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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
Coverpage
May-June 2017
Volume 28 | Issue 3
Page Nos. 477-684

Online since Thursday, May 18, 2017

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ORIGINAL ARTICLES  

Carnitine reduced erythropoietin dose required and improved cardiac function of patients on maintenance hemodialysis Highly accessed article p. 477
Yosuke Aoki, Takako Yamamoto
DOI:10.4103/1319-2442.206445  
Intravenous administration of 2 g carnitine in every hemodialysis (3 times/week), for 8–10 months, reduced doses of darbepoetin alfa required to maintain adequate hemoglobin levels (10–11 g/dL) into 10% of the initial doses. There was also a significant increase in plasma transferrin saturation, increase in left ventricular ejection fraction, and decrease in plasma brain natriuretic peptides.
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The relationship between serum homocysteine and highly sensitive C- reactive protein levels in children on regular hemodialysis p. 483
Manal Abdel-Salam, Soheir Ibrahim, Shaimaa Abdelmalik Pessar, Eman Al-morsy
DOI:10.4103/1319-2442.206442  
Hyperhomocysteinemia has attracted a lot of attention in renal patients, not only because of its close relationship with renal function but also because it has been implicated as an independent cardiovascular risk factor in these patients. An increased level of C-reactive protein (CRP) has been reported to be a strong predictor of cardiovascular mortality in hemodialysis (HD) patients. The aim of this study was to assess the association between homocysteine (Hcy) and highly sensitive CRP (hsCRP) in cardiovascular risk prediction in children with chronic kidney disease (CKD) on HD. This case-control study was conducted on 40 children with CKD on regular HD and 20 age- and sex-matched healthy children as controls. Their ages ranged from 4 to 18 years, and they were selected from the pediatric nephrology and HD unit at Al-Azhar University Hospital, during the period from May 2015 to April 2016. Complete blood count, serum ferritin, cholesterol, triglycerides, calcium, phosphorus, parathormone (PTH), Hcy, and hsCRP levels were measured in both groups. Measurements of anthropometry and blood pressure (BP) were performed. There was a significant increase in serum Hcy levels in cases than controls; it was 17.22 ± 9.66 pmol/L and 6.32 ± 1.47 pmol/L, respectively (P <0.01). Furthermore, there was a significant increase in hsCRP in patients than controls; 2.73 ± 2.65 and 0.9 ± 0.85, respectively (P <0.01). There was a significant positive correlation between hsCRP and Hcy with BP, cholesterol, triglyceride, PTH, and ferritin levels. Our data highlighted the important correlation between serum Hcy and hsCRP to detect high-risk patients for subsequent cardiovascular disease and utility of preventive strategies that attenuate inflammatory risk.
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Effect of fluorescein angiography on renal functions in type 2 diabetes patients: A pilot study Highly accessed article p. 491
Waleed H Almalki, Ashraf Nabiel Abdalla, Ahmed F Elkeraie, Ahmed M Abdelhadi, Mahmoud Elrggal, Mohamed E Elrggal
DOI:10.4103/1319-2442.206444  
Fluorescein angiography (FA) is an important tool for the diagnosis and management of diabetic retinopathy. However, the safety of fluorescein sodium on renal functions is not fully understood. One hundred type 2 diabetes patients, within the Ophthalmology Outpatient Clinic at Alexandria Main University Hospital, Egypt, were enrolled in this prospective observational study to determine the safety of FA on renal function. Serum creatinine and cystatin C were measured pre- and 2 days post-FA. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) was measured pre- and 4 hours post-FA. Renal injury was defined as a 25% increase in serum creatinine, cystatin C, or uNGAL. The study included 71 females and 29 males, with a mean age of 55.73 ± 7.29 years. Baseline serum cystatin C and uNGAL were 0.89 ± 0.34 mg/L and 21.7 ± 2.39 ng/mL, respectively. Serum cystatin C and uNGAL significantly increased after FA to 0.95 ± 0.36 and 27 ± 2.81, respectively (P <0.001). Eleven patients (11%) experienced more than a 25% rise in serum cystatin C from baseline, whereas 40 patients (40%) experienced more than a 25% increase in uNGAL levels after FA. However, the mean serum creatinine level did not change significantly after FA (P = 0.061). Only one patient experienced more than a 25% rise in serum creatinine from baseline. FA showed a significant increase in early sensitive acute kidney injury biomarkers (as serum cystatin C and uNGAL) in substantial number of patients, suggesting but still not proving, a potential harmful effect of FA on kidney functions. These findings were not demonstrated using ordinary serum creatinine.
