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Saudi Journal of Kidney Diseases and Transplantation
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    Table of Contents - Current issue
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May-June 2019
Volume 30 | Issue 3
Page Nos. 560-754

Online since Wednesday, June 26, 2019

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REVIEW ARTICLES  

Rabies, rabies vaccine, and renal failure: Clinical issues Highly accessed article p. 560
Won Sriwijitalai, Viroj Wiwanitkit
DOI:10.4103/1319-2442.261327  PMID:31249218
Rabies is an important neurological infection that is prevalent in tropical countries. The rabid animals can bring rabies to humans by biting. The disease can result in serious neurological problem and death is the end result. The best way is prevention of disease by postexposure prophylaxis against rabies. The effect of rabies on the renal system is little mentioned in the literature. In the previous literature, acute kidney injury was observable in half of the rabies patients. Rabies is also transmittable by organ transplantation. Although it is rare and <10 cases had ever been reported in literature, it is proven that kidney transplant patients are at risk of getting rabies if the donor come from endemic country or with a history of travel to endemic country and has unclear cause of death. Regarding rabies immunization, the use of vaccination for patients with the underlying renal failure is interesting. In this short article, the authors summarize on those important clinical issues of rabies and renal failure.
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Perinephric transplant fluid collection approach and management Highly accessed article p. 564
Iman Alshamsi, Hefsa Alshamsi, Salamah Al Falahi, Ajay Sharma, Ahmed Halawa
DOI:10.4103/1319-2442.261328  PMID:31249219
Renal transplant is the treatment of choice for end-stage renal disease. Perirenal fluid collections are a common surgical complication postrenal transplant that may lead to early graft loss, considerable morbidity, and excess financial loss, if not diagnosed and managed early. The causes of posttransplant fluid collections are urinary leak, lymphocele, hematoma, and seroma, which can be further complicated by abscess formation if becomes infected. Urine leak is considered the most common urological complication postrenal transplant. Diagnosis can be made by biochemical analysis of the fluid drainage with the simultaneous comparison to that of serum. Radiological imaging is also essential for confirming the diagnosis of urinary leak that may not necessarily identify the site of the leak. The management of urinary leak is usually surgical unless the leak is small. The choice of surgery depends on the location of the leak, the vascularization of the involved ureter, and the presence of any complications caused by the leak. This article reviews the differential diagnoses of perirenal fluid collections in postrenal transplant period and focuses on the clinical assessment of urinoma and management options according to the latest evidence-based medicine.
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ORIGINAL ARTICLES Top

Vascular calcification in patients with chronic kidney disease on dialysis in the Kingdom of Saudi Arabia: A cross-sectional study Highly accessed article p. 571
Mohammed Abdulrahman AlGhonaim, Adel A Fathalla
DOI:10.4103/1319-2442.261329  PMID:31249220
The study aimed to provide a unique nationwide data and a valuable update on the current situation of vascular calcification (VC) among chronic kidney disease (CKD) patients in the Kingdom of Saudi Arabia. The study included all patients diagnosed with CKD over a period of one year and six months from September 2015 to February 2017 and underwent dialysis. All analyses were done using IBM-SPSS. Of the 842 enrolled patients, 836 (99.3%) constituted the descriptive population. The mean age of patients was 51.8 ± 15.4 years. A total of 759 (90.8%) patients had cardiovascular risk factors. The prevalence of VC in patients with CKD is 40.8%. In the multivariate analysis, prognostic factors for VC were physical inactivity with odd ratio 2.87 [95% confidence interval (CI): (1.89–4.63), P < 0.01], history of ischemic heart disease 2.34 [95% CI: (1.30–4.22), P < 0.01], dyslipidemia 1.56 [95% CI: (1.01–2.40), P = 0.04], and older age 1.06 [95% CI: (1.05–1.07), P <0.01]. At inclusion, the mean ± standard deviation for high-density lipoprotein cholesterol, low cholesterol, total cholesterol, and triglycerides was 41 ± 30, 79.7 ± 29.9, 144.2 ± 38.5, and 143.4 ± 95.3 mg/dL, respectively. This study reports useful information about the prevalence of VCs in CKD stage 5D in a Middle Eastern country as the Kingdom of Saudi Arabia. Furthermore, it offers information on the predictors or associated factors of a VC in CKD patients.
