease (ESRD), particularly in patients with advanced renal failure at presentation. This study aims to evaluate the clinical and histo- pathological features of renal involvement and investigate factors associated with ESRD. Patients with renal biopsy-proven ANCA-associated glomerulonephritis were included retrospectively over a period of nine years (June 2007 to March 2016). The renal survival, defined as time to reach ESRD, was evaluated based on clinical parameters, histopathological classification, and renal risk score. A total of 37 patients with crescentic glomerulonephritis were included in the study. The average age was 54 ± 16 years (range: 17-80) and 51.3% were female. Twenty-two patients were diagnosed with microscopic polyangiitis and 15 had granulomatosis with polyangiitis. The median glomerular filtration rate at presentation was 16.73 mL/min/1.73 m2. Thirty-five patients (94.5%) had renal failure at presentation and 23 patients (62.1%) required initial hemodialysis (HD) therapy. The pattern of glomerular injury was categorized as sclerotic in 48.6% of cases, crescentic in 24.3%, mixed in 24.3%, and focal class in 2.7%. Regarding renal risk score, we had five patients with low risk, 17 with intermediate risk and 15 with high risk. ESRD occurred in 47% of intermediate-risk group and 66% of the high risk group. During follow-up, 17 patients (45.9%) developed ESRD. Tobacco addiction (P = 0.02), alveolar hemorrhage (P = 0.04), hypertension (P = 0.04), initial HD (P = 0.04), and sclerotic class (P = 0.004) were associated with ESRD. In our patients, a sclerotic class was associated with a higher risk of ESRD, suggesting that histo- pathological classification is potentially an important parameter to predict outcomes in renal disease secondary to ANCA-associated vasculitis.
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RENAL DATA FROM THE ARAB WORLD Top

Diabetic kidney disease in patients newly diagnosed with type-2 diabetes mellitus: Incidence and associations p. 191
Mohamed Sabry Aboelnasr, Ahmed Kotb Shaltout, Mabrouk Ramadan AlSheikh, Amal Helmy Abdelhameed, Waleed Elrefaey
DOI:10.4103/1319-2442.279940  PMID:32129213
The global prevalence of type 2 diabetes mellitus (DM) in adults is increasing all over the world. Diabetic kidney disease (DKD) is one of the most common complications of DM. The aim of the present work is to study chronic kidney disease (CKD) in patients newly diagnosed with type 2 DM as regards incidence and associations. This is a comparative cross-sectional study. The study included 153 patients with newly diagnosed type 2 DM over the past six months. DKD was diagnosed if urinary albumin to creatinine ratio >30 mg/g in two out of three-morning urine samples collected within three to six months and/or estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 using 2009 CKD-Epidemiology Collaboration creatinine equation. DKD was present in 45.75% of patients. In our study, 54.9% of patients had microalbuminuria, 39.2% had macroalbuminuria, and 5.9% had severely increased albuminuria. As regards eGFR, 5.2% of patients had eGFR <60 mL/min/1.73 m2. Regression analysis showed that increased levels of cholesterol, triglyceride, and glycated hemoglobin were associated with an increased likelihood of developing nephropathy while nonsmoking and elevated high-density lipoprotein cholesterol levels were associated with a reduction in that likelihood. DKD was present in a substantial proportion of our patients at diagnosis. Routine screening for DKD is recommended in all patients early at the onset itself of diagnosis with type 2 DM.