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Outcome of recipients of human leukocyte antigen incompatible kidney transplants who underwent desensitization at King Fahad Specialist Hospital, Dammam, Saudi Arabia p. 499
Mohammed Abdulrahim Idris, Akhtar Hossain, Mohammed Abdulrahman Muntasir, Adnan Marmi, Ahmed Abdulfattah Aldajani, Yousef Mohammed Aljamaan, Mahmood Akhtar, Abdulrahman Housawi
DOI:10.4103/1319-2442.206447  
In patients whom are highly sensitized immunologically, the benefit of kidney transplantation can be extended to this population through the utilization of organs from human leukocyte antigen incompatible (HLAi) donors. This retrospective observational study was designed to identify the incidence and predictors of acute antibody-mediated rejection/acute cellular rejection (AMR/ACR) in our kidney recipients from living kidney donors (sensitized and those with low immunologic risk). This single-center study has been conducted at King Fahad Specialist Hospital, Dammam (KFSH-D), Saudi Arabia; during the period of September 2008- August 2013. All eligible recipients of living donor kidneys during the study period were included (n = 213) in the study. Over 60% of patients in the study were females. Thirty of the 213 kidneys were from HLAi donors. During the follow-up period (median follow-up time = 16 months; 3–27 months), the incidence rate of ACR among HLA compatible (HLAc) and HLAi groups was 22.2% and 16.7%, respectively (P >0.05). The incidence rate of AMR was 2.6% in HLAc group and 16.7%in the HLAi group (P<0.05). The significantly higher incidence of AMR in HLAi group can be explained by the presence of the donor-specific antibodies in weak titers. These results are consistent with studies from similar populations in published literature. However, the relatively small number and short duration of the study are considered, and longer follow-up of this population will be needed for conclusions on the sustainability of our findings.
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Effect of hemodialysis on oxidants and antioxidant factors in chronic renal failure p. 507
Ramin Tajbakhsh, Mostafa Qorbani, Golbarg Mehrpour, Mitra Rahimzadeh, Mohammad Mehdi Azimzadeh, Hossein Mirmiranpour
DOI:10.4103/1319-2442.206446  
The current study was conducted to assess the effect of hemodialysis (HD) on the status of plasma oxidants and antioxidants among patients with end-stage renal disease (ESRD). These parameters can have an influence on the HD process and can also be useful for follow-up of these patients. The participants of this cross-sectional study comprised 91 patients with a mean age of 51.1 ± 8.2 years on chronic HD with kt/v between 1.2 and 1.4. The etiology of ESRD in these patients was as follows: diabetes mellitus in 39, hypertension in 35, and glomerulonephritis in 17 patients. All patients were on maintenance treatment with phosphate binder, 1,25 Vitamin D, iron, and erythropoietin therapy as per the K/DOQI guidelines. They were selected by random method from Shahid Bahonar Hospital, Karaj, Iran. The height, weight, waist circumference (WC), and blood pressure were measured according to standardized protocols, and blood samples were obtained before and after HD. Blood samples were checked for advanced glycation end products, advanced oxidation protein product, malondialdehyde (MDA), oxidized low-density lipoprotein (ox-LDL), and ferritin reducing ability of plasma, catalase, glutathione peroxidase (GPx), superoxide dismutase (SOD), and blood urea nitrogen (BUN). The means of MDA, BUN, advanced glycation end product (AGE), and ox-LDL plasma level postdialysis significantly decreased compared to the predialysis level. The mean of plasma catalase, GPx, and SOD increased significantly postdialysis compared to the predia- lysis level in these patients. Factors including age, body mass index, WC, and diastolic blood pressure affected changes in levels of oxidants and antioxidants after HD. Our study results revealed that the status of antioxidants and oxidants tends to improve after HD.
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Evaluation of medication use in Malaysian predialysis patients Highly accessed article p. 517
Muhammad Salman, Amer Hayat Khan, Azreen Syazril Adnan, Syed Azhar Syed Sulaiman, Naureen Shehzadi, Nauman Asif, Khalid Hussain, Fahad Saleem, Muhammed Hussnain Raza, Muhammad Shahid Farooq
DOI:10.4103/1319-2442.206451  
Chronic kidney disease (CKD) patients suffer from multiple comorbidities and complications as a cause or consequence of kidney disease. Information regarding medication- prescribing patterns in predialysis patients is sparse. We conducted a retrospective study to evaluate the medication prescription patterns among predialysis patients. Medical records (both paper based and computerized) of patients at CKD Resource Centre, Hospital Universiti Sains Malaysia, were reviewed. A total of 615 eligible cases were included in the study. The mean number of medications prescribed per patient was 8.22 ± 2.81, and medication use was correlated to the renal function (stage 3a < stage 3b < stage 4 < stage 5; P <0.001). The top three prescribed medication groups were found to be lipid-lowering agents, calcium channel blockers, and antiplatelet agents. Some medication classes such as nonaluminum/noncalcium phosphate binders, erythropoietin-stimulating agents, and renin-angiotensin-aldosterone system blockers, particularly in advanced stage, were found to be underutilized. In conclusion, predialysis patients are prescribed a large number of medications. Our findings highlight the need for assessing the impact of current medication-prescribing patterns on morbidity and mortality rates in Malaysian predialysis population.