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Using single-item survey to study the prevalence of burnout among medical residents-influence of gender and seniority p. 581
Rehab A AlSayari
DOI:10.4103/1319-2442.261330  PMID:31249221
The objective of this study was to evaluate the prevalence of burnout among medical residents in and assess the influence of certain demographic factors. The residents were asked to classify their level of burnout (according to one out of five levels of burnout) using their own definition of burnout. This survey was undertaken away from any examination time and confidentially ascertained. The frequency of burnout and itself level were calculated and compared between genders and year of training using the Chi-square. Eighty-two residents responded to the survey (100% of attendees and 91.1% of all residents in the department); 74.2% were male and 25.8% of female, 38.7% were in their 1st year of training, 24.2% in their 2nd year, 29.0% in their 3rd year, and 8.1% in their 4th year. The overall burnout frequency was 41.9% (29% with moderate burnout, and 12.9% with severe burnout). Overall twice as many female residents had burnout than males (P = 0.017). The prevalence of “moderate burnout” among males and females was 19.8% and 56.3%, respectively. However, no difference between males and females was seen in the “severe burnout” category (13% and 12.5%, respectively). The overall burnout rate was the lowest in the 1st year of training (33.3%) and the highest in the last (60%) but with no statistical significance (P = 0.4). Whereas 2/3rd of the male residents had no burnout, only 1/3rd one their female counterparts had no burnout (P = 0.017). Conversely, the prevalence of “moderate burnout” among males and females was 19.8% and 56.3%, respectively (P = 0.002). However, no difference between males and females was seen in the “severe burnout” category (13% and 12.5%, respectively. In conclusion, 50% of the residents had burnout which was significantly more prevalent in females. The rate of burnout is the highest in the last year of training and the lowest in the 1st year
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Estimating glomerular filtration rate in adult kidney transplant recipients in the Asian population p. 587
Lydia Kamaruzaman, Rozita Mohd, Faizah Mohd Zaki, Rozita Hod, Aini Ab Aziz
DOI:10.4103/1319-2442.261331  PMID:31249222
Estimation of glomerular filtration rate (GFR) in renal transplant patients is often assessed by application of creatinine-based equations. The aim was to correlate the estimated GFR (eGFR) using creatinine-based equations [Cockroft-Gault, Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Nankivell] with gold standard 51Cr-EDTA in kidney transplant patients in the Asian population. This is a single-center, cross-sectional study involving adult renal transplant patients. Background demographic data, medications, office blood pressure, and baseline investigations were taken. Correlations between measured GFR and eGFR were analyzed and Pearson’s correlation coefficients, bias, and accuracy were assessed. Thirty-seven renal transplant patients with a mean age of 46 ± 13 years were recruited. Majority were Chinese (68%), Malay (24%), and Indian (8%). The median duration of the transplant was 84 (interquartile range 60,132) months. The mean measured GFR was 71 ± 21 mL/min/1.73 m2. Cockroft-Gault and CKD-EPI has the best correlation with 51Cr-EDTA with Pearson correlation coefficients of 0.733 (P <0.001) and 0.711 (P < 0.001), respectively. All formulae showed >80% accuracy with eGFR lies between 30% of the measured value. CKD-EPI and MDRD had the greatest accuracy with 89.2% each. Clinician may use any of these three serum creatinine-based equations to estimate GFR in kidney transplant recipients.
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Incidence and risk factors of common viral infections among renal transplant recipients during the first year post-transplant in North-eastern Iran p. 597
Elham Shaarbaf Eidgahi, Zahra Lotfi, Maryam Tayefi, Afsane Bahrami, Seyyede Fatemeh Shams, Sepideh Shakeri, Maryam Sheikhi
DOI:10.4103/1319-2442.261332  PMID:31249223
Despite major therapeutic advances, management of viral infections in renal transplant recipients is still a major challenge. Hence, it is urgently needed to establish protocols for appropriate control and the prevention of viral infection. We evaluated demographic/clinical characteristics, frequency, and risk factors of symptomatic viral infections in renal transplant recipients during the 1st year posttransplant, in northeastern Iran. We retrospectively reviewed medical files of 247 patients including 146 males and 101 females who had undergone renal transplantation at Montaserie organ transplantation hospital of Mashhad during 2012–2014. These patients were followed up for one year after transplantation for the detection of any symptomatic viral infection. Demographic and clinical characteristics of recipients were collected and analyzed using the Statistical Package for Social Sciences version 18 software; P < 0.05 was considered as statistically significant. Data were presented using descriptive statistics. Furthermore, logistic regression analysis was used to determine risk factors for infection. The mean age of the patients was 34.94 ± 13.89 years. During the 1st year posttransplant, 68 episodes of viral infections were detected in 64 patients (25.9%). Cytomegalovirus (CMV, 21.9%), Varicella Zoster virus (2.8%), herpes simplex virus (2.0%), and human polyomavirus BK virus (0.8%) were the most common symptomatic viral infections found. Age of the patients was the only significant risk factor for viral infections (odds ratio = 1.066; 95% confidence interval: 1.002–1.134; P = 0.042). The incidence of symptomatic viral infections, particularly CMV disease, is high in our center. Hence, it is recommended to use appropriate prophylaxis and monitor the patients during the first six months post-transplant.
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The use of sirolimus in patients with recurrent cytomegalovirus infection after kidney transplantation: A retrospective case series analysis p. 606
Ali M Shendi, Rachel K. Y Hung, Ben Caplin, Paul Griffiths, Mark Harber
DOI:10.4103/1319-2442.261333  PMID:31249224
Cytomegalovirus (CMV) is one of opportunistic infections post solid organ transplant and remains a cause of morbidity and mortality. Mammalian target of rapamycin inhibitors has a theoretical antiviral advantage compared to conventional immunosuppression. The primary outcome was to assess the viremic response and kidney function in a cohort of kidney transplant recipients (KTRs) with difficult to manage CMV infection when converted to sirolimus. We retrospectively analyzed the outcome of substituting sirolimus for mycophenolate mofetil (MMF) or tacrolimus in 18 KTR with difficult to manage, resistant/recurrent CMV viremia unresponsive or intolerant of standard anti-CMV treatment, or immunosuppression reduction. Safety and feasibility of sirolimus conversion were assessed through studying CMV viral loads, creatinine levels, immunosuppression, antiviral therapy, kidney function, and acute rejection episodes before and after starting sirolimus as well as the sirolimus side effects. Data were collected from the hospital filing system. The Wilcoxon matched-pairs signed-rank test and Friedman test were used for statistical analysis. The area under the curve for Log10 CMV viral load (log10 copies/ml) was significantly higher before than after the sirolimus switch (P = 0.0156). The median number of days on antiviral treatment was reduced after conversion to sirolimus [48 days (0–95); vs. 68 days (21–146)]. Acute rejection occurred more commonly before than after starting sirolimus [n =5 (27.7%) vs. n = 2 (11.1%)]. Median serum creatinine before conversion to sirolimus was 175.5 μmol/L (79–243), and showed no deterioration three months and one year after conversion [148 (69–271) and 162.5 (69–287) μmol/L, respectively, P = 0.002]. The use of sirolimus, often alongside tacrolimus and after discontinuation of MMF, is a useful strategy in treating recurrent CMV viremia without provoking rejection.