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Incidence, risk factors and causative bacteria of urinary tract infections and their antimicrobial sensitivity patterns in toddlers and children: A report from two tertiary care hospitals p. 200
Ezzat K Amin, Ali M Abo Zaid, Abd El Rahman I. Kotb, Mohamed A El-Gamasy
DOI:10.4103/1319-2442.279941  PMID:32129214
Urinary tract infection (UTI) is one of the most common bacterial infections among children. It is noted that the risk of renal damage from UTI is the greatest in children younger than five years, thus early diagnosis and prompt treatment are important. The aim of this study was to assess the incidence of UTI in children attending pediatric outpatient clinics in Zagazig and Tanta University Hospitals as tertiary care hospitals. Furthermore, we attempted to determine related risk factors, isolate the organisms that cause UTI in children, and study their antibiotic susceptibility patterns. This cross-sectional descriptive study was conducted on 1200 toddlers and children, (754 boys and 446 girls) aged between 30 months and seven years attending the pediatric outpatient clinics of Zagazig and Tanta University Hospitals. All patient groups were subjected to full medical history, physical examination, dipstick analysis by using both nitrite and leukocyte esterase (LE) detectors, microscopic examinations, and urine culture for cases with the positive LE, positive nitrite dipstick test for urine or positive for both LE and nitrite. The incidence of UTI among children included in the current study was 7%. Positive LE was seen in 112 (9.3%), nitrite positivity was seen in 94 (7.8%), and both LE and nitrite positivity in 34 (2.8%). Escherichia coli was the most common organism. Cefotaxime and amikacin were the most common sensitive antibiotics to the isolates.
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RENAL DATA FROM ASIA–AFRICA Top

Cost implication of inpatient care of chronic kidney disease patients in a tertiary hospital in Southwest Nigeria p. 209
Oluseyi A Adejumo, Akinkunmi A Akinbodewa, Adeyemi Ogunleye, Adenike C Enikuomehin, Olutoyin M Lawal
DOI:10.4103/1319-2442.279942  PMID:32129215
The financial cost of inpatient care of chronic kidney disease (CKD) patients has not been well described in Nigeria; even though, the majority of these patients require inpatient care at the time of diagnosis due to late presentation. This study determined the cost implication of inpatient care among CKD patients in a Kidney Care Center in South-west Nigeria. This was an 18-month descriptive retrospective study. The financial records of the ward, laboratory, dialysis, pharmacy, and dietary services were obtained for each patient during their hospital stay and the sum of these costs was taken as the total direct cost of care. One hundred and twenty- three CKD patients with a male:female ratio of 2.3:1 and mean age of 50 ± 17 years were studied. One hundred and six (86.2%) patients had Stage 5 CKD, 105 (85.4%) had emergency hemodialysis (HD) at presentation and all patients paid out of pocket. The median number of HD sessions and days spent on admission was 4 and 14 days, respectively. The major contributors to the cost of care were total dialysis, ward, and pharmacy expenses with a median total cost of ₦70,000 (US $200), ₦28,000 ($80), and ₦22,230 ($66), respectively. The median total direct cost of inpatient care of CKD was ₦150,770 ($431). The cost of care was higher in those with Stage 5 CKD and diabetic nephropathy. The cost of inpatient care of CKD is beyond the reach of most Nigerians. There is a definite need for the government to include CKD care under the national insurance scheme.
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Intradialytic hypotension and associated factors among patients on maintenance hemodialysis: A single-center study in cameroon p. 215
Marie Patrice Halle, Djantio Hilaire, Kaze F Francois, Teuwafeu Denis, Fouda Hermine, Ashuntantang E Gloria
DOI:10.4103/1319-2442.279944  PMID:32129216
Intradialytic hypotension (IDH), one of the most frequent acute complications of hemodialysis (HD), is associated with increased patient’s morbidity and mortality. The aim of this study was to determine its prevalence and associated factors among patients on maintenance HD in Cameroon. This was a prospective longitudinal study carried out from June 20, to July 30, 2016 (5 weeks), including adult patients on HD >3 months at a tertiary hospital in Douala. During this period, patients were followed up at each HD session, and their blood pressure and occurrence of clinical events possibly related to IDH were recorded. In this study, IDH was defined as a decrease in systolic BP by >20 mm Hg or a decrease in mean arterial pressure by >10 mm Hg, associated to a clinical event. Logistic regression analysis was used to determine associated factors. We included 104 patients (69 males) with a mean age of 50.74 ± 15.18 years and a median duration on HD of 30.5 (interquartile range: 12.25-58.75) years. Hypertension 99/104 (95.2%) and diabetes 32/104 (30.8%) were the main comorbidities encountered. A total of 1032 HD sessions were followed up with an average of 9.88 ± 1.57 sessions per patient. IDH occurred in 11.6% of HD sessions. Associated factors were age, female sex, HIV infection, feeding during dialysis, and use of antihypertensive drug during or within 2 h before dialysis. The prevalence of IDH in our study was low. Associated factors were mainly related to patient’s characteristics and comorbidities.