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Assessment of renal function in Indian patients with sickle cell disease p. 524
Bhaskar V. K. S. Lakkakula, Henu Kumar Verma, Mona Choubey, Suneeta Patra, Prafukka Kumar Khodiar, Pradeep Kumar Patra
DOI:10.4103/1319-2442.206440  
Sickle cell disease (SCD) and its variants are genetic disorders resulting from the presence of a mutated form of hemoglobin. Renal disease is one of the most frequent complications, and kidney damage starts very early and progresses throughout life causing severe complications. The present study is aimed to analyze creatinine-based estimated glomerular filtration rate (eGFR) in 616 SCD patients (507 HbSS and 109 HbSB+), receiving medical care at outpatient wing of Sickle Cell Institute, Chhattisgarh. Glomerular filtration rate (GFR) estimated using the Modification of Diet in Renal Disease (MDRD), Cockcroft-Gault, chronic kidney disease epidemiology collaboration (CKD-EPI) (<17 years analyzed with Schwartz), and SCD specific Jamaica Sickle Cell Cohort Study (JSCCS)-GFR equations were compared. Further, eGFR calculated using the CKD-EPI and Schwartz equations was used to define various stages of kidney function and compared with clinical and hematological variables. The mean age of patients was 15.8 years. Comparison of eGFR using various formulas revealed that MDRD and JSCCS formulas overestimated the GFR. Among SCD patients, prevalence of glomerular hyperfiltration (GHF) is high followed by renal insufficiency (RI) and renal failure (RF). However, no differences were found in hematological profiling among different functional stages of kidney. Age and body surface area are significantly more in SCD individuals with normal kidney function and GHF. Participants with RF showed a higher level of blood urea and fetal hemoglobin. In summary, this is the first study to analyze different functional stages of kidney among SCD patients of India. Our study revealed that the GHF and RI are the important indicators of kidney damage.
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Patterns of glomerulonephritis with crescents: Experience at a tertiary medical center in Saudi Arabia p. 532
Turki Al-Hussain, Shuaa Asiri, Sadiq Amer, Hadeel Al Mana, Mohammed Akhtar
DOI:10.4103/1319-2442.206448  
A series of 78 cases of glomerulonephritis (GN), in which renal biopsy revealed changes of GN associated with crescent formation, were reviewed. Renal pathology findings were correlated with clinical features including patient’s age, renal function, and serologic findings. In most of the cases (71.8%), the crescents were due to immune complex-mediated GN. This was followed by pauci-immune GN (20.5%) and anti-glomerular basement membrane antibody (GBM) GN (7.7%). The percentage of glomeruli with crescents was the highest in cases of anti-GBM disease (mean of 93.3%), followed by pauci-immune GBM (mean of 48.2%) and immune complex GN (30.9%). In cases with the pauci- immune GN, there were additional features of glomerular injury including fibrinoid necrosis, disruption of the GBM, and rupture of Bowman’s capsule. These changes were generally more pronounced in a subset of pauci-immune GN associated with serum elevation of antineutrophil cytoplasmic antibody (c-ANCA). In biopsies from patient with immune complex disease, systemic lupus erythematosus was the most common cause of crescentic GN.
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Prevalence of osteoporosis in patients with chronic kidney disease (stages 3–5) in comparison with age- and sex-matched controls: A study from Kashmir Valley Tertiary Care Center p. 538
M Saleem Najar, Mohamad Muzzafer Mir, Mudasir Muzamil
DOI:10.4103/1319-2442.206439  
Chronic kidney disease (CKD) is associated with a range of metabolic bone diseases. Fracture rates are higher in CKD patients than age-matched controls throughout all the five stages of CKD. Dialysis patients have 4 times as many hip fractures as expected for their age. CKD forms an independent risk factor for osteoporosis, even in the absence of traditional risk factors. This study was carried out at the nephrology unit in a tertiary care center of Kashmir to know the prevalence of osteoporosis in CKD patients having glomerular filtration rate (GFR) <60 mL/min (stages 3–5). Among the 151 cases studied, the average estimated GFR was 16.78 ± 10.714 mL/min. There were 98 males (64.9%) and 53 females (35.1%). Their mean age was 51.01 ± 14.138 years. Osteoporosis based on femoral neck T-Score was seen in 31 patients (31.6%) while 43 patients (28.5%) had osteoporosis at L1, L2 lumbar vertebrae. The prevalence of osteoporosis based on femoral neck T-Score as well as osteopenia was highest in stage-5 CKD. In our study, the body mass index (BMI) had a positive correlation with osteoporosis; low BMI patients were at higher risk for osteoporosis (P = 0.014). In the Kashmir valley, the prevalence of osteoporosis was 31.8% in CKD patients against 22% in controls. Thus, CKD forms an important risk factor for osteoporosis even in the absence of traditional risk factors. We recommend early screening, detection, and management of osteoporosis to reduce the burden of morbidity and mortality in this subset of patients.