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Evaluation of dialysis practice patterns in children having end-stage renal disease on maintenance hemodialysis at a pediatric nephrology unit p. 615
Ghada M El-Mashad, Zein Abdellatif Omar, Eman Salah Seif
DOI:10.4103/1319-2442.261334  PMID:31249225
Hemodialysis (HD) involves purifying the blood of waste products through diffusion through a semipermeable membrane. We aimed to evaluate dialysis practice patterns among children with end-stage renal disease (ESRD) on maintenance HD (MHD). This cross-sectional study was conducted on 30 children with ESRD on MHD at the pediatric nephrology unit of Menoufia University and 18 age- and sex-matched children who served as the control group. Consent was obtained from children more than seven years old and their parents and from parents of younger children. They were all subjected to full history, complete physical examination, efficiency measures estimation (for cases), and laboratory investigations. Risk factors for death were determined using the logistic regression model; data were analyzed using the Statistical Package for the Social Sciences software. The study showed that the causes of ESRD in children were unknown in 43.3%; about 73.3% of cases were short-statured and 53.3% were underweight. About 40% of the cases were hypertensive showing a significant difference from controls (P <0.01). A double-lumen jugular catheter (DLJC) was the initial access in 80% of cases. The urea reduction ratio and Kt/V were significantly higher in children with arteriovenous fistula (AVF) than those with DLJC (P <0.0001 and 0.004), respectively. About 66.7% of cases had anemia showing a significant difference from controls (P <0.01). Hypoalbuminemia, anemia, elevated C-reactive protein, and left ventricular hypertrophy were the significant risk factors resulting in death (P <0.0001). Although the most common initiating vascular access used for HD patients was a DLJC, the efficiency of dialysis was significantly higher in patients who had AVF. Stature was affected more than weight in HD patients in the study group.
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Pattern of renal diseases and the need for establishment of renal biopsy registry in Saudi Arabia p. 628
Mohammed Al-Homrany, Saeed Alghamdi, Abdullah Al-Hwiesh, Dujanah Mousa, Jamal Alwakeel, Ahmad Mitwalli, Khalid Alsaad, Ali Alharbi, Jameela Kari
DOI:10.4103/1319-2442.261335  PMID:31249226
Renal disease is a common medical problem in Saudi Arabia. Varieties of renal lesions if not treated properly or not discovered early will lead to a chronic kidney disease. Identifying the types of renal lesions can help in identifying the high-risk patients and appropriate treatment can be provided. Glomerulonephritis (GN) is considered one of the leading causes of end-stage renal disease in Saudi Arabia. The prevalence of different renal lesions were identified by different reports; however, these reports showed inconsistency. One important reason for such differences is related to the lack of unified methods in diagnosing and processing renal tissues and to the fact that different reports were reported by different pathologists. In addition, the differences in the reported results may reflect patient selection biases for renal biopsy or to the different policies and protocols adopted by different nephrologists. This is a prospective, multicenter study that involves different patients from different institutes and from different regions in Saudi Arabia to delineate the pattern of renal diseases based on renal biopsies. Four hundred and five cases were selected and studied over two years. This preliminary report shows that the most common primary renal lesion in Saudi Arabia is focal segmental glomerulosclerosis in 24.1%, followed by IgA nephropathy (15.2%), mesangioproliferative non-IgA, (13.2%), and membranoproliferative GN (12.4%). Lupus nephritis was the most common cause of secondary GN in 66% of the secondary causes.
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Effect of high-dose Omega 3 on lipid profile and inflammatory markers in chronic hemodialysis children p. 634
Zein Abdellatif Omar, Belal Abdelmohsen Montser, Mohamed Ahmed Reda Farahat
DOI:10.4103/1319-2442.261337  PMID:31249227
Atherosclerosis, cardiovascular diseases (CVDs), and inflammation are important problems in chronic kidney disease (CKD) patients on chronic hemodialysis (HD). Prevention of CKD patients of CVD can lower the mortality rate in them. Omega 3 may help in the treatment of inflammation and lipid abnormalities in end-stage renal disease (ESRD) patients on chronic HD. This study aimed to evaluate the effect of high-dose Omega 3 on lipid profile and inflammatory markers in ESRD children on chronic HD. This clinical trial was conducted on 49 ESRD children on chronic HD selected from pediatric HD unit of Menoufia University Hospital. The study was conducted for a period of three months. The selected children were supplemented with 2000-mg Omega 3 tablets daily; lipid profile and inflammatory markers were assessed at the beginning and at the end of the study. Supplementation with high-dose Omega 3 resulted in a highly statistically significant decrease in total cholesterol, triglyceride, low-density lipoprotein, interleukin-6, C- reactive protein levels and a highly statistically significant increase in high-density lipoprotein (P <0.001). The differences between hemoglobin, platelets, iron profile, parathyroid hormone, albumin, phosphorus, calcium, potassium, sodium, and efficiency of dialysis before and after Omega 3 supplementation were not statistically significant (P >0.05). Supplementation with highdose Omega 3 caused significant improvement in lipid profile and inflammatory markers of children on chronic HD.