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Clinical spectrum of community-acquired acute kidney injury: A prospective study from central India p. 224
Shraddha Goswami, Bhavani M Raju, Ashish Purohit, Naresh Pahwa
DOI:10.4103/1319-2442.279945  PMID:32129217
The aim is to study the epidemiology of acute kidney injury (AKI), since it differs from country to country and varies from center to center within a country. Owing to the absence of a central registry, data on overall epidemiology of AKI are scanty from India. This study was conducted in an urban tertiary care center in central India with the aim to identify the etiology and outcomes as well as the factors associated with in-hospital mortality of community-acquired AKI (CAAKI) patients. A two-year prospective study of all patients with CAAKI admitted to the Nephrology Department from January 2014 to December 2015 was performed. Of the 9800 admitted patients, 286 patients (2.9%), with a mean age of 48 ± 17.1 years, were diagnosed to have CAAKI as per our specified criteria. The most common cause of CAAKI was medical (77.27%), followed by obstetrical (13.98%) and surgical (9%) causes. Among the medical causes, hypoperfusion (57.4%) was the most common, followed by sepsis (26.69%), glomerulonephritis (8.14%), and drugs (7%). Nephrolithiasis was the most common surgical cause. Puerperal sepsis (52.5%), preeclampsia (20%), hemorrhage (17.5%), and thrombotic microangiopathy (10%) were the obstetric causes of CAAKI. The overall in-hospital mortality among patients with CAAKI was 20% and 8% of patients became dialysis dependent. Sepsis had the highest in-hospital mortality (44%). The epidemiological characteristics of CAAKI are changing rapidly. There has been an increase in the overall incidence of AKI with changing etiology in recent years. In contrast to developed nations, CAAKI is more common in developing countries. It often affects younger individuals. For early diagnosis of kidney injury and reducing the risk of poor outcome, patients should be referred to nephrologists early in the course of disease.
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Acute kidney injury in pediatric patients with malaria: A prospective cross-sectional study in the shai-osudoku district of Ghana p. 235
Richard K D. Ephraim, Prince Adoba, Samuel A Sakyi, Josephine Aporeigah, Linda A Fondjo, Felix A Botchway, Rebecca P Storph, Emmanuel Toboh
DOI:10.4103/1319-2442.279946  PMID:32129218
Acute kidney injury (AKI) is a highly fatal complication of malaria. We used the Kidney Disease Improving Global Outcomes (KDIGO) and Pediatric Risk, Injury, Failure, Loss, End-Stage Kidney Disease (pRIFLE) guidelines to assess AKI among children. One hundred children with Plasmodium falciparum malaria were recruited from the St. Andrew’s Catholic Hospital. Admission and 48-h serum creatinine were estimated. Weight and height of the participants were measured, and AKI status determined with the KDIGO and pRIFLE guidelines. A questionnaire was used to collect the socio-demographic and clinical data of participants. Two percent and 5% of the participants had AKI according to the KDIGO and pRIFLE criteria, respectively. Per the KDIGO guidelines, 1% of the participants had Stage 2 and 1% also had Stage 3 AKI. Four percent had Stage 1 (risk) and 1% had Stage 2 (injury) AKI per the pRIFLE criteria. Participants with AKI were dehydrated, and neither had sepsis or on antibiotics when the KDIGO guideline was used. Participants who had AKI were dehydrated, with 80% having sepsis and 40% on antibiotics when the pRIFLE criteria were used. There was no association between the KDIGO and pRIFLE criteria with respect to AKI status of participants (k = -0.029, P = 0.743). Two percent and 5% of the study participants had AKI when the KDIGO and pRIFLE guidelines were used respectively. One percent of the participants had Stage 2 and 1% also had Stage 3 AKI per KDIGO; 4% had Stage 1 (risk) and 1% had Stage 2 (injury) AKI per the pRIFLE.