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Chronic renal failure: An autopsy study p. 545
Anitha Padmanabhan, Sanjay Gohil, NM Gadgil, Prerna Sachdeva
DOI:10.4103/1319-2442.206441  
Diabetes and hypertension are at present the major causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) worldwide. The stages 0–5 of CKD are defined according to the estimated glomerular filtration rate. The term chronic renal failure (CRF) typically corresponds to CKD stages 3–5. Cardiovascular disease is the main cause of morbidity and mortality in patients of CRF and ESRD. This study was undertaken to analyze the age and sex incidence, clinical features, etiology, pathology of various organs in detail, and causes of death of CRF patients. All autopsies performed on known cases of CRF and those who were diagnosed as CRF at autopsy at a tertiary care hospital in India over a 7-year period were studied. The highest number of cases of CRF fell within the 56–65 years age group with a male/female ratio of 1.38:1. Oliguria and anasarca were the most common presenting features. Chronic pyelonephritis was the most common cause of CRF in our study, followed by hypertension, diabetes, and chronic glomerulonephritis. Other causes included amyloidosis, autosomal poly- cystic kidney disease, and ischemic and multiple myeloma. Most common cause of death found was cardiovascular, followed by infections, cerebrovascular, metabolic, and other causes.
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BRIEF COMMUNICATIONS Top

Aldosterone synthase gene is not a major susceptibility gene for progression of chronic kidney disease in patients with autosomal dominant polycystic kidney disease p. 552
Gnanasambandan Ramanathan, Ramprasad Elumalai, Soundararajan Periyasamy, Bhaskar V. K. S. Lakkakula
DOI:10.4103/1319-2442.206464  
Autosomal dominant polycystic kidney disease (ADPKD) is the most common heritable kidney disease and is characterized by bilateral renal cysts. Hypertension is a frequent cause of chronic kidney disease (CKD) and mortality in patients with ADPKD. The aldosterone synthase gene polymorphisms of the renin-angiotensin-aldosterone system have been extensively studied as hypertension candidate genes. The present study is aimed to investigate the potential modifier effect of CYP11B2 gene on the progression of CKD in ADPKD. One hundred and two ADPKD patients and 106 healthy controls were recruited based on Ravine inclusion and exclusion criteria. The three tag-SNPs within CYP11B2 gene (rs3802230, rs4543, and rs4544) were genotyped using FRET-based KASPar method. Cochran-Armitage trend test was used to assess the potential associations between these polymorphisms and CKD stages. Mantel- Haenszel stratified analysis was used to explore confounding and interaction effects of these polymorphisms. Of the three tag-SNPs genotyped, rs4544 polymorphism was monomorphic and rs3802230 deviated Hardy-Weinberg equilibrium. The CYP11B2 tag-SNPs did not show significant association with ADPKD or CKD. Further, these polymorphisms did not exhibit confounding effect on the relationship between CKD progression and hypertension. Our results suggest that aldosterone synthase gene is not a major susceptibility gene for progression of CKD in South Indian ADPKD patients.
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Comparison of intradialytic hemodynamic tolerance between on-line hemodiafiltration and acetate-free biofiltration with profiled potassium dialysate concentration p. 558
George Kosmadakis, Enrique Da Costa Correia, Frederic Somda, Didier Aguilera
DOI:10.4103/1319-2442.206436  
Intradialytic hypotensive episodes are deleterious for hemodialysis (HD) patients. Acetate-free biofiltration with profiled potassium (AFBK) dialysate concentration may improve their cardiovascular stability. The aim of the present crossover study was to compare intradialytic hemodynamic tolerance and biological parameters between online hemodiafiltration (olHDF) and AFBK. Ten frail HD patients (8 males) with a mean age of 66.71- ± 12.31 years were studied for three months on olHDF and AFBK. There was a significant reduction of the hypotensive episodes during the AFBK period compared to the olHDF period. Mean intradialytic systolic and diastolic blood pressures were significantly higher during the AFBK period. There was a significant postdialytic increase in serum sodium concentration with the AFBK compared to olHDF. The dry weight and ultrafiltration indices were significantly higher, and the Kt/V was significantly lower during the AFBK period. Serum albumin concentration significantly increased during the AFBK period. AFBK leads to a significantly improved intradialytic tolerance in hemodynamically instable HD patients.