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A study of the main determinants of kidney allograft long-term survival in the era of new immunosuppressive drugs p. 640
Reza Hekmat, Mark Sturdevant
DOI:10.4103/1319-2442.261338  PMID:31249228
The outcome of long-term kidney allograft is extremely important. The present study aimed to discern the factors affecting long-term kidney allograft survival, including the type of donation and the use of extended criteria donors. Seven hundred and thirty-seven kidney transplant alone patients entered this retrospective cross-sectional study. The impact of different factors on death-censored long-term kidney allograft survival was evaluated. The Cox proportional survival model was employed to identify these factors. A value of P < 0.05 was considered statistically significant. The data were analyzed using IBM Statistical Package for the Social Sciences version 19.0. The study was conducted at the Mashhad University of Medical Sciences, Mashhad, Iran. In comparison with living kidney donations, both nontraumatic and traumatic brain death cadaveric kidney donations showed statistically significant inferior graft survival. Furthermore, the Kaplan–Meier survival analysis showed better durability of living kidney donations in comparison with traumatic and nontraumatic deceased donors (Log-rank test value = 0.001). Patients with delayed graft function (DGF) had a significantly shorter long-term death censured long-term graft survival in comparison with those without this complication. The Cox proportional models showed that DGF occurrence and the type of donation play a statistically significant role in long-term kidney graft survival. In addition, regarding graft survival, there was no difference between standard criteria and extended criteria donors. The occurrence of DGF and living or deceased types of donations have a significant effect on long-term kidney allograft survival.
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Creatinine and cystatin C-based evaluation of renal function among obese subjects in Benin City, Nigeria p. 648
Abiodun K Alaje, Tewogbade A Adedeji, Adebukola R Adedoyin, Sylvester E Idogun
DOI:10.4103/1319-2442.261339  PMID:31249229
Obesity is a recognized worldwide epidemic with increasing prevalence in developing nations. Studies have shown that obesity is an independent risk factor for the development of chronic kidney disease (CKD) besides its link with diabetes mellitus and hypertension. We evaluated the renal status of obese patients using both the established [creatinine (Cr)] and new (cystatin C) markers of renal function. This was a cross-sectional study. Fifty-nine consenting adults attending the clinic for routine medical checks were recruited for this study. They were divided into obese and non-obese based on their body mass index. Serum from specimens collected were assayed for Cr and cystatin C. CKD equations were used to estimate glomerular filtration rate based on Cr (eGFR-Cr), cystatin C (GFR-Cystatin), and Cr/cystatin C (GFRCr/cystatin) while modification of diet in renal disease equation was also used to eGFR-Cr. The eGFR results generated were compared in assessing renal function. The obese participants and the controls were age-matched (50.6 ± 9.7 vs. 50.7 ± 7.8 years, P = 0.2). The obese participants had a significantly higher serum cystatin C (1.3 ± 0.7 vs. 0.9 ± 0.4 mg/L, P < 0.001) and significantly lower eGFR-cystatin C (75.4 ± 38.9 mL/min/1.73 m2 vs. 90.9 ± 25.1 mL/min/1.73 m2, P < 0.001) than the controls, respectively. There was a significant difference between the eGFR-Cr and eGFR-cystatin C in the obese participants (97.4 ± 21.4 vs. 75.4 ± 38.9 mL/min/1.73 m2), P = 0.019). The results showed that mild renal impairment exists among obese participants. Routine assessment is recommended to pre-empt deterioration in renal function. Cystatin C appears to be a better marker of renal function in obesity than serum Cr.
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ABO incompatible kidney transplantation: the Saudi experience p. 655
Tariq Ali, Dieter Broering, Hassan Aleid, Jens Brockmann, Hind Alhumaidan, Ehab Hammad, Yaser Shah, Hazem Elgamal, Ibrahim Alahmadi, Mohamed Hussein, Syed Raza, Amira Alabassi, Ihab Ibrahim, Mohamed Shoukri, Khalid Almeshari
DOI:10.4103/1319-2442.261340  PMID:31249230
Although the outcomes of ABO-incompatible (ABOi) kidney transplant recipients are quite favorable, these patients are at increased risk of early antibody-mediated rejection (AMR) and graft loss. Some studies have also shown high mortality in the ABOi group mainly due to increased risk of infections. The AMR rates have been reported anywhere from <10% to >50% in the literature. The outcomes of the ABOi kidney transplants in the Saudi population are not known. In this study, we aimed to determine the graft and patient survival in ABOi kidney transplant recipients in the Saudi population. We included all adult patients who underwent ABOi transplantation between 2007 and 2016. All patients received rituximab, therapeutic plasma exchange, thymoglobulin, intravenous antibiotics, and intravenous immunoglobulin. The maintenance immunosuppression was prednisone, mycophenolate mofetil, and tacrolimus. The data were collected from a prospectively maintained database. A total of 77 patients were included in the study. The most common blood group mismatch was A to O (44.2%), followed by B to O (26.0%) and A to B (16.9%). In the 1st year, 17% of patients developed acute cellular rejection and AMR occurred in 7.8% of patients. Two patients were diagnosed with BK nephropathy. In the 1st year, urinary tract infection occurred in 25 (32.5%) patients. No patient was diagnosed severe viral or fungal infection. In the 1st year, four grafts were lost (graft survival of 94.8%); all grafts were lost within two weeks, three due to AMR and one due to technical reason. One year patient survival was 100%. In this study of ABOi kidney transplant recipients, we observed low risks of infectious complications with excellent patient and graft survival. Our immunosuppressive protocol can be considered safe.