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Deceased donor organ transplantation potential: A peep into an untapped gold mine p. 245
Ademola Alabi Popoola, Benjamin Olusomi Bolaji, Timothy Olusegun Olanrewaju, Tajudeen Olalekan Ajiboye
DOI:10.4103/1319-2442.279947  PMID:32129219
Organ transplantation is the gold standard for treating end-stage organ diseases, many of whom are on waiting lists. The reasons for this include the nonavailability of suitable organs to be transplanted. In many nations, most of these challenges have been surmounted by the adoption of deceased donor program, which is not so in sub-Saharan countries such as Nigeria. This study is to audit the potentially transplantable organs available from potential deceased donors from a Nigerian tertiary hospital. This is a study of deaths in the intensive care unit (ICU) and the accident and emergency units of the University of Ilorin Teaching Hospital, Nigeria. Data included the biodata, social history, diagnosis or indications for admission, time of arrival and death, causes of death, associated comorbidities, potential organs available, social history, and availability of relations at the time of death. There were 104 deaths in the ICU and 10 patients in the accident and emergency unit. There were 66 males (57.9%) and 48 females (42.1%). Eighty patients were Muslims (70.2%) and 34 were Christians (19.8%). A total of 33 participants were unmarried (28.9%),whereas 81 (71.1%) were married. The tribes of the patients were Yoruba (105, 92.1%), Igbo (7, 6.1%), Hausa (1, 0.9%), and Nupe (1, 0.9%). The age range was 0.08-85 years. Twenty-two (19.3%) had primary and the remaining had at least secondary education. The causes of death were myriad, and there were relatives available at the times of all deaths. The Maastricht classification of the deaths were Class I - 1 (0.9%), Class II - 37 (32.2%), Class III - 9 (7.8%), Class IV - 20 (17.4%), and Class V - 47(40.9%). There were no transplantable organs in 42 (36.5%), one organ in eight (7%), two organs in two (7%), three organs in one (0.9%), four organs in 13 (11.3%), five organs in six (5.2%), six organs in 11 (9.6%), seven organs in 11 (9.6%), eight organs in five (13%), and nine organs in five (4.3%). Deceased donor sources of organs are worthy of being exploited to improve organ transplantation in Nigeria.
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SPECIAL ARTICLE Top

Neurocysticercosis p. 254
Tayyaba Siddiqua, Ayesha Habeeb
DOI:10.4103/1319-2442.279948  PMID:32129220
Neurocysticercosis (NCC) is one of the common parasitic central nervous system (CNS) infections. Improperly cooked pork and eggs of the tapeworm Taenia solium, entering the body through the feco-oral route, are the common sources of its infection. Affected person may remain asymptomatic for long periods and can present with a variety of neurological manifestations, including focal neurological deficits and generalized seizures. Neuroimaging along with serological test can aid in its diagnosis. Treatment of NCC varies from case to case and must always be individualized based on the patients’ condition. Common therapeutic strategies include surgery and treatment with drugs, such as antiparasitic agents (albendazole) and corticosteroids (hydrocortisone), apart from other agents which are based on the patient presentation. Proper prevention strategy has to be followed to control the spread of infection within and among the individuals. We herewith present a case of NCC in a tertiary care hospital of Hyderabad, India.