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A randomized controlled trial of the effects of hydrochlorothiazide on overactive bladder and idiopathic hypercalciuria p. 566
Parsa Yousefichaijan, Fatemeh Dorreh, Mohammad Rafiei, Mahdyieh Naziri, Atefeh Azimnejad
DOI:10.4103/1319-2442.206458  
Overactive bladder is a stressful condition which affects around 15%—20% of 5- year-old and up to 2% of young adults. One of the most common causes of overactive bladder is hypercalciuria. Our study investigated the effect of hydrochlorothiazide (HCTZ) on overactive bladder and hypercalciuria. This randomized controlled trial was conducted on 88 patients with overactive bladder and idiopathic hypercalciuria. They were randomly divided into the intervention group receiving 1 mg/kg/day of HCTZ for 3 months, and the control group receiving training without any intervention. Treatment compliance and response were reviewed monthly in each patient using a 30-day bedwetting diary. In the 1st month, the mean of bedwetting was 14.47 ± 7.06 and 12.61 ± 7.57 in the intervention and control groups, respectively (P = 0.23). In the 2nd month, it was 10.04 ± 6.32 and 10.79 ± 7.83 in the intervention and control groups, respectively (P = 0.62); and in the 3rd month, it was 6.49 ± 7.13 and 7.64 ± 7.95 in the intervention and control groups, respectively (P = 0.59). There was no significant difference between the two groups. Thus, use of HCTZ was not found to be better than urine retention control training. Therefore, one may conclude that treating hypercalciuria with HCTZ had no demonstrable effect on overactive bladder.
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RENAL DATA FROM THE ARAB WORLD Top

Pattern of acute glomerulonephritis in adult population in Dubai: A single-center experience p. 571
Amna K Alhadari, Fakhriya J Alalawi, Ayman Aly Seddik, Kaneez Zahra, Dileep Kumar, Hussain Yousif, Hind Alnour, Michael Jansen, Mohammad J Railey
DOI:10.4103/1319-2442.206443  
Epidemiological data of renal diseases have great geographic variability throughout the world. Due to the lack of a national renal data registry system, there is no information on the prevalence rate, clinical and pathological features of various glomerulonephritis (GN) in the United Arab Emirates (UAE). In a retrospective cross-sectional study, we analyzed 158 renal biopsies done in Dubai Hospital, UAE, between the years of 2005 and September 2014, with an aim to determine the prevalence rate and frequency of different pathological patterns of GN in adult patients who presented with proteinuria ± hematuria. In our study, primary GN still remains more common than secondary GN (66.4% vs. 33.5%). Among the primary GN in our analysis, minimal change disease was the most common primary GN affecting 20% of the study population (13.2% of the total GN causes) followed with membranous GN (18.2%), then membrano- proliferative GN (15.3%) and focal segmental glomerulosclerosis (13.46%), while among the secondary causes lupus nephritis (LN) is the most prevalent GN in UAE, predominantly in the Emirati national population whom constituted 48% of total biopsies. Indeed, LN had the highest incidence among all types of GN even the primary ones, constituting 23.4% of total GN in Dubai (74% of the total secondary causes). Furthermore, systemic lupus erythematosus was the most common GN in women while the minimal change was widely affecting male patients. Among elderly, the most common pathology was diabetic glomerulosclerosis followed by amyloidosis.
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Postrenal transplant malignancy: Incidence, risk factors, and prognosis p. 579
Nabil Abdelfadil Elserwy, Esam Elden Lotfy, Mohamad Ashraf Fouda, Medhat Ibrahim Mahmoud, Ahmed Farouk Donia, Mohamed Elsayed Mashaly, Mohamed Hamed Abbas, Mohamed Megahed Abuelmagd, Rasha Kamal Abouelenein, Mabrouk Ibrahim Ismail, Mohamed Adel Bakr
DOI:10.4103/1319-2442.206456  
The newer and potent immunosuppressive agents have successfully reduced the risk of rejection after kidney transplantation, but the development of cardiovascular diseases, infections, and malignancy is major factors limiting their success. Posttransplantation malignancy is the second most common cause of death in renal transplant recipients after cardiovascular disease; it is expected that mortality due to malignancy may become the most common cause of death within the next two decades. This study is designed to evaluate the incidence, risk factors, and types of malignancies occurring after renal transplantation and their impact on patient and graft survival. A total of 2288 patients underwent living donor renal allotransplantation in the Urology and Nephrology Center, Mansoura University, during the period between 1975 and 2011. Among these patients, 100 patients developed posttransplantation malignancy. Patients were categorized into five major groups according to their type of malignancy; Kaposi’s sarcoma (KS), non-Kaposi’s skin tumors (non-KS), posttransplant lymphoproliferative disorders (PTLD), solid tumors, and genitourinary and reproductive system (GU and RS). Overall, the incidence of cancer in renal transplant recipients was 4%. There were 83 male (83%) and 17 female patients (17%). The most frequent cancer was KS seen in 33 patients (33%). The lowest median time to development of cancer was observed in KS (35 months). The highest median time to development of cancer was observed in PTLD (133 months). The best graft survival was observed in PTLD and the worst in non-KS tumors. The best patient survival was observed in KS and the worst in GU and RS tumors. Azathioprine-based regimen was associated with a higher rate of cancer. The number of patients who died was 65 (65%). Our results indicate that the occurrence of malignancy has an important impact on short- and long-term graft and patient survival.