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Cryoglobulinemia in a moroccan nephrology department p. 663
Mounia Azizi, Hicham Rafik, Yassir Zajjari, Dina Ibrahim Montasser, Driss El Kabbaj
DOI:10.4103/1319-2442.261341  PMID:31249231
Cryoglobulinemia is a rare cause of kidney disease that occurs in patients with various diseases. Renal involvement often occurs after appearance of various clinical manifestations dominated by purpura and neuropathy. The aim of this study is to describe clinical, biological, and pathological characteristics of cryoglobulinemic glomerulonephritis (GN), as well as treatment and outcome. This is a retrospective study including all patients with positive cryoglobulin test and biopsy-proven GN secondary to cryoglobulinemia. Fourteen patients with cryoglobulinemic GN were collected. Their mean age was 46.92 ± 15.82 years with male predominance (64.28%). Weight loss, fever (71.42%), and purpuric rash (57.14%) were the main extrarenal manifestations. Eight patients presented with nephrotic syndrome (NS), associated with renal impairment in three patients. Four patients had rapidly progressive GN and two patients had acute kidney injury. Renal biopsy, performed in all patients, revealed membranoproliferative GN with glomerular thrombi in all patients. Crescents and necrotizing vasculitis were present in four patients. Hepatitis C virus (HCV) infection was the most common etiology. Antivirals and steroids or other immunosuppressive agents were used in most of the patients. During follow-up, complete response was observed in three patients and partial response was observed in four patients. Five patients had no response with renal injury requiring hemodialysis. NS with hematuria and renal insufficiency were the main clinical manifestations of cryoglobulinemic GN. In our study, HCV infection dominated the etiologies, although not well described earlier. A half of our patients had poor outcome even after antiviral and immunosuppressive therapy.
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Management of phosphate abnormalities in hemodialysis patients: Findings from Malaysia p. 670
Saiful Nizam MV Mohamed Koya
DOI:10.4103/1319-2442.261343  PMID:31249232
Studies have shown that the mean or median phosphate levels were related to certain factors although applying this finding into the clinical setting is challenging. In this study, we attempted to determine treatment characteristics for patients with end-stage renal disease (ESRD) on maintenance hemodialysis (MHD) having hyperphosphatemia or hypophosphatemia in comparison with those with normal phosphate level. This was a cross-sectional survey conducted at HD units of Central Pahang Cluster Hospitals, Malaysia, in April 2017 involving 110 ESRD patients on MHD. About 40% of the study patients had normo-or hyperphosphatemia. As many as 84.5% (n = 93) of our patients were prescribed calcium carbonate (CC); the phosphate level was not affected by phosphate binder (PB) adherence. None of our patients received more than one type of PBs. Although there were no significant differences in any factors between normo- and hyperphosphatemic patients, 64% (n = 28) of the hyperphosphatemic patients did not receive the recommended maximum PB dose. In addition, 42% (n = 30) of patients with normo- and hyperphosphatemia prescribed CC received more than the recommended daily elemental calcium. On the other hand, our hypophosphatemic patients tended to be significantly older and had lower HD duration compared to normophosphatemic patients. No other significant differences were found in medication factors between normo- and hypophos-phatemic patients. There is potential to maximize phosphate control in hyperphosphatemic patients in Malaysia by maximizing PB therapy. On the other hand, proactive supervision is required in caring and prescribing for hypophosphatemic patients, especially the older patients.
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RENAL DATA FROM THE ARAB WORLD Top

Epidemiology, diagnosis, and etiology of acute kidney injury in the elderly: A retrospective analysis p. 678
Yosra Selmi, Yosra Ben Ariba, Jannet Labidi
DOI:10.4103/1319-2442.261344  PMID:31249233
The increased incidence of the acute kidney injury (AKI) in the elderly is becoming a disturbing reality in our days, mainly with the aging of the general population, and the predisposition of old persons to chronic diseases, drug toxicity, and infections. The aim of this study was to investigate the epidemiological, clinical, and biological features and to assess variant etiologies and outcomes of AKI in the elderly. Data were collected from the medical records of patients older than 65 years age having AKI admitted in the Internal Medicine Department of the Military Hospital of Tunis from January 2006 to June 2014. One hundred and seventeen cases were included in the study. The median age was 74.2 years. Male:female ratio was 1.6. Hypertension and diabetes were the most frequently found comorbidities seen in 69.2% and 48.7% of patients, respectively. The percentage of patients having acute-on-chronic renal failure was 13.7%. The AKI was manifested by nausea or vomiting in 33.3% of cases. One patient had hematemesis. The other symptoms were dyspnea in 14.5% of cases, uremic encephalopathy in 6.8% of cases, and oligoanuria in 16.2% of cases. The AKI was discovered fortuitously in 31.6% of cases and was diagnosed early within the 48 h after admission in 94% of cases and after this delay, in 6% of cases. It was ranked Acute Kidney Injury Network 1, 2, or 3, respectively, in 29.9%, 24.8%, and 45.3% of cases. Organic etiologies were observed more frequently (53.8%) followed by functional etiologies (37.6%) and then by obstructive ones (8.5%). Hemodialysis was performed for 9.4% of the patients. Of all the patients, 70.1% had favorable outcome, 49.6% of patients recovered totally. There was aggravation of the AKI in 29.9% of cases. Death occurred in eight cases (6.8%). The epidemiological, clinical, biological, and etiological profile of AKI in the elderly emphasizes the effect of aging of the human being on determining the pathology.