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CASE REPORTS Top

Persistent hypokalemia due to a rare mutation in gitelman's syndrome p. 259
Dimitrios Mamalis, Theodora Stratigou, Natalia G Vallianou, Georgios G Ioannidis, Theofanis Apostolou
DOI:10.4103/1319-2442.279949  PMID:32129221
Chronic hypokalemia is the main finding in patients with Gitelman’s syndrome (GS). GS, a variant of Bartter’s syndrome, is an autosomal recessive renal disorder characterized by hypokalemia, hypomagnesemia, metabolic alkalosis, and hypocalciuria. GS is caused by inactivating mutations in the thiazide-sensitive sodium-chloride cotransporter gene. It is also called the “milder” form of Bartter’s syndrome, as patients with GS are usually diagnosed in adulthood during routine investigation. Our objective is to highlight the impact of correct distinction between the causes of hypokalemia on management and the need of long-term follow- up after the restoration of normokalemic status. Herein, we report an asymptomatic 40-year-old male, whose persistent hypokalemia was due to GS. The diagnosis was first established by laboratory tests, and he was treated with low-dose aldosterone antagonists (spironolactone), angiotensin-converting enzyme inhibitors, and potassium and magnesium supplements. Genetic testing confirmed the diagnosis of GS and revealed a rare mutation. We conclude that GS is a rare and real diagnostic and therapeutic challenge, for which a close collaboration between endocrinologists and nephrologists is mandatory, as also the thorough genetic investigation of the mutations associated with this syndrome.
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Intrathoracic kidney within bochdalek hernia: A diagnosis of high index suspicion p. 263
Bhoopat Singh Bhati, Dipen Patel
DOI:10.4103/1319-2442.279950  PMID:32129222
Intrathoracic kidney is a rare developmental anomaly representing <5% of all ectopic kidneys. Here, we present a case of a 60-year-old woman who presented with nonspecific abdominal pain for two years, on and off in nature. She was investigated and found to have intrathoracic kidney within Bochdalek hernia. The idea of presenting the case is to have familiarity with this rare condition and keep a high index of suspicion to diagnose the same.
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Calcified renal artery aneurism in the right kidney causing hypertension p. 266
Neslihan Gunay, Ayşe Seda Pınarbaşı, İsmail Dursun, Aydın Tunçay, Deniz Demirci, Güven Kahriman, Ruhan Düşünsel
DOI:10.4103/1319-2442.279951  PMID:32129223
The renal artery aneurysm (RAA) is defined as a renal artery segment that is twofold dilated than normally. It is very rare in children and often asymptomatic. However, it can cause severe hypertension (HTN) and kidney failure. Herein, we report a 14-year-old boy who with RAA which was presented with back pain. His medical history was remarkable for essential HTN that was refractory to antihypertensive medications. Plain abdominal radiography revealed calcification at the right flank area. On computed tomography images, calcification surrounding the right renal artery was detected. Selective renal angiography showed totally occluded right renal artery segment. Calcified RAA was detected on the operation and removed. Two months after, blood pressure was under control, but there was no functioning right kidney on DMSA. We think that clinicians should keep in mind RAA in the differential diagnosis of treatment-resistant HTN and use other radiologic methods even if Doppler is normal.
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De novo chromophobe renal cell carcinoma in the graft three decades after renal transplantation in a patient with a history of three renal transplants p. 271
Mohamed H Zahran, Mohamed A Soltan, Ahmed I Kamal, Mona Abdelrahim, Islam Fakhreldin, Yasser Osman, Bedeir Ali-El-Dein
DOI:10.4103/1319-2442.279952  PMID:32129224
De novo renal allograft tumors were reported sporadically. Most of them were small, low-grade, and papillary renal cell carcinoma (RCC) type. A 46-year-old male presented with hematuria three decades after the first transplant. The patient had a history of three renal transplants. A tumor (12 cm × 13 cm) was diagnosed in the nonfunctioning first transplanted kidney. Radical nephrectomy of the graft harboring the tumor with preservation of the adjacent functioning graft was done and identified to be chromophobe RCC. After two-year follow-up, the patients had a perfect graft function with no evidence of oncological failure. We suggest that allograft tumor be considered in patient evaluation for hematuria. Regular follow-up imaging of transplanted kidney is mandatory even after graft failure for early detection of graft tumors.