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Pediatric nephrology practice in Jordan p. 589
Kamal Akl, Issa Hazza
DOI:10.4103/1319-2442.206457  
The practice of pediatric nephrology in a developing country such as Jordan is governed by social, cultural, and economic issues. The prevalence of consanguinity contributes to the emergence of rare heredofamilial disorders and congenital anomalies of the kidneys and urinary tract. Epigenetic factors modify underlying genetic defect predisposing to symptomatic crystalluria. Future research should be directed at prevention.
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RENAL DATA FROM ASIA-AFRICA Top

Assessment of quality of life in children with nephrotic syndrome at a teaching hospital in South India p. 593
Sonia Agrawal, Sriram Krishnamurthy, Bijaya Nanda Naik
DOI:10.4103/1319-2442.206452  
This study was conducted to assess the quality of life (QOL) in children between 2 and 18 years of age with primary idiopathic nephrotic syndrome (NS) using Pediatric Quality of Life Inventory (PedsQL 4.0 Generic Core Scales). This cross-sectional comparative study was conducted at a tertiary care hospital in South India between December 2014 and February 2015. In this questionnaire-based study, 50 children with primary idiopathic NS and an equal number of age-matched controls with other chronic ailments were recruited. Their clinical and demographic details were recorded, and QOL was assessed using PedsQL 4.0 Generic Core Scales. The median (interquartile range) total QOL score in children with NS [65 (59–68.75)] was found to be higher compared to controls [62.19 (58.05–65.78)] (P = 0.012). Children with NS had significantly higher QOL scores in physical (P = 0.004), emotional (0.029), and social functioning (0.010) domains as compared to controls; however, the school performance was not different from controls. The QOL scores did not significantly differ between the various clinical pheno- types of NS. Demographic details such as age, gender, duration of illness, and steroid resistance did not significantly influence the total QOL scores among the nephrotic children. The present study shows that the overall QOL in children with NS was better than in children with other chronic illnesses. Further studies are needed to confirm these findings and explore the underlying cause of poor school performance.
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Gender differences in perceptions and attitudes of general population towards organ donation: An Indian perspective p. 599
Vijayalakshmi Poreddi, TS Sunitha, Rohini Thimmaiah, Suresh Bada Math
DOI:10.4103/1319-2442.206460  
Globally, shortage of organs available for organ transplantation is a major problem. Studies assessing awareness and attitudes towards organ donation are limited from India. The aim of this study is to assess gender differences in the perceptions and attitude of general population toward organ donation. A cross-sectional descriptive study was carried out among randomly selected patient relatives (n = 193) at the outpatient department of a tertiary care center. Data were collected through face-to-face interview using a structured questionnaire. Our findings revealed that majority of men than women were aware and in favor of promoting organ donation (χ2 = 10.428, P < 0.001). Best part of men (70.9%) compared to 52.3% of women were willing to donate their organs after death (χ2 = 18.080, P <0.001). Similarly, more number of (48.5%) men were willing to sign on the organ donation card. There is an urgent need to uncover the myths and misconceptions of the general population toward organ donation. Further, healthcare providers and governmental and nongovernmental agencies should take active initiation in motivating the public to give their consent for organ donation.
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Quality of life of hemodialysis patients in Togo: A single-center study on 64 hemodialysis patients at the Sylvanus Olympio University Hospital in Lomé, Togo p. 609
Kossi Akomola Sabi, Béfa Noto-Kadou-Kaza, Eyram Yoan Amekoudi, Jacques Vigan, Kokou Ayamekpe, Dégnon Amedegnato
DOI:10.4103/1319-2442.206463  
This study aims at assessing patients’ quality of life during hemodialysis (HD) and determining influencing factors. This prospective study was conducted over a three-month period (December 1, 2012-February 28, 2013) at the Sylvanus Olympio University Hospital (CHU-SO) HD unit, the only center to provide such services in Togo. Respondents used the standard Medical Outcome Survey-Short Form 36 questionnaire. This study was conducted on 64 patients (44 males and 20 females = M/F ratio 2.2). Mean patient age was 45.51 ± 14.00 years old with the vast majority in the 16–44-year-old group (90.82%), and mean dialysis vintage was 2.84 ± 2.37 years (1 month to 9.5 years). The mean global quality of life score was 35.58 (standard deviation ± 15). Quality of life physical score and mental score were, respectively, 31.84 and 40.64. Physical limitation scores were 15.23, followed by general ill-health score 37.38 and poor physical function score 47.37. Mental limitation score was 30.20 and vitality score was 43.75. The quality of life was inversely proportional to patient age and the dialysis vintage, with female quality of life scores worse than male in all questionnaire parameters. Togolese dialysis patients suffer from poor quality of life. Factors underlying such poor quality of life include advanced age, female gender, long-standing history of dialysis, and patient profession.