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RENAL DATA FROM ASIA-AFRICA Top

A study of prevalence and correlates of nonadherence to immunosuppressive medications in renal transplant recipients of South Indian population and their impact on long-term graft function p. 686
Karunamoorthy Saravanakumar, Avinash Prakash, Balasubramaniyan Thopalan, Jeyachandran Dhanapriya, Dineshkumar Thanigachalam, Sakthirajan Ramanathan, Natarajan Gopalakrishnan
DOI:10.4103/1319-2442.261345  PMID:31249234
Nonadherence to immunosuppressant medications leading onto poor graft outcome is frequent among renal transplant recipients. In this study, we sought to assess the prevalence and correlates of nonadherence to immunosuppressants and its impact on graft function. A singlecenter, retrospective cum cross-sectional study of renal transplant recipients of age >18 years and who had completed at least six months after transplantation was performed. Nonadherence was assessed based on the Immunosuppressant Therapy Adherence Scale questionnaire. Factors attributed to nonadherence were assessed based on the Immunosuppressant Therapy Barriers Scale (ITBS) questionnaire. Social, economic, demographic data, and all transplant related information were recorded. Two hundred and seventy-nine patients were included in the study, of whom 78% were male. Median follow-up period was 46 months (interquartile range – 24 months to 82 months). Seventy-four patients (26.5%) admitted nonadherence to immunosuppressants. The nonadherence was significantly related to the male gender, late acute rejection episodes, rise in serum creatinine from > 0.5 mg/dL from nadir level, lower blood levels of calcineurin inhibitor, and higher ITBS scores. Refill rates and use of alarm reminders were not significantly associated with better adherence.
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Asymptomatic proteinuria in Indonesian adolescent students p. 694
Partini Pudjiastuti Trihono, Nanda Wulandari, Bambang Supriyatno
DOI:10.4103/1319-2442.261347  PMID:31249235
Proteinuria is one of the common manifestations of kidney disease that has a serious impact on the progressive deterioration of kidney function. In developed countries, school screening for asymptomatic proteinuria is routinely performed, especially in adolescent students, to detect early stage of chronic kidney disease. This study aimed to find out the prevalence of asymptomatic persistent proteinuria in adolescent students. This was a multi-assessment study. Screening for proteinuria was conducted on five junior high schools across Jakarta, Indonesia, in April-June 2015. Healthy students aged 12–14 years whose parents provided informed consent were selected randomly. Urine collections were performed thrice. We used dipstick tests and protein-to-creatinine ratio to measure protein in the urine. From 536 students, 485 were eligible and recruited for this study. They were more female and well-nourished students. Hypertension constituted 12.9% of students. Proteinuria accounted for 7.42%. Transient, orthostatic, and persistent proteinuria were found in 5.77%, 1.03%, and 0.62% of students, respectively. The prevalence of asymptomatic persistent proteinuria among adolescent students in Jakarta is higher than that in other populations in Asia. Consequently, a routine screening to detect proteinuria should be considered in Indonesia to detect chronic kidney disease in children.
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CASE REPORTS Top

Does severe ADAMTS13 deficiency in thrombotic microangiopathy rule out complement-mediated atypical hemolytic uremic syndrome p. 701
Venkatesh Arumugam, Rohit Bhowmick, Indira Agarwal, Manjusha Arumadi
DOI:10.4103/1319-2442.261349  PMID:31249236
In evaluating a patient with thrombotic microangiopathy (TMA), it is necessary to rule out thrombotic thrombocytopenic purpura before a diagnosis of atypical hemolytic uremic syndrome (aHUS) is made. There have been reports that mutations of complement factors can coexist with partial A Disintegrin and Metalloproteinase with a ThromboSpondin type 1 motif, member 13 deficiency. Here, we report the case of a 6-year-old girl who was initially diagnosed as nephrotic syndrome and developed TMA after five years of onset of illness. She had poor response to treatment and had multiple relapses due to associated complement factor mutation. Hence, genetic evaluation has to be considered in all children presenting with aHUS.