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Plasmapheresis in a case of acute kidney injury with severe hemolysis and thrombocytopenia due to hematotoxic (Russell's viper) snake bite p. 276
Puneet Arora, Shantanu Belwal, Bhupesh Uniyal, Sanjay Saxena
DOI:10.4103/1319-2442.279953  PMID:32129225
We present a case of a male patient after being bitten by a vasculotoxic snake (Russell’s viper) with severe hemolysis, thrombocytopenia, and acute kidney injury requiring hemodialysis. As attempt to administer anti-snake venom (ASV) failed because of development of anaphylactic reaction, a single session of plasmapheresis was done to stop hemolysis and fall in platelets, which was refractory to all other measures and proved to be a lifesaving procedure in this patient. The role of plasmapheresis in the management of snakebite victims is yet to be established, but can be beneficial in snake bite victims refractory to ASV or nonavailability of ASV or intolerant to ASV as in this case.
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De novo isolated gastrointestinal tract vasculitis without associated systemic disease in renal transplant recipients successfully treated with rituximab p. 281
Cigdem Mengus, Sultan Ozkurt, Erkin Oztas, Nazife Sule Yasar Bilge, Serap Isiksoy, Ahmet Ugur Yalcin
DOI:10.4103/1319-2442.279954  PMID:32129226
Systemic vasculitic diseases can show recurrence after kidney transplantation, but de novo systemic vasculitis is rarely seen after kidney transplantation, and in literature, there are only a few cases. In general population, the incidence of isolated organ vasculitis is unknown, and according to the best of our knowledge, there is no information about de novo isolated organ vasculitis after renal transplantation. We report, most probably, the first case of a 40-year-old woman who was restarted on dialysis treatment after renal transplantation and developed isolated gastrointestinal vasculitis and intestinal hemorrhage under immunosuppressive treatment. She was treated successfully with rituximab.
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Lowe syndrome – Case report with a novel mutation in the oculocerebrorenal gene p. 285
Suman Sethi, Nitin Sethi, Sudhir Mehta, Simran Kaur, Vikas Makkar, PM Sohal
DOI:10.4103/1319-2442.279955  PMID:32129227
The oculocerebrorenal (OCRL) syndrome, also known as Lowe syndrome (LS), is an X-linked recessive disorder that predominantly affects males and is characterized by growth and mental retardation, congenital cataract and renal Fanconi syndrome. OCRL1 is the gene responsible for LS and encodes an inositol polyphosphate-5-phosphatase. We report a male child from North India, with LS with missense mutation in exon 14 of the OCRL gene.
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Red herrings in crossmatching kidneys for transplant p. 289
Asif Wani, Anupma Kaul, Dharmendra Singh Bhaduaria, Zafirah Zahir, Narayan Prasad, Amit Gupta, Raj Kumar Sharma
DOI:10.4103/1319-2442.279956  PMID:32129228
Crossmatching of prospective renal transplant donors against recipients is a mandatory component of the transplant workup, being performed for over 40 years now. Allografting patients with human leukocyte antigens which are recognized by preformed antibodies constitutes the main cause of hyperacute or acute rejections. The existence of these donor-specific anti-human leukocyte antigen antibodies (DSAs) is regarded as a contraindication for graft trans-plantation, both cadaveric and live kidney. We present two unusual cases in which both complement-dependent cytotoxicity crossmatch and DSA by Luminex were falsely positive due to autoimmune and infectious causes, but single-antigen bead assay showed these antibodies to be against nondonor antigens. After treating their basic disease, thought to be responsible for false-positive DSA, these patients became DSA negative and underwent transplantation with an uneventful posttransplant period. Our aim through these examples is to highlight the problem of false-positive crossmatch in potential renal allograft transplant recipients. Further, we propose antigenic determination of donor-specific antibodies in such patients where we suspect the immune system to be chronically activated to pick up false-positive cases and therefore increase the donor pool without compromising the transplant outcome.
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Acute kidney injury among thai pediatric patients with dengue shock syndrome: A re-estimation p. 294
Beuy Joob, Viroj Wiwnaitkit
DOI:10.4103/1319-2442.279957  PMID:32129229
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Reducing suicidal ideation in hemodialysis patients treated in Urmia, Iran p. 296
Nader Aghakhani, Rahim Baghaei
DOI:10.4103/1319-2442.279958  PMID:32129230
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