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CASE REPORTS Top

Postinfectious glomerulonephritis with a broken heart: A case report study p. 615
Hafiz Omer, Abdulla Ali, Ahmed Aljizeeri, Elmonttasir Uthman
DOI:10.4103/1319-2442.206470  
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Primary focal segmental glomerulosclerosis recurring rapidly as collapsing glomerulopathy in a renal allograft recipient p. 621
Vinita Agrawal, Narayan Prasad, Pritpal Singh
DOI:10.4103/1319-2442.206465  
Recurrent focal segmental glomerulosclerosis (FSGS) develops in about 30%-40% of patients of FSGS undergoing renal transplantation. We report a patient who received a live- related renal transplant for end-stage renal disease due to a primary FSGS (not otherwise specified) in the native kidney and presented with graft dysfunction in the immediate posttransplant period. The first and the second biopsy showed no evidence of rejection or glomerular lesion. A repeat biopsy done on the 30th day revealed recurrent FSGS morphologically presenting as collapsing variant. The patient was found to have massive proteinuria. Electron microscopy done retrospectively showed glomerular foot process effacement even in the first biopsy. This case highlights the presence of an early minimal change disease-like phase in recurrent FSGS and the necessity of evaluation for proteinuria even in immediate and early posttransplant period. It also shows that different variants of FSGS may represent a spectrum of the same disease and suggests a likely role of a pathogenic circulating factor even in collapsing FSGS requiring further evaluation.
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Recurrent syndrome of inappropriate antidiuretic hormone secretion due to tolterodine in an elderly male patient p. 625
Abdullah K Alhwiesh, Husain Alsharani, Eman Fathi Ibrahim, Zaid Alanazi, Bushra Ahmed AlGhamdi, Nadia Alaudah, Feras Alzahrani, Adnan Alsarawi, Ashwaqu Almohaws, Ibraheem Saeed Abdurrahman
DOI:10.4103/1319-2442.206471  
Hyponatremia is defined as serum sodium of <135 mmol/L and equates with a low serum osmolality once translocational hyponatremia and pseudohyponatremia are ruled out. True hyponatremia develops when normal urine-diluting mechanisms are disturbed. In elderly patients, this complication is not uncommon, especially in nursing homes and assisted living facilities. Medications are often the most common cause of hyponatremia in these patients. Herewith, we reported a 65-year-old Saudi male, a known case of benign prostatic hypertrophy and hypertension, who developed recurrent hyponatremia secondary to tolterodine. To our knowledge, this is the fifth case reported in literature of such association.
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Utilization of plasmapheresis in the management of bismuth intoxication with acute renal failure p. 629
Nezihat Rana Disel, Ayça Açikalin, Ahmet Sebe, Yüksel Gokel
DOI:10.4103/1319-2442.206438  
A 34-year-old female patient who ingested 2400 mg bismuth subcitrate in a suicide attempt was brought to the emergency department. She had mild encephalopathy and acute renal failure on admission. One session of plasmapheresis was performed to remove bismuth, and needed three sessions of hemodialysis and was discharged on the 24th day of hospitalization with the recovery of the renal function.
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Tuberous sclerosis complex (Bourneville-Pringle disease) in a 25-year- old female with bilateral renal angiomyolipoma and secondary hypertension p. 633
Sahar El Aoud, Faten Frikha, Mouna Snoussi, Raida Ben Salah, Zouhir Bahloul
DOI:10.4103/1319-2442.206461  
Tuberous sclerosis or tuberous sclerosis complex (TSC) is an autosomal dominant inherited neurocutaneous disorder that variably affects the brain, skin, kidneys, heart, and other organs. It is characterized by skin and renal lesions in addition to central and peripheral nervous system tumors, with neurological and psychiatric findings. We report such a rare case of tuberous sclerosis in a 25-year-old female who presented with abdominal pain and hypertension. Physical examination showed dermatological signs that included hypopigmented maculae, shagreen plaque, angiofibromas on the centrofacial areas, periungual fibromas on toes, and molluscum pendulum around the neck. Abdominal ultrasonography revealed bilateral renal angiomyolipoma. Brain magnetic resonance imaging showed subependymal nodules and cortical tubers. She also presented retinal and oral lesions. Our patient has a definitive diagnosis of TSC. Hypertension was related to the renal involvement of TSC, and the patient benefitted from oral angiotensin- converting enzyme inhibitors with a favorable outcome.
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An overlap of granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis p. 639
Sujit Surendran, Chandramohan Gundappa, Arun Gandhi, Anila Abraham Kurien, Edwin Fernando
DOI:10.4103/1319-2442.206450  
We present a case report of overlap of granulomatosis with polyangiitis (GPA; formerly known as Wegener’s granulomatosis) and eosinophilic granulomatosis with polyangiitis (EGPA; formerly known as Churg-Strauss syndrome). We report a 45-year-old female who presented with rapidly progressive renal failure associated with fever, polyarthralgia, and respiratory symptoms with cytoplasmic antineutrophilic cytoplasmic antibody (ANCA) and proteinase (PR-3) antigen positivity. Computerized tomography scan of the chest showed diffuse alveolar hemorrhage with renal biopsy revealing pauci-immune necrotizing crescentic glomerulonephritis with intense eosinophilic infiltration suggestive of eosinophilic GPA (EGPA). Our patient had ANCA-associated vasculitis (AAV) with features suggestive of both GPA and EGPA. She was treated with methylprednisolone and cyclophosphamide and attained remission after 2 weeks of therapy. This is a rare report of a patient with AAV having features of both EGPA and GPA.