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Gas in the kidney in asymptomatic Escherichia coli urinary tract infections in a patient with severe vesicoureteral reflex p. 706
Abbas Pakkyara, Amitabh Jha, Issa Al Salmi, Ehab Mohammed, Vinayak Jothi, Sadiq Al Lawati, Said al Maamari, Faisal A. M. Faisal
DOI:10.4103/1319-2442.261351  PMID:31249237
Diabetes mellitus (DM) is a common disease in Oman as in rest of Gulf Cooperation Council where metabolic syndrome is of high prevalence. DM is a foremost risk factor for urinary tract infections (UTIs). It is also linked to more complicated infections such as emphysematous pyelonephritis (EPN), emphysematous pyelitis (EP), renal/perirenal abscess, emphysematous cystitis, xanthogranulomatous pyelonephritis, and renal papillary necrosis. The diagnosis of these cases is frequently delayed because the clinical manifestations are generic and not different from the typical triad of upper UTI, which include fever, flank pain, and pyuria. A middle-aged female with DM and chronic kidney disease stage IV was admitted with recurrent UTI with extended-spectrum beta-lactamase-producing Escherichia coli. At presentation, she was afebrile, clinically stable, had no flank pain and there was no leukocytosis. Laboratory test for C- reactive protein done twice and was only mildly elevated at 7 and 11 mg/dL. A computed tomography scan of kidney-ureter-bladder (CT-KUB) was recommended and reported as “no KUB stone but small atrophic left kidney with dilatation of the pelvicalycial system and ureter and the presence of air in the collecting system suggestive of EP.” Thus, commonly associated with DM, especially in females, debilitated immune-deficient individuals, and patients harboring obstructed urinary system with infective nidus. Air in the kidney is not always due to EPN. UTI with a gas-producing organism can ascend to the kidney in the presence of vesicoureteral reflux.
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Stroke and renal artery stenosis from Takayasu’s arteritis diagnosed in a 57-year-old male patient p. 710
Sayed Shakeel ur Rahman, Abdulrahman Al Shehri, Mansour Al Ghamdi, Mohammad Al Shareef
DOI:10.4103/1319-2442.261353  PMID:31249238
Takayasu arteritis (TA) is a rare chronic granulomatous inflammatory arterial disease of unknown etiology that affects the aorta, its main branches and pulmonary artery. The clinical presentation is nonspecific, with signs and symptoms that vary according to the affected arterial segment. The most commonly affected vessel is the subclavian artery, while renal artery stenosis is relatively uncommon. We report a case of a 57-year-old male patient with late diagnosis of TA and various related complications including stroke in the left middle cerebral artery territory, predominant left renal artery stenosis, and hypertension with discrepancy of blood pressure between two arms due to predominant left subclavian artery stenosis. Thus, physicians should keep in their mind this late presentation after the age of 40 years. The aim is to increase the awareness of this condition because of early diagnosis and the timely introduction of treatment can lead to improved outcomes in this poorly understood clinical enigma.
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Bilateral endophthalmitis and symmetrical peripheral gangrene in a patient with chronic kidney disease on maintenance hemodialysis p. 715
Jishu Deb Nath, Abul Kashem, Ayesha Mohammad Osman, Tapas Das
DOI:10.4103/1319-2442.261355  PMID:31249239
Dialysis patients have greater number of complications due to multiple comor-bidity and access-related infections as well as nosocomial infections due to reduced immunity and more frequent hospitalizations. Endogenous endophthalmitis is a potentially blinding ocular infection occurring in chronically debilitated patients and the use of invasive procedures. Symmetric peripheral gangrene (SPG) is defined as symmetrical distal ischemic damage in two or more sites in the absence of a major vascular occlusive disease. It carries a high mortality rate with a very high frequency of multiple limb amputations in the survivors. However, only a few case reports have described endogenous endophthalmitis in dialysis patients. Concomitant endophthalmitis and disseminated intravascular coagulation (DIC), presenting as SPG, is extremely rare and no such case was found in the literature survey. Herein, we report a very rare association of bilateral endophthalmitis with DIC and SPG in a patient with chronic kidney disease on maintenance hemodialysis.
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Recurrence of membranoproliferative glomerulonephritis post transplant – Is this mere recurrence of pattern or recurrence of disease? p. 719
Umesh Lingaraj, Shivanagouda Ramanagouda Patil, Kishan Aralapuram, Shivaprasad Sasivehalli Mallappa, Sreedhara Chikkanayakanahalli Gurusiddaiah, Mahesha Vankalakunti
DOI:10.4103/1319-2442.261356  PMID:31249240
Recurrence of membranoproliferative glomerulonephritis (MPGN) is seen in 1965% cases of postrenal transplant resulting in graft loss in up to 35-50% of cases. A 31-year-old female, after 1% years on maintenance hemodialysis, underwent ABO compatible deceased donor kidney transplantation with basiliximab induction. During the immediate posttransplant period, the patient had delayed graft function, but achieved nadir creatinine of 0.9 mg/dL by 10 days. Nine months posttransplant, the patient developed fever, anasarca, and decrease in urine output with albuminuria 3+, active sediments in urine, serum creatinine 3.5 mg/dL, 24-h urine protein 7.5 g, and low C3. The patient underwent graft biopsy. Subsequently, the patient received pulse steroid for three days and five sessions of plasmapheresis. Renal biopsy report was suggestive of MPGN with focal crescents and acute tubular necrosis. Immunofluorescence showed Ig G3+, C3 3+, к 3+, and negative for λ or other immunoglobulins or complements. As her native kidney disease was immune-complex-mediated MPGN with no light chain restriction, paraffin tissue of the native kidney was reexamined for light chain restrictions by immunoperoxidase method, but did not show light chain restriction. The patient underwent extensive workup for paraproteinemias, but results were negative. Subsequently, she received four doses of bortezomib. The patient’s serum creatinine got reduced to 0.8 mg/dL and proteinuria reduced to 800 mg/day. Our case is unique as we were not able to demonstrate monoclonal deposits in native kidney sample although there was recurrence of MPGN with monoclonal light chain deposits post transplant. Our findings emphasize the need for thorough evaluation of paraproteinemias in patients with idiopathic MPGN even in the absence of light chain deposition in biopsy.
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Adenine phosphoribosyltransferase deficiency and 2, 8-dihydroxyadenine renal stones: A preventable cause of pediatric renal stones and kidney disease p. 723
Mital Dipakkkumar Parikh, Abhijit Konnur, Sishir Gang
DOI:10.4103/1319-2442.261357  PMID:31249241
Adenine phosphoribosyltransferase deficiency is an inherited condition presenting from infancy to late adulthood. The common features are recurrent kidney and urinary tract stones and obstructive symptoms. The stones are characteristically radiolucent. 2, 8-Dihydroxyadenine (2, 8-DHA) formation is blocked by xanthine oxidase blocker allopurinol. Here, we report the case of an eight-month-old baby girl who presented with obstructive acute kidney injury secondary to calculi which was treated with surgical removal of stone. The analysis of the calculi revealed 2, 8-DHA crystals.
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Manifest interstitial and vascular pathology in anti-neutrophil cytoplasmic antibody-associated renal disease p. 726
Satish Haridasan, Rajesh Nachiappa Ganesh, Sreejith Parameswaran, PS Priyamvada
DOI:10.4103/1319-2442.261359  PMID:31249242
Rapidly progressive renal failure in anti-neutrophil cytoplasmic antibody (ANCA)- associated renal disease customarily implies crescentic glomerulonephritis with approximately 50% of the glomeruli will have crescents. The tubulointerstitial inflammation is often proportionate to the glomerular inflammation and may have granulomatous pattern adjacent to the glomeruli or an inflamed vessel. A 77-year-old male with rapidly progressive renal failure was myeloperoxidase-ANCA positive, and renal histopathology revealed thrombotic microangio-pathy, significant interstitial inflammation, interstitial granulomas, and arteritis. Pathology is unique for the paucity of the classical crescents and the myriad of extraglomerular features. His renal function improved and stabilized after induction with cyclophosphamide and maintenance with azathioprine.
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Acute kidney injury due to sucrose-containing intravenous immunoglobulins p. 732
Wasim Siddiqui, Sadiq Al Lawati, AM Shaheen Faissal, Suad Hannawi, Marwa Al Riyami, Issa Al Salmi
DOI:10.4103/1319-2442.261361  PMID:31249243
Intravenous immunoglobulins (IVIGs) are pooled polyvalent immunoglobulin G antibodies extracted from the human plasma. Stabilizers in IVIG may include sugars, such as sucrose, glucose, or maltose. Sucrose in IVIG preparations may cause acute kidney injury (AKI). We report the case of a renal transplant patient who developed AKI due to sucrose nephropathy following the administration of sucrose-containing IVIG.
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A very rare pathogen in peritoneal dialysis peritonitis: Serratia liquefaciens p. 738
Ozant Helvaci, Kenan Hızel, Galip Guz, Turgay Arinsoy, Ulver Derici
DOI:10.4103/1319-2442.261363  PMID:31249244
Peritoneal dialysis (PD) peritonitis has been decreasing in frequency in recent years. However, it still causes significant morbidity and mortality. Nearly 1%–6% of all peritonitis attacks result in death. Hospitalizations, loss of PD access, and intravascular catheter insertion for hemodialysis are some examples of morbidity. Approximately 15%–20% of the infectious mortality of PD patients is attributed to peritonitis. The responsible pathogens are usually Gram-positive bacteria, but unusual pathogens may be present. Prognosis is worse when Gram-negative and fungal pathogens are involved. We report a case of Serratia liquefaciens peritonitis due to defiance of hygienic practices which presented with severe abdominal pain and fever and led to loss of PD access.
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LETTER TO THE EDITORS Top

Biochemical profile of mineral and bone disorder in prevalent hemodialysis patients p. 741
Fatimah R Alquraini, Rabab H Alnazer, Ohood A Albahrani, Ramlah Alkhars, Samir H Almueilo
DOI:10.4103/1319-2442.261364  PMID:31249245
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Experience of systemic lupus erythematosus in South-Western Bangladesh p. 743
Muhammed Arshad Ul Azim, Abdus Salam, Sk Nishat Abdullah
DOI:10.4103/1319-2442.261365  PMID:31249246
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Inferior vena cava compression and acute kidney injury p. 747
Hiroyasu Nakano, Naohiko Imai, Yugo Shibagaki
DOI:10.4103/1319-2442.261366  PMID:31249247
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Ralstonia infection among hemodialysis patients: A summary p. 749
Won Sriwijitalai, Viroj Wiwanitkit
DOI:10.4103/1319-2442.261367  PMID:31249248
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Estimated prevalence of BK virus infection from screening among kidney transplant recipients: A summary from an Indochina country p. 751
Pathum Sookaromdee, Viroj Wiwanitkit
DOI:10.4103/1319-2442.261368  PMID:31249249
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Prognostication of acute kidney allograft rejection through urinary molecular signatures: A noninvasive approach to ameliorate kidney rejection dynamics p. 752
Rashid Bin Hamid, Muhammad Tassaduq Khan, Akbar Shoukat Ali
DOI:10.4103/1319-2442.261369  PMID:31249250
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Sulfamethoxazole crystal-induced acute kidney injury p. 754
Wei Han, Naohiko Imai, Kaori Kohatsu, Tomo Suzuki
DOI:10.4103/1319-2442.261370  PMID:31249251
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