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Oliguric acute kidney injury as initial presentation of renal non-Hodgkin’s lymphoma infiltration p. 645
Tacyano T Leite, Alexandre B Libório, Geraldo B Silva Junior, Elizabeth De Francesco Daher
DOI:10.4103/1319-2442.206459  
We report a case of a 20-year-old man presented to the emergency department with oliguria and renal failure requiring urgent dialysis. An ultrasound revealed enlarged kidneys, and a renal biopsy showed non-Hodgkin’s lymphoma, subtype diffuse large B-cell.
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Two unusual cases of microvascular thrombosis in the immediate posttransplant period p. 648
Swarnalata Gowrishankar, Srinivasan Krishnan, MS Ravishankar, Swapna Nuguri
DOI:10.4103/1319-2442.206469  
We present two unusual cases of microvascular thrombosis in the immediate posttransplant period resulting in graft loss. The first was a 20-year-old female with a cadaveric renal transplant with immediate graft dysfunction due to microthrombi of probable donor origin, with nonrecovery of renal function nine months’ posttransplant. The second was a 23-year-old male with unrelated live kidney transplant with hyperacute rejection due to anti-endothelial antibodies.
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Unusual presentation of systemic lupus erythematosus p. 653
E Mahesh, Parampalli Rakesh Madhyastha, Vijay Varma, KC Gurudev, MS Gireesh, Sujeeth Reddy Bande
DOI:10.4103/1319-2442.206468  
Bullous systemic lupus erythematosus is a rare distinctive subepidermal blistering disorder that can occur in patients with systemic lupus erythematosus (SLE). It is histologically characterized by a neutrophil-predominant infiltrate in the subepidermal region with deposition of immunoglobulins (IgG, IgA, IgM), C3, and auto-antibodies against collagen VII. Herein, we report a case of a 13-year-old girl who presented with bullous SLE and Class III lupus nephritis, which is extremely rare at this age.
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Rituximab-induced urticarial dermatitis during the treatment of membranous nephropathy p. 657
Radhika Chemmangattu Radhakrishnan, Gopal Basu, Renu E George, Harshad Parmar, Veerasami Tamilarasi
DOI:10.4103/1319-2442.206462  
Rituximab is a monoclonal antibody directed against B cells and is being increasingly used for various renal indications. Acute dermatologic manifestations such as urticaria are well known to occur during rituximab infusion. Here, we report the case of a 53- year-old female who was treated with rituximab for membranous nephropathy and developed an exanthematous rash, which progressed with a further dose of rituximab and was diagnosed as urticarial dermatitis. A review of literature showed that urticarial dermatitis following rituximab therapy has been seldom reported and identification of this complication is very important to avoid giving further doses and thus, increasing the severity of lesions.
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LETTERS TO THE EDITOR Top

Hand-assisted laparoscopic donor nephrectomy: A single-center study p. 661
Durre Shohab, Imran Jamil, Iftikhar Ali Khan, Muhammad Athar Khawaja, Muhammad Ayaz Khan, Saeed Akhter
DOI:10.4103/1319-2442.206455  
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The role of hypercalciuria in pathogenesis of recurrent abdominal pain p. 664
Majid Malaki
DOI:10.4103/1319-2442.206437  
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New-onset diabetes after kidney transplantation and the role of cytomegalovirus p. 666
Aidin Lotfiazar, Behzad Einollahi, Seyed Mostafa Hosseini Zijoud, Shima Shahyad
DOI:10.4103/1319-2442.206467  
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Dengue and acute kidney injury: A need for aggressive maneuvers p. 667
Tauqeer Hussain Mallhi, Amer Hayat Khan, Yusra Habib Khan, Azreen Syazril Adnan, Azmi Sarriff
DOI:10.4103/1319-2442.206453  
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Author’s reply p. 668
Viroj Wiwanitkit
DOI:10.4103/1319-2442.206454  
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Peritonitis associated with infective endocarditis and vertebral osteomyelitis in a peritoneal dialysis patient p. 670
Yao-Ko Wen
DOI:10.4103/1319-2442.206466  
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Factors affecting on hepatitis B seroprotection in hemodialysis patients p. 672
Majid Malaki
DOI:10.4103/1319-2442.206472  
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Asymptomatic bilateral giant angiomyolipoma p. 675
Gagandeep Kaur, Bijin Thajudeen
DOI:10.4103/1319-2442.206449  
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SCOT DATA Top

Hospital Contributing in Organ Donation Program p. 678

DOI:10.4103/1319-2442.206565  
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